The Use of Simulators for Teaching Practical Clinical Skills to Veterinary Students

Abstract

In the context of veterinary education, simulators are devices or sets of conditions aiming to imitate real patients and enable students to practice skills without the need for live animal use. Simulator use in veterinary education has increased significantly in recent years, allowing consistent practical teaching without reliance on clinical cases. This review examines the available literature regarding the use of simulation and simulators for teaching practical day one competences to veterinary students. Scientific databases were searched and 73 relevant articles were reviewed. The reviewed articles revealed that there are a number of simulators currently available to veterinary educators, that simulators can enhance student skills and provide an alternative learning environment without the need for live animal and/or cadaver use, and that they usually receive positive feedback from the students who use them. There appears to be a bias towards small animal simulators — however, some skills that are developed through the use of small animal or table-top models will be transferrable to other species. The majority of large animal simulators focus on bovine rectal palpation and/or pregnancy diagnosis. Further research is required to increase the repertoire of available simulators for use in veterinary education, in order to improve the practical skills of veterinary students and reduce the use of live animals and cadaver material for teaching purposes.

Keywords

clinical education practical simulation teaching veterinary

Introduction

Simulation is, in its simplest definition, the imitation of a situation or process. In the context of veterinary or medical education, a simulator is “a device or set of conditions that aims to imitate real patients, anatomic regions, or clinical tasks”.¹ The use of simulators for teaching in healthcare professions has increased significantly in recent years,² and it is likely to continue increasing with the advent of new technologies and increasing drive of academic institutions and regulatory bodies to ensure a consistent level of competence in new graduates. Scalese and Issenberg² discuss a worldwide shift towards outcomes-based education and standard-setting by universities and professional regulators for quality assurance in order to produce consistency amongst graduates. According to Edwards, “there is a societal expectation that veterinarians everywhere will all have graduated at the same standard and have the same basic competencies”.³ In the UK, veterinary curricula aim to ensure that students graduate with all of the skills designated by the Royal College of Veterinary Surgeons (RCVS) in their List of Day One Competences, and there is a drive to ensure that all students achieve a consistent learning experience during their time at university.⁴

Teaching of practical clinical skills is crucial for veterinary education, in order to ensure that graduates comply with the RCVS Day One Competences, but also because confidence and proficiency in performing clinical procedures is important to veterinary students.⁵ The strongest predictor of skill level is the number of hours of deliberate practice,⁶ and this time can be limited in veterinary education due to the variable availability of practical teaching opportunities on live patients, as such opportunities are reliant on case exposure and consent from the animal’s owner (the client).

Historically, veterinary students would have been trained in surgical and other clinical skills via the use of dissection of cadaver materials, observation of clinical cases and some institutions may have utilised live animals obtained and anaesthetised for the purposes of surgical training. These practices were commonplace at all education levels in a range of subjects and at a number of institutions until the ethical issues surrounding the use of animals for teaching purposes were highlighted and widely discussed, both within education and society in general.^7,8 The concern observed within educational institutions and society paralleled the increasing concern for use of animals in science more generally, and the growing desire for the development of non-animal alternatives across multiple sectors.

This movement led to the development of non-animal alternatives for educational purposes which, according to a 2005 review by Hart et al.⁹ appeared to gain popularity in the early 1970s — although the earliest non-animal alternatives identified in this current literature review were surgical ligation simulators dating from the early 1990s. Around this time, the UK-based resource centre for general non-animal alternatives, InterNICHE (the International Network for Humane Education), was founded (originally as EuroNICHE in 1988),¹⁰ and the Animals (Scientific Procedures) Act 1986 was passed into UK law.¹¹

There is no doubt that observing and then practising clinical techniques on live animals provides the most accurate and applicable ‘real-life’ scenario for veterinary students and will provide the most benefit to their future patients. However, the obtainment and use of live animals purely for teaching is strictly controlled within ethical guidelines in a number of countries and veterinary institutions across the globe, and there is a drive within veterinary pedagogy to develop and utilise alternatives to live animals when teaching certain practical clinical skills in order to protect animal welfare without compromising student teaching and learning. The use of simulators in veterinary education is a relatively new and progressive field of study and although the use of simulators cannot fully supersede the use of live animals for teaching, simulators may provide a suitable facility for students to practice skills prior to performing procedures on live patients.

Teaching simulators allow the development of practical skills in the absence of a live patient, and can produce more confident graduates and greater proficiency in practical skills, in addition to protecting animal welfare and reducing the need for live patients in teaching.^2,5,12–15 It can also be postulated that the use of simulators provides a safe, low-risk environment for students in which to practice their skills and not experience concerns regarding animal welfare or pressure from observing parties, such as the client. A safe, low-stress environment might also increase learning potential, as student anxiety has been demonstrated to inhibit learning, and stress in medical situations inhibits judgement.^16,17 The availability of clinical skills laboratories at veterinary institutions is considered to be beneficial for enhancing student learning, complementing traditional training and benefitting animal welfare by reducing the requirement for live animals or cadaver materials in teaching sessions.¹⁸ As aforementioned, the facility to practice skills on live animals is a crucial component of veterinary education, and the use of simulators cannot supersede this. However, simulators can aid the development of skills prior to practising on a live animal, and can improve the levels of student competence and confidence when they then need to perform a procedure on a live clinical case requiring veterinary treatment or intervention. This, in turn, can improve animal welfare, as tasks will be performed more skillfully with less stress and lower risk of harm to the patient.^2,5,12

A number of teaching simulators are already employed within veterinary schools, ranging from simulators to teach clinical skills (such as clinical examinations, intramuscular and intravenous injections, rectal examinations, ophthalmic examinations and anaesthetic monitoring), to more complex surgical simulators (such as for neutering and arthroscopy).^1,2,12,19,20 It is highly likely that there are additional smaller, less publicised simulators used within veterinary schools that are unique to individual establishments. Martinsen and Jukes²⁰ divided simulators into four categories:

1. Models, mannequins and simulators;

2. Multimedia computer simulation;

3. Virtual reality;

4. Ethically sourced animal cadavers and tissues.

The categories described above do not allow for the distinction between the different types of learning outcomes that simulators can be used to achieve (e.g. to gain practical clinical skills versus anatomical knowledge or communication skills). The aim of this article is to summarise the available literature regarding the use of practical simulators for teaching practical clinical skills to veterinary students. Therefore, simulators within this article are separated into the following broad categories:

— Model-based practical simulators: for teaching practical clinical skills via the use of non-cadaver model simulators.

