#31214: Teaching Healthcare Professionals Using Simulation

When used as a teaching method and not just a piece of technology, simulation can be invaluable in educating students. It is difficult to use simulation to replace physical contact with live patients, but it can make student and faculty time in actual clinical environments more valuable and cost-effective [1]. It creates a learner-centered environment whereby students can take on the role of the healthcare provider, allowing students an avenue to practice skills within their potential scope of practice (instead of under the limitations of a student). Students can face situations they will need to manage as new practitioners in an environment where they can make mistakes and see the consequences without risking patient harm [18,46]. When taught in the hospital setting, students must function as students, with limited scope and responsibilities. When used in a lab, simulation allows students to act out scenarios to learn about specific procedures and case presentations.

Creating realistic, student-driven simulations can increase critical-thinking skills and knowledge retention. However, these scenarios can prove difficult for educators who are more accustomed to teacher-centered, traditional, lecture-style instructional methods [19,56]. However, when used as an immersive learning environment, simulation scenarios require minimal faculty involvement limited to facilitation. In these scenarios, students are provided the opportunity to link didactic material to the clinical environment without the fear or anxiety of possibly inflicting patient harm. Students also have the luxury of having instant feedback on their interventions and actions.

When used as an adjunct to traditional lecture courses, simulation can keep students engaged in the classroom. Bringing a mannequin to the classroom can bring case studies to life, providing a means for demonstrating procedures, physiologic responses, or case presentations. For example, instead of having students read and listen to a lecture about bacterial meningitis, a hands-on option could be added. A simulation exercise coupled with this lecture content could show students the characteristic rash, how the acute illness can rapidly progress if untreated, and a demonstration of positioning for a lumbar puncture procedure or possibly even intubation for airway management. Instead of appealing to one type of learner (the auditory style), the lesson would also engage the active and visual learners to make a richer learning experience for everyone.

Simulation can also be used as a supplement for clinical experiences. With student enrollments increasing to meet the demands of projected shortages, clinical site competition between schools is growing, making it difficult for faculty to provide everyday clinical experience for students. Days with a dearth of patients, surgeries, or experiences do occur, most commonly in specialty areas like pediatrics or maternity. Simulation can be a solution to these situations, allowing for a productive use of resources instead of wasted down time.

Simulation may also be a way for clinical instructors to evaluate the level of performance of their students. Often, instructors can only be with one student at a time, running from one student to the next to pass medications, help interpret charts, answer questions, and possibly assist with procedures. Simulation allows instructors to work with and evaluate multiple students instead of only one at a time.

Watching students during a simulation exercise can provide a wealth of knowledge to educators. They can see which of their students understand the content, which students need practice with communication skills, which can step up to the leadership role, and which need remediation. This is the ultimate tool for students who have not previously had patient contact. Educators can evaluate students in a standardized environment. For example, students may be assessed on their ability to perform a pediatric physical assessment without the participation of parents, an uncooperative child, or clinical area activity (i.e., distractions), unless the instructor designs these factors into the experience.

Educators in staff development are also increasing the use of simulation as a means of working with licensed healthcare professionals. From physicians in residency programs to graduate nurses, the flexibility and personalization of this teaching modality appeal to most everyone. The most commonly used application in this area is for training purposes, to teach new skills, or reinforce previously learned ones. The skills can be task-focused for beginner-level learners, and complexity can be increased with the level of knowledge of the learner. For example, the instructor may be interested in teaching staff how to perform a breast exam on female patients. This very personal task is objectively simple to perform, but it can be intimidating to students due to the importance of doing it right to detect breast cancer and the intimate nature of the patient contact. The students can be presented with the methods used and then given breast exam task trainer models on which to practice. When they can demonstrate proper completion of the breast exam on the models, a level of complexity can be added. The task trainer can next be applied to a person or a mannequin. This adds a more personal element and can help students overcome the social anxiety that may be associated with the exam. Students would have to also practice communication skills when interacting with the "patient" as well. For the most advanced students, the model could even contain a lump, which would then require the student to deliver bad news and treatment options to the patient. Tying the emotional aspect to the clinical knowledge in these exercises creates a memorable learning experience and can help with knowledge retention and transference into clinical practice.

