|Year : 2015 | Volume
| Issue : 1 | Page : 17-21
Development of simulation curriculum in postgraduate programs
Hani Lababidi1, Fadi Munshi2
1 Department of Academic and Training Affairs, King Fahad Medical City; Department of Medical Education, College of Medicine, King Fahad Medical City, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Medical Education, College of Medicine, King Fahad Medical City, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
|Date of Web Publication||4-Feb-2015|
King Fahad Medical City, P. O. Box: 59024, Riyadh 11525
This paper outlines the primary steps required in developing a simulation curriculum. We examine forms of simulation in postgraduate training, instructional design models, learner assessment, and modular pattern of postgraduate simulation curriculum. Further, we provide examples of how each of these components are practically described in the literature and applied at the Center for Research, Education, and Simulation-Enhanced Training.
Keywords: Curriculum, postgraduate, simulation, training
|How to cite this article:|
Lababidi H, Munshi F. Development of simulation curriculum in postgraduate programs. J Health Spec 2015;3:17-21
| Introduction|| |
Simulation-based education (SBE) is gaining great momentum in medical education. The use of various forms of simulation can provide an effective and safe learning environment.  There are several factors driving SBE; these include a shortage of clinical training sites to accommodate the increasing numbers of medical students, patient safety and the greater efficiency of SBE.  Medical simulation has been recommended as a method to bridge these educational gaps.  The effectiveness of SBE in teaching procedural skills, communication, teamwork, and other proficiencies has been demonstrated in multiple studies of undergraduate and postgraduate medical education.  SBE has been integrated in the undergraduate curriculum as early as the 2 nd year of undergraduate medical studies for teaching fundamental clinical skills and procedures.  The postgraduate medical education is even a more worthwhile setting for SBE given the plethora of new skills, technologies, and procedures that are introduced on a regular basis. Nevertheless, to reach the best outcomes, SBE in postgraduate training should be part of a structured curriculum rather than periodic courses and interventions. In this article, we describe the approach to develop simulation curriculum for postgraduate medical training. Specific examples about our experience at the Center of Research, Education and Simulation-Enhanced Training (CRESENT), King Fahad Medical City in Riyadh, Saudi Arabia will be illustrated.
| Forms of simulation in postgraduate training|| |
There are multiple forms of simulation that can be used in postgraduate training. In addition, more than one form of simulation can be combined in one module depending on its objectives, target population, and availability of simulators. A fundamental characteristic of any simulation activity is its fidelity level. Fidelity is defined as the believability, or the degree to which a simulated experience approaches reality; as fidelity increases, realism increases. There are different factors that determine the level of fidelity; these include: The environment, the tools and resources used, and many factors associated with the participants. Fidelity can involve a variety of dimensions, including:
Of note is the difference between high fidelity and high technology. These two terms are not at all synonymous. For example, simulating an extraction of a sick patient from his or her bedroom for emergency medical services training, this scenario can be made of high fidelity by replicating the bedroom's physical environment, having background sounds of a television or radio, and even spraying special smell to engage more senses. At CRESENT the common simulation modes we use for postgraduate training in order of popularity include.
- Physical factors such as environment, equipment, and related tools;
- Psychological factors such as emotions, beliefs, and self-awareness of participants;
- Social factors such as participant and instructor motivation and goals;
- Culture of the group; and
- Degree of openness and trust, as well as participants' modes of thinking. 
Part-task trainer based simulation
This form of simulation consists of either ready-made models designed to simulate a specific task or procedure, or improvised models made of easily available items that can closely mimic human tissue and allow for near replication of actual procedural steps. They are used for repeated practice of technical skills. Some of these devices may be used for self-guided teaching with validated metrics. Examples of readily available models include a forearm for practicing intravenous cannulation, airway models for intubation skills [Figure 1], and synthetic skin pads for practicing suturing. However, examples of improvised models include chicken bone for practicing intraosseous needle placement and cow bone for practicing skull drilling [Figure 2].
