Chapter 29 Simulation in Healthcare EducationValerie HowardKim.docx

Chapter 29 Simulation in Healthcare Education
Valerie Howard
Kim Leighton
Teresa Gore
The emergence of technology for educational purposes
creates a need for faculty and health science educators to
understand how to not only operate the technology but also
implement it within the academic and service settings while still
using sound academic principles.
Objectives
At the completion of this chapter the reader will be prepared to:
1.Define the different types of simulation modalities
available
2.Describe the challenges and opportunities inherent to
simulation
3.Apply the Standards of Best Practice: Simulation to the
simulation lab
4.Discuss the use of simulation-based education in
interprofessional experiences
5.Analyze the similarities and differences related to the
available simulation resources
6.Develop evidence-based simulation activities for graduate-
level education
Key Terms
Clinical scenario, 459
Debriefing, 461
Fidelity, 455
Learning environment, 457
Simulation, 454
Simulation experience, 457
Standards of Best Practice: Simulation, 460

Abstract
The use of simulated learning experiences has rapidly emerged
in healthcare education as a method of training healthcare
providers in a safe environment without subjecting patients to
harm. Multiple definitions of simulation-related terms exist, so
the importance of the use of standardized terminology is
stressed. Best practice standards for implementing simulated
learning experiences are discussed in this chapter. These should
be provided in a standardized manner while adhering to
guidelines to maximize learning. Simulated learning
experiences directly correlate with the Core Competencies for
Interprofessional Collaborative Practice. Finally, issues,
challenges, and opportunities for the future of healthcare
education and the use of simulation are outlined.
Introduction
Simulation is a time-honored method of teaching that has been
used in health education for decades. It is defined as the use of
“one or more typologies to promote, improve, and/or validate a
participant's progression from novice to expert,”1(pS6) where
the novice to expert continuum is consistent with that promoted
by Benner.2 Experiential learning theory is used in health
professions education to emphasize the importance of clinical
practice in the educational process.3 Simulation is one method
of experiential, hands-on application learning and can range
from a simple activity used to mimic reality (e.g., the process of
injecting an orange to create the feel of puncturing skin) to the
use of high-fidelity simulation to create the comprehensive
experience of interacting with a healthcare team during a
clinical emergency. In each case the simulated clinical
experience “includes pre-briefing, the clinical scenario, and
debriefing; it is the engagement part of a clinical
scenario.”1(pS6)
Types of Simulations
Several types of simulation are used in healthcare education,
including written case studies, computer models such as Second
Life, standardized patients, partial task trainers, and medium- to

high-fidelity patient simulators. Simulators are used to help
students to improve critical thinking, clinical judgment,
communication, and teamwork skills while assisting learners to
meet psychomotor, cognitive, and affective learning objectives.
Most of the growth in simulation is with standardized patients,
task trainers, and simulators.
Standardized patients consistently portray a patient or other
individual in a scripted scenario for the purposes of instruction,
practice, or evaluation.4 Standardized patients may be actors
who require little training. Others may be people who respond
to requests for assistance with healthcare training and require
significant resources for training. Still others may actually have
the disease, illness, symptom, or injury under study. In most
cases standardized patients are paid for their assistance to the
educational process.
Partial task trainers typically represent anatomic parts of the
human body and are used to practice skill acquisition.5 This
type of simulator assists learners to meet psychomotor
objectives, those accomplished when a student demonstrates the
ability to perform a task such as inserting a urinary catheter,
giving an injection, or attaching a heart monitor. Partial task
trainers can range from low to high levels of realism. Examples
of low-realism partial task trainers are when learners practice
giving intradermal injections using a silicone pad that is
flexible enough to allow a bleb to form when fluid is injected or
using a hot dog with skin for the same purpose. An example of a
more realistic partial task trainer is a model that promotes
practice of intravenous needle insertion through a virtual model
that includes haptic technology. Haptics is a feature allowing
tactile sensation, for example, when the needle enters a vein.
Simulators include full-body mannequins and can range from
static mannequins that do not respond to any intervention to
high-fidelity computerized simulators designed to realistically
respond to learner interventions. High-fidelity mannequins can
have blinking eyes, a chest that rises and falls with breaths,
heart and lung sounds, and palpable peripheral pulses and can

be capable of being intubated, having chest tubes inserted, and
having other assessments and procedures performed on them.
High-fidelity simulators are particularly useful for
interprofessional training on cooperative activities such as
codes. An example is the mannequin shown in Figure 29-1
marketed by Laerdal. These simulators are considered the most
lifelike compared to human patients. The most realistic
simulators in healthcare education are, of course, real persons.
Obviously, numerous skills and conditions cannot be recreated
for safety reasons. Instead, educators often use a hybrid
simulation involving two types of simulators. A
FIG 29-1 Sample high-fidelity simulator.
(Photo courtesy of Laerdal Medical Corporation.)
student can explain the procedure, risks, and potential
complications to the standardized patient while performing the
procedure on the partial task trainer. Standardized patients can
assist learners to meet objectives while enhancing
communication, clinical judgment, critical thinking, and
teamwork skills.
Fidelity
Fidelity is the standard term used to describe the realism
involved in simulated learning activities. There are a variety of
ways to create fidelity in the learning experience, which can be
confusing for educators. It recently has been recognized that
fidelity has very little to do with what equipment is used and
much more to do with how that equipment is used. Fidelity can
involve a variety of dimensions, including the following:
•Physical factors such as environment, equipment, and
related tools
•Psychological factors such as the emotions, beliefs, and
self-awareness of participants
•Social factors such as participant and instructor motivation
and goals
•Culture of the group

