Education and simulation techniques for improving reliability
of care
Alison E. Fox-Robichauda and Graham R. Nimmob
Purpose of review
Multiple factors influence the dependability of intensive care
provision. The management of a group of unstable, critically
ill patients requires focused attention from the clinical team.
Medical simulation is an important tool to improve safety
and team work within the ICU.
Recent findings
The critical care healthcare team needs to work both
individually and together in such a way as to optimise
patient care and prevent error. This involves nontechnical
skills including decision making, task allocation, team
working and situation awareness, all of which are
underpinned by communication, cooperation and
coordination. The use of integrated simulators to create
realistic patient scenarios with structured debriefing is an
excellent method for teaching in these domains. There has
been a huge increase in the delivery of training and
education using an expanding variety of clinical simulators.
Summary
This review summarises the evidence and opinion about
how simulation tools can be optimally used. In addition, we
propose an educational strategy to optimise the impact on
clinical practice by embedding simulation training in a
multidisciplinary teaching programme based upon a
specifically developed curriculum focusing on the teaching
of crisis resource management and patient safety.
Keywords
crisis resource management, curriculum, multidisciplinary,
nontechnical skills, patient safety, simulation
Curr Opin Crit Care 13:737741.
2007 Wolters Kluwer Health | Lippincott Williams & Wilkins.
a
Division of Critical Care, Faculty of Health Sciences, McMaster University,
Hamilton, Ontario, Canada and bIntensive Care Unit, Western General Hospital,
Edinburgh and Scottish Clinical Simulation Centre, Stirling Royal Infirmary,
Stirling, UK
Correspondence to Dr Graham R. Nimmo, MD, FRCP (Edin), FFARCSI, Consultant
Physician in Intensive Care Medicine and Clinical Education, Western General
Hospital, Edinburgh and Deputy Director, Scottish Clinical Simulation Centre,
Stirling Royal Infirmary, Stirling, UK
E-mail: g.r.nimmo@stir.ac.uk
Current Opinion in Critical Care 2007, 13:737741
Abbreviation
NTS nontechnical skills
2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
1070-5295
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Introduction
The exponential growth of simulation in medical edu-
cation has been well documented in reviews which have
comprehensively highlighted the history of simulation
development [1], categorised simulators on a continuum
from low to high fidelity [2] and examined the evidence
for educational efficacy [3].
Simulators can be divided into two main categories:
those which are instructive of facts or technical skills
(web-based, part-task trainers) and those which, by dint
of an immersive experience, lend themselves to
the teaching of nontechnical skills and ergonomics
(mid- and high-fidelity simulators, simulated patients).
Evidence from high-reliability industries, such as the
nuclear, aviation, air traffic control, and petro-chemical,
demonstrates that errors, near misses and critical inci-
dents result mainly from human factors [4] and princi-
pally, as in anaesthesia, from inadequate nontechnical
skills (NTS) application [5]. There is ample evidence
that the same is true in other healthcare settings, and this
supports the integration of NTS teaching into both
undergraduate and postgraduate curricula [6].
A curriculum for teaching patient safety
The position paper by Cosby and Croskerry, Patient
safety: a curriculum for teaching patient safety in emer-
gency medicine [7] details an approach to integrating
education on patient safety into the traditional teaching
curriculum. It is composed of seven sections, each organ-
ised into four divisions: concepts, content, teaching
methods, and recommended reading. In this article they
emphasise that awareness of medical error and risk must
be increased and that clinicians should be cognisant of
the principles of error. The third, Cognitive error and
clinical decision making, and fourth, Learning from
the experience of others, sections are those where
high-fidelity simulation has most to offer. Maran and
colleagues have already integrated this into their
CARMA (Crisis Avoidance and Resource Management
for Anaesthetists) [8] course, where human error and
human performance limitation are integral components.
These researchers also emphasise prevention of pro-
blems. Abraham provides evidence that some of these
theoretical principles can be applied to rapidly change
safety protocols in a crisis situation such as in cardiac
arrests during the severe acute respiratory syndrome
(SARS) epidemic [9].
