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Use of Screen-Based Simulation in Nursing Schools in France: A National, Descriptive Study

Open AccessPublished:November 01, 2022DOI:https://doi.org/10.1016/j.ecns.2022.09.004

      Highlights

      • Screen based simulation (SBS) most frequently conducted by students in pairs at school or alone at home.
      • SBS most frequently used for decision making and clinical reasoning.
      • SBS most likely to be used when leaders are trained in simulation.
      • Debriefing with an instructor is considered an essential element in SBS.
      • SBS was least used in mid-size nursing schools (100-200 students).
      • Most common barriers to implementation of SBS include cost and faculty development.

      Abstract

      Background

      Clinical simulation is a major component of undergraduate healthcare training. However, data are lacking regarding simulation modalities used in Europe. The purpose of this national study is to describe how screen-based simulation (SBS) is being used as well as identify the barriers to its use in nursing schools in France.

      Methods

      This study employed a descriptive design with 207 nursing schools in France. Nursing school leaders (Deans, Heads of School, Simulation Coordinators or Leaders) were asked to complete an online survey.

      Results

      Traditional simulation was used in 92% of the nursing schools, but only 41% used SBS. Most nursing schools used SBS in a face-to-face format with students paired at a computer followed by a debriefing or alone at home. SBS is used mostly to teach decision making and clinical reasoning. SBS was used to complement traditional clinical time rather than replace it. Barriers included cost of SBS solutions, lack of recent computer equipment, high-speed internet network and training of the trainers. SBS is more frequently used in small nursing schools or large nursing schools where leaders are trained in simulation.

      Conclusion

      Although simulation is broadly adopted by nursing schools in France, the use of SBS remains limited. Nurse leaders in mid-size nursing schools (with 100-200 nursing students) should consider investing more resources in SBS. A post-pandemic assessment is warranted.

      KEYWORDS

      Introduction

      In nursing education, clinical simulation as a pedagogy is well recognized (
      • Bogossian F.
      • Cooper S.
      • Kelly M.
      • Levett-Jones T.
      • McKenna L.
      • Slark J.
      • Seaton P.
      Best practice in clinical simulation education - are we there yet? A cross-sectional survey of simulation in Australian and New Zealand undergraduate nursing education.
      ;
      • Kable A.K.
      • Levett-Jones T.L.
      • Arthur C.
      • Reid-Searl K.
      • Humphreys M.
      • Morris S.
      • Witton N.J.
      A cross-national study to objectively evaluate the quality of diverse simulation approaches for undergraduate nursing students.
      ;

      National Council of State Boards of Nursing. (2016). national council of state boards of nursing. Retrieved from simulation guidelines for prelicensure nursing education programs. https://www.ncsbn.org/16_Simulation_Guidelines.pdf, Décembre 2020.

      ). Not only does it promote learning in a safe environment (
      • Cant R.P.
      • Cooper S.J.
      The value of simulation-based learning in pre-licensure nurse education : A state-of-the-art review and meta-analysis.
      ,
      • Cant R.
      • Cooper S.
      • Sussex R.
      • Bogossian F.
      What’s in a name? Clarifying the nomenclature of virtual simulation.
      ;
      • Peddle M.
      • Mckenna L.
      • Bearman M.
      • Nestel D.
      Development of non-technical skills through virtual patients for undergraduate nursing students : An exploratory study.
      ), it enhances learning outcomes for healthcare students such as nurses (
      • Hayden J.K.
      • Smiley R.A.
      • Alexander M.
      • Kardong-Edgren S.
      • Jeffries P.R.
      The NCSBN National simulation study : A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education.
      ). Simulation replicates clinical scenarios and engages students to foster clinical competence (
      • Lioce L.
      • Lopreiato J.
      • Downing D.
      • Chang T.
      • Robertson J.
      • Anderson M.
      • Diaz D.
      • Spain A.
      Healthcare simulation dictionary-Second Edition. Rockville, MD: Agency for Healthcare Research and Quality.
      ). In general, simulation has been found to be an effective learning tool (
      • Cant R.P.
      • Cooper S.J.
      The value of simulation-based learning in pre-licensure nurse education : A state-of-the-art review and meta-analysis.
      ) and is endorsed by professional organizations with guiding standards (
      INACSL Standards Committee
      Healthcare simulation standards of best practicetm.
      ).

