Challenges and opportunities in the uptake of simulation in healthcare education in the developing world: a scoping review

Background Simulation is increasingly being adopted by healthcare educators throughout the developed world as it offers a safe environment to practice skills. While there is literature on learning via simulation in healthcare in the developed world, more studies are required to investigate the factors influencing this approach in the developing world. Objective This scoping review highlights the key factors that act as deterrents as well as encouragement to the uptake of simulation as a teaching methodology in healthcare education in developing countries. Design The MEDLINE (via OVID, using keywords and MeSH in OVID), and PubMed (via NCBI using MeSH), and CINAHL databases were searched between January 2000 and January 2024 for research articles published in peer reviewed English language journals using a combination of keywords. Results A total of 48 articles were included in the final analysis. Challenges and opportunities were divided into professional, academic, and resource-based factors, and their individual sub-themes. The main challenges reported were the lack of a contextual curriculum, content heavy curricula, dearth of trained simulationists and cost of simulators. Performance anxiety was an important challenge reported by both trainers and trainees. Main opportunities were an interest in adopting simulation-based education from both trainers and trainees, and the opportunity to improve patient safety and quality of education. Other findings were that academic leadership and faculty show interest and urgency to adopt simulation in curricula and allocate funds for this. Facilitators need to be provided with protected time to become simulationists. Local manufacturers need to be sourced for simulators, and transfer of technology and expertise needs to be negotiated. Conclusion Simulation needs to be looked at from the lens of not only education, but more importantly of patient safety in developing countries to allow simulation-based education to be mainstreamed in health professions education in low- and middle-income contexts.


Introduction
Simulation is increasingly being adopted by healthcare educators throughout most of the developed world as it offers a safe and controlled environment in which to train a particular set of clinical skills.The field of medicine requires pre-service practitioners to be adept with complex and often invasive procedural skills, while learning them without causing harm to patients 1 .Simulation-enabled health sciences education aims to reproduce clinical scenarios using simulators.This approach provides a vital link between theoretical medicine and the practical application of management guidelines, preparing preservice practitioners for real-life high-pressure situations.Simulation is therefore immensely beneficial to students and faculty as it decreases the burden on human resources, prevents wastage of clinical equipment, provides a safe environment, and enables effective learning without compromising patient safety 2 .
The application of simulation to healthcare education is widespread in the developed world.For example, in Hungary, the national simulation network includes three universities and 16 hospitals and has a formalized national protocol for simulation-related research, 3D-printing technology, and virtual/augmented reality utilization in health sciences education 3 .While there is literature on experiences from learning via simulation in healthcare in the developed world, more studies are required to investigate the factors influencing the advancement and embedding of this approach in the developing world 4 .As simulation in healthcare education requires immense pedagogical, financial, and logistical resources, a detailed analysis of the barriers and facilitators is imperative to inform how low to middle-income regions can implement sustainable simulation-enabled medical learning environments.
Scoping reviews are being used increasingly being utilized to review and understand complex research evidence in areas where there is a dearth of randomized controlled trials 5 .It enables researchers to include a range of different study designs that address questions beyond those related to the effectiveness of a particular intervention and provide a structured approach to the collection and organization of the existing evidence base related to a precise research question 6 .The PRISMA ScR guidelines were used as the guiding document in the conduct of this study 7,8 .

