SYNCHRONOUS AND OBSERVATIONAL TELESIMULATION IN HEALTH: A SCOPING REVIEW

ABSTRACT Objective: to map the necessary steps and components for operationalizing a synchronous and observational telesimulation design in the context of developing clinical competencies aimed at students and health professionals. Method a scoping review supported by the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews: Checklist and Explanation, and by the assumptions of the Joanna Briggs Institute Reviews’ manual method. The search was carried out in November 2021 in 13 databases, totaling nine studies in the final sample, which were then analyzed using Thematic Analysis. Results two categories were developed: steps and components for operationalizing a synchronous and observational telesimulation design; and challenges to implement synchronous and observational telesimulation. Conclusion operationalizing a synchronous and observational telesimulation has been supported by a six-step instructional design, characterized by planning, preparation, participation, teledebriefing, learner assessment/feedback collection and additional learning, capable of developing the students’ cognitive and affective skills. The relevant challenges to this context were also highlighted, configured by the need to obtain a sufficient technological structure for remotely transmitting the telesimulated scenario and an adequately trained faculty.


INTRODUCTION
The long pandemic period caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus hampered the pedagogical processes supported by face-to-face clinical practice and made implementing simulation-based education challenging 1 .
In addition to demanding a quick adaptation to the teaching approaches adopted in health around the world, this condition has also encouraged the use of new educational technologies based on high-level simulated experiences which are capable of reaching remote environments of difficult access and establishing online learning methods such as telesimulation [1][2] .
During the International Conference of the Society for Simulation in Health held in 2016 in the United States, it was proposed to expand the definition of telesimulation, characterizing it as a process by which telecommunication and simulation resources are adopted to provide education, training and/or assessment for students at an offsite location [2][3] .
Based on this concept, researchers believe that telesimulation enables reaching learners where there are distance limitations which prevent efficient instruction, minimizing time constraints or the lack of available educators with experience in a specific content, taking advantage of interactive audiovisual resources to implement models capable of providing a student-centered simulation and learning objectives 2,4 .
Although a common taxonomy for telesimulation has not yet been established, it is already possible to identify its classifications named according to the synchronicity between the instructor and the learner, defined as synchronous (both experience and/or observe the activity in real time) and asynchronous (the learner experiences part of the activity offline through pre-recorded videos and part online with the help of an instructor, or even when all the proposed activity takes place offline and without the presence of the instructor) 1,5.Also, according to the nature of student participation characterized by mobile telesimulation (when the learner receives materials for their practical training remotely), by observational telesimulation (the learner only observes the scenario execution and participates in the teledebriefing from a distance), and also according to the number of strategies used during the telesimulation, called hybrid 1,5 .
Regarding the synchronicity classification of telesimulation between instructors and apprentices, it is worth mentioning that scientific evidence points to a greater development of clinical competencies such as knowledge and psychomotor skills focused on surgical techniques (for example) when applied to synchronous telesimulation, meaning that students and teachers live the experience in real time and online, than when using asynchronous telesimulation based on self-practice offline 6 .However, even with the potential of synchronous telesimulation, this is an issue which also instigates the need for further deepening and scientific exploration given the scarcity of literature capable of clarifying this context and the intention to successfully optimize its adoption in view of the variability of implementations 4 .
The classifications of telesimulation are also noteworthy, and in order to overcome the barriers imposed by the lack of financial resources which make the mobile type possible by sending simulators and anatomical parts for the student's training, observational telesimulation, in which the student only contemplates the simulated experience at a distance, has been gaining considerable pedagogical space in developing countries 1,4 , but which requires planning and implementing a validated design/ protocol that contains the steps and components of telesimulation 4 .
Furthermore, there is still no evidence in the literature of a guideline capable of standardizing a common language and defining the ideal operationalization of telesimulation, making it difficult to systematize this pedagogical strategy 5 .In this context, it is necessary to recognize the challenges for adopting telesimulation in teaching and learning in health, such as the incipience of research which addresses the most effective methodological path to carry it out 7 , and above all, considering that the best way to optimize synchronous and observational telesimulation nature is still not clear, especially at the national level 8 .
The present study aims to map the steps and components necessary for operationalizing a synchronous and observational telesimulation design in the context of developing clinical skills aimed at students and health professionals.

