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Written by a leading team from the Australian Society for Simulation in Healthcare (ASSH), Simulation Australasia, Healthcare Simulation Education is a new resource for a rapidly expanding professional healthcare simulation community. Designed as a core reference for educators who use simulation as an educational method, it outlines theory, evidence and research relevant to healthcare simulation. Containing examples of innovations from around the world, the book offers opportunities to make clear connections between the underlying rationale for the use of simulation, and what this looks like in practice. Healthcare Simulation Education: * Helps readers gain a systematic understanding of theory and application of simulation * Facilitates access to high quality resources to support Healthcare Simulation Education and research * Edited by a leading team from the Australian Society for Simulation in Healthcare (ASSH), the leading body for healthcare simulation in Australia * Contains information on educational theory, the elements of simulation practice and contemporary issues in simulation An important text in healthcare literature and practice, Healthcare Simulation Education provides a unique cross-disciplinary overview of an innovative subject area, and is ideal for medical, nursing and allied health educators, policy makers and researchers.

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Table of Contents

Cover

Title Page

Copyright

Contributors

Foreword

Acknowledgements

Section I: Introduction

Chapter 1: An introduction to healthcare simulation

Overview

Introduction

Origins of this book

Editors and authors

Structure of the book

References

Section II: Theoretical perspectives and frameworks for healthcare simulation

Chapter 2: Theories informing healthcare simulation practice

Overview

Introduction

Behaviourism

Constructivism and associated social learning theories

Critical theories in education

Conclusions

References

Chapter 3: Historical practices in healthcare simulation: What we still have to learn

Overview

Introduction

Background

Simulation in obstetrics

Simulation in bronchoscopy

The lost history of simulation in healthcare

References

Chapter 4: Exploring realism in healthcare simulations

Overview

Introduction

Realism and its synonyms

The broader landscape of realism

Realism in healthcare simulations

Realism and meaningfulness

Strategies for managing realism and meaningfulness to promote learning

Examples of realism in healthcare simulation

Conclusions

References

Chapter 5: Applying a framework to healthcare simulation: Micro, meso and macro levels

Overview

Introduction

Micro, meso and macro framework

Conclusion

References

Section III: Contemporary issues in healthcare simulation

Chapter 6: Strategies for research in healthcare simulation

Overview

Introduction

Professional societies and research strategies

Accessing healthcare simulation research

Sourcing funding for healthcare simulation research

Conclusion

References

Chapter 7: Simulated participant methodologies: Maintaining humanism in practice

Overview

Introduction

Caring for simulated participants

Before the simulation

During the simulation

After the simulation

Conclusions

Acknowledgements

References

Further Reading

Additional Resources

Chapter 8: Narrative dramaturgy and sense making in healthcare simulation

Overview

Introduction: dramaturgy, narrative and simulation

The pilot study

Conclusion

References

Chapter 9: Haptics-driven healthcare training simulator systems

Overview

Introduction

Issues of haptics-driven simulator systems and their solutions

Application examples

Conclusion and future work

References

Chapter 10: Virtual environments and virtual patients in healthcare

Overview

Introduction

Virtual environments and virtual patients

Virtual patients

Virtual environments and interactive virtual patients: some examples in healthcare

Virtual environments and interactive virtual patients: rationale and issues

Virtual environments and interactive virtual patientss: futures in healthcare

References

Chapter 11: Consistency in simulation: A measurement perspective

Overview

Introduction

Simulation event validity

Other approaches to reliability in simulation

Disadvantages and advantages of simulators in assessment

References

Chapter 12: Taking simulation beyond education in healthcare

Overview

Healthcare education using simulation for non-healthcare industries

Knowledge and skills development beyond the clinical context: life skills

Applying simulation to design and evaluation in healthcare

Simulation as therapy

Conclusion

References

Chapter 13: The value of professional societies to the healthcare simulation community of practice

Overview

Introduction to professional societies

Professional representation in healthcare simulation

Discipline-specific professional societies with special interest groups

Single-disciplinary healthcare simulation societies

Multidisciplinary healthcare simulation societies

Regional groups and alliances

A theoretical perspective

Conclusion

References

Chapter 14: Faculty development in healthcare simulation

Overview

Introduction

The case for faculty development

Structure and components of an effective faculty development programme

Final considerations to ensure longevity and impact

References

Chapter 15: Programme development and sustainability in healthcare simulation

Overview

Introduction

Development

Sustainability

Conclusion

References

Section IV: Elements of simulation practice

Chapter 16: Ethics of healthcare simulation

Overview

Introduction

Benefits and risks of simulation

The four principles applied to simulation

Virtue ethics: building character through simulation

Conclusion

References

Chapter 17: Teamwork and healthcare simulation

Overview

Introduction

Key Considerations in Simulation-Based Team Training

Challenges in Teamwork Simulation

Current Trends and Future Directions

Conclusion

References

Chapter 18: Designing simulation-based learning activities: A systematic approach

Overview

Introduction

Conclusion

References

Additional Resources

Chapter 19: Facilitating healthcare simulations

Overview

Introduction

Attributes of a facilitator

The process of facilitation

Conceptualization

Planning for facilitation

Level of feedback and cueing

Facilitating large groups

Briefing

Facilitating the simulation activity

Facilitating debriefing, providing feedback and triggering reflection

Evaluation of facilitation

Conclusion

References

Chapter 20: Strategies for managing adverse events in healthcare simulations

Overview

Introduction

Adverse events in simulation

Preparation of learners

Preparing a safe physical environment

Preparing a safe psychological ‘container’ for learning

Conclusion

References

Chapter 21: Debriefing: The state of the art and science in healthcare simulation

Overview

Introduction

The science of debriefing

The art of debriefing

Future directions

Conclusion

References

Section V: Innovations in healthcare simulation practice

Chapter 22: Simulation of home births: Developing safe practices

Overview

What was the need?

What did we do?

Method

What was the impact?

What lessons were learnt?

References

Chapter 23: Optimizing learning in simulation-based education using video-reflexivity

Overview

What was the need?

What did we do?

What was the impact?

What lessons were learnt?

