Simulation in Healthcare in the Realm of Education 4.0

Abstract

The advent of Education 4.0, in parallel with Industrial Revolution (IR) 4.0, has translated into an evolution in healthcare education. Simultaneously, as a result of concerns in doctors' competency and patient safety, simulation shot into center-stage in the field of healthcare education. Generally, there are five modalities in healthcare education, namely role-play (verbal), standardized patient, part-task trainer, computer or screen-based simulation, and electronic patients including virtual reality. Dissecting the nine principles of Education 4.0, this article reviews the relevance and role of the five different modalities of simulation in easing healthcare education into the mold of Education 4.0. © 2020 Penerbit Universiti Kebangsaan Malaysia. All rights reserved.

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Sains Malaysiana 49(8)(2020): 1987-1993
http://dx.doi.org/10.17576/jsm-2020-4908-21
Simulation in Healthcare in the Realm of Education 4.0
(Simulasi dalam Penjagaan Kesihatan di Alam Pendidikan 4.0)
ZALEHA ABDULLAH MAHDY, MUHAMMAD MAAYA, IXORA KAMISAN ATAN , AZLAN HELMY ABD SAMAT, MOHD
HISHAM ISA & ISMAIL MOHD SAIBOON*
INTRODUCTION
River
ABSTRACT
The advent of Education 4.0, in parallel with Industrial Revolution (IR) 4.0, has translated into an evolution in healthcare
education. Simultaneously, as a result of concerns in doctors’ competency and patient safety, simulation shot into
center-stage in the eld of healthcare education. Generally, there are ve modalities in healthcare education, namely
role-play (verbal), standardized patient, part-task trainer, computer or screen-based simulation, and electronic patients
including virtual reality. Dissecting the nine principles of Education 4.0, this article reviews the relevance and role of
the ve dierent modalities of simulation in easing healthcare education into the mold of Education 4.0.
Keywords: Education 4.0; healthcare; industrial revolution; mobile learning; simulation
ABSTRAK
Kemunculan Pendidikan 4.0, selari dengan Revolusi Industri (IR) 4.0 telah melahirkan sebuah evolusi dalam pendidikan
penjagaan kesihatan. Seiring dengan perkembangan tersebut serta kebimbangan mengenai kecekapan para doktor
dan keselamatan para pesakit, simulasi menyerlah sebagai salah satu kaedah yang penting dalam bidang pendidikan
penjagaan kesihatan. Pada umumnya terdapat lima modaliti simulasi kesihatan iaitu lakonan (bertutur), pesakit
piawai, simulator-tugasan-separa, simulasi komputer atau berasaskan skrin dan pesakit elektronik termasuk realiti
maya. Dengan merujuk kepada prinsip Pendidikan 4.0, kertas ini mengulas kerelevanan dan peranan yang dimainkan
oleh kelima-lima modaliti tersebut dalam pendidikan penjagaan kesihatan berasaskan simulasi dalam kerangka wadah
Pendidikan 4.0.
Kata kunci: Pembelajaran bergerak; pendidikan 4.0; penjagaan kesihatan; revolusi industri 4.0; simulasi
INTRODUCTION
Over the last few centuries, the world has been greatly
shaped by four industrial revolutions (IR): The steam
engine (IR 1.0); The production line (IR 2.0); The computer
(IR 3.0); and The internet (IR 4.0) (Intelitek 2018), with
the latest revolution merging the physical and virtual
domains. Healthcare education is no exception in having
to keep up with the latest ideas and practice of education
in general, which must be kept abreast with the industrial
revolutions. It is unreasonable to stick to older methods
of teaching and learning when the needs of the healthcare
profession has changed in line with IR 4.0. To reach out
towards an improved outcome, a paradigm shift is in order.
New objectives and aspirations require a new mindset and
skillset, accompanied by new tools and armamentarium.
Medical education must gear itself towards competency
based education with the aim of achieving mastery skills
rather than remaining merely knowledge based.