— Practical virtual simulation: using virtual reality or augmented reality to deliver practical skills.

— Non-practical virtual simulation: using computer software or virtual reality programs to deliver teaching material or example case scenarios, which are mainly theoretical.

— Communication-based or scenario-based simulation: using actors, multimedia software or example communication scenarios, to teach professional or communication skills.

It is acknowledged that non-practical virtual simulation, multimedia computer simulation and communication or scenario-based simulation are of extremely high value to the veterinary curriculum. The former may indeed be an area of advancing research and technology in the near future, with the advent of modern virtual reality technology. However, the focus of this review is on the use of practical simulators for teaching practical clinical skills. As such, any discussions on non-practical, virtual and communication-based simulation will be limited.

Materials and methods

The research question set for this review was: What simulators are available for teaching practical Day One Competences to veterinary students and are they efficacious? Sub-questions as part of the main research question included:

— Do simulators realistically mimic the task being performed when compared to a live animal?

— Do simulators improve student learning and skills?

— Do students provide positive feedback regarding simulators?

— Do students prefer training on live animals?

— Do simulators improve the welfare of animals?

— What challenges do educators face in simulator use and development?

Search strategy

Four databases (CAB Abstracts, Scopus, ScienceDirect and Wiley Online Library) were searched using the terms below and Boolean operators. Google Scholar was not included due to unmanageably high number of articles yielded on initial searching (71,400), and a lack of clear refining tools, as documented by Halevi et al.²¹ The search yielded a total of 73 relevant articles. The search terms were:

— Search 1: Simulation OR Simulator AND Veterinary AND Education

— Search 2: Simulator OR Simulation AND Veterinary

— Search 3: Model AND Veterinary AND Education

— Search 4: Simulation OR Simulator AND Veterinary AND Training

— Search 5: Model AND Veterinary AND Training

Further searches were performed with: Simulation OR Model AND Veterinary AND (Education OR Training) AND <species> bovine, ovine, porcine, feline, canine, equine, cattle, sheep, pigs, cats, dogs, horses. Searches were also performed using the plural forms (simulations/simulators), and it was found that the search results were the same, regardless of singular or plural form.

Certain journals with a number of relevant articles were searched separately, in addition to the main database searches (e.g. Journal of Veterinary Medical Education, Alternatives to Laboratory Animals). Reference lists and bibliographies of discovered articles were examined to identify other relevant publications. The Wiley Online Library and ScienceDirect searches yielded high numbers of articles on initial searching, necessitating subject refinement to Veterinary Medicine/Science and original research articles. The following dates were covered in the database searches (the latter date being the date the search was performed):

— CAB Abstracts: 1973 to 16 January 2022

— PubMed: ‘unknown’ to 16 January 2022

— ScienceDirect–Elsevier: ‘unknown’ to 16 January 2022

— Scopus: ‘unknown’ to 16 January 2022

— Wiley Online Library: ‘unknown’ to 16 January 2022

The following exclusion criteria were applied: non-English language; non–peer-reviewed articles; full text unavailable or articles not relevant to the research question. The inclusion criteria consisted of peer-reviewed articles written in the English language and relevant to the research question(s).

Results

Small animal simulators

Of the 73 articles reviewed, 45 (61.6%) focused on small animal simulators; the majority of these were canine models (73.3%, n = 33/45), with four being feline models and two being lagomorph (rabbit) models. Six articles described a model that could be utilised for both canine and feline applications. It must be noted, however, that the anatomy of mammalian species for the purposes of clinical skill simulator modelling is often very similar, and therefore certain skills learnt through the use of some canine models (e.g. skin suturing or ligation of blood vessels) will be transferrable to other species.

The most common procedures featured in the reviewed articles were: laparoscopy; venepuncture and/or intravenous catheterisation; and anaesthetic procedures and monitoring (with four articles each). This was closely followed by neutering (orchiectomy and ovariohysterectomy), endotracheal intubation, and endoscopy.

Most of the articles were experimental studies (93.3%, n = 42/45), plus two cross-sectional surveys and one observational study via analysis of case records. Of the experimental studies, 30 involved the creation of a simulator and then the assessment of its validity by comparing the ability of simulator-trained participants when subsequently performing the task (either on the simulator, a cadaver or a live animal) with a control group (non–simulator-trained). The majority of the experimental studies obtained participant feedback on the perceived usefulness of the simulator, or their perceptions on their change in confidence and/or competence following use of the simulator (n = 36/45).

