How Simulation Can Refine Individual and Team Skills and Competencies

You’re responding to a reported cardiac arrest. Dispatch has advised that a 33-year-old male collapsed while moving a ladder outside. Initial reports from bystanders indicate the patient isn’t breathing.

Dispatch is trying to give CPR instructions to the caller but is having a difficult time hearing them over the background noise. The closest emergency response unit is two minutes away and the ALS unit is approximately five minutes away.

Several questions should come to mind as an EMS provider responding to this scene: Is the scene safe? Is this a trauma or medical patient? Do we have enough resources on the scene? Are there multiple patients? What could have caused a 33-year-old male to collapse? Do we have the necessary equipment to care for this patient? Who’s the team leader?

There are routinely more questions than answers during the initial response, adding stress to an already stressful situation. However, this is also an opportunity to assess how well EMS personnel function within a team, how effective their communication is, and if providers have the knowledge and skills necessary to manage the scene and deliver a well-choreographed management of cardiac arrest response.

What if an educator ran through different variations of this scenario? By leveraging simulation technology and educational methodologies that drive knowledge and skills acquisition, educators create an environment that allows EMS providers to practice realistic scenarios in a controlled environment. Would this make the team more confident and competent in the patient care they provide when responding to a similar call? Could adjustments to the scenario be made to teach and allow for practice of any refinements to patient care resulting from the 2015 American Heart Association (AHA) Guidelines Update?

Thinking Forward

Analyzing the impact training has when responding to real-world events provides an opportunity for EMS providers to understand how they can prepare for the unexpected. Similarly, reflecting on what went well on a call and what didn’t is a powerful form of debriefing that helps make each team member stronger.

As adult learners, we leverage the power of our experiences and previously learned foundational knowledge to understand what we’ve read, been shown or taught. If we see something unexpected happen in a real-world event, we question it. If we see it happen in training, we question it. These questions help learners understand the impact a particular process has or set of processes have during the event, while also helping identify gaps in knowledge.

As responders, we’ve developed the ability to think on our feet. But what we’ve been taught is actually a learned behavior driven by countless hours of practicing in a controlled environment and through years of real-world experiences.

Think about it: Would you be able to perform high-quality CPR at a moment’s notice without knowing and practicing compression rate and depth? Would you be able to safely care for an Ebola patient without practicing donning, doffing, and performing the practical skills while wearing personal protective equipment in a controlled setting?

There’s tremendous power in practicing the skills and applying the knowledge gained in the classroom setting in a controlled simulated environment. Without the opportunity to use foundational or new knowledge or practice relevant skills, providers not only put themselves in harm’s way, but they also put the patient and their team in danger. The key to successfully managing any situation is practice.

The Power of Simulation

Applying knowledge and practicing a skill isn’t always enough, particularly when there’s limited supervision and training aides, such as checklists.

Students must be given the opportunity to practice skills with experienced clinical educators to ensure they understand the steps and use each process the right way.

EMTs and paramedics constantly manage situations in an uncontrolled environment. It’s important to be situationally aware, have situational recollection, and possess intuitive decision-making skills.

One of the best ways to do this is to be exposed to situations where these skills are used.

There’s tremendous power in leveraging a simulated situation where foundational skills can be tested and new skills taught. When learning a high-performance skill such as CPR, policies, procedures, protocols, guidelines and even checklists won’t get you beyond the first stage of skill acquisition (i.e., the novice level).1

A simulated environment, however, allows educators to help build the situational recollection and intuitive decision-making required for competency and proficiency.

The foundational principles of simulation are based on several different educational models, including Gibbs Reflective Cycle, Knowles’ Principles of Adult Learning, Vella’s 12 Principles for Effective Adult Learning, and Kolb’s Learning Cycle. The Dreyfus Model of Skill Acquisition guides a learner through a series of five levels (novice, advanced beginner, competent, proficient and expert) and requires that educators understand how the novice learner interprets information while engaged in a classroom or skills session environment.

The environment can also be a simulated setting that depicts a real-world event. By allowing the learner to follow an established set of rules without feeling responsible for making mistakes, a baseline of their knowledge can be obtained and the acquisition of foundational knowledge will occur.1

For the EMS educator, knowing what the learner knows will help in the development of a relevant and impactful simulation experience.

Remember, the simulation setting isn’t about the technology; it’s about the situation, the methodology, and the people in that environment. Technology such as manikins or simulated patient monitors/defibrillators help to enhance realism but should never be the main focus when designing scenarios.

Designing relevant scenarios is crucial in allowing educators to help learners build upon their foundational knowledge and skills.

Learners must also be able to demonstrate their knowledge and skills. Simply testing individuals in a skills session may measure skills competency, but not the application of those skills, their proficiency in making a decision or their ability to formulate time-sensitive plans.1 Educators can utilize their own experiences to develop realistic simulation scenarios that allow students to demonstrate competency. Realism can be further enhanced by using real data. This gives the scenario relevance and students will better accept the realism of the simulation.

In addition to using educational methodologies for skills acquisition, it’s just as important for educators to help students understand how humans make decisions in a complex, high-stressful environment. Educators can analyze critical thinking processes by having students to walk through their assessment of the environment and a patient. Adding realistic elements will allow the educator to see how various factors can impede an individual’s ability to formulate a plan and act upon it.

This can also be accomplished by having students work in small groups and going through a case study, discussing a plan of action before an event (e.g., pre-briefing before a mass gathering event), practicing various skills and processes, and testing each other. There’s also value in conducting skills and oral board sessions in a controlled setting. What may be missed, however, is the ability to ask why a student opted to follow a different protocol or process instead of using the one outlined for them. Did inexperience drive their decision or was there a distraction? Answering this question allows educators to contribute to the development of new protocols, guidelines, policies and procedures.