Remediation is another application for staff development. There are times when staff require additional practice or another chance to catch on to a procedure, skill, or task. Simulation can be a way to put individuals in a safe learning environment, so remediation can be most effective. Instead of capitalizing on those negative thoughts and singling a staff member out to demonstrate a specific skill, simulation can be used to put them into a clinical setting and recreate their comfort zone, helping them to relax and perform at their optimal level.

Simulation as an evaluation method can be used in many facets of healthcare education. The value of using simulation for evaluation is being increasingly appreciated, as traditional methods of testing (such as observation and oral exams) are limited in their ability to distinguish between adequate and inadequate clinical performance [20,57]. For example, the Objective Structured Clinical Examination (OSCE) medical and nurse practitioner students pass to obtain licensure is incorporating more simulation in place of real patients. OSCEs may even have a place in other health profession's licensing exams in the future.

On a simpler scale, simulation can be used for individual courses. It provides a unique opportunity for instructors to create a clinical environment conducive to testing without the variability of real-life circumstances. Simulation can be used as a tool to test simple skills such as Foley catheter insertion or more complex concepts such as shift reports or hand-off communication.

However, using simulation as an evaluation method is not without its downside. There is a risk that using simulation this way will ruin the safe learning environment created for education. It is important to be upfront with learners about the goals of the experience. When students know what is expected of them, they can feel prepared and act accordingly. When they come with one expectation (the experience is for learning) and are asked to complete another (an examination), they may feel that they were not informed or allowed the opportunity to be prepared. In addition, the technology can be distracting for some learners, who may focus entirely on the mode of simulation and ignore the patient.

Many professionals complete tests to validate their level of performance and to continue clinical practice. This can be specialty-specific skills, such as how to work certain equipment or complete certain documentation methods, or it can be a renewal of certifications required to work, such as advanced cardiac life support (ACLS), pediatric advanced life support (PALS), or neonatal resuscitation. Whatever they may be, organizations are required to show their staff have displayed the skills necessary to safely practice.

The traditional method of evaluating these designated competencies is skill demonstration stations. Using this model, staff demonstrate their designated requirements to a validator, who would then sign them off to the organization as safe to continue to practice. This can be time-consuming and labor-intensive and is not the most effective means of completing competency validation. Staff usually also have the option of being signed off on the skill when performing patient care, but this can be dangerous and may take unnecessary risks.

Simulation can be used in place of or in conjunction with demonstration stations to help evaluate staff and develop professional knowledge, skills, and attitudes while protecting patients [21,49]. Creating a simulation that incorporates the essential elements of competency can be a more effective means of testing. Small teams could participate and be evaluated, and teams could include various disciplines. This would allow individual skills to be tested, as required, and would promote team building and communication skills.

Using simulation for team training shows promise in impacting knowledge, attitudes, and behaviors of a team's skills [22,58]. The goal is to produce efficient healthcare teams that optimize the use of people, resources, and communication to create a safer care environment for patients. In aviation, these team-building simulations were called crew resource management; the adaptation in health care is commonly termed crisis resource management (CRM).

CRM has become a training methodology to develop healthcare professionals who can efficiently work within a team to perform in high-stress, life-threatening situations by applying concepts of leadership, communication, assertiveness, decision-making, and team performance [23,59]. Emphasis in CRM courses is placed on behavioral skills, such as communication, leadership, and situational awareness [24,59,60]. Within healthcare organizations, professionals have often become accustomed to working in silos; nurses work well with nurses, respiratory therapists work well with respiratory therapists, and physicians work well with physicians. When members of these various disciplines are pulled together, it can be confusing to determine who takes the lead, how to communicate effectively, or how to understand each other's scope of practice. Problems in the interdisciplinary team are enough of a problem when they happen during a less risky task, such as transporting a patient to a new room. However, when team breakdown and communication difficulties occur in an ad hoc crisis group, such as a cardiac arrest team, this disconnect can lead to sentinel events and poor patient outcomes. CRM is geared to address these concerns.