Farm animal simulators

Of the 73 articles reviewed, 10 (13.7%) focused on farm animal simulators. All of these were experimental studies, and all were based on the use of bovine simulators. Nine out of the ten studies assessed bovine rectal palpation simulators, such as the Haptic Cow (Virtalis Ltd, Cheshire, UK; https://www.virtalis.com/haptic-cow/) and/or Breed’n Betsy (Brad Pickford, Australia; http://www.breednbetsy.com.au/) or a Bovine Trans-rectal Palpation Phantom created by the researchers.^19,22–27 One article focused on a calving simulator.²⁸

Equine simulators

Nine of the 73 articles reviewed (12.3%) focused on equine simulators. All of the studies were experimental, and the techniques included: intravenous and intramuscular injections;²⁹ intra-articular (joint) injections;³⁰ diagnostic regional anaesthesia (nerve blocks);³¹ endoscopy of the upper respiratory tract;³² gynaecological examination;^33,34 laparoscopic ovariectomy;³⁵ and cardiac dissection.³⁶ Cardiac dissection was included as a clinical skill for the purposes of this article, due to the RCVS listing the ability to perform a post-mortem examination in their Day One Competences, and the assumption that the cardiac dissection procedure would be required as part of a thorough post-mortem examination.⁴

Simulators applicable to all species

Ten articles focused on skills which were not species-specific, or ones that used multiple species in their methodology. Eight of these studies were experimental, one was descriptive and one was a cross-sectional survey. As mentioned previously, some of the skills learnt through the use of small animal-specific models are transferrable to other species (e.g. ligation), so the categorisation of the model is not absolute. Topics covered in the non-species-specific articles included: student perceptions of alternative teaching methods;³⁷ table-top simulators for basic surgical skills training (venepuncture, placement of peripheral venous catheters);³⁸ laparoscopic surgery;³⁹ enterotomy skills;⁴⁰ ligation (haemostasis);⁴¹ suturing;⁴² and one study to assess the potential use of a commercial human patient simulator to educate veterinary students.⁴³ Table 1 provides a summary of all the simulators described in the reviewed literature.^{14,15,19,22–36,39–88}

Table 1.

The simulators detailed within the reviewed literature.

Category	Simulator(s)	Author [species]
Examination	Canine prostate examination	Capilé et al., 2015⁴⁴ [C]
	Cardiac dissection	Allavena et al., 2017³⁶ [E]
	Feline abdominal palpation	Williamson et al., 2015⁴⁵ [F]
	Gynaecological examination	Nagel et al., 2015³³ [E]
	Gynaecological examination	Nagel et al., 2015³⁴ [E]
	Ophthalmic examination	Banse et al., 2021⁴⁶ [C]
		Nibblett et al., 2015⁴⁷ [C]
		Williams et al., 2016⁴⁸ [C]
	Orthopaedic examination	Troy and Bergh, 2015⁴⁹ [C]
	Otoscopy	Nibblett et al., 2017⁵⁰ [C]
Clinical procedure	Anaesthetic procedures and monitoring	Jones et al., 2017⁵¹ [C]
		Jones et al., 2019⁵² [C/F]
		Lewis et al., 2017⁵³ [A]
		Modell et al., 2002⁴³ [A]
		Musk et al., 2017⁵⁴ [A]
	Calving	French et al., 2018²⁸ [B]
	Cardiopulmonary resuscitation (CPR)	Fletcher et al., 2012⁵⁵ [C]
	Cerebrospinal fluid (CSF) sampling	Langebaek et al. 2021⁵⁶ [C]
	Dentistry (cleaning)	Hunt et al., 2021⁵⁷ [C]
	Dentistry (cleaning)	Lumbis et al., 2012⁵⁸ [C/F]
	Diagnostic ultrasound	Mariano Beraldo et al., 2017⁵⁹ [C]
	Endoscopy	Elnady et al., 2015³² [E]
		McCool et al., 2020⁶⁰ [C]
		Pérez-Merino et al., 2018⁶¹ [C]
		Usón-Gargallo et al., 2014⁶² [C]
	Endotracheal intubation	Aulmann et al., 2015⁶³ [C]
		Clausse et al., 2020⁶⁴ [F]
		Musk et al., 2017⁵⁶ [C]
	Female urinary catheterisation	Aulmann et al., 2015⁶³ [C]
	Intra-articular injection	Fox et al., 2013³⁰ [E]
	Rectal palpation and/or pregnancy diagnosis	Annandale et al., 2018²² [B]
		Baillie et al., 2003²³ [B]
		Baillie et al., 2005²⁴ [B]
		Baillie et al., 2010¹⁹ [B]
		Bossaert et al., 2009²⁵ [B]
		Kinnison et al., 2009²⁶ [B]
		Zolhavarieh et al., 2016²⁷ [B]
	Regional anaesthesia	Gunning et al., 2013³¹ [E]
	Regional anaesthesia	Neves et al., 2020⁶⁵ [C]
	Thoracocentesis	Williamson, 2014⁶⁶ [C/F]
	Thoracocentesis	Williamson and Rito, 2014⁶⁷ [C/F]
	Ultrasound guided invasive procedures	Hage et al., 2016⁶⁸ [C]
	Venepuncture and/or intravenous catheterisation	Hunt et al., 2020¹⁵ [F]
		Lee et al., 2013⁶⁹ [C/F]
		Musk et al., 2017⁵⁴ [C]
		Pérez-Rivero and Rendón-Franco, 2011⁷⁰ [L]
		Silva et al., 2021⁷¹ [C]
		Williamson et al., 2016²⁹ [E]
Surgical procedure	Biopsy	Grimes et al., 20220⁷² [A]
	Orchiectomy (castration)	Griffon et al., 2000⁷³ [C]
		Hunt et al., 2020¹⁴ [C]
		Motta et al., 2018⁷⁴ [C]
	Enterotomy	Grimes et al., 2019⁴⁰ [A]
	Laparoscopy	Balsa et al., 2020⁷⁵ [C/F]
		Chen et al., 2017⁷⁶ [C]
		Elarbi et al., 2018³⁵ [E]
		Kilkenny et al., 2019³⁹ [A]
		Tapia-Araya et al., 2016⁷⁷ [C]
		Usón-Gargallo et al., 2014⁷⁸ [C]
	Ligation	Giusto et al., 2015⁴¹ [A]
		Olsen et al. 1996⁷⁹ [A]
		Smeak et al., 1991⁸⁰ [C]
	Ovariohysterectomy (OVH/spay)	Annandale et al., 2020⁸¹ [C]
		Au Yong et al., 2019⁸² [C]
		Badman et al., 2016⁸³ [F]
		Elarbi et al., 2018³⁵ [E]
		Langebæk et al., 2015⁸⁴ [C]
		MacArthur et al., 2020⁸⁵ [C]
		Read et al., 2016⁸⁶ [C]
	Suturing	Baillie et al., 2020⁴² [A]
		Caston et al., 2016⁸⁷ [A]
		Pérez-Rivero et al., 2015⁸⁸ [L]

