Simulation in Medicine

Simulation 1

  • What are the Definitions of ‘Simulations’ and ‘Simulators’?
  • Simulation
    • Simulation is an Educational Technique
    • Allows the student to gain an emotive and immersive learning experience.
    • Allows the recreation of a clinical experience without risk to patients.
  • Simulator
Simulation in Healthcare
  • Why has Simulation developed as a major teaching technique in healthcare?
In the 1960s and 1970s airline crash investigations revealed that up to 70% of crashes had a component of human error in the cause of the accident.  As a result ‘human factors’ were identified as a potential area for improved training in aspects of teamwork, communication and critical decision making.  Crew Resource Management (CRM) evolved into Crisis Resource Management teaching in medicine which was pioneered by the Anaesthetists in the 1990s.
Sim Human
  • What communication strategies can be learned and taught through Simulation  for use in Time Critical Emergencies?
  • Convey Information
    • Strategy for Best Results:
      • Be Technically accurate and Specific in use of language
  • Co-ordinate the Team
    • Strategy for Best Results:
      • Use CRM and have and effective team leader
  • Team Cohesiveness
    • Strategy Best Results:
      • Develop a healthy team climate.
      • Train together
      • Use team member names
      • Pre-brief and debrief
  • Disagreements within the Team
    • Strategy for Best Results:
      • Negotiation
  • Listen to and Address Concerns within in the Team
    • Possible Strategy:
      • Graded Assertiveness
      • Use C.U.S.S:
        • I am CONCERNED about the Oxygen level falling and lack of ETCO2
        • I am UNSURE that we can be sure if the ET tube is in the right spot as I observing that there is no ETCO2, tube fogging and that the stomach looks bigger.
        • This is a SAFETY issue – the patients saturations are rapidly falling
        • STOP – this patient needs to be ventilated with a BVM and then re-intubated
      • Graded Assertiveness requires the team leader to tell the team this is okay and that there will be no adverse circumstances as the result of questioning actions


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Harvard Crisis Resource Management Review


  • Why use simulation?

– Simulation, by providing a representation of a real world experience, fits with the principles of effective adult education (adult learning theory).  David Kolb and Donald Schonn developed the concept of ‘Experential Learning‘:


– Developing Competencies requires the learner to build on past knowledge and practise problem solving (Miller’s Pyramid):


– Simulation may be helpful in developing training and assessments for new undergraduate and postgraduate programs.  In particular, Work Based Assessments (WBA) and Entrustable Professional Competencies (EPA).

  • What are the PROS and CONS of using Simulation?


  • Patient Safety
    • Scenarios protect patients.
      • They do this by improving teamwork and communication as well as avoiding exposure of patients to ‘practice’ by very junior staff and students.
    • Good for Uncommon Scenarios (exposure to rare events in simulation may been the only access in terms of training)
    • Good for Common Emergencies (Link – Team Drills of Emergencies such as Cardiac Arrest)
  • Skills Training
    • Rapid Acquisition of Skills
    • Opportunity for Drill
  • Team Training
  • Curriculum and Convenient Timing
    • Standardised Scenarios presented to all learners
  • Adult Learning
    • Reflective and Experential Learning (see above)
  • Assessment
  • Recertification and Continuous Professional Development


  • Expensive (dollars to establish a centre and maintain the facility)
  • Negative Transfer
    • Due to simulation lack of fidelity or debriefing
  • Non valid application of Technique
  • Lack of Trained Staff
  • Lack of Equipment
  • Adequate or Appropriate Fidelity


Development of Simulation in Medicine:

  • 1960s Laerdal: ‘Resusci-Annie’ Simulator
  • 1967: SIM ONE Simulator
  • 1987 CASE 1.2 at Stanford University (Med Sim Eagle)
  • 1990s – 2000s
    • METI Human Patient Simulator (HPS)
    • Laerdal SimMan – cheaper version of HPS
    • Increasing Training and Education in Simulation
    • Literature on the effectiveness of Simulation
Types of Simulation
  • High Fidelity Simulation
  • Hybrid Simulation
  • Patient Based Simulations (Simulated Patients)
  • Part Task Trainers
  • Computer Based Simulation
High Fidelity Simulation
  • High fidelity simulation involved the use of life like mankins to create realism in scenarios.
  • Fidelity can be:
    • Environmental (simulation area should look like a hospital and have similar equipment)
    • Physical (haptic feedback and life like features of the manikin)
    • Psychological (degree of immersion in scenario)

