Implementation guide for Simulation based learning.


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Implementation guide for Simulation based learning.

  2. 2. The SIMBASE committee This project has been financed with the support of the European Commission. This publication is exclusively the responsibility of its authors and the Commission is notDocument authorised by: responsible for any use that is made of the content of the document.THE MINISTRY FOR HEALTH AND SOCIAL WELFARE OF THE REGIONAL GOVERNMENTOF ANDALUSIA This work is licensed under Creative Commons Reconocimiento-NoComercial- CompartirIgual 3.0. To see a copy of this license, follow this link http://creativecommons.Written by: org/licenses/by-nc-sa/3.0/es/• Teresa Campos García.• Yusnelkis Milanés Guisado Document Title Implementation handbook for simulation and ICT-based learning in training and healthcare centres.With the collaboration of:• Armando Romanos Rodríguez Project Title Promotion of ICTs for improving simulation-based learning in• Carmen de Vicente Guilloto healthcare centres (SIMBASE)• Almudena de la Serna Bazán. Deliverable D4.2 – Implementation handbook for simulation and ICT-based• Mª Jesús Escribano Rivero learning in training and healthcare centresFurther collaboration: Grant agreement 2010-4079 / 001-001IAVANTE: number• Juan Chaves Work package WP 4 –Maximisation of impact and integration of ICT-based• Javier Vásquez Granado Patient Simulation• Iván Herrera Pérez• David Riley Confidentiality status PublicCopyright: © 2013, Consejería de Salud y Bienestar Social y Consorcio de SIMBASEEdited by: Knowledge Innovation Centre (KIC). Malta. Project number -511811-LLP-1-2010—1-ES-KA3-KA3MPSIMBASE committee: Programme: Lifelong Learning Programme1. Consejeria de Salud de la Junta de Andalucia SCJA ES Sub-programme: KA3 ICT2. Laerdal Medical AS LM NO Call for proposals: DG EAC/41/09 Jorge Vilaplana Action: Multilateral projects3. Faculdade de Ciencias de Saude, Unversidad de Beira UDB PT Sub-Action: N/A Miguel Castelo Branco, Isabel Neto4. Fundacion IAVANTE IAV ES David Riley, Javier Vázquez, Iván Herrera5. University of Duisburg-Essen UDE DE Christian Stracke, Tatiana Shamarina-Heidenreich6. National Institute for Quality- and Organizational Development in Healthcare and Medicines GYEMSZI HU Ildikó Szögedi7. Postgraduate Deanery Wales PDW GB James Ansell, Jared Torkington, Neil Warren, Peter Donnelly8. Knowledge Innovation Centre KIC MT Justin Fenech, Anthony Camilleri 02 03
  3. 3. Table of Contents: 1. Justification 07 2. Objectives 09 3. To whom is it directed? 11 4. Production methodology 13 5. Best practises for the integration of simulation into healthcare and training centre learning processes: 17 6. Different learning scenarios 21 7. Steps towards implementation of simulation. 25 References 4204 05
  4. 4. 1Justification At this time there exists an extensive incorporate elements considered as bibliography relating to the use of simulation critical success factors, as well as for the in the training of healthcare professionals, use of ICTs throughout the development, and there is a wide consensus regarding monitoring and evaluation process in order the need for training based on this to ensure maximum impact. methodology as it allows for preparation for real-life situations and, as a result, initiates the process of integration of knowledge with relational and technical skills, thereby ensuring best professional practises and maximum patient safety. Healthcare centres and training providers, however, as well as all other types of professional training centre at all levels (graduate, post-graduate, specialised, or on-going training), need to find the most effective, efficient way of implementing simulation into their learning processes. Only by achieving this will they ensure their contribution to the creation of more meaningful learning methods that are safer for both professionals and patients alike, methods that will result in the greatest possible impact on the organisation and on the healthcare systems themselves. For these reasons, and based on the results of the study performed by the SIMBASE European Project, a proposal has been put forward both for the development of this HANDBOOK TO SIMULATION IMPLEMENTATION in centres that06 07
  5. 5. 2 Objectives General Objective: • Provide recommendations adapted to the particular training stages catered Develop a support tool for the planning and for in the training centres (universities, implementation of simulation in healthcare healthcare centres, etc.) and professional training centres. • Define some of the elements that will allow us to approach the evaluation Specific Objectives: of the transfer and impact of the simulation implementation programme. • Define the steps to be taken for the implementation of an integrated • Define the criteria for the administration simulation programme in the centres. of the required resources. • Provide recommendations for • Incorporate the use of ICTs in all these integrating simulation into professional processes to maximise the impact of healthcare training programmes. our programme.08 09
  6. 6. 3 To whom is it directed? This handbook is directed towards those And finally, in the graduate stage the people within the centres who perform the situation is considerably diverse as role of expert in the design and planning of regards the level of development of learning processes for both students and innovative learning strategies and, in many professionals. faculties, Education Units are beginning to emerge. While it is possible that this role, or reference, does not exist in some centres, This handbook, or catalogue of its existence becomes a necessity if we are recommendations for initiating a to ensure that the training programmes comprehensive programme of simulation constitute a coherent process for implementation, is directed at all those students and professionals alike. mentioned above. In the majority of healthcare centres there is generally an employee who is responsible for the planning and organisation of on- going training of healthcare professionals, and it is they who should ensure that simulation-based training responds to the known quality criteria, depending on the available resources. In training centres for health science specialists (in some countries this refers to the universities, in others, to the universities in collaboration with healthcare centres and, in others still, to the healthcare system itself), there exists the role of guarantor of the combined learning processes and maintenance of accreditation status, and it is they who oversee the securing of specialist status.10 11
