Why and How To Train Anesthesia and Intensive-Care Nurses in A High Fidelity Simulated Environment?

Bachelort h e s i s
„Why and how to train

anesthesia and intensive-care nurses in a
high fidelity simulated environment?“
- A descriptive literature review -
submitted in partial fulfillment

of the requirements for the academic degree
Bachelor of Science in Nursing
Grobbauer, Benedikt
Matriculation Nr.
07PMU03004
First Reader:
Dr. Andre Ewers, MScN
Second Reader:
Dr. Gerard Hogan, MScN
Place and date submitted:

Salzburg, am 25.5.2010
Running head: WHY AND HOW TO TRAIN NURSES IN A SIMULATOR
“There was a shift away from autocratic and individualist styles of aircraft
command to one that is more team-based with mutual interdependence and
shared responsibility.”
(Musson & Helmreich, 2004)
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Content
1. Preface .......................................................................................................... 3
2. Introduction .................................................................................................. 4
2.1. Background ............................................................................................. 4
2.2. Objectives................................................................................................ 5
2.3. Methods................................................................................................... 6
2.4. Goals ....................................................................................................... 6
3. What is simulation in health-care? ............................................................. 7

3.1. Definition.................................................................................................. 7
3.2. Levels of fidelity ....................................................................................... 7
3.3. Model-based vs. On-the-fly.................................................................... 10
3.4. The effect of “immersion”....................................................................... 10
4. Why train anesthesia and intensive-care nurses? .................................. 11

4.1. Nurses as professional experts ............................................................. 13
4.2. Nurses as adult learners........................................................................ 13
4.3. Nurses as team members...................................................................... 14
5. How to train nurses in a simulated environment? .................................. 15

5.1. Scenario design..................................................................................... 15
5.2. Workload ............................................................................................... 17
5.3. Identification of learning goals ............................................................... 18
5.4. Function of Pre-briefing and de-briefing................................................. 19
5.5. The essence of debriefing ..................................................................... 20
5.6. Fundamental concepts for training ........................................................ 25
5.6.1. Experiential Learning Theory .......................................................... 25
5.6.2. Situated cognition............................................................................ 26
5.6.3 (Anesthesia) Crisis Resource Management..................................... 26
5.6.4 The 15 CRM key points (Miller, 2009):............................................. 30
5.6.5 Situation – Background – Assessment – Recommendation............. 36
5.6.6. Stop-Procedures ............................................................................. 37
6. Conclusion.................................................................................................. 38
7. References............................................................................................... 40
Appendix - Internet resources for simulation.............................................. 46
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1. Preface
This thesis presents the results of a literature review of articles related to human
patient simulation as a tool for the training of, especially anesthesia and
intensive care, nurses. The included information is structured from general to
detail.
After a short background update on human factors, safety and error

management in modern clinical settings the following will be presented:
Methods, objectives and goals of this thesis in chapter two, “Introduction”.
Chapter three includes basic definitions on simulation, levels of fidelity and the
effect of immersion by answering the question “What is simulation in health-
care?” Due to the high costs of high-fidelity simulation, one has to have sound
arguments as to answer the question “Why anesthesia and intensive care
nurses should receive training in simulated environments?” An answer to this
question is provided in chapter four.
Chapter five deals with the time, when the decision to pick up simulation is
already made and provides an answer to the question “How should anesthesia
and intensive care nurses be trained?” Next to the “essence of debriefing”, it
contains the most cited learning theories as well as the basics of Crew
Resource Management and other trainable protocols like SBAR (Situation,
Background, Assessment, Recommendation) CUS (I am concerned, This is
unsafe), or the World Health Organization proposed Stop-procedures, also
known as time-outs. Chapter six includes conclusions of this review and as an
appendix, there are useful Internet resources related to the topics discussed, as
well as simulation centers and providers of simulation systems.
Concluding this short preface I would like to acknowledge the support of Drs.
Andre Ewers and Gerard Hogan as well as Prof. Dr. John McDonough and Prof.
Dr. Juergen Osterbrink for supporting, reviewing and correcting my work,
whenever needed.
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2. Introduction
2.1. Background
The Institute of Medicine (IOM), the health arm of the United States National
Academy of Sciences stated in their 1999 report, entitled To Err is Human, that
„at least 44,000 people, and perhaps as many as 98,000 people, die in
hospitals each year as a result of medical errors that could have been
prevented” (IOM, 1999). Compared to the U.S death toll of 2006, these
numbers would somewhere rank in between deaths by septicemia and
pneumonia. Deaths by preventable errors in hospitals are still not stated in the
Center for Disease Control and Prevention reports (Heron, Hoyert, & Murphy,
2009).
In those areas of the hospital, which afford highly invasive treatment, namely
anesthesia and intensive care units, errors, no matter how small they might
seem, can have a highly adverse effect on the patients’ outcome. Valentin,
Cappuzzo, Guidet, Moreno, et Metnitz analyzed medication errors on 113
intensive care units in 27 countries over a period of 24 hours. There were 861
reported medication errors committed. Most consisted of medication being
given at the wrong time. However, they also included wrong patient, product,
dose, or even wrong route in seven percent of all counted errors. Some patients
experienced even two or more errors within a day. Assuming that most of the
medication can be harmful or even deadly, even when used correctly these data
indicate that dangerously emerging incidents are waiting to happen (Valentin et
al., 2009).
The IOM defines medical errors “as the failure of planned action to be
completed as intended or the use of a wrong plan to achieve an aim.” Further
on they say “High error rates with serious consequences are most likely to
occur in intensive care units and operating rooms” (IOM, 1999).
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The question is not, if functioning planning is needed for proper crisis

management, but rather how one can get the formal training to acquire the
needed skills and properties as a team for the better of the patient. In
healthcare, as in aviation, crew-centered Crisis Resource Management (CRM)
might be one useful tool. CRM showed to be true, that this kind of preparation is
specific for each industry, if not even for each organization (Musson &
Helmreich, 2004).
In 1989 Gaba et. al. developed the first anesthesia simulation system, inspired
by aviation safety, and adopted the so called Cockpit Resource Management to
the formal training concept as Anesthesia Crisis Resource Management. They
developed a system of 15 key points to reflect on the medical aspects as well
as on general principles for crisis management that apply to the complexity of
emergency situations (Miller, 2009).
Other high-hazard industries already apply team-training as a required

component. Morgan stated as a result of a descriptive study: “simulation
provides an ideal venue for practicing without risk at any level of medical
education” and “the future will probably expand the use of simulation in high-risk
areas such as the operating room, delivery room, trauma room, disaster
medicine, critical care medicine and emergency medicine as only some
examples” (Morgan & Cleave-Hogg, 2005).
2.2. Objectives
For over 20 years now, there have been formal concepts known, that can be
applied to the complex field of crisis management in anesthesia and intensive
care. The skills and knowledge can be acquired in simulated environments,
without putting patients to risk. Human Patient Simulation is developing rapidly,
as the technical possibilities continue to expand. The purpose of this review is
to show what simulation can do for the training of anesthesia and intensive-care
nurses.
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It targets either faculty, planning to implement simulation within their nursing

curricula, or nurses who plan to take part in a simulated training. Members of
both groups may want to gather more information about the applied principles.
Effective users of simulation will need to “open up to” human factors and create
standards for communication about safety concerns, to establish a “shared
mental model” and acceptable ways to cross-check and challenge ourselves
(Musson & Helmreich, 2004).
2.3. Methods
A literature review was undertaken on CINAHL, OVID and Pub MED to identify
articles from 1990 up to 2010 relating to the following keywords: simulation –
patient safety – CRM – Crew resource management – Crisis resource
management - anesthesia training – SBAR – high fidelity – intensive care -
emergency – human patient simulation - adverse events – medication errors –
errors. Furthermore related books were taken into review. Literature that did not
relate to simulation, learning, health-care or aviation was excluded.
2.4. Goals
One goal of this review is to raise awareness concerning human factors in

