搜索结果：Simulation in healthcare : journal of the Society for Simulation in Healthcare

Welcome to the 9th Annual International Meeting for Simulation in Healthcare. I am pleased to be here and very honored to have been asked to serve as president of the Society for Simulation in Healthcare (SSH) in 2009. Those promoting simulation in the healthcare environment are a pretty diverse and rapidly growing group dedicated to the promotion and implementation of simulation in healthcare. (Figs. 1 and 2). Although the groups we represent may have competing priorities, we nevertheless have shared goals. I would like to discuss briefly the present state of healthcare simulation, a vision for the future, and our role in helping simulation reach its fullest potential in healthcare education, design, and safety.Figure 1.: Self-identified professional fields of Society for Simulation in Healthcare members. Source: Society for Simulation in Healthcare.Figure 2.: Growth of Society for simulation in Healthcare membership. Source: Society for Simulation in Healthcare.The SSH has left infancy and now has in place many of the structures of a mature professional organization. The SSH has developed or is developing (1) focused meetings among interested individuals, (2) an organized group that self-regulates, educates, and sets standards for the field, and (3) a journal and website that are widely accessible and focused sources of information. This year, under the guidance of David Gaba, Editor in Chief, our journal, Simulation in Healthcare, has been accepted for indexing by the National Library of Medicine in MEDLINE, an important measure of value. They deserve our heartfelt congratulations on achieving this milestone. The simulation field and the SSH are mature in the sense that it has achieved identity and created these structures to help lead growth and impact. WHERE ARE WE GOING? One of the questions we might ask ourselves is, “Where are we going?” Embedded in this question are a number of other questions that are related: Who are the people that should be included in the field? What are the needs of those involved in simulation to do it well? What are the needs of the healthcare educational system? How might simulation impact more fully healthcare design (architecture and processes)? What is the appropriate role of simulation in undergraduate and post graduate training programs? And perhaps most intriguingly, “What is simulation's full potential?” I think simulation outside of healthcare has reached wide acceptance even if it may not have been experienced by most people in this world. I look not only to the real world of aviation and warfare preparation upon which we have modeled many or our curricula but also to the imagined world of artists. In a sense, their progression is a path we might echo if not follow. In the 1970s “The Enforcer,” Clint Eastwood and a character played by David Soul engaged in a simulation exercise that has become iconic in film. Both navigate a wood-prop town and “criminals” or “friendlies” pop up, creating the opportunity to simulate killing innocents or bad guys. In the end, Clint “kills” a wooden cop. This sequence is an example of how relatively low tech and low fidelity simulation can be used for assessment, a goal which is now commonplace in healthcare simulation. Two subsequent films, “Police Academy” and “Men in Black,” parody this sequence and we see a panoply of errors in one and brilliant out of the box behavior in the other. Simulation has the ability to demonstrate the variety of ways errors can be made and how it can be used to test personality traits like problem solving behaviors. Both these objectives have real world healthcare analog: simulation techniques can identify latent system errors, and aid selection of medical school applicants.1 These practices will be refined and grow in scope and penetrance. Probably everyone remembers how Luke Skywalker learned to use a light saber, the simulation being high tech but low fidelity. It is a great demonstration of a partial task trainer and the need (or lack thereof) for high fidelity in training. It makes obvious how level of technology is not necessarily the same as fidelity and suggests the importance of selecting these qualities independently. A basic question for any educator is: “How can I best fulfill the goals of this exercise?” Movies are now progressing to more complex full-scale simulations. Take for example “Monsters Inc.” In the beginning of the film, one of the monsters sneaks up on a sleeping child, who suddenly awakens and is scared by the grotesque beast. Only after lights “go up” does the observer recognize the scene as a full scale, high tech, high-fidelity simulation. The same simulation used for demonstrative (lecture style) education, full-scale immersive education, as part of a sort of credentialing process, and finally as remediation. We do some of this now in the real world healthcare arena (especially as pertains to immersive and demonstrative education). Some organizations are using simulation techniques to remediate poor performers to “bring them up-to-speed.” I expect this practice to increase, although more data are needed to support its use in this manner. But my personal favorite simulation is in “Star Trek: the Wrath of Khan.” A young captain is commanding a starship manned by our favorite officers. A difficult tactical situation is encountered, and against advice, the captain goes against procedure to try a daring rescue. Many are killed. When they are surrounded by Klingon vessels, the captain tries to surrender only to find that Klingons, of course, take no prisoners. We later discover that this too is a simulation exercise. It is remarkable because it is a very high tech and ultra high fidelity simulation. I wonder if healthcare will ever need to be this realistic. It begs the questions we and all simulation workers must confront: “Is this type of simulation and degree of fidelity worth the cost? Does improving fidelity (and cost) add to the ability to achieve the goals of the exercise?” These are important questions that should be asked of any simulation application. As simulation leaders, it is our responsibility to show not only what can be done but also why it adds value. I am pleased to see that these questions are more commonly being addressed in manuscripts describing research in this realm, although more research is needed. The Star Trek simulation is remarkable also because no behavior by the trainee can lead to “success.” The exercise is designed so that the crew and the starship are always lost. The focus is not whether the trainee's choice, but rather how the trainee confronts highly stressful situations and deals with failure? The goal is to assess and promote the psychosocial “strength” of the trainee. In an ingenious twist, we learn that only Captain Kirk has succeeded in this simulation. He cheated of course by reprogramming the simulator, but this does nevertheless reveal a lot about his persona. The goal of the exercise—to assess and improve how the trainee deals with failure—was nevertheless achieved. Simulation exercises operating in the same domains exist, and focus on helping clinicians with end of life care, decision making, and professionalism.2 Computer simulations in film were used for epidemiology to demonstrate how a deadly plague will engulf the world unless the hero prevents it. Or help undo the plague: in “The 12 Monkeys,” experts use data to “rewind” a pandemic to identify the location of the trigger point, and then send a time traveler to prevent the outbreak. Error remediation at its finest! Desktop computer simulation for disease vectors in the Intensive Care Unit (ICU) mimics the movies,3 and holds potential for reducing labor intensive epidemiologic studies and perhaps may enable in computer simulated “controlled” studies. But as a safety officer, I think my favorite use of simulation is demonstrated in the film “Apollo 13.” A full-scale simulator designed for training astronauts' performance was used instead for equipment and process design. Confronted with scarce resources, and no procedures for a moribund spacecraft, National Aeronautics and Space Administration (NASA) created a plan for the astronauts to build a carbon dioxide scrubber from materials available. Then, to come up with the procedure to conserve energy and still power the spacecraft to earth, a multidisciplinary team, reconstructed the nearly dead ship in mission control to simulate the environment. They performed, reiterated, and revised in a simulated setting the process. They improved the result until it was successful in simulation. The simulation designed and tested process is sent to the astronauts, who used it and of course survived. But for the use of simulation, the ship and crew would have been lost. Best of all, the story is fact. Simulation can and perhaps should be a central methodology to process planning. So, where are we, and what can we learn from all this fiction and fact? We do not need to prove that simulation as used in the movies can work for healthcare. Rather, we need to imagine how it can be expanded to reach its full promise in healthcare design, education, and assessment. These movies I have mentioned show a vision of where we might go. During this meeting, we will all have the opportunity to see who is doing what, and how. We will see demonstrations of microsimulations, full-scale simulations, partial task training exercises, and standardized patients. We will also see new technologies: manniquins, trainers, computer based and virtual reality simulators. They will have been used for immersive education, remediation, assessment, and credentialing. Some will demonstrate how simulation can be used for healthcare design or forensic reconstruction of errant processes. We will learn from these sessions. We will want to own or copy these products. These projects are new and truly exciting, but in a sense are beside one of the major points I would like to make: we are currently operating in a healthcare environment that views simulation as supplementary or at best as an adjunct. Even at the most modern of simulation centers, simulation is a relatively minor adjunct. My question for you, and for the SSH is “What should the role of simulation be in healthcare?” To answer this, we must also ask, “What can we imagine it to become?” I want to explore in three realms healthcare education, safety, and healthcare design. EDUCATION Clinical healthcare education was revolutionized in the United States by Osler near the turn of the last century when he brought together the sickest patients, outstanding physicians, and trainees into a single academic hospital. This confluence of disease and faculty created not only a remarkable treatment arena but also an unsurpassed educational environment. The Flexner Report identified educational gaps, poor performance (and quackery), and lack of clinical experience in medical schools.4 He recommended the type of education Osler had created at Johns Hopkins. Their training model exists today in all the healthcare professions: preclinical lecture and book, followed by supervised clinical practice. It is a century later. Is this methodology the best way still? I asked a number of our simulation leaders to send me photos of their simulation center, or room, or technology (Figs. 3–5). All show great ingenuity and enterprise. They represent the leading edge of emphasis of simulation in education. And yet their programs are small relative to the total education trainees receive. What I mean is that they are for the most part outside of, or a small part of their healthcare educational system. Look at any medical school or a nursing school. Huge impressive buildings, with many lecture rooms of various sizes, more or less internet connected, a number of laboratories, and a library or two. Simulation labs, if they have any, are usually small in comparison to the rest of the physical plant. Simulation training hours are small relative to the whole educational experience (Fig. 6).Figure 3.: Danish Institute for Medical Simulation occupies the top floor of Herlev Hospital, Copenhagen, Denmark. Courtesy of Doris Ostergaard, Director, Danish Institute for Medical