Experiences of Healthcare Professionals Regarding Simulation Based Training Approach During COVID 19 – a descriptive qualitative study from a Low Middle-Income Country, Pakistan.

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Sana Hirani, Laila Ladak, Amber Sabeen, Zohra Kurji, Sahir Noorani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6241378/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The significance of continuing education has always been emphasized since the beginning of the nursing profession, and during the COVID-19 pandemic, the need for simulation-based- training in managing the global crisis increased considerably. However, experiences regarding simulation-based-training have yet to be explored in low-middle countries like Pakistan. This study aimed to explore the experiences of simulation-based training during the COVID-19 pandemic and identified the challenges and barriers with this learning approach. Methods Using a descriptive, qualitative, semi-structured design, interviews were conducted with 17 healthcare professionals who had worked in the COVID areas. The data were collected from April to June 2022 through purposive sampling. Interviews were stopped upon data saturation. The Consolidated-Criteria-for-Reporting-Qualitative-Research (COREQ) guidelines were used, and a thematic analysis was conducted. Results Three main themes were identified: (1) simulation-based-learning experience, (2) factors affecting simulation-based-training during COVID-19, and (3) recommendations for improvement. Participants reported that simulation-based learning enhanced self-efficacy and provided innovative learning opportunities through technology, with many perceiving that it contributed to better patient outcomes. However, challenges such as organizational constraints, insufficient facilitator training, and logistical and resource limitations were also noted. These insights informed recommendations centered on optimizing resource allocation and strengthening capacity building for future training initiatives. Conclusion Simulation-based-training has proven to be vitally important during the COVID-19 Pandemic. However, strategies must be developed for improving facilitator competencies as well as addressing human and logistic factors to achieve a better learning experience. Simulation Healthcare professional Covid 19 training learning Figures Figure 1 1. Background Continuous education has always been central to the nursing profession, and today, healthcare professionals are embracing innovative training methods like simulation-based training (SBT).[ 1 ] SBT offers hands-on exposure to clinical scenarios in a safe, controlled environment before healthcare professionals face real-life patient care.[ 2 ] Over the past 20 years, it has evolved into a core teaching methodology that provides realistic clinical experiences.[ 3 , 4 ] Moreover, the benefits of SBT extend beyond skill development. Studies have shown that it enhances healthcare professionals' knowledge, attitudes, and confidence, not only during routine practice but also in crisis scenarios like the COVID-19 pandemic.[ 5 , 6 ] The World Health Organization (WHO) underscores the importance of such training programs, linking improved competencies in healthcare workers to better outcomes and reduced disease burden.[ 7 ] Overall, SBT ensures consistent training, adherence to best practices, and the maintenance of high competency levels.[ 8 , 9 ] In March 2020, when WHO declared SARS-CoV-2 as an outbreak of pandemic disease, the need for SBT in managing the global crisis increased considerably.[ 10 ] Healthcare systems worldwide were under immense strain, forcing institutions to rapidly expand medical and surgical capacities and redeploy staff. Furthermore, training on real patients was not an option due to safety concerns, making SBT a vital tool.[ 11 ] It provided a safe, structured environment where professionals could practice critical skills like using personal protective equipment (PPE), managing ventilators, and triaging patients, all while minimizing risk to themselves and others.[ 12 , 13 ] Moreover, in low-middle income countries (LMICs), where access to traditional training resources and healthcare infrastructure is limited, SBT can be especially valuable.[ 14 ] This approach not only enhances the skills and competencies of healthcare professionals but also contributes to strengthening overall healthcare systems and preparedness for future crises. [ 10 ] Additionally, the Centers for Disease Control and Prevention (CDC) predict that the COVID-19 virus, or similar pathogens, will continue to pose challenges, further emphasizing the need for robust training systems in these regions.[ 15 ] Although much work has been done to evaluate the effects of SBT on nursing students and novice healthcare professionals, more research is needed on the experiences of practicing healthcare professionals in implementing and applying SBT during the pandemic. In Pakistan, for example, earlier studies have largely focused on feedback regarding virtual simulations and healthcare workers' willingness to care for COVID-19 patients.[ 16 ] What remains unclear are the real-world barriers and challenges that experienced professionals face when adopting SBT in resource-constrained settings during critical times. This study aims to fill that gap by exploring the experiences of healthcare professionals in Pakistan with SBT during the COVID-19 pandemic. It seeks to uncover the barriers they encountered and highlight areas for improvement, especially in the context of resource-limited settings. In doing so, the study hopes to contribute valuable insights into how SBT can be optimized for future crises. The study addressed the following research questions: What are the healthcare professionals' experiences related to simulation-based training during COVID-19 in LMIC, Pakistan? What factors are associated with this training approach in LMIC in Pakistan? 2. Methods This study utilized a descriptive exploratory design using interpretive ontological and epistemological stances. The 32-item checklist Consolidated Criteria for Reporting Qualitative Research was used to report the findings.[ 17 ] 2.1 Recruitment Process and Ethical Procedure: Participants were recruited through purposive sampling. Participants who had at least two years of direct patient care experience and attended simulation-based training during the COVID-19 pandemic were eligible for this study. For recruitment, a systematic stepwise process was followed. Initially, written approval was acquired from the chief medical officer (CMO), the chief nursing officer (CNO) of the hospital, and the ethical review committee (ERC: 2022-7228-21224) of the institution. In addition, all methods were carried out in accordance with relevant guidelines and regulations, including the Declaration of Helsinki. Head nurses, clinical nurse instructors, and nurse specialists were informed about the study's aim and significance for accessing the healthcare professionals. A request email was also sent to the leadership for sharing the list of SBT courses conducted during the pandemic, along with the names of the staff members who had attended (n = 66). Prior to the interviews, participants were given detailed information about the study’s goals, and their signed informed consent was obtained before any interviews were recorded. The anonymity of the participants and their responses was guaranteed through the use of aliases or codes in quotations, and participation was entirely voluntary with the option to drop out at any time without affecting their academic progress. After obtaining the list, emails were sent to all eligible healthcare professionals for participation. The 17 participants who met the inclusion criteria and were willing to participate signed the consent form, and all interviews were conducted in person to ensure real-time interaction. 2.2 Study Setting: The study was conducted in a COVID-19-designated area of one of the private tertiary care hospitals in Karachi, Pakistan. This hospital has a Centre of Education (CIME) that served as the venue for all the SBT programs conducted in this study and is the first simulation centre in Pakistan. During the COVID-19 pandemic, numerous training sessions were organized to raise awareness and enhance healthcare professionals’ skills in critical topics such as sepsis management, respiratory care, proper usage of personal protective equipment (PPE), and training in proning (a position for increasing oxygenation) techniques. The responsibility for conducting these training sessions rested with the area supervisor, who collaborated closely with the CIME educator. The training programs followed well-defined course curriculum guidelines to ensure consistency and effectiveness in the educational process. Healthcare professionals participated in these quarterly training sessions to remain updated and proficient in their skills. Moreover, to provide a realistic and immersive learning experience, both high-fidelity and low-fidelity mannequins and simulators were employed, closely mimicking real-life patient scenarios. 2.3 Jeffries Theoretical Model Framework: Jeffries's theoretical model was used for this study's conception and conduct as illustrated in Fig. 1 . This model allows testing the impact of SBT on participants and acts as a guide to help the facilitator design, implement, and evaluate the entire simulation experience.[ 9 ] This model beautifully explains that to enhance the simulation experience, several factors work together, for instance, environment, simulation design, facilitator, and strategies. The dynamic collaboration between the facilitator and the participants affects the entire SBT experience, and it is not limited to skills but progresses from preparation to the outcome of the simulation training (Fig. 1 ). 2.4 Data Collection: An interview guide was developed by the primary author, based on a literature review, in which Jeffries’s theoretical model and prior knowledge of the researcher were utilized to develop a semi-structured interview guide (Supplementary file). The interview guide included six different categories of questions, starting from participants’ experiences and understanding regarding the simulation concept and its significance, followed by practice implementation, the role of the facilitator, the significance of briefing and debriefing, and a comparison of previous simulation training experience with the current experience. The research team reviewed the interview guide as content and methodological experts. Certain probes were also used during the interviews to acquire a thorough understanding from the participants. The semi-structured interview guide was developed in both English and Urdu, according to the participants’ comfort, to obtain rich information and capture the actual feelings of the healthcare professionals. Notably, all the participants were comfortable speaking Urdu. Additionally, three interviews were initially conducted for pilot testing. After pilot testing, the interview guide was deemed appropriate and understandable to the participants, and only minor amendments were made to add the last question about the recommendations. The healthcare professionals interviewed for pilot testing were not included in the sample size, and their interviews were not included in the data analysis. Data collection was conducted from April to June 2022, based on the participants’ availability. Each interview lasted 40–45 minutes, depending on the participant’s response. Data collection continued until data saturation was attained, ensuring that no new information was forthcoming and that there were no repetitions during data collection. Since data saturation was achieved after the 15th interview, two additional interviews were conducted, making the total enrollment 17. No further new findings were observed in the subsequent interviews, and data collection was then concluded. Efforts were made to minimize bias and ensure that the sample was representative of the broader population of healthcare professionals in our setting. Those who declined participation shared demographic and professional characteristics similar to those who agreed, suggesting no significant differences between respondents and non-respondents. Moreover, qualitative data collection continued until data saturation was achieved, ensuring that all relevant themes were thoroughly explored and that no new information emerged. 