      Screen-Based Simulation

      With various terms being utilized, screen-based simulation (SBS), serious games, web-based, online, or virtual simulations play an important role in healthcare education as a tool to complement or replace face-to face training (
      • Donovan L.M.
      • Argenbright C.A.
      • Mullen L.K.
      • Humbert J.L.
      Computer-based simulation : Effective tool or hindrance for undergraduate nursing students?.
      ;
      • Wang R.
      • DeMaria S.
      • Goldberg A.
      • Katz D.
      A systematic review of serious games in training healthcare professionals.
      ).
      SBS captures the attention of students by adapting technological innovations to healthcare education. This technology allows the learner to practice while playing (
      • Koivisto J.-M.
      • Multisilta J.
      • Niemi H.
      • Katajisto J.
      • Eriksson E.
      Learning by playing : A cross-sectional descriptive study of nursing students’ experiences of learning clinical reasoning.
      ). Similarly, SBS promotes the development of new skills in a safe environment (
      • Petit dit Dariel O.J.
      • Raby T.
      • Ravaut F.
      • Rothan-Tondeur M.
      Developing the serious games potential in nursing education.
      ). Finally, the SBS allows the student to train in an unlimited way and to self-correct due to the feedback mechanisms. In recent years, confusion has risen around virtual simulation terminology due to heterogeneity and lack of consensus of definitions (
      • Cant R.P.
      • Cooper S.J.
      The value of simulation-based learning in pre-licensure nurse education : A state-of-the-art review and meta-analysis.
      ). Pre-pandemic interest and awareness of virtual simulation modalities (
      • Gorbanev I.
      • Agudelo-Londoño S.
      • González R.A.
      • Cortes A.
      • Pomares A.
      • Delgadillo V.
      • Muñoz Ó.
      A systematic review of serious games in medical education : Quality of evidence and pedagogical strategy.
      ;
      • Maheu-Cadotte M.-A.
      • Cossette S.
      • Dubé V.
      • Fontaine G.
      • Mailhot T.
      • Lavoie P.
      • Mathieu-Dupuis G.
      Effectiveness of serious games and impact of design elements on engagement and educational outcomes in healthcare professionals and students : A systematic review and meta-analysis protocol.
      ), and the new paradigm of virtual learning imposed by COVID 19 (
      • Tyerman J.
      • Luctkar-Flude M.
      • Baker C.
      Rapid development of a COVID-19 assessment and PPE virtual simulation game.
      ) have contributed to the “terminological chaos.”
      • Foronda C.L.
      What is virtual simulation?.
      defined virtual simulation as “the use of partial immersion through a digital learning environment (e.g., computer, tablet, phone, screen, etc.) to foster a perceived lived experience for an intended outcome (e.g., learning, entertainment, etc.)” (p. 8). Between 2020 and 2021, the use of “virtual simulation” as a term in publications increased by 5% (
      • Luctkar-Flude
      • Tyerman J.
      The rise of virtual simulation: Pandemic response or enduring pedagogy?.
      ). Efforts have been made by leading professional organizations in simulation to improve clarity with definitions (
      • Lioce L.
      • Lopreiato J.
      • Downing D.
      • Chang T.
      • Robertson J.
      • Anderson M.
      • Diaz D.
      • Spain A.
      Healthcare simulation dictionary-Second Edition. Rockville, MD: Agency for Healthcare Research and Quality.
      ). The Healthcare Simulation Dictionary's definition of screen-based simulation is used to describe the modality of interest for this study. Screen-based simulation refers to “a simulation presented on a computer screen using graphical images and text, similar to popular gaming format, where the operator interacts with the interface using keyboard, mouse, joystick, or other input device” (
      • Lioce L.
      • Lopreiato J.
      • Downing D.
      • Chang T.
      • Robertson J.
      • Anderson M.
      • Diaz D.
      • Spain A.
      Healthcare simulation dictionary-Second Edition. Rockville, MD: Agency for Healthcare Research and Quality.
      , p. 43).
      A review of the literature showed the added value of screen-based simulation in the training of health professionals to improve student learning outcomes (
      • Foronda C.L.
      • Fernandez-Burgos M.
      • Nadeau C.
      • Kelley C.N.
      • Henry M.N.
      Virtual simulation in nursing education : A systematic review spanning 1996 to 2018.
      ;
      • Gentry S.V.
      • Gauthier A.
      • L'Estrade Ehrstrom B.
      • Wortley D.
      • Lilienthal A.
      • Tudor Car L.
      • Car J.
      Serious gaming and gamification education in health professions : Systematic review.
      ;
      • Gorbanev I.
      • Agudelo-Londoño S.
      • González R.A.
      • Cortes A.
      • Pomares A.
      • Delgadillo V.
      • Muñoz Ó.
      A systematic review of serious games in medical education : Quality of evidence and pedagogical strategy.
      ;
      • Verkuyl M.
      • Djafarova N.
      • Mastrilli P.
      • Atack L.
      Virtual gaming simulation : Evaluating players’ experiences.
      ). SBS was widely used during the lockdowns imposed by the pandemic of COVID-19 () to attempt for pedagogical continuity. Many schools of nursing tried substituting traditional face-to-face simulation with virtual simulation and synchronous, virtual activities (