Methods
For the purpose of our scoping review on the challenges and opportunities to the uptake of simulation in healthcare education in low-and middle-income contexts, we searched for research articles published between January 2000 and January 2024 using PubMed (via NCBI using keywords), EBSCO CINAHL Plus (using keywords), EBSCO Dentistry and Oral Sciences Source (via keywords), Wiley Cochrane Library (via keywords) and ProQuest Theses and Dissertations Database (via keywords).Only articles in peer-reviewed journals in English were considered.Table 1 shows the combination of keywords used and summarizes the selection process for the articles.This search produced 906 articles in total which were organized in ENDNOTE™ (Version 21, Zotero is a tool that can be used as a freely available alterantive to ENDNOTE) based on reference links, sources, and abstracts.The inclusion and exclusion criteria, as shown in Table 2, were extensively discussed amongst the team.
Of the 906 articles retrieved after the first search, 556 articles were excluded after the first iteration as they did not meet the inclusion or exclusion criteria; included reasons were that papers were not from the context of a developing context, advocated the use of simulation as a teaching strategy, not identifying barriers or facilitators, or discussed the role of simulation in non-health care settings.
The four researchers split into independent dyads and divided the remaining 350 articles amongst themselves to select ones which distinctly focused on the research question.The fifth researcher was approached for a decision in case of a disagreement.
A total of 302 articles were excluded after this iteration as they did not include the barriers and facilitators, often dealing with delivery of specific simulations or use of simulation in healthcare settings, but not medical education.Thus, 48 articles were selected for final analysis which contributed to identification of themes emerging and organization into categories to address the aim of our scoping review.The organization is illustrated in Figure 1.
Using Microsoft Excel™ (2021 Version), a spreadsheet was created to organize the data from the 48 articles with the following headings: Author and Year of Publication, Title, Keywords, Objective, Methodology, Study Population, Key Findings of Barriers, and Facilitators that increase the uptake of simulation as a strategy (Table 3).

Results
Based on the review of the selected articles, two broad categories of challenges and opportunities were identified.They were then divided into sub-categories of academic, resourcerelated, and professional factors.Within the sub-categories, there were various themes which are reflected in Figure 2 and Figure 3.

Challenges
The general category of barriers or challenges faced in the uptake of simulation fell within three sub-categories (Figure 2).These were: 1. Academic factors (three themes and ten sub-themes) 2. Resource based factors (three themes)

Opportunities
The general category of facilitators or opportunities in the uptake of simulation were also divided into three sub-categories (Figure 3).

Discussion
Simulation aims to avert harm to patients by reducing exposure to inexperienced learners while providing trainees with a 'substitute' learning environment that emulates reality for experiential opportunities.Identifying factors impacting use of simulation in health sciences education in the low-and middle-income regions is key to constructing a viable and contextually relevant curriculum that optimizes simulation 9 .Knowing the benefits of simulation in healthcare education is insufficient on its own until the influencers of success can be categorized, analyzed, and explored comprehensively.Such an approach not only increases the perceived importance but also the potential uptake of simulation in medical education.For the developing world, the barriers and facilitators are often significantly different from those of developed regions; hence, this scoping review is an essential and necessary contribution.
The following sections will describe the opportunities and challenges to the uptake of simulation in low-and middle-income countries in more detail.For ease of understanding, we

Reviewed by 2 independent dyads of researchers using the following:
Inclusion Criteria:

1.
Studies highlighting barriers &/or facilitators to uptake of healthcare simulation.

2.
Studies conducted in developing nations.

Studies related to the delivery of simulation-based health sciences education
Exclusion Criteria: 1.
Studies/reviews highlighting benefits of simulation.

2.
Studies describing the process of the simulation classified both opportunities and challenges into academic, resources, and professional factors, which highlights the significant interplay between these factors.

Academic challenges
The category of academic challenges encompasses constraints related to three sub-categories of 'curriculum design and delivery', 'the educator', and 'the learner'.
Curriculum design and delivery.At the curricular level, barriers included lack of context-specific curriculum 10 , difficulty accommodating a simulation-embedded curriculum due to a packed schedule 11 , limited number of trainers to deliver the curriculum 4 , and lack of support from leadership to implement a simulation curriculum 12 .
Lack of context appropriate curriculum was cited as an important barrier in the implementation of a simulation-enabled/ embedded curriculum in low-and middle-income countries in numerous studies 4,[9][10][11] .It is challenging to design and implement a simulation program that aligns with the clinical context.This is a relatively new curricular direction for the developing world which, because of contextual health related issues, requires adaptation or creation of simulation-based case scenarios reflecting conditions of the developing world 13 .Since there is limited existing literature on simulation in health education in the developing world, it will take some time for these regions to create an effective simulation-enabled/embedded curriculum to address their situational realities 12,14 .However, many studies concluded that learning can be better applied when the simulation environment is closer to day-to-day clinical scenarios 15 .
There are other important curricular barriers to the uptake of simulation, that are more complex and interlinked.Due to lack of finances and limited exposure to technology, curricula have been based on traditional methods of teaching with little flexibility for change and remain content heavy 16 .in Uganda.

