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Management in clinical simulation: a proposal for best practices and process optimization

Gestión en simulación clínica: una propuesta de buenas prácticas y optimización de los procesos

ABSTRACT

Objectives:

to develop a best practices document with facilitating components and processes for simulation management.

Methods:

the methodological research was conducted between April and October 2017, using four approaches: observational research, conducted in an international simulation institution; Definition of theoretical framework, from the International Nursing Association for Clinical Simulation and Learning; integrative literature review, in international databases; and comparative analysis. It used Bardin's analysis for the categorization of the information.

Results:

creation of a document with good practices in simulation regarding management and practice in simulation and management of resources and data, highlighting the use of technology and the training of professionals as the most important allies for overcoming the main limitations found.

Final Considerations:

the product of this study is a compilation of strategies for simulation management as a tool to enhance the application of the method with greater effectiveness.

Descriptors:
Nursing; Simulation; Learning; Nursing Education; Educational Technology

RESUMEN

Objetivos:

desarrollar documento de buenas prácticas con componentes y procesos facilitadores a la gestión de simulación.

Métodos:

investigación metodológica realizada entre abril y octubre de 2017, utilizando cuatro abordajes: investigación observacional, realizada en institución internacional de simulación; Definición de referencial teórico, de la International Nursing Association for Clinical Simulation and Learning; Revisión integrativa de la literatura, en bases de datos internacionales; y análisis comparativo. Utilizado el análisis de Bardin para categorización de informaciones.

Resultados:

creación de documento de buenas prácticas en simulación en lo que respecta a gestión y práctica en simulación, así como gestión de recursos y datos, resaltando el uso de tecnología y formación de profesionales como los más importantes aliados a la superación de las principales limitaciones encontradas.

Consideraciones Finales:

producto de esto estudio es un compilado de estrategias para gestión de la simulación a ser utilizado como herramienta potencializadora para aplicación del método con mayor efectividad.

Descriptores:
Enfermería; Simulación; Aprendizaje; Educación en Enfermería; Tecnología Educacional.

RESUMO

Objetivos:

desenvolver um documento de boas práticas com os componentes e processos facilitadores para a gestão da simulação.

Métodos:

pesquisa metodológica realizada entre abril e outubro de 2017, utilizando quatro abordagens: pesquisa observacional, realizada em instituição internacional de simulação; Definição de referencial teórico, da International Nursing Association for Clinical Simulation and Learning; Revisão integrativa da literatura, em bases de dados internacionais; e análise comparativa. Utilizou-se a análise de Bardin para categorização das informações.

Resultados:

criação de documento com as boas práticas em simulação no tocante à gestão e prática em simulação, assim como gestão dos recursos e dados, ressaltando o uso da tecnologia e a formação dos profissionais como os mais importantes aliados para a superação das principais limitações encontradas.

Considerações Finais:

o produto deste estudo é um compilado de estratégias para gestão da simulação a ser utilizado como ferramenta potencializadora para aplicação do método com maior efetividade.

Descritores:
Enfermagem; Simulação; Aprendizagem; Educação em Enfermagem; Tecnologia Educacional.

INTRODUCTION

Simulation is a reality in the curricula of healthcare courses and professional training processes. The technologies and methods for its implementation have been discussed, as well as the competencies to be achieved by professionals for its application. To enhance the value of simulation laboratories and expand the method, there is a need to incorporate them into the pedagogical project of courses, teacher training, and contextualization to the local reality and studies and best practice guidelines to guide it. The teaching-learning process must allow for the training of technical skills, communication, and clinical reasoning11 Brandão CFS, Carvalho-Filho MA, Cecilio-Fernandes D. Simulation centers and pedagogical planning: two sides of the same coin. Sci Medica. 2018;28(1). https://doi.org/10.15448/1980-6108.2018.1.28709
https://doi.org/10.15448/1980-6108.2018....
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The use of simulation as a teaching strategy for skill development has become the international gold standard in the training of students, professionals, and healthcare teams. To this end, it is necessary to implement the method according to its principles and techniques through planning, the definition of strategies, and constant evaluation2 2 019;27:e3187. https://doi.org/10.1590/1518-8345.2936.3187
https://doi.org/10.1590/1518-8345.2936.3...
. In this context, educators should have the same teaching conduct33 Kaneko RMU, Lopes MHBM. Cenário em simulação realística em saúde: o que é relevante para a sua elaboração?. Rev Esc Enferm USP. 2019;53:e03453. https://doi.org/10.1590/s1980-220x2018015703453
https://doi.org/10.1590/s1980-220x201801...
-44 Fabri IRP, Mazzo A, Martins JCA, Fonseca ASF, Pedersoli CE, Miranda FBG, et al. Development of a theoretical-practical script for clinical simulation. Rev Esc Enferm USP. 2017;51. https://doi.org/10.1590/s1980-220x2016265103218
https://doi.org/10.1590/s1980-220x201626...
, and the management of material resources should be carried out using a conference system that allows double-checking and replacement without waste, requiring a high level of preparation and guidance regarding this management55 Cai L. Potential applications of latent variable modeling for the psychometrics of medical simulation. Mil Med. 2013;178(10suppl). https://doi.org/10.7205/MILMED-D-13-00214
https://doi.org/10.7205/MILMED-D-13-0021...

