The Scope of Simulation-based Healthcare Education

Simulation-based healthcare education has expanded tremendously over the past few years, as witnessed by the creation and growth of the Society for Simulation in Healthcare and its journal. These developments represent a turning point at which simulation is no longer seen as a novelty whose existence needs to be justified or defended by a few staunch believers. We can now move beyond reporting on the potential role of simulation or how it compares to other more traditional (yet often unproven) methods of training, and focus instead on the most effective use of simulation for healthcare education. From the perspective of the training program, the effective use of simulation may be seen as the product of three components (Fig. 1): training resources, trained educators, and curricular institutionalization. It is important to note that if any of these components are missing or deficient, the product will become zero and effective training will not occur. For example, it is not rare for an institution to obtain a simulator only to see it collect dust because faculty members were not properly trained in its operation or did not know how to introduce it into the curriculum. These components include the following.FIGURE 1.: Formula for the effective use of simulation-based medical education: Effective Simulation-based Healthcare Education = Training Resources × Trained Educators × Curricular InstitutionalizationTraining Resources This component refers to having appropriate simulators, task trainers, standardized patients, and computer software that meet a program’s needs. In addition, it includes having the necessary physical space and associated equipment (eg, monitors, beds, cameras, microphones, recording and playback equipment) for simulation-based training. It also encompasses the associated curriculum (eg, crisis resource management,1 advanced life support, laparoscopic surgery), outcome measures (eg, checklists, rating forms), learning strategies (eg, experiential learning, deliberate practice2), and curriculum management systems (to schedule and track learners’ time and performance). Trained Educators This component includes healthcare professionals trained in the proper use of simulation-based medical education. It also includes individuals involved in the operation, management, and administration of simulation-based training, as well as researchers dedicated to advancing the field. Curricular Institutionalization This component includes elements necessary for full adoption and integration of simulation-based medical education into an institution’s mission and culture. It involves the decision of an institution to fully embrace its goal of improving patient care and patient safety through reducing and preventing medical errors, as well as more individual goals of improving a wide range of competencies (eg, acute care skills, surgical skills, crisis resource management, teamwork, and communication). During the past four decades of simulation use in healthcare, the literature has focused almost entirely on the first component of training resources. To illustrate, a recent systematic review of the literature on high-fidelity simulation identified 10 features that led to effective learning (Table 1).3 Nine out of the 10 features are related to training resources/strategies, and only one is related to curricular institutionalization. Most surprising is that none addressed the expertise/attributes of the educators involved in the process, yet we often know from experience that the faculty often determine the success and effectiveness of simulation-based training. Published reports and studies often describe the features of the simulator, the curricular content, learning environment, teaching strategies, and outcome measures, but provide few details on the knowledge or expertise of the faculty, or details related to how simulation gained acceptance and adoption at the local institution. It is time to address more formally the other important components of simulation-based healthcare education—educators and curricular institutionalization.TABLE 1: Features of Simulations that Lead to Effective LearningHow does simulation become adopted and integrated into an existing curriculum that is already overcrowded with content? Rogers4 provides a model that describes five stages for innovation adoption that we can adapt here for simulation. Stage 1 (Awareness) Institution is exposed to information about simulation-based healthcare education but lacks knowledge about it. Stage 2 (Interest) Institution becomes interested in simulation-based healthcare education and seeks additional information about it through attending meetings, visiting other simulation facilities or inviting experts to the institution. Stage 3 (Evaluation) Institution mentally applies the use of simulation to its present and anticipated future situation, and then decides whether or not to try it. This is often done with a local “champion” or through an expert consultant. Stage 4 (Trial) Institution makes first use of simulation, typically in a course headed by the local “champion.” Stage 5 (Adoption) Institution decides to continue the full use of simulation throughout its curriculum based on the experience and feedback from the trial and/or additional opportunities or needs that arise from increased exposure to the simulation. For each of these stages, the “institution” is usually represented by one or more educators who provide the link between the training resources and institutional adoption and implementation of simulation. What type of individual is key to making this happen? Ryan and Gross5 initially classified individuals who ultimately choose to implement innovation and Rogers further described their qualities.4 These categories (with relative proportions) include: Innovators (2.5%) These are risk takers with the initiative and willingness to expend time, effort, and resources in trying something new. These are individuals such as Gaba, Gordon (see related article in this journal issue), Gravenstein