Essential Simulation in Clinical Education E-Book

Kirsty Forrest

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: essentials
• Sprache: Englisch

Seitenzahl: 668

Veröffentlichungsjahr: 2013

Beschreibung

This new addition to the popular Essentials series provides a broad, general introduction to the topic of simulation within clinical education. An ideal tool for both teaching and learning, Essential Simulation in Clinical Education provides a theoretical and practical introduction to the subject of simulation, whilst also offering strategies for successful use of simulators within general clinical education and demonstrating best practice throughout.

This timely new title provides:
The latest information on developments in the field, all supported by an evidence-base
Content written by a global team of experts
Discussion of policy and strategy initiatives to ground simulation within the healthcare context
Practical examples of cases, including inter-professional learning.

A superb companion for those involved in multi-disciplinary healthcare teaching, or interested in health care education practices, Essential Simulation in Clinical Education is the most comprehensive guide to the field currently available.

Leseprobe

Table of Contents

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Title page

Copyright page

Contributors

Foreword

Glossary and abbreviations

Features contained within your textbook

CHAPTER 1: Essential simulation in clinical education

History

Evidence

Teaching, learning and assessment

The people

The skills: technical, non-technical and team working

The places

Doing it

Real-life examples

The future

CHAPTER 2: Medical simulation: the journey so far

Definition

Taxonomy

Early simulators

Part task trainers

Real people as simulators

Screen-based simulation

Simulated environments

Virtual reality

Guidelines and regulation

CHAPTER 3: The evidence: what works, why and how?

Essential features for effective learning: what works?

Feedback

Repetitive practice – deliberate practice

Curriculum integration

Outcome measurement

Moving forward – challenges and perspectives

CHAPTER 4: Pedagogy in simulation-based training in healthcare

Three related dimensions in skills learning

Pedagogy and learning theory

Instructional strategies

Creating learning opportunities

Recognizing learning opportunities

Using a learning opportunity

Issues related to learners

Issues related to task

Issues related to context

Facilitators, learners and their interaction

CHAPTER 5: Assessment

Purposes of assessment in education

Principles of assessment

Advances in technology

Assessment: the practicalities

Challenges and future directions

CHAPTER 6: The roles of faculty and simulated patients in simulation

Faculty

Ethical and professional values

Educational context

Roles and skills required

Faculty training

The principles of a faculty development programme

Standards, quality assurance and recognition

Educational leadership

Simulated patients

Definitions and nomenclature

A brief history of SPs

Educational contexts

Integrated teaching of technical skills and communication (‘hybrid simulation’)

SPs as teachers

SPs as assessors

Using SPs to assess clinical practice and healthcare systems

Recruitment and selection of SPs

Being an SP

Training and assessment of SPs

Training SPs in the history and consultation

Training SPs to portray physical signs

Training SPs to provide feedback and facilitate a small group

Training the trainers and clinical educators

Assessment of SP preparation

Professional and personal development

CHAPTER 7: Surgical technical skills

Technical skills

Simulation in technical skills training

Simulation in Interventional Specialities

Integration of simulation into formal technical skills training

Beyond technical skills training: selection, stressors and revalidation

Infrastructure

CHAPTER 8: The non-technical skills

Human factors and non-technical skills in safety

CRM training in healthcare

Non-technical skills in healthcare

Use of behavioural marker systems for feedback

First, acquire the technical skill – then make the context real

The design process

Designing and running your own scenarios with embedded non-technical skills

CHAPTER 9: Teamwork

Introduction

A call for improved teamwork in healthcare: drivers and barriers

On teams, teamwork and training: definitions, evidence and perspectives

Team training: content, environment, design and implementation

Designing and implementing SBTT

Assessing teams: what to assess, measurement tools and common outcomes

CHAPTER 10: Designing effective simulation activities

Introduction

Justification for developing a simulation facility

Embedding simulation into training

Funding

Users of the facility

Quality assurance

Stakeholder engagement

The planning continuum

Faculty development and support

Participant considerations

Sustainability

Use of space and resources

Equipment

Staffing

Running a facility

CHAPTER 11: Distributed simulation

Introduction

Distributed simulation: conceptual and theoretical foundations

Design process and anatomy of the distributed simulation system

Exploring and investigating the distributed simulation concept

Future work on distributed simulation

Conclusion

CHAPTER 12: Providing effective simulation activities

Case background

Introduction

Pre-briefing

Course/setting introduction

Orientation to the simulated learning environment

Scenario briefing

Simulation scenario

Using audiovisual equipment

Debriefing

Course ending

CHAPTER 13: Simulation in practice

Simulation for learning cardiology

Background

What was done

Results and outcomes

Take-home messages

Assessing leadership skills in medical undergraduates

Background

What was done?

Results and outcomes

Take-home message

What went well/worked well

What would you do differently?

Simulation for interprofessional learning

Background

What was done

Results and outcomes

Take-home messages

Use of in situ simulations to identify barriers to patient care for multidisciplinary teams in developing countries

Background

What was done

Results and outcomes

Take-home messages

What went well/worked well

What would we do differently

Clinical skills assessment for paediatric postgraduate physicians

Background

What was done

Results and outcomes

Take-home messages

What went well/worked well

What would we do differently

The challenge of doctors in difficulty: using simulated healthcare contexts to develop a national assessment programme

Background

What was done

Results and outcome

Take-home messages

What went well/worked well

What would you do differently

Simulation for remote and rural practice

Background

What was done

Results and outcomes

Take-home messages

What went well/worked well

What would you do differently

The use of incognito standardized patients in general practice

Background

What was done

Results and outcomes

Take-home messages

What went well/worked well

What would you do differently

Integration of simulation-based training for the trauma team in a university hospital

Background

What was done

Results and outcomes

Take-home messages

Conclusion

Acknowledgements

CHAPTER 14: The future for simulation

Horizon scanning: the impact of technological change

A patient's journey

In the clinic

From clinic to operating theatre

In the operating theatre

In transition and on the ward

A surgeon's journey

Before surgical training

During surgical training

As a consultant

Delivery and costs

Summary

Guiding the role of simulation through paradigm shifts in medical education

The shift to competency-based education

Mastery learning

Continuing professional development

Assessment of competencies for lifelong learning

Scholarship in simulation-based education

Summary

The future of training in simulation

Integration with curriculum

Content

Future curriculum development

Faculty

Educational resources

How will we develop training?

