Modern simulation was developed to meet the training and risk-management needs of complex and high-risk industries and organizations such as aviation, nuclear power production, and the military. Despite their associated hazards, these industries have experienced remarkably low failure rates (Gaba, 2004). Recognizing simulation’s applicability to healthcare, health professions education (HPE) has, in piecemeal fashion, adopted elements of simulation for procedural skill enhancement over the last several decades.

For clarity and consistency, a few terms related to simulation require definition. Gaba (2004) has defined simulation as a “ ...technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” (p. i2). He further describes a simulator as a “device” that mimics a real patient or a part of the human body, and that is capable of interaction with the learner. Cooper and Taqueti (2004), too, have noted that any device that replicates a part of a system or process may appropriately be defined as a simulator.

The use of simulation in educating health professionals enables learners to practice necessary skills in an environment that allows for errors and professional growth without risking patient safety. The use of simulation in educating health professionals enables learners to practice necessary skills in an environment that allows for errors and professional growth without risking patient safety. The appropriate use of simulation in a professional education program allows students to hone their clinical skills without danger of harming the patient during the learning process (Ziv, Wolpe, Small, & Glick, 2003). Although proponents of simulation assert that the use of simulation in health professions education promotes patient safety, others argue that to date there is insufficient research to link simulation to increased patient safety. Despite what some feel is a lack of firm evidence relating simulation to patient safety, there is evidence that simulation training has enhanced learner satisfaction and safety in other high-risk fields, such as the field of aviation (Gaba, 2004; Institute of Medicine, 2003; Ziv et al., 2003).

From an educational perspective, the amount of knowledge required today to practice safe patient care demands the adoption of a pedagogy that goes beyond traditional didactic teaching. Traditional education relies heavily on linguistic intelligence and rote memorization. In contrast, a well-designed simulation curriculum draws upon multiple intelligences and is learner-centered.

Benner (2001) has noted that a sound background in the theoretical underpinnings of nursing is necessary for nurses to advance their clinical expertise. She has developed a continuum describing the various levels of clinical expertise. Competency lies midway between the novice level and the expert level on this continuum. Within nursing, it is the role of the nurse educator to create learning experiences that tie the theoretical underpinnings of nursing to clinical experience. Only when the nurse is able to make the connection between the didactic information and clinical experience, will a nurse reach the level of competence.

The aim of this article is to describe simulation techniques currently being used in healthcare education and identify future directions for the use of simulation in healthcare. The author will describe various types of simulators and simulated experiences, including role playing, standardized patients, partial task trainers, complex task trainers, integrated simulators, and full mission simulation. Next, the use of simulation in undergraduate nursing programs, continuing education programs, interdisciplinary team training, and competency assessment will be presented. Resources for simulation faculty and costs associated with simulation will be discussed. The author will conclude by noting that next steps in using simulation to strengthen the provision of healthcare include providing healthcare educators with the motivation and competencies needed to create and use meaningful simulation learning experiences and initiating more research regarding the benefits of simulation in healthcare education.

Types of Simulation and Simulators

This section will describe the current use of a variety of simulators and simulation experiences. The use of role playing, standardized patients, partial task trainers, complex task trainers, integrated simulators, and full mission simulation will be presented. The post-simulation debriefing process and considerations in deciding whether to use simulated learning experiences will be discussed.

Role-Playing

Fidelity to the real clinical situation helps students to react as they would in a real-life scenario. Role playing involves asking learners to act out an event or situation. Although it is helpful to conduct role playing in a realistic setting, elaborate, mock set-ups or other props are not necessary. Hence the cost of this type of simulation can be relatively low. The objective in creating any simulation experience is achieving fidelity, i.e., a close replication of the real-life, human situation (Aldrich, 2005). Fidelity to the real clinical situation helps students to react as they would in a real-life scenario. Despite its relatively low fidelity, role-playing can reap substantial benefits, especially in the realms of team training and/or change in attitudes (Aldrich).

