Introduction

Curriculum refers to all the planned educational experiences that allow students to reach specific learning goals and objectives. It is also definable as activities that shape students' behavior. An educational curriculum's main components are content, teaching and learning strategies; assessment processes; and evaluation processes.

Simulation provides a learning environment that allows learners to integrate theoretical knowledge by participating in realistic clinical scenarios. Also, simulation offers the opportunity to meet learning objectives during debriefing.

Medical simulation has been shown to improve clinical competence across all levels in medical education. One of the main advantages of utilizing simulation in clinical training is substituting real patients for mannequins or task trainers. This substitution decreases the chances of harming patients when practicing procedures or clinical skills. Simulation is especially useful in this instance since clinical skill acquisition depends to a greater extent on practicing over theoretical learning.

Curriculum Development

Needs Assessment

The first step to building a curriculum that meets the desired learning objectives is identifying the problems or needs in a particular group that will receive education; this is a "needs assessment." In a medical simulation, the need assessment focuses on finding the clinical or procedural skills that need to be reinforced and identifying those where the simulated setting is more valuable in acquiring specific knowledge or skills.[1] A needs assessment can take place following a formal or informal method. A formal needs assessment involves applying an assessment tool for learners to self-identify educational needs. In an informal needs assessment, the teacher identifies the students' educational needs using knowledge about the context and learners' educational status.[2]

Learners Analysis

To provide valuable educational resources, the learners' characteristics must be analyzed before curriculum implementation. Knowing the audience or participants helps the teacher in the development and educational plan capable of covering the learners' needs. Some of the important characteristics are level of education, skills, limitation, and motivation level. 

Stablishment of Learning Objectives

Learning objectives in the context of medical education refer to the expected result after the educational experience. For instance, during peripheral intravenous catheter insertion training with a task trainer, one learning one of the learning objectives is: Upon completion of the theoretical and practical training for peripheral intravenous catheter placement, 4th-year medical students will be able to demonstrate the technique to the instructor using an IV-arm task trainer. Learning objectives have to be specific and utilize appropriate verbs. Benjamin Bloom designed a taxonomy of measurable verbs based on the assumption that some observable actions correlate with cognitive activity. Bloom's work helps the educational institution design learning objectives that aim for critical thinking, knowledge, comprehension, etc.[3] Also, a learning objective must explicitly outline who is performing the activity, describe the activity, and when to expect the result.

Goals and learning objectives are commonly confused terms. Goals are results to the expected at the end of an educational experience, and it usually refers to a long-term target. On the other hand, objectives are specific actions of results that occur as an immediate consequence of the educational activity.[4]

Selection of Instructional Methods

The instructional method refers to the educational activity that allows students to achieve the learning objective. Simulation per se is an instructional method, but it has different components and/or enhancing activities that can be combined to create an educational experience to complete specific learning goals. In general, simulation-based training offers active learning activities over passive learning. For example, simulated scenarios require the participant to be fully engaged with the situation to be able to analyze, make decisions, and take action. Likewise, debriefing after simulated scenarios is a versatile and active learning activity that can allow students to meet several learning objectives after one educational experience. 

The concept of debriefing has been widely used in the military to learn from past missions. Debriefing refers to the reconstruction of elements from past experience and identifying those elements that are considered appropriate or detrimental to each particular situation. The goal of debriefing in healthcare simulation is that participants identify their mistakes and appropriate actions during a clinical scenario. Also, it provides the opportunity to reflect, summarize, and analyze better actions and discover new insights applicable to future clinical practice.[5]

Educators can include other instructional methods in the curriculum, such as debates, discussions, task trainers, and virtual reality.

Assessing Learning

Tracking the learning progress is essential to evaluate the students and the simulation curriculum. There are several assessment methods with different values. In simulations, the most common assessing tools include confidence and performance self-perception, checklists, pre, and post-tests, knowledge tests, and group evaluation.

Evaluation of simulation activities:

Formative evaluation occurs during the educational activity and allows the teacher to assess the learner's knowledge, skills, and critical thinking. Formative assessment allows the teachers to evaluate the effectiveness of the instructional method used to achieve the learning objectives.[6] Also, it allows for immediate and continuous feedback or corrections during an educational activity or program. 