The entries are categorised by simulator type, including author, publication date and species. [C] = canine; [F] = feline; [L] = lagomorph (rabbit); [B] = bovine; [E] = equine; [A] = all. It should be noted that some articles, such as Pérez-Rivero and Rendón-Franco³⁸ and Sachana et al., 2014³⁷ were descriptive surveys of veterinary student and faculty staff opinions on the use of simulators and therefore are not included in Table 1.

Discussion

The use of simulators for teaching purposes in veterinary and medical education has been extensively studied, and the reviewed literature illustrates that simulators are being developed and implemented into veterinary curricula across the globe, with the overall aim of improving practical skills in students (and therefore new graduates) and reducing the use of live animals and cadavers in veterinary education.

A notable species discrepancy

From the reviewed literature, there appears to be a notable species discrepancy within the field of simulator development, with small animal simulators seemingly over-represented compared with simulators based on other species. Simulator development for large animal species might be hindered by the costs involved or by the availability of materials, as large simulator models are likely to be more expensive and more difficult to construct from readily available everyday materials than table-top simulators. These factors may therefore contribute to the apparent bias towards the use of small animal simulators that are documented in the reviewed literature.

It must be noted that, for the purposes of clinical skill simulator modelling, the anatomy of mammalian species is very similar and therefore skills learnt through the use of certain models (for example skin suturing or ligation of blood vessels) will be transferrable to other species. However, there is a paucity of literature regarding the use of simulators based on large animals, as compared to those based on small animals — for example, although venepuncture simulators appear to be available for small animals and horses, none were found in the reviewed literature that were specifically designed to relate to farm animals. The procedure for jugular venepuncture in horses is very similar to that used in cattle, though phlebotomy (bleeding) of cattle is often performed via venepuncture of the tail vein (median ventral coccygeal vein), as this is considered to be quicker and easier to perform in cattle when restrained in a race or cattle crush, or when free-standing in cattle stalls, and provides little disturbance to the animal.⁸⁹ However, it should be noted that the lack of peer-reviewed literature detailing such simulators does not necessarily preclude their existence. Indeed, it is a distinct possibility that clinical skills laboratories within numerous veterinary schools hold a vast range of simulators which have never been described in the published literature.

Simulator efficacy

Many of the studies described in the reviewed articles appear to document that simulators can be used effectively to improve student skills in performing certain practical tasks.^{29–31,34,38–40,42,50,52,58,67,71,74,76,80–84,86,88} The time taken to carry out a surgical procedure, as well as the respective performance scores of students using simulators, have been correlated with live surgical performance and procedure times.^15,89 Training on models has been shown to achieve learning outcomes that are equivalent⁸⁶ or superior^71,72,78,82 to those achieved through the use of cadaver or live animal practical classes. Training based on simulators can increase student confidence in performing a task,^{56,71,73,80–83} and in identifying anatomical structures or landmarks, even if the students did not increase their competency in performing the practical task itself.^65,84 Simulators have also been shown to decrease student anxiety prior to performing a task on a live animal.^56,71,82

Positive feedback was received from students for the majority of the simulators documented in the reviewed literature, but in some studies, a few students provided feedback stating that they would prefer more live animals to be used for teaching purposes.^44,54

The humane evaluation and validation of simulators

A small number of the reviewed articles described how the procedural success of simulator training was monitored, by subsequently observing students performing the task on live animals; some studies used live animals obtained specifically for research purposes, and others used animals obtained for undergraduate or postgraduate teaching purposes. It must be noted that the use of live animals for invasive procedures (i.e. surgery), in this type of follow-up monitoring study, would be considered unethical in some veterinary schools, and thus would not pass the stringent ethical review process in those institutions. Indeed, the use of live animals obtained specifically for the purposes of teaching surgery is prohibited by some institutions. At the author’s institution, all surgical teaching is performed under direct and continuous supervision from a qualified veterinary surgeon registered with the Royal College of Veterinary Surgeons (MRCVS) on clinical cases undergoing surgery for medical reasons, with full informed consent from the animal’s owner. At no point in the veterinary course at the author’s institution are live animals obtained, anaesthetised, used for the purposes of teaching and then euthanised; such practices are forbidden in accordance with the institution’s ethical framework and guidelines.

However, it is understood that the purpose of certain types of study, involving the use of live animals, is to ensure that a simulator under development can mimic the real-life situation. If the simulator is thus validated, then it could replace the use of live animals for teaching certain skills, and therefore reduce the number of live animals used for teaching purposes in the longer term. However, alternative methods of simulator validation — ones that do not necessitate the use of live animals obtained solely for this purpose — would be preferred from an ethical standpoint. For example, it would be preferable to observe students performing a certain task on clinical cases requiring veterinary intervention, rather than obtaining animals and performing the task solely for validation purposes and without a clinical need.

