Medical education is imperative to ensuring healthcare providers have the requisite knowledge, skills, and attitudes (KSAs) to provide quality healthcare.1 2,3 4 5–7 8–12 13 14 15–17 18 4,19–21
The success of SBT is facilitated by the thoughtful development of simulation scenarios purposefully designed to meet critical needs and assessment tools that can be used to guide delivery of specific and poignant feedback.22,23
The purpose of this article is to present the Template of Events for Applied and Critical Healthcare Simulation (TEACH Sim), a tool created to assist in the development of pedagogically based clinical simulation scenarios. We begin by exploring the landscape of previously existing templates. Such an examination will orient the reader to the variety of available templates and facilitate discussion of TEACH Sim’s unique contribution to this area. Lastly, we describe TEACH Sim’s individual sections so that it may be more accessible to users.
Previous Templates
It is not the objective of this article to provide an exhaustive history and comparison of all extant templates. Instead, we contrast a representative collection of templates readily available in the published literature or online with the aim of providing readers a cursory introduction to healthcare simulation templates. We hope by doing so readers will be able to make their own educated judgments about the various strengths and weaknesses of simulation templates. We focus our examination on easily accessible templates and do not include any proprietary templates in our sample. We believe a focus on readily available templates is a more useful approach because it does not limit readers from using or adapting any of the tools we present, should they so desire. Table 1 presents the selected templates and features.
TABLE 1: A Comparison of the Features of 5 Healthcare Simulation Templates
The selected templates incorporate a number of features into their design. We categorized these features into 6 themes via thematic analysis. To complete this analysis, we reviewed the selected templates, listed features characteristic of each, sorted similar features into clusters, and assigned labels to the resultant themes. We were then able to compare the templates across features. In doing so, we assumed each template was designed to be completed in the order in which its components are presented. Thus, some features (e.g., describes purpose before content) were categorized based on the template layout and may not reflect the template author’s original intention. The first theme we extracted is accessibility, which describes the source(s) where the template may be obtained or accessed. All 5 templates in our sample are available online and 2 are published. The second theme, generalizability, captures whether the template is intended for certain participants or simulators. Some templates are oriented toward particular healthcare disciplines or simulators, whereas others are applicable to a broad range of disciplines and simulators. The third theme is participant information. The features in this category refer to data related to targeted learners and scenario confederates. For instance, a template that details participation prerequisites lists any previous coursework, experience, and/or KSAs the learner needs for the scenario to be appropriate, whereas a template that distinguishes scenario cast members describes the roles confederates and/or learners will play while in the scenario. Participant information is useful for introducing the important players to individuals unfamiliar with the scenario. The fourth theme, instructional methods, captures the pedagogic practices adopted in each template. These features set the instructional foundation for the scenario and relate to theories of adult learning. For example, developing an assessment plan and preparing debriefing adhere to the well-accepted tenets that adult learning is improved with feedback and the opportunity to discuss their performance.24,25
Upon examination of Table 1 , a few commonalities are observed. Every template specifies the scenario’s learning audience, requires that instructional designers define the scenario learning objectives, and describes patient data. The prevalence of these 3 features is unsurprising, but it does provide compelling evidence favoring their importance to the development and delivery of successful SBT scenarios. Evidently, the 3 most critical things to know when using SBT are as follows: (1) who will be trained, (2) what they must learn, and (3) how it will be learned.
Another common template feature is scripting events representing the scenario plotline. Scripting events imposes structure, which is necessary for the standardization of the scenario across use. At a minimum, detailing events provides instructors with an idea of how the scenario should flow. At a maximum, well-defined events enable measurement of how well learning objectives are met. Thus, the predominance of templates recommending scripted events is not unexpected, as events compose the scenario storyline.
Choosing a template is, ultimately, a matter of preference and need. As such, a template’s strengths and weaknesses are relative to the user. We hope the information provided here and in Table 1 helps interested readers choose a suitable template.
Why Use TEACH Sim?
