Barriers and facilitators of simulation-based research

Lack of funding and/or protected time from clinical service were two commonly cited barriers to simulation-based research activity across the country. This is consistent with prior literature identifying barriers to simulation-based research.^{Reference Cheng, Auerbach and Hunt7,Reference Savoldelli, Naik, Hamstra and Morgan15} If simulation-based research is to be a priority within EM, then funding in the form of specific grants, access to “seed” money to encourage new projects, and both departmental and institutional level support will be necessary. Comments from several simulation-leads also spoke to the importance of clarity within departments on deliverables and metrics specific to simulation-based research. A lack of mentorship with interest and expertise in simulation-based research was identified as an additional barrier to scholarship with a large variation between institutions. Simulation-based research “champions” within an institution create an environment that fosters further scholarship. Academic emergency departments might consider investing in an individual simulation-based research champion to motivate and focus others on a shared vision.

While all FRCPC-EM training programs report access to high-fidelity patient simulators and task-trainers,^{Reference Russell, Hall and Hagel3} lack of access to additional infrastructure (e.g., reliable videotaping equipment, paid confederates, access to simulation laboratories for long periods, and supportive colleagues) required to conduct simulation-based research was indicated as a significant barrier. This speaks to the importance of articulating simulation-based research as a priority both within departments and simulation facilities. Further, collaboration at the departmental, institutional, and national level is needed to engage in simulation-based research. This can be facilitated through supporting a local champion, as discussed previously, developing a national position statement that supports simulation-based research as a priority in EM, and creating a platform at the national level that would enable inter-institutional sharing of ideas, resources, and data.

Simulation in competency-based medical education

As postgraduate EM training in Canada transitions to competency-based medical education, simulation will play an increasingly important role in both the delivery of high-quality training experiences and the assessment of entrustable professional activities.¹⁶ Competency-based medical education requires direct observation of learners; however, the clinical environment in EM is unpredictable and certain high-acuity events are rarely encountered, making them challenging to observe.^{Reference Wang, Quinones and Fitch17} Simulation can assist with these challenges by providing safe and reproducible experiences while also allowing expert observation, focused feedback, and deliberate practice.^{Reference Issenberg, McGaghie, Petrusa, Lee Gordon and Scalese18}

Simulation for interdisciplinary and interprofessional learning

EM is practised within a social context involving interactions within teams and across disciplines and specialties. In situ simulation conducted within the actual workplace represents a unique opportunity to observe teams within their clinical environment^{Reference Rosen, Salas and Wu19} and to evaluate team function within the broader healthcare system.^{Reference Petrosoniak, Brydges, Nemoy and Campbell20} Multiple studies demonstrate improvements in team performance following simulation-based training.^{Reference Armenia, Thangamathesvaran and Caine21} Less is known about the translational impact of simulation-based team training on patient outcomes, though recent data are promising.^{Reference Josey, Smith and Kayani22,Reference Andreatta, Saxton, Thompson and Annich23} Simulation-leads agree that future simulation-based research should seek to establish the optimal role of both laboratory-based and in situ simulation, and how simulation can best serve team-based learning objectives and the assessment of “collective competencies.”

Simulation for high-stakes assessment

The standardization, fidelity, and reproducibility of simulation make it well-suited for the assessment of clinical competence,^{Reference McGaghie, Issenberg, Petrusa and Scalese5} and it will likely take on a greater role within competency-based medical education programs of assessment. In EM, this process is well underway, with most postgraduate program directors indicating they would be comfortable incorporating simulation-based assessments^{Reference Russell, Hall and Hagel3} and several programs already using simulation-based examinations.^{Reference Hagel, Hall and Dagnone24,Reference Dagnone, Hall and Sebok-Syer25} Postgraduate training in anesthesia now includes a national standardized mid-training, simulation-based examination,^{Reference Chiu, Tarshis and Antoniou26} and a similar examination for EM residents may complement current high-stakes assessment processes. Despite the potential benefits of using simulation for assessment, caution should be exercised given the current limited evidence for validity in higher-stakes decisions^{Reference Cook, Brydges, Zendejas, Hamstra and Hatala27} and the potential threat that the introduction of assessment may pose to the paradigm that the simulation suite is a “safe-space” for practice and failure.^{Reference Rudolph, Raemer and Simon28}

Simulation for continuing professional development

Simulation has been recognized as a powerful tool to facilitate learning beyond residency training.^{Reference Jensen and Torsher29,Reference Hobgood, Mulligan and Bodiwala30} There is emerging evidence for procedural task-training, theatre-based simulation, and in situ simulation in continuing professional development to enhance both individual and team performance in critical situations.^{Reference Petrosoniak, Auerbach, Wong and Hicks31} Recent culture shifts emphasize inter-professional collaboration and enhanced patient safety by developing more learner-driven and problem-based curricula, often delivered in a simulated environment.^{Reference Kilian, Binder and Marsden32} As competency-based medical education moves beyond postgraduate training, simulation will assume a more prominent role in the maintenance of skills and development of new competencies. However, best practices and strategies for continuing professional development using simulation have not been described, creating a significant opportunity for innovation and scholarship.