6 Landman AB, Redden L, Neri P, Poole S, Horsky J, Raja AS, et al. Using a medical simulation center as an electronic health record usability laboratory. J Am Med Inform Assoc. 2014;21(3). https://doi.org/10.1136/amiajnl-2013-002233
https://doi.org/10.1136/amiajnl-2013-002...
-77 Nimbalkar A, Patel D, Kungwani A, Phatak A, Vasa R, Nimbalkar S. Randomized control trial of high fidelity vs low fidelity simulation for training undergraduate students in neonatal resuscitation. BMC Res Notes. 2015;8. https://doi.org/10.1186/s13104-015-1623-9
https://doi.org/10.1186/s13104-015-1623-...
.

Programming a simulated activity requires the educator/facilitator's preparation in terms of educational design and management, a process that is still lacking today. Mistakes and failures are likely to happen during the activity; if not anticipated and prevented by the simulation developers, they may compromise the strategy's success and create trauma in the participants. In this sense, institutions have decided to standardize and validate their simulation scenarios, developing good practices with error prevention and process optimization, but there is still a need for further development and practical application for this training88 Almeida RGS, Mazzo A, Martins JCA, Coutinho VRD, Jorge BM, Mendes IAT. Validation to Portuguese of the Debriefing Experience Scale. Rev Bras Enferm. 2016;69(4):705-11. https://doi.org/10.1590/0034-7167.2016690413i
https://doi.org/10.1590/0034-7167.201669...
.

This study brings, with unprecedentedness, the search for issues that go beyond the opportune moment of application of simulated teaching and that permeate the entire process involving the simulation regarding the preparation of its administrative management and resources, planning and articulation of all points that culminate in teaching and learning through the method.

OBJECTIVES

To develop a document of good practices with the components and processes that facilitate the simulation management.

METHODS

Ethical aspects

The study respected the ethical precepts laid out in CNS Resolution No. 466 of 12/12/2012. It was submitted to and approved by the Research Ethics Committee through submission on Plataforma Brasil. Due to international characteristics and respecting requirements, it was approved and authorized by the Administration and Ethics Committee of the Simulation Center.

Type of study

Methodological study99 Polit DF, Beck CT. Fundamentos de Pesquisa em enfermagem: avaliação de evidências para as práticas da enfermagem. 7a ed. Porto Alegre (RS): Artmed; 2011. 669 p. employs four approaches (Figure 1) to create a protocol with facilitating components and processes for simulation management development. It was used the COREQ instrument to guide the methodology1010 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57. https://doi.org/10.1371/journal.pone.0228587.s001
https://doi.org/10.1371/journal.pone.022...
.

Figure 1
Methodological approaches

Methodological procedures - Stage 1

A qualitative observational study to raise the real needs and strategies present in the practice of simulation.

It was observed the activities carried out in an institution that is an international reference in Clinical Simulation from April to July 2017. The following were considered inclusion criteria for the observations: (1) activities accompanied in its entirety; (2) actions that involved research themes. Exclusion criteria: actions that depended on processes external to the simulation center.

The following actions were: 11 medical training classes (undergraduate), with theoretical approaches and practical activities with low and medium-fidelity simulation; 14 high-fidelity clinical simulation sessions for medical specialization; 21 medium-fidelity simulation sessions for scientific research; 14 high-fidelity clinical simulation sessions for multidisciplinary training; 2 professional training courses for simulation educators; 3 resource management meetings; 2 simulation educational planning meetings; 3 simulation research group meetings. There was also daily monitoring of the professional educators and technicians in managing human resources and daily maintenance of the center.

Study setting - Stage 1

This stage was conducted in a French reference laboratory in Clinical Simulation, which has several healthcare courses at different training levels. The institution has the essential services and resources recommended for establishing a highly efficient and faithful simulation center, with a planning, management, and educational and technical execution team, high-tech facilities, and resources, as well as the provision of specific consumable supplies.

Collection and organization of data - Stage 1

Data collection took place through observation without intervention in the scenario. The observer was not part of the research universe. Information was collected through the construction of an observation diary during the performance of the activities, filling out an instrument with the following information: (1) origin of the action - resource management, educational management, simulation practice, data and instrument manipulation; (2) type of activity - routine activity, direct simulation activity, planning activity, educational activity, research activity, evaluation activity; (3) description of the activity - which activity was being performed; (4) limitations - listing of limitations in the execution of the action; (5) strategies and facilities contributing to the performance of the activities; (6) general observations.

Methodological procedures - Stage 2

The second methodological stage was the choice of an international theoretical framework. The choice was defined as a stage, as it included a process of assessment and indication of international experts in the simulation area, through a form suggesting referrals and pointing out the positive and negative points of each referral. After collecting this information, it was compiled and validated by an evaluating panel.

