North Dakota Nursing Education Consortium. Impact of Legislative Support for High-Fidelity Simulation. February, 2012

Transcription

1 North Dakota Nursing Education Consortium Impact of Legislative Support for High-Fidelity Simulation February, 2012 Patricia Moulton, PhD Sheila Johnson, BS North Dakota Center for Nursing Research Publication #1 Funding for this study was provided by the North Dakota Nursing Education Consortium as a part of North Dakota legislative appropriated funding. 1

2 Contents Executive Summary 3 Introduction 4 Assessment Procedure 5 Results 6 References 19 2

3 Executive Summary The North Dakota Nursing Education Consortium composed of all of the nursing education programs in North Dakota has over the last four years worked to develop greater opportunities to incorporate high-fidelity human patient simulation. The use of simulation in the training of future nurses has several benefits including the ability to practice clinical situations in a safe environment, especially when patient census can be a constricting factor in expanding clinical practice sites in some rural areas of the state. Information about the use of simulation in all ND nursing education programs has been collected in 2005 and in 2010 through interviews and through a survey in late These results are presented in this report along with comparisons with existing information from similar data collection conducted in Illinois and Florida in Primary findings include: A marked increase in the use of high-fidelity human patient simulators from 25% of nursing programs to 87% in In comparison, only 55% of Florida human patient simulation centers and 66% of Illinois nursing programs utilize this level of simulation. In addition, most ND programs have the ancillary equipment needed to conduct sessions including video cameras for videotaping sessions for debriefing. Little space is available for simulation across all nursing programs. ND programs have an average of ¼ of the space as compared to Florida programs. This limits program s ability to have quality simulation sessions. ND nursing programs have utilized simulation equipment across several courses including health assessments, skills, medical-surgical and maternal-newborn courses. This includes for skills practice and demonstration, validating skills to determine competency and for practicing critical thinking and decision making. ND nursing programs have started to utilized simulation to substitute for direct patient care experiences, particularly in pediatric course work. ND nursing programs have nearly doubled the number of available high-fidelity simulators in programs over the last four years including the addition of more adult, birthing and child/adolescent simulators. Faculty and students have indicated that the simulators have had a great impact on their programs. This includes more creativity in presenting class materials and practice and excitement by students that have the opportunity to practice skills in a safe environment. ND nursing programs have also indicated barriers including the addition to faculty workload from learning, planning and carrying out simulation sessions and the need for more training and technical support. 3

4 Introduction What is Simulation? Simulation is designed to imitate the clinical environment and provides the opportunity for the student to demonstrate knowledge and skills learned within their education program as well as the opportunity to practice decision making and critical thinking (Li, 2007; Decker et al., 2008). Several studies have demonstrated that simulation training allows the training agenda to be determined by the needs of the students and not the patients; that it is a safe learning environment to practice rare and critical events (Decker et al, 2008); and that it provides objective feedback to students (Good, 2003; Kneebone, 2003). Several studies have found simulation to be an effective way to increase clinical competence, to build confidence in skills in a supportive environment and providing repetitive practice which can help speed acquisition of skills (Steadman et al., 2006; Gordon et al., 2001; Maran & Glavin, 2003), enhance technical, behavioral and social skills (Small et al., 1999) and provide reflective learning through debriefing feedback (Gaba, 2000). There are many different types of simulation available for nursing education programs (Sole & Guimond, 2010). These include: Task Trainer: anatomical models designed to practice a specific skill such insertion of IVs Static mannequins- a mannequin designed to practice a specific set of skills, is not connected to a computer and is also labeled low-fidelity Human patient simulator- computerized mannequin that provides the ability to mimic a range of clinical conditions and provides physiological feedback to the student, also labeled high-fidelity Virtual Reality- multi-sensory environment that is computer generated and allows student to interact within the environment and allows the student to experience clinical conditions or train in particular skills in the virtual world. Standardized patients- trained individuals that act out medical conditions and scenarios and allows students to practice interviewing and physical examination skills. North Dakota Nursing Education Consortium The North Dakota Nursing Education Consortium was created by the ND legislature in the biennium to provide simulation support to all nursing education programs in North Dakota including publically funded, private funded and tribal programs. Members of the Consortium include the department or college of nursing at: University of North Dakota (lead) North Dakota State University North Dakota State College of Science Jamestown College Dickinson State University United Tribes and Technical College Fort Berthold Community College Williston State College University of Mary Minot State University Lake Region State College MedCenter One College of Nursing Bismarck State College Sitting Bull College Dakota College- Bottineau 4