Standardized Patients

Also known as simulated patients, or actors, these live simulators can be utilized in teaching students to conduct a physical assessment, take a patient history, communicate bad news, practice a psychiatric intervention, and even perform a pelvic or prostate exam. The use of standardized patients has been found to help students gain self-awareness of their communication and clinical strengths and weaknesses, their reactions to stressful situations, and also their biases (Shemanko & Jones, 2008). A well-trained standardized patient with a good script is very effective at suspending disbelief in the scenario and creating a valuable learning simulation. Disadvantages of teaching using standardized patients can include recurring cost and scheduling of the actors (Durham & Alden, 2008).

Partial Task Trainers

Partial task trainers are designed to replicate a part of a system or process. The learning objectives associated with partial task trainers are often task specific. Examples include intubation mannequins; IV arms; and machines involved in processes, such as surgery, resuscitation, or emergency scenarios. Advantages of these simulators include product sustainability, standardization, portability, and skill specificity. Disadvantages include lower level of ability to suspend disbelief in a simulation scenario due to the single task purpose of the trainer. When used in conjunction with integrated simulators or a full mission simulation, this disadvantage is largely overcome (Beaubien & Baker, 2004).

Complex Task Trainers

Haptic systems allow a learner to perceive tactile and other stimuli to the senses through a complex, computer-generated environment. These virtual-reality scenarios offer an opportunity for the learner to practice skills, including surgical skills, bronchoscopy, and intravenous and central line catheterization via computer-based training. These sophisticated systems are sometimes housed in a partial task trainer to lend greater fidelity to the partial task trainer educational experience (Decker, Sportsman, Puetz, & Billings, 2008). Sensors placed within the partial task trainer can detect pressure and presence during learner activities, such as pelvic exams and surgical procedures (Durham & Alden, 2008). These high fidelity trainers lend an added dimension to simulations, but also increase the simulator cost.

Integrated Simulators (Human Patient Simulators)

Integrated simulators are whole body mannequins (adult, child, or infant) that are capable of responding to certain medications, chest compressions, needle decompression, chest tube placement, and other physiologic interventions and subsequent responses. Integrated simulators, also known as human patient simulators (HPS), help suspend disbelief during a simulation due to the integrated computer technology housed in the mannequin that allows the mannequin to respond in real time to specific care interventions and treatments. What makes these integrated simulators so appealing to health professions educators is their ability to contribute high degrees of realism (fidelity) to the simulation scenario.  Fidelity can range from low to high with cost rising as the fidelity increases (Durham & Alden, 2008). Although these integrated systems are generally whole body mannequin simulators, the integrated computer technology is sometimes built into the partial task trainers.

Full Mission Simulation

A full mission simulation brings the learner into a complex situation or task that usually involves a team. Full mission training is limited only by the simulation resources available to the educator. The scenario typically begins with a pre-brief, is followed by the execution of the task, and concludes with the instructor leading a review of the event in a debrief session, as described below (Beaubien & Baker, 2004). One example of a full mission simulation would be an emergency scenario carried out in a replicated emergency room. A more sophisticated example of a full mission simulation would be rehearsing complex or rare surgical cases with a full operating room team in a simulated operating room that incorporates high fidelity, complex task trainers and/or human patient simulators.

Debriefing

The formal, reflective stage in the simulation learning process is the “debrief.”  Debriefing follows the actual simulation and serves to help learners clarify and integrate the simulation experience with previous knowledge. When debriefing is skillfully facilitated with a positive attitude and constructive criticism, learning is reinforced and the learner advances to transference, the next and final step in the simulation learning pyramid described below (Doerr & Murray, 2008). Transference is the ability of the learner to incorporate the lessons learned from simulation and debriefing and apply them to real world situations. This is the ultimate goal of simulation.