Simulation.Figure 4.: Center for Medical Simulation (CMS) is located on the first floor of this laboratory building in Cambridge, MA. CMS primarily serves hospitals in the Harvard Medical School system. With permission from D. Raemer.Figure 5.: MSR, Israel Center for Medical Simulation Virtual Hospital and Auditorium, is in essence an entire hospital, simulated. Reprinted with permission from MSR, Israel Center for Medical Simulation.Figure 6.: Relative emphasis on educational modality in healthcare education.Imagine the future: What is the best way to learn and to teach? Should and will these undergraduate organizations consider that simulation (immersive) techniques will be central to the educational process rather than being just a small adjunct to the learning “menu?” There is early evidence that the best way to learn, understand, behave, and retain, may be through simulation experiences. It is by doing that we learn best (at least that is the common sense if not evidence-based conclusion). Flexner and Osler moved education firmly into the clinic because that was the only way to accomplish experiential learning. Although our professors did the best they could with the technology they had available to them as they taught us, those tools may not be as effective and efficient as newer ones. We now have (or can develop) the technology to create a huge, organized library of simulation experiences. They may be simulated to be sure, but the mere fact that they can be organized and delivered at the instructor's convenience enables the healthcare educator to ensure that every trainee encounters and masters the clinical problem or skill. Consistent training to yield consistent results. This corrects a major problem with total reliance on clinical learning. In a sense, every one of us has had a different education, even if we went to the same school at the same time, with the same teachers. Our clinical experiences were highly variable. They shared only time frames and perhaps expectations. We saw different patients, diseases, and clinical dilemmas. Heterogeneous education results in heterogeneous quality. I would like us to embrace an educational system in which simulation is a core educational modality and not a minor supplement. Lectures can prepare for a simulation encounter (or may employ simulation techniques themselves). Journals and books can provide background or supplemental support for principles practiced in simulation. But simulation should be the core because it is measurable, focused, reproducible, mass producible, and importantly, very memorable. The change in educational improvement will be difficult and long. The onus will be on us to prove simulation works so well that it demands simulation's central role in education. It may be more ethical as well. Training clinical competence during simulation reduces patient risk. What is the role of simulation in the medical and nursing school? I think on the horizon is a revolution in educational methodology no less important than the changes Osler and Flexnor promoted over a century ago. Although it seems that much simulation education is now occurring, we do not know how much simulation is used in any educational setting. There are many outstanding centers, but there is no accurate count of how many simulation centers there are or where they are located. I am pleased to say that the Association of American Medical Colleges and SSH are engaging in such an inventory currently. It should be a model for other professions to use. An inventory is essential so we know where we are, to inform discussions of where we should focus effort, and to suggest how we need to grow as a field. SAFETY AND QUALITY The Institute of Medicine reports To Err is Human,5 and Crossing the Quality Chasm6 have shown us the clinical harm that occurs, and provides a roadmap for remediation. The desire to improve patient outcome has generated a new emphasis on safety and reducing variability is yielding profound changes in clinical care and safety. A cornerstone of some interventions is use of simulation education as it seems to produce error reduction in the clinic. The impact of simulation suggests a relative failure of other educational methods for clinical behavior that had previously not been well recognized. What is the measure of failed education in the preclinical educational environment? In part, it is low test scores. Remedial education can focus on improving the test scores but may have no impact on performance. The point is that the clinical education feedback loop and the basic knowledge feedback loop outside the clinical setting are not sensitive to failure. Put another way, measuring knowledge with testing may not be an accurate assessment of competence and ability to prevent errors. How should we measure a successful educational intervention? How prepared for clinical work can graduates be? We simply do not know the answer. But they are important questions. The answer may be fundamental to defining how we should prepare trainees to safely and competently care for patients. As we work to improve safety, we need to be cognizant of where our work fits into the education, safety, and cultural framework of our organization. I think as simulation leaders in our local environment, we need to integrate simulation methodology into core education for all healthcare professionals at all levels and in all fields. The picture of the nursing, medical, pharmacy, and respiratory care school should in the future conjure up an image of education fundamentally based on simulation methodology instead of an image of the blackboard, book, powerpoint, or teaching rounds. Those latter methodologies are not bad per se, but I think simulation has special potential for measurable impact on performance and safety. DESIGN There are two clinical design considerations that simulation can augment: equipment and process. I think many manufacturers are now using more and more simulation as they design of new devices, from the simple (defibrillators) to the highly complex (heart pumps). It is hoped that the practice will increase and lead to fewer latent design flaws. To date, simulation has not been reported often for process design, and yet it has huge potential. Take for example, the Toyota Production System (TPS) for process improvement originally created for making cars better. TPS requires observing practice and then making a series of small changes to improve consistency, efficiency, and quality. It has been successfully applied to healthcare, often by watching actual care delivery to patients. Although I approve of TPS, I can only wonder whether there may be a safer, more efficient, and more ethical method for improving process. Imagine doing any TPS project but using a simulated environment instead (as in “Apollo 13”). It is possible that the same results can be achieved more efficiently, and without having to catch failures as they happen in the course of patient care. Simulation TPS was a key to our process improvement and role delineation for resuscitation response, something we found very tough to address in the real world. Speaking of resuscitation response, the data are good that healthcare profession as a group need improvement at this interdisciplinary team process. Teamwork in healthcare is underdesigned and undereducated. It may be that the very medical, nursing, and allied healthcare provider schools we rely on contribute to the problem of poor teamwork. Evidence of the failure is the degree of unpreparedness that graduates demonstrate upon entering the clinical environment, especially in team efforts. To use a basketball analogy, it is as if we are training guards in guard school, forwards in forward school, and centers in center school, and then expecting them to compete well in the National Collegiate Athletic Association (NCAA) playoffs. Not a model for success. Simulation team training is moving out of its infancy and there are many examples of well designed teams (Figs. 7–9 show a few examples). It seems that these exercises have the potential to improve process for high frequency and rare events. We need to expand this use because all healthcare is a team activity.Figure 7.: Full scale, high-fidelity surgical simulation team exercise. Harvard University. This simulation is used to improve efficiency and reduce error. Performance and teamwork improve in this high-frequency high-risk clinical situation. Role delineation and process can be reinforced.Figure 8.: team simulation exercise at University. is a high-risk setting that can be error can improve performance. with permission of Center for and Hospital at simulation team exercise for is an ultra low ultra high-risk It is hoped that a setting that professionals will simulation nevertheless enables the to which will be Reprinted with permission from MSR, Israel Center for Medical SSH The Society for Simulation in Healthcare had two important meetings The first was a In it we to imagine the place the simulation field should in healthcare education, assessment, and design, and which to some I have Although those results are still in process of being and I can that there was no that simulation should be a core in education, or design, and safety. Although data from Star and support emphasis and time the was based on the data currently available the impact of simulation education other of education. are needed to the potential for simulation and improve our practice. We need it to enable us to conjure what the future role of simulation can and should The upon this and focused on the for the and what are needed to achieve identified goals. These will be reported but in the SSH has identified goals for the field, and and to those goals. I am very about the future of simulation. I am about our and its ability to impact that It is my that the work we are doing today and contribute as much to healthcare as the changes by Osler which have come to the healthcare environment in which we work and Although the movies are not they can our of what we might

“Medical Simulation Bill before Congress; National Consensus Conference to Identify Key Priority Areas . . .” (Society for Academic Emergency Medicine (SAEM) press release, May 28, 2008) Together with colleagues across health care, emergency medicine (EM) has played an important national role in the development of medical simulation as an academic discipline, a field in which realistic artificial environments are used to practice medical skills, procedures, and protocols. In fact, the field is currently the subject of a bill before Congress designed to enhance federal support for simulation initiatives nationwide.1 Across the country, growth in the use of high-fidelity mannequin simulators among EM residency programs increased from 29% to 85% over the past 5 years;2 entire residency curricula at some programs are now structured around simulation.3 Given this extraordinary growth, the 2008 Academic Emergency Medicine (AEM) Consensus Conference, “The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise,” was organized to help define a national research agenda for maximizing effective use of simulation across undergraduate, graduate, and continuous medical education. Because EM operates at the intersection of multiple specialties, we hoped the conference would be of multidisciplinary interest. In 1999, the Institute of Medicine’s report “To Err is Human”4 identified patient simulation as an opportunity for enhancing medical safety in the same way that flight simulation is used to enhance quality in aviation. In 2002, a Simulation Interest Group formed within the Society for Academic Emergency Medicine (SAEM) to explore EM’s use of dynamic simulation technology. At that time, the focus was primarily on the use of sophisticated robot-mannequins to train anesthesiologists in operative crisis management. An international Society for Simulation in Healthcare was formed in 2004 with input from the SAEM Interest Group leadership, including membership on the new society’s board of directors. In 2005, the SAEM Board of Directors convened a Simulation Task Force to intensify SAEM exploration in this area, which by then had attracted the attention of federal funding agencies, as well as legislative