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TECHNOLOGY, COMPUTING, AND SIMULATION

General Concepts in Full Scale Simulation: Getting Started

Departments of Anesthesiology and Peri-Operative Medicine and Pediatrics, Oregon Health & Science University, Portland

Address correspondence and reprint requests to Michael A. Seropian, MD, Oregon Health & Science University, Department of Anesthesiology & Peri-Operative Med, Mail code UHS-2, 3181 Sam Jackson Park Rd., Portland, OR 97239. Address e-mail to seropian{at}ohsu.edu

	Abstract

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Over the past decade, medical simulation has developed to a point where it now is poised to become ubiquitous in teaching curricula. Despite this experience, there is little up-to-date information to help new instructors and operators learn the general principles of simulation. The purpose of this article is to provide prospective simulation instructors with basic concepts and a practical approach to patient simulation. The main focus is on full-scale or high fidelity simulation. The article is intended to (a) prepare instructors to use full-scale simulation to educate students; (b) teach some of the complexities and terminology of simulation; (c) prepare for and complement the curriculum of a formal instructor course; and (d) teach the basic elements required to run a successful simulation. This article should be used as an adjunct to practical experience gained from using simulation units.

IMPLICATIONS: Medical simulation replicates normal and abnormal physiology and pathology. It is a tool that is intended to increase experiential learning. Establishing a functional and useful simulation program involves many factors. This paper presents a detailed introduction to the concepts and methodology of simulation in medicine.

	Introduction

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Simulation in health care is gaining widespread acceptance as a teaching tool (1–8). Simulation allows personnel to practice and learn principles in a controlled environment that will better prepare them for the safe administration of health care to patients. Patient simulation is the result of the combined efforts of many institutions and individuals over the last 15 years. Simulation has a broad application throughout the health care industry (1–4,9,10) and will become an integral part of teaching and training programs in most health care areas (11). To maximize the use and potential of patient simulation, instructors should work in conjunction with other individuals outside their disciplines to develop and expand simulation curricula.

Using a sophisticated mannequin, software, and a full complement of actual medical equipment and personnel, realistic full-scale simulation is now possible. Part-task training devices (e.g., IV-insertion arms or laparoscopic aides) and computer-aided learning also have reached a sufficient level of sophistication to be of substantial benefit in training health care professionals (12). All simulation modalities are designed to accelerate experiential learning and to enhance knowledge acquired from written material (2,10,13). The intent is not to replace learning through real patient contact but rather to enhance it and to give the learner a broader perspective. Simulation has already begun to play a prominent role in quality and patient safety assurance (14). Several health professions are already moving to use simulation as an adjunct for competency testing and continuing training (3,15).

Particular advantages of simulation include the fact that no harm can come to patients. Acquisition of skills can be obtained through repeated practice of scenarios and actions. Simulation is particularly useful for learning to manage rare or infrequent events. Similarly, by using a full spectrum of health care personnel, team training and crisis management can also be effectively taught. Simulation is also unique in that it can exist both in real time and outside of it (if desired). It can alter the time stream and level of complexity unlike any other teaching modalities. This may be useful for basic learners who may require increased reaction time to appreciate the situation being presented. As student skills improve and objectives change, complexity can be increased and the time stream made to parallel real time. Knowledge and skill sets may also be taught and assessed using simulation technology.

Ideally, a simulation center should include education, research, and development. The opportunity to develop curricula and techniques that can be validated allows sharing of experience across disciplines and institutions. Validation tools that test whether simulation has taught a specific subject or area can be developed. Creating validation tools that try to bridge simulated experience with real experience is a difficult task. Translating simulated experience into real experience is difficult if not impossible. The ability to control for the complexities of real life experiences precludes a simple solution to validation. Many early adopters of simulation have done this by intuition rather than validation. Many elements of residency training remain unvalidated. The tools used in simulation will change as technology continues to develop. Teaching goals and objectives, although at times static, will need to adapt to these technological changes quickly.

This guide will provide the framework for understanding the basic simulation process. It is derived from the author’s cumulative experience in building two simulation centers and through the development of multiple scenarios and curricula over the past decade. It is not intended to be a training course. There are several well-established simulation courses in North America (16)¹. It is likely that more will develop as the focus of simulation shifts from anesthesiology to larger markets such as nursing, prehospital personnel, and the military. As trainers become more experienced with simulation, increased understanding and skill will be gleaned from practical experience. To fully maximize the skills of simulator instructors, discussion among trainers and reflection on teaching will be an integral part of the teaching process.