The International Nursing Association for Clinical Simulation and Learning (INACSL) benchmark was chosen due to its relevance in the participation of international simulation communities, which follow the quality standard in education and health, serving as a reference for creating protocols and evidence-based studies1111 The INACSL Standards Committee. INACSL standards of best practice: Simulation SM: Outcomes and Objectives. Clin Simulat Nurs. 2016;12(S):S13-S15. https://doi.org/10.1016/j.ecns.2016.09.006
https://doi.org/10.1016/j.ecns.2016.09.0...
.

The following standards were used to support this study: SimulationSM Operations; SimulationSM Debriefing; and SimulationSM Design - which are the main types that oversee the management and practice in simulation1111 The INACSL Standards Committee. INACSL standards of best practice: Simulation SM: Outcomes and Objectives. Clin Simulat Nurs. 2016;12(S):S13-S15. https://doi.org/10.1016/j.ecns.2016.09.006
https://doi.org/10.1016/j.ecns.2016.09.0...
.

Methodological procedures - Stage 3

In the third methodological stage, an integrative review1212 Ganong LH. Integrative reviews of nursing research. Res Nurs Health [Internet]. 1987 [cited 2020 Feb 11];10(1):1-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/3644366
https://www.ncbi.nlm.nih.gov/pubmed/3644...
was performed to find studies that contemplated solutions, strategies, and technologies for the qualification of the management of the simulation process (educational and administrative aspects), answering the question: "What knowledge has been produced regarding methodologies in simulation management and the use of technology?".

An integrative review research protocol was developed, validated by a researcher expert in integrative review methods and by an expert in the field of clinical simulation.

Study setting - Stage 3

One search for articles occurred by accessing the following databases: Latin American and Caribbean on Health Sciences Literature (LILACS); and Medical Literature Analysis and Retrieval System Online - MEDLINE.

Data source - Stage 3

The following inclusion criteria were stipulated: (1) Studies that contained the predefined descriptors via the Medical Subject Headings (MESH) platform: Health Information Management AND Simulation Training; Management Information Systems AND Simulation Training; Materials Management, Hospital AND Simulation Training; Practice Management AND Simulation Training; Planning Techniques AND Simulation Training; Methods AND Simulation Training; Technology AND Simulation Training; (2) original articles; (3) articles that referred to Clinical Simulation and its stages of development, educational and resources management, and new technologies (4) articles available in Portuguese, Spanish, English, and French; (5) articles published from January 1, 2013, to January 1, 2017, with the last update in June 2019; and (6) articles available in its entirety.

Collection and organization of data - Stage 3

The search was done for each database individually, without pre-defining a starting base. The information extracted from the articles was (1) year of publication; (2) country of production; (3) focus worked within the theme; (4) origin of the action described in the article - resource management, educational planning, educational action, simulation practice, simulation planning, data, and instrument handling; (5) limitations; (6) strategies and facilities; (7) new themes and technologies.

After searching the articles classified by the selected descriptors, the inclusion and exclusion criteria (Stage 1) were applied to select the articles and read the titles and abstracts (Stage 2), excluding those repeated between the bases and descriptors composing, the final selection of articles.

Data analysis

For data analysis, it was used Content Analysis1313 Carlomagno MC, Rocha LC. Como criar e classificar categorias para fazer análise de conteúdo: uma questão metodológica. Rev Eletrôn Ciênc Pol [Internet]. 2016 [cited 2020 Feb 11];7(1):1-16. Available from: https://revistas.ufpr.br/politica/article/view/45771/28756
https://revistas.ufpr.br/politica/articl...
. The categorization and subcategorization occurred in a non-aprioristic way, in which the instrument previously defined the main categories, and the subcategories and contextual information emerged entirely from the context of the research material1313 Carlomagno MC, Rocha LC. Como criar e classificar categorias para fazer análise de conteúdo: uma questão metodológica. Rev Eletrôn Ciênc Pol [Internet]. 2016 [cited 2020 Feb 11];7(1):1-16. Available from: https://revistas.ufpr.br/politica/article/view/45771/28756
https://revistas.ufpr.br/politica/articl...
. We did not consider quantitative data of repetitions of actions and problems or strategies, but the depth, origin, and uniqueness of the information.

Besides, Stage 4 of the study was also part of the content analysis, which was characterized by a qualitative method comparing the categories defined and needs found in Stage 1 with the reference literature, the findings of the integrative review, and the adopted framework.

RESULTS

Chart 1 represents the information obtained from Stage 1 of the study, named "observational research," after data analysis and categorization.

As a result of Stage 3, literature review, the first search for articles classified by the selected descriptors showed a total of 19,426 articles, of which 17,565 in MEDLINE; and 1,861 in LILACS.

Next, by applying the inclusion and exclusion criteria, the study excluded 17,831 articles. Soon after, the titles and abstracts were read, and 1,565 publications were excluded since they did not contemplate the present study's scope. In the third phase, the survey identified 11 articles that were repeated in databases and descriptors and were excluded, according to the flowchart shown in Figure 2.

