Setting a Research Agenda for Simulation-Based Healthcare Education

Abstract

Although the use of simulation as a methodology for learning continues to grow at a rapid pace throughout all of the healthcare professions and disciplines, research in this field is still at an early stage. Increasingly, decision makers and stakeholders must see evidence that the use of such a methodology leads to desired and demonstrable learning outcomes. These include the assurance that simulation may serve as a complement and in some cases a substitute for clinical experience in improving the quality and safety of patient care. Research will be a key factor in advancing the field of simulation to the benefit of patients and healthcare professionals. The simulation community needs an improved understanding of conceptual issues and evidence for their effectiveness to guide simulation use in optimizing the interplay of healthcare professionals, technology, organizational systems, and patients. This recognition extends beyond those educators in the simulation community. In a recent publication summarizing the findings of a task force that identified priorities for medical education research based on their perceived national importance, feasibility, fundability, and amenability for multi-institutional research,1 the no. 1 research issue to emerge was to study the impact of medical school simulation learning on residents' performance. Within the simulation community, there have already been several initiatives involving systematic literature reviews, task forces, committees, and summits whose goal was to identify a research agenda for the use of simulation for learning.2–8 Leadership from the Society in Europe for Simulation Applied to Medicine and Society for Simulation in Healthcare (SSH) sought to further these efforts with a special emphasis to include broad international, multidisciplinary, and interprofessional representation. The Utstein Style Meeting process that has proven successful for catalyzing international, multidisciplinary, and interprofessional research in emergency medicine was adopted for a simulation expert meeting.9,10 The organizers of this meeting recognized that the field of simulation is broad and considered a range of research categories including research about simulation (eg, learning effectiveness and methods, engineering of anatomy and physiology, theoretical frameworks on simulation, and sociological investigation) and research using simulation (eg, human factors oriented investigation, incident analysis, and usability studies).11 While the organizers chose to focus on research related to simulation-based healthcare education, they recognized that in some instances research using simulation to study other factors (eg, using simulation to study the effects of fatigue on human performance) will be used to inform the educational focus. Within the educational domain, the overall goals were to (1) identify the state of the art of educational simulation-based research; (2) identify future directions for educational simulation-based research with headline topics and research questions; and (3) identify methodological issues when conducting educational simulation-based research and provide guidelines on reporting and publishing this research. This effort complements the SSH simulation research summit that took place in January 2011 in conjunction with the International Meeting on Simulation in Healthcare. This report has two sections: a summary of the process to develop a research agenda and a research agenda with proposed research questions. PROCESS TO DEVELOP SIMULATION RESEARCH AGENDA—UTSTEIN STYLE MEETING Selection of Participants For the selection of participants in the meeting, the aim was to build on existing collaborations and experience of simulation research experts with international, multidisciplinary, and multiprofessional representation. The organizers chose individuals with a strong research record, experience in participating in collaborative projects, and who represented key target stakeholder groups, reflecting a diversity of professional (eg, nursing, medicine, and psychology) and geographical backgrounds (eg, Europe, North America). Because the “traditional” size of Utstein Style Meetings is approximately 20 participants, and as this has proven to be a good balance between representativeness and effectiveness, a total of 20 participants (in addition to the four organizers) were invited to take part (Table 1).Table 1: Summary of Participants in the Utstein MeetingPreparation of the Utstein Style Meeting The meeting organizers, consisting of the authors of this article, planned the meeting and its structure. A deliberate decision was made to work with the knowledge and expertise represented in the group by collecting it in an inductive process so that the topics and their priorities would be developed during the meeting. However, it was recognized that collection and synthesis of prior knowledge were important elements to inform the meeting. Consequently, participants were requested to send in recommendations for five references seen as important for the theme of the Utstein Style Meeting (Appendix). Process of the Utstein Style Meeting The meeting took place in June 2010 in Copenhagen, Denmark, and began with an informal evening gathering to build an open, constructive, and trustful working relationship. Day 1—Introduction and Plenum Presentations On day 1, the meeting began with an outline about the idea of the Utstein Style Meetings in general and of this specific one. Two plenum presentations sketched the state-of-the-art and the open questions in simulation-based educational research (noting that much of the research is not grounded in a theory) and presented a model outlining the concepts and challenges in theory-based educational