Summary

Index

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Library of Congress Cataloging-in-Publication Data

Essential simulation in clinical education / edited by Kirsty Forrest, Judy McKimm, Simon Edgar.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-470-67116-0 (softback : alk. paper) – ISBN 978-1-118-65934-2 (eMobi) -- ISBN 978-1-118-65935-9 (ePDF) – ISBN 978-1-118-65936-6 (ePub)

I. Forrest, Kirsty. II. McKimm, Judy. III. Edgar, Simon.

[DNLM: 1. Education, Medical–methods. 2. Computer Simulation. 3. Patient Simulation. W 18]

R735.A1

610.71–dc23

2013003063

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: Northwestern Simulation

Cover design by Visual Philosophy

Contributors

Mark Adler MD

Associate Professor of Pediatrics and Medical Education

Center for Education in Medicine

Northwestern University Feinberg School of Medicine

Ann & Robert H. Lurie Children's Hospital of Chicago

Division of Emergency Medicine

Chicago, USA

Rajesh Aggarwal MA PhD FRCS

NIHR Clinician Scientist in Surgery

Imperial College London

London, UK

Joanne Barrott RN RM BSc (Hons) MMedSci

Regional Clinical Skills Manager

Leeds Metropolitan University

Leeds, UK

Bryn Baxendale MB ChB FRCA FAcadMedEd

Consultant Anaesthetist and Director

Trent Simulation and Clinical Skills Centre

Nottingham University Hospitals NHS Trust;

Honorary Professor of Clinical Simulation

School of Psychology

University of Nottingham

Nottingham, UK

Fernando Bello PhD

Senior Lecturer in Surgical Graphics and Computing

Imperial College London

London, UK

Andrew Buttery MSc

Specialist Trainer

Trent Simulation & Clinical Skills Centre

Nottingham University Hospitals NHS Trust

Nottingham, UK

Aidan Byrne MBBCh MSC MD

Professor

Medical School

Cardiff University

Cardiff, UK

Frank Coffey MB DCH MMedSci Dip Sports Med MRCPI FRCSEd FCEM

Consultant in Emergency Medicine

Nottingham University Hospitals NHS Trust;

Associate Professor

University of Nottingham

Nottingham, UK

Academic-Residence

Royal College of Surgeons in Ireland

Dublin, Ireland

Ara Darzi KBE FMedSci HonFREng MD FRCSI FRCS FACS FRCPSG

Professor of Surgery

Imperial College London

London, UK

Peter Dieckmann PhD DiplPsych

Director of Research

Danish Institute for Medical Simulation (DIMS)

Capital Region of Denmark

Herlev Hospital

Herlev, Denmark

Simon Edgar MBChB FRCA MSC Med Ed

Consultant Anaesthetist

Director of Medical Education at NHS Lothian

Edinburgh, UK;

Educational Co-ordinator

Scottish Clinical Simulation Centre

Larbert, UK

Walter J. Eppich MD MEd

Assistant Professor of Pediatrics and Medical Education

Center for Education in Medicine

Northwestern University Feinberg School of Medicine

Ann & Robert H. Lurie Children's Hospital of Chicago

Division of Emergency Medicine

Chicago, USA

Kirsty Forrest MBChB BSc Hons FRCA MMEd FAcadMed

Professor

Director of Medical Education

Australian School of Advanced Medicine

Macquarie University

Sydney, Australia

Thomas Gale BM BS FRCA MEd

Associate Professor;

Director of Clinical Skills

Peninsula Schools of Medicine and Dentistry

Plymouth, UK

Ronnie Glavin MB ChB MPhil FRCA FRCP (Glas)

Consultant Anaesthetist

Victoria Infirmary

Glasgow, UK

Stanley J. Hamstra PhD

Research Director, University of Ottawa Skills and Simulation Centre

Assistant Dean, Academy for Innovation in Medical Education

Associate Professor, Departments of Anesthesiology, Medicine, Surgery

University of Ottawa

Ottawa, Canada

Iliana Harrysson BSc

Honorary Research Fellow

Imperial College London

London, UK

Jean Ker BSc MD FRCGP FRCPE FHEA

Professor of Medical Educations

Director Clincal Skills Centre

University of Dundee

Dundee, UK

Roger L Kneebone PhD FRCS FRCSEd FRCGP

Professor of Surgical Education

Imperial College London

London, UK

Jimmy Kyaw Tun MBChB MA

Clinical Research Fellow

Imperial College London

London, UK

Nikki Maran MB ChB FRCA

Consultant Anaethetist

Associate Medical Director Patient Safety

NHS Lothian

Educational Co-ordinator

Scottish Clinical Simulation Centre

Larbert, UK

Alistair May MBChB FRCA FCARCSI

Educational Co-ordinator

Scottish Clinical Simulation Centre;

Consultant in Anaesthesia

NHS Greater Glasgow and Clyde

Glasgow, UK

Michelle McKenzie Smith MSc

Senior Clinical Educator/Deputy Manager

Montagu Clinical Simulation Centre

Montagu Hospital

Mexborough, UK

Judy McKimm MBA, MA (Ed), BA (Hons), CertEd, DipH&SW, SFHEA, FAcadMed

Dean of Medical Education

Swansea University

Swansea, UK

Amit Mishra MBBS, BSc (Hons)

Honorary Research Fellow

Imperial College London

London, UK

Viren N. Naik MD Med FRCPC

Vice Chair Education;

Associate Professor

University of Ottawa

Ottawa, Canada

Jane P. Nicklin MA PGCE RODP

Clincal Skills Project Worker

Leeds Metropolitan University

Leeds, UK

Lanty O’Connor BA

Manager of Simulation Technologies

Northwestern University Feinberg School of Medicine

Chicago, USA

Doris Østergaard MD PhD

Associate Professor of Anaesthesiology

Danish Institute for Medical Simulation

Herlev University Hospital

Herlev, Denmark

Charlotte Ringsted MD, MHPE, PhD

Professor of Medical Pedagogy

Director of Centre for Clinical Education

University of Copenhagen and Capital Region

Copenhagen, Denmark

Martin Roberts MSc

Research Fellow

Institute of Clinical Education

Peninsula Schools of Medicine and Dentistry

Plymouth, UK

Jacob Rosenberg MD DSc FRCS FACS

Professor

Herlev Hospital

University of Copenhagen

Copenhagen, Denmark

Ann B. Sunderland RGN BSc (Hons) NPDip PGCHE MMedSci

Academic Lead for Simulated Practice and Clinical Skills;

