How to be a Simulation Instructor
This section of the website is designed for a range of instructors in medical education: those who have not used simulation before, instructors with limited experience using simulation, and instructors who have a lot of experience with simulation. We cover simulation competencies and techniques, and we provide basic guidelines on integrating simulation into current curricula. There is also a section which acknowledges the culturally diverse learner population participating in Simulation-Based Clinical Education (SBCE).
What is simulation and what are the benefits?
Simulation-Based Clinical Education (SBCE) re-creates a clinical setting for the purpose of clinical training; typically this is done through the use of several methods (e.g., role-play or scenario-based teaching) and the use of a variety of technologies (e.g., mannequins, task trainers, virtual patients or standardized patients). With a long history of use in specialized areas of medical education, simulation is now a central thread in the fabric of all medical education.
Role of the Instructor
SBCE is placing instructors in new roles, which can be exciting as well as frustrating. Understanding the reasons for this change is as important as the instruction itself and may help clarify the instructors' roles.
The goal of using simulation technology is to allow "SimInstructors" to facilitate learning using new techniques and simulated medical situations. These techniques require students to participate in hands-on, real-time problem solving. SimInstructors utilize simulation for recurring instructions and processes which allow for learner practice and for feedback from the SimInstructor. This fosters proper learner response and mastery.
The SimInstructors' objective is to:
- Facilitate the education and training of clinicians.
- Educate with an emphasis on conceptual knowledge, basic skills and an introduction to the actual work.
- Train with an emphasis on the actual tasks and the work to be performed in an authentic setting.
- Assess performance and competency of both individual learners and teams. top
General Competencies for SimInstructors
These competencies are categorized into six areas. Some of the ideas and principles of SBCE can be found across several of these categories and in the Techniques section. This overlap is expected because of the integrated nature of SBCE.
The SBCE competencies include:
The primary goal is to ensure smooth course operations and reduce instructor and learner overload. The SimInstructor will:
- Provide an unambiguous roadmap through the instruction.
- Provide clear objectives, expectations, and policies regarding performance measures and use of equipment.
- Post course materials (syllabus, assignments, discussion topics, etc.) in advance so learners can plan. Convey changes and updates in a responsive manner.
- Ensure that all learners are 'on board' at the beginning of a course.
- Return learner calls/emails quickly to allow learners to progress.
- Establish a communication system so that learners can address issues during independent work (emails, discussion boards, help desk resources, facilities management, etc.).
Note: a media release form is legally required for any video recording, audio recording, or photographic documentation in which any individual faces or identifiable characteristics are present.
- VA General Release Form (VA Form 10-3202)
- VA Guidelines related to Privacy and Release Forms
The primary goal is to become familiar with one or more systematic instructional models (e.g., ADDIE) and to become adept at leading SBCE activities within the structure of that model. The SimInstructor will:
- Have a detailed understanding of the broader curriculum and learning objectives of the institution for which he/she teaches.
- Have a detailed understanding of the learning objectives for the specific course for which he/she is a SimInstructor.
- Preserve the learning and teaching principles of SBCE, plan the topics, materials, learner participation, and evaluations according to the instructional model.
- Ensure that the model, its framework, instructional content and schedule are all sanctioned by the institution for which he/she teaches.
- Be flexible in adapting aspects of the instructional model, schedule, and components of SBCE to be responsive to the learners and the institution.
The primary goal is to become familiar with one or more systematic instructional models (e.g., ADDIE) and to become adept at leading SBCE activities within the structure of that model. The SimInstructor will:
- Plan activities that allow learners to attach personal meaning to content.
- Plan activities that allow learners new to SBCE to become comfortable with new way of learning (i.e. practice sessions for lessons and for equipment).
- Provide opportunities for every student to get hands-on practice and application.
- Balance course design and integration of simulation design to help learners manage load.
- Help learners assess their learning and attain personal learning goals.
- Provide a realistic environment, present multiple viewpoints, and overcome anonymity between learners.
- Facilitate simulations that support learning materials.
The primary goal is to provide social benefits and enhance learning. The SimInstructor will:
- Establish communication rules, group decision-making norms, and simulation or classroom protocols.
- Provide compelling opportunities for discussion, negotiation, debate.
- Contribute advanced content knowledge and insights, models desired methods of communication.
- Foster sharing of knowledge, questions, and expertise among learners.