References

Further Reading

Chapter 24: Conversations about organ and tissue donation: The role of simulation

Overview

What was the need?

What did we do?

What was the impact?

What lessons were learnt?

References

Chapter 25: Commencing a simulation-based curriculum in a medical school in China: Independence and integration

Overview

What was the need?

What did we do?

What was the impact?

What lessons were learnt?

Acknowledgement

Chapter 26: Transport of the critically ill patient: Developing safe practices

Overview

What was the need?

What did we do?

What was the impact?

What lessons were learnt?

References

Chapter 27: From routine to leadership: Extending the role of simulation technicians in Southeast Asia

Overview

What was the need?

What did we do?

What was the impact?

What lessons were learned?

Conclusion

Appendix 27.1: Email questionnaire

Chapter 28: Incorporating simulation in a medical city: A case study from King Fahad Medical City

Overview

Introduction

What was the need?

What did we do?

What was the impact?

What lessons were learnt?

Conclusion

References

Chapter 29: ‘Who’ and ‘how’ in simulation centre development: Buddies and ground rules

Overview

What was the need?

What did we do?

What was the impact?

What lessons were learnt?

References

Further Reading

Chapter 30: Operationalizing a new emergency department: The role of simulation

Overview

What was the need?

What did we do?

What was the impact?

What lessons were learnt?

Conclusion

References

Chapter 31: Simulation modelling and analysis to test health systems

Overview

What was the need?

What did we do?

What was the impact?

What lessons were learnt?

Next steps

What the simulation did to benefit the project

References

Further Reading

Additional Resources

Section VI: Conclusions and future practice

Chapter 32: Twenty years on… forecasting healthcare simulation practices

Overview

Introduction

Conclusion

References

Index

End User License Agreement

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Guide

Cover

Table of Contents

Foreword

Acknowledgements

Begin Reading

List of Illustrations

Chapter 3: Historical practices in healthcare simulation: What we still have to learn

Figure 3.1 Mannequin-based obstetric teaching at the Chattanooga Medical College, circa 1903.

Figure 3.2 A per-oral endoscopy simulator developed in the Hajek Clinic in Vienna [20]. The text explained: ‘This robot makes a nervous patient for the medical student and lights up or rings a bell if the probe goes right or wrong. At right, the insides of the model that cause it to respond to stimuli.’

Chapter 4: Exploring realism in healthcare simulations

Figure 4.1 Simulation realism and meaningfulness applied to scenario-based learning.

Figure 4.2 Considerations for realism in healthcare simulations. The text in italics offers examples of actions to address elements of realism before, during and after simulations.

Chapter 5: Applying a framework to healthcare simulation: Micro, meso and macro levels

Figure 5.1 A framework for system approaches to applying simulation in healthcare illustrated with examples from the text.

Chapter 9: Haptics-driven healthcare training simulator systems

Figure 9.1 Examples of existing single-point desktop kinaesthetic haptic devices: (a) Phantom Omni from Geomagic (formerly Sensable); (b) Omega 6 from Force Dimension.

Figure 9.2 Illustration of the control layout for SimOptiX. The highlighted controllers were originally mechanical ones, but have been replaced by electronic sensors that feed the user input directly into the training simulation programming.

Figure 9.3 The SimOptiX system in action. Multiple cameras have been employed to shoot both system overview and detailed operations.

Figure 9.4 A comparative demonstration to the approach on avoiding deformation distortion on soft tissues during haptic training simulation: (a) how the deformation would look like without the technique for guarding the edges of the deformation patch; (b) with the technique.

Figure 9.5 (a) X-ray view of multiple layered organs and tissues of pleural cavity for assisting trainees in validating haptic feedback with the actual organ/tissue touched. (b) Both mid-clavicular and mid-axillary approaches are shown.

Figure 9.6 Different incisions based on the user's stroke through a soft body.

Figure 9.7 The interactive curve-simplification algorithm to render the user's stroke in grid-based segments. The actual simplification algorithm involves higher resolution of the grids and the simplified incision segments are much closer to the incision curve.

Chapter 10: Virtual environments and virtual patients in healthcare

Figure 10.1 Learners in CliniSpace cooperating in treating a patient.

Figure 10.2 The use of virtual environments in healthcare.

Figure 10.3 Example of a virtual patient in a virtual clinical environment.

Chapter 15: Programme development and sustainability in healthcare simulation

Figure 15.1 Moore's strategic triangle. Source: Reproduced with permission from Moore M. Creating Public Value: Strategic Management in Government: Harvard University Press; 1997.

Figure 15.2 Sustainability matrix map. Source: Reproduced with permission from Bell J, Masaoka J, Zimmerman S. Nonprofit Sustainability: Making Strategic Decisions for Financial Viability: Jossey-Bass; 2010.

Chapter 17: Teamwork and healthcare simulation

Figure 17.1 A framework for effective teams.

Chapter 18: Designing simulation-based learning activities: A systematic approach

Figure 18.1 Phases in simulation design.

Chapter 19: Facilitating healthcare simulations

Figure 19.1 Strategies for facilitating simulation with large numbers of tutors and novice students.

Chapter 22: Simulation of home births: Developing safe practices

Figure 22.1 Hybrid simulation incorporating a woman with a task trainer to replicate a birthing scenario authentically.

Chapter 25: Commencing a simulation-based curriculum in a medical school in China: Independence and integration

Figure 25.1 Simulation-based training may involve all of the teaching methods.

Chapter 26: Transport of the critically ill patient: Developing safe practices

Figure 26.1 Transport-oriented variation of the acronym DRSABCDE.

Figure 26.2 Students transporting a mannequin around the clinical school accompanied by a facilitator.

Chapter 27: From routine to leadership: Extending the role of simulation technicians in Southeast Asia

Figure 27.1 Screenshot of the Simulation Technician Course site.

Figure 27.2 The next-generation simulation technicians (centre) and mentors (Sabrina Koh far left and Chaoyan Dong far right). Reproduced with permission.

Chapter 28: Incorporating simulation in a medical city: A case study from King Fahad Medical City

Figure 28.1 Part of King Fahad Medical City complex.

Figure 28.2 Housekeeper trainee, part of multidisciplinary training on Ebola preparedness.

