Background
Clinical training for health care professionals has traditionally relied on learning from actual patients, even for invasive procedures and life-threatening situations. As exemplified by the medical residency maxim "see one, do one, teach one," there has been little emphasis on learning in a simulated environment prior to clinical encounters.
However, considerable evidence documents the dangers posed by inexperienced clinicians and poorly functioning clinical teams. Based in part on its success in other industries such as aviation, simulation-based training has therefore emerged as a key component of the patient safety movement and is increasingly being used to improve clinical and teamwork skills in a variety of environments. When applied properly, simulation-based training allows the opportunity to learn new skills, engage in deliberate practice, and receive focused and real-time feedback. The goal of simulation-based training is to enable the accelerated development of expertise, both in individual and team skills, by bridging the gap between classroom training and real-world clinical experiences in a relatively risk-free environment.
Methods and applications of simulation-based training
There are several approaches to simulation training, and depending on the material being emphasized, simulation curricula may employ one or more of these methods:
Simulation was initially utilized as a tool for teaching clinical skills and has been successfully applied to develop and assess foundational clinical skills as well as more advanced cognitive and technical skills, in both medical school and residency training. Simulation is also being widely integrated into teamwork training in a variety of environments, including the emergency department, operating room, and obstetrics units. Teamwork training that incorporates simulation often focuses on improving the ability of multidisciplinary teams to handle acute situations. Teamwork training with simulation has also been used with non-clinical personnel, such as one study in which non-clinician leadership and management had to respond to a simulated patient safety crisis.
The application of human factors engineering methods to patient safety represents another application of simulation. Usability testing, which refers to testing new equipment and technology under real-world conditions, can be thought of as a form of simulation designed to identify latent safety issues and workarounds.
Evidence supporting simulation-based training
Simulation training is clearly effective as an educational modality. A recent systematic review analyzed results from more than 600 studies that evaluated technology-enhanced simulation training programs and found strong positive associations between simulation training and improved outcomes of knowledge, skills, and behaviors.Another systematic review identified 38 studies—most of which used simulation to teach procedural skills—and found that simulation augments team behaviors, procedural competence, and patient care outcomes. Simulation approaches have been shown to enhance safety outcomes, such as preventing central line infections. While technology-enhanced simulation is effective, increasing technological sophistication of simulation may not always be necessary. According to another review, the key features of successful simulation education are those of successful curricula in general: individualized feedback, cognitive interactivity, deliberate practice, and longer duration of the curricula. The effect of high-fidelity technology-enhanced simulation remains controversial, and although the cost of such high-technology simulators is decreasing, their high costs may deter increasing use of this approach until more definitive evidence emerges.
The evidence supporting the use of simulation in teamwork training is more mixed. A systematic review that examined simulation training in the operating room found that most studies suffered from one of several methodological concerns, such as lack of standardization of training techniques and measurement methods. While participants generally had positive impressions of the programs, there was no clear effect on participant behaviors or clinical outcomes. Another review of multidisciplinary simulation-based team training in obstetrics did show improvement in participants' knowledge and skills, but also did not demonstrate improvement in safety or clinical outcomes. Variation in simulation approaches and curricula likely account for these disparate findings. There is increasing interest in using in situ simulation as a way of providing more realistic simulation experiences and potentially identifying latent safety hazards in the real-world clinical environment.
Current context
All graduating medical students are required to complete a simulated patient encounter in order to pass the United States Medical Licensing Examination. The Accreditation Council for Graduate Medical Education requires that residency programs provide simulation training, although the specific requirements vary between specialties. The American Board of Anesthesiology requires practicing anesthesiologists to complete a simulation course in order to maintain board certification, but this requirement is not present for other specialties. It is important to note that simulation has been shown to be effective as an educational tool for both practicing clinicians as well as trainees.
Clinical training for health care professionals has traditionally relied on learning from actual patients, even for invasive procedures and life-threatening situations. As exemplified by the medical residency maxim "see one, do one, teach one," there has been little emphasis on learning in a simulated environment prior to clinical encounters.