Favourable departmental attitude
2. Enthusiasm to participate.

Departmental sensitization and engagement in simulation activities
1.Competing time demands.
Simulation not integrated into curriculum.
2. Skepticism towards realism in medical simulation  Additionally, a limited number of appropriately trained staff, as well as lack of support from the leadership, possibly due to lack of prior exposure and comfort with the conventional pedagogy, have resulted in curricula that are outdated and unable to adapt and respond to contemporary teaching and learning techniques 17 .

Inadequacy of medical simulation equipment
Educators.At the level of the educator, we found that lack of prior use and/or familiarity with simulation contributed to resistance to the uptake of simulation in healthcare education 9 .These factors contribute to the lack of simulation-savvy human resources.According to a prior study regarding design of simulation-enabled/embedded medical education, lack of qualified simulation instructors was a constraint in the development of a simulation-embedded curriculum 13 .Educators also feel hesitant in conducting a simulation session if they are not trained prior to it 15,18 .
Learners.An academic challenge for learners in adopting simulation was having a high number of fellow students in training programs.This would impact the quality of the exposure the student would get during training 10 .Additionally, institutional resources in developing regions are limited, often rendering them unable to maintain even the basic needs of trainees, such as libraries and lecture halls.In such contexts, transitioning to a simulation-based curriculum would be challenging, as significant investment in equipment will be required to cater to the large number of students 4,16 .This results in the limited ability of healthcare universities in developing countries to adopt new approaches such as simulation 16,19 .
Learners may also not be convinced of the pedagogical advantages of a curriculum incorporating simulation 4 , have experienced simulator breakdown, or have limited accessibility due to equipment deficiencies, which resulted in an unsatisfactory experience 10,12 .Moreover, students who participated in simulation activities sometimes described them as stressful and challenging.Interestingly, these feelings were usually reported when they were expected to perform on unfamiliar simulators in front of their peers and teachers 20 .

Synthesis.
We found lack of familiarity with technology and associated performance anxiety are limiting factors for both facilitator and trainee 16,17,21 .Given that most institutes from primary school to university in the low-and middle-income regions have limited financial resources, most students and teachers lack exposure to technology throughout their educational journeys.When such an exposure commences at a later stage, the fear of learning and handling new technologies can be overwhelming, especially when superimposed with curricula which are content-ladened as is common in traditional medical and health science programs 22,23 .

Academic opportunities
Curriculum design and delivery.According to our review, motivation to learn with simulation and acknowledging its ability to add value, competence, and safety served as important facilitators in the development of simulation-embedded curriculum 14,18,24 .The opportunities that a simulation integrated curriculum afforded for increased practice, real time feedback, and clarity in outcomes measured were important factors identified in our review as being facilitators in the uptake of a simulation-based curriculum 9,10,[21][22][23] .
Educators.If educators recognize the potential of simulation, and offer effective feedback to the institution, the transition to simulation-engaged medical/health provider education will be potentiated 16,25 .Faculty desire to develop themselves in simulation-based education, which would increase the availability of experts and mentors in the field, countering the barriers discussed previously 21 .The momentum towards simulationengaged/embedded medical/health provider education will eventually lead to an increased number of faculty undergoing training in simulation-based education, providing the opportunity to refine education delivery systems, and to equip educators appropriately for diverse and emergent clinical challenges 15,26 .
Learners.There is evidence to show that learners are interested in simulation-based education.This interest stems from the novelty of simulation, the opportunity to practice, and the realization that it promotes patient safety 27 .This eagerness from the learners will, in turn, encourage faculty to become more acquainted with simulation and to more effectively embed this technology in teaching approaches 28 .
Synthesis.At the level of both trainer and trainee, an important facilitator was the opportunity to achieve novelty and the acknowledgement that simulation sessions have a positive impact on the ability to diagnose, perform procedures, and integrate basic sciences and clinical medicine 27,29 .Trainees appreciate that simulation makes them safer practitioners.It also conveniently provides real time debriefing.The ability to simulate different environments to practice skills is a great advantage 30,31 .These are very important factors that motivate facilitators and students and should encourage program and institutional leadership to actively incorporate simulation in curricula 28,32,33 .

