Medical education is imperative to ensuring healthcare providers have the requisite knowledge, skills, and attitudes (KSAs) to provide quality healthcare.1 Following its success in industries such as aviation and the military,2,3 simulation-based training (SBT) is now used in healthcare as a mechanism for improving patient care and safety.4 Indeed, the popularity of SBT as a strategy for teaching healthcare KSAs is demonstrated by its use in disciplines such as anesthesiology,5–7 emergency medicine,8–12 radiology,13 pediatrics,14 nursing,15–17 and trauma.18 Simulation-based training is an instructional technique for garnering expertise through the provision of structured, practice-based learning experiences.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 Unfortunately, the development and implementation of simulation scenarios are no easy tasks. They require attention to and orchestration of a number of pedagogic elements and practical considerations so that finished scenarios are feasible, relevant, and capable of achieving their intended purposes. As such, many instructional designers rely on templates to guide simulation development and/or implementation and to document finalized scenarios. Simulation templates are models for building and/or delivering a SBT lesson plan. Although no template is a substitute for experience and careful planning, well-developed templates can help users organize their thoughts and avoid oversights during development and implementation. Thus, templates may make the design and delivery process smoother and have the added benefit of documenting the major scenario pieces.
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.
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.
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 The fifth theme, design strategy, encompasses template format characteristics and approaches to scenario development. For instance, some templates prompt users to identify the cues of the event transitions that move the scenario forward, whereas other templates do not require such triggers to be pinpointed. The final theme, supporting details, captures additional information useful in understanding or administering the scenario but that is supplemental to scenario content. A number of possible features might be included in this category. Examples of those we observed include: provides equipment or props options, describes learning location, and describes patient data. Some templates list potential support options, whereas other templates require users to brainstorm the details on their own.
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 SMARTER is a peer-reviewed, event-based approach to training (EBAT)26–28 design and measurement technique specifically intended for clinical contexts.21 EBAT techniques create learning opportunities by identifying and introducing events within practice exercises that provide known opportunities to observe specific KSAs of interest.27 Because of its foundation in science and application to clinical contexts, SMARTER was adopted as the framework underlying the organization of TEACH Sim.
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 Approaching design systematically results in a standardized and structured learning experience23 that is advantageous for learning compared with minimal guidance.22 In fact, multiple empirical investigations and reviews have established solid evidence in favor of structured, guided learning.29,30 Consequently, when aiming to impart meaningful, long-term change as opposed to no or even negative learning, adherence to a systematic methodological approach to simulation is recommended.31
It is important to note that although assessment is a critical aspect of simulation and learning,32,33 it is beyond the scope of TEACH Sim to assist in the development of scenario measurement tools or the implementation of finished scenarios. TEACH Sim is specifically a scenario design template and, as such, ensures that event-based KSA performance opportunities are deliberately constructed so that corresponding measurement tools may be easily developed. There are a number of approaches to performance measurement and tool development.34 For more information on measurement and tool development, we direct readers to work by Salas and colleagues.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 This literature contends that when simulation is aimed at education, assessment, or feedback, effective and instructionally sound SBT is developed by linking vital competencies with the scenario content (i.e., what happens during the scenario) and context (the situation in which the content occurs).21,25,37 Remembering multiple pieces of information at once is cognitively taxing, so some users, particularly novices to SBT design, may be interested in a template that encourages written connections between all of the scenario elements as a way for them to identify potential gaps or incidents unrelated to the learning experience. We attempt to appeal to such users by presenting TEACH Sim (Appendix 1).
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 Of course, no template can actually “force” a user to adopt a given design approach. The instructor is free to choose how he or she will design a SBT scenario; however, the instructor is also ultimately responsible for SBT success, and one would be wise to adhere to an evidence-based methodology. TEACH Sim exists to assist instructors wishing to follow the SMARTER approach to organize and document their thoughts during scenario development. As part of the development process, TEACH Sim facilitates in determining how, where, and when the scenario unfolds, which makes the design process smoother for the learner as well as the facilitator.38 Consistent use of a template ensures that students have the same experience across multiple uses of a simulation scenario.
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 http://links.lww.com/SIH/A159 for richer detail and more information regarding how to effectively use TEACH Sim).
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 Simply stated, they are what the learners are expected to know, think, and/or do after training has concluded.