  7. 7. 4 Methodology a. Literature review b. Piloting the impact evaluation model of the SIMBASE Project Upon performance of an extensive review of international databases relating to The SIMBASE Project has piloted research on simulation-based medical a simulation-based training impact education, approximately 1300 articles evaluation model which employs both were found, from which the 50 most a diachronic perspective of the entire quoted on an international level were training process based on the ISO model, selected for analysis. Among these as well as the integration of a variety of there are some which stand out for perspectives based on examination of their particular relevance, such as those the variables and tools employed in other published by Issenberg and McGahie impact evaluation models. The models (2005; 1999), Epstein and Ronald selected were specifically those which (2007), Ziv et al. (2003), Bradley (2006), emphasised the critical factors relating etc. Special emphasis was placed on the to the surroundings in which the training analysis of reviews of meta-analytical takes place, the training requirements publications which provide relevant detection methodology, and the culture of information about the best practises and the organisation. critical success factors of simulation as well as possible tendencies in simulation- The constituent committee for this based training up to the year 2020 project comprises many different profiles, (Gaba, 2004; Issenberg and McGahie, providing a polyhedral perspective on 2005; Fessler, 2012, Bradley, 2006 and the problems of implementation and McGahie 2006, 2009, 2010 an 2011). dissemination of this type of learning, a characteristic that has made us more Strategies and recommendations aware of the relevance of these factors. provided by international organisms regarding the quality of training in general Training providers from different training and, in particular, the training of healthcare stages have intervened in this pilot, including professionals, were also reviewed (ISO/ graduate medical students, medical IEC 19796-1; WHO, 2012; WFME, training specialists and professionals 2012, Lindgren and Gordon, 2012; Grant, from on-going nursing training. 2011). Coordination was maintained between an expert training innovation centre and12 13
  8. 8. a public healthcare administration, thelatter providing the perspective of a publichealthcare body, the principle receiver ofhealthcare professionals, and thereforejointly responsible for their training.This handbook has employed quantitativeand qualitative analysis methodologiesof critical success factors selected fromrelevant publications.c. Analysis, information processing,synthesis and drafting of proposals.Following an analysis of the informationgathered from the pilot, in which someof the variables have not been open toexamination with the proposed level of detail,and including the perspectives identified inthe reviewed publications, a committee ofinternational experts has clearly identified agroup of best practises and critical successfactors necessary for a effective, efficientimplementation of simulation as well as thebest methods for employing information andcommunications technologies, which providesupport for our actions providing they arecorrectly focussed. The objective of thishandbook is precisely that - to focus on thesteps that should be taken by a healthcarecentre (as training provider), a university, ora training centre in order to ensure successwith the assistance of ICTs. 14 15
  9. 9. 5 Best practises for the integration of simulation into healthcare and training centre learning processes: It is important to point out that, before • suitable course design directed at the initiating simulation implementation, an learners analysis of the existing learning processes in the centre in question should be • team-based learning design, bringing performed. The reason being that the the model closer to the reality of the aim of this handbook is to use simulation job implementation as an additional element in the evolution towards a new paradigm or, • the guarantee of learner-directed where applicable, the promotion of existing feedback best practises which allow for orientation of • the offer of staged deliberate practise the training activities towards achievement by encouraging repetition and of the greatest possible impact. retention of competencies • integration of simulated activities Quality standards in the learning, into the students’ training itinerary education and training process. and curriculum, as well as that of the Standards for the use of specialists. simulation • particular emphasis and attention The conclusions reached on the basis of our paid to suitable performance of the efforts lead us to propose that the following role of the instructor and suitable factors be taken into consideration for formation and training based on the an efficient, effective use of healthcare competencies specifically required to simulation: perform the role • the healthcare requirements, which • the search for balance between we wish to attend to with greater the fidelity of the scenario and the competence available ICT resources • the available resources of the centre, or And, finally, ensuring the acquisition system, including possible collaborators and retention of the skill being trained and, above all, its transfer to clinical16 17
  10. 10. practise, which requires that elements of The actors and development of time and place for their professionals earlier. This demand may also be seen asorganisation and educational context be the implementation. to practise. The director of a university an opportunity to integrate competencytaken into account. In order to achieve all department responsible for a specific evaluation into the learning process.this, we need to measure the results in We are all aware that, for the realisation knowledge area will incorporate simulationterms of health. of any project, the most important factor is practise as part of the curriculum and will This evaluation, coupled with the creation of the people involved in providing motivation afford it suitable import in the evaluation. scenarios for the performance of deliberate for the project. There is little doubt that practises, also allows us to acquaintThe impact of professional training this depends on the level of commitment Therefore, we should bear in mind the ourselves further with all the elements thatin terms of health to the learning process and whether or areas in which the professionals carry intervene in good professional practises not this is coherent with the rest of their out their duties and the role played by in real-life situations and with patients,We must insist on the idea that, in order activities. This is true for organisers, their respective managers when required and transforms simulation into a powerfulto guarantee impact, we must have teachers, instructors and students alike. to facilitate translational elements to tool for innovation and research intocontrol over the aspects relating to the the workplace and, as a result, facilitate human behaviour for advancement