Introduction

According to adult learning theory, participants learn well when they understand why they learn, and how new knowledge will be applied in real life.[1] Instructors can help the learner identify learning gaps, bridge the gaps, and acquire skills for continuous and life long learning.[2] It is irrelevant and useless to spend much time and effort teaching learners materials that they do not need. One of the ways for instructors to discover the knowledge gaps of learners is to administer a pre-course test, including knowledge testing and/or self-reported ability to perform skills of interests. Simulation-based education can be used to teach cognitive and psychomotor skills.

Function

Even though simulation-based medical education is gaining popularity in academic medicine, there is a scarcity of data on how instructors can run the scenario and moderate the discussion to address the specific gaps of learners. This article intends to describe different techniques that can be used by instructors to conduct the scenario and the debriefing based on the needs of the learners.

Curriculum Development

Though there are several concepts of curriculum development, Kern's Six-Step Approach to Curriculum Development is widely used to guide simulation-based curriculums.[3] Kern's six steps are as follows:

1. Problem identification and general needs assessment: The initial step aims at identifying the problem needing to be solved by an educational program. Issues range from individual to institutional to global healthcare problems. This step can be accomplished by using one or a combination of different methods, including literature or document review, interviews, Delphi methods, or surveys.

2. Targeted needs assessment: This step entails the identification of the specific needs of the learners that are relevant to their specific context. This requires understanding the baseline knowledge, skills, and attitudes of trainees relative to the context in which they work and live. Identification of specific needs allows the instructor to tailor the training towards addressing the specific needs of the learners. This results in an increased likelihood for the learners to implement new knowledge and skills in real life. One way of having a targeted needs assessment is to conduct mock codes or in-situ simulation. In-situ simulation is simulation activities that occur in the clinical environment.[4] In-situ simulation has the advantages of testing both the human factors and system factors that can impact patient outcomes.[4][5]

3. Goals and objectives: After identifying the needs and gaps in knowledge, the instructors set the learning goals and specific objectives. The goal may be broad, but the objectives need to be specific, measurable achievable, realistic, and time-bound. The objectives may target the cognitive, psychomotor, or affective level.[6]

4. Educational strategies: Educational objectives determine educational strategies. Simulation-based education has the advantage of offering the opportunity to teach cognitive, psychomotor, and affective skills. Educational strategies may be lectures, group discussions, simulation-based courses, and online courses.  While developing a simulation-based education curriculum, the instructor must create scenarios, set expected learner activities, and choose both assessment methods (observable behaviors of the learners), and the assessment tools (that will help the instructor to assess if learners have met the expected learning outcomes). The scenario can be geared towards procedural, psychomotor (technical), affective (non-technical skills), or both procedural and non-technical skills. 

5. Implementation: The implementation takes place in a simulation center, and it is run based on the learning outcomes and learners' actions. 

6. Program evaluation: Evaluation aims at assessing how learners met the learning objectives, if the program has achieved its goals, and if it was run as it was planned. Learner assessments may be either formative (assessment for improvement, usually done during the program) or summative (evaluation of knowledge gained, usually done after completion of the course).

Clinical Clerkships

Pre-briefing phases: For the simulation-based course to be successful, the instructor has to build a safe learning environment for the learners. During this phase, the instructor invites learners to reflect and share their thoughts during the simulation event. For the learners to remain engaged with the simulation, the instructor has to run the scenario based on the learners' actions; this is referred to as maintaining fidelity, both physical, conceptual, and emotional.[7] The instructor must ensure to learners that the session is not intended for their performance assessment, but their performance improvement. This concept allows the learner to feel safe to make mistakes and to reflect on their actions to improve. In addition to this, the instructor encourages learners to be respectful to their colleagues during the simulation session.[7]

Case facilitation during the scenario: Though instructors need to prepare how to run the scenario during the simulation, they also must remain flexible and adjust the flow of the scenario based on the learners' actions or lack thereof. Adjusting the scenario based on learners' behaviors improves the realism of the scenario. It helps learners to understand their performance and identify the gaps or strengths in knowledge, skills, and attitudes. Instructors have to adjust physiological and verbal responses based on the learners' actions. The beginning of the case may be the same, but the flow should vary based on how learners perform. In the end, the main goal of the simulation is for the learners to discover their strengths and weakness through actions, reflection, and discussion. Simulation offers the opportunity to try, fail, and learn from mistakes without compromising patient safety.

Guiding the debriefing after the case: Debriefing is an essential part of simulation-based education, it offers the opportunity for learners to reflect and discuss their performance in simulation and to identify how they can improve. The role of the instructor is to guide the discussion rather than directing it. The debriefing starts with the instructor asking learners to share their reactions to the simulation event. During this phase, the instructor identifies the topics that are most important to the learners and includes them in the debriefing plan.[8] After identifying the learners' agenda, the instructor must use strategies that promote self-assessment and explore the rationale for learners' behaviors. Plus, Delta debriefing technique has instructors invite participants to assess their performance. Debriefing with good judgment can be a useful approach to explore the rationale of the learners' behaviors.[9]

Several tools can help instructors assess the performance of the learners in simulation. The Non-Technical Skills for Surgery (NOTSS) rating tool is used to assess the observable non-technical skills of a surgeon, both in simulation or clinical environment.[10] The Team Emergency Assessment Measure (TEAM) is used to measure the non-technical skills of medical emergency teams.[11] In addition to these tools, there are multiple other tools for different specialties that are used to assess and give feedback on non-technical skills performance.[12][13] The instructor has to ensure to bridge the performance gap either through learners' reflection and discussion or through a didactic approach.[8]

Concluding: The instructor can conclude the debriefing phase by inviting learners to share their take-home messages from the simulation events. During this phase, the instructor has to find a balance between learner-driven take-home messages and the instructor's take-home message in order to ensure safe patient care.

Procedural Skills Assessment

Objective Structured Assessment of Technical Skill (OSAT) is one of the commonly used and validated tools to assess the procedural skills of the learners both in the clinical and simulation environments. OSAT is used for multiple surgical procedures, including open or laparoscopic, obstetric and gynecology, orthopedic, and cardiac surgeries.[14] In addition to OSAT, other tools such as the Global Operative Assessment of Laparoscopic Skills (GOALS), the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills, and other task-specific tools have been developed. They are used to assess procedural skills both in the clinical and simulation environments.[15]

Medical Decision Making and Leadership Development

Simulation is an effective method of teaching non-technical skills like leadership, decision making, situational awareness, communication, and teamwork to multidisciplinary healthcare providers teams.[16] While managing scenarios in the simulation, trainees get the opportunity to learn and practice not only technical skills but also non-technical skills. During the scenarios, the instructor can assess the non-technical skills of learners and use the observed behaviors in the debriefing as a way of introducing the learners' self-assessment and discussion about their performance.[8]

Clinical Significance

Instructors should use approaches that promote life-long learning. Given that healthcare providers are adult learners, educators must apply adult learning theories to engage them. Adult learners are more apt to learn when they participate in the learning process and have an active role in deciding what they will learn. Instructors and learners will both benefit from spending time interacting and discussing topics they each believe are essential to the learning process.[17] 

Enhancing Healthcare Team Outcomes

Delivering care to patients occurs in an environment that requires multidisciplinary practice and teamwork skills. Simulation-based instruction provides the opportunity to teach medical knowledge, clinical expertise, and interprofessional communication skills that will assist healthcare providers in working in a coordinated environment.[18] [Level 3]

Adult learners have different learning preferences than traditional learners. The use of multiple learning strategies and variation in clinical scenarios is associated with improved clinical skills and patient outcomes.[19][20] [Level 2]