Abstract
KEYWORDS
Standard
Background
- Barsuk J.H.
- Cohen E.R.
- Feinglass J.
- McGaghie W.C.
- Wayne D.B.
- Draycott T.
- Sibanda T.
- Owen L.
- Akande V.
- Winter C.
- Reading S.
- Whitelaw A.
- O'Brien J.E.
- Hagler D.
- Thompson M.S.
- 1Simulation-based experiences (SBE) should be designed in consultation with content experts and simulationists knowledgeable in best practices in simulation education, pedagogy, and practice.
- 2Perform a needs assessment to provide the foundational evidence of the need for a well-designed simulation-based experience.
- 3Construct measurable objectives that build upon the learner's foundational knowledge.
- 4Build the simulation-based experience to align the modality with the objectives.
- 5Design a scenario, case, or activity to provide the context for the simulation-based experience.
- 6Use various types of fidelity to create the required perception of realism.
- 7Plan a learner-centered facilitative approach driven by the objectives, learners’ knowledge and level of experience, and the expected outcomes.
- 8Create a prebriefing plan that includes preparation materials and briefing to guide participant success in the simulation-based experience.
- 9Create a debriefing or feedback session and/or a guided reflection exercise to follow the simulation-based experience.
- 10Develop a plan for evaluation of the learner and of the simulation- based experience.
- 11Pilot test simulation-based experiences before full implementation.
- •Simulation designers should have formal or informal training in simulation pedagogy and practices.
- •Suggested methods for developing competency include (but are not limited to):
- ○Joining professional simulation organizations.
- ○Incorporating the Healthcare Simulation Standards of Best PracticeTM (HSSOBPTM).
- ○Literature survey and review.
- ○Mentorship and networking.17.,18.
- ○Formal coursework or certification.18.,19.
Park, C. S., Murphy, T. F., & the Code of Ethics Working Group (2018). Healthcare simulationist code of ethics. Retrieved from http://www.ssih.org/Code-of-Ethics
- ○Simulation conference attendance or workshops.17.,18.
- ○Continuing education offerings focusing on pedagogy or andragogy.
- ○
- •Be knowledgeable of ethical standards of simulation-based experiences and adhere to the Healthcare Simulationist Code of Ethics19.(Follow the HSSOBPTM Professional Integrity).
Park, C. S., Murphy, T. F., & the Code of Ethics Working Group (2018). Healthcare simulationist code of ethics. Retrieved from http://www.ssih.org/Code-of-Ethics
- •Content experts should have a general knowledge of simulation and scenario design principles, debriefing methods, and evaluation approaches.18.
- •Follow the HSSOBPTM Professional Development.
- •The needs assessment may include analysis of:
- ○Underlying causes of concern (e.g., root cause or gap analysis).
- ○Organizational analysis (e.g., Strengths, Weaknesses, Opportunities and Threats analysis).
- ○Surveys of stakeholders, learners, clinicians, and/ or educators.
- ○Outcome data (e.g., from pilot testing; certification or licensure exams, previous simulation-based experiences; aggregate health care data; patient safety data).
- ○Standards (e.g., certifying bodies, rules and regulations, practice guidelines).
- ○
- •The needs assessment includes examining knowledge, skills, attitudes, and/or behaviors of individuals; organizational initiatives; systems analysis; clinical practice guidelines; quality improvement programs; and/or patient safety goals.
- •Use the needs assessment results to guide the development of an overarching goal or broad objective for the simulation, which directs the designer(s) in the development of simulation-specific objectives (Follow the HSSOBPTM Objectives and Outcomes).
- •Use the results of the needs assessment to create relevant, innovative, and interactive simulation-based experiences that aim to:
- ○Enhance curriculum in the classroom and/or clinical areas.
- ○Provide just-in time training in the clinical practice setting.
- ○Provide opportunities for standardized clinical experiences.
- ○Address relevant and identified competencies.
- ○Improve the quality of care and patient safety.
- ○Promote readiness for clinical practice.
- ○
- •Develop broad and specific objectives to address identified needs and optimize the achievement of expected outcomes. These objectives provide a blueprint for the design of a simulation-based experience.