Simulation is a technique to replace or amplify
real patient experiences with guided experiences that
are articially contrived and evokes or replicates
substantial aspects of the real world in a fully immersive
and interactive manner (Gaba 2004). It is mainly
used as a teaching and learning method, apart from
assessment and research (Ismail et al. 2019), having
been practiced in various other elds outside healthcare
such as aviation, judicial, and military education (Riley
2015). In healthcare education, simulation is in fact
not new either, and has been in practice since ancient
Chinese civilization. More recently, simulation has
revolutionized healthcare education, with much renewed
interest and scaling greater heights in terms of usage,
variety, and creativity. Apart from formal teaching and
learning, simulation plays an important role in preparing
healthcare workers in anticipation of managing crisis and
disease outbreaks, like the recent COVID-19 pandemic
(Wong et al. 2020). The rapid progress in electronics,
communication technology and articial intelligence has
enhanced the world of simulation in healthcare education
to a huge extent.

1988
WHAT IS EDUCATION 4.0?
Education 4.0 came into existence in response to the
needs of IR 4.0, each version of ‘Education’ having
been tied to its corresponding ‘IR’ counterpart, from 1.0
onwards (Hussin 2018). I IR R 4.0 signied Computer
Connectivity, i.e. The Internet, and encompasses
connections between computers, robots, printers, and
the Internet of Things (IoT). Whilst some claim that IR
4.0 is still ongoing, others argue that we are presently
sitting on the threshold of IR 5.0 (Intelitek 2018) that
deals with personalization.
There are nine principles or features that describe
Education 4.0 (Fisk 2017): A learning process unlimited
by time and place; Personalized learning; Learning
tools customized to the learner’s choice; Project-
based learning; Hands-on and experiential learning;
Data interpretation; Formative and workplace-
based assessment; Learners’ feedback in shaping the
curriculum design and review; and Independent learning
whilst teachers facilitate.
The delivery of healthcare education is no
exception in the need to conform to Education 4.0
for the greater good of mankind. The nine tenets of
Education 4.0 must be able to impart the desired learning
outcomes in healthcare education. The Malaysian
Qualications Framework (MQF) outlines ten learning
outcome domains (Figure 1) for any discipline, which
correlates well with the six core competencies put forth
by the Accreditation Council for Graduate Medical
Education (ACGME) and the American Board of Medical
Specialties (Satava 2009) which are: Interpersonal and
communication skill, medical knowledge, patient care,
practice-based learning and improvement, system-based
practice, and professionalism. The Canadian CanMEDs
2005 Framework describes seven key competencies
required in a medical practitioner in order to provide
high quality care (Figure 2), which again conforms to
the previous two sets of learning domains (Aggarwal et
al. 2010).
FIGURE 1. The Malaysian Qualications Framework set of learning
outcome domains (O’Brien 2015)

1989
SIMULATION IN HEALTHCARE EDUCATION
According to Gaba (2004) there are several modalities
in healthcare simulation which include verbal (role
playing), standardized patients (actor/s), part-task
trainers (physical and virtual reality), computer patient
or screen-based simulation (computer screen, screen
based ‘virtual world’), and electronic patient (replica
of clinical site, mannequin based, full virtual reality)
(Cooper & Taqueti 2004).
Simulation in healthcare education strives to
achieve two objectives - assurance of clinical competence
of the healthcare worker, and maintenance of patient
safety. Fidelity, which is the degree of similarity to
reality of the simulation technique or scenario, depends
heavily on the creativity of the module, program design
and the conduct of the simulation. There is no direct
correlation between the level of simulation technology
and the quality of the delity. Thus, low technology
simulation does not equate low delity and similarly,
high technology (hence, usually high cost) simulation
does not necessarily translate into high delity. This is
one mistake frequently committed by a person who is
unfamiliar in choosing simulators. Regardless of the
cost, all simulators are precious. They are not mere
toys - they are generally expensive items that should be
responsibly purchased, wisely used and well-maintained.
HOW DOES SIMULATION FULFILL THE PRINCIPLES OF
EDUCATION 4.0?
IR 4.0 has signicant impact on the skills required
of a healthcare worker, hence it is only reasonable
for healthcare educational principles and practice to
comply with Education 4.0. For example, the advent
of electronic connectivity is accompanied by remote
control mechanisms leading to robotics surgery. The
lesson learnt from the dawn of laparoscopic surgery is
that the insucient numbers of competent laparoscopic
surgeons to teach the skill at that time led to inadequate
supervision and training, with disastrous consequences.