- Provide acknowledgment of learner contributions to simulations, feedback, or discussion.
- Moderate disagreements and group problems.
- Be aware and accommodate students who come from different cultural, social, and learning environments.
The primary goal is to ensure that learners know how they will be evaluated and help learners meet course objectives. The SimInstructor will:
- Provide learners with clear grading criteria. Uses rubrics, grading criteria, or examples to help learners understand expectations.
- Determine students who are having difficulty with the material or undertaking simulation exercises and assist as necessary (on an individual-by-individual basis).
- Practice evaluation protocols and share the outcomes with students in a manner which allows them to track their progress. This will help students address problem areas.
- Provide feedback and help with remediation, as needed.
The primary goal is to ensure learners overcome barriers due to technical components. The SimInstructor will:
- Become proficient with all simulation equipment and technical systems used in the course prior to facilitating the given SBCE process, activity, session, or lesson.
- Help learners troubleshoot technical systems.
- Refer problems to appropriate simulation facilities sources.
- Follow up to assure technical or equipment issue has been resolved.
- When finished, leave or prepare equipment and technical components in a clean, orderly fashion, ready for use by a subsequent group of learners.
SBCE Techniques and Best Practices
There are 12 key features and best practices of SBCE that SimInstructors should know in order to make the most of their use of simulation. Taken from a 2010 critical retrospective from McGaghie, Issenberg, Petrusa & Scalese , these flexible elements can be incorporated into any instructional model. They can contribute to a higher degree of learning success for the participants.
Feedback is the most important component in effective SBCE. Through the use of debriefings and instructor insights, SimLearner(s) have a better chance of improving their clinical performance. In contrast, a simple letter grade or pass/fail status will not give SimLearners the opportunity to understand how they could have improved their performance. Feedback in debriefings can come from several sources, including the facilitator, the simulation device, and video or digital recordings. Research shows that simulation training with feedback produces significantly better student performance than a no-feedback strategy. This improved performance in the SimLearner(s) transfers directly into the clinical setting.
The components of the Deliberate Practice model are used to shape, refine and maintain medical practitioners' knowledge, skills, and attitudes. Deliberative Practice can be very challenging for SimLearners This model is grounded in information processing and behavioral theories, and is used for skill acquisition and maintenance. The nine features or requirements used to achieve medical education goals are:
- Highly motivated learners with good concentration
- Engagement with well-defined learning objectives or task
- An appropriate level of difficulty
- Focused, repetitive practice
- Rigorous, precise measurements
- Informative feedback from facilitators and simulators
- Learners monitor their own learning experiences and correct strategies, errors and levels of understanding
- Learners strive to reach mastery standards
- Learners advance to another task or unit
The value of deliberate practice as an educational method was noted more than a century ago. In 1910, medical educators observed "Learning medicine is not fundamentally different from learning anything else. If one had 100 hours in which to learn to ride a horse or speak in public, one might profitably spend perhaps one hour (in divided doses) in being told how to do it, four hours in watching a teacher do it, and the remaining ninety-five hours in practice, at first with close supervision, later under general oversight."
SBCE is intended to complement clinical education. Simulated events and practice should be integrated into other educational events, such as lectures, reading, laboratory work, problem-based learning and labs. SBCE must be planned, scheduled, and focused on helping learners achieve both general and specific learning objectives from the curriculum.
It's important to plan for and collect reliable data for evaluating learners' performances. Outcome measurement is crucial in helping facilitators make informed decisions, judgments, or accurate assessments about learners. Reliable data is also vital for providing accurate feedback to learners about educational progress or areas of improvement. In addition, accurate outcome measurement is fundamental when gathering data for research.
There are three primary sources of SBCE evaluation and research data. Each of these has its strengths and should be used when most appropriate
- Observational ratings of learner performance – These may be done in many ways, including anecdotal notes, lists of criteria, or a customized notation system designed for a specific activity. Observations may be done live or they may be carried out by reviewing audio or video media. Caution: this type of measurement is subject to many sources of potential bias (unreliability) unless they are conducted under controlled conditions.
- Learner responses – These responses are either selected as part of a formal assessment instrument (e.g., multiple-choice question) or a constructed deliverable generated by the learner and assessed by the instructor (e.g. a patient note or a response to a simulated patient question). Understanding the assessment criteria for constructed responses is essential for the learners. It helps them meet performance goals and place their simulation activities in the proper clinical context.
