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Concepts and Commentary

Ten Years of Simulation in Healthcare

A Thematic Analysis of Editorials

Nestel, Debra PhD, FSSH

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doi: 10.1097/SIH.0000000000000230
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Abstract

In 2006, the first edition of Simulation in Healthcare was published, celebrated, and endorsed as the official journal of the Society for Medical Simulation,1 soon after renamed the Society for Simulation in Healthcare (SSH).2 A decade on it is appropriate to reflect on the offerings of the journal. Two recent editorials offer personal and historical perspectives on the journal authored by the founding Editor-in-Chief, Dr David Gaba,3 and the current Editor-in-Chief, Dr Mark Scerbo.4 In preparation for my own role as editor-in-chief of a competitor journal, Advances in Simulation, I wanted to explore the role of the editorial segment in a professional journal of obvious relevance.

Editorials are intended to be a forum to express opinions, reconcile contrary perspectives, offer balance in analysis of evidence or events, and be somewhat crusading in tone.5 Editorials also represent expert syntheses of the current state of issues. They offer a fascinating data set for analysis. Author guidelines for Simulation in Healthcare state that editorials are typically solicited. A similar article type published by the journal is the Concept and Commentary, described as “brief reviews and commentary … focused on specific topics of relevance to the simulation community.”6 However, I have not included these in this analysis because they are not necessarily solicited by the editor-in-chief. I have only included articles that have “editorial” in their header. There are discrepancies in article types between the journal index and the published articles. That is, several articles are classified in the index as Editorial but published as Concept and Commentary.

For me, reading the editorials was like a second reading of a favored book. I remembered some chapters more than others, warmly anticipating story lines and endings. Importantly, on the second read, the circumstances were different. I read the editorials consecutively, in historical sequence and often in isolation of the associated journal papers, letters to the editor, and subsequent responses from authors (occasionally, I referred to the papers for clarity). I also know more about almost all of the authors and their work now than I did at the time of the first read.

In summary, up to and including the April 2016 edition, there have been 38 articles classified as “editorials,” written by 27 authors, and 19 (50%) by the founding Editor-in-Chief, Dr Gaba (Table 1). Of the 27 authors, 14 (63%) were medical doctors, 2 (7%) were nurses, and 9 (33%) were PhD/EdD-degree holders (although some can be counted in more than one category). Eighteen authors were male (67%) and nine were female (33%). All authors were based in the United States except for two from the United Kingdom/Europe (7%) and two from Canada (7%). Twenty-nine editorials (76%) were single-author articles, and all but two were written by males. The remaining nine editorials were co-written, usually in pairs. In the first 5 years, there were 24 editorials (3–7 annually), and in the last 5 years (excluding 2016), there were 12 editorials (zero-4 annually). There were no editorials in 2012.

TABLE 1
TABLE 1:
Summary of Editorials Published Between January 2006 and April 2016

Thematic Analysis and Themes

On reading the editorials, I used an inductive approach to thematic analysis.7 That is, I developed the themes as I read each editorial starting from the oldest, returning to earlier editorials to confirm or negate the presence of themes. Inevitably, several themes were seen in editorials:

  1. “Embedding” simulation;
  2. Simulation responding to clinical practice;
  3. Educational considerations for simulation;
  4. Research practices; and
  5. Communicating leadership and scholarship about the community.

Table 1 documents the themes in each editorial.

Communities of Practice

In addition, I used Etienne Wenger's influential theoretical notion of “communities of practice” lens, to make meaning of these themes. With Jean Lave, Wenger studied how people learn, initially their work explored learning in the workplace8 and later extended to learning in networked and other environments.9 According to Wenger, “communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.”9 Communities of practice are distinguished from other types of communities by the following: the domain (this is the shared interest of practice to which members are both committed and have specific competence), the community (this is the network of opportunities used by members to interact and share information and experiences in efforts to advance the practice of their domain), and the practice (this describes the activities and resources that members use to manifest their commitment to the domain). Wenger further identifies key features of communities of practice as the following: joint enterprise (the shared interest of the purpose of the community), mutual engagement (the interactivity of the community members), and shared repertoire (the resources of the community).9Table 2 provides examples of the features of communities of practice in the healthcare simulation community and examples from selected editorials.