2.5 Data Analysis: The data analysis unit were the individual interviews, focusing on each participant’s experiences. Content analysis was performed by reading all the transcripts multiple times to derive codes. The recordings were given quote numbers to maintain the participants’ anonymity. The key themes were well saturated with the data in terms of richness (i.e., detailed meaning and expression) and thickness (amount of data to support themes). Participants’ verbatim quotes were used to support these themes. To ensure comprehensive coverage of the themes, negative exemplars were also included to provide diversity in the data. Each transcript was coded independently by the primary author. Once all the codes were generated, each quote was discussed with the research team, and major themes and sub-themes were identified. Study rigor was maintained, ensuring Lincoln and Guba's (1985) criteria for evaluating qualitative research.[ 18 ] Credibility was further ensured through triangulation, with two researchers reviewing the transcripts and the codes. Additionally, the interviewers discussed their reflections with the other authors to avoid potential bias during data collection and interpretation. Field notes were also maintained, and for reporting the findings, the 32-item checklist Consolidated Criteria for Reporting Qualitative Research was used (Supplementary file). 3. Results 3.1 Participant Characteristics and Training Exposure: Seventeen healthcare professionals participated in this study, including six doctors, eight nurses, and three physiotherapists. To ensure diverse perspectives, participants were recruited from different specialty teams. There was an equal distribution of gender , with a median age of 30 years (range: 25–45 years). Most participants had extensive clinical experience, with a median of four years (range: 2–17 years). The majority (82%, n=14) attended two simulation-based training (SBT) sessions annually, while 53% (n=9) received training on a quarterly basis. High-fidelity simulation was the predominant training modality (41%, n=7). Training duration varied, with 35% (n=6) attending sessions lasting 1–2 days and 65% (n=11) participating in shorter sessions of 2–3 hours. These findings are outlined in Table 1 . Table 1: Participant Demographics and Simulation Training Exposure Demographic Characteristics Frequency Number of Participants n (%) Age 25-30 30-35 35-40 40-45 8 (47%) 3 (18%) 3 (18%) 3 (18%) Gender Male Female 8 (47%) 9 (53%) Qualification Diploma BScN MScN FCPS Doctorate of Physiotherapy 2 (12%) 4 (23%) 2 (12%) 6 (35%) 3 (18%) Designation RN Senior Instructor Instructor Physiotherapist 8 (47%) 5 (29%) 1 (6%) 3 (18%) Area of Specialty COVID ICU Emergency Internal Medicine 9 (53%) 3 (18%) 5 (29%) Number of Experiences 2-5 5-10 10-15 15-20 10 (59%) 5 (29%) 1 (6%) 1 (6%) Number of Simulation-Based Training 2 3 14 (82%) 3 (18%) Frequency of Courses Quarterly Half Yearly 9 (53%) 8 (47%) Type of Simulation-Based Training High Fidelity Low Fidelity High and Low Fidelity High and Task Trainer 7 (41%) 1 (6%) 2 (12%) 7 (41%) Duration of Training 1-2 days 2-3 hours 6 (35%) 11 (65%) 3.2 Participation in Simulation-Based Workshops: We also examined participation in various simulation workshops, reflecting the diverse training that our participants received [Table 2]. The number of healthcare professionals engaged in these sessions varied, with the Safe Proning session involving the highest participation (n=30) and Code Blue Management the fewest (n=10), thereby highlighting the tailored focus of the training interventions. Table 2: Participation in Simulation Workshops Workshop/ Mannequin Number of Participants Donning and Doffing/Demonstration and redemostraation 20 Advance Respiratory Workshop/ SIM-MAN 3G 16 Safe transportation of patient/SIM-MAN 3G 15 Safe Proning/SIM-MAN 3G 30 Code blue management/SIM-MAN 3G 10 Noninvasive Ventilation Management/SIM-MAN 3G 18 Invasive Ventilation Management/SIM-MAN 3G 12 Advance Hemodynamic Workshop 16 3.3: Themes, sub-themes, and categories of the findings: Table 3 displays the theme, sub-theme, and categories that emerged from the data analysis. Three major themes emerged: 1) simulation-based training experience, 2) Factors affecting simulation-based training during Covid, and 3) Recommendations for improvement. Table 3 : Themes, sub-themes, and categories of the findings Themes Sub-Theme Categories Simulation-based training Experience Simulation learning opportunities Innovation in education through technology Bridging the theory-practice gap. Self -Efficacy Increased self confidence Improved knowledge, attitude, and competency Patient Outcomes Perceived improvement in patient Outcomes Factors affecting simulation-based training during COVID 19 Organizational Factors Unrealistic expectations and lack of support from the management Impact of COVID-19 guidelines on training Facilitator training and Competencies Lack of realism in the training Ineffective debriefing and self- reflection Lack of interprofessional training Logistics and Human Resources Unavailability of material resources during training and in the clinical setting Shortage of human resources Recommendations for improvement Resource Allocation Staffing plan and resources Expansion of training Capability Building Simulation educator courses Advanced simulation training experience Theme 1: Simulation-based training opportunities: Participants highlighted several positive aspects of simulation-based training, viewing it as an innovative bridge between theory and practice. They noted that SBT not only enhanced their theoretical knowledge but also offered hands-on experiences that truly prepared them for real-world clinical challenges. Overall, the training was seen as a transformative tool that boosted self-confidence and improved readiness for clinical practice. A. Innovation in education through technology : Most healthcare professionals shared that they were privileged to be a part of an institution with a center of excellence within the hospital. For example, one participant, stated, "Being a part of this prestigious organization, I am privileged that we have a 'Centre of Excellence', where teaching and training are linked together for better patient outcomes; however, in the public sector, despite knowledge, implementation of such pedagogy is a challenge" (P1). He further noted, "I first heard about simulation technology when I was a resident in my third year of medical school. At that time, I felt it was unsafe to practice on live patients." The growing complexities of healthcare require professionals to excel not only in theoretical knowledge but also in practical skills, and simulation-based training (SBT) serves as a bridge between the two. Several other participants endorsed this view describing their simulation experiences as "safe," "helpful," and "convenient" since it allowed them to practice real-world scenarios before managing actual patients. One participant explained, "During COVID, I was transferred to the COVID area for help. At that time, I was shocked that I was not willing to work in that area… we all were progressing, and COVID-19 was new for all. When such a situation arises, we start learning at a different level" (P12). Both theoretical knowledge and hands-on practice are essential, and simulation training provides an effective way to bridge this gap. A participant shared, "I had mixed feelings during COVID-19; when the pandemic started, expectations from me increased. I was neither prepared nor motivated. Believe me, but after multiple simulated-based sessions, it was easier for me to comprehend" (P8). B. Self-Efficacy: After discussing their experiences, most participants emphasized the importance of this training approach in building self-confidence. They explained how SBT helped reduce COVID-19-related anxieties and strengthen their decision-making skills. One participant stated, "COVID-19 scared everyone; no one wanted to go inside [patients' room], as they feared the transmission" (P4). Participants also recalled that staff, especially females and mothers, were initially reluctant to work because of contamination concerns. As one participant observed, "They did not want to take the virus home, but their anxieties decreased when we were told how to take the proper precaution" (P9). Similarly, regarding the learning process, another participant remarked, "Single-method learning has never been effective. Learning by doing hands-on skills is always beneficial as it allows staff to experience their actions, which helps to retain information and concepts for a longer period" (P10). Additionally, one participant stated, "I had never seen the Emergency department in such a mess. Patients and their families were begging for a bed and losing their battle. I still remember I was doing family counselling, and suddenly code blue was announced; I prioritize my task and act" (P5). C. Perceived Improvement in Patient Outcomes: Participants reported that simulation-based training improved their ability to manage critical situations more effectively. For example, one participant noted that accidental removal of the orotracheal tube during proning was common before training, but after repeated practice on mannequins, these incidents decreased noticeably. He explained, "Every other day, we’d have an incident where the equipment was accidentally removed. But after practicing on mannequins repeatedly, we saw a noticeable improvement, and it felt like those incidents happened less often" (P10). Another participant reflected, "We were putting so much effort into proning because it required a lot of physical strength. After the session, we learned specific techniques that made it easier and less physically demanding" (P13). Although these are personal accounts rather than hard clinical data, many participants expressed confidence that the training enhanced their ability to provide better patient care. Theme 2: Factors affecting simulation-based training during COVID-19: Besides sharing their positive experiences, participants identified several challenges that hindered their learning during the pandemic. They mentioned that organizational issues, insufficient facilitator training, and a lack of interprofessional training were the major obstacles they faced. A. Organizational factors: Participants explained that unrealistic expectations and limited support from management were major issues. Some described their SBT experience as "purposeless," "confusing," and "hectic," noting that instead of alleviating stress, the training added pressure by requiring last-minute duty rearrangements. One participant stated, "It was extremely hectic and stressful to arrange duties for such training. Most of the time, I was informed in the middle of