What This Chapter Is About: An Overview

“Simulation training in all its forms will be a vital part of building a safer health care system” [p. 55]. Sir Liam Donaldson, CMO Annual Report (2008)

In concert with other modalities, simulation can improve patient safety by informing personnel about best practices, guiding established clinical practice, and strengthening human performance. Unfortunately, simulation in health care is still not used as widely and systematically as needed, compared to its use in other high-risk/high-reliability industries. From the authors’ point of view, anesthesia professionals, anesthesia departments, and health care organizations need to strive to embrace the use of simulation for the many purposes mentioned in this chapter. Simulation, in combination with human factors training (CRM, see Chapter 6 ), has the potential to substantially improve the quality and safety of health care.

Anesthesiology has pioneered the field of simulation in health care. The rather new, mannequin-based patient simulators have been in regular use in anesthesiology since the early 1990s. Over the last two decades, there have been many technologic advances in simulation and a wide variety of applications of simulation in anesthesiology have been developed in the domains of education and training, research, system and equipment probing, and assessment. Considerable collective experience has already been achieved with simulation devices, sites, pedagogy, and assessment rubrics. What was once an arcane and small niche activity has expanded enormously. Simulation can be thought of like playing a musical instrument: almost everybody can somehow coax a tone out of it, but to play it well and use it optimally can only come about after considerable practice.

This chapter aims to provide the reader—whether a simulation participant or a novice or experienced instructor—with a solid and nuanced understanding of many aspects of patient simulation in anesthesiology and other parts of health care.

Modern simulation with advanced teaching concepts and the integration of human factors training (CRM) is much more than traditional basic life support and advanced cardiovascular life support (“megacode”) training. Modern simulation team training is academically demanding, personally stimulating, and involves many disciplines and lines of thinking. As a simulation instructor, you are operating at the core of our profession!

Simulation in Anesthesia: Why Is It Important?

See one—do one—teach one? Read one—do one—teach one? Many decades ago anesthesiology trainees might have been “given a long leash” (inadequately supervised) and asked to gain experience by “sink or swim,” often with a clinical population of indigent patients. Using actual patients in this way as if they are expendable “simulators” is unethical, and the presumed learning experiences were extremely uneven. In the last few decades unacceptable practices have been eliminated, but it increasingly begs the question of how can clinicians at all levels of experience feel the difficulties of patient care, including managing very difficult situations, without putting patients at undue risk? How does someone go from a total novice to a fully competent independent anesthesia professional? And of increasing importance, how can clinicians—during both initial and recurrent training—learn and hone skills of dynamic decision making, situation awareness, leadership, communication, and teamwork?

Anesthesiology is a “hands-on” discipline. It is not likely for medical students and residents to learn simply by “looking,” “time passing,” or by “osmosis.” The application of (rare) technical skills, the correct use of medical knowledge and algorithms, as well as the reliable utilization of anesthesia nontechnical skills (see Chapter 6 )—such as teamwork, communication, and leadership behavior—need to be learned and then trained repeatedly. At the same time, experience is no substitute for excellence (see Chapter 6 ). This is especially true for nonroutine events, such as emergencies or rare complications. Not only trainees but also experienced clinicians require continuous education and training of their clinical and nontechnical skills in order to stay current and avoid bad habits or the normalization of deviance (see Chapter 6 ).

Health care, with anesthesiology as the pioneering discipline, borrowed and adapted alternative educational approaches to teach knowledge and gain procedural experience from years of successful service in other industries that faced similar problems. These approaches focused on “simulation.” Simulation is a technique well known in the military, aviation, space flight, and nuclear power industries. Simulation refers to the artificial replication of sufficient elements of a real-world domain to achieve a stated goal. The goals include for example education and training of technical and nontechnical skills, system probing, testing of equipment and supplies, and assessment as well as evaluation of students and personnel. These different topics are covered in this chapter, even though there is a focus on simulation as a training and education tool.

In 2000, the National Academy of Medicine (then the Institute of Medicine) released a report, “To Err Is Human: Building a Safer Health System,” that suggested the use of simulation training in health care in order to reduce preventable errors. The American College of Critical Care Medicine recommended the use of simulation to improve training in critical care. With anesthesiologists being the pioneers for simulation-based training in health care, simulation in anesthesia already has a long tradition. At the same time, its comprehensive and profound implementation has come a long and rocky way over the last decades and, despite many benefits, still needs further implementation and continuous evaluation. Major recognition of simulation in anesthesia by the clinical world is highlighted by the fact that it is now a highly utilized training course for the practice improvement component of Maintenance of Certification in Anesthesiology (MOCA) in the United States. In Australia and New Zealand, it is an integral part of anesthetic training. In their reviews, Lorello and colleagues, LeBlanc and colleagues, and Higham and Baxendale give an overview of simulation-based training in anesthesia. In many parts of the world, including industrial countries, the use of simulation is way behind the United States or Australia.

A fundamental part of the future vision for simulation is that clinical personnel, teams, and systems will undergo periodic and systematic simulation activities across their entire career using various modalities of simulation and for diverse purposes of education, training, performance assessment, refinement in practice, and system probing. This vision is inspired in part by the systems in place in various high-reliability industries, especially commercial aviation and nuclear power (see Chapter 6 ). Needless to say, using simulation as part of the process of revolutionizing health care is more complex than merely attempting to stick simulation training on top of the current system. Moreover, beyond training, simulation may provide indirect ways to improve safety, including facilitating recruitment and retention of skilled personnel, acting as a lever for culture change, and improving quality and risk management activities.

Application of Simulation in Anesthesia and Health Care

Simulation techniques can be applied across nearly all health care domains. A few books are devoted solely to the topic of simulation and its use in and outside of anesthesiology.

In the upcoming section, an overview of the main objectives of simulation in health care and anesthesiology are presented in the following sequence: (1) education and training of technical and nontechnical skills, (2) system probing, (3) testing of equipment and supplies, (4) assessment/evaluation, (5) research, and (6) further purposes.

Use of Patient Simulation for Training and Education

With respect to the first objective—education and training—anesthesiology remains a driving force in the use of simulation in health care, although simulation has spread to nearly every discipline and domain. As used in this chapter, education emphasizes conceptual knowledge, basic skills, and an introduction to nontechnical skills and work practices. Training emphasizes preparing individuals to perform actual tasks and work of the job.

Disciplines successfully applying simulation for training besides anesthesia are, for example, emergency medicine and emergency field responders, trauma care, neonatology and pediatric anaesthesia, labor and delivery, surgery, radiation oncology, intensive care, and infectious disease. Simulation serves almost all resuscitation trainings, which have advanced over the years. Fig. 7.1 gives several impressions of simulation training.

Different impressions of simulation training sessions in different health care environments.

Photos from left to right:

(1) In situ simulation training on a ward. (2) In situ simulation team training in the anesthesia environment. (3) Simulation exercise during the annual simulation congress INSiM, Frankfurt Main, Germany. The photo shows a simulated patient that is rescued out of a crashed car. (4) Full-scale in situ simulation team training in the emergency department. (5) Military simulation training with Tactical Combat Casualty Training and Care under Fire conditions, InPASS, Photo with permission by M. Rall. (6) Simulation Training at the Simulation Center TüPASS in Tübingen, Germany. Shown is a handover moment where a traumatized patient is handed over from the ambulance team to the trauma team. Photo with permission by director M. Rall 2010. (7) Simulation training on the intermediate care unit. (8) Simulation exercise with a standardized patient that is rescued out of a crashed car. Photo provided by M. Rall. (9) In situ simulation training in an operating room (OR) showing the beginning of a full team obstetric scenario for emergency cesarean. The photo is taken through an OR window from the temporarily established simulation control room outside the OR.

Photo provided by M. Rall.

Nearly every anesthesia residency program in the United States offers some cogent simulation training experiences, although the scope, frequency, and target content vary. Other disciplines and other countries may not have adequate simulation training coverage during residency, as evidenced by a study by Hayes and colleagues.

The military and the U.S. Department of Homeland Security also have been heavy users of simulation in health care; simulation has been applied to the initial training of new field medics and to the recurrent training of experienced clinicians and clinical teams. In 2013, a first instructor course for the North Atlantic Treaty Organization (NATO) Special Operations Forces (SOF) was held at NATO headquarters in Brussels to bring together medical experts from the United States SOF, the NATO SOF, and some civilian instructor experts (including authors Rall and later Oberfrank).

Simulation is relevant from the earliest level of vocational or professional education (students) and during apprenticeship training (interns and residents), and it is increasingly used for experienced personnel undergoing periodic refresher training. Simulation can be applied regularly to practicing clinicians (as individuals, teams, or organizations; the latter for example for disaster drills, or for preparing to care for patients with Ebola virus disease ) regardless of their seniority, thus providing an integrated accumulation of experiences that should have long-term synergism. Thus, it is applicable to health care providers with a range of experience, including experts, novices, advanced residents, medical, nursing, other health care students, and even children. Simulation rehearsals are now being explored as adjuncts to actual clinical practice; for example, surgeons or an entire operative team can rehearse an unusually complex operation in advance by using a simulation of the specific patient.

