Simulation‐based education for medical radiation students: A scoping review

Abstract Simulation‐based education is a significant aspect of teaching clinical skills in tertiary medical radiation science programmes, allowing students to experience the clinical setting in a safe environment. As an educational tool, simulation exists in many valid forms including role play, interprofessional simulation and virtual reality simulation. This scoping review looks at the current literature in this field to identify the evidence surrounding simulation‐based education for medical radiation students. The purpose of this review is to provide an evidence‐based guide for educators, identify gaps in the literature and suggest areas of future research. Data extraction was performed on 33 articles where the interventions could be categorised into either role play simulation, virtual simulation, simulation videos or online learning environments. Most studies demonstrated that simulation could improve clinical competence and increase preparedness and confidence for clinical placement. Student satisfaction remained high throughout the studies; however, it is the view of many that although simulation‐based education is a valid and effective tool, it is complementary to and not a replacement for clinical placement.


Introduction
Clinical education is a core component of medical radiation university programmes (Medical Imaging/ Diagnostic Radiography, Radiation Therapy and Nuclear Medicine) with simulation recognised as an essential preparatory tool for work-integrated learning and clinical practice. Over the course of their undergraduate studies, students are required to develop a solid grounding in academic knowledge together with the associated technical and patient-centred capabilities to facilitate a holistic approach in their own discipline. Globally, there is increasing pressure for training institutions to develop the competency of their students without the negative impacts that may be associated with clinical placements. This has resulted in university educators reassessing how to best facilitate the development of practical clinical skills in effective, safe and supported learning environments. Students not only need to be academically prepared for placement, but also need opportunities to develop technical skills outside the clinical learning environment.
Simulation-based education is a highly effective tool for mimicking the clinical environment to teach skills to students and practitioners in healthcare. 1 Founded on educational theories, a simulation program can provide training and professional development as well as opportunities for student assessment. 2 All phases of the simulation, from preparation, pre-briefing, the simulation activity, feedback, debriefing, to evaluation and reflection, play significant roles in the individuals' learning. 3 Of particular importance is the reflection process, with Levett-Jones and Lapkin 4 suggesting that the advantages of the debrief phase outweigh the actual simulation activity.
While virtual simulation has been successfully embedded within radiation therapy programs in Australia, the use of virtual simulation within diagnostic radiography has not been widely adopted despite some promising recent studies. 5,6 An Australian study confirmed the effectiveness of simulating clinical practice using anthropomorphic phantoms to develop patient positioning and communication skills. 7 Another Australian study, Gunn and colleagues, 8 demonstrated that virtual reality simulation is more effective at improving clinical skills than conventional teaching methods. In addition, other studies have shown that medical radiation students benefit from simulation in an interprofessional context, resulting in improved confidence, teamwork and preparedness. [9][10][11] A systematic review concluded that simulation training increased students' knowledge, confidence and satisfaction. 12 Students value simulation training because they can see, practise and perform techniques/skills that may not be possible while on placement.
Despite the recent studies conducted in this field, many educators continue to use conventional teaching methods rather than seeking the potential benefits that simulation has to offer. Student preparation for clinical practice is essential and should be conducted with the most appropriate teaching methods to achieve the best results. Several scoping reviews and meta-analyses have been performed in the field of nursing and medicine. There is, however, a scarcity of comprehensive literature review on this contemporary pedagogical approach. It is also unknown if medical radiation simulation curricula have been designed according to current best practice guidelines incorporating the cycle of simulation phases. The aim of this scoping review is to provide a contemporary evidenced-based guide to simulation-based education in medical radiation programs.

Materials and Methods
A scoping review was performed to assess the current literature on the use of simulation for medical radiation students in an academic setting. Our existing knowledgebase and initial literature review of this topic have discovered a wide variety of alternate approaches to simulation education in medical radiation science. These aspects differ particularly in terms of the setting, duration and technology utilised by educators. Scoping reviews are particularly useful in this case, especially as our topic exhibits a complex and heterogeneous nature not amenable to a more precise form of review. 14 Overall, this review was intended to 'map out' the current literature, attempting to explore the conceptual boundaries of the topic and provide a clear indication of the volume of literature and an overview of its focus.
The organisational framework described by Arksey and O'Malley 13 was chosen as the preferred method in evaluating the extent of available evidence for this mapping overview. Specifically, this method entails: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data and (5) collating, summarising and reporting the results. These stages form the basis of the methods and results section of this review.

