Advances in Simulation

Simulation research that seeks to solve the problem of silence among interprofessional teams has focused almost exclusively on training subordinate team members to be more courageous and to speak up to team leaders using direct challenge scripts despite the great interpersonal cost. Consequently, the existing literature overemphasizes the responsibility of subordinate team members for speaking up and fails to consider the role and responsibilities of team leaders in sustaining silence. The purpose of this study is to identify and describe the subtle behaviors and actions of team leaders that both promote and discourage speaking up. This study used a simulation-primed qualitative inquiry approach. Obstetricians (OB) at one academic center participated in an interprofessional simulation as an embedded participant. Five challenge moments (CM) were scripted for the OB involving deliberate clinical judgment errors or professionalism infractions. Other participants were unaware of the OB embedded participant role. Thirteen iterations were completed with 39 participants. Twelve faculty members completed a subsequent semi-structured interview. Scenarios were videotaped; debriefs and interviews were audio-recorded and transcribed verbatim. Data were analyzed using an inductive thematic approach. After participating in an interprofessional simulation, faculty participants reflected that being an approachable team leader requires more than simply avoiding disruptive behaviors. We found that approachability necessitates that team leaders actively create the conditions in which team members perceive that speaking up is welcomed, rather than an act of bravery. In practice, this conceptualization of approachability involves the tangible actions of signaling availability through presence, uncertainty through thinking aloud, and vulnerability through debriefing. By using faculty as embedded participants with scripted errors, our simulation design provided an ideal learning opportunity to prompt discussion of the subtle behaviors and actions of team leaders that both promote and discourage speaking up. Faculty participants gained a new appreciation that their actions create the conditions for speaking up to occur before critical incidents through their verbal and non-verbal communication.

Health care professionals, including general practitioners, have an important role in the care of those affected by domestic abuse. Therefore, it is important that healthcare professionals are adequately trained in recognising features of domestic abuse and supporting victims in disclosure. Founded by Augusto Boal, Forum Theatre is a drama methodology that can permit an experiential and immersive learning experience; lending itself well to a subject matter of oppressed individuals. In this study we aimed to gain a deep understanding of medical students’ lived experiences of training in consulting with individuals who experienced domestic abuse using an online format of forum theatre. A multidisciplinary team developed an online forum theatre training exercise, which involved a simulated consultation between a general practitioner and domestic abuse victim. Our qualitative approach used hermeneutic phenomenology to explore the participants’ lived experiences of this training. Following the online forum theatre experience, we analysed 11 participant interviews using template analysis to structure the phenomenological interpretation. We developed five themes through our analytical process: 1) ‘Almost being there…but not quite’: the realistic experience of forum theatre; 2) ‘Taken on an emotional journey’ 3) ‘Opening and controlling a privileged space’; 4) ‘Small things matter…’: cultivating and maintaining rapport and 5) Critically reflecting on future professional self. This study offers fine-grained insights into medical students’ experiences of an online immersive forum theatre training exercise in consulting with individuals who have been affected by domestic abuse. Online forum theatre has the potential to provide a simulated and meaningful approach to train medical students about domestic abuse. By providing students with a unique opportunity to step into a General Practitioner’s shoes in a domestic abuse consultation, students can practise how they manage a consultation with an impacted individual through a safe, guided, and experiential approach.

Experiential learning through simulation can play a very significant role, not only in hospital settings but also in community contexts (Lubbers and Rossman, Nurse Educ. Today 48:140-144; Wheeler and McNelis, Nurs. Educ. Perspect 35:259-261). This paper discusses the concept of creating a novel simulated village set-up within a modern simulation center, to effectively deliver contemporary learning outcomes. It also highlights the challenges and risks of developing a simulated village set-up and strategies to counteract them. Furthermore, it describes the role of simulation specialists as innovators and explicates the gamut of expertise in education, management, and technologies that are required to deliver excellence in simulation-based education.