Chart 1
Results of Stage 1

Figure 2
Flow of article collection in Stage 3

Therefore, 19 studies were selected44 Fabri IRP, Mazzo A, Martins JCA, Fonseca ASF, Pedersoli CE, Miranda FBG, et al. Development of a theoretical-practical script for clinical simulation. Rev Esc Enferm USP. 2017;51. https://doi.org/10.1590/s1980-220x2016265103218
https://doi.org/10.1590/s1980-220x201626...

5 Cai L. Potential applications of latent variable modeling for the psychometrics of medical simulation. Mil Med. 2013;178(10suppl). https://doi.org/10.7205/MILMED-D-13-00214
https://doi.org/10.7205/MILMED-D-13-0021...

6 Landman AB, Redden L, Neri P, Poole S, Horsky J, Raja AS, et al. Using a medical simulation center as an electronic health record usability laboratory. J Am Med Inform Assoc. 2014;21(3). https://doi.org/10.1136/amiajnl-2013-002233
https://doi.org/10.1136/amiajnl-2013-002...
-77 Nimbalkar A, Patel D, Kungwani A, Phatak A, Vasa R, Nimbalkar S. Randomized control trial of high fidelity vs low fidelity simulation for training undergraduate students in neonatal resuscitation. BMC Res Notes. 2015;8. https://doi.org/10.1186/s13104-015-1623-9
https://doi.org/10.1186/s13104-015-1623-...
,1414 Livingston P, Bailey J, Ntakiyiruta G, Mukwesi C, Whynot S, Brindley P. Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership. Pan Africa Med J. 2014;17. https://doi.org/10.11604/pamj.2014.17.315.4211
https://doi.org/10.11604/pamj.2014.17.31...

15 Maglio PP, Sepulveda MJ, Mabry PL. Mainstreaming modeling and simulation to accelerate public health innovation. Am J Public Health. 2014;104(7). https://doi.org/10.2105/AJPH.2014.301873
https://doi.org/10.2105/AJPH.2014.301873...

16 Liaw SY, Chan SW, Chen FG, Hooi SC, Siau C. Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: randomized controlled trial. J Med Internet Res. 2014;16(9). https://doi.org/10.2196/jmir.3322
https://doi.org/10.2196/jmir.3322...

17 Bullock A, Webb K. Technology in postgraduate medical education: a dynamic influence on learning?. Postgrad Med J. 2015;91(1081):646-50. https://doi.org/10.1136/postgradmedj-2014-132809
https://doi.org/10.1136/postgradmedj-201...

18 Jaye P, Thomas L, Reedy G. "The Diamond": a structure for simulation debrief. Clin Teach. 2015;12(3):171-5. https://doi.org/10.1111/tct.12300
https://doi.org/10.1111/tct.12300...

19 Liaw SY, Wong LF, Chan SW, Ho JT, Mordiffi SZ, Ang SB, et al. Designing and evaluating an interactive multimedia Web-based simulation for developing nurses competencies in acute nursing care: randomized controlled trial. J Med Internet Res. 2015;17(1). https://doi.org/10.2196/jmir.3853
https://doi.org/10.2196/jmir.3853...

20 Nestel D, Bearman M, Brooks P, Campher D, Freeman K, Greenhill J, et al. A national training program for simulation educators and technicians: evaluation strategy and outcomes. BMC Med Educ. 2016;16(25). https://doi.org/10.1186/s12909-016-0548-x
https://doi.org/10.1186/s12909-016-0548-...

21 Gordon CJ, Jorm C, Shulruf B, Weller J, Currie J, Lim R, et al. Development of a self-assessment teamwork tool for use by medical and nursing students. BMC Med Educ. 2016;16(218). https://doi.org/10.1186/s12909-016-0548-x
https://doi.org/10.1186/s12909-016-0548-...

22 House JB, Choe CH, Wourman HL, Berg KM, Fischer JP, Santen A. Efficient and effective use of peer teaching for medical student simulation. West J Emerg Med. 2017;18(1). https://doi.org/10.5811/westjem.2016.11.32753
https://doi.org/10.5811/westjem.2016.11....

23 Nyström S, Dahlberg J, Edelbring S, Hult H, Dahlgren MA. Debriefing practices in interprofessional simulation with students: a sociomaterial perspective. BMC Med Educ. 2016;16. https://doi.org/10.1186/s12909-016-0666-5
https://doi.org/10.1186/s12909-016-0666-...

24 Oikawa S, Berg B, Turban J, Vincent D, Mandai Y, Birkmire-Peters D. Self-Debriefing vs Instructor Debriefing in a Pre-Internship Simulation Curriculum: Night on Call. Hawaii J Med Public Health [Internet]. 2016 [cited 2019 Oct 01];75(5):127-32. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872264/
https://www.ncbi.nlm.nih.gov/pmc/article...

25 LaFond CM, Blood A. Targeted simulation instructor course for nursing professional development specialists. J Nurses Prof Dev. 2016;32(6). https://doi.org/10.1097/NND.0000000000000306
https://doi.org/10.1097/NND.000000000000...