Research question
The intention of this scoping review is to answer the question, 'What is the current literature on simulationbased education for medical radiation students'? For this review, we refined our search strategy based on a PICO approach, where P (population) is the medical radiation student/curriculum, I (intervention) is simulation-based education, C (comparator) is other forms of learning and O (outcome) is knowledge retention/satisfaction/ perceptions/experiences.

Search strategy
A scoping search was performed on three databases: PubMed, Scopus and Medline from 2010 to 2021. These databases were selected to capture the existing literature in allied health and higher education. To identify the search terms, a preliminary search was conducted in the Scopus and Medline databases. The following terms were entered: 'simulation', 'simulated learning', 'computed tomography', 'medical radiation', 'medical imaging', 'radiation therapy', 'nuclear medicine', 'radiologic technology' and 'radiography'. Later, synonyms for each search term were used and applied with the Boolean operators 'AND' and 'OR' to capture all possible relevant articles (see Table 1). Although no relevant MeSH terms  14 as a narrow timeframe might severely limit the number of eligible studies.
Following the addition of studies identified through snowballing and reference list searching, duplicate studies were removed by a single researcher and titles and abstracts were screened according to the inclusion and exclusion criteria (see Table 2). The independent screening and reviewing of eligible studies was consistent with the 2005 scoping review framework by Arksey and O'Malley, 13 as well as the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. 15 This process has been visually represented using the 2020 PRISMA flow diagram template in Figure 1. Any disagreement was discussed and resolved by consensus among the team members. The research team also had extensive experience conducting scoping reviews, systematic reviews and meta-analyses, which they used to inform their practice on this reviewing literature. Table 3 summarises the characteristics of all included studies. Publication dates span from 2010 until the four most recent studies in 2021, highlighting the contemporary nature of simulation. The majority of studies were conducted in developed English-speaking nations (AUS = 12, UK = 9, IRE = 2, NZ = 2 and USA = 1), with the remaining conducted in the UAE, Finland, Sweden, Norway, France/Switzerland and Portugal. Twelve studies presented quantitative findings, while seven adopted a wholly qualitative approach. Another 14 studies adopted an approach combining both paradigms. Outcomes were most commonly measured based purely from the self-reported perception of participants (n = 30), with Likert scale questionnaires being the most popular tool (n = 21). Only seven studies incorporated performance-based measures to assess skills or knowledge in their data collection. In two of these studies, however, performance-based assessments were not a prominent feature. Six studies also employed a control group which did not experience the simulation intervention, while one additional study utilised a crossover study approach. None of the studies with a control group employed blinding, though it is noted that effective blinding is largely inconceivable. The total sample size of participants across the studies was 2343, with individual sample sizes ranging from five to 293. 'Radiography' was the sole focus for 20 articles, while seven had an interprofessional focus. The remainder focused on a combination of 'radiation therapy' (n = 5) or 'sonography' (n = 1). Role play simulation was the most common intervention (n = 16) followed by virtual/digital simulation (n = 13). Two studies each used simulation video clips or online learning environments as interventions.

Results
The use of performance-based outcome measures, as adjudicated by external observers or questionnaires was only a major part of the data collection in five studies. 8,9,[16][17][18] Each of these five studies featured a control group which received either conventional educational interventions or no intervention. All studies using performance-based outcome measures reported significant improvement in favour of simulation other than Lee, Baird, 17 where no significant difference was found. In this study, the control group received conventional teaching methods, with both groups significantly improving in their core CT knowledge.
Seventeen of the nineteen studies analysing selfreported quantitative data, demonstrated an increase in competence after completing the simulation intervention. Students reported benefits in areas including empathy, attitudes towards patients, preparedness, confidence, content knowledge, reflection and technical skills. A control group was not utilised in 95% of studies, with Shiner 19 being the outlier. Leong, Herst 20 however, employed a crossover study design contrasting conventional teaching methods to VERT, finding that an integrated teaching approach may be of most benefit to the students. Only Jimenez, Thwaites 21 and Liley, Ryan 22 identified either no significant difference or decreased perceived competence post-intervention. Liley, Ryan 22 reported a significant decrease in the students' perception of confidence in their clinical skills after the intervention with 68% indicating that simulation did not help them to prepare for their clinical placements.
The studies including qualitative findings used many methods during data collection, namely open-ended Table 2. Inclusion and exclusion criteria.