- Haptic sensors – These are components of simulation equipment designed to safely replicate the conditions or anatomy of a simulated procedure. Haptic sensors capture and record learner 'touch' and control in terms of anatomical location, dexterity, and depth of pressure under simulated conditions. The information gathered from haptic sensors can be in many forms, including video and numerical data.
Simulation Fidelity (low to high, multi-mode)
In SBCE, educational goals and curriculum influence decisions about the specific simulation technology needed for teaching and testing. In other words, the effective use of simulation technology depends on a close match of education goals with simulation tools. Fidelity refers to the level of "realism" the simulation technology provides under clinical situations, tasks, or contexts.
Low fidelity refers to basic procedural skills like suturing, intubation, and lumbar puncture which can be delivered using simple devices that mimic body parts or regions, called task trainers. These are described as those that feel least-real to the learner. Other examples include paper- or computer-based static activities which allow for little interaction from the learner.
High fidelity refers to complex clinical events which require training that uses more sophisticated medical simulators. These include lifelike full-body mannequins that have computer-driven physiological features, respond to physical interventions and drug administration and interactions. This technology records clinical events in real time and the data can be used for evaluation and performance appraisal.
Hi-Fidelity also refers to virtual reality (VR) simulators which are now used to educate surgeons and medical subspecialists in complex procedures that are too dangerous to practice on live patients.
Multi-mode educational simulation combines "inanimate models attached to simulated patients [in order to] provide a convincing learning environment." These scenarios often use Standardized Patients (a person trained to portray an actual patient) "for the instruction, assessment, or practice of communication and/or examining skills of a health care´┐Ż provider." Clinical skills are taught and evaluated coincidentally with attention to doctor-patient interaction, patient comfort and privacy. Multi-mode units are the best features of low and high fidelity to present realistic clinical challenges for education and evaluation.
Skill Acquisition and Maintenance
This area of SBCE focuses on clinical and procedural skill acquisitions that can be maintained or allowed to decay over time. In other words, "practice." Skill acquisition and maintenance are the most common learning objectives of SBCE. SBCE research in this area explores the degree to which skill decay depends on the specific skill acquired, the degree of the skill learned, and the time allowed to elapse between learning and follow-up measurement.
Mastery learning is a rigorous approach to competency-based education. It has seven complementary features:
- Baseline testing
- Clear learning objectives, sequenced as units ordered by increasing difficulty
- Engagement in educational activities that focus on reaching the objectives
- Establishment of a minimum passing standard for each educational unit
- Formative testing to gauge until completion at a preset minimum passing mastery standard
- Advancement to the next educational unit given measured achievement at or above the mastery standard
- Continued practice or study on an educational unit until the mastery standard is reached
The goal in mastery learning is to ensure that all learners accomplish all educational objectives with little or no outcome variation. Mastery learning presents a paradigm shift from the way simulation-based and many other education activities are currently carried out. Time becomes a factor as learners may vary in their ability to reach the mastery standard. This will have a significant impact on the program and instructional design, implementation, and resource use.
Transfer to Practice
Transfer to practice describes skills acquired in SBCE laboratory settings and how they are generalized to real clinical settings. The result of successful transfer to practice is more skillful behavior in clinical settings, improved patient care, and improved patient outcomes. Studies have shown simulation-trained learners show greater compliance, significantly fewer procedural complications, and overall improved patient outcomes.
SBCE for health care team training is an important educational goal because team interaction is the root cause of almost 70% of errors in clinical practice. Team training provides an opportunity to practice both task- and team-related skills in a "consequence-free" environment, where errors become opportunities for learning and providing constructive feedback. Studies have shown there are eight evidence-based principles for effective planning, implementation, and evaluation of team training programs specific to health care:
- Identify critical teamwork competencies and use these as a focus for training content
- Emphasis teamwork over task work, design teamwork to improve team processes
- Let the team-based learning outcomes desired, and organizational resources, guide the process
- Provide guided, hands-on practice
- Ensure training relevance to transfer environment
- Feedback must be descriptive, timely and relevant
- Evaluate clinical outcomes, learning, and behaviors on the job
- Reinforce desired teamwork behaviors, sustain through coaching and performance evaluation
The standardization, fidelity and reproducibility of medical simulation in SBCE make the technology well suited for evaluations of clinical competence. The medical community can begin to use SBCE to make 'high-stakes' decisions, such as those that involve the learner passing a program or course of study, or gaining certification or licensure. High-stakes testing demands highly reliable data that permits valid inferences about the competence of medical candidates. Medical simulation can be an effective tool for evaluating candidates' personal qualities and attributes, not just their procedural skills.