Simulation General Concepts
Simulation is an attempt to mimic reality. The quality of simulation has a range, as do many other things. A simulation may be (a) so detailed that it is a close emulation of reality, or (b) it can be a grouping of elements that are brought together to give only a partial semblance of reality. On one hand, there is full-scale (high-fidelity) patient simulation with real physical inputs and real environmental interactivity, and on the other hand, there are computer-based simulations and part-task training devices. Full scale or high-fidelity simulation attempts to recreate all elements of a situation that are perceptible to a participant. Computer-based simulations rely on the participant to transform a two dimensional screen-based experience into a meaningful metaphor of a real-life situation. Part-task training devices are more focused on specific skills or areas of the human anatomy.

Part-Task Trainers
Part-task trainers, such as IV arms and haptic (force-feedback) IV trainers, are designed to focus the attention of the participant on a particular task rather than a situation. They vary in quality, and care should be taken to ensure that the simulation trainers ensure a reasonable rate of achievement of objectives. They should be of sufficient quality to allow them to be of benefit to the participant. The products should be reliable, robust, and medically meaningful. Courses using this type of training device are generally skill oriented, with specific skill level goals.

Computer-Based Learning
Computer-based simulation products also vary in quality (17). The advent of interactivity with the computer has greatly enhanced these products. They are especially useful for decision-making courses. By their very nature they are often reliable and reproducible. The quality of the teaching from these programs will vary, and use should be accompanied by some form of classroom encounter to allow for questions and detailed exploration of issues discovered during the use of the software. Problem based learning and the use of computer-based programs make for a well-integrated course.

Full-Scale Simulation
For a full-scale simulation to succeed, the instructor must be able to create a seamless transition between reality and simulation. It is the responsibility of the instructor to create an environment that gives the participant a heightened perception of the reality. The instructor or operator encourages and expedites the participant to suspend disbelief. This is achieved by the use of convincing props, personnel, and interactions. The simulation must make sense to the participant (Table 1). It must convince the participant that what she is experiencing is actually real or at least realistic. This is at times a difficult task because the participant, through her unscripted actions, will change the reality as she interacts with the environment.

The Manipulation of Reality: General
It is important to imagine time as a linear entity that can be represented by a course of sequential events. In simulation, participants and team members undertake a course of events that they may be faced with in real life. Our interactions with our environment actively impact outcome. We therefore have the ability to alter the course of a given timeline during a simulation (18). The degree of our actions can vary from extremely passive (no appreciable change in the course or outcome of events) to extremely active (great effect on the course or outcome of events). The importance of this concept lies in understanding the degree of influence one can have in determining the outcome of an event (Fig. 1). In simulation, the trainee is not the only factor determining what the course of events will be. The simulation team can have a profound effect on the course of a scenario either by active interference or by passive indifference. This underscores the importance of understanding and calculating each and every action.

View larger version (80K): [in this window] [in a new window]   Figure 1. Influence of active interaction on reality timeline.

The Practical Aspects of Full-Scale (High-Fidelity) Simulation
Full-scale simulation requires considerable preparation. Typically, this form of simulation requires the following:

1. Team leader
   
2. Actors
   
3. High-fidelity mannequin
   
4. Elaborate re-created environment
   
5. Audiovisual equipment
   
6. Participant(s)
   
7. Facilitator (de-briefer)
   

Team Leader
One must approach a simulation much in the same way a director approaches the production of a film. The main difference is that, at times, scenarios may unfold in ways other than anticipated. As in crisis management, it is paramount that the team leader be established at the outset of the session. Many of the principles at the core of crisis resource management are applicable to the role of the simulation team leader. The leader should do as follows:

• Assign and delegate tasks or roles to team members;
  
• Assure proper set-up;
  
• Assure that the participants are exposed to a quality experience;
  
• Be prepared to direct in the console room (may include operating computer) or may choose to delegate this task;
  
• Handle unexpected problems and situations dynamically;
  
• Be familiar with all aspects of the current simulation;
  
• Be an effective team communicator;
  
• Understand the physiology and pharmacology involved in the simulation.
  

