BACKGROUND AND PURPOSE
Simulation is an established method for building knowledge and ensuring competence in the aviation industry and military training.1 Health care simulation has been widely adopted in medical and nursing education with simulated experiences emerging in program accreditation requirements. Simulation is growing in use for health care staff development, including using simulations in the providers’ practice environment. Physical therapy education has a long tradition of simulations, using standardized patients and role playing.2–5 Interprofessional and mannequinbased simulation in physical therapy education is a growing in popularity.6–8 Research in health care simulation consistently reveals the importance of sound debriefing strategies to realize the desired learning objectives.9,10
In part, health care simulation has been driven by the increasing sensitivity and attention to inherent risk to patients posed by novice and inexperienced health care providers. Clinical training of physical therapy students is challenged by declining availability of clinical educational experiences and stipulations requiring close supervision of students.11,12 Clinical education cannot be scripted to present the range of situations that prompt the safe execution of skills and decision-making that a physical therapist (PT) must possess. Simulation can introduce the high risk/low frequency clinical events or highly sensitive patient interactions that have low tolerance for error within a learning experience that does not impose risk to actual patients. Furthermore, simulation allows feedback and repetition of events to achieve mastery. This practice can be aided by temporal manipulation of the experience with use of pause to think, rewind to a critical point, or a do-over following a suboptimal performance. Within clinical practice, simulation can also be a risk management strategy to revisit a breakdown of care, evaluate a near miss event, or rehearse a new workflow process.13 Simulation is particularly useful for developing team functioning.14
Growing use of simulation in physical therapy education and professional development calls for an evidence-based approach. Best simulation practices require experiences purposely designed to expose the learner's frameworks, the cognitive foundation that directs clinical decisions and actions.15 Research in health care simulation has established essential conditions to create an effective learning environment. Simulation in medical education has demonstrated the importance of supporting realism, using prompts, effectively using confederates, and scripting key elements of the simulation. The key piece to participant learning is postsimulation debriefing, methods that serve to uncover and shape decision frame-works. Ideally, a simulation is purposefully designed to expose any decision errors or performance gaps, which can then lend to fruitful debriefing. Various debriefing tools that have been developed and researched can be translated to physical therapy simulation. Evidenced-based simulation and debriefing strategies have the potential to sharpen skills and transform the learner's decision frameworks, which leads to durable improvements in clinical knowledge and competency.
The purpose of this perspective is to justify the integration of simulation in physical therapy education and professional development. Simulation grounded in an evidence-based, pedagogical approach is a powerful learning tool independent of the technology available. The perspective will offer strategies, tools, and scripts that physical therapy educators can apply to their own simulations, leading to positive learning outcomes and replacing traditional instructional methods. Furthermore, simulation can support professional development for practicing PTs.
Despite its recognized value, the pedagogy and learning theory that supports simulation and debriefing is often overshadowed by simulation technology. When time constraints are imposed, debriefing times are often shortened. Simulation experiences risk being designed to maximize technology with cursory attention to learning objectives. Our position is that learning theory and outcomes, not technology capabilities or availability, should drive simulation and the debriefing session. Purposeful designed simulation with structured and effective debriefing will maximize learning outcomes.
What is Simulation?
The term simulation describes a wide range of experiences along a continuum of complexity, realism, and technical requirements. Beginning on the low-tech end of the spectrum, written case studies support prolonged deliberation, a type of simulated clinical decision-making. Standardized patients allow practice of interpersonal behaviors, interview skills, and patient handling skills on a human actor. Part task trainers are useful for practicing procedural components of care (eg, auscultation, joint mobilizations, or basic life support procedures). Full mission simulations attempt to replicate the clinical environment, clinical team functioning, and an authentically responsive patient.16 Full mission simulations can occur in a simulation lab or in the clinical setting as an “in situ” simulation, and may involve a patient mannequin or standardized patients to complete the team. Virtual environments also offer a range of immersions in practice or community settings that are applicable to physical therapy.17
A Theoretical Framework for Simulation
A key component of simulation is active, emotional engagement of the learner, as this facilitates long-term learning. Feldman-Barrett and Russell18,19 introduced a bipolar continuum between activation-deactivation and unpleasant-pleasant. The model proposes 4 quadrants of learner affect: (1) pleasantly activated, (2) pleasantly deactivated, (3) unpleasantly deactivated, and (4) unpleasantly activated. Learning is most effective in the activated area, as depicted in Figure 1. Experiential learning activities like simulation, which induce a level of stress and activation, create high levels of learner engagement and memorable learning experiences.20 A simulated environment decreases the overall stakes of the interaction when compared to a clinical experience with real patients, while simultaneously remaining sufficiently unpleasant or stress-inducing to keep the learner activated. In contrast, traditional lecture usually rests in the lower quadrants, or deactivated areas, where long-term learning is less likely to occur.
