This document provides an implementation handbook for integrating simulation and ICT-based learning into training and healthcare centres. The handbook was created based on the results of the SIMBASE European Project. It aims to define the steps for implementing an integrated simulation program and provide recommendations for incorporating simulation into professional healthcare education programs. The handbook is intended to support planning and guide individuals responsible for designing learning processes at universities, healthcare centers, and other professional training institutions.

1. IMPLEMENTATION HANDBOOK
FOR SIMULATION AND ICT-BASED
LEARNING IN TRAINING AND
HEALTHCARE CENTRES

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 not
Document 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 GOVERNMENT
OF 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 centres
Further collaboration: Grant agreement 2010-4079 / 001-001
IAVANTE: 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 Public
Copyright: © 2013, Consejería de Salud y Bienestar Social y Consorcio de SIMBASE
Edited by: Knowledge Innovation Centre (KIC). Malta.
Project number -511811-LLP-1-2010—1-ES-KA3-KA3MP
SIMBASE committee: Programme: Lifelong Learning Programme
1. Consejeria de Salud de la Junta de Andalucia SCJA ES Sub-programme: KA3 ICT
2. Laerdal Medical AS LM NO Call for proposals: DG EAC/41/09
Jorge Vilaplana Action: Multilateral projects
3. Faculdade de Ciencias de Saude, Unversidad de Beira UDB PT Sub-Action: N/A
Miguel Castelo Branco, Isabel Neto
4. Fundacion IAVANTE IAV ES
David Riley, Javier Vázquez, Iván Herrera
5. University of Duisburg-Essen UDE DE
Christian Stracke, Tatiana Shamarina-Heidenreich
6. National Institute for Quality- and Organizational
Development in Healthcare and Medicines GYEMSZI HU
Ildikó Szögedi
7. Postgraduate Deanery Wales PDW GB
James Ansell, Jared Torkington, Neil Warren, Peter Donnelly
8. Knowledge Innovation Centre KIC MT
Justin Fenech, Anthony Camilleri
02 03

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 42
04 05

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 that
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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. 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. 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 and
12 13

8. a public healthcare administration, the
latter providing the perspective of a public
healthcare body, the principle receiver of
healthcare professionals, and therefore
jointly responsible for their training.
This handbook has employed quantitative
and qualitative analysis methodologies
of critical success factors selected from
relevant publications.
c. Analysis, information processing,
synthesis and drafting of proposals.
Following an analysis of the information
gathered from the pilot, in which some
of the variables have not been open to
examination with the proposed level of detail,
and including the perspectives identified in
the reviewed publications, a committee of
international experts has clearly identified a
group of best practises and critical success
factors necessary for a effective, efficient
implementation of simulation as well as the
best methods for employing information and
communications technologies, which provide
support for our actions providing they are
correctly focussed. The objective of this
handbook is precisely that - to focus on the
steps that should be taken by a healthcare
centre (as training provider), a university, or
a training centre in order to ensure success
with the assistance of ICTs.
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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 clinical
16 17

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 as
organisation and educational context be the implementation. to practise. The director of a university an opportunity to integrate competency
taken 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 simulation
terms 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 acquaint
The impact of professional training this depends on the level of commitment Therefore, we should bear in mind the ourselves further with all the elements that
in 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 powerful
to guarantee impact, we must have teachers, instructors and students alike. to facilitate translational elements to tool for innovation and research into
control over the aspects relating to the the workplace and, as a result, facilitate human behaviour for advancement in the
detection 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 service
the 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 its
provide the best response to healthcare as the elements that directly affect them into practise using the same materials professionals, these may also provide a
needs. 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 are
On many occasions a particular bear this in mind at the time of planning, centres, the incorporation of simulation the best qualified to detect the necessity
healthcare requirement which gives designing or implementing an activity, prior to practise with real patients is a key for new simulators, and may also be the
rise 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 the
professional competency gets lost during proposal and dissemination of design
the 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 system
We must emphasise the importance of student, we must take into consideration the learning space, namely, instructor itself, are prepared for it and are willing to
direct 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 the
as this will surely help us to find more direct remainder of the levels of responsibility
routes that will free us of unnecessary within the training centre. Simulation as a resource for
baggage and focus our efforts on the most promoting innovation and
efficient way to achieve our objective. This On another level, the clinical service excellence in education.
exercise alone greatly strengthens the managers must consider the activity
alignment of the training activity with real- as both necessary and pertinent, which Correct use of simulation methodology
life requirements, which is precisely the requires, on the one hand, recognition demands its incorporation as a further
revolution 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. 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 must
20 21

