Introduction

The development of simulation has been evolving in technology and utilization over the last several centuries, with the increased application over the past 2 to 3 decades in the field of pediatrics. Today, simulation-based medical education (SBME) is widely used by a majority of pediatric training programs and is marked by a large variety of technologies and continued interest and availability of research in the field. 

The history of simulation in medicine has its origins in fields such as the military, commercial aviation, and NASA.[1] Disciplines, like medicine, where the importance of safe knowledge acquisition and practice is of utmost importance, quickly followed suit. The application of medical simulation to pediatrics had its infancy as an adjunct to obstetrics and surgical training. One of the earliest examples of simulation for the express purpose of medical education is from the late 1700s, where pelvic part-task trainers were developed with a pelvis, glass uterus filled with fluid, and a flexible fetus used to teach midwives delivery skills.[2] Over the next two hundred years, there were continued improvements in the “realism” of part-task trainers and even some full-body mannequins, but the modern era of mannequin trainers had their roots in the field of anesthesia. In the mid-1900s, more sophisticated mannequins were developed. Unfortunately, while these proved to be effective training tools but were far too expensive for mass production.[3] The anesthesia community then led a medical education reform over the coming decades to incorporate simulation-based medical education into the mainstream.  

Today, there are numerous simulation centers and hospitals that utilize a variety of human patient simulators that range from low to high fidelity mannequins, the most sophisticated of which are capable of responding to learner stimuli such as drug administration, compressions, voice, physical exam, and even procedural interventions.[4] The simulation armamentarium also includes task trainers, standardized patients, desktop/screen-based, and virtual and augmented reality (VR and AR). Each technology has its utility both alone and in combination, depending on the educational objective hoping to be met.[5][6][7][8]

Issues of Concern

Simulation has provided pediatric educators an invaluable tool in which to practice high-risk and low-frequency events safely. As with any educational modality, several challenges must be faced to optimize effectiveness. Cost is one of the most common constraints cited in implementing a simulation curriculum. In addition to the purchase prices, there are costs associated with the storage, maintenance, and management of equipment as well as associated personnel costs. The time and commitment required for the development of a high-quality scenario-based curriculum must also not be underestimated.[9] To combat this challenge, there are several low-fidelity options, including home-made simulators, along with peer-reviewed published scenarios and curricula available for use that can be utilized in low-resource settings.

In regards to the clinical application, translation to patient care outcomes and skill retention has been debated in the past. Though there has been conflicting data, a meta-analysis published in 2015 showed a frequently positive correlation between simulation-based assessments and patient-related outcomes.[10] Additionally, several studies effectively show both technical and knowledge skill retention. However, it has been noted that skills can decay quickly over time.[11] This decay makes it imperative to utilize evidence-based best practices of SBME during instructional design, which will be highlighted below.[4] 

High-quality simulation research is critical to continue to provide the best practice of evidence-based educational modalities. A review of healthcare simulation research shows a consistent need for high-quality methodologies between adult and pediatric specialties.[12][8] Authors Issenburg et al. and McGaghie et al. review literature from 1969-2009 using a subjective and qualitative critical appraisal of selected articles to summarize what has been learned and what is left to be explored in SBME. Overall, these authors are skeptical of historical methods used to study medical simulation, but note that this is improving overall. Researchers suggest future research directions in medical simulation should focus on the following four components: feedback, deliberate practice, curriculum integration, and outcome measurement.[12][3] SBME research is reaching a turning point of methodological rigor for the better due to the recognition of prior literature being of poor design or power.[12][3]

The desire for improved simulation research in pediatrics has led to the development of research groups, including the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE) group, which is dedicated to advancing pediatric simulation training and research. In pursuing their mission, INSPIRE published a guideline for simulation-based research in 2014, and again reemphasize the difficulty in measuring patient outcomes of simulation training. They hope that the creation of registries of educational interventions will improve power and sample size of simulation studies to draw better conclusions from SBME research.[13] Answering a call to improve rigor in simulation research, the INSPIRE group has also been offering mentorships and fellowships to advance their mission.[14]

Curriculum Development

SBME has become an integral part of pediatric training programs. It is useful not only as a training tool but as a means of formative as well as summative assessments. The methodology of curriculum development, along with simulation delivery, has been explored in various studies, and some important principles are necessary to understand to maximize learning outcomes. 

Debriefing has invariably been thought of as a key tenet in simulation training and is an example of the utilization of simulation as a formative assessment tool. There is variability on how and when the debrief can occur, but should always focus on reflection with feedback delivered and a learner-centered plan to improve future performance.[15] Debriefing was the factor most cited in successful learning in a review of simulation best practices.[4]

Other best practice frameworks to consider when developing curricula in pediatric simulation include deliberate practice, mastery learning, and rapid cycle deliberate practice, all of which exemplify a means of summative assessment (i.e., comparing the learner performance to a benchmark and, ideally, to a minimum level of competency in a skill).