hospital organizations and of ways to train nurses for the coping with difficult
emergency situations. Anesthesia and Intensive-Care nurses can get formal
training in crisis management in high-fidelity simulated environments. After
rapidly developing in several directions, there seems to be a consensus of
various aspects of simulation relating to definition of fidelity, hardware, setting,
facilitation and debriefing techniques, as well as scenarios designed to create a
successful learning experience, while applying relevant theories. At the dawn of
the “fourth movement, […] it is apparent that using simulation in health care and
nursing education has gone beyond the nuts and bolts of how to create a
simulation center and has progressed to evaluation of teaching practices and
scholarship.
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Many users of simulation technology are critically evaluating the teaching and
learning literature and are merging this body of knowledge with the practices
conducting simulation” (Harder, 2009).
Another goal of this review is to show, that the successful accomplishment of an

emergency situation is always a product of a well conducted team effort, and
therefore nurses must be part of any “team-training” in either anesthesia or
intensive care. In aviation CRM has existed for 30 years and as a result of the
change in crew training, there were many changes concerning safety culture in
daily routine.
3. What is simulation in health-care?
3.1. Definition
The Latin word “simulare” means to pretend or counterfeit. The Oxford

Dictionary of Current English offers a further meaning of simulation explicitly “to
reproduce the conditions (of a situation) e.g. for training” (Thompson, 1996). In
nursing education “simulation is a technique to replicate real patient
experiences in an interactive manner” (Waxman & Telles, 2009). Schiavenato
(2009) defines simulation as “techniques used to represent nursing processes
and actions in an educational context”.
3.2. Levels of fidelity
Fidelity measures how “real” a simulation system is, meaning to which extent
conditions of reality can be represented. Low-fidelity simulation for example
may be a simple model of a limb, representing the vessel structure in a human
forearm, to train puncture techniques. Those models may be useful for the
training of a specialized skill, but they do not represent reality in its’ time-based,
interactive and dynamic nature. Low-fidelity simulation could also be a pen-and-
paper case-study (Jeffries & Rizzolo, 2006).
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Medium-fidelity simulation implements interactive and dynamic elements to

recreate the demanding environment of a hospital setting, by using instructed
patient actors, each with their own history and furniture resembling the
workplace surroundings. From this level through increasing levels of fidelity,
emotional aspects start to have influence on behavior and performance.
Therefore facilitating and debriefing techniques can be applied (Clapper, 2010).
In the sophisticated high-fidelity human patient simulation, a computer-system is
used to represent physiologic behaviors through a manikin, to directly
demonstrate the effects of behavior and treatment enacted by the participants.
The level of fidelity is supported by “rebuilding” an operating-room or an
intensive-care-surrounding (see Figure 1). The single scenarios are embedded
in Simulated Clinical Experiences (SCE), giving a logical story underlying each
simulation to enhance the effect of immersion, so that participants can act as if
this experience would be real.
Although this review is focused on high-fidelity simulation, there is a trend of

“housing various simulation techniques in one unit” (Morgan & Cleave-Hogg,
2005). It seems explicitly important not to support an existing myth that “higher
levels of simulation fidelity lead to increased training effectiveness” (Baubien &
Baker, 2004).
As we have seen, high-fidelity simulation systems always process vital

parameters to present changes of the patient situation to the participants, using
a humanoid mannequin and attached monitoring. The commercial products
currently available vary in the ways these data are presented. There are
differences in means of diagnostic and therapeutic maneuvers that can be
applied including such factors such as intravenous fluid management,
drainages, available pulses, pupil reactions, changes of skin color and so on. A
multi-centered study on 403 students showed no significant difference in
learning, when training on a static mannequin compared to a high-fidelity
system. Responding on the Simulation Design Scale they did have a greater
sense of reality and a more satisfying learning experience.
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The nursing students taking part in the full-scale, high-fidelity human patient
simulation had “a greater sense of being involved in diverse ways of learning,
and they valued this educational practice more than the two other groups”,
namely a group training on a static mannequin and a group trained with a pen
and paper case study only (Jeffries & Rizzolo, 2006).
Figure 1. Schematic drawing of the setup for video-assisted high-fidelity

simulation; While one crew is in the simulation room, practicing on a scenario;
facilitators are controlling the simulation system. The other participants can
watch the currently active group, enabled by live audiovisual transmission to the
debriefing room. After the conduct of the scenario the facilitators and the crew
immediately move to the debriefing room, where they can watch relevant
scenes from the recorded session. Adapted from Rall & Dieckmann in Miller’s
Anesthesia, 7th edition, Elsevier, 2009.
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3.3. Model-based vs. On-the-fly
Another distinguishing feature defines the way processed data are influenced
by the instructor. Either the instructor has to indirectly manage the data via
fluids and drugs, based on a “physiologic-model” or enters a target value “on-
the-fly”, which means directly into the system, accepting that participants could
see an instant “unphysiologic” change in the mannequins’ parameters. No
literature could be found, if there is, or is not, influence on the learning
experience through the implementation of a “physiologic-model”. This aspect
awaits further research, although it does make a difference in “steering the
wheel”, meaning the way and effort for the instructors to get the intended
parameter values on screen (Jones, 2009).
3.4. The effect of “immersion”
Whenever participants experience high-fidelity simulation, the goal should be to

let them enact an “as if…” behavior and attitude and role-playing seems to be
an essential part of it. Each participant perceives “reality” on a different level, as
do the instructors.
Every person will bring his own frame of interpretation to the artificially-real
setting. Especially when people have the feeling of having failed, they might
want to reject the experience. Some may even identify the simulation as
“unreal”, because they are unhappy with their performance (Dieckmann, 2005).
The moment the participant begins to forget that this is not a real patient, is
when immersion takes over, so we are not so much talking about “role-playing”,
but more about “role-being”. They accept the reality of the simulation and start
to act like this experience was under real conditions.
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Jeffries et al. (2006) identified role assignment, (either primary nurse one or
secondary nurse) as a significant influencing factor on how successful a training
experience can be transferred into confidence and assertiveness to handle
future situations. In the Jeffries study 395 students were asked about their “self
perceived judgment performance, providing information about students’
perceptions of their clinical performance in the simulation”. From the four
available roles in the scenario, the role of nurse 1 and the significant other rated
themselves significantly higher than nurse 2 or the observer. There seemed to
be different grades of involvement by each individual depending on the
assigned role during simulation.
As a conclusion the authors support the view that “immersion in a simulation

provides the opportunity to apply and synthesize knowledge in a realistic and
nonthreatening environment” and “in addition, when students are more active
and immersed in a learning situation, the feedback they receive […] can greatly
facilitate their learning” (Jeffries & Rizzolo, 2006). Simulation as a team-based
learning activity enables the participants to “work together to solve problems in
a situation and share in the decision-making process” (Jeffries & Rizzolo, 2006).
This may be the main advantage, that in contrast to pen and paper case studies
or part-task training, as “[high-fidelity] simulation can promote collaborative
learning among students, instructors and other health-care professionals to
provide an environment in which everyone works together, mimicking what is
actually done in real life” (Jeffries, 2004).
4. Why train anesthesia and intensive-care nurses?
In a team-based inter-professional approach, as we experience in most clinical

