The use of simulation in healthcare has increased in recent years. It is frequently used for replicating clinical scenarios and allows for the acquisition of skills in a safe environment. Whilst enabling candidates to make mistakes and learn from them without fear of harming patients is used across many specialities including paediatric emergency medicine for a range of teaching across all professional groups, Lateef [1] identifies that in order for it to reach its maximum potential, it needs to be integrated in traditional training programmes. This is becoming more commonplace. In order to know how to fully integrate it into practice, an understanding of how it is currently being used is essential. This scoping view aims to explore how simulation training is being used and what it is used for within paediatric emergency medicine (PEM), as reported by the literature.

Methods:

This review followed a five-step scoping review framework outlined by Arksey and O’Malley [2]. Literature searches were conducted in Medline and CINAHL with no limitation applied. Sixty-six studies were screened. Reference lists were also screened. Of the screened studies, 25 were subject to full test review and 19 were included in the final review. Articles were screened at all levels by one reviewer. Data extraction was also carried out by one reviewer.

Results:

No papers focused on the delivery of simulation within paediatric emergency medicine in the UK, with the majority of papers originating from the USA. There was also no paper that outlined the varied uses of simulation in PEM. Many of the papers described and evaluated single scenarios that were used in varying settings or simulation courses that were not specific to PEM. Both high and low fidelity simulations were reported with much of the focus on high-fidelity simulation. Delivered through either simulation suite-based learning or in situ simulation. There is little discussion about the use of simulation for interpersonal and communication skills with only one paper mentioning this. Frequently simulation focuses on the acquisition of individual procedures and skill acquisition. Alongside this simulation is also reported to be used to test responses to rare or complicated cases or high-pressured scenarios such as resuscitation.

Conclusion:

This scoping review reveals that the extent to which simulation is used within PEM is largely unknown and requires further investigation.

Ethics statement:

Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Simulation-based learning is an increasingly popular pedagogical approach. In some areas of physiotherapy, it is better been documented, for example, cardiorespiratory physiotherapy [1]. However, its use in other physiotherapy-related settings is less clear. Therefore, the aim of this project was to review the literature on simulation-based learning in prequalifying physiotherapy education, in order to explore where studies have taken place, which physiotherapy settings it is used in and indication of its effectiveness in teaching.

Methods:

This study was carried out based on the scoping review methodology outlined by Arksey and O’Malley [2]. The following databases were searched: AMED, BNI, CINAHL, Embase, Emcare, HMIC, Medline and PsychInfo, using specific search terms, to find studies involving the use of simulation in a prequalifying physiotherapy setting. Returned papers were screened using inclusion and exclusion criteria by two reviewers. The database search results were recorded and managed using Rayyan™ [3].

Results:

The database search retrieved 280 papers. Following the removal of duplicates, screening titles and abstracts and then screening full-text papers, 39 papers were included. The included studies were conducted in USA (n = 23), Australia (n = 10), Canada (n = 1), Finland (n = 1), Germany (1), Spain (1), Taiwan (1), UK (1). Simulation-based learning activities took place in a variety of physiotherapy settings. Most took place in an acute care or cardiorespiratory setting. There was a high level of variation in the reporting of the described simulation activity. This made it difficult to establish whether simulations were of high or low fidelity. Where reporting was well described, simulation activities tended to follow a framework of pre-brief, simulation and then debriefing. The majority of studies reported some measure of the effectiveness or feasibility of simulation-based learning.

Conclusion:

This scoping review identified a growing body of evidence supporting simulation-based learning in prequalifying physiotherapy education. However, to date, its use in pedagogical research has tended to focus on the cardiorespiratory setting, and it has often been researched as a tool to explore or enhance interprofessional collaboration. Whilst both of these areas are of value to the profession, there is scope to explore the use of simulation-based learning in settings such as musculoskeletal teaching. Further work on its use and value in the teaching of discrete complex tasks, in addition to collaborative practice, such as team working, de-escalation and communication is also needed.

Ethics statement:

Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

On-call respiratory physiotherapy is utilized when an acutely unwell patient could deteriorate without immediate assessment and treatment overnight. Education related to this topic varies greatly and is often of poor quality. Simulation-based education (SBE) has been increasingly used within other areas of healthcare yet, Gough et al. [1] completed a study in 2013, which found only 39% of acute trusts used simulation for respiratory on-call training.

Aim:

To determine from existing research, whether SBE can enhance the development of registered physiotherapists respiratory ‘on-call’ skills in order to impact future practice.

Methods:

A qualitative literature review was completed as part of a PgCert in Health Simulation at Coventry University, in March 2023. Ethical approval was gained from Coventry University (P149952). Studies included were found by searching AMED, CINAHL Embase and Medline databases. Figure 1-A20 presents the PRISMA flow diagram [2]. Final reports included were critically analysed using the Critical Appraisal Skills Programme framework [3] and data extracted and formatted into a table. General themes were identified using an inductive approach.