As programs develop and refine simulation experiences that better help students understand the impact of their decisions in a controlled setting, educators can subsequently help them see the value in an uncontrolled environment.

By asking the right questions, educators can shape the simulation environment and help students gain competence, confidence and situational awareness.

Teamwork & Communication

A team with strong communication skills can efficiently and adequately manage a simple or complex situation.2 A strong team is driven by a strong leader who routinely encourages team members to communicate both during and after a call. The goal should always be to improve how well the team functions.

By utilizing simulation technology and well-designed simulations based on established educational methodologies, educators can develop scenarios that catalyze team interaction and promote team-based competencies.

By creating an environment where learners must walk through each step of the emergency response process, the team must work together to manage the situation and the patient in the same manner as if the incident was real. These types of scenarios are ideal for practicing a team’s response to cardiac arrest and for refining pit crew and high-quality CPR. And how about a scenario that involves multiple victims or an active shooter?

Good scenario design begins after completing a needs assessment and developing a series of goals and objectives. Teamwork and communication should always be at the top of both the goals and objectives. By utilizing Vella’s 12 Principles for Effective Adult Learning, educators can help learners see the impact and value simulation has at the end of the simulation experience.3

If you’re looking to evaluate the impact at the system level, consider integrating an evaluation tool that helps observers evaluate clinical teamwork.4 The tool could further evaluate the team’s ability to communicate, make decisions individually and as a team, assess role responsibility and situational awareness, and evaluate bedside manner.5

Skills requiring group coordination further benefit from simulation technology, the educational methodology, and an evaluation tool as it helps to develop and assess effective teamwork and communication-two key components outlined in the 2015 AHA Guidelines Update.

The Power of Feedback

Although the simulation experience offers a rich learning environment, the scenario itself only accounts for a third of the overall learning experience. Having a discussion about the upcoming simulation experience (i.e., pre-brief) and a facilitated debrief at the end of the simulation are truly where learning happens. Discussing the simulation experience allows educators the opportunity to uncover causes of active cognitive, procedural, affective and teamwork errors as well as to identify latent, environmental and system issues that may facilitate an error-producing environment.

A facilitated debriefing that provides both negative and positive feedback is a good way to help learners understand their individual knowledge/skill gaps and those of the system or team. Just as debriefing after a real-world event makes systems, teams and learners stronger, so does a debriefing that immediately follows a simulation experience.

Educators should also utilize the feedback devices available within the simulation technology. These tools may provide the student with valuable information to help them improve their patient care, such as how well they’re compressing or ventilating during a cardiac arrest scenario, which will allow the learner to improve their CPR quality and get a better feel for proper compression depth and rate.

Performing the skills in combination with accurate and immediate feedback helps develop muscle memory that translates to real-world situations. This technology can also allow educators to capture data that can contribute to developing a data-driven educational program focused on improving human and system processes before an error occurs.

The data obtained during simulation can directly contribute to changes in individual and system practices. Take for example the desire to improve a system’s post-cardiac arrest quality assurance and quality improvement program; an educator could identify the challenges faced by the resuscitation team and incorporate them into a simulation experience.

Data provided by the team while running through the simulation allows for the re-creation of the event and the outlining of the processes. These processes can then be analyzed, and each step redefined and refined more accurately and efficiently.


A real-world event will always allow for opportunities to reflect on how important education is in preparing for the unexpected. Combining reflection with simulation, the EMS community can better understand what they’re prepared for and where improvements need to be made. By leveraging simulation technology and various educational methodologies, we can decrease patient risk, ensure the needs of the system and providers are being met, enable deliberate practice, and allow for an immersive learning environment.6

There were minimal changes to the 2015 AHA guidelines; however, the update does allow the medical community to see how science is driving the changes. There’s a greater focus on high-quality CPR, and with this focus the medical community has an opportunity to refine individual performance, system processes, teamwork and communication skills required for positive outcomes. Take the time to understand the value simulation has in any educational program and utilize the methodology and technology to ensure that learning is purposeful, impactful and fun.


1. Peà±a A. The Dreyfus model of clinical problem-solving skills acquisition: A critical perspective. Med Educ Online. 2010;15(4846).

2. Dingley C, Daugherty K, Derieg MK, et al. Improving patient safety through provider communication strategy enhancements. In: Henriksen K, Battles JB, Keyes MA, et al. (Eds), Advances in patient safety: New directions and alternative approaches (Vol. 3: Performance and tools). Agency for Healthcare Research and Quality: Rockville, Md., 2008.

3. Vella J. Learning to listen, learning to teach: The power of dialogue in educating adults. Jossey-Bass/John Wiley & Sons Inc.: San Francisco, 2012.

4. Garbee D, Paige J, Bonanno L, et al. Effectiveness of teamwork and communication education using an interprofessional high-fidelity human patient simulation critical care code. J Nurs Educ Pract. 2012;3(3):1-12.

5. Miller D, Crandall C, Washington C, et al. Improving teamwork and communication in trauma care through in-situ simulations. Acad Emerg Med. 2012;19(5):608-612.

6. Maran N, Glavin R. Low- to high-fidelity simulation: A continuum of medical education. Med Educ. 2003;37(Suppl 1):22-28.

EMS simulation trainingThis article is sponsored by Laerdal Medical. For more information on key issues and changes in the 2015 American Heart Association Guidelines Update, visit

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