Many simulation centers offer continuing medical education (CME) and training for experienced practitioners, and many aspects of simulation training for residents can be expanded for this purpose. Several studies have shown that experienced anesthesiologists have deficiencies in the management of critical patient situations and make severe errors comparable to those of anesthesia residents. Because crisis situations are rare during routine clinical work, these results are not startling. In addition, experience in terms of years on the job and hierarchy probably do not correspond to expertise and excellence. Crisis management training with patient simulation should be started early in education and training and applied on a recurring basis during practice.

Concerning education of health care professionals about patient safety, patient simulation can be a tool that contributes to changing the culture in an organization bottom-up to create a culture of safety. First, it allows hands-on training of junior and senior clinicians in practices that enact the desired culture of safety based on the principle of high reliability organizations (see Chapter 6 ). Simulation can be a rallying point about culture change and patient safety that can bring together experienced clinicians from various disciplines and domains (who may be captured because the simulations are clinically challenging and show the need of change in direct relation to patient treatment), along with health care administrators, executives, managers, risk managers, and experts on human factors, organizational behavior, or institutional change. For these groups, simulation can convey the complexities of clinical work, and it can be used to exercise and probe the organizational practices of clinical institutions at multiple levels (see section on system probing). Various curricula and recommendations for curricula development for simulation training exist.

Use of Patient Simulation for Research

In regard to the fifth objective—research—simulation-based research falls into two categories: (a) research about simulation—testing or improving the techniques, technologies, and didactics of simulation; and (b) research that uses simulation as a tool to study other things, such as human performance and clinical cognition (see Chapter 6 ), or clinical care processes. Box 7.1 provides a sampling of these types of questions.

Box 7.1

Exemplary Research Issues That Can Be Addressed by Using Simulation

Cognitive Science of Dynamic Decision Making (see Chapter 6 )

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  What is the interaction of precompiled procedural knowledge (Type I thinking) versus deep medical knowledge and abstract reasoning (Type II thinking)?

  
  
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  How does supervisory control of observation relate to vigilance, data overload, and visual scanning patterns?

  
  
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  What is the information content and utility of watching the surgical field?

  
  
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  How are optimal action planning and scheduling implemented?

  
  
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  How does reevaluation fail and result in fixation errors?

Human-Machine Interactions

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  What is the distraction penalty for false alarms?

  
  
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  Do integrated monitors and displays have an advantage over multiple stand-alone devices and displays?

  
  
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  How easy to use are the controls and displays of existing anesthesia equipment in standard case situations and in crisis situations?

Teaching Anesthesia in the Operating Room (see Chapters 4 , Chapters 9 )

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  How much teaching can be accomplished in the operating room without sacrificing the anesthesia crew’s vigilance?

  
  
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  How well can faculty members detect and categorize the performance of anesthesia trainees?

  
  
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  What teaching styles are best integrated with case management in the operating room?

Issues of Non-Technical Skills/Teamwork on Anesthesiologist Performance

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  How does an anesthesia crew interact during case and crisis management?

  
  
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  How is workload distributed among individuals?

  
  
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  How do crew members communicate with each other, and how do they communicate with other members of the operating room team?

Effects of Performance-Shaping Factors on Anesthesiologist Performance

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  How do sleep deprivation, fatigue, aging, or the carryover effects of over-the-counter medications, coffee, or alcohol affect the performance of anesthesiologists?

  
  
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  Can smart alarm systems or artificial intelligence provide correct and clinically meaningful decision support in the operating room or intensive care unit?

Development of New Devices and Applications: Research Regarding Techniques of Simulation

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  How well can simulations re-create perioperative clinical settings? Can they provoke the same actions as used in real clinical care (ecologic validity of simulators)?

  
  
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  How much does debriefing add to learning from simulation? Are specific techniques of debriefing, or combinations thereof, of greater applicability or utility, overall or for particular situations?

  
  
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  How do various aspects of simulation scenarios influence aspects of perceived reality, and how do they influence transfer of training into the real world?

  
  
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  Does simulation training lead to better clinical practice and improved clinical outcomes?

Regarding research about simulation, some examples would include the design of debriefing approaches such as Debriefing with Good Judgement, Debriefing-Diamant, PEARLS, TeamGAINS, and others ; methods for designing simulation scenarios such as PARTS ; the efficacy of using videos in debriefings ; the creation and maintenance of an inviting learning atmosphere ; the effective design of specific training interventions such as for resuscitation, airway management, and avoidance of catheter-related infections ; and testing of specific training interventions such as for facilitating speaking up, briefings, and feedback.

Patient simulation is now used sometimes to address the medical management of chemical, biologic, or nuclear threats from accidents, weapons of mass destruction, or terrorism. One group in Germany, used simulation to test the constraints of treating patients in full chemical protection gear to optimize the strategies of the German Ministry of Internal Affairs for dealing with terror attacks or chemical plant disasters ( Fig. 7.2 ). Several investigators have performed multidisciplinary studies with combined simulation modalities (script-based simulators, model-based mannequin simulators, and simulated acted patients) to teach the management of victims of an attack with weapons of mass destruction and terrorism. The demand for such training is substantial in nations engaged in active military conflicts or with an ongoing need to prepare for war or terrorist attacks.

Realistic patient simulation as a test bed for studying the performance of medical rescue teams in full chemical protection gear. Teams wore normal uniforms or full protection suits while performing basic resuscitation actions (e.g., placement of intravenous lines, drawing up drugs, intubation). With full protective gear, communication within the team and with the patient (while still conscious) is difficult.

Photograph taken by M. Rall at the Center for Patient Safety and Simulation, Tübingen, Germany.

Regarding (b) simulation as a research tool, it offers some unique features, and it can be thought of as a complementary window on the clinical world relative to other modalities. It can be applied, for example, when complex phenomena such as medical team processes are studied. Examples are investigations of how teams adapt from routine to non-routine situations and how this adaptation is related to performance, communication processes such as information processing, talking to the room and speaking up, problem-solving and decision-making, and coordination requirements during resuscitation. Important milestones for simulation-based research of both types was the creation by the Society for Simulation in Healthcare (SSH) in 2007 of its flagship peer-reviewed journal, Simulation in Healthcare followed in later years by other peer-reviewed journals (e.g., Advances in Simulation , BMJ Simulation & Technology Enhanced Learning , Clinical Simulation in Nursing ). In addition, for research that is linked tightly to a specific clinical domain, the traditional medical specialty journals have become more welcoming to articles about simulation or that use simulation as an experimental technique.

Cooperation between simulation directors or instructors and psychologists, human factors engineers, or educators has proved useful in research and training. Such collaborations have helped delineate the theoretical foundations of simulation-based experiential learning, improve the understanding of debriefing, and research on work psychology and human performance in health care. Many institutions have integrated psychologists or educators, or both, into their simulation center staff.

History, Development, and Types of Simulators and Simulation

The following section gives a short, non-exhaustive overview about the history and the development of the main simulators in health care and anesthesia. For a more in-depth examination of the topic, the reader is referred to further literature. Particularly the mannequin-based simulators that are in wide use have been well covered in several review articles and a whole book chapter by Rosen written in 2013 is dedicated to the topic in detail. Another comprehensive textbook on the history of simulation in health care tracing it back 1500 years was published by Owen.

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  Simulation probably is as old as mankind. Simulation has probably been a part of human activity since prehistoric times. Rehearsal for hunting activities and warfare was most likely an occasion for simulating the behavior of prey or enemy warriors. In medieval times soldiers learned the art of swordsmanship on dummy soldiers. Hundreds of years ago, models were used to help teach anatomy and physiology, and simulators were used to train surgical procedures and to help midwives and obstetricians handle complications of childbirth. Italy was the major source of simulators early in the 18th century, but in the 19th century, dominance in clinical simulation moved to France, Britain, and then Germany. In modern times, preparation for warfare has been an equally powerful spur to the development of simulation technologies, especially for aviation, navy and armored vehicles. These technologies have been adopted by their civilian counterparts, but they have attained their most extensive use in commercial aviation. The aircraft simulator achieved its modern form in the late 1960s, but it has been continuously refined.