Figure 1-A20:

PRISMA flow diagram

Results:

Eleven papers were selected to be reviewed after the removal of duplicates, screening and the exclusion criteria were applied. The main themes identified were the use of high-fidelity simulation, the measure of confidence and/or competence, and findings of positive implications for practice. SBE is widely used for other healthcare professions with positive outcomes; however, its use within respiratory physiotherapy is limited. Most studies chose to measure self-reported levels of competence and confidence, which is an example of Kirkpatrick level-one evaluation. These measures have only casual links to transfer of knowledge and behaviour change, which are key requirements when applying training to clinical settings. Interestingly, the review also demonstrates favourable use of high-fidelity manikins within this population. Although this was not discussed by the researchers, this may be a barrier for further implementation due to cost and technical knowledge required to use the equipment.

Conclusion:

The use of SBE has been beneficial in other healthcare professions and similar positives were found for its use with respiratory physiotherapists. However, much of the research is of low quality, and further research is required to review other confounding factors that may influence the outcomes and longitudinal staff behaviour.

Ethics statement:

Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Simulation can immerse learners in scenarios that mimic clinical situations, simultaneously mitigating safety risks and increasing standardization in healthcare education [1]. Through simulation, learners can get the chance to develop clinical reasoning with focused learning opportunities [2]. Clinical reasoning is multidimensional in nature, and underdeveloped clinical reasoning skills and the risk of cognitive overload can potentially threaten patient safety and delay care, so it is important to systematize, optimize and structure clinical reasoning for simulation-based education [3]. That can be achieved through using valid clinical reasoning models but with careful consideration to the contributing and influencing factors of case complexity, staff seniority, competence, scope of practice, specialty and subspecialty.

Methods:

A scoping review was undertaken to answer the questions: what are the best available valid and reliable clinical reasoning models for simulation-based education? We searched Medline, Scopus, Education Research Complete and Google Scholar to identify relevant recent primary research conducted on this topic from 2000 onwards. The search included MeSH topics of ‘Clinical reasoning’, ‘Simulation-based education’ and ‘Clinical Reasoning models’. The inclusion criteria were primary studies describing the clinical reasoning models developed for simulation-based courses. Two independent researchers agreed on the inclusion of the identified articles for full-text review. This review followed the review guidelines of Joanne Briggs Institute.

Results:

Five valid and reliable models to structure the clinical reasoning process while attending simulation-based training were identified and are reported in Table 1-19. However, their validity and reliability were tested on working and undergraduate student nurses, and there was no consideration for different seniority and competence levels, and applicability to other healthcare professions.

Table 1-A19:

Identified clinical reasoning models based on the scoping review

Model	Objective	Methodology/description	Findings
TANNER’s Model (Tanner 2006)	To describe the clinical judgment of nurses, and to guide educators to help undergraduate students diagnose breakdowns, identify areas for improvement, and consider learning experiences that focus attention on those areas.	Literature synthesis on clinical judgment and conclusions derived from the literature.	Nurses enter the care of patients with a fundamental sense of clinical judgment about what is good and right, and a perception for what is high quality care.
DML Model Debriefing for meaningful learning (Dreifuerst, 2011).	To discover the effect of the use of DML on the development of clinical reasoning in undergraduate nursing students.	Exploratory, non-equivalent group quasi-experimental, pre-test/post-test design. Participants were assigned to either the experimental or control group where the DML was compared to customary debriefing using the Health Sciences Reasoning Test (HSRT) before and after the debriefing experience, and the Debriefing Assessment for Simulation in Healthcare–Student Version (DASH–SV)	DML Model positively influenced the undergraduate nursing students’ development of clinical reasoning skills, as compared to customary debriefing.
The Outcome-Present State Test (OPT) clinical reasoning model (Pesut and Herman, 1998).	The OPT model is a concurrent, iterative model of clinical reasoning that emphasizes reflective self-monitoring. It requires learners to use all the elements of the nursing process and to build on prior knowledge in an iterative fashion to further hone nursing thinking skills.	The model is designed based on the literature review of the history of nursing process over time. The components of the OPT model include the client-in-context story, keystone issue, cue logic, reflection, framing, testing, decision-making, and judgments. The OPT model focuses on outcomes and encourages backward thinking to move the client from his or her current health status (present state) to the desired (outcome) state. The present state is derived from an analysis and synthesis of relationships between and among nursing and client nursing care needs.	The model can be used to enhance educational practices. It reinforces thinking skills, as learners analyse nursing problems from different aspects based on a high-level thinking process. It also serves as a structure for teaching, for clinical supervision, and for developing middle range theories organized around nursing knowledge taxonomies.
The Self-Regulated Learning (SRL) Model for reflective clinical reasoning (Kuiper and Pesut, 2004).	To explore the impact of self-regulated learning theory on reflective practice in nursing, and to advance the idea that both cognitive and metacognitive skills support the development of clinical reasoning skills.	Integrative review of published literature in social science, educational psychology, nursing education, and professional education. The SRL model describes self-regulation as a dynamic process that includes the observations of behaviours and self-regulation of reactions to make self-judgments of competence and areas for improvement for clinical reasoning. The environmental self-regulation of skills, activities, physical context and relationships with preceptors, staff and patients is necessary to determine the context where clinical reasoning takes place. Metacognitive self-regulation includes metacognitive (reflective) self-correction associated with the use of knowledge and thinking strategies that are used to determine goals.	The SRL model is offered to support teaching and learning of reflective clinical reasoning. The model supports the development and acquisition of higher order thinking skills such as interpretation, analysis, inference, explanation, and evaluation.
The Clinical Reasoning Model (CRM) (Levett-Jones, 2010)	To enhance nurses’ clinical reasoning skills and consequently their ability to manage ‘at risk’ patients.	A literature review and an examination of research data to identify commonly occurring thinking strategies. The model describes an eight-step cyclical process: look, collect, process, decide, plan, act, evaluate, and reflect. Effective use of the CRM by nursing students and its application in practice by novice nurses is directly linked to the five rights of clinical reasoning, that is, the ability to collect the right cues and take the right action for the right patient at the right time, and for the right reason	The CRM has applications for classroom teaching and provides a structure that links well with problem-based and enquiry-based learning. The phases and steps in the model are appropriate for self-directed learning and can be used to develop computerized learning packages and case studies. The CRM also provides an approach that can be used in simulation-based learning experiences using patient simulators or standardized patients