Simulation allows the learner to have scripted, repetitive practice of skills and clinical decision-making followed by guided reflection and analysis. Simulation is based on seminal learning theory by Ericsson,21–23 who first described deliberate practice as “a form of training that consists of focused, grueling, repetitive practice in which the subject continuously monitors his or her performance, and subsequently corrects, experiments, and reacts to immediate and constant feedback, with the aim of steady and consistent improvement.”
Ericsson's research has been translated to medical training based on its implementation principles: repetitive performance of targeted skills, skill assessment, and specific feedback that leads to graded improvements in performance.24 Mastery acquired through deliberate practice is contingent on development of the learner's personal skills in planning, concentration, tolerance of repetition, and reflection.24,25 Development of these personal skills supports regular practice and can lead to expertise. Skills and knowledge acquired through deliberate practice is more durable and is not susceptible to the rapid decay of learning gained through less challenging conditions. Simulation, as a mechanism to engage the learner in deliberate practice followed by purposeful reflection, could be the antidote to arrested professional development.
Experiential Learning Theory, described by Kolb,26,27 builds on Ericsson's research by providing additional theoretical structure for simulation, forming the bridge from simulation to postsimulation debriefing, and creating a model to depict the experiential learning process. Kolb's theory begins with the Concrete Experience. The Concrete Experience, which requires active learner participation, is the simulation itself (or Ericsson's “deliberate practice”). After the simulation is complete, the learner engages in Reflective Observation, a conscious reflection about the experience of the simulation. These 2 components of Kolb's theory are individual exercises, and as Duvivier et al24 suggest, the extent to which a learner is effective at this process is variable.
During Abstract Conceptualization, the third phase of Kolb's model and the crux of debriefing, the learner's decision frameworks are challenged and alternate approaches or theories are presented. The debriefer guides the discussion so that the learning objectives of the experience are addressed, introducing diverse ideas, as needed, to achieve the learning objectives and shift the learner's decision frameworks. Debriefing and feedback offers the learner the opportunity to bring the reflection to consciousness and to expert evaluation. Purposefully designed simulation experiences followed by structured debriefing ensure that the learner accurately selfevaluates performance and that the intended learning occurs. Lastly, during Active Experimentation, the debriefer guides the learner through plans to apply the reshaped and refined knowledge.
Debriefing: The Simulation Instructor as a Detective Uncovering a Learner's Framework
Debriefing is analogous to a structured postgame discussion. After a game, players and coaches review game tapes, discuss their actions, and list modifications that they may make for the future. The simulation itself is not always self-teaching, and quite often learners require facilitated reflection to achieve all of the objectives of the experience. In order to achieve this, it is necessary to understand prior experiences that directed the learner's decisions and actions, as well as the meaning gained from the simulation experience. A learner's clinical decision framework is shaped by academic, clinical, and personal experiences. In simulation, these driving decision frameworks that learners bring into the simulation are coined “frames.”28 In order to facilitate an improved performance, it is important that both the learner and debriefer understand the frames. It is only after acknowledging gaps between current conceptions with expected understanding that a student can adjust their behavior or thinking. Postsimulation debriefing exposes and develops the learner's reflective process. Schön29,30 described that the learner can reflect on his/her performance at several points: in action, on action, or for action. Debriefing acts to guide reflection on action after the simulation experience. This prepares the learner for future exchanges, reflection for action, and is the end product of the simulation experience. Through reflection, the learner may realize independently that their current frames are incomplete, inappropriate, or unsuccessful. In many cases, however, the learner is incapable of modifying their frames with independent reflection alone, thereby requiring debriefing to assist with this process.
