For more than 20 years, we have been witnessing a slow cultural change in healthcare, which moves safe procedures into focus. While different methods are being used to enhance the whole system's safety, thus directly influencing patient and HCW safety, simulation has been critical in this quest. The most common way of demonstrating and learning about safety culture is simulation training [10].
Although today no other high-risk professional training exist without simulation, the progress in healthcare simulation has not been as rapid as initially predicted [10]. This might be due to several factors, most prominently that while most other professions implementing a wide use of simulation are heavily based on technology, healthcare systems operate on humans, making simulation challenging to apply [11, 12]. Simulation training is a valuable method for uncovering latent safety threats in healthcare systems [13–15]. The use of simulation during the COVID-19 crisis could be beneficial in this regard [7, 16].
Owing to its superior ability to detect latent safety threats, in situ simulation has been more widely used during recent years, while this development varies on a global level [14, 17]. Collaborative multicenter research offers many advantages over single-center simulation debriefing, including larger sample sizes for more generalizable findings, the ability to share findings amongst collaborative simulation sites, and networking capabilities [18]. However, the response rates we achieved from various international regions might indicate that the numbers of COVID-19 simulations vary across various settings.
According to our study, about 45% of the surveyed centers conducted at least 5 COVID-19 drills till May 2020, and in 40% of the cases, it was conducted twice weekly or even daily since the announcement of the pandemic, which reflects a high alert level within few months of the announcement across the healthcare system. Some simulation centers reported conducting more than 100 COVID-19 simulation scenarios, both in situ and in their simulation labs [19]. When centralized regional COVID-19 simulations were implemented, the number of simulations was rapidly increased to more than 400 acute care simulation session requests across Alberta's broad geographical zones within five weeks [20].
The sessions involved at least 50 personnel on total and reached more than 100 in 30% of the surveyed institutes; in at least 75% of the surveyed institutes, the sessions lasted at least 30 minutes and more than an hour in about 10%; those facts reflect the effective and highly resourced planning of those sessions in many centers withing few months of the global alert.
Almost 90% of the drills were conducted either in simulation centers, E.R. or ICU setting and by their staff, pointing that those institutes took COVID-19 drills at high consideration level and conducted the drills at the portal of entry of such patients or in areas where handling them might go hectic (Table 2).
The drills were well-conducted most of the time as reflected by staff satisfaction and feeling of improvement post drills, pointing to those drills' efficacy to face the pandemic and reassure the anxious staff. Fear is an irrational sense that can hamper performance and may hinder learning. It is vital that HCWs feel safe while learning, and a simulation scenario provides a safe environment to learn and practice a broad range of possible hazardous situations [21]. We noticed that the feeling of fear regarding caring for infectious patients requiring strict isolation was reduced after the participants had completed the simulation and drill courses, as the majority of the HCW reported that their preparedness improved "a lot" to "a great deal" (78.5%) in comparison to those (5%) for whom preparedness improved only a little. Based on these findings, we believe that simulation-based learning positively imparts confidence, capability, and knowledge to HCWs. When they feel safe, they will be able to deliver better care to the patients and protect themselves from acquiring the infection. Varying results were reported in other studies regarding perceptions of readiness after simulation-based training. Prescott and Garside reported that all the participants in their study felt better prepared for the assigned tasks after a simulation-based training [22]. However, another study found fewer participants felt prepared for tasks for which they had received simulation-based training [23]. Our study showed a noteworthy improvement in perceptions of preparedness among the HCWs after the training. In a COVID-19 simulation assessment, Cheung et al. found significant improvement in all domains of personal strengths among 1,415 hospital staff members [19]. 65.9% of the surveyed staff in our study were highly or fully engaged during the sessions in comparison to 3.2% for whom engagement was little and minimal; Khan and Kiani found that the participants in their simulation courses believed from the start that their colleagues who did not attend the course were less prepared to handle COVID-19 patients [24]. At the end of the course, this perception was strengthened. This implies that respondents perceived that the course had better prepare them for the challenge of caring for COVID-19 patients compared to their colleagues who had not trained with them.
Our findings indicate variability in the video recordings of the COIVD-19 drills. Such video recordings, either for the debriefing or educational purposes, were also applied to the COVID-19 simulation. Ahmed et al. reported using video recordings of the session that were then played before the subsequent COVID-19 simulation learning session as a pre-briefing [25]. Mistakes in performance could be systematically identified and discussed among the participants.
The most frequent and highly ranked challenges in infection control and team dynamics-related issues faced during the COVID-19 simulations were reflective of real clinical practice challenges. For example, similarities between the reported HCWs crowdedness around the patient and issues with lack of compliance with infection control practices during in situ simulations in this study have been reported as leading causes of HCW-related infection in many healthcare systems' COVID-19 outbreaks [26, 27]. The same findings were noted by Erich Hanel et al. in their surveys [28].
The top-ranking challenging team dynamics issues were related to the difficulty in communicating while masks and face shields on, application of advanced cardiac life support, and lack of role clarity in the newly formed COVID-19 teams. Besides, there were challenges with providing basic life support and institutional COVID-19 policy and procedures. A recent nationwide Canadian study identified many similar findings and challenges across urban and rural health care settings and addressed simulation-based education to achieve system-based learning [20].
During in situ simulation, the reported challenges provide a rich source for individual, team, and institutional gap analysis and work as a need assessment tool. These challenges serve as a stimulus for rapid cycle deliberate practice, resulting in increased preparedness. Such an approach has been successfully used in many healthcare systems to prepare hospitals or a particular healthcare facilities section during the COVID-19 crisis worldwide [29, 30].
Previous studies have demonstrated the utility of in situ simulation to advance healthcare provider skills and aid in developing protocols and procedures [31, 32]. However, the use of simulation under the constraints inflicted by a pandemic has not yet been addressed. Indeed, the COVID-19 pandemic poses new challenges to the execution of in situ simulation. These challenges include limited time, personnel, personal protective equipment (PPE), and changing guidelines. Although simulation lab capacities are overwhelmed internationally during this pandemic, only 29% of HCWs considered this a challenge. Given these legitimate concerns, it is essential that simulation continues to be used. Despite these difficult times and to overcome these challenges, formats of combined in situ and virtual video-based simulation might offer the most protected, safe environment. This combination model also allows simulation leaders to identify and modify site-specific latent safety threats, which are system-based threats to patient safety that were not previously recognized [14]. Moreover, this method offers a means of rapid knowledge dissemination, using very few resources and saving time, PPE, and simulation equipment, while allowing for social distancing, eliminating geography as a limitation to education delivery, and allowing use by HCWs in preparation for in situ simulation training, as more than half of them want to be prepared [14, 33]. Of note, a recent COVID-19 simulation study found no significant differences between in situ and lab-based simulations for all domains of personal strengths that were assessed among their candidates [19].