in thedetection of training requirements, and Therefore, we must consider it good the possibility of incorporating hours of education of healthcare sciences.whether or not these are in line with what practise to identify the various actors who simulation-based learning into the servicethe healthcare system requires in order to appear during a learning process, as well timetable. It is often possible to put this For the healthcare system and itsprovide the best response to healthcare as the elements that directly affect them into practise using the same materials professionals, these may also provide aneeds. and which, as critical success factors, and scenarios as are available in the usual source of technological innovation, as the must be taken into consideration. If we workplace. In the case of educational healthcare professionals themselves areOn many occasions a particular bear this in mind at the time of planning, centres, the incorporation of simulation the best qualified to detect the necessityhealthcare requirement which gives designing or implementing an activity, prior to practise with real patients is a key for new simulators, and may also be therise to the performance of a training whether it involves simulation or not, we success factor and requires a high level of source of possible technological proposals.activity designed to develop a specific can improve the results. coordination among the trainers. This provides a great opportunity for theprofessional competency gets lost during proposal and dissemination of designthe planning and design processes. Aside from the simulation monitor and the In this way, the final actors to share prototypes if the centre, and the systemWe must emphasise the importance of student, we must take into consideration the learning space, namely, instructor itself, are prepared for it and are willing todirect effect, prior identification of health the knowledge area teacher in order and students, can function with all the provide suitable stimuli and promotion.indicators, and continual consideration of to achieve the necessary curricular elements in their favour.the final objective of the learning process, integration as well as to define theas this will surely help us to find more direct remainder of the levels of responsibilityroutes that will free us of unnecessary within the training centre. Simulation as a resource forbaggage and focus our efforts on the most promoting innovation andefficient way to achieve our objective. This On another level, the clinical service excellence in education.exercise alone greatly strengthens the managers must consider the activityalignment of the training activity with real- as both necessary and pertinent, which Correct use of simulation methodologylife requirements, which is precisely the requires, on the one hand, recognition demands its incorporation as a furtherrevolution we are looking for by the director and the centre where the step in the learning process of the activity is to take place and, on the other professionals prior to their coming into hand, their commitment to providing contact with patients, as we mentioned 18 19
  11. 11. 6 Different learning scenarios a. Medical and nursing faculties We also know that, when applied correctly, and any other training centres both simulation and patient contact are important motivators for the students, that provide healthcare graduate and that motivation is a fundamental qualifications. ingredient of effective learning. For this reason simulation should be strategically Simulation, as we have said, must be incorporated into the existing project for integrated into the learning processes the centre. from the beginning of the curriculum. Faculties must invest in specific simulators of greater or lesser complexity, b. Accredited healthcare centres a procedure that requires knowledge of the full potential of this methodology. and/or universities for the The faculties should also make the most training of healthcare science of the opportunity to create learning specialists scenarios which allow for the training of the maximum number of possible With regard to specialist training, the competencies by integrating the training explicit incorporation of deliberate-practise- of several of these simultaneously. based training before approaching certain activities with the patients, particularly We are aware that, for simulated where these may be at risk, is of paramount activities, students require some prior importance. knowledge, and we also know that this methodology permits training of attitudes It is fundamental, therefore, to bear in mind, and other emotional aspects and that first of all, that we must have a training these influence behaviour in real-life programme that defines the competencies environments. For this reason it is that are to be developed by the specialists convenient to incorporate simulation from in training before they receive their the beginning of the training in the same qualification. Secondly, that this programme way that it is important to incorporate should include competencies that should be contact with patients from the beginning trained through simulation. of the graduate programmes. Thirdly, in healthcare centres that are accredited for specialist training, there must20 21
  12. 12. be work spaces available for the performance time required for these practises. For thisof deliberate practises or simulations and reason, the on-going training programmesthese aspects must be incorporated into must be consistent with these requirementsthe qualification requirements. In many and should employ a methodology that willcases, these may simply refer to the same guarantee their effectiveness and spaces, or even the same resources,when used outside the normal activity Suitable training with simulators should betimetable of the centre, or service. For an element that is taken into considerationthe training of more technically complex in professional recognition, in other words,competencies, agreements may be made in their qualifications, or accreditations, aswith other centres in order to make the best well as in their careers. In any case, theof the significant investments made, where centres where the professionals carry outpossible. their duties should bear this in mind. Similarly, training providers should offerc. Healthcare centres for on-going training which, where required, includesprofessional training. simulation, particularly when this is difficult to provide in healthcare centres due to theOver the course of a professional career, significant investment required. They shouldsuitable orientation in on-going training also design activities that bear in mind on-is essential for maintenance of the going training in the healthcare centres. Allcompetencies required for the performance this requires the configuration of resourceof their duties and for their professional networks that allow the application of adevelopment. scaled economy to the training, making it more accessible to the professionals,If they wish to take into consideration centres and healthcare systems that arethe content of the previous section, obliged to bear the financial burden of thehealthcare centres must know, or define, training.the competencies required by theirprofessionals in order that they may carryout their duties. They must also know whichof these require performance of deliberatepractises with a certain frequency.This knowledge should be reflected in theorganisation of services, resources andwork spaces, so that the centre, in as far aspossible, may provide the work space and 22 23
