Post COVID-19 trends in simulation use within diagnostic radiography and radiation therapy education

Purpose Simulation is used within medical radiation science training. Recent global events and simulation resource uptake has led to significant changes. The aim of this study was to capture post COVID-19 trends and activity of simulation-based education (SBE) in diagnostic radiography and radiation therapy. Methods An online survey was designed to investigate the role of simulation within diagnostic radiography and radiation therapy education. Survey design was based on literature and experience within the research team. Questions were based around access and use of simulation, future trends and the effects of COVID-19. Participants were diagnostic radiography and/or radiation therapy educators. Data captured in this study was undertaken in March 2022 and compared with previous data from Bridge and colleagues (2021). Results Sixty-seven responses were received across five continents (two from North/South America), Europe was the most widely represented (n = 58, 87%). Fifty-three (79%) of participants reported that they use simulation as part of their teaching and learning. Twenty-seven (51%) respondents reported that they had increased their use of simulation because of COVID-19. Sixteen (30%) respondents stated that they were now able to enrol more students because of the pandemic. Fixed models and immersive environments were the two most common simulation activities. Participants reported, to different degrees, that simulation was used across all parts of the curriculum. Conclusions Simulation is deeply embedded into diagnostic radiography and radiation therapy education. Evidence suggests that the growth of simulation may be slowing. Opportunities exist for the development of guidance, training and best practice resources around simulation. Implications for practice Simulation is a key pedagogical approach for diagnostic radiography and radiation therapy education. Key stakeholders now need to work collaboratively to define standards and best practices.


Introduction
Simulation is a well-established component of diagnostic radiography and radiation therapy training 1e3 that embraces a wide range of activities and resources all aiming to provide a safe environment in which to practice clinical skills. Recent studies have highlighted the main advantages of simulation-based education (SBE). Evidence demonstrates the significant impact that software-based simulation can have on technical and psychomotor skills in both diagnostic radiography 4 and radiation therapy. 5 Complex simulation activities using a mixture of scenarios, simulated and expert patients, moulage and clinical equipment have also been shown to be beneficial for helping development of interpersonal skills such as team-working, inter-professional working, 6 communication skills 7 and clinical decision-making. 8 Alongside these skills gains, SBE increases the confidence of learners 9e12 and may play a part in reducing anxiety and stress that can often accompany placement. 13 Rehearsing high-pressure skills 2,14 and safe working protocols in a radiation-free environment allows learners to make mistakes that would otherwise threaten their wellbeing and that of their patients. 15 SBE also allows training to be conducted away from the clinical environment; while this enables students to learn in a safe unpressured environment, it also brings benefits to the clinical workplace by reducing pressure on clinical educators and footfall. In addition, evidence indicates that prior training using SBE increases student skills ahead of clinical placement, making their placements more efficient and effective. In many cases this has now led to partial replacement of clinical placement (PRCP). A recent multi-professional Delphi study 16 reported that 46% of respondents (final round) agreed that between 11% and 20% of clinical time could be replaced with SBE. Over recent years, SBE has helped to increase training capacity by providing students with alternative placement opportunities. 7 These simulated placements played a pivotal role in ameliorating the impact of COVID-19 restrictions on clinical learning opportunities, enabling training to continue.
An audit of SBE uptake during the final phases of the COVID-19 restrictions 3 aimed to quantify the current usage of simulation resources and an indication of what resources were being utilised and for what learning outcomes. Unsurprisingly the work identified rapid uptake of SBE with a mean usage of 100 h per learner per year. It also highlighted how COVID-19 restrictions acted as a driver for increased usage of SBE and suggested that future studies could identify the long-term impact of this.
This study, therefore, aimed to capture post COVID-19 SBE usage data to identify the extent to which this activity has been sustained and to help inform future research and practice.

Survey design
An online survey was designed to investigate the role of simulation within diagnostic radiography and radiation therapy education and identify trends following the COVID-19 pandemic. The survey instrument design (see Supplementary Material) was informed by a prior review of the literature, a previous international survey 3 and experience within the research team. It comprised two open and 27 closed questions designed to ascertain data across four domains: 1) type of training environment of the respondent (n ¼ 13), 2) access to and 3) use of simulation within the participants' institution (n ¼ 13) and 4) possible future trends in simulation (n ¼ 3). Consultation and pilot testing with colleagues within the research team was used to establish face validity. Feedback from colleagues who participated in the pilot, resulted in only minor edits to the English language. A series of study definitions and examples relating to medical simulation were provided within the introduction to the survey (see Supplementary Material). Participants were also reminded that responses should be based on their own experiences and should focus on activities that support the training of diagnostic radiographers and radiation therapists. The electronic survey was developed and deployed in English via the Microsoft Forms (Microsoft Corp, Redmond, WA) platform and all responses were collected anonymously. No incentive was offered for participation.