Most CRM trainings consist of different parts. The first is a didactic portion that covers the background and principles of CRM. Then, there is trainee participation in a simulation scenario, whereby they manage a crisis event. This is followed by a debriefing of all the participants, during which a critical analysis of the simulation event and self-reflection of their performance is completed, often utilizing video debriefing [23,59]. The participants should be multidisciplinary, including for example, nurses, physicians, and respiratory therapists. Having representatives from various disciplines fosters collaboration, understanding, and communication among the team.

To properly facilitate better communication, some healthcare organizations have adopted the SBAR technique for communicating information among healthcare professionals of various disciplines. The acronym SBAR refers to four steps in effective conveyance of patient information [42]:

Simulation scenarios may be used to gauge a team's communication techniques and adherence to the SBAR standard.

Derivatives of CRM and SBAR courses have been created for team training. The Agency for Healthcare Research and Quality has established the TeamSTEPPS program, a three-phase teamwork system that is evidence-based and aimed at improving patient safety by improving communication and teamwork skills among healthcare professionals [25]. Other trainings exist, but the basis is the same: improve patient safety by teaching healthcare professionals how to work effectively in a team.

The very first step when creating a simulation scenario is to establish the educational goals of the session. These goals will determine the complexity and the type of scenario that should be created. For example, is the goal for the students to practice taking vital signs while distracted by patient questioning, or is it to know when to call a physician for orders? Maybe the goal is more complex, such as teaching how to prioritize patient care needs or to develop and utilize critical-thinking skills. After the goals are defined, then the scenario can be formulated.

When the goals have been set, the topic or content to be covered must be selected. This can be overwhelming if a large amount of content is being taught. Most often, the content of a simulation stems from a disease process. For example, the simulation content might be on postpartum hemorrhage, exacerbation of congestive heart failure, or care of a pediatric patient with an asthma attack. There may be an abundance of resources available when choosing a simulation topic, but they may need to be looked at from a new perspective. Possible resources include case studies, real experiences, course content students seem to struggle with understanding, test scores, or exam blueprints.

Many healthcare teachers already rely on case studies to teach content, and these can be adapted easily into a simulation. Consider using a simulator to show physiologic changes instead of having students read about them. Use test scores to identify students' weak areas or topics that require supplemental instruction; students may historically seem to have trouble comprehending a certain set of material. This material can be provided in a simulation activity that will appeal to more learning styles and possibly close the gap between comprehending the didactic material and applying it to a clinical situation or the gap between classroom instruction and the unpredictability of clinical areas [27,54,54].

When goals have been set and content chosen, it is then time to create measurable objectives. It is vitally important to write clear, specific, and measurable objectives, as successful simulations rely on carefully planned scenarios with clear learning goals and objectives [28]. Objectives will guide the instructors and the participants. This is a great time to determine if the simulation is going to be used for learning, remediation, or educational purposes. As discussed, being upfront about the purpose of the session will keep students on task, focused, and in a learning-centered consciousness while participating.

Clear objectives are also very important if the person writing the scenario will be different than the person running it. For example, some institutions have faculty who write a scenario for a course, and the learning activity will be used by all students and taught by other clinical instructors. To maintain as much consistency as possible for the students between the clinical groups, the objectives must be clear and specific, so all faculty and participants are held to the same standards.

Learning objectives should also have a time frame. They should specify if learners are expected to meet the target(s) during the simulation scenario, before arriving for the simulation activity, or in the debriefing session afterwards. Objectives should also be specific. If students are expected to complete a cardiac assessment, explain what that means. Is it expected they listen to heart sounds in all fields, attach the patient to a monitor and interpret their electrocardiogram rhythm, and/or obtain a history of all related illnesses and medications? Definitions may vary among faculty members, so being specific will clarify discrepancies. Lastly, make sure the objectives are measurable. These are all important things to be considered; examples of properly written learning objectives will be provided later in this course.

