Introduction

Simulation-based education is an essential instructional modality to facilitate learning for nearly every healthcare professional. There are various reasons simulation may be incorporated into the curriculum, including the teaching of procedural skills, and assessment of communication skills, teamwork, and clinical decision making. This modality is implementable just in time education, formative, and summative evaluation, along with implementation in reviewing clinical competence.

Issues of Concern

Learning Theories

There are a few major learning theories that require consideration when developing and executing simulation scenarios; social cognitive, behavioral, constructivist, and cognitive load. Social cognitive posits that the learner learns best in the real or simulated environment to develop self-efficacy and self-regulation. In doing so, learners will develop the confidence to execute the skills needed for their job, while concurrently setting goals to improve and maintain those skills.[1][2]

Adult learning theory operates under the assumption that learners are self-motivated and self-directed; simulation offers a suitable method for adults to accomplish their learning goals. The ability to practice a variety of procedural skills for deliberate practice and participating in simulated patient scenarios with a well-run debrief offers adult learners the opportunity to identify and reflect upon performance, readjust goals, and work towards mastery learning of any number of concepts.[3]

Behavioral learning theory surrounds the principle that deliberate practice and reflection support performance improvement. By adding simulation to curricular activities, competence, along with the acquisition of memory and patterns, occurs.[1]

Constructivist learning theory is supported by using instructors as facilitators instead of as coaches. The principles of this theory realize that learners need to self-reflect and formulate their particular patterns of learning to support decision making.[3]

Cognitive load theory is arguably one of the most important to consider. Much of the literature points to finite working memory capacity, especially when presenting new educational material.[4][3] When developing a simulation curriculum, too much information or stressors can impede the retainment, synthesis, and transfer of knowledge. For this reason, the level of fidelity and the objectives require careful consideration; too much fidelity or realism, too many emotions, and too many objectives or the expectation of synthesizing a large volume of material should be avoided, especially if new concepts are to be introduced.[3][4]  While every effort may be made to prevent breaching the cognitive load threshold, there may be times that it occurs unintentionally; instructors must be able to recognize possible signs in the learners during and after the scenario. Outward signs of psychological stress, such as anxiety and diaphoresis, should be monitored. During the debrief, the activity immediately following a simulation, learners might demonstrate, and unwillingness to participate and shut down. Segmenting material into smaller, more manageable opportunities, along with providing a more collaborative learning environment, can help learners digest material more effectively, allowing for the development and maturation of working memory.[4]

Feedback

Several items should be considered concerning feedback; the type, by whom, and timing. Performance-oriented feedback provides learners with their individual results, while learning-oriented feedback provides results and explanations. Feedback can be self-assessed or provided by a subject matter expert. The self-assessment, while a component of adult education and self-directed motivation, should be weighed carefully as a sole method; literature is mixed on the accuracy. Timing of feedback can be in the moment, immediately afterward, or delayed.[5]

Curriculum Development

Building a curriculum that utilizes simulation can be a daunting task. Several factors must be taken into account; using a framework that takes into consideration instructional design, learning theories, and methods of feedback and assessment are crucial.[5][1][6][7][8]  The process of Assess, Design, Develop, Implement, and Evaluate (ADDIE) can help instructor methodically work the process of designing simulation-based education. Assess is the process of working through a needs assessment and is derived through knowledge of program standards/accreditation, quality/performance improvement indicators, or specific needs of learners. Design is the actual process of instructional design, development of goals and objectives, assessment, and feedback methods. Develop is the process of bringing together the materials that will get put into use during the delivery of educational material. Implementation is the process of delivery of the material. Evaluate is the process of reviewing learner performance and the effectiveness of the delivery methods. This stage is also one that should inform any changes for the future.[3]

Instructional design is the process of developing the actual curriculum and includes a step-wise approach once the simulation has been determined to be the instructional medium. The simulation modality is the next item chosen. Modalities include computer-generated simulation, procedural skills (i.e., suturing, chest tube thoracostomy, thoracentesis), the environment in which the simulation will actually occur, either a designated simulation space or in the actual clinical environment, and lastly, the use of standardized patients, individuals who are trained to portray patients/family members/colleagues. Following modality, the curriculum builder decides on the instructional method. This method can either be self-directed or instructor-led. It is important to note that the simulation literature demonstrates mixed results on the effectiveness of self-directed learner assessment. Finally, the presentation phase incorporates decisions about fidelity (i.e., realism) during the simulation.[5] When in the instructional method and presentation phases, learning theories, methods of feedback, assessment, and outcomes must be taken into account.

Procedural Skills Assessment

A typical framework with which to develop objectives lies within one or more of the following domains: knowledge, skills, clinical decision making, and communication.[5]  By utilizing and moving through the six levels of Bloom’s taxonomy to inform the development of objectives, instructors can continue to improve and build upon a learner’s body of knowledge. Level one is to recall information, level two is understanding information, level three is the application of information, level four is analyzing information, level five is synthesizing information, and level six is evaluating information.[3]  Objectives will also help instructors to choose the fidelity method and level.[9]

Outcomes are based on a number of factors and are a direct extension of the learning goals and objectives that are decided upon during the curriculum development process. One must consider accreditation standards, clinical competency measures, and are generally a direct extension back to course objectives. Simulation has also been utilized by a variety of healthcare professions to supplement clinical rotations, given the growing need for placements and reduction of sites and preceptors.

Assessment methods have their basis in Miller’s pyramid. Following instructional delivery methods, instructors should be able to assess what learners are capable of doing and what needs improvement. By reviewing what a learner knows, knows how, shows how, and does, can inform levels of competency.[3]  Two forms of assessment exist: formative and summative. Formative assessment methods collect information while the learning is still happening, while summative assessment measures the collective learning that has occurred at the conclusion of the delivery of materials.

Clinical Significance

Simulation offers a unique opportunity for learners to practice a variety of skills confidently before working with patients, family members, and colleagues. Healthcare providers can utilize the opportunity to hone clinical decision-making skills, psychomotor skills, and synthesize theory into practice, thus facilitating skills transfer.[10]  Ensuring that instructional design and learning theories are taken into account will ensure the closing of gaps in knowledge, skills, attitudes, and behaviors while providing a safe learning environment.

Enhancing Healthcare Team Outcomes

Simulation is also a well-known mechanism to test interprofessional and an interprofessional collaboration for various reasons; rapid response and code blue scenarios are commonly tested in simulation settings to review team dynamics and roles.