This has given emphasis to the importance of alternative
training methods, which include simulation. Simulation
oers the capacity for deliberate practice, which allows
skills to be developed by repetitive and focused training
in an alternative articial setting without compromising
patient safety or imposing unnecessary stress to the
trainee.
FIGURE 2. The CanMEDs framework comprising seven key
competencies required of a doctor to provide high quality care
(Aggarwal et al. 2010)

1990
TIMELESS LEARNING ANYWHERE
Simulation enhances temporal and spatial learning
accessibility to a previously unimaginable extent.
Programs depicting computer patients allow the practice
of screen-based simulation. These programs can easily
be uploaded to any online platform that is readily
accessible by learners through an asynchronous learning
modality. Computer patients allow the recreation of real
life clinical case scenarios like managing emergency
situations, and practicing the proper steps of surgical
procedures, as well as the skill of making the right
decision in any given clinical situation. Screen-based
simulation promotes cognitive training that can be done
at any time and in any location according to learners’
preference.
Apart from cognitive training, simulation modalities
like part-task trainer and virtual reality (VR) also support
training of psychomotor skills or procedures. The
presence of exible access open simulation laboratories,
help learners practice some of the important basic as well
as advanced procedural skills before they are allowed
to perform on real patients. One example is the open
learning concept in certain medical schools in Kuala
Lumpur, where medical students are allowed access to
simulation laboratories at their convenience, in order
to practice procedures whilst watching related videos
provided on site. In UKM, through such self-instructional-
video (SIV) (Ismail et al. 2014) that is easily accessible
online, medical students can practice on their own, after
which they capture their performance of the procedure
and send it to supervisors for a more personalized
coaching, without any face to face encounter with the
supervisor. This frees up considerable time for the
lecturers and allows students to practice as much as they
wish. At the other end of the technology spectrum, task
trainers for robotic surgery allows surgeons to practice
the procedures before they perform it on real patients.
Compared to basic task trainers, advanced robotic
simulators may be less transportable, although temporal
accessibility may be unlimited.
VR simulation helps solve some of the procedural
skill training accessibility in terms of time and location.
Not only does it allow exible learning opportunities, it
also lls the learning gap for cases, clinical scenarios or
situations that are infrequently or rarely encountered,
e.g. mass disaster response in emergency medicine,
prolapse of the umbilical cord or shoulder dystocia in
obstetrics, and many other uncommon situations, which
are unique to various disciplines of medicine.
PERSONALIZED LEARNING
Most simulation modalities promote personalized
learning, especially role play, part-task trainer, and
screen-based and electronic patients including VR,
by articially contriving real patient experiences. In
fact, usage of standardized patients (SP) also allows
personalized learning depending on SP availability with
some additional cost. Learning by simulation is generally
customizable to the learner’s own pace and time, and
learning style. The learner may learn repetitively to
gain competency with neither penalty nor negative
repercussions, with no threat to patient safety in the case
of procedural tasks (Issenberg et al. 2005). Learning
either knowledge or skills can also be achieved on a one
to one level of supervision.
CUSTOMIZED LEARNING TOOLS
Apart from the dierence in the time taken to gain
skills, each person learns best by dierent methods.
The spectrum of simulation modalities that is available
provides a variety of learning tools (screen-based,
role play, and electronic patient) for the learner to
conveniently choose from. The choice of learning tool is
indeed important, as learners will be able to learn better
when using methods of learning that suits them best.
Dierent learning tools have dierent learning tasks
that are best suited to each individual. For example, if a
learner wishes to know how to treat a patient in cardiac
arrest, apart from simply reading about it, he/she can
learn and practice through electronic patient simulation,
or VR simulation or screen-based patient simulation. All
these modalities allow learners to manage patients and
perform important clinical skills, and decision making.
Moreover, the chosen tool can be personalized to enhance
the learning experience, e.g. the AHA HeartCode
(Montgomery et al. 2012).