      Schiavenato, M., Edwards, S., Tiedt, J., & Owens, J. (2022). Comparing the learning effectiveness of three virtual simulation tools with nursing students during the COVID-19 pandemic. Clinical Simulation In Nursing, 0(0), https://doi.org/10.1016/j.ecns.2022.03.003

      ;
      • Tyerman J.
      • Luctkar-Flude M.
      • Baker C.
      Rapid development of a COVID-19 assessment and PPE virtual simulation game.
      ;
      • Verkuyl M.
      • Djafarova N.
      • Mastrilli P.
      • Atack L.
      Virtual gaming simulation : Evaluating players’ experiences.
      ). Despite the virtual component of SBS, debriefing is recommended (
      • Cheng A.
      • Kolbe M.
      • Grant V.
      • Eller S.
      • Hales R.
      • Symon B.
      • Eppich W.
      A practical guide to virtual debriefings : Communities of inquiry perspective.
      ;
      • Dale-Tam J.
      • Thompson K.
      • Dale L.
      Creating psychological safety during a virtual simulation session.
      ;

      Decker, S., Alinier, G., Crawford, S. B., Gordon, R. M., Jenkins, D., & Wilson, C. (2021). Healthcare simulation standards of best practiceTM the debriefing process. clinical simulation in nursing, 58, 27‑32. https://doi.org/10.1016/j.ecns.2021.08.011

      ;
      • Luctkar-Flude M.
      • Tyerman J.
      • Verkuyl M.
      • Goldsworthy S.
      • Harder N.
      • Wilson-Keates B.
      • Gumapac N.
      Effectiveness of debriefing methods for virtual simulation : A systematic review.
      )

      Screen-Based Simulation Prior to the Pandemic

      SBS was studied in a national survey in North America (e.g.,
      • Tranel G.E.
      • Johanneck M.D.
      • Thompson R.J.
      • Campbell K.K.
      Results of a nationwide descriptive survey on simulation center operations.
      ). However, in the pre-pandemic period, there was a paucity of literature on systematically collected descriptive data surrounding SBS in Europe and especially in France. France's healthcare governance body encourages the use of simulation both for undergraduate and lifelong training (

      Granry, J. C., & Moll, M. C. (2012). Rapport de mission : État de l'art (national et international) en matière de pratiques de simulation dans le domaine de la santé dans le cadre du développement professionnel continu (DPC) et de la prévention des risques associés aux soins [Rapport de mission]. https://www.has-sante.fr/portail/upload/docs/application/pdf/2013-01/guide_bonnes_pratiques_simulation_sante_format2clics.pdf, Décembre 2020.

      ). SoFraSimS (French Society for Simulation in Healthcare) made a report about SBS in a limited number of educational simulation institutions (

      Blanié, A., Rihane, S., Decormeille, G., & Benhamou, D. (2020). Rapport enquête jeux sérieux en France – Décembre 2020 [Société savante]. https://sofrasims.org/rapport-enquete-jeux-serieux-en-france-decembre-2020/, Décembre 2020.

      ). The sample consisted of 40 simulation centers and 16 nursing schools. Blanié found 45% of responds (n = 25) were using serious games (all media) most of the time including a debriefing with an instructor to compliment traditional teaching. Among the 31centers not using serious games, 17 were considering it.
      Data are still lacking on the implementation and perception of SBS in nursing schools in France. Study is necessary to explore the extent and approaches to how SBS is implemented into the curriculum. This information could guide future curriculum development, such as defining hours accepted for clinical replacement, and influence administrative decisions. The purpose of this national study is to describe how screen-based simulation is being used as well as identify the barriers to its use in nursing schools in France.

      Materials and Methods

      This study employed a descriptive design using surveys. The national study was conducted from June 01, 2019 to September 01, 2019. The study obtained written ethical permission N°227933 of the French declaration of conformity in health study and complied with both French and European (GDPR) data protection laws.
      A 29-item questionnaire was sent via email to French nursing educators and leaders through the databases of the following professional organizations: The French Association of Care Directors (AFDS), Nursing and Executive Education Agreement Committee (CEFIEC) and National Association of Paramedical School Directors (ANDEP). Any of the nursing school leaders (deans, heads of school, simulation leads or coordinators) could complete the survey. However, the survey specified that only one response per nursing school could be submitted.

      Survey

      The survey was developed by the lead researcher (G.D.) based off of the literature and adapted from the SoFraSimS Serious Games National Survey (

      Blanié, A., Rihane, S., Decormeille, G., & Benhamou, D. (2020). Rapport enquête jeux sérieux en France – Décembre 2020 [Société savante]. https://sofrasims.org/rapport-enquete-jeux-serieux-en-france-decembre-2020/, Décembre 2020.