and others within the simulation community responsible for its creation and development. These individuals dominated the field of simulation during its first 25 years. Early Adopters (13.5%) These tend to be respected group leaders, the individuals essential to adoption by the whole group. These include many of the current leaders in the Society for Simulation in Healthcare and on the editorial board for Simulation in Healthcare who have been instrumental in the field’s growth over the past 10 years. Early Majority (34%) These are careful, safe, deliberate individuals unwilling to risk time or other resources without demonstrated evidence of the innovation’s effectiveness. These are individuals just recently involved in simulation-based education, and they represent the largest audience for the Society and journal. Late Majority (34%) These individuals are suspicious of or resistant to change and are difficult to move without significant influence. These individuals will eventually “come aboard,” but can sometimes provide a critical viewpoint that prevents wholesale adoption of innovation without slow, careful consideration and planning. Laggards (16%) These are individuals who are consistent or even adamant in resisting change. Pressure is often needed from leadership to force change. Rogers argues that the “Early Adopters” and “Early Majority” are the most important groups for an innovative technology to reach its tipping point for successful adoption and implementation.4Table 2 illustrates characteristics of individuals in these two groups. The educators comprising the “Early Majority” are the largest target audience for the Society and this journal and are receptive to guidance and support as they look to implement simulation at their local institutions. We should not underestimate the importance of this group as it represents the greatest chance for the long term success of simulation-based healthcare education.TABLE 2: Characteristics of Early and Successful Adopters/Implementers of Simulation TechnologyMany different approaches have been taken by institutions that have adopted simulation. The above stages can be achieved through a measured, deliberate process as part of a school’s strategic plan or obtained in a matter of a few days. For example, a relative novice can attend the International Meeting on Simulation in Healthcare and gain tremendous awareness, insight, and understanding of the use of simulation for training. Furthermore, the adoption of simulation can range from integrating a task trainer into a component of a course (eg, airway training during an emergency medicine clerkship) to creating a simulation-based curriculum such as Anesthesia Crisis Resource Management,1 or establishing a simulation center that serves multiple disciplines and professions both locally and regionally. At any level of integration, there should be certain minimum criteria that are met to better ensure success. This includes identifying the training needs for a given population, defining the outcomes that are expected from these learners, using the appropriate type of simulation that is based on the defined outcomes rather than the technical features, and measuring outcomes. At some point, there should be buy-in or formal adoption by the institution’s curriculum committee (or whatever body determines new curricula) so that early on it becomes a stakeholder in the process. What will it take for institutions to make that first step toward curricular adoption of simulation? Many of the institutions, hospitals, and agencies that have fully operational simulation-based training programs were started and maintained by the “Innovators” and “Early Adopters” who recognized the promise and potential value of simulation. However, Gaba points out that there are several other driving forces besides motivated teachers, researchers and simulation societies that will ultimately “push” or “pull” an institution toward full integration of simulation.6 This includes local institutional pressure from students, residents, and faculty who feel competition from other schools as well as professional societies, professional licensing/accrediting bodies and health care organizations. In addition, it also includes healthcare insurers, liability insurers, accrediting organizations, government agencies, and ultimately the public. In his commentary, Gaba predicts and describes how each of these driving forces may contribute to the successful integration of simulation throughout healthcare. One of these predictions has already occurred. Clinical societies have begun to establish processes to provide accreditation to training programs that offer healthcare providers a wide range of learning opportunities through the use of state-of-the-art educational methods and advanced technology. The accredited institution is expected to ensure achievement of clinical competence and development of expertise through the use of bench models, simulations, simulators and virtual reality.7 The American Society of Anesthesiologists recently approved the process for formal designation of simulation training programs8 and the American College of Surgeons (ACS) has already instituted a process to grant formal accreditation to programs that meet and demonstrate compliance with established standards and criteria.7 To date, seven institutions have successfully met the program requirements and, as a result, are designated as Level I ACS Accredited Education Institutes.9 Although the criteria related to training tools, administrative resources, technical support, and curricula are well defined, criterion 2.4, related to educators, simply states, “uses faculty/preceptors that are appropriately trained.”10 Clearly, there needs to be better guidance and opportunities to develop educators who are prepared to optimally use simulation. The role of the healthcare educator is arguably the most important component to ensure effective simulation-based healthcare education and, although often implicit in studies of simulation-based training, many of the skills required