METHOD
This is a scoping review on synchronous and observational telesimulation made possible by the real-time online participation of instructors and students with the observation of the clinical scenario by the students 5 .This type of review was chosen when considering the demand for information and the scarcity of manuscripts which clarify the operationalization of this simulation modality, and constitutes a condition capable of justifying the inclusion of conventional and non-conventional documents to identify gaps on the subject and provide significant bases for future research 9 .
The research protocol was registered on the Open Science Framework platform (https://osf.io/6amvb) supporting its methodological path in the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation 9 and method assumptions from the Joanna Briggs Institute Reviews' manual 10 .Five steps were performed: (1) identification of the research question; (2) identification of relevant studies; (3) selection of studies for review; (4) data mapping; and (5) collection, summary and reporting of results 11 , as detailed below.
The research question was elaborated through the fundamental elements of the mnemonic Population -Concept -Context (PCC) 10,12 , defined as: "P" (population): undergraduate and graduate students and professionals in the health field; "C" (concept): the operationalization of synchronous and observational telesimulation as a teaching and learning modality; and "C" (context): the development of clinical and cognitive skills, psychomotor and affective skills in the health field.Thus, the following question was obtained: what steps and components are necessary to operationalize a synchronous and observational telesimulation design applied to the context of the development of clinical skills aimed at students and health professionals?
The search for evidence took place in November 2021 in the following databases: US National Library of Medicine National Institutes Database Search of Health (Medline/PubMed ® ), Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Education Resources Information Center (ERIC), Latin American and Caribbe an Literature in Health Sciences (LILACS).In addition, non-conventional databases in review studies were searched to cover the gray literature, characterized by: Catalog of Theses and Dissertations of the Journal Portal of the Coordination for the Improvement of Higher Education Personnel (CAPES), Europe E-Theses Portal (DART), Electronic Theses Online Service (EThOS), Repositorio Científico de Access Aberto de Portugal (RCAAP), National ETD Portal and Theses Canada.
The health descriptors available on the Health Sciences Descriptors Portal (DeCS) in the Virtual Health Library (VHL) in Portuguese, English and Spanish were used, in addition to the descriptors from Embase Subject Headings (Emtree) and Medical Subject Headings (MESH) in English, including: "Health Sciences Students", "Health Personnel", "Training by Simulation"; "Clinical Competence", and the keywords: "Telesimulation" and "Virtual Simulation".
The studies were identified by combining the elements of the PCC strategy, Boolean operators and search codes, specific for each database, since each one works in a unique way and responds to different commands, which implies adapting the strategy.Furthermore, it should be noted that the

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keywords "Virtual Simulation" and "Telesimulation" were adopted with the intention of directing the search to the intended study object, and that the keyword Telesimulation was adopted in its English, Spanish and Portuguese versions in non-conventional databases for the selection of gray literature, given that such repositories do not allow the use of advanced search strategies.The adopted databases, descriptors, keywords and respective search strategies are presented in Chart 1, below.