  
  
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  Mannequin-based simulators (MBSs). In 1969, the first electromechanical mannequin-based simulator in modern health care—Sim One—was produced by an aerospace company working with an educator and an anesthesiologist at the University of Southern California. It consisted of a mannequin comprising an intubatable airway and upper torso and arms, and in many respects was years ahead of its time. It was originally used as an aid for students or residents learning to intubate, as well as to induce anesthesia but the project died out in the early 1970s. In the following years, several other mannequin-based patient simulators were developed and introduced in the middle to late 1980s. Noteworthy among others is Harvey, a cardiology mannequin simulator released in 1976, which is able to simulate the arterial pulse, blood pressure, jugular venous wave, precordial movements, and heart sounds in normal and diseased states. In 1986, a team at Stanford, headed at first by Gaba and DeAnda, developed a full-scale simulator called the Comprehensive Anesthesia Simulation Environment (CASE); they used it initially to study the decision-making processes of anesthesia professionals during critical events, but they were also interested in its use for training. Over a few years, with their recognition of the parallels with Crew/Crisis/Cockpit Resource Management (CRM) in aviation this team developed their flagship simulation training course Anesthesia Crisis Resource Management (ACRM, see Chapter 6 ). Newer commercially-available mannequin-based patient simulators have been in use in anesthesiology since about 1995, and considerable collective experience with the devices already has been achieved. Currently, full-size mannequin-based simulation devices are used in most simulation centers (available now, for example, from the manufacturers Laerdal, Gaumard, CAE Healthcare, and others). Such devices allow the simulation of rapidly changing physiology and can support a variety of hands-on interventions (e.g., airway management, vascular cannulation, drug administration, electric countershock, or pacing). Some devices allow the system automatically to recognize injection of specific medications or therapeutic maneuvers, such as cardiac massage, and then—with or without instructor input—to respond in an appropriate manner. Even though highly developed, mannequins still miss important features. Box 7.2 shows desirable features of future MBS systems.

  
  
  
  

  Box 7.2

  
  

  Desirable Features of Future Mannequin-Based Simulator Systems

  
  

  
  

  
  

  
  
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    Ability to interface to or to mimic advanced brain monitoring such as: AEP, Auditory evoked potential; BIS, bispectral index; EEG, electroencephalographic; PSI, patient state index.

    
    
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    Advanced skin signs such as: change in skin color to cyanotic or pale, improved diaphoresis, change in skin temperature (e.g., as a result of shock or fever), rash, hives, or generalized edema

    
    
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    Regurgitation, vomiting, airway bleeding or secretions

    
    
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    Physical coughing (currently only sounds are simulated)

    
    
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    Realistic convulsions

    
    
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    Purposeful movements of extremities

    
    
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    Improved or possible support for spinal, epidural, or other regional anesthesia procedures

    
    
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    Improved EEG signals (e.g., for BIS, AEP, PSI)

    
    
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    Improved intracranial pressure

    
    
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    Support for physical central venous and arterial cannulation

    
    
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    Improved fetal and maternal cardiotocogram

  Please note: This list contains features that are not currently incorporated. Some features may be under development and could be available after publication of this book. In addition, some features are currently available as third-party or homemade add-ons.
  

  
  

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  (Computer) Screen-based simulators (microsimulators). Beginning in the mid-1980s, several screen-based, also called screen-only simulators (microsimulators), were developed by anesthesiologists. These included (1) screen-based part-task trainers that simulated isolated aspects of anesthesia, such as the uptake and distribution of anesthetic gases in the body given different physiologic and physical chemistry situations (e.g., the well-known Gasman program ); and (2) screen-based overall-task trainers that represented nearly all aspects of the patient and clinical environment. Originally, the patient was represented by drawings or animations, but increasingly in these systems the representation of the patient is by photographs or videos. Vital signs appearing on virtual monitors may mimic real clinical devices. Actions are selected typically using a graphic user interface, pointing and clicking on menus and buttons, and using sliders and numeric entry boxes to allow control of most kinds of interventions that clinicians use on a regular basis.

  
  
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  Part-task trainers and virtual procedural simulators. In the 21st century, advancements in engineering and computer science have stimulated a new era of simulator technology, including:

  
  
  
  
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    Part-task trainers in the form of anatomic mock-up devices that are made from synthetic material to represent human body parts, such as models that allow training of central line placement, epidural catheter insertion, cricothyroidotomy, or chest drainage. Over several decades, tissue-based simulation—representing some sort of part-task trainer—has become more common, with trainees no longer learning procedural skills using animal models because of cost and issues of animal rights.

    
    
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    Virtual simulators for surgical and procedural skills (i.e., hardware and software that provide haptic feedback for performing realistic laparoscopic cholecystectomy, bronchoscopy, colonoscopy, echocardiography, and endovascular procedures). In these systems, the synthetic (virtual) environment exists solely in the computer. The real procedure is performed by using a video display that can be recreated by the simulator. The person simulating the procedure interacts with the video display through the eyes (without or with head-mounted glasses) and the ears, and usually the hands, if the simulator features special instruments, instrumented gloves, or sensors. For anesthesia, for example, there exist VR simulators to train the conduct of fiber-optic intubation and regional anesthesia. Two systematic reviews are available for more in-depth information on the general use of simulation teaching regional anesthesia.

  
  
  
  
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  Virtual reality and augmented reality (usually via head-mounted displays). Both immersive virtual reality (VR), which fully integrates the human user into the computer’s world, and augmented reality (AR), which adds computer-generated imagery onto or next to the real-world view, typically use head-mounted displays to either replace ordinary vision or to augment it. Both approaches have been described in the literature, often in prototype or research-only settings. This chapter will discuss only VR and not AR. The authors (DG in particular) have been evaluating commercially available systems for head-mounted display VR. For health care they seem to fall into two categories: (1) visualization of objects or spaces—typically for anatomical structures, or for architectural environments, and (2) physically interactive clinical environments— meaning the clinicians themselves can move with the space and interact directly with each other and the virtually presented patient, essentially the VR equivalent of physical mannequin-based simulation. Visualization applications are much more common and are direct applications of consumer VR hardware and software (e.g., visualizing the human heart in all its detail inside and out instead of, say, the Taj Mahal). Fully interactive VR makes use of commercial head-mounted displays and other gear but is more complex to create the clinical space, patient, and equipment while providing for multiple physical participants to interact with seamless head and body movements.

  
  

  Both types of VR are still in quite early stages of practical implementation in health care and how these approaches can best be used in health care remains to be seen, but the tide is now turning away from arcane research or “vaporware” to an era of rapidly improving practical devices and applications. Although Gaba has previously written that VR would soon (by 2020-2025) completely replace all physical simulation, this now seems unlikely in that time frame; in fact, it is likely that VR will join the spectrum of simulation modalities each of which has a set of unique advantages and disadvantages relative to the others.

  
  
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  Virtual Environment/Virtual World. A related type of virtual simulation is the virtual environment or virtual world. According to Wikipedia, a virtual world is a computer-based simulated environment intended for its users to inhabit and interact through avatars (users’ graphic representation of themselves). Such systems typically allow multiple participants to control their own avatars (including speech) simultaneously over a network and to interact verbally and by virtual physical actions within a commonly perceived virtual environment. This technology currently portrays the virtual world as perspective three-dimensional images (or possibly true 3D) on a computer screen with sound. Virtual worlds are most commonly used for computer games. In a medical virtual world, the patient may be an automated avatar controlled by the computer, or the patient may be an avatar inhabited by a human participant. Kleinert and colleagues published a review of such systems in 2015 and concluded that the development and validation of such simulators will need to be the subject of further research.

  
  
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  Standardized patients. Standardized patients (SPs; in some countries referred to as “simulated patients”) are actors/role players who are trained to represent a patient’s condition (e.g., symptoms or social situation) and may be trained to score a participant’s performance and to provide informative feedback. Over the last three decades, students increasingly learn skills in medical history taking and physical examinations using SPs. Overviews of the use and implementation of SPs in anesthesia education are available. SP-based simulations are increasingly being used for issues such as disclosure of bad news and other difficult conversation as well as in pain medicine.

  
  
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  Hybrid simulation. Hybrid simulation means combining different types of simulation modalities during a simulation scenario. It can be used in different ways and serves several purposes: (1) Pairing simulation devices in parallel. This way, a training atmosphere can be established, in which different professions can have credible clinical work for their role. For example, when training the management of complications in the OR with surgeons and anesthesiologists together, it is helpful if both professions have clear functions during the scenario. For example, Kjellin et al. performed a multidisciplinary OR team training, where training was performed in a mock-up OR equipped with a mannequin-based patient simulator and a laparoscopic simulator. Another option is to integrate manufactured life-like surgical models with the mannequin, as used by Weller et al. for multidisciplinary OR team training. (2) Pairing simulation devices in sequence. This way, the best characteristics of each simulation modality can be used in a scenario and create a simulation that is more than the sum of the parts. For example, a scenario can start with a standardized patient/role player presenting in a patient bed or gurney; the simulation can be transferred to a mannequin at a critical point, such as when invasive activities are needed (e.g., intubation or CPR) or when giving birth. Cantrell and Deloney offer suggestions for integrating SPs into high-fidelity simulation scenarios.

Simulation Fidelity and Classification of Simulators

Simulation is becoming more commonly used for education and training purposes as well as for continuing professional development. But people often have very different perceptions of the definition of the term simulation. This highlights the need for definitions of simulation modalities, simulation fidelity, a classification of the relevant technologies and features, and also a brief overview about the methods of teaching.