Deliberate practice provides learners with immediate feedback and coaching to allow necessary adjustments to their practice of a skill. Repetitive practice is a key component to deliberate practice and allows for multiple repetitive training/practice opportunities. This strategy has been applied in pediatrics for improved CPR performance and lumbar puncture success in pediatric residents.[16][17]

Mastery learning takes deliberate practice one step further; the learners practice the skill until they have reached a competency, meaning it is performed at a mastery level without coaching.[4] This process requires repetition that may take place in rapid succession or longitudinally over more extended periods. In pediatric resuscitation SBME, learning to mastery has been shown to result in significant skill attrition by six months in pediatric residents; therefore, frequent repetition, as previously mentioned, is essential for ongoing maintenance of skills.[18] A minimum level of competency must be achieved in courses like Pediatric Advanced Life Support (PALS) or Trauma Resuscitation in Kids (TRIK), a Canadian based pediatric trauma course, and simulation has assisted in both the learning steps and assessment of proficiency by integrating the above principles.[19] The RETAIN (resuscitation training) game is a board game that has been shown to improve knowledge retention for neonatal resuscitation but has been suggested for summative assessments and is an example of serious games developed for pediatric SBME.[20]

Some novel developments in SBME include rapid cycle deliberate practice, which combines the above learning principles into one instructional design. The learner proceeds with a scenario and is interrupted frequently or “paused” to receive corrective feedback from an expert and continues or starts over the scenario in a corrected way. The learner receives many chances to achieve mastery of the skills being taught. This method has been shown in pediatric residents to improve skill acquisition in resuscitation and septic shock management but has not demonstrated long term retention compared to other modalities.[16][21]

There are currently several published, expert-reviewed, simulation curricula in the field of pediatrics, notably in the fields of pediatric emergency medicine (PEM), and pediatric critical care; this includes longitudinal curricula for pediatric fellows, pediatric residents as well as emergency medicine residents.[22] Early pediatric simulation curricula focused on procedure skills, cardiopulmonary resuscitation, trauma, and disaster management. Newer innovative methodologies in PEM simulation added learning objectives surrounding both patient and family-centered care, breaking bad news, and medical error disclosure. Grant et al., also suggest the future of pediatric simulation curricula will include the utilization of the electronic medical record, extensive system-level integration, and the extension of programs into rural and community-based programs.[22]

Clinical Clerkships

The liaison committee on medical education (LCME) highly encourages the use of simulation in a medical student curriculum. It has been shown that the incorporation of high fidelity simulator-based scenarios into a third-year pediatric clerkship curriculum had high student satisfaction and led to improved objective structured clinical exam (OSCE) performance.[23]

Furthermore, there is a trend in medical student education to place greater emphasis on patient encounters early within a student’s training. As an example, a pre-clerkship pediatric simulation curriculum was implemented at Johns Hopkins that consisted of a 5-day simulation course, after which the shelf scores and procedure performance evaluations improved.[24] This curriculum first identified the needs of their learners, such as the appropriate cardiac exam, as this differs from adults, and other interviews and physical exam techniques helpful for children. The instructors then implemented a comprehensive curriculum to address these needs, including part-task trainers, mannequins, real children, and discussion format. Including the previously mentioned objective measures of performance, the students also much preferred the new curriculum over clinical time that was replaced.

Procedural Skills Assessment

The ACGME requires pediatric residents to gain competence in thirteen procedures, and despite formal training, studies show that residents desire more procedural training.[25] Given academic constraints, simulation provides an excellent outlet to expand and improve procedural confidence and competency among trainees, as well as to maintain skills for faculty.  

Classically observational checklists have been utilized in the assessment of procedural skills; the scores are then based on completed or omitted observed steps. Another form of competency assessment is a global rating scale (GRS), which provides a more global impression on a skill's performance [26]. Validated checklists and GRS are being developed in pediatrics to ensure standardized skill assessment.[27][28][13][29][30][31] Notably, these checklists and GRS measure competency in several pediatric-specific areas, including intubation, lumbar puncture, intraosseous access, bag-mask ventilation, and resuscitation skills. The advantage of using these tools includes the ability to compare the learner to a standard and peers, and if it has been validated, then the reliability of the checklist will also have been verified. Each tool offers its advantages and disadvantages, and the future of procedural assessment will likely utilize a combination of the two. 

Some high technology simulators such as mannequins and computer-based simulators can also provide real-time procedural feedback, including depth of compressions, bag-mask pressure, or timing of procedures. The usefulness of data like those mentioned in real patient practice, however, is not well understood. As Cheng et al. note, compressions on a mannequin do not translate well to appropriate compressions on a live infant.[13]

Further studies identifying standardized methods of evaluating procedure skills, solidifying time to skill decay, defining best practice for skill maintenance, and improved patient outcomes are several goals of future pediatric SBME.

