Human Simulation Training in the ICU: Applicability, Value, and Disadvantages
By John O’Donnell, MSN, CRNA, Michael Beach, MSN, CRNP, and Leslie A. Hoffman, RN, PhD
Mr. O’Donnell is Director, Nurse Anesthesia Program, University of Pittsburgh School of Nursing; Mr. Beach works in the Acute Care Nurse Practitioner Program, University of Pittsburgh School of Nursing, and Dr. Hoffman works in the Department of Acute/Tertiary Care School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert
Mr. O’Donnell, Mr. Beach, and Dr. Hoffman report no financial relationship to this field of study.
Simulation training has a long history with examples ranging from "modeling" in the animal kingdom (eg, a lion teaching hunting skills to a cub), to "war games" designed to better prepare soldiers for battle.1,2 In health care, simulation can be used in a broad range of situations, ranging from simple part-task trainers, such as IV arms, to computer-driven mannequins that emulate adult, pediatric, and obstetric events.3-13 In its most complex form, high fidelity human simulation provides a mechanism to provide safe, realistic training for a wide range of common, emergent and/or rarely encountered situations across multiple practice domains.
The introduction of advanced yet affordable simulators has encouraged clinical critical care educators to learn more about this form of education. Simulation training is not a panacea or replacement for traditional clinical education. In our experience, this approach is a valuable adjunct to traditional education that allows educators to enhance cognitive and psychomotor skills in a safe environment and thereby improve practice. This essay will review advantages and disadvantages of simulation training and describe lessons that we have learned in our work in this area.
Ethical Issues. Traditionally, health care professional education has extensively relied on the apprenticeship model. Typically, clinical experience begins with a lecture, followed by demonstration and, when the time is right, performing a procedure or managing a case with faculty supervision. This approach has several notable disadvantages. First, clinical settings are designed to provide care, not educational experiences. Second, expertise in critical care practice is acquired over time. There is no guarantee that appropriate exposure will occur before a novice practitioner must make critical decisions.4,6-9,12 Prior to the development of lower-cost, high fidelity simulators, no reasonable alternative existed. With simulation, it is possible to train critical care practitioners to manage common and rarely occurring events before encountering them in clinical practice. Third, simulation provides a forgiving environment. Trainees can respond to scenarios designed to mimic critical care practice and observe consequences of their actions, effective or ineffective.4,6-9 Using computer feedback logs and integrated audio-visual capability, faculty can review actions taken during these scenarios in a debriefing session. Together, faculty and trainees can collaboratively critique decision-making and identify more appropriate actions. Trainee errors can be used to learn from one’s mistakes—a powerful teaching tool.2,4 This training can be very realistic because scenarios can be designed to branch in several directions, dependent on participant actions. Also, presenting conditions can be designed to be ambiguous to better mimic critical care events, since most real life critical care situations do not have clear decision points.
With simulation, learning occurs during and after the event. Lighthall and colleagues6 evaluated the performance of medicine, anesthesia and surgery residents who participated in scenarios designed to replicate medical crises, or observed while others performed the scenarios. A number of common errors were noted that were categorized as technical (improper drug selection or dosage), vigilance related (failure to notice dysrhythmias, ventilator alarms), judgment related (inappropriate delay of therapy, uncorrected abnormality) or communication related (ineffective use of personnel). The residents easily recognized many of these errors and, in debriefings, agreed they were everyday occurrences in medical emergencies. Using such observations, it is possible to refine teaching and reduce the likelihood of such events.
Rare Event Training. One particular benefit of simulation is that all trainees can experience rare events and receive immediate feedback with an opportunity for expert modeling and correction. Barsuk et al13 assessed the performance of 36 physicians who completed Advanced Trauma Life Support (ATLS) training using simulation scenarios and noted practice errors. They modified the training to include an additional 45 minutes of simulation that incorporated skills involved in ATLS training and repeated testing in a second group of 36 physicians. The addition of simulation produced a significant decrease in the number of individuals not performing critical actions or taking appropriate steps in the recognition and management of tension pneumothorax, hypovolemic shock, and cervical spine mobilization.