TABLE 2
TABLE 2:
Examples of the Features of aCommunity of Practice in a Healthcare Simulation Community and in the Editorials

Theme 1: “Embedding” Simulation

Patient safety was the principal driver for “embedding simulation into the fabric of healthcare”.10 Early successes of embedding simulation were documented across 2007.10–12 Instead of the populist question of the next big invention in simulation, Dr Gaba and Dr Dan Raemer promote a meaningful alternative, “What is the next big step for simulation?”10 Addressing organizational change was prominent among the answers. Specific calls were made to the simulation community to establish practice standards and metrics, coordinate efforts, form partnerships with other organizations, establish regulatory mandates, and develop public engagement.10,13 In 2016, Dr Jennifer Adams and Dr Steven Lisco provided an excellent example of how simulation embedded in a healthcare service facilitated a rapid response to Ebola virus disease.14 At the level of curriculum, embedding simulation was reflected in the goal that simulation-based education “… no longer be seen as optional extras but rather as crucial components that are firmly integrated into existing curricula.”12 Even in 2007, the following four important recommendations were made in the context of US-based medical education: (1) simulation is seen as a complement to other educational methods, (2) that the integrated use of various simulation modalities be explored, (3) performance-based and patient-centered outcomes be adopted, and (4) multicenter approaches to simulation as a means to stimulate the use of simulation and its efficacy be explored.12 In 2009, there were several examples of how embedding simulation could respond to specific clinical issues.15–17

Theme 2: Simulation Responding to Clinical Practice

Clinical practices were examined using simulation—a feature was decision making, by individuals and by teams and remained an important focus across the decade.18,19 The role of heuristics and notions of simple and complex problems was considered.20 Specific examples of clinical practice included the translation of clinical guidelines to practice for “do not resuscitate,”17 of “surviving sepsis,”15 of “handoffs” described as “… moments of greatest vulnerability in the process of care”21 and for diverse elements of practice associated with Ebola virus disease.14,22,23 Simulation was used to explore and support learning and test systems. Promoting patient self-care posthospitalization through simulation was an exciting development.24

Theme 3: Educational Considerations for Simulation

From 2006, the importance of standards for simulation educators was presented, and three essential components for effective simulation education outlined training resources, trained educators, and curricular institutionalization.25 Faculty development was flagged as key. Although not reported in these editorials, it is a significant achievement that SSH has established certification of educators and operations specialists and accreditation of centers.

In 2007, Dr Jenny Rudolph, Dr Robert Simon, and Dr Raemer showed forward thinking discussing realism and related concepts including “as if” the “fiction contract” and “engagement,”26 and in 2010, Dr Alex Kirlik the theoretical concept of “representative design.”18 In 2014, Dr Karen Szauter shared her thoughts on the “human dimension” of simulation. This was explored through a discussion on the contribution of professional actors and role portrayal practices informed by theories from the dramatic arts. In most editorials, a pragmatic voice was heard, and here, with the recommendation, “… that the person chosen for a role in simulation is dedicated to the process and is provided with adequate information and training to allow for an effective portrayal.”27 This was the first editorial featuring simulated (standardized) participant methodology.

The ethics of simulation-based education were identified in response to studies that used deception,28 itself a contested term. Editorials offered different and at times opposing perspectives. Should simulators die? The principle of creating a safe learning environments for participants is partly based on establishing trust, where deception does not sit comfortably. Authors drew on classic psychology experiments to make meaning of educational practices. Again, pragmatism surfaced from the debate with guidelines for “instructors” including thinking about ethical and psychological aspects before and during the simulation, taking into account vulnerabilities of participants during the design and conduct of simulations, briefing participants on psychological components to the extent that learning is not compromised, anticipating and preparing to deal with emotional and psychological challenges, and following up with participants after such simulations.29 These studies in the latter part of the decade revealed an orientation that acknowledged the power of simulation for participants and the need for caring for learners although there was an early notable exception from Dr Rudolph and colleagues.

A cornerstone of simulation-based education is debriefing, and appropriately, there were editorials across the decade exploring its origins, rationale (“… individuals learn far better as active participants responsible for their own learning process, rather than as passive recipients of wisdom imparted from instructors”),30 and its relationship to feedback.31 The essence of debriefing was linked to essential elements of professionalism, “the ability to critically analyze one's own performance retrospectively— not just what went well and what went wrong, but why it went that way—which requires practitioners to critically re-examine how they mentally framed the situation confronting them.”30 This was extended from individuals reflecting to that of teams.

Simulation for assessment was addressed in three editorials. Approaches to assessment of individuals32,33 and of teams19 were presented. Key concepts were explored such as competencies, measurement instruments, and standard setting,32 and theoretical approaches were explored such as inputs, processes, and outputs outlined.19 The expertise required for simulation-based assessment was made explicit—subject matter experts, educationalists with psychometric skills, and simulation practitioners.32

Theme 4: Research Practices

The theme of research practices was explored in different ways, with advancing the science prioritized34 and discussions of gaps, approaches, types, and standards. The SSH Research Summit provided a platform to reflect on the nature and reasons for gaps in research literature including the relatively short history of contemporary simulation, the specialized knowledge and skills required to undertake simulation research, the complexity of measuring outcomes, and that research funding is relatively scarce.35 Research can focus on the use of simulation itself (ie, about simulation), or research can use simulation to study something else (ie, with simulation). Editorials offered examples of both approaches. Translational research was promoted, and recommendations were made for specific types of research, especially comparative studies of one simulation format with another, of association studies—that is, “[we] can learn much from exploring relationships among and between aspects of the learning experience that are not amenable to change …, contextual features …, specific educational objectives/content areas, and outcomes such as satisfaction, performance, and noncompulsory usage.”34 Longitudinal studies, validity studies, and rigorous qualitative studies were recommended because they are “ideally suited to exploring the complexity surrounding interpersonal dynamics and contextual factors in simulation activities….”34 Evaluation strategies were explored and standards for reporting educational interventions recommended, especially making explicit faculty expertise, and the context in which the innovation was offered.25 In 2011, there was confidence that the journal had gone some way toward “raising the bar on [research] standards.”35

