Clinical simulation is a teaching, learning and evaluation methodology that offers advantages in the training of health professionals compared to traditional methods (Nestel et al., 2011; Corvetto et al., 2013; Abas and Juma, 2016; Herrera-Aliaga and Estrada, 2022). Seeks the learner’s interaction with environments that mimic reality, in order to acquire skills necessary for clinical performance (Fraser et al., 2012); conceives practical and perfectible learning, involving emotions, analysis and reflection on one’s own performance (Cleary et al., 2020), through an experiential experience, which implies a meaningful and, therefore, long-term learning (Herrera-Aliaga and Estrada, 2022). Simulation allows better problem solving using clinical reasoning (Armijo-Rivera et al., 2020) and allows the student to increase his self-confidence in relation to learning (Abas and Juma, 2016).

In simulation, the participation of standardized patients is common, constituting a widely accepted tool for teaching and with important benefits for the student in health science field (McNaughton and Anderson, 2017), including in nutrition and dietetics field (O’Shea et al., 2019). The standardized patient is defined as an actor or trained person who simulates a health condition, which increases the fidelity of the experience (McNaughton and Anderson, 2017; O’Shea et al., 2019). The standardized patient generates “standard responses” and allows the development of various skills such as attitudinal and procedural, which are necessary for optimal professional preparation and for interaction with real users (McNaughton and Anderson, 2017).

The COVID-19 pandemic generated the massive incorporation of “remote” methodologies, multiplying the use of tele-simulation or online simulation (MacKenna et al., 2021), which corresponds to a relatively recent modality for health education and consists of linking, through the internet, of an instructor and a trainee in a simulated scenario (McCoy et al., 2017). There are successful applications of this methodology especially in the area of laparoscopic surgery (Henao et al., 2013; McCoy et al., 2017; Jarufe et al., 2018). When the on-site participation of students and instructors is not possible, remote training is possible in specific situations, being able to use standardized patients for that purpose, maintaining the same principles of a face-to-face simulation: Brief, Scenario and Debriefing. This methodology was incorporated in the University, in the Nutrition and Dietetics Program in the context of the pandemic, for the development of the necessary skills to carry out the food anamnesis, which is part of the Nutritional Care Process (NCP; Buchholz et al., 2018, 2020).

The NCP is a “systematic method that allows problem solving for nutrition professionals based on reasoning, critical thinking and scientific evidence to make decisions and guarantee comprehensive, quality, adequate, timely, safe, rigorous and effective” (Ichimasa, 2015; Carbajal et al., 2020). It has application in the clinical or public health field, adapting to the physiological, pathological, psychological and social needs of the individual (Hammond et al., 2014; Carbajal et al., 2020), and is considered essential for professional performance. It consists of four consecutive stages: i. Assessment, ii. Diagnosis, iii. Intervention, and iv. Monitoring or Follow-up (Buchholz et al., 2018). In the assessment, the antecedents such as the clinical, social and nutritional history, biochemical and physical examinations are collected, and anthropometric measurements are made, which also implies verifying and interpreting the nutritional information (Bueche et al., 2008a,b; Petermann et al., 2017; Carbajal et al., 2020). At this stage, surveys are applied through food anamnesis (Petermann et al., 2017), which aim to identify dietary alterations, know the habits and food intake of patients (Troncoso-Pantoja et al., 2020). The most common methods used are the 24-Hour Dietary Recall (24hDR) and Food Frequency Questionnaire (FFQ). The 24hDR is for the patient to remember everything they ingested the day before, both solid and liquid foods, so that the nutritionist can quantify the intake (Foster and Bradley, 2018). The FFQ consists of knowing the frequency of consumption of certain foods during a certain period of time (Troncoso-Pantoja et al., 2020). NCP is related to better results in nutritional intervention in the treatment of malnutrition due to excess in the adult population (Petermann et al., 2017) and children (Kim et al., 2019). In addition, it improves the productivity and communication and interaction of the health team (Ichimasa, 2015; Carbajal et al., 2020). Therefore, the NCP should be addressed in the training of students of the discipline, since its proper application can impact the clinical results of the patient (Petermann et al., 2017; Kim et al., 2019).

As a research problem, tele-simulation is a relatively recent incorporation and its impact on students’ perception and learning is not known. In this research, a tele-simulation experience with a standardized patient was implemented in third year students of the Nutrition and Dietetics Program. The objective of this research was to know the academic performance and the student’s perception of their ability to apply a dietary anamnesis through 24hDR thought the tele-simulation methodology.

The present investigation corresponds to quantitative, longitudinal study in three times, between the months of June to November 2021.

Due to the COVID-19 pandemic, forms of education were modified to adapt to the health needs of distance education (Beshgetoor and Wade, 2007; Dieckmann et al., 2020; MacKenna et al., 2021). A series of technological changes were evidenced to support the new modalities of education, learning and assessment. Given this scenario, the concern was on the impact of these new modalities on academic training beyond how novel they may seem. The incorporation of online simulations or telesimulations was established in our institution as a useful measure to continue learning in the different health disciplines.

Tele-simulation as a teaching-learning-evaluation experience based on remote interaction was perceived by students as a positive experience, highlighting it as a viable and applicable one in contexts where there is a need for social distancing (McCoy et al., 2017). Likewise, the students perceived that the tele-simulation was realistic, and they agreed that it favored the development of professional skills. Although changes are observed in the assessment of the first and third tele-simulation, it does not represent a significant event, which could be explained in the empowerment of the student given the repetitive practice that is an inherent quality of the simulation (McCoy et al., 2017). These results coincide with previous studies, where the simulation was perceived as real, and its ability to promote learning was highlighted (Beshgetoor and Wade, 2007; Sa-Couto and Nicolau, 2020). Another aspect well evaluated by the students was that this methodology allows the development of skills to relate to the patient, being essential in undergraduate teaching since it is one of the most difficult aspects to develop, since for its execution they converge, beyond technical capabilities, communication, active listening, among other skills (Porter et al., 2019).