  13. 13. 7 Steps towards implementation of simulation. The steps to be taken (listed below) are 1. Orientation towards healthcare conditioned by critical success factors requirements selected by the SIMBASE Project for the implementation and promotion of Aspects to be taken into consideration: deliberate practises. As a differentiating characteristic, the following factors, listed in • Who, or what organism, decides publications, have been added: orientation on the Training Programmes in towards healthcare requirements, design the centre? Is there is a unit which of the training activity, organisational and specialises in medical or healthcare educational context and administration of science training and proposes the available resources. training models for the centre? If this is so, it may greatly favour the implementation strategy. Critical success factors • Are the programmes are based on 1. Orientation towards healthcare competencies and the definition of requirements best practises? 2. Integration into the curriculum 3. Available resources • How are the programmes aligned 4. Design of the training activity with the community healthcare 5. Fidelity in Simulation requirements? 6. Team-based learning 7. Feedback • How are the required competencies, 8. Deliberate practises which are incorporated into the 9. Role of the instructor and training training programmes, defined? roles 10. Skills acquisition and retention The identification of the health, or care 11. Translation to practise indicators in the workplace are important 12. Measurement of results and may provide information about the 13. Organisational and educational context success of the training programme. Revision of the existing information systems in the professionals’ workplace is recommended in order to avoid, as24 25
  14. 14. far as possible, the development of new • Identify representative clinical is due to the fact that the training plans methods and clinical practises in order tosystems, unless they are considered professionals. established these days are based precisely maximise learning and ensure retentionnecessary. In this aspect, the use of on that, purely technical training that does of the competencies being trained.ICTs may facilitate access to numerous not include skills training which, up until Furthermore, actions should be developedinformation sources. 2. Integration into the Curriculum now, was obtained in the hospital with the during the simulation training sessions patients themselves.” to strengthen the correlation with theirFinally, any training programme in general, Both the publications consulted and courses or training plans.and simulation programmes in particular, our experience in this project serve Simulation may be used to provideshould be able to rely on the assistance to demonstrate that simulation in the synthesis to the training experience, Actions:of representative clinical healthcare context of medical education is a highly whereby the students apply theirprofessionals, as these may facilitate effective method of attaining learning knowledge, develop their skills, and acquire • Encourage questions from thethe orientation towards the healthcare objectives. It is an excellent complement the experience necessary to complete students relating to their individualrequirements. to real-life clinical practises, though not the training programme. For this reason, requirements and their levels of a substitute for them, given that real- simulation based on deliberate practises knowledge, skills and experience priorActions: life experience possesses aspects that should be an educational characteristic to the training session. simulated environments cannot hope to that is carefully integrated alongside other• Identify the specific healthcare reproduce. educational events, clinical experiences, • Allow the instructors to make small requirements where training may problem-based learning, and others. As changes to the course material based result in change. Based on the SIMBASE experience, it one of the project experts commented “the on the requirements of the students, is proposed that courses be planned, students may be introduced to simulation or where necessary for the group as• Identify information systems and outlined and developed bearing in mind a whole. at an early stage of their curriculum as a health indicators which we intend to the context of the curriculum of the means of evaluating their level of practise modify, either directly or indirectly. healthcare professional in question and • Send information about the training and their psychomotor skills and, as the as a complementary aspect to clinical session to the educational centres• Diagnose to what extent the training programme progresses, they may get education. Curricular integration is one (university, those responsible for action is relevant to the organisation involved in more complex scenarios as the of the characteristics of high fidelity specialised training, healthcare and its context. complexity of both their knowledge and the simulation (Vásquez-Mata, 2009; centres), with references to the competencies to be developed during the McGahie 2010; Riancho, 2012; McGahie educational context.• Identify the competencies to be programme increases.” et al. 2009). trained, according to the identified • Get the tutors involved in all the requirements. While it is true that learning objectives Regarding the necessity of including course content. should, from our perspective, stem from simulation in training plans, one of the identified requirements, the design team,• Design the training action objectives Achieving suitable curricular integration of experts consulted on the Spanish course when developing the activity, should link and the possible results to be obtained the simulation programmes may ensure considers that “...From the moment it with the existing training timetable and depending on these requirements successful integration of simulation into the they leave the faculty, they receive make it as flexible as possible. A prior and the relevance of simulation- the organisational strategy and, as a purely theoretical training and, therefore, diagnosis should be performed to evaluate based training programmes for the result, into the educational strategy. though it is important to have theoretical the level to which existing programmes relevant agents of the healthcare knowledge, they do not have the skills are complemented by other educational system. necessary to perform the techniques. This 26 27