Simulation Development Officer for Yorkshire and Humber

Leeds Metropolitan University

Leeds, UK

Jessica Janice Tang PhD

Research Psychologist

Imperial College London

London, UK

Jennifer M. Weller MD MClinEd MBBS FANZCA FRCA

Associate Professor

Head of Centre for Medical and Health Sciences Education;

Specialist Anaesthetist

University of Auckland

Auckland, New Zealand

Foreword

When a new scientific or technical advance begins everyone laughs at it, downplays its significance and applicability to progress or real-world application. Manuscript submissions to journals are rejected because reviewers and editors just don't ‘get it’. As the field matures these things abate, until everyone agrees that of course it makes sense and we knew it all along. Ultimately, of course, one of the best signs that a field is maturing – or has downright matured – is that textbooks on the topic appear. This book: Essential Simulation in Clinical Education, edited by Kirsty Forrest, Judy McKimm and Simon Edgar, is an interesting member of a new wave of textbooks on simulation in healthcare that is just coming on the market.

I am proud that two of the editors are from my own clinical field of anesthesiology – or given the British editors of this book, perhaps I should say ‘anaesthetics’. Many people ask why anesthesia professionals have had such a large role to play in simulation in healthcare, both in the early days (for me at least going back to the mid-1980s) and in the current period almost 30 years later? There are indeed several reasons, and I suspect the editors of this book would agree with them. First, anesthesia (excluding management of acute and chronic pain outside the operating theatre) is almost never therapeutic in itself; it is a means to facilitate needed surgery. Second, anesthesia is a very abnormal state for the human body – evolution didn't mean for people to be temporarily rendered unconscious, insensitive to pain, and paralyzed only to be restored to normalcy a few minutes or hours later. And, to date, nearly every form of making this happen is dangerous, and in fact can readily harm or even kill patients. This made anesthesia professionals very, very interested in patient safety, in minimizing risk, and in finding ways of training that best prepared the practitioners of this arcane art (as well as their coworkers in surgery) to handle all the kinds of adverse event that nature, or their own inevitable mistakes, might throw at them. Thus, surgery and anesthesia along with a host of other clinical domains, qualify as endeavors that I classify as being of ‘high intrinsic hazard’. Others in this class include aviation and spaceflight (evolution certainly didn't prepare human beings to travel in the air or outer space, and at least for the former, what goes up must come down), production of electricity via nuclear reactions, or military combat with increasingly long-range and lethal weaponry. All these other endeavors of high-intrinsic hazard adopted simulation as a core component of the initial and recurrent training of their personnel and teams. Thus, it should come as no surprise that anesthesia professionals facing similar problems were, and are, in the vanguard of leadership in clinical simulation, not only for our own fields of operative anesthesia and intensive care, but now extending to a whole host of clinical domains, for nearly all disciplines of healthcare personnel, at all levels of training and experience.

This book is interesting in part because it leans heavily on editors and authors from the UK, with a small set of authors from areas that were former British colonies, provinces, or dominions (the USA, although Chicago was not under British control, Canada, and New Zealand). Several authors are from Denmark – which Britain never ruled; instead the Great Danish Army conquered major parts of England in 865 ce, so it is perhaps only fitting that these authors also join this work. The authors include many very-well-known names in the world's pantheon of simulation experts. The UK has been a hotbed of simulation for many years, and the integration of simulation into some components of their healthcare system has outstripped that in many other parts of the world. Moreover, their take on simulation – while appropriately represented in the peer-reviewed literature – has not been thoroughly disseminated to the rest of the world (and certainly not to my side of “the pond”). The book is also interesting in covering the full panoply of simulation – as the editors put it in their introduction: overview, history, evidence, teaching learning and assessment, people, skills, the places, doing it (meaning actually conducting simulation, not the more colloquial connotation of the term), complete with some fascinating real-life examples, and some viewpoints on the future of clinical simulation. Hence it is with pleasure that I mark the publication of this book and hope that it will thoroughly teach and fascinate (and perhaps even once in a while astonish or exasperate?) its readers.

February, 2013

David M. Gaba, MD

Associate Dean for Immersive and Simulation-based Learning

Professor of Anesthesiology, Pain, and Perioperative Medicine

Stanford University School of Medicine

Co-Director, Simulation Center at VA Palo Alto Health Care System

Founding and current Editor-in-Chief, Simulation in Healthcare

Los Altos, California, USA

(a part of the country which was once under the rule of Spain, but never of Great Britain)