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Studies were selected considering the following inclusion criteria: primary research, literature reviews, editorials, dissertations and theses, which addressed the steps and/or components necessary to establish a telesimulation design/protocol aimed at teaching and learning for students and professionals in the health field without delimiting time frame and language, published electronically.Records which addressed simulation types other than synchronous and observational were excluded.
Literature identified in conventional sources (primary and secondary manuscripts) was first considered, and then the source information was exported to a free single-version web review program called Rayyan Qatar Computing Research Institute (Rayyan QCRI), capable of excluding duplicate articles and facilitating the initial screening, blinding the assistant researcher and incorporating a high level of usability, effectiveness and reliability in the selection process 13 .After this step, the studies exported to Rayyan were selected by reading titles and abstracts by two independent researchers, experts in the theme of simulation.A total of 37 articles were selected by the researchers, which were then sent to a third researcher who was responsible for deciding whether or not to include them in the sample.
The identified gray literature (theses and dissertations) was then manually selected by reading the titles and abstracts by two researchers specializing in the proposed theme, and then the entire selected literary collection was read (articles, dissertations and theses) for defining the final sample.
Portuguese: (("Estudantes de Ciências da Saúde") AND ("Pessoal de Saúde") AND ("Treinamento por Simulação" OR Telessimulação) AND ("Competência Clínica")) English: (("Students, Health Occupations") AND ("Health Personnel") AND ("Simulation Training OR Telesimulation) AND ("Clinical Competence")) Spanish: ("Estudiantes del Área de la Salud" AND "Personal de Salud" AND "Entrenamiento Simulado" OR Telesimulación AND "Competência Clínica") ‡CAPES Use of the keyword: It should also be noted that a search was carried out in the reference list of the studies that made up the sample in order to verify the possibility of new inclusions; however, no new articles or gray literature were inserted.
The information from the manuscripts relevant to the research question was extracted using an instrument 14 constructed and validated by Brazilian researchers with the intention of facilitating the extraction of findings and scientific evidence in review studies, composed by the domains: (1) identification of the original article; (2) methodological characteristics of the study; and (3) assessment of methodological rigor, measured interventions and results found.This instrument was adapted for the present study contemplating the information of interest: authors of the manuscript; year of publication; country of origin of the study; purpose and clinical scenario addressed; kind of study; target audience; assessed skills; procedure to carry out the telesimulation; main outcomes; and level of evidence 15 .
The analyzed studies were mapped according to previously defined criteria and deepened in light of the principles of Minayo's Thematic Analysis 16 .Next, three stages were conducted in order to obtain the axes and their categories: (1) pre-analysis stage, in which the manuscripts of the final sample were read, and the evidence or information which was similar in each article was noted.The information that was repeated about the elements which support a telesimulation design or protocol responding to the intended objective were grouped and called recording units.Thus, the challenges to operationalize this tele-simulation modality were highlighted by grouping the findings regarding its components and stages, which led to the second category of results; (2) material exploration: with the registration units identified, the information that characterized the same subjects was grouped, generating both categories; (3) finally, data treatment: after structuring, the categories were analyzed, interpreted and described to clarify all steps and components of synchronous and observational telesimulation, as well as all the challenges inherent to this context.

RESULTS
A total of 1,901 studies were identified, and nine composed the final sample of this study.The selection process is demonstrated in Figure 1 below.
The findings mapped through this scoping review enabled structuring two categories: (1) Steps and components for operationalizing a synchronous and observational telesimulation design; and (2) Challenges to implement synchronous and observational telesimulation.
The first category considered the identification, synthesis and description of the steps and respective components capable of characterizing how synchronous and observational telesimulation has been operationalized in contemporary times, with the intention of supporting the planning and execution of an instructional design in this type of telesimulation.Chart 3 below presents the first category of results.Next, the second category called "Challenges to implement synchronous and observational telesimulation" addressed the difficulties mapped in the selected literature to plan to execute and obtain the effective participation of learners in a synchronous and observational telesimulated experience in the scope of the teaching and learning process in health, namely: (1) requirement of an institutional structure based on technological, human and funding resources capable of enabling the live transmission of telesimulation for learners 3,7,18-20 ; (2) commitment, training and knowledge of a teaching staff capable of planning and executing a telesimulated activity 3,[18][19][20] .The following are less prominently described in the literature: (3) poor access to the internet or technological resources of learners in certain remote areas 15,18 ; (4) learner acceptance of a new pedagogical strategy 20 ; (5) learner communication barrier in an online environment 20 ; (6) incipience of and available and validated instruments for assessing learning outcomes 3 ; (7) incipient insertion of the telesimulated strategy in the pedagogical plans of undergraduate courses in the health area 3 .

