For the past decade, much of the simulation expertise and literature has been related to anesthesiology. Although considerable success has been achieved in this arena, the installed simulation base remained relatively level or had small amounts of growth, compared to the current boom. This current boom stems from both lower equipment costs and a maturation of the market to accept simulation as a viable educational tool. The belief that wisdom and clinical experience alone will produce safe, confident, and effective providers is likely fiction, so many nursing education programs are now using simulation to address issues of patient safety, as well as other issues.
The fundamental problem in the proliferation of new programs is the lack of accessible expertise. Few, if any, basic, how-to resources exist, without the burden of considerable cost (Kurrek & Devitt, 1997). Institutions typically take what may be called the “three-step process to simulation.” The first step is deciding that simulation is interesting and likely to have some value. The individuals involved research it and learn some of the more common uses of this educational tool, and a person or group is identified to lead the effort for the institution. The second step usually involves contacting simulation manufacturers and sampling their wares through local demonstrations or at trade shows or conferences. These introductions often lead to purchases of high-fidelity units. The attraction to high-fidelity units is not surprising, as they provide the most realism and, therefore, are perceived as the most likely to be useful. The third step is the gathering of support for the equipment and program. This is where problems often occur, which can prolong or impede the process. Up to this point, no one has thought about who the students will be, who will teach the courses, how simulation will be integrated into the curriculum, what courses will be taught, who will support the infrastructure required for this teaching tool, and so forth.
In this article, we will summarize an approach to the development of a simulation facility. This is intended to serve as a template for individuals or groups in the process of integration and development of simulation education in their institutions.
Development of a Simulation Program
First, one must realize that not only is there much more to using simulation than buying a manikin, but also that a considerable amount of organization and thought should precede much of what has been described in the introduction to this article. In fact, the process is not actually a three-step process, but rather has multiple steps determined by the needs of the institution and its membership. The remainder of this article contains a brief description of some of the important steps required in developing a successful simulation program. However, it does not include the intricacies of day-to-day management issues. That level of detail will be included in future literature as centers gain experience. There is no single right way to develop and use a simulation program, but we offer one way that has been successful for both large and small facilities. The approach is robust and flexible enough to accommodate change and unforeseen issues. A timeline for the components is presented in Figure 1. We must emphasize that this plan can be applied to both large and small projects, and although Figure 1 suggests a specific timeline, it can be adjusted to suit any institution and budget.
Timeline for components involved in the development of a simulation program.
Vision development is crucial to the establishment of a viable simulation program. The vision must address several issues:
- Size of the facility.
- Collaboration with other disciplines.
- Population to be served.
- Type of simulation to be used.
- Structure of “ownership.”
Before purchasing equipment and embarking on a simulation project, the individuals involved must understand the scope of the project. The scope will be defined by the budget and degree of collaboration. Collaborating with other schools, disciplines, and health care systems has the benefit of cost sharing but may introduce certain political hurdles that must be overcome. Collaboration requires stakeholders to shed their individual identities and assume the common goal of bringing simulation education to the population they intend to serve. Having a governance structure with equal representation is also important. The foundation of collaboration is trust, but this is a cultivated phenomena, not an instantaneous one.
The type of simulation and how it will be used must also be addressed in the overall vision. This will guide training, purchasing, budget, and the scope of the project.
After developing a vision, the planners must then put much of this information into a standardized and understandable form. A business plan, with an executive summary, is paramount when seeking “buy-in” from potential stakeholders. A business plan shows the direction the facility will take, as well as its basic governance and budgetary plans. In addition, the exercise of developing a business plan is a worthwhile educational experience.
With a well-developed vision and business plan, the likelihood of achieving buy-in from potential funding sources is increased. The vision describes the project, and the business plan defines fiscal obligations. It is important for planners to convey their enthusiasm to potential stakeholders. We believe the success rate increases if buy-in occurs at the executive leadership level. Seeking buy-in at mid-level management can be and has been done, but it may not be the most efficient way to proceed. Executive-level buy-in increases the likelihood of mass mid-level acceptance. A directive from the executive level (i.e., as primary stakeholders) carries considerable power to encourage faculty to integrate simulation as a key educational and competency assessment tool. Similarly, it is more likely that the executive will be able to allocate the necessary funds to successfully complete the project.
Facility Construction and Equipment Purchase
The construction phase is clearly defined by the vision and budget. The planners must ensure the construction and architectural companies selected are comfortable designing simulation facilities. The decision to retrofit an existing site or construct a new facility depends on the institution. Retrofitting is a reasonable course to take, but planners must be aware that it can be costly and may introduce unwanted political ramifications. Collaboration partners must perceive the facility as neutral ground.
Seeking outside expertise from others who have constructed simulation facilities is paramount. Thousands of dollars are spent on architectural and engineering time to solve and overcome issues that have already been solved and addressed by other individuals and centers. Money is better spent asking these institutions to consult, in partnership with the architects and engineers. These experts understand the nuances of center construction and likely have learned valuable lessons in their own facilities. In addition, it is important to seek experts who are able to listen to your needs, rather than those trying to replicate their own facilities.
Equipment purchasing can begin at this point. Simulation equipment includes audio and video devices, simulation tools or systems, necessary furniture and props, computers, and other elements required to make the facility function. Working with a simulation expert is invaluable for this portion of the project. One must proceed with caution at this point and avoid overbuying simulation equipment. At this stage, purchasing equipment to help train personnel will likely suffice. The purchase of a more complete set of equipment should wait until the individuals who are developing the curriculum have been consulted. Skipping this step or being overzealous can be costly.