It is important to note that the team leader and operator are not necessarily the same person. The team leader is responsible for ensuring a smooth day of simulation. "Operator" is a descriptive term, referring to the person running the computer and perhaps the communications. The operator makes the simulation happen in real time. The team leader may assume the role of operator, but his main function is to lead the simulation troop through the day.

Actors
Actors must be able to effectively perform in a dynamic situation. They should be familiar with basic health care concepts and terms that are pertinent to their role. Sources of actors can be varied and depend on the resources of the center using them. Centers may opt to use participants themselves or go to other sources such as retired medical personnel. Medical, nursing, and pre-med students are also usually willing volunteers for this activity. The performance of actors is directly correlated to their level of experience and their ability to perform and adapt. An actor’s interactions with the participant may affect the participant passively or actively. Although it seems easy to act, it is not. The actor must respond quickly and spontaneously to interactions within the environment. Awkward prompts and responses will detract from the reality of the situation, as will extreme renditions of certain personality types. The actor should interact with the participant in a way that is familiar. Actors should avoid prejudices and preconceptions to provide a smooth/realistic rendition of their character role. The provision of appropriate guidance for the participants, without overt interference with the direction of the clinical management, is the actor’s greatest challenge.

Actors and control room personnel are often in communication with each other through the use of wireless electronic audio devices. This allows for multidimensional communication and quick adaptation to the unfolding simulation. This communication also allows the operator (not necessarily the day’s team leader) to maintain some degree of control over the simulation to ensure that teaching objectives are met.

Actors are important elements in simulation when used. They are a de-facto part of the environment, much as a real nurse or family member would be. They are required elements for high-fidelity simulation. These elements in our day-to-day lives play roles that have significant impact on our actions. It would be impossible to guess reliably what the outcome would be of an interaction between two people or a set of people. This is what differentiates simulation from classroom and problem-based learning. Input from actors or individuals is a dimension no textbook can deliver. This is also how real-time experiences differ from other experiences. Advanced cardiac life support MegaCode training are a wonderful example of an attempt to mimic reality while stripping away the input (stressful or not) of other people usually present in real life. Lower-fidelity simulation is less likely to benefit from the use of actors.

Participant(s)
Participants include any individual seeking experience using simulation. Experience with simulation shows that most participants are intimidated by fear of evaluation and criticism. It is important to address these issues early on in the process and state the desired objectives of the simulation. Advance distribution of material is often helpful. As people become accustomed to simulation, these fears often dissipate. Participants must be treated with respect and should have the opportunity to familiarize themselves with the equipment (especially the mannequin and monitor) before the start of simulation. The need for familiarization should decrease in participants who have already been exposed to simulation.

Participants often enter a simulation scenario with a heightened sense of awareness of their surroundings (similar to the Hawthorne effect). They often are expecting something to happen. It is important to allow the participant time to relax and integrate into the environment before introducing an event or crisis. Actors engaging the participant often can accomplish this quite easily. Many methods may be used for this purpose. The main goal is to seamlessly get the participant to suspend disbelief. This process may be immediate when a person is thrust into an ongoing simulated crisis or may take several minutes in a less pressurized situation. Despite a participant’s attempts to ask questions such as, "can I do this..." or "do I need to actually give this drug," at no time can the actors or any other element of the simulation "break out" of the reality being depicted to answer these questions. Questions such as "do I actually need to give this drug..." can be met by responses (from a nurse) such as "what do you mean, you’re the doctor." The actor remains in the reality of the moment and also forces the participant to realize that he controls whether the patient will be exposed to the drug or not. This is very important to maintain the fidelity of the simulation. Questions like these can be challenging but can be easily dealt with by experienced personnel.

Environment
Every effort should be made to re-create the environment for the desired simulation. When practical, real equipment should be used. Physical materials and props must give the outward appearance of being real and useful. There is no point in using poor props because they will only diminish the realism of the simulation. Props have a place in simulation only if they enhance or aide the perception of the reality one is trying to recreate. One should not handicap the simulation with useless, unconvincing props.

It is important to provide both visual and auditory environmental feedback to participants and actors. Materials and props should be evaluated for visual, auditory, tactile, and interactive realism. It is not the absolute ability of a prop to pass each test that matters but the combination of the four attributes that will produce a useful prop. Some props will require only certain attributes. For example, announcing a cardiac arrest call over a hall speaker will only require auditory realism. A prop should be considered successful if it convinces the participant that it is real. The most convincing props are, of course, the real things. The way a prop is used by an actor can also influence the success of that item. For example, using surgical instruments in a convincing manner, although they may not be intended for that purpose, may be sufficient to convince the participant that a true surgical procedure is occurring.

