TELESIMULACIÓN SÍNCRONA Y OBSERVACIONAL EN SALUD: SCOPING REVIEW

Bernardinelli, Fabiana Cristina Pires; Nascimento, Juliana da Silva Garcia; Nascimento, Kleiton Gonçalves do; Amorim, Gustavo Correa de; Silva, Amanda Diniz; Chavaglia, Suzel Regina Ribeiro

Fabiana Cristina Pires Bernardinelli

visualization

data curation

formal analysis

validation

writing – original draft

writing – review & editing

Universidade Federal do Triângulo Mineiro, Programa de Pós-Graduação em Atenção à Saúde. Uberaba, Minas Gerais, Brasil.

https://orcid.org/0000-0002-8524-1449

Juliana da Silva Garcia Nascimento

data curation

formal analysis

validation

Universidade de São Paulo. Ribeirão Preto, São Paulo, Brasil.

https://orcid.org/0000-0003-1118-2738

Kleiton Gonçalves do Nascimento

data curation

formal analysis

validation

Universidade Federal do Triângulo Mineiro, Programa de Pós-Graduação em Atenção à Saúde. Uberaba, Minas Gerais, Brasil.

https://orcid.org/0000-0002-2717-6837

Gustavo Correa de Amorim

writing – original draft

writing – review & editing

Universidade Federal do Triângulo Mineiro, Programa de Pós-Graduação em Atenção à Saúde. Uberaba, Minas Gerais, Brasil.

https://orcid.org/0000-0001-9695-7904

Amanda Diniz Silva

writing – original draft

writing – review & editing

Universidade Federal do Triângulo Mineiro, Programa de Pós-Graduação em Atenção à Saúde. Uberaba, Minas Gerais, Brasil.

https://orcid.org/0000-0001-5547-2652

Suzel Regina Ribeiro Chavaglia

visualization

Universidade Federal do Triângulo Mineiro, Programa de Pós-Graduação em Atenção à Saúde. Uberaba, Minas Gerais, Brasil.

https://orcid.org/0000-0001-7033-0185

CORRESPONDING AUTHOR
Suzel Regina Ribeiro Chavaglia suzel.ribeiro@yahoo.com.br

CONFLICT OF INTEREST

There is no conflict of interest.

EDITORS

Associated Editors: Gisele Cristina Manfrini, Monica Motta Lino. Editor-in-chief: Elisiane Lorenzini.