•Degree of openness and trust, as well as participants' modes
of thinking1(pS5)
On a trajectory from low fidelity to high fidelity, task trainers
are considered of lower fidelity than high-fidelity simulators
and finally standardized patients. However, this type of
classification is not without controversy. Alinier places
computer-controlled simulators above standardized patients in
his continuum.6 For example, a high-fidelity mannequin used in
a cardiopulmonary arrest situation may not even be turned on,
depending on the level of the learner. A low-fidelity task trainer
used in a high-fidelity environment may allow the combination
to rank higher than the task trainer alone. Other types of
simulation (e.g., written, screen-based) fall into the trajectory,
depending on how they are used. The decision about the level of
fidelity needed for any simulated clinical experience should
always be based on the learning objectives. Thus it is not
always necessary to have high fidelity, especially when cost as
well as technology needs are both considered. The example in
Table 29-1 involves inserting a central line.
The most common fidelity consideration is the type of simulator
to be used; however, educators have become aware of additional
types of fidelity such as environment. Fidelity of the
environment considers the location in which the simulated
clinical experience takes place. A high-fidelity mannequin may
need to be used within a psychomotor skills lab, a classroom, or
even office space. An environment most similar to where real
patient care takes place is highly desirable. Additionally, the
equipment, furniture, and supplies should all be as realistic as
possible to the traditional clinical environment. Creating
methods to add patients' emotions, beliefs, spirituality, culture,
and communication are also ways to make the experience more
realistic. Table 29-2 outlines ideas for meeting learning needs
in the developmental, spiritual, sociocultural, and psychological
dimensions.
Benefits of Simulation

Simulation offers the chance for learners to practice in a safe
environment without placing patients at risk. Simulation
significantly increases learners' knowledge,7,8 competence,9
self-efficacy,10 and confidence11 at no added risk to patients.
While the former are intermediate outcomes, a longer-term
outcome of better training is higher quality of patient care.
Deliberate practice, the process of practicing a skill multiple
times until mastery is reached, is facilitated within the
simulation environment through the use of task trainers, further
reducing the risk of harm to patients.9 Simulation also offers
the opportunity to create standardized learning experiences in a
controlled environment and provides exposure to low-
occurrence, high-risk situations with opportunities to practice
critical thinking skills, problem solving, and decision making.
TABLE 29-1 Fidelity Correlated with Objectives
OBJECTIVE: THE LEARNER WILL …
TYPE OF SIMULATOR
Accurately place central line catheter
Task trainer
Maintain sterile technique when placing a central line
Task trainer
Clearly communicate risks when obtaining consent from patient
Standardized patient
Use various communication techniques to calm patient's anxiety
Standardized patient
Recognize need for central line insertion during hypertensive
crisis
High-fidelity simulator
Insert central line when rapid blood transfusion is required

High-fidelity simulator
TABLE 29-2 Dimensions of Learning and Fidelity
DIMENSION
SIMULATED PATIENT
IMPROVING FIDELITY
Developmental
42-year-old male patient with myocardial infarction (MI); works
as laborer
Place frame with picture of young family at bedside. Does the
learner recognize that patient likely will not be able to return to
work? Does he or she consider how the family will have their
financial needs met?
Spiritual
Patient will be having emergent surgery
Place religious or spiritual book or icon at the bedside. Does the
learner recognize the need to ask the patient about his or her
beliefs and practices?
Sociocultural
Patient is being discharged with five new prescriptions
Provide discharge instruction sheet. Does the learner determine
whether the patient has the resources to get new prescriptions
filled?
Psychological
Postoperative knee replacement patient cannot return home to
care for self
The patient reveals that there are 10 steps before entering his

home. Does the learner explore how the patient feels about the
loss of his or her independence?
An evaluation of any educational training program should align
with evaluation models of training, for example, Kirkpatrick's
model.12 Kirkpatrick identified the following four different
levels of outcomes of training programs:
•Level 1: Reaction, measures the learners' reactions to the
training program. For example, were the learners satisfied with
the program and how do they plan to use the information
provided?
•Level 2: Learning, measures the amount of knowledge,
attitudes, or skills that have changed and the level of the change
as a result of the training.
•Level 3: Behavior or Training Transfer, measures the
amount of “on the job” behavior change by the learner
following the training sessions.
•Level 4: Results, measures the organizational impact of the
training program, on either performance or cost savings.
Much of the research related to simulation has focused on the
first two levels, measuring the learner's perspective,
satisfaction, and knowledge gain related to the experience.
However, ultimately simulation researchers will want to
demonstrate the benefit of simulation training and its impact on
patient outcomes (level 4). As an example, most recently
simulation training has been correlated with lower central line
infection rates,13 decreased complications resulting from
shoulder dystocia obstetrical emergencies,14 and healthcare
cost savings related to decreased malpractice claims.15
Challenges and Opportunities
While simulation is an ideal environment for creating
standardized learning opportunities and applying theoretical
knowledge in the practice setting, inherent challenges exist
related to the ease of implementation.
Cost

High-fidelity simulation mannequins can be expensive to
purchase and maintain. Highly computerized mannequins can
cost between $30,000 and $125,000 while task trainers can cost
as little as $250 depending on the level of complexity and
fidelity. Standardized patient experiences also have higher costs
because of the need to hire and train actors. Hourly pay for
actors differs depending on the region and the level of the
actors' experience but can range between $12 and $40 per hour.
Educators need to factor in time for preparation, training, and
participation per actor. If the simulation center is recording
each simulation experience for use in debriefing, as is typical,
the audiovisual software systems can cost between $10,000 and
$50,000 per simulation room depending on the functions needed
and levels of complexity. In addition to costs related to the
simulation modalities, financial resources must be committed to
support the center and faculty time and training. Resource
considerations can include workload release time to learn and
understand how to use the simulation technology and how to
implement simulations into the curriculum, funding for
conference attendance, purchase of related journals and books,
and membership dues for simulation organizations.
After the initial purchase costs, annual maintenance funds are
required. These costs include ongoing maintenance,
depreciation, and upgrades to the technology. Extended
warranties can be purchased to cover the ongoing maintenance
needed to ensure proper working order of the computerized
mannequins. Most simulator mannequins are classified as
capital purchases, so it is important to discuss the purchase,
maintenance, and any insurance coverage with your institution's
business office prior to making a commitment. Also, when
planning for a simulation mannequin purchase, consider
budgeting for costs related to replacement parts. Each piece of
simulation equipment may have different suggestions related to
replacement parts, including “skins,” appendages, and moulage,
so it is important to have conversations with simulation vendors
prior to purchase so that appropriate budgetary planning and

