EDUCATION NEWSNina Turcato, CRNA DNP

Cliff Roberson. CRNA MSKarl Covert, PhD

Simulation-Based Education: What's in it for NurseAnesthesia Educators?

This column presents an overview of the current stateof the art of simulation-based training. It shares theresults of a recent national survey, describing the cur­rent use of simulation technology among nurse anes­thesia programs. It reviews the theoretical advantagesof simulation-based instruction. Barriers to the devel­opment of simulation in nurse anesthesia programs are

discussed, as well as strategies educators can use toovercome these challenges.

Keywords: Crisis resource management, experientiallearning, nurse anesthesia education, simulation-basedtraining.

Simulationmode Examples

low fidelity Patient actors

Simulated interViews

Table 1. Simulation Modalitiesa laerdal Medical Corporation, WappingersFalls, New Yorkb Medical Education Technologies, Inc,Sarasota, Florida

95 directors invited to participate, 52responded. Ninety-six percent (91)indicated they use some form of sim­ulation in their curriculum. Task

trainers are frequently used acrossprograms; the most common areintubation manikins (98.1 %,52) and

spinal models (92.5%, 50). In thearea of high fidelity simulation, thereis a significant drop in program uti­lization rates. The 2 most widelyavailable simulation systems,

New technologies are revolutionizinghealthcare education across manydisciplines. "High fidelity" simula­tion now allows students to learn in

an environment representative ofactual operational conditions. Thesetools are engendering an importantparadigm shift that presents uniquechallenges to nurse anesthesia educa­tors. This column presents anoverview of the current state of the

art of simulation-based training,results of a national survey about useof simulation technology amongnurse anesthesia programs, and abrief summary of the advantages ofsimulation as a pedagogic strategy.Barriers and strategies to overcomethem are identified, with the goal ofpromoting this tool in the educationof safe, competent nurse anesthetists.

Simulation DefinedSimulation is defined as any activitythat reproduces a task environmentwith sufficient realism to serve a

desired pedagogic goal. I The out­come for high-skill professions is toimprove student competence in both

technical and nontechnical

domains.I•2 Modalities vary fromrole-playing scenarios, to task train­ers, and to high fidelity, roboticsimulation systems (Table 1).2Simulation is not new to healthcare

education, yet new technology hasallowed simulators to replicatehuman physiology in an extraordi­narily realistic manner. They cannow interface with actual monitoringequipment and anesthesia machines.Learners can manage uncommonclinical scenarios or be allowed tomake errors in routine decision mak­

ing and have those errors reach theirnatural conclusions. The resultallows students to learn from deci­

sions without the risk of harmingpatients. I

Simulation in NurseAnesthesia ProgramsTo what extent are nurse anesthesia

educators using simulation-basedinstruction? We disseminated a sur­

vey 10 program directors asking themto describe simulation modalities

they currently use (Figure I). Of the

Task trainers

High fidelity

Written problems

Intubation manikins

Invasive monitoringand spinal trainers

SimManaHPSb

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Patient actors 14.8

Radial arterial line model

42.5

HPS'

44.4

SimManb

51.8

Central line model

181.4

Spinal model-J

192.5

Manikin

I

II

IIIIIIIII0

102030405060708090100

Percentage

Figure 1. Percentage of Nurse Anesthesia Programs Using Various Simulation Modalities

a Medical Education Technologies. Inc, Sarasota, Florida

b Laerdal Medical Corporation, Wappingers Falls, New York

SimMan (Laerdal Medical

Corporation, Wappingers Falls, NewYork) and HPS (Medical Education

Technologies, Inc, SarasOla, Florida),were integrated into the curriculumof programs at 51.8% (28) and 44.4%(24), respectively. Results indicatethe newer technologies are only usedin half of the programs thatresponded.

The survey also queried respon­dents about barriers preventing themfrom using the latest technologies(Table 2). The most common con­straint was cost. High fidelitysimulation equipment requires a sig­nificant financial investment. Thecurrent model of SimMan lists for526,995; HPS costs 5245,000. Thesesystems also require considerableoutlays for peripherals, technicalsupport, media equipment. andphysical plant allocation. Facultycosts are unavoidable; courses

designed to train educators atnationally recognized centers rangefrom 5685 to 51,995.