26 Herbstreit F, Merse S, Schnell R, Noack M, Dirkmann D, Besuch A, et al. Impact of standardized patients on the training of medical students to manage emergencies. Medicine (Baltimore). 2017;96(5). https://doi.org/10.1097/MD.0000000000005933
https://doi.org/10.1097/MD.0000000000005...
-2727 Martin D, Bekiaris B, Hansen G. Mobile emergency simulation training for rural health providers. Rural Remote Health. 2017;17(3). https://doi.org/10.22605/RRH4057
https://doi.org/10.22605/RRH4057...
. Afterward, articles were exhaustively read to extract the units of meaning related to this review's objective. Categories and subcategories were created based on the studies' focus themes to discuss the information, dialoguing with other authors and realities.

After carrying out Stages 1, 2, and 3 of the research and the comparative analysis, Chart 2 was created with the compilation of the results by analysis categories, presenting the suggestions of processes and components needed to qualify the practical and managerial process of simulation.

Chart 2
Final result of the study: instrument with the suggestion for process optimization

DISCUSSION

In the Educational Management category, when we point out that the simulation is an active methodology, the role of the student/professional must be rethought. The student/professional must take an active position in the teaching-learning process, while the educator/facilitator takes a facilitating position. By placing one as totally responsible for the simulation, and the other passive to the process, just executing what was thought for him, we regress to traditional methods, in which the professor holds the knowledge and the teaching choice, and the student is limited to submission and reproduction of what is transmitted3030 Carneiro KKC, Moraes Filho IM, Santos OP, Arantes AA, Félis KC, Guilherme IS. Simulação Realística como Instrumento de Ensino-Aprendizagem de Enfermagem. Revisa Rev Div Cient Sena Aires[Internet]. 2019 [cited 2020 Jul 05];3(8). Available from: http://revistafacesa.senaaires.com.br/index.php/revisa/article/view/423
http://revistafacesa.senaaires.com.br/in...
.

Another problem found is related to the unpreparedness of educators/professionals for the development of simulation in terms of planning and application. That happens due to lack of training and delay in keeping up with the method's rapid evolution. In some education centers, the educators in charge lack simulation training, resulting in management limiting these centers' expansion and potential2020 Nestel D, Bearman M, Brooks P, Campher D, Freeman K, Greenhill J, et al. A national training program for simulation educators and technicians: evaluation strategy and outcomes. BMC Med Educ. 2016;16(25). https://doi.org/10.1186/s12909-016-0548-x
https://doi.org/10.1186/s12909-016-0548-...
.

New simulation hybridization strategies are increasingly present, using distance learning resources (e-learning) for pedagogical internships, or even other simulated practices (e-simulation), such as the serious game resource, games that allow the development of theoretical skills complementary to the simulated practice. The Virtual Patient, a system that helps in the decision-making and clinical evaluation according to the patient's deterioration, using 2D visual resources, can be a complementary practice to the simulation and theoretical instrumentalization1616 Liaw SY, Chan SW, Chen FG, Hooi SC, Siau C. Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: randomized controlled trial. J Med Internet Res. 2014;16(9). https://doi.org/10.2196/jmir.3322
https://doi.org/10.2196/jmir.3322...
,3131 Lee LT, Hung JC. Effects of blended e-Learning: a case study in higher education tax learning setting. Hum Cent Comput Inf Sci. 2015;5(13). https://doi.org/10.1186/s13673-015-0024-3
https://doi.org/10.1186/s13673-015-0024-...
-3232 McCutcheon K, Lohan M, Traynor M, Martin D. A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. J Adv Nurs. 2015;71(2). https://doi.org/10.1111/jan.12509
https://doi.org/10.1111/jan.12509...
.

As for the Simulation Practice category, education, assessment, research, and integration of the healthcare system as objectives of the simulation are unanimous in the literature, and its origin is linked to the actual application of patient safety3333 Society for Simulation in Healthcare. Healthcare simulations can be said to have four main purposes - education, assessment, research, and health system integration in facilitating patient safety [Internet]. 2020[cited 2020 Feb 07]. Available from: http://ssih.org/about-simulation
http://ssih.org/about-simulation...
-3434 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM: Operations. Clin Simulat Nurs. 2017;13(12):681-7. https://doi.org/10.1016/j.ecns.2017.10.005
https://doi.org/10.1016/j.ecns.2017.10.0...
.

A fundamental principle found in the articles is related to simulation stages. The references produce diversified names, applications, and strategies, but all within the same design and scope, bringing at least three of the four stages described below: (1) Informative or pedagogical session - face-to-face or distance phase in which participants receive study guidance being e-learning of great use; (2) Pre-briefing or briefing - is a moment of contextualizing the clinical situation that will be experienced (3) Simulation - is the phase of scene development; and the (4) Debriefing - the moment of reflection on the experience experienced, which allows the exploration, analysis, and synthesis of the actions developed, the thought processes formulated and the emotions triggered, to improve performance in real situations44 Fabri IRP, Mazzo A, Martins JCA, Fonseca ASF, Pedersoli CE, Miranda FBG, et al. Development of a theoretical-practical script for clinical simulation. Rev Esc Enferm USP. 2017;51. https://doi.org/10.1590/s1980-220x2016265103218
https://doi.org/10.1590/s1980-220x201626...
,2828 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM: Simulation design. Clin Simulat Nurs. 2016;12(S):S5-S12. https://doi.org/10.1016/j.ecns.2016.09.005
https://doi.org/10.1016/j.ecns.2016.09.0...
,3535 Oliveira SN, Massaroli A, Martini JG, Rodrigues J. Da teoria à prática, operacionalizando a simulação clínica no ensino de Enfermagem. Rev Bras Enferm. 2018;71(Suppl-4):1791-8. https://doi.org/10.1590/0034-7167-2017-0180
https://doi.org/10.1590/0034-7167-2017-0...
.