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  Simulation fidelity and simulator capability. In the simulation literature the term fidelity—which means how closely something replicates reality—is often used to refer to specific devices or products. In contrast, the authors believe strongly that this is a misnomer and that the concept of fidelity is a property of the simulation activity and not primarily of the device(s) or products used. That is, fidelity is determined by the number of aspects that are replicated by the simulation (not only physical ones) and the applicable representation of each aspect relative to that of the real world (see subchapter on simulation realism) . The fidelity required of a simulation depends on the stated goals and participant population. Some goals can be achieved with minimal and low fidelity, whereas others require very high fidelity.

  
  
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  Classification of simulators. For some purposes it is useful to compare the levels or specifics of the particular technological capabilities of simulator devices. There is no universally accepted classification scheme for describing simulators in anesthesia. Any classification involves some overlapping and gray areas. Cumin and Merry describe a classification that is based on the three pillars of (1) user interaction, (2) physiology base, and (3) use. Gaba classifies simulation modalities according to the following scheme: verbal simulation (i.e., “what-if” discussions, storytelling, trigger videos, role playing), SPs, part-task trainers (including realistic mock-up devices and tissue simulation), computer patient (i.e., VR simulation, microsimulators/screen-based simulators), and electronic patient.

  
  

  In this chapter, a patient simulator (as opposed to a part-task trainer) is a system that presents an approximation of a whole patient (not only parts of it) and a clinical work environment of immediate relevance to anesthesiologists (e.g., operating room, postanesthesia care unit, ICU, etc.). A patient simulator system contains several components ( Fig. 7.3 ). Some of the currently available features of typical mannequin-based patient simulators are presented in Table 7.1 .

  
  

  
  

  
  

  

  
  

  
  

  Schematic diagram of the generic architecture of patient simulator systems.

  
  

  The simulator generates a representation of the patient and the work environment with appropriate interface hardware, display technologies, or both. The representation is perceived by the anesthesia professional, whose actions are input to the simulator through physical actions or input devices. The behavior of the simulated scenario is manipulated by the instructor or operator through a workstation that allows selection of different patients, abnormal events, and other features of the simulated patient. The control may be manual, script based, or model based with manual adaptation to reach optimal learning outcomes. ICU , Intensive care unit; OR , operating room.

  
  

  Diagram by D.M. Gaba.

  
  
  
  

  Table 7.1

  
  

  Functionality of Typical Current Mannequin-Based Simulator Systems ^∗

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Clinical Area	Features and Functions	Remarks
  Airway	Appropriate pharyngeal and glottic anatomy	The airway often provides an acceptable seal for ETT; the seal for supraglottic airway devices can be variable, but it generally does allow positive pressure ventilation. The facemask seal is variable (plastic on plastic) Cricothyrotomy of modest anatomic realism; the tissue does not feel like real skin and lacks a subcutaneous fat layer; no bleeding occurs; however, the simulation does allow going through the physical steps of inserting a subglottic surgical airway.
  	Placement of facemask, ETT, supraglottic airway devices, Combitube
  	Laryngospasm, tongue and airway swelling, cervical immobility, jaw closure, breakable teeth
  	Cricothyrotomy
  	Transtracheal jet ventilation
  	Bronchial anatomy (to the lobar bronchus level)
  Head	Eyelid movement, pupil dilation, and reaction to light or medications
  	Patient voice and sounds such as coughing and vomiting (through built-in loudspeaker)	A live voice is preferred to the prerecorded audio clips because of higher flexibility in scenarios.
  	Palpable carotid pulses
  	Cyanosis represented by blue light at the edge of the mouth	The blue light is a cue that the patient is cyanotic, but it does not physically replicate the appearance of cyanosis.
  	Tearing, sweating
  Chest	Physiologic and pathophysiologic heart and breath sounds Spontaneous breathing with chest wall movement	Breath and heart sounds through loudspeakers; sounds contain artifacts and mechanical noise. Often sound level depends on position of stethoscope relative to loudspeaker.
  	Bronchospasm
  	Adjustable pulmonary compliance
  	Adjustable airway resistance
  	Pneumothorax
  	Needle thoracotomy and chest tube placement	As for cricothyrotomy the anatomy is not very realistic, but the mannequin may allow performance of these procedures.
  	Defibrillation, transthoracic pacing ECG
  	Chest compressions
  Extremities	Palpable pulses (dependent on arterial pressure)
  	Cuff blood pressure by auscultation, palpation, or oscillometry
  	Modules for fractures and wound modules
  	Intravenous line placement
  	Thumb twitch in response to peripheral nerve stimulation
  	Arm movement	Most current simulators do not provide even limited robotic movement of limbs.
  	Representations of tonic-clonic seizure activity	These representations are cues that lack anatomic reality.
  Monitoring (waveforms or numeric readouts)	ECG (including abnormalities in morphology and rhythm) SpO 2	Most simulators provide a simulated virtual vital signs display; some can interface to actual clinical monitors.
  	Invasive blood pressure
  	CVP, PAP, PCWP
  	Cardiac output
  	Temperature
  	CO 2 (may be actual CO 2 exhalation)
  	Anesthetic gases (may have actual uptake and distribution of agents)
  	Cardiopulmonary bypass	Some simulators include(d) a virtual cardiopulmonary bypass machine.
  Automation and sensors	Chest compressions Ventilation rate and volume
  	Defibrillation and pacing (including energy measurement)
  	Gas analyzer (inspired O 2 , anesthetics)
  	Drug recognition (drug identification and amount)

   
  

  CO ₂ , Carbon monoxide; CVP, central venous pressure; ECG, electrocardiogram; ETT, endotracheal tube; O ₂ , oxygen; PAP, positive airway pressure; PCWP, pulmonary capillary wedge pressure; SpO ₂ , saturation of peripheral oxygen.

  
  

  ∗ The features listed are each present in some existing simulators, but not all features are present on any single device. Sets of features depend on the device and model.

  
  
  
  

  In the following, the major education and teaching purposes of main simulator classifications are presented. The presentation is partly based on the idea of the Miller prism (also pyramid or triangle) of clinical competence. For a more elaborate overview the reader is referred to further literature.

  
  
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  Miller’s learning pyramid. For each simulation a variety of different learning objectives exist. Largely they can be aligned to the Miller pyramid shown in Fig. 7.4 . On the cognition level, simulations can be used to help learners acquire new knowledge and to better understand conceptual relations and dynamics (“knows,” “knows how”). For example, physiologic simulations allow students to watch cardiovascular and respiratory functions unfold over time and how they respond to interventions—in essence, bringing textbooks, diagrams, and graphs to life. The next step on the spectrum is acquisition of isolated skills to accompany knowledge (“knows how,” later “shows how”). Some skills follow swiftly from conceptual knowledge (e.g., cardiac auscultation) while others involve intricate and complex psychomotor activities (e.g., catheter placement or intubation). Isolated technical and non-technical skills must then be assembled into care processes and existing workflow concepts, creating a new layer of clinical practices (“shows how,” later “does”). Over time those assembled skills get integrated into practice and become part of daily performance (“does”). The expert health care professional performs only in the “does” triangle, except when honing old skills or learning new ones. However, there may be a gap between the level of performance that individuals—or teams or work units—“do” compared to the optimal level. Often, clinicians might be able to demonstrate “knows how”—“shows how” without necessarily being able to “do” under all relevant circumstances and occasions. Simulation can be a valuable tool to close such gaps.

  
  

  
  

  
  

  

  
  

  
  

  Miller’s learning pyramid, also known as Miller’s prism of clinical competence. Based on the Miller’s learning pyramid, the clinical competence of an anesthesia professional is built on four different competence levels, that can be divided into theory (a person’s cognition: “knows”-”knows how”) and practice (a person’s behavior: “shows how”-”does”). The most relevant clinical competence is the real time performance (“does”). Those four levels need to be considered when addressing learning goals as well as assessment goals of simulation. The figure is modified from a publication of Alinier, indicating that simulation fidelity, simulation realism, and simulation complexity increase with different levels of competency.

  
  

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  Non-technological simulation. Verbal simulations (“what-if” discussions), storytelling, paper and pencil exercises, and experiences with SPs require little or no technology, but can effectively evoke or recreate challenging clinical situations. Similarly, even pieces of fruit or simple dolls can be used for training in some manual tasks. Some education and training on teamwork can be accomplished with role playing or discussion of videos of relevant events.

  
  
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  (Computer) Screen-based simulators (microsimulators) that present the patient on the screen as drawings, photos, or videos, while allowing clinical actions or changes to be chosen can be used to teach basic concepts and technical material, such as the uptake and distribution of inhaled anesthetics or the pharmacokinetics of intravenous drugs. Such programs are inexpensive and easy to use. They allow the presentation of and practice with the concepts and procedures involved in managing normal and abnormal case situations, mostly targeting the parts of the Miller pyramid referred to as “knows” and “knows how,” commonly for early learners.

