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Barriers to use of simulation-based education

ARTICLE in CANADIAN JOURNAL OF ANAESTHESIA · DECEMBER 2005

Impact Factor: 2.5 · DOI: 10.1007/BF03022056 · Source: PubMed

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944 GENERAL
CANADIAN JOURNAL ANESTHESIA
OF ANESTHESIA

Barriers to use of simulation-based education

[Les barrières à l’utilisation de la formation basée sur simulateur]
Georges L. Savoldelli MD MEd,*† Viren N. Naik MD MEd FRCPC,*† Stanley J. Hamstra PhD,*‡
Pamela J. Morgan MD CCFP FRCPC§

Purpose: Barriers to simulation-based education in postgradu- Objectif : Les barrières à la formation fondée sur la simulation en
ate and continuing education for anesthesiologists have not enseignement universitaire supérieur et en formation continue pour
been well studied. We hypothesized that the level of training les anesthésiologistes ne sont pas bien connues. Nous avons émis
may influence attitudes towards simulation-based education l’hypothèse que le niveau de formation pouvait influencer l’attitude
and impact on the use of simulation. This study investigated this face à ce type de formation et avoir un effet sur l’utilisation de la
issue at the University of Toronto which possesses two sites simulation. Notre étude a été réalisée à l’université de Toronto qui
equipped with high-fidelity patient simulators. possède deux sites équipés de simulateurs de haute fidélité.
Methods: A 40-question survey of experiences, perceptions, Méthode : Un questionnaire de 40 questions sur les expériences,
motivations and perceived barriers to simulation-based education, les perceptions, les motivations et les barrières perçues de la for-
was distributed to 154 anesthesiologists attending a departmental mation par simulation a été distribué à 154 anesthésiologistes en
conference. Data were analyzed using descriptive statistics and réunion départementale. Les données ont été analysées par des
associations between responses were assessed using either the statistiques descriptives et les liens entre les réponses par le test
Chi-Square statistic or a one-way analysis of variance. chi-deux ou une analyse simple de la variance.
Results: The rate of response was 58%. Residents had experi- Résultats : Le taux de réponses a été de 58 %. Les résidents
enced simulation-based education (96%) more often than staff avaient plus d’expérience de la simulation (96 %) que les spéciali-
(58%) and fellows (36%), (P < 0.001 respectively). Residents stes (58 %) et les boursiers (36 %), (P < 0,001 respectivement).
had also attended more simulation sessions than staff and fellows Les résidents avaient aussi assisté à plus de sessions de simulation
(mean 2.8 vs 1.05 and 1.04, P < 0.001 respectively). Residents que les spécialistes et les boursiers (moyenne de 2,8 vs 1,05 et
and fellows found simulation-based education more relevant for 1,04, P < 0,001 respectivement). Les résidents et les boursiers
their training than staff (88% vs 65%, P < 0.05). Eighty-one per- ont trouvé la simulation plus pertinente que les anesthésiologistes
cent of the respondents identified at least one significant barrier (88 % vs 65 %, P < 0,05). Parmi les répondants, 81 % ont
that prevents or limits them from attending simulator sessions. reconnu au moins une barrière importante qui empêche ou limite
Staff anesthesiologists perceived multiple barriers and identified la participation à des sessions de simulation. Les spécialistes ont
‘time’ and ‘financial issues’ as significant barriers. perçu de multiples barrières significatives dont le «temps» et «les
Conclusion: Anesthesiologists’ level of training influences their questions financières».
attitudes towards and their perceptions of simulation-based Conclusion : Le niveau de formation des anesthésiologistes in-
education. This survey has identified perceived barriers that fluence l’attitude face à la simulation et leurs perceptions de la
may limit a wider utilization of simulation. These results may formation par simulation. Les limites à un plus grand usage de la
be used to implement targeted actions such as course design, simulation, reconnues dans l’enquête, pourraient servir à des inter-
incentives, and information strategies, which could improve ventions ciblées comme l’organisation d’un cours, des incitatifs et
access and future use of simulation. des stratégies d’informations pour améliorer l’accès à la simulation
et son usage futur.