the shift … it becomes extremely difficult to arrange duties at the eleventh hour" (P15). Furthermore, they believed that these training activities required prior notification, which was not provided due to the heavy workload. One participant recalled, "Duties were tough those days; I still remember not getting time to drink water or use the restroom for the entire shift. I kept controlling my urge till the end of the shift; I was exhausted and fed up" (P14). He further explained, "It was not humanly possible to attend such training after such physical and mental drain… it seemed that the organization had very high expectations from us, which was very difficult..." (P12). Rapid changes in COVID-19 guidelines also contributed to confusion, as one participant stated, "I can still recall; I was nominated for a workshop on the 10th day of my isolation. I needed clarification about whether to go for the session because, initially, the CDC guidelines were of 14 days' isolation, then it switched to five days. I was confused about which guidelines to follow" (P13). B. Facilitator training and competencies: Participants expressed mixed feelings about facilitator competencies. While some were reluctant to elaborate, others were more forthright. They noted a significant difference between the scenarios practiced in simulation and the complex realities of clinical practice. One participant shared, "I witnessed a code blue during the transfer of the patient. Nevertheless, there needed to be proper teaching in this regard. These were the cases that should be emphasized during simulation training, but, unfortunately, we were not prepared for that" (P16). Moreover, some participants felt that the true complexity and criticality of clinical situations were missing in the simulations. As one participant remarked, "I believe the facilitators should make the scenario more complex to give us the actual flavor of reality because sometimes it gets difficult to manage these situations… I believe the facilitators were not considering what was needed" (P6). Additionally, although participants acknowledged the importance of debriefing, most felt that, during the pandemic, debriefing sessions were ineffective due to time constraints, which led to missed opportunities for self-reflection. Even though facilitators debriefed participants via video recording in a few sessions, the collective feedback was not well received. One participant explained, "Due to lack of feedback during debriefing, my query was not resolved even after the session" (P16). C. Lack of Interprofessional Training: Participants noted that SBT was not conducted as a multidisciplinary approach, and there was no alliance between physicians and nurses during training. One participant recalled, "[with a deep breath] I still remember, I was already trying hard to adjust to a new setting and was fixing the patient's ETT tube with my team leader when the duty doctor rudely told me, 'Don't touch the ETT, it will come out. You [nurses] are doing it wrong,' even though I was following the practice taught by my facilitator during simulation-based training" (P7). According to the participants, healthcare professionals should train together under one umbrella for the same practice. However, during the simulation sessions, individual activities were planned for nurses and doctors, which resulted in conflicts during patient management. This separation led to confusion, particularly among nurses, as one participant stated, "While doing patient proning, everyone [doctors and nurses] was following their own sequence of care, and at that time, I was a bit confused about whom to follow, which was extremely upsetting" (P12). One participant further noted, "Most of the time in the clinical area, conflict arose due to changes in practice because the nurses were not aware of what we [doctors] had already learned in the simulation-based training session, as that training was only for doctors" (P5). He added, "I believe this can only be resolved if we conduct a parallel session for the entire healthcare team so that any conflict that arises can be resolved effectively" (P15). Theme 3: Recommendations for improvement: At the end of the interviews, participants were asked to share specific recommendations to improve the training process and system, particularly if another pandemic were to occur. Their recommendations fell under two major domains: Resource Allocation and Capacity Building. A. Resource allocation: Several participants suggested potential solutions to enhance the simulation experience within a resource-constrained setting. For instance, they proposed in situ simulation experiences, where training activities are planned in an actual clinical setup to expose participants to real-life events. One participant stated, "For actual exposure; simulation scenarios should be real along with the setting to have an actual flavor of the clinical area" (P5). B. Capacity building: Participants also emphasized the need for specialized training for instructors who conduct simulation training. They suggested that, in addition to enhancing overall competency, instructors should receive dedicated training in simulation teaching to effectively implement all the principles of simulation-based education. One participant remarked, "…to conduct simulation training it requires expertise; technology is not everyone's cup of tea" (P14). 4. Discussion This study is, to our knowledge, the first in-depth exploration of healthcare professionals’ experiences with simulation-based training (SBT) in an LMIC in Pakistan. Our findings contribute to the growing global conversation on how SBT can transform learning in resource-limited settings, particularly during crises like the COVID-19 pandemic. Recent studies have shown that tailored simulation training can enhance clinical decision-making and improve learning outcomes and our findings support this idea while offering insights that can help refine SBT methods in similar environments.[ 1 , 19 ] In addition, while high-income countries have widely embraced simulation, its adoption in LMICs has been slower due to financial and infrastructural constraints.[ 20 ] Therefore, initiatives to develop cost-effective simulation solutions and provide training resources in these regions are crucial for improving healthcare education and outcomes worldwide. Our findings show that SBT is seen as a safe and effective way to gain hands-on experience. Participants appreciated the realistic practice opportunities that not only boosted their self-confidence but also provided fresh, innovative ways to learn. The existing literature also corroborated this finding.[ 9 , 21 , 22 ] Looking ahead, these insights lay the groundwork for further research into refining SBT methods that can be adapted and scaled across similar low-resource settings. Furthermore, as our study suggests, embracing SBT is critical in today’s evolving healthcare landscape. Despite these clear benefits, several challenges emerged. Many participants noted that organizational issues, such as limited supervisor support and last-minute notifications for training sessions, often made it hard to fully engage with SBT. These challenges, which have also been observed elsewhere, appear to affect both the quality of training and the mental well-being of staff.[ 23 ] For future practice, addressing these organizational barriers will be critical to enhancing the overall effectiveness of simulation-based learning and ensuring sustainable workforce support. Moreover, our findings underscore the need for comprehensive faculty training and development. Effective SBT requires instructors who are not only adept at operating complex simulation equipment but also skilled in designing realistic scenarios and conducting structured debriefing sessions.[ 24 ] Overcoming these challenges is essential to fully unlock the potential of SBT in enhancing learning outcomes and ultimately improving patient care. Another key challenge was the absence of a strong simulation culture. Participants described significant gaps in infrastructure, with limited access to high-quality mannequins; issues that are especially critical in low-resource settings.[ 25 ] Moreover, simulated environments may lack certain elements of actual clinical settings, such as the emotional stress of managing real patients, the variability of patient responses, and the complexities of working within a live healthcare team.[ 26 ] To address these issues, institutions can mitigate challenges through strategic planning and resource allocation. For instance, developing partnerships with technology companies, securing grants, and investing in cost-effective simulation solutions can help alleviate financial burdens.[ 1 ] Additionally, incorporating blended learning approaches that combine simulation with traditional clinical experiences can enhance the realism and transferability of skills.[ 27 ] Frequent changes in COVID-19 guidelines added to the uncertainty, leaving many unsure which protocols to follow during training. This highlights the need for training programs that can adapt quickly to evolving clinical standards.[ 28 , 29 ] Moreover, the absence of interprofessional training was frequently mentioned; when doctors and nurses train separately, miscommunication and conflicts can arise, undermining teamwork.[ 22 ] Moving forward, integrating flexible protocols and promoting interprofessional training will be essential to enhance team cohesion and improve overall patient care. Strengths and Limitations : A major strength of our study is its qualitative approach, which provided a deep understanding of the personal experiences of healthcare professionals during a challenging time. Using established guidelines like COREQ and Jeffries’s theoretical model added rigor to our findings. However, there are some limitations. Our study was carried out in a single tertiary care private hospital, so the findings may not be applicable to other settings. Despite our best efforts, there may have been some translation bias during data collection. Finally, our research focused solely on the perspectives of healthcare professionals, leaving out those of facilitators and other key stakeholders. These limitations point to the need for future multi-site studies and broader stakeholder engagement to validate and extend our findings. 