According to the National Centre for the Replacement, Refinement and Reduction of Animals in Research (NC3Rs⁷) guidelines on the responsible use of animals in bioscience research, “All experimental work should seek where possible to avoid the use of animals if the work has the potential to cause animals pain, suffering, distress or lasting harm. Where use of animals is considered necessary, the researcher should advance sound scientific reasons for their use, explaining in proposals for support why no realistic alternative exists.”⁷ It could therefore be argued that if researchers were to follow these guidelines, then the procurement and use of animals purely for the purposes of validating teaching simulators would be prohibited, as there is no justifiable reason why veterinary students could not be observed performing such tasks on actual clinical cases during their training. The logistics of obtaining the data for such a follow-up study would be more complex and potentially lengthier than if it were solely generated within the veterinary school clinical laboratories, but this would not necessarily preclude such data from being obtained.

Academic and student opinion

Knight⁹⁰ documented that certain veterinary academics were opposed to the introduction of more-humane methods of teaching, and listed a number of institutions in which veterinary students had requested more-humane methods and had been met with opposition from their faculties. The majority of these institutions were in the USA. He also documented the introduction of a conscientious objection policy, for practicals involving the use of live animals or cadaver materials.⁹⁰ A number of reasons for academics objecting to the introduction of more-humane methods were also postulated — however, this article by Knight was published more than 15 years prior to the current review. It is hoped that the overall progress in the field of veterinary education, the quality improvements and enhancements in simulator use, and the advances made in virtual and augmented reality technologies that have occurred in the intervening years will have led to veterinary students no longer facing such opposition today.

According to Sachana et al.³⁷ students would like traditional training methods to be paired with alternative approaches, such as simulations, with 68.8% of students expressing a desire for alternative classes. Students did express a desire to be exposed to as many humane models for teaching as possible; however, 52.1% of students would not refuse a live animal class even if an alternative was offered. The study³⁷ appeared to show that simulations can be an effective supplement to traditional teaching methods, but it seems that, alongside some academics (as documented by Knight⁹⁰), some students still prefer live-animal or cadaver practical classes.⁵⁶ The preference for live-animal classes amongst some students could be due to increased realism and the perception that simulators cannot provide a true representation of performing tasks on live patients, even if the learning outcomes achieved through the use of simulators have been documented to be equivalent or superior to those achieved by using live animals.⁹¹ More research is required on this topic, particularly in light of recent advancements and growth in the area of simulators and simulations for use within veterinary education.

It should be noted that students raised concerns regarding the use of live animals in teaching in some studies,^44,48,79 but similarly some students provided feedback stating that they would prefer more live animals to be used for teaching purposes,^44,54 or that they did not consider the welfare of the animals used to be a concern due to the significant educational value provided by the practical class.⁴⁸ According to Verrinder and Phillips “veterinary students are sensitive to animal ethics issues and are motivated to prioritize the interests of animals but have little experience in taking action to address these issues”,⁹² which could be interpreted that veterinary students are aware of ethical guidelines surrounding the use of animals in a general sense, but perhaps do not know how to act in response to them. It therefore remains the responsibility of the educational establishment to ensure that any animal use adheres to their own ethical framework or guidelines, and that it is in line with national ethical guidelines. They should also aim to teach veterinary students the importance of animal welfare and the ethical use of animals in teaching and/or research. This includes providing access to a conscientious objection policy, if appropriate for the particular procedure being performed, and ensuring that this policy does not interfere with the compulsory aspects of the curriculum at the individual institution.⁹⁰

A future perspective

It is the author’s sincere hope that more simulators are developed and validated in the future, in order to help educators adhere to modern ethical guidelines that aim to protect animal welfare and reduce the need to obtain live animals solely for teaching or pedagogic research purposes. In addition, these simulators will provide veterinary students with opportunities to learn practical skills in a safe, low-risk environment. As aforementioned, it is not envisioned that simulators will completely supersede the use of live animals for teaching purposes, as this is a crucial aspect in many areas of veterinary training. It is hoped that the use of live animals, particularly for the teaching of invasive skills such as surgical techniques, will be restricted to clinical cases requiring veterinary intervention, rather than using animals that have been obtained solely for the purpose of teaching such skills. In these cases, however, the use of simulators will serve to increase student competence and confidence prior to their exposure to the actual clinical cases.

Conclusions

It was clear from the reviewed articles that there are a number of simulators and simulations currently available to veterinary educators, and that they can effectively enhance student skill acquisition, provide suitable alternatives to the use of live animals or cadaver material, and that they are usually well-received by students. There is a bias towards small animal simulators — however, some skills learnt through the use of small animal or table-top models will be transferrable to other species. The farm animal simulators reviewed were biased towards bovine rectal palpation and/or pregnancy diagnosis, and it was clear that there is scope for further research into large animal simulators, both for farm animals and for horses. The use of live animals to validate simulators in some of the reviewed studies would not be in adherence of current ethical guidelines in the UK. Further research is required, in order to develop an increased repertoire of available simulators for use in veterinary education. This will, in turn, serve to improve practical skills in veterinary students and also reduce the use of live animals and cadaver material in veterinary education, with the long-term aim of both improving animal welfare and the competence and confidence of veterinary graduates.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Helen R. Braid

References

Kustritz

. Simulations in veterinary education. Clin Therio 2014; 6: 607–610.

Scalese

Issenberg

. Effective use of simulations for the teaching and acquisition of veterinary professional and clinical skills. J Vet Med Educ 2005; 32: 461–467.

Edwards

. Global perspectives of veterinary education: Reflections from the 27th World Veterinary Congress. J Vet Med Educ 2004; 31: 9–12.