Glossary and abbreviations

ACLSAdvanced Cardiac Life Support.ANTSAnaesthetists' Non-Technical Skills.ASPiHAssociation of Simulated Practice in Healthcare.Behavioural marker systemsA list or matrix of observable, non-technical behaviours linked to specific social or cognitive criteria that contribute to superior or substandard performance within a work environment.BEMEBest Evidence Medical Education.BlueprintingThe process of identifying the particular outcomes or parts of a curriculum that are assessed by specific components of an assessment.BodySimUses clinician-assessors rather than independent judges. After scoring each candidate, assessors grade them as pass, fail or borderline and the pass score is the average score obtained by those in the borderline group.Borderline groups methodAssessment method in which appropriately qualified and experienced individuals are first asked to describe the competence of individuals deemed to be on the borderline between competence and incompetence. Next specific individuals predicted to lie in this zone are identified and their test scores analysed.CASEComprehensive Anesthesia Simulation Environment.Cavalier attitudesCasual, dismissive manner: ‘It's only a plastic dummy!’.ChecklistA list of observable actions and/or outcomes that contribute to competent clinical performance in an assessed scenario.Contrasting groups methodJudges are asked to examine the overall performance of a sample of candidates and award each one a pass or fail, regardless of the actual scores awarded. The score distribution within the pass group is then compared with that for the fail group and used to establish a cutpoint where the distributions overlap.CPDContinuing Professional Development.CRMCrew Resource Management.DSDistributed Simulation.EBATEvent-based approach to training.Fixed percentage methodRelative method whereby the proportion of examinees who will pass is predetermined for each cohort.GASGainesville Anesthesia Simulator.GasManA software-based tool allowing for the clinical simulation of volatile anesthesia uptake and distribution within the body.Global rating scaleAn list of increasing levels of clinical performance in an assessed scenario to which numerical scores may be attributed.GTAsGynaecology Teaching Associates.HapticsTactile feedback technology which takes advantage of the sense of touch by applying forces, vibrations, or motions to the user to develop and enhance motor skills (e.g. in surgical techniques).HEAHigher Education Academy.Hofstee methodA cutpoint is created by combining the Angoff and fixed percentage methods. The panel of expert judges is asked to set minimum and maximum pass scores and minimum and maximum acceptable failure rates. A graphical method is then used to identify a cutpoint that falls between these extremes.Hybrid simulationProcess of attaching part-task trainers to simulated patients so that assessment of clinical skills can include added complexity to measure aspects of the doctor–patient interaction.HypervigilanceAn enhanced state of sensitivity combined with an exaggerated intensity of behaviours whose purpose is to detect threats.ICEPSImperial College Evaluation of Procedure-specific Skill.Internal metricsPhysical measurements, recorded by instruments in the simulation environment, that can be related to aspects of clinical performance.ISBAR (Identify self, Situation, Background, Assessment, Recommendations)A tool to improve information sharing in patient handover between team members, or when referring a patient to another health profession for their input.KISMET (Kinematick Simulation, Monitoring and off-line Programming Environment for Telerobotics)A software tool for planning, simulation, programming and monitoring of remote handling equipment, industrial robots and various types of mechanisms.Maastricht Assessment of Simulated Patients (MaSP)Tool designed to assess and develop the quality of the SPs feedback to the student at the end of a simulation session.MATTUSMinimal Access Therapy Training Unit.Mini-CEXMini-Clinical Evaluation Exercise.Mini-Clinical Evaluation Exercise (Mini-CEX)A structured workplace based assessment of an observed clinical encounter designed to help focus trainer feedback on skills essential to the provision of good clinical care by the learner.Minimally Invasive Surgical Trainer (MIST)A part task trainer utilising haptic feedback and either real or virtual (MIST-VR) targets allowing for the development of minimally invasive or laparoscopic skills.MISTELSMcGill Inanimate System for Training and Evaluation of Laparoscopic Skills.MOCMaintenance of Certification.Modified Angoff processA panel of expert judges determine a score that would be achieved by a borderline (‘just passing’) candidate. The average of these scores is then the final pass mark.MoulageMake-up and other products are applied to the simulator to augment the realism of a scenario in a relevant way by creating physical manifestations of disease (a rash) or injury (abrasions, lacerations, burns, or other trauma). The moulage only needs to be sufficiently realistic to trigger a target response.NOTSSNon-Technical Skills for Surgeons.OSATSObjective Structured Assessment of Technical Skills.OSCEObjective Structured Clinical Examination.PACER (Probe, Alert, Challenge, Emergency, Response)PACER and the Two Challenge Rule Tools to assist team members to speak up or challenge decisions by the team leader.Postgraduate Ward Simulation Exercise (PgWSE)Provides direct evidence of performance using simulation based education. It lasts for twenty minutes and during the exercise the doctor receives timed interruptions whilst dealing with a new admission, an emergency situation and a specific communication issue.RAPIDSRescuing a Patient in Deteriorating Situations.RCRSRochester Communication Rating Scale.Resusci AnneA training mannequin first introduced in 1960 by Norwegian toy maker Åsmund Laerdal designed to accurately simulate the human respiratory system and external body landmarks in order to facilitate training and used for teaching cardiopulmonary resuscitation (CPR) to both emergency workers and members of the general public.SAGESAmerican Gastrointestinal Endoscopic Surgeons.SBARSituation, Background, Assessment, Recommendation.SBCESimulation-based Clinical Education.SBTTSimulation-based Team Training.Selective abstractionA key concept that highlights the notion that elements of a given scenario need to be recreated with greater or lesser degrees of authenticity to heighten perceived realism depending on how central a certain element is to the case.Sequential Simulation (SqS)A method of condensing an extended clinical pathway into a shorter time frame. Achieved by selecting representative components and linking then across different sectors of the healthcare system and different time frames.Sim OneThe first realistic anesthesia simulator produced in the late 1960's at the University of Southern California. It was used mainly for the training of endotracheal intubation and the induction of anesthesia. The mannequin had outputs for peripheral pulses and heart sounds, but no outputs for electronic monitors.Simulated patient (SP)An individual who is trained to act as a real patient in order to simulate a set of symptoms or problems providing reliable and reproducible clinical material for training and assessment of skills in communication and physical examination.SNAPPI (Stand back and get attention, Notify team of the situation, Assessment of situation, Plan and Priorities, Invite ideas)A tool to structure a team call out, where the team is brought together to ensure shared situational assessment, shared goals and inviting team input into the problem.SPLINTSScrub Practitioners' List of Intra-operative Non-Technical Skills.Spotlight ModelProposes that a shift of visual attention corresponds to a shift in processing resources among several analysed locations, like moving a spotlight.Standardized patientAn individual who typically has real clinical signs and symptoms and who has been trained to provide a standardized history and/or feedback to learners.StoryboardA template populated with the integral components relating to the design, running and debrief of a simulation scenario.Team-oriented medical simulationSimulation-based developmental activity where the learning outcomes of the scenario are focused on group interaction, team dynamics and overall performance rather than at an individual level.UtsteinUtstein is an abbey in Norway, which has hosted several meetings, where a group of international experts come up with recommendations or guidelines for a given topic. Utstein is now synonymous with reporting guidelines for resuscitation.Vocal cuesAddition of a patient's voice in manikin-based simulation can be particularly helpful to help participants engage with the simulation. Learners can gather relevant information for clinical decision-making and management as well as assess the patient's mental status.WBAWorkplace-based Assessment.Zoom Lens ModelUtilizes the properties of the Spotlight Model, but also includes the property of changing size in visual attention. This property was inspired by the zoom lens function on a camera in which there is a trade off between the size of the visual attention region and processing efficiency.

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CHAPTER 1

Essential simulation in clinical education

Judy McKimm1 and Kirsty Forrest2

1Swansea University, Swansea, UK; 2Australian School of Advanced Medicine, Macquarie University, Sydney, Australia

‘The use of patient simulation in all its forms is widespread in clinical education with the key aims of improving learners' competence and confidence, improving patient safety and reducing errors. An understanding of the benefits, range of activities that can be used and limitations of simulation will help clinical teachers improve the student and trainee learning experience.’ [1]

Overview

The use of simulation for the training of healthcare professionals is becoming more and more popular. The drivers of improved patient safety and communication have led to a significant investment in the expansion of facilities and equipment across Western healthcare organizations. For example, Royal Colleges in the UK are including mandatory training using simulation within their curricula and politicians have also jumped on to the bandwagon extolling the virtues of simulation training. The use of simulation in training is becoming synonymous with effective learning and safer care for patients and is fast becoming a panacea for all the perceived ills of teaching and training. However, simulation is not a substitute for health professionals learning with and from real patients in real clinical contexts. As Gaba reminds us:

‘simulation is a technique, not a technology’ [2, p. 2]

Other authors [3,4,5] note that we must take care in case the seductive powers of simulation lead to dependency, become self-referential and produce a ‘new reality’. Simulation must not become an end in itself, disconnected from professional practice.