5. Conclusion Simulation-based training (SBT) proved to be a vital tool during the COVID-19 pandemic, providing healthcare professionals with a safe and effective method for developing essential skills in a time of crisis. However, to fully unlock its potential, strategies must be developed to improve facilitator competencies and address human and logistical challenges. It is crucial to develop approaches that ensure facilitators are well-equipped and that resources are optimized for a more seamless training process. Healthcare organizations must also acknowledge the unique challenges faced by professionals during the pandemic, such as heightened anxiety, overwhelming workloads, and limited resources. By addressing these factors, SBT can be better tailored to meet the needs of healthcare workers, improving training effectiveness and ultimately leading to improved patient care. Declarations Ethics approval and consent to participate : The ethical approval for the study was acquired from the ethical review committee of The Aga Khan University Hospital (ERC: 2022-7228-21224). All methods were carried out in accordance with relevant guidelines and regulations or the Declaration of Helsinki. Participants were given detailed information about the study’s goals before interviews were conducted, and their signed informed consent was obtained before any interviews were recorded. The anonymity of the participants, their responses, and the use of aliases or codes in quotations were guaranteed. Participation in the research was entirely voluntary and they were given the option to drop out at any time. Both the interview and encoding data were encrypted before being saved to a personal hard drive for long-term storage. Conflict of Interest: I confirm that this article is original and has not been published elsewhere, neither is it at present under consideration for publication elsewhere. There are no conflicts of interest to disclose. We believe that this manuscript would be of interest to your readership and contribute to the science and scholarship of Nurses. As this was my Master thesis as well so it will be a boost up for young researchers to submit their work in a high impact journal for dissemination of finding. Acknowledgment We would like to thank the participating nurses for sharing their experience and the Nursing Service Department of the hospital for allowing us to do the study. Funding sources This study received no external funding. Availability of data and materials All data generated or analyzed during this study are included in this published article [and its supplementary information files]. Author Contributions Conceptualization: (LL and SH) - Conceived and designed the study on simulation-based learning among healthcare professionals during COVID-19, particularly focusing on low- and middle-income countries. Methodology: (SH and AS) Developed the research design, including selection of the simulation frameworks and survey instruments, and established protocols for data collection and analysis. Investigation: (SH) Conducted data collection and initial analysis and cross check with LL and ZK Data Curation: (SH and LL) organized the data and made themes and subthemes. Writing – Original Draft Preparation: (SH) wrote the first draft of the manuscript, detailing the study's methodology, findings, and significance. Writing – Review & Editing: (SH, LL, AS, ZK, SN] - Reviewed and edited the manuscript, contributed to critical revisions, and improved clarity, coherence, and consistency. Supervision: (LL and AS) Provided guidance throughout the research process and offered expertise. References Elendu C, et al. The impact of simulation-based training in medical education: A review. Medicine. 2024;103(27):e38813. Motola I, et al. Simulation in healthcare education: a best evidence practical guide. AMEE Guide 82. Med Teach. 2013;35(10):e1511–30. Kim J, Park J-H, Shin S. Effectiveness of simulation-based nursing education depending on fidelity: a meta-analysis. BMC Med Educ. 2016;16:1–8. McGaghie WC, et al. Powerful medical education improves health care quality and return on investment. Med Teach. 2024;46(1):46–58. Alanazi AA, Nicholson N, Thomas S. The use of simulation training to improve knowledge, skills, and confidence among healthcare students: a systematic review. Internet J Allied Health Sci Pract. 2017;15(3):2. Aldekhyl SS, Arabi YM. Simulation role in preparing for COVID-19. Ann Thorac Med. 2020;15(3):134–7. World Health Organization. Regional Office for, E., Simulation in nursing and midwifery education. 2018, World Health Organization. Regional Office for Europe: Copenhagen. Cipresso P et al. The past, present, and future of virtual and augmented reality research: a network and cluster analysis of the literature. Frontiers in psychology, 2018. 9: p. 2086. Adamson K. A systematic review of the literature related to the NLN/Jeffries simulation framework. Nurs Educ Perspect. 2015;36(5):281–91. Shrestha R, Kanchan T, Krishan K. Simulation Training and Skill Assessment in Disaster Medicine , in StatPearls . 2025, StatPearls Publishing Copyright © 2025, StatPearls Publishing LLC.: Treasure Island (FL). Pan D, Rajwani K. Implementation of Simulation Training During the COVID-19 Pandemic: A New York Hospital Experience. Simul Healthc. 2021;16(1):46–51. Fealy S, et al. The integration of immersive virtual reality in tertiary nursing and midwifery education: A scoping review. Nurse Educ Today. 2019;79:14–9. Karaman D, Taşdemir N. The effect of using virtual reality during breast biopsy on pain and anxiety: a randomized controlled trial. J PeriAnesthesia Nurs. 2021;36(6):702–5. Seymour NE, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236(4):458–64. CDC. Preparing for the Next Pandemic: Lessons Learned and the Path Forward https://www.cdc.gov/washington/testimony/2024/t20241114.htm. 2024. Khan JA, Kiani MRB. Impact of multi-professional simulation-based training on perceptions of safety and preparedness among health workers caring for coronavirus disease 2019 patients in Pakistan. J Educ Eval Health Prof. 2020;17:19. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. Lincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Dir program evaluation. 1986;1986(30):73–84. Tudor Car L, et al. Outcomes, measurement instruments, and their validity evidence in randomized controlled trials on virtual, augmented, and mixed reality in undergraduate medical education: systematic mapping review. JMIR Serious Games. 2022;10(2):e29594. Wayne DB, et al. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133(1):56–61. Aebersold M. Simulation-based learning: No longer a novelty in undergraduate education. Online J Issues Nurs, 2018. 23(2). Chernikova O, et al. Simulation-based learning in higher education: A meta-analysis. Rev Educ Res. 2020;90(4):499–541. Francis C, Hollingworth D, Valentine S. Supervisor behavior and character: A simulation study of employee helpfulness. J Manage Organ. 2022;28(1):165–83. Mekbib DB, et al. Virtual reality therapy for upper limb rehabilitation in patients with stroke: a meta-analysis of randomized clinical trials. Brain Injury. 2020;34(4):456–65. Ghimire R et al. The Growing Need for Web-Based Simulation in Low-and Middle-Income Countries. J Nepal Med Association, 2024. 62(279). Al-Elq AH. Simulation-based medical teaching and learning. J family Community Med. 2010;17(1):35–40. Scalese RJ, Obeso VT, Issenberg SB. Simulation technology for skills training and competency assessment in medical education. J Gen Intern Med. 2008;23:46–9. Khalid A, Ali S. COVID-19 and its challenges for the healthcare system in Pakistan. Asian Bioeth Rev. 2020;12(4):551–64. Yang Y-P, et al. The impact of COVID-19 pandemic on healthcare workers under the Ten New Guidelines in Taizhou, China. Prev Med Rep. 2024;37:102550. Additional Declarations No competing interests reported. Supplementary Files DataCollectionInterviewGuide1.docx Consolidatedcriteriaforreportingqualitativestudies1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6241378","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453202218,"identity":"07e39986-5a27-448b-8134-b22dd80b3fad","order_by":0,"name":"Sana Hirani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBACA2YwCWYzPgASPHykaGEGUTxsBLUgsdkkwCQhLebsvA8/FxQw2PPPbn5W+TXHToaNgfnhoxt4tFg2sxtLzzBgSJxx55jZbdltyUCHsRkb5+Bz2GE2BmkeA4YEhhsJZrcltzEDtfCwSRPQwvwbqMVe/kb6t2LJbfVEaWED2cK44UaOGePHbYeJ02LNYyCRuPFGTrE047bjPGzMhPxy/hjzbZ4/NvZyN9I3fvy5rdqen7354WN8WqAAHCMMzDxgkrByBGD8QYrqUTAKRsEoGDEAADSeO78tDajGAAAAAElFTkSuQmCC","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Sana","middleName":"","lastName":"Hirani","suffix":""},{"id":453202220,"identity":"98e9cf71-116a-4c25-9777-d3071cd0c7b5","order_by":1,"name":"Laila Ladak","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Laila","middleName":"","lastName":"Ladak","suffix":""},{"id":453202222,"identity":"d385418a-dcf8-4050-bf7b-48a6c309e0d5","order_by":2,"name":"Amber Sabeen","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Amber","middleName":"","lastName":"Sabeen","suffix":""},{"id":453202225,"identity":"5d7e8c95-27cd-4b3f-bc53-e715b497343e","order_by":3,"name":"Zohra Kurji","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zohra","middleName":"","lastName":"Kurji","suffix":""},{"id":453202228,"identity":"85c59f30-e9ee-47cf-946d-cd6421700dfb","order_by":4,"name":"Sahir Noorani","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sahir","middleName":"","lastName":"Noorani","suffix":""}],"badges":[],"createdAt":"2025-03-17 06:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6241378/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6241378/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82352912,"identity":"aea030a9-3057-4886-821c-58555982fdea","added_by":"auto","created_at":"2025-05-09 11:04:07","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":332498,"visible":true,"origin":"","legend":"\u003cp\u003eJeffries Theoretical Model Framework (figure used with permission)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6241378/v1/ed883679b952a918d3d57ea3.jpeg"},{"id":86434287,"identity":"65f7f6cd-79fa-4d31-9f9e-5dbd54b51d39","added_by":"auto","created_at":"2025-07-10 15:16:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1478172,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6241378/v1/437eac40-d676-4b19-88df-80b1a4118f4d.pdf"},{"id":82352908,"identity":"61c370d8-4f1b-45a0-b70f-0d399da9e217","added_by":"auto","created_at":"2025-05-09 11:04:07","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":22655,"visible":true,"origin":"","legend":"","description":"","filename":"DataCollectionInterviewGuide1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6241378/v1/ecadcd960106ae4b533c8d9a.docx"},{"id":82352906,"identity":"fa7a28db-c1f5-4c34-b86d-1788d72328e8","added_by":"auto","created_at":"2025-05-09 11:04:07","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26148,"visible":true,"origin":"","legend":"","description":"","filename":"Consolidatedcriteriaforreportingqualitativestudies1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6241378/v1/4adcb51705c688091d802086.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experiences of Healthcare Professionals Regarding Simulation Based Training Approach During COVID 19 – a descriptive qualitative study from a Low Middle-Income Country, Pakistan.","fulltext":[{"header":"1. Background","content":"\u003cp\u003eContinuous education has always been central to the nursing profession, and today, healthcare professionals are embracing innovative training methods like simulation-based training (SBT).[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] SBT offers hands-on exposure to clinical scenarios in a safe, controlled environment before healthcare professionals face real-life patient care.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Over the past 20 years, it has evolved into a core teaching methodology that provides realistic clinical experiences.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Moreover, the benefits of SBT extend beyond skill development. Studies have shown that it enhances healthcare professionals' knowledge, attitudes, and confidence, not only during routine practice but also in crisis scenarios like the COVID-19 pandemic.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] The World Health Organization (WHO) underscores the importance of such training programs, linking improved competencies in healthcare workers to better outcomes and reduced disease burden.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Overall, SBT ensures consistent training, adherence to best practices, and the maintenance of high competency levels.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn March 2020, when WHO declared SARS-CoV-2 as an outbreak of pandemic disease, the need for SBT in managing the global crisis increased considerably.