Learning occurs best when it can be applied to multiple learning domains. The affective, cognitive, and psychomotor learning domains are important because they address the types and styles of learning among students. The affective domain applies to attitudes, beliefs, values, feelings, and emotions. Learning in this domain occurs when students relate their feelings or emotions to the content they are learning. Many faculty members find it difficult to address this domain when instructing, as traditional, faculty-centered education for large numbers of students often does not directly relate to feelings, emotions, or values. The cognitive domain includes knowledge, comprehension, application, analysis, synthesis, and evaluation. Conventional lecture-style courses typically apply to the cognitive domain, as their purpose is to transfer knowledge from the professor to the students. Finally, the psychomotor domain relates to motor skills, including both gross and fine. It encompasses the physical doing of things or the demonstration of skills [29]. Demonstration requires the student to perform or physically do the skill in the objective directed to address the psychomotor domain. For example, teaching a child to tie his or her shoelaces is a type of psychomotor learning. Examples of objectives as they apply to each of the learning domains include:

The verbs of each objective are directly related to the associated learning domain.

Students who learn best in the cognitive domain may not comprehend material when it is only addressed in the psychomotor format. This is important to consider when designing any learning session ensuring domains are used to help multiple learners increase their comprehension. The simulation modality can appeal to all three learning domains. Students must recall knowledge (cognitive) to perform the appropriate interventions to care for a patient (psychomotor) that will then be discussed in the debriefing session (affective).

The next step in creating a simulation scenario is to write the content. An easy method to begin is the creation of an outline. The major headings of the outline should answer the following questions:

This outline will tell the person managing the simulation how it should be set up (I), how the simulator should be programmed (II), how they should adjust simulator settings based on the student performance (III), and when to end the session (IV).

There are simulation scenario templates available from publishers and organizations and in the literature. For example, the National League for Nursing's (NLN's) Simulation Innovation Resource Center (SIRC) has free, downloadable templates available on its website (https://www.nln.org/education/education/sirc/sirc/sirc). Exploring these templates may be helpful in finding a format that is easiest to understand, adapt, and work from when managing and writing scenarios. The templates often include areas to create supportive documents and information for students, such as physician orders or test results.

The following is an example of an outline for a simulated learning experience. The case is designed for nursing students learning how to manage a patient during a postpartum hemorrhage.

Title: Postpartum Hemorrhage Simulation

The concept of success for a debriefing session should begin before the simulation experience. The first component of a debriefing session is a pre-simulation scenario briefing. This consists of a few quick moments before an exercise during which the educator briefly covers a few items. It is important that the educator creates an environment of trust and respect early, typically in these pre-briefing sessions [35,63]. The objectives of the scenario, expectation of participation from learners, and intent of the learning experience (i.e., mistakes are acceptable or the time will be used for evaluation) should be covered. In addition, participants should be told that there will be a debriefing after the exercise. These items set the stage for the debriefing and prepare the participants to be involved. It primes learners' brains for a discussion after the events.

There are parts of the debriefing session that should occur in specific order to create an environment for learning: a discussion of the experience, time for students to reflect on the activity, and evaluation with the facilitator and peers regarding what they learned and what could be done to modify behaviors based on the experience. These parts can be clarified as description, analysis, and application [35,47]. Without a facilitator, participants may have trouble moving past the initial descriptive phase of the debriefing process. Faculty should be the guide in the session to address these areas and help participants address all the parts of the debriefing.

There are two basic roles during the debriefing session: faculty and student. Students should be involved in an active discussion that is facilitated by the faculty member. Students should have the most active role, directing the course of discussion and engaging in the majority of talking. It should be emphasized that participation is expected of all students. Treat the group with respect, and appreciate that they all have something to contribute to the session. Allowing student answers and comments to lead the debriefing gives participants an active role and creates personal accountability in the learning process.