12. be work spaces available for the performance time required for these practises. For this
of deliberate practises or simulations and reason, the on-going training programmes
these aspects must be incorporated into must be consistent with these requirements
the qualification requirements. In many and should employ a methodology that will
cases, these may simply refer to the same guarantee their effectiveness and impact.
work spaces, or even the same resources,
when used outside the normal activity Suitable training with simulators should be
timetable of the centre, or service. For an element that is taken into consideration
the training of more technically complex in professional recognition, in other words,
competencies, agreements may be made in their qualifications, or accreditations, as
with other centres in order to make the best well as in their careers. In any case, the
of the significant investments made, where centres where the professionals carry out
possible. their duties should bear this in mind.
Similarly, training providers should offer
c. Healthcare centres for on-going training which, where required, includes
professional training. simulation, particularly when this is difficult
to provide in healthcare centres due to the
Over the course of a professional career, significant investment required. They should
suitable 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. All
competencies required for the performance this requires the configuration of resource
of their duties and for their professional networks that allow the application of a
development. scaled economy to the training, making
it more accessible to the professionals,
If they wish to take into consideration centres and healthcare systems that are
the content of the previous section, obliged to bear the financial burden of the
healthcare centres must know, or define, training.
the competencies required by their
professionals in order that they may carry
out their duties. They must also know which
of these require performance of deliberate
practises with a certain frequency.
This knowledge should be reflected in the
organisation of services, resources and
work spaces, so that the centre, in as far as
possible, may provide the work space and
22 23

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, as
24 25

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 to
systems, unless they are considered professionals. established these days are based precisely maximise learning and ensure retention
necessary. 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 developed
information 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 their
Finally, 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 provide
should 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 their
professionals, as these may facilitate effective method of attaining learning knowledge, develop their skills, and acquire • Encourage questions from the
the orientation towards the healthcare objectives. It is an excellent complement the experience necessary to complete students relating to their individual
requirements. 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 prior
Actions: 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. 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 widely
3. 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 of
The implementation of simulation has or training units, and the simulation of this are the simulators for training cost/benefits, sources and recovery
a technical component and being able models should be adapted according to basic or advanced cardiopulmonary methods. For this purpose we should
to rely on all the required resources these requirements. resuscitation, or the primary training make use of platforms that allow us to
may influence the level of satisfaction phase for endoscopic surgery using register all the information required
of 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 and
process. 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 the
means at its disposal, namely, simulation higher than those of other methodologies. availability of suitably trained instructors
rooms, instructors and the simulators Our results have shown that, in general, and an organisation that will provide the
themselves. 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 is
be orientated in accordance with the reflected in a variety of publications.
28 29