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Healthcare systems worldwide were under immense strain, forcing institutions to rapidly expand medical and surgical capacities and redeploy staff. Furthermore, training on real patients was not an option due to safety concerns, making SBT a vital tool.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] It provided a safe, structured environment where professionals could practice critical skills like using personal protective equipment (PPE), managing ventilators, and triaging patients, all while minimizing risk to themselves and others.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eMoreover, in low-middle income countries (LMICs), where access to traditional training resources and healthcare infrastructure is limited, SBT can be especially valuable.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] This approach not only enhances the skills and competencies of healthcare professionals but also contributes to strengthening overall healthcare systems and preparedness for future crises. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Additionally, the Centers for Disease Control and Prevention (CDC) predict that the COVID-19 virus, or similar pathogens, will continue to pose challenges, further emphasizing the need for robust training systems in these regions.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAlthough much work has been done to evaluate the effects of SBT on nursing students and novice healthcare professionals, more research is needed on the experiences of practicing healthcare professionals in implementing and applying SBT during the pandemic. In Pakistan, for example, earlier studies have largely focused on feedback regarding virtual simulations and healthcare workers' willingness to care for COVID-19 patients.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] What remains unclear are the real-world barriers and challenges that experienced professionals face when adopting SBT in resource-constrained settings during critical times. This study aims to fill that gap by exploring the experiences of healthcare professionals in Pakistan with SBT during the COVID-19 pandemic. It seeks to uncover the barriers they encountered and highlight areas for improvement, especially in the context of resource-limited settings. In doing so, the study hopes to contribute valuable insights into how SBT can be optimized for future crises.\u003c/p\u003e \u003cp\u003eThe study addressed the following research questions:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWhat are the healthcare professionals' experiences related to simulation-based training during COVID-19 in LMIC, Pakistan?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhat factors are associated with this training approach in LMIC in Pakistan?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis study utilized a descriptive exploratory design using interpretive ontological and epistemological stances. The 32-item checklist Consolidated Criteria for Reporting Qualitative Research was used to report the findings.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Recruitment Process and Ethical Procedure:\u003c/h2\u003e \u003cp\u003eParticipants were recruited through purposive sampling. Participants who had at least two years of direct patient care experience and attended simulation-based training during the COVID-19 pandemic were eligible for this study. For recruitment, a systematic stepwise process was followed. Initially, written approval was acquired from the chief medical officer (CMO), the chief nursing officer (CNO) of the hospital, and the ethical review committee (ERC: 2022-7228-21224) of the institution. In addition, all methods were carried out in accordance with relevant guidelines and regulations, including the Declaration of Helsinki. Head nurses, clinical nurse instructors, and nurse specialists were informed about the study's aim and significance for accessing the healthcare professionals. A request email was also sent to the leadership for sharing the list of SBT courses conducted during the pandemic, along with the names of the staff members who had attended (n\u0026thinsp;=\u0026thinsp;66). Prior to the interviews, participants were given detailed information about the study\u0026rsquo;s goals, and their signed informed consent was obtained before any interviews were recorded. The anonymity of the participants and their responses was guaranteed through the use of aliases or codes in quotations, and participation was entirely voluntary with the option to drop out at any time without affecting their academic progress. After obtaining the list, emails were sent to all eligible healthcare professionals for participation. The 17 participants who met the inclusion criteria and were willing to participate signed the consent form, and all interviews were conducted in person to ensure real-time interaction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study Setting:\u003c/h2\u003e \u003cp\u003e The study was conducted in a COVID-19-designated area of one of the private tertiary care hospitals in Karachi, Pakistan. This hospital has a Centre of Education (CIME) that served as the venue for all the SBT programs conducted in this study and is the first simulation centre in Pakistan. During the COVID-19 pandemic, numerous training sessions were organized to raise awareness and enhance healthcare professionals\u0026rsquo; skills in critical topics such as sepsis management, respiratory care, proper usage of personal protective equipment (PPE), and training in proning (a position for increasing oxygenation) techniques. The responsibility for conducting these training sessions rested with the area supervisor, who collaborated closely with the CIME educator. The training programs followed well-defined course curriculum guidelines to ensure consistency and effectiveness in the educational process. Healthcare professionals participated in these quarterly training sessions to remain updated and proficient in their skills. Moreover, to provide a realistic and immersive learning experience, both high-fidelity and low-fidelity mannequins and simulators were employed, closely mimicking real-life patient scenarios.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Jeffries Theoretical Model Framework:\u003c/h2\u003e \u003cp\u003eJeffries's theoretical model was used for this study's conception and conduct as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. This model allows testing the impact of SBT on participants and acts as a guide to help the facilitator design, implement, and evaluate the entire simulation experience.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] This model beautifully explains that to enhance the simulation experience, several factors work together, for instance, environment, simulation design, facilitator, and strategies. The dynamic collaboration between the facilitator and the participants affects the entire SBT experience, and it is not limited to skills but progresses from preparation to the outcome of the simulation training (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Collection:\u003c/h2\u003e \u003cp\u003eAn interview guide was developed by the primary author, based on a literature review, in which Jeffries\u0026rsquo;s theoretical model and prior knowledge of the researcher were utilized to develop a semi-structured interview guide (Supplementary file). The interview guide included six different categories of questions, starting from participants\u0026rsquo; experiences and understanding regarding the simulation concept and its significance, followed by practice implementation, the role of the facilitator, the significance of briefing and debriefing, and a comparison of previous simulation training experience with the current experience. The research team reviewed the interview guide as content and methodological experts. Certain probes were also used during the interviews to acquire a thorough understanding from the participants. The semi-structured interview guide was developed in both English and Urdu, according to the participants\u0026rsquo; comfort, to obtain rich information and capture the actual feelings of the healthcare professionals. Notably, all the participants were comfortable speaking Urdu. Additionally, three interviews were initially conducted for pilot testing. After pilot testing, the interview guide was deemed appropriate and understandable to the participants, and only minor amendments were made to add the last question about the recommendations. The healthcare professionals interviewed for pilot testing were not included in the sample size, and their interviews were not included in the data analysis.\u003c/p\u003e \u003cp\u003eData collection was conducted from April to June 2022, based on the participants\u0026rsquo; availability. Each interview lasted 40\u0026ndash;45 minutes, depending on the participant\u0026rsquo;s response. Data collection continued until data saturation was attained, ensuring that no new information was forthcoming and that there were no repetitions during data collection. Since data saturation was achieved after the 15th interview, two additional interviews were conducted, making the total enrollment 17. No further new findings were observed in the subsequent interviews, and data collection was then concluded. Efforts were made to minimize bias and ensure that the sample was representative of the broader population of healthcare professionals in our setting. Those who declined participation shared demographic and professional characteristics similar to those who agreed, suggesting no significant differences between respondents and non-respondents. Moreover, qualitative data collection continued until data saturation was achieved, ensuring that all relevant themes were thoroughly explored and that no new information emerged.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Analysis:\u003c/h2\u003e \u003cp\u003e The data analysis unit were the individual interviews, focusing on each participant\u0026rsquo;s experiences. Content analysis was performed by reading all the transcripts multiple times to derive codes. The recordings were given quote numbers to maintain the participants\u0026rsquo; anonymity. The key themes were well saturated with the data in terms of richness (i.e., detailed meaning and expression) and thickness (amount of data to support themes). Participants\u0026rsquo; verbatim quotes were used to support these themes. To ensure comprehensive coverage of the themes, negative exemplars were also included to provide diversity in the data. Each transcript was coded independently by the primary author. Once all the codes were generated, each quote was discussed with the research team, and major themes and sub-themes were identified.\u003c/p\u003e \u003cp\u003eStudy rigor was maintained, ensuring Lincoln and Guba's (1985) criteria for evaluating qualitative research.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Credibility was further ensured through triangulation, with two researchers reviewing the transcripts and the codes. Additionally, the interviewers discussed their reflections with the other authors to avoid potential bias during data collection and interpretation. Field notes were also maintained, and for reporting the findings, the 32-item checklist Consolidated Criteria for Reporting Qualitative Research was used (Supplementary file).