projections can begin.
Many health professional programs include student simulation
lab fees. Others may seek grant funding from foundations,
corporations, or private donors to support these efforts. Funding
success can be maximized by developing a relationship with the
potential funder, correlating the funding proposal with the
mission and vision of the funding agency, and forming
collaborative partnerships to demonstrate a unique and
sustainable project.
Technology
The high-fidelity simulation mannequins can be difficult to
operate by faculty who lack technological experience or
knowledge. In addition, skills are required to operate the digital
audiovisual equipment to record simulation experiences.
Box 29-1 Job Description for Simulation Technician
Under the direction of the Simulation Center Director, the
technician will provide technical support for all simulation
experiences and operations, including preparation, maintenance
and repair of computerized mannequins, task trainers,
simulation-related hardware and software systems, audiovisual
equipment, administrative website management, and digital
recording systems.
Partnering with simulation vendors may allow specific training
opportunities to enhance understanding of the simulator
technology and promote ease of use. Hiring a full-time or part-
time simulation technician may be necessary. Generally,
previous experience with computers, information technology,
and even sound or recording can enhance the effectiveness of
the simulation technology. Box 29-1 offers a sample job
description for a simulation technician.
Informatics principles and processes can be used for simulation
projects and for developing simulation centers. For example, the
systems life cycle (SLC) introduced in Chapter 2 can be applied
to the purchase and installation of products. To review, the
phases of the SLC are as follows:

1.Analyze
2.Plan
3.Develop or purchase
4.Test
5.Implement or go-live
6.Maintain and evolve
7.Evaluate
8.Return to analyze
The SLC is tailored to the project at hand; however, the
processes and activities are similar to those used for any other
project.
Faculty Development
Simulation is just one example of an experiential teaching and
learning strategy, but many faculty lack the understanding of
educational principles related to the best methods for
implementing experiential learning strategies within the
curriculum. Therefore knowledge of the following educational
principles will assist the simulation facilitator in developing
academically sound experiences:
•Educational theory
•Application of theory to practice
•Development of clear and measurable objectives
•Instructional design
•Formative and summative learner evaluation
•Program evaluation
•Facilitation of learning
•Debriefing strategies
•Creating a safe learning environment in the simulation lab
To maintain a safe environment for learning and ensure
commitment to academic principles, each simulation facilitator
should have an orientation period to learn the aforementioned
principles and observe experienced simulation facilitators,
similar to a mentorship model. If schools do not have the

appropriate experts within their organizations, resources should
be committed to educate the simulation facilitator. Likewise,
institutions will need to develop policies that require the
simulation facilitator to have appropriate training before
interacting with learners in the lab.
Several organizations, such as the International Nursing
Association for Clinical Simulation and Learning (INACSL),
the National League for Nursing (NLN), the American
Association of Colleges of Nursing (AACN), and the Society for
Simulation in Healthcare (SSH), offer annual meetings,
conferences, and faculty development webinars to assist with
this challenge. In addition, several higher education institutions
offer graduate-level certificates with concentrations in
simulation. Two scholarly journals are devoted to simulation:
Clinical Simulation in Nursing and Simulation in Healthcare.
Finally, other organizations offer continuing education
programs with continuing education credits for their ongoing
developmental programs.
TABLE 29-3 Kotter's Principles Applied to Simulation
KOTTER'S PRINCIPLE
APPLICATION TO SIMULATION EDUCATION
Creating a sense of urgency
• Identify the need for simulation based training within
institution
• Share simulation based research and evidence with
stakeholders
Developing a guiding coalition
• Identify simulation champions and other like-minded
individuals in your organization to form your simulation team
• Choose representatives from all stakeholders (faculty,

administrators, clinicians, educators, learners, students, staff,
patients, families)
Developing a vision
• Develop a mission, vision, name, and strategic plan for
your simulation program or center
• Create a business plan
• Include input from all stakeholders
Communicating that vision
• Share the plan with all stakeholders
• Use a marketing or branding approach for the name of your
organization
• Consult with your public relations department
Empowering stakeholders to act upon that vision
• Develop an organizational structure to support each team
member
• Schedule regular meetings for progress updates and
document the minutes from each meeting
• Develop clear and concise roles and responsibilities for
simulation related activities and ensure accountability
• Seek resources from administration, outside funding
agencies, participant fees to support the structure
Create short term wins
• Develop one or two simulation activities based upon sound
educational principles and implement this according to the best

simulation evidence available
• Celebrate the successes of each individual in your
simulation team
Consolidation of improvements
• Collect data on each simulation experience and use the data
to improve quality
Institutionalizing new approaches
• Develop and implement policies and procedures related to
simulation (i.e.: simulation facilitator, facilitation, simulation
design, scheduling, debriefing)
• Maximize use of your simulation center
• Continue to share the positive simulation evaluation data,
both quantitative and qualitative, with administrators, faculty,
clinicians, educators, and all stakeholders
Adapted from Kotter, JP. Leading Change. Boston, MA:
Harvard Business Review Press; 1996.
Faculty or Administrative Buy-In
The use of simulation modalities to enhance learning can be
considered an organizational change and resistance to change
efforts has been widely reported in all disciplines, including
business, organizational behavior, psychology, and healthcare.
Faculty may be resistant to learning the new technology,
administrators may not understand the importance of dedicating
time and resources to the successful implementation of the
simulation efforts, and students may be anxious about the
possibility of being recorded as they practice in the simulation
center.
Successful change efforts can be facilitated by having a
thorough understanding of change theories and using this

theoretical knowledge to guide the efforts. One change model
used in healthcare was developed by John Kotter, who suggests
following eight steps when leading a change effort (Table 29-
3).16 These steps can be applied to simulation efforts with
health practitioners. Creating a mission and vision statement for
the simulation program and developing a strategic plan can also
guide future efforts related to integrating advanced practice
experiences within the simulation program.17 Evaluating the
participants' satisfaction related to the simulation experiences
through the use of postsimulation surveys can also provide
necessary data to share with administrators in an effort to gain
support. Faculty members can be given an opportunity to visit
the simulation lab and experience first-hand the learners'
reaction to this powerful educational tool. Finally, sharing the
positive experiences of students both quantitatively and
qualitatively, through reflections and stories, can also generate
buy-in.
The Simulation Process
Learning Theories Applied to Simulation
Simulation is often accepted without any validation and based
on the technology instead of a theoretical underpinning.
Kneebone identified the following four areas for using
theoretical underpinning:
1.Gaining technical proficiency with psychomotor skills
2.Learning theory with repetitive practice and frequent
reinforcement
3.Tailoring support to the individual learner's need using
situated learning
4.Addressing the affective domain of emotions with
learning18
In addition, Kneebone identified the following four criteria for
evaluating existing and new simulations:
1.Allow sustained, repetitive, and purposeful practice in a