The debriefer may act as a facilitator, assisting the learners to reveal what they learned from the experience through verbal or written dialog and reflection. This can be done either on an individual basis, or more commonly, within a group setting. Although the traditional facilitator role should be held by a neutral party, in a situation where curriculum content needs clarification, the facilitator may be called upon to transition, temporarily, to role of educator. It is important to note that if there appears to be a significant knowledge deficit among the learners regarding a specific aspect of the experience, the simulation curriculum must be reviewed to determine wherein the knowledge gap lies (Doerr & Murray). For a complete discussion on simulation debriefing, the reader is encouraged to consult the excellent reference by Doerr and Murray mentioned above.

How to Know When Simulation is an Appropriate Learning Tool

The cost of incorporating simulation tools into the educational experience can range from a small to a considerable expense. The cost of incorporating simulation tools into the educational experience can range from a small to a considerable expense. To make effective and convincing use of these practices and techniques, the educator must assess the learning needs and environment of the institution where it will be used. Glavin (2008) suggests evaluating the appropriate use of simulation according to a performance pyramid in which the base reflects factual or didactic knowledge and higher levels of the pyramid move upward into higher levels of skill competency. If the learner is required to show or demonstrate a skill, simulation will likely be an appropriate learning tool during the skill phase development.

Other criteria for evaluating the potential benefit of simulation in the education program include the degree of necessary skill sustainment in a high risk, low volume clinical setting and a desire to minimize or decrease potential risk or threat of injury to the patient or learner. The overarching questions that must be assessed are: (a) who are the learners? and (b) what do they need to know?  The answer to these questions may be found by asking learners, supervisors, instructors, risk managers, and patient safety experts, and by reviewing the literature (Kyle & Murray, 2008).

Uses of Simulation in Nursing Education and Practice

Numerous articles in the nursing literature reflect on the benefits of using various types of simulation to enhance confidence and clinical skills at multiple levels of nursing education and professional practice. Durham and Alden (2008) cite the Institute of Medicine’s (IOM) recommendation for institutionalizing simulation as a method of teaching effective responses to complex and high risk situations encountered in clinical practice. The Agency for Healthcare Research and Quality (AHRQ) publication, Patient Safety and Quality: An Evidence-Based Handbook for Nurses (2008) devotes an entire chapter to the subject of simulation as a means to improving patient safety.

The Institute of Medicine’s 2003 Report, Health Professions Education: A Bridge to Quality, was prompted by the 2002 Health Professions Education (HPE) Summit. The Summit was organized in response to the IOM report To Err is Human, which revealed the chasm between quality care and patient safety in the United States. The HPE report concluded that nurses, doctors, and other allied health professionals lack the education and training necessary to meet 21^st century healthcare needs. The report urged all health professionals to develop proficiency in five common core competencies, specifically: delivering patient-centered care, working as interdisciplinary teams, practicing evidenced-based medicine, focusing on quality improvement, and using information technologies (IOM, 2003).  

Simulation-based learning strategies applied to HPE can aid healthcare professionals in meeting all these core competencies. These learning strategies are supported in the IOM HPE report which states that “distance learning technology, standardized patients, and clinical skills testing technology also hold potential for revolutionizing HPE...offering students an opportunity to customize their learning and progress at their own pace...” (IOM, 2003, p. 90).

The author will discuss below the various settings in which simulation can be used to enhance learning. These settings include undergraduate programs, continuing and in-service education, interdisciplinary team education and training, and competency assessment programs.

Undergraduate Programs

One undergraduate nursing program recently revamped its curriculum to reflect suggestions found in the IOM reports and the nursing education literature (Giddens et al., 2008). Two of the changes introduced related to information technology, namely moving to a web-based teaching platform and developing new strategies to deliver clinical education. Simulation, using integrated simulators, has been incorporated into all phases of the curriculum to allow students increased clinical experience in a safe environment.

At Virginia Commonwealth University (VCU), nursing faculty have incorporated simulation into their undergraduate psychiatric nursing program. They cite decreased access to real clinical experience and legal and ethical concerns about evaluating student and acutely ill patient interactions by direct observation as valid reasons for using patient simulation scenarios in the curriculum.