Resources-related challenges
Challenges of resources were broadly encapsulated as financial, infrastructure, and of trained personnel.
Financial limitation was an important barrier to the use of simulation 4,11,13,14,34 .For example, the financial cost to buy simulators was the most important factor identified as a barrier to implement simulation in an undergraduate curriculum in obstetrics 9 , a finding that was echoed in a study from Ghana as well 18 .This finding is understandable given the context of low-and middle-income countries which frequently exhibit unstable economies and limited budget allocation to the health sector 35 .It is routine for hospitals to run out of necessities like medications, syringes, blood pressure apparatus, and oxygen supplies.Likewise, medical colleges often lack up-to-date libraries, access to medical journals, cadavers, anatomy models, and basic technology important for modern student learning 21,36 .Under these circumstances, adopting a health curriculum that utilizes simulation may not be a priority for such institutes.Moreover, another associated barrier was maintenance of available infrastructure -the equipment used for simulation is not only costly but incurs ongoing expenses for its maintenance.For many simulators, a specialized staff is required for its handling which adds to overall financial constraints 37,38 .The resource challenges do not end at the level of finances.Major electricity blackouts/instabilities and the resultant connectivity issues were reported in our review.In many regions of the developing world, power outages for long periods are not uncommon related to insufficient power production or heavy rainfall which damages the power delivery systems.While hospitals may have backup power generators, these units are focused on lifesaving areas, such as emergency and operating theatres.Such barriers related to infrastructure not only deter the use of simulation but potentially damage simulation related equipment because of abrupt shutdowns or instability 39,40 .
Unit cost and operator expertise remain notable areas of concern regarding simulation-based education in resource poor settings 41,42 .Inadequate cost reporting is known to occur in simulation related research 43 .Nevertheless, the availability of modern low-cost simulators could promote self-reliance in LMICs.This is important as it will prevent unnecessary disruptions in the continuity of SBE due to bureaucratic tribulations and will open more avenues for access to simulators 42 .
Difficulties in coordinating simulation sessions between facilitators and students by administrative staff was a predictable resource challenge in our review 32,40,44 .Limited resources must be allocated to large numbers of students by a small number of staff -which means that multiple simulation sessions must be organized for different groups of students for one topic resulting in problems related to scheduling of students, faculty and space.This finding is reflected in a prior study which also highlighted lack of coordination amongst user groups as an important challenge to simulation in medical education 40,42 .

Resource-related opportunities
While finances are major barriers to simulation-enabled medical education in developing contexts, an efficient economic evaluation can assist in gradually transitioning to a simulation embedded curriculum 25,33 .According to a previous study, such an evaluation can inform program leadership and simulation staff on efficiencies in using resources 23,25 .Our scoping review found that less expensive equipment can be utilized to meet the target of the curriculum with availability of cheap options in the low to middle income regions when undertaking a hybridization of traditional and sophisticated systems 45,46 .Some countries have engaged local industry to manufacture low-cost, contextually appropriate task-trainers 47,48 .Tele-simulation is another low-cost intervention that may be successful, as is a computerized patient simulator 49,50 .These modifications in content delivery or curriculum will not only improve access to trainees and opportunities to deliver education but can be an income generating opportunity by offering the novelty of simulation related workshops and attracting student intake.Both factors may make it easier and more attractive for an organization to adopt and invest in simulation-based training [51][52][53] .The financial barriers can thus be countered with a long-term approach which transitions into the new curriculum gradually, gathers data continuously, and, as the situation becomes economically feasible, uses the flexibility of the technology to expand.Moreover, utilization of low-cost simulators, electrical generators to provide power, and increasing investments in the sector could potentially mitigate the challenges discussed above 54,55 .The increased use of standardized patients for teaching and assessment in resource poor countries is yet another strategy to increase the scope of simulation-based education in these regions 56 .