Medications and blood products provide particular challenges. Medications can often be water. If special coloring is required, appropriate food dye can be used. Sugar-containing solutions can be problematic for cleanup but can be a viable option. Blood product recipes abound and can be found on the Internet through many acting and theatrical sites. The main problem with making blood-like products is that they often involve the use of thickening agents (such as corn syrup) that are sugar based. These products can be difficult or time consuming to cleanup. All participants must be made aware at the beginning of the course that no medications are intended for human use. Also it must be stressed that no controlled substances are on the premises.

Actors (a part of the environment) have been discussed previously and are a pivotal in their verbal, kinetic, and tactile interactions. As the simulation team gains experience, more environmental factors and materials will be introduced and used. Experience will also allow the team to recognize common techniques to distract or attract participants. An obvious example is the use of a changing pulse oximetry tone to catch a participant’s attention.

Audiovisual (AV) Equipment
AV equipment is essential for a successful full-scale simulation. It has two distinct purposes: (a) to allow the operator and other people in the console room to see the simulation from all angles and (b) to record and provide the participant(s) with a video feedback of the simulation. The equipment design and placement should maximize the amount of information gathered. Information recorded can include audio/video, vital signs, and multiple angles. A time stamp is a good reference tool during recording. Not all simulations will require video debriefing/playback. Video playback can be a very powerful teaching tool and should not be relegated to full-scale simulations only. The use of video is always an option and will vary with course requirements.

Systems may be as basic as single camera set-ups or may become more complex using entry-level "pro-sumer" equipment like the Videonics MXPro DV video mixer. This type of equipment allows for basic recording and mixing of signals (e.g., overlaying the patient monitor output with that of the video action) for eventual playback. Beyond these more basic options, center designers have a wide range of options to choose from. The budget and scope of the project are the dictating factors. Ease of use is also important. The majority of users will likely not be video broadcast experts. If complex equipment is used, then personnel trained in its use should be available. This, of course, will add to the cost of the center. There are products evolving, such as the Newtek VideoToaster 3, that provide midlevel options for users (under $10,000). This type of equipment allows live broadcast, replay, real-time storage, and real-time video streaming. More sophisticated professional equipment is widely available but prohibitively expensive. Large centers may require this type of equipment. Each center must decide on its needs and choose the system right for it.

Storage and recording of audio and video present special challenges for any center. VHS has long been the de-facto standard. Optical media such as DVD will likely replace this standard. The advantages of such digital storage systems include improved AV quality, ease of storage, and increased life span of media (when compared with VHS). When using digital media, it is important to choose digital storage formats that are well established standards and are widely accepted. Examples include MPEG-1, MPEG-2, QuickTime, and AVI. Using standardized formats will increase the likelihood of forward portability of the media. It is wise not to use storage formats that are not supported by major digital player developers. Most of these issues are software based. DVD media is most useful for storage of large amounts of compressed video data (4.7 gigabytes) that can be later played using software based computer video players. CD-R/RW media is currently limited to 700 MB (0.7 gigabytes). New CD formats are coming, but their future is uncertain with the increasing availability and popularity of DVD media. DVD media simply provide larger storage capacity for today’s larger video files. The use of commercial DVD players (as opposed to computer based DVD-ROM) is limited to strict standards set by the media industry. To use this type of device, one must literally create a movie that is encoded in such a way that is understandable to the particular DVD player. This use of DVD in this way is limited and not of great use.

A detailed review of a completed simulation adds substantially to the learning experience. For this reason, a reliable video capture and storage system is imperative. The system must be robust and relatively bug-free, with a near 100% capture rate. Figure 2 shows a schematic of a digital/analog hybrid AV system.

View larger version (19K): [in this window] [in a new window]   Figure 2. Schematic of a digital-analog hybrid AV system.

It is fundamental to understand that the recorded material (and discussion) in a simulation must remain confidential and must be protected to assure the full participation of the participant. The establishment of this trust-bond with the participant is pivotal. There are circumstances where the use of recorded material outside of the center is permitted, when specific permission is granted by all members of the simulation (including actors). We have often made recordings for educational purposes. As long as the participants know that they are coming to the simulation with that as one of the goals, then the trust-bond is not broken. Surprising participants with this is not ideal and may place undue and unwelcome pressure on them.