Active ‘hands-on’ participation in the ‘hot-seat’ during immersive simulation-based training (SBT) induces stress for participants, which is believed to be necessary to improve performance. We hypothesized that observers of SBT can subsequently achieve an equivalent level of non-technical performance as ‘hot-seat’ participants despite experiencing lower stress. We randomized 37 anaesthesia trainees into two groups to undergo three consecutive SBT scenarios. Eighteen ‘hot-seat’ trainees actively participated in all three scenarios, and 19 ‘observer’ trainees were directed to observe the first two scenarios and participated in the ‘hot-seat’ only in scenario 3. Salivary cortisol (SC) was measured at four time points during each scenario. Primary endpoint for stress response was the change in SC (ΔSC) from baseline. Performance was measured using the Anaesthetist’s Non-Technical Skills (ANTS) Score. Mean SC increased in all participants whenever they were in the ‘hot-seat’ role, but not when in the observer role. Hot-seat ΔSC (mcg/dL) for scenarios 1, 2, and 3 were 0.122 (p = 0.001), 0.074 (p = 0.047), and 0.085 (p = 0.023), respectively. Observers ΔSC (mcg/dL) for scenarios 1, 2, and 3 were −0.062 (p = 0.091), 0.010 (p = 0.780), and 0.144 (p = 0.001), respectively. Mean ANTS scores were equivalent between the ‘hot-seat’ (40.0) and ‘observer’ (39.4) groups in scenario 3 (p = 0.733). Observers of SBT achieved an equivalent level of non-technical performance, while experiencing lower stress than trainees repeatedly trained in the ‘hot-seat’. Our findings suggest that directed observers may benefit from immersive SBT even without repeated ‘hands-on’ experience and stress in the hot-seat. The directed observer role may offer a less stressful, practical alternative to the traditional ‘hot-seat’ role, potentially rendering SBT accessible to a wider audience. ClinicalTrials.gov Identifier NCT02211378 , registered August 5, 2014, retrospectively registered.

Running simulation centre activities requires a substantial amount of human resources. Here we present ideas on how medical students can be integrated into the simulation centre workforce to support the goal of delivering simulation-based education. The ideas are centred around the many different roles the students can fulfil and how this can be applied in other centres interested in integrating medical students into the workforce. The ideas are based on the experience from a regional Danish simulation centre, the Copenhagen Academy for Medical Education and Simulation (CAMES), where the work of medical students appears to be beneficial for both students, teaching and research faculty, and the growth of the simulation centre.

The association between team performance and patient care was an immense boost for team-based education in health care. Behavioural skills are an important focus in these sessions, often provided via a mannikin-based immersive simulation experience in a (near) authentic setting. Observation of these skills by the facilitator(s) is paramount for facilitated feedback with the team. Despite the acknowledgement that trained facilitators are important for optimal learning, insight into this observation process by facilitators is limited. What are the self-reported current practices and difficulties regarding the observation of behavioural skills amongst facilitators during team training and how have they been trained to observe behavioural skills? This cross-sectional study used a pilot-tested, content-validated, multi-linguistic online survey within Europe, distributed through a non-discriminative snowball sampling method. Inclusion was limited to facilitators observing behavioural skills within a medical team setting. A total of 175 persons filled in the questionnaire. All aspects of behavioural skill were perceived as very important to observe. The self-perceived difficulty of the behavioural skill aspects ranged from slightly to moderately difficult. Qualitative analysis revealed three major themes elaborating on this perceived difficulty: (1) not everything can be observed, (2) not everything is observed and (3) interpretation of observed behavioural skills is difficult. Additionally, the number of team members health care facilitators have to observe, outnumbers their self-reported maximum. Strategies and tools used to facilitate their observation were a blank notepad, co-observers and predefined learning goals. The majority of facilitators acquired observational skills through self-study and personal experience and/or observing peers. Co-observation with either peers or experts was regarded as most learn some for their expertise development. Overall, participants perceived themselves as moderately competent in the observation of behavioural skills during team training. Observation of behavioural skills by facilitators in health care remains a complex and challenging task. Facilitators’ limitations with respect to attention, focus and (in)ability to perform concomitant tasks, need to be acknowledged. Although strategies and tools can help to facilitate the observation process, they all have their limitations and are used in different ways.

There is a need for improved research in the field of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. The present paper argues for the potential of simulation for prehospital research, e.g., through the development of an advanced simulation-based prehospital research laboratory. However, the prehospital context is different from other healthcare areas, which implies special requirements for the design of this type of laboratory, in terms of simulation width (including the entire prehospital work process) and depth (level of scenario detail). A set of features pertaining to simulation width, scenario depth, equipment, and personnel and competence are proposed. Close tailoring between these features and the prehospital research problems and context presents great potential to improve and further prehospital research.

Face-to-face clinical simulation has been a powerful methodology for teaching, learning, and research, and has positioned itself in health science education. However, due to the COVID-19 pandemic, social distancing has forced universities to abandon simulation centers and make use of alternatives that allow the continuation of educational programs safely for students and teachers through virtual environments such as distance simulation. In Latin America, before the pandemic, the use of non-presential simulation was very limited and anecdotal. This article has three main objectives: to establish the efficacy of online-synchronized clinical simulation in the learning and performance of medical students on the management of patients with COVID-19 in simulation centers of three Latin American countries, to determine the quality of the online debriefing from the students’ perspective, and to deepen the understanding of how learning is generated with this methodology.