16. 4. Design of the training activity 5. Simulation fidelity As many authors say, the quality of
simulation programmes depends more
A 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 with
clearly reflect the situation we are trying well employed and highly regarded during the teachers and the context of the
to reproduce for the performance of this pilot. The simulation technologies have organisation, than with the level of fidelity
deliberate 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 to
The objectives and required results training in surgical and primary care measure the results of simulated learning
should be precisely defined. This requires competencies, part-task trainers and but, in the end, what we really need to
identification of the competencies to video analysis have been used and, in gauge is behaviour in real-life situations
be 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 learning
The course script should be adapted to
the student profiles and to the previously Furthermore, there are many authors These days, group learning of the
identified requirements. It should be clear (Issenberg et al. 2005; McGahie et healthcare team is recognised as one
to the student, or professional, that this al. 2010) who are of the opinion that of the objectives to be attained within
practise is just another element in their one of the best practises in simulation the educational framework of future
educational 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 are
Actions: 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. This is one way of making an effort to 7. Feedback Actions: and group levels, establishing the best
facilitate transfer to clinical practise and moments for one or the other.
to patient care. Healthcare is a “team Feedback consists of the application of a • Incorporate reflection as a diagnostic
sport”, 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 much
of common objectives and help clarify the requiring improvement. as possible.
roles played by each member of the team. Our experience has demonstrated the
It helps raise awareness of the situation effectiveness of the use of a variety • Incorporate reflection into training • Store all possible results and established
and of the importance of leadership and of feedback techniques specifically as a complementary element to objectives during the reflection phase
mutual support, all of which is reflected in orientated towards improving the clinical feedback, allowing the learning to in order to facilitate future analysis in
the 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 simulation.
training should be incorporated throughout • Ensure that the organisation
the training cycle as a complement to the The reflection phase is of vital importance takes into consideration a learning 8. Deliberate practise
individual 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 important
with opportunities to practise teamwork
learning and performance results. The property which should characterise
skills in simulation environments and,
standards and suitable methods should • Ensure that the team participants are simulation sessions in order to train, refine
subsequently, transfer these to patient
be established for each of the expected relaxed, confident and comfortable and conserve acquired knowledge, skills
care.
results. during the reflection phase. and attitudes through the promotion of
Actions: 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. 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. 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 care
technical skills with others skills such as behaviour in the operating room. • Take into consideration the factors
teamwork 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 acquired
We 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 the
and 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 trained
recommended in certain publications, the skills acquired have been applied to the physical surroundings, suitable competencies and the role of the
set 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 the
improvement and retention of acquired Due to time restraints, we have not expectations of the students. Analysis of • Evaluate the importance of
competencies over time. This factor is been able to study this as part of our the environmental and contextual factors communication and teamwork skills
closely 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 relevant
The 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 on
the 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, the
the objectives and results to be attained
influence of the confidence acquired
by the organisation. In this manner the Bearing this in mind, the inclusion of
Authors such as Kuduvalli (2009), Fraser and encourage awareness of the
organisation will promote and emphasise questionnaires from models such as
et al., and Sturm et al. (2008), have shown limitations that still exist
their 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 a
Actions. clinical learning.
life clinical environments improves the level fundamental variable in the evaluation
1 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 of
2 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. 12. Measuring the results conditions, after extensive training
and with clearly defined measurement
Measurement of results is essential criteria.
in the implementation of a simulation
programme, as it is in other aspects of • Responses of the students, either
medical education. to multiple choice questionnaires or
on the basis of written examinations.
In general, the results to be taken into Direct measures of students
consideration are, first of all, evaluation learning outcomes are preferred
of performance, in other words, as they more reliable and less
measurement of the increase in the influenced by individual responded
competencies acquired by the students. characteristics2.
Secondly, measurement of the transfer
to real-life situations, in other words, • Simulator recording and filing of the
whether or not the students transfer behaviour of the students during
what they have learned to clinical training.
practise. Finally, we need to identify the
changes in healthcare that result from In the second case (transfer
the training, and whether or not these measurement), this should be done
lead, directly or indirectly, to improved via measurement of: 1) transfer of
results in healthcare. competencies acquired to clinical
practise, 2) the number of times this is
In the first case (performance performed, and the level of expertise,
measurement) it is essential to 3) the level of confidence shown by the
have reliable information about the student in the use of the technique, 4)
competencies trained and how these have The students’ perception of the level of
improved, and to develop measurement improvement in patient care, 5) the level in the workplace. depth in the SIMBASE Impact Evaluation
tools 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 the
in the evaluation of simulation-based of necessary resources, the existence of level of satisfaction of the patient with the
learning results, and which should always This can be done using the following an open, positive attitude of the students attention received, the level of improvement
be 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. 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 have
2. 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-depth
3. 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 simulation
4. Define the evaluation team who will implementation plan
apply the tools practise34.
While this factor requires more in-depth 3 Place the simulation implementation
5. 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 standards
6. 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 of
13. Organisational and educational communication within the organisation, 6)
context the local remuneration system, 7) cultural
barriers, 8) the resistance to change in
The inclusion of the organisational the organisation and 9) the existence of
and educational context as a critical an open system that considers change
success factor for the implementation of as strategic and is capable of providing
simulation, in conjunction with orientation feedback of the results of the simulation
towards the training and organisational to the organisation itself.
needs, is one of the objectives of this
handbook. 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

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http://www.qed-info.de/downloads
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38:1006-12. Seymour NE. (2008). VR or OR: a review of the evidence that virtual reality simulations
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Epstein, Ronald M. (2007). Medical education - Assessment in medical education. NEW
ENGLAND JOURNAL OF MEDICINE, 356 (4), 387-396 WHO. (2012). World Health Organization. Consulta en: http://www.who.int/en/
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23. Adress: Consejería de Salud y Bienestar Social.
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Telephone: +34 955048207
Mobile Phone: +34 677906032
Email: info@simbase.co
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