  15. 15. In any case, the required investment may Actions: be made using efficient models, bearing in mind the following factors: • Identify the required resources: technological resources and suitable First of all, the use of e-learning platforms simulation rooms, depending on for all activities that may be performed the number of students, groups, or online, reserving onsite sessions for when instructors. strictly necessary. • Organise learning into small groups. Secondly, the provision of learning spaces Under no circumstances should there and scenarios within the workplace, where be more than five students together possible, thereby saving on unnecessary in the simulation scenario. costs in time and travel. • Identify the communications tool In third place, the search for synergies and the e-learning phase platform with other centres in the region so that, (materials, forums, chats, etc.) that with the same expenditure in time and will make the best use of the students’ travel, the training possibilities may be time. extended, particularly those that require greater investment and generally have • Make use of accredited websites in reduced attendance. order to access cases, incorporating the possibility of linking these to the In fourth place, it is possible to begin available simulators. with competencies that are more widely3. Available Resources previously identified requirements and needed and that do not require expensive, • Identify the measurement indicators should rely on the support of the centres, highly complex simulators. Clear examples that allow for posterior analysis ofThe implementation of simulation has or training units, and the simulation of this are the simulators for training cost/benefits, sources and recoverya technical component and being able models should be adapted according to basic or advanced cardiopulmonary methods. For this purpose we shouldto rely on all the required resources these requirements. resuscitation, or the primary training make use of platforms that allow us tomay influence the level of satisfaction phase for endoscopic surgery using register all the information requiredof both students and teachers and, as The principle limitations for generalised pelvitrainers. for general analysis and, in particular,a result, in the success of the learning application, with respect to resources and for analysis of cost/benefits andprocess. The training programme, the benefits of simulation, are the costs And, in fifth place, any investment should impact.therefore, should have suitable technical inherent in the implementation, which are be preceded by the guarantee of themeans at its disposal, namely, simulation higher than those of other methodologies. availability of suitably trained instructorsrooms, instructors and the simulators Our results have shown that, in general, and an organisation that will provide thethemselves. simulation is expensive, but its benefits necessary time and work space for use by are far greater and, therefore, more the professionals.The availability of resources should than justify the investment, a fact that isbe orientated in accordance with the reflected in a variety of publications. 28 29
  16. 16. 4. Design of the training activity 5. Simulation fidelity As many authors say, the quality of simulation programmes depends moreA script and design for the training In our experience it has been demonstrated on educational integration in the centre,sessions are required. These should that high fidelity simulation has been very or on the programme being in line withclearly reflect the situation we are trying well employed and highly regarded during the teachers and the context of theto reproduce for the performance of this pilot. The simulation technologies have organisation, than with the level of fidelitydeliberate practises. been selected according to the different and the type of simulator (K.E.Littlewood learning scenarios and objectives. For 2011), and that simulation is used toThe objectives and required results training in surgical and primary care measure the results of simulated learningshould be precisely defined. This requires competencies, part-task trainers and but, in the end, what we really need toidentification of the competencies to video analysis have been used and, in gauge is behaviour in real-life situationsbe acquired according to the different other cases where we are dealing with and results with the patients.learning domains in the simulation highly complex operations, the use of(cognitive, psychomotor, or affective). virtual simulation has received very positive evaluations. 6. Team-based learningThe course script should be adapted tothe student profiles and to the previously Furthermore, there are many authors These days, group learning of theidentified requirements. It should be clear (Issenberg et al. 2005; McGahie et healthcare team is recognised as oneto the student, or professional, that this al. 2010) who are of the opinion that of the objectives to be attained withinpractise is just another element in their one of the best practises in simulation the educational framework of futureeducational strategy, in their timetable. implementation is to look for High fidelity healthcare professionals. These people simulation, as the simulation technology work together as a team and areActions: should come as close as possible to the interdependent in all their activities and, reality of clinical practise. as a result, their affinity ensures success• Identify the student profiles, their in healthcare. This is a competency, needs We need to consider precisely what therefore, that should be incorporated competencies and objectives we wish to into the training programmes and should• Clearly identify the competencies to achieve in order to find a balance between be trained via simulation in conjunction be trained the required resources and the fidelity of with other technical competencies.• Define precise objectives for the the scenario. training activity In our experience, not only is it one of the While suitable technological resources competencies that has been identified• Identify the principle elements that are a requirement, as Scalese (2008) as imperative, it is also one that could characterise the deliberate practise states, decisions regarding the use of possibly benefit from its own development and scenario to be used simulation technologies must take into through simulation and become a factor consideration the connection between that encourages participation in the• Define the evaluation methodology for learning objectives and tools. training activity, thereby increasing the the results of the learning efficiency of the activity. 30 31