However, this is often a difficult practice for faculty educators. The concept that the students have the most important information to share and the faculty are there only to guide others is unfamiliar and can take some practice to perfect. The easiest way to facilitate discussion in the group is with the use of open-ended questions. There will be times when responses are not immediate following these questions. It is important to allow time for silence to draw out participant comments. Consider the silence as time when the participants are gathering their thoughts and forming their answers to the question. The open-ended questions will not require students to regurgitate facts and figures; they require critical thinking and individual reflection. The responses will not be as immediate as some educators expect.

Understanding the process and concepts of debriefing is important. It can be helpful to find an experienced faculty member in these practices and model an approach to his or her strengths. These experienced members can also be very helpful in providing constructive feedback on the management of debriefings.

Instructors may wish to use a video of the simulation scenario in a debriefing session. This can be useful but also distracting to learners. Studies are mixed regarding the effectiveness of using video in debriefing on learners' outcomes. Grant, Moss, Epps, and Watts reported there seemed to be little impact on the scoring of outcomes between simulation participants, but those debriefed with video often exhibited more desirable behaviors during scenarios than the control group [38,68]. It can be helpful to show participants a global image of how the group performed (the actual performance of participants versus their perceived performance) to give an added perspective to the scenario [35,65,66]. However, the thought of being recorded and knowing the video will then be used for debriefing later can be distracting to some individuals. It is important to ensure students' privacy and to let them know how the video will be used.

When using video, it can be very easy to collapse into focusing on the negative—what went wrong or one person's mistakes. This can create a negative learning environment and may even be embarrassing for individuals whose poor performance is emphasized on screen. If using a video in debriefing, utilize open-ended questions and let students guide the discussion whenever possible. Be sure to let students know what went well and show clips of this, as well as examples of behaviors needing improvement.

Historically, teaching in health care has been authoritarian in nature, with the experts imparting their knowledge to novice learners. However, this method can create anxiety and reproach in learners, especially when they are about to be critiqued on their performance. In a debriefing session, this type of relationship can be disruptive to the reflective learning process. As the facilitator, a few key points can keep the learning experience positive. Before the simulation experience starts, set a culture of mutual respect among all involved parties to foster open communication. In this environment, team members can review their performance without being judged. If all learners are encouraged to participate, it will lead to an adoption of open communication [32].

One of the simplest ways to provide a safe environment in debriefing sessions is to ensure confidentiality. Simply put, the motto of "what happens in the simulation lab, stays in the simulation lab" should be adopted. Because simulation can be used for a variety of educational and training purposes, it may not just be the participants who have concerns about errors or systems issues that occur. For example, doing a simulation of cardiac arrest scenarios at a hospital site where systems concerns arise, such as paging errors or delays in the arrival of life-saving equipment or response teams, could have an impact on patient outcomes. A privacy agreement will protect all involved while creating a safe environment in which debriefing and learning can occur.

As the facilitator, avoid accusatory and negative questioning. This can be particularly hard when an obvious error has occurred. A technique called "debriefing with good judgment" is an excellent method to employ at all sessions, but especially in these circumstances. It creates an environment that is safe for participants but challenges them to analyze and fairly critique the team's performance via guidance by the facilitator. Under this method, there are levels of debriefing competence from low performance (i.e., a judgmental debriefer) to the highest performance (i.e., debriefing with good judgment). Educators whose focus is solely on students doing the right thing (as defined by the educator) would fall into the judgmental category. These educators typically make participants feel bad about mistakes or performing poorly. For these types of educators, students feeling inferior or bad about themselves is fine because it is for the purpose of learning. A blaming and accusatory tone is often used, and the instructor often directly provides the solution to students [37,65].

A nonjudgmental approach avoids blame and accepts that people make mistakes, particularly in the name of learning. These educators are concerned about maintaining a good relationship with students. They want to deliver a critical message while avoiding negative feelings and defensiveness, ensuring the psychological safety of everyone involved [37,65]. The dilemma for these educators is how to provide constructive and serious feedback while maintaining a positive relationship with students. At this level, the educator withholds judgment and tries to lead the students in a kind and accepting tone. Often, this technique fails because participants never realize they need to improve or change practice, as it is not addressed correctly.