and regulatory bodies. In 2007, the Task Force became a standing committee focusing on technology in medical education. The field of simulation within SAEM is now a unified effort of both the original interest group and the task force/committee structure, which maintains an informational website, a case bank in collaboration with the Association of American Medical Colleges (AAMC) MedEdPORTAL, a biannual newsletter, and a consultation service to assist academic development in the field. The SAEM simulation groups have worked to collaborate with other EM groups on the topic, including the American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM), and the EM Council of Residency Directors (CORD). These efforts complement dedicated simulation initiatives that have also emerged as part of other medical and surgical specialty society agendas, including those of the American College of Surgeons and the American Society of Anesthesiologists. After publishing an initial review and assessment of research opportunities in the field,5 the SAEM Simulation Task Force proposed simulation as the special topic for the annual Consensus Conference sponsored by the editors of AEM. The topic was selected in a competitive process; the project required 12 months of planning with the assistance of both an AEM Consensus Conference Planning Committee and an expert Faculty Advisory Group (see Appendix A for full listings). The end result was the full-day conference upon which this special issue of the Journal is based, held in Washington, DC, on May 28, 2008. Approximately 325 individuals attended the event (see listing of registrants included later in this issue), and nearly 40 original manuscript submissions competed for a spot in this issue; both were a record for an AEM Consensus Conference venue and represented our hope that the diverse scope of EM practice would enable the work to apply broadly across specialties. Financial support for the conference was provided by: the Agency for Healthcare Research and Quality (AHRQ), the Josiah Macy, Jr. Foundation, the AAMC’s MedEdPORTAL, the Risk Management Foundation of the Harvard Medical Institutions, and over 30 medical organizations and academic departments nationwide, along with unrestricted educational grants from major simulator manufacturers (see full listing in Appendix B). The program was also endorsed by the Society for Simulation in Healthcare, ACEP, and AAEM; the President of the American Board of Medical Specialties (ABMS) began the day with a welcoming keynote. An expert panel of cognitive scientists and educators was recruited to serve as keynotes to help guide our deliberations (see Appendix A for full listing). The morning was dedicated to discussing how simulation can help develop expertise (“teaching” through deliberate practice sessions), and the afternoon was devoted to discussing how simulation can help define expertise (“testing” through formative and summative assessment modalities/metrics). The lunch sessions explored training and transference to the “real world,” focusing on simulation-based approaches to team training. After both morning and afternoon keynotes, participants broke out into one of four 90-minute “consensus discussion groups” representing four domains of medical expertise: Individual/cognitive expertise: global provider competency (Consensus Track 1); Group expertise: effective teamwork and communication (Consensus Track 2); Technical expertise: procedural and surgical skill (Consensus Track 3); Systems expertise: effective simulation at the organizational level (Consensus Track 4). Breakout groups ranged from approximately 20 to 130 participants depending on individual interest (see attendance detail below); an attendee could participate in different tracks between morning and afternoon sessions. Each session was audio-recorded as a post hoc aide to the session leaders in preparation of their proceedings papers (included in this Journal issue) or as a method to help breakout leaders review and define consensus items for their topic report (also included in this issue). To facilitate consensus discussion, conference organizers and participants were also invited to post discussion items on a shared website both before and after the conference (http://www.patientsimulation.net/). The conference venue was equipped with wireless Internet access so that participants could e-mail questions and comments to the session leaders in real time and in follow-up after the session. This was one way of encouraging diverse communication in addition to routine oral discussion and debate, which ranged from “town hall”–style meetings to panel presentations with audience participation. Each consensus paper reflects significant review and consideration among individual writing teams who formed their own consensus prior to the conference (up to 10+ authors per writing group), which was then refined and complemented by the larger on-site discussion. The conference began with special remarks by Kevin Weiss, MD, MPH, President and CEO of the American Board of Medical Specialties, who spoke on the role of simulation within the board certification process. He suggested a significant potential for simulation to impact medical training and certification across disciplines, in the near future. K. Anders Ericsson, PhD, next outlined the theory of expert performance, describing “deliberate practice” as the key ingredient for expertise development in any high-performance domain, including medicine. William McGaghie, PhD, then described how simulation equated to deliberate practice in medicine and outlined an approach to simulation-based educational research, citing a current body of work supporting the effectiveness of simulation teaching modalities. The lunch session began with Eduardo Salas, PhD, who outlined the empirical basis for team training and described simulation-based approaches in medicine. Robert Hanscom, JD, then described the real-world application of simulation-based team training within a large health system, explaining the positive actuarial experience of a medical malpractice insurer who offers incentives for simulation training. The afternoon session began with remarks by Jenny Rudolph, PhD, who described the role of simulation-based debriefing as a formative assessment tool. Jack Boulet, PhD, then described the promise of simulation for high-stakes summative evaluation and discussed the psychometric and logistical issues of using technology-enhanced simulation for board certification; his remarks brought us full-circle back to Dr. Weiss’s introductory comments. In addition to the plenary papers included in this issue of the Journal, the presentations themselves can be found online at http://www.patientsimulation.net/. The overriding question upon which the consensus groups deliberated was: “What are the most effective approaches to simulation-based education (morning sessions) and evaluation (afternoon sessions) in undergraduate, graduate, and continuing medical education?” The charge to each group was to review the current literature, to identify high-priority gaps in current knowledge, and to outline research strategies to answer the pressing questions in the field. Below is an edited version of key questions and research directions that emerged from each consensus session, along with a notation of how many individuals participated in on-site consensus building; morning (A) sessions are paired with the afternoon (B) sessions in the same expertise domain. Track 1A—Education (William Bond, MD, Group Leader [∼130 Discussants]). Dr. Bond’s group identified the following broad areas of hypothesis testing as research priorities in the development of individual expertise: How can simulation help identify expert behavior? Can simulation produce more competent physicians? In a shorter time frame? What is the optimal teaching and debriefing strategy for simulation cases? Can simulation be used to diagnose learning deficits and performance problems? Can simulation be effectively used as a remediation tool? Can we prove that transfer of learning to the real environment has occurred? This group explored the role of intuitive versus analytical thought in individual cognition and discussed how the deconstruction of complex tasks can be facilitated in the simulation lab. Simulation not only provides opportunities for deliberate practice and reflection, it also allows for the presentation and study of a diversity of case material and learning problems. Dr. Bond’s team posed numerous questions for future research and provided an extensive review of what is known about the development of individual expertise. They conclude that diverse collaboration between academic communities including medicine, cognitive psychology, and education will be required to illuminate, refine, and test hypotheses in this area. Track 1B—Assessment (Linda Spillane, MD, Group Leader [∼50 Discussants]). Dr. Spillane’s breakout group considered the following questions in exploring a research agenda focused on the assessment of individual expertise: What competencies can/should be assessed using simulation-based assessment? How should we assess performance? What factors may threaten the validity of simulation-based assessment? Does performance on simulated patients accurately reflect the quality of care provided to actual patients and how can this be assessed? How often should practicing physicians be evaluated, and does simulation-based assessment have a role in continuing assessment and credentialing for practicing physicians? The research agenda proposed by the group seeks to prioritize the competency domains best addressed by simulation-based assessment in terms of validity, reliability, and practicality, and to explore how those domains are optimally measured. The group identified the need to develop rigorous rater training programs, explore the impact of lab fidelity on scoring systems, and identify quality-of-care benchmarks that may link simulator-based performance to real-world clinical care. The group concluded that EM is well positioned to conduct research into the use of simulation-based assessment for high-stakes testing across competency domains. Track 2A—Education (Rosemarie Fernandez, MD, Group Leader with Paul Phrampus, MD [∼80 Discussants]). As a method of grounding future research in teamwork, Drs. Fernandez and Phrampus’s group proposed use of a standardized taxonomy of team competencies (see separate article in this issue). The group discussed the following key questions: What team-oriented competencies are most relevant to EM practice? How important is leadership training for EM physicians? What components are necessary for an effective team training program? What are the biggest challenges to implementing team training programs in EM? What is the optimal approach to debriefing and the provision of feedback? What kind of simulation technology is most effective in team training programs? Future work to define and teach optimal team leadership skills in EM was considered essential. Individual initiatives should be tailored to a local needs analysis and grounded in sound instructional methodology and debriefing techniques. The fidelity of the simulated experience should be customized to each set of learners and objectives in a manner that fosters measurable improvement and transfer to the clinical environment. Track 2B—Assessment (Marc Shapiro, MD, Group Leader [∼80 Discussants]). Dr. Shapiro’s group discussed the following questions in considering the measurement of group expertise: How can simulation exercises diagnose team-based weaknesses and strengths? What are the critical principles for simulation-based team training that will improve clinical performance? Is there a “criterion standard” team performance metric? How good are existing metrics? How does one create simulation scenarios to measure leadership behaviors? The group emphasized that team competencies, just like individual competencies, must be well-defined to be measured. Simulation scenarios should be designed to produce triggers for team behaviors; in turn, meaningful team performance metrics will then guide effective feedback. The group also embraced a standardized taxonomy and agreed that leadership