- •Use broad objectives to reflect the purpose of the simulation-based experience and are related to organizational goals.
- •Create specific objectives for learner performance measures.
- •During the design phase, determine which objectives will or will not be available to the learner(s) before the experience. For example, it may be appropriate to disclose general information and context for the learner (care of a postoperative patient), but specific critical actions (interventions for sepsis) may not be disclosed until the debriefing session. Objective disclosure will be determined by the overall purpose of the simulation-based experience.
- •Follow the HSSOBPTM Objectives and Outcomes.
- •Develop the simulation-based experience format based on the needs assessment, resources available, learning objectives, the targeted learners, and the type of assessment or evaluation method.
- •Choose a theoretical and/or conceptual framework20.,21.,22.based on the identified purpose and the targeted learners (e.g., adult learning, inter-professional teams.23.
- •Select the appropriate modality for the simulation-based experience. The modality is the platform for the experience and includes simulated clinical immersion, in situ simulation, computer-assisted simulation, virtual reality, procedural simulation, and/ or hybrid simulation. These modalities may incorporate, but are not limited to the following: standardized patients, manikins, haptic devices, avatars, partial task trainers, and so forth.24.
- •Develop all simulation-based experiences to include a starting point, structured learner activities, and an endpoint.
- ○The starting point represents the patient's initial circumstances or situation when the learners start their engagement in the simulation-based experience.
- ○Structured activities are designed for learner engagement (e.g., a simulated case or an unfolding scenario, and/or psychomotor skill teaching/evaluation).
- ○The endpoint is the stage at which the simulation-based experience is expected to end; usually, when desired learning outcomes have been demonstrated, time is exhausted, or the scenario can proceed no further.
- ○
- •Design the scenario, case, or activity to include:
- •A situation and backstory to provide a realistic starting point from which the structured activity begins.
- ○The complete picture of this context may be given verbally to the learners, found in the patient's file, or be revealed if requested through adequate inquiry.
- ○
- •A script for a scenario or case is developed for consistency and standardization to increase scenario repeatability/reliability.
- ○Variation from the planned dialogue may add distractions that could interfere with the objectives and affect the validity and/or reliability of the scenario or case, especially when the activity is expected to be run with consecutive groups of learners.
- ○
- •Clinical progression and cues provide a framework for the advancing of the clinical case or scenario in response to learner actions, including standardization of cues to guide the learner(s).
- ○Cues, if used, should be linked to performance measures and used to refocus learners when they stray from the intended objectives.28.
- ○Cues can be delivered to learners in a variety of ways, including verbally (e.g., through the patient, provider, or embedded participant, visually (e.g., through changes in vital signs on a monitor), through additional data (e.g., new laboratory results), and so forth (Follow the HSSOBPTM Facilitation).
- ○Planned time frames serve to facilitate the progression of the scenario and ensure that there is a reasonable time to achieve the objectives.12.
- ○
- •Identification of critical actions/performance measures that are required to evaluate achievement of scenario objectives.29.
- ○Each measure should be evidence-based. Use content experts to strengthen validity of the simulation scenario and the critical performance measures.
- ○
- •A clear and concise scripted explanation provides the context for the activity to be undertaken.
- •A setting represents the clinical environment so the learner(s) can practice or undertake the task in an ergonomics matching the experience in the actual clinical setting.30.
- •Identification of critical actions/performance measures that are required to evaluate achievement of the activity objectives.31.
- •Design the simulation through attention to physical, conceptual, and psychological aspects of fidelity that can contribute to the attaining objectives. Specifically, this is less about specific “reality” and should instead focus on representing stimuli and cues that would typically be present to drive decision-making and action.32.These aspects of fidelity must be considered from the perspective of the learners.33.,34.,35.,36.,37.
- ○Physical (or environmental) fidelity relates to how realistically the physical context of the simulation-based activity compares to38.the actual environment in which the situation would occur in real life. Physical fidelity includes such factors as the patient(s), simulator/manikin, standardized patient, environment, equipment, embedded actors, and related props.39.,40.,41.
- ○Conceptual fidelity ensures that all elements of the scenario or case realistically relate to each other so that the patient makes sense as a whole to the learner(s) (e.g., vital signs are consistent with the diagnosis). To maximize conceptual fidelity, cases or scenarios should be reviewed by the content expert(s), and pilot tested before use with learners.39.,40.