safe, controlled environment
2.Level interaction with the expert or mentor depending on
the proficiency of the student
3.Simulation should mimic actual life experiences
4.The simulated environment should foster a learner-centered
approach that inspires and supports students18
Through deliberate practice students can develop a foundation
for incorporating evidence-based practice (EBP) in bedside
patient care. This should result in better patient outcomes from
safe, quality nurses.19–22
A foundation for a theoretical background for simulation can be
based on experiential learning. Several experiential learning
theories have been applied to the use of simulation, as
follows.23–25
•Knowles' adult learning theory. This theory originally stated
that adults learn differently due to andragogy (theory of adult
learning).26 Characteristics of adult learners are that they are
self-directed, want to be involved in planning and evaluating
their learning experience, use past experiences to build new
learning, need to understand the reason for learning, want
immediate application of knowledge to solve problems, and are
more invested when the learning is associated with a new role.
In 1984 Knowles changed his position to recognize that the
assumptions about andragogy are situation specific and not
unique to adults.27 In 2010 Clapper expanded on this
assumption regarding what adult learners wanted educators to
know. These learners want educators to create a safe learning
environment that uses active and collaborative learning
experiences, encourage reflection on current and past
experiences, and focus more on the assessment of improvements
made instead of pure evaluation.
•Kolb's experiential learning. This refers to a person's ability
to transfer knowledge from theory into practice, thereby leading
to acquisition of knowledge.28 Waldner and Olson combined

Benner's first three stages of learning (novice, advanced
beginner, and competent) and Kolb's framework using high-
fidelity patient simulation in academia.29
•Situated cognition. Learning occurs as a social activity
incorporating the mind, the body, the activity, and the tools in a
context that is complex and interactive. This incorporates all
domains of learning: psychomotor, cognitive, and affective.27
•Lasater's Interactive Model of Clinical Judgment
Development. Four areas of clinical judgment are noticing,
interpreting, responding, and reflecting.30,31 This model can be
applied to simulation for noticing and assessing patient
situations and conditions, interpreting the assessment findings,
responding by developing a plan of care and interventions, and
reflecting during the debriefing process.
•Jeffries/NLN simulation framework. This is a conceptual
framework developed for use in nursing education to design,
implement, and evaluate simulation experiences.32 This model
depicts the triadic relationship of students, faculty, and
educational practices and their influence on the simulation
design and desired outcomes. The five possible outcomes of
simulations are increased knowledge, skill performance, learner
satisfaction, critical thinking abilities, and self-confidence of
the participants.
•Gaba's 11 dimensions of simulation. These are as follows:
1.The purpose and aims of simulation activity
2.Unit of participation
3.Experience level of participants
4.Healthcare domain in which simulation is applied
5.Healthcare disciplines of participants
6.Type of knowledge, skills, attitudes, or behavior
addressed in simulation
7.Age of patient being simulated
8.Applicable or required technology
9.Site of simulation participation
10.Extent of direct participation
11.Feedback method accompanying simulation33(pp13-16)

For students to envision themselves successfully assuming a
new role, practicing that role in a realistic environment will
assist with role identification, mental visualization for
performing in the role, and bridging the gap from didactic to
practice. Through participating and acting in a specific
simulation case the participants can then generalize the
information in order to apply it to new situations.23,34
Best practices are available for many aspects of simulation
practice. A clinical scenario should be developed based on the
specific learning objectives of the participants. During the
planning and development of a scenario it is important to
construct an experience that is appropriate to the participant's
level of learning as well as the participant's objective. Since
many simulation experts believe that the majority of learning
occurs during the debriefing process, a planned debriefing
strategy should guide the facilitator in the process. The last
aspect is the identification and application of a theoretical
framework to plan and guide a simulation to provide the
theoretical underpinning for that simulation and simulation
program.1,32,34–36 These aspects will be explored further in
the next section.
Summary of Standards of Best Practice: Simulation
Standards of Best Practice: Simulation was developed by the
INACSL board of directors at the request of its membership
after an extensive needs analysis was conducted via member
email and listserv. The purpose of the analysis was to determine
the priority and ranking of the INACSL membership. Top
priorities were established as standards and the lower priorities
are under development as guidelines. The work of the Standards
Committee is ongoing, with a current focus on developing
guidelines to support the standards. Simulation standards have
been developed to assist with the planning and implementation
of simulation experiences.6 Following Standards of Best
Practice: Simulation will likely lead to better learning
experiences and improved learning outcomes for participants.

The first seven standards were presented at the 2011 conference
and published for all members in the fall of 2011 by Elsevier.
These initial standards are terminology, professional integrity
of the participants, participant objectives, facilitation methods,
simulation facilitator, the debriefing process, and evaluation of
expected outcomes.
Standards and Their Application to the Simulation Process
The simulation experience will depend on the objectives to be
obtained by the participants. The objectives are the guiding
principle of the entire simulation. Once the objectives have
been established, the level or type of facilitation should be
determined based on the level of experience of the participants
and the type of evaluation of the participants. The simulation
process should follow the steps outlined in Box 29-2 in
designing the scenario or experience to assist the participants in
achieving the objectives.
Standard I: Terminology
The main terminology used in simulation is defined based on a
review of literature. To begin the simulation experiences, have
standard definitions for the application and possible publication
and replication of research and evidence-based practices.37
Also, with more emphasis on interprofessional collaboration,
standardized terminology is the key to increasing understanding
between team members by not having only one discipline's
terminology used.
Box 29-2 Steps for the Simulation Process
1. Assign the presimulation or prescenario exercises to be
completed by the participants
2. Prebriefing sessions immediately prior to the simulation
3. Simulation scenario with appropriate facilitation by a
trained facilitator
4. Debriefing and/or guided reflection
5. Postsimulation exercises
Standard II: Professional Integrity of the Participants