The objectives of the AV equipment should include at minimum the ability to do as follows:

• Record audio and visual fact and context accurately;
  
• View and record multiple viewpoints;
  
• Provide reliable, durable, and easy to use equipment;
  
• Store recorded material easily and safely;
  
• Create recorded material that is visually appealing;
  
• Secure recorded material.
  

The Simulation Center
There are many options when designing a simulation center. The design team must have clear objectives from the outset. These objectives are largely based on the scope of the center or room. If multiple disciplines or schools are involved, then consideration for each must be addressed.

Not all institutions will have the luxury of a new construction option (19,20). Space usage is governed by cost, local politics, and availability. Practical options, when new construction is not an option, include unused areas in the operating room (OR), intensive care unit (ICU), wards, or other parts of a medical or teaching facility. Although these options seem more practical, they may also impose limitations on the flexibility of a project. For example, emergency room (ER) and ICU scenarios may not be able to be played out realistically in a room designed to be an OR. Likewise, home care and ward scenarios may be limited in the same way. It is unfortunate, but use of a simulation center or room can also be influence by politics and inherent divisions between disciplines. Disciplines may hesitate to use a facility that clearly is designed in another’s image. These factors are largely local and must be considered before embarking on the development of a simulation center.

The center itself can be small and limited to a single room (some rooms as small as 10 x 10 have been used), or they can be expansive. Larger centers are more likely to have a constellation of simulation opportunities ranging from computer-based learning and skill-task training to full-scale simulation. A center that dedicates itself to full-scale simulation should have a conference area, a simulation room, a control room, a supply room, and a storage area. If applicable, audio and video from the simulation room can be transmitted to the control room to be recorded while simultaneously being broadcast (live) to the conference area for other participants to see. The simulation room can also be used for courses that require the simulation mannequin alone without the need for audio and video systems.

The Simulation Room
The simulation room (Fig. 3) is the room in which the core of a full-scale simulation occurs. The room should ideally be flexible in that it can be converted into a range of rooms and spaces where patient care occurs (OR, ICU, ER, ward, or home care). The flexibility of appearance does not only influence the type of scenario that can be presented but also in the type course that can be taught. A realistic environment is equally important for courses that teach knowledge and skill sets, as well as more specialized courses such as crisis resource management. Because a course is not taught in real time, it does not preclude the need for realism.

View larger version (18K): [in this window] [in a new window]   Figure 3. Sample simulation room.

For simplicity, we will limit the discussion to a room designed such that two of its walls are exact replicas of each other. The simulation instructor has the flexibility to change the orientation of the room to best suit her application. Both these locations (walls) can be used as the "head of the room" (e.g., where the head of the bed is or where the anesthesia machine is). Each of these walls should have air, O₂, and vacuum (suction) capabilities. The use of nitrous oxide (N₂O) and other volatile gases require ventilation that meets strict federal codes and may increase cost substantially.

Proper consideration should be given to the hook-ups required to run the mannequin. Connectors routing back to the control room are essential to avoid wires on the floor. Sufficient AC outlets are also imperative. The flooring should be standard hospital vinyl flooring that is easy to clean. Avoidance of carpeting is strongly suggested. The room should have one wall with a one-way mirror (smoked glass) for the operator to have a direct visual line into the room.

Actions outside the operator’s direct line of vision can be captured by mounted cameras. Video cameras should be located at each corner at minimum. It is important to ensure that all important angles are covered. We have at least four active cameras at any given time. Although fewer cameras can be used, it is best to be prepared for the unexpected (retro-fitting can be expensive). The number of cameras really is a function of the room design and the indeed use of the space. A high-quality microphone (balanced) should also be placed in a position that will yield optimal results. The room should be designed with acoustical and visual factors in mind. For example, a room should not be a perfect square because this would produce audio nodes (areas of cancellation, distortion, or amplification). Audiovisual requirements are discussed in an earlier section.

Although not part of the actual simulation room, there should be a realistic supply room in the facility to allow the participants to have access to required supplies. This room should not be confused with a storage room for simulation equipment for other scenarios. Storage space is often underestimated and should be carefully considered.