However, considerable evidence documents the dangers posed by inexperienced clinicians and poorly functioning clinical teams. Based in part on its success in other industries such as aviation, simulation-based training has therefore emerged as a key component of the patient safety movement and is increasingly being used to improve clinical and teamwork skills in a variety of environments. When applied properly, simulation-based training allows the opportunity to learn new skills, engage in deliberate practice, and receive focused and real-time feedback. The goal of simulation-based training is to enable the accelerated development of expertise, both in individual and team skills, by bridging the gap between classroom training and real-world clinical experiences in a relatively risk-free environment.
Methods and applications of simulation-based training
There are several approaches to simulation training, and depending on the material being emphasized, simulation curricula may employ one or more of these methods:
- Part-task trainers: These are used to train specific clinical skills through simulation. An example would be anatomically correct limb models, which are used to demonstrate phlebotomy skills or placement of intravenous catheters.
- Full-scale simulators: The most common example is a full-body manikin, which in addition to anatomic landmarks can offer realistic physiologic simulation (such as heart sounds and respirations). These are increasingly used to teach the physical examination and other fundamental clinical skills.
- Virtual reality: In this modality, learners are immersed in a highly realistic clinical environment, such as an operating room or intensive care unit. Learners physically interact with the environment as they would in real life, using systems that are increasingly complex and technologically sophisticated.
- In situ simulation: This approach refers to simulation carried out in the actual clinical environment with the providers who work in that location. It may involve use of part-task or full-scale simulators as well.
- Standardized patients: Employing trained actors to simulate real patients has long been used to teach basic history taking and physical examination skills, and this strategy is also being applied to teach patient safety skillssuch as error disclosure.
Simulation was initially utilized as a tool for teaching clinical skills and has been successfully applied to develop and assess foundational clinical skills as well as more advanced cognitive and technical skills, in both medical school and residency training. Simulation is also being widely integrated into teamwork training in a variety of environments, including the emergency department, operating room, and obstetrics units. Teamwork training that incorporates simulation often focuses on improving the ability of multidisciplinary teams to handle acute situations. Teamwork training with simulation has also been used with non-clinical personnel, such as one study in which non-clinician leadership and management had to respond to a simulated patient safety crisis.
The application of human factors engineering methods to patient safety represents another application of simulation. Usability testing, which refers to testing new equipment and technology under real-world conditions, can be thought of as a form of simulation designed to identify latent safety issues and workarounds.
Evidence supporting simulation-based training
Simulation training is clearly effective as an educational modality. A recent systematic review analyzed results from more than 600 studies that evaluated technology-enhanced simulation training programs and found strong positive associations between simulation training and improved outcomes of knowledge, skills, and behaviors.Another systematic review identified 38 studies—most of which used simulation to teach procedural skills—and found that simulation augments team behaviors, procedural competence, and patient care outcomes. Simulation approaches have been shown to enhance safety outcomes, such as preventing central line infections. While technology-enhanced simulation is effective, increasing technological sophistication of simulation may not always be necessary. According to another review, the key features of successful simulation education are those of successful curricula in general: individualized feedback, cognitive interactivity, deliberate practice, and longer duration of the curricula. The effect of high-fidelity technology-enhanced simulation remains controversial, and although the cost of such high-technology simulators is decreasing, their high costs may deter increasing use of this approach until more definitive evidence emerges.
The evidence supporting the use of simulation in teamwork training is more mixed. A systematic review that examined simulation training in the operating room found that most studies suffered from one of several methodological concerns, such as lack of standardization of training techniques and measurement methods. While participants generally had positive impressions of the programs, there was no clear effect on participant behaviors or clinical outcomes. Another review of multidisciplinary simulation-based team training in obstetrics did show improvement in participants' knowledge and skills, but also did not demonstrate improvement in safety or clinical outcomes. Variation in simulation approaches and curricula likely account for these disparate findings. There is increasing interest in using in situ simulation as a way of providing more realistic simulation experiences and potentially identifying latent safety hazards in the real-world clinical environment.
Current context
All graduating medical students are required to complete a simulated patient encounter in order to pass the United States Medical Licensing Examination. The Accreditation Council for Graduate Medical Education requires that residency programs provide simulation training, although the specific requirements vary between specialties. The American Board of Anesthesiology requires practicing anesthesiologists to complete a simulation course in order to maintain board certification, but this requirement is not present for other specialties. It is important to note that simulation has been shown to be effective as an educational tool for both practicing clinicians as well as trainees.
