Introduction

A simulation scenario is an artificial representation of a real-world event to achieve educational goals through experiential learning. Designing an effective simulation scenario requires careful planning and can be broken into several steps. Simulation scenarios are designed to assess, educate, and help learners to self-identify gaps in their understanding of material or application of knowledge. Simulation may also be used to address patient safety issues, clinical cases, teamwork opportunities, communication challenges, procedural competencies, and leadership skills. Designing an effective scenario requires planning, including knowledge of the target learners, goals and objectives, intended outcomes, and context. Knowledge of educational principles, including Bloom's Taxonomy, which describes the progression from novice to expert, helps develop educational goals. Scenario design must also include consideration of the level of fidelity, use of props, moulage, embedded participants, simulators, and standardized patients.[1] All simulation scenarios should be designed to address a perceived knowledge or performance gap. The finished scenario should take place out in a safe and nonjudgemental setting.

Function

Simulation design is viewable as a professional stage production. A well-designed scenario includes a script with instructor document, simulation tech document and supply, and equipment needs. The director/writers are the faculty; production staff includes education specialists, simulation technicians, and visual effects (moulage). The audience is the learners. Simulation scenario templates or storyboarding should serve as a tool in designing simulation scenarios. Simulation scenarios used for assessment should be at a level that the learners should perform well. The designs of scenarios for educational purposes should be at a more challenging level, to provide for growth.

Writing a Simulation Scenario

The scenario must be approached systemically, including intended outcomes, context, and goals/objectives. When constructing a simulation scenario, begin by identifying the learners, followed by the desired outcomes; this must include the knowledge and behaviors the learner is to acquire after participation in the simulation. After the outcomes have been set, determine the context, including the type of case/patient, fidelity, equipment, and supplies. Then construct goals and objectives. Identifying the relevant teaching points the learners should acquire and remember. Goals are what you want the learners to learn. Objectives are what you expect the learner to be able to do at the end of the simulation. Use the SMART template to construct specific goals and objectives.

• S-specific            
• M-measurable
• A-achievable
• R-relevant
• T-timely

Specific

• What do you need to achieve?
• Who needs involvement to accomplish the goal?
• When do you want to have your goal finished?
• Why exactly should you achieve this goal?

Measurable

• How can you measure progress and know if you’ve successfully met your goal?

Achievable

• Are you capable of achieving the goal?
• Do you have the needed skills?
• Can the learners meet the goals through simulation?

Relevant

• Why should you achieve this goal?
• What is the impact?

Timely

• What is the due date of your goal?
• Can the goal be achieved until this date?
• Can the learning objectives be met in the time allotted for the scenario?

Scenario Development

Multiple steps need to be addressed to construct a successful simulation.[2]

Preparation includes the case, case stem, flow, role and scripts, resources, pre-briefing, debriefing, and dry run.

1. Simulation: Simulation is a live-action production with instructors, learners, simulation technicians, roles and scripts, debriefing, and evaluations.
2. Design:  Put ideas on paper; two methods are possibilities. First, storyboarding and second, a scenario design template. A storyboard is a graphic organizer of a scenario in the form of illustrations displayed to allow visualization. A scenario design template is a written description and flow of the case. Multiple scenario templates are available online or have published, including CASST (California Simulation Alliance Simulation Scenario Template), HPSSDPCT (Human Patient Simulation Scenario Development Patient Care Template), SDT (Simulation Design Template), SIGSST (Special Interest Group Simulation Scenario Template), TSPD (Template for Simulation Patient Design), and Teach Sim. [1]  The templates include chief complaint, PMH, medications, allergies, data summary, labs, imaging, and exam, along with the following sections. The scenario design must also include branch points to allow for a planned response.
3. Pre-brief:  A short introduction to the simulation is key to ensuring a meaningful learning experience. The pre-brief also introduces learners to the concept of simulation, orients them to the simulation environment, equipment, and embedded participants. It allows for expectation setting for performance, confidentiality, and is a crucial component to a practical simulation experience. The instructor should also disclose the purpose of the simulation scenario upfront: education versus assessment. Simulation scenarios for evaluation should be at a level of difficulty greater than the learner should be expected to manage well to allow for growth. Simulation scenarios designed for assessment should be at the expected level of performance for the person evaluated. 
   1. Instructor document:  includes primary goals and objectives, case summary, instructor notes, including ideal flow, anticipated learner mistakes, branch points, tips to keep scenario running, and hard stops.  A critical action checklist, as well as a list of critical errors, can be utilized to assess and document the learner’s interactions.
   2. Simulation technician document: includes equipment required, props, fidelity, including standardized patients, moulage, and mannequins. The goals and objectives dictate the appropriate level of fidelity. For example, if the goal is to teach learners to place a central line, then a low-fidelity approach using a task trainer is appropriate. If the goal is the effective management of a deteriorating patient with a team, then a high-fidelity immersive scenario would best meet the objectives.[3]
   3. Roles and scripts: are needed for standardized patients, mannequins, or embedded participants. It is in the details, what words to say, what to avoid, what emotions do you want to portray, and behaviors you wish to exhibit. 
   4. Debriefing: at the end of the scenario, a debrief is undertaken to review, emphasize, and provide feedback covering the goal and objectives; this is a guided period of self-reflection that should take approximately twice as much time as the scenario itself.
   5. Final planning: should include meeting with all involved to review the scenario, goals and objectives, critical actions, expected outcomes, resources, and production needs. Schedule a dry run/rehearsal to optimize the process with attention to time and flow.

Clinical Significance

The ultimate goal of experiential learning through simulation is to improve clinical practice and patient safety. Several studies have analyzed the outcome and benefit of simulation in healthcare, including improved teamwork, procedural skills, leadership, communication, and clinical outcomes.

• Okuda reviewed the utility of simulation in medical education with a focus on the evidence.[4]
• Barsuk showed residents involved in simulation-based learning performed thoracentesis with low rates of complications.[5]
• Schmidt-Huber demonstrated leadership skills developed in simulation training.[6]

Pearls and Other Issues

A successful scenario must be clean and concise, including:

• Education goals and objectives
• Intended outcome
• Critical actions checklist
• Simulation set-up
• Case narrative
• Scenario flow diagram with branch points
• Instructor notes
• Debriefing plan

Additional steps for scenarios:

1. Design with a story-board or a scenario builder template.
2. Simulation scenario design is best completed in a stepwise fashion focusing on intended learners, goals and objectives, gaps to fill, level of fidelity, feedback, and didactics.
3. The goal of an educational scenario is to make it challenging enough to be engaging, but not so challenging that it is frustrating. Know your audience.
4. Dry run/rehearsals are key to success.
5. Allow enough time for debriefing sessions; this is the most important aspect, and simulation without debriefing solidifies rather than corrects mistakes and misconceptions.
6. Use feedback for the learners and participants to modify and fine-tune scenarios for future success.

Enhancing Healthcare Team Outcomes

Simulation education crosses all fields and disciplines in health care, from the secretary, nurse, tech, administrator, physician to the chief of staff. Simulation-based education correlated with small to moderate patient benefits regarding outcomes in a systemic review by Zendejas.[7][8]