Journal Logo

Highly Communicable Disease Management Theme Issue

Health Worker Focused Distributed Simulation for Improving Capability of Health Systems in Liberia

Gale, Thomas C. E. BM, BS, MEd; Chatterjee, Arunangsu PhD; Mellor, Nicholas E. MSc; Allan, Richard J. MSc

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: April 2016 - Volume 11 - Issue 2 - p 75-81
doi: 10.1097/SIH.0000000000000156


Fragile health systems” in West Africa have been damaged further by significant reduction in numbers of health care workers because of Ebola virus disease—efforts to recruit and train local workers have been highlighted as an extremely important measure to help fight the outbreak, build up trust in the local community, and improve the health system so that sustainable improvements in health care can be made.1

Effectiveness of traditional training in the Ebola outbreak is constrained by affordability, the number and location of experts, and the logistical difficulty of accessing workers in daily contact with patients in remote regions. It is extremely difficult to sustain the learning required and spread best practices using traditional training techniques, especially in areas with low literacy levels.

Immersive simulation using virtual reality (VR) has been shown to enhance learning outcomes through both the learning experience and the interactive experience. Interaction during VR simulations allows participants to have an element of control where instructional choices can be made, which promote active learning and reflective thinking.2 Virtual reality provides an adaptable learning platform, which can be widely distributed to workers from varied educational backgrounds to convey important safety principles regarding infection prevention control (IPC). Benefits of using virtual environments for learning allow “acting on the world” in experiential spaces, where participants “learn by doing” and observe the outcomes of their actions.3

Kneebone et al4 have recognized the need to provide low-cost, portable facilities to improve accessibility of simulation and provide just-in-time training” when and where it is needed through the concept of the “distributed simulation” model. Combining distributed simulation and VR on a conventional laptop or tablet could provide simulation training, which is standardized, more affordable to the whole community, and widely accessible with just-in-time training within reach of all.

The main aim of this study was to produce an adaptable learning platform using VR and distributed simulation, which could be used to train health care workers, across a wide geographical area in Liberia, key safety messages regarding IPC.


The prototype module for IPC training was developed for a 3-month process as part of a rapid response initiative to the Ebola crisis in West Africa.

Design of distributed simulation4 involves the following 3 main stages:

  1. Identification of key elements from real clinical settings
  2. Presentation of these elements in a lightweight, inexpensive, and portable environment, and
  3. The ability to recreate and replay clinical scenarios

The development team comprised infection control experts and key stakeholders in Liberia tasked with building capacity of the health service and implementing IPC training. These members were responsible for identifying key content for the training such as IPC guidelines and sourcing authentic elements from the clinical environment, which could be incorporated into the tool. Simulation- and technology-enhanced learning specialists were responsible for presenting these elements in the VR platform and for designing the tool so that engaging and immersive clinical simulations were created for the participants.

The heterogeneity of end users and the prospect of constantly changing needs in Liberia required an evolutionary development process that relied on incrementally adding and testing new features on an iterative basis to ensure that the clinical scenarios provided in the tool were acceptable and appropriate for health care workers in Liberia. Agile development methodologies were of particular interest for the purpose of the study because these involve building products by empowering and trusting people, acknowledging change as a norm, and promoting constant feedback.5 Key principles, which influenced the conduct of this development phase, were the following:

  • End-user satisfaction
  • Open to changing requirements
  • Harmonious involvement of end users and developers
  • Sustainable development
  • Self-organizing teams
  • Regular feedback and reflection

A number of agile methodologies were available, for example, Agile Unified Process, Dynamic Systems Development Method, Essential Unified Process, Extreme Programming, Feature Driven Development, Open Unified Process, and Scrum.5 Among these approaches, Scrum was chosen to fit best within the context of our study. The key differentiators that made Scrum the preferred choice as compared with other approaches were the following:

  • Only what is needed gets developed
  • Stringent quality mechanism through iterative and incremental process
  • Very flexible to change (as situation changes on a daily basis in Ebola-affected countries)
  • A highly transparent process for all stakeholders

Founded on the concept of empirical process control, Scrum is a lightweight agile methodology, which enables delivery of software in small iterative cycles without prescribing stringent processes.6 Such an approach is ideal for a study where there is an environment of high changeability with conflicting and competing multiple stakeholder interests requiring an open and flexible development process. A combination of software platforms was chosen for the development; “Unity 3D” was used for the game engine, “Blender” for 3D modeling and animations, “Mixamo” library for 3D models, and “Adobe audition” for audio management.