Description of the steps and the respective components
Step 1 -Planning Initial step of the telesimulation in which the instructors/facilitators describe and validate their instructional design composed of the necessary steps and components.For this step, a period of 30 days is generally used for planning and 60 days to validate the content of the instructional design, carried out by professionals who are experts in the subject, and preferably adopting the Delphi technique until reaching a Total Content Validity Index equal to or greater than 0. It should be noted that most of these components are addressed in the simulated scenario design section.
Step 2 -A) Preparation: pre-simulation Step which provides the study and prior preparation of learners on the subject of learning and peculiarities for online and remote participation in the telesimulated activity, which can be made possible by instructional platforms of the educational institution or via electronic mail (email of learners), providing references and study materials about the activity.A period of 15 days is recommended to establish this step.[18][19][20] B) Preparationpre-briefing/ Briefing After the online reception of the students, the facilitators present themselves and pre-test instruments are applied, if necessary, for evaluation.8] Chart 3 -Steps and components to operationalize synchronous and observational telesimulation in health.Uberaba, MG, Brazil, 2021.

Steps Description of the steps and the respective components
Step 3 -Participation: telesimulated clinical scenario design The participation stage corresponds to executing the simulated clinical scenario transmitted live, generally in a period of 10 to 15 minutes.This design must be described by the researchers and validated by specialists in the proposed theme, selected through well-established criteria using the Delphi technique, which recommends several "rounds" of construct evaluation until there is agreement between the experts involved.[18][19][20] Step 4 -Teledebriefing Step characterized by an analytical moment of reflection/discussion of the telesimulated scenario observed by the learners remotely online and live, and conducted by one or more facilitators.It is recommended to carry out the teledebriefing until all the learning objectives are discussed and contemplated.It usually lasts twice as long as it takes to perform the clinical scenario.[18][19][20] Step 5 -Learner assessment and feedback collection Definition of tools or instruments for assessing cognitive abilities (instrument for assessing knowledge, generally of the pre-and post-test type on the theme addressed for teaching and learning through tele-simulation) and affective (such as: Scale of Student Satisfaction and Self-Confidence in Learning 21 , in which it is intended to be developed through the proposed telesimulated educational strategy.Generally lasts from 30 to 40 minutes.Organization of the selected feedback format for feedback on the telesimulated activity from the perspective of the facilitators. 8,17ep 6 -Additional learning Support instructional resources such as: podcast, national and international guidelines, texts, articles, video class, video simulation, power point class, available after the end of the telesimulation to enhance knowledge on the selected topic with a period of 10 days to the feedback. 4,174/19

DISCUSSION
Mapping the steps and components inherent to operationalizing a synchronous and observational telesimulation design was the focus of this investigation.As this is a simulation modality of recent scientific exploration 1,4,8,[17][18][19][20] , no nationally authored manuscripts were identified whose outcomes portray the practice of telesimulation, signaling a research gap in this territory.Only two Brazilian studies [22][23] have encouraged its adoption, mainly in pandemic times, but do not delve into its management.
Adopting telesimulation in nursing is noted 1,7,[18][19] even in view of the predominance of evidence aimed at teaching students and medical professionals.An essential nature of research expansion and investment in preparing teachers and facilitators for this teaching strategy is highlighted 8 , as well as stimulating research in this professional context 18 , advancing in the nature of studies produced in face of the preponderance of descriptive studies and low level of evidence 4,8,[17][18][19][20] , further justified by the need to explore the theme to understand it before proceeding to evaluate its effectiveness or other scientific questions [18][19] .
It is important to clarify that one of the main differences between synchronous and observational telesimulation and face-to-face simulation is the potential of these strategies to develop clinical skills 24 , since it is possible to manipulate the clinical scenario in a face-to-face experience and repeat the actions which will refine psychomotor, cognitive and affective skills, whereas knowledge is developed in observational telesimulation, and the behavior of learners is aligned with one of the limitations of this teaching modality to the detriment of practical skills 1,3,4,[7][8][17][18][19][20] .
The recommendations highlighted by the International Nursing Association for Clinical Simulation and Learning (INACSL), published in 2021, encourage the purposeful, systematic, flexible and cyclical planning of a simulation design with an emphasis on the face-to-face aspect 25 , but do not yet address the telesimulation modality or its peculiarities 26 .
Regarding the step which refers to preparing the telesimulation in the pre-briefing/briefing phase, it is essential that the facilitators address specific criteria of online learning, such as turning off the cameras of remote learners during the scenario so the actors can better concentrate and then turning on the cameras at the time of the teledebriefing with explanations which require the attention and planning of the teacher, since there is no such need in simulation activities as in the face-to-face format 1,3,[7][8][17][18] .
A study was carried out in Singapore in the year 2021 in which the evaluation of a telesimulation aimed at teaching 42 medical students about communication skills was described.It emphasized that a sufficient didactic contract should be established during the pre-briefing/briefing to prepare the learner on the subject to be addressed, on how and when they should interact remotely and the impact of this practice on their learning 27 .
On the other hand, the participation step in telesimulation may be exposed to the same pedagogical mistake that permeates this step in a face-to-face simulation, when only considering the description of a clinical case as being a simulation scenario 1,3,4,[7][8][18][19][20] . This satement is corroborated by a study that evaluated the methodological quality of a study which developed and validated clinical scenarios in nursing and pointed out a common practice of adopting a clinical case, calling it a scenario, simulating and devaluing fundamental criteria of this step 28 .