sites, especially during emergency situations, it is most important that all
members of the team “share the same mental model” (Musson & Helmreich,
2004).
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“However, it appears from multiple accounts and the experience of our own and
other research groups the implementation of such programs is as complex a
question as what to train” (Musson & Helmreich, 2004). Therefore anesthesia
and intensive-care nurses should be trained in simulators, as part of the team
training together with their own colleagues and all other involved professionals,
resembling the daily working routine.
Compared to modern medical training, “where it can be said that the pursuit for
safe patient care and therefore the need to acquire competence […] has fueled
the development and implementation of educational techniques such as
simulation […] in nursing education, this progression does not appear to be as
natural or as succinct. A cohesive ideology is lacking for the very existence of
simulation in nursing education”. Schiavenato (2009) suggests some reasons,
why nurses should experience simulation:
€ Patient safety
€ Decreased opportunities for clinical practice
€ Nursing faculty shortage
€ Increased clinical complexity
€ Technology trend
Of course there are more aspects, which still await further research. Assuming
simulation training can be used to enhance nursing staff continuing
development, as a consequence adherence to clinical protocols, improved
symptom management, prevention and reduction of adverse events, reduction
in human resource costs due to improved retention of nurses may well result
(Covell, 2009).
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4.1. Nurses as professional experts
It takes quite some time until a nurse reaches the expert level, and all this
expertise is still gained by practicing on real patients. “Although progression
along the continuum is not time dependent, expert nurses typically have a
minimum of 5 years or more of experience. As a result, although patient care
needs demand an expert nurse, often, there is a non-expert at the bedside”
(Burrit & Steckel, 2009).
In this highly demanding environment of a modern Intensive Care Unit or an

Operating Room, mainly dominated by a fast-paced change, nurses do need
to get support by formal training. “It is expected that the expanded use of
simulation in nursing education will facilitate increased learning and skill
transfer when students care for patients in today`s complex, health care
environment” (Jeffries & Rizzolo, 2006). There seems to be a lack of data, that
actually measures the impact on patient safety, due to the complex nature of
human factors, but “simulation is a viable option to allow for continuity in
educational experiences. Nurse educators have embraced this method as a
way to teach, empower students, and promote critical thinking despite the lack
of studies validating this teaching method” (Schoening, Sittner, & Todd, 2006).
4.2. Nurses as adult learners
Considering nurses as adult learners they have the “readiness to learn and
grow orientation to the developmental tasks of their social roles” and “the
internal motivation to learn” as long as “they know why something should be
learned.” Further, it is most important, that the experience “does not focus on
evaluation, but instead on assessment that improves practice”, following the
concept of Malcolm Knowles’ andragogy (Clapper, 2010). The simulation
laboratory could eventually develop as the “interface”, the one place, where
the adult clinical expert catches up with the standards brought up and
developed by qualified facilitators’ valid research (Freshwater, 2003).
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4.3. Nurses as team members
In a recent New York Times article a young resident describes her first
experience in a simulator-based training, which reminded her of “the Three
Stooges, in white coats. One resident stood at the patient`s side, holding a
rubber tube in one hand and a syringe in the other, unsure of which to use
first. The other resident kept bumping into the nurses and the respiratory
therapist as he paced alongside the patient. I watched myself standing at the
head of the bed mumbling orders that no one could hear“.
In a blaming environment within the boundaries of clinical expectations, this

incident would somehow be shameful, although in an explaining environment it
is just a perfect example for human factors having influence on teamwork. The
cause for this inefficient behavior was not a lack of knowledge, but merely a
break-down of leadership, attitude, collaboration and communication. “Other
than the one experienced nurse in the room and the senior surgeon who
showed up 10 minutes into the resuscitation, no one seemed to know what to
do or how to coordinate their actions with everyone else’s” (Chen, 2010).
Two questions from this newspaper article arise and remain unanswered.
First, why did the experienced nurse not take over leadership, and second,
why did efficient help not arrive earlier? Human factors are not related to our
scientific knowledgebase about encountered phenomena, but more how we
apply theory to a complex and dynamic environment. They are emerging from
our conditio humana, which means the limitations we experience by the fact
that we are “only” human beings (Green, 2004).
The question is how we successfully organize all available resources, not

despite being human, but integrating this circumstance as a factor. “Resources
include all people involved with their skills, abilities and attitudes – as well as
their limitations, in addition to equipment” (Rall & Dieckmann, 2005).
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If any of the teams’ limitations remain unapproached, their plan as a whole

might not be as efficient as possible. “The barriers to effective teamwork can
be narrowed down to problems in the four areas described [..]: leadership,
attitude, collaboration and communication. A breakdown in any of these four
areas can create issues needing to be resolved” (Phillips, 2009).
5. How to train nurses in a simulated environment?
“Less is known about simulation in nursing education than is implied by its

seemingly universal adoption. Some high-fidelity mannequins have been known
to turn into little more than expensive bed weights” (Schiavenato, 2009). Once
the decision is made to train nurses in a simulator, the question is which
learning goals should be accomplished and how to facilitate the needed
learning effects?
It would seem that, nurses’ continuing development through means of

simulation still awaits further research. In most of the retrieved literature,
describing empirical data, undergraduate, sometimes graduate nursing students
make up the study population. The development of standards for nurses’
continuing professional development in simulated environments still seems to
be in the beginning.
5.1. Scenario design
“Rather than thinking of the healthcare organization as a conglomerate of units,

think of it as a system – a combination of processes, people, and other
resources that, working together, achieve an end” (Schyve, 2009). If this
“system” is adequately familiar to the instructors, it should be blueprint for the
scenarios designed.
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Most of the reviewed literature treats the training of students in preparation for
their new jobs, so the main goal is often to train procedures, that the trainees
get exposed to on a seldom basis (Bantz, Dancer, Hodson-Carlton, & Van
Hove, 2007). The content of training is furthermore often directed by the
flexibility of the available equipment (Morgan, Pittini, & Regehr, 2007).
It seems quite seldom (Blum, 2004), (Sittner, Schmaderer, & Zinnerman, 2009)
that instructors have the possibility to design courses in an evaluation based,
self-reflected manner in the sense of a tailor-made solution for the individual
branch of the organization (Musson & Helmreich, 2004).
Scenario designers must be careful about that, because “considerations for the
application of simulation in nursing education must, at the very least, include its
conceptualization beyond a single product or technology, lest that product or
technology become the concept itself” (Schiavenato, 2009).
Hicks, Coke & Li emphasize in their study, that “in addition to the need for high
equipment-fidelity, simulation requires psychological fidelity. This reflects the
degree to which the trainee perceives the simulation to be a believable
representation of the reality it is duplicating. Students may not take it seriously,
since mistakes or errors have no real consequences on patient safety”.
Psychological fidelity is also important to avoid negative transfer. “Negative
Transfer occurs if the students learns something incorrectly due to imperfect
simulation […], because the instructor fails to make clear to the students the
differences between these training device and the real situation” (Hicks et al.,
2009).
When designing a scenario one should also take into consideration, that every
single twist and turn causes workload for faculty and participants and is a
source of error during conduction (Jones, 2009). Every recognizable “logical
break” in the simulations’ reference to reality carries the risk of reducing the
effect of immersion.
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Instructors have to identify learning goals as a result of a thorough task analysis