Professional challenges
In terms of professional challenges, our review identified competing professional interests as an important challenge to the uptake of simulation 57,58 .Given the context, healthcare facilities in developing regions cater to dense populations with a low healthcare provider to patient ratio 58 .Furthermore, not all the centers are tertiary care and the ones that are receive an overwhelming number of patients.All these factors essentially mean that most healthcare providers must work beyond their hours to cater to their heavy clinical mandates 58,59 .Within this busy schedule, they still try to accommodate teaching via bed side teaching and short lectures 57,60 .However, operating sophisticated simulators to conduct teaching sessions requires time and effort to understand the equipment, and faculty may require many practice sessions to become comfortable with the technology 61,62 .This results in simulation being under-utilized due to the time required to address the learning curve 63,64 .This finding mirrors in a study from Uganda, where the simulation centers faced limited local teaching capacity due to faculty being too busy clinically to devout time to be trained for simulation teaching 65 .
While simulation in health sciences education decreases the risk for patient and trainees and may have a positive impact on the competence and confidence of the learners, leadership support may be somewhat limited due to a perception that there are limited studies showing its advantages in the 'real-world' clinical context 37,41,64 .
Although these challenges might dissuade institutions from establishing a simulation-based curriculum, we also investigated opportunities associated with a simulation-based curriculum that would facilitate the change in education format.

Professional opportunities
Our review pointed out that the opportunity to provide mentorship and be recognized as a mentor, and a simulationist are important opportunities to increase the usage of simulation 38,44,51 .It is essential that the leadership shows interest and promotes simulation for users to engage more with it 53,58 .Trainers indicate willingness to become users of simulation if they were provided protected time and benefits by the academic leadership to enable them to do so [61][62][63] .
Both trainers and trainees reported that peer assisted learning and debriefing, which are standard in simulation-based education are its biggest advantages to increase uptake 66,67 .However, faculty needs to be trained in proper debriefing techniques to be truly effective 68 .The opportunity to teach technical as well as non-technical skills, and the ability to impart remote simulation were factors that trainers found attractive to increase the utilization of simulation-based education in the developing world 69,70 .
Professional development of trainers may be possible remotely and in collaboration with simulation societies and provision of scholarships 58,65,70 .Including post-graduate trainees as medical simulation educators may be a good strategy to increase the pool of trainers and increase simulation utilization 71 .
Educators also feel professionally satisfied that they are contributing to a better trained workforce, while improving patient safety, and contributing to better quality of care when imparting simulation-based education.This was a very important motivating factor 72 .
The scoping review employed rigorous and transparent methodologies throughout the search phase.We systematically explored various electronic bibliographic databases to ensure a comprehensive survey of existing literature.Each citation and article underwent evaluation by two independent pairs of reviewers, who convened regularly to resolve any discrepancies.All citations and articles were accounted for during the process.
Despite our efforts to achieve inclusivity, it's possible that not all scoping reviews in both published and gray literature were identified.Our search strategy encompassed a range of terms; however, alternative terms may also exist.It's worth noting that our search was limited to English terms, which could pose a constraint.Furthermore, we did not engage with researchers or experts to identify additional scoping reviews that may have escaped our attention.

