Introduction

Healthcare education is more complex now than ever before. Evolving practice patterns, learner time constraints, and the constant influx of new medical information have made it increasingly difficult for educators to expose trainees to the breadth and depth of clinical experiences necessary to develop proficiency and expertise.[1] Also, the growing emphasis on patient safety has made it ethically challenging for trainees to “practice” on actual patients without first gaining experience elsewhere.[1][2] 

Medical simulation has emerged as a powerful instructional technique that can replicate or amplify patient care scenarios through guided, interactive experiences and allow for feedback and assessment without putting real patients at risk.[3] These characteristics, combined with recent technological advancements that have increased simulator fidelity and availability, have led to widespread acceptance of simulation-based training as an integral component of medical education across many disciplines in healthcare.[4]

Despite its growing popularity, different learners may have markedly disparate levels of experience with and acceptance of simulation as a training modality. As such, orienting learners to the medical simulation environment is a critical step in enhancing learner engagement and providing a safe and effective educational experience.[5][6][7]

Function

There are a number of potential barriers to providing effective experiential learning in the medical simulation environment. Some learners have no prior exposure to simulation, while others may have preconceived understandings of how to behave in the simulation environment based on their previous experiences. These participants may feel misled or humiliated if their expectations for the simulation session differ from those of the instructors and staff.[8]

Learners may also find the realism of the simulation problematic, which can negatively impact their willingness and ability to immerse themselves in the fictional scenario and fully engage in the learning activity. Additionally, participants may have concerns about the logistical details of the simulation exercise, which can distract them from focusing on the learning objectives of the session. Finally, and perhaps most importantly, learners may feel exposed by the simulation experience in a manner that threatens their professional and social identity, which can lead to defensiveness and resentment.[5]

Educators can directly address many of these potential threats to learner engagement by orienting participants to the medical simulation environment.[7] This introduction, also known as the “prebriefing,” sets the tone for the entire learning experience. It allows instructors to review the goals and expectations for the simulation, collaborate with participants to optimize the realism of the simulated environment, clarify the logistical details of the session, and communicate their commitment to respect learners.[8] The simulation orientation helps to establish a psychologically safe context for learning, known as a “safe container.”[5]

In such a setting, learners can fully engage in a challenging educational experience, venture beyond their intellectual and interpersonal comfort zones, and reflect on all aspects of their performance without worrying that they will be shamed or embarrassed.[5] Thus, an effective prebriefing enables educators and learners to take full advantage of the immersive learning experience provided in the simulation environment.

Issues of Concern

Instructors should conduct a complete orientation to the simulation environment at the start of each simulation session.[9] If the session consists of multiple cases or modules, instructors may provide additional prebriefing at specific time points to orient learners to elements that are unique to certain scenarios.

For learners who will participate in simulation as part of a larger training program (e.g., medical school, nursing school, medical residency), an initial orientation should ideally take place at the beginning of the program to lay the foundation for the many simulation sessions that will follow. Some educators may choose to record a video or provide reading materials to standardize the orientation process. However, these strategies should not replace a live prebriefing, as learners must receive an opportunity to voice their concerns and ask clarifying questions about the simulation experience.[6]

Curriculum Development

As part of the orientation to the simulation environment, educators should clarify the objectives and expectations for the simulation. When learners clearly understand what to expect and what is expected of them, they are more willing to engage and more likely to meet those expectations.[5] Instructors should start by introducing themselves and describing their role in the session, which might include conducting the simulation scenario, facilitating the debriefing, or serving as a resource in a specific area of expertise. It may also be beneficial to invite learners to describe their prior experiences with simulation and explore their personal goals for participating in the current session.

Educators should then state the intended learning objectives of the course.[10] Additionally, they should specify the level of performance that is expected from the learners. For example, resident physician learners might be expected to recall the correct doses of certain resuscitation medications. In contrast, pre-clinical medical student participants might be permitted to consult a pharmacist or ask for the “standard” doses of these medications to be administered. Instructors should also clarify how they will assess the learners’ performance. Formative assessment is typically a low-stakes process in which educators monitor a learner’s knowledge or performance gaps and provide targeted instruction and ongoing feedback to close these gaps.[11] In contrast, summative assessment is generally a high-stakes evaluation of a learner’s competence that may impact their professional advancement.[12] Being transparent about the type of assessment that will take place helps to build trust between instructors and trainees and is critical to establishing a psychologically safe context for learning.[5]

Instructors should also discuss matters of confidentiality with the simulation participants. This may include a review of who will be observing the simulation activity and who will be informed of the learners’ performance. Faculty should obtain permission from learners if they wish to record or conduct research on the session. At the same time, participants should be instructed to refrain from divulging the details of the simulation experience to other learners. Addressing these privacy issues provides learners with clear expectations and empowers them to fully engage in the simulation and debriefing.[6]