Figure 28.3 Sketches of the future Simulation Hospital at King Fahad Medical City.

Chapter 29: ‘Who’ and ‘how’ in simulation centre development: Buddies and ground rules

Figure 29.1 MDSSC department photo with the administrative, simulation and IT team members. Centre directors in second row: Dr LY Ho (third from left), Dr Eric So (third from right), Dr George Ng (second from right).

Chapter 31: Simulation modelling and analysis to test health systems

Figure 31.1 The simulation running with two X-ray machines, each having two changing areas. The metrics displayed include census, costs, throughput, completion times, length of stay, distance walked and so on.

List of Tables

Chapter 10: Virtual environments and virtual patients in healthcare

Table 10.1 Virtual patient (VP) framework

Chapter 13: The value of professional societies to the healthcare simulation community of practice

Table 13.1 Cycle one – immediate value: indicators of interactions

Table 13.2 Cycle Two – Potential (future) value: Knowledge capital

Table 13.3 Cycle Three – Applied value: Indicators of changes in practice

Table 13.4 Cycle Four – Performance improvement indicators

Table 13.5 Cycle Five – Reflection on what is success for the community

Chapter 17: Teamwork and healthcare simulation

Table 17.1 Some useful communication behaviours

Table 17.2 Teamwork measurement tools

Chapter 18: Designing simulation-based learning activities: A systematic approach

Table 18.1 Observational rating form

Chapter 19: Facilitating healthcare simulations

Table 19.1 Strategies for planning and delivering simulation for large student cohorts

Chapter 21: Debriefing: The state of the art and science in healthcare simulation

Table 21.1 The art of skilful debriefing: Critical components

Chapter 23: Optimizing learning in simulation-based education using video-reflexivity

Table 23.1 Interactions and considerations for educational programmes when using simulation and video-reflexive methods

Chapter 27: From routine to leadership: Extending the role of simulation technicians in Southeast Asia

Table 27.1 STSDP modules

Healthcare Simulation Education

Evidence, Theory and Practice

 

EDITED BY

 

Debra Nestel

The University of Melbourne & Monash University, Victoria, Australia

 

Michelle Kelly

Curtin University, Western Australia, Australia

 

Brian Jolly

University of Newcastle, New South Wales, Australia

 

Marcus Watson

University of Queensland, Queensland, Australia

 

 

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Contributors

Pamela B. Andreatta

PhD EdD CHSE

Institute for Simulation and Training, University of Central Florida College of Medicine, Orlando, FL, USA

Rafidah Atan

MBBS MAnaes FANZCA EDIC GradCertClinSim GradCertHigherEd

Monash University Malaysia, Johor Bahru, Malaysia

Komal Bajaj

MD MHPEd

New York City Health & Hospitals, New York, USA

Margaret Bearman

PhD BComp (Hons) Cert PA

Centre for Research and Assessment in Digital Learning (CRADLE), Deakin University, Victoria, Australia

Adam Cheng

MD FRCPC

Section of Emergency Medicine, Alberta Children's Hospital, Calgary, Canada

Department of Paediatrics, University of Calgary, Calgary, Canada

Ian Civil

CNZM MBE (Mil) KStJ ED MBChB FRACS FACS

Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

Teresa Crea

DCA

University of Canberra – Centre for Creative and Cultural Research, Canberra, Australia

Asia Pacific Simulation Alliance, South Australia & Australian Capital Territory, Australia

Dick Davies

Ambient Performance Ltd, London

Parvati Dev

PhD

Los Altos Hills, California, USA

Chaoyan Dong

PhD MS CHSE

Sengkang Health, Singapore

Mike Eddie

BMBS BMedSci (Hons)

Dorset County Hospital, Dorchester, United Kingdom

Simon Edgar

MBChB FRCA MScEd FAcadMEd

NHS Lothian, Edinburgh, Scotland

Nathan Emmerich

PhD

School of History, Anthropology, Politics and PhilosophyQueen's University Belfast, Northern Ireland, UK

Walter Eppich

MD MEd

Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Illinois, USA

Mick Fielding

BEng PhD

Institute for Intelligent Systems Research and Innovation (IISRI), Deakin University, Australia

Kirsty J. Freeman

BNurs PGradDipMid GradDipEd CHSE

WA Country Health Service, Perth, Australia

Jonathan Gatward

BSc MBChB FRCA DICM FCICM Cert Ed FHEA

Intensive Care Unit, Royal North Shore Hospital, St Leonards, Australia

University of Sydney, Sydney, Australia

Gerard Gormley

MD FRCGP FHEA

School of Medicine, Dentistry and Biomedical Sciences, Centre for Medical Education, Queen's University Belfast, Northern Ireland

The Wilson Centre, University of Toronto, Faculty of Medicine and University Health Network, Toronto, Canada

Suzanne Gough

BSc (Hons) MA Ed (Research) PhD PGC-AP Physiotherapy PFHEA

Department of Health Professions, Manchester Metropolitan University, Manchester, UK

Vincent Grant

MD FRCPC

Departments of Paediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada

Stephen Guinea

PhD

Faculty of Health Sciences, Australian Catholic University, Victoria, Australia

Carrie Hamilton

RGN BSc MSc

Training and Innovation, SimComm Academy, Southampton, UK

Owen Hammett

BN DipIMC (RCSEd) RN

University Hospital Southampton NHS Foundation Trust, Southampton, UK

Fei Han

MD PhD

Tianjin Medical University, Tianjin, China

William L. Heinrichs

MD PhD

Stanford University, California, USA

LY Ho

MBBS MRCS FCSHK FHKAM(Surgery) FRCSEd(Urol)

Queen Elizabeth Hospital, Hospital Authority, Hong Kong SAR

Phil Hyde

BSc BM MRCPCH FRACP FFICM FIMC RCSEd

Southampton Children's Hospital, Southampton, UK

Dorset and Somerset Air Ambulance, Wellington, UK

Brian Jolly

BSc(Hons) MA(Ed) PhD

School of Medicine & Public Health, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia

Michelle Kelly

PhD MN BSc RN

Curtin University, Perth, Australia

Bee Leng Sabrina Koh

RN MHSc(Ed) PGDip(CC) BN CHSE

Sengkang Health, Singapore

Michaela Kolbe

PhD PD

University Hospital Zurich, Simulation Center, Zurich, Switzerland

Kristian Krogh

MD PhD

Department of Anaesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark

Centre for Health Sciences Education, Aarhus University, Aarhus, Denmark

Arunaz Kumar

MBBS MD MRCOG FRANZCOG GCHPE

Faculty of Medicine Nursing and Allied Health, Monash University, Clayton, Australia

Department of Obstetrics and Gynaecology, Monash Health, Clayton, Australia

Hani Lababidi

MD FCCP

Center for Research, Education & Simulation Enhanced Training (CRESENT), King Fahad Medical City, Riyadh, Saudi Arabia

Ralph J. MacKinnon

BSc MBChB FRCA

Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, UK

Kenny Macleod

MScOR

TMN Simulation, Melbourne, Australia

Stuart Marshall

MBChB MHumanFact MRCA FANZCA

Department of Anaesthesia and Perioperative Medicine, Monash University, Victoria, Australia

Alistair May

BSc MBBS FRCA

Scottish Centre for Simulation and Clinical Human Factors, Forth Valley Royal Hospital, Larbert, Scotland

Melissa McCullough

PhD FHEA

School of Medicine, Department of Clinical Medicine, Brighton & Sussex Medical School, Brighton, UK

Cate McIntosh

MBBS FANZCA

Hunter New England Simulation Centre, John Hunter Hospital, Newcastle, Australia

Leigh McKay

RN BAS (Nursing) MPH Cert Intensive Care

NSW Organ & Tissue Donation Service, Kogarah, Australia

Nancy McNaughton

MEd PhD

Centre for Learning Innovation and Simulation, Michener Institute of Education, Wilson Centre for Research in Education, University Health Network, Toronto, Canada

Michael Meguerdichian

MD MHPEd

New York City Health & Hospitals, New York, USA

Michael Moneypenny

BSc(Hons) MBChB(Hons) MD FRCA FHEA

Scottish Centre for Simulation and Clinical Human Factors, Forth Valley Royal Hospital, Larbert, Scotland

Robert Moody

St. Vincents Hospital, Melbourne, Australia

Saeid Nahavandi

BSc (Hons) MSc PhD

Institute for Intelligent Systems Research and Innovation (IISRI), Deakin University, Australia

Zoran Najdovski

BEng PhD

Institute for Intelligent Systems Research and Innovation (IISRI), Deakin University, Australia

Debra Nestel

PhD FAcadMEd CHSE-A

Department of Surgery, Melbourne Medical School, Melbourne, Australia

Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Melbourne, Australia

Faculty of Medicine, Nursing & Health Sciences, Monash University, Victoria, Australia

George Ng

MBBS MRCP FHKCP FHKAM(Medicine) FCICM MPH

Queen Elizabeth Hospital, Hospital Authority, Hong Kong SAR

Harry Owen

MB BCh MD FANZCA

School of Medicine, Flinders University, Adelaide, Australia

Richard Page

BMedSci MBBS FRACS (Orth) FAOrthA

School of Medicine, Faculty of Health, Deakin University, Australia

Naganathan

MBBS FRCPI AM

Monash University Malaysia, Johor Bahru, Johor

Jessica Pohlman

MPA MEd

New York City Health & Hospitals, New York, USA

Kate Pryde

BMedSci BMBS MRCPCH

Southampton Children's Hospital, Southampton, UK

Jill Sanko

PhD MS ARNP CHSE-A

University of Miami, School of Nursing and Health Studies, Coral Gables, FL, USA

Taylor Sawyer

DO MEd CHSE-A

Seattle Children's Hospital, Seattle, WA, USA

Eric So

MBBS FHKCA FHKAM(Anaesthesiology) BSc (Biomedical Science) PGDipEcho

Queen Elizabeth Hospital, Hospital Authority, Hong Kong SAR

Suneet Sood

MBBS MS MAMS

Monash University Malaysia, Johor Bahru, Malaysia

Kim Sykes

MBChB DCH MRCPCH FFICM

Southampton Children's Hospital, Southampton, UK

Katie Walker

RN MBA

New York City Health & Hospitals, New York, USA

Marcus Watson

PhD

School of Medicine and School of Psychology, University of Queensland, Queensland, Australia

Matthew Watson

BEng PhD

Institute for Intelligent Systems Research and Innovation (IISRI), Deakin University, Australia

Lei Wei

BEng PhD

Institute for Intelligent Systems Research and Innovation (IISRI), Deakin University, Australia

Jenny Weller

MD MClinEd MBBS FANZCA FRCA

Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand

Auckland City Hospital, Auckland, New Zealand

Nor'azim Mohd Yunos

MBBS MAnaes EDIC GradCertHigherEd

Monash University Malaysia, Johor Bahru, Malaysia

Hailing Zhou

BEng PhD

Institute for Intelligent Systems Research and Innovation (IISRI), Deakin University, Australia

Foreword

The old English proverb ‘You can’t know where you're going until you know where you've been' rings true with many innovations and developments that have the potential to alter the way we think about how we educate and work. The use of simulation in healthcare education is not a new method, but its adoption and rate of innovation have been rapid in recent years in Australia and worldwide. This has been supported through a range of funding opportunities, training initiatives and, more importantly, through recognition by governments and the World Health Organization of the importance that simulation can have in providing safe and efficient healthcare services. As a simulation community we continue to strive for new ways to incorporate simulation, technology and innovation into our education to improve patient safety and to train clinicians to become acutely aware of the influence of human factors on performance.

Simulation needs to become central to education and improvement processes in an effort to provide a more safety-conscious environment. To assist in this, work is continually being undertaken to make explicit the underpinning theory and application of simulation in the healthcare sector. Researchers, educators and clinicians alike are working together to provide evidence to support current practices in healthcare.

The challenge is to build on the work already undertaken in health and broader disciplines to develop a robust programme of education and research with the central premise of improvement – that is, the safer delivery of healthcare and higher-quality education and training. This book assists the simulation community in understanding the successes and the complexities of simulation-based education in the context of healthcare.