Time commitment was another

barrier to integrating advanced sim­ulation. Scheduling puts demandson instructors who already haveteaching obligations, as well asscholarship and service require­ments. Simulation-based instruction

can also represent a time-intensiveendeavor for the entire program.Current literature suggests idealstaffing for high fidelity simulationsessions is a minimum of 2 to 3

instructors.3 High fidelity simulationexerts pressure on an already con­gested program schedule.

Value-Added LearningUtilization rates suggest adoption ofhigh fidelity simulation is far fromuniversal, despite the general trend inhealth care education. The critical

question is: Does high fidelity simula­tion provide a learning experienceworth the cost, time, and effort? The

answer to this question is complexand has at least 3 important dimen­sions. Simulation must offer

educators a methodology that fosterscritical skills not readily acquired

1.Time

Faculty developmentImplementation

2. Cost

EquipmentFaculty development

3. Distance from programTravel to access simulators

4. SchedulingCompetition with other learners

5. Lack of technical support

6. Lack of laboratory space

7. Lack of full-time equivalents

8. Administration unsupportive

Table 2. Rank of Barriers to the Use

of Simulation in Nurse Anesthesia

Programs

through traditional approaches. It

must also present learning opportuni­ties not possible in the classroom orclinical arena. In addition, it shouldassist educators in addressing exter­nal realities that impinge on theformation of safe, competent nurseanesthesia graduates.

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Figure 2. Bloom'sTaxonomy of Cognitive SkillsEva!. indicates evaluation.

(Adapted from Anderson LW, Sosniak LA. eds. Bloom's Taxonomy: A Forty-Year

Retrospective. National Society for the Study of Education: Chicago, IL; 1994.)

Enhancing Higher OrderSkillsThe cognitive sciences help usunderstand the advantages highfidelity simulation-based learningoffers. Cognitive skills are hierarchi­cal; that is, students must developproficiency in lower order skillsbefore tackling more complex learn­ing behaviors. Bloom's taxonomyoffers a useful classification of the

intellectual processes essential tolearning (Figure 2).4 We can easilyfacilitate lower order skills with tra­

ditional classroom methods. Creatinglearning activities that aid in the

Analysis

Application

Comprehension

Knowledge

development of higher order skills ismore difficult and requires educatorsto engage students in a participatoryexperience. Simulation scenarios maybe easily designed to emphasize thehigher order cognitive skills.

Experiential learning may be oneof most effective means to help stu­dents gain the most from theirclinical training. Scientists havedescribed the process wherebyknowledge is produced through thetransformation of experience.Learning by doing takes place whenthe student moves through a cycle of4 distinct phases (Figure 3).5

Higher orderthinking skills

Lower order

thinking skills

Reflection is critical, and it is least

likely to take place in the busy clini­cal world in which students train.

Simulation not only provides stu­dents with a realistic clinical

experience but also offers an oppor­tunity for structured reflection. Inaddition, experiential learning assiststhe student in learning how to learnfrom experience, gaining awarenessof strengths and vulnerabilities.6Advanced simulation optimizes cur­rent training and provides a templatefor lifelong learning to facilitate pro­fessional development.

A Unique LearningEnvironmentEducators should also consider theenvironment that is hest suited for

learning the content and assessingoutcomes. Anesthesia Crisis

Resource Management (ACRM), forexample, is not easily taught in theclinical arena, as critical events areinfrequent and ill suited for theactive participation of learners.7 Highfidelity simulation is uniquely adapt­able to this content; the crisissituation is simulated without jeop­ardizing the well-being of the patient.Expert opinion suggests simulation­based ACRM should be a compulsoryfacet of all anesthesia curriculums

and continuing education programs.sAnd yet, only 48% (26) of our surveyrespondents incorporate ACRM

Concrete experience

Testing in new situations

Forming abstract concepts

Observation and reflection

Figure 3. Experiential Learning Model(Adapted from Smith MK. David A. Kolb on experientiallearnmg. In: the encyclopedia of informal education.

hnp://www.infed.org/bibliolb-explrn.htm. Accessed June 10, 2008.)

