With technological advances and a greater understanding of the educational benefits of health professionals being immersed in real life experiences for educational purposes, simulation has grown into a popular modality of clinical training (Issenberg, 2006). Simulation has many roles to play in healthcare education—not only can it teach specific skills, but it is also becoming imperative in patient safety training, interdisciplinary training, communication, team training, and crisis resource management (Smith and Cole, 2009). These points have also been emphasized in one of the latest annual reports from the Chief Medical Officer for England (Donaldson, 2009) where the use of simulation at all levels is strongly recommended. As described by one of the recognized pioneers:
‘When integrated appropriately into learning and competence testing, simulation plays an important role in acquiring the critical and reflective thinking skills needed to provide competent, safe patient care.’ (Gaba, 2004)
Many well established simulation centres already exist across Europe and Australia, and the highest number of simulation centres are located in the US (Bristol Medical Simulation Centre (BMSC), 2011). Centres such as the Mayo Clinic Simulation Centre, Harvard, Hertfordshire, and Bristol are a very small sample of institutions that have been pioneers in developing simulation programmes, techniques, and simulation research across the disciplines (Friedrich, 2002; Alinier, 2007b; Gardner, 2007; Malec et al, 2007).
The continents these centres represent also lead the way in building a growing simulation community, with societies and associations such as the Society for Simulation in Healthcare (SSH, www.ssih.org); the Society in Europe for Simulation Applied to Medicine (SESAM, www.sesam-web.org); the Association for Simulated Practice in Healthcare (ASPIH, www.aspih.org.uk), and the Australian Society for Simulation in Healthcare (ASSH, www.assh.org.au).
Simulation education across frontiers
A number of simulation facilities, programmes, and research projects have recently emerged or are taking place in Asia and Africa. In order to promote the development of simulation in other parts of the world, some of the aforementioned societies support the organization of affiliated conferences in other continents such as the first Asia Pacific conference which took place in June 2011 in Hong Kong, affiliated with SSH; and the second European/Latin-American meeting on Health Care Simulation and Patient Safety (ALASIC, www.alasic.net) in November 2011 in São Paulo, Brazil, affiliated with SESAM.
In addition, initiatives such as workshops or humanitarian projects supported by industry help simulation developments in many countries where simulation is not current practice due to a simple lack of awareness, or for cultural or economical reasons.
Such examples are the ‘Helping Babies Breathe’ project (Korioth, 2010) which is also supported by the World Health Organization (WHO), the American Academy of Pediatrics and many other partners, as well as other courses run by experts in their field to update clinicians on the current best practice. Other activities include more realistic simulation workshops for educators such as the one illustrated in Figure 1.
Although many of these activities have a limited short time effect, it is expected that they will empower some enthusiastic participants to become the local educational pioneers and implementers of the knowledge and ideas they will have acquired during the workshop. In turn, the simulation activities of these people will impact on others and more importantly, improve training standards, eventually benefiting patients in the region.
The published evidence of the globalization of simulation
A PubMed search using the MESH terms; education, patient simulation or computer simulation, Africa or Caribbean region or Central America or Latin America or South America or Antarctic Regions or Arctic Regions or Asia or Indian Oceans was performed to retrieve relevant research articles published. The regions of interest are shown in green in Figure 2.
143 articles were found using this search criterion, of which 26 were eliminated as not directly linked to simulation education or the research emerged from Europe, North and Central America, or Oceania. The Middle East has been separated from Asia in the results presented in Table 1 due to its unique economical context and the current expansion in healthcare simulation activities in this particular region.
| Geographic Location | Africa | Asia | Middle East | South America | Other (Arctic) | Total |
|---|---|---|---|---|---|---|
| Number of articles found in PubMed | 16 | 55 | 33 | 12 | 1 | 117 |
| Percentage of articles from each location | 14% | 47% | 28% | 10% | 1% | 100% |
Reviewing the trends within the published research
Asia
As reported in Table 1, when excluding Europe, North and Central America, and Oceania, the majority of the published research at present appears to be emerging from Asia. This trend is clearly reflected in the number of centres that have opened in South East Asia in recent years and been registered on the informal and worldwide database of simulation centres hosted by the Bristol Medical Simulation Centre website (Table 2, BMSC, 2011).