training should be a priority area for EM-based simulation and team training. Track 3A—Education (Ernest Wang, MD, Group Leader [∼60 Discussants]). Dr. Wang posed his questions within the framework of the Core Content of EM and focused on the list of procedural skills within the scope of EM practice. His group identified the following key questions for future research in developing procedural expertise: How much training is enough? What is the ideal balance of part versus whole practice? What is the ideal balance of block practice versus distributive practice? What instructional methods will best limit skill decay for specific procedures? How often must procedures be practiced, once mastered, to limit skill decay? What is the retention interval for different procedures? Does the complexity of the procedure influence the rapidity of skill decay? Is overlearning necessary? Does proficiency of a task trainer translate to the clinical setting? Is mastery necessarily achievable in a 3- to 4-year training program or is a minimum acceptable level of performance more realistic? Consensus discussion focused on the simulation platforms that currently exist, and the literature available, to support various training techniques. It was acknowledged that individual procedural studies may not be generalizable, given the uniqueness of individual tasks and trainers, and that virtual reality simulation has been most successful for screen-based procedures. The group recommended a programmatic focus on inherently high-risk procedures and important low-frequency procedures, with explicit emphasis on relevant instructional theory. Track 3B—Assessment (Richard Lammers, MD, Group Leader [∼70 Discussants]). Dr. Lammers’s group focused on the following research questions related to the measurement of procedural expertise: What are the best methods for measuring technical performance? How should performance standards for procedural competencies be set? How can we best evaluate the quality of simulation training and assessment tools? What are the optimal conditions for learning procedural skills using simulators? How effectively are simulated procedure skills transferred to real patients? What factors influence skill retention? Current knowledge? Several consensus statements were produced by the group, recommending procedure-specific evaluations and scoring protocols and appropriate methods for standard-setting and implementation. The group suggested future research into identifying factors that influence skill acquisition and transfer into the clinical environment, as well as defining learning and decay curves for individual procedures. Track 4A—Microsystems (Leo Kobayashi, MD, Group Leader [∼30 Discussants]). Dr. Kobayashi’s group identified methodologies for studying EM microsystems and addressed the following questions: How should simulation be applied to improve and study EM microsystems? Is there a rational way to propose and determine which types of simulation, in what setting, at what time, for whom, and with what objectives and outcomes will prove useful for EM microsystems improvement? What research methodologies should be applied to study the use of simulation and establish its value for EM microsystems? How does one elicit microsystem processes in an integrated manner to unify the simulated care of individual patients (e.g., interactive computer-controlled mannequin) with the simulation of larger-scale systems (e.g., PC-based modeling); i.e., are microsystem and macrosystem simulations reconcilable? What are some limitations of using a systems approach with in situ simulations? This group presented an argument that EM systems require evaluation just like medical need testing and that relevant can be by and techniques. The group provided for current to improve future systems and the special of studying complexity in Track MD, PhD, Group Leader Discussants]). Dr. group discussed the use of simulation to improve our of patient care, and The following questions were posed as the group the current literature and presented for study What methods and may be used to that simulator training patient How can we effectively back from systems into simulation training and improve patient How can simulator training be used to identify and improve How can simulation be used to assess and enhance What methods and should be used to that teamwork simulation training How can the of systems be The group recommended key in clinical care to safety and using real-world quality to simulation training and and simulation to diagnose and improve and The 2008 AEM Consensus Conference was designed to help define future directions in simulation-based research in EM and across health care. The conference approaches to both developing and defining expertise in four group, and The of this conference in Washington, DC, with a Simulation Bill before represented a opportunity to help identify priority funding areas and to collaborate with colleagues across hope the proceedings of the the consensus topic and the original in this special issue of the Journal useful in to the of simulation in health care. the Conference Planning the Faculty Advisory and the and leadership for their and the significant effort and work of of the Simulation Task Interest and in Medical of this conference A special to MD, SAEM President who the Simulation Task Force and and have and to MD, MD, and MD, PhD, who provided AEM and leadership support the MD, Medical MD, MD, William Bond, MD SAEM Simulation Interest MD MD, Robert MD, MD, SAEM Simulation Task Force and in Medical MD, Board MD SAEM Simulation Interest Group and Simulation Spillane, MD SAEM Simulation Interest MD SAEM Simulation Interest MD, Wang SAEM Simulation Interest Consensus William Bond, MD and Fernandez, MD MD, Kobayashi, MD Lammers, MD Paul Phrampus, MD of Shapiro, MD Spillane, MD of Wang, MD Jack Boulet, for of Medical and K. Anders Ericsson, Robert Hanscom, Risk Management William McGaghie, Jenny Rudolph, Eduardo Salas, of Kevin Weiss, MD, Board of Medical Agency for Healthcare Research and Quality of and MD Josiah Macy, Jr. Foundation Risk Management Foundation of the Harvard Medical Medical Association of American Medical Colleges (AAMC) Washington, Medical Medical and Medical Simulation of Emergency Medical of of Emergency of at Medical Clinical Medical of Emergency for Simulation and Academic Research of Emergency and of Emergency of of Emergency of of Emergency Medicine Residency for Research in Medical of of of Emergency Institute for and Research of of of Medicine of Medical of Emergency Emergency Simulation of of Emergency for Medical and of of of Emergency College of of Emergency Medicine Simulation Medical of Emergency Simulation for Medical and of Emergency of Emergency of Medical of Emergency of of Emergency Institute for Medical Simulation for Medical Simulation for Simulation of at Medical Medical of Emergency Medicine Simulation for of Medicine and in Medical Medical The Conference was also endorsed by: The Society for Simulation in Healthcare American College of Emergency Physicians American Academy of Emergency Medicine

Cyberpsychology, Behavior, and Social NetworkingVol. 23, No. 7 EditorialConnecting Through Technology During the Coronavirus Disease 2019 Pandemic: Avoiding “Zoom Fatigue”Brenda K. WiederholdBrenda K. WiederholdBrenda K. Wiederhold, Editor-in-Chief Search for more papers by this authorPublished Online:10 Jul 2020https://doi.org/10.1089/cyber.2020.29188.bkwAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail View article"Connecting Through Technology During the Coronavirus Disease 2019 Pandemic: Avoiding “Zoom Fatigue”." Cyberpsychology, Behavior, and Social Networking, 23(7), pp. 437–438FiguresReferencesRelatedDetailsCited byQuantitative analysis of communication changes in online medication counseling using the Roter Interaction SystemResearch in Social and Administrative Pharmacy, Vol. 20, No. 1“Who Said That?” Applying the Situation Awareness Global Assessment Technique to Social Telepresence13 December 2023 | ACM Transactions on Human-Robot Interaction, Vol. 12, No. 4The good and bad of an online asynchronous general education course: Students’ perceptions18 December 2023 | Psychology Teaching Review, Vol. 29, No. 2Face-to-face more important than digital communication for mental health during the pandemic17 May 2023 | Scientific Reports, Vol. 13, No. 1Videoconference fatigue from a neurophysiological perspective: experimental evidence based on electroencephalography (EEG) and electrocardiography (ECG)26 October 2023 | Scientific Reports, Vol. 13, No. 1The ‘Zoomification’ of Collaboration: How 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An exploratory study of the associations between social networks, sense of community and spatial colocation28 December 2021 | Journal of Corporate Real Estate, Vol. 24, No. 4Governing in the time of Covid-19: how board meetings went online and the implications of this for considering the role of the governing board19 October 2022 | Journal of Further and Higher Education, Vol. 51The Effects of Attributes of Non-Immersive Virtual Reality on Customers’ Experience of Video Tours under Social Distancing for COVID-1914 October 2022 | International Journal of Human–Computer Interaction, Vol. 6Moving intensive onsite courses online: responding to COVID-19 educational disruption15 June 2022 | International Journal of Ethics Education, Vol. 7, No. 2Webinars, podcasts, Tweetorials, oh my!Journal of Vascular Surgery, Vol. 76, No. 4Resilience and Wellbeing Strategies for Pandemic Fatigue in Times of Covid-1930 September 2022 | International Journal of Applied Positive Psychology, Vol. 78Zoom Yorgunluğu: Bir Gözden Geçirme30 September 2022 | Psikiyatride Güncel Yaklaşımlar, Vol. 14, No. 3Being Prepared and Preparing the Students for the Central Exam with Distance Education22 September 2022 | Pamukkale University Journal of EducationBridging social distance during social distancing: exploring social talk and remote collegiality in video conferencing11 November 2021 | Human–Computer Interaction, Vol. 37, No. 5Variations in consumer acceptance, sensory engagement and method practicality across three remote consumer-testing modalitiesFood Quality and Preference, Vol. 100Remote learning experiences of African Nova Scotian households in Canada during the COVID-19 temporary school closure: implications for inclusive education policy implementation7 August 2022 | International Journal of Inclusive Education, Vol. 36Individual and Situational Factors Influencing Active Behavior in Professional Video Conferences With Strangers7 August 2022 | Social Science Computer Review, Vol. 6From frequency to fatigue: Exploring the influence of videoconference use on videoconference fatigue in SingaporeComputers in Human Behavior Reports, Vol. 7“Seeing and Being Seen” or Just “Seeing” in a Smart Classroom Context When Videoconferencing: A User Experience-Based Qualitative Research on the Use of Cameras4 August 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. 15Understanding patterns of internal migration during the COVID‐19 pandemic in Spain16 June 2022 | Population, Space and Place, Vol. 28, No. 6Blended (online and in‐person) Women’s Health Interprofessional Learning by Simulation (WHIPLS) for medical and midwifery students18 April 2022 | Australian and New Zealand Journal of Obstetrics and Gynaecology, Vol. 62, No. 4Ten simple rules for leveraging virtual interaction to build higher-level learning into bioinformatics short courses28 July 2022 | PLOS Computational Biology, Vol. 18, No. 7AbGradCon 2021: lessons in digital meetings, international collaboration, and interdisciplinarity in astrobiology6 July 2022 | International Journal of Astrobiology, Vol. 17Recommendations for Building Telemental Health Relationships with Youth: A Systematic Review and Resource for Clinicians22 October 2021 | Evidence-Based Practice in Child and Adolescent Mental Health, Vol. 7, No. 3A National Study of Zoom Fatigue and Mental Health During the COVID-19 Pandemic: Implications for Future Remote Work Eric B. 