Prior to beginning any simulation the participants need to be
oriented to the simulation program and understand the need for
professional integrity to maintain confidentiality and integrity
of the simulation.38 Professional integrity is needed in order for
all participants to have the same learning experience. If
participants share what occurred in the simulation with future
participants prior to the simulation, then those participants do
not have the same opportunity to use critical thinking and
clinical judgment. This could affect their confidence level and
take away learning experiences. Participants must be informed
of the type of evaluation and expectations prior to any
simulation.
Standard III: Participant Objectives
The simulated clinical experience should focus on course,
clinical, or program objectives and be based on the participants'
level of experience rather than on the fidelity of the equipment.
The technology does not guide the learning but rather is a
supplement to the educational experience. It is important to
identify the methodology for implementing the scenario prior to
the simulation to construct the best learning experience for
participants. This will provide a foundation or guide for the
simulation experience by identifying the appropriate scenario,
the level of fidelity (mannequin, standardized patient, or a
hybrid), the type of facilitating, the facilitator, and the
environment.33,34,39
There is no evidence that suggests or dictates a specific time
recommendation for each scenario. The scenario time should be
based on the time required to meet the objectives; however, a
time limit should be identified for each scenario. Some
commercially purchased simulation products incorporate
presimulation (prescenario) and postsimulation (postscenario)
exercises for undergraduate education; however, this is not
available for graduate-level education at this time.
Presimulation or prescenario exercises are designed to prepare
the student for participation in the simulation. Prescenario
exercises are to be completed by the participants prior to

participating in the simulation and can include, but are not
limited to, reading assignments for major concepts in the
simulation, pretest questions, skills review, and audiovisual
material.
Standard IV: Facilitation Methods
Facilitation type should be determined by the level of the
participant and the type of evaluation.40,41 Several types of
facilitation are instructor driven, partial instructor driven, or
participant driven. As might be obvious from the labels,
beginning participants usually require more instructor cueing or
prompting (instructor driven). As the level of experience
increases, less instructor prompting is required (partial
instructor driven). During a summative evaluation, such as
high-stakes testing, minimal to no prompting by the instructor is
performed (participant driven).
Standard V: Simulation Facilitator
The facilitator is the major component that provides the link
between the scenario and the participant to provide guidance for
meeting the objectives of the simulation. The role of the
facilitator is to adjust the scenario to respond to the actions or
inactions of the participants according to the objectives of the
scenario. The facilitator also leads the participants in the
debriefing process in a positive manner to reflect on ways to
improve the care provided for better patient outcomes.41
Standard VI: The Debriefing Process
The purpose of a debriefing is to promote participant reflective
thinking by allowing the participants to think about and clarify
actions that occurred during the simulation (Box 29-3).42
Feedback is provided to the participants by the facilitator to
ensure that concepts are understood and the participants are
given the right “take-home message” to incorporate into their
professional practice. The debriefing process has been reported
as the most important component of simulation because of the
learning that occurs when concepts are clarified.42–44
Literature suggests that debriefing should last at least as long as
the simulation scenario but current practices range from half as

long as the simulation scenario to twice as long as the
scenario.45
Box 29-3 Sample Debriefing Questions for a Pediatric Patient in
Isolation for Pneumonia with Cystic Fibrosis
Ask at least one question from each section.
Aesthetic Questions
“I would like each of you to talk to me about the problems
_________ was experiencing today.”
“What was your main objective during this simulation?”
“How did patient safety and isolation issues affect the patient
care you provided?”(scenario specific)
Personal Questions
“Was there any point during the scenario when you felt
unsure of your decisions? If yes, how did you manage your
feelings and focus on the patient's needs?”
“What made you choose the actions, interventions, and focus
that you chose for _________?”
Empirical Question
“I would like each of you to talk with me about the
knowledge, skills, attitudes (KSA), and previous experiences
that provided you with the ability to provide evidence-based
care to _________.”
Ethical Question
“Talk to me about how your personal beliefs and values
influenced the care provided to _________.”
Reflection Questions
“Please tell me how you knew what to do for a cystic fibrosis

patient with pneumonia in isolation and why.”
“If we could repeat this scenario now, what would you
change and why?”
“How will you use this in your professional practice?”
Standard VII: Evaluation of Expected Outcomes
The evaluation and assessment of the participants' performance
during the simulation should be based on the focus and desired
outcomes of the simulation scenario. The participants should be
aware of the evaluation or assessment methods being used
before beginning the simulation.35,46,47
While there is growing interest in adoption of clinical
simulation within educational programs, there is a gap in
empirical research identifying valid and reliable tools to
evaluate simulation effectiveness, especially in translating
knowledge and skills from simulation experiences to actual
clinical practice; research is needed.36,48,49 Also, the National
Council of State Boards of Nursing (NCSBN) is conducting a
longitudinal national simulation study to determine the
appropriate use of simulation for best student outcomes.50
Types of evaluations are skills checklists, formative assessment
of performance, or summative evaluation. Skills checklists may
be used during a skills validation, such as an indwelling
catheter or chest tube insertion for students or an endotracheal
intubation for respiratory therapy students.
Formative assessments measure a participant's progress toward
overall or long-term program objectives. This type of
assessment provides the participant with feedback that will aid
in professional growth and promote self-reflection.
Summative evaluations are traditionally measured at the end of
a learning experience, to correlate with the end of the course or
program. This type of evaluation may have a grade assigned or
use another method to determine student progression. An
example of a summative evaluation is an objective structured
clinical examination (OSCE). An OSCE summative evaluation
can be a graduate student's evaluation at the end of the
advanced assessment course to determine his or her ability to

perform in a traditional clinical setting. Some medical boards
require an OSCE to become certified. Regardless of the type of
evaluation, the instrument used should have reported
psychometric data demonstrating reliability and validity.
The evaluation tools currently used in simulation were
described in a review by Kardong-Edgren and colleagues and
were categorized within the cognitive, psychomotor, and
affective learning domains.51 The cognitive domain focuses on
application with thinking such as perform, identify, maintain,
communicate, prioritize, and provide. An example is that the
participant will be able to identify the signs and symptoms of
congestive heart failure and provide appropriate interventions
for best patient outcomes. The psychomotor domain focuses on
the precision of performing the assessment or skill, such as
insertion of an intravenous catheter and effective therapeutic
communication using Situation-Background-Assessment-
Recommendation (SBAR) communication. The affective domain
reflects the emotion of reflective thinking by responses to and
prioritization of patient care (Box 29-4).
Box 29-4 Learning Domains
Cognitive domain. Simulation evaluation tools included the
Basic Knowledge Assessment Tool 6 (paper-and-pencil test);
the Outcome Present State Test Model for Debriefing
(worksheets that participants complete during the structured
debriefing); the Lasater Clinical Judgment Rubric, based on
Tanner's Clinical Judgment Model for student evaluation during
simulation; and the Simulation Evaluation Instrument,
developed to evaluate the American Association of Colleges of
Nursing core competencies for undergraduate nursing students
during simulation.
Psychomotor domain. There were no tools identified for the
psychomotor domain for simulation that reported validity and
reliability testing.
Affective domain. The evaluation tools identified in this
section were developed to measure student satisfaction and