Medical Decision Making and Leadership Development

An important skill to acquire in high acuity situations like pediatric resuscitation is the ability to communicate well within a team. A desire for more standard measures to evaluate communication skills has led to validated performance checklists to assist in pediatric resuscitation leadership evaluation.[32][33] Communication and control of a resuscitation scenario are featured prominently in these checklists. These checklists can help to provide formative feedback to a trainee and also to evaluate simulation curricula interventions within a research setting. 

Good communication skills can lead to improved teamwork in a healthcare setting. Teamwork has demonstrated to result in improved clinical performance after a simulation education intervention.[34] A simulation-based resuscitation curriculum, in turn, has also been shown to promote teamwork and communication amongst pediatric residents.[35]

In addition to communication with interdisciplinary teams, it is equally important for a pediatrician to communicate with patients and families. Standardized patients have shown to be an effective communication teaching tool for palliative care training in pediatric critical care fellows.[36]

Clinical Significance

There are many reasons pediatric SBME has increased in utilization, demand, and necessity over the past 20 years. One of the most important is medicine's increasing focus on patient safety. This has obvious implications on a trainee's experience, including the pressure of increased faculty supervision and a push for demonstration of competence. In line with improving patient safety includes a push to practice evidence-based medicine. A growing trend in medicine is the desire to reduce unnecessary interventions and decrease iatrogenic complications; specific to pediatrics is an interest in decreasing lumbar puncture rates in neonatal fever, increased utilization of bag-mask ventilation over intubation, and reduction in appendectomies for uncomplicated appendicitis to name a few.[37][38][39] While decreased unnecessary intervention is undoubtedly better for patient care, it will inevitably continue to lead to increasing education gaps in pediatric medical education. 

In addition to decreasing procedure necessity, medical students and residents are increasingly under work hour restrictions.[40] A transforming medical education space prioritizing work-life balance and mental health of medical trainees has the risk of less exposure to learning cases, and pediatrics already suffers from a lack of volume of high acuity resuscitation scenarios compared with adult specialties. This landscape change prioritizes high yield simulation education to improve exposure to rarely encountered cases/procedures in pediatrics without prolonging education time.

Pearls and Other Issues

• Simulation education had its roots in the aviation and space industry, but anesthesia advanced the modern renaissance of medical simulation; in the past 2 to 3 decades, simulation-based medical education has increasingly played an essential role in the field of pediatrics.
• Appropriate use of simulation technology for specific learning objectives requires careful consideration. 
• Several best practices of SBME include debriefing/feedback, deliberate practice, and mastery learning. 
• Simulation can be utilized for both formative and summative assessment.
• The debrief with dedicated feedback is cited as the most valuable part of the simulation session. 
• Deliberate practice involves direct, immediate feedback or coaching to ensure the practice is done correctly. 
• Mastery learning sets the minimum competency requirement goal for the learner to perform independently without coaching and is seen in ACGME residency requirements and other clinical and procedure skills training. 
• Rapid cycle deliberate practice is a form of deliberate practice that incorporates constructive criticism during simulation, but with each mistake or feedback, the simulation restarts to ensure the practice is done correctly.  
• Simulation is ideally suited to teach pediatric cardiopulmonary resuscitation skills, procedural skills, trauma, and disaster management.
• More innovative uses of simulation in pediatrics include the practice of delivering bad news, medical error disclosure, family-centered care, and system-integration.
• Medical student education and resident education will improve with early and frequent use of SBME specific to pediatrics that address learning gaps like differences in pathophysiology and training in rarely encountered procedures and clinical scenarios.
• Pediatric procedures can be taught to a minimum competency by using validated checklists and/or Global Rating Scales to measure learner performance. 
• Simulation can assist in evaluating is communication skills. With an improvement in communication and teamwork skills, patient outcomes can be improved. 
• Increasing demand for simulation education is being driven by increased work hour restrictions, increased safety measures, and decreased exposure to high acuity patient scenarios.

Enhancing Healthcare Team Outcomes

Simulation-based medical education is an evolving area of growth in training medical personnel, particularly because of the demand for increased efficiency of training time. Multiple fields of medicine, including clinicians and nurses, are focusing attention on improving simulation education. A focus on high-quality simulation ensures the best outcomes of educational interventions.[16][21] [Level 5, 2]

Multiple personnel in-training can be involved in the implementation of a medical simulation curriculum, particularly when it comes to training to improve teamwork among nurses, clinicians, and pharmacists. Indeed, communication skills are an important skill to acquire to be an effective leader of a team and enhance teamwork in medicine. Simulation has been used to enhance team communication in pediatric healthcare settings and demonstrate improved patient outcomes.[35][34] [Level 5]