Databases, descriptors and keywords	Search strategy
Medline/PubMed^® *MeSH: Students, Health Occupations”; “Health Personnel”; “Simulation Training”; “Clinical Competence”* and the keywords: Telesimulation; “Virtual Simulation”.	("Students, Health Occupations"[All Fields] OR "Health Occupations Students"[All Fields] OR "Health Occupations Student"[All Fields] AND "Health Personnel"[All Fields] OR "Personnel, Health"[All Fields] OR "Health Care Professionals"[All Fields] OR "Health Care Professional"[All Fields] AND "Simulation Training"[All Fields] OR "Training, Simulation"[All Fields] OR Telesimulation[All Fields] OR "Virtual simulation"[All Fields] AND "Clinical Competence"[All Fields] OR "Competency, Clinical"[All Fields])
Scopus *MeSH: “Students, Health Occupations”; "Health Personnel"; "Simulation Training"; "Clinical Competence" and the keywords: Telesimulation; "Virtual Simulation*".	TITLE-ABS-KEY(({Students, Health Occupations} OR {Health Occupations Students} OR {Health Occupations Student} OR {Occupations Student, Health} OR {Occupations Students, Health} OR {Student, Health Occupations}) AND ({Health Personnel} OR {Personnel, Health} OR {Health Care Professionals} OR {Health Care Professional}) AND ({Simulation Training} OR {Training, Simulation} OR Telesimulation OR {Virtual simulation}) AND ({Clinical Competence} OR {Competency, Clinical}))
Embase ‡‡Emtree: “Health Student”; “Health Care Personnel”; “Simulation Training”; Clinical Competence” and the keywords: “Telesimulation” and “Virtual Simulation”.	(“Health Student” AND “Health Care Personnel” AND “Simulation Training” OR Telesimulation OR “Virtual Simulation” AND “Clinical Competence”)
CINAHL Títulos/Assuntos: “Students, Health Occupations”; "Health Personnel"; "Simulation Training"; "Clinical Competence" and the keywords: Telesimulation; "Virtual Simulation*".	SU((“Students, Health Occupations”) AND (“Health Personnel”) AND (Telesimulation OR “Virtual simulation”) AND (“Clinical Competence”))
ERIC Thesaurus: “Graduate Study”; "Health Personnel"; "Simulation”; "Competence" and the keywords: Telesimulation; "Virtual Simulation".	(“Graduate Study” AND “Health Personnel” AND Simulation OR Telesimulation OR “Virtual simulation” AND Competence)
Web of Science *MeSH: “Students, Health Occupations”; "Health Personnel"; "Simulation Training"; "Clinical Competence" and the keywords: Telesimulation; "Virtual Simulation*".	AK=((“Students, Health Occupations” OR “Health Occupations Students” OR “Health Occupations Student” OR “Occupations Student, Health” OR “Occupations Students, Health” OR “Student, Health Occupations” AND “Health Personnel” OR “Personnel, Health” OR “Health Care Professionals” OR “Health Care Professional” AND “Simulation Training” OR “Training, Simulation” OR Telesimulation OR “Virtual simulation” AND “Clinical Competence” OR “Competency, Clinical”))
†LILACS ††DeCS: Descriptors in Portuguese, English and Spanish. The Portuguese version was: “Estudantes de Ciências da Saúde”, “Pessoal de Saúde”, “Treinamento por Simulação”, “Competência Clínica” and the keyword: Telessimulação.	Portuguese: ((“Estudantes de Ciências da Saúde”) AND (“Pessoal de Saúde”) AND (“Treinamento por Simulação” OR Telessimulação) AND (“Competência Clínica”)) English: ((“Students, Health Occupations”) AND (“Health Personnel”) AND (“Simulation Training OR Telesimulation) AND (“Clinical Competence”)) Spanish: (“Estudiantes del Área de la Salud” AND “Personal de Salud” AND “Entrenamiento Simulado” OR Telesimulación AND “Competência Clínica”)
‡CAPES	Use of the keyword: Telessimulação (https://catalogodeteses.capes.gov.br/catalogo-teses/)
§DART	Use of the keyword: Telesimulation (https://www.dart-europe.org/basic-search.php.)
\|\|EThOS	Use of the keyword: Telesimulation (https://ethos.bl.uk/SearchResults.do)
¶RCAAP	Use of the keyword: Telessimulação (https://www.rcaap.pt/)
National ETD Portal	Use of the keyword: Telesimulation (http://www.netd.ac.za/?query=telesimulation&action=search)
Theses Canada	Use of the keyword: Telesimulation (https://www.bac-lac.gc.ca/eng/services/theses/Pages/list.aspx?AW_S=telesimulation)