(Hamman, 2004) and remember that the participants are said to sit on a “hot
seat”, because their faces are blushed by real vegetative stress responses.
One has to take into account, that although the simulated experience is unreal,
the participants’ reactions are real. Before and after the exposure there have to
be strategies to help people transform their emotional impressions to deepen
the learning experience (Arnold, 2009). This means that the “creation of an
environment in which trainees feel both challenged and psychologically safe
enough to engage in rigorous reflection” should be the mantra of all facilitators
“to allow trainees to explain, analyze, and synthesize information and emotional
states to improve performance in similar situations” (Rudolph, 2007).
5.2. Workload
“The goal for every session should be to promote a positive experience that
leads to better understanding” (Clapper, 2010). To facilitate a successful
experience it seems to be important to reflect on how adults learn. In synthesis
of “Knowles’s theory of andragogy and McClusky’s theory of margin, we would
be aware that they will be coming to the center with many other responsibilities
weighing heavily on their minds. Courses and simulation experiences have to
be timely, convenient, and accessible to ease the burden of moving to this
learning environment”, on the other hand we learn, “that overloaded adults will
do all they can, regardless of the load they carry, so long as they view those
activities as essential and meaningful” (Clapper, 2010).
That means that participants will give all their best, as long as the instructors
can facilitate useful learning experiences to improve practice. It also means that
you can design the scenarios as demanding as good as your skills are, in the
sense of linking the simulated experiences to the real world. Therefore it is most
important to use scenarios that match the participants’ skill level and learning
needs.
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5.3. Identification of learning goals
As the actual proof of effectiveness for simulation based learning is still missing,
it seems even more important to spend resources on the actual identification of
learning goals and how to represent them within a valid simulated environment.
“Clarity about the objectives of any educational exercise is essential, and the
choice of educational method should be informed by the particular
characteristics of the task in question, not by the fact that one happens to own a
simulator” (Merry, 2007).
As mentioned above course content is mostly defined by curricular aspects,

available equipment and last but not least the feasibility of research, as most
articles still try to deliver proof for effectiveness of simulation itself.
“Rather than a consistent theory or unified ideology leading to focused goals
and outcomes, we have a situation where the technology itself is fueling
application” (Schiavenato, 2009).
Other ways to identify essential learning goals would be to either to interview

potential participants, about what they are insecure or even afraid of, or take
part in their daily routine, just like Manser and Rall stated: “If the actions in the
simulator resemble the actions in the real OR environment (“behavioral
validity”), it`s much more likely that, for example, the results of research
conducted in a simulator setting or lessons learned in the simulator environment
will be transferable to the context of actual care” (Miller, 2009). All available
measurements should be undertaken to perform a sophisticated task analysis.
“This analysis is a detailed examination of the knowledge, skills, and attitudes

important to any given job or task. Task analysis results provide a detailed
blueprint of the competencies that guide the development of learning outcomes
and scenarios or the scenario selection process” (Guimond & Salas, 2009).
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Learning goals should be tied to CRM concepts (Dismukes, Jobe, & McDonnell,
1997) and therefore team-based, just as “professional sports team members do
not train individually and then get together only on game days; they train
together day in and day out so that they are prepared for the real thing”
(Kardong-Edgren, 2010).
5.4. Function of Pre-briefing and de-briefing
As we have seen, participants bring their own set of experience and also
expectations to their center and it maybe that quite a proportion of them is in
fear of the judging through educators and colleagues (Savoldelli, Naik, &
Hamstra, 2005). Thus the instructors have the ethical (Fanning & Gaba, 2007)
and andragogical (Clapper, 2010) obligation to create a safe and protective
atmosphere facilitating and promoting learning, typically during pre-briefing.
“This pre-brief period is a time, when the facilitator illustrates the purpose of the
simulation, the learning objectives, the process of debriefing, and what it entails.
It is the period when the participants learn what is expected of them and sets
the ground rules for their simulation-based learning experience” (Fanning &
Gaba, 2007). Additionally, as an instructor you must “clarify your role and detail
your expectations for crew participation. You should provide a persuasive
rationale for why the debriefing should be crew-centered and tell the crew how
long the session will last” (Dismukes et al., 1997).
Contributing to the high educational value, standards seem essential and the
aviation-based ACRM (Anesthesia Crisis Resource Management) is seen as
the global standard concept for application of simulated clinical experiences in
anesthesia. Therefore “the most important part of simulator training is the self-
reflective video-assisted debriefing session after the scenarios. The debriefing
is most strongly influenced by the quality of the instructor, not the fidelity of the
simulator” (Miller, 2009).
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Whereas the simulated part may take up to 20 minutes only, at least 45 minutes
of each session are assigned under “debriefing”. This accounts to the
circumstance that the actual learning from an experience seems to be triggered
by reflecting on the management of the incident in hindsight. “Like good
scenario design, effective debriefing can substantially enhance the pedagogical
impact of simulation-based practice” (Freeman & Salter, 2004).
In a study 42 anesthesia residents were, after completing a pre-test scenario,

randomly assigned to one of three groups receiving either no debriefing at all,
an oral one, or a video-assisted oral debriefing. The debriefing sessions were
guided by CRM principles and were focused on improvement of non-technical
skills. “Participants’ nontechnical skills did not improve in the control group,
whereas the provision of oral feedback, either assisted or not assisted with
videotape review, resulted in significant improvement. There was no difference
in improvement between oral and video-assisted oral feedback groups”. This
leads the authors to the conclusion that “exposure to a simulated crisis without
constructive debriefing by instructors, offers little benefit to trainees. The
addition of video review did not offer any advantage over oral feedback alone.
Valuable simulation training can therefore be achieved even when video
technology is not available” (Savoldelli & Naik, 2006).
5.5. The essence of debriefing
Once invented by the military and National Aeronautics and Space

Administration, (NASA) trainings in aviation seem to stay on stage as a role-
model for the implementation of such in both, medical and nursing continuing
education (Dismukes et al., 1997). The value of debriefing within the process of
simulation cannot be overrated, but seems to be too easily overlooked. Jones et
al. report from their first implementation of high fidelity simulation to support the
biannual nursing competency events. While handling the conduct of the
scenario at the first event, facilitators did not plan time for a debriefing. “The
importance of providing time for the debriefing was not fully understood.”
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This is underlined by the fact, that on the second occasion “unfortunately,

adequate time was still not available for a proper debriefing. In the process of
learning how to use the pedagogy of simulation correctly and foster a
collaborative relationship, planners unintentionally left out some important
items, such as debriefing. Given the time it takes to learn how to pick the right
scenario, program the manikin, and learn how to facilitate this type of teaching
pedagogy, some flexibility and patience with the process are required from all
parties involved” (Jones, 2009).
Debriefing techniques are often denied to be trainable, in the sense of

standardized transfer (Gaba, 2004), because “facilitation is very much a
personal skill and each instructor must develop an approach with which he or
she is comfortable” (Dismukes et al., 1997). Hence most of the authors see their
“facts” about the instructional design more as suggestions than as rules. This
seems understandable, as a “standardized terminology still needs to be
developed and accepted” (Decker, 2009). The essence of debriefing itself
seems to create a continuum, defined by the instructors’ “level of self-
awareness” and the “facilitator vulnerability” as a confounding factor, ranging
from those “who lecture and intimidate to those who have the ability to
transform” (Arnold, 2009). The debriefing person should rather catalyze than
analyze the process. One has to act in a very watchful and self-reflected way to
facilitate a successful debriefing, while remaining calm and friendly to the
participants. It`s not only important what the debriefer says, but also how it is
said.
Tone of voice, body language and other conscious and unconscious messages
may or may not invite trainees to share their state of mind with the other
crewmembers. “Their nonverbal language and the measure of their opportunity
for critical dialogue tell the story of the facilitator’s transformational abilities”
(Arnold, 2009). Input and topics should be generated by the crewmembers
themselves.
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Instructors should try to “keep the discussion crew-centered and encourage