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t--Dedicated course

2.0

f--

Module in

7.3existing course -Workshop

9.2

- Incorporate in

29.6various courses -Do not incorporate

51.9in curriculum

10

I310I

510600 2040

Percentage

Figure 4. Nurse Anesthesia Programs and Crisis Resource ManagementTeaching

instruction in their curriculum

(Figure 4). Of these, a little morethan a third (39%, 21) use simula­

tion to teach these principles. Whilestudents can be taught how to man­age critical events in a classroomsetting, it has definite limitations.ACRM with simulation can illumi­nate errors in care and decision

making, which can identify furthereducational needs.1

Simulation is also well suited for

assessing student clinical perform­ance. Problem behaviors can be

identified in a realistic setting so thestudent can gain insights in a mean­ingful way.9 A student whose clinicalevaluations indicate the learner rou­

tinely fails to exhibit due vigilanceduring cases can be placed in a sim­ulated situation. The student's

performance can be videotaped andreviewed during the debriefingprocess. This process promotes self­awareness, helps validate clinicalissues, and permits faculty to facili­tate the student's active refiection on

problem behaviors. The student andfaculty can then create a meaningfulremediation plan.

External ForcesSimulation-based teaching must sup­port educators in addressing externalforces that have an impact on theirability to prepare graduates. One isthe shortage of nurse anesthetists. Itis estimated the demand for CRNAs

will exceed 35,000 by 2010, and thenumber of graduates may not satisfythis need.to The shortfall places pres­sure on educators to meet the

demand, without a correspondingincrease in the resources to do so.

Healthcare systems will have limitedpersonnel to support the clinicaltraining of students. The currentapprenticeship system has alreadybecome burdensome in the face of

newer standards of quality and effi­ciency in the 21st century operatingroom; a shortage of nurse anes­thetists will only compound theproblem. Simulation can help educa­tors meet some of these challenges. Itwill allow students to gain a consid­erable degree of mastery ofanesthesia skills befort: entering theclinical environment. High fidelitysimulation may, in fact, acceleratestudent learning. II This creates an

enormous advantage in a tight labormarket, by allowing preclinical train­ing to promote a level of competencyunseen before and by preparing safeand competent graduates of a qualityunmatched by the current educa­tional system.

Another external force is the

increasingly complex environment inwhich healthcare is delivered.

Perioperative services have become amore strategically important compo­nent of the financial and operationalwell-being of healthcare organiza­tions. Clinical decision making notonly has an impact on the health andsafety of the patient but also on sys­tem function. A delayed emergence,for example, can echo throughoutthe organization in terms of cost andmanpower. The operating room staffhas evolved into a complex, multidis­ciplinary team that requires a highdegree of competency in interper­sonal communication. Advanced

simulation-based teaching is ideal forthe instruction of the skill sets neces­

sary to negotiate this environment.Scenarios may be designed to [ostersituational awareness, decision mak-

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Table 3. Goals and Strategies to Confront Barriers to High Fidelity Simulation

ing and team communication, andallow students to develop strategiesthey can apply to multiple situationsalong their professional practice con­tinuum.12

Promotion of anesthesia safetyhas always been an important com­ponent of nurse anesthesiaeducation. In recent years it has alsobecome a significant external forcefrom an institutional and regulatoryperspective. The Institute ofMedicine has urged educators toconfront the problem of humanerror and strive to limit negativeoutcomes. 13 The Joint Commissionhas highlighted patient safety byasking providers to improve commu­nication among caregivers. 14 Thekey question is: Does simulation­based teaching serve to reduce errorsand improve safety? The verdict isstill out, hut preliminary data arepromising. Procedural simulationstudies in surgery show intraopera­tive errors can be reduced with

simulation training.15 Many organi­zations are proceeding on theassumption that simulation doesindeed improve safety. Malpracticecarriers, recognizing the impact ofpoor team communication and crisismanagement on claims, are offeringsignificant reductions in insurancefor teams who undergo simulation­based training.16 Nurse anesthesiaeducators can make the same

assumptions in adopting simulation­based learning in their programs.

Confronting BarriersHow can educators confront the

barriers to integrating advanced sim­ulation in their curriculum (Table

3)? Strategies begin with disseminat­ing the merits of simulation-basededucation. Administrators must be

made aware of the growing body ofevidence suggesting simulation accel­erates the speed and quality oflearning and may improve patientsafety and outcomes. Moreover, it ispoised to become a standard meth­odology by which programs will bejudged by prospective students and

Goal

Disseminate benefits to decision makers.

Generate enthusiasm among colleagues.

Pool resources with colleagues.

faculty, as well as accreditation agen­cies. Organizalions, such as theSociety of Simulation in Health Care,puhlish peer-reviewed research onthe utilization and effectiveness ofsimulation-based education across a

number of disciplines, which can bea useful source of information toshare with decision makers.