Although few “off-the-shelf” psychiatric nursing scenarios for use with simulation techniques are currently available, there are several options for building a reference library of scenarios for use in simulation-based education. Professionally produced film vignettes developed by Fidler, a professor of psychiatry, feature a variety of psychiatric disorders portrayed by actors. These vignettes demonstrate both the disorder characteristics and psychiatric interview techniques. These vignettes may be accessed and purchased online (West Virginia University, 2009). In addition, the faculty at VCU has produced video clips to illustrate concepts studied in the didactic portions of the psychiatric nursing curriculum. Role plays, followed by discussion and interactive games, have also been used successfully in teaching and evaluating competencies for psychiatric nursing.

Continuing and In-Service Education

Simulation is increasingly used in continuing and in-service education...settings. Simulation is increasingly used in continuing and in-service education in healthcare staff-education settings. Because of the increases in patient co-morbidity, acuity, and demand for safety, the healthcare system can no longer be sustained by, or satisfied with nurses who remain at the beginner level. Competent nurses who gain expertise through experience are needed. Nurses routinely have the most frequent and intense contact with patients; and it is the nurse who must be able to recognize changes in patient condition that require early collaboration with other members of the healthcare team. It is not uncommon for the nurse to make the initial decisions regarding a patient whose condition is rapidly deteriorating. Rehearsing and gaining experience through the use of simulation can help the nurse gain confidence and knowledge about how to act in an emergency. Additionally, competent and even expert nurses in one care setting may not be competent or expert in a new patient-population setting (Benner, 2001). Staff development educators can create carefully crafted simulations that will assist in developing the expertise needed in a new setting. They can enable nurses to increase their confidence as they move into new settings. Simulation has been used in a variety of clinical setting to increase nurses’ level of expertise as described below.

Recently, a simulation-education team implemented a human-simulation continuing education program for experienced nurses on a bone marrow transplant (BMT) unit (Kuhrik, Kuhrik, Rimkus, Tecu, & Woodhouse, 2008). Case scenarios and algorithms were developed based on pathophysiology and real emergencies. Education and training topics included BMT policies and procedures, critical complications, ventilatory support, pressure monitoring, pharmacology and medication administration, telemetry skills, and neuromuscular blockade. The goal of the program was to enhance the skills of BMT unit nurses, enable them to recognize changes in patient condition, and safely care for critically ill BMT patients. An integrated human patient simulator became the centerpiece of this program. The team participated in debriefing after each session to discuss the case and enhance learning. Twelve experienced BMT nurses took part in this program. Pre-evaluations were completed by 11 participants and post-evaluation was completed by 12 nurses. Likert-scale evaluation items addressed confidence and competence in recognizing, assessing, and correctly responding to oncology emergencies; interpersonal skills; and effectiveness in a team setting. Although all post-evaluation scores were higher than pre-evaluation scores, the small sample size limited the ability to draw sound conclusions from this study regarding the benefits of simulation. Informally, however, investigators reported that nurses who took part in the simulation continued to share that their learning was enhanced and their skills were strengthened as a result of the simulation training. No attempt was made to objectively evaluate competency in an actual care setting.

It is not uncommon for the nurse to make the initial decisions regarding a patient whose condition is rapidly deteriorating. Rehearsing and gaining experience through...simulation can help the nurse gain confidence and knowledge.... Emergency department nursing is another area in which rapid assessment and advanced decision-making skills can make the difference between life and death. One community hospital sought to strengthen triage skills by implementing a staff development program that incorporated both lectures and scenario-based clinical practice using an integrated human patient simulator. In a study by Wolf (2008), 13 nurses with at least six months of emergency department experience took part in an initial four-hour didactic class that covered principles of triage and symptom presentation categories. Of the original 13 nurses, 6 nurses went on to complete between three and five simulation cases as the second phase of the training. A retrospective chart audit, completed before the didactic and simulation sessions, showed that an average of 40% of patients were under triaged by all nurses. A chart review completed after the didactic and simulation sessions revealed that accurate triage occurred between 70% and 100% of the time by the nurses who completed the simulated clinical scenarios. Unfortunately, due to the lack of tracking of the specific nurses who completed the simulation scenarios, researchers were not able to conclude that the simulation exercise contributed to the increase in triage accuracy.