| Name of Centre or Institution | Country |
|---|---|
| Anhui Shengli Hospital (Chinese Public Hospital) | China |
| Beihua University, Jilin Medical College | China |
| Aomori Prefectural Hospital | Japan |
| Seoul National University College of Nursing | Seoul |
| Buddhist Tzu Chi General Hospital | Taiwan |
| Chi-Mei Medical Center Taiwan | Taiwan |
| Busan Fire Department Central Headquarters | Korea |
| Universiti Malaysia Sabah | Malaysia |
| Ngee Ann Polytechnic | Singapore |
| SAAD Specialist Hospital | Saudi Arabia |
| Al-Zarqa Private University | Jordan |
| Arelano University Manila | Philippines |
| University of Kwazulu-Natal Inkosi Albert Luthuli Central Hospital | South Africa |
| University of Kwazulu-Natal Simulation Lab | South Africa |
| Hospital Israelita Albert Einstein | Brazil |
| University Diego Portales | Chile |
The reported projects from South East Asia use a mix of standardized patients, mannequin-based simulation, and computer-based or virtual reality simulators. Researchers from Japan, Korea, Malaysia, and China have published on the use of standardized patients as a mode of assessing clinical performance in their clinical education programmes (Tai and Chung, 2008; Loh and Kwa, 2009; Myung et al, 2010; Taguchi and Ogawa, 2010) demonstrating that simulation developments are not necessarily driven by the adoption of technology, but rather by the adoption of a new educational modality underpinned by an emerging pedagogy (‘andragogy’, in fact as we are talking of adult education) engaging learners to put safely in practice what they have learnt.
This part of the world is also active in terms of simulation related technological developments. For example, work from four related projects (the Visible Human Project, the Visible Korean, the Chinese Visible Human, and the Virtual Chinese Human (VCH)) resulted in serially sectioned images of whole cadavers becoming available worldwide and to be used for interactive computer or virtual simulation applications (Tang et al, 2010). The researchers encourage the use of the data from their four human cadavers into virtual reality surgical simulators with haptics capability.
Middle East
Another region of the world which is currently experiencing a huge growth in building up its simulation-based training capacity with well-funded projects is the Middle East.
Many large scale simulation centres have recently opened or are in the planning or building phase in Oman, Saudi Arabia, United Arab Emirates, and Qatar. It is expected that all of them will adopt most simulation modalities and be fitted out with state-of-the-art simulation and audio/visual equipment. These centres are being set up because of the recognized need to expand their healthcare workforce and to keep clinical staff up-to-date with their practice. The clinical workforce expansion will usually involve recruiting staff from all over the world with a variety of skills and educational backgrounds.
Simulation is one modality of learning that is now being recognized as an evaluation technique to skill-validate healthcare workers; these new simulation centres will play an important role in the recruitment and on-boarding of new clinical staff to meet patient safety goals. This is in line with the philosophy that simulation can be used to facilitate staff recruitment, improve safety, and foster changes in work procedures and systems (Gaba, 2004).
In this particular context, simulation will have an even more significant role as clinical staff, coming most probably from a wide range of cultural backgrounds, will need to adapt their practice to a different cultural environment while ensuring patient safety and patient-centred care at all times. Simulation will provide the most appropriate context for the remodelling of clinical practice, to raise cultural awareness, and in some cases to up-skill the clinical staff recruited.
Some of these centres are linked to the opening of a new hospital and are in a unique position to fully integrate and use simulation to its maximum potential. The Sidra Medical and Research Centre due to open in 2011 in Qatar (www.sidra.org) is one of these examples which has a unique opportunity to conduct research on the effectiveness of recruiting, on-boarding, and orientating new staff using a significant simulation component. It will involve skill validation and competency assessment using various modalities of simulation including objective structured clinical examination (OSCE) and scenario-based simulation type sessions (Alinier, 2003; Seropian, 2003).
More established centres do exist in Saudi Arabia, Bahrain, and Israel. The Israel Centre for Medical Simulation (MSR), is a comprehensive, national, multimodality, multidisciplinary medical simulation centre dedicated to enhancing hands-on medical education, performance assessment, patient safety, and quality of care by improving clinical and communication skills (Ziv et al, 2006). This pioneering centre uses an ‘error-driven’ educational approach, which recognizes that errors provide an opportunity to create a unique and beneficial learning experience (Ziv et al, 2005) whereby participants have the opportunity to temporarily ‘live through’ the consequences of their errors in a safe environment and be guided in their reflection process during a post-simulation debriefing session. Allowing participants to make errors in the simulation environment is expected to help them learn not to make the same errors in the clinical setting, and to enhance patient safety.
