August 29, 2022By Jill Sanko

The Future of Virtual Simulation in Healthcare Education Post-COVID

The intrusion of COVID-19 forced healthcare simulation programs to pivot to meet educational demands and adhere to mandated in-person gathering restrictions. Most programs did this through the use of some form of distance simulation (also referred to as virtual simulation). This article explains how the use of virtual simulation vastly expanded during COVID-19, and shares where the practice currently stands today. Overall, author Jill Sanko notes that out of necessity a greater awareness of the benefits of distance simulation was established helping to solidify usage across healthcare simulation but still questions: does simulated practice from remote locations add more to clinical education than in-person learning?

In the early days of the pandemic, the presidents of the leading U.S. healthcare simulation societies shared position statements supporting the use of distance simulation, aka remote-based learning or virtual learning, as a substitute for clinical hours. Given that there was no in-person learning in many areas of the country, these position statements served as foundational support for the educational equivalency of these SBE approaches.

Today, however, there remains a paucity of evidence to back up the equivalency of SBE outcomes predicated on the delivery method / SBE platform. Given the state of community disease presence and the likelihood that distance-SBE will remain, the healthcare simulation community needs to generate evidence. Now appears to be as good of a time as any to really explore questions about the impact of all forms of SBE as potential substitutes for clinical hours. Given the current ongoing pandemic that continues to disrupt education and force SBE innovation, educators and nursing programs really need to have solid ideas established regarding what works and what doesn’t.

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Are all simulation modalities created equal? Do all delivery methods result in equivalent outcomes? Given the recent necessary shift to a distance platform, many also wonder, is distance-SBE equivalent to in-person immersive simulation? What about virtual reality (VR) /augmented reality (AR) simulation and virtual simulation? What are their educational impacts? What do we / should we assume about new platforms that become available?

Studies on the use of distance / virtual simulation including virtual reality (VR)-SBE in nursing education appear to be leading the way in providing evidence to demonstrate educational equivalence of in-person and other SBE delivery platforms.

Distance Simulation Background

First, learners and educators must understand the Society for Simulation in Healthcare’s dictionary definition of distance-simulation is important and includes “simulation or training at a physical distance from the participant(s). (1) The definition provided by the organization includes the practice of operating a simulator via some type of remote access where the operator remotes into a simulator stationed where the participants are located; otherwise known as remote-controlled (1). Or, distance simulation can refer to a time when a participants remote into something like the cameras during a medical simulation where the simulator is stationed at a different site, which may be called “distance-based high-fidelity human patient simulation training.” (2)

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While many educational institutions rely on the use of video conference systems coupled with asynchronous and/or synchronous learning strategies during COVID-19, healthcare could not solely rely on this approach because of the requirements needed to meet clinical hours. Healthcare educators had to deliver education that would serve as a proxy for clinical hours; given known successes with simulation-based education (SBE) as a substitute for clinical hours, SBE, therefore, appeared to be the path forward but required innovation.

Educators worked to make SBE accessible and impactful at a distance. The exact structure of what distance-SBE took on was determined by individual programs’ resources; whereas, those with well-equipped clinical simulation centers were able to creatively structure education to be able to shepherd learners successfully toward graduation without interruption in their course work.

Where Distance Simulation is Headed

Fast forward two years, distance-SBE appears to be on the track to live on as a staple across SBE offerings. In being forced to utilize a distance platform, many discovered that there is a utility and efficiency in doing so. Distance-SBE can be less labor intensive (e.g. less personnel needed), in some cases less costly (especially when one considers labor costs), and virtual simulation can bring together learners that are not geographically nearby. Ultimately, this has helped to expand opportunities for more interprofessional growth with the added benefit of broadening clinical simulation into areas that are less well resourced (e.g. rural communities, developing nations). Moreover, the use of distance-SBE may be the answer to another challenge plaguing nursing education: clinical placements.

In some areas of the country – even prior to COVID-19 – securing clinical placements for learners to be able to complete required clinical hours was already difficult to find. Yet, during COVID-19 this became nearly impossible. In some instances, securing clinical placements was more challenging as this was accompanied by the need to find adequate opportunities for learners in hospital settings.

Now, with in-person learning for healthcare programs nearly ubiquitously back to a brick and mortar environment, classroom and healthcare simulation centers have been able, to largely return to a “new normal.” However, hospitals and clinical environments have yet to rebound fully or find their stride amidst continued COVID. Many clinical environments continue to be burdened by staffing and personnel shortages, making asking to send learners a burdensome request.

On this topic, a landmark study published in 2014 explored high-quality SBE as a replacement for required clinical hours for pre-licensure nursing learners. This multi-site study provided the initial evidence to support SBE as a substitution for clinical hours. Data showed that educational outcomes (knowledge, clinical competency, critical thinking, NCLEX pass rates) were substantially similar in study participants when up to 50% of clinical hours were substituted with high-quality SBE. This finding provided support for boards of nursing to begin to recognize the educational impacts of SBE and make allowances for clinical hour substitutions as a way to meet educational requirements for students in undergraduate nursing programs. Webinar: “Using Distance Simulation to Supplement Clinical Hours”

Not only was this a win for SBE, but for the programs where clinical placements have been difficult to find. This change provided much-needed flexibility and the ability to continue to graduate nursing learners in areas of the country where clinical placements were limited.

Since the publication of this sentinel work, a Meta-narrative review explored the progress and current trends of clinical hour substitution in nursing programs. Findings of this 2019 review suggested that, while evidence still supports SBE as a substitution for clinical hours, there remains a need for further regulation on the type of simulation employed as a clinical hour substitution.

Another more recently published white paper presents a discussion of several potential virtual simulation issues found citing noteworthy studies. For example, a 2020 literature review found that virtual patient simulation produced educational outcomes similar to traditional in-person human manikin simulator SBE and virtual-patient (computer-based) SBE was found to engage students effectively.

A 2021 study showed that, when asked, learners reported that virtual patient simulation was easy to use and provided a useful educational experience. A 2019 national survey found that the majority of nursing school programs are using some type of SBE as a clinical hour substitution.

Moving forward, expanding the understanding of the impacts and limitations of each type of simulation as a clinical hour substitution is vastly important across the healthcare simulation community. A 2021 survey study by Leighton, et al showed that learners perceived that their education and training were best during face-to-face clinical compared to both face-to-face and virtual simulation. This provides counter-evidence to other studies demonstrating support for virtual simulation as substitutes for clinical encounters.

Overall, despite multiple years of increased distance simulation use, the healthcare simulation community appears to be no closer to garnering a definitive answer to the equivalence of in-person versus SBE at a distance. Yet, with this tactic still widely in use and no sense that distance simulation is going to the wayside, more studies examining outcomes are imperative. Through increased studies, the healthcare simulation community can determine what is most effective for continued use.

Learn More About Distance Simulation Educator Guidelines in Healthcare


  1. LeFlore JL, Sansoucie DA, Cason CL, et al. Remote-controlled distance simulation assessing neonatal provider competence: A feasibility testing. Clin Simul Nurs 2014;10(8):419-424.
  2. von Lubitz D, Carrasco B, Gabbrielli F, & Ludwig T. Transatlantic medical education: preliminary data on distance-based high fidelity human patient simulation training. Medicine Meets Virtual Reality (J. Westwood et al., EDs) 2003.

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