- ○Psychological fidelity maximizes the simulation environment by mimicking the contextual elements found in clinical environments. Some examples include an active voice for the patient(s) to allow realistic conversation, noise and lighting typically associated with the simulated setting, distractions, family members, other health care team members, time pressure, and competing priorities. Psychological fidelity works synergistically with physical and conceptual fidelity to promote learner engagement.39.,40.
- ○Develop the simulation using the appropriate types of fidelity that create the required perception of realism that will allow learners to engage in a relevant manner.33.,36.,37.,39.,42.,43.,44.,45.
- ○Fidelity should also be broken down to focus on patient, facility, and scenario. This framework would be used in conjunction with the concepts of physical, conceptual, and psychological fidelity to create the highest possible fidelity in each element of the simulation.
- ○
- •As appropriate, use moulage to replicate features or characteristics of the patient situation and when possible, select manikins that respectfully represents the race and culture of the patients in the scenario to promote the sensory perceptions of learners and support the fidelity of the scenario.44.,45.,46.
- •It is important to reiterate the distinction between fidelity and modality or technology. These terms are independent of one another and need to remain so.32.,39.High-technology does not necessarily equate to high-fidelity, and any single modality (manikin, task trainer, etc.) may or may not be high-fidelity without caveat. Not every simulation requires the highest fidelity of realism. Determinations about the degree of fidelity and the implementation of this fidelity need to be determined through the examination of several factors.33.,36.,37.,39.,42.,43.,44.,45.These factors may include, but are not limited to:
- ○Learner level
- ○Learning objectives
- ○Available time and resources
- ○Available equipment
- ○Desired learning outcomes
- ○Clinical significance
- ○
- •Facilitators who have formal training in simulation-based pedagogy.
- •Determine the planned facilitative approach during the simulation in the design phase and include preparatory activities.48.
- •If the plan is to have more than one facilitator, applying a structured approach to preplan certain aspects of the prebriefing and debriefing session.49.
- •Facilitators should incorporate evidence-based components of cultural diversity within the simulation design or scenarios.
- •Use a level of facilitator involvement that is appropriate to the learner's knowledge, competency and experience.50.,
- Forstrønen A.
- Johnsgaard T.
- Brattebø G.
- Reime M.H.
Developing facilitator competence in scenario-based medical simulation: Presentation and evaluation of a train the trainer course in Bergen, Norway.Nurse Education in Practice. 2020; 47 (https://doi.org/)102840https://doi.org/10.1080/0142159050004692451. - •Predetermine the delivery of cues as part of the facilitation planning to be delivered during the simulation activity.52.
- •Facilitators should be aware and mindful of the learners’ diverse cultural differences, values and responsibilities and consider that during the simulation design phase.53.
- •Facilitators should refer to the Healthcare Simulationist Code of Ethics with respect to confidentiality, mutual respect, and creating a safe educational environment.19.
Park, C. S., Murphy, T. F., & the Code of Ethics Working Group (2018). Healthcare simulationist code of ethics. Retrieved from http://www.ssih.org/Code-of-Ethics
- •Follow the HSSOBPTM Facilitation47.and Professional Integrity.
- 1)Situating the learners into a shared mental model and preparing participants for the simulation-based experience's educational content (preparation).
- 2)Conveying important ground rules for the simulation-based experience (briefing).
- •Prebriefing should be developed according to the purpose and learning objectives of the simulation-based experience.54.,55.,56.,57.,58.
- •Consider the experience and knowledge level of the simulation participant when planning the prebriefing.54.,55.,56.,57.,58.,59.
- •Develop preparation materials to assure that participants are prepared for the experience and can meet the scenario or procedural objectives based on the experience's needs assessment and purpose.54.,55.,56.,57.,58.,60.,61.
- •Convey important information to participants regarding expectations, agendas, and logistics before beginning the simulation-based experience.54.,55.,56.,57.,59.,60.
- •Conduct a structured orientation to the simulation-based learning environment including the modality.55.,56.,60.
