Nick Peres + Tim Mason. Virtual simulation, Don't Forget the Bubbles, 2020. Available at:
What do you think of when you hear the words Virtual Sim? If your mind goes to Neo (Editors note: Keanu was actually quite good in the first Matrix- feel free to argue) then we are of like mind. If you think of the stereotypes of mainstream media, you will likely think Ready Player One, Tron, or even Lawnmower Man!
COVID-19 has changed our world with “socially close” teaching universally banned. Simulation is no different and I, for one, miss it! We know sim has its benefits, in situ, and for hands-on practice. Can we get back to that reflective learning we know and love?
Medical simulation is a tactile, experiential teaching modality, however, as sim trainers, we are often told “the learning is in the debrief”. This leaves us to beg the question – can we re-create or port something like a debriefing session virtually? And if so, should we be pausing activity in our sim centres and giving all trainees a VR headset?
Looking at the realm of Twitter and our practical experience, how have people tried to bridge this gap? What’s out there?
Passive: Watching a live simulation session streamed to a video conferencing application via the sim centre camera(s) (or mobile) whilst a team perform the sim. This is then followed by a facilitated debrief taking place remotely, again utilising a video conference platform.
Interactive: A simulation takes place but there may be some interactivity with a confederate in the room being directed via video by a learner as a team lead. The debrief then follows on the video conferencing platform. Pre-recorded video can be repeated as appropriate.
A quick note on cameras
We are investigating the types of camera that best convey a remote simulation scenario. These include fixed-angle cameras (such as utilising those cameras already within a simulation suite), handheld or accessible cameras, such as a body-worn GoPro or even utilising a 360-degree camera, which can then be explored by participants or debriefer using their mouse to navigate the 360 recorded space.
The advantage of the passive approach is that we do get to be involved in the process, however, there may only be one or two fixed-view cameras impacting on your impression of the scenario. It may recreate some of the visceral feelings we get in a resus but you are still physically and psychologically removed. The alternate scenario adds an element of interactivity but the action in the room won’t reflect reality as it won’t directly represent the real team. Both measures will need clear learning objectives that fit these new methods. One interesting thought is if this actually represents the way senior doctors view their department and “direct” their juniors remotely without the need to physically be present (i.e. overnight on calls)?
Others have tried methods such as Telesimbox where a video is played whilst a facilitator guides the learners (over video) through a pre-set scenario.
Other paid-for services include app-based 360° films which may have a degree of interactivity or higher-tech solutions using headsets.
We’ve been doing something a little bit different which is 360° Virtual sim. 360° video is filmed using a fancy camera that can record all the way around it with two fisheye lenses. The camera then stitches together the images into a sphere which you can then look around by swiping the screen on a tablet or moving your head around a VR headset. 360° video has been used as a debriefing tool in itself with some success. Medical students found it gave them a deeper appreciation of their communication skills during the simulation.
Two years ago I was helping run a Return to Paediatric Training Sim course in the south-west, We didn’t have any time to add in resus but felt that it was an area people worry about. With the expert help of Nick of the Torbay VR team, we made a Neonatal Life Support (NLS) and an Advanced Paediatric Life Support (APLS) simulation utilizing 360° video which participants could access at home. The learners on the course loved it, though some felt it was stressful or uncomfortable, The sights and sounds of the room meant everything soon felt familiar. For others, it inspired them or put them back in the zone.
When the world became socially distant, it gave us the opportunity to debrief these videos over a video conferencing platform. Using 360° videos, the viewer becomes an active observer right in the centre of the action. Although they can’t truly interact with the scene, they are still placed in media res. This really helps to bring about discussion of non-technical skills, with associated feelings and humanistic considerations, in the debrief.
If you have content that is created and shared with you to use, it then essentially becomes an accessible and free setup with no need for manikins, faculty, or dealing with the frustrating lack of parking spaces. Here’s an example of a 360° sepsis sim we ran and debriefed remotely.
There is also the potential to teach larger groups than what would normally be run through an in-person simulation session.
Making your own 360° content
- Write your simulation with learning objectives appropriate to your learners – think, medical, technical and non-technical.
- Think about which scenarios work. Emergencies with lots of different teams to follow may be fun, but think about the difficult communication scenarios (safeguarding, breaking bad news) as it may be a safe way to sharpen communication skills.
- A 360° camera (roughly £400) and stand (grip/ microphone stand).
- A computer capable of editing (it needs a good graphics card)
- When filming, position your camera at eye height in the centre of the action (hanging from the curtain rail is good).
- Take away all patient identifying info if in situ (the camera sees all).
- Think if you are going to tell the sim participants the theme of the sim. It adds to psychological safety but you may not get the authentic simulation experience.
- Film it again if things go wrong as it is harder to edit afterwards.
- Editing- steep-ish learning curve but simple things can be done easily in free packages.
Running your remote or 360° virtual Sim teaching session
#VirtualSim via @MicrosoftTeams this am @RDE_ED @RDEhospitals#athome 🏨
….. it actually went better than expected
Read below for some thoughts….@aspih @INSPIRE_Network@SESAMSimulation @IPSSorg @sim_aware @drauerbach
— RD&E Simulation (@RDE_Sim) April 29, 2020
- Planning is key- time and place are less of an issue but think of your learners. How is the session going to meet their learning needs? Is there something particular that you are going to focus on?
- Pick your video conferencing application of choice – we all have our favourite/ the one our trust allows us to use. Are you sharing your screen? Are you using sim centre cameras or mobile phones?
- Practice using the kit/ technology before you do it live – not once but a good few times.
- Solid Pre brief/ ground rules for the session are important.
- Beware of “Zoom Fatigue”- try not to run a session longer than 1 hour. Most of ours have been 45 minutes at most.
- Is the Wifi good enough? Will the videos cut out?
- During the sim think about allowing learners/ observers to type thoughts and feeling that come to mind that you can then cover in the debrief.
Some thoughts on the virtual debrief
In a study looking at debriefing after medical serious games, in-person and virtual debrief both rated highly (self was the lowest). Remote debriefing has been used to train teams and faculty in countries that do not have access to resources or experience in simulation.
Make sure someone is designated to lead the debrief. Use the standard sim structure- Defusing, Discovery and Deepening. This model is based on Kolb’s experiential learning theory. This has made its way into many different models including Diamond, Pearls and ITRUST.
Who’s watching the watchmen? We’ve had more consultants during our sessions than the usual weekly sim. This changes the dynamic of the discussion. It skipped the medicine and went straight to the communication and processes seen. This may not be a positive for the junior members who needed experiential medical learning. If using pre-recorded 360° content that is not live make sure you make it personal exploring real-life experiences. Has anyone seen this before? How does this work in your ward? Where’s the protocol kept?
As with all forms of online facilitated tuition, it is important to set the ground rules at the offset. Do you have learners muted? This will depend on the numbers in the debrief considering microphone echo verus silence. You may need to use a signal to talk (i.e. Zoom thumbs up!). Everyone should keep their cameras on so you can see everyone and try to “read the room” keeping all involved.
So what might the future hold? It may be live streaming 360° content (which a lot of 360 cameras can do), a virtual space we can easily watch 360° video together, or Mozilla hubs where our avatars we can meet to watch content together. I don’t see this a replacement for regular simulation. It is an adjunct, a complimentary tool for the SBE toolkit.le.