Patient safety outcomes are based only on what one did, not what one thought or intended to do. Often the disparity between health care workers’ intentions and actions is what causes patient harm. One of the most effective ways to assess and improve patient safety is to create realistic patient care situations where students or professionals can practice patient assessment, diagnosis, and treatment without putting patients at risk. Medical simulation does just that and provides a wealth of opportunities to challenge respiratory therapists in a safe environment where they are given permission to make mistakes and learn in a controlled environment without patient harm.

When designing a simulation, it is important to have a few things prepared ahead of time. First, instructors need to know how they plan to use their simulations. They also need to know what makes simulation an effective educational tool—then they can decide whether it is the best training modality to use. Finally, instructors need to prepare high-quality learning outcomes, which will drive their simulation design and help ensure learning.

Various Uses of Simulation

Medical simulation takes many forms, from a simple intubation training head to a fully integrated virtual reality computer simulation. But, in general, simulation can fall into three basic categories—instructional, diagnostic, and assessment.

Instructional simulation. When most instructors design simulation, it is instructional simulation they are developing. An instructional simulation demonstrates something new to a person or group of participants. There are assorted views on how much education participants should be given on topics prior to attending instructional simulation. Traditionally, respiratory students attend a lecture on asthma before they manage a patient (simulated or real) with asthma. The lecture model of teaching is not effective for adult learners,1 and therefore it is not until the simulation that many students master knowledge. Instructional simulations succeed through David Kolb’s experiential four-step learning cycle: 1) a concrete experience; followed by 2) observation and reflection; 3) forming abstract concepts; then 4) testing in new situations.2 Simulation allows a group of people to have the same patient care experience (step 1), then instructors observe and debrief students, discussing important concepts in patient assessment, decision making, and therapy delivery (step 2 and 3). A second similar simulation can be presented after debriefing to allow students to test their new knowledge and practice new skills (step 4). This learning cycle can augment or replace some clinical experiences, like traumas or high-risk deliveries, that aren’t guaranteed to all students prior to graduation.

Diagnostic simulation. A diagnostic simulation answers the question, “Why are specific errors occurring?” These health care simulations are developed with patient safety as the overarching goal and assess why a particular team or hospital location may not be prepared to safely manage emergency situations. A diagnostic simulation can find latent errors (less apparent failures of organization or design that contribute to the occurrence of errors or allow them to cause harm to patients3) that could affect patient care, though they may not have occurred yet (a “near miss”). For example, a diagnostic simulation would ask, “Is our unit prepared to quickly, safely, and effectively care for a patient with an airway emergency?” It would look at staffing adequacy, equipment and storage issues, availability of resources, and assessment and decisions in patient care. It could answer more specific questions such as: Is there always a ventilator available on the unit? If not, how long will it take to get there? Can all members of the emergency team arrive within 1 minute of being called? Is the defibrillator easy to get to—or are wheelchairs, IV poles, bed scales, etc stacked in front of it?

Assessment simulation. This simulation evaluates a person’s ability to perform certain tasks, including patient assessment, decision-making, psychomotor skills, and evaluating the effectiveness of care. It can also be used to assess something new—say, a new ventilator prior to deciding to purchase a dozen for the hospital, or a new therapist-driven protocol prior to launch. Assessment simulations can be used with students prior to beginning clinical rotations to answer such questions as, “Can my students safely suction a patient with an artificial airway per the AARC’s Clinical Practice Guidelines (CPG)?” Simulation can also be used at the end of clinical rotations to assess whether students’ clinical skills have improved, for example: “Have my students improved in suggesting mechanical ventilator changes based on clinical findings, such as arterial blood gas, chest radiograph, peak airway pressures, flow-volume loops, and other requested data?”

What Makes Simulation Effective?

There are many aspects of simulation that can influence whether it is an effective learning tool. Through trial and error, many simulation users stumble across aspects of their simulations that make them more or less useful for participants. In 2005 a Best Evidence Medical Education (BEME) systematic review was completed to determine what aspects of medical simulation suggest that it can facilitate learning.4 The results compiled 10 key points, which include:

1. Providing feedback. Debriefing in simulation occurs when the facilitator and the participant have a dialogue to discuss the events of the simulation and why certain behaviors occurred, and develop a plan to effect change in future patient care. This cannot be stressed enough as one of the most important events during simulation. Even simulations where nothing is done correctly can improve patient safety if there is an effective debriefing.

2. Repetitive practice. Simulation allows participants to repeat a skill until it is done successfully, which is usually impossible on real patients. Vince Lombardi has been credited as saying, “Practice doesn’t make perfect. Only perfect practice makes perfect.” This mantra is a core concept in most simulation labs, stressing the importance of supervised repetitive practice to discourage wrong or bad habits.