The Clinical Guides, documents that guide the simulation in its planning and execution, were indispensable strategies in good practices. They are subdivided into Management, Procedure, and Study Guides. The Management Guides help in the assembly and maintenance of simulators and scenarios and help laboratory coordination. The Procedure Guides are checklists containing the procedures' steps, guiding the study of the participants in skills training, and facilitating the verification of strengths and weaknesses to be improved or enhanced. Study Guides present the clinical case, the simulator to be used, and require further development of the participant's theoretical knowledge to articulate the resources, knowledge, and scenario with the learning44 Fabri IRP, Mazzo A, Martins JCA, Fonseca ASF, Pedersoli CE, Miranda FBG, et al. Development of a theoretical-practical script for clinical simulation. Rev Esc Enferm USP. 2017;51. https://doi.org/10.1590/s1980-220x2016265103218
https://doi.org/10.1590/s1980-220x201626...
,1414 Livingston P, Bailey J, Ntakiyiruta G, Mukwesi C, Whynot S, Brindley P. Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership. Pan Africa Med J. 2014;17. https://doi.org/10.11604/pamj.2014.17.315.4211
https://doi.org/10.11604/pamj.2014.17.31...
,2727 Martin D, Bekiaris B, Hansen G. Mobile emergency simulation training for rural health providers. Rural Remote Health. 2017;17(3). https://doi.org/10.22605/RRH4057
https://doi.org/10.22605/RRH4057...
-2828 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM: Simulation design. Clin Simulat Nurs. 2016;12(S):S5-S12. https://doi.org/10.1016/j.ecns.2016.09.005
https://doi.org/10.1016/j.ecns.2016.09.0...
,3434 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM: Operations. Clin Simulat Nurs. 2017;13(12):681-7. https://doi.org/10.1016/j.ecns.2017.10.005
https://doi.org/10.1016/j.ecns.2017.10.0...
.

The release of data for the development of the simulation was a practical aspect that presented difficulties due to the absence of information noticed only during the session. To this end, the pre-briefing or briefing, which is the informative meeting stage of the simulation to score the necessary aspects for the case's contextualization and development, must be well structured and follow the objectives competencies to be addressed. The literature's good practice strategy was the early release of this information and keeping it available during the simulation in the form of exams and images, which allow realism and instrumentalization for the practice, either by monitors or printed medical charts44 Fabri IRP, Mazzo A, Martins JCA, Fonseca ASF, Pedersoli CE, Miranda FBG, et al. Development of a theoretical-practical script for clinical simulation. Rev Esc Enferm USP. 2017;51. https://doi.org/10.1590/s1980-220x2016265103218
https://doi.org/10.1590/s1980-220x201626...
,1717 Bullock A, Webb K. Technology in postgraduate medical education: a dynamic influence on learning?. Postgrad Med J. 2015;91(1081):646-50. https://doi.org/10.1136/postgradmedj-2014-132809
https://doi.org/10.1136/postgradmedj-201...
,2828 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM: Simulation design. Clin Simulat Nurs. 2016;12(S):S5-S12. https://doi.org/10.1016/j.ecns.2016.09.005
https://doi.org/10.1016/j.ecns.2016.09.0...
,3434 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM: Operations. Clin Simulat Nurs. 2017;13(12):681-7. https://doi.org/10.1016/j.ecns.2017.10.005
https://doi.org/10.1016/j.ecns.2017.10.0...
-3535 Oliveira SN, Massaroli A, Martini JG, Rodrigues J. Da teoria à prática, operacionalizando a simulação clínica no ensino de Enfermagem. Rev Bras Enferm. 2018;71(Suppl-4):1791-8. https://doi.org/10.1590/0034-7167-2017-0180
https://doi.org/10.1590/0034-7167-2017-0...
.

The debriefing is considered the most significant step in the simulation because it connects and reflects the intended competencies and objectives with the actions performed. It is the opportunity to weave together theoretical and practical knowledge and generate a moment of self-reflection and self-learning. Several methods were pointed out for its development, and each one related to the objective of the simulation in question55 Cai L. Potential applications of latent variable modeling for the psychometrics of medical simulation. Mil Med. 2013;178(10suppl). https://doi.org/10.7205/MILMED-D-13-00214
https://doi.org/10.7205/MILMED-D-13-0021...
,88 Almeida RGS, Mazzo A, Martins JCA, Coutinho VRD, Jorge BM, Mendes IAT. Validation to Portuguese of the Debriefing Experience Scale. Rev Bras Enferm. 2016;69(4):705-11. https://doi.org/10.1590/0034-7167.2016690413i
https://doi.org/10.1590/0034-7167.201669...
,1818 Jaye P, Thomas L, Reedy G. "The Diamond": a structure for simulation debrief. Clin Teach. 2015;12(3):171-5. https://doi.org/10.1111/tct.12300
https://doi.org/10.1111/tct.12300...
,2222 House JB, Choe CH, Wourman HL, Berg KM, Fischer JP, Santen A. Efficient and effective use of peer teaching for medical student simulation. West J Emerg Med. 2017;18(1). https://doi.org/10.5811/westjem.2016.11.32753
https://doi.org/10.5811/westjem.2016.11....