Authors/ Year of publication/ Country of origin	Objective and clinical scenario	Type of study, target audience and assessed skills	Telesimulation procedure, outcomes and evidence level
McCoy et al., 201733. McCoy CE, Sayegh J, Alrabah R, Yarris LM. Telesimulation: an innovative tool for health professions education. AEM Educ Train [Internet]. 2017 [cited 2021 Sep 22];1(2):132‐6.Available from: https://doi.org/10.1002/aet2.10015 https://doi.org/10.1002/aet2.10015... United States.	Compare the effectiveness of telesimulation with face-to-face simulation. Cardiac arrest scenarios.	Clinical, randomized study. Medical students. Assessment of cognitive and affective skills.	Randomization of 32 students divided into a control group (traditional simulation) and an intervention group (telesimulation). The intervention group observed the scenario through a live television connection to the internet. There was no significant difference regarding knowledge of groups and preference for modalities. Although both modalities have positive effects for learning, telesimulation provides benefits in the absence of face-to-face resources. Level of evidence: 2
McCoy et al., 201977. McCoy CE, Alrabah R, Weichmann W, Langdorf MI, Ricks C, Chakravarthy B, et al. Feasibility of Telesimulation and Google Glass for Mass Casualty Triage Education and Training. West J Emerg Med [Internet]. 2019 [cited 2021 Sep 22];20(3):512-9.Available from: https://doi.org/10.5811/westjem.2019.3.40805 https://doi.org/10.5811/westjem.2019.3.4... United States	Evaluate the feasibility of telesimulation. Pre-hospital emergency scenarios.	Intervention study. Doctors; nurses; paramedics; pharmacists; educators and administrators. Assessment of affective skills.	The telesimulation was based on a mass accident scenario in the pre-hospital environment. Content and study materials were delivered using telecommunication resources. Standardized patients and high-fidelity mannequin simulation were combined. The teledebriefing was carried out. All 32 participants provided a favorable response to telesimulation and reported that this experience added educational value. This study demonstrated the success of a medical emergency triage course using telesimulation. Level of evidence: 3
Naik et al., 202011. Naik N, Finkelstein RA, Howell J, Rajwani K, Ching K. Telesimulation for COVID-19 ventilator management training with social-distancing restrictions during the coronavirus pandemic. Simul Gaming [Internet]. 2020 [cited 2021 Sep 22];51(4):571-7.Available from: https://doi.org/10.1177/1046878120926561 https://doi.org/10.1177/1046878120926561... United States.	Evaluate the effectiveness of a telesimulation. Mechanical ventilator management scenario in patients with COVID-19.	Intervention study. Doctors; nurses and nursing faculty. Assessment of affective skills.	A telesimulation was developed using a high fidelity simulator, locally operated by a tablet. Vital signs were displayed on a monitor, and a test lung was positioned over the dummy’s chest, connected to a mechanical ventilator to mimic lung compliance. A portable camera system was used to provide real-time images of the ventilator and monitor, and each group of students formed a virtual care team. A 20-minute teledebriefing was held. Students found telesimulation useful and similar to traditional simulation. Level of Evidence: 3
Yang et al., 20211717. Yang T, Buck S, Evans L, Auerbach M. A Telesimulation Elective to Provide Medical Students With Pediatric Patient Care Experiences During the COVID Pandemic. Pediatr Emerg Care [Internet]. 2021 [cited 2021 Sep 22];37(2):119-22. Available from: https://doi.org/10.1097/pec.0000000000002311 United States.	Describe the implementation of a telesimulation. Pediatric emergency scenario.	Descriptive study with a qualitative approach. Medical students. Assessment of affective skills.	Telesimulation sessions brought together participants from different locations via personal computer, phone or tablet. A professional actor played the role of the father, using a virtual background to display images of a pediatric patient. An actress played the role of a nurse and conveyed the patient’s clinical status. A facilitator led the pre-briefing. The students were divided into two teams. While one team actively cared for the patient, the other team observed and participated in the teledebriefing. Ninety percent of the students were comfortable and confident with the subject after the tele-simulation, in addition to demonstrating satisfaction with this teaching modality. Level of evidence: 6