From the Wilson Center for Research in Education Faculty of Medicine;* the Department of Anesthesia,† St. Michael’s Hospital; the
Departments of Surgery,‡ and Anesthesia,§ Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Toronto,
Ontario, Canada.
Address correspondence to: Dr. Georges L Savoldelli, Department of Anesthesia, St. Michael’s Hospital, 30 Bond Street, Toronto,
Ontario M5B 1W8, Canada. Phone: 416-864-5071; Fax: 416-864-6014; E-mail: [Link]@[Link]
Reprints will not be available from the author.
Accepted for publication May 3, 2005.
Revision accepted June 3, 2005.

CAN J ANESTH 2005 / 52: 9 / pp 944–950

Savoldelli et al.: BARRIERS TO SIMULATION 945

O
VER the last decade, there has been a
tremendous growth in the use of high-
fidelity simulators worldwide.1 Many
universities across North America and
Europe are considering purchasing this technology
or have recently acquired simulator facilities. Within
the specialty of anesthesia, simulation has been used
for various educational purposes, including anesthesia
crisis resource management (ACRM), advanced life
support algorithms, rare events, airway management,
and technical skills to name a few. These education
events exist for a wide range of levels of training and
experience.1–6
Anesthesiologists find simulation learning experi-
ences rewarding, valuable and likely to have positive
influences on their clinical practice.7,8 At the same FIGURE Age distribution according to the level of train-
time, they also find this education stressful and ing.
intimidating.9 Interestingly, little is known about the
motivations that attract them towards this learning
modality or about the perceived barriers that may
deter them from it. Studies on conventional continu-
ing education have shown that factors such as age and a good representation of every level of training in a
position may influence anesthesiologists’ attitudes and convenient way.
perceived barriers towards continuing education.10 The survey was developed by the authors and
Drawing from our personal experiences as educators piloted on ten different occasions to guarantee clarity
involved in simulation, we hypothesized that these and absence of ambiguity of the questions. Answers
factors may similarly affect anesthesiologists’ attitudes to open-ended questions in the pilot surveys were also
towards simulation-based education. used to generate additional closed questions for the
Considering the potential implications for the final survey. The questionnaire was self-administered
dissemination of this educational modality and the and anonymous and was designed to gather informa-
accessibility to simulation, we decided to test this tion regarding demographics, previous experiences,
hypothesis and conducted this survey at our univer- perceptions, motivation and perceived barriers related
sity. Currently, the Department of Anesthesia at the to simulation as an educational modality (Appendix,
University of Toronto benefits from two simulation available as Additional Material at [Link]).
centres fully equipped with high fidelity mannequins Data were entered into a spreadsheet and analyzed
in a mock operating room. Since 1995, educational using SSPS 10.0 (Chicago, IL, USA). Traditional
sessions have been offered to medical students, resi- descriptive statistics were used to examine the data
dents, academic anesthesiologists, and community- and the responses to various questions were cross-tab-
based anesthesiologists. The purpose of this study ulated. Responses derived from five point Likert scales
was to investigate anesthesiologists’ previous experi- (1 = strongly disagree; 2 = disagree; 3 = undecided; 4
ences, perceptions, motivations and perceived barriers = agree; 5 = strongly agree) were classified into three
related to simulation as an educational modality, and categories: either disagree (1 or 2), undecided (3),
to determine if the level of training of the responders or agree (4 or 5). Associations between responses
influences their opinions. to different questions were assessed using either the
Chi-square statistic or a one-way analysis of variance,
Methods depending on the nature of scale. A P < 0.05 was
Following Institutional Research Ethics Board approv- considered significant.
al, a 40-item questionnaire was distributed to 154
anesthesiologists attending a departmental conference Results
in 2004. The participants were staff, fellows and resi- Responses and demographics
dents currently working in all hospitals affiliated with Forty staff anesthesiologists, 22 fellows, and 27 resi-
the University of Toronto. This method of sampling dents returned the questionnaire for a response rate of
was chosen because it was felt that it could guarantee 58%. The Figure summarizes the age distribution of the
946 CANADIAN JOURNAL OF ANESTHESIA