The simulation and debriefing approach designed to reveal learner's frames and support reflection is substantiated by the work of Lewin and Schein,31 who outline a 3-stage theory of behavior change. The first stage of “unfreezing” is characterized by an individual's drive to alter their behavior. Unfreezing is achieved through a simulation experience that emotionally activates the learner, demands engagement beyond rote performance, and exposes knowledge or skills gaps. While debriefing, the learner gathers new information via reflection or feedback that is incongruent with their current beliefs, thus creating anxiety. It may be survival anxiety stemming from recognition that current beliefs are inadequate, or learning anxiety, which acknowledges that further knowledge or new skills need to be developed. To achieve mastery, the individual must overcome anxiety by accepting performance gaps, thereby moving to the second stage. This second “unfrozen” phase allows a shift in the learner's belief system, characterized by receptiveness to instructor feedback and targeted teaching. The final stage of “refreezing” is marked in the learner's reshaped belief system based on feedback and reflection.
Postsimulation debriefing can occur at the individual, team, or class level. The format and environment of debriefing should consider the purpose and requirements of the simulation experience. Team debriefing is effective if interpersonal communication and team functioning are an objective of the experience. Team debriefing increases efficiency if general themes that apply to most in a cohort appeared during the simulation. A simulation designed as a more summative, individual assessment may dictate the confidentiality and necessity of individual debriefing.
Key Considerations in Structuring the Simulation Experience
Setting the Scene for the Learners. Simulation requires careful planning and scripting to strategically reveal learner frameworks. To optimize learner performance and learning, creating realistic conditions and authentic learner responses is critical. The first part of the learning experience consists of briefing, where the learners must be properly prepared to enter the simulation experience.32,33 Briefing establishes performance expectations, outlines the capabilities of the simulation environment, and generally prepares the learner for the experience. Various strategies have been used to introduce the learner to the simulation environment, particularly for mannequin-based simulations. Methods range from written summaries describing lab and mannequin capabilities to hands-on, simulation lab orientation. Review of the range of orientation approaches reveals that briefing should concentrate on the team's and learners’ performance expectations more than the technical or equipment aspects of the experience.34–36 While learners can be expected to apply skills and knowledge introduced outside the simulation lab to a simulation experience, introducing novel patient care equipment in simulation may limit learner performance and heighten anxiety.
An aspect of simulation briefing is acknowledgement by the instructors that the simulation environment is not real. A simulation experience requires participants to agree to suspend disbelief and accept simulation elements as reality. The literature refers to this condition as a fiction contract.34 By explicitly requesting agreement, the simulation participants take ownership of realistic engagement in the scenario. Putting less attention on the instructors, simulation environment, and technology shifts the learners’ focus to their clinical skills and decision-making, allowing for learning to occur. At the onset of a simulation, a consistent script can be used to stage the participant expectations and to request agreement to enter into the Fiction Contract, as follows: “We have tried to represent the clinical environment and an actual patient as realistically as possible. We ask you to suspend disbelief and accept the simulation as a real clinical experience. We are not introducing anything with intent of tricking you. Within the simulation, please respond as you would in an actual clinical situation.”
The simulation and debriefing must be perceived as a safe learning environment to create a milieu for learners to openly discuss decision-making and dissect performance. Learners must agree to confidentiality, as details of participant performance and information revealed during the debriefing are not allowed to leave the simulation experience. Participants are reminded that simulation requires respect for instructors and peers. Furthermore, participants are not permitted to discuss cases outside the simulation. Educators and simulation lab personnel may decide that written agreement in simulation rules of engagement and confidentiality is necessary. At a minimum, consent with a nod from each participant during presimulation briefing at every simulation is recommended.