Theme 5: Communicating Leadership and Scholarship About the Community

Editorials were often information rich, directly addressing readers, especially SSH members. Their ideas were invited, and an expressed intent of meeting their needs was stated.1 Issenberg25 recommended that the SSH take a leadership role in “helping to find meaningful structure to achieve the community's long-term goal of using simulation to achieve safer patient care.” The integrity of review processes was explained,36 courageous scholarship acknowledged,36 the initial “remarkable” impact factor (2.04) celebrated,37 and subsequent milestones reported.38 Terms, spelling, and language were examined, sometimes from a journal style perspective (eg, mannequin, patient simulator),39 whereas others provide a forum for debate (eg, “non” technical skills).40 The editorials seem in part aligned with the SSH offering an indirect and partial history. The editorials made connection to the SSH through the International Meeting for Simulation in Healthcare—keynote speakers invited to publish, inclusion of conference abstracts—the Research Summit outcomes, and more. Many editorials were authored by leaders in the SSH community including members of the editorial board. However, during the decade, there has been much less SSH-oriented communication in the last few years than the early ones.

So What Does This Mean?

The editorials seem to have both shaped and responded to contemporary simulation practices. It is apparent that the editorial is a powerful forum in which to frame issues relevant to the healthcare simulation research community. The wider journal content informed the content of editorials. However, the extent of the relationship was beyond the scope of this work. As the founding Editor-in-Chief, Dr Gaba has made an extraordinary contribution to the SSH, in these editorials, and to the broader healthcare simulation community. I am confident that individuals new to healthcare simulation would benefit from reading some of the early editorials.

The editorials are true to the journal's stated mission, “…dedicated to publishing on the use of simulation for education, training, performance assessment, and research in healthcare.”1 It is unsurprising then that the themes that were developed inductively loosely resemble the mission statement. Although there have been changes, I cannot detect substantive shifts in the themes across the decade except for communicating leadership and scholarship about the community. There was leadership and scholarship in all editorials, and it is just that it was not about the community in the latter part of the decade. The very recent editorials by Dr Gaba and by Dr Scerbo are exceptions but were outside the inclusion criteria.

The themes reveal strong alignment with an evolving community of practice. Although the joint enterprise of patient safety was explicit in some editorials, it was implicit in most. The provision of high-quality simulation-based education was also a prominent joint enterprise as was striving for high standards in research practice. Thus, joint enterprise was a cross-cutting feature of communities of practice in all themes.

Similarly, mutual engagement was also reflected in all themes with authors sharing their own ideas, drawing on the work of others, and making invitations to readers to consider or apply specific simulation practices. This was most noticeable in the themes of simulation responding to clinical practice, educational considerations, research practices, and communicating leadership and scholarship about the community. One editorial was very explicit in this regard promoting online continuing education opportunities through a journal club.41

Finally, the shared repertoire was apparent in all themes and perhaps where the editorials had the most to offer enabling readers to access the resources the community needs to function —what we use, how we use it, and when we use it. This shared repertoire evolved during the decade building on what was already known and practised and what and how the community was challenging and developing. The theme of simulation responding to clinical practice had several excellent examples with the evolution of simulation practices for communicable diseases being the most profound. The theme of educational considerations was rich in shared repertoire with examples reflecting variation in practices between centers (eg, training simulated participants, permitting the mannequin to die, etc). It is likely that the growth of simulation as an educational method has enabled emergence of these issues. Shared repertoire was also present in the theme of research practices. A recent advance but again outside the scope of this study was the publication of guidelines for reporting simulation science.42

What's Next?

Simulation in Healthcare operates in a different publishing environment to that in which it commenced. There are now three additional journals with a strong focus on healthcare simulation (Advances in Simulation, Clinical Simulation in Nursing, and BMJ Simulation and Technology-Enhanced Learning). In his first editorial as Editor-in-Chief, Dr Scerbo extends an open invitation for all to participate in the next phase of history.4 This is surely a characteristic of a well-functioning community of practice. I am confident that the editorial voice of Simulation in Healthcare will continue in the true spirit of scholarship. How the journal shapes its identity will in part reside with the Editor-in-Chief and with all of those who submit and read the offerings of this pioneering journal. I look forward to revisiting the editorials and themes in 2026.

REFERENCES

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Keywords:

Simulation; research; community of practice

© 2017 Society for Simulation in Healthcare