Ongoing and outstanding discussions include the following questions: What do participants learn from simulation? How are they expected to learn? How will the knowledge and skills be transferred to clinical practice? Will general or specific aspects of performance be transferred? Do our current methods and techniques make this transfer possible? When in a clinician's training should simulation be used? How should simulation be introduced into the curriculum? When should the team be trained as opposed to the individual? Can simulation impact on patient safety? Can and should we look for a return on investment when talking about simulation education?

This book will provide the reader with evidence around these questions and much more. The contents of the chapters build from the broader themes of history, best practice and pedagogy through to the practical aspects of how to teach and train with simulation and ends with examples and possible future developments. However each chapter can stand alone for those who wish to explore a single topic. Each is written by authors who are highly experienced in the development of simulation-based education. Our thoughts on and synopses of the various chapters follow.

History

Simulation in medical training has a long history, which started with the use of very basic models to enable learners to practice skills and techniques (e.g. in obstetrics). In spite of this early start, medical simulators did not gain widespread use in the following centuries, principally for reasons of cost and a reluctance to adopt new teaching methods. With advances in materials and computer sciences, a wide range of modalities have developed including virtual reality and high-fidelity manikins, often located in dedicated simulation centres. Chapter 2 describes these developments in detail, reminding us that the combination of increased awareness of patient safety, improved technology and increased pressures on educators have promoted simulation as an option to traditional clinical skills teaching. The chapter also defines and describes a classification for stimulation. Although a wide range of simulation activities exist, these are still often linked with specific medical specialities rather than ‘centrally’ managed or resourced. How simulation can best be supported in low-income countries, where the need is great but resources are not always available, is an issue still to be addressed. The impact of simulation on patient safety and health care improvements is still relatively under-researched although an evidence base is growing.

Evidence

There is widespread agreement, supported by robust research, systematic reviews and meta-analyses, on what makes for effective simulation. This theme is further explored in Chapter 3, which considers the evidence base underpinning the widespread use of simulation-based training in undergraduate and postgraduate contexts, general and specialty-based curricula, and clinical and non-clinical settings. Simulation supports the acquisition of procedural, technical skills through repetitive, deliberate practice with feedback, and also supports the acquisition of non-technical skills, such as communication, leadership and team working. The evidence base for the former is more extensive and robust than for the latter, which has been identified as an area for further research. The value of embedding or integrating simulation within curricula or training programmes is highlighted, as is the benefit of a programmatic, interval-based approach to simulation. In addition, workplace-based simulation for established multiprofessional teams (when supported by the institution's leaders) is seen as effective way of embedding sustainable changes in practice.

Teaching, learning and assessment

Simulation is no different from many other forms of education and training: instructors or facilitators need to be skilled and knowledgeable about educational theory and how this relates to their teaching practice. As with any educational intervention, activities need to be designed to enable learners to achieve defined learning outcomes and meeting their own learning needs. However, simulation offers particular challenges to both facilitators and participants: it requires some suspension of disbelief; it may feel threatening, challenging and unsafe (particularly for experienced health professionals); and it requires skills in giving feedback, both ‘in the moment’ and through more structured debriefings. Chapter 4 considers some of the most relevant learning theories and educational strategies that help to provide effective training and overcome some of the inherent barriers to learning through simulation.

Providing high-quality educational experiences is vital if learners are to engage in simulation with all its challenges; however, assessment drives much of learning, and simulation has a huge role to play in ensuring that health professionals are fit, safe and competent to practise. In Chapter 5, the authors consider the important elements which contribute towards effective assessment of both technical and non-technical skills at all stages of education and training. As with any assessments, those using simulation should possess the attributes of reliability, validity, feasibility, cost-effectiveness, acceptability and educational impact. Assessments need to be integrated within the curriculum and within an overall assessment scheme which utilizes a range of methods. Simulation can provide opportunities for both formative (developmental) and summative (contributing to grade or score) assessments, although appropriate levels of fidelity and realism need to be selected based on the specific context. Well-designed simulation provides excellent opportunities for learners to receive timely and specific feedback from educators and real, virtual and simulated patients and so helps develop and hone clinical and communication skills. Simulation also enables those involved in assessment to consistently and reliably assess clinical performance by using increasingly sophisticated technology such as haptic trainers which incorporate internal metrics and can measure fine motor skills and give in the moment feedback, or combinations of simulations (such as simulated patients and part task trainers) which can assess complex clinical activities or team working.

A large number of checklists and global rating scales have been developed, tested and validated in various settings which give rise to both opportunities and challenges for educators. Chapter 5 describes some of the most widely used instruments. The ability to measure performance more consistently and reliably provides assurances for patients and the public that healthcare professionals are safe to practice. However, the more reliable simulated assessments become, the possibilities of using such assessments in selection, relicensing and performance management increase. For such assessments, and also for high-stakes ‘routine’ assessments, educators must be satisfied that the assessment instruments selected are appropriate and validated, that the personnel and equipment involved and scenarios chosen are appropriate and that all those involved in delivering the assessment (including standard setting, development of checklists, marking and giving feedback) are suitably trained.

The people

Although the range and potential of simulation equipment and computer-based technologies seems almost infinite, without the continued involvement of trained, enthusiastic and skilled people, simulation education will not flourish and grow. Chapter 6 considers the recruitment, education, training and professional development of two of the main groups involved in simulation-based education: the educators or faculty, and simulated (or standardized) patients (SPs). As with any type of education, simulation facilitators (trainers, instructors or educators) need to be trained to teach, assess, give feedback and evaluate the effect of the education alongside other teachers on healthcare programmes. As a learning modality, simulation has some unique features in which teachers require development so that they can provide high quality educational experiences, such as using technical equipment and computers and working with simulated, real and virtual patients (Figure 1.1).

Figure 1.1 Teaching using simulation requires an ability to use technical equipment and be able to work with simulated, real and virtual patients. Photo by Laura Seul, copyright Northwestern Simulation.