5 During the Biennium, $500,000 in funding was utilized to purchase high-fidelity simulation equipment at each of the programs. This report details how the simulation equipment has been utilized within the programs, success and barriers encountered and further assistance needed. Assessment Procedure This report includes information from three assessments of simulation use in nursing education programs in North Dakota. In 2005, all nursing education programs were interviewed regarding their use of a range of instructional technologies including synchronous and asynchronous distance learning, simulation, overall level of technology utilization and faculty/student readiness. In January 2010, all of the programs were interviewed again to determine changes over the last five years. The current report incorporates simulation specific findings from these two sets of interviews. For the full reports including interview methods see Lang & Moulton (2010) and King & Moulton (2005) at In December 2010, all programs received an online survey that was designed to measure the impact of the nursing education consortium funding on the incorporation of simulation in nursing programs and to provide a set of quantitative data regarding simulation use. The survey tool was developed based on similar surveys in Florida (Sole, Guimond & Amidei, 2010) and Illinois (Roberts, 2010). 5

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7 Results In 2010, all ND nursing programs utilized task trainers and static mannequins which are considered low-fidelity simulation and 87% utilized human patient simulators (see Figure 1). In 2005, 25% of programs had started to use human patient simulation and 25% were working on installing new simulators at the end of the year (King & Moulton, 2005). In comparison, 66% of Illinois nursing programs utilize human patient simulators (Roberts, 2010). Fifty-five percent of Florida simulation centers utilize human patient simulators and nearly 8 utilize static mannequins and task trainers (Sole, Guimond & Amidei, 2010). Figure 1: Current Use of Technology Virtual Reality 14% 47% Human Patient Simulator 55% 87% Static Mannequin 8 10 Task Trainer 79% FL ND Nursing programs had an average of 510 square feet for simulator space which included the space allocated for all of their program s simulators, technical equipment including computers and video cameras (if used) and space for students and faculty. There was a wide range of space between programs in North Dakota with one program utilizing nursing lab space for their simulator (48 square feet for simulator) to a few programs with separate simulator, control and debriefing rooms (approximately 1,200 to 1,700 square feet). The amount of space allocated to simulation has increased in the last two years in 6 of the nursing programs. In many cases, office or classroom space was re-allocated to simulation lab space, some with funding from their college/university. One program converted a former dorm room into a simulation lab and a few are building new labs. In Florida, the average simulation space was 1,916 square feet (Sole, Guimond & Amidei, 2010) with a range between 50 and 13,495 square feet. 7

8 In 2010, most ND nursing education programs had video cameras, control panels and microphones for running simulations (see Figure 2). In most cases, this equipment came with simulators when they were purchased. Two programs had not been able to fully utilize this equipment due to lack of space and faculty time. Few programs had equipment to stream or transmit simulations to another room or archival equipment to store simulations. In comparison, simulation centers in Florida had much less supportive equipment (Sole, Guimond & Amidei, 2010). Figure 2: Additional Simulation Equipment Archival equipment Streaming equipment 13% 1 33% 33% Control panel for scenerios Microphones 21% 27% 75% 75% Video cameras 31% 83% FL ND A few nursing programs have shared their simulation lab with another program or a health care facility. This includes allowing clinical faculty to use the simulation lab to increase competencies, sharing a birthing simulator with a local hospital, using simulators during high school career days, and for training nursing aides. Simulation is one component of the curriculum to develop students critical thinking for safe nursing practice. North Dakota Nursing Education Program 8