  
  
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  Part-task trainers include artificial (and occasionally animal or human cadaver) models used to teach particular procedural skills, for example intubation, intravenous or intraosseous access, regional anesthesia techniques, thoracic drainage, and use of difficult airway management devices. These target “knows how” and “shows how.” Such trainers are most commonly used with novices having little experience with the procedure, or to retrain experienced personnel in the application of the particular tools.

  
  
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  Mannequin-based simulators , representing most or all of a patient, can be used to capture the full complexity of the real task domain, including application of clinical skills and clinical algorithms in combination with human-machine interactions and the complications of working with multiple personnel. They can be used to address “shows how” extending into “does,” at least in simulation (see later section on translational research levels). Therefore, MBS are appropriate to teach diagnosis and management of challenging situations as well as non-technical skills and human-factor-based behavior (see Chapter 6 ). These can be used, with different educational approaches, for all levels of learners. For early learners it is common to use a teacher in the room as an advisor or coach, and to control the simulation by “pause and reflect” allowing the scenario to be stopped and continued or restarted as necessary to maximize their learning.

Sites of Simulation

Some types of simulation such as nontechnological ones and those that use videos or computer programs can be conducted in the privacy of the learners’ home or office using their own equipment. Part-task trainers and mannequin-based simulation are often used in a dedicated simulation center, but MBS is increasingly also done “in situ” (in place)—in a real patient room/bed—or “peri-situ” (near the place)—nearby elsewhere in the clinical work unit. For large-scale simulations (e.g., disaster drills ), the entire organization becomes the site of training, or in the case of a “moving” simulation, different parts of an organization become the site of training. If the simulation training takes place outside the organization, but uses the equipment and personnel of the organization, it is called “mobile” simulation.

Often simulation personnel that work in a dedicated center may either also conduct simulations “in situ,” “peri-situ,” “mobile,” and “moving patients exercises” or may mentor others who do so. The advantages and disadvantages of different simulation sites are discussed in each respective section and summarized in Table 7.2 . Sørensen and associates give an overview of the advantages and disadvantages of different simulation sites in a recent publication in 2017.

Dedicated Simulation Center

Many institutions have chosen to construct one or more complete simulation centers in which to conduct a variety of education and training sessions. At a few places entire “simulation hospitals” have been created (e.g., Miami, https://simhospital.sonhs.miami.edu/ ). Some useful websites of simulation centers and other resources are listed at the end of the chapter ( Appendix 7.1 ). The cost structure of a simulation center is a complex issue (see later subchapter). But these programs and their managers in charge have already voted with their feet on the issue of cost versus benefit.

In a dedicated simulation center, one or more simulators may be used, typically in rooms that partially or fully replicate, in a relatively generic fashion, various clinical environments (e.g., operating room, ICU, labor and delivery, emergency department, etc.). Fig. 7.5 and Fig. 7.6 show the floorplan of a medium-sized and a large simulation center. Fig. 7.6 shows the floor plan of the Immersive Learning Center at Stanford University, a pioneering center for health care simulation.

Simulation Center Floor Plan. An intermediate-sized simulation center with four simulation rooms (sim room), a computer-based training room, and several multipurpose rooms, equipped with audio-video patch panels to adjust the room use flexibly to the needs of different training activities (e.g., the large seminar room can be used as a large intensive care unit [ICU] or postanesthesia care unit [PACU] ).

Figure by M. Rall & E. Stricker, Center for Patient Safety and Simulation [TuPASS], Tübingen, Germany.

Simulation Center Floor Plan. Floor plan of a large interdisciplinary simulation center for multiple domains (anesthesia, surgery, students) with several multipurpose simulation rooms (sim room) and skills laboratories.

Figure by D. M. Gaba at the Immersive Learning Center at the Stanford School of Medicine, Stanford, California.

Typically, simulation centers provide a separate control room to allow complex simulations to be presented without an instructor intruding on the simulated case. Fig. 7.7 shows a simulation control room. Many simulation centers have audio-video systems allowing the recording of multiple views during patient simulation. Some centers have computer-based systems to allow annotation of video on the fly and rapid search to the marked portions, but others have found that such mechanisms are not necessary to support debriefing. Dedicated centers typically provide one or more debriefing rooms, often with video replay capability. Ideally a center is located to be easily accessible to a variety of participant populations. Designing, equipping, and overseeing construction of a simulation center may benefit from special knowledge or prior experience.

Simulation control room.

Through a window wall the simulation control room is separated from the actual simulation room. Several instructors can have a look on the simulation either via the windows, or via one of the several screens that show different views of the simulation room. In front of the instructors the workstation for control of the simulator system itself is placed, including an audio control desk with control of the simulated patient voice, the voice for in-scenario guiding, and several wireless headset channels.

Photograph provided by D.M. Gab; control room of the Stanford Immersive Learning Center.

Universities and hospitals or hospital networks are increasingly constructing very large multidisciplinary and multimodal simulation facilities that often still have anesthesiologists in leadership positions. Often, these kind of facilities combine all the types of simulation and immersive learning in one large unit, including actors playing SPs (usually in clinic settings), mannequin-based simulation, part-task and surgical and procedural trainers, wet and dry work (e.g., plaster casting or procedures on food products), and different forms of VR. Sometimes these incorporate facilities for dissection of cadavers or the use of anesthetized animals but often these are in other pre-existing sites. Some institutions have many simulation centers, associated with different learner populations, in different locales, or featuring different kinds of simulation equipment.

Advantages and Disadvantages of Dedicated Simulation Centers

Simulation in a dedicated center facilitates scheduled training and allows the use of complex audiovisual gear and a variety of simulation and clinical equipment, with substantial storage. Devices can be preset, tested, and ready to go, with briefing and debriefing facilities immediately at hand. In a dedicated center inexpensive discarded, flawed, or outdated clinical equipment and supplies can be safely used. When a center incorporates all modalities of simulation in one place it fosters hybrid techniques, as when an actor playing a standardized patient is combined with a part-task trainer, or when a surgical simulator is combined with a mannequin-based patient simulator.

The main disadvantage of a dedicated center is its cost of construction and outfitting. Moreover, no matter how well equipped it is, it can never replicate the equipment, layout, and clinical processes of any specific clinical workplace. Also, participants know from the very beginning that the activity is a simulation and not the real thing.

Training and Probing Where Clinicians Work

There are several approaches to conducting simulations in or near actual sites of clinical work. By necessity institutions without a dedicated simulation center must use one of these approaches, but they are useful for many other reasons.

In Situ Simulation

In situ simulation is conducted in an actual bed/gurney/bay of a real clinical workplace, such as, for example, OR, ICU, trauma room, postanesthesia unit, or ward. ISS training is often used for complex patient simulation scenarios with experienced single-discipline or interprofessional staff. It is typically used for training in order to create high environmental fidelity and/or to probe procedures or the system (see earlier subchapter “Application of Simulation”). ISS can be a useful training option especially for training in unique workplaces that are difficult to recreate with adequate realism (see later subchapter on simulation realism) in a simulation center or elsewhere, such as a catheterization laboratory, a CT scanner, an ambulance, or an air rescue aircraft ( Figs. 7.8 to 7.15 ).

In situ mobile simulation in a catheterization laboratory (cath lab).

The simulator is placed on the cath lab table, surrounded by the x-ray equipment, thus complicating treatment of the patient by limiting space. The vital signs monitor provides relevant data to the clinical team. The simulator is controlled from the cath lab control room. Multiple mobile cameras and a scan converter for vital signs provide a live video transmission to a temporary debriefing area for the nonactive part of the training group and allows for crisis resource management–based debriefings.

Photograph by M. Rall.

In situ mobile simulation in a dentist chair.

The simulator was equipped with artificial teeth gum and a chalk tooth to drill, thereby simulating the dentist’s procedures. Then emergencies developed, allowing the team to respond. Training focused on crisis resource management key points and medical aspects including use of an automated external defibrillator.

Photograph by M. Rall.

In situ mobile simulation team training in the operating room (OR).

The mobile simulation control room is set up outside the OR. The instructors can watch the simulation scenario either indirectly via live video coverage (left photo) or directly via the OR window (right photo).

Photograph provided by M. Rall, InPASS in situ training in the OR at Scuol Hospital, Switzerland, Chairman: J. Koppenberg.

In situ mobile simulation team training in a medical air rescue helicopter.

The mobile simulation control room with several cameras and microphones is set up outside the helicopter and provides a multi-perspective view inside to monitor the scenario and react to activities performed.

Photograph taken by M. Rall at Airmed 2008 with the German Air Rescue (DRF) team.

In situ mobile simulation trauma team training at a large trauma center.

Photo provided by M. Rall.

In situ mobile simulation in an intensive care unit (ICU)/intermediate medical care unit location.

The training in clinical areas is especially useful for ICU-like surroundings. Crisis resource management–based trainings showcase these highly complex problems and the interactions needed to coordinate high-performing ICU teams. The training allows for checking the local arrangement of equipment and the readiness to react to certain emergencies. There are already a few examples of permanent in situ simulation facilities in ICUs (see text).