23 Nyström S, Dahlberg J, Edelbring S, Hult H, Dahlgren MA. Debriefing practices in interprofessional simulation with students: a sociomaterial perspective. BMC Med Educ. 2016;16. https://doi.org/10.1186/s12909-016-0666-5
https://doi.org/10.1186/s12909-016-0666-...
-2424 Oikawa S, Berg B, Turban J, Vincent D, Mandai Y, Birkmire-Peters D. Self-Debriefing vs Instructor Debriefing in a Pre-Internship Simulation Curriculum: Night on Call. Hawaii J Med Public Health [Internet]. 2016 [cited 2019 Oct 01];75(5):127-32. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872264/
https://www.ncbi.nlm.nih.gov/pmc/article...
,2828 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM: Simulation design. Clin Simulat Nurs. 2016;12(S):S5-S12. https://doi.org/10.1016/j.ecns.2016.09.005
https://doi.org/10.1016/j.ecns.2016.09.0...
,3535 Oliveira SN, Massaroli A, Martini JG, Rodrigues J. Da teoria à prática, operacionalizando a simulação clínica no ensino de Enfermagem. Rev Bras Enferm. 2018;71(Suppl-4):1791-8. https://doi.org/10.1590/0034-7167-2017-0180
https://doi.org/10.1590/0034-7167-2017-0...
.

There is a need for a trained educator/facilitator to conduct and employ the appropriate technique; and instruments that provide sufficient objective and subjective data for an efficient evaluation, which show the points for improvement for the participant to achieve the objectives and competencies. Debriefing can be developed in different techniques, but all be based on confidentiality, truth, open communication, self-analysis, participant-centered feedback, and reflection88 Almeida RGS, Mazzo A, Martins JCA, Coutinho VRD, Jorge BM, Mendes IAT. Validation to Portuguese of the Debriefing Experience Scale. Rev Bras Enferm. 2016;69(4):705-11. https://doi.org/10.1590/0034-7167.2016690413i
https://doi.org/10.1590/0034-7167.201669...
,1818 Jaye P, Thomas L, Reedy G. "The Diamond": a structure for simulation debrief. Clin Teach. 2015;12(3):171-5. https://doi.org/10.1111/tct.12300
https://doi.org/10.1111/tct.12300...
,2929 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM Debriefing. Clin Simulat Nurs. 2016;12(S):S21-S25. https://doi.org/10.1016/j.ecns.2016.09.008
https://doi.org/10.1016/j.ecns.2016.09.0...
,3535 Oliveira SN, Massaroli A, Martini JG, Rodrigues J. Da teoria à prática, operacionalizando a simulação clínica no ensino de Enfermagem. Rev Bras Enferm. 2018;71(Suppl-4):1791-8. https://doi.org/10.1590/0034-7167-2017-0180
https://doi.org/10.1590/0034-7167-2017-0...
.

The Resource Management category did not appear linked to failures or errors but rather to aspects such as the difficulty of controlling materials, the division of tasks, and the time spent by human resources for its execution. For the comprehensive performance of the simulation, there must be a support network with a clear division of roles so that this aspect is not overloaded or expected in a single professional role66 Landman AB, Redden L, Neri P, Poole S, Horsky J, Raja AS, et al. Using a medical simulation center as an electronic health record usability laboratory. J Am Med Inform Assoc. 2014;21(3). https://doi.org/10.1136/amiajnl-2013-002233
https://doi.org/10.1136/amiajnl-2013-002...
,2020 Nestel D, Bearman M, Brooks P, Campher D, Freeman K, Greenhill J, et al. A national training program for simulation educators and technicians: evaluation strategy and outcomes. BMC Med Educ. 2016;16(25). https://doi.org/10.1186/s12909-016-0548-x
https://doi.org/10.1186/s12909-016-0548-...
.