Key Case and Environment Considerations. Once learners have accepted their roles and agreed to their level of responsibility in participation, the educator must execute the simulation that holds a level of realism. Realism is reinforced physically, conceptually, and psychologically.34 In health care simulation, physical realism is primarily patient or mannequin voice, appearance, and capability (pulse, pupil response, respiration, and breath sounds), and the physical environment (operational hospital bed and equipment). Higher level of physical fidelity is not necessarily equivalent to the level of technology. Conceptual realism is the level that the simulation events match cognitive processes of clinical decision-making, pattern recognition, and prediction. Conceptual fidelity requires plausible and expected “if/then” relationships.34 For example, if the patient is taking a beta blocker for hypertension, the heart rate response to exercise should be diminished. Psychologic fidelity is the extent that the simulation replicates roles, team dynamics, emotionality, and cognitive processes within an actual clinical environment, including during team conflict or critical events. Psychologic fidelity pushes the simulation participant to approach a true clinical self that is individually shaped through ongoing experience and social interaction.34,37,38
Learners have wide-ranging thresholds for acceptance of the simulation realism. When the realism threshold is sufficiently met, the learner can conceptually engage without being derailed by physical discrepancies from real clinical situations. Transferable learning occurs when the learning objectives and learner readiness are compatible with the experience represented in simulation. Levels of physical fidelity, particularly technologybased elements, are less important than the design of the experience and attention to psychologic fidelity. Physical fidelity will support psychologic fidelity, but poorly designed scenarios cannot achieve realism with high technologic or physical fidelity alone. If psychologic realism is high, learning will take place.37 It is not constructive to argue simulation realism or the degree that simulation performance is replicated in practice. During postsimulation debriefing, the instructor may redirect a learner by acknowledging the learner's vulnerability without dismissing the simulation relevance, as in the following statement: “We know that if this were a real clinical situation, you would likely respond a bit differently. Let's talk about the decisionmaking at play in this simulation that might enter into actual practice.”
Another aspect of fidelity to consider is inclusive and patient-centered care. It is important to consider all potential opportunities to demonstrate a patient's diversity, including family, support networks, and development of a rich canvas of racial, ethnic, and psychosocial factors. Other health care providers within the simulation should also demonstrate diversity, consisting of variation of provider sex and background across all provider levels and roles, use of ethnically diverse names, and avoidance of stereotypes or unnecessary negative characterizations.
Tying the Experience Together for the Learner: Good Judgment Debriefing
The power of simulation is in its capacity to reveal the decision-making and rules that direct the learner's actions or inactions; however, the impact of simulation is enhanced when debriefing strategies are used that allow the learner to safely dissect performance, honestly discuss the rationale directing actions, and accept corrections to misconceptions. This guided reflection, based on principles of learning theory and reflective practice, has been adapted for simulation debriefing.
Debriefing is conducted in an environment of psychologic safety. It is important for the learner to realize that a suboptimal performance is not a personal flaw, but rather an opportunity to refine knowledge and skills. The foundation for this method is learners and instructors sharing a common goal of quality and safe patient care. It is assumed that learners can correct any deficiencies through feedback and practice, accept simulation and feedback as an aspect of clinical improvement, and recognize that the instructor offers expertise to support improvement. Simulation using good judgment debriefing relies on an environment that welcomes open and honest discussion and the analysis of error that holds potential in achieving high levels of clinical safety. These assumptions are succinctly captured in the basic assumption that the simulation instructors accept,39 as noted: “We believe everyone participating is intelligent, well-trained, cares about doing their best, and wants to improve.”
Good judgment debriefing contrasts with a common debriefing technique, nonjudgmental debriefing, which is characterized by giving a critical message with protective social strategies, such as downplaying or “sugarcoating” the feedback.28 An instructor using a nonjudgmental approach will coddle the learner by diluting negative feedback with positive feedback rather than pressing to fully understand the problem or performance breakdown. A nonjudgmental delivery can create distrust between learner and instructor. The adult learner will detect incongruent social behaviors with the message, sense the instructor is holding back criticism, or attempt to guess instructor intent or judgment based on the instructor's leaked nonverbal cues. Alternatively, the learner may not hear the negative feedback and will not learn from the experience.
An alternative approach of good judgment debriefing has been described in the literature and has been incorporated in simulation training.15,28,39,40 Good judgment debriefing shifts the focus to the underlying frames that directed the learner's observed behaviors. Frames are built through experiential learning and sense-making. Teaching through simulation builds upon the theory of Lewin and Schein by reshaping the learner's previous frames and building a solid decision-making scaffold of frames for future experiences. The role of the good judgment debriefer is to offer performance critiques that encourage the learner to nondefensively divulge motivations, conceptions, and emotions that directed actions. The debriefer serves as a reflective practice coach, pushing the learner in rigorous reflection, and also acts as a “cognitive detective,”28 exploring the learner's frames (knowledge, assumptions, and feelings) that consciously or subconsciously directed the learner's actions. The debriefer must enter the discussion with open-minded, genuine curiosity, tabling any preconceptions of the learner's frame.