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 This underscores an important point regarding the match between learning objectives and KSAs. Because a systematic approach to scenario development requires consistency of purpose across SBT development stages, the product of each stage must build on the last. Therefore, to meet the specified objectives of training, at least one KSA must be identified for each learning objective.
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.
TEACH Sim is a template for creating medical simulation scenarios founded on the SMARTER approach.21 As such, it assists systematic development of simulation scenarios that meet learning objectives through scripted events aimed at eliciting learner responses and corresponding KSAs. Finished scenarios offer standardized learning and practice opportunities that can be supported by performance measurement and diagnostic feedback. Although there exist a number of other easily accessible healthcare–oriented templates that assist with SBT design, documentation, and delivery, we believe that TEACH Sim meets a critical gap in the SBT literature as a science-based tool suitable for both expert and novice users. We encourage anyone interested in using a healthcare SBT template to consider TEACH Sim but ultimately select a template appropriately suited to their needs.
1. Ziv A, Small SD, Wolpe PR. Patient safety and simulation-based medical education. Med Teach
2000; 22 (5): 489–495.
2. Ressler EK, Armstrong JE, Forsythe GB. Military Mission Rehearsal, Innovative Simulations for Assessing Professional Competence
. Tekian A, McGuire C, McGaghie WC, eds. Chicago, IL: Department of Medical Education, University of Illinois Medical Center; 1999: 157–174.
3. Salas E, Priest HA, Wilson KA, et al. Scenario-Based Training: Improving Military Mission Performance and Adaptability, Military Life: The Psychology of Serving in Peace and Combat, Volume 2, Operational Stress
. Britt TW, Adler AB, Castro CA, eds. Westport, CT: Praeger Security International; 2006: 32–53.
4. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care
2004; 13 (suppl 1): i2–i10.
5. Gaba DM. Improving anesthesiologists’ performance by simulating reality. Anesthesiology
1992; 76: 491–494.
6. Gaba DM, Howard SK, Flanagan B, et al. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology
1998; 89: 8–18.
7. Jacobsen J, Lindekaer AL, Østergaard HT, et al. Management of anaphylactic shock evaluated using a full-scale anaesthesia simulator. Acta Anaesthesiol Scand
2001; 45: 315–319.
8. Bond WF, Deitrick LM, Arnold DC, et al. Using simulation to instruct emergency medicine residents in cognitive forcing strategies. Acad Med
2004; 79: 438–446.
9. Bond WF, Spillane L. The use of simulation for emergency medicine resident assessment. Acad Emerg Med
2002; 9: 1295–1299.
10. McLaughlin SA, Doezema D, Sklar DP. Human simulation in emergency medicine training: a model curriculum. Acad Emerg Med
2002; 9: 1310–1318.
11. Okuda Y, Bond W, Bonfante G, et al. National growth in simulation training within emergency medicine residency programs, 2003–2008. Acad Emerg Med
2008; 15: 1113–1116.
12. Small SD, Wuerz RC, Simon R, et al. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med
1999; 6: 312–323.
13. Sica GT, Barron DM, Blum R, et al. Computerized realistic simulation: a teaching module for crisis management in radiology. AJR Am J Roentgenol
1999; 172: 301–304.
14. Fiedor ML. Pediatric simulation: a valuable tool for pediatric medical education. Crit Care Med
2004; 32 (2 suppl): S72–S74.
15. Hayden J. Use of simulation in nursing education: national survey results. J Nurs Regul
2010; 1 (3): 52–57.
16. Kardong-Edgren S, Willhaus J, Bennett D, et al. Results of the national council of state boards of nursing simulation survey: part II. Clin Simul Nurs
2012; 8 (4): e117–e123.
17. Nehring WM, Lashley FR. Current use and opinions regarding human patient simulators in nursing education: an international survey. Nurs Educ Perspect
2004; 25: 244–248.
18. Lee SK, Pardo M, Gaba D, et al. Trauma assessment training with a patient simulator: a prospective, randomized study. J Trauma
2003; 55: 651–657.
19. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach
2005; 27: 10–28.
20. McFetrich J. A structured literature review on the use of high fidelity patient simulators for teaching in emergency medicine. Emerg Med J
2006; 23: 509–511.
21. Rosen MA, Salas E, Silvestri S, et al. A measurement tool for simulation-based training
in emergency medicine: the simulation module for assessment of resident targeted event responses (SMARTER) approach. Simul Healthc
2008; 3 (3): 170–179.