Manikins based simulation
This kind of simulation uses full or part-body manikins to create a patient case or scenario. Most of the manikins used in postgraduate medical training are of high fidelity/high tech type [Figure 3]. They can replicate situations with heart and lung sounds, palpable pulses, voice interaction, monitor vital signs, movement (e.g., seizures, eye blinking), bleeding, blood flushback with intravenous insertion, and other realistic human events. They may model the effects of pathological states and pharmacological interventions as well. Computers or tablets are usually utilized to control this kind of manikin.
Standardized patient based simulation
This type of simulation uses subjects who are trained to act as a real patient in order to simulate a set of symptoms or problems used for healthcare education, evaluation, and research.  Standardized patients (SP) are sometimes called "patient actors" and "simulated patients." SP's are utilized in our center for the Objective Structured Clinical Exam, communication skills, Advanced Trauma Life Support and ultrasound simulation courses [Figure 4].
This mode of simulation relies on computer software that can simulate clinical settings. It can have different formats such as simple interactive clinical cases, advanced virtual reality (VR), and three-dimensional simulation and training environments. At CRESENT, we utilize VR for bronchoscopy, endoscopy, laparoscopy [Figure 5], endovascular [Figure 6], neurosurgery, and robotic surgery training.
|Figure 5: Virtual reality simulators for endoscopy and laparoscopy training|
Click here to view
| Instructional design models in simulation|| |
A simulator is a means for training, but it on its own does not train. The way in which a simulator is used yields the benefit. Drown and Mercer stated "It is easy to be impressed by the latest, largest full-mission simulator, but what is more important than the technology is how the educational methodology is applied and whether it increases training effectiveness significantly, incrementally, or at all."  Therefore, instructional model designs enable the designer of a simulation curriculum to understand the essential structural components. The models break down the components into discrete, manageable units.
Instructional Systems Design (ISD) is a term used to describe the systematic process used for planning the delivery of training to the learner.  The process includes the assessment of learning needs and the development of learning materials. Examples of ISD models are Analysis, Design, Development, Implementation and Evaluation (ADDIE) as well as the Dick and Carey models. , A fundamental approach widely used from this category is ADDIE; [Figure 7] illustrates the five phases of the ADDIE model.
The ADDIE model encompasses a linear process that is criticised as being costly and time-consuming. These disadvantages led to the development of innovative approaches such as the Successive Approximation Model, which follows the newer fundamental approach to ISD and Agile Learning Design (ALD).  ALD is an approach to learning development that focuses on speed, flexibility, and collaboration or "rapid prototyping." The basic idea is to receive continuous formative feedback during the design of instructional materials. This process can lead to resolving problems while they are still at an early stage and soluble, which may save time and money.
At CRESENT, we are currently using the ADDIE model in postgraduate curriculum development; nevertheless, we are also experimenting with the three-step approach for efficacy and speediness. The initial request to develop a simulation course starts with a request from the owner or champion of the course. During the analysis phase of an ADDIE model, the coordinator recognizes the learner's needs, the learning problem and what are the possible solutions for the problem. In the design phase, the learning objectives are constructed; it is at this stage where all stakeholders will agree on the course content. It is wise to define between 3 - 5 objectives only and try to make them as specific as possible. Outlining the instructional goals follows this and the way the simulation course will be presented. We involve the simulation technicians heavily in the development phase. During this phase, the mode of simulation is defined, and all learning materials and supporting documents are produced. Checklists and testing matrices are created as well throughout this phase. The implementation of the simulation course occurs in two stages. The initial pilot enactment is fully recorded for analysis and feedback. Alterations and tweaking are made to the course after reflecting on the pilot course, and then the course is implemented on a larger scale. Finally, it is the evaluation or assessment phase that will be detailed in the next section.
| Assessment of learners in simulation|| |
Assessment drives learning as learners usually study in a manner that best matches the requirements of testing.  Assessment can serve summative or formative purposes. Summative assessment is for pass/fail decisions while formative (feedback) is mainly for learning purposes.
There is no single assessment tool that is inherently "better." The preference of one assessment method over the other is based on the context and purpose for which it is utilized.  In choosing the appropriate type of assessment method, critical consideration should be given to:
The latter two assessment components are more crucial in summative high stake exams.