The debriefing session can be conceptualized as 3 acts: (1) reactions, (2) understanding, and (3) summary (Figure 2).39 Immediately following the simulation, emotionality can be high. The debriefer should elicit emotional reactions first so learners are allowed to express the emotional aspects of the experience. Otherwise, these reactions may overshadow the technical and cognitive aspects of the simulation performance.40 Reaction can be prompted with the direct question, “How did that feel?” It is not the role of the debriefer to minimize or dismiss the emotions that the learners display. For example, a learner response of “I felt unprepared” or “I felt tricked” does not demand the instructor to counter those perceptions. These reactions serve as a platform to initiate discussion about the experience. An important component of learning can be achieved if the debriefer capitalizes on the high emotionality in the initial debriefing session, as according to the work of Feldmen-Barrett and Russell.
The heart of debriefing occurs in the understanding phase, the crux of good judgment debriefing. The learning conversation is communicated through a stance of curiosity and objective observation. Questioning follows a format of observation, followed by a statement of concern, which then leads to an open-ended inquiry. Observation uses firstperson language targeted toward direct observations, not judgments based on debriefer assumptions. An example of a first-person observation by the debriefer is: “I noticed that the patient's oxygen saturation dropped below 92%.” Then, the debriefer interjects judgment or a level of advocacy by explicitly stating concern about the direct observation. For example, “I was concerned that the patient's oxygen saturation was trending toward a critically low level.” The debriefer's concern is followed by an inquiry that opens discussion for the learner to reveal their understanding. An example of a curious inquiry might simply be, “Tell me what you thought.” A hypothetical debriefing of a clinical instructor questioning a student following a patient encounter in a critical care setting is depicted in Figure 3.
Video and/or audio with time tagging of simulation performance are commonly captured. The good judgment approach uses recordings to support recall or to recover “in the moment thinking” during the understanding phase of debriefing. Video can serve as a metacognitive aid for the learner to talk through decision-making or reflection on action. Video is best used at provocative times in a scenario (eg, before a change in vital signs or clinical status to facilitate learner reflection). The good judgment approach would find it counterproductive to use recordings to refute learner recall or perceptions.
The final step in the debriefing approach is the summary. Consistent with Kolb's Experiential Learning Theory,26 Schön's29,30 reflection for action, and Lewin and Schein's31 concept of refreezing, the summary allows the learner to articulate and solidify the reshaped frame. Postsimulation written reflection and assessments have been used to support the summary phase.41 Learners discuss or provide written reflection on performance elements that were positive, as well as those that need to be changed to improve performance. A specific action plan to achieve the targeted improvement can be integrated in this approach.
Planning and Executing Simulation
Planning the entirety of the simulation experience can be daunting. A well-designed simulation should be sufficiently challenging to unfreeze the learner, expose knowledge or skill gaps, and engage an appropriate level of decision-making. Rote performance does not uncover performance gaps or reveal learner frames. David Gaba,42 a pioneer in medical simulation, has proposed dimensions of simulation application. Each dimension is defined within a continuum (eg, from simple to complex, individual to team, case-based to full clinical replication). These dimensions, as well as components to support fidelity, can be applied to simulations of physical therapy practice. We offer adaptation for simulations in physical therapy practice and education. This framework presented in Table 1 may serve as a planning guide for simulation planning.
The simulation may be designed for training, assessment, professional development, or workflow rehearsal. The first consideration involves the level of the simulation participants ranging from novice trainees to experienced or expert providers. The unit of participation in an experience may be a single individual or an entire team. An individual simulation may be part-task training of a component of care or objective assessment of individual competency. A full mission simulation would involve an entire interprofessional team of providers. A simulation must be designed to align the level of participant and the unit of participation to the simulation purpose and learning objectives.
Simulation briefing may include a practice of the simulation by the planning team. The planning requires that all equipment needs are anticipated and available. In lieu of practice of simulation events, a minimum rehearsal by the confederates, where individuals are placed in the simulation roles with scripted responses, is necessary. Simulation aims to produce authentic responses, not role playing. Therefore, planners should be cautioned when placing learners out of their provider role in a simulation. For example, placing a PT student in role as a nurse creates the risk of misrepresentation of the competence and scope of nursing practice, but more importantly, this places the student in a situation of simulating an unfamiliar role in the simulation experience. This practice counters the explicit request for participants to respond authentically rather than simulating or acting a role. Table 2 serves as a checklist for the preparation of a simulation.
