Patient Safety Primer

Simulation Training

Background

Clinical training for health care professionals has traditionally relied on learning from actual patients, even for invasive procedures and life-threatening situations. As exemplified by the medical residency maxim "see one, do one, teach one," there has been little emphasis on learning in a simulated environment prior to clinical encounters.

However, considerable evidence documents the dangers posed by inexperienced clinicians and poorly functioning clinical teams. Based in part on its success in other industries such as aviation, simulation-based training has therefore emerged as a key component of the patient safety movement and is increasingly being used to improve clinical and teamwork skills in a variety of environments. When applied properly, simulation-based training allows the opportunity to learn new skills, engage in deliberate practice, and receive focused and real-time feedback. The goal of simulation-based training is to enable the accelerated development of expertise, both in individual and team skills, by bridging the gap between classroom training and real-world clinical experiences in a relatively risk-free environment.

Methods and applications of simulation-based training

There are several approaches to simulation training, and depending on the material being emphasized, simulation curricula may employ one or more of these methods:

  • Part-task trainers: These are used to train specific clinical skills through simulation. An example would be anatomically correct limb models, which are used to demonstrate phlebotomy skills or placement of intravenous catheters.
  • Full-scale simulators: The most common example is a full-body manikin, which in addition to anatomic landmarks can offer realistic physiologic simulation (such as heart sounds and respirations). These are increasingly used to teach the physical examination and other fundamental clinical skills.
  • Virtual reality: In this modality, learners are immersed in a highly realistic clinical environment, such as an operating room or intensive care unit. Learners physically interact with the environment as they would in real life, using systems that are increasingly complex and technologically sophisticated.
  • In situ simulation: This approach refers to simulation carried out in the actual clinical environment with the providers who work in that location. It may involve use of part-task or full-scale simulators as well.
  • Standardized patients: Employing trained actors to simulate real patients has long been used to teach basic history taking and physical examination skills, and this strategy is also being applied to teach patient safety skills such as error disclosure.

These methods are not mutually exclusive, and successful curricula often use combinations of these approaches.

Simulation was initially utilized as a tool for teaching clinical skills and has been successfully applied to develop and assess foundational clinical skills as well as more advanced cognitive and technical skills, in both medical school and residency training. Simulation is also being widely integrated into teamwork training in a variety of environments, including the emergency department, operating room, and obstetrics units. Teamwork training that incorporates simulation often focuses on improving the ability of multidisciplinary teams to handle acute situations. Teamwork training with simulation has also been used with non-clinical personnel, such as one study in which non-clinician leadership and management had to respond to a simulated patient safety crisis.

The application of human factors engineering methods to patient safety represents another application of simulation. Usability testing, which refers to testing new equipment and technology under real-world conditions, can be thought of as a form of simulation designed to identify latent safety issues and workarounds.

Evidence supporting simulation-based training

Simulation training is an effective educational modality, with strong evidence demonstrating improvement in learners' knowledge, skills, and behaviors. For example, a classic systematic review of more than 600 studies of technology-enhanced simulation training programs in health care found that technology-enhanced simulation training was associated with improvements in learners' knowledge, skills, and behaviors, and also improved patient outcomes. Unlike many other commonly used educational modalities, simulation approaches have been shown to improve patient-level outcomes, especially when used to teach procedural skills. It is important to note that simulation has been shown to be effective as an educational tool for both practicing clinicians as well as trainees.

Simulation can be used to teach individual skills (such as technical skills or cognitive skills in specific clinical scenarios like resuscitation), or may be used as part of teamwork training programs. Studies have shown that multidisciplinary simulation-based teamwork training can yield improvement in participants' knowledge and skills in teamwork. However, other reviews have raised concerns regarding the methodological limitations of many studies, including lack of standardization of training techniques and measurement methods. The recent evidence on simulation as a modality for teaching nontechnical skills is summarized in a 2018 PSNet perspective.

The choice of the simulation method likely depends on the specific skill being taught. While technology-enhanced simulation is effective, increasing technological sophistication of simulation may not always be necessary. According to another review, the key features of successful simulation education are those of successful curricula in general: individualized feedback, cognitive interactivity, deliberate practice, and longer duration of the curricula. The effect of high-fidelity technology-enhanced simulation remains controversial, and although the cost of such high-technology simulators is decreasing, their high costs may deter increasing use of this approach until more definitive evidence emerges. There is increasing interest in using in situ simulation as a way of providing more realistic simulation experiences and potentially identifying latent safety hazards in the real-world clinical environment.

Current Context

All graduating medical students are required to complete a simulated patient encounter in order to pass the United States Medical Licensing Examination. The Accreditation Council for Graduate Medical Education requires that residency programs provide simulation training, although the specific requirements vary between specialties. The American Board of Anesthesiology requires practicing anesthesiologists to complete a simulation course in order to maintain board certification, but this requirement is not present for other specialties. A WebM&M commentary discusses emerging approaches to simulation, including virtual reality and other technological advancements, as well as the potential for using simulation to assess and remediate individual clinician performance issues.

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