Strategies that can generateenthusiasm for simulation amongcolleagues are key. Faculty work­shops can be used to educate andpersuade others to consider simula­tion in their curriculum. Interest can

be generated with presentations atlocal, state, regional, and nationalmeetings. While articles and casereports about simulation are anessential means of understandinghigh fidelity simulation, nothing candefine the methodology and sparkinterest better than viewing "liveclips" of simulation-based teachingscenarios. The ideal situation is to

entertain colleagues in a simulationlaboratory so they may see for them­selves what it is like to be a learner.

Collaboration between nurse

anesthesia programs is essential.Mechanisms to share resources can

be negotiated among programs withgeographic or institutional similari­ties. i\'urse anesthesia programs

StrategiesEducate administrators.

Impart peer-reviewed state of theeVidence.

Emphasize accreditation andcertification trends.

Organize faculty informationsessions.

Tour a Simulation center.

Report simulation specific outcomedata.

Share faculty training costs.

Negotiate contracts with preexistingcenters.

Codevelop scenarios.

Create user groups.

without access to advanced simula­tion can share resources with those

who do hy arranging fee-for-servicecontracts and sending students toengage in specific learning activities.These arrangements can be mutuallybeneficial as students from one insti­

tution are afforded meaningfullearning experiences, while the othercan use external fees to offset the

often high maintenance costs associ­ated with high fidelity simulation.This revenue source can be essential

to a simulation center's survival, asequipment often needs to beupdated or replaced after 5 years.17

Other mechanisms for promotionof advanced simulation may involverecruitment of staff from clinicalsites to serve as simulation instruc­

tors. This collaboration can solidifythe link between the simulation cur­riculum and the clinical arena, as

well as improve faculty workloadproblems. Links may also beextended between programs by theformation of simulation task forces,

whose goal is collaboration andsharing of resources to promote sim­ulation among member programs.The pooling of energies can be fur­ther enhanced with external fundinggrants to support collaborativeteaching enterprises.

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Interdisciplinary collaboration canalso reduce simulation costs. Strengthin numbers keeps simulation on theradar screen of administrators anddecision makers. Areas of collabora­

tion may include development ofresearch projects and case scenarios.Multidisciplinary simulation usergroups also offer an opportunity toupdate faculty on policies, equip­ment, software, and Internet

resources. Taped learning cases canbe presented at meetings to discussthe nuts-and-bolts of advanced simu­

lation teaching and learning.Members may also cross disciplinesto participate as "actors" in eachother's clinical scenarios and as facili­

tators in debriefings. Cross staffingoffsets the time and costs associatedwith simulation-based instruction

throughout the institution.

SummarySimulation-based instruction can

help educators meet the challengesof training nurse anesthetists in anincreasingly complex world. It isbased on sound pedagogy that fostersthe acquisition of critical skills.Simulation allows replication notonly of the complex interplaybetween patient physiology, anesthet­ics and equipment but also thedynamic clinical environment inwhich students must function.

Tentative but growing evidence sug­gests simulation accelerates the speedand quality of student learning andmay enhance our capacity to preventhuman error. Practice may indeedmake perfect, as deliherate learningexperiences allow students to honecritical skills in an authentic learningenvironment. The creation of collab­

orative alliances may help surmountthe barriers to universal use ofadvanced simulation-hased instruc­

tion in our programs. Curtailment of

time and financial constraints are

essential, so that more student nurseanesthetists can be exposed to thisvaluable teaching tool and theunique and important learning expe­rience it offers.

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AUTHORSNina TurcaLO, CR~A, D~P' IS director at theSchool of ~urse Aneslhesla, University of NewEngland. Portland. MaIne. Email: nturcalo@une.edu.

ClIff Roberson, CRNA, MS. IS assistantdirecLOr, School of Nurse Anesthesia, Universityof New England. Portland, MaIne. Ematl:jroberson@une.edu.

Karl Covert, PhO, IS adjunct professl\r at theUmverslty of New England. Portland, MaIne.

ACKNOWLEDGMENTSWe thank the followmg: Margaret Fallt-Calla­han, CRNA, DNSc, FAA~, Rush UmversJly Col­lege of NursIng Nurse Anesthesia Program, forher mentorshlp; the AANA f'"undation f,'rfundIng Nina TurcaLOs doctoral work on simu­lation-based education In the New Englandarea; James Botkin, PhD, Botkin Chemie, forassistance With data presentation.

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