A simulation script keeps all the personnel coordinated and can provide anticipated learner prompts that should be introduced based on student performance. A complex simulation may be best represented in an algorithm depicting divergent pathways dependent on participant decision points or performance. However, it is important to recognize that decision points are not discreet events within a simulation. Rather, clinical decision-making is a fluid and continuous process that can be represented in the simulation flow sheet through observed actions or inactions. For a mannequin-based simulation, responses should be scripted to support conceptual fidelity. For example, as the patient's oxygen saturation drops, a corresponding increase with heart rate would be scripted. An example of a detailed simulation script is presented in Table 3.
Mannequin responses, as well as confederate and environment cues, are included in the script. Prompts serve as signals for participant response while distracting, conflicting, highly complex, or detailed information can provide noise that demands higher-level decision-making and prioritization. Based on observed participant actions, the simulation signal can be amplified in the patient, environment, and/or confederate cues. Through tempered use of cues based on observed behavior, the progress through the planned simulation events can be achieved under variable levels of participant performance.
Well-executed simulation can be time and resource intensive, but research continues to reinforce the positive and powerful impact of simulation-based training.43 A focus on patient safety requires educators to achieve seemingly contradictory goals: train health care providers with high levels of competence and place students in increasingly complex health care environments with low tolerance for error. This is not achievable by following outdated health care training traditions (eg, see one, do one, teach one). Training methods must evolve and accept new strategies to ensure safe, competent practice of entrylevel providers who are at the front lines of patient care. Simulation shows great promise in achieving entry-level competence and developing expert practice.
Health care delivery is shifting and the physical therapy practice is repositioning to focus on the PT as a primary care provider, collaborate with extenders in practice, and team with other providers to achieve interprofessional, patient-centered care. This level of practice complexity is challenging to represent in the classroom. Simulation is an effective and engaging strategy to convey teamwork and interprofessional roles.17,44,45 Interprofessional practice deconstructs the traditional hierarchical relationships among health care providers. An aspect of reorganized care is accountability for quality and safety by all providers. This requires a safe environment that allows any providers to voice concern. Research found that although a provider may recognize a safety issue, an action gap often follows; that is, the knowledge of the issue does not translate to action. Speaking up or exercising the action can be efficiently fostered through simulation.46–48 Simulation (and debriefing) uncovers the frames that inhibit speaking up and allows practice of appropriately assertive team communication.
Using simulation to represent team functioning and interprofessional communication under conditions of uncertainty may be a higher-level competency that is more relevant for practicing PTs or physical therapist assistants. Evidence shows the value of using simulation to improve the individual and the team; however, further research is needed to demonstrate the impact on patient safety and patient outcomes.49,50
Student feedback and anecdotal instructor assessment of simulation alludes to the effectiveness and value of simulation, and medical and nursing education studies describe simulation's learning outcomes, appropriate use in nursing, substitution for clinical training, and clinical practice outcomes.51–53 These studies provide a framework for the study of simulation in physical therapy education and practice. As physical therapy education explores the best strategies to transition students from academic to clinical curriculum, it is important to systematically and objectively determine the role of simulation in clinical training.
Shared language describing simulation and debriefing within physical therapy education and practice supports systematic study of best practices. Simulation offers opportunities for high impact professional development and authentic representation of the role of the PT in interprofessional practice. While simulation experiences can be designed with high variability, educators should be able to consistently define instructional elements, including debriefing approaches with common descriptors directed at exposing core competencies. Research continues to reinforce the value of simulation in complementing instruction, and future research can define optimal quantity in entry-level physical therapy education. Simulation can be costly and requires intensive preparation by the instructor. Cost/benefit analysis of simulation instruction, specifically when simulation is used as a substitution for other learning experiences (clinical education), is beyond the scope of this perspective, but is warranted. Simulation may be the next frontier of experiential learning in physical therapy that must be approached with thoughtful attention to the essential pedagogical elements to achieve desired learning outcomes.
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