Inclusion criteria
Exclusion criteria • Peer-reviewed papers using simulation education.
• Reported the use of simulation learning in medical radiations.
• Published in English between 2010 and 2021.
• Only evaluated the software/equipment/ instruments.
• Conference abstracts, case-control studies or case series.
• Outside the scope of the medical radiation curriculum.
• Narrative/systematic/scoping reviews or meta-analysis. The use of simulation as an intervention was received positively by the students in 16 of the 17 studies reporting on satisfaction levels, with only Liley, Ryan 22 receiving substantial negative feedback. The students in studies by Carramate, Rodrigues, 31 Elshami and Abuzaid 32 and Halkett, McKay 33 agreed that simulation was able to positively impact on their learning and is an important educational tool, endorsing its use into the future.

Discussion
The review of the literature highlighted key aspects of simulation education, being the influence of type (e.g. roleplay and digital simulation); the capacity of simulation to achieve a variety of outcomes (e.g. clinical skills and preparedness); the mode of delivery (e.g. selfdirected and teacher-led) and student satisfaction.
All studies included in this review explored simulation as a means for education in a tertiary setting for medical radiation sciences; however, two primary subgroups emerged with regard to the intervention used; role play simulations and virtual/digital simulation. Bleiker, Knapp 23 and Williams, Brown 34 both used video clips while Mc Inerney and Baird 35 and Paalim€ aki-Paakki, Virtanen 36 employed an online learning environment as a means to simulate the clinical setting.
The role play simulation studies can be broken down into further subgroups; practical targeted simulation and interprofessional simulation. For the purpose of this study, 'practical targeted simulation' will refer to any simulation-based teaching approach that was given to a specific population of students, whereas 'interprofessional simulation' will refer to any simulation-based teaching approach given to students as part of a multidisciplinary team. Practical targeted simulation was the intervention of choice for eleven studies, eight of which were specific to radiography participants. The other three studies included participants from radiation therapy 30,31 and sonography programs. 27 Six studies simply simulated the clinical environment with the use of role play, three of which incorporated actors to enhance realism. 26,30,33 Four studies used practical effects such as masks, suits and        It is noteworthy that the use of actors and practical effects was received well by the students, assisting them to suspend disbelief and fully engage in the activity. 30 Interprofessional role play accounted for five of the studies, in which participants were involved in a multidisciplinary, situational simulation. This intervention was met with positive feedback from the participants, citing increased levels of confidence, teamwork and better understanding of roles as its benefits. Alinier, Harwood 9 was the only study to incorporate a control group and measure outcomes based on knowledge gained, finding that the intervention group scored 3.23% higher in the knowledge-based questionnaire post-intervention. Students often have their first exposure to interprofessional environments such as trauma or ward radiography during clinical placement and are likely to feel unprepared in the absence of formal training. 10 Overall, studies which offered interprofessional simulation were seen to be beneficial for preparing students, which could have potential future implications for graduates as they enter the workforce and must work collaboratively with other professions to provide higher quality care.
The intervention that was most common among the virtual simulation studies was virtual radiography software (n = 5), allowing the students to position patients and operate an X-ray tube in a digitally simulated clinical environment. Similarly, four studies used virtual Computed Tomography (CT) software, three used VERT 5,20,21 while Elshami and Abuzaid 32 used virtual Magnetic Resonance Imaging (MRI) software. These studies viewed virtual simulation as an effective educational tool. Many noted that it provided the students with a safe environment to make mistakes and learn while also preparing the students for their clinical placements.
Leong, Herst 20 reported increased engagement when contrasted to conventional teaching methods; however, they did not identify any significant benefits to achieving learning outcomes. Rather, its real benefit lies in integrating the two learning models. Student satisfaction remained positive throughout these studies with common responses indicating that the experience was beneficial to their education. Self-reported improvement was seen in many categories including understanding of image quality, dose, critical thinking, image evaluation and clinical skills. Students enjoyed having free access to the software to work at their own pace with less stress while developing familiarity in a clinical context. Having a safe environment to repeat examinations and learn from their mistakes were also positive outcomes. Conversely, confusing software, technical difficulties and lack of support led to some negative experiences. One study by Liley, Ryan 22 noted mixed results among the students with a decrease in their perceived clinical skill levels. The participants expressed a desire for 'hands-on' experience in preference to remote access learning.
Simulation video clips were found in one study to significantly increase empathy levels in an interprofessional context. 34 Although radiography students exhibited the second lowest empathy levels in the pre-test measurement, medical radiation students (radiography and radiation therapy) benefitted the most from the intervention. Similarly, Bleiker, Knapp 23 also noted themes of increased empathy as well as linking theory to practice, demonstrating that simulation videos can be an effective tool in medical radiation.
Although quite different in execution, both studies involving online learning environment simulations allowed the students to experience the clinical environment and learn remotely. Mc Inerney and Baird 35 demonstrated that most students (70%) believed the simulation to be beneficial to their professional judgement and clinical decision making; however, only 52.55% reported that the simulation was an effective link between theory and practice. The students participating in the study by Paalim€ aki-Paakki, Virtanen 36 found the interactive environment was suitable for familiarisation of the department and equipment in the clinical context, but did not explore this in great detail. As only two studies were found utilising this intervention, it makes it difficult to draw conclusions. Further studies with similar methodologies and interventions are warranted.
Student outcomes across all studies were generally positive towards simulation. The studies using performance-based outcome measures demonstrate its capability to achieve a variety of outcomes ranging from theoretical knowledge to clinical skills. Each of these studies reported statistical significance in the improvements over the control group, highlighting the advantages of simulation over conventional teaching methods. The favourable results from Alinier, Harwood 9 and Stowe, O'Halloran 18 reflect well on their respective interventions; however, their control groups received no intervention. This fails to address the question regarding the effectiveness of simulation compared with conventional teaching methods.
Similarly, the self-reported benefits from the students demonstrate the versatility of simulation to achieve a desired outcome. While only a few studies employed control groups, the results show that most students are able to reflect on the intervention and identify benefits to their learning. Although this is less rigorous than other methodologies, outcomes such as preparedness and confidence are difficult to assess via alternate means without participant bias. Of the two studies receiving mixed qualitative responses, both used CT virtual simulation as the intervention. These responses were primarily due to the unfamiliar systems and lack of support but were also influenced by the lack of interaction with a physical CT environment. 17,22 It is important to note that although the benefit of simulation is clear, most studies are of the opinion that it should complement clinical placement rather than replace it. 5,22,27,37 This is in accordance with Thoirs, Giles 6 where it was the view of tertiary educators, accrediting bodies and clinicians that simulation should not replace clinical placement.
Students commonly reported that they enjoyed the simulation and that similar experiences should be incorporated into their respective courses. A large factor for this was the capacity for self-directed learning for online simulations whereby the students could complete the tasks in their own time. The high-fidelity nature of many simulations was also a contributor to the satisfaction levels. 26,30,38 The lack of control groups in these studies may again skew the results in favour of the intervention as the students had no comparative teaching method. Liley, Ryan 22 was the only study to report mixed satisfaction levels within the students. This was primarily due to the remote-access nature of the intervention leading to frustration within the participants and was also seen to a lesser extent in other virtual interventions. 37 However, it is important to note that this was a pilot study with a relatively small sample size.