Photograph by M. Rall.

In situ mobile crisis resource management (CRM)–focused simulation team training inside an operating room. This debriefing room is temporarily set up in an induction room. The use of videos for debriefing (here on a 42-inch flat panel placed over the basin) is feasible even in this setting. Training inside a hospital often includes training actual teams with the same setup, if possible conducting training for a large proportion of the relevant personnel. “En-bloc” training sessions may have a greater impact and longer-lasting effects of the lessons learned, including CRM behaviors.

Photograph by team TuPASS [Center for Patient Safety and Simulation, University Hospital, Tübingen, Germany], who performed a full team training of the anesthesia department at Steinenberg Medical Center, Reutlingen, Germany.

Neonatal crisis resource management and resuscitation training at a neonatal emergency workplace.

The experienced instructor (on the right side of the infant) is a confederate acting as part as the team, whereas others in the control room preside over simulation.

Photograph taken at Stanford Simulation Center, Stanford University, Palo Alto, California; provided by M. Rall.

Rosen and colleagues reviewed the use of in situ simulation in the continuing education for health care professions. They summarized that a positive impact of ISS on learning and organizational performance has been demonstrated in a small number of studies. They also indicated that the evidence surrounding ISS efficacy is still emerging and that existing research is promising.

Most ISS is performed mobile as a temporary setup only for the training sessions. In very few institutions a simulator is permanently installed in a clinical workplace, for example, creating a simulation-specific patient room in the actual ICU.

Advantages and Disadvantages of In Situ Simulation

ISS seems ideal in that it probes and challenges personnel and systems as they actually exist, thus unmasking real issues of patient care. It is available, in principle, to all sites, even those without a dedicated center, and it is conducive to short courses and unannounced mock event drills.

Because it takes place in the actual work unit, it will eliminate travel time to a dedicated center and will put participants at ease. Some substantial disadvantages include potential distractions by ongoing clinical work, lack of privacy, logistics of setup and takedown, reduced availability of AV and simulation equipment, and supply costs (many ISS activities use the unit’s real clinical supplies as needed). ISS can be difficult to organize, schedule, and control. The clinical area planned for simulation may not be vacant or may be needed on short notice. Staff members engaged in the simulation are prone to being pulled into clinical duty, and training sessions may be interrupted. Raemer summarized potential risks of ISS and amplified some of the safety hazards of simulation itself including maintaining control of simulated medications and equipment, limiting the use of valuable hospital resources, preventing incorrect learning from simulation shortcuts, and profoundly upsetting patients and their families. In our experience, patients and families are rarely upset and in fact often are pleased to see that such serious training is going on.

Peri-situ or Off-site Simulation

If simulation is, in principle, worthwhile, then doing simulation anywhere is probably better than not doing it at all. Peri-situ simulation (PSS) means simulating in the clinical work unit, but not in an actual patient room/bay/bed—for example in a conference room, or even hallway of the unit. This may be done when an ISS session is planned but there is no actual clinical spot available, or it may be done this way on purpose. PSS has some of the advantages of ISS in terms of locale, systems, and supplies, but it lacks the ideal realism of an actual bedside. When simulation is done outside a clinical unit (say a nonclinical conference room) or in a public area of a hospital it is referred to as off-site simulation (OSS).

Sequential Location Simulation

This is sometimes called moving simulation and it simulates the patient moving between different sites of care in one scenario, at each stop enacting what might transpire in that location. For example, the patient could be brought to the emergency department by ambulance; assessed and treated; then taken to CT scan, interventional radiology, or OR; and finally transferred to an ICU. Moving simulation may be best accomplished as ISS or PSS, but again, there will be some value to it even if each stop cannot be simulated perfectly. To do it with full veracity requires intensive coordination and complex choreography of simulation equipment and personnel. It is probably only worth it if done occasionally and primarily with a focus on systems probing and improvement. Moving simulations can address different specific issues at each stop, depending on the most important systems probing and learning issues for each.

Advantages and Disadvantages of Moving Simulation

Like all kinds of ISS, moving simulation is a powerful tool to detect latent threats in the system. Apart from a focus on latent threats in certain workspaces, this kind of ISS can detect challenges in the course of transport to those workspaces. As mentioned above, the organizational and technical preparations, the technical challenges, and the movement of the whole simulation gear paired with the clinical staff needed in order to make moving simulations work imply huge effort.

Simulation Team Training Participants: Who Should Be Trained and in What Composition?

Each discipline in health care can be considered a crew containing one or more individuals. Several crews may work together closely as a team . The operating room team, for example, consists of an anesthesia crew, a surgery crew, and a nursing crew (and crews of technicians and support personnel). The members within a crew are likely to be more familiar with each other than with members of other crews. Such mutual professional (and private) “knowing about each other”—perhaps by enhancing their shared mental model—could be an important influence on their performance.

Many simulation applications are targeted at individuals. These may be especially useful for teaching knowledge and basic skills or for practice on specific psychomotor tasks. As in other high-reliability industries (including anesthesiology, see chapter 6 ), individual skill is a fundamental building block, but empiric findings show that individual performance is not sufficient to achieve optimal overall performance, and to achieve optimal safety. Performance and safety unfold in the interplay between people and in their interaction with each other, equipment, and organizational structures and processes. That is the reason why in high-reliability organizations a considerable emphasis is applied at higher organizational levels, in various forms of teamwork and communication training, and interpersonal relations. This approach is often summarized under the rubric of crisis resource management (see Chapter 6 and later section). The importance of teamwork and team training is widely accepted in health care and anesthesia, although team training is still not widely implemented. The prerequisites for effective teamwork (e.g., team leadership, mutual performance monitoring, back-up and speak-up behavior, adaptability and team orientation, the concept of team cognition, etc.) are discussed in Chapter 6 . One of the special features of health care teams that poses several challenges is the frequently changing composition of teams with changing crews. Within a discipline, crew membership may fluctuate. For example, in anesthesia or the resuscitation team. Those teams or crews are also referred to as “action teams” (see Chapter 6 ).

When simulation is intended to go beyond specific medical and technical skills for individuals (as, for example, in CRM-oriented patient simulation) and to involve non-technical skills and teamwork, one can distinguish between single-discipline and multidiscipline approaches. CRM-based “team training” may be addressed first to crews (known as single-discipline teams ), and then to teams (known as multi-discipline teams ). Commonly, in a broader sense and used this way in this chapter, the term “team training” refers to both single-discipline as well as multidiscipline training. For both approaches the best way to train and transfer learning for everyday instances at work is to arrange the training (1) interprofessional (doctors, nurses, allied health personnel, etc.) and (2) in realistic crew/team compositions and roles in regard to the learning objective (“train as you work”—see patient simulation action box below).

Furthermore, teams exist in actual work units in an organization (e.g., a specific ICU), each of which can be its own target for training, and in organizations as a whole (e.g., entire hospitals or networks). Each unit can have specific characteristics, culture, etc., that will influence how receptive participants are for training and how easily they can apply in the clinical setting what they learned during simulation. Growing interest and experience have been shown in applying simulation to nonclinical personnel and work units in health care organizations (e.g., to managers, executives, informal leaders).

Addressing teamwork in the single-discipline approach in contrast to the multidiscipline approach has advantages and disadvantages. For maximal benefit, these approaches are used in a complementary fashion.

Patient Simulation Timing: Announced in Advance Versus Unannounced in Advance

Regardless of site, simulations can be conducted as pre-scheduled exercises either for personnel in their regular-duty roles or for personnel on off-duty or education days. Typically, unannounced mock events (announced as if the real thing) would be implemented in a department after making potential participants aware of this possibility on a general level. Again, scheduled and unscheduled ISSs are complementary approaches, each with its own pros and cons. An obvious challenge is that it takes participants away from their actual patient care activities so that ground rules need to be established concerning when and how to abort the exercise when necessary. On the other hand, when done only occasionally and with appropriate safeguards, the clinical system needs to probe its ability to ensure good patient care when an emergency team is called to an event. In summary, the technique has high potential for organizational learning when done carefully.

A number of recent publications discuss the advantages and disadvantages of unannounced mock events as well as issues concerning the implementation of such programs.

Scopes of Simulation in Health Care: The 12 Dimensions of Simulation

Many different aspects and variations of simulation have been presented so far; they represent examples of combinations of choices from 12 (originally 11 ) different dimensions of the simulation universe. Each dimension has a variety of choices—a spectrum—to choose from ( Fig. 7.16 ). Any particular simulation activity can be classified by delineating one or more characteristics in each of the 12 dimensions. The different attributes can be combined as needed to achieve the pursued objectives. Clearly, some combinations are useless or irrelevant, some are similar to each other, and others are redundant, but the total number of unique combinations across all dimensions is still very large and only some combinations have been implemented. Dimensions of particular relevance are the goals and purposes of the simulation, the target population, the modalities of simulation, and the pedagogical approach that is used.

The 12 dimensions of simulation applications.