The range of chapters in this book will help readers gain a systematic understanding of the theory and application of simulation. The book offers a fantastic opportunity to make a clear connection between the underlying rationale for the use of simulation and what it looks like when applied. Although the authors offer chapters on educational theory, the elements of simulation practice and contemporary issues in simulation, they have taken a new and critical approach to these topics. The book goes beyond the healthcare sector to help inform our practices. It also contains examples of innovations from around the world that have emerged from specific challenges that each author has experienced in their simulation practice, providing us all with opportunities to learn.

This text will prove an excellent resource for those at any level of experience. It is a valuable reference that can be revisited to reflect on what is known in order to know how to move forward.

Robert P. O'BrienChair, Australian Society for Simulation in Healthcare (ASSH)Clinical Education FellowMelbourne Medical SchoolUniversity of Melbourne

Acknowledgements

We acknowledge the contributions of the following colleagues:

Fernando Bello, Peter Brooks, Roberta Brown, Chris Browne, Dylan Campher, Chris Christophi, John Collins, Jane Dacre, Stephen Duckett, Rosalind Elliott, Richard Fielding, Brendan Flanagan, Carol Goldstein, Carolyn Hayes, Robert Herkes, Jane Kidd, Roger Kneebone, Ellie McCann, Liz Molloy, NSW Organ and Tissue Donation Service, Stephanie O'Regan, Lin Perry, Julie Potter, Ray Raper, Adam Roshan, Peter Saul, Myra Sgorbini, Patsy Stark, Robyn Tamblyn, UTS: Health Laboratory Staff, UTS: Health Simulation Technicians, Leonie Watterson and Christopher Williams.

In memory of Adelle Collins, who provided project support to form the Australian Society for Simulation in Healthcare.

Debra Nestel, Michelle Kelly, Brian Jolly, Marcus Watson

Section I

Introduction

Chapter 1An introduction to healthcare simulation

Debra Nestel and Michelle Kelly

Key Messages

Healthcare simulation plays a critical role in patient safety.

There are benefits of integrating simulation in all phases of education and training of individuals involved in the provision of healthcare.

Although simulation modalities are diverse, there appear to be commonalities in designing for learning using simulation.

The focus of this book is on simulation as an educational method.

Overview

This chapter introduces essential concepts for simulation-based education (SBE) in healthcare. The role of patient safety as an endpoint for many healthcare simulation practices is highlighted. The chapter also orientates readers to the book. There are six sections, this chapter being the first, the second on theoretical perspectives and frameworks, the third on contemporary issues, the fourth on elements of simulation practice, the fifth on innovations in simulation and, finally, the sixth, crystal ball gazing 20 years from now. We invite readers to work through the book sequentially. However, it is also designed so that each section and chapter can be reviewed independently.

Introduction

Simulation offers an important route to safer care for patients and needs to be more fully integrated into the health service

.

Sir Liam Donaldson (2009)

In 2009, the Chief Medical Officer in the United Kingdom, Sir Liam Donaldson, wrote that simulation was one of the top priorities of the health services for the next decade [1]. He emphasized the role of simulation in rehearsal for emergency situations, for the development of teamwork and for learning psychomotor skills in settings and at times that do not place patients at risk. He also questioned the logic of charging clinicians to undertake training to make their practice safer. Although progress has been made in some areas, much remains to be done. In this book we share some of these advances, offer guidance in others and explore new ideas and practices.

Professor David Gaba, a pioneer in healthcare simulation, is widely quoted for the following definition: ‘Simulation is a technique – not a technology – to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner’ [2]. This definition sits well in the educational context for which it was developed. Like Donaldson, Gaba argues for integrated training approaches where ‘clinical personnel, teams, and systems should undergo continual systematic training, rehearsal, performance assessment and refinement in their practice’ [2].

Most healthcare simulation has patient safety as its ultimate goal. The drivers for SBE are well reported and include the expanding numbers of health professional students and clinicians balanced with constraints on work time. There is a shift to competency-based education and growing evidence supporting SBE as a strategic instructional approach [3, 4]. Healthcare simulation has a long history that includes images, layered transparencies, tactile models and simulated (standardized) patients [5–7]. Developments in computer-driven technologies such as task trainers, mannequin simulators and virtual environments have increased access to SBE for all health professions. New modalities are developing and blending and refinement of existing ones are occurring. To facilitate SBE, health services and academic institutions around the world have invested in infrastructure in the form of skills labs, simulated clinical settings and mobile training spaces [4]. Faculty development programmes have emerged to support the quality of simulation educational practices [8, 9]. There is a vibrant research community, witnessed by the proliferation of healthcare simulation–oriented scholarly journals and publications.

Since the visions of Donaldson and Gaba, professional and regulatory organizations have begun to accept time spent in SBE as a proxy for some clinical placements [10, 11] and to provide credentialing for simulation-based operative skills [12]. SBE has also emerged as a valuable approach for preparing students across the health disciplines for upcoming clinical placements and for supporting the development of effective interprofessional practice and respectful team-based cultures.

Healthcare simulation also has limitations and information on these is shared across the book. Assumptions are often made about learning in simulation being safe. Although it is patient safe, it is not necessarily safe for participants. High levels of stress, anxiety, different power relationships and the same sorts of physical risks of working in a clinical setting may all be present during SBE. Clinician safety is essential and in this educational context largely refers to the creation of a safe learning environment in which clinicians (and students) can learn and/or improve their practice without psychological and/or physical harm.

Origins of this book

When in the role of Chair of the Australian Society for Simulation in Healthcare (ASSH), one of the editors (DN), in conversation with the Chair Elect (MK), reflected on the extraordinary contribution of the Society's members to the Australian and international healthcare simulation communities, especially offerings showcased annually at the SimHealth conference [13]. Acknowledging this contribution, we proposed a book that would be jointly edited by four consecutive Chairs of the ASSH. This book is the product of that conversation. It is intended to be a valuable resource for simulation educators, technicians, simulated participants and administrators. However, it is likely to have a wider reach in two directions: to those interested in patient safety, policy and governance of healthcare professionals; and to those interested in educational and training methods.