TABLE I Experience and participation in simulation education according to the level of training

Residents Fellows Staff Significance

Respondents who had participated in simulation training (%) 98 36 58 P < 0.001 (χ2)
Respondents who had participated in simulation within the last 2 yr (%) 93 27 15 P < 0.001 (χ2)
Number of simulation sessions attended (mean ± SD) 2.8 ± 1.4 1.0 ± 1.9 1.1 ± 1.3 P < 0.001
(ANOVA)

TABLE II Proportion of responders who classify a given course content as a high priority

Opportunities to manage rare events (e.g., malignant hyperthermia, anaphylaxis) 81%

Teaching non-technical skills (ACRM principles, decision making) 62%
Practicing and learning guidelines and algorithms (airways, ACLS, ATLS) 61%
Fostering teamwork and involving other professionals (surgeons, nurses, etc.) 48%
Teaching technical skills (e.g., airways, chest tubes, etc.) 25%
Proportions show overall responses as there was no difference between faculty, residents or fellows. ACRM = anesthesia crisis resource
management; ACLS = advanced cardiac life support; ATLS = advanced trauma life support.

respondents according to their level of training. The What type of simulation-based education is relevant to
proportion of female responders among residents, fel- anesthesiologists?
lows and staff was 30, 27 and 33% respectively. In our Five possible "course content" items were suggested.
department, the average age of residents, fellows, and Responders were asked to prioritize these suggestions
staff is 31, 35, and 46 respectively, and the proportion according to their relevance for their own education.
of women is 29, 27, and 30% respectively. Therefore, A four-point rating scale (1 = not a priority, 2 = low
in terms of age and gender, the sample was found to priority, 3 = medium priority, 4 = high priority) was
be representative of the study population. With one used. The proportion of responders who classified a
exception, all responders were based predominantly given course content as a high priority is displayed in
in a university-based practice within the last year. Foci Table II. There was no difference in course content
of anesthesia practice consisted of all types of surgi- prioritization between faculty, residents or fellows.
cal intervention (74%), specialized anesthesia (24%),
intensive care (6%), and pain management (9%). In Perceptions of simulation-based training and willing-
addition to their clinical activity, 78% of the staff, 27% ness to go or return to the simulation centre
of the fellows, and 11% of the residents reported at Overall the majority of the responders agreed that
least one other academic responsibility (i.e., involve- simulation may contribute to patient safety (85%),
ment in administration, research, or education). is a useful educational technology (85%), and offers
advantages over more traditional training (79%).
Experience and participation in simulation education There was a significant association between holding a
Table I summarizes responders’ experiences and par- trainee position (resident or fellow) and 1) willingness
ticipation in simulation-based education stratified by to go or return to the simulation centre (trainees 90%
their level of training. Overall, residents were more vs staff 68%, P < 0.05), 2) finding simulation-based
likely to have participated in simulation-based training education relevant for one’s own training (trainees
and experienced simulation more often and recently 88% vs staff 65%, P < 0.05), and 3) supporting the
than staff and fellows. Amongst the responders who mandatory use of simulation during residency (train-
had participated in simulation-based education, the ees 84% vs staff 58%, P < 0.05).
vast majority (92%) agreed that its educational value
was good and that it was an enjoyable experience Simulation and continuing medical education (CME)
(86%). However, only one third thought that simu- Two-thirds of the responders (including 58% of the
lation training had influenced their clinical practice, staff) agreed that simulation should be recommended
with the majority being undecided. for CME, while 26% were undecided. However,
less than half of the staff (45%) were aware that
Maintenance of Certification credits (MainCert cred-
its) are currently granted when attending simulation-
Savoldelli et al.: BARRIERS TO SIMULATION 947

TABLE III Proportion of responders who selected the suggested reasons to the question: "What would increase your likeli-
hood of attending a simulation-based course?"