PROJECT BASED LEARNING
Simulation opens up the opportunity to project based
learning which underpins organizational, collaborative
and time management skills. Through simulation,
learners can be given a project or clinical problem,
and teachers can see how they work together through
the project. Furthermore, enhancement of team work
is one of the benets underlying simulation-based
learning. Improving coordination and communication
within a team is the key aim of certain simulation-based
learning tools, especially scenario-based simulation e.g.
enhancing the usage of ISBAR (Identication, Situation,
Background, Assessment, Recommendation) (Horgan
2013). In fact, due to the characteristic advantage of
simulation (Issenberg et al. 2005), learners can be
exposed to dierent levels of task diculties and
capture multiple variations in the task. One example of
implementing this is through Problem Based Learning
(PBL) either with screen-based simulation, or augmented
or VR simulation. PBL may be conducted using a screen-
based computer simulation such as the DxR Clinician
(Fida & Kassab 2015). Learners can work in groups to
discuss what and how best to manage clinical problems

1991
or cases. In fact, during the COVID-19 pandemic, PBL
through screen-based simulation has been utilised to help
in teaching medical students in UKM.
HANDS-ON AND EXPERIENTIAL LEARNING
Not every medical practitioner in their junior years is
fortunate enough to encounter opportunities to learn
various procedures whilst on clinical duty. Even when
a rare opportunity arises, there may be more than one
trainee eagerly awaiting the chance to perform the task.
Besides, one chance will denitely not be adequate
to fulll the need to attain competence. The old adage
of ‘see one, do one, teach one’ is no longer applicable,
particularly in this era of litigation and social media
complaints. This is where simulation gives a great
edge. Through simulation, deliberate practice leading
to mastery learning oers a signicant advantage. Role-
play can be used to teach communication skills; part-task
trainers allow repeated chances to perform specic skills
e.g. endotrachael intubation; electronic patient simulation
provides the chance to have a life-like resuscitation code
team training or an acute crisis resource management.
Rare or uncommon procedures can be taught eectively
through simulation, thereby overcoming learning merely
by chance, which is often inadequate and dangerous in
developing the competence of a healthcare personnel.
With the advent of newer devices, skills related
to older equipment can deteriorate. There are crucial
times when the usage of these older devices are either
essential or is the only safe option for managing a patient.
Deskilling of using these older but still useful devices,
such as the beroptic intubating scope, can also be
prevented via simulation.
DATA INTERPRETATION
Data can be created from real life patients or invented
based on logic and used to assess knowledge repeatedly
in various simulation modalities, e.g. role play, screen-
based, virtual or web-based modules. Simulation oers an
ideal opportunity for learners to interpret data while they
are at the bedside. Solutions or applications that can vary
the patient’s vital signs and allow the learner to interpret
and respond to the situation accordingly, either in an
emergency or non-emergency situation, provide learning
opportunities that can only come with simulation. There
are several applications available nowadays that are easily
accessible, either web-based or simulator-based e.g.
Vital Sign Simulator & Patient Monitor, which is freely
downloadable from the internet (healthysimulation.com)
or iSimulate (isimulate.com) simulator.
FORMATIVE ASSESSMENT
Simulation provides for formative assessment with
opportunity for improvement through repetitive practice,
and the subject matter that is assessed are practical skills
required at the workplace. This form of assessment
is indeed the fundamental objective of simulation-
based education. The current trend is to move towards
this mode of assessment, especially for postgraduate
clinical specialty training (Humphrey-Murto et al. 2017).
Formative assessment, in the realm of competency based
training, allows the learner ample room for improvement
in a safe and non-threatening environment. Feedback
can be immediate, formative and repetitive, hence
accelerating learning in the form of deliberate practice.
This forms the Rapid Cycle Deliberate Practice (RCDP) of
simulation (Taras & Everett 2017). Immersive simulation
through high delity modules enhances a more realistic
formative assessment for the learner. This can be achieved
through electronic patient simulation or VR.
LEARNERS AS STAKEHOLDERS IN CURRICULUM
DEVELOPMENT
The development of a curriculum based on simulation
techniques is dynamic as the interaction between
students and module developers (who are usually
the trainers) happens continuously and ends with
feedback and evaluation of the session. The cycle of
simulation teaching-learning is vital in simulation-based
healthcare education (Figure 3) (Nestel & Gough 2018).
Preparation, brieng and orientation, simulation activity,
debrieng, reection, and evaluation are important
steps to be followed. During evaluation, assessing the
eectiveness of the scenario based on learners’ feedback
and performance is of utmost importance. Through this,
simulation teaching has become a natural way of how
a student or learner contributes to the development of
the curriculum that ts their purpose or objective. This
constant engagement ensures a continuum of opportunity
for improvement of the training module and allows
learners to get involved in planning their learning process.