crewmembers to participate actively and do most of the talking”. They should
not “lecture or make long speeches, or interrupt or leave a topic while the crew
has still something to say” (Dismukes et al., 1997). It seems, that silence is
golden, as facilitation “with minimal lecture-style”, is recognized as a marker for
debriefing expertise (Sweeney, 2009). Most important is to remain silent, while
the crew is reflecting on the questions asked. “Don’t answer for the crew when
they don’t immediately respond to your questions” (Dismukes et al., 1997).
When Dismukes et al. observed 36 debriefings of commercial airline crews they

reported, that quite often the addressed goals are missed, as “many instructors
did not engage trainees in setting the debriefing agenda or explain to them the
need to candidly and actively critique their own performance. Instructors asked
ineffective questions that did not elicit critical or insightful comments from
aircrew. Some abandoned facilitation in favor of lecturing to aircrew; they asked
little and talked a lot” (Freeman & Salter, 2004). In the worst case, lecture style
is mixed with humiliation. Rudolph et al. label this debriefing approach as
“judgmental”. On the other hand they identify the danger to “shy away from a
shame and blame approach to expressing their critical feelings and move
toward a nonjudgmental approach.
The central dilemma facing instructors who want to move away from this
judgmental approach is how to deliver a critical message while avoiding
negative emotions and defensiveness, preserving social face, and maintaining
trust and psychological safety”. Rudolph et al. propose to let participants
recognize and share their fundamental “frames”, in the sense of mental
presumptions leading to certain actions. Based on the “reflective practice
model” the authors introduce the “debriefing with good judgment approach” and
therefore combine “rigorous feedback with genuine inquiry” (Rudolph, 2007).
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As the value of simulated training is strongly connected to the quality and nature
of the debriefing, the design of the training is to follow the function of the
debriefing. Fritzsche, Leonard, & Boscia (2009) propose, as a result of a panel
discussion a classification of debriefing procedures by the way topics are
addressed and the way questions are formed. Furthermore this is a good
example how the participants’ attention and mood can be guided by the nature
of questions the debriefer uses.
Results of the panel discussion on how various debriefing styles could be

classified (Fritzsche et al., 2009):
1. Personal reactions – Nancy Leonard

€ What did you enjoy most about the simulation?
€ What did you enjoy least about the simulation?
€ How did you feel about participating in the simulation?
€ How did you feel about your interaction with your team members?
€ Why was (not) this a worthwhile activity in terms of learning? Enjoyment?
€ Why do you think the instructor had you work as members of groups?
€ What did you learn from this?
€ What personal long-term effects […] you may have gained from this
experience? What emotions did you experience as you participated in
the simulation?
2. Discussion of events – Phil Anderson

€ What were the main events of the simulation?
€ What decisions were you asked to make?
€ What were the differences between short-term and long term effects
(consequences) of your decisions in the simulation?
€ What do you predict they would be in real life?
€ What kinds of trade-offs or compromises did you make during the
simulation?
€ What trade-offs do you think would be necessary in real life?
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3. Discussion of problems – Dave Fritzsche

€ What problems did you encounter in making decisions or as a result of
your previous decisions?
€ What caused those problems?
€ Do the events, decisions and problems occur in real life?
€ Are the causes of the problems similar in real life?
€ What could you do to avoid these types of problems in real life?
4. Intended learning outcome – Marian Boscia

€ What did you learn that was new to you during this simulation?
€ What things that you already knew took on new meaning?
€ From what aspect of the simulation did you learn the most?
€ What did you learn?
€ What kind of connections among things you already knew did the
simulation create? What is about the simulation that caused this to take
place?
5. Links to the real world

€ Describe this simulation’s connections to (is it part of) a much larger
situation (company, industry, country, world).
€ In what ways did your decisions during the simulation affect the whole
simulation environment?
€ How did that make you feel?
€ What are some decisions you made that have not been tried in the real
world?
€ Why do you think that is so?
(Fritzsche, Leonard, & Boscia, 2004)
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5.6. Fundamental concepts for training
Conducting a simulation experience involves guiding the participants through

the process focusing on core concepts. According to Salas & Burke “trainees
who are given unguided practice often: Learn the wrong thing; do not focus on
practicing the right behaviors; may spend too much time on only one particular
aspect of training; may not be able to transfer the skills to the job.” (Salas &
Burke, 2002). Furthermore Salas & Burke emphasize the fact that “initial data
regarding [the effectiveness of simulation] are encouraging.” In contrast
“however, simulation is only a tool, and training developers and practitioners
must rely on the science of training to maximize the effectiveness of it. There
are known principles. Our recommendation is to apply them, and develop a
partnership with those who understand what it takes to design and deliver
effective training”. Remains the question, when guiding a group of participants,
which concepts are there to focus on in training and how are they applied?
5.6.1. Experiential Learning Theory
Experiential learning, different from cognitive learning, is seen as a valid

theoretical framework for the process of training in simulated environments
(Clapper, 2010). Developed by Kolb it “has its intellectual origins in the
experiential works of Dewey, Lewin and Piaget. […] Experiential learning theory
defines learning as the process whereby knowledge is created through the
transformation of experience. Knowledge results from the combination of
grasping and transforming experience.” (Kolb, Boyatzis, & Mainemelis, 2000).
Kolb developed the “four-stage learning cycle” in which “concrete experiences
are the basis for observations and reflections. These reflections are assimilated
and distilled into abstract concepts from which new implications for action can
be drawn” (Kolb et al., 2000). The simulated session delivers concrete
experience, whereas the following (video-assisted) debriefing enables
observations and reflections, which then, under the right facilitation, lead to
abstract conceptualization.
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As “health care education is much more formal and rank driven than other
disciplines and as “even in hospitals dedicated to teaching, patients in an
operating room are not there with the purpose of being a clinical teaching
resource for students”, simulated environments may allow educators to provide
a more personalized learning experience taking various learning styles into
account (McDonough, Loriz, & Macha, 2009), (McDonough & Osterbrink, 2005).
5.6.2. Situated cognition
Another theoretical framework is connected to simulation by Paige et al. The