  17. 17. This is one way of making an effort to 7. Feedback Actions: and group levels, establishing the bestfacilitate transfer to clinical practise and moments for one or the patient care. Healthcare is a “team Feedback consists of the application of a • Incorporate reflection as a diagnosticsport”, and this incorporation should allow variety of methods, sources and means of tool to analyse both the strong points • Try to reduce the time between task-us to provide training in the development increasing the impact on the participants. of the group as well as the aspects performance and feedback as muchof common objectives and help clarify the requiring improvement. as possible.roles played by each member of the team. Our experience has demonstrated theIt helps raise awareness of the situation effectiveness of the use of a variety • Incorporate reflection into training • Store all possible results and establishedand of the importance of leadership and of feedback techniques specifically as a complementary element to objectives during the reflection phasemutual support, all of which is reflected in orientated towards improving the clinical feedback, allowing the learning to in order to facilitate future analysis inthe patients’ results. performance of the student through the extend beyond a purely mechanical simulation-based learning programmes use of different strategies in conjunction exercise. within the organisation.The fundamental message is that team with performance of the should be incorporated throughout • Ensure that the organisationthe training cycle as a complement to the The reflection phase is of vital importance takes into consideration a learning 8. Deliberate practiseindividual training needs, and will provide us within the feedback strategy, and should environment which is suitable for the be encouraged in order to obtain improved reflection (debriefing) phase. Deliberate practise is an importantwith opportunities to practise teamwork learning and performance results. The property which should characteriseskills in simulation environments and, standards and suitable methods should • Ensure that the team participants are simulation sessions in order to train, refinesubsequently, transfer these to patient be established for each of the expected relaxed, confident and comfortable and conserve acquired knowledge, skillscare. results. during the reflection phase. and attitudes through the promotion ofActions: repetition and actions designed for on- In short, simulation-based learning • Encourage teamwork during critical going improvement of these competencies.• Identify teamwork as a competency should be implemented with a focus analysis, describing beforehand the Deliberate practise using simulation to be trained and use it as one of on an overall feedback strategy that type of interactions expected. has been shown to improve medical the central points in content training includes reflection. Feedback is an performance in many surgical specialities. • Focus on specific performance during the simulation implementation. essential aspect that should be taken indicators during feedback to Actions which ensure deliberate practise into consideration from the design• On completion of the training, ensure maximum performance and through simulation: phase of the activity and in relation to emphasise the influence of teamwork subsequent transfer. the scenario, the learning environment as an influential factor in transfer to and the expected results. Research • Ensure dissemination of the message • Provide feedback results and that, in order to conserve the skills clinical practise. results have demonstrated that integrate them into strategies for learned in the primary stages, the simulation-based training with a focus training and on-going improvement of• Encourage teamwork during the on feedback produces significantly students must continue with simulator feedback and reflection (debriefing) the acquired competencies practise in the future. better performance than a strategy that phases. does not include feedback. This focus • Provide suitable complementary • Ensure that the feedback is updated with maximises transfer to clinical practise. activities for feedback on both individual new techniques to provide a response 32 33
  18. 18. retention of the trained competencies. What is certain is that, bearing in mind the role of the instructor in simulated According to Riancho et al. (2012), learning contexts, it is crucial that they students who are offered the opportunity play the role of facilitator, guide and to get involved in deliberate and repetitive motivator for the students in order to practise with simulation appear to acquire maximise their interaction, learning and the necessary skills more quickly than retention. The most important factor, those who are exposed to routine clinical however, is to ensure that both feedback situations with real-life patients. and reflection (debriefing) occur. Investment in instructor training is one of 9. The role of the instructor and the questions that should be taken into training roles consideration in order to ensure greater benefits and results from simulation- McGahie (2010) summarises that, with based learning. In this regard, Riancho regard to simulation instructor training, (2012) considers instructor training to clinical experience alone is no guarantee be a key element requiring investment, of the effectiveness of the simulation and that this investment should form instructor, and neither is it a requirement part of the implementation plan budget. that instructors and students come from the same healthcare area or even, it Actions: follows, from the same speciality. 1 Select instructors with prior From the experience of our study we experience in simulation can deduce the need for instructors to changing patient requirements, the • Introduce a learning method based on to have experience in simulation and, 2 Define the requisite general principles of current education, and simulation problems. with respect to instructor selection, competencies of the instructor best practises. some guarantee of prior experience in • Maintain a high level of motivation in the simulation, as a complimentary element 3 Facilitate education and training of• Once the course has been completed, students. to clinical experience, would appear to be these provide opportunities for practise a requirement. at all times and ensure that these • Encourage deliberate practise through opportunities continue to be available. precise definition of the learning and In the SIMBASE experience, however, Practise time is always short. task objectives. we have not been able to demonstrate the need for accredited experience in• Use an analysis and feedback process Deliberate practise is a factor that is very the precise simulation devices that will and keep a register of the sessions. much sought after by the students, and be used in the particular sessions, or its relation to educational integration and whether or not more specific, or more• Ask the students’ opinion about the training programmes must be coherent general skills are required. course. in order to ensure development and 34 35
