The initial outbreak of the COVID-19 pandemic was an enormous challenge to hospitals around the world. In many countries, hospitals experienced that the number of patients exceeded their capacity. The risk of spreading the virus required changes in clinical routines, treatment protocols, patient logistics, and physical environments. During the first wave of the COVID-19 pandemic, there was limited knowledge about the course of the disease, the treatment possibilities, and the contagiousness of the virus. A study investigating preparedness assessment in a Middle East hospital revealed several safety threats due to the pandemic such as constantly shifting routines in the treatment protocols, lack of confidence in infection control, as well as overall panic in an unknown situation . Videos and news from Italian hospitals revealed chaotic conditions which put significant psychologic stress on healthcare professionals, and hospitals around the world were told to prepare for worst-case scenarios [2, 3].
One way to prepare for a situation that requires new ways of working is scaling up simulation-based activities (SBA), which was a chosen strategy by the case hospital in this study. SBA are recognized as an excellent method to increase competence in healthcare professionals and has shown to improve patient outcomes in numerous specialties such as obstetrics, trauma care, pediatrics, and emergencies due to better communication between team members, optimized workflow, and better routines for transferring patients to appropriate ward levels [4,5,6,7,8,9,10,11,12].
Several recent studies worldwide have investigated hospitals’ utilization of SBA during the COVID-19 pandemic. For example, So et al. described how a hospital in Hong Kong established a COVID-19 training task force to run multidisciplinary endotracheal intubation training . In the US, a large community teaching hospital used in-situ simulation to revise their code blue protocol to meet COVID-19 challenges, and train staff . Other studies have also investigated hospitals’ experiences from utilizing SBA during the COVID-19 pandemic, with varying focus; improving care and identifying safety issues , training hospital staff and system learning , preparing teams and environment for covid-19 patients , describing the use of simulation in covid-19 , observing safety threats and test possible solutions , process optimization , testing PPE in resuscitation  and devices as well as predicting resources and the contagiousness of the virus [22,23,24,25,26,27].
An alternative strategy in a pandemic would be to cancel all SBA for fear of infection of healthcare workers in an uncertain situation. A potential benefit of the latter move would be to shift simulation facilitators with clinical backgrounds to clinical work and thereby increase their capacity. However, this would reduce capacity and ability to run SBA for staff, and probably require re-entry training of educational staff.
Simulation and simulation-based activities
Simulation is defined as “an educational technique that replaces or amplifies real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner” . SBA may be understood as “the entire set of actions and events from initiating to termination of an individual simulation event; in the learning setting, this is often considered to begin with the briefing and end with the debriefing” . In-situ simulation, which means SBA taking place at the workplace of those participating, is particularly suitable for difficult work environments, due to space constraints and the advantages of training in the environment where the skills are to be used. For example, an ambulance, a small aircraft, a dentist’s chair, a catheterization lab – all of these settings present physical characteristics that are relevant for task management, but which are difficult to re-create . In-situ SBA is recognized as appropriate to probe systems and the workflow, safety risks may thereby be identified, and corrections can be made without harming patients or hospital staff in real situations [30,31,32,33].
SBA is also recognized as a method to build confidence and well-being at an individual level by increasing healthcare professionals’ self-confidence in working in teams, and in performing technical skills for example donning and doffing personal protection equipment (PPE) [34,35,36].
To improve teamwork capabilities, one needs to practice skills that require interactions to succeed which can be accomplished by teamwork simulations [16, 30, 35, 37].
SBA has become more common in hospitals over the last decades  but is not yet systematically implemented as an educational method in all Norwegian hospitals .
Trust, or confidence, among participants, is essential in the successful execution of simulation in hospitals [40, 41]. This is also critical to maintaining an absorptive capacity among the employees, which in turn ensures that the lessons learned are fully explored and acted on in the organization . Studies have found that SBA, and in particular debriefings, may produce the trust required for learning [4, 41].
Schön points out that learning in an institutional setting depends on the practitioners’ reflection . The debriefing part, happening after the simulation, enables those involved to reflect on the simulated experience. By jointly reconstructing the event – possibly seeing inconsistencies and misunderstandings, by finding explanations for different dynamics, and by analyzing the consequences of actions, a deeper insight into ones’ own dynamics and the dynamic in the group can become more obvious. When the discussion is then also related to recognized theoretical concepts, a deeper understanding and a more efficient and safe way of acting can be identified and implanted . A challenge is to enlarge the learning effect from those directly involved in the session to the whole organization and current simulation practice is focusing on this process of distribution of expertise. We assume that SBA, performed with good quality, may contribute with learning-opportunities not only to the individuals taking part in in the SBA, but also to institutional learning. For example, allowing members of the organization to act as “learning agents” and disseminate knowledge to other members of the organization, and to learn from the experiences of others .
Dieckmann et al. describe the potential contribution of simulation during the COVID-19 pandemic in three areas: creating new learning opportunities, optimizing workflows, and dealing with the emotional stress of employees .
Summing up simulation-based activities and learning in hospitals.
The advantages of using large-scale SBA in hospitals are numerous and beyond individual and team learning. SBAs have the potential to identify learning needs and risk factors both at the individual and systemic levels. SBA also provides methods to test new ways of working without harming patients or staff and reducing personal stress among employees. In the end, the advantages may contribute to improved patient outcomes. Even though many studies have been focused on the role of SBA in preparing for the COVID-19 pandemic, none of these studies focused on the experiences of the responsible staff for initiating and executing SBA in such demanding circumstances. This study contributes to the existing body of related studies by focusing on the experiences of the responsible staff at the case hospital.
Three research topics were predefined:
What did hospital leaders and simulation facilitators expect of SBA in the preparation for the pandemic?
What drivers and barriers for SBA were experienced during the pandemic?
How did SBA contribute during the first wave of COVID-19, according to hospital leaders and simulation facilitators?