Types of High Fidelity Manikin and Approximate Costing

  • METI Man HPS (CAE) – Unit Cost >$200,000
  • SIM MAN 3G – Unit Cost $96,000
  • Mega-code Kelly – Unit cost $11,000
  • SIM MAN Essential – Unit Cost $20,000
Cost Benefit Analysis of 2 Manikins (Lapkin et al):
While the overall utility of the more expensive Manikin is higher the cost to utility ratio favours the cheaper manikin.  Achieving fidelity through other means may also be an option.  In my own experience, younger and inexperienced students benefit from the ‘high tech’ manikins because it helps immersion.  More experienced doctors and students are able to achieved immersion with less haptic feedback and apparent realism.
Hybrid Simulation
Hybrid Simulation Models are a combination of a human subject and either part task trainer or monitoring equipment.  Monitoring equipment from an electronic simulator such as an ALS manikin or SIM MAN 3G can be used.
Combining a Human Subject with a Task Trainer can add to the student’s experience as they will have to communicate as well as do the procedure.  Examples of Hybrid Simulation include simple cannulation, catheterisation, obstetrics cases and intimate examination.
At our simulation we have hybrid scenarios using members of staff including a GI bleeding case and a Septic (Delerium) Case.  While the use of an existing high or medium fidelity simulator for observations is useful much cheaper stand alone systems are also an option (Basic IPAD Apps such as SIM MON or the I-SIMULATE Device)
Patient Based Simulation
Part Task Trainers
  • A variety of manikins representing body parts are commonly used for training:

Part task

Preparation of Scenarios
Planning scenarios is a key component of success.  Like any educational activity planning based around delivering key learning objectives is a crucial step.  Knowing the learners level of simulation experience can also be useful in relation to the selection of the best form of training.  We suggest using a Simulation Template to plan and write the scenario:
Setting up the Simulation
sim 11
Allocating separate faculty team members to Setup, Debriefing and Directing can be helpful to run multiple simulations effectively
Use of  Local Protocols, Equipment and Actors can add to both the applicability and fidelity of the scenario
Brifing Learners
Pre Briefing the Learners with information about the simulation environment and agreement on confidentiality are important.
Agree with the learners on the basic assumption that they are competent professionals who want to do their best
Address the Leaners Basic Needs:
  • Pause and Discuss
    • Probably best used for simple emergency proceadures (e.g. Pacing) orsmall groups who are new to simulation
  • +/Δ
    • Plus Delta Model of Debriefing: rapid pointing out of gaps in learner’s knowledge and skills by debriefer


  • Advocacy Enquiry
    • Also known as the Harvard Debriefing Method
    • Essentially making the debrief into a puzzle to unravel…
    • Go over what they did well…
    • Go over what the facilitator thinks would be an alternative (not necessarily better) approach
    • Key phrase – ‘I am Curious’ about what you were thinking when you did this (specific)
    • Can you help me understand what was happening?
  • Pendleton’s Rules of Debriefing
    • What went well?
    • What could have gone better?
    • What do you think of this?
  • General Tips
    • Follow the team into the room and listen to their conversation
    • Assess the learners frames (the basis of knowledge and experience behind their actions)
    • Give the learners space
    • Address serious safety issues with the learner (privately) and speak with senior faculty about the best approach
Evidence Based Simulation
The Evidence Base (EBM) for simulation is growing.  There are now both Randomised Trials and Good Quality Qualatative Data suggesting that Simulation in Health Care has a reasonable evidence base:
  •  Short term benefits seem to be reproducible but patient quantantive outcomes as a result of simulation are hard to quantify with high level evidence.
  • Cost Effectiveness Unclear.
  • Applying existing clinical guidelines in a high fidelity simulation environment can be used for training and learning as well as potential assessment and revalidation of health care workers

EBM References

  1. Weller J, Robinson B, Larsen P, Caldwell C. Simulation-based training to improve acute care skills in medical undergraduates. N Z Med J 2004; 117:
  2. Grantcharov T et al. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004; 91: 146-150.
  3. Weller J et al. Simulation in Clinical Teaching and Learning. MJA 2012; 196 (9) 594
Australian Simulation Links
Sim Aus

Further Reading

(1) Harvard Debriefing – Harvard Debrief

(2) Simulation Overview – Simulation Overview


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