Interdisciplinary Team Training

One innovative use of simulation is that of teamwork training. Promoting patient safety through team efforts is one of the five HPE core competencies identified by the IOM (2003). Effective and powerful teams are composed of members who understand the team’s mission, are aware of other team member’s roles and responsibilities, and believe in the importance of team work. These teams exhibit characteristics of leadership, orientation, mutual respect, and goal accomplishment (Beaubien & Baker, 2004). Although interdisciplinary teamwork is strongly encouraged by the IOM, and Durham (2008) reported that interdisciplinary education encouraging healthcare professionals to work in teams promotes the interdisciplinary skills needed for practice, HPE remains largely discipline specific with minimal interaction between the healthcare disciplines. An excellent report conducted by the Canadian Interdisciplinary Health Collaborative Consortium (2007) showed that the interdisciplinary team core competencies most frequently cited in the literature include: problem solving, respect, communication, shared knowledge and skills, patient-centered practice, and ability to work collaboratively. All these competencies can be developed through interdisciplinary simulation experiences.

One innovative use of simulation is that of teamwork training. Paige et al. (2009) conducted a study to assess the effectiveness of simulation team training on participants’ beliefs in their ability (confidence) to carry out teamwork-related competencies. This study utilized a mobile, mock operating room (OR) complete with an integrated human patient simulator, a complex task cholecystectomy model, and the required surgical equipment. A total of 38 professionals from a variety of surgical disciplines took part in at least one training session. The interdisciplinary teams included a surgeon, a nurse anesthetist, a circulating nurse, and a surgical technician. Scenarios were designed to elicit team interaction and dialogue during the training. The researchers reported that four of the fifteen Likert-scale items measuring confidence related to teamwork skills were statistically significant. Specifically, significant gains in role clarity, anticipatory response, cross-monitoring, and overall team cohesion and interaction supported the hypothesis that the simulated OR team training could increase self-efficacy related to team work. Although the literature reports a number of demonstrations of simulation applied to interdisciplinary team training, additional, well-designed research is needed to develop an evidence base regarding the effectiveness of interdisciplinary simulation education.

Competency Assessment

Simulation can pave the path between formal education and professional practice for experiences that can be difficult to find, but are essential for progressing to the level of competence and beyond. Another use of simulation for healthcare professionals is in the area of competency validation. Decker et al. (2008) have observed that with declining faculty resources and often limited exposure to real patients, simulation has become a frequent method for evaluating student’s psychomotor skill competency. Competency assessment using various simulation techniques and technologies has been used in a number of nursing degree programs and specialty areas. These areas include, for example, emergency, psychiatric/mental health, gerontology, oncology, and operating room settings. Simulation can pave the path between formal education and professional practice for experiences that can be difficult to find, but are essential for progressing to the level of competence and beyond.

Resources and Costs Related to the Use of Simulation

Faculty development is necessary to ensure competency with the technical resources and to develop an understanding of the strategic thinking and planning necessary for building the interactive learning scenarios that the Millennial learners relish. The use of simulation technology as a learning technique requires that faculty who use it have the knowledge base needed to utilize these techniques in their teaching. The instructor must be able to demonstrate competence with the simulator or risk losing credibility with students. Many of today’s students are millennial generation men and women. This generation has grown up with computer-based technology in their everyday environments ranging from cell phones and I-Pods to high-tech, interactive-learning Smart Boards in each of their classrooms. Millennial learners prefer experiential learning methods and are comfortable with web-based and virtual environments (Parker & Myrick, 2008). Faculty development is necessary to ensure competency with the technical resources and to develop an understanding of the strategic thinking and planning necessary for building the interactive learning scenarios that the Millennial learners relish.