Editors and authors

The editors all hold academic appointments and work to varying degrees in healthcare simulation education and research. Although many of the authors are very experienced researchers, the common thread is that they all use simulation in their practices. Contributions are truly international, with authors' current workplaces located in Australia, Canada, China, Denmark, Hong Kong, Ireland, Malaysia, New Zealand, Saudi Arabia, Singapore, Switzerland, the United Kingdom and the United States.

Structure of the book

The book is divided into six sections. The first consists of this introduction. The remaining sections lightly hold an exciting and thoughtful range of topics. We use the term lightly because inevitably there is overlap between sections. For example, Emmerich et al.'s contribution on the ethics of simulation practice (Chapter 16) would sit well within the sections on contemporary issues and elements of simulation practice, but we have located it in the latter as we envisage it will increasingly become core to any SBE.

Theoretical perspectives in healthcare simulation

The second section addresses theoretical perspectives in healthcare simulation. Bearman et al. write: ‘Theories can be considered coherent frameworks of ideas, which inform learning and other simulation practices’ (Chapter 2). Frameworks or structures help organize, situate and make meaning, so are an obvious way to start a book. We then look to the past to make sense of current healthcare simulation practices. In Chapter 1, Owen is clear that we have not leveraged the learning of pioneers in healthcare simulation. If so, ‘we would not have had to reinvent the tools and rediscover the value of it in education and training’. Centuries-old simulation-based curricula have gone unnoticed. We then shift to a discussion of the contested notion of realism in simulation by Nestel et al. (Chapter 4). Synonyms of realism are presented and the concept considered outside of healthcare. The authors then place realism against meaningfulness, focusing on educational goals rather than aspiring to heightened realism. The section closes with an alternative structure from a social science framework of micro, meso and macro levels, first applied to healthcare simulation by Arora and Sevdalis [14]. This framework shifts the focus of much educational work at the micro level to opportunities at meso and macro levels. InChapter 5, Watson shares several examples from his practice to illustrate this framework.

Contemporary issues in healthcare simulation

The third section explores contemporary issues in healthcare simulation. Nestel and Kelly describe research agendas and programmes of research in healthcare simulation (Chapter 6). They draw on work from several simulation or discipline-specific communities where agendas provide strategic direction. In Chapter 7, Nestel et al. use the overarching term simulated participants to refer to various roles that individuals may be asked to portray in scenarios (e.g. patients, relatives, healthcare professionals etc.). They describe ways in which simulated participants contribute to healthcare simulations and the importance of caring for them. From Crea et al. we are given insights into ways in which narrative arts offer insights to the complexity of clinical practice (Chapter 8).

Wei et al. direct attention to the role of haptics in simulation training, and particularly the benefits of visual-haptic systems in training healthcare professionals (Chapter 9). Heinrichs et al. orientate readers to the expanding role of virtual environments and virtual patients (Chapter 10). Jolly offers guidance on issues of consistency in simulation from a measurement perspective (Chapter 11). Watson looks beyond simulation in healthcare to its application in other industries in an effort to inform our practice (Chapter 12). From Andreatta et al. we learn about the critical role of professional communities in developing simulation practices (Chapter 13) and the related topic of faculty development is addressed by Edgar et al. (Chapter 14). The section closes with a chapter from Bajaj et al. on the role of the simulation centre in programme development and its positioning within the landscape of education and the health service (Chapter 15).

Elements of simulation practice

The fourth section focuses on elements of simulation practice. Ethical practices in education are increasingly being made explicit. Such practices deserve particular attention in healthcare simulation, as we have the ability to manipulate elements, which is in stark contrast to teaching and learning opportunities in the clinical practice setting. Ethical issues relate to learners, faculty and simulators too – especially in the form of simulated patients (and as Nestel et al. in Chapter 7 discuss, are relevant to the broader roles of simulated participants). Emmerich et al. apply four principles of bioethics to SBE and extend considerations to include virtue ethics and the role of building character through simulation (Chapter 16). From Weller and Civil we learn how simulation can support the development of effective teamwork (Chapter 17). Nestel and Gough share basic structures for healthcare simulation practice and draw on those used in a national simulation educator programme, NHET-Sim. Phases of simulation include preparing, briefing, simulation activity, debriefing, reflecting and evaluating (Chapter 18). The next two chapters explore in greater detail elements of these phases. Kelly and Guinea focus on the role of facilitation across each simulation phase and also consider the characteristics of facilitators (Chapter 19). Marshall and McIntosh offer guidance on dealing with unexpected events in simulations (Chapter 20). Finally, Cheng et al. review approaches to debriefing – a cornerstone of effective SBE (Chapter 21). Using evidence and theory, they suggest frameworks that provide structure to this important conversation. We are reminded that debriefing approaches are characterized by particular methods of questioning, flow of discussion, overarching goals and contextualizing learning to clinical practice.

Simulation applied to practice

The fifth section contains ten innovations of simulation practices. Each innovation is drawn from challenges that the authors have faced when introducing or trying to sustain healthcare simulation. The micro, meso and macro framework from Chapter 5 has been used to order the case studies. For example, at a micro level, that of individual behaviours and actions, Kumar and Nestel share experiences of using simulation to enhance safe practices of home birthing in Australia (Chapter 22); Gough describes her experiences of video-reflexivity to amplify learning through simulations (Chapter 23); and Gatward et al. document the outcomes of SBE to augment the national organ and tissue donation requestor training programme (Chapter 24).

At the meso level, from a curriculum perspective, Han writes about his journey in reconfiguring and integrating SBE into a medical degree in China (Chapter 25). Next, Atan et al. provide their collective experience of using simulation to help junior doctors identify critical elements of transporting critically ill patients in Malaysia (Chapter 26). Koh and Dong share their success in creating a programme to extend the role of simulation technicians (Chapter 27). This initiative in Singapore and Malaysia has led to increased job satisfaction and retention and continuity of simulation centre operations.