Royal College of Veterinary Surgeons (RCVS) . Day one competences. https://www.rcvs.org.uk/news-and-views/publications/rcvs-day-one-competences-feb-2022/ (2022, accessed 11 April 2022).

Williams

Nettifee-Osborne

Johnson

. A model for improving student confidence and experience in diagnostic sample collection and interpretation. J Vet Med Educ 2006; 33: 132–139.

Ericsson

. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79: S70–S81.

NC3Rs, BBSRC, Defra, MRC, NERC, Royal Society and Wellcome Trust . Responsibility in the use of animals in bioscience research: Expectations of the major research councils and charitable funding bodies. 3rd ed. London: NC3Rs, 2019, 24 pp.

UK Government . Animal Welfare Act. https://www.legislation.gov.uk/ukpga/2006/45/contents (2006, accessed 7 April 2022).

Hart

Wood

Weng

. Mainstreaming alternatives in veterinary medical education: Rlc development and curricular reform. J Vet Med Educ 2005; 32: 473–480.

10.

InterNICHE . About InterNICHE . https://www.interniche.org/en/about (2022, accessed 12 April 2022).

11.

UK Government . Animals (Scientific Procedures) Act . https://www.legislation.gov.uk/ukpga/1986/14/contents (1986, accessed 12 April 2022).

12.

Baillie

. Utilisation of simulators in veterinary training. Cattle Pract 2007; 15: 224.

13.

Crossan

Brewster

Reid

, et al. A horse ovary palpation simulator for veterinary training. In: Brewster

Murray-Smith

(eds) Haptic human–computer interaction. Berlin: Springer Berlin Heidelberg, 2000, pp. 157–164.

14.

Hunt

Heydenburg

Kelly

, et al. Development and validation of a canine castration model and rubric. J Vet Med Educ 2020; 47: 78–90.

15.

Hunt

Hughes

Asciutto

, et al. Development and validation of a feline medial saphenous venipuncture model and rubric. J Vet Med Educ 2020; 47: 333–341.

16.

Parasuraman

Tippelt

Hellwig

. Brain, cognition and learning in adulthood. In: Understanding the brain: the birth of a learning science. Paris: OECD Publishing; 2007, pp. 211–237. https://doi.org/10.1787/9789264029132

17.

Wetzel

Kneebone

Woloshynowych

, et al. The effects of stress on surgical performance. Am J Surg 2006; 191: 5–10.

18.

Dilly

Read

Baillie

. A survey of established veterinary clinical skills laboratories from Europe and North America: Present practices and recent developments. J Vet Med Educ 2017; 44: 580–589.

19.

Baillie

Crossan

Brewster

, et al. Evaluating an automated haptic simulator designed for veterinary students to learn bovine rectal palpation. Simul Healthc 2010; 5: 261–266.

20.

Martinsen

Jukes

. Towards a humane veterinary education. J Vet Med Educ 2005; 32: 454–460.

21.

Halevi

Moed

Bar-Ilan

. Suitability of Google Scholar as a source of scientific information and as a source of data for scientific evaluation—review of the literature. J Informetr 2017; 11: 823–834.

22.

Annandale

Fosgate

, et al. Training method and other factors affecting student accuracy in bovine pregnancy diagnosis. J Vet Med Educ 2018; 45: 224–231.

23.

Baillie

Crossan

Reid

, et al. Preliminary development and evaluation of a bovine rectal palpation simulator for training veterinary students. Cattle Pract 2003; 11: 101–106.

24.

Baillie

Mellor

Brewster

, et al. Integrating a bovine rectal palpation simulator into an undergraduate veterinary curriculum. J Vet Med Educ 2005; 32: 79–85.

25.

Bossaert

Leterme

Caluwaerts

, et al. Teaching transrectal palpation of the internal genital organs in cattle. J Vet Med Educ 2009; 36: 451–460.

26.

Kinnison

Forrest

Frean

, et al. Teaching bovine abdominal anatomy: Use of a haptic simulator. Anat Sci Ed 2009; 2: 280–285.

27.

Zolhavarieh

Sadeghi-nasab

Ghanbari

, et al. Preliminary evaluation of learning performance of the simplest bovine trans-rectal palpation phantom for training veterinary students. Iranian J Ruminant Health Res 2016; 1: 21–30.

28.

French

Dascanio

Peterson

, et al. Development and student evaluation of an anatomically correct high-fidelity calf leg model. J Vet Med Educ 2018; 45: 126–130.

29.

Williamson

Dascanio

Christmann

, et al. Development and validation of a model for training equine phlebotomy and intramuscular injection skills. J Vet Med Educ 2016; 43: 235–242.

30.

Fox

Sinclair

Bolt

, et al. Design and validation of a simulator for equine joint injections. J Vet Med Educ 2013; 40: 152–157.

31.

Gunning

Smith

Fox

, et al. Development and validation of an equine nerve block simulator to supplement practical skills training in undergraduate veterinary students. Vet Rec 2013; 172: 450–450.

32.

Elnady

Sheta

Khalifa

, et al. Training of upper respiratory endoscopy in the horse using preserved head and neck. ALTEX 2015; 32: 384–387.

33.

Nagel

Ille

Erber

, et al. Stress response of veterinary students to gynaecological examination of horse mares—Effects of simulator-based and animal-based training. Reprod Dom Anim 2015; 50: 866–871.

34.

Nagel

Ille

Aurich

, et al. Teaching of diagnostic skills in equine gynecology: Simulator-based training versus schooling on live horses. Theriogenology 2015; 84: 1088–1095.

35.

Elarbi

Ragle

Fransson

, et al. Face, construct, and concurrent validity of a simulation model for laparoscopic ovariectomy in standing horses. J Am Vet Med A 2018; 253: 92–100.