737
 738 Ethical, legal and organizational issues in the intensive care unit
The focus in Section III of Cosby and Croskerry is on the
key nontechnical skill of decision making. It is suggested
that teaching on the mechanisms by which critical clinical
decisions are made, and how patient safety may be
jeopardised by cognitive error, could in itself reduce error
and improve reliability [10]. The crux is that if we
identify the issues of how we think and how we make
decisions we can try to improve decision making by
changing systems to reduce cognitive load (algorithms,
protocols) and to share responsibility by team working
[11]. They also propose that by understanding about
cognitive bias and by employing cognitive forcing strat-
egies heuristically, the praxis of decision making will
be improved.
In Learning from the experience of others, they accept
that most of this knowledge base is anecdotal, but under
the teaching methodology heading they propose that
story-telling is an effective way to share this common
knowledge [12]. Much of our intensive care work and
decision making takes place in an evidence-deficient
zone, so the passing on of experience individually is
important.
Effective and believable clinical event scenario simu-
lation training relies heavily on narrative: the patients
voice; the predicted clinical course made realistic by a
combination of environment, props and acting: illness
scripts. This is one of the reasons why simulation training
should be delivered by clinically active teachers, who are
subject matter experts in their own field.
In their discussion they propose that it is not a traditional
curriculum which they have produced. They are not
trying to invest the student solely with knowledge and
skills but are endeavouring to teach concepts and philo-
sophies to promote the learner as a problem solver. In
practical terms they attempt to allay the anxieties of
potential teachers (who are often busy clinicians) by
pointing out that the implementation of the curriculum
(10 pages of lists and references) will not be a great
amount of additional work. They suggest using estab-
lished fora: bedside teaching, morbidity and mortality
meetings, and case conferences. Clearly, these are all
storytelling modes of teaching with ample opportunity for
narrative and anecdote [13]. They also suggest that the
teaching will be most effective if the teachers lead by
example in clinical practice: tell the story and act it out in
reality. They also highlight the potential of what they call
alternative teaching methods: problem-based learning,
team projects, and patient simulation, in contrast to
traditional lectures, tutorials and didactic teaching.
We believe that the definition of a curriculum for patient
safety training in intensive care medicine is necessary
and that the gamut of simulation technologies and
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techniques should be utilised to support this framework,
particularly by concentrating on human factors. In
particular such a curriculum should highlight the rela-
tively unique working environment of the intensive
care unit, with the focus not only on the technical
demands of such an environment [14], but also on the
team approach to care. It should also incorporate the
philosophy of intensive care without walls, as much
of modern intensive care is practised in clinical areas
outside the physical confines of the ICU. This should be
reflected in the way that simulation is embedded in the
teaching programme.
Such education should begin at the undergraduate level
and rely on simulation to reinforce new knowledge. A
recent study by Steadman and colleagues demonstrated
that the visual feedback provided by medical simulation
was more effective than problem-based learning in
retaining new knowledge [15]. The use of simulation
for critical care education is not limited to medical
students but has also been implemented with under-
graduate nursing [16,17] and pharmacy [18] students.
Currently, there is little information about cross-
discipline training, but Smith-Strom and colleagues
provide compelling evidence that, in critical care, the
team approach to care can be taught at the undergraduate
level using high-fidelity simulation [19].
Within residency training programmes, high-fidelity
simulation has been used to improve skills such as airway
management [20] and sepsis recognition and treatment
[21]. Part of the challenge at both the undergraduate and
postgraduate level is that, while there are several
examples of how simulation can enhance education,
there is a paucity of evidence about its use as an evalua-
tive tool. Kim and colleagues [22], using the Canadian-
developed ACES (Acute Critical Events Simulation)
course, have recently provided us with a tool which
encompasses some of the factors we highlighted above.
Further validation of this tool by other centres and
scenarios is necessary.