      ). Permission was received to adapt and use the instrument. The final version of the questionnaire was reviewed by the research team and approved by the SoraASimS team members.
      The survey had 29 items exploring nursing schools’ characteristics (location, number of students), different simulation modalities used, SBS, and nursing school leaders’ perceptions. The questions widely explored the following topics in the context of SBS: the modalities and frequency of use, the educational objectives addressed, the duration of SBS scenario, the use of the feedback reports and scores provided by SBS software, and debriefing use. The last questions elicited nursing school leaders’ perceptions of the potential of SBS in undergraduate and lifelong education. Questions included Likert-style, closed-ended, single or multiple choice, and number-scale formats. Nursing schools were classified in three groups according to their use of SBS. The nursing schools using SBS are named uSBS, the nursing schools considering to use SBS are named cSBS and nursing schools not considering to use SBS are named nSBS. The survey was built using Qualtrics (Qualtrics, Provo, UT) software and contains instructions describing: the target population, inclusion criteria, study details, and an agreement to participate prior to beginning. All responses were de-identified and shared only within the research team.

      Data Analysis

      Data from the survey questions were exported from Qualtrics (Qualtrics, Provo, UT) into Microsoft Excel (Microsoft, 2019), coded and uploaded into the free software Jamovi 1.1.9.0 (version 1.8) (The jamovi project, 2021). Descriptive statistics were calculated. Independent t-test was applied to compare the pedagogical approach of SBS conducted by the nursing schools using SBS and considering using SBS. To establish a correlation on the simulation training level of the simulation school leaders and SBS implementation, Spearman's rank correlation coefficient was carried out followed by linear regression. Multinomial logistic regression was carried out to establish a comparison between the different sizes of nursing schools (factors) that use and consider using SBS (dependent variable). The cutoff score for the significance level of statistical tests was set at alpha = 0.05.

      Results

      Among the 323 French nursing schools, 98% of leaders or simulation coordinators completed the survey. Of note, 36% surveys were excluded as they were not fully completed or were duplicate (Figure 1). A total of 207 analyzable records were kept in the dataset (64%). Nursing schools were exposed by location (regions) (Figure 2) and the rate of nursing school responders versus nursing school non-responders were compared by location (Figure 3). Of the nursing schools’ leaders who responded, 77% of them indicated having formal simulation training as instructors.
      Figure 2
      Figure 2Description of responding nursing schools by regions across France.
      Figure 3
      Figure 3Nursing schools answering the survey compared to the total of nursing schools by region (N = 207/323, 64%).

      Demographic Data (N = 207)

      Table 1 shows the distribution of the nursing schools according to their size, the different simulation modalities used, the use of SBS or not considered and finally, the level of training in simulation of the nursing school leaders. Most of the nursing schools that replied to the survey had less than 150 students per academic year (81%) The most frequent simulation modalities used in nursing schools were role play (67%), standardized patient (66%), technical skills simulator (58%), SBS (41%), manikin-based simulation (39%) and hybrid simulation (33%). Among all nursing schools, 42% were considering using SBS (n = 88) and 16% were not considering to use SBS (n = 34). Just 13% of nursing schools’ leaders were not simulation instructors (Table 1).
      Table 1Demographics of nursing schools with modalities of simulation per group)
      All

      (N = 207)

      N (%)
      Using SBS

      (n = 85)

      n (%)
      Considering to Use SBS

      (n = 88)

      n (%)
      Not Using SBS

      (n = 34)

      n (%)
      What is the size of the nursing school (students per promotion/cohort)?<100 students98 (47)46 (54)45 (51)7 (20)
      Between 100 and 15070 (34)27 (32)26 (29)17 (50)
      Between 150 and 20024 (11)5 (6)12 (14)7 (20)
      >20015 (7)7 (8)5 (6)3 (9)
      • What simulation modalities do you use (or willing to use)? (Yes)
        Multiple choice question
      Role play with actor139 (67)59 (69)64 (8)16 (47)
      Standardized patient137 (66)63 (74)60 (68)14 (41)
      Technical training simulator121 (58)51(60)58 (66)12 (35)
      Screen based simulator85 (41)85 (100)NANA
      Mannikin-based simulator81(39)40 (47)34 (39)7 (20)
      Hybrid69 (33)36 (42)26 (29)7 (20)
      Are you using (or considering to use) SBS for undergraduate training in your NS?85 (41)88 (42)34 (16)
      Are you formally trained as a simulation instructor?Yes147 (71)68 (80)71(80)8 (23)
      No27 (13)1 (1)1 (1)25 (73)
      I would like to be33 (16)16 (19)16 (18)1(3)
      Note. SBS = Screen-Based Simulator; NA = Not Available; NS = Nursing School
      low asterisk Multiple choice question