  19. 19. 10. Skills acquisition and retention and, in the long term, maximise the methods that do not include simulation. In • Evaluate the inclusion of the different effects of the training. the surgical field, Seymour1 has published, actors involved in the transfer:As the study has revealed, the acquisition along with convincing evidence, that training students, managers, co-workers,of competencies should be the central with virtual simulation transfers directly to service managers, etc.objective of all training sessions, combining 11. Transfer to clinical practise daily practise and improves patient caretechnical skills with others skills such as behaviour in the operating room. • Take into consideration the factorsteamwork and communication. Transfer to clinical practise is the that have a positive or negative principle objective of simulation-based Transfer may be conscious (intentional, impact on the transfer of acquiredWe know, however, that over time, training programmes, and it should be or “high road” transfer), or automatic. competencies to clinical practise.competencies cannot be maintained incorporated into the evaluation of results. Automatic transfer is enriched with theand begin to decline. Our teachers, as is We must be able to know the level to which local learning contexts and includes • Bear in mind the retention of trainedrecommended in certain publications, the skills acquired have been applied to the physical surroundings, suitable competencies and the role of theset in motion a series of actions that real-life clinical situations. performance of the roles of the instructor in the learning attained.allow the development of strategies for different actors and evaluation of theimprovement and retention of acquired Due to time restraints, we have not expectations of the students. Analysis of • Evaluate the importance ofcompetencies over time. This factor is been able to study this as part of our the environmental and contextual factors communication and teamwork skillsclosely related to deliberate practise. investigation. We do know, however, that that affect transfer, either positively or ensuring the transfer of competencies • Consider the educational and negatively, is one of the most relevantThe acquisition and retention of these to clinical situations in the workplace is a organisational aspects of transfer to aspects to be taken into consideration,competencies should be coherent with critical factor which must be evaluated, as daily practise and one which we are committed to onthe requirements identified as well as with it allows us to enhance the implementation the basis of our experience. and dissemination of clinical simulation. • Evaluate, along with the students, thethe objectives and results to be attained influence of the confidence acquiredby the organisation. In this manner the Bearing this in mind, the inclusion of Authors such as Kuduvalli (2009), Fraser and encourage awareness of theorganisation will promote and emphasise questionnaires from models such as et al., and Sturm et al. (2008), have shown limitations that still existtheir retention. Holten et al. (2007), or those esteemed by through case studies that the transfer of Tejada (2007) is a useful way of evaluating skills acquired through simulation to real- • Consider the time factor as aActions. clinical learning. life clinical environments improves the level fundamental variable in the evaluation1 Connect directly with the interests of of retention as compared to traditional of the retention and transfer levels Actions: the centre, or service, to promote and teaching methods. Another study shows strengthen these competencies that medical interns who are trained to • Use of qualitative and quantitative attend to a cardiac arrest as a team in a tools for the gathering and analysis of2 Design the programme emphasising real-life environment tend to respond far information the need to develop a plan which more easily as a team to the application of will allow the students to retain and protocols than more advanced residents’ 1 Seymour NE. (2008). VR or OR: a review of the evidence that virtual reality simulation improves operating improve these competencies, achieve teams who have been trained using room performance. Word J Surg; 32:182-8. systematic transfer to the workplace 36 37
  20. 20. 12. Measuring the results conditions, after extensive training and with clearly defined measurementMeasurement of results is essential the implementation of a simulationprogramme, as it is in other aspects of • Responses of the students, eithermedical education. to multiple choice questionnaires or on the basis of written examinations.In general, the results to be taken into Direct measures of studentsconsideration are, first of all, evaluation learning outcomes are preferredof performance, in other words, as they more reliable and lessmeasurement of the increase in the influenced by individual respondedcompetencies acquired by the students. characteristics2.Secondly, measurement of the transferto real-life situations, in other words, • Simulator recording and filing of thewhether or not the students transfer behaviour of the students duringwhat they have learned to clinical training.practise. Finally, we need to identify thechanges in healthcare that result from In the second case (transferthe training, and whether or not these measurement), this should be donelead, directly or indirectly, to improved via measurement of: 1) transfer ofresults in healthcare. competencies acquired to clinical practise, 2) the number of times this isIn the first case (performance performed, and the level of expertise,measurement) it is essential to 3) the level of confidence shown by thehave reliable information about the student in the use of the technique, 4)competencies trained and how these have The students’ perception of the level ofimproved, and to develop measurement improvement in patient care, 5) the level in the workplace. depth in the SIMBASE Impact Evaluationtools that are coherent with the learning of improvement in the use of resources. Model document.objectives. In order to achieve this, we need to The following factors that are influential take measurements beforehand and in transfer should be taken into In the third case (impact measurement),The three primary sources of information afterwards, and compare them. consideration: teamwork, the availability we can achieve this by measuring thein the evaluation of simulation-based of necessary