“Simulation is the key to patient safety and medical quality.”
-John Nance, author of Why Hospitals Should Fly
One of the biggest challenges we face in healthcare is how to educate and train healthcare professionals without endangering patients—especially when we are teaching the management of high-stakes situations such as codes, trauma care, chest pain, or anaphylactic shock, in which any delay in treatment threatens the outcome. Often, new healthcare practitioners enter their profession without ever having seen—much less gotten experience with—many high-risk/low-volume patient conditions.
The use of simulation is growing exponentially in academic and service settings. Simulation can enable students, new graduates, and experienced clinicians to develop clinical competence and confidence in caring for patients in a learning environment that is cognitively and emotionally realistic and safe for the learner—and does not compromise patient safety or outcomes. Simulation can be applied to many clinical situations—far more than a learner can be exposed to in a live clinical environment. Simulation activities need not be bound by one profession, time, or place. Simulation can be expanded to include the systems dynamics of care, interprofessional teamwork, and considerations for hospital technology and equipment at any point in the healthcare continuum.
In a clinical setting, simulation can be used to onboard new graduates and experienced staff. Simulation also offers the ability to objectively assess the performance of healthcare professionals based on a well-defined standard of practice. Many organizations carefully assess the competency and performance of new staff, but—other than perhaps yearly skills fairs—do little to ensure that existing staff continue to meet standards of practice and follow evidence-based and best practice processes and protocols. Renewing nursing or medical licenses generally requires only paying a fee and completing continuing education programs—not demonstrating continued competence. Simulation can be developed for continued development of staff and educators. Although we know much more about healthcare education today than we did 20 years ago, much has yet to be discovered. Research is changing healthcare practice on an almost daily basis. To assume that all professionals who renew their licenses are competent in the knowledge and skills needed to practice in the current environment is naive at best and dangerous at worst—something Florence Nightingale knew and was passionate about more than 100 years ago. It often surprises people to learn that Nightingale opposed the registration of nurses. The reason was that she thought you could not know whether a nurse was competent based on just the fact that the nurse had finished nursing school or passed a written examination. In an 1888 letter to the probationer nurses at St. Thomas Hospital, Nightingale wrote:
She [the nurse] may have gone to a first rate course—plenty of examinations. And we may find nothing inside. It may be the difference between a nurse nursing and a nurse reading a book on nursing. Unless it bear fruit, it is all gilding and veneering; the reality is not there, growing, growing every year. Every nurse must grow. No nurse can stand still, she must go forward, or she will go backward, every year. And how can a certificate or public register show this?
Simulation can be used to improve an organization's ability to ensure that all its clinicians maintain competence. Knowing is not doing. Simulation can demonstrate the successful application of knowledge.
There is also growing evidence that simulation is effective in developing, assessing, and improving the performance of healthcare teams. Much as the aviation industry first used flight simulators to teach the “hard” skills of piloting airplanes, such as takeoffs, landings, and handling mechanical emergencies, healthcare began using simulators to teach the “hard” skills of caring for patients—diagnosing and using medications and other interventions in response to a patient's physiological changes. A series of high-fatality plane crashes caused the aviation industry to look beyond the hard-skill training solutions to improve how their people worked together and communicated with each other. This led to the development of what is now called crew resource management (CRM). CRM redefined roles and expectations; created a culture of transparency; encouraged people to learn from errors; and pushed for the development of training, processes, and standards to enable leaders to quickly create highly functional teams from a group of crew members who very often have never worked together. All these practices have been integrated into the aviation industry's simulation experiences. As a result, air travel is safer than ever. Like the aviation industry, the healthcare industry has come to understand that how healthcare professionals work together can have a major impact on patient safety and improving patient outcomes. Just as aviation uses simulation to teach CRM to its professionals, healthcare can use simulation to develop highly functional teams.
Simulation can contribute to risk management and quality improvement activities. It can be used to identify latent threats to patient and clinician safety, allow clinicians to test “what if” scenarios (e.g., what if we used another drug? Or, what if we did intervention B before intervention A?), and perform trial runs of new techniques, equipment, and patient-care areas.