- •Establish a psychologically safe learning environment during the prebriefing.55.,57.,58.,59.
- •Follow the HSSOBPTM Prebriefing: Preparation and Briefing.
- •Use a planned debriefing, feedback session, or a guided reflection exercise to enrich learning and contribute to the consistency of the simulation-based experiences for learners and facilitators.64.
- •Debriefing and feedback are different, but both are critical elements that should be structured using best practices. In the case of a skills-based or testing simulation activity, debriefing may be replaced by feedback, so the learners are guided to improve further or confirm their practice.65.,66.
- •Guided reflection is an intellectual and affective activity that explores the critical elements to gain understanding and insight. It can be integrated with debriefing or accomplished after the event through journaling or open discussions.65.
- •Debriefing facilitators should have formal training in debriefing techniques.65.,67.
- •Follow the HSSOBPTM The Debriefing Process
- •Determine the assessment and evaluation processes in the design phase to ensure quality and effectiveness of simulation-based experiences.27.
- •Consider an assessment framework to guide the selection and/ or development of a valid and reliable tool to measure expected learner outcomes.68.
- •Ensure that participants understand the method of assessment (formative, summative, and/or high stakes) before or at the onset of the simulation.
- •Follow the HSSOBPTM Evaluation of Learning and Performance.
- •Plan an evaluation process to determine the quality or effectiveness of the simulation- based experience Use evaluation data for continuous quality improvement. Include feedback from participants, peer clinicians and educators, stakeholders, and simulation program faculty and staff68.,69.,70.in the evaluation process.
- •After the design is complete, pilot test the entire simulation-based experience to ensure that it accomplishes its intended purpose, provides opportunity to achieve objectives, and is effective when used with learners.
- •Select a participant similar to the target learner group for the optimal test environment.
- •Select any tool(s), checklists, or other measures to assess for validity and to ensure consistency and reliability (i.e., content validity, expert review, inter-rater reliability).
- •During pilot implementation, identify any confusing, missing, or underdeveloped elements of the simulation-based experience.
- •Make improvements based upon the pilot and revise before the full implementation of the simulation-based experience.
- •Recognize that it may not always be possible to pilot test simulation-based experiences prior to facilitation (For example, just in time training or with limits to time and resources).
Original INACSL Standard
Subsequent INACSL Standard
About the International Nursing Association for Clinical Simulation and Learning
References
- Beyond Knowles: What those conducting simulation need to know about adult learning theory.Clinical Simulation in Nursing. 2010; 6: e7-e14https://doi.org/10.1016/j.ecns.2009.07.003
- On becoming an experiential educator.Simulation & Gaming. 2014; 45: 204-234https://doi.org/10.1177/1046878114534383
- Learning style impact on knowledge gains in human patient simulation.Nurse Education Today. 2015; 35: 63-67https://doi.org/10.1016/j.nedt.2014.05.013
- Instructional design dogma: Creating planned learning experiences in simulation.Journal of Critical Care. 2008; 23: 595-602https://doi.org/10.1016/j.jcrc.2008.03.003
- Evidence-based nursing education: Effective use of instructional design and simulated learning environments to enhance knowledge transfer in undergraduate nursing students.Journal of Professional Nursing. 2013; 29: 203-209https://doi.org/10.1016/j.profnurs.2012.04.022
- Use of simulation-based education to reduce catheter-related bloodstream infections.Archives of Internal Medicine. 2009; 169 (https://doi.org/DOI): 1420-1423https://doi.org/10.1001/archinternmed.2009.215
- Does training in obstetric emergencies improve neonatal outcome?.Bjog-an International Journal of Obstetrics and Gynaecology. 2006; 113: 177-182https://doi.org/10.1111/j.1471-0528.2006.00800.x
- Evaluation of simulation in undergraduate nurse education: An integrative review.Clinical Simulation in Nursing. 2013; 9: E409-E416https://doi.org/10.1016/j.ecns.2012.11.003