      How SBS is Pedagogically Approached

      Results about how SBS is pedagogically approached or intended to be approached in France by nursing schools is indicated in Table 2. The major findings are illustrated below. How to use SBS: The nursing schools’ leaders considered that SBS should be implemented across all semesters. The majority of nursing schools’ leaders agreed that the use of SBS is done with the presence of a trainer (p < .001) and the best time for using SBS is during dedicated simulation time rather than on personal time (p < .001). The ideal length of the scenario is 30-60 minute. Also of note, the most common use of SBS was by pairing two students together at the computer rather than in a large group or plenary session (p < .001) or alone at home (p <.001).
      Table 2Comparison between nursing schools that Use Screen-Based Simulator (uSBS) and nursing schools Considering to use Screen-Based Simulator (cSBS) (N = 173)
      ItemsuSBS

      (N = 85) N (%)
      cSBS

      (N = 88)

      N (%)
      p-value
      Which semester are you using SBS?Semester 1-25 (6)7 (8).99
      Semester 3-46 (7)4 (4)
      Semester 5-61(1)0 (0)
      All semesters73 (86)77 (87)
      What time do you use the SBS?On a supervised simulation time with a trainer58 (68)51 (58)
      p < .0001, *(Multiple choice question)
      On the student's personal working time at NS14 (16)9 (10)
      One e-learning time at home13 (15)7 (8)
      I don't know0 (0)21 (24)
      Length of a scenario

      of SBS
      30 to 60 min44 (52)NANA
      15 to 30 min26 (30)NANA
      Less of 15 min8 (9)NANA
      > 60min7 (8)NANA
      • Which modalities are you using SBS?
      2 students by computer with a trainer56 (66)35 (40)
      p < .0001, *(Multiple choice question)
      Student alone at home56 (66)27 (31)
      p < .0001, *(Multiple choice question)
      1 student by computer with a trainer44 (53)20 (23)
      p < .0001, *(Multiple choice question)
      Plenary session with a trainer20 (23.5)16 (18).38
      > 2 students by computer with a trainer18 (21)6 (7)
      p < .001,
      2 students by computer without a trainer4 (4)3 (3)0.66
      1 student by computer without a trainer3 (3)10 (11)
      p < .05,
      > 2 students by computer without a trainer0 (0)0 (0)NA
      Relevance or importance of debriefing in SBSEssential69 (81)73 (82).21
      Optional16 (19)15 (17).21
      Which modalities of debriefing into the SBSAutomated debriefing in-game as well as a debriefing with a trainer55 (65)52 (59).59
      Debriefing with a trainer but without an automated debriefing of the game 326 (30)24 (27).33
      I do not know3 (4)10 (11)
      p < .05,
      Automated debriefing in-game but without debriefing with a trainer1 (1)2 (2).81
      Learning goal improve behavior and cognitive skillsYes85 (100)68 (77)
      p < .0001, *(Multiple choice question)
      I don't know0 (0)20 (23)
      Is the game used for the purpose of inter-professionalism?Yes44 (52)40 (45)
      p < .001,
      No41 (48)26 (29)
      I don't know0 (0)22 (25)
      How do you use the score (Yes)
      p < .05,
      Individual score84 (98.8)88(100).31
      Auto-scoring70 (82)80 (90)0.09
      Information for trainer69 (81)82 (93)
      p < .05,
      Learning curve69 (81)84 (95)
      p < .001,
      Validation European credit38 (45)37 (42).72
      Picking-up22 (26)23 (26).90
      Integration new score16 (19)24 (27).19
      Replace evaluation clinical practice7 (8)20 (23)
      p < .001,
      Same score for alone group0 (0)0 (0)NA
      Note. SBS = Screen Based Simulator, NA = Not Available
      low asterisk p < .05,
      low asterisklow asterisk p < .001,
      low asterisklow asterisklow asterisk p < .0001, *(Multiple choice question)
      Debriefing: Both groups indicated that debriefing is essential using SBS (81%) as well as those considering to use SBS (83%), when compared to optional debriefing (p < .001). Only three nursing schools use automated debriefing through the game without complementing with an educator or debriefer (Table 2).
      Skills taught using SBS: SBS is used mainly to teach clinical reasoning (54%), followed by decision making (49%) and lastly, leadership (10%). In both groups, SBS is generally thought to promote learning of behavior and cognitive skills (p < .001) and 100% of those using SBS consider that SBS can be used for training behavioral and cognitive skills. Table 3 shows the ranking of the use of 13 behavioral and cognitive skills items.
      Undergraduate Training: One hundred sixty-six of the leaders (80%) thought that SBS could complement a traditional simulation activity. Only 9% thought that the use of SBS could replace a traditional simulation activity. Fourteen leaders considered that SBS could be used as an assessment tool with undergraduate nursing students. Only one nursing school leader did not find that nursing students had adequate opportunity to train on SBS during their undergraduate training.
      Lifelong training: Seven percent of leaders considered the use of SBS "not important" in continuing education for nursing professionals and their presence in undergraduate education within five years.