Figure 1 displays a typical scrum project, which was adapted slightly in terms of the iteration cycle lasting 1 week rather than 2 to 4 weeks. Daily meetings were scheduled with the development team and sprint retrospective every week. Because of the volatile nature of the continually changing requirements based on outbreak situation on the ground, it was decided to convene videoconferences 3 times per week during the development phase that contributed toward the sprint retrospective. Table 1 shows how features of Scrum methodology were incorporated into the project design and Table 2 highlights key terms and definitions used.

Typical Scrum project. Overview showing development sprints (iterations) and feedback loops.
Features of Scrum Methodology, Which Were Implemented Within the Project
Key Terms and Definitions


The IPC module was developed into 4 sections, which were each aligned with specific adult learning principles (Table 3).8

Adult Learning Principles
  1. Introduction to the Ebola virus and importance of effective personal protective equipment (PPE) use
  2. Training in putting on PPE
  3. Identification of risks and hazards in the clinical environment
  4. Training in taking off PPE

Content was aligned with World Health Organization guidelines9 and the Ministry of Health (Liberia) priorities for building capacity in the health system. Personal protective equipment protocols were focused on use by health care workers in primary health facilities rather than Ebola treatment centers. In this regard, the study group had to differentiate between basic PPE (for use in triage of patients), enhanced PPE (for high-risk patients at primary health units), and full PPE (for use in Ebola treatment centers). The first prototype module was built around the need to build capacity in primary health units and is based on the use of enhanced PPE. The module was developed to effectively facilitate learning by introducing appropriate simulation learning features,10 demonstrated in Table 4.

Simulation Learning Features

The content of the module was delivered with minimal amount of text and the incorporation of voiceovers in local dialect. Individual steps for putting on and taking off PPE were identified through international consensus guidelines from the Centers for Disease Control and World Health Organization.9 These steps were reviewed by stakeholders in Liberia, plus infection control experts within the project team. Each step was merged into an interactive learning sequence, which participants could explore as an on-screen avatar in conjunction with a virtual buddy to provide, key learning points, commentary, and instruction throughout the process. The virtual buddy was incorporated into the simulations to promote the use of safety checklists when putting on and taking off PPE, plus to emphasize the importance that observers should take part in checking correct procedures. To add educational and professional context to the simulations and facilitate the “near-peer teaching” concept, the buddy was animated to look like a Liberian health care worker and voiceovers sourced from Liberia for both English and Liberian English versions of the script.

Gamification was incorporated into the digital components, as a mechanism to engage users during the module, through the isolation of active ingredients (time constraints, challenge, leader boards, clear goals, badges, number of turns, etc) that make games addictive, engaging, and fun.11,12 Various gaming mechanics that enable user engagement were mapped to appropriate learning mechanics (including key simulation features) as shown in Table 5. Instructional learning was incorporated into the tool with the use of an on-screen avatar (Fig. 2 and Video, Supplemental Digital Content 2, providing near-peer teaching through the use of short tutorials demonstrating the correct sequence of donning and doffing PPE, plus key critical actions for each step (slide 7, Supplemental Digital Content 1,, and Video, Supplemental Digital Content 4,, which demonstrates a mix of videos and animations used for critical steps). Discovery-based learning was embedded through the use of interactive choices throughout the module; participants were required to choose the correct equipment (Fig. 3 and Video, Supplemental Digital Content 3, and make decisions regarding sequence of steps and specific actions to progress to the next stage of the training. Incorrect decisions were highlighted immediately and prompts provided with the use of visual checklists to provide feedback during training (Fig. 4). Participants who successfully completed specific stages of training were rewarded and allowed to progress to higher levels of the module providing motivational learning within the tool (Fig. 5). A hazard perception section was designed as a higher stage level, where participants would be able to immerse themselves in a clinical area and identify risks and hazards (Fig. 6). Feedback was provided visually regarding the number of hazards identified and verbally by the on-screen avatar reinforcing key learning messages related to each hazard (Fig. 7). Please also refer to slides 5 to 10 (Supplemental Digital Content 1,, which further demonstrate these attributes.