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Participant Characteristics and Training Exposure:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeventeen healthcare professionals participated in this study, including six doctors, eight nurses, and three physiotherapists. To ensure diverse perspectives, participants were recruited from different specialty teams. There was an equal distribution of gender , with a median age of 30 years (range: 25\u0026ndash;45 years). Most participants had extensive clinical experience, with a median of four years (range: 2\u0026ndash;17 years). The majority (82%, n=14) attended two simulation-based training (SBT) sessions annually, while 53% (n=9) received training on a quarterly basis. High-fidelity simulation was the predominant training modality (41%, n=7). Training duration varied, with 35% (n=6) attending sessions lasting 1\u0026ndash;2 days and 65% (n=11) participating in shorter sessions of 2\u0026ndash;3 hours. These findings are outlined in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eParticipant Demographics and Simulation Training Exposure\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"436\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003cbr\u003e\u003c/strong\u003e25-30\u003c/p\u003e\n \u003cp\u003e30-35\u003c/p\u003e\n \u003cp\u003e35-40\u003c/p\u003e\n \u003cp\u003e40-45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;8 (47%)\u003c/p\u003e\n \u003cp\u003e3 (18%)\u003c/p\u003e\n \u003cp\u003e3 (18%)\u003c/p\u003e\n \u003cp\u003e3 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003cbr\u003e\u003c/strong\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;8 (47%)\u003c/p\u003e\n \u003cp\u003e9 (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQualification\u003cbr\u003e\u003c/strong\u003eDiploma\u003c/p\u003e\n \u003cp\u003eBScN\u003c/p\u003e\n \u003cp\u003eMScN\u003c/p\u003e\n \u003cp\u003eFCPS\u003c/p\u003e\n \u003cp\u003eDoctorate of Physiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;2 (12%)\u003c/p\u003e\n \u003cp\u003e4 (23%)\u003c/p\u003e\n \u003cp\u003e2 (12%)\u003c/p\u003e\n \u003cp\u003e6 (35%)\u003c/p\u003e\n \u003cp\u003e3 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesignation\u003cbr\u003e\u003c/strong\u003eRN\u003c/p\u003e\n \u003cp\u003eSenior Instructor\u003c/p\u003e\n \u003cp\u003eInstructor\u003c/p\u003e\n \u003cp\u003ePhysiotherapist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;8 (47%)\u003c/p\u003e\n \u003cp\u003e5 (29%)\u003c/p\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003cp\u003e3 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eArea of Specialty\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCOVID ICU\u003c/p\u003e\n \u003cp\u003eEmergency\u003c/p\u003e\n \u003cp\u003eInternal Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;9 (53%)\u003c/p\u003e\n \u003cp\u003e3 (18%)\u003c/p\u003e\n \u003cp\u003e5 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Experiences\u003cbr\u003e\u003c/strong\u003e2-5\u003c/p\u003e\n \u003cp\u003e5-10\u003c/p\u003e\n \u003cp\u003e10-15\u003c/p\u003e\n \u003cp\u003e15-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;10 (59%)\u003c/p\u003e\n \u003cp\u003e5 (29%)\u003c/p\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Simulation-Based Training\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;14 (82%)\u003c/p\u003e\n \u003cp\u003e3 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of Courses\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eQuarterly\u003c/p\u003e\n \u003cp\u003eHalf Yearly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (53%)\u003c/p\u003e\n \u003cp\u003e8 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Simulation-Based Training\u003cbr\u003e\u003c/strong\u003eHigh Fidelity\u003c/p\u003e\n \u003cp\u003eLow Fidelity\u003c/p\u003e\n \u003cp\u003eHigh and Low Fidelity\u003c/p\u003e\n \u003cp\u003eHigh and Task Trainer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;7 (41%)\u003c/p\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003cp\u003e2 (12%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Training\u003cbr\u003e\u003c/strong\u003e1-2 days\u003c/p\u003e\n \u003cp\u003e2-3 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;6 (35%)\u003c/p\u003e\n \u003cp\u003e11 (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Participation in Simulation-Based Workshops:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe also examined participation in various simulation workshops, reflecting the diverse training that our participants received [Table 2]. The number of healthcare professionals engaged in these sessions varied, with the Safe Proning session involving the highest participation (n=30) and Code Blue Management the fewest (n=10), thereby highlighting the tailored focus of the training interventions.\u003cbr\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Table 2:\u0026nbsp;\u003c/strong\u003eParticipation in Simulation Workshops\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorkshop/ Mannequin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDonning and Doffing/Demonstration and redemostraation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAdvance Respiratory Workshop/ SIM-MAN 3G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eSafe transportation of patient/SIM-MAN 3G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eSafe Proning/SIM-MAN 3G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eCode blue management/SIM-MAN 3G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eNoninvasive Ventilation Management/SIM-MAN 3G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eInvasive Ventilation Management/SIM-MAN 3G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAdvance Hemodynamic Workshop\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.3: \u0026nbsp;Themes, sub-themes, and categories of the findings:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 displays the theme, sub-theme, and categories that emerged from the data analysis. Three major themes emerged: 1) simulation-based training experience, 2) Factors affecting simulation-based training during Covid, and 3) Recommendations for improvement.\u003c/p\u003e\n\u003cp id=\"_Toc118967782\"\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThemes, sub-themes, and categories of the findings\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub-Theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSimulation-based training\u003c/strong\u003e \u003cstrong\u003eExperience\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSimulation learning opportunities\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eInnovation in education through technology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eBridging the theory-practice gap.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSelf -Efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIncreased self confidence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eImproved knowledge, attitude, and competency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003ePatient Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003ePerceived improvement in patient Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFactors affecting simulation-based training\u003c/strong\u003e \u003cstrong\u003eduring COVID 19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOrganizational Factors\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eUnrealistic expectations and lack of support from the management\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eImpact of COVID-19 guidelines on training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFacilitator training and Competencies\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eLack of realism in the training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIneffective debriefing and self- reflection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eLack of interprofessional training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eLogistics and Human Resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eUnavailability of material resources during training and in the clinical setting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eShortage of human resources\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecommendations for improvement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eResource Allocation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaffing plan and resources\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eExpansion of training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eCapability Building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSimulation educator courses\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eAdvanced simulation training experience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSimulation-based training\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eopportunities:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants highlighted several positive aspects of simulation-based training, viewing it as an innovative bridge between theory and practice. They noted that SBT not only enhanced their theoretical knowledge but also offered hands-on experiences that truly prepared them for real-world clinical challenges. Overall, the training was seen as a transformative tool that boosted self-confidence and improved readiness for clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eA. Innovation in education through technology\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost healthcare professionals shared that they were privileged to be a part of an institution with a center of excellence within the hospital. For example, one participant, stated, \u003cem\u003e\u0026quot;Being a part of this prestigious organization, I am privileged that we have a \u0026apos;Centre of Excellence\u0026apos;, where teaching and training are linked together for better patient outcomes; however, in the public sector, despite knowledge, implementation of such pedagogy is a challenge\u0026quot;\u003c/em\u003e (P1). He further noted, \u003cem\u003e\u0026quot;I first heard about simulation technology when I was a resident in my third year of medical school. At that time, I felt it was unsafe to practice on live patients.\u0026quot;\u003c/em\u003e\u003cbr\u003eThe growing complexities of healthcare require professionals to excel not only in theoretical knowledge but also in practical skills, and simulation-based training (SBT) serves as a bridge between the two. Several other participants endorsed this view describing their simulation experiences as \u0026quot;safe,\u0026quot; \u0026quot;helpful,\u0026quot; and \u0026quot;convenient\u0026quot; since it allowed them to practice real-world scenarios before managing actual patients. One participant explained, \u003cem\u003e\u0026quot;During COVID, I was transferred to the COVID area for help. At that time, I was shocked that I was not willing to work in that area\u0026hellip; we all were progressing, and COVID-19 was new for all. When such a situation arises, we start learning at a different level\u0026quot;\u003c/em\u003e (P12). Both theoretical knowledge and hands-on practice are essential, and simulation training provides an effective way to bridge this gap. A participant shared, \u003cem\u003e\u0026quot;I had mixed feelings during COVID-19; when the pandemic started, expectations from me increased. I was neither prepared nor motivated. Believe me, but after multiple simulated-based sessions, it was easier for me to comprehend\u0026quot;\u003c/em\u003e (P8).