36.

Allavena

Schaffer-White

Long

, et al. Technical skills training for veterinary students: A comparison of simulators and video for teaching standardized cardiac dissection. J Vet Med Educ 2017; 44: 620–631.

37.

Sachana

Theodoridis

Cortinovis

, et al. Student perspectives on the use of alternative methods for teaching in veterinary faculties. Altern Lab Anim 2014; 42: 223–233.

38.

Perez-Rivero

Rendon-Franco

. Experience of the use of table-top simulators as alternatives in the primary surgical training of veterinary undergraduate students. Altern Lab Anim 2012; 40: P10–P11.

39.

Kilkenny

White

Singh

. Evaluating veterinary student skill acquisition on a laparoscopic suturing exercise after simulation training. Vet Surg 2019; 48: O66–O73.

40.

Grimes

Wallace

Schmiedt

, et al. Evaluation of surgical models for training veterinary students to perform enterotomies. Vet Surg 2019; 48: 985–996.

41.

Giusto

Comino

Gandini

. Validation of an effective, easy-to-make hemostasis simulator. J Vet Med Educ 2015; 42: 85–88.

42.

Baillie

Christopher

Catterall

, et al. Comparison of a silicon skin pad and a tea towel as models for learning a simple interrupted suture. J Vet Med Educ 2020; 47: 516–522.

43.

Modell

Cantwell

Hardcastle

, et al. Using the human patient simulator to educate students of veterinary medicine. J Vet Med Educ 2002; 29: 111–116.

44.

Capilé

Campos

GMB

Stedile

, et al. Canine prostate palpation simulator as a teaching tool in veterinary education. J Vet Med Educ 2015; 42: 146–150.

45.

Williamson

Hecker

Yvorchuk

, et al. Development and validation of a feline abdominal palpation model and scoring rubric. Vet Rec 2015; 177: 151–151.

46.

Banse

McMillan

Warren

, et al. Development of and validity evidence for a canine ocular model for training novice veterinary students to perform a fundic examination. J Vet Med Educ 2021; 48: 620–628.

47.

Nibblett

BMD

Pereira

Williamson

, et al. Validation of a model for teaching canine fundoscopy. J Vet Med Educ 2015; 42: 133–139.

48.

Williams

Wager

Brearley

. Student attitudes regarding the educational value and welfare implications in the use of model eyes and live dogs in teaching practical fundus examination: Evaluation of responses from 40 students. Open Vet J 2016; 6: 172.

49.

Troy

Bergh

. Development and efficacy of a canine pelvic limb model used to teach the cranial drawer and tibial compression tests in the stifle joint. J Vet Med Educ 2015; 42: 127–132.

50.

Nibblett

BMD

Pereira

Sithole

, et al. Design and validation of a three-dimensional printed flexible canine otoscopy teaching model. Sim Healthc 2017; 12: 91–95.

51.

Jones

Rinehart

Spiegel

, et al. Development of veterinary anesthesia simulations for pre-clinical training: Design, implementation, and evaluation based on student perspectives. J Vet Med Educ 2018; 49(2): 232–240.

52.

Jones

Rinehart

Englar

. The effect of simulation training in anesthesia on student operational performance and patient safety. J Vet Med Educ 2019; 46: 205–213.

53.

Lewis

Sherfield

Fellows

, et al. The effect of experience, simulator-training and biometric feedback on manual ventilation technique. Vet Anaesth Analg 2017; 44: 567–576.

54.

Musk

Collins

Hosgood

. Teaching veterinary anesthesia: a survey-based evaluation of two high-fidelity models and live-animal experience for undergraduate veterinary students. J Vet Med Educ 2017; 44: 590–602.

55.

Fletcher

Militello

Schoeffler

, et al. Development and evaluation of a high-fidelity canine patient simulator for veterinary clinical training. J Vet Med Educ 2012; 39: 7–12.

56.

Langebæk

Berendt

Tipold

, et al. Evaluation of the impact of using a simulator for teaching veterinary students cerebrospinal fluid collection: A mixed-methods study. J Vet Med Educ 2021; 48: 217–227.

57.

Hunt

Schmidt

Perkins

, et al. Educational research report comparison of three canine models for teaching veterinary dental cleaning. J Vet Med Educ 2021; 48: 573–583.

58.

Lumbis

Gregory

Baillie

. Evaluation of a dental model for training veterinary students. J Vet Med Educ 2012; 39: 128–135.

59.

Mariano Beraldo

Lopes

Hage

, et al. The value of homemade phantoms for training veterinary students in the ultrasonographic detection of radiolucent foreign bodies. Adv Physiol Educ 2017; 41: 94–98.

60.

McCool

Bissett

Hill

, et al. Evaluation of a human virtual-reality endoscopy trainer for teaching early endoscopy skills to veterinarians. J Vet Med Educ 2020; 47: 106–116.

61.

Pérez-Merino

Usón-Gargallo

Sánchez-Margallo

, et al. Comparison of the use of fresh-frozen canine cadavers and a realistic composite ex vivo simulator for training in small animal flexible gastrointestinal endoscopy. J Am Vet Med A 2018; 252: 839–845.

62.

Usón-Gargallo

Usón-Casaús

Pérez-Merino

, et al. Validation of a realistic simulator for veterinary gastrointestinal endoscopy training. J Vet Med Educ 2014; 41: 209–217.

63.

Aulmann

März

Burgener

, et al. Development and evaluation of two canine low-fidelity simulation models. J Vet Med Educ 2015; 42: 151–160.

64.

Clausse

Nejamkin

Bulant

, et al. A low-cost portable simulator of a domestic cat larynx for teaching endotracheal intubation. Vet Anaesth Analg 2020; 47: 676–680.

