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Preparing for the Worst


Hands-on training and education are very important aspects of becoming better prepared for both natural disasters and terrorist events. Simulation in particular provides a mechanism in which future and current first responders can train on low-frequency, high-consequence responses.

Simulation is probably one of the most beneficial forms of training because it:
1. Provides a safe, forgiving environment for responders to acquire new skills;
2. Focuses on the trainee rather than the patient or incident;
3. Provides a controlled, structured method of training;
4. Incorporates feedback to allow for performance review; and
5. Increases confidence through deliberate and repetitive practice of difficult or seldom-used skills, such as those needed to effectively respond to disasters and acts of terrorism.

The ADDIE Model
For the past two decades, the University of Miami Gordon Center for Research in Medical Education (GCRME) has developed simulation-based training for response to disasters and acts of terrorism.

Specifically, the GCRME uses a modified Analysis, Design, Development, Implementation and Evaluation (ADDIE) simulation model because it's well suited for the development of large, multi-person simulations and small, isolated-skills exercises. This model also ensures an educationally sound and efficient product that's targeted at measurable objectives and appropriate teaching strategies, simulation methods, assessment tools and debriefing.

Below, we provide a detailed look at each phase of the ADDIE model.

The analysis phase determines which skills or procedures must be addressed through training, as well as the measurable competencies specific to the targeted skills and procedures. It’s important to keep the goals of the exercise in mind throughout this phase because they will direct the content and skills training, assessment criteria and performance feedback.

To help guide learning activities, use agency or department needs and lessons learned related to disaster response. For instance, your department may have acquired new personal protective equipment (PPE) that requires specific task training, or you may need to conduct a mass casualty incident (MCI) drill. In both cases, simulation is well suited to the educational activities, but it will be conducted very differently in each case to achieve the desired outcome.

The analysis phase may also involve the development of training objectives to guide what should be taught relative to operational procedures, such as your approach to triage and patient care management at an MCI. Use the “SMART” mnemonic—Specific, Measurable, Appropriate, Realistic and Time bound—when developing training objectives, because these terms are also employed when developing mission objectives during actual responses.1

The design phase of the ADDIE model is dependent on the objectives to be taught or assessed, as well as the necessary level of realism or fidelity. Generally, there are four types of fidelity:
1. Equipment/technical (the tools used by responders);
2. Environmental (the conditions in which the simulation occur);
3. Psychological (the learner’s belief that the simulation is real); and
4. Physical (the realness of the simulator to human anatomy and physiology).

In the previously mentioned examples of PPE and MCI simulations, the methods and fidelity may differ substantially. With PPE, the objectives may focus on task training of donning, doffing or using specialized equipment where equipment/technical fidelity is of critical importance. With the MCI example, physical, psychological and equipment/technical fidelity may all share an equal degree of importance in developing the right conditions for learning. Additional elements to consider during the design phase include providing clear goals and instructions, keeping learners motivated, and offering opportunities for self-assessment and constructive feedback.2

Development focuses on creating content and choosing appropriate delivery strategies. Simulation exercises may be devised to aid an individual in the acquisition of a new skill or assess the proficiency of a skill, while other instances may focus on a team’s ability to solve more complex problems of incident management.

Another key component of this process is to test-run the simulation. It’s helpful for designers and instructors to rehearse the simulation activity prior to learner participation to ensure it achieves the intended educational outcomes. This process also provides an opportunity to fine-tune the exercise.

Even though in many instances this phase is readily accomplished, in some cases it may be helpful to involve key stakeholders, such as the dispatch center or your medical director, to ensure that the simulation training is meeting their needs. Potential barriers to implementation include competitive training demands, non-supportive attitudes (learners and instructors) and scheduling conflicts of operational personnel.

The final phase of the ADDIE model—evaluation—addresses the most important feature of simulation-based training: providing learners with feedback about their performance. Providing clear and concise feedback is essential to ensuring that participants maximize their learning experience. A great deal of this feedback or evaluation occurs in a debriefing session following the simulation activity. Feedback regarding learner performance during the simulation allows for error correction and individual and team performance improvement.

Put It All Together
Simulation-based training offers emergency responders the opportunity to learn, practice and demonstrate competence on a wide range of skills necessary to respond to low-frequency, high-consequence incidents.3 A standardized approach, such as the ADDIE model, will ensure that training is consistent, reproducible, practical and efficient.

Disclosure: The authors have reported no conflicts of interest with the sponsor of this supplement.


1.Drucker, P. The Practice of Management. 1954; Harper and Row Publishers: New York.
2. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher. 2005;27:10–28.
3. Miller GT, Scott JA, Issenberg SB, et al. Development, implementation, and outcomes of a training program for responders to acts of terrorism. Prehospital Emergency Care. 2006;10:239–246.
This article originally appeared in an editorial supplement to the September 2010 issue of JEMS as “Preparing for the Worst: A review of the ADDIE simulation model for disaster-response training.”


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