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Ryan Wagner, and Jack Tsai11 July 2022 | Cyberpsychology, Behavior, and Social Networking, Vol. 25, No. 7The Influence of E-Scaffolding Sources in a Mobile Learning Environment on Students’ Design Skills and the Technology Fatigue Associated with a 3D Virtual Environment11 July 2022 | Electronics, Vol. 11, No. 14INVESTIGATION OF PARENTS’ VIEWS ON THE DISTANCE EDUCATION PROCESS DURING THE PANDEMIC22 June 2022 | Journal of Advanced Education Studies, Vol. 4, No. 1DATA COLLECTION BY ONLINE IN-DEPTH INTERVIEW IN QUALITATIVE RESEARCH: A POSTGRADUATE THESIS EXAMPLE14 June 2022 | Pamukkale University Journal of Social Sciences InstituteTwelve tips to enhance student engagement in synchronous online teaching and learning20 April 2021 | Medical Teacher, Vol. 44, No. 6Current and future influences of COVID-19 on the knowledge management function of conventions and exhibitions15 March 2022 | Service Business, Vol. 16, No. 2Robust Institutional Support and Collaboration Between Summer Training Programs in Cancer and Biomedicine Drive the Pivot to a Virtual Format in Response to the COVID January 2022 | Journal of Cancer Education, Vol. 37, No. of a Social Virtual Reality into the Vol. 29, No. Work Meetings During the COVID-19 Pandemic: The and May 2021 | Group Research, Vol. No. of in in the for New in for Use by May 2022 | Journal of Cognitive and Vol. 16, No. Online during COVID-19 Is Scientific February 2022 | Vol. 13, No. the Is and to It and K. June 2022 | Cyberpsychology, Behavior, and Social Networking, Vol. 25, No. learning Review of Education, Vol. May 2022 | Vol. 12, No. in the experiences and to and reflections the year of January 2022 | The Clinical Vol. 36, No. Psychological and Academic M. and May 2022 | Cyberpsychology, Behavior, and Social Networking, Vol. 25, No. of via videoconference on fatigue and Implications for the March 2022 | Healthcare Management Vol. No. Policy of Technology April 2022 | Education Sciences, Vol. 12, No. under A July 2021 | Journal of Family Vol. 44, No. Strategies During the COVID-19 Pandemic: Virtual Learning for Public Health and Cancer Health April 2022 | Frontiers in Public Health, Vol. during How a to online interaction and social April 2022 | Journal of Research on Vol. 16, No. a Roadmap for Technology in Social Training the of Social February 2022 | in Social Vol. No. Psychological for with Learning during the Pandemic: The Experiences of in the March 2022 | Journal of Mental Health Research in Vol. 15, No. to education and communication the and intensive community during the COVID-19 Vol. No. to education and communication the and intensive community during the COVID-19 Vol. No. and implementation of a virtual pain management programme to COVID-19: a September 2021 | British Journal of Vol. 16, No. Video Conference Fatigue of in the on Video Conference Social and April 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. of in during the COVID‐19 pandemic: the and of and challenges and the of mental health and in December 2021 | Journal of Research in Educational Vol. 22, No. New with COVID-19 and A Qualitative Study on Zoom Fatigue30 March 2022 | Vol. 19, No. distance une No. Social in Remote Social A for of When the Social of Interactions via Videoconferencing March 2022 | Frontiers in Psychology, Vol. the stress of and of Zoom December 2021 | Electronic Vol. 32, No. social as of A study under in Human Behavior, Vol. the of to an online in to February 2022 | Sciences Education, Vol. 15, No. changes in social during COVID pandemic in the United December 2021 | Vol. 29, No. in Journal of and Vol. 13, No. or How online February 2022 | PLOS Vol. No. in Zoom Fatigue B. and February 2022 | Cyberpsychology, Behavior, and Social Networking, Vol. 25, No. of on mental August 2021 | Vol. 19, No. 1Videoconference Fatigue: A February 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. 4The Use of Videoconferencing in Higher January and digital communication in Australian December 2021 | Journal of the International for Business, Vol. No. and in Industry August Zoom Learning February and in During Coronavirus January of Leadership on June Online Social a from a of February An Approach to Social During Online June Virtual Reality August in a Mediated July – und February Teaching as an for Vol. 22, No. Video During the COVID-19 Pandemic and Effects on May 2021 | and Vol. No. During Remote Teaching in through a pandemic: impact of on and of Clinical Medicine, Vol. 18, No. during the pandemic A Systematic Review using April 2022 | Information Science, Vol. 6, No. Hybrid Learning Challenges and February de de de December 2022 | Vol. 4, No. of COVID‐19 with and variables in An analysis of September 2021 | The International Journal of Health and Management, Vol. 37, No. Design With Research for the Development of a Digital for and August 2022 | Journal of Research Vol. No. to Equity, and in Science and December 2021 | Frontiers in Science, Vol. December 2021 | Vol. 25, No. reality during the COVID-19 pandemic: A and and Vol. for study for a randomized controlled September 2021 | Pilot and Studies, Vol. 7, No. and A Design December in social of and mothers during the COVID-19 Vol. “Zoom A November 2021 | Applied Psychology, Vol. The from to of Human - and Psychology of the Pandemic November Through the October 2021 | Education, Vol. No. Practice During COVID-19 to and of November 2021 | Vol. 36, No. as the of Exploring and Perspectives of of Telehealth by a Australian Service during COVID-19 October 2021 | International Journal of Environmental Research and Public Health, Vol. 18, No. with The of technology and consumer July 2021 | International Journal of Consumer Studies, Vol. 45, No. of June 2021 | Annals of Surgery, Vol. No. and of Virtual in Video and Effects on of the ACM on Human-Computer Interaction, Vol. 5, No. How a Virtual Network during the COVID-19 of the ACM on Human-Computer Interaction, Vol. 5, No. May 2021 | American Journal of Clinical Vol. No. to and Education in the of December 2021 | Journal of Education, Vol. No. between social communication and during the early of September 2021 | Journal of Social and Vol. No. September 2021 | Vol. 11, No. Bir September 2021 | Vol. 5, No. of During the COVID-19 Pandemic by the of Medical of A Survey September 2021 | Frontiers in Medicine, Vol. student under remote learning using digital A June 2021 | Education and Information Vol. No. of the COVID-19 Pandemic on Higher Education: the

Simulation-based healthcare education has expanded tremendously over the past few years, as witnessed by the creation and growth of the Society for Simulation in Healthcare and its journal. These developments represent a turning point at which simulation is no longer seen as a novelty whose existence needs to be justified or defended by a few staunch believers. We can now move beyond reporting on the potential role of simulation or how it compares to other more traditional (yet often unproven) methods of training, and focus instead on the most effective use of simulation for healthcare education. From the perspective of the training program, the effective use of simulation may be seen as the product of three components (Fig. 1): training resources, trained educators, and curricular institutionalization. It is important to note that if any of these components are missing or deficient, the product will become zero and effective training will not occur. For example, it is not rare for an institution to obtain a simulator only to see it collect dust because faculty members were not properly trained in its operation or did not know how to introduce it into the curriculum. These components include the following.FIGURE 1.: Formula for the effective use of simulation-based medical education: Effective Simulation-based Healthcare Education = Training Resources × Trained Educators × Curricular InstitutionalizationTraining Resources This component refers to having appropriate simulators, task trainers, standardized patients, and computer software that meet a program’s needs. In addition, it includes having the necessary physical space and associated equipment (eg, monitors, beds, cameras, microphones, recording and playback equipment) for simulation-based training. It also encompasses the associated curriculum (eg, crisis resource management,1 advanced life support, laparoscopic surgery), outcome measures (eg, checklists, rating forms), learning strategies (eg, experiential learning, deliberate practice2), and curriculum management systems (to schedule and track learners’ time and performance). Trained Educators This component includes healthcare professionals trained in the proper use of simulation-based medical education. It also includes individuals involved in the operation, management, and administration of simulation-based training, as well as researchers dedicated to advancing the field. Curricular Institutionalization This component includes elements necessary for full adoption and integration of simulation-based medical education into an institution’s mission and culture. It involves the decision of an institution to fully embrace its goal of improving patient care and patient safety through reducing and preventing medical errors, as well as more individual goals of improving a wide range of competencies (eg, acute care skills, surgical skills, crisis resource management, teamwork, and communication). During the past four decades of simulation use in healthcare, the literature has focused almost entirely on the first component of training resources. To illustrate, a recent systematic review of the literature on high-fidelity simulation identified 10 features that led to effective learning (Table 1).3 Nine out of the 10 features are related to training resources/strategies, and only one is related to curricular institutionalization. Most surprising is that none addressed the expertise/attributes of the educators involved in the process, yet we often know from experience that the faculty often determine the success and effectiveness of simulation-based training. Published reports and studies often describe the features of the simulator, the curricular content, learning environment, teaching strategies, and outcome measures, but provide few details on the knowledge or expertise of the faculty, or details related to how simulation gained acceptance and adoption at the local institution. It is time to address more formally the other important components of simulation-based healthcare education—educators and curricular institutionalization.TABLE 1: Features of Simulations that Lead to Effective LearningHow does simulation become adopted and integrated into an existing curriculum that is already overcrowded with content? Rogers4 provides a model that describes five stages for innovation adoption that we can adapt here for simulation. Stage 1 (Awareness) Institution is exposed to information about simulation-based healthcare education but lacks knowledge about it. Stage 2 (Interest) Institution becomes interested in simulation-based healthcare education and seeks additional information about it through attending meetings, visiting other simulation facilities or inviting experts to the institution. Stage 3 (Evaluation) Institution mentally applies the use of simulation to its present and anticipated future situation, and then decides whether or not to try it. This is often done with a local “champion” or through an expert consultant. Stage 4 (Trial) Institution makes first use of simulation, typically in a course headed by the local “champion.” Stage 5 (Adoption) Institution decides to continue the full use of simulation throughout its curriculum based on the experience and feedback from the trial and/or additional opportunities or needs that arise from increased exposure to the simulation. For each of these stages, the “institution” is usually represented by one or more educators who provide the link between the training resources and institutional adoption and implementation of simulation. What type of individual is key to making this happen? Ryan and Gross5 initially classified individuals who ultimately choose to implement innovation and Rogers further described their qualities.4 These categories (with relative proportions) include: Innovators (2.5%) These are risk takers with the initiative and willingness to expend time, effort, and resources in trying something