65.

Neves

ECD

Pelizzari

Oliveira

, et al. 3D anatomical model for teaching canine lumbosacral epidural anaesthesia. Acta Cir Bras 2020; 35: e202000608.

66.

Williamson

. Construct validation of a small-animal thoracocentesis simulator. J Vet Med Educ 2014; 41: 384–389.

67.

Williamson

Rito

RMF

. Development of a training model for small animal thoracocentesis and chest tube thoracostomy. Altern Lab Anim 2014; 42: 201–205.

68.

Hage

MCFNS

Massaferro

Lopes

ÉR

, et al. Value of artisanal simulators to train veterinary students in performing invasive ultrasound-guided procedures. Adv Physiol Educ 2016; 40: 98–103.

69.

Lee

, et al. Augmented reality intravenous injection simulator based 3D medical imaging for veterinary medicine. Vet J 2013; 196: 197–202.

70.

Perez-Rivero

Rendón-Franco

. Validation of the educational potential of a simulator to develop abilities and skills for the creation and maintenance of an intravenous cannula. Altern Lab Anim 2011; 39: 257–260.

71.

da Silva

Fernandes

Ventrone

, et al. The influence of low-fidelity simulator training on canine peripheral venous puncture procedure. Vet World 2021; 14: 410.

72.

Grimes

Appleton

Moss

, et al. A simulated tumour for teaching principles of surgical oncology for biopsy and excision of skin and subcutaneous masses to veterinary students. J Vet Med Educ 2021; 48: 636–639.

73.

Griffon

Cronin

Kirby

, et al. Evaluation of a hemostasis model for teaching ovariohysterectomy in veterinary surgery. Vet Surg 2000; 29: 309–316.

74.

Motta

Carter

Sweazy

, et al. Development and validation of a low-fidelity, low-cost surgical simulation model to teach canine orchiectomy. Clin Therio 2018; 10: 125–139.

75.

Balsa

Giuffrida

Culp

WTN

, et al. Perceptions and experience of veterinary surgery residents with minimally invasive surgery simulation training. Vet Surg 2020; 49(Suppl. 1): O21–O27.

76.

Chen

C-Y

Ragle

Lencioni

, et al. Comparison of 2 training programs for basic laparoscopic skills and simulated surgery performance in veterinary students. Vet Surg 2017; 46: 1187–1197.

77.

Tapia-Araya

Usón-Gargallo

Enciso

, et al. Assessment of laparoscopic skills in veterinarians using a canine laparoscopic simulator. J Vet Med Educ 2016; 43: 71–79.

78.

Usón-Gargallo

Tapia-Araya

Díaz-Güemes Martin-Portugués

, et al. Development and evaluation of a canine laparoscopic simulator for veterinary clinical training. J Vet Med Educ 2014; 41: 218–224.

79.

Olsen

Bauer

Seim

, et al. Evaluation of a hemostasis model for teaching basic surgical skills. Vet Surg 1996; 25: 49–58.

80.

Smeak

Beck

Shaffer

, et al. Evaluation of video tape and a simulator for instruction of basic surgical skills. Vet Surg 1991; 20: 30–36.

81.

Annandale

Scheepers

Fosgate

. The effect of an ovariohysterectomy model practice on surgical times for final-year veterinary students’ first live-animal ovariohysterectomies. J Vet Med Educ 2020; 47: 44–55.

82.

Yong JA

Case

Kim

, et al. Survey of instructor and student impressions of a high‐fidelity model in canine ovariohysterectomy surgical training. Vet Surg 2019; 48: 975–984.

83.

Badman

Tullberg

Höglund

, et al. Veterinary student confidence after practicing with a new surgical training model for feline ovariohysterectomy. J Vet Med Educ 2016; 43: 427–433.

84.

Langebæk

Toft

Eriksen

. The SimSpay –– student perceptions of a low-cost build-it-yourself model for novice training of surgical skills in canine ovariohysterectomy. J Vet Med Educ 2015; 42: 166–171.

85.

MacArthur

Johnson

Colee

. Effect of a spay simulator on student competence and anxiety. J Vet Med Educ 2021; 48: 115–128.

86.

Read

Vallevand

Farrell

. Evaluation of veterinary student surgical skills preparation for ovariohysterectomy using simulators: A pilot study. J Vet Med Educ 2016; 43: 190–213.

87.

Caston

Schleining

Danielson

, et al. Efficacy of teaching the gambee suture pattern using simulated small intestine versus cadaveric small intestine. Vet Surg 2016; 45: 1019–1024.

88.

Pérez-Rivero

Batalla-Vera

Rendón-Franco

. Development and validation of a low-fidelity simulator to suture a laparotomy in rabbits. Altern Lab Anim 2015; 43: P44–P48.

89.

Kramer

. A tail-bleeding technique for cattle. New Zeal Vet J 1962; 10: 41–41.

90.

Knight

. The effectiveness of humane teaching methods in veterinary education. ALTEX 2007; 24: 91–109.

91.

Hunt

Simons

Anderson

. If you build it, they will learn: A review of models in veterinary surgical education. Vet Surg 2022; 51: 52–61.

92.

Verrinder

Phillips

CJC

. Identifying veterinary students’ capacity for moral behavior concerning animal ethics issues. J Vet Med Educ 2014; 41: 358–370.

The Use of Simulators for Teaching Practical Clinical Skills to Veterinary Students — A Review

Abstract

Keywords

Introduction

Materials and methods

Search strategy

Results

Small animal simulators

Farm animal simulators

Equine simulators

Simulators applicable to all species

Discussion

A notable species discrepancy

Simulator efficacy

The humane evaluation and validation of simulators

Academic and student opinion

A future perspective

Conclusions

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

References