Africa and South America
One third of the published research analyzed, however, came from less resource rich areas such as Africa and South America. Similar to the majority of the work emerging from Asia, the projects within these continents also appeared to use standardized patients and part-task trainers to provide simulation-based learning opportunities to health workers. Some of these projects are part of wider initiatives supported by the WHO and other professional bodies, as in the earlier example of the ‘Helping Babies Breathe’ programme.
An innovative idea that is being used to provide education to birth attendants are a low-tech pregnancy simulation device called ‘Mama Natalie’ in combination with an inflatable baby called ‘Neo Natalie’ (Laerdal Medical). This helps to address the high costs of purchasing sophisticated mannequins and associated maintenance, but instead requires the use of an actor who plays the role of the pregnant woman. It creates a form of hybrid simulation experience whereby what can be considered a part-task trainer is used alongside a standardized patient as used, for example, in the assessment of communication skills during a simple clinical procedure such as suturing (Kneebone et al, 2002).
‘Mama Natalie’ is used to teach midwives in developing countries how to handle deliveries and emergency situations to increase the skills of the birth attendants in order to reduce maternal and infantile mortality and morbidity. This project has been put in place to help the WHO meet its goal of reducing child morbidity by two thirds from 1990 levels by 2015 (Korioth, 2010). Data are presently being collected to monitor the effect of this training intervention in terms of clinical outcome (www.laerdalglobalhealth.com and savinglivesatbirth.net). In addition, a team of clinicians from the US and Ghana striving to reduce maternal mortality have worked on the development of a low-cost simulator for bimanual compression training for the management of postpartum haemorrhage in the developing world (Perosky et al, 2011). They report that research is ongoing in this application.
The use of standardized patients has also been effective in developing education programmmes for healthcare workers and community health projects such as the management of sexually transmitted diseases in urban pharmacies in Gambia and evaluating client-provider interactions within clinical settings (Huntington and Schuler, 1993; Leiva et al, 2001).
Another example that highlights the importance of simulation training in a resource restricted area is an educational programme in Botswana, Africa, organized by the Department of Surgery, Toronto Western Hospital, Canada (Okrainec et al, 2009). A total of 20 surgeons and trainees participated in a 3-day fundamentals of laparoscopic surgery (FLS) course. This was the first time the FLS programme was taught in Africa and it enabled the participants to significantly improve their FLS technical skills, however most of the local surgeons did not reach the FLS passing scores. From the outcome of this training intervention, we can conclude that more than 3 days may have been required to help surgeons perform at a satisfactory level to obtain FLS certification. From our perspective, this programme highlights the importance of such courses being customised to the learners and the local context to develop the clinicians' skills.
These are examples of how, even with limited resources, educational programmes can be delivered using various modalities of simulation. Numerous other educational activities using simulation must be occurring globally but without any research infrastructure, limiting the chances of the work ever being published and shared with the simulation community for wider dissemination.
Conclusion
As many more simulation centres and education programmes are developing, more research will appear from outside the more developed simulation communities. The effect on patient outcome of enhanced education through simulation may be more visible outside of the western countries where no form of simulation was previously used. Educational projects aiming at reducing maternal and infantile mortality and morbidity are currently ongoing in several African, South American, and Asian countries. Collaborations across geographical frontiers through voluntary, sponsored, or humanitarian projects, regional conferences, workshops, and technological developments have a significant role to play in the development and use of simulation practice in parts of the world where it is not commonly used for training and education for cultural or economical reasons, or simply due to a lack of awareness of the learning opportunities offered by simulated practice.
Some of the initiatives presented in this article demonstrate that simulation training does not necessarily require the purchase of highly sophisticated and expensive equipment to run hands-on and highly beneficial training sessions. The development of clear and concise learning objectives, along with the approach adopted by the educators, play an important part in the learning experience.
The resources required to achieve the intended learning outcomes can often be kept to a minimum. Existing simulation programmes or courses sometimes need to be adapted to the local context to be run successfully or with the desired effect.