22. Kirschner PA, Sweller J, Clark RE. Why minimal guidance during instruction does not work: an analysis of the failure of constructivist, discovery, problem-based, experiential, and inquiry-based teaching. Educ Psychol
2006; 41: 75–86.
23. Rosen MA, Salas E, Wu TS, et al. Promoting teamwork: an event-based approach to simulation-based teamwork training for emergency medicine residents. Acad Emerg Med
2008; 15: 1190–1198.
24. Knowles M. The Adult Learner: A Neglected Species
. 2nd ed. Oxford, England: Gulf Publishing; 1978.
25. Salas E, Tannenbaum SI, Kraiger K, et al. The science of training and development in organizations: what matters in practice. Psychol Sci Public Interest
2012; 13: 74–101.
26. Fowlkes JE, Burke CS. Event-Based Approach to Training (EBAT), Handbook of Human Factors and Ergonomics Methods
. Stanton N, Hedge A, Brookhuis K, Salas E, Hendrick H, eds. Boca Raton, FL: CRC Press; 2005: 458–464.
27. Fowlkes JE, Burke CS. Targeted Acceptable Responses to Generated Events or Tasks (TARGETS), Handbook of Human Factors and Ergonomics Methods
. Stanton N, Hedge A, Brookhuis K, Salas E, Hendrick H, eds. Boca Raton, FL: CRC Press; 2005: 502–508.
28. Fowlkes JE, Dwyer DJ, Oser RL, et al. Event-based approach to training (EBAT). Int J Aviat Psychol
1998; 8: 209–221.
29. Mayer R. Should there be a three-strikes rule against pure discovery learning? The case for guided methods of instruction. Am Psychol
2004; 59: 14–19.
30. Moreno R. Decreasing cognitive load in novice students: effects of explanatory versus corrective feedback in discovery-based multimedia. Instr Sci
2004; 32: 99–113.
31. Salas E, Rosen MA, Held JD, et al. Performance measurement in simulation-based training
. Simul Gaming
2009; 40 (3): 328–376.
32. Commission Joint. Measurement: the heart of patient safety. Jt Comm Benchmark
2006; 8: 4–7.
33. Salas E, Wilson KA, Burke CS, et al. Using simulation-based training
to improve patient safety: what does it take? Jt Comm J Qual Patient Saf
2005; 31 (7): 363–371.
34. Furman GE, Smee S, Wilson G. Quality assurance best practices for simulation-based examinations. Simul Healthc
2010; 5 (4): 226–231.
35. Rosen MA, Salas E, Wilson KA, et al. Measuring team performance in simulation-based training
: adopting best practices for healthcare. Simul Healthc
2008; 3 (1): 33–41.
36. Salas E, Rosen MA, Weaver SJ, et al. Guidelines for performance measurement in simulation-based training
. Ergon Des
2009; 17 (4): 12–18.
37. Goldstein IL, Ford JK. Training in Organizations
. 4th ed. Belmont, CA: Wadsworth/Thomson Learning; 2002.
38. Alinier G. Developing high-fidelity health care simulation scenarios: a guide for educators and professionals. Simul Gaming
2011; 42: 9–26.
39. California Simulation Alliance. Simulation scenario template Website. Available at: http://cinhc.wpengine.netdna-cdn.com/wp-content/uploads/2010/04/CSA-Scenario-Template-4-2011.pdf. Accessed January 31, 2014.
40. Bray B. American Association of Colleges of Pharmacy. Human patient simulation scenario development patient case template Website. Available at: http://http://www.aacp.org
/meetingsandevents/AM/Documents/Simulation%20Scenario%20case%20template%206-8-10.pdf. Accessed January 31, 2014.
41. Jeffries PR. Simulation in Nursing Education: From Conceptualization to Evaluation
, New York, NY: National League for Nursing; 2007.
42. Society for Academic Emergency Medicine. SAEM Simulation interest group simulation scenario template Web site. Available at: http://stage.saem.org/sites/default/files/SAEM%20SIG%20scenario%20template%20RIHMSC%20rev%202.8.09.pdf. Accessed January 31, 2014.
43. Taekman JM. Duke University Human Simulation and Patient Safety Center. Simulation support Web site. Available at: http://simcenter.duke.edu/support.html. Accessed January 31, 2014.