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In addition to requiring the design of a complete simulated clinical scenario in which the clinical case is one of the existing criteria and not the only one responsible for the participation step, synchronous and observational telesimulation requires trained actors to experience the proposed scenario so that learners observe what you want to teach in real time and remotely 1,[3][4][7][8][18][19][20] .
Next, and considered the "cornerstone" for success in telesimulation, the teledebriefing step covers the virtual and online discussion/reflection, being conducted by the facilitators with the learners after observing the scenario execution regarding their feelings, perceptions and description of the experience, with the intention of developing knowledge and enhancing positive attitudes and feelings, such as satisfaction, self-confidence and self-efficiency 1,[3][4][7][8][18][19][20] .
In this context, and despite the fact that teledebriefing does not have a specific method indicated in the literature, a structured teledebriefing is performed online, live and orally by one or more facilitators for reflection and discussion by remote learners about the observed scene 2,29 .In addition, the use of Plus/Delta teledebriefing methods and Structured and Supported Debriefing (Gather Analyze Summarize -GAS) are more frequently mentioned 2,29 .
In a study carried out by American researchers who described 12 recommendations for telesimulation practice, it was suggested that the learners turned on their video cameras after observing the experience and saw each other in a virtual space different from the scenario form, then were submitted to the reaction, description and analysis phases of teledebriefing which characterize a structured model of teledebriefing, carried out in a period capable of covering the review of all learning objectives 4 .
Visualizing the participants faces during the teledebriefing can indicate to the facilitator their understanding or lack of clarity, helping them to adequately guide the discussion process, as well as relay their questions in search of a more organized, interactive, and inclusive online conversation 1,[3][4][7][8][17][18][19][20] finalized with the learners' assessment through feedback collection and providing additional study materials 3,17 .
This scoping review was also able to map the challenges to implement synchronous and observational telesimulation, highlighting the need to obtain a sufficient, humane and competent technological structure to enable live and online transmission of the intended scenario 3,7,[17][18][19][20] .
A study carried out in Mexico in 2021 was similar to this context, as it identified the technological aspects and a stable internet connection as being essential factors to perform telesimulation associated with technical support and financing 20 .The need to obtain a virtual platform capable of transmitting the simulated scenario to the learners remotely is a condition which hinders adoption of synchronous and observational telesimulation in the pedagogical plans of undergraduate health courses 4 .Added to this context is the incipience of specific training aimed at forming a faculty with telesimulation planning and execution potential 3,[17][18][19] .
While the technological/virtual aspects are challenges inherent to telesimulation, the lack of knowledge and skill of the facilitators for adequately handling this practice can be considered similarities in the difficulties detected to operationalize the face-to-face simulation and a limitation to achieve the learning objectives 20 .In this perspective, it is recommended that educators and facilitators master clinical simulation in principle before practicing telesimulation, since this modality also requires dexterity to solve technological problems 8 .
The absence of the "Postgraduate Education" descriptor in the search strategy is understood as a limitation in this study; in addition, the scarcity of manuscripts on the subject, especially in the national context, which instigates developing research which presents strategies capable of circumventing the challenges inherent in operationalizing telesimulation in teaching and learning in health 6,18,30 .