Participants
Participants were required to be diagnostic radiography and/or radiation therapy educators with experience in pre-registration training (academic, clinical or combined). The availability of the survey was advertised by EFRS Research Hub, a virtual online platform (www.efrs.eu) which promoted a series of online surveys among its member organisations and associates during March 2022 (ECR2022 online). Social media was also employed; whereby the research team posted advertisements for participants within their own professional networks and requested that recruitment links be forwarded to potentially suitable colleagues (snowballing). Surveys were completed over two months from March to April 2022.

Data analysis
All data from MS Forms was uploaded into a MS Excel (Microsoft Corp, Redmond, WA) spreadsheet for analysis. Quantitative data from closed questions were analysed using descriptive and inferential statistics. Frequencies were reported together with their respective percentages. Bar charts were used to display trends where appropriate. A formal component of this project was to undertake a comparison with simulation data collection prior to the COVID-19 pandemic. Bridge and colleagues deployed a 16-item online survey 3 during September 2020. Data from our study provided a unique opportunity to compare changes through the pandemic in terms of simulation activity within diagnostic radiography and radiation therapy education. It should be noted that the 2020 3 and 2022 surveys were not identical and thus some comparisons were not possible either due to a lack of data or lack of a comparative categories.
Results 67 responses were received to our online survey; Europe was the continent most represented accounting for 58 (87%) of total responses (Table 1). Of the respondents, half (n ¼ 33) provided diagnostic radiography programmes only, 30 (45%) diagnostic radiography and radiation therapy, two (3%) were diagnostic radiography, nuclear medicine and radiation therapy and one (2%) was radiation therapy only. Typical cohort sizes for the responding programmes are described together with comparisons with the 2020 3 data in Table 1.
Out of the 67 respondents in this study, 53 (79%) reported that they use simulation as part of their routine teaching and learning activities. Of the 53, 27 (51%) reported that they had increased the use of simulation because of the COVID-19 pandemic, six (11%) reported that they used simulation less and 20 (38%) stated no change. Of the 53 using simulation, 16 (30%) reported that they were able to admit more students to their programmes because of simulation. The majority reported that they were able to admit an extra 1 to 19 students (10, 63%), whereas five (31%) and one (6%) respondent were able to admit between 20 and 39 or 40e59 extra students, respectively. The 2022 respondents reported less change in simulation activity arising from COVID-19 than the 2020 cohort as seen in Table 2.
Of the 53 respondents reporting on the use of simulation in 2022, 26 (49%) stated that they had a dedicated staff member with responsibility for simulation activities and a further three (6%) stated that such an appointment was being planned. 18 (35%) respondents reported that their institution had both a formal strategy and external reputation for simulation, a further 12 (23%) had just a strategy and eight (15%) stated that they had a reputation for simulation activities.
The availability of different modes of simulation is illustrated in Fig. 1 and compared with the 2020 data. 3 The role of simulation is further detailed in Fig. 2. Interprofessional education (IPE) activities involving simulation were being delivered by 25 (47%) of respondents with a further 10 (19%) planning future simulationbased IPE.
Simulation was used in combination with traditional assessments for 29 (55%) of respondents. For seven (13%) it was used instead and for 17 (32%) simulation was not used in the assessment strategy. Role-play was reported to be used by 44 (83%) of respondents, 36 (68%) used either staff or students in the role-play and eight (15%) employed professional actors. Most (33, 75%) did not provide costumes or make-up, eight (18%) provided costumes and three (7%) make-up for those involved in the role-play.
16 responded that they used either a specific pedagogical theory or framework to plan and deliver simulation activities. 17 (25%) stated that national regulators had requirements for simulation within radiography pre-registration training, 26 (39%) did not know and 24 (36%) felt that regulators placed no requirements specifically around simulation. 23 out of 65 (35%) respondents felt that access to simulation provided an opportunity to reduce the amount of direct clinical placement time needed for student training. Future requirements for simulation are illustrated in Fig. 3. Participants in both cohorts were asked if lack of training was a barrier. Interestingly in the 2020 study 27% of respondents wanted more training while in 2022 over 93% felt the need for more training. It is not known why this is the case but possibly there is now greater acceptance or interest in simulation and thus educators wish to receive appropriate training.

Major differences between surveys
There are some confusing findings, especially related to the apparent increase in demand for training compared to 2020. There also seems to be a drop in the use of interprofessional simulation teaching which is hard to explain. There is a difference in geographic location of the cohorts with 89% of the 2022 data arising from Europe compared to wider geodiversity in the 2020 survey 3 (Europe 67% of the respondents). There were also some key differences in data collection and in particular the categories of simulation resources that make it challenging to compare these directly. It is possible that these account for some of the apparent differences in survey findings. Within our research, there was no aim to mirror the previous 2020 survey 3 but to use some of its components but to also consider some of the wider issues from the rapid increase in SBE use resulting from the COVID-19 pandemic.