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eB. Self-Efficacy:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter discussing their experiences, most participants emphasized the importance of this training approach in building self-confidence. They explained how SBT helped reduce COVID-19-related anxieties and strengthen their decision-making skills. One participant stated, \u003cem\u003e\u0026quot;COVID-19 scared everyone; no one wanted to go inside [patients\u0026apos; room], as they feared the transmission\u0026quot;\u003c/em\u003e (P4). Participants also recalled that staff, especially females and mothers, were initially reluctant to work because of contamination concerns. As one participant observed, \u003cem\u003e\u0026quot;They did not want to take the virus home, but their anxieties decreased when we were told how to take the proper precaution\u0026quot;\u0026nbsp;\u003c/em\u003e(P9). Similarly, regarding the learning process, another participant remarked, \u003cem\u003e\u0026quot;Single-method learning has never been effective. Learning by doing hands-on skills is always beneficial as it allows staff to experience their actions, which helps to retain information and concepts for a longer period\u0026quot;\u003c/em\u003e (P10). Additionally, one participant stated, \u003cem\u003e\u0026quot;I had never seen the Emergency department in such a mess. Patients and their families were begging for a bed and losing their battle. I still remember I was doing family counselling, and suddenly code blue was announced; I prioritize my task and act\u0026quot;\u003c/em\u003e (P5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eC. Perceived Improvement in Patient Outcomes:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported that simulation-based training improved their ability to manage critical situations more effectively. For example, one participant noted that accidental removal of the orotracheal tube during proning was common before training, but after repeated practice on mannequins, these incidents decreased noticeably. He explained, \u003cem\u003e\u0026quot;Every other day, we\u0026rsquo;d have an incident where the equipment was accidentally removed. But after practicing on mannequins repeatedly, we saw a noticeable improvement, and it felt like those incidents happened less often\u0026quot;\u003c/em\u003e (P10). Another participant reflected, \u003cem\u003e\u0026quot;We were putting so much effort into proning because it required a lot of physical strength. After the session, we learned specific techniques that made it easier and less physically demanding\u0026quot;\u003c/em\u003e (P13). Although these are personal accounts rather than hard clinical data, many participants expressed confidence that the training enhanced their ability to provide better patient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2:\u003c/strong\u003e \u003cem\u003e\u003cstrong\u003eFactors affecting\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003esimulation-based\u003c/strong\u003e \u003cstrong\u003etraining\u003c/strong\u003e \u003cem\u003e\u003cstrong\u003eduring COVID-19:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBesides sharing their positive experiences, participants identified several challenges that hindered their learning during the pandemic. They mentioned that organizational issues, insufficient facilitator training, and a lack of interprofessional training were the major obstacles they faced.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eA. Organizational factors:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants explained that unrealistic expectations and limited support from management were major issues. Some described their SBT experience as \u0026quot;purposeless,\u0026quot; \u0026quot;confusing,\u0026quot; and \u0026quot;hectic,\u0026quot; noting that instead of alleviating stress, the training added pressure by requiring last-minute duty rearrangements. One participant stated, \u003cem\u003e\u0026quot;It was extremely hectic and stressful to arrange duties for such training. Most of the time, I was informed in the middle of the shift \u0026hellip; it becomes extremely difficult to arrange duties at the eleventh hour\u0026quot;\u003c/em\u003e (P15).\u003c/p\u003e\n\u003cp\u003eFurthermore, they believed that these training activities required prior notification, which was not provided due to the heavy workload. One participant recalled, \u003cem\u003e\u0026quot;Duties were tough those days; I still remember not getting time to drink water or use the restroom for the entire shift. I kept controlling my urge till the end of the shift; I was exhausted and fed up\u0026quot;\u003c/em\u003e (P14). He further explained, \u003cem\u003e\u0026quot;It was not humanly possible to attend such training after such physical and mental drain\u0026hellip; it seemed that the organization had very high expectations from us, which was very difficult...\u0026quot;\u003c/em\u003e (P12).\u003c/p\u003e\n\u003cp\u003eRapid changes in COVID-19 guidelines also contributed to confusion, as one participant stated, \u003cem\u003e\u0026quot;I can still recall; I was nominated for a workshop on the 10th day of my isolation. I needed clarification about whether to go for the session because, initially, the CDC guidelines were of 14 days\u0026apos; isolation, then it switched to five days. I was confused about which guidelines to follow\u0026quot;\u003c/em\u003e (P13).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eB. Facilitator training and competencies:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants expressed mixed feelings about facilitator competencies. While some were reluctant to elaborate, others were more forthright. They noted a significant difference between the scenarios practiced in simulation and the complex realities of clinical practice. One participant shared, \u003cem\u003e\u0026quot;I witnessed a code blue during the transfer of the patient. Nevertheless, there needed to be proper teaching in this regard. These were the cases that should be emphasized during simulation training, but, unfortunately, we were not prepared for that\u0026quot;\u003c/em\u003e (P16). Moreover, some participants felt that the true complexity and criticality of clinical situations were missing in the simulations. As one participant remarked, \u003cem\u003e\u0026quot;I believe the facilitators should make the scenario more complex to give us the actual flavor of reality because sometimes it gets difficult to manage these situations\u0026hellip; I believe the facilitators were not considering what was needed\u0026quot;\u003c/em\u003e (P6).\u003c/p\u003e\n\u003cp\u003eAdditionally, although participants acknowledged the importance of debriefing, most felt that, during the pandemic, debriefing sessions were ineffective due to time constraints, which led to missed opportunities for self-reflection. Even though facilitators debriefed participants via video recording in a few sessions, the collective feedback was not well received. One participant explained, \u003cem\u003e\u0026quot;Due to lack of feedback during debriefing, my query was not resolved even after the session\u0026quot;\u0026nbsp;\u003c/em\u003e(P16).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eC. Lack of Interprofessional Training:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants noted that SBT was not conducted as a multidisciplinary approach, and there was no alliance between physicians and nurses during training. One participant recalled, \u003cem\u003e\u0026quot;[with a deep breath] I still remember, I was already trying hard to adjust to a new setting and was fixing the patient\u0026apos;s ETT tube with my team leader when the duty doctor rudely told me, \u0026apos;Don\u0026apos;t touch the ETT, it will come out. You [nurses] are doing it wrong,\u0026apos; even though I was following the practice taught by my facilitator during simulation-based training\u0026quot;\u003c/em\u003e (P7). According to the participants, healthcare professionals should train together under one umbrella for the same practice. However, during the simulation sessions, individual activities were planned for nurses and doctors, which resulted in conflicts during patient management. This separation led to confusion, particularly among nurses, as one participant stated, \u003cem\u003e\u0026quot;While doing patient proning, everyone [doctors and nurses] was following their own sequence of care, and at that time, I was a bit confused about whom to follow, which was extremely upsetting\u0026quot;\u003c/em\u003e (P12). One participant further noted, \u003cem\u003e\u0026quot;Most of the time in the clinical area, conflict arose due to changes in practice because the nurses were not aware of what we [doctors] had already learned in the simulation-based training session, as that training was only for doctors\u0026quot;\u003c/em\u003e (P5). He added, \u003cem\u003e\u0026quot;I believe this can only be resolved if we conduct a parallel session for the entire healthcare team so that any conflict that arises can be resolved effectively\u0026quot;\u003c/em\u003e (P15).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTheme 3: Recommendations for improvement:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt the end of the interviews, participants were asked to share specific recommendations to improve the training process and system, particularly if another pandemic were to occur. Their recommendations fell under two major domains: Resource Allocation and Capacity Building.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eA. Resource allocation:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral participants suggested potential solutions to enhance the simulation experience within a resource-constrained setting. For instance, they proposed in situ simulation experiences, where training activities are planned in an actual clinical setup to expose participants to real-life events. One participant stated, \u003cem\u003e\u0026quot;For actual exposure; simulation scenarios should be real along with the setting to have an actual flavor of the clinical area\u0026quot;\u003c/em\u003e (P5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eB. Capacity building:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also emphasized the need for specialized training for instructors who conduct simulation training. They suggested that, in addition to enhancing overall competency, instructors should receive dedicated training in simulation teaching to effectively implement all the principles of simulation-based education. One participant remarked, \u003cem\u003e\u0026quot;\u0026hellip;to conduct simulation training it requires expertise; technology is not everyone\u0026apos;s cup of tea\u0026quot;\u003c/em\u003e (P14).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study is, to our knowledge, the first in-depth exploration of healthcare professionals\u0026rsquo; experiences with simulation-based training (SBT) in an LMIC in Pakistan. Our findings contribute to the growing global conversation on how SBT can transform learning in resource-limited settings, particularly during crises like the COVID-19 pandemic. Recent studies have shown that tailored simulation training can enhance clinical decision-making and improve learning outcomes and our findings support this idea while offering insights that can help refine SBT methods in similar environments.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] In addition, while high-income countries have widely embraced simulation, its adoption in LMICs has been slower due to financial and infrastructural constraints.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Therefore, initiatives to develop cost-effective simulation solutions and provide training resources in these regions are crucial for improving healthcare education and outcomes worldwide.