Also noteworthy is the feedback provided by both the teacher and the simulated patient. Feedback is considered one of the central aspects in simulation-based education, and a constitutive part of all activities where this methodology mediates since it generates an impact on emotions and therefore results in reflective and long-term learning (Ramjan et al., 2016; Herrera-Aliaga and Estrada, 2022). Feedback is essential during debriefing, allowing to deepen learning (Davis, 2019), therefore, the possibility of doing it in online education is recommended on the one hand, and on the other, it is possible to do it while maintaining the same principles when it is done in person (McCoy et al., 2017). Debriefing is a fundamental strategy in simulation and tele-simulation, currently there are several types of debriefing (GAS, CORE, With Good Judgment, etc.), another modality is self-debriefing, which consists of self-management of reflection by students (Mackenna et al., 2021).

The tele-simulation led to improvements in academic performance, especially in aspects of skills in the structural items of the 24hDR, such as the ability to quantify specific aspects of the diet (Table 3; Quantification of intake), this point is remarkable given that the 24hDR is part of the assessment and this, in turn, from NCP (Hammond et al., 2014; Carbajal et al., 2020; Troncoso-Pantoja et al., 2020), which shows that tele-simulation with standardized patient contributes to the formation of skills for the execution of this process, however, it is necessary to know how other teaching-learning methodologies impact for the application of 24hDR, which have not been analyzed. Also, little variation is observed in the aspects of the survey that are related to analyzing the patient’s intake, a situation that could be explained since “analyzing” requires metacognition, a more complex ability to acquire, but which can be developed through simulation as an educational methodology (Medina et al., 2017) for which it is interesting to know if, when subjecting the student to more than three tele-simulations, this aspect presents improvements.

When the student’s self-perception survey to execute the 24hDR is analyzed, significant differences are observed in the ability to use an adequate verbal and non-verbal language with the standardized patient, specifically in the tele-simulation III, which coincides with another study where nutrition and dietetics students increase communication skills with simulated patients (Hampl et al., 1999; Henry et al., 2009; Buchholz et al., 2020). Despite not showing significant differences in the other aspects to be evaluated, it is striking to observe that in the subsequent evaluation the assessment decreased, that is, the students felt they had less capacity to apply the 24hDR, which can be explained by the fact that the students reflect on a more critical way about their own performance, which is part of what the simulation aims to achieve (O’Shea et al., 2019).

In summary, the incorporation of standardized patients is a strategy that allows the training of skills in nutrition students (Hampl et al., 1999; Henry et al., 2009) and among the advantages of the implementation of this methodology is the decrease in the use of physical and financial resources compared to a face-to-face instance (McCoy et al., 2017), in addition to maintaining the essence of the clinical simulation methodology that allows the interaction between professional and patient despite physical distancing. In addition, as a substantial aspect, this activity allows the evaluation of learning through ad-hoc instruments, which can later be analyzed and allow the identification of deficiencies and the elaboration of action plans that allow reinforcing content.

However, experience shows some disadvantages related to technological gaps, such as the student’s need to have computer equipment (personal computer, smartphone, web camera) with an internet connection, this implies that the study may not be replicable under the same conditions in other countries or regions with limited access to these technologies. Likewise, the impossibility of training technical skills, such as anthropometry, is also a disadvantage, relegating oneself to face-to-face activities. Another aspect that appears as an opportunity for improvement corresponds to the realism offered by the activity, where it would be necessary to establish technological improvements and teaching skills, so that the experience increases its realism. Also, it requires special emphasis on student self-regulation in relation to their learning processes (McCoy et al., 2017) and the emotions associated with learning (Fraser et al., 2012; Rogers et al., 2019; Pino et al., 2023). Likewise, this instance did not improve aspects of the diet analysis, since they are more complex skills such as clinical reasoning (Miles et al., 2016; Medina et al., 2017).

As limitations of the study, it is worth mentioning the type of sample, which was intentional and not randomized, as well as its size (n = 25), which limits the generalizability of the results. Another limitation emerges from the fact that only three tele-simulations were included in this study, which does not allow for longer observation over time with more interventions; it is possible that in further tele-simulations, different results will emerge, because repetitive exercise improves skills. Finally, it is necessary to incorporate other variables in future studies, for example, how students’ emotions impact on learning, because in the first simulations students present emotions such as “anxiety” or “fear,” which change to “calmness” and other “positive” emotions in successive simulations with standardized patients, according to a recent study (Pino et al., 2023).

It favors the development of clinical skills, despite the physical distance with the patient (McCoy et al., 2017), which also allows giving continuity to the teaching, learning and evaluation processes. In this research, an increase in the performance of nutritional interviewing skills was evidenced. In future research, it is important to evaluate how emotions are related to the development of learning through this methodology, since they can have a significant impact on cognitive processes (Fraser et al., 2012; Rogers et al., 2019).

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

RP, CM-C, EH-A, and CP-A participated in the conception of the study, application for funds, methodological design, construction of evaluation instruments, and data interpretation. RP and CP-A carried out the data collection. RP performed the quantitative analysis of the data. RP, CM-C, EH-A, CP-A, XR-P, and LE participated in the writing of the manuscript. All authors contributed to the article and approved the submitted version.