Limitations
The studies comprising this review primarily relied upon self-reported outcome measures which are considered much less reliable than objective measures. Quantitatively determining the effect of simulation interventions should be prioritised by employing objective outcome measures in future research. Control arms should also be included in future research where possible to improve methodological quality. It should be noted that many institutions would employ simulation but may not publish their practices. Additionally, publication bias may have impacted the results as there was no active search of grey literature (e.g. unpublished theses and conference proceedings), and this review only included Englishlanguage studies. Publication of studies with more favourable results are more likely to be published than those with contrary findings, meaning that the literature available may overestimate the true value of simulation interventions. Real-world outcomes such as cost were not reported in any included study. Data regarding costs of implementation and qualitative discussion concerning accessibility of resources would be advantageous in enabling financial and resource analysis of given interventions.

Conclusion
It is evident that the use of simulation-based education can have significant effects on the learning of students in medical radiation. Almost all studies included in this review viewed the use of simulation in Medical Radiation education positively. If implemented appropriately, simulation can provide students with opportunities to experience the clinical environment in a safe context and learn at their own pace. Both practical and virtual simulation have shown their potential in a variety of contexts in this review, with many students endorsing its use in medical radiation courses as a complementary learning tool rather than a replacement for clinical practice. Due to the small number of studies with objective performance-based outcome measures and control arms, it is difficult to arrive at a reliable comparative evaluation of the relative benefits of simulation versus traditional teaching methods. Nevertheless, this review highlights the benefits of simulation in medical radiation education and outlines the shortcomings in recent literature. There is a need for further research into simulation using objective outcome measures and control arms, particularly concerning modalities such as CT and MRI.