authors propose “situated cognition as a more concise learning framework to
support and guide [simulation] in nursing education” (Paige & Daley, 2009). This
theory defines learning, as “occurring as a social activity incorporating the mind,
the body, the activity, and the tools in a context that is complex and interactive”,
meaning that learning happens through interaction with people and an activity in
a complex environment. Some prerequisites, like prior knowledge skills, should
be brought into the session by the participants, so that they can take full
advantage of the session. “Situated cognition is an alternative to other dominant
views of learning based on psychological learning orientations, in which learning
is an individual and internal mental process whereby knowledge is gained for
future use in any context. Within situated cognition it is presumed that
behaviorist skill-oriented and cognitive understanding-oriented principles are
present to provide a holistic platform that the learner draws from” (Paige &
Daley, 2009).
5.6.3 (Anesthesia) Crisis Resource Management
In the late 1970’s commercial airlines started to realize “that 70% of commercial
flight accidents stemmed from communication failures among crew members,
CRM sought to standardize communication and teamwork” (Leonard, Graham,
& Bonacum, 2010).
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Although the whole concept of CRM is distilled within 15 key principles, “almost
anyone who uses simulation to teach or reinforce teamwork or crisis resource
management (CRM, or Crew Resource Management) has encountered
students who say they altered their fundamental way of doing things and
working with their colleagues” (Cooper, 2004). Applying CRM in simulated
trainings as a core concept means “to tie CRM concepts and techniques to
operational issues” (Dismukes et al., 1997). This means, that the instructors as
well as the crew, should be able to identify, categorize and analyze CRM key
principles, when debriefing the simulated event. As a facilitator one could
prepare and send out an article as a pre-read, in the case the participants are
not yet familiar with CRM key points.
One of the main features of CRM is that it is there to avoid the crisis in the first
place, so its’ application begins before the crisis. Rall & Dieckmann define, that
CRM is there to “coordinate, utilize and apply all available resources to optimize
patient safety and outcomes”. The authors recommend to “think through the
principles and ask yourself for each key point (Rall & Dieckmann, 2005):
€ How does it apply to your job and work environment?
€ Which problems have you experienced in your work related to the key
points?
€ Which problems have you observed in other people’s work?
€ How could you improve that using the key point?
€ How did you apply the key point so far?
€ How could you improve your ability to use this key point?
€ What problems or obstacles could you face in your real world?”
When looking at the 15 key points of CRM in detail, there are multiple ways to
do so. It is obvious that the concept as a whole was created for application in
real practice to raise patient safety. However the method and theory implied is
mostly taught in simulation centers, so it could be that participants do not fully
transfer the principles to their daily life.
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Most important seems to state out that not the application of one of the
principles alone will save the patient from harm, but “fundamental, lasting,
outcome-altering organizational change cannot come with single interventions
of one type” (Cooper, 2004). Furthermore “using simulation to improve safety
will require full integration of its applications into the routine structures and
practices of health” (Gaba, 2004).
Without the full implementation of CRM within a clinical facility, the simulation
training cannot have full effect. It`s like a participant is somebody who went to a
foreign country, which was indeed interesting, but his (and his families) own
cultural progress will stay untouched from these exotic experiences in a trusting,
while cross-checking environment. CRM implies to speak up, when concerned,
no matter of hierarchy. “All too frequently, effective communication is situation
or personality dependent” and this seems, culturally-dependent, problematic.
According to Leonard, Graham, & Bonacum (2010) the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO) assumes, after analyzing
2455 reported events, that “the primary root cause in over 70% was
communication failure”. Minor misunderstandings in our daily life may seem to
be acceptable, but when talking about medical treatment or nursing
interventions, those misunderstandings can sometimes lead to fatal outcome.
CRM is primarily a method to standardize communication for incident
management to make sure that “everyone is in the same movie, and no
surprises” (Leonard et al., 2010).
Crisis Resource Management clearly addresses the so called non-technical

skills, consisting of “the cognitive and social skills required in any operational
task involving decision making and team work, such as aviation or surgical
medicine” (Flin, Fletcher, & McGeorge, 2003).
- 28 -
Flin et al. propose in their ANTS system (Anesthetists’ Non-Technical Skills)

four dimensions of behavior, which can be rated by observers:
1. Leadership & management

2. Teamwork & cooperation
3. Problem-solving & decision-making
4. Situation awareness
Each of the CRM key points can be seen as an integral piece of a puzzle, which
pictures an organizations’ cultural approach towards human factors, patient
safety and the management of critical incidents. There has to be a clear
commitment from all levels of the organization to minimize “power distances”
and other distracters, which keep people from saying “something’s wrong, I`m
not sure what it is, but I need you here now” (Leonard et al., 2010). So CRM is
not actually about memorizing 15 key principles by heart. It is rather about
“lowering the threshold to obtain help, and treating the request respectfully”.
Leonard et al. therefore propose the adoption of “critical language” models as
very effective. “[..] derived from the CUS program at United Airlines. CUS
stands for ‘I am concerned, I am uncomfortable, this is unsafe […] and is
adopted within the culture as meaning ‘We have a serious problem, stop and
listen to me” (Leonard et al., 2010) and is a very effective tool to be integrated
as a standardized cue for re-evaluation and, if needed, the initiation of an
emergency protocol.
- 29 -
5.6.4 The 15 CRM key points (Miller, 2009):
In the following all 15 key points are listed and briefly commented on how
factors can influence simulation and the following debriefing. A general
interpretation of the key principles is already formulated in many sources
including Rall & Dieckmann (Rall & Dieckmann, 2005).
1. Know the environment

Next to equipment and psychological fidelity, the environmental fidelity is the
third major component of simulation fidelity (Baubien & Baker, 2004).
Depending of the mobility of the systems available, participants either have the
chance to train within their familiar work surroundings or they have to move to
the simulator environment, the latter provoking that the trainees are not fully
able to “know the environment”. Therefore it is most important to plan enough
time for the introduction to the simulated environment. One should also make
sure that this introduction is structured and includes all important information to
the simulated workplace, including expected artifacts that derive from the
simulation itself, or signs and symptoms the participants would expect, but the
system does not show.
2. Anticipate and plan

In the debriefing all crew members should share their “mental-models” of the
situation (Dismukes et al., 1997), to make sure “that they are in the same
movie” (Leonard et al., 2010). One indicator could be, if they all shared the
same plan. If they were all aware of the next steps the team is going to
approach? If they were able to anticipate, which ways this incident could take?
Was there enough exchange of relevant information to “fly ahead of the plane”?
(Rall & Dieckmann, 2005). To guide the participants, when they are losing their
plan completely and for giving additional information that cannot be presented
by the mannequin, there can be a so called “voice-of-god” installed. It gives the
instructors the possibility to add feedback during the simulated session and
sometimes help the trainees to get back on track.
- 30 -
3. Call for help early

A call for help may never come too early, but as participants merely await a
critical incident to arrive, they may call for help immediately after the scenario
started. There should be a twist in the scenario design to hold help back with a
plausible rationale. Simulation is moving within its own time frame, but it should
be consistent with the real world conditions to increase psychological fidelity
and therefore overall simulation fidelity.
If the participants do not call for help at all, the facilitator should try to find out
more about the underlying frame to these actions (Rudolph, 2007) and maybe,
if appropriate, briefly address the fact, that “heroes are dangerous” (Rall &
Dieckmann, 2005).
4. Exercise leadership and followership (with assertiveness)

Medical emergencies are often managed by so called “temporary teams” (Flin &
Maran, 2004), meaning that the involved people at the site of incident can be
quite unfamiliar with each other. “In the aviation industry, accident analyses,
simulator research, and cockpit voice recordings revealed that unsafe flight
conditions were frequently related to failures in pilots’ non-technical (cognitive
and social) skills, rather than a lack of technical knowledge, flying ability or
aircraft malfunction” (Flin & Maran, 2004). Concerning social skills, the way
hierarchical matters are approached seems to play an important role (Leonard
et al., 2010).
Power-distances very much define the way critical information is communicated

(Leonard et al., 2010). During debriefing make sure, that the lowest-in-
hierarchy is first to go, so that this input is not biased, “by what the captain said”
(Dismukes et al., 1997). Leadership and followership are most critical aspects of
teamwork. Power-distances may lead to breakdown in communication (Phillips,
2009). Such topics are sometimes difficult to debrief, because they are strongly
connected with how the “role of the leader” is socially constructed from an
individual and organizational level, meaning how the leader is legitimized
(Weber, 2006).
- 31 -
5. Distribute the workload

Leadership includes trying to keep an overview over the situation. So the leader
should primarily distribute workload, directly engaging only in some tasks. The
leader is for example not supposed to do exhausting chest compressions.
6. Mobilize all available resources