(A) Dimensions 1-9. ∗These terms are used according to Miller’s pyramid of learning.

The content of many dimensions has been addressed in detail in the earlier parts of the chapter. Therefore, for the sake of completeness, only a short description of the dimensions is given here and the reader is referred back to each section for more information. Those who seek a detailed description of the different dimensions are referred to other literature where the model is described as a whole in detail.

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  Dimension 1: Purpose and Aims of the Simulation Activity. The most obvious applications of simulation have been described in the subchapter “Application of Simulators in Anesthesia and Health Care.” For more detailed information the reader is referred back to this section. To summarize the main purposes shortly, they are (1) education, (2) training including clinical rehearsal, (3) performance assessment, (4) research about simulation, and (5) research with simulation, including (5a) testing of procedures, (5b) testing of equipment, and (5c) system probing.

  
  
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  Dimension 2: Unit of Participation in the Simulation. The units of participation have been described in the subchapter on the classification of simulation teams. For more detailed information the reader is referred back to this section.

  
  
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  Dimension 3: Experience Level of Simulation Participants. Simulation can be applied along the entire continuum of education of clinical personnel and the public at large. For more information see earlier subchapter on the use of simulation in education and training. As mentioned earlier, simulation training is applicable to health care providers with a range of experience, including experts, novices and advanced residents, medical/nursing/other healthcare profession students, and even children.

  
  
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  Dimension 4: Healthcare Domain in Which Simulation is Applied. Simulation techniques can be applied across nearly all health care domains. A summary of the different domains was given in the earlier subchapter on “Use of simulation.”

  
  
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  Dimension 5: Healthcare Disciplines of Personnel Participating in the Simulation. Simulation is applicable to a wide variety of professionals in health care, not only to physicians. In anesthesiology, simulation has been applied to novices and experienced trainees, board certified anesthesiologists, CRNAs, and anesthesia technicians. Simulation is not limited to clinical personnel. It may be directed at managers, executives, hospital trustees, regulators, and legislators.

  
  
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  Dimension 6: Type of Knowledge, Skill, Attitudes, or Behavior Addressed in Simulation. Different types of competences can be addressed with simulation: knowledge, skill, attitudes, behavior. Based on the Miller pyramid (see corresponding subchapter), competences can be classified with regard to their level of appearance to “knows,” “knows how,” “shows how,” and “does.” Apart from the competences described by Miller, Gaba added cognitive skills such as decision-making processes, attitudes, and behaviors to the competences that can be addressed with the spectrum.

  
  
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  Dimension 7: Age of the Patient Being Simulated. Simulation is applicable to nearly every type and age of patient. Fully interactive neonatal and pediatric patient simulators are available. Simulation can address aspects of end-of-life issues for every age.

  
  
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  Dimension 8: Technology Applicable or Required For Simulations. To accomplish the different simulation goals listed in dimensions 1, 3, 4, 5, 6, and 7 various simulation technologies—including no technology—are relevant for simulation. An overview is given in the earlier subchapters “History and Development of Simulators,” “Fidelity and Classification of Simulators,” and “So many simulators and simulation options: which one to use…?”.

  
  
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  Dimension 9: Site of Simulation Participation. The different sites of simulation have been described in detail in the correspondent subchapter. Video conferencing and advanced networking may allow even advanced types of simulation to be conducted remotely (see dimension 10).

  
  
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  Dimension 10: Extent of Direct Participation in Simulation. Not all learning requires direct participation. Some learning can occur merely by viewing a simulation involving others because the viewer can readily imagine being in the shoes of the participants. A further step is to involve remote viewers with interaction in the simulation itself or verbal interaction in debriefings about what transpired. Several centers have been using videoconferencing to conduct simulation-based exercises, including morbidity and mortality conferences. Because the simulator can be paused, restarted, or otherwise controlled, the remote audience can readily obtain more information from the on-site participants, debate the proper course of action, and discuss with those in the simulator how best to proceed. Further steps of participation are personal involvement (“hands-on”) either in a replicated clinical site or immersive personal participation in an in situ simulation.

  
  
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  Dimension 11: Feedback Method Accompanying Simulation. One can learn a great deal just from simulation experiences themselves, without any additional feedback. For many simulations, specific feedback is provided to maximize learning. On-screen-based simulators or VR systems, as well as the simulator (part-task trainer or mannequin) itself, may provide feedback about the participant’s actions or decisions, particularly for manual tasks for which clear metrics of performance are readily delineated. More commonly, human instructors provide feedback. This can be as simple as having the instructor review records of previous sessions that the learner has completed alone. For many target populations and applications, an instructor provides real-time guidance and real-time feedback to participants while the simulation is ongoing. The possibility to start, pause, and restart the simulation is valuable in this respect. Alternatively, brief post-hoc feedback is given by the instructor at the end of the simulation. For the most complex uses of simulation, especially when training experienced personnel, the typical form of feedback is provided by an instructor and is included in a detailed post-simulation debriefing session. More discussion of debriefing is given later in the subchapter on “Debriefing.”

  
  
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  Dimension 12: Embedding of Simulation in Relevant Organizational, Professional, and Societal Contexts. The final important dimension is how the simulation application is embedded into an overall context. Being highly embedded may mean that the simulation is a formal requirement of the institution or is mandated by the governmental regulator. Another aspect of embedding may be that—for early learners—the initial (steep) part of the learning curve is required to occur in a simulation training before the learners are allowed to work on real patients under supervision. In addition, complete embedding of simulation into the workplace means that simulation training is a normal part of the work schedule, rather than being an add-on activity attended in the spare time of clinicians.

Crisis Resource Management (ACRM; CRM): Part of Modern Patient Simulation Team Training

In the last subchapters, the benefits and the effectiveness of simulation-based education were highlighted and its ecologic validity was considered. This subsequent section now explores the idea that simulation-based education for a variety of simulation curricula, especially for team training, needs to take into account not only medical and technical skills, but also what is called anesthesia crisis resource management (ACRM), also referred to as crisis resource management (CRM). For detailed information on CRM see Chapter 6 .

The Roots of Anesthesia Crisis Resource Management Training

In 1989, based on earlier work, Cooper, Howard et al., and Gaba of the VA-Stanford and their colleagues identified gaps in the training of anesthesiologists regarding several critical aspects of decision making and crisis management that were not systematically taught during standard residency or postgraduate education. These gaps were inadequate learning and skills of (1) precompiled plans for dealing with perioperative events; (2) metacognition and allocation of attention; and (3) resource management behavior, including leadership, communication, workload management, monitoring, and cross-checking of all available information.

Historically, it had been assumed that anesthesiologists would acquire these plans and non-technical skills (see Chapter 6 ) by osmosis, solely by experience and by observing role models who had these qualities, rather than specific education and training about them. But similar to aviation, medicine had to learn that those kind of (non-technical) skills were not acquired unless specifically taught. For flight crews, CRM training was originally created to address these issues. Especially for anesthesia, but for other health care domains as well, the VA-Stanford group modeled their training after aviation CRM and named it ACRM. For a broader use in health care, oftentimes ACRM is also referred to solely as CRM. The ACRM approach has been highly influential. ACRM curricula and ACRM-like curricula are taught at simulation centers around the world, not only in anesthesia, but in many other domains of health care, including ICU, emergency medicine, labor and delivery, trauma, and field responders. . Fig. 7.17 shows a typical CRM crew training scenario.

Crisis resource management training scenario during crew training.

The surgical team is performing a complicated endoscopic surgical procedure replayed on screen. The anesthesia team must solve a clinical problem and coordinate with the surgical team. Video cameras, microphones, and loudspeakers provide the necessary connectivity and later debriefing tools.

Photograph taken by M. Rall at the Center for Patient Safety and Simulation, University Hospital, Tübingen, Germany.

Anatomy of a Patient Simulation Team Training Exercise

Whenever simulation is used it is important to consider its conceptual basis and the contextual factors that influence its use. Therefore, with a focus on (CRM-oriented) mannequin-based patient simulation conducted for health care professionals, the next subchapters (1) give an overview of the training setting and important elements of a simulation exercise; discuss (2) the design of simulation scenarios and their execution; and (3) the modalities of the professionals’ debriefing after a simulation scenario. Even though focused on the mannequin-based patient simulation conducted for health care professionals, many of the conceptual approaches presented below are identical or need to be modified only slightly to encompass other choices in the 12 dimensions of simulation.

Simulation activities vary in terms of goals and objectives. Most of the time, simulation scenarios are integrated into a multifaceted curriculum, which itself must be situated relative to the overall educational and training pathway of individuals and groups. Hence, for any given simulation activity both the conceptual and physical setting influence how the exercise is conducted, how it is perceived by participants, what participants learn, and which learned items are applicable in the clinical work domain .

A simulation course/training itself can be divided analytically in different, interconnected phases as shown in Fig. 7.18 . Not all phases need to be present at each exercise and conversely some phases—like “scenario” and “debriefing”—may be repeated several times in a longer session.