Conclusions
The developing world faces unique challenges where introducing a new method of education delivery and technology may be questioned.The fact that the conventional curriculum utilizing the traditional method of teaching and training remains in place in LMIC`s suggests that healthcare educators to yet to realize the full potential of simulation-based education.However, the first step is to analyze viability.Through our work, we provided a comprehensive evaluation of the factors that influence uptake of simulation in healthcare education -so that developing contexts can plan the basic framework and gradually prepare to transition into simulationenabled/embedded environments.
Our review highlighted the key areas of priority that act as deterrents as well as encouragement to the uptake of simulation as a teaching methodology in healthcare education.We feel that it is of utmost importance that academic leadership and faculty show interest and urgency to adopt simulation in curricula and allocate funds for this.Facilitators need to be developed and be provided with protected time to become simulationists.Local manufacturers need to be sourced for simulators, and transfer of technology and expertise needs to be negotiated with vendors.Simulation needs to be looked at from the lens of not only education, but more importantly from one of patient safety in developing countries to allow simulation-based education is mainstreamed in health professions education in low-and middle-income contexts.

Strengths and limitations
Scoping reviews are utilized to review and understand complex research evidence in areas where there is a dearth of randomized controlled trials.It enables researchers to include a range of different study designs that address questions beyond those related to the effectiveness of a particular intervention.
While it provides general information about a research question, further studies are subsequently required to probe specific areas of interest.Within the scope of developing countries, there are variations in socioeconomic conditions which may have affected the conduct and results of the studies.

Reporting guidelines
Figshare: PRISMA-ScR checklist for 'Challenges and opportunities in the uptake of simulation in healthcare education in the developing world: a scoping review'.https://doi.org/10.6084/m9.figshare.The first sentence of the last paragraph within the "introduction" section reads as so "Scoping reviews are being used increasingly being utilized to review and understand complex research evidence in areas where there is a dearth of randomized controlled trials.Is there a typo?Are the rationale for, and objectives of, the Systematic Review clearly stated?Yes

Are the conclusions drawn adequately supported by the results presented in the review? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: I am Professor of Simulation and Clinical skills and my research focuses on heuristics, digital simulation and immersive learning.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Figure 2 .
Figure 2. Challenges faced in the uptake of simulation.

Figure 3 .
Figure 3. Opportunities identified in the uptake of simulation.

25771791 8 .
Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Table 1 . The combination of keywords used.
Barriers OR Impedance OR Hurdles OR Challenges OR Hesitance OR Inhibition OR Difficulty OR Reluctance OR Hindrance OR Limitation OR Resistance OR Refusal Facilitators OR Factors OR Influencers OR Influences OR Promoters OR Causes OR Reasons OR Elements Uptake OR Acceptance OR Compliance OR Approval OR Agreement OR Embracing OR Willingness OR application OR Endorsement OR Amenableness Simulation OR Recreation OR Technology OR Simulators OR Medical Simulation OR Simulation-based Medical Education OR Simulation-based Healthcare education OR Simulation-based Heath Professions Education OR Simulation-based Training OR Simulation-based Interprofessional Training OR Simulation-based Inter-professional Training OR Medical Education OR Simulation-based Interprofessional Healthcare education OR Simulation-based Inter-professional Healthcare Education Health Professions Education OR Health Professions Training OR Healthcare Education OR Healthcare Training OR Medical Education OR Medical Training OR Medical Skills OR Health Professional Skills OR Health Professional Training OR Interprofessional Medical Education OR Inter-professional Medical Education OR Inter-professional Medical Training OR Interprofessional Healthcare Education PR Inter-professional Healthcare Education OR Inter-professional Healthcare training OR Healthcare Professional Skills OR Healthcare Training OR Healthcare Skills Teaching Strategy OR Strategy OR Methodology OR Teaching Method OR Teaching Methodology OR Training Strategy OR Training Method OR Training Methodology OR Educating Strategy OR Educating Method OR Educating Methodology OR Training Approach OR Teaching Approach OR Approach Countries with Developing Economy OR Low-middle-income countries OR Low-Middle Income Countries OR Low Middle-Income Countries OR Low Middle Income Countries OR Lower-Middle-Income Countries OR Lower Middle-Income Countries OR Lower-Middle Income Countries OR Middle Income Countries OR Middle-Income countries OR Medium Income countries OR Medium-Income Countries OR Developing Countries OR Developing World OR Developing Nations OR Underdeveloped Countries OR Underdeveloped World OR Underdeveloped nations OR Economically Developing Countries OR Economically Developing Nations