Conclusion:

There is an adequate number of clinical reasoning models to be used while taking part in simulation-based training; however, there is a significant basis to test the reliability and validity of these models against different competence and seniority levels, and applicability to other healthcare professions. The authors are presently working on the development of a new model using an innovative and rigorous approach.

Ethics statement:

Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

The effectiveness of simulation-based education (SBE) in improving healthcare education among practising healthcare professionals (HCPs) is well recognized [1–3]. However, there is limited research available that explores the facilitators and barriers to the use of these activities amongst this population. The aim of this study was to determine those barriers and facilitators that exist to the use of healthcare simulation amongst practising HCPs through the systematic review of existing qualitative literature.

Methods:

Searches were performed using Medline and CINAHL from February to May 2022 with an updated search performed in June 2022. Reference list searches of included studies were also conducted. English-language, peer-reviewed studies that used qualitative methodology to examine barriers and/or facilitators to the use of SBE activities amongst HCPs practising in a hospital setting were included. Data were extracted and a quality appraisal tool was applied by the primary author, with 30% of included studies independently extracted and appraised by a second author to examine the agreement. Barriers and facilitators were coded inductively using thematic analysis.

Results:

Thirteen studies were included out of a total of 2109 screened. Four main themes related to facilitators and barriers were identified: (1) management and leadership; (2) resources; (3) perceived impact and (4) learning experience (see Table 1-A18). Amongst studies, positive learning experience was a commonly identified facilitator (n = 10), while leadership and management were a frequently cited barrier (n = 13).

Table 1-A18:

Thematic analysis of facilitators and barriers to the use and uptake of SBE activities

Themes	Facilitator codes	No. of studies, empirical sources	Barrier codes	No. of studies, empirical sources
(1) Management and leadership	-Responsive/ supportive leadership -Effective scheduling -Dealing appropriately with difficult environment -Visibility of managerial personnel -Simulation as mandatory assessment and training tool -Collaboration with other centres -Common vision -Good communication	N = 7 (64.6%)	-Lack of responsive leadership -Lack of time/poor scheduling -Staff shortages -Perceptions of hierarchy -Lack of interprofessional involvement -Poor work culture -Competing vision -Poor communication	N = 13 (100%)
(2) Resources	-High standard equipment -Engaging scenarios -Familiarity with equipment/environment -Appropriate personnel -Adequate preparation -Advanced technology -High degree of realism	N = 8 (72.7%)	-Poor realism -Financial restraints -Lack of equipment/facilities -Limited technology -Lack of best practice standards -Lack of appropriate personnel (e.g., trainers, SP, limited learners) -Unfamiliar equipment or facilities	N = 10 (76.9%)
(3) Perceived impact	-Perceived quality and safety benefits -Improved culture -Multidisciplinary collaboration -Core job responsibility/role accountability -Valued experience -Improved teaching skills and techniques -Demonstrable cost-benefit	N = 7 (64.6%)	-Participant stress/anxiety/discomfort -Interprofessional conflict - Ineffective use of effort or time -Benefits of simulation unclear	N = 6 (46.2%)
(4) Learning experience	-Consistency in delivery -Material aligned to staff interest/needs -Trainer expertise -High-impact learning -Safe and positive environment -Individualized feedback	N = 10 (90.9%)	-Inconsistency in programme delivery -Trainers seen as outsiders -Limited engagement -Curriculum not adapted to needs -Purpose not clear	N = 7 (53.8%)

Conclusion:

This study identified common barriers and facilitators to the use of SBE activities. By anticipating and addressing these adequately, the use and uptake of SBE activities amongst practising HCPs can be further enhanced.

Ethics statement:

Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.