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The results of this review are useful in future research in the health field and nursing, in addition to being applicable to care and teaching, as they promote knowledge advancement in the scope of simulation by presenting the steps and components necessary to establish a design of synchronous and observational telesimulation with the potential to support facilitators and teachers in the face of this pedagogical practice, supporting and encouraging educational institutions to look differently at telesimulation, mainly in relation to the educational impositions of a pandemic period.

CONCLUSION
This scoping review mapped the steps and specific components for operationalizing synchronous and observational telesimulation, highlighting the importance of establishing an instructional design based on the planning steps; preparation; participation; teledebriefing; learner assessment/feedback collection; and additional learning, which culminate in developing the learner's cognitive and affective skills.The need to obtain a sufficient technological structure to remotely transmit the telesimulated scenario and a properly trained faculty is also highlighted as challenges for its operation.
Thus, a suggestion is to develop future research which appropriates the findings presented herein in order to subsidize the construction and validation of telesimulation protocols aimed at teaching and learning in health, as well as experimental and quasi-experimental studies capable of evaluating the effectiveness of telesimulation when compared to other pedagogical strategies.

Figure 1 -
Figure 1 -Study identification, selection and inclusion flowchart, prepared based on the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation.Uberaba, MG, Brazil, 2021.Note: *CINAHL: Cumulative Index to Nursing and Allied Health Literature; †LILACS: Literatura Latino-Americana e do Caribe em Ciências da Saúde; ‡CAPES: Catálogo de Teses e Dissertações do Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior; §DART: Europe E-Theses Portal; ||EThOS: Electronic Theses Online Service; ¶RCAAP: Repositório Científico de Cited Aberto de Portugal.

/ Year of publication/ Country of origin Objective and clinical scenario Type of study, target audience and assessed skills Telesimulation procedure, outcomes and evidence level
80. The components considered for description in this planning are: (1) definition of theoretical references that will support the telesimulation; (2) learning theme; (3) target audience; (4) learning objectives; (5) skills you want to develop through telesimulation (learning outcomes); (6) description of the type of instructional material and learning environment/platform to perform the pre-and post-simulation; (7) description of the elements that will be presented in the pre-briefing/briefing and of the fictional contract established with the learners by the facilitators; (8) description of the telesimulated clinical scenario design elements; (9) definition of scenario fidelity; (10) definition of the type of instrument adopted (simulator or simulated/standardized patient); (11) characterization of the simulator's fidelity, if adopted; (12) organization of the necessary human resources (laboratory technicians, specific technicians for the online and live transmission of the telesimulation, professors/facilitators, students); (13) description of materials needed to establish the clinical scenario; (14) definition of the technological resources that will enable telesimulation (teleconferencing platform, such as: computers, internet, camcorders, online transmission mechanisms); (15) establishment of technological resources for remote observation of the learner (personal computer, telephone or tablet, internet); mechanisms/formats/instruments for assessing learners' skills; (16) modality and technique of debriefing adopted; (17) learner feedback mechanisms; (18) time available for each step of the telesimulation; (19) format and guidelines for training facilitators and staff/personnel involved in telesimulation; (20) validation of the telesimulation instructional design; (21) pilot test of the proposed telesimulation.
target audience; (9) inclusion and exclusion criteria;(10)skills developed; (11) general and specific learning objectives; (12) duration of the scenario; (13) instruments -simulators or simulated/standardized patients; (14) clinical case; (15) description of the starting and ending point of the scenario; (16) actions and training script for actors, standardized patients or students who participated in the scene in person; (17) decision-making tree for guiding apprentices, if they are responsible for executing the scene; (18) material resources for the scene.Phase B: Description of the learner's assessment (instruments); Phase C: Validation of the telesimulated scenario design; Phase D: Pilot test of the scenario carried