Anatomy of the simulation exercise.

A simulation exercise consists of different modules or different phases (e.g., simulation introduction [SI] , simulator and clinical environment briefing/“familiarization” [SB] , theory input [T] , case briefing [C] , scenario [S] , debriefing [D] , ending [E] ). This figure shows a typical flow for a simulation course. If more than one scenario takes place during the course, the sequence form [C] to [D] is repeated for each scenario. The different modules are interrelated, and problems arising in one module can affect other modules (thin arrows) .

Figure with courtesy of P. Dieckmann.

Optimally the interconnected phases of the simulation exercise should be coordinated. If, for example, the briefing/familiarization is inadequate, participants may not be able to properly immerse themselves in the scenarios and debriefing might be impaired. The role of the simulation instructor changes throughout the different phases of the simulation training—from providing instruction in the beginning of a course to facilitating learning during debriefing. Based to a large extent on the work of Dieckmann, the different phases of a simulation exercise (see Fig. 7.18 ) are discussed next, using the timeframe and elements of a simulation-based course as an example.

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  Pre-Briefing (PB). The pre-briefing introduces or reminds participants in advance about the course, its goals, and processes to appropriately situate the activity in their overall training, establish a positive attitude, and review the schedule of activities. An exercise that can be useful (stemming from advice from Ruokamo and Keskitalo from the University of Lapland) is to ask and discuss with participants “what do you want to learn or explore” in today’s simulation course?, and similarly to ask the instructors “what are you interested in teaching or exploring?” This conversation engages the participants and demonstrates the instructors’ interest in trying to address many of the preferences of the learners.

  
  
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  Simulation introduction (SI). An important aspect at the beginning of a session is to provide an overview about the course and the rules and norms of conduct for the set of exercises. It is also important to provide a shared understanding for the simulation participants of the events that transpire during the course. Besides, it is important to create a positive atmosphere to maximize learning, often referred to as “psychological safety,” or as recently published a “ safe container. ” Edmondson has defined psychological safety as “the shared belief that the team is safe for interpersonal risk taking. ” Often this has a lot to do with ensuring the confidentiality of the simulation environment (i.e., “what happens here stays here”) and that debriefings will “critique the performance, not the performer.” Psychological safety “ is not about creating a comfortable space, it is about making it ‘ok’ to be uncomfortable.”

  
  
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  Simulator and clinical environment briefing (SB) (“familiarization”). Participants need to be familiar with the simulator and the simulated environment in order to perform the closest to reality as possible, and they should not be distracted by technical or procedural uncertainty during the scenario. The participants can best master the scenario and actively engage in it if they know (1) how the simulator works (“normal” breathing sounds, “normal” pulses, intubation, intravenous access, etc.); (2) what it is able to do or not do; (3) how the simulated environment works (how to call for help, how to use the simulated equipment, etc.); and (4) what participants are able to perform on the simulator and what they need to pretend doing. Familiarization is characterized through explanations, demonstrations, and hands-on time for the participants themselves. This phase is very important in order to help the participants to make the best use of the simulation experience during the scenario. The plastic mannequin is on the way to being seen and treated as a patient. The more comfortable participants feel with the simulator and the simulation equipment, the less they will be scared or tense during the scenario. And more reflective learning about medical and non-technical skills can take place during the debriefing because the debriefing will not become about discussing the confusions and challenges regarding the simulation technology or environment. Therefore, it benefits both the instructor and the participants to have enough time for the familiarization process.

  
  
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  Presentation or discussion of theory (T). Theories of human performance or of clinical work processes might or might not be part of the course. Most exercises have didactic or theory components on relevant content information. Those components can either serve for transfer of (new) medical or technical knowledge, or for a refresher lecture on certain algorithms, but also for the introduction of (anesthesia) crisis resource management-related skills (ACRM, CRM) and patient safety issues ( Chapter 6 ). Sometimes educational material is made available in advance through readings or online exercises. Sometimes lectures or group-work modules are put in place at different junctures of the training.

  
  
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  Breaks (B). For complex and long-lasting courses breaks are important for recreation and for socialization among participants and with instructors. Breaks provide a venue for informal sharing and storytelling, one of the many learning opportunities during a simulation training outside of a simulation scenario.

  
  
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  Case briefing (C). Because the simulator is not a real patient itself providing clinical information and because the environment of a simulation imposes several challenges, there are different ways to ensure that participants have certain relevant information concerning the case and the simulation reality before, or at the beginning of, the scenario. Sometimes it is natural for a participant to take over a case from another clinician (in fact in ACRM starting every case from the beginning would waste a lot of time). Such a handoff can be scripted to be complete or cursory as appropriate. In other cases the context information can be presented verbally or in written form by an instructor. Other information that would not be readily available in context might include the look or smell of the patient or the specific location of care (e.g., main OR vs. off-site ambulatory surgery center).

  
  
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  Simulation scenario (S). The scenario and—when possible—the debriefing together form the core of the learning experience during simulation. Simulation scenarios are more than clinical cases. They are the vehicle to reflect on medical knowledge as well as personal and team performance in a safe learning environment that elucidates similar behaviors as during real-world cases. Most simulation exercises involve a scenario that simulates a given clinical situation, challenging the participants to deal with the situation at hand. The scenario is designed in advance by the instructors in accordance with the learning objectives of the training (see later subchapter on scenario design). During the execution of the scenario, the instructor (or simulationist/simulation technician) regulates the responses of the simulator and adapts the scenario flow ; gives relevant patient, situation, or clinical information to the team that the simulator or clinical personnel does not provide itself (see later subchapter on live in-scenario guiding); manages the exercise to enable participants to optimally act as if treating a real patient (see later subchapter on scenario design).

  
  
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  Debriefing (D). Most training scenarios are immediately followed by some form of feedback or debriefing, respectively. Fanning and Gaba give an overview of the origin and background, the role, the models, the structural process, the elements, and several other modalities of debriefing in simulation-based learning in their recommended review. The learning objectives, the target audience, and the simulation modalities drive the decision whether a debriefing is useful and if so how in-depth the debriefing process needs to be. In some courses, feedback is only minimal, whereas other courses have a dedicated debriefing session after each scenario that take as long, or even longer, than the scenario itself (see later subchapter on debriefing techniques). Several different debriefing methods exist. Debriefing can be facilitated sometimes by strategically presenting snippets of the recording of the scenario.

  
  
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  Ending (E). Especially for multiple-scenario courses, a separate final session may be included to end the course. This phase represents an opportunity to summarize issues that were covered and to reflect on how best to apply these lessons to real patient care.

Scenario Design and Execution: Knowing the Learning Objectives and Making It Real

The design of scenarios for interactive simulation team trainings can be tricky and typically differs from preparing training exercises for traditional curricula.

“The key is the program, not the hardware” was a truth about simulation learned early in aviation simulation and similarly possesses validity for the scenario design and execution with patient simulation. Using simulation in a goal-oriented way is at least as much about the conceptual aspects of the technique as it is about the technology of the simulation devices. An understanding of the conceptual and theoretical aspects of simulation is helpful for determining the right applications of the technique and the important matchups to be made in the design and conduct of simulation exercises to obtain the best results. When used most effectively, simulation can be—to borrow a line from the music band U2—”…even better than the real thing.”

In the following sections the design and conduct of scenarios for a patient simulation are touched on more closely, considering (1) establishing learning objectives; (2) applying cognitive load theory to scenario design; (3) pointing out constraints and limitations of the design, discussing (4) conceptual issues of reality, realism, and relevance; and (5) in-scenario information and guiding.

There is a vast aggregation of literature concerning instructional design for all kinds of simulation applications. For detailed information the reader is referred to further literature. The topic is covered extensively in most of the instructor training curricula that are offered at sites around the world. International and regional simulation meetings (e.g., the International Meeting on Simulation in Healthcare [IMSH] of the SSH, or the annual meeting of the Society in Europe for Simulation Applied to Medicine [SESAM]) often provide workshops on scenario design. The user groups of the major simulator manufacturers also have workshops on the topic.

The following sections can only serve as an introduction to the topic and again focus mainly on (CRM) mannequin-based patient simulation conducted for health care professionals.

Scenario Design Templates AND Scenario Templates

Many centers have developed design templates for the development of their scenarios. Box 7.5 shows the key questions for the design of scenarios. Long scenario templates that are freely available include Dieckmann and Rall’s ( https://www.inpass.de/downloadshtml/downloadscenarioscript/ ) and the Duke University template ( https://anesthesiology.duke.edu/?page_id=825706 ). Some journals publish detailed scenario descriptions and some professional societies have created scenario repositories for members; the American Society of Anesthesiologists (ASA) Simulation Committee has a repository for scenarios to be shared among its ASA-endorsed simulation programs. By now, many scenario templates are freely available on the Internet. In general, long and detailed templates are only needed when a scenario is to be shared widely, or when there is a need to formally document it. Simpler templates will likely suffice for in-house use by a single simulation center.

Box 7.5

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