Simulation had been adopted in many professions before it took hold in health care. The most well-known early use of simulation was by the aviation industry. It was instituted in pilot training beginning in the 1970s after recognition of the devastation human error in this context could bring to the public [6,7]. The impetus for this change was the sentinel event of the tragic airport disaster in 1977 at Tenerife in the Canary Islands. This well-publicized aviation incident was the result of a breakdown in communication and flight crew errors that led to two Boeing 747 passenger crafts colliding on the runway, killing 583 passengers. It remains to this day the deadliest aviation accident in history. The incident received worldwide attention, and the airline ultimately claimed responsibility, paying millions in restitution to victims' families. Still used in a variety of trainings today, re-enactment videos and hundreds of articles regarding the incident have been published. In 1979, investigators for the National Transportation Safety Board reported that at the time, human error was the cause of 60% to 80% of aviation accidents [6]. In the 1990s, Crew Resource Management programs blossomed and are still widely used today [7,52]. These programs focused on interdisciplinary communication, team building, and simulation of crisis events to improve flight crew performance and lessen aviation errors that could potentially lead to civilian deaths or injuries [8,51].

The U.S. military also adopted the use of simulation as an effective means of training soldiers. Simulation is still used today for military medical personnel to teach or maintain skills for a variety of tasks, but most notably for high-acuity, low-circumstance situations. However, its use is not just health care related; simulation has been used for years in the military to teach everything from gun safety to military strategy with war games. The military uses a variety of simulation modalities, creating some of the most advanced virtual simulations and computer learning in the world. This is important, as simulation should mimic reality as much as possible to foster experiential learning in a realistic environment [9,5]. Although it is a very useful tool, the military also realizes there is only so much one can learn from electronic means. Some skills require tactile and psychomotor practice to perfect what a virtual world cannot replicate.

The U.S. military also adopted the use of simulation as an effective means of training soldiers. Simulation is still used today for military medical personnel to teach or maintain skills for a variety of tasks, but most notably for high-acuity, low-circumstance situations. However, its use is not just health care related; simulation has been used for years in the military to teach everything from gun safety to military strategy with war games. The military uses a variety of simulation modalities, creating some of the most advanced virtual simulations and computer learning in the world. This is important, as simulation should mimic reality as much as possible to foster experiential learning in a realistic environment [9,5]. Although it is a very useful tool, the military also realizes there is only so much one can learn from electronic means. Some skills require tactile and psychomotor practice to perfect what a virtual world cannot replicate.

Today, there are many forms of simulation. The most well-known simulation tool is the human patient simulator, a full-body mannequin model that may have various levels of technology. The technology is classified as fidelity, with ranges on a continuum from low to high according to the degree to which they most closely represent reality [5,16,55]. There are also task trainers, virtual or flat-screen simulations, also known as screen-based simulation, and standardized patients. However, as the most popular form of healthcare simulation, the human patient simulator will be the focus of this course.

Innovation and simulation have found their place in various arenas in the healthcare realm. Simulation activities focus on active learning, with the purpose of building learner confidence and enhancing clinical judgment [5,17,51]. Simulation provides a setting in which mistakes can be made without the repercussions of patient harm that may occur in real time [49]. The ultimate goal of the educator when using simulation should be to create a learner-centered educational experience to foster optimal educational outcomes. Simulation-based education has a wide variety of applications in health care, including academics, staff development, competency maintenance, and team development.

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.

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.

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.

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.

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).

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.

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:

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 level of the learner should dictate the complexity of the experience. Scenarios should address the learning objectives, but also be written to the level of the learner [30,61]. If participants are first-year nursing students, the scenario must contain more basic concepts, with many or obvious cues. For more experienced learners, such as for a staff development course, the concepts should be more complex, with subtle cues to invoke communication and foster critical thinking among participants. Distracters can also be used for higher-level students. Distracters refer to items worked into the scenario that students must manage to be successful. For example, a radio could be playing loudly, and students would be expected to manage the noise (turning the radio down or off) so communication is clearly heard and understood between participants.

The level of the learner should dictate the complexity of the experience. Scenarios should address the learning objectives, but also be written to the level of the learner [30,61]. If participants are first-year nursing students, the scenario must contain more basic concepts, with many or obvious cues. For more experienced learners, such as for a staff development course, the concepts should be more complex, with subtle cues to invoke communication and foster critical thinking among participants. Distracters can also be used for higher-level students. Distracters refer to items worked into the scenario that students must manage to be successful. For example, a radio could be playing loudly, and students would be expected to manage the noise (turning the radio down or off) so communication is clearly heard and understood between participants.

Moulage is also an excellent way to add realism to a scenario. Moulage refers to the application of makeup or decals to create mock versions of diseases or injuries in simulations. An example could be creating a necrotic pressure ulcer on the sacrum of a bed-ridden patient. Moulage can also utilize props, room set-up, or faux body fluids to simulate diseases. This can create a sense of realism for the activity and help to suspend the disbelief of the participants. Moulage should be added to scenarios whenever possible and kept in the context of the learning exercise. If it is used too much, however, it can be more of a distraction than a help to students. It is also important to investigate what materials are safe to be used on simulators before being applied, as many mannequins and models have skin that is easily stainable.

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 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.

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].

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.