simulation research. The model includes a core—the conceptual, theoretical framework—that is basic to any research approach and a rough clustering of research approaches in four main categories: exploratory studies (qualitative studies, psychometric studies, and descriptive studies), experimental studies (randomized controlled trials and quasi-experimental studies), observational studies (cohort, case-control, and associational studies), and translational studies (reviews and effect studies).12 This framework was used to guide the discussions during the meeting. Day 1—Discussion Rounds The groups were arranged to maximize the variety of expertise and, during each round, were facilitated by one of the authors. Discussion points were recorded on flip charts or using the electronic format and projection. In the first round, discussions followed a modified nominal group process.13 Each participant reflected on general topic areas that “we need to know more about” in regard to education, research, and simulation. In an iterative process, each participant suggested a new topic until no new aspects emerged. The contributions of each group were presented and collected in plenum, allowing for clarifying questions by the other groups. During this session, the organizers independently began grouping each of the topics into different themes as they were discussed. During the subsequent break period, the organizers synthesized their notes and agreed that three major themes emerged: (1) instructional design, (2) outcome measures, and (3) translational research. (Based on the charge to the Utstein Meeting and the agreed relevance of the topic, a fourth group was also formed to specifically address guidelines for reporting research on simulation and education. This report does not include the results of the fourth group as that will appear elsewhere.) In the next round, the groups discussed research problems within the topic in an open group discussion and reported the results back to the plenum. Day 2—Discussion Rounds At the beginning of day 2, the discussion round aimed to present a general outline of research questions for each topic. After that session, members of each group rotated to “critique,” “enlarge,” and “challenge” the findings of another group while two persons of each group stayed. In the following session, the original groups reconvened and refined the research questions along the challenges and newly developed ideas. Those refined research questions were subsequently presented in plenum and each briefly discussed. Day 2—Final Plenum In a final step, the plenum reflected on the implications of the discussions for formulating a general research agenda for educational simulation research and opportunities for greater international collaboration. The authors have synthesized and built upon the literature and the experts' contributions from the Utstein Style Meeting to present a research agenda relating to the three overall themes—Instructional Design, Outcome Measures, and Translational Research (Table 2).Table 2: Research Questions Grouped According to Three Main Themes of Utstein Style Meeting on SimulationTable 2: (Continued)RESEARCH AGENDA WITH PROPOSED RESEARCH QUESTIONS Instructional Design Deliberation by participants resulted in several topic questions they felt would provide focus and priority in the simulation research community. To facilitate grouping of the questions and to illustrate their interdependencies, an hourglass was chosen to represent this conceptually. Research related to learning theories and/or conceptual frameworks was placed at the top. At the next level down (neck of the hourglass), those research questions were placed that relate to resource requirements and systems challenges that often impact the theoretical application of simulation. At the bottom of the hourglass were research questions related to simulation program implementation that take into account the theoretical framework with the local resource challenges within a complex healthcare system. Learning Acquisition, Retention of Skills, and Cognitive Load It is recognized that there is a range of simulation modalities available to choose which may address similar learning outcomes. Studies grounded in context-based learning can provide guidance on the level of authenticity required for a particular competency.14 While there is ample evidence from the literature that the optimal use of a single modality such as mannequin-based simulation may lead to long-term retention of resuscitation skills and central venous catheter insertion skills,15,16 it has yet to be demonstrated whether these and other outcomes can be achieved with different, often less costly and more flexible, simulation modalities such as virtual patients or hybrid task trainers with standardized patients. The intended purpose of researching this topic is not to show superiority of one modality over another. The intent is to provide evidence for a range of options with the expectation that individual simulation programs will possess (or choose) at least a single modality that can be used to achieve a desired outcome. 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The research questions not and they intended to be and will over The participants in this meeting and the authors of this also to the of the topic groups presented at the SSH Research that the 2011 International Meeting on Simulation in Healthcare. These and that will complement each other and aim to provide further guidance to the simulation and healthcare community at improved understanding of conceptual issues and evidence of their effectiveness will guide the and of simulation. these efforts the that research and its publication to advancing the field of simulation for the benefit of healthcare clinical professionals, and patients.