Simulation can help healthcare teams overcome their real world challenges, but it requires an understanding of the complexity of performance, says Victoria Brazil

Performing safe and effective intubation of trauma patients who arrive in the emergency department is time critical and potentially life saving. Getting it right is vital. The textbook version of the procedure is pretty simple: take the tube, slide it down the patient’s throat until it enters the lungs, then start the ventilator. Practising it using simulation makes sense—just develop that psychomotor skill on a manikin. But intubation performance in the real world is far more complex.

Success depends on having the right people in a team, and coordinating a complicated sequence of medications, equipment, and steps, all within a chaotic environment where there are competing priorities. Performance is more than the sum of well rehearsed individual skills. Not surprisingly, real world trauma intubation performance is variable, and occasionally has catastrophic consequences.

Healthcare simulation is a potential game changer for improving patient care, but so far hasn’t realised that promise. We have cutting edge simulation technology and effective educational strategies, but we haven’t consistently applied them with a mature understanding of healthcare systems, culture, and behaviour change. The example of endotracheal intubation illustrates a dilemma that applies across healthcare contexts. Translational simulation—an approach connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions—may help deliver on that promise.

Where we have been: training

Practising skills like CPR, patient communication, and procedures are classic examples of healthcare simulation. This kind of training definitely “works”—if our measure is improving individual skills. But does it help our real world challenges? Education and training are necessary, but not sufficient, for excellent system performance and are weak instruments for complex system improvement.

Simulation for team training can be part of the solution. The early history of healthcare simulation was based on translating lessons from aviation and other high reliability organisations. Pioneers like Dr David Gaba (an anaesthetist and engineer) built human patient simulators and designed team training scenarios, allowing healthcare teams to practise their teamwork behaviours. 

But we’re still missing something.

Translation of these teamwork behaviours into practice requires understanding of complexity, and perhaps there is a better framework for considering how simulation might support improving quality in healthcare.

Where we are: exploring, testing, embedding

Firstly, healthcare simulation can help us explore healthcare environments and the people in them. Simulation delivered “in situ” is an emerging technique for this exploration: conducting simulations with native teams; within their own environment; with their equipment, protocols, and call systems. We can explore practical challenges—how do we get a patient with a head injury to the CT scanner safe and fast? We can find latent safety threats—equipment faults or poorly designed ergonomics in the resuscitation bay. We can observe whether clinical pathways and protocols are actually used in practice, and explore culture and relationships within and between healthcare teams. 

Secondly, healthcare simulation offers a test bed for planned interventions or new spaces.

Change is the only constant in healthcare, and is fundamental to most attempts at healthcare improvement. And yet we know that not all change leads to improvement; changes can have unintended consequences, and changes that look good on paper don’t always work in practice. For example, efforts around the world to prepare for the covid-19 pandemic using simulation provide an illustrative example. Rapidly drafted protocols were a start, but they needed to be tested and refined. Simulation offered a way to do that at scale, on demand, and in a way that facilitated robust data collection and sharing of lessons. Simulation can also offer a test bed for changes to equipment bundles, workflows, and physical infrastructure, allowing rapid cycle iteration. 

Thirdly, healthcare simulation can help embed good practice across an organisation. There’s no need to abandon our educational roots if we’re using simulation for quality improvement. We still need to draw on principles of effective learning and behaviour change, but we need a sharp focus on the overall improvement goals and training that emphasises collective competence.

Where we are going: shaping a culture of doing better, together

Maybe the biggest impact of simulation is the least obvious. Maybe, as Liberati and colleagues suggest, simulation is not simply an intervention or technique, but rather part of the context in which healthcare teams perform. Perhaps the impact of simulation is more about the ritual of that activity, and the “hidden curriculum.” We send powerful messages when we commit time and effort to get together to improve. Ideally, there is a blurring of lines between sim and reality, as simulation “sets a tone,” and cultivates habits for real world reflection and improvement. 

So, how could simulation activities translate to better intubation performance? Or to improve other areas of healthcare?

After exploring enablers and barriers to high performance in intubation of our trauma patients through translational simulation, we can test better ways, better equipment, better teamwork structures, and better trauma room layouts. And then we can embed those practices through simulation education and training of individuals and teams. But, perhaps most importantly, we can use simulation to send a message that we have high standards, and that we are committed to doing better, together.

This article was commissioned by The BMJ to coincide with THIS Institute’s annual conference, THIS Space 2020, which The BMJ is a media partner for. Victoria Brazil is a keynote speaker at the event.

Victoria Brazil is professor of emergency medicine and director of simulation at the Gold Coast Health Service, and at Bond University medical programme. She is an enthusiast in the social media and #FOAMed world. She is co-producer of Simulcast and she hosts the Harvard Macy Institute podcast. Twitter @SocraticEM 

Competing interests: None declared.