Learners therefore contribute to the simulation module
design by participating in the decision-making of what
is the best way to acquire certain knowledge or skillset in
their curriculum.
TEACHERS AS FACILITATORS OF INDEPENDENT LEARNERS
The concept of heutagogy (self-directed learning) is
the foundation of most simulation modules. In medical
education, self-directed personal learning, either alone or
more often in a small group, have long been practiced,
guided by lecturers. With the widespread use of electronic
media and gadgets in learning, the principle of heutagogy
is further strengthened in learning by simulation. As
mentioned earlier, most simulation modalities support
this concept of students becoming independent learners.
Part-task trainers, screen-based or computer patients,
electronic patients with VR, all promote self-directed
learning. Teachers no longer need to dictate or supervise
directly but merely observe, facilitate and debrief. This
augurs well with the last tenet of Education 4.0.

1992
COMPREHENSIVE SIMULATION IN HEALTHCARE
EDUCATION 4.0
Centers for comprehensive simulation in healthcare
training and education have started to sprout around
the globe. Such centers, like the MSR (Israel Centre for
Medical Simulation) (Aggarwal et al. 2010), provide
a fully simulated medical environment that includes
prehospital as well as inpatient settings with an extensive
audiovisual network for debrieng and feedback.
Healthcare professionals in-training, e.g. house ocers,
may be sent here for a short simulated training prior to
entering the real working world. This may be the best
and safest way forward in terms of training healthcare
professionals at all levels, whilst adhering to most if not
all principles of Education 4.0.
FUTURE RECOMMENDATIONS
In future, every institution that deals with healthcare
education has to have simulation as an essential part of
its setup. It is therefore imperative to develop an adequate
workforce of professional simulationists, supported by
simulation technologists, to train subject matter experts
to be adept at designing simulation programs and modules
for teaching and learning. This capacity building must
begin now, and the current tempo must be stepped up
if we are serious on developing progressive and future-
proof healthcare education.
CONCLUSION
Simulation provides the essence in terms of training
approach for healthcare education that complies
beautifully with Education 4.0. Whilst the importance
of direct patient contact is undeniable, simulationists
are set to steer the direction of healthcare education
to a whole new world of make-belief, as never before,
making simulation the heart and soul of future
healthcare education. Simulation is denitely a tool for
healthcare education to entrench a cultural shift towards
empowering the learner to be competent, leading to
better patient safety. Simulation should not be seen to
replace the age-old bedside teaching method where the
opportunities of learning only happens by chance. More
appropriately, simulation forms a beautiful bridge that
closes the educational gap left by traditional methods of
teaching.
REFERENCES
Aggarwal, R., Mytton, O.T., Derbrew, M., Hananel, D.,
Heydenburg, M., Issenberg, B., MacAulay, C., Mancini,
M.E., Morimoto, T., Soper, N., Ziv, A. & Reznick, R. 2010.
Training and simulation for patient safety. Qual. Saf. Health
Care 19(Suppl 2): 34-43.
Cooper, J.B. & Taqueti, V.R. 2004. A brief history of the
development of mannequin simulators for clinical education
and training. Qual. Saf. Health Care 13(Suppl 1): 11-18.
Fida, M. & Kassab, S.E. 2015. Do medical students’ scores
using dierent assessment instruments predict their scores in
FIGURE 3. The Cycle of Simulation Teaching (adapted from Nestel &
Gough 2018)

1993
clinical reasoning using a computer-based simulation? Adv.
Med. Educ. Pract. 6: 135-141.
Fisk, P. 2017. Education 4.0… The Future of Learning Will Be
Dramatically Dierent, in School and Throughout Life.
http://www.thegeniusworks.com/2017/01/future-education-
youngeveryone-taught-together. Accessed on 19 September
2019.
Gaba, D.M. 2004. The future vision of simulation in health care.
Qual. Saf. Health Care 13(Suppl 1): 2-10.
Horgan, M. 2013. Communication is key. WIN 21(1): 46-47.
Humphrey-Murto, S., Wood, T.J., Ross, S., Tavares, W., Kvern,
B., Sidhu, R., Sargeant, J. & Touchie, C. 2017. Assessment
pearls for competency-based medical education. J. Grad.