Post COVID-19 use
The data from this survey, when compared to previously published findings, indicated that the earlier heavy investment in simulation resources had not been sustained. This could be interpreted as a reduced reliance on simulation as normality resumed or could suggest that earlier investment provided sufficient simulation resources for a comprehensive simulation strategy to continue. Certainly, the evidence base reports increased use of simulation during COVID-19 and a commitment to its continuation 18 across a range of health profession training courses. 19 The 2022 respondents reported less change in simulation activity arising from COVID-19 than the 2020 cohort 3 as seen in Table 2. This triangulated well with the 2022 respondents reporting less plans to invest in simulation activity (55%) than the 2020 cohort (79%). This may indicate that there was a surge in investment during and immediately after COVID-19 which has now settled. Alternatively, this could represent the rising costs and economic difficulties for academic institutions post-Pandemic.
Despite evidence demonstrating the efficacy of healthcare simulation, 20 it is possible that some of the technical characteristics SBE may have proven difficult to implement in healthcare programs. 19 To remain effective simulation managers and technicians need to work closely. In addition, the financial reality of many simulation centres in developing countries may pose a barrier to meeting the expanding the needs for healthcare education. Many laboratories in such countries often face a lack of qualified teachers, inadequate infrastructure, equipment shortages, combined with the fact that simulation is still a novel strategy. 21  Simulated patients, service users and experts by experience use in simulation Simulated patients 'actors' have been used in SBE to increase its authenticity, interaction, emotions and aid with reflection of perspectives. 22 Actors 'simulated patients' can be students, academics, or service users who bring lived experiences to enrich activities. 23 One of many benefits to using simulated patients in health care education is gaining valuable insight from the patient's perspective. 24 However, use of simulated patients varies and there was less reported use in the 2022 survey (62%) compared with 2020 (100%). It is not clear what the reason for the decrease is, however, it could be due to ethical considerations, budget constraints, the organisational demands, or new COVID-19 procedures making the use of 'actors' more difficult, or the results could indicate a move away from human actor participants 'simulated patients' towards the technology available to institutions. A study by Kristoff (2022) found that using students from another programme as simulated patients was hindered by scheduling conflicts and that there was a lack of time and funds to adequate training of actors. 25 Engagement of service users in undergraduate training for Radiographers is a requirement of the HCPC, 26 but co-production can be achieved in varying ways and involvement in SBE is only one option. A systematic review in Nursing and Midwifery found that service users and carers were used in student recruitment, assessment, and in pedagogy planning. 27

Inter-personal skills training
There was a high usage of role play and a high uptake of simulation for interpersonal skills training revealed by both surveys. These were substantially higher in this latest survey than  other simulation activities, suggesting that this continues to be one of the most important aspects of simulation use. The value of simulation for interpersonal skills training was keenly demonstrated during COVID-19 and this ongoing role has been reported elsewhere. 28 Although role play is a form of SBE it needs to be considered in the context of learning outcomes, it is possible that inter-personal skills could be developed due to good construction of the scenarios the students are exposed to. Further research in this area is warranted.

Limitations
There were some key differences in data collection and in particular the categories of simulation resources that make it challenging to compare these directly. It is possible that these account for the apparent differences in survey findings. Identifying relevant and comprehensive standardised categories for resources and activities would help to develop a more coherent picture of simulation use in future comparative studies. It should be noted that survey distribution was primarily via the EFRS and the ECR2022 EFRS Research Hub and thus favourable European respondents. Results of the survey must be interpreted with this in mind and consider that the sample used in this survey was less diverse than the 2020 study. 3 The total number of radiography educations both within Europe and globally is difficult to define. It will be substantially higher than the sample size within our study and the submission of those who did not participate, and the reasons why should be considered when interpreting this report.

Recommendations & conclusion
The use of simulation within radiography and radiation therapy education has increased substantially over the past few years. This includes a surge in simulation activity driven by the COVID-19 pandemic. Findings from this study and the preceding study highlight how simulation-based education is embedded in many courses and is being used for a wide range of activities and specially to improve interpersonal skills training. To promote further integration into the international simulation community and greater standards for educational delivery a number of recommendations are suggested. Such guidance documents already exist and include the International Nursing Association for Clinical Simulation in Learning (INACSL) Standards of Best Practice: Simulation 29 and the Healthcare Simulation Dictionary. 30 Dedicated conceptual frameworks are recommended and should be developed by leading international organisations, recently the EFRS has suggested such a work package is on-going. 31 Further diversification of the simulation space is highly probable, for example Siemens CT/MRI simulators are now on the market. Future studies tracking use of simulation is recommended; this would be considerably enhanced by the adoption of standard categories of simulation resources and activities.