Some excellent resources for nurse educators include the Society for Simulation in Healthcare (SSIH, 2009). The SSH was founded in 2004 with the goal of improving patient safety through the use of teaching healthcare professions to use simulation techniques. Its membership is composed of educators and researchers in the field of simulation. Additionally, the Simulation Innovation Resource Center (SIRC), affiliated with the National League for Nursing, is a very helpful, online, e-learning site where faculty can go to learn how to implement simulation into the curriculum (SIRC, 2009). The Center offers free online presentations and other modest-cost opportunities to access the website and its learning modules. The Center also provides links to resources, SIRC publications, an online forum for discussion, and a featured simulation Simulation science has grown faster than the healthcare disciplines are able (and willing) to keep up with. center of the day.

The cost of simulation will vary depending upon the need. The sky is the limit in terms of how much money it will cost to incorporate simulation into health professional education (HPE), as is the case with almost any desirable technology. Kyle and Murray (2008), provide advice on how to assess the what, where, when, why and how to facilitate simulation “best fits” with a particular curriculum and organization. They also provide helpful hints describing how to present a simulation plan for budget approval, showing that generally the added value of incorporating simulation into the educational program outweighs the costs of not doing so.

Conclusion

Our patients trust us to care for them safely and skillfully. We must remain faithful to this trust and move forward using the simulation techniques available to us today and developing new techniques for tomorrow. Simulation-based learning has been looming on the periphery of health professions education for dozens of years. Quietly, multi-talented and insightful health professionals and their engineering and computer science colleagues have been developing increasingly sophisticated virtual learning environments. Simulation science has grown faster than the healthcare disciplines are able (and willing) to keep up with. Fortunately educators versed in simulation techniques have laid the foundation for a curriculum framework that removes a considerable amount of the angst and mystery associated with incorporating simulation into health professions education. Now we need only to listen and apply this framework where appropriate in the curricula of both initial and continuing educational programs (Kyle & Murray, 2008).

As noted above, the need for additional research regarding the benefits of simulation is great. Although much research remains to be done to establish a firm relationship between simulation and patient safety, it does not make sense to wait for all the evidence before implementing simulation experiences into today’s educational programs. There remains limited evidence of a firm relationship between consumer safety and simulation in the aviation, nuclear, and military industries. Yet who would want to be a passenger on an airline whose pilots did not practice on flight simulators? Don’t our patients deserve the same consideration? Simulation enables healthcare professionals to hone the clinical skills that are needed to provide safe care without harming patients as they develop these skills. As educators and as practitioners of healthcare, we have an obligation to actively engage in learning the pedagogy related to simulation-enhanced learning. We must inform ourselves about the currently available simulators to prepare tomorrow’s healthcare professionals and also be informed advocates for using simulation in our own cubicles of learning and beyond. Our patients trust us to care for them safely and skillfully. We must remain faithful to this trust and move forward using the simulation techniques available to us today and developing new techniques for tomorrow. 

Disclaimer: The views expressed are those of the author and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of the Defense, or the United States government.

Author

Susan Galloway, Commander, NC, USN, MSN, RN
E-mail: Navy_Nurse86@yahoo.com

Commander Galloway is a doctoral student in the Graduate School of Nursing at the Uniformed Services University of the Health Sciences in Bethesda, MD. She received her BSN degree from Winona State University, Winona, MN, and her MSN degree, with concentration in nursing education, from DePaul Univeristy in Chicago. She is currently the Chief of Health Professions Education for the Joint Task Force National Capital Region, Medical, in Bethesda, MD. In this role she is responsible for leading the integration of military health system professional education plans and policies in her region. She also partners with civilian and academic institutions, for example, the Washington Hospital Center and Uniformed Services University of the Health Sciences, to increase the regional education capacity through building a simulation infrastructure and capacity. A major goal in terms of simulation is to conduct research which will lead to an evidence-based curriculum in the area of simulation. Commander Galloway's current research focuses on the human factors related to the transfer of skill acquisition from simulation sites to the practice (real world) environment.