      Barriers to Implementation of SBS

      Nursing school leader's simulation training level

      A significant correlation on the simulation training level of the simulation school leaders and SBS implementation was found in undergraduate training (r = -0.248, p < .001). Leaders who were trained in simulation implemented more or were more likely to implement SBS than untrained leaders (R2 = 0.381, p < .001), 95% CI [2.33-2.52].

      The size of nursing schools

      The multinomial logistic regression shows that nursing schools <100 nursing students (per criteria provided) use more SBS compared to the larger nursing schools having 100-150 nursing students, OR = 4.1, 95% CI [1.5, 11.2], p = .005 and 150-200, OR = 9.2 [2.3, 37.2], p = .002, except for those with >200 nursing students OR = 0.9, 95% CI [0.6, 1.4], p = .91. On the other hand, no difference was found according to the using SBS group compared to the considering to use SBS group with respect to the size of the nursing school, OR = 0.9, 95% CI [0.6, 1.4], p= .92.

      Other limiting factors

      The leaders indicated some limiting factors. These factors included costs (34%), training of trainers (26%), computer equipment and internet networks (21%), educational innovation and resistance to change (16%), and lacking time for implementation (3%).

      Discussion

      America Compared to Europe: Different Cultural Perceptions

      This is the first national study in Europe to assess the use of SBS as a teaching tool before the pandemic. The study revealed that although simulation, and more specifically SBS, is used by 41% of nursing schools or is ready to be used by 42.5% of nursing schools, its diffusion remains limited in France. Conversely, nurse leaders in North America have shown a pronounced interest in SBS and its use has raised exponentially in the last five years (
      • Gentry S.V.
      • Gauthier A.
      • L'Estrade Ehrstrom B.
      • Wortley D.
      • Lilienthal A.
      • Tudor Car L.
      • Car J.
      Serious gaming and gamification education in health professions : Systematic review.
      ;
      • Gorbanev I.
      • Agudelo-Londoño S.
      • González R.A.
      • Cortes A.
      • Pomares A.
      • Delgadillo V.
      • Muñoz Ó.
      A systematic review of serious games in medical education : Quality of evidence and pedagogical strategy.
      ;
      • Maheu-Cadotte M.-A.
      • Cossette S.
      • Dubé V.
      • Fontaine G.
      • Lavallée A.
      • Lavoie P.
      • Deschênes M.-F.
      Efficacy of serious games in healthcare professions education : A systematic review and meta-analysis.
      ;
      • Maheu-Cadotte M.-A.
      • Cossette S.
      • Dubé V.
      • Fontaine G.
      • Mailhot T.
      • Lavoie P.
      • Mathieu-Dupuis G.
      Effectiveness of serious games and impact of design elements on engagement and educational outcomes in healthcare professionals and students : A systematic review and meta-analysis protocol.
      ). It is likely that this trend may spread similarly in Europe in the future. In this study, most of the 206 leaders (99%) consider that SBS is interesting for undergraduate training, and 93% of leaders indicated SBS will play an important role in nursing lifelong training in years to come. Although current discussions about replacing traditional clinical practice hours with SBS are occurring in North America, (
      • Killam L.A.
      • Luctkar-Flude M.
      Virtual simulations to replace clinical hours in a family assessment course : Development using H5P, gamification, and student co-creation.
      ;
      • Leighton K.
      • Kardong-Edgren S.
      • Gilbert G.E.
      Are traditional and simulated clinical environments meeting nursing students’ learning needs?.
      ), in Europe, these discussions are less frequent with clinical replacement not having been formally approached. Among all leaders surveyed, 80% declared that SBS could be used to complement traditional simulation activities (n = 166), and only 18 leaders (9%) declared that SBS could replace traditional simulation activities. Considering the new educational paradigm imposed by COVID-19, simulations completed virtually at home may become more commonplace in nursing education when obstacles for in-person clinical experiences are present (
      • Luctkar-Flude
      • Tyerman J.
      The rise of virtual simulation: Pandemic response or enduring pedagogy?.
      ).
      Table 3Nursing schools answering the survey compared to the total of nursing schools by region (N = 207/323, 64%)
      Educators in both North America and Europe share the perception that virtual simulation may be a cost-effective way to provide standardized education to a large group of students and offer several advantages in comparison to in person-simulation (
      • Tyerman J.
      • Luctkar-Flude M.
      • Baker C.
      Rapid development of a COVID-19 assessment and PPE virtual simulation game.
      ;
      • Verkuyl M.
      • Phc N.
      • Hughes M.
      Virtual gaming simulation in nursing education : A mixed-methods study.
      ). From the cost perspective, SBS or virtual simulation could be more affordable than manikin-based simulation. Although the cost of creating a virtual scenario is still high, the ratio of cost, human resources and number of people targeted is lower compared to training nurses with manikins. Learning via SBS versus using mannikins was shown to be cost-effective ($10.89 vs. $36.55/student) (
      • Haerling K.A.
      Cost-utility analysis of virtual and mannequin-based simulation: Simulation in Healthcare.
      ) and less consuming of human resources. This constitutes an advantage for larger nursing schools because these virtual solutions make it possible to ensure a harmonized distribution of educational content at the same time to a large group (
      • Tyerman J.
      • Luctkar-Flude M.
      • Baker C.
      Rapid development of a COVID-19 assessment and PPE virtual simulation game.
      ). All students can participate in the simulation unlike with a mannequin and can train according to their rhythm and level. Students can train in addition to class hours at the most opportune times. In addition, reassuring feedback allows them to have immediate answers. However, the initial purchase investment is still considered just as expensive (
      • Luctkar-Flude
      • Tyerman J.
      The rise of virtual simulation: Pandemic response or enduring pedagogy?.
      ). In accordance, our results showed that leaders perceived that the price remains a major barrier to implementation. In addition, the cost of teacher training or faculty development can be another barrier, as found in the national study by
      • Kardong-Edgren S.
      • Willhaus J.
      • Bennett D.
      • Hayden J.
      Results of the national council of state boards of nursing national simulation survey : part II.
      . The results revealed that SBS is used more by trainers who are trained in simulation. These data can be used to assist decision making regarding the current and future uses of simulation.