Common Event Training. With simulation, it is possible to train large groups of providers in patient scenarios that are common, but which pose a threat if performed incorrectly. Examples include:
- procedures such as endotracheal intubation, difficult airway management, central line insertion, and fiberoptic bronchoscopy;
- management of acute pathophysiologic conditions, such as shock, arrhythmia, hypotension, or hemorrhage; and
- team response during cardiac arrest, trauma resuscitation, or out-of-hospital rescue. The ability to teach crisis management skills is a particular advantage.6
When the apprenticeship model is used, students may be pushed to the background or asked to leave the room in the interest of patient safety. In a simulated environment, trainees are forced to assume a lead position and direct care. Marsch and colleagues12 tested ability of first responders to adhere to algorithms of cardiopulmonary resuscitation using a simulated cardiac arrest in an intensive care environment. The physician-nurse teams functioned well in areas such as recognizing the arrest and calling for help, but there were significant delays in the initiation of basic life support and defibrillation. Such observations called attention to the need to provide additional training in crisis team management.
Training Efficiency. Training efficiency is an often overlooked advantage of simulation training. Abrahamson and colleagues8 compared outcomes following usual training of anesthesiology residents to usual training plus simulation. The residents were able to attain proficiency in a smaller number of elapsed days, thus effecting a time saving of personnel, and achieved proficiency in a smaller number of trials in the operating room, thereby posing a significant lower burden of supervision and threat to patient safety. Our experience has been similar. Since introduction of simulation training, we have reduced the amount of time nurse anesthesia students require before assuming responsibility for intubation from 3 months to less than one day. Concurrently, the role of the faculty has changed from performing skills while students observe or directing student performance to coaching, cuing, and prompting. Simulation also appears to promote learning retention.12
Recruitment. An additional unique advantage of simulation education relates to recruitment and retention of personnel. We routinely schedule visits of applicants to our simulation training center as part of recruitment efforts. Students, prospective house staff and fellows immediately perceive the value of hands on practice and training and seek out these experiences when available.
Critical Thinking. One of the most important critical care competencies involves the ability to apply critical decision-making skills in routine, as well as emergent situations. Simulation training can facilitate learning to manage such situations independently or with support analogous to that available in the critical care setting. Such training provides an ideal opportunity to evaluate and refine communication skills required for effective clinical practice.10 Simulation training can also be used to explore common communication errors within professions and across multidisciplinary teams.10 Findings from qualitative studies suggest that this approach helps students work through problems, acquire skills and build confidence that can be transferred to the clinical setting. Faculty also benefit from simulation education by refining their clinical knowledge base and learning to develop innovative educational strategies.
Trainee Feedback. When formal evaluation is incorporated into simulation training, evaluations are almost unanimously positive. In anecdotal reports, trainees have expressed gratitude for being adequately prepared through the simulation experience. A recent nursing graduate recounted being present in a cardiac arrest situation during the night shift. She was able to function effectively until the cardiac arrest team arrived because she had prior simulation experience managing a code in the role of a critical care nurse. In our training, we use two facilities, a single high-fidelity human simulator (Laerdal SimMan) located in the School of Nursing and the WISER Center (www.wiser.pitt.edu) which houses 16 high-fidelity simulators and conducts training for approximately 6,000 practitioners yearly from within and outside the University.
In summary, simulation education offers the ability to provide a customized educational experience and, if administered as a component of an educational program that includes objectives, pre-course didactic preparation, well designed simulator programming, and effective evaluation tools, can be reliable and valid with development of true performance benchmarks. Reported benefits of simulation education include improved appreciation of team work, the ability to recognize and handle anxiety provoking situations, improved communication skills, and a potential for incorporation of skills developed through simulation into improving patient outcomes.
Artificial Environment. Although students state that they find the simulation training realistic and valuable, simulation is not reality. Manikins can provide realistic physical responses which mimic various pathologies. Many manikins have accurate airways which can be manipulated to demonstrate a range of easy to difficult airway scenarios. Few manikins have realistic eyes. Some allow for line placement or chest tube insertion. Many mimic bowel, lung, and heart sounds. At least one can talk, but none have the ability to mimic conversation with a patient, limiting patient provider interaction
Paucity of Supporting Evidence. An important challenge facing those who advocate this training relates to the need to objectively validate benefits of this training through methodologically sound studies. To date, few validation studies have been performed. Studies are needed to demonstrate the ability to improve knowledge and skills and transfer this knowledge to actual patient situations.
