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The Value of Simulation in Health Care: The Obvious, the Tangential, and the Obscure

Published:January 03, 2018DOI:https://doi.org/10.1016/j.ecns.2017.12.004
      A while ago, I was asked to speak about the value of simulation. With the increasing use of simulation in academic institutions and hospitals alike, there is a growing need for administration to determine whether the expense of setting up and maintaining simulation centers is viable. Coming from academic background, I did not think that I was qualified to discuss the return on investment in monetary terms, so I chose to look at simulation use in the health professions in terms of what value simulation has provided outside the direct return on investment models.
      Simulation use in the health professions is not new. There are many examples of simulation use in dentistry, nursing, and medicine that go back to the early 1900s. Regardless of the discipline, health care or otherwise, we are all conducting simulation for the same reasons and that is to reproduce an event or system before it happens or before the skills are required to engage in that system. We want to anticipate any problems or to find out if there are unanticipated issues that we might encounter. We simulate all sorts of things. Noise barriers to mitigate road noise, flight simulators, manufacturing, and model car crashes; we simulate to observe phenomenon and solve problems. We simulate as a way to experiment complex situations while minimizing risk. In health care, we simulate to improve patient safety and practitioner skill sets. So although we know why we simulate, the question still gets asked—what is the value of simulation, and is it worth it?
      This can be difficult to determine, as value can be subjective. Is it the return on investment or expectations? Can we break down the worth of simulation on a spreadsheet? Do we need to do this to prove that simulation has value? Or can the value of simulation be determined by patient safety outcomes? It likely is a bit of all the aforementioned. Irrespective of the reason, there is value to using simulation in the health professions, and I would like to highlight some of these reasons.
      Let us begin with the obvious. Many studies have found that simulation can improve patient safety (
      • Groves P.S.
      • Bunch J.L.
      • Cram E.
      • Perkhounkova Y.
      Development and feasibility testing of a patient safety research simulation.
      ,
      • Schmidt E.
      • Goldhaber-Biebert S.
      • Ho L.
      • McDonald K.
      Simulation exercises as a patient safety strategy: A systematic review.
      ). This is due to a variety of reasons, with repetition being a significant reason for improved team performance. The concept of deliberate practice, as described by
      • Ericsson A.
      • Krampe R.
      • Tesch-Romer C.
      The role of deliberate practice in the acquisition of expert performance.
      , is not only the quantity of practice but the quality of practice. This has influenced how we see simulation as more than a tool. Another obvious benefit is that of standardization. With standardization, you can ensure that all your participants have the same experience of, for example, caring for a deteriorating patient. The examples are numerous.
      With much literature outlining the obvious benefits of simulation, there are other areas that are somewhat tangential; however, they still point to the value of simulation. Think of the traffic that your simulation center receives. Tours of the classroom are just not that exciting. Bringing traffic through your laboratories attracts potential donors as well as makes your nursing program more visible. When the media want to take photos, where do they usually go? The media attention is courtesy of your simulation center.
      Assisting students in learning difficult concepts can be achieved with simulation. Have you tried teaching ethics or communication skills to undergraduate students? It is not the easiest thing to do. They can work in small groups on case studies, and they often say the right things, but in simulation, you can see how they actually apply some of the more abstract concepts. For example, we ran a scenario where the patient was palliative with a comfort care—advanced care plan status, and the daughter came in asking to insert a feeding tube because the patient was unresponsive and no longer eating. Of 120 students, their response was almost all the same—uncertainty. They answered these questions in class but found it challenging to apply the concepts in practice.
      Then there is the obscure, the value that simulation adds that we may not necessarily be aware of. One of the interesting aspects of introducing simulation into health professions education is that it created the need to evaluate this new pedagogy and provide evidence that it is, at minimum, not worse than what we are currently doing. In attempting to demonstrate that simulation can improve health care provider performance, we began to look at the appropriate environments to teach particular skills. In doing so, we see that the clinical environment is not the gold standard that we thought it was. In addition to studying simulation, there was a renewed interest in studying the clinical environment. In conducting a very cursory search of the literature, between the years 2000 and 2017 saw a fourfold increase in articles on clinical education than the previous 20 years, with more than half of those articles being written in the past six years. Although simulation itself has not increased the research of the clinical environments, it would go to reason that if simulation replicates clinical practice, there should be an increase in looking at what the clinical environment contributes to learning in the health professions.
      Going back to the initial question: What is the value of simulation? The gold standard that clinical skills can only be taught or learned in the clinical setting with live patients is being challenged, and by taking a healthy dose of skepticism, we are ensuring that the patient is the beneficiary of our planning, training, facilitating, and practicing. For me, therein lies the real value of simulation. It is not about return on investment or if someone likes it or not. It is about change and the value that comes with ensuring that current education practices benefit the patient. Simulation as it is currently known has been part of health professions education for the better part of 15 plus years, and I would like us to consider the following. Rather than ask “What is the value of simulation?” perhaps the question should be “What is the cost if we do not?”

      References

        • Ericsson A.
        • Krampe R.
        • Tesch-Romer C.
        The role of deliberate practice in the acquisition of expert performance.
        Psychological Review. 1993; 100: 363-406
        • Groves P.S.
        • Bunch J.L.
        • Cram E.
        • Perkhounkova Y.
        Development and feasibility testing of a patient safety research simulation.
        Clinical Simulation in Nursing. 2018; 15: 27-33https://doi.org/10.1016/j.ecns.2017.09.007
        • Schmidt E.
        • Goldhaber-Biebert S.
        • Ho L.
        • McDonald K.
        Simulation exercises as a patient safety strategy: A systematic review.
        Annals of Internal Medicine. 2013; 5: 426-432