It is not easy to find articles that address simulation management. Most of them deal only with methodological and educational issues or bring the experience of deployment and implementation of simulation centers, and the production of methodologies for management and maintenance by managers is still scarce. In this regard, it should be noted that these professionals are more connected to the educational area and do not have training directed to administrative and organizational domains. These aspects have been proven to be related to simulation quality and potential as an educational method33 Kaneko RMU, Lopes MHBM. Cenário em simulação realística em saúde: o que é relevante para a sua elaboração?. Rev Esc Enferm USP. 2019;53:e03453. https://doi.org/10.1590/s1980-220x2018015703453
https://doi.org/10.1590/s1980-220x201801...
,1414 Livingston P, Bailey J, Ntakiyiruta G, Mukwesi C, Whynot S, Brindley P. Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership. Pan Africa Med J. 2014;17. https://doi.org/10.11604/pamj.2014.17.315.4211
https://doi.org/10.11604/pamj.2014.17.31...
,2020 Nestel D, Bearman M, Brooks P, Campher D, Freeman K, Greenhill J, et al. A national training program for simulation educators and technicians: evaluation strategy and outcomes. BMC Med Educ. 2016;16(25). https://doi.org/10.1186/s12909-016-0548-x
https://doi.org/10.1186/s12909-016-0548-...
.

As for the category Handling of Data and Instrument, studies show that this is a necessary item, especially in evaluating the simulation and its organization, generating data to improve the simulation center and the resources and methods88 Almeida RGS, Mazzo A, Martins JCA, Coutinho VRD, Jorge BM, Mendes IAT. Validation to Portuguese of the Debriefing Experience Scale. Rev Bras Enferm. 2016;69(4):705-11. https://doi.org/10.1590/0034-7167.2016690413i
https://doi.org/10.1590/0034-7167.201669...
,1818 Jaye P, Thomas L, Reedy G. "The Diamond": a structure for simulation debrief. Clin Teach. 2015;12(3):171-5. https://doi.org/10.1111/tct.12300
https://doi.org/10.1111/tct.12300...
,2929 The INACSL Standards Committee. INACSL standards of best practice: SimulationSM Debriefing. Clin Simulat Nurs. 2016;12(S):S21-S25. https://doi.org/10.1016/j.ecns.2016.09.008
https://doi.org/10.1016/j.ecns.2016.09.0...
. The proposal is to create a routine for implementing data evaluation and analysis to serve as punctual teaching-learning actions and be presented as results for improving simulation as a method. It is necessary to develop the instruments used to improve data and take advantage of the technology to obtain results quickly1515 Maglio PP, Sepulveda MJ, Mabry PL. Mainstreaming modeling and simulation to accelerate public health innovation. Am J Public Health. 2014;104(7). https://doi.org/10.2105/AJPH.2014.301873
https://doi.org/10.2105/AJPH.2014.301873...
,2121 Gordon CJ, Jorm C, Shulruf B, Weller J, Currie J, Lim R, et al. Development of a self-assessment teamwork tool for use by medical and nursing students. BMC Med Educ. 2016;16(218). https://doi.org/10.1186/s12909-016-0548-x
https://doi.org/10.1186/s12909-016-0548-...
,2525 LaFond CM, Blood A. Targeted simulation instructor course for nursing professional development specialists. J Nurses Prof Dev. 2016;32(6). https://doi.org/10.1097/NND.0000000000000306
https://doi.org/10.1097/NND.000000000000...
.

Finally, it is essential to reflect on new technologies in the context addressed since most of the recommended strategies and actions are related to technology as a facilitator of the processes. That is because simulation involves many technological devices (such as mannequins, computers, and equipment), which require, in their planning and evaluation, resources that keep up with the rapid evolution of these components, besides generating data that need storage devices and technological evaluation66 Landman AB, Redden L, Neri P, Poole S, Horsky J, Raja AS, et al. Using a medical simulation center as an electronic health record usability laboratory. J Am Med Inform Assoc. 2014;21(3). https://doi.org/10.1136/amiajnl-2013-002233
https://doi.org/10.1136/amiajnl-2013-002...
.

Study limitations

The study does not present rigor in the choice of references regarding their evidence level. That could be justified by the lack of research about the subject concerning the management of simulation resources.

Contributions to the Fields of Nursing, Health or Public Policy

This study resulted in an instrument that provides a compilation of strategies based on the best practices for simulation management, which can be used to enhance the training, qualification, and improvement programs of health professionals, consequently allowing greater effectiveness in their educational and management actions.

FINAL CONSIDERATIONS

Simulation is an effective method in health education because it promotes patient safety and the development of skills related to students' safe educational practice. The evaluation and dissemination of systems and processes that optimize simulation can enhance the method's action, regardless of the material and human resources available, taking it to all institutions and contributing to the training and qualification of health professionals.

The development and implementation of methods and instruments that clarify both the educational and managerial stages of the simulation process are essential to ensure the methodology's effectiveness and potential. The usage of technology and its good application can facilitate the implementation, management, and evaluation of these processes, contributing to practice and research in Health and Nursing. Likewise, one must invest in training professionals in simulation and the best use of technological tools.

  • FUNDING
    The authors would like to thank the Centro Nacional de Desenvolvimento CiêntificoCientífico e Tecnológico (National Council for Scientific and Technological Development (CNPq) for granting a doctoral scholarship to conduct the study that generated this article.

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Edited by

EDITOR IN CHIEF: Dulce Barbosa
ASSOCIATE EDITOR: Maria Elisabete Salvador

Publication Dates

  • Publication in this collection
    16 Aug 2021
  • Date of issue
    2021

History

  • Received
    12 July 2020
  • Accepted
    02 Apr 2021
Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
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