9 ND nursing programs have utilized high-fidelity simulation equipment in a wide range of courses with the greatest utilization (93%) in skills courses, maternal-newborn and medicalsurgical (see Figure 3). Florida simulation centers have utilized the simulation equipment for coursework less frequently with 8 utilizing equipment for medical-surgical and 64% in maternal-newborn (Sole, Guimond, Amidei, 2010). Please note that not all nursing education programs offer all courses. Details regarding the use of high-fidelity simulation in each of these courses are below. Figure 3: Utilization of High-Fidelity Simulation Equipment in Courses Thirteen nursing programs utilized high-fidelity simulation in their health assessment course (87%), including seven LPN, three ADN, six BSN, one NP, one CRNA and one CNS program. Simulation was used primarily for skill practice/demonstration and skill validation/competency (see Figure 4) and was used to substitute for direct patient care experiences in two programs. In addition, two nursing programs indicated that they have trained LPN and one nursing program has trained RN staff in health assessment using simulation equipment. Figure 4: Use of High-Fidelity Simulation in Health Assessment Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training 8% 8% 8% 23% 23% 31% 46% 69% 92% 9

10 Fourteen programs utilized high-fidelity simulation in their skills-focused courses such as basic and advanced practice skills courses (93%), including seven LPN, three ADN and seven BSN programs. Simulation was used primarily for skill practice/demonstration and skill validation/competency (see Figure 5) and was used to substitute for direct patient care experiences in two programs. In addition, two nursing programs indicated that they have trained LPN staff, and one program has trained RN staff on basic or advanced skills using simulation equipment. Figure 5: Use of High-Fidelity Simulation in Skills-Focused Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training 7% 21% 36% 86% 79% Fourteen nursing programs utilized high-fidelity simulation in their maternal-newborn courses (93%), including five LPN, five ADN and six BSN programs. Simulation was used primarily for skill practice/demonstration and critical thinking/decision making (see Figure 6) and was used to substitute for direct patient care experiences in five programs. In addition, three nursing programs indicated that they have trained LPN staff and five nursing programs have trained RN staff on maternal-newborn skills using simulation equipment. Figure 6: Use of High-Fidelity Simulation in Maternal-Newborn Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training 7% 7% 21% 21% 29% 36% 71% 93% 93% 10

11 Eight nursing programs utilized high-fidelity simulation in their pediatric courses (53%), including three LPN, three ADN and five BSN programs. Simulation was used primarily for skill practice/demonstration and critical thinking/decision making (see Figure 7) and was used to substitute for direct patient care experiences in two programs. In addition, one nursing program indicated that they have trained LPN staff and one nursing program has trained RN staff on pediatric skills using simulation equipment. Figure 7: Use of High-Fidelity Simulation in Pediatrics Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training 25% 5 38% 13% Fourteen nursing programs utilized high-fidelity simulation in their medical-surgical courses (93%), including seven LPN, five ADN and seven BSN. Simulation was used primarily for critical thinking/decision making, skill practice/demonstration and skill validation/competency (see Figure 8) and was used to substitute for direct patient care experiences in three programs. In addition, three nursing programs indicated that they have trained LPN staff and three nursing programs have trained RN staff on medical-surgical skills using simulation equipment. Figure 8: Use of High-Fidelity Simulation in Medical-Surgical Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training 29% 29% 14% 21% 14% 7% 86% 86% 10 11

12 Four nursing programs utilized high-fidelity simulation in their perioperative/anesthesia courses (27%), including two ADN, two BSN and one CRNA program. Simulation was used primarily for skill practice/demonstration, skill validation/competency and critical thinking/decision making (see Figure 9) and was used to substitute for direct patient care experiences in zero programs. In addition, one nursing program indicated that they have trained RN staff on perioperative/anesthesia skills using simulation equipment. Figure 9: Use of High-Fidelity Simulation in Perioperative/Anesthesia Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training 25% 25% 25% Twelve nursing programs utilized high-fidelity simulation in their critical care courses (8), including two nursing assistant, five LPN and seven ADN programs. Simulation was used primarily for critical thinking/decision making, skill practice/demonstration and skill validation/competency (see Figure 10) and was used to substitute for direct patient care experiences in two programs. In addition, one nursing program indicated that they have trained LPN staff and three nursing programs have trained RN staff on critical care skills using simulation equipment. Figure 10: Use of High-Fidelity Simulation in Critical Care Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training 25% 33% 8% 17% 8% 17% 75% 75% 10 12