Finally, simulation needs to be utilised in the continuing
education of current critical care staff. The most recent
advance in the area has been the development of simu-
lation-based training for medical-emergency or critical-
care response teams. DeVita and colleagues [23] have
used a modified advanced cardiac life support (ACLS)
course to develop a behavioural based approach to critical
care resuscitation. In contrast, as part of a province-wide
training of nurses and respiratory therapist providers in a
critical care response team, the province of Ontario [24]
contracted the Canadian Resuscitation Institute Critical
Care Education Network [25] to develop a cognitive-
based training programme that included simulation.
This latter programme was based on an initial needs
 Education and simulation techniques for improving reliability of care Fox-Robichaud and Nimmo 739
assessment of pilot centres [26] and included the creation
of an accompanying text [27].
The Patient Safety Task Force of the Society for Academic
Emergency Medicines curriculum therefore provides us
with a useful frame of reference for content and delivery of
an analogous curriculum for intensive care. The process
would involve the definition of educational objectives and
the identification and development of learning materials
with recommended modes of delivery.
A curriculum for teaching patient safety in
intensive care
We have put forward a rationale for the development
of a plan to incorporate teaching on patient safety in the
curriculum for intensive care training, highlighting the
use of simulation in this regard.
Integration of clinical simulation
Clinical simulation is safe, reproducible, repeatable,
planned and convenient. Part-task trainers can be used
to rehearse practical skills and scenario-based simulation
to practise the clinical management of common, unusual
or infrequent problems and to explore the NTS domains
[2]. High-fidelity simulation is best delivered in small
groups and is expensive with respect to time, teaching
and physical resources. The precourse acquisition of
knowledge and individual technical skills means that this
valuable learning opportunity can be used optimally. The
crux, educationally, is to incorporate these learning
experiences at appropriate points within the delivery
of the curriculum and to use them incrementally to gain
the maximum educational capital.
Since individual learners have their own particular styles
of learning, it seems logical to utilise a variety of teaching
methods in delivering such a curriculum.
Using simulation techniques sequentially
Simulation training is expensive of learning time and
resources including faculty, so a programmed approach
which optimises the learning seems appropriate.
Knowledge
The starting point could be self-directed e-learning using
interactive software such as the Labyrinth decision-
making system [28] or the European Society of Intensive
Care Medicine (ESICM) web-based learning programme
PACT (Patient-centred Acute Care Training) [29]. These
deliver knowledge, and the interactive components allow
some development of key attributes such as diagnosis,
decision making and prioritisation
Procedures
In the learning of practical skills, part-task trainers,
which reproduce part of the clinical environment, allow
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familiarity to be gained with kit and process for invasive
lines, airway management, defibrillation and lumbar
puncture. This also allows discussion on decision making
in relation to procedures: when should we put a central
venous catheter in, and when should we avoid it and use
alternatives? The follow-on educational process is to
perform these tasks clinically under direct, experienced
supervision. This is currently achieved with only a small
number of courses such as ACES [25,30] and the Society
of Critical Care Medicines Fundamentals of Critical
Care Support (FCCS) course [31].
Immersive training on algorithms and basic
nontechnical skills
Mannequin-based cardiac arrest training allows rehearsal
of specific advanced life-support skills in context while
developing team-working and decision-making skills
(leadership and followership). A recent article from
Canadian intensivists highlights how ill-prepared internal
medicine residents feel to lead a cardiac arrest team [32],
and acknowledges the need for frequent simulation train-
ing to improve and retain skills.
Immersive simulation and enhanced
nontechnical skills training
By utilising high-fidelity clinical simulation supported by
structured debriefing (ideally informed by recording of
the scenario), it is possible to concentrate mainly on
nontechnical aspects of performance. In this regard,
the principles of the crew resource management system
developed for team training in aviation [33] have been
developed for anaesthesia training, and courses are being
run in simulation centres all over the world [3436], and
in an increasing range of specialties, including emergency
medicine [37], internal medicine [38], surgery [39] and
intensive care [23]. A step on from this has been the
development of a training course, Crisis Avoidance
Resource Management for Anaesthetists [8], based on
the anaesthetists NTS (ANTS) taxonomy (Table 1).