- Purpose of assessment (summative or formative);
- Matching assessment with intended objectives and goals of simulation;
- Psychometrics of the assessment tool (reliability and validity); and
- Standard setting. 
Three main sources of assessment are used in SBE.  The most common are observational ratings. Examples of observational ratings include the Simulation Team Assessment tool, Situation Background Assessment Recommendation tool for ensuring uniformity in communication within team simulated training, and the Just-in-Time Pediatric Airway Provider Performance Scale. ,, The second method of gathering outcome data is trainee responses. Trainee responses may be in the form of selected responses like multiple-choice questions or constructed answers like prescribing a medication. The third method of performance-based assessment in SBE is data measured by haptic sensors. Simulators record trainee procedures accuracy by sensors placed at certain anatomical sites. The later method is promising since it allows an objective computer-generated evaluation. It can be used as self-assessment tool as well. An example is the skills assessment for laparoscopic surgery training where the model was able to separate between different levels of expertise. 
| The modular pattern of postgraduate simulation curriculum|| |
There are many skills and competencies that residents and fellows can be trained on using SBE. The ultimate comprehensive simulation curriculum in a postgraduate medical specialty or subspecialty is a constellation of these simulation modules. SBE should not be based on lecturing and didactic teaching; rather it is centered on hands-on learning. Thus, the trainees need to have prior knowledge about the skills or tasks to be demonstrated during the course. The characteristics of the modular pattern of a simulation curriculum include.
Generic versus specialty modules
Generic modules can be used in more than one postgraduate curriculum without any structural modifications. While, specialty modules are specific for a certain specialty or specialties. Examples of generic modules would be "breaking bad news" or communication skills modules. These modules can be inoculated in any postgraduate curriculum for residents, fellows, and other healthcare givers. On the other hand, an example of a specialty module is the basic course for laparoscopy, it can be taught to general surgery, urology, or gynecology residents. Another example would be central line insertion under ultrasound guidance course that can be administered to emergency medicine, anesthesia, internal medicine, and surgery residents.
Level of complexity
The sequential postgraduate curriculum covers three main areas, namely knowledge acquisition, technical skills and judgment.  However, in each individual area, the level of complexity of the module can vary with the level and maturity of the postgraduate trainee. An example is airway management for anesthesia residents. Several modules can be constructed round the same theme with a gradual increase in complexity levels. It can vary from simple laryngoscopy skills to bronchoscopy intubation, and in terms of team scenarios from "can ventilate, can intubate," to "can ventilate, can't intubate" and finally to "can't ventilate, can't intubate" cases. Modern psychometric models like Rasch analysis can be applied to statistically assess task difficulty. This can help when designing a complexity continuum for a specific module.
Core versus noncore modules
Core SBE modules are mandatory or required modules for promotion from one postgraduate training year to another. While noncore modules are SBE that are available for interested trainees as elective courses. It is imperative to have the capacity for the core modules before classifying them as such. An example is the pulmonary core curriculum that was established by CRESENT for the Saudi Commission for Health Specialties. This curriculum includes five core modules: Basic bronchoscopy, advanced bronchoscopy, mechanical ventilation, lung and pleura ultrasound, and cardiopulmonary exercise testing. A noncore module in this curriculum is the airway management course.
Intra-versus inter-modular adaptability
The postgraduate SBE modules need to be flexible from within and in relation to each other. There are new tasks that are added to the armamentarium of skills a postgraduate trainee needs to acquire in a specific specialty. Thus, the SBE modules need to be adapted to these evolving procedures and technologies; this is especially true in surgical subspecialties. Moreover, a change in one module may affect other modules in the curriculum, hence, the need for inter-modular adaptability. We recommend a maximum of 2 years duration for revisions of postgraduate curricula.
| Conclusion|| |
Simulation-based curriculum development for postgraduate training presents a real challenge in many aspects. A thorough understanding and expertise in medical education theories and medical simulation are prerequisites for effective construction of such curricula. The modular approach in postgraduate SBE curriculum development is a practical way to achieve acceptable and satisfactory results. There remain many areas for future research in this field, such as effective assessment methods, acceptable competency levels, skills' acquisition, and maintenance rates and outcome measures.
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