- Five steps to develop checklists for evaluating clinical performance: an integrative approach.Academic Medicine. 2014; 89: 996-1005https://doi.org/10.1097/ACM.0000000000000289
- Designing Simulation Scenarios to Support Performance Assessment Validity.Journal of Continuing Education in Nursing. 2015; 46: 492-498https://doi.org/10.3928/00220124-20151020-01
- Patient outcomes in simulation- based medical education: a systematic review.Journal of General Internal Medicine. 2013; 28: 1078-1089https://doi.org/10.1007/s11606-012-2264-5
- Developing high-fidelity health care simulation scenarios: A guide for educators and professionals.Simulation & Gaming. 2011; 42: 9-26
- (Creating effective simulation environments)Mastering Simulation: A handbook for success.in: Ulrich B. Mancini B. Sigma Theta Tau International. 2014: 49-86
- Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.Medical Teacher. 2005; 27: 10-28
- NLN Jeffries Simulation Theory: Brief narrative description.Nursing Education Perspectives. 2015; 36: 292-293https://doi.org/10.5480/1536-5026-36.5.292
- The development of evidence-based clinical simulation scenarios: Guidelines for nurse educators.Journal of Nursing Education. 2010; 49: 29-35https://doi.org/10.3928/01484834-20090916-07
- Professional Development for Simulation Education.Annual Review of Nursing Research. 2020; 39: 201-221
- Formal training efforts to develop simulation educators: An integrative review.Simulation in Healthcare. 2020; 15: 271-281
Park, C. S., Murphy, T. F., & the Code of Ethics Working Group (2018). Healthcare simulationist code of ethics. Retrieved from http://www.ssih.org/Code-of-Ethics
- Monograph Review: The NLN Jeffries Simulation Theory (2016), edited by Pamela R. Jeffries.Nursing Science Quarterly. 2018; 31: 392
- Theory and simulation-based education: Definitions, worldviews and applications.Clinical Simulation in Nursing. 2015; 11: 349-354
- The role of simulation in pedagogies of higher education for the health professions: Through a practice-based lens.Vocations and Learning. 2015; 8: 269-285
- Core competencies for interprofessional collaborative practice: 2016 update.Interprofessional Education collaborative, Washington, DC2016
- A typology of educationally focused medical simulation tools.Medical Teacher. 2007; 29: e243-e250https://doi.org/10.1080/01421590701551185
- Determining content validity and reporting a content validity index for simulation scenarios.Nursing Education Perspectives. 2015; 36: 389-393
- The template of events for applied and critical healthcare simulation (TEACH Sim): A tool for systematic simulation scenario design.Simulation in Healthcare. 2015; 10: 21-30
- Simulation champions: Fostering courage, caring, and connection.Wolters Kluwer, 2017
- When things do not go as expected: Scenario life savers.Simulation in Healthcare. 2010; 5: 219-225
- A measurement tool for simulation-based training in emergency medicine: The simulation module for assessment of resident targeted event responses (SMARTER) approach.Simulation in Healthcare. 2008; 3: 170-179
- Optimal training design for procedural motor skills: A review and application to laparoscopic surgery.Psychological Research. 2014; 78: 878-891
- Learn, see, practice, prove, do, maintain: An evidence- based pedagogical framework for procedural skill training in medicine.Academic Medicine. 2015; 90: 1025-1033
- Redefining simulation fidelity for healthcare education.Simulation & Gaming. 2015; 46: 159-174
- The mannequin is more lifelike’: The significance of fidelity for students’ learning in simulation-based training in the social-and healthcare programmes.Nordic Journal of Vocational Education and Training. 2019; 9: 1-18
- Essentials of scenario building for simulation-based education.Comprehensive healthcare simulation: Pediatrics. Springer, 2016: 19-29
- Exploring suspension of disbelief during simulation-based learning.Clinical Simulation in Nursing. 2017; 13: 3-9
- Exploring realism in healthcare simulations. Healthcare Simulation Education: Evidence, Theory and Practice.Wiley Blackwell, 2018
- Beyond fidelity: Deconstructing the seductive simplicity of fidelity in simulator-based education in the health care professions.Simulation in Healthcare. 2017; 12: 117-123