Finally, we feature four macro-level initiatives that focus on the organizational or systems level of healthcare practice and delivery. Labibidi offers insights into the challenges of planning simulation for a unique healthcare facility in Saudi Arabia – the King Fahad Medical City – comprising four hospitals, four specialized medical centres and a Faculty of Medicine (Chapter 28). An integrated approach to simulation was adopted through central governance and funding, which still allows a level of independence in educational content and delivery in separate facilities. So and Ng write about the importance and benefits of establishing partnerships early in the process of developing a new simulation centre (Chapter 29). The example, from Hong Kong, highlights a tripartite relationship with leaders from the simulation centre, the hospital and the broader health authority. The impact of simulation on groups and their interactions is illustrated by Eddie et al., who report on the benefits of testing workflow and patient care processes in a new paediatric emergency department (Chapter 30). And finally, from Macleod and Moody comes a case study from simulation modelling showing how the configuration of space design features can be manipulated to maximize work efficiencies and patient flow (Chapter 31). In summary, these innovations illustrate the diversity of the application of simulation in healthcare contexts.

In the final section we look to the future of healthcare simulation. Crystal ball gazing, we consider directions for practice drawing on the contents of this book and our own experiences. We are enormously grateful to our colleagues for sharing their expertise in healthcare simulation to advance our practices.

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Section II

Theoretical perspectives and frameworks for healthcare simulation

Chapter 2Theories informing healthcare simulation practice

Margaret Bearman, Debra Nestel and Nancy McNaughton

Key Messages

Learning theories are guides rather than prescriptions.

Learning theories align with different ways of understanding the nature of knowledge.

Behaviourism emphasizes the achievement of an external standard through demonstrated behaviours; elements of ‘deliberate practice’ reflect behaviourist principles.

Constructivism is a broad umbrella term for theories concerned with individual and social constructions of knowledge, many with great relevance to simulation-based education.

Critical theory approaches focus outward on society and its effect on simulation practices.

Overview

Theories can be considered coherent frameworks of ideas, which inform learning and other simulation practices. This chapter provides a brief overview of different types of theories, illustrated by selected theorists and examples of application to practice. The first section provides a short overview of behaviourism and some of the key debates, as well as expanding on an additional theory, deliberate practice, which draws from behaviourist principles. The next section starts by describing constructivist approaches associated with theories such as reflective practice, before going on to explore a social learning theory, situated learning. The final section articulates the broad premise of critical theories, before focusing on one theorist, Michel Foucault, and providing an exploration of simulated patient (SP) practice through a critical theory lens. The development of patient-focused simulation is presented as an example of how theory can be applied to develop simulation practice.

Introduction

Ideas about how people learn underpin simulation-based education (SBE) in the health professions. When these ideas are formalized into coherent frameworks, they are referred to as learning theories. Learning theories permit educators to identify teaching approaches that can optimize the opportunity afforded by the simulation encounter, and thereby assist learners to acquire new knowledge or skills. They can be purely conceptual or derived from the rigorous collection of qualitative and quantitative data. Learning theories are not absolute; they guide rather than prescribe. Educators draw on them for different reasons. For example, theories can support the initial educational design such as making decisions about what simulation method to choose and why; they can assist with resolving specific dilemmas such as how to manage underperforming learners; or they can challenge accepted practices such as a longstanding approach to debriefing.

This overview of theories that inform healthcare simulation practice can assist in guiding simulation design, development, implementation and facilitation. It is by no means comprehensive, but gives an indication of both the value and the diversity of theories informing SBE. We provide our perspectives as SBE practitioners, researchers and scholars, noting that this is an area in which there is no definite expert consensus.

Learning theories are often very abstract. Educators may find theory most helpful by considering its value within local professional and environmental contexts. For example, the legacy of Western political domination may seem irrelevant to SBE, but thinking about this in theoretical terms can prompt educators to review whether their simulators and SP represent the skin colour and physical appearance of the local community.

We suggest that learning theories can be aligned with ways of understanding knowledge (epistemology) and reality (ontology). This chapter presents three overlapping categories of learning theories, which align with particular notions of knowledge and reality. Behaviourist learning theories align most easily with worldviews that are concerned with objective truths and measurement. These theories are less concerned with the internal mechanisms of learners, and more with their behaviours, which can be observed. Constructivist theories are focused on the learner's role in learning, while social learning theories extend this to consider the role of the learning environment. Both of these approaches are concordant with a worldview that is concerned with individual and social constructions of knowledge. Finally, critical theories consider the broader questions of society and social behaviours. These are not learning theories per se, but provide valuable lessons on understanding how the broader sociocultural context may influence learning. It is worth noting that there is little consensus on the categorization of learning theories and that educators draw from multiple theories for diverse reasons. We will present some of this complexity in our discussion while maintaining the focus on the practical value of learning theories to SBE.

Behaviourism

Behaviourism, unlike the other categories in this chapter, can be considered a coherent theory as well as a pedagogy. Behaviourism's dominance of the educational literature has waxed and waned over the last 80 years. Its current place in the learning theory landscape is controversial. Some people consider it to be primarily a notion of learning as response to a stimulus, and certainly Ivan Pavlov, a notable historical influence, studied stimulus and response in animals [1]. Rote learning, such as memorizing the sum ‘7 × 8 = 56’, is a simple example of this. In this instance, ‘7 × 8’ is the stimulus and ‘56’ is the learnt response. Behaviourism was once seen as being superseded by a cognitive view of learning [2], but over time discourses about behaviourism have continued to develop. Those who draw on it today distinguish a range of more nuanced features, although they still hold to the basic premise of stimulus and response [1].

We broadly define contemporary behaviourism as those approaches to learning that focus on achieving an external standard that must be achieved through demonstrated behaviours. This aligns with Woollard's view [1] that ‘behaviourism, in terms of learning, considers that it is through modifying behaviour and ensuring learners’ preparedness for learning that the best outcomes will be achieved. Behaviourism embraces a pedagogy built upon precision, rigour, analysis, measurement and outcomes' (p. 22). These notions provide the foundation for many of our historical educational practices. For example, the writing of learning objectives focuses on demonstrable change in behaviours, as proposed by Ralph Tyler in 1949 [3]. Equally, accreditation of learning with its concerns about valid and reliable assessment also aligns with behaviourist principles.