3. Curriculum integration. Simulation is not a stand-alone learning modality. It works best when integrated into a larger curriculum with other educational interventions.

4. Range of difficulty level. Scenarios can be adjusted based on the skill level of the participants.

5. Capture clinical variation. Simulators can be adjusted to capture similar patient states, but tweaking clinical conditions can create many unique patient care situations.

6. Controlled environment. Patients are often unpredictable. Simulation can allow you to control how patients respond to interventions, so facilitators can control what learning occurs in the simulation environment.

7. Individualized (active) learning. Participants in a simulation are active learners, not passive bystanders, which engages them and encourages learning.

Additional best practices for simulation design:

1. Ground rules. Simulation training can make novice participants very nervous. Setting ground rules helps them understand expectations. The rules comprise:

  • Confidentiality. Their behavior will not be discussed outside of the lab.
  • Safe environment. The simulation lab is a safe place where participants have permission to fail. Their behavior is not considered a reflection of the type of therapist they are, but a performance that is separate from their identity. The simulation environment is a place where participants can practice on plastic first, allowing them to perfect their skills before working on real patients.
  • Suspending disbelief and critical reflection—often known as a fiction contract.5 Facilitators ask participants to be open to reflection during the debriefing and care for the manikin the same way they would any patient they care for. In return, the facilitators agree to assume that participants act with the patient’s best interests in mind and that they always have the best intentions to provide good care to the patient.

2. Staging. Participants “play along” better during a simulation when the environment is as close to real life as possible. That includes providing the same ventilators, IV poles, disposables, and other equipment they would see in the clinical environment. Making things more convenient than in real life, like having intubation supplies within arm’s reach of the patient when they would normally be kept in a tackle box down the hall, can make participants subconsciously behave differently than they would in a real clinical environment, which detracts from the fidelity, or accuracy, of the scenario.

3. Orientation. It is not natural for participants to interact with an artificial patient in a fabricated environment. Orientation to the simulation lab helps participants play authentically and eases the transition. A full orientation to the manikin includes features like where pulses are located, where best to listen to breath sounds, what procedures can be performed, and how to read the monitor. It also includes what the manikin cannot do, which might include spontaneous eye or limb movement, bleeding, speaking, edema, mucous clearance, and other important features that are determined by other means. Orientation should also include available equipment and resources, whether there are real piped gases, and what to do if more hands are needed than are currently available. Any confederate (individual other than the patient in a simulation to provide realism or additional information for the learner6), like a nurse or doctor, should be identified during orientation.

Learning Outcomes

As listed in the BEME systematic review,4 one of the most important steps in simulation design is creating learning outcomes. When novice instructors decide to use simulation, they begin thinking of available equipment and try to design a simulation around that. Many people think, “I just bought a SimMan, or METI, now what?” Instead, the questions to ask would be, “What aren’t we teaching well right now?” or “What should every RT student/staff member be able to do that I don’t think (or don’t know if) they can do now?” These big questions identify topics for which simulation may be a good educational modality. Breaking down these topics into specific learning objectives will help develop a plan for training. This backward curriculum design plan is known as Understanding by Design,7 where instructors begin with the end in mind and work backward to determine how they will get learners to arrive at the correct outcome. The end is the simulation goal and is a general statement of the desired outcome,8 such as “Using the AARC’s Clinical Practice Guideline, participants will be able to safely suction an artificial airway.” Learning objectives are detailed statements of outcomes, which help you meet your goal.8 Objectives for the suctioning goal previously stated include:

  • Given a simulated patient, participants will preoxygenate using 100% FIo2 for at least 1 minute before beginning the suctioning procedure.
  • Upon being asked by a family member, participants will correctly describe at least two hazards/complications of suctioning an artificial airway.
  • Given all available ICU equipment, participants will gather all the necessary supplies for suctioning an artificial airway per AARC CPG within 3 minutes.

Objectives are the actions you expect to see from a perfect simulation performance. Facilitators should have one objective per behavior, which are descriptive enough that there is no debate whether participants meet stated objectives. Whenever possible, use published documents or validated checklists to define success. The AARC’s CPG, American Heart Association BLS and ACLS guidelines, hospital protocols, or manufacturer guidelines are good sources when building learning objectives.


Simulation is an exciting, engaging way to facilitate learning in medicine. A constant focus during the design phase will improve participant learning. Determining how simulation is to be used, focusing on the aspects of simulation that make it an effective educational modality, and building goals and objectives prior to launch will all improve the value of the learning experience.

Julianne S. Perretta, MSEd, RRT-NPS, is simulation educator, The Johns Hopkins Hospital, Baltimore. For further information, contact [email protected]


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