This allows the course to be supported by a framework
Table 1 Intensive care nontechnical skills
Task management Situation awareness
Planning and preparing Gathering information
Prioritising Recognising and
Providing and maintaining standards understanding
Identifying and utilising resources Anticipating
Decision making
Teamworking Identifying options
Coordinating activities with team Balancing risks and selecting
members options
Exchanging information Re-evaluating
Using authority and assertiveness Distributed decision making
Assessing capabilities Diagnosis/prognosis
Supporting others Interruptions management
Collective competence Transfer of accountability
Anaesthetists nontechnical skills categories in bold; potential new
domains related to intensive care in italics. Reproduced with permission
from Fletcher et al. [35].
 740 Ethical, legal and organizational issues in the intensive care unit
which has been developed by the specialists (anaesthe-
tists). The development of a taxonomy of intensivists
NTS (INTS) is therefore an important goal both for
clinical and simulation-based teaching [40], and the
ANTS taxonomy is a good starting point. The output
from work on INTS should inform the patient safety
curriculum and the choice of educational modalities used
to deliver it. Patient simulation with video-informed
structured debriefing on technical and nontechnical
aspects of performance is pivotal in this process.
While aviation and anaesthesia are clearly analogous,
however, the same cannot be assumed for intensive care.
Experience and expertise from other domains should be
accessed, in particular where the cognitive process of
decision making is shared by several clinicians in terms
of diagnosis, therapy, prognosis and putting this into
action [41]. We often have a responsibility for multiple
patients in several different clinical areas, and training
in distributed decision making could be important. The
work on distributed decision making in the arena of
Mediterranean forest firefighting might inform this
development [42]. Several investigators have high-
lighted the disparity in perceptions of communication
and team working in the ICU [43,44,45]. Interruptions
have also been identified as important [46,47], and
worthy of inclusion in a curriculum for patient safety
in intensive care. Table 1 contains some categories
and elements which might be included in the INTS
taxonomy.
Integrated training
An example of integration of simulation with an edu-
cational programme is the ESICM PACT/simulation
development SAINT (Simulation Applied to Intensive
care medicine and Nursing Training) [48]. Learners
work through a curriculum-based e-learning educational
package (including decision-making patient challenges)
subsequent to which they attend courses incorporating
advanced simulation based on the PACT materials
and aligned to the original PACT learning objectives.
They come with much of the underpinning knowledge
(and practical skills), so that the simulation teachers can
emphasise the nontechnical aspects of performance
rather than technical and factual aspects. The Canadian
Resuscitation Institute Education Network [25] also
provides a course that integrates team education. The
ACES course provides hands-on experience in basic and
advanced airway, breathing and circulation management,
and then integrates this within the simulation environ-
ment where physicians (non-ICU house staff, critical care
residents or nonintensivists) work with a skilled ICU
nurse and respiratory therapist. The feedback at the
completion of debriefing focuses on crisis-management
skills as well as medical knowledge, commensurate with
the level of training and experience.
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Conclusion
There are many factors which affect the translation of
learned material into improved clinical practice. These
include personal factors pertaining to the individual
learner, such as affect [49] and personal experiences;
local factors, such as unit/hospital geography [50] and
the skill mix, background and experience of the ICU
team; and, importantly, training and the curriculum,
and how these are delivered, particularly in the clinical
area.
The great challenge will be in demonstrating that the
educational approach has resulted in better clinical care.
Once again emergency medicine is ahead of the game
with their research agenda for the use of simulation [51].
In parallel with the development of a curriculum on
teaching patient safety in intensive care it would be
worthwhile to draft our educational research agenda.
Acknowledgement
AFR is a Master Instructor with the Canadian Resuscitation Institute
Critical Care Education Network and has received honoraria for
teaching the CRI EduNet courses described in this paper.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 773774).
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simulation and education into a research agenda, and it provides a road map for
intensive care.