new. These are individuals such as Gaba, Gordon (see related article in this journal issue), Gravenstein and others within the simulation community responsible for its creation and development. These individuals dominated the field of simulation during its first 25 years. Early Adopters (13.5%) These tend to be respected group leaders, the individuals essential to adoption by the whole group. These include many of the current leaders in the Society for Simulation in Healthcare and on the editorial board for Simulation in Healthcare who have been instrumental in the field’s growth over the past 10 years. Early Majority (34%) These are careful, safe, deliberate individuals unwilling to risk time or other resources without demonstrated evidence of the innovation’s effectiveness. These are individuals just recently involved in simulation-based education, and they represent the largest audience for the Society and journal. Late Majority (34%) These individuals are suspicious of or resistant to change and are difficult to move without significant influence. These individuals will eventually “come aboard,” but can sometimes provide a critical viewpoint that prevents wholesale adoption of innovation without slow, careful consideration and planning. Laggards (16%) These are individuals who are consistent or even adamant in resisting change. Pressure is often needed from leadership to force change. Rogers argues that the “Early Adopters” and “Early Majority” are the most important groups for an innovative technology to reach its tipping point for successful adoption and implementation.4Table 2 illustrates characteristics of individuals in these two groups. The educators comprising the “Early Majority” are the largest target audience for the Society and this journal and are receptive to guidance and support as they look to implement simulation at their local institutions. We should not underestimate the importance of this group as it represents the greatest chance for the long term success of simulation-based healthcare education.TABLE 2: Characteristics of Early and Successful Adopters/Implementers of Simulation TechnologyMany different approaches have been taken by institutions that have adopted simulation. The above stages can be achieved through a measured, deliberate process as part of a school’s strategic plan or obtained in a matter of a few days. For example, a relative novice can attend the International Meeting on Simulation in Healthcare and gain tremendous awareness, insight, and understanding of the use of simulation for training. Furthermore, the adoption of simulation can range from integrating a task trainer into a component of a course (eg, airway training during an emergency medicine clerkship) to creating a simulation-based curriculum such as Anesthesia Crisis Resource Management,1 or establishing a simulation center that serves multiple disciplines and professions both locally and regionally. At any level of integration, there should be certain minimum criteria that are met to better ensure success. This includes identifying the training needs for a given population, defining the outcomes that are expected from these learners, using the appropriate type of simulation that is based on the defined outcomes rather than the technical features, and measuring outcomes. At some point, there should be buy-in or formal adoption by the institution’s curriculum committee (or whatever body determines new curricula) so that early on it becomes a stakeholder in the process. What will it take for institutions to make that first step toward curricular adoption of simulation? Many of the institutions, hospitals, and agencies that have fully operational simulation-based training programs were started and maintained by the “Innovators” and “Early Adopters” who recognized the promise and potential value of simulation. However, Gaba points out that there are several other driving forces besides motivated teachers, researchers and simulation societies that will ultimately “push” or “pull” an institution toward full integration of simulation.6 This includes local institutional pressure from students, residents, and faculty who feel competition from other schools as well as professional societies, professional licensing/accrediting bodies and health care organizations. In addition, it also includes healthcare insurers, liability insurers, accrediting organizations, government agencies, and ultimately the public. In his commentary, Gaba predicts and describes how each of these driving forces may contribute to the successful integration of simulation throughout healthcare. One of these predictions has already occurred. Clinical societies have begun to establish processes to provide accreditation to training programs that offer healthcare providers a wide range of learning opportunities through the use of state-of-the-art educational methods and advanced technology. The accredited institution is expected to ensure achievement of clinical competence and development of expertise through the use of bench models, simulations, simulators and virtual reality.7 The American Society of Anesthesiologists recently approved the process for formal designation of simulation training programs8 and the American College of Surgeons (ACS) has already instituted a process to grant formal accreditation to programs that meet and demonstrate compliance with established standards and criteria.7 To date, seven institutions have successfully met the program requirements and, as a result, are designated as Level I ACS Accredited Education Institutes.9 Although the criteria related to training tools, administrative resources, technical support, and curricula are well defined, criterion 2.4, related to educators, simply states, “uses faculty/preceptors that are appropriately trained.”10 Clearly, there needs to be better guidance and opportunities to develop educators who are prepared to optimally use simulation. The role of the healthcare educator is arguably the most important component to ensure effective simulation-based healthcare education and, although often implicit in studies of simulation-based training, many of the skills required of these educators are ill-defined. Harden and colleagues11 have formally outlined the teaching roles of the healthcare educator (Table 3); one of these explicitly acknowledges the role of resource developers. Along these lines, simulation case scenarios such as the one by Singh and colleagues12 published in this issue of the journal represent a valuable and practical resource for our “Early Majority.” The cases are peer-reviewed and represent an additional opportunity for healthcare educators to demonstrate the many roles they serve, in addition to providing evidence of scholarship. Simulation case scenarios take considerable time, effort, and experience to develop and test, and are examples of the proven applications individuals in the “Early Majority” need.TABLE 3: Roles of the Healthcare Educator12 (for Simulation-based Training)Although these cases represent one type of resource for educators, the academic healthcare community needs to develop and manage competency-based programs of faculty training. The goal of these programs should be to produce healthcare educators certified in simulation-based training. Many “Early Adopters” in the field have already addressed this need and have created courses on developing and operating a simulation program and training educators. Table 4 lists just a few of the institutions and organizations that offer formal training for the simulation-based healthcare educator. Although none of these are officially “accredited” to provide formal certification, they do offer excellent faculty training and development opportunities. In my personal opinion, the Society for Simulation in Healthcare (SSH) is in a unique position to take a leading role in establishing formal criteria for certified training expertise in simulation-based healthcare education. Adopting the ACS model, I believe the SSH should aim to create a network of SSH-approved institutes that would offer individuals certified training on the essential skills of simulation-based healthcare education. These centers could in turn work with their own graduate programs to develop certificate, diploma, or masters degree opportunities for faculty who are committed to careers in simulation-based education. Just as the weight of evidence shows that clinical experience alone is not associated with the quality of delivered health care,13 educator competence in the expert use of simulation must be assured, not assumed.TABLE 4: List of Institutions and Organizations that Offer Formal Training for the Simulation-based Healthcare Educator*While the above vision may take some time to be realized, there are already several measures centered around the International Meeting on Simulation in Healthcare (IMSH) that the SSH has instituted to provide support for educators. The Society established a series of specialty tracks at the IMSH related to simulation center operations, nursing and prehospital education, and a full-day, postgraduate course on setting up a simulation center. Another novel approach would be to use the annual meeting as a venue to provide a formal certification course in simulation-based education. This has been done with success by the Association of Medical Education in Europe with its accrediting the Essential Skills in Medical Education (ESME) program,14 which provides an entry-level teaching qualification for those becoming involved in medical education for the first time, or who have been given some new responsibilities relating to teaching. The ESME program is organized to coincide with international medical education meetings. Typically, registrants participate in 1- or 2-day preconference workshops learning about the fundamentals of medical education. During the main conference they attend a wide range of sessions that not only cover broad topics applicable to all healthcare providers but also specific discipline-based tracts that address focused needs. Throughout the 2- to 3-day conference, ESME faculty members meet with course participants to review what they have learned from attending plenary and panel sessions, abstract presentations and workshops. The program concludes with a half-day postconference session in which participants report on what they have learned throughout the conference and how they will apply this to their local setting. They are also given the opportunity for further development in healthcare education by enrolling in an educator portfolio program. Participants spend the following year working with ESME faculty via email developing their portfolios as they provide evidence of their skills as an educator. A similar program could be developed around the IMSH and would provide the foundation for a more formal credentialing process. As the use of simulation for training continues to grow, there is an increasing need to focus on the institutional environment that encourages adoption and integration of simulation, and on the local faculty who must deliver the training. Another important role for the Society for Simulation in Healthcare and this journal is not only to disseminate information regarding the validity, reliability, and feasibility of the training resources, but also to provide assistance for the faculty who must use these resources and optimally integrate them into the programs of their local institutions. Finally, certified competence in healthcare education needs to be acknowledged and rewarded as a valued component of an academic career. Thus promotion and tenure processes at academic medical centers need to recognize the expression of educational expertise using simulation as legitimate work by healthcare educators.15 Healthcare professionals who research, develop, use, and evaluate simulation toward the goal of improving clinical competence and expertise and enhancing the quality and safety of patient care must be rewarded for their work. ACKNOWLEDGMENTS The author thanks Professor Ronald Harden for his assistance with the commentary’s concept, William McGaghie for his contribution on educator development, and Ross Scalese for his constructive feedback on early drafts.