After reviewing the session goals and expectations, instructors should collaborate with learners to optimize the realism of the simulated environment. First, it is important to establish a “fiction contract,” an explicit agreement between faculty and participants to contribute to the success of the simulation experience.[5] As part of this contract, educators should acknowledge that the simulated environment will not be identical to real life due to resource and technological limitations, but pledge to make the experience as real as possible. In return, learners should acknowledge that they might act differently in the simulated setting than in an actual clinical environment, but commit to trying their best to act as if everything is real.[13]

Next, instructors should provide an orientation to the physical components of the simulation environment. This should include a detailed description of the features and limitations of the various simulation technologies (e.g., mannequins, task trainers) that might be utilized in the simulation exercise.[14] It may be beneficial to give learners the opportunity to inspect the simulators (e.g., auscultate lung sounds, palpate pulses, test pupillary reactivity) to gain first-hand experience with their functionality before the start of the learning activity.[9] Instructors should also introduce learners to any other relevant items within the simulation environment (e.g., code carts, monitors, medications).[15]

The faculty should provide clarification on the learners’ roles within the simulated environment.[10] Learners will typically participate in simulation scenarios as themselves. However, learners who are asked to assume a different specialty, profession, or level of training (e.g., a nursing student who is expected to act as an anesthesiologist) should receive adequate guidance on how to function in this unfamiliar role.[6] Instructors should also delineate how participants should interface with actors in the simulation environment. Specifically, it is important to remind learners that the actors are doing their best to simulate individuals from an actual clinical setting. As such, they will portray a realistic set of knowledge, skills, attitudes, and limitations. Learners should be reassured that the actors are generally there to assist rather than mislead them. Finally, instructors should inform learners that there may be other personnel available who are not physically in the simulation environment (e.g., pharmacist, hospital administrator, poison control center) and specify how they can call upon these additional resources during a scenario. 

Another key element of the prebriefing is to review the logistical details of the simulation session.[5] This step helps to minimize distractions and allows participants to focus on the educational aspects of the simulation and debriefing. Instructors should delineate what learners may wear to the simulation environment, what they should bring versus what is provided (e.g., stethoscopes), and whether they are permitted to use their smartphones or other cognitive aids. Next, instructors should provide an overview of the schedule for the session, including the timing and duration of the simulation cases, debriefing, breaks, and any other relevant activities.[9] 

Faculty should also orient learners to the physical space in which the simulation experience will take place. It is important to highlight the specific locations of the simulation scenario and the accompanying debriefing, so that learners can move efficiently from one space to the next and minimize the gap time between their performance and the subsequent review of that performance.[8] Also, instructors should point out the locations of bathrooms and breakrooms, inform participants about the availability of food or drink, and provide accommodations for individuals with physical disabilities.[5]

Some learners must temporarily suspend their clinical work to participate in the simulation session. As such, instructors should clarify what learners should do if they receive pages or phone calls related to the care of real patients.[16] Faculty should also review the protocols for responding to unanticipated events in the simulation environment, such as a major technical malfunction or a disaster that threatens learner safety (e.g., a building fire, earthquake).[5]

Finally, the orientation to the simulation environment should include a promise to respect learners’ intentions and perspectives.[5] Instructors should pledge to hold the belief that the participants are intelligent, competent, but imperfect individuals who are motivated to learn and improve. At times, the simulation experience will challenge learners to function near the limits of their intellectual and interpersonal abilities. Learners should be reassured that the ensuing debriefing will not simply enumerate their “right” or “wrong” actions. Instead, educators and learners should collaboratively investigate the thought processes behind these actions in order to bridge performance gaps.[17] This commitment from instructors helps to establish a psychologically safe context in which learners can fully engage in the simulation and debriefing without feeling humiliated or threatened.

Clinical Significance

Simulation-based training has become an important component of medical education across many specialties and disciplines in healthcare. Providing trainees with an orientation to the medical simulation environment is an essential step in maximizing their engagement in the educational experience.[6][18] This prebriefing allows instructors to clarify the goals and expectations for the simulation, establish a “fiction contract” with learners, review the logistical details of the session, and express their commitment to respect learners’ efforts and perspectives.[5] The simulation orientation helps to build a psychologically safe setting in which participants can become fully immersed in experiential learning.

Enhancing Healthcare Team Outcomes

To provide safe and effective patient care, medical professionals must utilize highly organized team-based strategies. There is abundant evidence from a wide range of healthcare disciplines indicating that simulation is an effective instructional technique for training and assessing teamwork behaviors, especially in high-risk, high-stress environments.[19][20][21] It is becoming increasingly clear that orienting learners to the simulation environment helps them prepare for and engage in teamwork training.[6][22] As such, structured prebriefing is a critical component of simulation-based training aimed at enhancing team performance.