      SBS- a Key for Behavioral and Cognitive Skills

      The study showed that SBS is perceived by nursing school leaders as a modality to improve behavioral and cognitive skills such as clinical reasoning or decision-making for students. Current evidence establishes that these skills can be obtained through simulation (
      • Couarraze S.
      • Saint-Jean M.
      • Marhar F.
      • Carneiro J.-M.
      • Siksik G.
      • Weider A.
      • Geeraerts T.
      Does prior exposure to clinical critical events influence stress reactions to simulation session in nursing students : A case-control study.
      ;
      • LaManna J.B.
      • Guido-Sanz F.
      • Anderson M.
      • Chase S.K.
      • Weiss J.A.
      • Blackwell C.W.
      Teaching diagnostic reasoning to advanced practice nurses : Positives and negatives.
      ;
      • Levett-Jones T.
      • McCoy M.
      • Lapkin S.
      • Noble D.
      • Hoffman K.
      • Dempsey J.
      • Roche J.
      The development and psychometric testing of the Satisfaction with Simulation Experience Scale.
      ;
      • Maheu-Cadotte M.-A.
      • Cossette S.
      • Dubé V.
      • Deschênes M.-F.
      • Lapierre A.
      • Lavoie P.
      Differentiating the design principles of virtual simulations and serious games to enhance nurses’ clinical reasoning.
      ) and have been supported as a method to train and transfer clinical reasoning cognitive processes into the real world (
      • Petit dit Dariel O.J.
      • Raby T.
      • Ravaut F.
      • Rothan-Tondeur M.
      Developing the serious games potential in nursing education.
      ). Behavioral and cognitive skills such as clinical reasoning or decision making are among the most difficult skills for nursing students to acquire, but they play a crucial step to achieve clinical competence (

      Psiuk, T. (2019). L'apprentissage du raisonnement clinique : Concepts fondamentaux - Contexte et processus d'apprentissage (Second ed.). De Boeck Supérieur. https://www.deboecksuperieur.com/ouvrage/9782807314856-l-apprentissage-du-raisonnement-clinique, janvier 2021.

      ).