perceived effectiveness of the simulated clinical experience.
The tools identified included a satisfaction survey, the
Emergency Response Performance Tool (ERPT), and the
Simulation Design Scale. Other tools were reviewed for group
evaluation.
The Leighton Clinical Learning Environment Comparison
Survey (L-CLECS) was designed to compare how well
undergraduate students' learning needs were met in the
simulated clinical environment and the traditional clinical
environment.52 L-CLECS is one of the tools being used during
the current national simulation survey by the NCSBN.50
Validity and reliability evaluation measures have been
conducted on this instrument.
The Creighton Simulation Evaluation Instrument (C-SEI) is a
tool that evaluates simulation experiences by measuring
assessment skills.53 C-SEI is the second tool being used in the
NCSBN's National Simulation Study and has established
reliability and validity.50 The C-SEI tool is designed to be
modified to meet the specific outcomes of the simulation. The
goal of this tool was to evaluate student assessment skills for
improvement. As the assessment skills improve, so will clinical
performance.
Application of Simulation
General Application of Simulation to Education
The use of simulation in undergraduate nursing, graduate
schools for advanced practice nurses (especially nurse
anesthetists), medical schools, and interprofessional education
has been well documented in the literature. However, literature
is not available for simulation applied to doctoral education.
Multiple research studies revealed that students have higher
satisfaction with higher levels of fidelity.8,54 However, studies
have not shown that high-fidelity simulation increases students'
clinical reasoning skills.8 There is a growing body of health
literature evaluating the differences in student outcomes using
low- and high-fidelity simulation experiences. Multiple studies

indicated no statistically significant differences in student
learning outcomes using traditional pencil-and-paper testing
scores compared to varying levels of fidelity teaching
strategies.55–59
Some studies have demonstrated a statistically significant
difference in students' self-perceived improvements depending
on the level of fidelity used in simulation.60–64 The
participants of these studies preferred high-fidelity teaching
strategies as compared to low-fidelity strategies.
Several studies recommend that educators need to compare the
level of fidelity when considering cost and short- and long-term
participant outcomes.56,57 Some authors have questioned the
appropriate evaluation method: an OSCE or a paper-and-pencil
test.57,65 However, there have not been consistent results with
OSCEs in terms of finding differences in participants'
performances to compare acquisition of knowledge and applying
that knowledge to clinical practice.55
Application of Simulation to Interprofessional Education
Many professional medical organizations stated an increasing
need for interprofessional education (IPE), as evidenced by the
newly introduced Core Competencies for Interprofessional
Collaborative Practice sponsored by the Interprofessional
Education Collaborative (IPEC) (Table 29-4).66 IPEC was a
collaborative effort between multiple associations, including the
AACN, American Association of Colleges of Osteopathic
Medicine, American Association of Colleges of Pharmacy,
American Dental Education Association, Association of
American Medical Colleges, and Association of Schools of
Public Health.
To improve patient safety, evidence-based practice,
translational research, and more IPE opportunities are needed.
New teaching strategies have evolved. Some of these are in
response to the changing technology that has proliferated over
the past 25 years. The strategies include the following:
1.Communication tools such as SBAR for more effective

professional and interprofessional communication
2.Simulation scenarios to practice skills and techniques,
assessment, therapeutic communication, interprofessional
collaboration, reflection on actions and inactions of
participants, and incorporation of evidence-based practice
throughout the curriculum and applying these in simulation
3.Informatics capabilities to improve patient care with point-
of-care access to information through handheld devices and
electronic health records (EHRs)
If the interprofessional members of the healthcare team have
access to the pertinent information about a patient, healthcare
delivery can be more holistic and potentially decrease harm to
the patient. Health sciences students can learn the roles and
responsibilities of other healthcare team members for
collaborative purposes through IPE simulations to ensure the
best patient outcomes. For graduate school students, IPE
simulations are an excellent way to learn how to function and
adapt practices to achieve the best outcomes.
TABLE 29-4 Core Competencies for Interprofessional
Collaborative Practice
CORE COMPETENCY
FOCUS
APPLICATION WITH SIMULATION
OPPORTUNITY FOR IPE
Roles and responsibilities for collaborative practice
Use the knowledge of each profession's role to assess and
address the populations served
Demonstrate collaboration of team members in a scenario to
clearly communicate with each other and provide the best
holistic care to meet the needs of the individual or population

• Disaster drill simulation
• Prehospital injury requiring ambulance transport to the
emergency department
Interprofessional communication
Communicate in a team approach with individuals, families, and
communities in a responsive and responsible manner to support
well-being and quality of life
1. Communicate with confidence, clarity, and respect to
promote understanding of information and management of
issues
2. Actively listen and encourage sharing or input from others
3. Recognize one's uniqueness and role within the team and
contribute to effective communication, conflict resolution, and
positive interprofessional working relationships
Scenarios that require multiple professions in diagnosis and
planning the care of a patient:
• Code situation
• Respiratory decline of patient with unknown etiology
Interprofessional teamwork and team-based service
Apply relationship-building values and the principles of team
dynamics to perform effectively in different team roles to plan
and deliver services that are safe, timely, efficient, effective,
and equitable