What's New in Simulation Training on AHRQ PSNet
COMMENTARY
Using simulation to improve patient safety: dawn of a new era.
Cheng A, Grant V, Auerbach M. JAMA Pediatr. 2015 Mar 9; [Epub ahead of print].
STUDY
Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills.
Arora S, Hull L, Fitzpatrick M, Sevdalis N, Birnbach DJ. Ann Surg. 2015 Feb 6; [Epub ahead of print].
STUDY
Decision making in trauma settings: simulation to improve diagnostic skills.
Murray DJ, Freeman BD, Boulet JR, Woodhouse J, Fehr JJ, Klingensmith ME. Simul Healthc. 2015 Feb 23; [Epub ahead of print].
COURSE MATERIAL/CURRICULUM
Master of Science in Medical and Healthcare Simulation.
Philadelphia, PA. Drexel University College of Medicine.
STUDY
Learning through simulated independent practice leads to better future performance in a simulated crisis than learning through simulated supervised practice.
Goldberg A, Silverman E, Samuelson S, et al. Br J Anaesth. 2015 Jan 8; [Epub ahead of print].
STUDY
Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.
Bank I, Snell L, Bhanji F. Pediatr Emerg Care. 2014;30:879-883.
STUDY
Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial.
Barzallo Salazar MJ, Minkoff H, Bayya J, et al. J Am Coll Surg. 2014;219:1001-1007.
Using simulation to improve patient safety: dawn of a new era.
Cheng A, Grant V, Auerbach M. JAMA Pediatr. 2015 Mar 9; [Epub ahead of print].
Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills.
Arora S, Hull L, Fitzpatrick M, Sevdalis N, Birnbach DJ. Ann Surg. 2015 Feb 6; [Epub ahead of print].
Decision making in trauma settings: simulation to improve diagnostic skills.
Murray DJ, Freeman BD, Boulet JR, Woodhouse J, Fehr JJ, Klingensmith ME. Simul Healthc. 2015 Feb 23; [Epub ahead of print].
Master of Science in Medical and Healthcare Simulation.
Philadelphia, PA. Drexel University College of Medicine.
Learning through simulated independent practice leads to better future performance in a simulated crisis than learning through simulated supervised practice.
Goldberg A, Silverman E, Samuelson S, et al. Br J Anaesth. 2015 Jan 8; [Epub ahead of print].
Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.
Bank I, Snell L, Bhanji F. Pediatr Emerg Care. 2014;30:879-883.
Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial.
Barzallo Salazar MJ, Minkoff H, Bayya J, et al. J Am Coll Surg. 2014;219:1001-1007.
In Conversation With… David M. Gaba, MD.
AHRQ WebM&M [serial online]. March 2013
The Literature on Health Care Simulation Education: What Does It Show?.
David A. Cook, MD, MHPE. AHRQ WebM&M [serial online]. March 2013
What Does Simulation Add to Teamwork Training?.
David M. Gaba, MD. AHRQ WebM&M [serial online]. March 2006
Team Training: Classroom Training vs. High-Fidelity Simulation.
Stephen D. Pratt, MD and Benjamin P. Sachs, MB. AHRQ WebM&M [serial online]. March 2006
AHRQ WebM&M [serial online]. March 2013
David A. Cook, MD, MHPE. AHRQ WebM&M [serial online]. March 2013
David M. Gaba, MD. AHRQ WebM&M [serial online]. March 2006
Stephen D. Pratt, MD and Benjamin P. Sachs, MB. AHRQ WebM&M [serial online]. March 2006
Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Ann Intern Med. 2013;158(5 Pt 2):426-432.
Cumin D, Boyd MJ, Webster CS, Weller JM. Simul Healthc. 2013;8:171-179.
Technology-enhanced simulation for health professions education: a systematic review and meta-analysis.Cook DA, Hatala R, Brydges R, et al. JAMA. 2011;306:978-988.
Cooper JB, Singer SJ, Hayes J, et al. Simul Healthc. 2011;6:231-238.
Salas E, Wilson KA, Burke CS, Priest HA. Jt Comm J Qual Patient Saf. 2005;31:363-371.
Gaba DM, ed. Wheaton, IL: Society for Simulation in Healthcare. ISSN 1559-2332.
BMJ Qual Saf. 2013;22:449-519.
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