It is strongly advised that a design team familiar with construction, acoustic, and electrical concepts be included in your planning at your institution. There are several well-designed simulation centers in the United States. It is important to take the lessons learned from these centers when designing your own center.

The Presimulation Sequence
Once a scenario is selected, it is loaded onto the computer, and all pertinent props are readied. The team should spend a few moments discussing a basic game plan and should be clear about what role each member will play. Questions by team members will be fielded at this point. Wireless connectivity between actors and the operator should be confirmed.

Sequence Summary

• All simulator team members are gathered and prepared.
  
• All props are in place and appropriate.
  
• Scenario is loaded and functional.
  
• AV equipment is ready and running.
  
• Participants are accessible.
  
• Wireless communications are on-line.
  

Debriefing
A debriefing can be characterized in many different ways. The core element must be the ability of a facilitator to stimulate learning and discussion in a nonthreatening and organized way. Good facilitators (debriefers) are often good educators, although this may not always be true. The facilitator’s role is to identify the elements of the simulation (after it has concluded) that possess educational value and are pertinent to the objectives of the course. He then acts to facilitate discussion around these elements. The debriefing process is often undervalued as an educational tool. It is tempting to see all the educational value of a scenario within the moments of the scenario itself. The debriefing process is as important as the scenario itself. In this process the student is allowed to evaluate and assess the situation using tools not previously available to health care professionals. They are able to learn from their own self-analysis as well as from discussion with others. They are also given time for this process to evolve. The clinical arena rarely allows for this time and discussion. The debriefing is also a time when elements of a scenario’s evolution can be tied into the teaching of concepts and knowledge.

Video and other aides are often helpful. A debriefing facilitator learns to begin the discussion with open-ended questions that often entice the group members to verbalize their thoughts. Questions like "How did that feel?" often lead to a candid answer. Following up with a more directed question such as "What do you mean?" or "Can you explain that to us?" continues the discussion. As one can see, the discussion narrows itself down eventually to the issues at hand. The goal is for the other group members to feel inspired by the "opening" of the discussion and to become more at ease with the debriefing as it evolves (13). Often as time evolves, debriefing is much easier because the participants have gained trust in the individuals and the process. They also will likely feel the inherent benefit gained from the debriefing sessions.

Although most debriefing sessions go well, there are times that the stress of the scenario, as well as the stress of the debriefing, may be overwhelming for the participant. The facilitator must be acutely aware of this possibility and adjust for this as best as he can. The process of self-evaluation and peer-evaluation can be a very powerful positive tool, but it can also be a negative one. Centers need to be prepared for these situations with policies in place to deal proactively and empathetically with the participant that has difficulty with this process. Instructors and facilitators are encouraged to read resources on effective debriefing because it is truly an art. There are many courses and materials that can aide in this effort (13,21,22). There is considerable debriefing experience in the aviation, education, and law literature.

A Walk Through a High-Fidelity Simulation
In this section a sample simulation time line will be described. The timeline can vary depending on course objectives and targeted participants. This is just an example as things can be done in a variety of ways.

The moment a participant steps through the door, they must be made acutely aware that what they are experiencing is intended to be real. The operators and faculty of the facility must act as if the center or simulation area is a real hospital or real nursing home. They must instruct the participants early on that their reference to the center as a simulation center during the course will be met by answers such as "What do you mean this is hospital xx?" or "I really wish you wouldn’t talk like that with the patient right here." This will quickly get the participants to start entering into the world that you are trying to create. It is important, however, that you allow the participants to familiarize themselves with the center and the patient. They must be allowed to try things, but must do so in such a way that the equipment is never referred to as fake or simulated. When they are asked to listen to the mannequin’s breath sounds, they need to address him as a real patient and say things like "Mr. Santori, do you mind if I listen to your chest?." The operator in the control room will respond via microphone in an appropriate manner. Alternatively, the faculty can introduce Mr. Santori and initiate a conversation with him and the participants. This is helpful and allows the participants to really start to "suspend disbelief." Once the participants are familiarized with the environment and the mannequin, they are asked to leave the room.

