What is Simulation?
Simulation is the imitation or representation of one act or system by another. Healthcare simulations can be said to have four main purposes – education, assessment, research, and health system integration in facilitating patient safety.
Each of these purposes may be met by some combination of role play, low and high tech tools, and a variety of settings from tabletop sessions to a realistic full mission environment. Simulations may also add to our understanding of human behavior in the true–to–life settings in which professionals operate.The link that ties together all these activities is the act of imitating or representing some situation or process from the simple to the very complex. Healthcare simulation is a range of activities that share a broad, similar purpose – to improve the safety, effectiveness, and efficiency of healthcare services.
Simulation education is a bridge between classroom learning and real-life clinical experience. Novices – and patients - may learn how to do injections by practicing on an orange with a real needle and syringe. Much more complex simulation exercises – similar to aviation curricula that provided the basis for healthcare – may rely on computerized mannequins that perform dozens of human functions realistically in a healthcare setting such as an operating room or critical care unit that is indistinguishable from the real thing. Whether training in a “full mission environment” or working with a desk top virtual reality machine that copies the features of a risky procedure, training simulations do not put actual patients at risk. Healthcare workers are subject to unique risks in real settings too, from such things as infected needles, knife blades and other sharps as well as electrical equipment, and they are also protected during simulations that allow them to perfect their craft.
Simulation-based assessment refers to both “low stakes” learning for improvement, and “high stakes” testing to determine competency. Multiple choice tests and oral exams have been traditional methods to assess knowledge and ability for generations. Common sense dictates, however, that once technology advances to the point that real tasks can be accurately simulated, truly demonstrating competence becomes an indispensable part of effective evaluation. Directions in credentialing indicate that it will eventually be more meaningful to actually demonstrate competency than to provide a surrogate for competency – namely, a certain number
The goals of simulation-based research differ from training and evaluation. Researchers may be trying to understand why a particular event happened, and so simulate the event with the same and/or other clinicians. Just as with an airplane engine or wing in a wind tunnel, medical devices may be tested under a range of simulated conditions before the final device is marketed and used on actual patients. New procedures for giving dangerous drugs or using advanced resuscitation methods may be studied under simulated conditions. Entire populations, tests, and costs may be represented by patterns of data in a computer and multiple simulations run to find optimal solutions for attaining the best health of a community. Different types of simulations – live, virtual reality, and computer-based – may be combined to attack a question from different angles. The ultimate goal of increasing knowledge and understanding to improve training, evaluation, and design of systems is the same. Necessary research may also address two fundamental areas of need. One may ask, “Is the tool of simulation valid?”. A second question to be answered by necessary research is, “Is the tool of simulation useful?”. Answers to these fundamental questions will continue to be increasingly addressed within the research arena.
Systems integration refers to the integration of simulation into institutional healthcare training and delivery systems. Simulation-based processes may include quality assessment mechanisms, thereby facilitating patient safety. Simulation may also raise the bar for objectivity and hence fairness in evaluation, substituting visible, accepted metrics for performance for anecdotes and opinions. Simulation-based approaches can be effectively used to help evaluate organizational processes as well as individuals and team performance. Examples include disaster response or testing a new procedure before it is put into practice.
ADVANTAGES OF SIMULATION LEARNING
A range of easily accessible learning opportunities:
Learning in healthcare is too frequently in an apprenticeship model. In many disciplines, as opportunities to learn and practice come along, it is hoped that learners encounter enough situations to insure that they become competent. This is ultimately a haphazard way to learn, and puts learners and patients at a disadvantage. Simulation offers scheduled, valuable learning experiences that are difficult to obtain in real life. Learners address hands-on and thinking skills, including knowledge-in-action, procedures, decision-making, and effective communication. Critical teamwork behaviors such as managing high workload, trapping errors, and coordinating under stress can be taught and practiced. Training runs the gamut from preventive care to invasive surgery. Because any clinical situation can be portrayed at will, these learning opportunities can be scheduled at convenient times and locations and repeated as often as necessary.
The freedom to make mistakes and to learn from them: Working in a simulated environment allows learners to make mistakes without the need for intervention by experts to stop patient harm. By seeing the outcome of their mistakes, learners gain powerful insight into the consequences of their actions and the need to “get it right”.
The learning experience can be customized: Simulation can accommodate a range of learners from novices to experts. Beginners can gain confidence and “muscle memory” for tasks that then allow them to focus on the more demanding parts of care. Experts can better master the continuously growing array of new technologies from minimally invasive surgery and catheter-based therapies to robotics without putting the first groups of patients at undue risk. Some complex procedures and rare diseases simply do not present enough opportunities for practice, even to established clinicians. Examples include treating a severe allergic reaction or heart attack in an outpatient clinic setting, or handling a case of malignant hyperthermia in the operating room. This is a gap that simulation training methods can help fill.
Detailed feedback and evaluation: Real events and the pace of actual healthcare operations do not allow for the best review and learning about why things took place, or how to improve performance. Controlled simulations can be immediately followed by videotape-supported debriefings or after-action reviews that richly detail what happened. Advanced surgical and task simulators gather much data about what the learner is actually doing. These performance maps and logs provide a solid and necessary feedback mechanism to learners and help instructors target necessary improvements.
Healthcare simulation is coming of age, and has begun to share much with established methods in aviation, spaceflight, nuclear power, shipping and the military. The rapid advance of computer science, bioengineering, and design has met demands from all stakeholders for safer, more effective and efficient ethical healthcare. When the stakes are high and real settings do not lend themselves to artificial handling for other purposes, simulation methods will find applications.