TEACH Sim contributes to the present template landscape in 2 ways. First, TEACH Sim corresponds with an evidence-based SBT design methodology. Second, in accordance with this methodology, TEACH Sim encourages written documentation of the relationships among the instructional elements of the scenario. Interestingly, none of the templates we reviewed seem to correspond to a specific development methodology. This is not to imply that users of these templates are not adopting a rigorous SBT design approach of their own volition or that the templates are not useful in rendering highly effective scenarios but rather to point out that the templates themselves do not seem to be structured in such a way that would directly guide systematic SBT development. Alternatively, TEACH Sim was created and structured to align with an accepted SBT methodology, the Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER).21 26–28 21 27
TEACH Sim was developed with input from an interdisciplinary team of training and learning experts working in conjunction with simulation and medical experts and has been used to facilitate systematic scenario design. Systematic merely means that training is intentionally conducted to meet a known need through the specification of learning objectives, precisely controlled experiences to achieve those objectives, criteria for performance, performance evaluation, and feedback.25 23 22 29,30 31
It is important to note that although assessment is a critical aspect of simulation and learning,32,33 34 35,36
Although not surprising, none of the templates we identified prompt the user to formulate explicit linkages between scenario learning objectives, events, learner actions, and teaching points. This may be a result of the varied applications and purposes of SBT, which can be used to enhance KSAs, provide practice opportunities, assess performance formatively or cumulatively, facilitate feedback, and orient novices to simulators. It may also indicate that most templates were designed primarily as implementation agents rather than design guides. Alternatively, templates may not emphasize strategic alignment of scenario elements because it is time consuming and labor intensive to do so. Yet, the science to SBT development described earlier articulates a clear process for creating scenarios.21 21,25,37
We recommend using TEACH Sim because it serves as a tool for building structured lesson plans for engaging in any form of SBT, whether high or low fidelity, by walking users through the SMARTER design methodology.21 38
To gain the greatest benefit from using TEACH Sim, users are encouraged to progress through its sections completely and linearly. Doing so will help users adopt the SMARTER design methodology. Next, we briefly describe the contents of TEACH Sim (Text, Supplemental Digital Content 1 https://links.lww.com/SIH/A159
OVERVIEW OF TEACH Sim
TEACH Sim is composed of 7 major sections: (a ) scenario overview, (b ) learner(s), (c ) learning objectives, (d ) scenario context, (e ) KSAs, (f ) scenario development, and (g) ancillary information. The purpose of the scenario overview section is to serve as a reference guide for the scenario. TEACH Sim begins following the SMARTER methodology with the learner(s) section. Identifying who the simulation is intended to train is the first step in the scenario design process and is why the learner(s) section is labeled with a “1” in TEACH Sim (Appendix 1). When instructors clearly know who the training audience will be, they can create scenarios tailored to those individuals’ needs. Thus, the second step in the scenario design process is to specify learning objectives that match the needs of the particular learners identified. This section is the scenario foundation because all proceeding aspects of the scenario will be rooted in the learning objectives. Formally defined, “learning objectives are the specifications of what the scenario is intending to instruct.”21
The third step in TEACH Sim as well as the SMARTER methodology is to select a scenario context, which is the clinical situation in which the scenario will take place. We define context differently from content. Whereas we conceptualize the context as the clinical backdrop to the scenario, we define content as the events and learner actions that happen against that backdrop. It should be noted that although it may be tempting to begin scenario development with an interesting case study, building a scenario to fit a clinical context can undermine the value of the scenario as a learning tool. By beginning with a context in mind, instructional designers risk creating scenarios that are inappropriate for learner needs. Therefore, it is best to first identify learning objectives and match the clinical context to these aims.
The fourth step is to identify context-specific KSAs. Knowledge, skills, and attitudes represent what learners must know (i.e., knowledge), be able to do (i.e., skills), and/or feel (i.e., attitudes) to demonstrate proficiency on the learning objectives.21
The fifth step is to craft the content of the scenario. TEACH Sim includes the scenario development table to assist users in creating guided practice opportunities. Instructors can use the table to organize their thoughts as they draft and refine events and associated learner responses. However, the scenario development table goes a bit further by prompting users to consciously think about the linkages among KSAs, associated learning objectives, and scenario events. Doing so should help users identify overlooked learning objectives and KSAs or recognize misalignment between the written events and scenario objectives. When used appropriately, the development table can help instructors ensure that the finished scenario is appropriate for meeting planned learning objectives and practicing the KSAs that signal competency with training material.
The final section of TEACH Sim, ancillary information, does not correspond to a step in the SMARTER design methodology. Its presence is to help the user document important information associated with the scenario. As such, it may be used and filled out as the user progresses through each of the 5 numbered sections (learners to scenario development) in TEACH Sim.
Limitations of TEACH Sim
Like most templates, TEACH Sim is not without limitation. However, as is also true of other templates, its limitations are somewhat in the “eye of the beholder.” What may be a nuisance to one user may be helpful to another. In light of this, we would like to point out a few aspects of TEACH Sim that we believe some users may perceive as unfavorable. First, because TEACH Sim was specifically designed as a development template, it is not oriented to scenario implementation. That is, its structure may not be the most intuitive or useful during the implementation of the scenario. For instance, if one wanted to use TEACH Sim to implement a high-fidelity mannequin scenario, he or she may need to add information regarding mannequin baseline setup requirements.
Second, the scenario development table is very linear in nature, so it does not clearly show the contingent relationship between events and learner responses to previous events. There are often a number of ways that learners could (correctly or incorrectly) respond to a given event, and sometimes, these responses change how the rest of the scenario unfolds. In these circumstances, it is wise to have scripted contingency plans so that no matter how the learner behaves while in the simulation, the scenario events make sense. A flowchart easily allows readers to see what would happen in the scenario should a learner behave a certain way, but converting this diagram to a table format can obfuscate the plotline if there are many contingencies. That is not to say that one could not replicate different contingency plans in the scenario development table. For instance, a user could create a labeling schema that would connect contingent events to previous learner responses. However, some might see this as a limitation of TEACH Sim.
CONCLUSIONS
TEACH Sim is a template for creating medical simulation scenarios founded on the SMARTER approach.21
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APPENDIX 
