4 Simulation
Simulation-Based Learning
Simulation-based IPE provides the opportunity for learners to collaborate across disciplines, make decisions, and acquire skills in realistic scenarios (Arthur et al., 2013). Interactive simulation-based IPE helps healthcare professionals to work together in a particular context and understand their roles in the spectrum of healthcare (Arthur et al., 2013). This strategy helps promote cooperation and build confidence for similar situations (Labrague et. al., 2018). Simulation–based Interprofessional Education has demonstrated a significant improvement in students’ self-confidence, high satisfaction from the learning process, and improved attitude and perception towards the whole training process (Onan et al., 2017).
Key Features of Simulation Based Learning
- Students apply their knowledge and skills in realistic scenarios.
- Has led to improvements in confidence, skill, and cooperation.
- Often pulls in elements of case-based learning and experiential learning.
- Students report high satisfaction.
Resources for Simulation-based IPE:
An example of a simulation-based IPE (Mills et al., 2020)
A review developing best practices in interprofessional simulation (Astbury et al., 2021)
Best-practices for interprofessional simulation share many elements with simulation in uniprofessional simulation. Best-practice guidelines for designing, implementing, facilitating, and evaluation for uniprofessional simulation still serve as a foundation for interprofessional simulation, however interprofessional simulation has unique elements that require specific considerations. As noted previously, the interprofessional instructor team should be involved with design components reflective of their discipline, scope of practice and intended learning objectives. If simulated patients are to be involved, and where available, it is highly recommended that you engage with a simulated patient educator (SPE). At Dalhousie, please contact the Centre for Collaborative Clinical Learning and Research (C3LR) [NewTab] that you work with an SPE to ensure evidence-based best practice standards in simulation patient education (ASPE standards [NewTab]) are in place for simulation-based learning and assessment methods.
The INACSL Healthcare Simulation Standards of Best Practice™ [NewTab] provide guidance on simulation in general. Those unfamiliar with simulation may wish to consult these resources for a more thorough understanding of simulation in healthcare.
Particular considerations for interprofessional simulation design, facilitation, and evaluation are discussed below.
INACSL Best Practices in the design and development of SIM-IPE (INACSL, 2021):
Required Elements (INACSL, 2021, p. 50)
- Develop the design in consultation with experts and representatives of the targeted interprofessional learners.
- Consider multiple experiences to achieve the expected outcomes.
- Incorporate authentic, challenging, reality-based activities/scenarios developed and reviewed by the professions involved in the simulation.
- Develop mutual goals among the professions involved in the experience
- Base activities on learning objectives, learners knowledge, skills, needs, and experiences.
- Ensure a safe learning environment.
- Provide appropriate team-based structured prebriefing, debriefing, and feedback, as appropriate for the goal of the simulation.
The interprofessional simulation scenario should be designed by members of all professions represented in the simulation. This ensures appropriate integration of professions roles and scopes of practice. In designing the simulation content, all professions should ensure:
- The scenarios are relevant to all professions (Boet et al., 2014)
- Each profession has a significant role (Boet et al., 2014)
- The level of learning and application of skills matches the learners’ readiness to demonstrate and apply those skills (INACSL, 2021)
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- This includes consideration of the timing/placement of the interprofessional simulation within each profession’s curriculum.
- The scenario is authentic, reality based, and reflects current practice standards for all professions involved in the scenario (Boet et al., 2014),
- Consider power hierarchies that may exist between professions (Boet et al., 2014), and work to design the simulation in ways that break down problematic and ineffective hierarchies.
- “Does your simulation reproduce the same hierarchy and power relations that are found in the clinical environment and can be a barrier to good teamwork?” (Boet et al., 2014, p. 855)
Resources for Designing IPE Simulation:
Twelve tips for a successful interprofessional team-based high-fidelity simulation education session [NewTab]
Additional tips on designing interprofessional simulations (Boet et al., 2014)
SIM Scenario Exchange [NewTab]
Simulation Canada offers a variety of simulation scenario templates and scenarios, some of which are interprofessional. You may consider consulting these options for ideas of interprofessional scenarios (Simulation Canada, 2022).
Care should be taken in simulation design to prevent the unintentional construction of the exotic other, or reinforce prejudices, stereotypes, and biases, as these can harm both learners and others involved in facilitating the simulation experience (Picketts et al., 2021).
Important considerations for incorporating cases with a focus on promoting social justice, equity, diversity, and inclusion in case content include:
- What degree of curricular exposure and preparation do the learners have for the simulation? (Picketts et al., 2021)
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- If students are participating in simulations that involve addressing content related to social justice, they should have developed foundational skills in this content, the same as they would need for other technical components of the simulation.
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- With interprofessional simulation, where learners are involved from different professions, each with different curricula on these topics, all learners should have a foundational understanding of relevant considerations of diversity before applying it in a simulation.
- What are the learning objectives of the simulation? (Picketts et al., 2021)
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- Do the learning objectives directly address a patient’s identity? Or do they focus on using a particular therapeutic technique, or a particular disease state? If the learning objectives do not relate to the identity of the patient, then only including individuals portraying particular identity characteristics may reproduce biases or stereotypes.
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- When learning objectives do relate to a patient’s identity, consultation with members of that identity community is recommended (Picketts et al., 2021).
- What are the risks and benefits of including the simulation in the curriculum? (Picketts et al., 2021)
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- These may include risks to learners and/or simulated patients who may or may not identify with marginalized group.