Summative evaluation: It occurs after completing the educational activity. The goal of summative assessment is to evaluate the extent to which learning objectives were met, and it is presented as an assigned grade or score. One of the main disadvantages of summative assessment is that it doesn't allow modification of the instructional methods because it is obtained after the end of the program, course, or educational activity.[7]

Procedural Skills Assessment

Procedures are a common denominator in medical practice. Some areas of medicine involve complex and risky types of procedures to be performed on patients. Simulation-based procedural skills training offers a safe environment where students can learn and practice procedures without representing a risk to the patient. This is particularly important for high-risk and low-volume procedures. Some of the important steps in developing a procedural skill include theoretical knowledge, instrumentation knowledge, instruction, teacher's feedback, and technique correction. 

Skills assessment represents an important tool to protect the patients by evaluating the learner's proficiency and capabilities. Assessment of procedural skills is not standardized, but different methods have been described to serve the purpose. These are some of the tools that can be used to assess procedural skills:

Questionnaires: The purpose of a questionnaire in simulation-based training is to obtain feedback on a perceived feeling of knowledge or comfort when performing a procedure. They provide valuable information about the perceived usefulness of the educational activity. Questionnaires are low-cost, easy to apply and interpret. However, this tool is not ideal for testing procedural proficiency since its basis is self-report. Validating questionaries can be challenging because of their subjectivity and concomitant biases.[8][9]

Objective Structured Assessment of Technical Skill (OSATS): The OSATS consists of observers evaluating a trainee performing a procedure and filling out a checklist containing the essential maneuvers or actions necessary for the specific procedure. This evaluation method allows the teacher to obtain a quantitive evaluation of the trainee's performance. When more than one observer is evaluating the procedure, training and standardization increase the interobserver reliability. OSATS are great tools to evaluate essential actions needed to perform a procedure. However, this method is not capable of assessing finesse or action quality.[10][11]

Global Rating Scale (GRS): GRS is an assessment instrument that contains items that are considered relevant to each procedure, and every item has a scale to grade it. GRS is a commonly used tool to assess surgical procedures along with OSATS and can serve to assess the finesse or characteristics of a specific surgical action. For example, GRS can evaluate force used in a movement, respect for soft tissue, instrument handling, the fluidity of movement, etc., with a rating scale like the Linkert scale. Even though OSATS and GRS are different measurement tools, they are often used together to achieve a comprehensive assessment.[12]

Motion Tracking and Analysis (MTA): The use of metrics to assess procedure performance has been widely used in surgical simulation. The most common metrics used to test a trainee are time and accuracy. These two parameters can provide objective information about expertise and familiarity with the procedure. MTA refers to the use of technology capable of sensing movements to evaluate and measure different motions. The main disadvantage of this method is the need to attach sensors to surgical instruments or wear equipment by the trainee, which can be impractical and/or cumbersome.[13]

Video Recording (VR): Video Recording of a trainee performing a procedure has many advantages. OSATS and GRS can be used to evaluate the trainee's performance by different observers at different moments and physical spaces. Also, the video allows the trainer to provide feedback to the trainee with images of the performance.[14]

Crowd-Sourced Assessment of Technical Skills (C-SATS): Crowdsourcing refers to a model used by an organization in which unbiased observers or "the crowd"  perform a service. In procedural skills assessment, a video recording of the performance is shared with the crowd, and then they are asked to evaluate the performance using an assessment instrument. The crowd is usually comprised of a significant number of observers trained to examine the videos using the same instructions. The size of the crowd significantly decreases interobserver variability and increases objectivity. Increasing evidence shows that the crowd assessment correlates with surgical experts, demonstrating that crowd-sourcing can be used as an objective evaluation method.[15]

Clinical Significance

Curriculum development is the main function of educational program leadership. The curriculum establishes and explains all the learning experiences planned to meet goals and objectives. Therefore, the curriculum defines all the different roles needed to deliver the intended educational experiences. Also, the establishment of leadership and administrative structure is a result of the curriculum design. 

Enhancing Healthcare Team Outcomes

Simulation implementation for healthcare education has been growing exponentially in recent years. Medicine has learned simulation from professions with a larger experience such as aviation, space exploration, and military. The growing focus on patient safety can explain the increasing integration of simulation to healthcare professions' educational curriculum, the search for alternative learning models to apprenticeship, and the use of technology to facilitate learning.

Teamwork is an essential factor in the various healthcare professions. Teamwork training and multidisciplinary practices are essential in simulation curriculum development since success depends on effective communication and reliability of team members, similar to aviation, military, and space exploration. Teamwork between healthcare providers from different professions is critical. Evidence presented by the Joint Commission showed that ineffective communication is a contributing factor to over 60% of the reviewed adverse events.[16][17] [Level 3]