- Simulations at work—A framework for configuring simulation fidelity with training objectives.Computer Supported Cooperative Work (CSCW). 2020; 29: 85-113
- The How When Why of High Fidelity Simulation.StatPearls. 2020; (Retrieved from)
- Moving beyond fidelity.Clinical Simulation. Elsevier, 2019: 539-554
- The impact of contextualization on immersion in healthcare simulation.Advances in Simulation. 2016; 1: 1-11
- Determining student nurses’ opinions of the low-fidelity simulation method.Nursing Practice Today. 2019; 6: 71-76
- Do fellows and faculty share the same perception of simulation fidelity? A pilot study.Simulation in Healthcare. 2020; 15: 266-270
- Investigating the impact of moulage on simulation engagement—a systematic review.Nurse Education Today. 2018; 64: 49-55
- Does appearance matter? Current issues and formulation of a research agenda for moulage in simulation.Simulation in Healthcare. 2017; 12: 47-50
- Expert opinions on the authenticity of moulage in simulation: A Delphi study.Advances in Simulation. 2019; 4: 1-10
- INACSL Standards of Best Practice for Simulation: Past, Present, and Future.Nursing Education Perspectives. 2015; 36: 294-298https://doi.org/10.5480/15-1670
- Development and psychometric evaluation of the facilitator competency rubric.Nursing Education Perspectives. 2018; 39: E3-E9
- Co- debriefing for simulation-based education: a primer for facilitators.Simulation in Heatlhcare. 2015; 10: 69-75https://doi.org/10.1097/sih.0000000000000077
- Developing facilitator competence in scenario-based medical simulation: Presentation and evaluation of a train the trainer course in Bergen, Norway.Nurse Education in Practice. 2020; 47 (https://doi.org/)102840https://doi.org/10.1080/01421590500046924
- Twelve tips for facilitating and implementing clinical debriefing programmes.Medical Teacher. 2020; : 1-9
- Benner's novice to expert model: An application for simulation facilitators.Nursing Science Quarterly. 2017; 30 (https://journals.sagepub.com/doi/10.1177/0894318417708410?url_ver=Z39.88- 2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed): 227-234
- Cultural humility: A concept analysis.Journal of Transcultural Nursing. 2016; 27 (https://journals.sagepub.com/doi/10.1177/1043659615592677?url_ver=Z39.88- 2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed): 210-217
- Prebriefing in nursing simulation: A concept analysis.Clinical Simulation in Nursing. 2015; 11: 335-340
- The prebriefing concept: A delphi study of CHSE experts.Clinical Simulation in Nursing. 2016; 12: 219-227
- Use of prebriefing in nursing simulation: A literature review.Journal of Nursing Education. 2014; 53: 136-141
- Pre- simulation preparation and briefing practices for healthcare professionals and students: a systematic review protocol.JBI Evidence Synthesis. 2016; 14: 80-89
- Prebriefing: A Historical Perspective and Evolution of a Model and Strategy (Know: Do: Teach).Clinical Simulation in Nursing. 2020; 49: 40-49
- Establishing a safe container for learning in simulation: The role of the presimulation briefing.Simulation in Healthcare. 2014; 9: 339-349
- Cognitive load measurement, worked-out modeling, and simulation.Clinical Simulation in Nursing. 2018; 23: 10-15
- Causes of student anxiety during simulation: What the literature says.Clinical Simulation in Nursing. 2013; 9: e507-e512
- Identifying best practice guidelines for debriefing in surgery: A tri-continental study.The American Journal of Surgery. 2012; 203: 523-529
- Cultural prototypes and differences in simulation debriefing.Simulation in Healthcare. 2018; 13: 239-246
- Focusing on explicit debriefing for novice learners in healthcare simulations: A randomized prospective study.Nurse Education in Practice. 2020; 102914
- Pocket book for simulation debriefing in healthcare.Springer, 2018
- The utilization of debriefing for simulation in healthcare: A literature review.Nurse Education in Practice. 2020; 43102698
- Learning through debriefing: Students' perspectives.Clinical Simulation in Nursing. 2014; 10: e249-e256
- Evaluation of simulation outcomes.Annual Review of Nursing Research. 2020; 39: 149-180
- Development and psychometric evaluation of the facilitator competency rubric.Nursing Education Perspectives. 2018; 39: E3-E9
- An updated review of published simulation evaluation instruments.Clinical Simulation in Nursing. 2013; 9: e393-e400