13 Five nursing programs utilized high-fidelity simulation in their mental health courses (33%), including one LPN, two ADN and two BSN programs. Simulation was used primarily for critical thinking/decision making and skill practice/demonstration (see Figure 11) and was used to substitute for direct patient care experiences in zero programs. In addition, one nursing program indicated that they have trained LPN staff and one nursing program has trained RN staff on mental health skills using simulation equipment. Figure 11: Use of High-Fidelity Simulation in Mental Health Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training Two nursing programs utilized high-fidelity simulation in their outpatient/home health/public health courses (13%), including two ADN and two BSN programs. Simulation was used primarily for critical thinking/decision making, training in new specialty/new clinical units and in multi-disciplinary team training (see Figure 12) and was used to substitute for direct patient care experiences in zero programs. In addition, two nursing programs indicated that they have trained RN staff on outpatient/home health/public health skills using simulation equipment. Figure 12: Use of High-Fidelity Simulation in Outpatient/Home Health/Public Health Courses Orientation Skill practice/demonstration Skill validation/competency Critical thinking/decision-making Substitution for clinical absence Refresher training Training in new specialty/new Education/training for Multi-disciplinary team training

14 Few programs have utilized their simulation lab for interdisciplinary training, although several programs plan to or have started working on building relationships with other disciplines to start joint simulations. Sixty-two percent of programs indicated an interest in developing multidisciplinary simulations. Approximately 1/3 of nursing programs have utilized high-fidelity simulation to augment or replace clinical time or to simulation complex, multi-system situations. Programs that have used simulation to augment or replace clinical time incorporated a total average of 23 hours of adult simulation in which is similar to the 22.7 hours anticipated in For pediatric simulation, in programs included 12.5 hours of simulation time and plan to include an average of 12 hours of simulation time in Nursing programs have also included several hours of multi-system, complex simulation (see Figure 13). Figure 13: Average Number of Hours of Clinical Time Used by Simulation Multi-System (complex) 11.4 Augment Clinical Time 16 7 Replace Clinical Time Multi-System (complex) 12.5 Augment Clinical Time Replace Clinical Time Adult (fundamental/basic) Pediatric Multi-System (complex) Some barriers to using simulation equipment include the high cost of the simulation equipment, lack of technical support and enough faculty trained on the simulation equipment (Lang & Moulton, 2010). Currently, only one nursing program has a simulation coordinator, and this one coordinator contributes 2 of their effort to simulation within their program. We need someone dedicated to the simulator. North Dakota Nursing Education Program 14

15 Scenarios are the programming and instructions used to run simulation equipment for a particular simulated condition or situation in a learning situation. For example, a scenario could be written to simulate a cardiac arrest. The scenario would include the instructions for the computer interface and the simulator, the supplies needed and the interaction of the simulation with the students and faculty. Currently, most programs (92%) utilized pre-packaged scenarios that come with the simulation equipment from the vendor (see Figure 14). In comparison, 58% of nursing simulation centers in Florida use pre-packaged scenarios (Sole, Guimond & Amidei, 2010). Figure 14: Use of Scenarios Write own scenerios 46% 66% Modify scenerios developed by others 42% 69% Use "open source" or shared scenerios 21% 31% Use pre-packaged scenerios from vendor 58% 92% FL ND ND programs indicated that high-fidelity scenario sessions range from minutes to four hours. Debriefing sessions following a scenario range from minutes. Faculty identified several challenges to using pre-packaged scenarios or using scenarios designed by others including faculty time needed to adapt scenario to their lab equipment/resource, the inability to change medications, treatment and overall objectives during the simulation and the faculty expertise and time needed to modify scenarios. Primary barriers identified for developing own scenarios included time to develop and trial the new scenarios and the faculty expertise to write them. Setting up and staging the scenario properly can be a challenge. North Dakota Nursing Education Program 15