resources, the existence of level of satisfaction of the patient with thelearning results, and which should always This can be done using the following an open, positive attitude of the students attention received, the level of improvementbe used with caution, are: sources of information: a) Direct during the learning, the coordination in waiting times, the level of influence on observation in the workplace, b) Surveys and supervision of the team by the the improvement in hospital services and,• Direct observation of performance: of the trainees, co-workers and area managers, the resistance to change in terms of surgery, by measuring the to be performed under controlled managers and c) Analysis of documents or the adaptation of the strategy of the reoperation rates. Measurement may organisation to simulation-based learning. also be made by introducing changes to 2 Downing SM. (2004). Reliability: on the reproducibility of assessment data. Med Educ; 38:1006-12. These factors are discussed in more the centre’s information systems and the 38 39
  21. 21. patient register. Simulation-based training that ignores the have been proposed throughout the organisational and educational context various steps considered in this handbook.Actions: of teaching, evaluation and application to In addition, however, we propose the clinical practise, is a lost cause. following:1. Select the variables and indicators to be studied for each of the fields Each context is considered to contain Actions: a number of inherent factors that have2. Where possible, select accredited profound effects on the essence and 1 Incorporate innovation and quality tools or design and accredit other quality of the learning results and how training into the strategic plan of the tools where necessary healthcare professionals transfer them centre to clinical situations. There exist in-depth3. Define the occasion and manner of 2 Use training innovation as a tool studies that approach the way in which application of the tools for change via the design and simulation provides visible witness to the importance of context in both learning and development of a simulation4. Define the evaluation team who will implementation plan apply the tools practise34. While this factor requires more in-depth 3 Place the simulation implementation5. Define the required resources, plan within the framework of process incorporating platforms that allow research than that performed by this project, we consider it necessary to bear and resource reorganisation online access to all the actors involved strategies for the centre: work spaces in the evaluation in mind the influence of certain contextual variables, such as 1) organisational and times within the healthcare support for the training, 2) coherence quality standards6. Consider evaluation feedback activities with trainers, teachers, and integration with the objectives of managers and the organisation the organisation, 3) differences among the evaluated groups, 4) the changing rhythms of local contexts, 5) ease of13. Organisational and educational communication within the organisation, 6)context the local remuneration system, 7) cultural barriers, 8) the resistance to change inThe inclusion of the organisational the organisation and 9) the existence ofand educational context as a critical an open system that considers changesuccess factor for the implementation of as strategic and is capable of providingsimulation, in conjunction with orientation feedback of the results of the simulationtowards the training and organisational to the organisation itself.needs, is one of the objectives of thishandbook. For the majority of these variables, actions 3 Kneebone R. Simulation and transformational change: the paradox of expertise. Acad Med 2009; 84:954-7. 4 Kneebone R et al. see article and copy reference. 40 41
  22. 22. ReferencesBradley, P. (2006). The history of simulation in medical education and possible future Stracke, Christian M. (2007): “Quality Standards for Quality Development in e-Learning:directions. MEDICAL EDUCATION. 4(3); 254-262 Adoption, Implementation, and Adaptation of ISO/IEC 19796-1”. [also online available on: SM. (2004). Reliability: on the reproducibility of assessment data. Med Educ;38:1006-12. Seymour NE. (2008). VR or OR: a review of the evidence that virtual reality simulations improves operating room performance. Word J Surg; 32:182-8.Epstein, Ronald M. (2007). Medical education - Assessment in medical education. NEWENGLAND JOURNAL OF MEDICINE, 356 (4), 387-396 WHO. (2012). World Health Organization. Consulta en:, KA. (2007). An expert-performance perspective of research on medical WFME.(2012). World Federation for Medical Education. Consulta en: http://www.wfme.expertise: the study of clinical performance. Med Educ 2007; 41:1124-1339. org/Fessler, HE . (2012). Undergraduate medical education in critical care. CRITICAL CARE Ziv, A; Wolpe, PR; Small, SD; et al. (2003). Simulation-based medical education: An ethicalMEDICINE. 40(11); 3065-3069. imperative. ACADEMIC MEDICINE, 78(8); 783-788Gaba, D. (2004). The future vision of simulation in health care. Qual Saf Health Care. Holton EF III. (1996). The flawed four-level evaluation model. Human Resource Quarterly,13:i2-i10. 1996;7(1):5–25.Issenberg SB, McGaghie WC, Petrusa ER, et al. (2005). Features and uses of high-fidelity Holton, III, E.F., Bates, R.A., Bookter, A.I. & Yamkovenko, V.B. (2007) Convergent andmedical simulations that lead to effective learning: A BEME systematic review. Med DivergentTeach.; 27:10–28. Validity of the Learning Transfer System Inventory. Human Resource DevelopmentKneebone R et al . Simulation and transformational change: the paradox of expertise. Quarterly, 18(3) pp. 385_419.Acad Med 2009; 84:954-7. Fernández, T. and Fernández, E. (2007). La evaluación Del impacto de la formaciónKuduvalli et al. (2009). Retention and trasnferability of team resource managment skills como estrategia de mejora en las organizaciones. Revista Electrónica de Investigaciónin anaesthetic emergencies: the long-term impact of a high-fidelity simulation –based Educativa; 9 (002). Disponible en: European Journal of Anaesthesiology. 26:17-22.McGaghie WC, Issenberg SB Choen ER et al. (2011). Does Simulation based medicaleducation with deliberate practice tield better results than traditional clinical education?A meta-analytic comparative review of the evidence. Academic medicine; 86(1): 706-711.McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. (2010). A critical review ofsimulationbased medical education research: 2003–2009. Med Educ.;44:50–63Riancho, J. et al. (2012). Simulación clínica de alto realismo: una experiencia en elpregrado. Educ Med. 15(2): 109:115. 42 43
  23. 23. Adress: Consejería de Salud y Bienestar Social. Avda. De Hytasa, nº 14, Edificio Junta de Andalucía. Sevilla, 41071Telephone: +34 955048207Mobile Phone: +34 677906032Email: info@simbase.coWebsite: 44