Gaming and Learning Mechanics
Instructional learning used in the module. Near-peer teaching embedded within the module through the use of an avatar buddy. The buddy explains key learning messages regarding Ebola and PPE throughout the module.
Learner enabled selection fostering discovery process. Learners select equipment for the module on the basis of locally available resources.
Repetitive self-assessment/feedback through the use of visual checklists and audio feedback from virtual buddy. Learner enabled interaction to make choices regarding correct PPE donning and doffing steps.
Continuous encouragements throughout the module. Learner moves to higher levels of the module once each stage is complete to provide motivation.
Risk assessment and hazard perception scene. Identification of hazards required before progression to next scene.
Visual feedback provided regarding the number of hazards identified in the hazard section. Feedback also provided verbally by the on-screen avatar reinforcing key learning messages.


Agile development using Scrum methodology has been used in this study to link concepts applied to best practices in simulation-based medical education, pedagogic principles related to adult learning, and key learning outcomes regarding IPC, as a rapid response initiative to the Ebola outbreak in West Africa. Our approach uses 3D simulation and graphics with an interactive experience to enhance learner engagement, on a platform that can be accessed in a conventional laptop browser or tablet (with minor alterations). No active Internet connection is required for running the simulation and results are logged locally on the device. The results are reported to our server whenever Internet connection is detected and as a backup could also be copied and e-mailed by the trainer. Virtual reality and distributed simulation have been combined to remind, refresh, and reinforce key learning messages acting as enablers to improve knowledge retention and reach a dispersed workforce.

Stakeholder engagement in the development process has been instrumental in using expert input and end-user feedback to address these priorities and provide a simulated environment, which can be distributed widely. Best evidence in the use of simulation-based medical education includes the integration of simulation within an overall curriculum, choosing appropriate fidelity for interventions, participants playing their own roles in the correct educational and professional context, and allowing opportunities for repetitive practice and feedback.13 We have attempted to include all these principles in the IPC module through the use of internationally agreed protocols for PPE, near-peer teaching, on-screen avatars, realistic clinical environments, gamification, and self-assessment.

The original model of distributed simulation by Kneebone et al4 involved an inflatable igloo and other lightweight props, to replicate a clinical environment where surgeons can practice psychomotor skills without the need to attend a high-fidelity simulation training center. Our interpretation of the distributed simulation model is physically different because we have incorporated VR into the solution but the following theoretical specifications of distributed simulation have been embedded in the tool:

  • An immersive virtual clinical environment has been created, where participants can interact as an on-screen avatar in a clinical area, which closely resembles their own health care facilities.
  • All cues are incorporated within the learning tool without the need for additional cues or clinical equipment.
  • The tool incorporates deliberate practice of key critical steps with built-in feedback mechanisms to facilitate feedback/“observation” from an on-screen buddy (slide 8, Supplemental Digital Content 1,, which shows repetition pattern and checklist-based feedback).
  • The laptops/tablets are practical, lightweight, and easily transportable.
  • A wide range of clinical settings can be recreated easily according to individual needs and changing circumstances, without the need for costly manikins/additional equipment.

In a recent editorial, Norman14 emphasized the fact that simulation should not be part of a stand-alone simulation program but combined with other educational methods within the notion of simulation-augmented medical education rather than simulation-based medical education. Norman14 argues that simulation should be more easily accessible for all and that faculty should abandon the requirement for “authenticity at any cost.” In this respect, the use of high-frequency, low-fidelity simulation could be more effective than high-fidelity simulation, especially if combined with other educational methods as part of an overall program. High-frequency, low-fidelity simulation has been shown to make major differences to morbidity and mortality in situations with resource-limited circumstances such as the Helping Babies Breathe Program.15 Rapid distribution of the IPC module through improved accessibility to laptop devices and tablets could potentially make marked changes to disease transmission rates in West Africa through high-frequency, low-fidelity simulations designed to increase the number of workers who are confident and competent to treat patients at risk of Ebola.