16 Nursing programs have nearly doubled the number of high-fidelity simulators from a total of 14 to 27 simulators utilizing Nursing Education Consortium funds (see Figure 15). Back in 2005, nursing programs had only two adult simulators in use. Figure 15: High-Fidelity Simulators Available Due to Education Consortium Funding Adult Simulator 6 7 Vitalsim 5 11 Child/Adolesent Simulator 1 4 Baby/Newborn Simulator 1 0 Birthing Simulator with low-fidelity newborn 1 5 Previous Simulators Purchased with Funding Note: Adult simulators include Metiman, Emergency Care Simulator, Simman, Nursing Anne Vitalsim, and Susie products. Vitalsim simulators include Nursing Annie, S2000 Suzie, and Vital Sim Complete. Child/Adolescent simulators include PediaSim, Pediatric HAL 1 and 5 year and Nursing Kid (vitalsim capable). Baby/newborn simulators are Babysim. Birthing simulators with a low-fidelity newborn are Noelle. Direct impacts to nursing program faculty include increased excitement about incorporating high-fidelity simulation into instruction and the potential for more creativity and for increasing instruction in critical thinking and skill development. The high-fidelity simulators have increased team work between faculty and between education programs as they have worked together to utilize scenarios and schedule simulators. The high-fidelity simulators also make it easier to demonstrate skills to students rather than just describing the skill. Indirect impacts include that faculty have had increased responsibility and have needed to increase their knowledge and skills. Faculty have also adjusted clinical time and incorporated alternatives to hospital clinical experiences along with the thinking about the balance of clinical time versus simulation time. The high-fidelity simulators also allow a mechanism for evaluating clinical performance earlier in the curriculum. Some employers have also indicated that students are more prepared for clinicals after using the simulators. 16

17 Faculty have indicated that there is a great amount of time that accompanies simulation use that is not incorporated into workloads. This increased time includes time for developing or modifying scenarios, set-up and preparing for simulations, carrying out simulations with multiple small groups of students, debriefing with each group and evaluation. ND nursing programs have noted that students gain competence and confidence in a safe learning environment and see the added value simulation gives to their education. All of the programs that have used simulators reported that the technology was very successful and that the students were pleased with their experiences (Lang & Moulton, 2010). Students are understanding the significance of making decisions independently and communicating with other health professionals. North Dakota Nursing Education Program Direct impacts to nursing students include that students have been very excited about using the high-fidelity simulators as it provides hands-on practice. The high-fidelity simulators have helped students understand the role of nurses and have been able to practice leadership, delegation and decision-making skills which can be difficult to practice in a direct patient care situation. Students appreciated the opportunity to practice before working with a real patient, especially in rescue and emergency scenarios. Students also value the opportunity to practice on particular skills which can be difficult to ensure each student has an opportunity to do in direct patient care such as pediatric patients, vaginal exams and high risk obstetric patients. Indirect impacts to students include the ability to evaluate each student s role in a scenario and increased engagement and excitement by students. Students also have the opportunity to experience patient death or other events. ND programs have indicated that the nature of the technology limits the number of students who can use it at any one time, thus requiring the purchase of more units should there be an increase in the number of students in each program. Each high-fidelity simulator unit can only be used by 4-8 students- so depending on class size, simulator time must be staggered or additional units purchased. The need to purchase more units, and in the case of high-fidelity simulations, to build rooms in which these simulators are housed, has severely limited the ability of some programs to add these technologies (Lang & Moulton, 2010). 17