In this time period, selected individuals should begin training in the use of simulation tools. As with facility construction, the presence of experts is valuable. Without expertise, individuals gain only a basic understanding of the equipment. They lack context of use, as well as an understanding of the equipment’s potential and limitations. Individuals in this situation often plateau at a middle level of expertise, which is unnecessary and can be avoided through networking with other simulation sites. Learning simulation alone is a long process and may take years to achieve.
Assuming the presence of experts, faculty must be trained to become simulation specialists regarding the construction, use, and scope of the tools. They also need to understand the context and limitations of the tools at their disposal. They must learn to design scenarios that are evidence and objective driven, as well as how to implement these scenarios and refine them to suit the curriculum they serve. In addition, faculty must be trained to help course directors understand how simulation can be implemented in the curriculum. Only after faculty members have reached a high level of understanding of the above components and are comfortable with simulation are they considered simulation specialists. Simulation specialists should not take over the courses but should act as consultants for other faculty.
The time of greatest learning for simulation specialists is when they are actually using the equipment in real scenarios. Here they learn how to interact with students and how to provide realistic simulation and debriefing. They probably will learn equally from their mistakes and their successes. Concepts will be transformed into real actions, and trainees will experience the benefits of this learning process.
Curriculum planning and development is crucial. After the facility has been completed, several things must come together: experienced simulation specialists; facility infrastructure; faculty acceptance; curricula designed to use simulation; a decision to use simulation as an evaluative tool or a training tool or both (Devitt et al., 1998; Devitt, Kurrek, Cohen, & Lam-McCulloch, 1999; Dillon, Clyman, Clauser, & Margolis, 2002; Rosenblatt & Abrams, 2002). Faculty normally in charge of curricular development must meet and determine how they wish to incorporate simulation into the overall curriculum. Is the facility to be a simple skills laboratory, or will it work in concert with the curriculum to act as an adjunct at multiple levels?
After having made decisions such as these, faculty can proceed to create curricula that include simulation, if appropriate. This is a time-consuming process, but it cannot be skipped. After the curricula are complete, they will likely need refinement but will act as a starting point for the facility. Simulation specialists can guide this process and help others understand the tool and its application. The scope of curricular change will depend on the vision and the degree and level of institution, school, and department buy-in.
Simulation is new enough that there are many people who still doubt its worth and significance. It is important to allow faculty and other health care system partners to see and experience the technology in a nonthreatening environment. Requiring faculty to participate in a crisis simulation may not be a prudent starting point. It is essential to first gain their trust and answer any questions truthfully. Admitting that simulation may not work in certain situations may be as powerful as stating when it will work. Faculty must be given time to learn the scope of the equipment and should have access to simulation specialists to help them incorporate simulation into their curricula.
Buy-in from institutional decision makers is vital because they can often provide the direction that encourages faculty to learn about this tool. Simulation specialists must be prepared for demands of proof of validation. This is a difficult subject, and several validation studies are underway, with hopes that their results will fulfill this demand. However, it is important for faculty to understand that asking for validation that simulation actually makes a difference in the clinical world holds it to a standard to which other educational tools have not been held. Many teaching tools in nursing education have been adopted through intuition, experience, and, sadly, habit but have never been validated. Simulation as an educational tool makes inherent sense because it provides hands-on experience for students. Acceptance of simulation as a teaching tool is occurring and will likely parallel validation attempts.
Infrastructure and Policies
Policies and procedures will allow the facility to function under standardized and referable rules. The policies will likely change over time but are crucial in establishing boundaries and order during implementation. They give staff something to consult when asked to make a decision. A facility that is perceived to be run in an arbitrary manner will likely be met with resistance. Issues such as scheduling, equipment use, cost sharing, and priority lists must be addressed.
As simulation specialists become more proficient and as curricula are developed, everyone involved will gain a better understanding of the overall needs of the facility to be a success. At this point it is appropriate to begin planning to purchase additional equipment deemed necessary. By splitting the purchasing phases, some volume discount opportunities may be lost, but it is likely that considerably more money will be saved by purchasing based on firmly grounded knowledge and an understanding of the products. Rather than relying on guesswork, only products needed to support the vision are being purchased.
All types of decisions about simulation tools need to be made. What items are needed now, rather than later, and how many high-fidelity or moderate-fidelity simulation tools are needed? Moderate-level simulation units tend to be approximately one quarter of the cost of high-fidelity units. There is a strong argument that it may be worthwhile to purchase four moderate-fidelity simulators, instead of just one high-fidelity simulator.
Simulation as an educational tool in health care has reached a level of maturity that brings with it much enthusiasm. Many institutions are trying to adapt this form of education to their curricula. Institutions have little guidance in this process and are left to guess through trial and error. It is important to realize that using simulation effectively involves more than just buying a manikin (Figure 2). It involves organization, curricular thought, simulation skill, and a whole new view of health care education and clinical experience.
Issues involved in using simulation as an educational tool.
Institutions should proceed in a manner that makes sense for their individual programs. This article outlines one approach, but there will inevitably be many. Institutions that need help may find it useful to seek the advice of others who have experience in this area. Simulation manufacturers may also be of assistance.
It is important to realize that the process of establishing a simulation program involves multiple steps prior to purchasing the equipment. This approach not only saves money but also decreases the likelihood of being overwhelmed during the process. Selection of the right people and team to lead the project (big or small) is very important. As the doors of a new or retrofitted simulation facility open, the infrastructure, curricula, and training should be well under way, so students can begin to enjoy the benefits of simulation education.