Multidisciplinary simulation for patient safety training: putting human factors theory into action (Neuhaus)

Simulation to educate practitioners

Around 30 years ago, medicine started to explore the use of simulation to educate practitioners about human factors.269,270 Modelled after experiences from the aviation industry, training programmes were created to address various cognitive and social competencies that were identified as, or presumed to be, relevant and essential for the safe provision of peri-operative care. These oftentimes called ‘nontechnical skills’ (NTS) were meant to complement traditional skill-based medical education, and their training concepts resemble evolutions of the initial ‘Cockpit Resource Management’ programmes in the aviation industry.271–273 Subsequently, more differentiated frameworks such as ‘Anaesthesia Crisis Resource Management (CRM)’ or ‘Emergency Medicine CRM’ have emerged over the years.269,274 Initially, simulation-based training programmes were established for emergency teams (e.g. trauma teams or cardiac arrest teams). Later the benefit of training healthcare professionals in recognising and treating the critically ill patient on the internal medicine or surgical ward has been recognised.


It is important to note what almost amounts to an amalgamation in terminology in regard to human factors interventions. Significantly, the terms ‘CRM’ or ‘CRM training’ have become often-used synonyms for a multitude of training concepts. While not automatically tied to simulation, most human factors training programmes in health care today employ both high-fidelity and low-fidelity simulation to teach and train CRM principles.275,276 Moreover, a certain overlap exists between the terms NTS and CRM, to the point where the original authors talk about ‘NTS/CRM training’ (for further information, refer to Table 14).277 One explanation lies in the fact that both terms can describe general areas of interest for human factors research. NTS has been defined as ‘the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance’.277 The NTS encompass the cognitive skill areas ‘situation awareness’ and ‘decision-making’ as well as the social skills ‘communication’, ‘cooperation’ and ‘leadership’. Behavioural marker systems have been developed for a wide variety of healthcare specialties like Anaesthetists’ Non-Technical Skills (ANTS) or Non-Technical Skills for Surgeons, but have also been adapted for certified anaesthesia nurses (N-ANTS) and operating room nurses (SPLINTS).278–281

Table 14: Comparison of elements in the anaesthesia nontechnical skills system and the crisis resource management system282

Application and effect

Over the last 25 years, simulation-based CRM training in health care has raised awareness about the influence of human factors in medicine, and generally contributed to positive attitudes towards patient safety and CRM training.282,283 As a speciality, anaesthesiology has been at the forefront of developing and promoting simulation-based education for the development of clinical skills and improved teamwork, as well as disseminating human factors and quality improvement science.284

The basic didactic concept of simulation-based medical education is that participants engage in a pre-scripted scenario that is managed up to a predetermined endpoint. This is followed up with a debriefing session facilitated by trained faculty, often supplemented with audio/video recordings, to promote reflection and feedback among the participants.285 If managed well by the instructing staff, the ensuing interaction between participants, as well as emotions spurred by the simulation, can be harnessed to enhance learning and increase training effectiveness. While different debriefing techniques exist, one cannot overemphasise the importance of high-quality standards and professional development of the debriefing faculty: instead of mere teaching, their role is to promote learning by stimulating critical self-reflection among participants and steer their discussion while striking the fine balance between the delivery of constructive critique and the maintenance of psychological safety.282,286

While simulation as a training modality can take on many different forms (e.g. full-scale simulation of clinical environments, role play, standardised patients), it has been shown to be incorporated in roughly 2/3 of team training programmes.275 The basic assumption is that simulation can offer a sufficiently realistic yet safe learning environment in which stress, ambiguities, time-pressures and goal conflicts of daily practice are mirrored, and where new skills, behaviours and strategies can be experienced and trained without endangering the patient.271 In addition, critical situations that cannot be trained in the clinical setting, such as anaphylactic shock or the unexpected difficult airway, can be trained in the simulated setting. While not exclusively tied to positive training effects or a measurable reduction in mortality and morbidity, results indicate that simulation can greatly supplement and enhance the effect of training programmes.287 The most sensible approach seems to be one where simulation training is incorporated into a broader curriculum for residents in training and for healthcare teams to achieve sustainable results. Effect of simulation-based training on learning is easier to show at the individual level than on the team level, even though behavioural marker systems have been developed for specific teams (e.g. Observational Teamwork Assessment for Surgery).282 Ideally, simulation training is coupled with further peer support and learning opportunities during daily practice to build a comprehensive bundle design supporting a systems-based approach to patient safety.287 As a sufficiently large amount of proof-of-concept studies (as in ‘does simulation work?’) has been published, researchers are advocating for a shift towards more granularity as to how and why simulation has certain effects.276