The challenging nature of some simulation encounters also requires educators to be explicit about and adhere to high professional standards and values so as to maintain a safe atmosphere which encourages learning. Educators also need to be able to adopt a range of styles, such as an instructing style for novices learning a technical skill or a coaching or facilitative style for an expert group, and be proficient in techniques such as giving feedback and the debrief. Educators must also be credible, whether they are clinically qualified or not; this may mean acquiring new skills or knowledge or team teaching with clinical colleagues. In common with many areas of practice, professional standards of educators are now being widely adopted alongside increasing regulation and quality assurance. Educators therefore need to be aware of these changes and prepared to take a lifelong learning approach to their own development.

SPs have been widely used in both the teaching and assessment of health professionals and provide a valuable adjunct to involving both real and virtual patients. SP interaction with learners can vary from fairly minimal interaction with limited responses to a highly standardized and scripted encounter, in which the SP might have a lot of flexibility in how they respond to the learner. The role of SPs in providing timely and accurate feedback from the ‘patient's perspective’ is one of the key advantages of involving SPs. Many SPs are also trained as educators who can work unsupervised in both teaching and assessment situations. As with any involvement in education, it is important that SPs are selected, trained and supported in their role, particularly when they are involved in high-stakes assessments or in evaluating qualified doctors' performance. SPs have also been used as covert patients to evaluate health services and the practice of individual doctors. Although planning and managing an SP service is time-consuming and can be costly in the initial stages, experienced SPs can replace clinicians in both teaching and assessments, which can lead to more standardized experiences for learners and cost savings over time. Recent international developments include consideration of SP accreditation, standards and certification as part of a drive to ensure high-quality education and training.

The skills: technical, non-technical and team working

Simulation takes place in a range of settings, but is probably most widely used and has had the most measurable impact in surgical settings, led by anaesthetists and surgeons. Taking an historical approach, Chapter 7 looks at surgical technical skills, highlighting some of the key drivers behind the introduction of simulation training and its impact on patient safety and error reduction. This chapter describes some of the key developments in developing and enhancing surgical skills. The need for further training and development via simulation training has been driven by the need to ensure higher standards of patient safety and error reduction; patient expectations of healthcare; the introduction of new operating procedures (such as laparoscopy); and technological advances (e.g. endoscopes, miniaturization of equipment and imaging technology). Technological advances have also enabled simulation to utilize different materials and harness computing power in the form of virtual reality simulators and other devices that facilitate and measure haptic (tactile) feedback in real time in order to ensure surgical technical skills are of a required standard. Such simulations enable doctors to improve operating techniques, particularly in the learning curve stage, when patients are deemed most at risk (Figure 1.2).

Figure 1.2 Simulations enable doctors to improve their operating techniques. Photo by Laura Seul, copyright Northwestern Simulation.

As the dividing line between surgeons, radiologists and other physicians becomes increasingly blurred with the more widespread use of minimally invasive procedures and interventional radiology, virtual reality simulators are being used to train a variety of health professionals. This brings its own challenges and opportunities. For example, as we are better able to measure fine response times and technique, simulation-based proficiency tests that incorporate ‘real-time’ pressures and stressors (as used in aviation and military settings) may well be used to discriminate between applicants for specific posts. If the use of simulation training and assessment expands, then new simulation centres may need to be established that can efficiently utilize resources, equipment and expertise to train and assess large numbers of doctors and other health professionals. This would require a ‘whole-system’ approach to simulation.

Chapter 8 considers and explores the training and development of non-technical (social and cognitive) skills and the way in which human factors impact on patient safety. In many high-risk industries, human factors have been shown to cause the majority of errors and often these are not due to lack of knowledge or inability to perform a technical skill, but due to lack of so-called ‘softer’ skills like team working, communication, leadership and decision-making. This chapter describes the development and implementation of Crew Resource Management (CRM) and behavioural marker systems to observe, assess and give feedback to individuals and teams. Examples are given of scenarios and details of each of the steps required in designing training in alignment with defined behavioural markers.

The healthcare team has been called the ‘cornerstone’ of health services, yet teamwork failures are widely viewed as a major contributor to adverse health outcomes and errors. Chapter 9 explores some of the reasons why this is the case and discusses how simulation-based team training (SBTT) delivered by trained instructors can help address some of the common issues concerning poor or ineffective communication and differing perceptions about the goals of healthcare, team roles and leadership. A number of models and strategies are discussed in the chapter, along with their application and relevance for training uni- and multiprofessional teams. These strategies focus on improving team performance through enhancing team cog­nition, developing shared mental models and problem-solving approaches, and facilitating team members to challenge the attitudes and perceptions of other professional groups. Structured observation charts that focus on assessing behaviours help instructors and team members to give more helpful feedback. Because most teams are multidisciplinary, SBTT should also aim to involve different professional groups, ideally in authentic work situations, both in the actual workplace and in simulation centres.

The places

In many contexts, a dedicated simulation centre (whether established on a local or regional scale) is seen as an efficient and effective way of centralizing resources and expertise, particularly those around high-fidelity simulators or when large numbers of people are to be trained. For those involved in, or considering, establishing a simulation centre, Chapter 10 provides a highly detailed, step-by-step guide to all the factors that need to be considered. The authors draw from their own experience of running a large-scale simulation centre, providing many ‘hints and tips’ and ideas applicable to many contexts. Factors that need attention include securing initial and ongoing funding; determining training needs and the numbers of users of the centre; recruiting, training and retaining faculty; identifying the right equipment and ensuring that this is maintained well; providing high-quality training that is pedagogically sound that meets learners' (and funders') needs; and quality assuring all activities. Collaboration with key stakeholders is vitally important, especially to ensure sustainability of the centre and its activities, as is engagement with national and international simulation and clinical skills networks, whose members have wide expertise. At the operational level, administrative and technical staff are central to the effective and efficient delivery of training and maintenance of equipment and, as other writers have stressed, it is essential that simulation activities are embedded within curricula or training programmes so that learners gain the most benefit.

As health service and education budgets become increasingly constrained, many simulation groups are starting to explore more cost-effective solutions to delivering high-quality simulations away from dedicated simulation centres. Distributed simulation (DS) is one solution to these problems. Chapter 11 describes the work of the Imperial College London team in researching into the most effective ways of setting up effective ‘portable’ simulation activities in a range of settings and specialties. Working with a multidisciplinary team, the research group has drawn on the psychological theories of selective attention and applied these in the development of a range of DS models which can be applied in a variety of settings. This ‘selective abstraction’ is what makes DS so useful when resources are limited as only the most important features are used which help to generate a realistic scenario in any given context. Portability is achieved through the use of simple, user-friendly equipment for observing, recording, playback and debriefing, similar to that used in static simulation centres and practical, lightweight and easily transportable components which can be erected quickly by a minimal team. This gives the flexibility to recreate a range of clinical settings according to individual requirements.