Equipment and Personnel Costs. Developing and maintaining a simulation program is costly. Computer-based high-fidelity human simulation will cost more than $50,000 for the manikin and support equipment. The environment necessary for full utilization of the experience, cameras and recording equipment, a dedicated area in which to establish the equipment, additional manikins of varied ages and physical conditions, adds significantly to this cost. Time is also a consideration. Simulation training involves a substantial amount of time in set up and evaluation. Although the scenarios or experiences may take a relatively short period of time, analysis of the student’s actions, mistakes and options can be time consuming. Lectures can be provided to a large number of students, but the number that can participate in a simulation activity is dependent on the number of manikins and faculty. Others may observe and add to their learning experience, but it is not hands-on experience.
Perhaps the most costly aspect is the expense of providers being away from the clinical setting for training. In undergraduate nursing programs, this problem can be solved by having the faculty who would be supervising students in the clinical setting involved in simulation training. Other programs do not have the same access to faculty who can leave the bedside. An additional problem involves finding and training a cadre of faculty to run simulation courses. Despite the standardized, open-ended programming capability of the Laerdal SimMan and SimBaby products, many clinicians have little interest in creating their own programming for scenarios or do not feel they have time to do this writing. This represents a substantial burden for technical staff associated with simulation facilities, but will likely be minimized in the near future with the emergence of commercial simulation educational products.
Despite challenges, affordable high fidelity simulator devices (such as the Laerdal SimMan, among others) are becoming increasingly integrated into the education of critical care professionals. Although simulation education cannot replace all aspects of traditional clinical training, it is clearly a valuable supplement. The key to a successful simulation program includes several important considerations. These include:
- at least one dedicated advocate within the clinical faculty who is willing to catalyze the effort;
- strong administrative support for the effort; and
- the ability and dedication conduct studies that quantify the value of training in regard to translation to the clinical setting and thereby data that can be used to evaluate training and modify this as needed.
As research in this area continues, we believe that simulation training will become essential for evaluation and benchmarking of key cognitive and psychomotor skills. This benchmarking will provide assurance that all personnel have the requisite skill and ability to safely practice in an increasingly complex clinical environment.
- Loyd GE, et al. Practical health care simulations. Philadelphia, PA: Elsevier, Mosby, 2004.
- Tekian A, et al. Innovative Simulations for Assessing Professional Competence: From Paper-and-Pencil to Virtual Reality. Chicago, IL: University of Illinois-Chicago, 1999.
- Grenvik A, Schaefer J. From ResusciAnne to SimMan: the evolution of simulators in medicine. Crit Care Med. 2004;32(2 Suppl):S56-S57.
- O’Donnell J, et al. Planning and implementing an anesthesia crisis resource management course for student nurse anesthetists. CRNA. 1998;9:50-58.
- Kneebone R, et al. An innovative model for teaching and learning clinical procedures. Med Educ. 2002;36:628-634.
- Lighthall GK, et al. Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents. Crit Care Med. 2003;31:2437-2443.
- DeVita MA, et al. Improving medical crisis team performance. Crit Care Med. 2004;32(2 Suppl):S61-S65.
- Abrahamson S, et al. Effectiveness of a simulator in training anesthesiology residents. 1969. Qual Saf Health Care. 2004;13:395-397.
- Shapiro MJ, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care. 2004;13:417-421.
- Flanagan B, et al. Making patient safety the focus: crisis Resource Management in the undergraduate curriculum. Medical Education. 2004;38:56-66.
- Mayo PH, et al. Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Crit Care Med. 2004; 32:2422-2427.
- Marsch SC, et al. Performance of first responders in simulated cardiac arrests. Crit Care Med. 2005;33:963-967.
- Barsuk D, et al. Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care. Anesth Analg. 2005;100:803-809.