O’Era et al., 20211818. O’Era A, Ferreira C, Hnatyshyn T, Krut B. Family nursing telesimulation: Teaching therapeutic communication in an authentic way. Teach Learn Nurs [Internet]. 2021 [cited 2021 Sep 22];16(4):404-9.Available from: https://doi.org/10.1016/j.teln.2021.06.013 https://doi.org/10.1016/j.teln.2021.06.0... Canada	Describe the application of a telesimulation. Therapeutic care for a family scenario.	Descriptive study with a mixed approach. Nursing students.	A total of 101 nursing students provided care for a family through telesimulation. Each event lasted 10 minutes of pre-briefing/briefing, 20 minutes of scenario and 40 minutes of teledebriefing. A telecommunication tool was used to connect students, patients and facilitators. The simulated patients played the roles of family members. 56% of students completed the online assessment and appreciated this teaching strategy. Telesimulation supported students’ ability to practice their decision making. Level of evidence: 6
Kurji et al., 20211919. Kurji Z, Aijaz A, Aijaz A, Jetha Z, Cassum S. Telesimulation Innovation on the Teaching of SPIKES Model on Sharing Bad News. Asia Pac J Oncol Nurs [Internet]. 2021 [cited 2021 Sep 22];8(6):623-7.Available from: https://doi.org/10.4103/apjon.apjon-20108 https://doi.org/10.4103/apjon.apjon-2010... Pakistan	Describe the implementation of a telesimulation. Communicating bad news scenario.	Descriptive study with a qualitative approach. Nurses. Assessment of cognitive and affective skills.	A telesimulation module provided its theoretical component on communicating bad news via PowerPoint with an online communication challenge. Nursing students were invited to be simulated patients. The 141 interns were divided into seven discussion groups in which each one was accompanied by an instructor. Students were divided into pairs to interact with the simulated patient. Faculty and interns took notes of their observations for the teledebriefing. The interns rated the activity within the parameters of good to excellent and the learning experience as positive and engaging. Telesimulation is an innovative and useful tool for teaching communication skills. Level of evidence: 6
Gutierrez-Barreto et al., 20212020. Gutierrez-Barreto SE, Argueta-Muñoz FD, Ramirez-Arias JD, Scherer-Castanedo E, Hernández-Gutiérrez LS, Olvera-Cortés HE. Implementation Barriers in Telesimulation as an Educational Strategy: An Interpretative Description. Cureus [Internet]. 2021 [cited 2021 Sep 22];13(9):e17852.Available from: https://doi.org/10.7759/cureus.17852 https://doi.org/10.7759/cureus.17852... Mexico.	Identify the barriers to implementing telesimulation in medical graduation. Prenatal consultation scenario.	Descriptive study with a qualitative approach. Medicine students. Assessment of affective skills.	The study sample consisted of 18 professors, 26 standardized patients and 407 students. There was a pre-briefing (10 minutes), simulated scenario (20 minutes) and teledebriefing (30 minutes). The simulation addressed a standardized patient and a videoconferencing platform. The scenario consisted of a prenatal consultation. Teledebriefing was conducted. A taxonomy of five telesimulation barriers was structured: knowledge; installations; financing; attitude and participants. The description of the barriers can improve the quality of the telesimulation. Level of evidence: 6
Thomas et al., 202144. Thomas A, Burns R, Sanseau E, Auerbach M. Tips for conducting telesimulation-based medical education. Cureus [Internet]. 2021 [cited 2021 Sep 22];13(1):e12479.Available from: https://doi.org/10.7759/cureus.12479 https://doi.org/10.7759/cureus.12479... United States.	Describe 12 tips on how to implement telesimulation.	Descriptive study. Medicine Students.	Twelve recommendations were described: (1) selection of the telesimulation classification; (2) consideration of telesimulation limitations; (3) identification of learning objectives; (4) identification of audiovisual materials; (5) preparation of faculty, staff, and telesimulation testing; (6) student preparation, including pre-briefing; (7) allowing “timeouts” during the pre-briefing; (8) establishing team and communication roles; (9) debriefing preparation; (10) involvement of silent participants; (11) sharing additional learning resources; (12) feedback collection. Although telesimulation does not replace face-to-face simulation, it can be used to actively engage participants and serve as a pedagogical alternative. Level of evidence: 6
Diaz; Walsh, 202188. Diaz MCG, Walsh BM. Telesimulation-based education during COVID-19. Clin Teach [Internet]. 2020 [cited 2021 Sep 22];18(2):121-5.Available from: https://doi.org/10.1111/tct.13273 https://doi.org/10.1111/tct.13273... United States	Analyze the criteria for developing telesimulations.	Descriptive study. Students and health professionals.	This study presented criteria for the development of telesimulation: (1) needs assessment; (2) learning outcomes; (3) equipment; (4) practice; (5) pre-briefing; (6) facilitators; (7) teledebriefing; (8) feedback. Telesimulation as an educational platform is evolving and can be considered an interactive and exciting way to learn. Level of evidence: 6

