Historical perspective

Medical simulation is the use of a device or series of devices that emulate a real patient care situation for the purposes of training, assessment, or research. It exposes learners to both rare and common clinical situations in a predictable manner. It can enable novice learners to have mentored practice of technical skills at a pace that facilitates skill acquisition, and more-advanced learners the repetitive exposure to attain mastery.

Simulators can be employed for the acquisition and assessment of cognitive, technical, and behavioral skills, and as a tool for research, product development, and process improvement. Medical simulation has likely been around for millennia, as simulation has long been recognized as a valuable educational strategy. The first modern simulators were developed in the early 1960s as a tool to teach both clinicians and the lay public the technique of cardiopulmonary resuscitation. These task trainers provided learners the opportunity to practice the necessary resuscitation skills individually or while being overseen and corrected by instructors. Over the years more complex tasks have been simulated, and there are now sophisticated physiologically based whole-body simulators that enable novices and practicing clinicians to hone their skills.

Riding on the coattails of other high-reliability industries, modern medical simulation began to transcend its role in resuscitation training in the late 1980s and early 1990s. In response to the recognition that flight mishaps were typically caused by or made worse by communication failures, the aviation industry developed a set of principles, “cockpit resource management.” These principles were developed, learned, and assessed in flight simulators. These principles were adapted to the operative environment in a program called Anesthesia Crisis Resource Management. Anesthesiologists started to teach these principles more broadly, and other disciplines rapidly began to adapt them to their specialties. In 2003 new human-patient simulators were released that changed the face of simulation forever. Prior to this, medical simulators were extraordinarily expensive. Few institutions could afford them, resulting in limited familiarity with the technology and, as a result, an impediment to further innovation. These new, more-affordable simulators brought about a dramatic increase in their availability and use, which resulted in both increased use and a corresponding increase in exploration and innovation. As team training continued to advance, increased use led to a broadening of applications. New simulation modalities were introduced, and there was also a proliferation of research in simulation. Simulation became established in a variety of health care professions, including nursing, emergency medical service(s) (EMS), other allied health fields, and increasingly in disaster preparedness.

Educational theory in simulation

Medical simulation takes advantage of adult learning theory. First described by Malcolm Knowles, the adult learner differs from the child learner. The adult brings a vast experience database to each learning event. They are also very much goal and relevancy oriented; if they do not see the need for the knowledge, they are less likely to learn it. Although the “see one, do one, teach one” model also takes advantage of adult learning theory by making the training relevant and the learner goal oriented, its patient safety limitations among other limitations, has contributed to the emergence of simulation for clinical education.

Russell and Feldberg in 1999 put forth a theory that implicates human emotion as an important element in adult learning. Their “Circumplex Model of Emotion” provides an excellent representation of how emotionality plays into adult learning. Although many learning opportunities, such as lectures, provide a pleasant milieu for both the learner and instructor, the learner is most often in a deactivated state. Adults learn best when they are both activated and under some degree of stress. This is one of the underpinnings of the adult learning model. However, too much stress can actually be counterproductive, creating an environment that can be cognitively challenging. The making of a clinical error is a frequent motivator of learning. If an error is recognized, the now motivated clinician typically seeks out the cause of the error by reading an article, looking it up on the Internet, or consulting a colleague in an attempt to avoid a similar error in the future. Another example of the importance of emotionality in learning is the enhanced motivation to learn after the debriefing of a disaster response. Not only is the identification of the error important, its effect on the emotions of the responders will influence the degree to which people are motivated to address change. Simulation attempts to activate learners; commonly introducing a modicum of stress, and thus enhancing the learning experience by increasing the motivation to learn. Another illustration of how simulation can enhance learning is through its effect on the learner’s perception of competence in a subject. The adult learner typically comes to the learning encounter with two levels of competence. The first is their perceived competence (how well they think they know something); the other is their actual competence (how well in reality they know it). Although in some cases the learner may actually have greater knowledge than he or she thinks, in the majority of cases, the learner’s actual competence is eclipsed by his or her perceived competence. The “competence gap” is the difference between actual and perceived competence. At the conclusion of a simulated (or actual encounter for that matter), the learner is provided with a real sense of their competence. Narrowing of the “competence gap” is motivational to the adult learner. This now motivated learner has an enhanced hunger for knowledge. If the same material were being presented in a lecture format, the learner would likely remain at their initial level of perceived competence, making the learning interaction less relevant and providing less motivation to pay attention.

Ericsson, in his landmark work, theorizes that people are not naturally born with the skills necessary to become experts; they achieve expertise only after thousands of hours of practice and repetition; enhanced under the watchful eyes of a coach. This is as true for clinicians as it is for athletes. In athletics, it is common for training to occur away from the competitive arena. For instance, the expert golfer has spent thousands of hours practicing and perfecting his skills under the tutelage of a coach before playing in a professional tournament. It is not unusual for surgeons to hone their skills in the operating room, let alone to do the procedure there for the first time. In fact, clinicians learn while “playing in the tournament.”

Simulation offers clinicians an opportunity to learn new skills and develop a minimal level of competence prior to performing the skill on a real patient. Certainly, the honing of skills into expertise should involve practice on simulators, as well as on real people. Simulation also enables clinicians to practice rare or infrequently performed skills so that they are more prepared to perform them successfully when needed. This advantage is clearly leveraged in disaster preparedness; simulations being an often-used modality for the training and preparation for disaster response.

Debriefing , a term originating in the military, involves the review of operations at the conclusion of a mission to learn from the experience and improve future performance. A critical element of scenario-based simulation, debriefing enables learners to reflect on their performance in the scenario. Integrating experiences into this process, the facilitator(s) leverages the activated and somewhat stressed state that the scenario has generated into an effective learning experience. It is postulated that this activated, interactive, and self-reflective experience creates an advantageous milieu for durable learning to occur. Even though a degree of nervous tension is intended, the development of frank anxiety is thought to impede the process, making the development and framing of the experience a critical element.