The optimal approach has been described as debriefing with good judgment. With this method, facilitators share their observations, opinions, and judgments from the perspective of their expertise and experience. However, this method creates a safe environment in which adult learners (including the facilitator) are enabled to meet learning objectives collaboratively [37,65]. It is important for educators not to present themselves with omnipotence, as having all the answers and a sense of righteousness. Instead, the facilitator has the responsibility of fostering curiosity and learning while maintaining mutual respect among participants in the group. When debriefing with good judgment, the educator should avoid shame by not blaming learners. In this approach, mistakes are acceptable in the safe learning environment of simulation. The goal is to have an active discussion in which everyone involved feels empowered and comfortable discussing what occurred in the scenario, including difficult topics. As the leader, the educator will set the stage for learning by putting the occurrences of the scenario into the context of clinical practice. However, this approach can be flawed if not used carefully. Despite the attempts to withhold judgments, the attitudes and criticisms of the instructor can come across in facial expressions or body language [37]. It is important to be cognizant of this when using this approach.

An educator who debriefs with good judgment remembers that participants enter the simulation intending to learn and they most likely participated to the best of their ability and skill level. If a mistake is made, the team's experiences, knowledge, and frame of mind should be taken into consideration. Facilitators using good judgment realize they are not the only ones who have valuable input to share, and they let their learners' know this by encouraging their participation in discussion. As adult learners, they too may learn while leading the group.

Teaching using these techniques is foreign to some educators, but there are steps to take to help reach this higher level of debriefing skill. Be clear when providing input to students. Use open-ended questions to invite learners to participate and share insights. Framing the questions to be nonjudgmental is also helpful. Begin by stating an observation, and then voice your question or concern; this helps maintain an objective approach. For example, an educator could say something like, "I noticed there was trouble deciding when to start chest compressions for CPR. Someone share what you were considering during this time." This type of question promotes inquiry for the group to join the discussion while considering their backgrounds as adult learners.

There are some other factors to keep in mind to help create a successful debriefing session. Whenever possible, avoid singling out one student, task, or skill. Keep the discussion broad, and focus on the performance and not the individuals. This is helpful in keeping participants from feeling attacked or vulnerable and becoming defensive or quiet. Be sure to give as much weight and attention to what went well as to what did not. It can be easy to get trapped into analyzing mistakes and to overlook the achievements that occurred during the simulation session [35,65,66]. Identify mistakes as teaching moments or chances for learning instead of negative actions. Making sure there is enough time dedicated to the debriefing can also help to prevent this as well, as the instructor will not feel rushed to cover only the mistakes.

Time allotment can be tricky when it comes to scheduling a debriefing session. It can be difficult to decide on an amount of time to allow for debriefing, and recommendations vary widely in the literature. For example, Decker recommends 20 to 30 minutes, while Arafeh, Hansen, and Nichols recommend three times the length of the simulation scenario [32,39]. As a general rule, it is a good idea to allow at least half the amount of time of the simulation for a debriefing at the end. For example, a one-hour simulation should have at least 30 minutes for debriefing afterward. The most important message is that debriefing is an essential part of learning in simulation education and time must be allocated for this purpose [4,40,69,70]. Other factors can influence the amount of time needed, including the skill level of students, how successful the participants were in the simulation, and the need for remediation. Students with higher skill levels may require less time, as there could be faster completion of the simulation exercise or there may be fewer questions. If the simulation runs well, it usually leads to a smoother and quicker debriefing session. If students require remediation on skills, do not understand the concepts of the simulation, or need help making sense of the session, then debriefing will take longer.

Whenever possible, it is important to have the debriefing immediately after the simulation scenario. This allows for easier transition of thoughts and emotions while they are still very fresh to learners. Avoid interruptions in the simulation scenario whenever possible, because it will break the flow of the session and the students' train of thought, saving suggestions and critiques until the end of the scenario. If available, use a room separate from the simulation room for debriefings. Changing locations allows students a mental break before beginning the discussion. If a debriefing takes place in the simulation room, students often stay in task mode or are distracted by what they could have done. This distraction can be a barrier to their participation in the discussion.