Steps	Description of the steps and the respective components
Step 1 - Planning	Initial step of the telesimulation in which the instructors/facilitators describe and validate their instructional design composed of the necessary steps and components. For this step, a period of 30 days is generally used for planning and 60 days to validate the content of the instructional design, carried out by professionals who are experts in the subject, and preferably adopting the Delphi technique until reaching a Total Content Validity Index equal to or greater than 0.80. The components considered for description in this planning are: (1) definition of theoretical references that will support the telesimulation; (2) learning theme; (3) target audience; (4) learning objectives; (5) skills you want to develop through telesimulation (learning outcomes); (6) description of the type of instructional material and learning environment/platform to perform the pre- and post-simulation; (7) description of the elements that will be presented in the pre-briefing/briefing and of the fictional contract established with the learners by the facilitators; (8) description of the telesimulated clinical scenario design elements; (9) definition of scenario fidelity; (10) definition of the type of instrument adopted (simulator or simulated/standardized patient); (11) characterization of the simulator’s fidelity, if adopted; (12) organization of the necessary human resources (laboratory technicians, specific technicians for the online and live transmission of the telesimulation, professors/facilitators, students); (13) description of materials needed to establish the clinical scenario; (14) definition of the technological resources that will enable telesimulation (teleconferencing platform, such as: computers, internet, camcorders, online transmission mechanisms); (15) establishment of technological resources for remote observation of the learner (personal computer, telephone or tablet, internet); mechanisms/formats/instruments for assessing learners’ skills; (16) modality and technique of debriefing adopted; (17) learner feedback mechanisms; (18) time available for each step of the telesimulation; (19) format and guidelines for training facilitators and staff/personnel involved in telesimulation; (20) validation of the telesimulation instructional design; (21) pilot test of the proposed telesimulation. It should be noted that most of these components are addressed in the simulated scenario design section.1,3-4,7-8,17-201. Naik N, Finkelstein RA, Howell J, Rajwani K, Ching K. Telesimulation for COVID-19 ventilator management training with social-distancing restrictions during the coronavirus pandemic. Simul Gaming [Internet]. 2020 [cited 2021 Sep 22];51(4):571-7.Available from: https://doi.org/10.1177/1046878120926561 https://doi.org/10.1177/1046878120926561...
Step 2 - A) Preparation: pre-simulation	Step which provides the study and prior preparation of learners on the subject of learning and peculiarities for online and remote participation in the telesimulated activity, which can be made possible by instructional platforms of the educational institution or via electronic mail (email of learners), providing references and study materials about the activity. A period of 15 days is recommended to establish this step. The following components are considered: (1) Dialogued expository class with the aid of a powerpoint presentation; (2) tutorial videos; (3) video lessons; (4) video simulations, guidelines, among other formats.1,3-4,7-8,17-201. Naik N, Finkelstein RA, Howell J, Rajwani K, Ching K. Telesimulation for COVID-19 ventilator management training with social-distancing restrictions during the coronavirus pandemic. Simul Gaming [Internet]. 2020 [cited 2021 Sep 22];51(4):571-7.Available from: https://doi.org/10.1177/1046878120926561 https://doi.org/10.1177/1046878120926561...
B) Preparation - pre-briefing/ Briefing	After the online reception of the students, the facilitators present themselves and pre-test instruments are applied, if necessary, for evaluation. Then, the pre-briefing/briefing phase will be established by the facilitators in a calculated time of 5 to 10 minutes, covering: (1) presentation of the simulation environment; (2) description of the clinical case proposed for learning; (3) activity time; (4) scenario start and end time; (5) definition of the instruments (explanation about the simulator or role played by the simulated patient (actor trained for the scene), or standardized patient (individual from the community trained for the scene), or roles of the learners, if students are adopted to participate in demonstrating the scenario in person, while the others observe remotely and live; (6) clarification of the learning objectives; (7) materials available; (8) clues/hints which will be offered by the facilitators to conduct the scene; (9) need for silence on the part of the remote learners and to remain with their cameras turned off (offline) during execution of the scenario; (10) need to turn on the cameras and participate in the teledebriefing after executing the scene; (11) explanation about the evaluation tool, if a spreadsheet of criteria and notes is made available to learners to contribute to the discussion. 1,3,7-8,17-181. Naik N, Finkelstein RA, Howell J, Rajwani K, Ching K. Telesimulation for COVID-19 ventilator management training with social-distancing restrictions during the coronavirus pandemic. Simul Gaming [Internet]. 2020 [cited 2021 Sep 22];51(4):571-7.Available from: https://doi.org/10.1177/1046878120926561 https://doi.org/10.1177/1046878120926561...