The participant is chosen (usually randomly but not required) and is asked to enter the simulation room in the context of the current script. For example, the participant is asked to go to ER Room 3 where a patient has just entered and is in need of some assistance. The simulation is started, and the participant is expected to perform as she would in real life. At this point, the complex relationship among all the people in the simulation room and the control room will dictate how the simulation evolves. The participant may ask for help if allowed by the course objectives. The help may be a fellow course participant or may come in the form of one of the center’s faculty. This is entirely dependent on the course objectives and outline. If a participant is to be a helper, then she must be isolated from any knowledge of what is occurring in the simulation room (unless the script dictates otherwise). The other members of the participant group are escorted to a conference room where they can see a live broadcast of the events in the simulation.

Once the simulation is complete, the group should be given a time to break. After the break the group re-assembles with the facilitator or instructor and members of the simulation cast and begin the debriefing process. Once the process is complete, a new simulation may begin.

It is imperative to note that full-scale simulation cannot be successful if core principles central to the objectives of the course have not been previously taught. The simulation must seek to either reinforce previously taught principles or to introduce new ideas based on other foundations. Consideration must be given to the different possible objectives of a full-scale simulation: (a) to teach principles of behavior and management, with the presumption that the knowledge foundation exists and (2) to teach knowledge and skill in a realistic environment with the presumption that that knowledge does not exist.

Script Writing for Full-Scale Simulation (Scenario Writing)
In the following discussion, we will use the word "SCRIPT" (instead of scenario) to signify the sum of all elements of a simulation. As in the movie industry, the script calls for elements and actions to play out so that a certain image and illusion is created. The difference here is that the script is only a basic shell and is, in fact, descriptive and interactive with the participant. The unknown in a medical simulation revolves almost entirely around people. The participant, the operator, and the actors may interact in a way not anticipated. It is, therefore, imperative for the operator and actors to always keep the learning objectives in mind and to be able to identify potential learning points without straying from the original objectives too much.

Writing a Script
There are many ways to write a script. A uniform format is the foundation for an organized and understandable system. The following sections provide a single example of a script format for full-scale simulation. Centers must rely on their resources to develop a comprehensive, concise, and reproducible method of script writing. Smaller, more concise formats may be used for more basic courses. There are many approaches to compiling a script. Two goals must be met: (a) a method to document all the elements of a script and (b) a method to retrieve the details of a script. Centers with access to software programmers may choose to develop a software-based script database. A program that functions using the common wizard metaphor would be ideal to achieve the first goal. It would walk the writer through each step and ensure complete preparation and documentation.

Retrieval of information is more complex. The most basic format, and in fact a useful metaphor, is a three-ring binder with dividers and labels. I will use this format/metaphor for this section. The metaphor is valid and will likely be the foundation of commercial software developed for this application. It is not intended to suggest that three-ring binders should be the method of choice.

Objectives (Section 1).
The first section of the template includes the title of the script, the intended audience, difficulty level, participant group size, whether it is a group or individual activity, and, finally, the objectives. The objectives must be clear and have a defined start and end point. They must clearly state what is intended to be taught and through what mechanism or strategy. This section should also include possible common pitfalls. It is important to remember that teaching occurs not only from the right answer but also from the wrong.

Personnel and Equipment (Section 2).
In this section, it is important to anticipate how many people will be required to achieve the objectives. The number of operators and actors are important to define. It is recommended to have two operators for high-fidelity simulation but it is not imperative.

The environment that is being simulated should be defined. For example, the script should clearly state that "This is an emergency bay..." or "This is an OR where a patient is undergoing a Whipple procedure." The narrative should continue to give description of what the environment should look like down to the time of day on the clock. It is not required at this point to describe the demeanor or status of the patient or actors.

A complete list with check boxes should be used to describe exactly what equipment is required. Do not forget to include items like paperwork and radiographs that would be normally found around the environment you are recreating (described below). Obviously, once the checklist has been used, a new one that is ready for the next time that script is used must replace it. Several strategies can be used for this: (a) a separate binder with unused copies of checklists divided into script specific sections; (b) laminate the checklist and use a Sharpee pen to check things off. The marks can be easily removed with a cloth using acetone based nail polish remover; and (c) blank sheets may also be inserted into the inside cover pocket (if there is one) of the binder. Someone in the simulation room should be communicating with the checklist holder to confirm equipment items.