When jobs are being done in the OR or on the ICU, providers act as
professionals, who exactly know what is going on. They are supposed to act
and react accordingly to the patients’ status. When an emergency situation
arises, there often seems to be a threshold to inform other people that “your”
patient is in trouble. This can be observed, when the (instructed) surgeons,
who chronically lack of information about the patients’ vital parameters, ask if
the patient may be in trouble and the anesthesia team responds unanimously,
that everything is correct, no matter, with which situation they are confronted.
This can be a good hook for a debriefing-point that using all resources does not
mean, that the teams’ performance is weak and that there is nothing to be
ashamed of. The priority must be that there is nothing left undone to help the
patient.
7. Communicate effectively
Communication is the central aspect of CRM, because it is the means of
transportation for most of the other tasks. Information is passed on by
communication between team members, workload is distributed and resources
are mobilized that way. Communication can be seen as the “backbone” of CRM.
To standardize communication is the main aim of CRM. It is apparent, that
stress, especially the one of an emergency situation, affects our sensorium, so
that “normal” communication is endangered. Under the influence of stress
people tend to overhear each other, so in CRM it is sought to “close the loop”,
meaning that the sender of a message makes sure, that the content of the
message is received, understood and considered. “Meant is not said, said is not
heard, heard is not understood, understood is not done” (Rall & Dieckmann,
2005).
- 32 -
8. Use all available information

This key point is also closely related to communication. Information intake is
merely communicating with the environment, while filtering relevant signals
which contain: monitoring, mannequin, voice of god, (instructed) surgeons,
relatives on phone.
9. Prevent and manage fixation errors

Fixation occurs within simulated as in real situations. Rall & Dieckmann
differentiate between three different types (Rall & Dieckmann, 2005):
1. “This and only this!”

Some fixation errors are hard to handle when debriefing, because the
participants seem to believe that abnormal or unexpected behavior is to be
seen as a simulation artifact. Instructors wait to see the participant react to a
meaningful stimulus, but the participant simply ignores that (e.g. loss of
available data, defective equipment).
2. “Everything but this!”

This type of fixation can be observed, when participant seem not to grasp what
to treat. They see the signs and symptoms and maybe even the right diagnosis
comes to their mind, but they somehow do not want to realize, that it is really
the worst-case happening, but the participants seem to exclude this possibility
specifically for no reason, but fixation.
3. “Everything is o.k.!”
When all the alarms keep ringing or are constantly pushed away without any
visible reaction, the participants might have got stuck with their mantra of
“everything is ok!” No matter what, the patient is safe and there is no need for
action. For this and all the other cases of fixation, meaning the team cannot
establish productive effort to save the scenario, there should be scripted
“scenario life-savers”, that either let the instructed actors or the instructors
themselves interfere and give cues.
- 33 -
10. Cross (double) check

One of the main symptoms of an organizations’ safety culture is the way control
mechanisms are perceived, valued and implemented and how cross-checking
each others’ work is accepted. A “safety attitude” should be part of any
simulated training, so that team-members can realize, that it is actually a good
thing to supervise each other in a fear-free environment.
11. Use cognitive aids

Due to the dynamic settings participants will probably not be able to use aids
extensively, but you can make sure that there is a calculator in the simulator
and debrief on why/why not the participants used it. Whenever it is part of the
scenario to grade the patients’ status, make sure that adequate score tables are
available and applicable within the simulated environment. One could also
prepare on water-proof cards, containing the 15 key principles of CRM, as a
take-home.
12. Re-evaluate repeatedly

Crisis Management is a dynamic process as the situation progresses
constantly. Decision-making is an integral part of this process, as the patients’
situation keeps demanding them. Even to do nothing should be a conscious
decision in the context of emergency action patterns. Sometimes it is to be
observed that the teams fall into a kind of “blind activity”, without any basic
overview or major plan. To avoid this gap of “doing before thinking” Rall et al.
developed the 10-seconds-for-10-minutes principle, whereas it says, that the
team should take its’ time to evaluate the situation and inform all the team-
members about the planned action. After at least ten minutes the team gets
together for re-evaluation of the scenario and appropriate adoption of the teams’
plan (Rall, Glavin, & Flin, 2008).
- 34 -
13. Use good teamwork

Salas et al. see, as a condition, that “simulation for training is effective when the
simulation contains opportunities for assessing and diagnosing individual or
team performance” (Salas & Burke, 2002). Crew interaction, during and after
the session, should be used to reinforce CRM. The participants should address
each other directly and discuss how they were affected by each other`s action.
Facilitators should “push the crew to go beyond just describing what happened”
(Dismukes et al., 1997).
14. Allocate attention wisely

As opposed to the commonly accepted myth it has to be shown that the multi-
tasking ability of either male or female is very limited. Whenever a situation
turns to be overwhelming, because there is sensory overload or many actions
are to be done at the same time, there is a tendency to concentrate and focus
on details. The amount of concentration we are able to invest is limited by
attention, so it seems useful to remember, that there might be things happening
out of focus, so it is good to have a routine in paying attention to the
“peripherals” as well. All team members should think about that, especially
when passing on vital information.
15. Set priorities dynamically

All of the team members should understand that the environment in emergency
situations is dynamic and so are decisions to be made. There has to be some
“tolerance to frustration” caused by change and adaption of the major plan.
Priorities most often change and sometimes it can be observed that team
members reduce themselves to mere operative functioning without sharing their
model. In the beginning of the scenario they might by eagerly engaged, but as
soon as another person turns out to be the leader and has ignored or overruled
some decision proposed, the primarily motivated team member steps back, so
that the leader can handle the case.
- 35 -
Under no circumstance should the leader nor any of the team-members be

supposed to lose assertiveness and they shall keep communicating actively and
passively all along the duration of the incident. This can be a good debriefing
point, as to ask how the leadership questions were handled under the influence
of the dynamically changing environment of the simulation.
5.6.5 Situation – Background – Assessment – Recommendation (SBAR)
SBAR stands for situation, background, assessment and recommendation and

can be used as an effective tool for standardizing emergency communication
(Leonard et al., 2010). The authors see a gap between communication cultures
of physicians and nurses, as physicians often expect a clear and concise
statement on the patients’ condition, if not some diagnosis. The nurses in
contrast have a more holistic approach and rather “seem to paint the big
picture” (Leonard et al., 2010).
This difference may somehow lead to minor misunderstandings, which should

be avoided. SBAR could reduce this gap by standardization of the
communication protocol for emergency situations. Leonard et al. also state, that
experienced personnel often has a “feeling” for something being wrong with the
patient, without having the precise words for what is happening. It is presented
and recommended and multiple sources (Haig, Sutton, & Whittington, 2006).
Situation:
The description of the situation should explain what happened and triggered the
emergency protocol: “The patient collapsed!”
Background:
Quickly drafts the patients’ history, like relevant preexisting conditions: “He`s is
a 45 year old diabetic Type II.”
- 36 -
Assessment:
Consists of what signs and symptoms does the patient present now? “He is
unconscious, but still breathing and I can feel a pulse.”
Recommendation:
Are there any suggestions on how to progress? “We should measure the
patients’ blood pressure and blood sugar. We could stabilize his position or lift
the legs of the patient to raise the blood pressure.”
5.6.6. Stop-Procedures
Within all of the single interventions and concepts to raise patient safety, none
has proven as effective as setting standardized “stop-procedures” at certain
critical points during the operational procedure, like proposed by the World
Health Organization. Before induction of anesthesia, before skin incision and
before the patient leaves the OR the whole team stops the routine tasks to
verify certain aspects following a standardized check-list. This makes sure,
more than any else single intervention, that “everybody is in the same movie,
and no surprises” (Leonard et al., 2010). It is also a good example, that training
on a sole basis will not affect patient safety very likely, but that in a simulator
new and innovative approaches can be blended with tried and true principles to
create an adequate safety culture in an explaining environment.
- 37 -
6. Conclusion
From the learner feedback we received at the PMU simulation-based