18 Additional barriers to implementation that have been identified by nursing programs include the need to modify existing space to accommodate new high-fidelity simulators without the availability of remodeling funding, faculty time to learn new simulation equipment and to develop scenarios, a need for more technical support for using the simulators including electrical, computer and video interfaces, deciding which simulator to purchase as there are multiple simulation needs and difficulty/delays with purchasing through the university system. ND nursing programs were asked about their current needs regarding high-fidelity simulation (see Figure 16). Ninety-three percent of nursing programs indicated that their greatest needs are for more faculty/educator education on the use of simulation. This includes more orientation to using the simulators, training on developing/using scenarios, the need for dedicated faculty to learning and running the simulation labs, the need to train new faculty. In comparison, 54% of Florida nursing simulation centers indicated a need for more training (Sole, Guimond & Amidei, 2010). Figure 16: Current High-Fidelity Simulation Needs Technical Support Research opportunities Evaluate outcomes related to simulation Development of mulit-disciplinary simulations Development of simulation scenerios Availability of simulators Funding/sustainability of simulation Need more faculty buy-in for using simulation More faculty/educator education 22% 21% 47% 45% 36% 45% 39% 48% 36% 46% 54% 48% 62% 64% 79% 77% 79% 93% FL ND Seventy-nine percent of nursing programs also indicated a need for more technical support including simulation coordinators and IT staff in order to help with setting up high-fidelity simulation labs, assist with scenario set-up, interfacing the simulation equipment with computer and video equipment, updating equipment and for trouble-shooting. Forty-seven percent of Florida nursing simulation centers indicated a need for more technical support (Sole, Guimond & Amidei, 2010). 18

19 Seventy-nine percent of nursing programs indicated a need for funding and sustainability including funding for additional high-fidelity simulators for additional sites within programs and for increasing numbers of students, simulation center (building renovation costs), simulation coordinators and technical support, repairing simulators, extending warranties, supplies/equipment for simulators and upgrading of scenarios. Fifty-four percent of Florida nursing simulation centers indicated a need for more funding/sustainability (Sole, Guimond & Amidei, 2010). Seventy-seven percent of nursing programs indicated a need for assistance in evaluating highfidelity simulation outcomes including determining the impact of simulation on students once they are practicing, developing evaluation materials/checklists/rubrics for simulation experiences including debriefing. Forty-five percent of Florida nursing simulation centers indicated a need for more assistance in evaluation (Sole, Guimond & Amidei, 2010). Nursing programs need financial assistance from the legislature to achieve full potential of nursing simulation. North Dakota Nursing Education Program 19

20 References Decker, S., Sportsman, S., Puetz, L. & Billings, L. (2008). The evolution of simulation and tis contribution to competency. Journal of Continuing Education in Nursing, 39, pp Gaba, D.M. (2000). Anesthesiology as a model for patient safety in health care. British Medical Journal, 320 (7237) Good, M.L. (2003). Patient simulation for training basic and advanced clinical skills. Medical Education, 37.(Suppl 1): Gordon J.A., Wilkerson, W.M., Shaffer, D.W. (2001). Practicing medicine without risk: Students and educators responses to high-fidelity patient simulation. Academic Medicine, King, B. & Moulton, P. (2005). North Dakota Nursing programs use of Technology: A Statewide Assessment. North Dakota Needs Study. Lang, T. & Moulton, P. (2010). Utilization of Technology by Nursing Programs in North Dakota. North Dakota Nursing Needs Study. Li, S. (2007). The role of simulation in nursing education: A regulatory perspective. Presented at the American Association of Colleges of Nursing Hot Issues Conference; Denver, CO. Retrieved Dec. 30, 2010 from Maran, N.J. & Glavin, R.J. (2003). Low- to high-fidelity simulation- A continuum of medical education? Medical Educators, 37 (Suppl 1), Roberts, L. (2010). IDFPR/Illinois Center for Nursing (ICN) Simulation Lab Capacity Survey. Small S.D., Wuerz R.C., Simon, R. (1999). Demonstration of high-fidelity simulation team training for emergency medicine. Academic Emergency Medicine, Sole, M.L. & Guimond, M.E. (2010). Addressing the Nursing Shortage Through Simulation. Promoting the Use of Simulation Technology in Florida Nurse Education. Sole, M.L. & Guimond, M.E. & Amidei, C. (2010). Promoting the Use of Simulation Technology in Florida Nurse Education: A Partners Investing in Nursing s Future Project. University of Central Florida College of Nursing, Orlando, FL. Steadman, R.H., Coates, W.C., Huang, Y.M., Matevosian, R., Larmon, B.R., McCullough, L., & Ariel, D. (2006). Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Critical Care Medicine,