There are some areas where we think behaviourism is most valuable in SBE. In particular, health professional practice is full of simple and complex practices, which should occur automatically without the practitioner thinking deeply about how to complete the tasks as they do them. These activities can be psychomotor skills such as suturing, cognitive tasks such as pattern recognition, or even communication skills, such as always introducing oneself to the patient or healthcare consumer by name. These activities are also often well taught in simulation, due to the emphasis on repetitive practice to ensure automaticity.

McGaghie et al. [4], in their 2011 critical review, noted a number of ‘best practices’ in SBE that draw from behaviourist principles. One of these is deliberate practice, which is presented as an example of a theory with particular relevance to SBE. Deliberate practice was conceptualized by Anders Ericsson, a cognitive psychologist, who sought to understand how elite performers achieved excellence [5]. From this empirical basis, he concluded that a necessary part of excellence was the notion of focused, repetitive practice. He described essential elements: a highly motivated individual can develop expertise through repetitive practice that also involves receiving feedback on performance, goal setting that continuously seeks to extend performance, individual coaching and practice occurring under different conditions. Like many approaches, this is not purely behaviourist in its approach, but there are key elements – ‘well-defined learning objectives’ and ‘rigorous precise measurements’ of demonstrated behaviours [4] – that align with behaviourism. See Box 2.1 for an example of how deliberate practice can be integrated into simulation educational design.

Box 2.1 Theory in Action: Patient-Focused Simulation

Deliberate practice, reflective practice and situated learning were developed in real rather than simulated settings and are appropriated with caution to the world of healthcare simulation. Drawing on these three theories, Roger Kneebone, a surgeon educator, and Debra Nestel, a communications educator, developed the concept of patient-focused simulation for learning procedural skills [11]. Patient-focused simulation involves a learner performing a procedural skill while working with a simulated (standardized) patient (SP) aligned with a task trainer (bench-top simulator). Kneebone and Nestel had noticed that teaching basic procedural skills on a task trainer was effective inasmuch as correct sequencing of psychomotor skills could be observed, but the experience was out of context. When the learner was required to perform the procedure on a patient in a clinical setting, the bench-top simulator experience alone was insufficient because it was not situated. That is, there was little resemblance to the setting in which the learner would be required to practise. Notably, there was no patient, no human interaction. Nestel and Kneebone argued that safe training approaches need to include ways in which learners can integrate complex sets of skills (psychomotor and professional) as they will be required in clinical settings. At a minimum, patient-focused simulation comprised a SP trained to respond as if undergoing the procedure in a simulated clinical setting. The learner in patient-focused simulation was offered the opportunity to perform the whole procedure in simulation and to receive feedback on their performance – from the SP and experienced clinicians and further individual reflection, to make sense of the experience from the learner's perspective. Elements of deliberate practice included motivating individuals, encouraging goal setting, multiple repetitions in different contexts and feedback. From situated learning, patient-focused simulation located the procedural skill in a clinical context with a SP; and from reflective practice, reflection-on-action was adopted, most commonly as facilitated dialogue between the learner, SP and observers after the simulation.

Constructivism and associated social learning theories

Constructivist theories of learning argue that individuals construct knowledge and meaning based on their experiences and ideas. Fosnot [6] claims that educators adopting constructivist theories enable learners to use ‘concrete, contextually meaningful experience through which they can search for patterns, raise their own questions, and construct their own models, concepts, and strategies’ (p. ix). Adopting this stance, educators may be seen to be orienting their role to that of facilitator rather than teacher. Using Sfard's metaphors [7], constructivists sit more comfortably within the metaphor of learning as participation than within that of learning as acquisition. Education is seen as what the learner can learn rather than what the teacher can teach.

Constructivism is an umbrella term for many theories that acknowledge the role of the learner in constructing their own meaning from experiences. Cognitive constructivism respects traditions of cognitivist theories, of acknowledging individuals' characteristics such as their stage of development, motivation, engagement and preferences for learning. Social constructivism emphasizes how understanding and meaning emerge from social encounters. Imagine a simulation educator who has been asked to design an activity for medical students to safely put in a drip (that is, establish a peripheral intravenous infusion, IVI). Adopting a constructivist stance, the educator is likely to use some of the following techniques:

Finding out what other similar procedures students have been learning and how.

Asking students about their relevant knowledge, prior experiences and practices relevant to IVI.

Demonstrating, talking through and inviting questions from students on IVI performed on a task trainer.

Encouraging students to set goals related to performing the IVI.

Providing opportunities for students to perform the IVI on a task trainer.

Providing opportunities for students to observe others performing the IVI on a task trainer and then share their observations.

Providing opportunities for students to receive feedback on their performance on the task trainer from experts and peers.

Promoting students' reflections on their performance of IVI on the task trainer.

Asking students to identify what they found easy and why, and what they found difficult and why.

Discussing how the level of skill experienced by the student on the task trainer may align with performing IVI in a clinical setting.

Discussing the links between IVI and other clinical procedures that students need to be able to perform.

Promoting students' reflections on the feedback offered.

Encouraging students to set goals that enable them to use their learning.

Each of these techniques acknowledges that individuals make sense of designed learning activities in their own way, based on their own ideas, prior experiences and practices. Conversation or dialogue is heavily weighted. The simulation educator's role is to help surface these ideas and experiences, offer new experiences through the designed learning activity, and support students in locating the (new) experiences in their existing knowledge and practice.

Also widely cited in health professions educational literature is the work of Donald Schön [8]. His concepts of reflection-in-action (immediate ‘thinking on your feet’) and reflection-on-action (later analysis of actions in light of outcome, prior experience and new knowledge) characterize ways in which practitioners react to unexpected experiences in their work. Schön argued that practitioners seek to place new and unexpected experiences within a personal framework by identifying similar past experiences and then giving consideration to possible outcomes by selecting new actions. In SBE, reflection-on-action can usually be facilitated by clinicians, teachers or peers. However, reflection-in-action requires an immediate response, especially in time-urgent clinical scenarios. Techniques that simulation educators use such as pause and discuss (stopping the scenario at certain points) enable access to learners' thoughts and feelings and discussion of their proposed actions. Where pause and discuss