More recently discussed issues concern the specific design principles regarding multidisciplinary simulation in an effort to maximise its utility and effectiveness. Heavily intertwined are questions about the influence of the setting, which can be either in situ in the actual work environment or off-site in a simulation centre. Moreover, training concepts have started to incorporate unannounced in situ ‘drills’ to complement traditional, scheduled training interventions.288,289 In a comprehensive review, Sþrensen et al.290 recently compiled and discussed various advantages and disadvantages of different training designs (Table 15). From a learning perspective, announced in situ simulation is more favourable than unannounced. However, one key characteristic of any type of simulation-based education remains the clear definition of learning objectives at the individual, team, and organisational level.291 This is of utmost importance in a multiprofessional setting, where a multitude of curricula have to be aligned, and different participants from various specialties need to be included in a simulation scenario.292

Table 15: Influence of various aspects of simulation-based medical education on the physical simulation setting (from 288)

Limitations and criticism

While favourably received in general, several issues have been critically appraised in the literature with regard to multidisciplinary simulation training. One issue concerns technical limitations and their possible effects on participants and their learning experience. Another addresses the reality of limited resources in medical education: it has been questioned if profound weaknesses that are discovered in training can be adequately reviewed, given their ensuing potential professional and psychological consequences, or are likely to be glossed over.293 There is clearly a need for preparing the participants as thoroughly as possible for the simulation-based training using e-learning, video or written material as well as developing initiatives that can facilitate the implementation of learning in daily tasks. From a financial perspective, it remains to be determined which educational activities can be stopped if simulation-based training is finally implemented.

In a critical review, Salas et al.294 point out a lack of standardisation of human factors content across various domains, which is potentially confusing for practitioners if not carefully adapted to the respective setting and speciality. A review on the impact of CRM training by the same researchers could only find partial support for its effectiveness: there seems to be a limited influence on teamwork attitudes as well as demonstrated behaviours, as well as a certain ‘ceiling effect’ related to trainees’ experience.269,283 Moreover, we currently have little to no standard for faculty qualification in regard to human factors in health care. In a review of 48 studies on team training in health care, Weaver et al.275 report that ‘[n]one of the studies provided meaningful details regarding how trainers themselves were prepared to train teamwork skills or explicated the skills sets important for trainer effectiveness’. In addition, the evidence for so-called train the trainer activities is very limited. Especially due to the growing commercial availability of a variety of training concepts, the literature suggests that individual needs are only rarely established for training development and implementation, thereby supporting a ‘one-size-fits-all’ approach to team training.275 It has been reinforced that careful adaptation to local culture and context have to be considered as prerequisites for successful teaching and learning practices.295 In an attempt to improve these limitations, the development of the Debriefing Assessment for Simulation in Healthcare tool is intended to address the need for a debriefing assessment based on a behaviourally anchored rating scale.

On a more conceptual level, it has been suggested that research contributions from social sciences are partially being excluded from the current discourse on patient safety and human factors training.296,297 With much focus on individual skills and behaviours that are subsequently extrapolated to the team level as a unit of analysis, it has been cautioned that complex, systemic issues are effectively obfuscated while much of the responsibility for undesired outcomes is pushed towards the ‘sharp end’ in an act of responsibilisation.298 Instead, it has been suggested to position team training in a wider, more comprehensive context of resource allocation and systems redesign.


Medical simulation training has come a long way since its first inception several decades ago, especially with the development and integration of multiprofessional curricula into comprehensive training concepts. As an indispensable tool for the education of practitioners in human factors principles, simulation can provide the canvas for modern concepts of patient safety training in anaesthesiology. Current limitations can be overcome by careful training conception that incorporates contemporary advances in safety science in combination with increased efforts of faculty development and standardisation.

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