Journal of Palliative MedicineVol. 3, No. 1 Innovations in End-of-Life CareTaking a Spiritual History Allows Clinicians to Understand Patients More FullyDr. Christina Puchalski and Anna L. RomerDr. Christina Puchalski and Anna L. RomerPublished Online:19 Apr 2005https://doi.org/10.1089/jpm.2000.3.129AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byVerbalizing spiritual needs in palliative care: a qualitative interview study on verbal and non-verbal communication in two Danish hospices4 January 2022 | BMC Palliative Care, Vol. 21, No. 1Implementation of an Educational Toolkit to Increase Nurse Competence in Spirituality and Spiritual Care of Oncology Patients8 November 2022 | Journal of Holistic Nursing, Vol. 5Posicionamento sobre a Saúde Cardiovascular nas Mulheres – 2022Arquivos Brasileiros de Cardiologia, Vol. 119, No. 5Experiences of German health care professionals with spiritual history taking in primary care: a mixed-methods process evaluation of the HoPES3 intervention15 October 2022 | Family Practice, Vol. 29Religious and spiritual journeys of LGBT older adults in rural Southern Appalachia25 October 2021 | Journal of Religion, Spirituality & Aging, Vol. 34, No. 4The CASH assessment tool: A window into existential suffering19 May 2021 | Journal of Health Care Chaplaincy, Vol. 28, No. 4Integrating religion/spirituality into professional social work practice27 July 2022 | Journal of Religion & Spirituality in Social Work: Social Thought, Vol. 41, No. 4The Concept of Spirituality in the Health Sector: Contributions from the Study of Religion27 September 2022 | International Journal of Latin American Religions, Vol. 12Systematic review: The relationship between religion, spirituality and mental health in adolescents who identify as transgender13 September 2022 | Journal of Gay & Lesbian Mental Health, Vol. 26„Des Lebens Ruf an uns wird niemals enden“ – Sinnzentrierte Interventionen im Überblick30 August 2022 | Zeitschrift für Palliativmedizin, Vol. 23, No. 05Case discussion: The critically ill older adult in spiritual distressGeriatric Nursing, Vol. 47Australian Patient Preferences for the Introduction of Spirituality into their Healthcare Journey: A Mixed Methods Study3 August 2022 | Journal of Religion and Health, Vol. 27Religion, Spirituality, and Ethics in Psychiatric Practice30 March 2022 | Journal of Nervous & Mental Disease, Vol. 210, No. 8Spiritual distress in dialysis: A case report21 July 2022 | Progress in Palliative Care, Vol. 211Interprofessional communication training to address spiritual aspects of cancer care19 July 2022 | Journal of Health Care Chaplaincy, Vol. 29Spirituality in Serious Illness and HealthJAMA, Vol. 328, No. 2What is the role of spiritual care specialists in teaching generalist spiritual care? 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M. Puchalski as an for an interdisciplinary in January | Journal for of and Social Vol. 21, No. the of Spiritual A Pain and Palliative Care Service Quality of Pain and Symptom Management, Vol. No. of Spiritual Assessment in September | Vol. No. the of Christian Nursing, Vol. 32, No. 4Spiritual care: is the assessment tool for palliative Journal of Palliative Nursing, Vol. 21, No. und Spiritualität in der September | Vol. 60, No. of September of spirituality assessment in palliative care patients in November 2014 | Progress in Palliative Care, Vol. 23, No. 4The for Spiritual A Mixed-Methods July | Oncology Nursing Vol. 42, No. 4The Integration of Religion and Spirituality in Social Practice: A May | Social Vol. 60, No. 3The and Educational of a Spiritual Life Review for Patients with and June 2014 | Journal of Cancer Education, Vol. 30, No. in Geriatric Palliative in Geriatric Medicine, Vol. No. An for Spiritual Well-Being May | Journal of Religion & Spirituality in Social Work: Social Thought, Vol. 34, No. Spiritual Assessment March | Journal of Health Care Chaplaincy, Vol. 21, No. American on Mental Health, and Help April | and Vol. 60, No. of Christian Nursing, Vol. 32, No. the Spiritual Needs and of Oncology Patients in Nursing Practice, Vol. 29, No. Care Training to Healthcare Professionals: A Systematic April | Journal of Pastoral Care & Counseling: Advancing theory and professional practice through scholarly and reflective publications, Vol. 69, No. analysis of spiritual

Medical Writings7 August 2001"Let Me See If I Have This Right …": Words That Help Build EmpathyJohn L. Coulehan, MD, Frederic W. Platt, MD, Barry Egener, MD, Richard Frankel, PhD, Chen-Tan Lin, MD, Beth Lown, MD, and William H. Salazar, MDJohn L. Coulehan, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Frederic W. Platt, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Barry Egener, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Richard Frankel, PhDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Chen-Tan Lin, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Beth Lown, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, and William H. Salazar, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-135-3-200108070-00022 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Consider these two physician–patient dialogues:1. Patient: You know, when you discover a lump in your breast, you kind of feel—well, kind of—(her speech tapers off; she looks down; tears form in her eyes).Dr. A: When did you actually discover the lump?Patient: (absently) I don't know. It's been a while.2. Patient: (same as above)Dr. B: That sounds frightening.Patient: Well, yeah, sort of.Dr. B: Sort of frightening?Patient: Yeah … and I guess I'm feeling like my life is over.Dr. B: I see. Worried and sad too.Patient: That's it, Doctor.Dr. A's patient ...References1. Konrad TR, Williams ES, Linzer M, McMurray J, Pathman DE, Gerrity M, et al . Measuring physician job satisfaction in a changing workplace and a challenging environment. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Med Care. 1999;37:1174-82. [PMID: 10549620] CrossrefMedlineGoogle Scholar2. Donelan K, Blendon RJ, Lundberg GD, Calkins DR, Newhouse JP, Leape LL, et al . The new medical marketplace: physicians' views. Health Aff Millwood. 1997;16:139-48. [PMID: 9314685] CrossrefMedlineGoogle Scholar3. Bates AS, Harris LE, Tierney WM, Wolinsky FD. Dimensions and correlates of physician work satisfaction in a midwestern city. Med Care. 1998;36:610-7. 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Being in the present moment: developing the capacity for mindfulness in medicine. Acad Med. 1999;74:420-4. [PMID: 10219225] CrossrefMedlineGoogle Scholar43. Epstein RM. Mindful practice. JAMA. 1999;282:833-9. [PMID: 10478689] CrossrefMedlineGoogle Scholar44. Miller SZ, Schmidt HJ. The habit of humanism: a framework for making humanistic care a reflexive clinical skill. Acad Med. 1999;74:800-3. [PMID: 10429589] CrossrefMedlineGoogle Scholar45. Barrett-Lennard GT. The phases and focus of empathy. Br J Med Psychol. 1993;66 Pt 1 3-14. [PMID: 8485075] CrossrefMedlineGoogle Scholar46. Gallop R, Lancee WJ, Garfinkel PE. The empathic process and its mediators. A heuristic model. J Nerv Ment Dis. 1990;178:649-54. [PMID: 2230750] CrossrefMedlineGoogle Scholar47. Hall JA, Roter DL, Rand CS. Communication of affect between patient and physician. J Health Soc Behav. 1981;22:18-30. [PMID: 7240703] CrossrefMedlineGoogle Scholar48. Larsen KM, Smith CK. Assessment of nonverbal communication in the patient–physician interview. J Fam Pract. 1981;12:481-8. [PMID: 7462949] MedlineGoogle Scholar49. Suchman AL, Matthews DA. What makes the patient-doctor relationship therapeutic? Exploring the connexional dimension of medical care. Ann Intern Med. 1988;108:125-30. [PMID: 3276262] LinkGoogle Scholar50. Suchman AL. Control and Relation: Two Foundational Values and Their Consequences.. In: Suchman AL, Botelho RJ, Hinton-Walker P, eds. Partnerships in Healthcare: Transforming Relational Process. Rochester, NY: Univ of Rochester Pr; 1998. Google Scholar51. Branch WT, Malik TK. Using "windows of opportunities" in brief interviews to understand patients' concerns. JAMA. 1993;269:1667-8. [PMID: 8455300] CrossrefMedlineGoogle Scholar52. Pinderhughes EB. Teaching empathy: ethnicity, race and power at the cross-cultural treatment interface. American Journal of Social Psychology. 1984;4:5-12. Google Scholar53. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-8. [PMID: 626456] LinkGoogle Scholar54. Platt FW, Gaspar DL, Coulehan JL, Fox L, Adler AJ, Weston WW, et al . "Tell me about yourself": the patient-centered interview. Ann Intern Med. 2001;134:1079-85. LinkGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Dr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902Corresponding Author: John L. Coulehan, MD, Department of Preventive Medicine, HSC L3-086, State University of New York at Stony Brook, Stony Brook, NY 11794-8036; e-mail, [email protected]sunysb.edu.Current Author Addresses: Dr. Coulehan: Department of Preventive Medicine, HSC L3-086, State University of New York at Stony Brook, Stony Brook, NY 11794-8036.Drs. Platt and Lin: University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80222.Dr. Egener: American Academy on Physician and Patient, Legacy Clinic Northwest, 1130 NW 22nd Avenue, Suite 220, Portland, OR 97210.Dr. Frankel: Highland Hospital, 1000 South Avenue, Rochester, NY 14620.Dr. Lown: Mount Auburn Hospital, 300 Mt. Auburn Street, Cambridge, MA 02238.Dr. Salazar: Medical College of Georgia, 1120 15th Street, HS2010, Augusta, GA 30902. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited ByHow does narrative medicine impact medical trainees' learning of professionalism? 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PhD, M. MD, and and role in education about care in Competencies in Care for and Communication in patients with in the Care of Cancer in of and of Empathic during When Being Not empathy learning for be and for effective the role of care in with and in the of the medicine and outcomes of physician empathy in A structural focus study of and perceptions of the of of Medical Student role of empathy in in the a new and in the a of the An or Do You to to Patients Do Not or with Challenges and a of of the of a for children with Care. A to in care: The role of perceptions in Older in Clinical during Health and H. or Not to Is That the Right empathy and sympathy: responses to troubles on a health care with to make the patient the Communication and With Patients in Your as a of The of Medicine, and How to and A Patient-Centered Communication Illness Using to Communication Care and Social in the office approach to the Words That in to and MD, M. MD, and Frederic Platt, I Student August August August by American College of