Combining immersive simulation, local hands-on training, and assessments of understanding and skills would be able to accurately mimic “the critical cognitive and motor elements in the criterion task,” which are prerequisites for appropriate fidelity of simulations.14,16

There are an increasing amount of academic publications advocating the need to rethink the “traditional in-class, lecture-based course model” and to use the “flipped classroom” format, which allows the learner to cover educational coursework by themselves online, before face-to-face training time.17 Contact time with expert faculty can then focus on difficult concepts during student-centered activities. The use of VR and distributed simulation for responding to crisis situations has a great potential to save limited resources if the training is worked into a “flipped classroom” format. Contact time with expert trainers could be used more efficiently when protective equipment and clothing is made available during workshops. Participants could then focus on practicing key critical actions highlighted by the module and reinforce key learning messages from national and international curricula, which have been previously experienced through simulation training.

Bill Gates, philanthropist, has identified the use of simulation for building stronger health systems in developing countries as being crucial in global preparation for future epidemics, as well as providing significant benefits in terms of improving primary health care in these countries.18 Our project is committed to implementing and evaluating VR and distributed simulation across West Africa to build capacity, resilience, and sustainability of the health care system. Further studies are required to evaluate how learners engage with various conceptual elements incorporated within the VR and distributed simulation model and how they complement other educational interventions.


The authors wish to acknowledge the contribution of Geoff Eaton, Jon Meadows, Austin Hunt from Masanga Mentor Ebola Initiative; Richard Weeks, Anya Trounce from Total Monkery; Elizabeth Seymour, Tom Lacey-Johnson from TELMeD, Plymouth University; Dave Luke, Hetty Horton, Elton Golbie, Julie Pontarollo from the Mentor Initiative Liberia, and Simon Mardel from Manchester Medical School, for their continued support and commitment towards various aspects of the project.


1. Boozary AS, Farmer PE, Jha AK. The Ebola outbreak, fragile health systems, and quality as a cure. JAMA 2014; 312(18): 1859–1860.
2. Ai-Lim Lee E, Wong KW, Fung CC. How does desktop virtual reality enhance learning outcomes? A structural equation modeling approach. Comput Educ 2010; 55(4): 1424–1442.
3. Hew KF, Cheung WS. Use of three-dimensional (3-D) immersive virtual worlds in K-12 and higher education settings: a review of the research. British J Educ Tech 2010; 41(1): 33–55.
4. Kneebone R, Arora S, King D, et al. Distributed simulation—accessible immersive training. Med Teach 2010; 32(1): 65–70.
5. Schuh P. Integrating Agile Development in the Real World (Programming Series). Rockland, MA: Charles River Media, Inc; 2004.
6. Schwaber K. Agile Project Management With Scrum. Redmond, WA: Microsoft Press; 2004.
7. Gutierrez M, Vexo F, Thalmann D. Stepping Into Virtual Reality. London: Springer; 2008.
    8. Bryan RL, Kreuter MW, Brownson RC. Integrating adult learning principles into training for public health practice. Health Promot Pract 2009; 10(4): 557–563.
    9. Infection prevention and control guidance for care of patients in health-care settings, with focus on Ebola. World Health Organisation 2014. Available at: Accessed April 15, 2015.
    10. Bradley P. The history of simulation in medical education and possible future directions. Med Educ 2006; 40: 254–262.
    11. Deterding S, Dixon D, Khaled R, et al. From game design elements to gamefulness: defining gamification. Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments; MindTrek 11; 28–30 September 2011; Tampere, Finland. Envisioning Future Media Environments; 2011.
    12. Chatterjee A, Gale T, Luke D, Mardel S, Hunt A, Mellor N. Using gamification for distributed IPC PPE simulation. Available at: Accessed April 18, 2015.
    13. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Med Educ 2010; 44(1): 50–63.
    14. Norman G. Simulation comes of age. Adv Health Sci Educ Theory Pract 2014; 19(2): 143–146.
    15. Msemo G, Massawe A, Mmbando D, et al. Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics 2013; 131: e353–e360.
    16. Grierson LE. Information processing, specificity of practice, and the transfer of learning: considerations for reconsidering fidelity. Adv Health Sci Educ Theory Pract 2014; 19(2): 281–289.
    17. McLaughlin JE, Roth MT, Glatt DM, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med 2014; 89(2): 236–243.
    18. Gates W. The next outbreak? We’re not ready. Available at: Accessed April 15, 2015.

    Simulation; Virtual reality; Gamification of learning; Infection prevention control

    Supplemental Digital Content

    © 2016 Society for Simulation in Healthcare