1. Work with others to develop consensus on the ethical
principles to guide all aspects of interaction with individuals
and teamwork
2. Use process improvement strategies
3. Reflect on individual and team performance for individual
as well as team performance improvement
• Home health scenario that requires collaboration via phone
• Focus the debriefing process on improvement of any
interprofessional simulation
Values and ethics for interprofessional practice
Work with individuals of other professions to maintain a
climate of mutual respect and shared values
1. Provide care for the community
2. Demonstrate high standards of ethical conduct
3. Act with honesty and integrity in relationships with all
team members and clients
4. Maintain competence in one's profession
Complex scenarios that include moral or ethical decision
making and counseling with the patient or family:
• Organ transplant decisions
• Hospice care
• Cultural themes
IPE, Interprofessional education.
Simulation is a strategy to assist team members with effective
communication and promote collaboration with other

professionals. According to an INACSL survey in 2010, only
about half of the respondents provided any IPE. Of the
programs providing IPE experiences, only a few institutions
stated that the practice was used more than occasionally in the
simulation community.44 Challenges to this type of education
exist. In particular, the logistics of scheduling multiple
professions for simulation is one of the major obstacles for IPE
experience.67–70 The Institute of Medicine (IOM) also called
for the federal government and professional organizations to
study the approaches and foci to determine their contribution to
improving the workforce.21,22 The professional organizations
have a responsibility to determine the best resources and
methods for improving the education of the healthcare
workforce, both in initial education and in continuing
professional development.
Example
The following scenario was used in a doctorate of nursing
practice program to evaluate nurse practitioner students' ability
to assess and develop a differential diagnosis with a patient
presenting with angina. Students participated in this experience
at the end of their clinical diagnostics course and this was used
for summative evaluation purposes. Prior to any simulation
experience, a curricular simulation integration form was used to
document objectives, evaluation measures, and the specific
details related to the scenario (Fig. 29-2). This plan mapped out
the specific details related to the simulation experience and
contributed to a successful simulation experience for both the
faculty and the students. To prepare, the students received the
evaluation rubric to review prior to entering the simulation lab
for testing (Fig. 29-3).
FIG 29-2 Simulation integration and planning form. ASA,
Acetylsalicylic acid; BP, blood pressure; DNP, doctor of
nursing practice; HTN, hypertension; NP, nurse practitioner;
prn, as needed; SL NTG, sublingual nitroglycerin; SOAP,

subjective, objective, assessment, and plan; SOB, shortness of
breath.
(Developed by C. Ross, PhD, RN, and V. Howard, EdD, RN.
Courtesy of RMU Regional RISE Center.)
FIG 29-3 Student evaluation rubric. BP, Blood pressure; NP,
nurse practitioner; PVC, premature ventricular contraction; RR,
respiratory rate; SOAP, subjective, objective, assessment, and
plan.
The detailed evaluation rubric (Fig. 29-4) was used by the
faculty member to evaluate the students and provide summative
feedback. After the scenario the students completed a Scenario
Evaluation Form to evaluate the quality of the learning
experience (Fig. 29-5).7 These evaluation data were reviewed
by the simulation facilitators after the scenario activity to
ensure that the scenario met the needs of the students and
reflected the highest quality and evidence.
Simulation Resources
Organizations
INACSL was founded after discussions by several attendees of
the annual Learning Resource Center Conference in 2001. The
nonprofit organization has grown to more than 1500 members
worldwide. The organization's mission statement is to promote
research and disseminate evidence-based standards for clinical
simulation methodologies and learning environments. Its vision
is to be nursing's portal to the world of clinical simulation
pedagogy and learning environments. The majority of members
are nurses, although anyone is welcome to become a member.
Institutional membership is also available. The organization is
affiliated with SSH and a founding member of the Global
Network for Simulation in Healthcare (GNSH), an organization
composed of the leadership of simulation organizations
worldwide.
SSH was founded in 2004 and has a membership of
approximately 3000 healthcare providers in all specialty areas.
SSH began offering a program to accredit simulation

laboratories in 2010. The most recent benefit offered by SSH is
the ability to receive certification as a simulation educator. Box
29-5 lists additional organizations that support simulation in
health education.
Leaders
There are many experts in the field of simulation; however,
some deserve special recognition for the work they have done to
further the use of this teaching modality. Asmund S. Laerdal
may be the most recognized name in simulation, as he was the
founder of the Laerdal Company, now known as Laerdal
Medical. Initially making partial and full mannequins to further
the education of cardiopulmonary resuscitation
FIG 29-4 Detailed faculty evaluation rubric. JVD, jugular
venous distention; PQRST, provokes, quality, radiates, severity,
time; SOAP, subjective, objective, assessment, and plan.
FIG 29-5 Simulation evaluation. DNP, Doctor of nursing
practice.
(Developed by V. Howard. 2010. Courtesy of RMU Regional
RISE Center.)
the company branched out into mannequins and supplies for all
areas of patient simulation. Dr. J.S. Gravenstein from the
University of Florida led the team that created the Human
Patient Simulator (HPS), the first and only full-body simulator
that responded to gas inhalation, making it an appropriate tool
for anesthesia education. Dr. David M. Gaba, Associate Dean
for Immersive and Simulation-based Learning at Stanford
University School of Medicine, has experience and opinions
regarding patient simulation that are sought after by clinicians
worldwide. Pamela Jeffries, PhD, RN, contributed the first
framework for the development of simulation experiences
through her work with the NLN and Laerdal. All of these
leaders have made significant contributions to the education of
clinicians, including graduate nurses. There are many others

whose expertise and contributions could also be mentioned here.
Box 29-5 U.S. Organizations That Support Simulation in Health
Education
International Nursing Association for Clinical Simulation and
Learning (INACSL): www.inacsl.org
Society for Simulation in Healthcare (SSH): www.ssih.org
National League for Nursing (NLN): www.nln.org
American Association of Colleges of Nursing (AACN):
www.aacn.nche.edu
The Joint Commission (TJC): www.jointcommission.org
Institute of Medicine (IOM): www.iom.edu
National Council of State Boards of Nursing (NCSBN):
www.ncsbn.org
Agency for Healthcare Research and Quality (AHRQ):
www.ahrq.gov
Conclusion and Future Directions
The use of simulation is rapidly emerging as a preferred way to
train healthcare professionals in a safe, controlled manner with
no risk to patients. One of the reasons for its emergence is that
simulation can ameliorate current barriers with traditional
clinical experiences. There is a shortage of clinical sites,
patients can have complex conditions that a novice learner is
unprepared to manage, and clinical sites may have limited
student experiences for EHRs, administering medications to
pediatric patients, and other situations. These factors, combined
with a nursing and nurse educator shortage and the aging
population, will further increase the need to teach healthcare
providers in a simulation environment.
Newer approaches that reflect the advances in technology are
virtual reality computer-based simulations and gaming. Gaming
is a type of simulation technique that meets the needs of
millennial learners. However, this new approach has not yet
been as fully developed as the approaches discussed in this
chapter. The emergence of technology for educational purposes

creates a need for faculty and health science educators to
understand how to not only operate the technology but also
implement it within the academic and service settings while still
using sound academic principles. Standards of Best Practice:
Simulation will continue to serve as a foundation for all types
of simulation-based teaching methodologies.
A potential future step is the integration of EHRs into
simulation experiences. Simulation experiences that include
EHRs are less common and only a few simulation centers have
embedded EHRs and other clinical information systems. In the
future the entire suite of technical experiences will be available
in a simulation center experience.
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Discussion Questions