of these educators are ill-defined. Harden and colleagues11 have formally outlined the teaching roles of the healthcare educator (Table 3); one of these explicitly acknowledges the role of resource developers. Along these lines, simulation case scenarios such as the one by Singh and colleagues12 published in this issue of the journal represent a valuable and practical resource for our “Early Majority.” The cases are peer-reviewed and represent an additional opportunity for healthcare educators to demonstrate the many roles they serve, in addition to providing evidence of scholarship. Simulation case scenarios take considerable time, effort, and experience to develop and test, and are examples of the proven applications individuals in the “Early Majority” need.TABLE 3: Roles of the Healthcare Educator12 (for Simulation-based Training)Although these cases represent one type of resource for educators, the academic healthcare community needs to develop and manage competency-based programs of faculty training. The goal of these programs should be to produce healthcare educators certified in simulation-based training. Many “Early Adopters” in the field have already addressed this need and have created courses on developing and operating a simulation program and training educators. Table 4 lists just a few of the institutions and organizations that offer formal training for the simulation-based healthcare educator. Although none of these are officially “accredited” to provide formal certification, they do offer excellent faculty training and development opportunities. In my personal opinion, the Society for Simulation in Healthcare (SSH) is in a unique position to take a leading role in establishing formal criteria for certified training expertise in simulation-based healthcare education. Adopting the ACS model, I believe the SSH should aim to create a network of SSH-approved institutes that would offer individuals certified training on the essential skills of simulation-based healthcare education. These centers could in turn work with their own graduate programs to develop certificate, diploma, or masters degree opportunities for faculty who are committed to careers in simulation-based education. Just as the weight of evidence shows that clinical experience alone is not associated with the quality of delivered health care,13 educator competence in the expert use of simulation must be assured, not assumed.TABLE 4: List of Institutions and Organizations that Offer Formal Training for the Simulation-based Healthcare Educator*While the above vision may take some time to be realized, there are already several measures centered around the International Meeting on Simulation in Healthcare (IMSH) that the SSH has instituted to provide support for educators. The Society established a series of specialty tracks at the IMSH related to simulation center operations, nursing and prehospital education, and a full-day, postgraduate course on setting up a simulation center. Another novel approach would be to use the annual meeting as a venue to provide a formal certification course in simulation-based education. This has been done with success by the Association of Medical Education in Europe with its accrediting the Essential Skills in Medical Education (ESME) program,14 which provides an entry-level teaching qualification for those becoming involved in medical education for the first time, or who have been given some new responsibilities relating to teaching. The ESME program is organized to coincide with international medical education meetings. Typically, registrants participate in 1- or 2-day preconference workshops learning about the fundamentals of medical education. During the main conference they attend a wide range of sessions that not only cover broad topics applicable to all healthcare providers but also specific discipline-based tracts that address focused needs. Throughout the 2- to 3-day conference, ESME faculty members meet with course participants to review what they have learned from attending plenary and panel sessions, abstract presentations and workshops. The program concludes with a half-day postconference session in which participants report on what they have learned throughout the conference and how they will apply this to their local setting. They are also given the opportunity for further development in healthcare education by enrolling in an educator portfolio program. Participants spend the following year working with ESME faculty via email developing their portfolios as they provide evidence of their skills as an educator. A similar program could be developed around the IMSH and would provide the foundation for a more formal credentialing process. As the use of simulation for training continues to grow, there is an increasing need to focus on the institutional environment that encourages adoption and integration of simulation, and on the local faculty who must deliver the training. Another important role for the Society for Simulation in Healthcare and this journal is not only to disseminate information regarding the validity, reliability, and feasibility of the training resources, but also to provide assistance for the faculty who must use these resources and optimally integrate them into the programs of their local institutions. Finally, certified competence in healthcare education needs to be acknowledged and rewarded as a valued component of an academic career. Thus promotion and tenure processes at academic medical centers need to recognize the expression of educational expertise using simulation as legitimate work by healthcare educators.15 Healthcare professionals who research, develop, use, and evaluate simulation toward the goal of improving clinical competence and expertise and enhancing the quality and safety of patient care must be rewarded for their work. ACKNOWLEDGMENTS The author thanks Professor Ronald Harden for his assistance with the commentary’s concept, William McGaghie for his contribution on educator development, and Ross Scalese for his constructive feedback on early drafts.