DS could herald the way forward for future developments as it can provide a cost-effective, accessible and versatile approach to teaching and learning tailored to the needs of individual groups at the right level of fidelity. Although the preliminary exploration and validation work of the DS was conducted in a surgical setting with clinicians at different levels of experience and different surgical procedures, DS is now starting to be utilized in different hospital and community-based settings such as emergency medicine and, utilizing concepts such as sequential simulation, considering how to simulate care pathway modelling in different domains of medicine and support services. This has potential for widespread application in low income countries or contexts in which static, expensive simulation centres are unlikely to be established.

Doing it

Although the context and nature of the simulation activity might vary, including the types of participants, the locality and the purpose of the training, it is essential that simulation education provides a safe environment in which participants can actually learn. Because simulation is often perceived as challenging and sometimes threatening, simulation educators need to pay close attention not only to the achievement of learning outcomes, but to the process of group dynamics and individuals' psychological safety. In Chapter 12, the authors take a structured approach to designing effective simulation education, considering each of the components of the simulation setting, and suggest ways in which educators can help support learners gain the most from the encounter. As we have mentioned, simulation educators need to utilize best practice from other areas of education, including small group facilitation skills, giving constructive feedback and defining clear learning outcomes. However, the simulation encounter also benefits from attention to specific elements such as scenario design and the structured debrief. Ensuring that participants are appropriately introduced to the scenario, the simulation context and the other people involved in the simulation is very important. Also important is setting ground rules and either using a structured approach to simulation design and delivery, such as the event-based approach to training (EBAT), or making sure that educators have the skills and expertise to deliver training on-the-fly. The chapter also discusses the use of confederates, moulage and audiovisual equipment and provides an in-depth guide to the use of the debrief as part of the provision of effective and useful simulation.

Real-life examples

Chapter 13 introduces a fascinating insight into the practice of simulation ‘on the ground’ through a series of nine short, structured case examples of simulation teaching, learning and assessment activities in a range of different clinical settings with learners from various health professions at different stages of education and training. Examples are from Australia, the Netherlands, the USA, Africa and the UK, and from both primary and secondary care. Each worked example describes the background and context; what was done; the results and outcomes; take home messages; and hints and tips.

The case studies cover a range of topics and uses of simulation:

using the simulator Harvey™ to teach cardiologyassessing leadership skills in medical under­graduatesinterprofessional learning of airway managementa multicountry and multicultural study using simulation in emergency careclinical skills assessment of postgraduate paediatric traineesa national assessment programme for ‘doctors in difficulty’the use of incognito standardized patients in general practiceteam-based simulation for rural and remote practicetrauma team training in a university hospital.

All the case studies demonstrate the importance of evaluating interventions so that practice can be improved. Evaluation needs to be not just of the simulation activity itself, but also aimed at improving health outcomes. The case studies also indicate the clear links between simulation, policy and practice and that simulation-based education needs to be located as near as possible to the workplace (at the very least to workplace needs and involving clinicians) and that interprofessional and multiprofessional working enhances the experience for all. The case studies also demonstrate the value of, and indeed the need for, collaboration: among professions, disciplines, organizations, teams and countries. Lessons learned and hints and tips provide valuable ideas for those developing and establishing simulation-based activities.

The future

The final chapter comprises three sections. In each section the authors give their personal perspective on what they see as some of the key developments in simulation and how these will impact on future development and implementation.

The first section focuses on the use of simulation technologies, specifically in surgical training and education, to improve patient safety and reduce errors in the operating theatre and associated settings. Taking the concepts of a patient's and surgeon's journey, the section considers how simulation can help provide more seamless care as well as support the professional development of surgeons throughout their working lives. The use of virtual patients, three-dimensional high-definition holographic technology to simulate real patients' anat­omy and physiology and team-based training will enable the surgical team to plan and deliver personalized optimum pre-operative, surgical and post-operative interventions, to practise complex skills and manoeuvres, and to rehearse strategies should complications arise (Figure 1.3). As technologies develop, the use of laparoscopic, miniaturized and robotic surgery will increase; thus surgeons will need regular updating, training and refreshment of skills and techniques. Selection (for general surgery or for sub-specialties) might also involve simulation once technologies can provide reliable, consistent and accurate estimation of performance. Simulated environments or worlds such as SecondLife™ will enable non-technical skills and activities (such as handover or discharge planning) to be practised safely using avatars (Figure 1.4). Over time, as part of the drive to reduce error and improve performance, ‘black box’ recorders might be placed in all theatres to measure and record real time performance.

Figure 1.3 Coronary angiography simulator (a) and screen shot (b). Courtesy of Jivendra Gosai, Hull Institute of Learning and Simulation.

Figure 1.4 Avatar example. Courtesy of Henry Fuller. http://secondlife6750.wordpress.com.

The second section takes a different look at simulation-based education and its role and place within a changing education and training context. Taking two main paradigm shifts in medical education, the shift from time-based to competency-based education and the move towards lifelong learning, the authors explore how simulation can help to support and drive these shifts. The move towards competency-based education is more goal oriented and requires deliberate practice and ongoing measurement and assessment of skills, both technical and non-technical, or competencies at all stages of training. To demonstrate mastery at defined levels, accurate, reliable assessments are needed. Simulation is well placed to help provide opportunities for deliberate practice, integration and mastery and assess defined competencies through formative and summative assessments without the need for practice on real patients all the time. This can help accelerate learning and skills, and thus move away from a time-based model of education towards one that acknowledges and is responsive to the needs and attributes of individual learners throughout life. To evaluate the high-level impact of simulation interventions, more scholarly research is required and educators need to be supported and equipped with the expertise and time needed to develop research, evaluation and writing skills. Medical education research units that are populated with qualified and experienced educators can support education scholarship by collaborating with and mentoring clinician educators. The importance of gathering the right evidence to evaluate interventions is highlighted, and the Kirkpatrick evaluation hierarchy is cited as helping guide the rationale for education interventions and the quality and impact of teaching innovations.