Observation and experience in SBCE suggests that effective SBCE is challenging. It involves a new and dynamic way of instructing learners, and clinical experience alone is not a proxy for simulation instructor effectiveness. The effectiveness of the instructor using SBCE plays a dominant role in the success of the learner - interestingly, research suggests that simulation instructors and learners need not be from the same health care profession.
Educational and Professional Context
Contexts of education and professional practice have profound effects on the substance and quality of learning outcomes and on how professional competence is expressed clinically. "Authenticity should have a high priority when programs for the assessment of professional competence are being designed. This means that situations in which a candidate's competence is assessed should resemble the situation in which the competence will actually have to be used." SBCE programs that recognize this need for an authentic learning context in order to teach, evaluate and provide practice will be successful.
Culturally-focused Best Practices for SimInstructor
Because medical students and learners in the medical field come from nations all around the globe, SimInstructor should get in the practice of addressing multi-cultural issues that may occur in their teaching environment.
SimInstructors should reflect on two potential multi-cultural interaction issues related to SBCE:
- Language Issues (ESL, EFL, international students) include:
- Self-consciousness about speaking abilities - the learner may not participate in discussions or communicate effectively during simulation activities.
- Idioms and Expressions - many phrases and references that English speakers may take for granted could make their way into a simulation; international students may not understand these at first and it could impact the success of the simulation.
- Culture and customs may influence learning styles to include:
- Preferences for - concrete and informative guidance from the authority rather than peers.
- Students from a culture of high context - the learner has a low tolerance of ambiguity.
- Students from a culture of collectivism - the learner feels relationships can be a top priority. This means that this learner's contributions to discussions may be guarded or reserved (or non-existent). Learner may also feel uncomfortable disagreeing with a classmate or colleague in the SBCE.
- Students from a culture of "losing face" (or shame) - the learner may be concerned that he/she will "say something stupid" or worry that their English is not understandable - the learner be may hesitant to participate in discussions or other collaborative situations.
- Students from a culture where instructors are the single authority - the learner will prefer guidance from the instructor rather than value the contributions from peers or team members. Feedback directed to this student may be one-way: from instructor to learner (with a low degree of discussion).
The SimInstructor should reflect on potential multi-cultural implementation issues related to SBCE:
- Be responsive to international learners if they demonstrate a need. Try to determine their instruction styles and use them as a starting point to integrate their activities to a more productive and effective degree. Provide prompt, informative, and constructive feedback.
- Provide well-organized and structured learning materials (i.e. syllabus, rubric, criteria for success, etc.).
- Foster a sense of community within the larger group.
- Foster a learning environment that learners from other cultures regard as "safe." For example, encourage learners from collectivism culture expressing opinions, making comments, and taking positions with the presence of evidence. This is particularly important in the medical field.
- Encourage autonomy learning and self-regulated learning, tolerate ambiguity and mistakes.
- Take learners' language challenges into consideration. Assessment should be the combination of: process (formative) and product (summative).
- Help learners understand the "why" of the activities and assessments, as well as the "what" and the "how." When students from other cultures understand the reason for activities, they have a better chance of shifting behavior patterns to the culture of the SBCE environment.
 Rovai, A. P. (2000). Online and traditional assessments: what is the difference. Internetand Higher Education, 3, 141-151.
 Quoted in Flexner, A. (1910). Medical Education in the United States and Canada. Carnegie Foundation for the Advancement of Teaching, Bulletin 4, New York. Retrieved 4/6/2010 from http://www.carnegiefoundation.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf
 McGaghie, W. C.. Issenberg, S. B., Petrusa, E. R., & Scalese, R. J. (2010). A critical view of simulation-based medical education research: 2003-2009. Medical Education, 44 50-63.
 Retrieved 4/6/2010 from: http://www.aspeducators.org/sp_info.htm
 Retrieved 4/6/2010 from: http://en.wikipedia.org/wiki/ADDIE