anesthesia and intensive care CRM courses, we learned that “it’s very realistic”
and that “the stress is real”. One participant stated it like this: “I never learned
so much in a day”. They valued very much the “non-punishing atmosphere” and
that there was finally “a chance to make mistakes, and learn from them”. So,
after considerable effort we seemed to now be conducting useful simulation
learning experiences. Peter Dieckmann, an organizational psychologist spoke
at the annual symposium of SESAM (Society in Europe for Simulation Applied
to Medicine) in 2009. He suggested we should: “Think of a dancing bear.
People are not excited about the fact, that the bear is dancing so graciously, but
the fact, that he is dancing at all.”
Although those who conduct simulation may like to hear from participants, that
they liked the simulation experience, the question remains: How do they go on
from there? Did they really grasp the concepts we want them to apply? What
about CRM? Are they going to close the loop? What happens the first time they
hear, that they sounded like parrots, when repeating orders? Could the
participant really raise his/her level of confidence/assertiveness? Will they have
the possibility to speak up, when concerned? At this point there are no firm
answers to such questions.
Establishing a simulation center is easy. All that is needed is money to

purchase equipment and space. However, when one arrives at the steering
wheel of a physiologic based full-scale human patient simulator, trying to handle
the system, guide participants and actors, while looking out for good debriefing
points, one may well soon realize, that this can be a difficult and demanding
undertaking. In the debriefing itself one may find out, how well the scenarios fit
to the learning needs and reality of the participants on one hand and to the
application of CRM principles on the other.
- 38 -
As the word “training” implies, this has to be a repeated process to have lasting
impact on daily practice alongside with changes in the organizations’ safety
culture and approach to errors. Simulation cannot fulfill all the hopes it is
brought to, but maybe in combination with all the other measurements, like
stop-procedures, checklists, Critical Incidents Report Systems, awareness of
Human Factors and so on, it could be, that one day hospital care will fulfill “six-
sigma” criteria, meaning that only one in a million goes wrong.
Projecting the pace of technological advance into the future, it seems

reasonable to predict a further progress in the fidelity of simulation. Facilitators
and simulation theorists are called to keep up with this pace in developing
profound frameworks that, combined, will eventually help to define a unified
theory of simulation in health-care to let teams train together interprofessionally
on an evidence based, standardized protocol in a less threatening, but more
empowering and self-reflective environment. With the successful
implementation of simulation based Crisis Resource Management (CRM)
training in aviation in mind, there is no valid excuse for hesitating over the
implementation of similar measurements to train nurses, as well as all other
health care professionals who might get involved in critical incidents.
- 39 -
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- 44 -
Erklärung
Hiermit erkläre ich, dass ich die vorliegende Arbeit selbstständig und ohne
fremde Hilfe angefertigt, sowie die verwendeten Quellen und Hilfsmittel in
einem vollständigen Umfang angegeben habe.
Ort, Datum Unterschrift
- 45 -
Appendix - Internet resources for simulation
http://sirc.nln.org/ . Simulation Innovation Resource Center
http://www.nursingsimulation.org/ - Clinical Simulation in Nursing
http://www.harvardmedsim.org/ - Center for Medical Simulation
http://www.med.stanford.edu/VAsimulator/ - Virtual Anesthesia Pat.

Simulation
http://www.socmedsim.org/ - Society for Medical Simulation
http://www.inacsl.org/ - Int. Nursing Association for Clin. Nursing

Simulation
http://www.mayo.edu/simulationcenter/ - Mayo Multidisciplinary

Simulation
http://www.simulatorcentrum.se/ - Karolinska Univ. Hospital Medical

Simulation
http://www.d-i-p-s.de/Tupass2008/ - Institute for Patient Safety, Tübingen
http://www.bmsc.co.uk/home.htm - Medical Simulation Center, Bristol
http://www.simulation.ch/ - Univ. Hospital Sim Center, Basel
http://www.pmu.ac.at/en/1320.htm - Medical Simulation Center, Salzburg
http://sirc.nln.org/mod/glossary/view.php?id=282 – List of Sim Centers
http://www.meti.com – Manufacturer of simulation systems
http://www.laerdal.com/ - Manufacturer of simulation systems
- 46 -

Why and How To Train Anesthesia and Intensive-Care Nurses in A High Fidelity Simulated Environment?

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3. What is simulation in health-care? ............................................................. 7

4. Why train anesthesia and intensive-care nurses? .................................. 11

5. How to train nurses in a simulated environment? .................................. 15

Appendix - Internet resources for simulation.............................................. 46

After a short background update on human factors, safety and error

The question is not, if functioning planning is needed for proper crisis

Other high-hazard industries already apply team-training as a required

It targets either faculty, planning to implement simulation within their nursing

One goal of this review is to raise awareness concerning human factors in

Another goal of this review is to show, that the successful accomplishment of an

3. What is simulation in health-care?

The Latin word “simulare” means to pretend or counterfeit. The Oxford

3.2. Levels of fidelity

Medium-fidelity simulation implements interactive and dynamic elements to

Although this review is focused on high-fidelity simulation, there is a trend of

As we have seen, high-fidelity simulation systems always process vital

Figure 1. Schematic drawing of the setup for video-assisted high-fidelity

3.3. Model-based vs. On-the-fly

3.4. The effect of “immersion”

Whenever participants experience high-fidelity simulation, the goal should be to

As a conclusion the authors support the view that “immersion in a simulation

4. Why train anesthesia and intensive-care nurses?

In a team-based inter-professional approach, as we experience in most clinical

4.1. Nurses as professional experts

In this highly demanding environment of a modern Intensive Care Unit or an

4.2. Nurses as adult learners

4.3. Nurses as team members

In a blaming environment within the boundaries of clinical expectations, this

The question is how we successfully organize all available resources, not

If any of the teams’ limitations remain unapproached, their plan as a whole

5. How to train nurses in a simulated environment?

“Less is known about simulation in nursing education than is implied by its

It would seem that, nurses’ continuing development through means of

5.1. Scenario design

“Rather than thinking of the healthcare organization as a conglomerate of units,

Instructors have to identify learning goals as a result of a thorough task analysis

5.3. Identification of learning goals

As mentioned above course content is mostly defined by curricular aspects,

Other ways to identify essential learning goals would be to either to interview

“This analysis is a detailed examination of the knowledge, skills, and attitudes

5.4. Function of Pre-briefing and de-briefing

In a study 42 anesthesia residents were, after completing a pre-test scenario,

5.5. The essence of debriefing

Once invented by the military and National Aeronautics and Space

This is underlined by the fact, that on the second occasion “unfortunately,

Debriefing techniques are often denied to be trainable, in the sense of

Instructors should try to “keep the discussion crew-centered and encourage

When Dismukes et al. observed 36 debriefings of commercial airline crews they

Results of the panel discussion on how various debriefing styles could be

1. Personal reactions – Nancy Leonard

2. Discussion of events – Phil Anderson

3. Discussion of problems – Dave Fritzsche

4. Intended learning outcome – Marian Boscia

5. Links to the real world

5.6. Fundamental concepts for training

Conducting a simulation experience involves guiding the participants through

5.6.1. Experiential Learning Theory

Experiential learning, different from cognitive learning, is seen as a valid