      SBS- Key Reflective Tool in a Safe Environment

      The pre-pandemic results revealed that SBS was used with two students per computer rather than in a group session or alone at home. Working in pairs promotes socio-constructivism – an experience sharing and reflecting on practice through face-to-face exchanges (
      • Vygotsky L.S.
      Mind in society : The development of higher psychological processes.
      ). A non-threatening learning environment is necessary to promote learning and leads to better outcomes (
      • Rudolph J.W.
      • Raemer D.B.
      • Simon R.
      Establishing a safe container for learning in simulation : The role of the presimulation briefing.
      ). SBS generates a safe psychological setting where students can make mistakes without feeling embarrassed about their performance (
      • Luctkar-Flude
      • Tyerman J.
      The rise of virtual simulation: Pandemic response or enduring pedagogy?.
      ) and without harming patients (
      • Borg Sapiano A.
      • Sammut R.
      • Trapani J.
      The effectiveness of virtual simulation in improving student nurses’ knowledge and performance during patient deterioration : A pre and post test design.
      ). Additionally, the presence of the instructor promotes psychological safety (
      • Cheng A.
      • Kolbe M.
      • Grant V.
      • Eller S.
      • Hales R.
      • Symon B.
      • Eppich W.
      A practical guide to virtual debriefings : Communities of inquiry perspective.
      ). In fact, instructor feedback showed a positive effect on learners' use of deep and shallow cognitive strategies as well as on learning efforts (
      • Zhang H.
      • Lin L.
      • Zhan Y.
      • Ren Y.
      The impact of teaching presence on online engagement behaviors.
      ). Finally, the use of debriefing SBS in this study is perceived as essential by 82% of the leaders (N = 142). This is consistent with what is reflected in the literature about virtual simulation (
      • Dale-Tam J.
      • Thompson K.
      • Dale L.
      Creating psychological safety during a virtual simulation session.
      ;
      • Luctkar-Flude M.
      • Tyerman J.
      • Verkuyl M.
      • Goldsworthy S.
      • Harder N.
      • Wilson-Keates B.
      • Gumapac N.
      Effectiveness of debriefing methods for virtual simulation : A systematic review.
      ).

      Challenges with SBS in France

      The results of the study reveal how SBS is used and provide insight about the perceptions of nurse leaders about SBS. The largest concern, not surprisingly, was about cost of licenses. However, use of SBS may arguably be more cost-effective and accessible than traditional simulation (
      • Haerling K.A.
      Cost-utility analysis of virtual and mannequin-based simulation: Simulation in Healthcare.
      ;
      • Kalkman C.J.
      Serious play in the virtual world : can we use games to train young doctors?.
      ).
      • Tyerman J.
      • Luctkar-Flude M.
      • Baker C.
      Rapid development of a COVID-19 assessment and PPE virtual simulation game.
      ) has shown that the experience of CAN-SIM in this field of use is important for both creation and use (
      • Keys E.
      • Luctkar-Flude M.
      • Tyerman J.
      • Sears K.
      • Woo K.
      The Integration of virtual simulation gaming into undergraduate nursing resuscitation education : A pilot randomised controlled trial.
      ). The lack of training of educators and the fear of change when integrating new technologies are the main barriers to use. Nevertheless, additional research is needed to understand the acceptance of SBS as a pedagogical tool and its impact on learning outcomes (Cant &
      • Cant R.
      • Cooper S.J.
      Simulation in the Internet age : The place of Web-based simulation in nursing education. An integrative review.
      ) both at the level educational and clinical practice level and in pre-simulation preparation (
      • Keys E.
      • Luctkar-Flude M.
      • Tyerman J.
      • Sears K.
      • Woo K.
      The Integration of virtual simulation gaming into undergraduate nursing resuscitation education : A pilot randomised controlled trial.
      ).

      Limitations

      This study had some limitations. The study is based only on the opinions and perceptions of the nursing school leaders who completed the surveys. However, the excellent response rate and the large sample size likely offered a reliable representation of the leading perceptions about SBS in France. Further, the study explored SBS in a broad context and there may have been differences in the products and experiences of SBS amongst schools. Last, this study was carried out in 2019 before the COVID-19 pandemic. A comparison study post-pandemic would be useful with similar surveys from other European countries.

      Conclusion

      This study revealed that traditional simulation is used by a large number of nursing schools in France. However, SBS has not been widely adopted yet. The use of SBS remains limited due to the costs of supplies and faculty development or training. Given the lessons learned from the pandemic, nursing school leaders, especially those of mid-size schools, may wish to request future funding for use of innovation and technologies including SBS. Future work surrounding faculty development, cost-benefit analyses, and comparison of SBS modalities to student learning outcomes is recommended.

      Declaration of Competing Interest

      This study has not received funding, and is part of a PhD series of papers about Virtual Simulation approved by the University of Toulouse (Ref N°227933 ). The principal researcher of the study Guillaume Decormeille works as a technical specialist for Simforhealth a simulation company which sells virtual simulation products.

      Funding

      No funding was provided.

      Acknowledgments

      The authors thank the three French Association of Care director (AFDS), Nursing and Executive Education Agreement Committee (CEFIEC), National Association of Paramedical School Director (ANDEP) and directors or simulation leaders of all French nursing schools for participating in the study.

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