National curricular development

Postgraduate EM training programs in Canada have embraced simulation-based education; however, there is great variation in its quantity and curricular delivery due to local differences in funding, resources, barriers, and clinical contexts.^{Reference Russell, Hall and Hagel3} There is increasing pressure on postgraduate training programs to improve efficiency in training and to ensure that all training experiences are optimized for effective learning.^{Reference Nousiainen, Caverzagie, Ferguson, Frank and Collaborators33} A national simulation-based curriculum, similar to that derived for pediatric EM^{Reference Bank, Cheng, McLeod and Bhanji34} or the Nightmares Course^{Reference McMurray, Hall, Rich, Merchant and Chaplin35,Reference Chaplin, Egan and Cofie36} , would support the development of more ambitious simulation programs.

Best practices in simulation-based education

A previous systematic review identified 12 features and best practices of simulation-based medical education.^{Reference McGaghie, Issenberg, Petrusa and Scalese5} Many of the research gaps identified therein were highlighted again in our study, including questions pertaining to the optimization of feedback for learning and how to best integrate simulation within multiple other teaching modalities. There is also merit in examining the use of standardized templates, the sharing of case content or entire curricula,^{Reference Chaplin, Egan and Cofie36} and the development of valid and reliable simulation assessment tools for the EM-specific context. Similar to other pedagogical methods, simulation-based education is context-dependent, and best practices should be reflexive to allow for differing implementations and environments.

Simulation-based education outcomes

In order to justify the substantial costs associated with simulation, simulation-based research is needed to demonstrate improved educational outcomes. While there are data emerging to support this, studying the impact of simulation-based education has been a longstanding priority in the literature.^{Reference Bradley4,Reference McGaghie, Issenberg, Petrusa and Scalese5,Reference Okuda, Bryson and DeMaria37,Reference McGaghie, Issenberg, Petrusa and Scalese38} Determining a return-on-investment of simulation in EM training will be important to assist administrators in the allocation of resources. Recently, Cook et al.^{Reference Cook, Andersen, Combes, Feldman and Sachdeva39} argued that modern simulation-based research should focus on the “value proposition” of simulation-based education, with a goal to guide future research that focuses on outcomes and costs, measuring resource requirements, provider performance, patient outcomes, and impact on the healthcare organization. Assigning monetary value to simulation-based education is riddled with difficulties, but simulation-leads underscored the importance of this theme in order to provide a concrete justification.

Simulation as an investigative methodology

Simulation can be used as a research platform with several benefits over clinical-based research.^{Reference Cheng, Auerbach and Hunt7} The safety and ethical considerations related to clinical research are less relevant in the simulation lab. Furthermore, the research environment in a simulated setting can be controlled and reproduced in order to mitigate confounding influences and focus on the research variable in question.^{Reference Cheng, Auerbach and Hunt7} These features make it an attractive methodology to explore clinical and non-clinical research questions. For example, simulation has been used to identify latent safety threats in trauma resuscitations,^{Reference Fan, Petrosoniak and Pinkney40} inform staffing workload and responsibilities in a new emergency department,^{Reference Geis, Pio, Pendergrass, Moyer and Patterson41} and develop and implement novel technologies.^{Reference McGraw, Chaplin and McKaigney42,Reference Szulewski, Braund and Egan43}

Limitations

This project has several limitations. Firstly, as a survey-based study coordinated by a self-selected group of simulation-leads, the perspectives of other stakeholders with respect to simulation-based research, although solicited, may not have been represented. In addition, the questionnaires were not anonymous. The resultant bias is a potential threat to the validity of the results. Secondly, the response rate to Q1 cannot be reported. We relied on individual simulation-leads to administer Q1 within their institution to all EM faculty involved in simulation scholarship, but the denominator was not collected. Thirdly, this project only surveyed departments of EM with an active FRCPC postgraduate program, so any important simulation-based research activity outside of these centres is not represented. Finally, we have not included the pediatric EM community, which has a well-established simulation-based research network.^{Reference Cheng, Auerbach and Calhoun44}