Step 3 -Participation: telesimulated clinical scenario design	The participation stage corresponds to executing the simulated clinical scenario transmitted live, generally in a period of 10 to 15 minutes. This design must be described by the researchers and validated by specialists in the proposed theme, selected through well-established criteria using the Delphi technique, which recommends several “rounds” of construct evaluation until there is agreement between the experts involved. The telesimulation planning stage covers four phases with the following components: Phase A: Simulated clinical scenario design planning - components: (1) responsible for preparing and facilitating (conducting) the scenario; (2) classification of the adopted telesimulation; (3) scenario theme; (4) theoretical-methodological framework to elaborate the scenario; (5) theoretical foundation of the learning theme; (6) scenario fidelity; (7) physical space in which the scenario will be broadcast; (8) target audience; (9) inclusion and exclusion criteria; (10) skills developed; (11) general and specific learning objectives; (12) duration of the scenario; (13) instruments - simulators or simulated/standardized patients; (14) clinical case; (15) description of the starting and ending point of the scenario; (16) actions and training script for actors, standardized patients or students who participated in the scene in person; (17) decision-making tree for guiding apprentices, if they are responsible for executing the scene; (18) material resources for the scene. Phase B: Description of the learner’s assessment (instruments); Phase C: Validation of the telesimulated scenario design; Phase D: Pilot test of the scenario carried out at a pre-scheduled time, and establishing a number of participants for the experience according to the guidance of a professional statistician, with the intention of testing the feasibility of telesimulation and aligning any type still existing bias.1,3-4,7-8,17-201. Naik N, Finkelstein RA, Howell J, Rajwani K, Ching K. Telesimulation for COVID-19 ventilator management training with social-distancing restrictions during the coronavirus pandemic. Simul Gaming [Internet]. 2020 [cited 2021 Sep 22];51(4):571-7.Available from: https://doi.org/10.1177/1046878120926561 https://doi.org/10.1177/1046878120926561...
Step 4 -Teledebriefing	Step characterized by an analytical moment of reflection/discussion of the telesimulated scenario observed by the learners remotely online and live, and conducted by one or more facilitators. It is recommended to carry out the teledebriefing until all the learning objectives are discussed and contemplated. It usually lasts twice as long as it takes to perform the clinical scenario. It must be based on a debriefing method and technique.1,3-4,7-8,17-201. Naik N, Finkelstein RA, Howell J, Rajwani K, Ching K. Telesimulation for COVID-19 ventilator management training with social-distancing restrictions during the coronavirus pandemic. Simul Gaming [Internet]. 2020 [cited 2021 Sep 22];51(4):571-7.Available from: https://doi.org/10.1177/1046878120926561 https://doi.org/10.1177/1046878120926561...
Step 5 -Learner assessment and feedback collection	Definition of tools or instruments for assessing cognitive abilities (instrument for assessing knowledge, generally of the pre- and post-test type on the theme addressed for teaching and learning through tele-simulation) and affective (such as: Scale of Student Satisfaction and Self-Confidence in Learning2121. Almeida RGS, Mazzo A, Martins JCA, Baptista RCN, Girão FB, Mendes IAC. Validation to Portuguese of the Scale of Student Satisfaction and Self Confidence in Learning. Rev Lat Am Enfermagem [Internet]. 2015 [cited 2021 Sep 22];23(6):1007-13.Available from: https://doi.org/10.1590/0104-1169.0472.2643 https://doi.org/10.1590/0104-1169.0472.2... , in which it is intended to be developed through the proposed telesimulated educational strategy. Generally lasts from 30 to 40 minutes. Organization of the selected feedback format for feedback on the telesimulated activity from the perspective of the facilitators.8,178. Diaz MCG, Walsh BM. Telesimulation-based education during COVID-19. Clin Teach [Internet]. 2020 [cited 2021 Sep 22];18(2):121-5.Available from: https://doi.org/10.1111/tct.13273 https://doi.org/10.1111/tct.13273...
Step 6 - Additional learning	Support instructional resources such as: podcast, national and international guidelines, texts, articles, video class, video simulation, power point class, available after the end of the telesimulation to enhance knowledge on the selected topic with a period of 10 days to the feedback.4,174. Thomas A, Burns R, Sanseau E, Auerbach M. Tips for conducting telesimulation-based medical education. Cureus [Internet]. 2021 [cited 2021 Sep 22];13(1):e12479.Available from: https://doi.org/10.7759/cureus.12479 https://doi.org/10.7759/cureus.12479...

[1] CORRESPONDING AUTHOR
Suzel Regina Ribeiro Chavaglia suzel.ribeiro@yahoo.com.br

Brasil

Brasil

TELESIMULACIÓN SÍNCRONA Y OBSERVACIONAL EN SALUD: SCOPING REVIEW

RESUMEN

Objetivo

Método

Resultados

Conclusión