The provision of an individual evaluation profile (strengths and weaknesses) for my personal use 64%
If the course were given in my own hospital (e.g., mobile simulation centre in a trailer) 48%
The provision of a certificate that would reduce malpractice insurance premium 43%
If more MainCert credits were given per hour of simulation time 36%*
The provision of a ranking that compares my performances to others (for my personal use) 34%
Others (open ended comment) 10%
*Associated with holding a staff position (P < 0.05 (χ2). MainCert = Maintenance of Certification credits.

TABLE IV Proportion of staff and trainees (residents and fellows combined) who perceived barriers to simulation-based
training and association with the level of training

Perceived barrier Staff (n = 40) Trainees (n = 49) Significance (χ2)

Perceive at least one barrier (%) 90 73 P < 0.05

Number of perceived barriers (mean ± SD) 1.8 ± 1.1 1.3 ± 1.2 NS*
"Lack of free time" (%) 55 33 P < 0.05
"Financial consequences of missing work" (%) 18 0 P < 0.01
"Lack of training opportunities" (%) 23 39 NS
"Stressful/intimidating environment" (%) 25 22 NS
"Fear of educator’s/peer’s judgments" (%) 25 18 NS
"Fear of inaccurate reflection of clinical ability" (%) 25 12 NS
"Distance to simulation centre" (%) 8 8 NS
NS = not significant. *Comparison performed by ANOVA.

based education. time" and "financial consequences of missing work"

as a barrier. The lack of "publicized courses" and
Potential incentives and motivations "policy promoting this type of education" were men-
Five possible reasons were suggested as potential tioned in the open-ended comments section. Table IV
motivations or incentives to increase the likelihood of summarizes the type of barriers and their association
attending a simulator-based course. Table III shows with the level of training.
the proportion of responders who selected the various
responses. Except for the provision of more MainCert Discussion
credits, which was associated with holding a staff posi- Our results indicate that anesthesiologists value simula-
tion (P < 0.05), no other significant association with tion-based education. However, they perceive barriers
the level of training was present. In the open-ended to this type of training. A significant proportion of the
comments, 10% of the responders mentioned other responders feared educators’ or peers’ judgments and
potential incentives which varied from "having time were concerned by the stressful and intimidating envi-
booked for it", "receiving financial compensation", to ronment created in the simulator setting. Compared
"increased accessibility and course offering". with trainees, staff anesthesiologists had less experience
with simulators, found it less relevant for their current
Perceived barriers training, and perceived more barriers.
Respondents were asked if they perceived significant Simulation, using high-fidelity mannequins in
barriers that prevent or limit them from pursuing a realistic environment, is being increasingly used
simulator-based education. A list of nine potential bar- in undergraduate, postgraduate and CME.3,6,11–15
riers, including a "none" and an "other/open ended" Anesthesia has been and remains among the leading
category was suggested. Eighty-one percent of the specialties in the field, and the number of anesthesia
respondents identified at least one significant barrier. simulation centres worldwide is increasing exponen-
Compared with trainees, staff anesthesiologists were tially.1 The University of Toronto has over a decade
more likely to perceive at least one barrier (P < 0.05) of experience with simulation based education. Ten
and although not significant, on average they per- years ago, when simulation was emerging in North
ceived more barriers. Holding a staff position was also America, Kurrek et al. surveyed anesthesiologists’
significantly associated with considering "lack of free opinions.9 They showed that despite significant antic-
948 CANADIAN JOURNAL OF ANESTHESIA