Computer Set-up and Operator Instructions (Section 3).
Here the computer software is initialized if it has not already been. If a previous script has occurred, it is important to reset the patient at this point to remove any unanticipated effects. The required prewritten scenarios and trends should be loaded at this time. If a scenario is not being used, then the vital signs should be entered as defined in this section. It is optional here if the operator wishes to use a checklist-based system or not. Given the multiple tasks involved in a short period of time it is probably a good idea. Someone in the simulation room should be communicating with the operator in the control room to confirm that the simulator mannequin and monitor are appropriately set before the participant enters (e.g., breathing, heart rate, blood pressure, and so on).

The operator should also have a loose road map of where the script is intended to go. This may be a description of a prewritten scenario or may be a description of the manual steps required to achieve a certain physiologic appearance. The operator must keep in mind that unless the script requires predefined steps, the actual direction taken may vary widely from participant to participant. A road map becomes less important in this circumstance and the objectives more important!

Paperwork and Supporting Documentation (Section 4).
A special section is devoted to this because it is a vital part of any medical situation. The paperwork that is expected (whether blank or filled out) should be present. With the advent of inexpensive cost ink jet printers, these documents should be reproduced in the highest quality possible. Avoid copies that look like copies. Color copying helps in this regard. The only exception is paper that has carbon copies attached to it. In this case, it may be required to either sacrifice the carbon copy element or to manually fill an actual blank sheet each time. This first option is obviously preferable in terms of time. Experience also shows that the presence of carbon copies does not seem to be a significant distracter for the participants. Charts containing information can be premade. The use of facility-familiar binders is a plus for this purpose.

Context (Section 5).
This section describes the overall event and what is expected to be the most likely outcome. Here the actors learn their road map. A brief description of the patient and environment is given. The actors must know a realistic level of detail about the case, consistent with the expectations of the average participant. Each actor must read this information. It is pointless to have someone in the simulation that does not know what to do or what is happening (unless that is the intention).

It is also in this section where each actor is instructed in her specific role. Starting demeanor, level of aggressivity, and general character are all helpful pieces of information. Describing character is very important and must include limits on personality traits permitted in the scenario. It is impossible to completely predict what will evolve in the event. Intra-event communication with the actors helps with this considerably. It allows the operator, who has the best overall view of the situation, to guide the actors to maintain the fidelity of the simulation.

Knowledge and Teaching Information (Section 6).
Depending on the course objectives, the script may benefit from some teaching tools or methods that could be used before, during, or after the simulation. An example would be a brief computer presentation of fundamental principles being taught in the scenario or series of scenarios. The principles of crisis resource management are often taught this way.

References (Section 7).
Any references to educational material or the basis for some of the objectives or pitfalls in the scenario should be listed here. An extensive list is not required. References add credibility to the basis of the scenario. This is particularly important when sharing or selling scenarios.

Notes (Section 8).
This section is used to write notes about the script after it is completed and used. It is in essence a feedback section so that script writers may be able to correct, add, or remove elements as periodic script reassessments are made. This section is essential for the growth and maturation of the script into a reliable and valid teaching tool.

Summary
Simulation is a powerful tool. In many respects, it is as close to reality as one can get before moving to reality itself. Many departments have tried simulation with varying degrees of success. Planning, implementing, and sustaining a simulation center can be time-consuming and costly. It requires dedication, persistence, and adaptability.

The purpose of this guide is to provide assistance to those who anticipate incorporating simulation into their programs, as well as give ideas to those who already have simulation units. The guide is not intended to answer all questions. Hopefully books dedicated to this subject matter will evolve with the exponential growth in simulation. The need for a "how-to" book for simulation is greater than ever. Nursing, prehospital personnel, and other medical specialties are all looking at simulation with real interest. Cost has decreased tremendously, and we will likely see a resurgence of good peer-reviewed material in the area.

Prospective simulation users must understand how reality can be recreated and manipulated. The simulation team must be functional and understand that each member has a role and effect on the day’s outcome. A firm understanding of the equipment (AV, props, and simulation units) is paramount. Choices of center design, AV equipment, and center size all are important factors that will vary from institution to institution. Beyond the equipment the foundation of any good simulation center is a clear set of objectives and a curriculum in which they reside. Competent teachers and facilitators (for debriefing if required) are also important, as with any other teaching tool. We encourage prospective simulation centers to research and visit other sites. From conversation and observation, successes and failures will become readily apparent.

	Footnotes

 
¹ Kurrek M, Small S, Feinstein D, et al. Anesthesia crisis resource management (ACRM) instructor course: teaching the teachers (abstract). Anesth Analg 1996;82(3):S256.

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