Med. Educ. 9(6): 688-691.
Hussin, A.A. 2018. Education 4.0 made simple: Ideas for
teaching. Int. J. Educ. Lit. Stud. 6(3): 92-98.
Intelitek 2018. The Education 4.0 Revolution: An Analysis of
Industry 4.0 and Its Eect on Education. http://www.intelitek.
com/what-is-education-4-0. Accessed on 19 September 2019.
Ismail, M.S., Johar, M.J., Siraj, H.H., Arif, K., Jalina, K.,
Iva, M.I., Saidah, M.H., Balakrishnan, M., Syahira, J. &
Phrampus, P.E. 2019. Inuence of simulation in Malaysian
healthcare education and research (ISIM-HERE): A two-
decade experience. Med. Health 14(1): 53-67.
Ismail, M.S., Jaafar, M.J., Ahmad, N.S., Nasarudin, N.M.A.,
Mohamad, N., Ahmad, M.R. & Gilbert, J.H.V. 2014.
Emergency skills learning on video (ESLOV): A single-
blinded randomized control trial of teaching common
emergency skills using self-instruction video (SIV) versus
traditional face-to-face (FTF) methods. Med. Teach. 36(3):
245-250.
Issenberg, S.B., McGaghie, W.C., Petrusa, E.R., Gordon, D.L.
& Scalese, R.J. 2005. Features and uses of high-delity
medical simulations that lead to eective learning: A BEME
systematic review. Med. Teach. 27(1): 10-28.
Montgomery, C., Kardong-Edgren, S.E., Oermann, M.H. &
Odom-Maryon, T. 2012. Student satisfaction and self-report
of CPR competency: HeartCodeTM BLS courses, instructor-
led CPR courses, and monthly voice advisory manikin
practice for CPR skill maintenance. Int. J. Nurs. Edu.
Scholarsh. 9(1): 1-14.
Nestel, D. & Gough, S. 2018. Designing simulation-based
learning activities: A systematic approach. In Healthcare
Simulation Education: Evidence, Theory and Practice, edited
by Nestel, D., Kelly, M., Jolly, B. & Watson, M. West Sussex:
John Wiley & Sons Ltd.
O’Brien, G. 2015. The Malaysian Qualications Framework.
www.slideplayer.com. (Google search: mqf para 15).
Accessed on 24 February 2019.
Riley, B. 2015. Using simulation-based medical education to
meet the competency requirements for the single accreditation
system. J. Am. Osteopath. Assoc. 115(8): 504-508.
Satava, R.M. 2009. The revolution in medical education - the role
of simulation. J. Grad. Med. Educ. 1(2): 172-175.
Taras, J. & Everett, T. 2017. Rapid cycle deliberate practice in
medical education - A systematic review. Cureus 9(4): e1180.
Wong, J., Goh, Q.Y., Tan, Z., Lie, S.A., Tay, Y.C. & Ng, S.Y.
2020. Preparing for a COVID-19 pandemic: A review of
operating room outbreak response measures in a large tertiary
hospital in Singapore. Can. J. Anaesth. 67(6): 732-745.
Zaleha Abdullah Mahdy & Ixora Kamisan Atan
Department of Obstetrics and Gynaecology
Faculty of Medicine
Universiti Kebangsaan Malaysia Medical Centre
Jalan Yaacob Latif, Bandar Tun Razak
56000 Cheras, Kuala Lumpur, Federal Territory
Malaysia
Muhammad Maaya
Department of Anaesthesiology & Intensive Care
Faculty of Medicine
Universiti Kebangsaan Malaysia Medical Centre
Jalan Yaacob Latif, Bandar Tun Razak
56000 Cheras, Kuala Lumpur, Federal Territory
Malaysia
Azlan Helmy Abd Samat, Mohd Hisham Isa & Ismail Mohd
Saiboon*
Department of Emergency Medicine
Faculty of Medicine
Universiti Kebangsaan Malaysia Medical Centre
Jalan Yaacob Latif, Bandar Tun Razak
56000 Cheras, Kuala Lumpur, Federal Territory
Malaysia
*Corresponding author; email: fadzmail69@yahoo.com.my
Received: 1 October 2019
Accepted: 1 April 2020