ipated anxiety, anesthesiologists were enthusiastic riculum, the latter must plan his/her own continuing
about the use of simulation. However, a large majority education according to individual needs. Simulation-
of the responders had not been exposed to the simula- based education is mandatory at our university during
tion environment. Interestingly, staff anesthesiologists undergraduate clerkship rotation and during resi-
that had taken the ACRM course at the time recom- dency, but it is completely optional at the CME level.
mended that it should be taken on average every 18 Our findings that more residents have participated in
months. Ten years later, this survey suggests that simulation are therefore not surprising. At the CME
simulation has largely failed to establish itself as a reg- level, the learner has a great deal of autonomy and
ular educational activity at the CME level. Our results choice. In this context, age and familiarity can influ-
show that although there is general agreement that ence the type of CME activity and it has been sug-
simulation should be part of CME, simulation is not gested that perceived barriers may impact continuing
a regular CME activity among staff anesthesiologists. training.10,16 In our survey, staff were not only older
Only 58% of the staff had ever participated in simula- but they also perceived more barriers than trainees.
tion-based training, and only 15% participated within It is possible that these barriers, combined with the
the last two years. Conversely, simulation appears absence of mandatory participation at the CME level,
very well entrenched during residency training. One have contributed to the relative lack of success of
explanation for the difference in participation is that simulation for CME.
simulation was not found to be as relevant for staff as This study is the first to specifically explore the
it is for trainees (65% and 88% respectively, P < 0.05). perceived barriers to simulation among anesthesiolo-
However, both faculty and trainees identified similar gists. The most common barrier for staff was the "lack
course content as relevant to their education. of free time". The most common barrier for trainees
The reasons to participate in educational activi- was the lack of training opportunity, even though
ties differ between staff and trainees. For faculty, the they had participated more often in simulation-based
relevance for clinical practice and the need to keep education than staff. Compared with trainees, staff
up to date with new technology are important moti- clearly perceived more barriers, and not surprisingly
vations at the CME level.10,11,16 Simulation has the identified "lack of free time" and "financial issues" as
potential to meet these needs. As educators, our role significant barriers.
is to provide course content and learning objectives Other perceived barriers included the stressful and
that are relevant and adapted to the level of training intimidating environment, the fear of educator’s or
of the learners. Simulation is such a versatile educa- peer’s judgment, and the fear of an inaccurate reflec-
tional tool, that the way we use it is even more impor- tion of one’s own clinical ability. It is recognized
tant than the tool itself. In ACRM type courses for that a simulated scenario may be stressful, may trig-
example, the emphasis is put on non-technical skills ger strong emotions, and may increase the number
that have been identified as major determinants of of errors committed by the participant. The issues
successful anesthesia crisis management.17 These skills of having one’s performance analyzed and reflected
encompass cognitive skills and interpersonal skills that upon from a critical perspective can be very daunt-
are not necessarily acquired and practiced through ing. Nonetheless, this ability highlights the power and
routine clinical experience. Ideally, they should be the strength of high-fidelity simulation. Simulation
specifically taught and regularly practiced by anes- sessions provide the venue to commit errors and to
thesiologists independent of their level of training.5 reflect on them.15 Since stress and emotions are gen-
Simulated scenarios followed by reflection, feedback, erated, the overall learning experience is potentially
and the opportunity to practice again, offer the ideal more intense and more effective. Recognizing those
environment to teach and refine those skills. Equally assets is relatively easy, but implementing them suc-
relevant for the fully trained anesthesiologist is the cessfully and getting them accepted are more difficult.
fact that the simulation room can be used as a risk This issue is at the heart of a much broader problem
free environment for interactive, hands-on training within the health care system. In fact, it illustrates how
involving the use of new medical equipment, devices, difficult it is to move away from an inherited culture
or drugs. Therefore, there is no reason why simulation of silence and blame when an error is made to a new
should be less relevant for the continuing education of "culture of safety", where error disclosure and error
more experienced anesthesiologists. analysis are central tenets.15,18 It has been argued
Another important difference between a trainee that simulation-based education has the potential to
and a staff anesthesiologist, in terms of education, promote this new culture.7,15,18 Unfortunately, our
is that while the former follows a predefined cur- results suggest that the existing culture threatens the
Savoldelli et al.: BARRIERS TO SIMULATION 949

acceptance of simulation-based education. The imple- education in a university setting. These results may
mentation of simulation-based education should ide- help in developing targeted actions such as improved
ally be part of a system and organizational approach course design, incentives, and marketing strategies,
to quality improvement and patient safety, where both which could improve access and future utilization of
approaches reinforce and nurture the other. simulation. Better access to simulator-based education
This type of cultural change is a slow process, but may translate into enhanced performances in the clini-
the type of education one receives can influence it cal setting, and potentially improve patient safety.
favourably. It is therefore possible that as residents and
younger trainees experience high-fidelity simulation, References
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