1. You are a graduate teaching assistant at the local
university. A faculty member approaches you to “do” a
simulation for class. What information do you need prior to
developing the simulation? Provide a rationale for the
information needed.
2. As a faculty member facilitating a debriefing, list five
questions that you would ask to promote self-reflection.
3. Provide an example of an interprofessional simulation that
would facilitate your graduate-level education. List the specific
learning objectives, the team members, the participants'
experience level and learning, and the type of facilitation and
debriefing to guide this simulation scenario.
4. You are a faculty member struggling with generating
support for your simulation program. You are experiencing
resistance from faculty members and administration with the
implementation of this new technology. What can you do to
enhance buy-in?
Case Study
You have been hired to teach in a graduate health program.
Your newly developed course has an objective that states: Upon
completion of this course, the learner will be able to
demonstrate interprofessional team building concepts. As a new
educator, you would like to include simulation as a teaching
methodology.
After you are hired, you find a rarely used, high-fidelity Human
Patient Simulator in the corner of your skills lab. You inquire
about using it for your course but are met with resistance from
other faculty members, who tell you that “there is no reason to
use simulation. We've always taught our content using written
case scenarios and we're doing just fine.”
1. Use Kotter's eight steps leading to successful change to
develop a plan to implement simulation for teaching team

concepts.
2. What information should you incorporate when developing
the scenario?
3. Unfortunately, students who experienced the scenario at 8
a.m. are sharing information with students scheduled later in the
day. Which INACSL standard addresses this issue and how can
you deter this behavior?
4. Which published document can assist you in clarifying
interprofessional competencies?
Pageburst Integrated Resources
Valerie Howard
Kim Leighton
Teresa Gore
The emergence of technology for educational purposes creates a
need for faculty and health science
educators to understand how to not only operate the technology
but also implement it within the
academic and service settings while still using sound aca
demic principles.
Objectives

1.Define the different types of simulation modalities available
simulation
3.Apply the Stan
dards of Best Practice: Simulation to the simulation lab
4.Discuss the use of simulation
-
based education in interprofessional experiences
6.Develop evidenc
e
-
based simulation activities for graduate
-
level education
Key Terms
Debriefing, 461
Fidelity, 455

Simulation, 454
Abstract
The use of
simulated learning experiences has rapidly emerged in
healthcare education as a method of
training healthcare providers in a safe environment without
subjecting patients to harm. Multiple
definitions of simulation
-
related terms exist, so the importance of
the use of standardized terminology is
Valerie Howard
Kim Leighton
Teresa Gore
The emergence of technology for educational purposes
creates a need for faculty and health science
educators to understand how to not only operate the technology
but also implement it within the
academic and service settings while still using sound academic
principles.
Objectives
1.Define the different types of simulation modalities
available

simulation
3.Apply the Standards of Best Practice: Simulation to the
simulation lab
4.Discuss the use of simulation-based education in
interprofessional experiences
6.Develop evidence-based simulation activities for graduate-
level education
Key Terms
Debriefing, 461
Fidelity, 455
Simulation, 454
Abstract
The use of simulated learning experiences has rapidly emerged
in healthcare education as a method of
training healthcare providers in a safe environment without
subjecting patients to harm. Multiple
definitions of simulation-related terms exist, so the importance
of the use of standardized terminology is
PAGE 471
university. A faculty member approaches you to “do” a
simulation for class. What information do you need prior to
developing the simulation? Provide a rationale for the
information needed.

Case Study
Your newly developed course has an objective that states: Upon
completion of this course, the learner will be able to
demonstrate interprofessional team building concepts. As a new
educator, you would like to include simulation as a teaching
methodology.
Patient Simulator in the corner of your skills lab. You inquire
about using it for your course but are met with resistance from
other faculty members, who tell you that “there is no reason to
use simulation. We've always taught our content using written
case scenarios and we're doing just fine.”
develop a plan to implement simulation for teaching team
concepts.
PAGE 471
1. You are a graduate teaching assistant at the local university.
A faculty member approaches you to
“do” a simulation for class. What information do you need prior
to developing the simulation?
Provide a rationale for the information needed.
Case Study

Your newly developed course has an
objective that states: Upon completion of this course, the
learner will be able to demonstrate
interprofessional team building concepts. As a new educator,
you would like to include simulation as a
teaching methodology.
After you are hired, you find a rare
ly used, high
-
fidelity Human Patient Simulator in the corner of your
skills lab. You inquire about using it for your course but are
met with resistance from other faculty
members, who tell you that “there is no reason to use
simulation. We've always taught
our content
using written case scenarios and we're doing just fine.”
develop a plan to implement simulation
for teaching team concepts.
PAGE 471
university. A faculty member approaches you to
“do” a simulation for class. What information do you need prior
to developing the simulation?

Provide a rationale for the information needed.
Case Study
Your newly developed course has an
objective that states: Upon completion of this course, the
learner will be able to demonstrate
interprofessional team building concepts. As a new educator,
you would like to include simulation as a
teaching methodology.
Patient Simulator in the corner of your
skills lab. You inquire about using it for your course but are
met with resistance from other faculty
members, who tell you that “there is no reason to use
simulation. We've always taught our content
using written case scenarios and we're doing just fine.”
develop a plan to implement simulation
for teaching team concepts.

Chapter 29 Simulation in Healthcare EducationValerie HowardKim.docx

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