\u003c/p\u003e \u003cp\u003eOur findings show that SBT is seen as a safe and effective way to gain hands-on experience. Participants appreciated the realistic practice opportunities that not only boosted their self-confidence but also provided fresh, innovative ways to learn. The existing literature also corroborated this finding.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Looking ahead, these insights lay the groundwork for further research into refining SBT methods that can be adapted and scaled across similar low-resource settings. Furthermore, as our study suggests, embracing SBT is critical in today\u0026rsquo;s evolving healthcare landscape.\u003c/p\u003e \u003cp\u003eDespite these clear benefits, several challenges emerged. Many participants noted that organizational issues, such as limited supervisor support and last-minute notifications for training sessions, often made it hard to fully engage with SBT. These challenges, which have also been observed elsewhere, appear to affect both the quality of training and the mental well-being of staff.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] For future practice, addressing these organizational barriers will be critical to enhancing the overall effectiveness of simulation-based learning and ensuring sustainable workforce support. Moreover, our findings underscore the need for comprehensive faculty training and development. Effective SBT requires instructors who are not only adept at operating complex simulation equipment but also skilled in designing realistic scenarios and conducting structured debriefing sessions.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Overcoming these challenges is essential to fully unlock the potential of SBT in enhancing learning outcomes and ultimately improving patient care.\u003c/p\u003e \u003cp\u003eAnother key challenge was the absence of a strong simulation culture. Participants described significant gaps in infrastructure, with limited access to high-quality mannequins; issues that are especially critical in low-resource settings.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Moreover, simulated environments may lack certain elements of actual clinical settings, such as the emotional stress of managing real patients, the variability of patient responses, and the complexities of working within a live healthcare team.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] To address these issues, institutions can mitigate challenges through strategic planning and resource allocation. For instance, developing partnerships with technology companies, securing grants, and investing in cost-effective simulation solutions can help alleviate financial burdens.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Additionally, incorporating blended learning approaches that combine simulation with traditional clinical experiences can enhance the realism and transferability of skills.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e Frequent changes in COVID-19 guidelines added to the uncertainty, leaving many unsure which protocols to follow during training. This highlights the need for training programs that can adapt quickly to evolving clinical standards.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] Moreover, the absence of interprofessional training was frequently mentioned; when doctors and nurses train separately, miscommunication and conflicts can arise, undermining teamwork.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Moving forward, integrating flexible protocols and promoting interprofessional training will be essential to enhance team cohesion and improve overall patient care.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and Limitations\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eA major strength of our study is its qualitative approach, which provided a deep understanding of the personal experiences of healthcare professionals during a challenging time. Using established guidelines like COREQ and Jeffries\u0026rsquo;s theoretical model added rigor to our findings. However, there are some limitations. Our study was carried out in a single tertiary care private hospital, so the findings may not be applicable to other settings. Despite our best efforts, there may have been some translation bias during data collection. Finally, our research focused solely on the perspectives of healthcare professionals, leaving out those of facilitators and other key stakeholders. These limitations point to the need for future multi-site studies and broader stakeholder engagement to validate and extend our findings.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eSimulation-based training (SBT) proved to be a vital tool during the COVID-19 pandemic, providing healthcare professionals with a safe and effective method for developing essential skills in a time of crisis. However, to fully unlock its potential, strategies must be developed to improve facilitator competencies and address human and logistical challenges. It is crucial to develop approaches that ensure facilitators are well-equipped and that resources are optimized for a more seamless training process. Healthcare organizations must also acknowledge the unique challenges faced by professionals during the pandemic, such as heightened anxiety, overwhelming workloads, and limited resources. By addressing these factors, SBT can be better tailored to meet the needs of healthcare workers, improving training effectiveness and ultimately leading to improved patient care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical approval for the study was acquired from the\u0026nbsp;ethical review committee\u0026nbsp;of The Aga Khan University Hospital\u0026nbsp;(ERC: 2022-7228-21224).\u0026nbsp;All methods were carried out in accordance with relevant guidelines and regulations or the Declaration of Helsinki. Participants were given detailed information about the study’s goals before interviews were conducted, and their signed informed consent was obtained before any interviews were recorded. The anonymity of the participants, their responses, and the use of aliases or codes in quotations were guaranteed. Participation in the research was entirely voluntary and they were given the option to drop out at any time. Both the interview and encoding data were encrypted before being saved to a personal hard drive for long-term storage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI confirm that this article is original and has not been published elsewhere, neither is it at present under consideration for publication elsewhere. There are no conflicts of interest to disclose. We believe that this manuscript would be of interest to your readership and contribute to the science and scholarship of Nurses. As this was my Master thesis as well so it will be a boost up for young researchers to submit their work in a high impact journal for dissemination of finding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the participating nurses for sharing their experience and the Nursing Service Department of the hospital for allowing us to do the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization:\u003c/strong\u003e (LL and SH) - Conceived and designed the study on simulation-based learning among healthcare professionals during COVID-19, particularly focusing on low- and middle-income countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e (SH and AS) Developed the research design, including selection of the simulation frameworks and survey instruments, and established protocols for data collection and analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInvestigation:\u003c/strong\u003e (SH) Conducted data collection and initial analysis and cross check with LL and ZK\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Curation:\u003c/strong\u003e (SH and LL) organized the data and made themes and subthemes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWriting – Original Draft Preparation:\u003c/strong\u003e (SH) wrote the first draft of the manuscript, detailing the study's methodology, findings, and significance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWriting – Review \u0026amp; Editing:\u003c/strong\u003e (SH, LL, AS, ZK, SN] - Reviewed and edited the manuscript, contributed to critical revisions, and improved clarity, coherence, and consistency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupervision:\u003c/strong\u003e (LL and AS) Provided guidance throughout the research process and offered expertise.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eElendu C, et al. 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Prev Med Rep. 2024;37:102550.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Simulation, Healthcare professional, Covid 19, training, learning","lastPublishedDoi":"10.21203/rs.3.rs-6241378/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6241378/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe significance of continuing education has always been emphasized since the beginning of the nursing profession, and during the COVID-19 pandemic, the need for simulation-based- training in managing the global crisis increased considerably. However, experiences regarding simulation-based-training have yet to be explored in low-middle countries like Pakistan. This study aimed to explore the experiences of simulation-based training during the COVID-19 pandemic and identified the challenges and barriers with this learning approach.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing a descriptive, qualitative, semi-structured design, interviews were conducted with 17 healthcare professionals who had worked in the COVID areas. The data were collected from April to June 2022 through purposive sampling. Interviews were stopped upon data saturation. The Consolidated-Criteria-for-Reporting-Qualitative-Research (COREQ) guidelines were used, and a thematic analysis was conducted.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree main themes were identified: (1) simulation-based-learning experience, (2) factors affecting simulation-based-training during COVID-19, and (3) recommendations for improvement. Participants reported that simulation-based learning enhanced self-efficacy and provided innovative learning opportunities through technology, with many perceiving that it contributed to better patient outcomes. However, challenges such as organizational constraints, insufficient facilitator training, and logistical and resource limitations were also noted. These insights informed recommendations centered on optimizing resource allocation and strengthening capacity building for future training initiatives.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSimulation-based-training has proven to be vitally important during the COVID-19 Pandemic. However, strategies must be developed for improving facilitator competencies as well as addressing human and logistic factors to achieve a better learning experience.\u003c/p\u003e","manuscriptTitle":"Experiences of Healthcare Professionals Regarding Simulation Based Training Approach During COVID 19 – a descriptive qualitative study from a Low Middle-Income Country, Pakistan.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 11:04:02","doi":"10.21203/rs.3.rs-6241378/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eeed8c73-677b-4003-b14a-d4fa3035d173","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-10T15:08:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 11:04:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6241378","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6241378","identity":"rs-6241378","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}