The final section considers the future of training in simulation through consideration of three interlinked elements: curriculum integration, resources and faculty development. As many writers have emphasized, simulation needs to be integrated within a curriculum or programme to enable learners to achieve defined learning outcomes. It is suggested that simulation should be thought of not just as a method of learning or assessing ‘content’, but as significantly influencing the content of the curriculum. Through engagement with simulation activities, educators from many disciplines (e.g. psychology, anthropology, computer and materials sciences, as well as biomedical scientists and clinicians) have together co-created curricula and learning interventions that would not have been considered possible decades ago. A vision for the future of simulation training is of groups of healthcare workers coming together to rehearse and practice and prepare for the introduction of new clinical challenges or new protocols or ways of safely implementing new practices. Faculty development will also continue to be informed by simulation through involvement of multiple stakeholders including those from performing arts, psychology and business.

In common with all areas of education, increasing constraints on resources mean that educators and managers have to provide robust evidence of value for money and efficiency. As well as essential resources such as time, space, administrative and practical support, simulation activities require specialised (and often expensive) equipment and technology. Many developments have only been made possible because of close collaboration between simulation users, commissioners, manufacturers and even regulators. In the future this will require more robust mechanisms to ensure that the resources required for investment are likely to bring about a significant return and that transparent and meaningful quality assurance mechanisms are established. It is also important to ensure that resources are focused towards areas of need, such as low-income countries, where well-designed simulation can have great impact. The final challenge highlighted is that of continuing to develop and understand the theoretical basis that underpins simulation-based education and devise models and explanatory frameworks that can be used in scholarly practice and research. Taking a programmatic approach to this work through international collaboration provides the best way forward to ensure simulation-based education trains and prepares health profes­sionals to deliver safe, high-quality healthcare and meet tomorrow's global challenges.

Summary

We hope that the ideas, thoughts and concepts in this book will stimulate readers to think about how they can improve learning with simulation. Those who are involved in the development and delivery of simulation healthcare education need to have a better understanding and the most recent evidence of its use. If simulation education is used by those that are not aware of its challenges or previous work, the outcomes could be costly and lead to the technique being abandoned. Keeping pace with the implications of published research, new technologies and influences from other disciplines is important.

Discussion in the literature can tend towards the sceptic, such as editorial headlines of ‘High fidelity and fun: but fallow ground for learning?’ [6]. The article the editorial refers to concludes that some participants do not perform as well as others if under too much stress during simulated scenarios [7]. Other published research discusses how surprising or unanticipated events (which are inherently stressful) in an immersive virtual reality game can foster deeper learning [8]. Both these results, though conflicting at first, emphasize that learners are individuals; however, current research tends to look at how groups respond to simulation education. Which brings us back to the question: what is simulation education for? The range of modalities, uses and applications means that simulation based education cannot be purely labelled as good and bad for any one healthcare professional or team.

Evidence suggests that simulated scenarios have to be distinct, novel and incremental in their learning objectives for those who have repeated exposure to simulation training. This has been described as ‘episodic’ training and been postulated as the way forward for sustainable improved clinical performance [9]. The use of social media in clinical simulation education and training programmes, for example the use of smart phones to provide short, sharp ‘teaching points’ either with blogs, podcasts or interactive questions before and after training is increasing. When it comes to new technologies, the pace of development is probably not matched by those who develop and deliver simulation education. We are often constrained by our own education, experience and imagination when it comes to truly utilizing the full range and benefits of simulation education. With rapid advances in technology and expanding research programmes in simulation in clinical education, one might speculate that the best is yet to come.

References

1. Forrest K, McKimm J (2010) Using simulation in clinical education. British Journal of Hospital Medicine, 71: 345–349.

2. Gaba DM (2004) The future vision of simulation in healthcare. Quality and Safety in Health Care 13: i2–i10.

3. Bligh D, Bleakley A (2006) Distributing menus to hungry learners: can learning by simulation become simulation of learning? Medical Teacher 28: 606–613.

4. Kneebone RL, Kidd J, Nestel D, Barnet A, Lo B, King R, Yang GZ, Brown R (2005) Blurring the boundaries: scenario-based simulation in a clinical setting. Medical Education 39: 580–587.

5. Kneebone RL, Scott W, Darzi A, Horrocks, M (2004) Simulation and clinical practice: strengthening the relationship. Medical Education 38: 1095–1102.

6. Basu Roy R, McMahon, GT (2012) High fidelity and fun: but fallow ground for learning? Medical Education 46: 1022–1023.

7. Fraser K, Ma I, Teteris E, Baxter H, Wright B, McLaughlin K (2012) Emotion, cognitive load and learning outcomes during simulation training. Medical Education 46: 1055–1062.

8. van der Spek ED, van Oostendorp H, Meyer J-J Ch (2012) Introducing surprising events can stimulate deep learning in a serious game. British Journal of Educational Technology 44: 156–169.

9. Reader T (2011) Learning through high-fidelity simulation in anaesthesia: The role of episodic memory. British Journal of Anaesthesia 107: 483–487.

CHAPTER 2

Medical simulation: the journey so far

Aidan Byrne

Cardiff University, Cardiff, UK

Overview

The story of simulation is dominated by the efforts of pioneers who have struggled to improve training by using the resources available to them. These individuals have, however, largely worked in isolation and often failed to identify prior, related work that would have provided them with valuable guidance [1]. It is therefore difficult to write a definitive history of simulation, as any one innovation can rightly be ascribed to multiple groups and publication of results has often followed many years after the development of the technique. As Rosen suggests:

Many great ideas are ignored or dismissed only to be rediscovered at a future date with better understanding and acceptance [2, p. 157].

The published work on medical simulation highlights that the main aim of those developing simulators has been to improve the performance of students or trainees and thereby to improve the quality of healthcare delivery and patient safety. The view of what performance is, how learning occurs and how performance should be measured does, however, take many different forms.

Throughout the early history of simulation, advocates and pioneers were often derided, by those wedded to the apprenticeship model of learning and the practice of medicine as an art, for ‘playing with dolls’ and taking the students away from ‘real’ patients and by implication, ‘real’ learning.

This chapter takes a selective dip in and out of the history of medical simulation, focusing on some of the key innovators and the technological developments that allowed innovation to take place. Apologies are offered to those innovators whose efforts have been unintentionally omitted.

Definition

Simulation has been defined as:

The technique of imitating the behaviour of some situation or process (whether economic, military, mechanical, etc.) by means of a suitably analogous situation or apparatus, especially for the purpose of study or personnel training [3].

Taxonomy