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- If there are substantial risks, it may be important to consider if simulation is the best option for facilitating these learning objectives at this point in the students’ learning. Or, is there a less risky way of facilitating the same objectives?
- What diversifying traits are required to meet the learning objectives? (Picketts et al., 2021)
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- Particularly when working with simulated patients, this requires special consideration for recruitment, training, and pre- and debriefing.
Design team members may also wish to consult the SIM-EDI: A tool for sim team reflexivity [NewTab] to support team discussion around EDI in simulations (Purdy et al., 2023).
Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants (Picketts et al., 2021) [NewTab]
Provides more information on recruitment, training, pre- and debriefing with simulated patients.
Designing the Simulation Structure
All simulations require pre-briefing, simulation, and debriefing components. These components not only help to facilitate learning, but help to promote a psychologically safer environment throughout the simulation event (INACSL 2021). Psychological safety is present when those participating in the simulation perceive “a sense of confidence, that the team will not embarrass, reject or punish someone for speaking up. This confidence stems from mutual respect and trust among team members” (Edmonson, 1999, p. 354).
Based on a systematic review by Lackie et al. (2023), enablers and barriers of psychological safety that be built into the simulation design include:
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Enablers |
Barriers |
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Well thought out, structured design, with ample time |
Evaluative tool that focuses on ‘getting it right’ |
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Distinct session goals |
Not knowing what to anticipate |
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Pre-established groups of students |
Different expectations among facilitators |
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Detailed information readily available |
Too much or too little time for tasks |
Table 2: Enablers and Barriers of psychological safety in simulation (Lackie et al., 2023)
At Dalhousie, Simulated Patient Educators assist with the design and development of simulation content to ensure the safety of simulated patient actors and relevant and respectful inclusion of the patient voice. Please consult with a simulated patient educator when preparing your case. They will help with the design based on the learning objectives you have identified. Additional training in case development, piloting, and collaboration with patient and practitioner experts is recommended.
Consider what resources are needed in terms of:
- Time (for the pre-briefing, simulation, simulation re-set, breaks and debrief)
- Space (for the pre-briefing, simulation, and debrief)
- Recording/observation space
- Equipment
- Technology
- Facilitators (which professions?)
- Facilitator training and preparation
- Simulated patients
- Simulated patient educators
- Simulation technologists
- Administration
- Practice space
- Number of simulations in a session
A pre-briefing occurs prior to the simulation experience to help prepare learners to effectively engage in the simulation. To promote psychological safety and the effective running of a simulation, the pre-briefing should include:
- The basic assumption (Boet et al., 2014)
- “We believe that everyone participating in the simulation is intelligent, capable, cares about doing their best and wants to improve.” (Harvard Centre for Medical Simulation)
- Consideration of the social dynamics of the group (Boet et al., 2014). Power dynamics between professions may harm perceptions of psychological safety (Lackie et al., 2023).
- Set up expectations for the simulation (Boet et al., 2014).
- Orient learners to components of the simulation including (Daniel et al., 2023; INACSL, 2021):
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- The equipment
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- The environment
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- Simulators or mannequins if applicable
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- Roles
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- Time allotment
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- Objectives
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- Patient Situation
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- Cultural humility framework
For simulations involving potentially sensitive topics, such as racism, 2SLGBTQIA+ identities, or other social justice topics, consider using the Prebriefing for Cultural Humility© GRASPED framework during the prebriefing.
To support the diversity of learners during the pre-briefing, consider having information available in multiple formats, including verbal and written information. Providing relevant information ahead of time and ensuring learners have the option to refer back to the information helps to support diverse learning needs.
Debriefing
The purpose of the debrief is to consolidate learning from the simulation experience (INASCL, 2021). In designing a debrief for a simulation, consider the timing, facilitation, and structure or tools that may be used during the debrief.
Debriefing in healthcare simulations typically takes between one and three times the length of the simulation (Kim & Yoo, 2020). Longer debriefs may be needed when the simulation involves sensitive topics, many participants, and multiple professions. Having ample time for the debriefing promotes psychological safety (Lackie et al, 2023). Debriefs may occur in small chunks of time during the simulation, immediately after the simulation, immediately after the simulation but with a short break in between, the same day as the simulation, or the day after the simulation (Kim & Yoo, 2020).
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Debriefing Type |
Benefits |
Challenges |
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Co-Debriefing (Abulebda et al., 2019) |
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Debriefing Script or Tool (Abulebda et al., 2019) |
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Within-Team Debriefing
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Table 6: Benefits and challenges of different debriefing styles
Debriefs may use different structures but they share common elements. To promote psychological safety during the debrief, the debrief should (Abulebda et al., 2019):
- Set the stage (for the debrief):
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- Provide a debriefing stance or reminder of the basic assumption
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- Establish debriefing expectations (i.e., confidentiality and participation)
- Establish a shared mental model of what happened
- Address key learning objectives
- Incorporate and analyze the learning objectives within the discussion
Tools and structures to promote successful debriefing include single phase debriefing, three-phase debriefing, and multi-phase debriefing (Abulebda et al., 2019). Tools that support each type of debriefing are described below. Using a tool is recommended to assist facilitators to provide an effective debriefing experience.
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Type |
Example Types and Domains |
Links to Tool |
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Single-Phase Debriefing |
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Three-Phase Debriefing |
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Multi-Phase Debriefing |
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Table 7: Examples and links to different debriefing styles