No AccessDisaster Risk Management1 Feb 2013Natural Disaster HotspotsA Global Risk AnalysisAuthors/Editors: Maxx Dilley, Robert S. Chen, Uwe Deichmann, Arthur L. Lerner-Lam, and Margaret ArnoldMaxx Dilley, Robert S. Chen, Uwe Deichmann, Arthur L. Lerner-Lam, and Margaret Arnoldhttps://doi.org/10.1596/0-8213-5930-4SectionsAboutPDF (29.3 MB) ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinked In Abstract:Earthquakes, floods, drought, and other natural hazards cause tens of thousands of deaths, hundreds of thousands of injuries, and billions of dollars in economic losses each year around the world. Many billions of dollars in humanitarian assistance, emergency loans, and development aid are expended annually. Yet efforts to reduce the risks of natural hazards remain largely uncoordinated across different hazard types and do not necessarily focus on areas at highest risk of disaster. Natural Disaster Hotspots presents a global view of major natural disaster risk hotspots – areas at relatively high risk of loss from one or more natural hazards. It summarizes the results of an interdisciplinary analysis of the location and characteristics of hotspots for six natural hazards – earthquakes, volcanoes, landslides, floods, drought, and cyclones. Data on these hazards are combined with state-of-the-art data on the subnational distribution of population and economic output and past disaster losses to identify areas at relatively high risk from one or more hazards. 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No AccessJournal of UrologyCLINICAL UROLOGY: Original Articles1 Nov 2002A Randomized Prospective Blinded Study Validating Acquistion of Ureteroscopy Skills Using A Computer Based Virtual Reality Endourological Simulator JAMES D. WATTERSON, DARREN T. BEIKO, JAMES K. KUAN, and JOHN D. DENSTEDT JAMES D. WATTERSONJAMES D. WATTERSON , DARREN T. BEIKODARREN T. BEIKO , JAMES K. KUANJAMES K. KUAN , and JOHN D. DENSTEDTJOHN D. DENSTEDT View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)64265-6AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: Surgical simulation has emerged in the last decade as a potential tool for aiding acquisition of technical skills, including anesthesia protocols, trauma management, cardiac catheterization and laparoscopy. We evaluate and validate the use of a computer based ureteroscopy simulator (URO Mentor, Simbionix Ltd., Lod, Israel) in the acquisition of basic ureteroscopic skills. Materials and Methods: We assessed 20 novice trainees for the ability to perform basic ureteroscopic tasks on a computer based ureteroscopy simulator. Participants were randomized to receive individualized mentored instruction or no additional training, and subsequently underwent post-testing. Pre-training and post-training improvement in performance was assessed by objective simulator based measurements. Subjective overall performance was rated using a validated endourological global rating scale by an observer blinded to subject training status. Results: Demographics and pre-test scores were similar between groups. Post-testing revealed a significant effect of training on objective and subjective measurements. Spearman rank correlation demonstrated a significant association between objective simulator based measurements and the endourological global rating scale. Conclusions: Use of a computer based ureteroscopy simulator resulted in rapid acquisition of ureteroscopic skills in trainees with no prior surgical training. Results of this study demonstrate the use of a virtual reality ureteroscopy simulator in endourological training. Correlation of simulator based measurements with a previously validated endourological global rating scale provides initial validation of the ureteroscopy simulator for the assessment of ureteroscopic skills. References 1 : Anaesthetic simulators: training for the broader health-care profession. Aust N Z J Surg2000; 70: 735. Crossref, Medline, Google Scholar 2 : Use of a human patient simulator in the development of resident trauma management skills. J Trauma2001; 51: 17. Crossref, Medline, Google Scholar 3 : The virtual reality arthroscopy training simulator. 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Yan H, Liu H, Lu Y, Li T and Qiu X (2021) "Dawn of South Lake"——Design and Implementation of Immersive Interactive System Based on Virtual Reality Technology BDET 2021: 2021 the 3rd International Conference on Big Data Engineering and Technology, 10.1145/3474944.3474959, 9781450389280, (88-93), Online publication date: 16-Jan-2021. Gupta A, Cecil J and Pirela-Cruz M (2020) Immersive Virtual Reality based Training and Assessment of an Orthopedic Surgical Process 2020 IEEE International Systems Conference (SysCon), 10.1109/SysCon47679.2020.9381832, 978-1-7281-5365-0, (1-7) Gupta A, Cecil J and Pirela-Cruz M (2020) A Cyber-Human based Integrated Assessment approach for Orthopedic Surgical Training 2020 IEEE 8th International Conference on Serious Games and Applications for Health(SeGAH), 10.1109/SeGAH49190.2020.9201817, 978-1-7281-9042-6, (1-8) Raskolnikov D, Chen T and Sweet R (2020) Simulation and Ureteroscopy (URS) Ureteroscopy, 10.1007/978-3-030-26649-3_16, (221-237), . Abe T, Dar F, Amnattrakul P, Aydin A, Raison N, Shinohara N, Khan M, Ahmed K and Dasgupta P (2019) The effect of repeated full immersion simulation training in ureterorenoscopy on mental workload of novice operatorsBMC Medical Education, 10.1186/s12909-019-1752-2, VOL. 19, NO. 1, Online publication date: 1-Dec-2019. Gupta A, Cecil J, Pirela-Cruz M and Ramanathan P A Virtual Reality Enhanced Cyber-Human Framework for Orthopedic Surgical TrainingIEEE Systems Journal, 10.1109/JSYST.2019.2896061, VOL. 13, NO. 3, (3501-3512) Cecil J, Gupta A, Pirela-Cruz M and Ramanathan P (2019) WITHDRAWN: An IoMT-based Cyber Training Framework for Orthopedic Surgery using Next Generation Internet TechnologiesInformatics in Medicine Unlocked, 10.1016/j.imu.2019.100234, (100234), Online publication date: 1-Aug-2019. Abboudi H, Shamim Khan M, Dasgupta P and Ahmed K (2019) Simulation in Urology Blandy's Urology, 10.1002/9781118863343.ch1.3, (27-38), Online publication date: 22-Mar-2019. Zhao Z and Sweet R (2018) Endoscopic Training/Simulation Smith's Textbook of Endourology, 10.1002/9781119245193.ch10, (159-172) Kowalewski T and Lendvay T (2019) Performance Assessment Comprehensive Healthcare Simulation: Surgery and Surgical Subspecialties, 10.1007/978-3-319-98276-2_9, (89-105), . Baas W and Schwartz B (2019) Simulation in Urology Comprehensive Healthcare Simulation: Surgery and Surgical Subspecialties, 10.1007/978-3-319-98276-2_24, (289-317), . Cecil J, Gupta A, Pirela-Cruz M and Ramanathan P (2018) A Network-Based Virtual Reality Simulation Training Approach for Orthopedic SurgeryACM Transactions on Multimedia Computing, Communications, and Applications, 10.1145/3232678, VOL. 14, NO. 3, (1-21), Online publication date: 31-Aug-2018. Baas W, Davis M and Schwartz B (2018) Simulation in Surgery Surgeons as Educators, 10.1007/978-3-319-64728-9_24, (439-488), . Yiasemidou M, de Siqueira J, Tomlinson J, Glassman D, Stock S and Gough M (2017) "Take-home" box trainers are an effective alternative to virtual reality simulatorsJournal of Surgical Research, 10.1016/j.jss.2017.02.038, VOL. 213, (69-74), Online publication date: 1-Jun-2017. Yonghang Tai , Wei L, Zhou H, Nahavandi S, Junsheng Shi and Qiong Li (2016) Integrating virtual reality and haptics for renal puncture surgical simulator 2016 2nd IEEE International Conference on Computer and Communications (ICCC), 10.1109/CompComm.2016.7924747, 978-1-4673-9026-2, (480-484) Aydin A, Raison N, Khan M, Dasgupta P and Ahmed K (2016) Simulation-based training and assessment in urological surgeryNature Reviews Urology, 10.1038/nrurol.2016.147, VOL. 13, NO. 9, (503-519), Online publication date: 1-Sep-2016. Stunt J, Kerkhoffs G, Horeman T, van Dijk C and Tuijthof G (2014) Validation of the PASSPORT V2 training environment for arthroscopic skillsKnee Surgery, Sports Traumatology, Arthroscopy, 10.1007/s00167-014-3213-0, VOL. 24, NO. 6, (2038-2045), Online publication date: 1-Jun-2016. Borsci S, Lawson G, Jha B, Burges M and Salanitri D (2016) Effectiveness of a multidevice 3D virtual environment application to train car service maintenance proceduresVirtual Reality, 10.1007/s10055-015-0281-5, VOL. 20, NO. 1, (41-55), Online publication date: 1-Mar-2016. Hu W, Feng J, Wang J, Song Y, Xu X, Zhou H and Huang C (2015) Ureteroscopy and cystoscopy training: comparison between transparent and non-transparent simulatorsBMC Medical Education, 10.1186/s12909-015-0380-8, VOL. 15, NO. 1, Online publication date: 1-Dec-2015. Nomura T, Mamada Y, Nakamura Y, Matsutani T, Hagiwara N, Fujita I, Mizuguchi Y, Fujikura T, Miyashita M and Uchida E (2015) Laparoscopic skill improvement after virtual reality simulator training in medical students as assessed by augmented reality simulatorAsian Journal of Endoscopic Surgery, 10.1111/ases.12209, VOL. 8, NO. 4, (408-412), Online publication date: 1-Nov-2015. Stunt J, Kerkhoffs G, van Dijk C and Tuijthof G (2014) Validation of the ArthroS virtual reality simulator for arthroscopic skillsKnee Surgery, Sports Traumatology, Arthroscopy, 10.1007/s00167-014-3101-7, VOL. 23, NO. 11, (3436-3442), Online publication date: 1-Nov-2015. Cloutier J and Traxer O (2015) Do high-fidelity training models translate into better skill acquisition for an endourologist?Current Opinion in Urology, 10.1097/MOU.0000000000000143, VOL. 25, NO. 2, (143-152), Online publication date: 1-Mar-2015. Brunckhorst O, Aydin A, Abboudi H, Sahai A, Khan M, Dasgupta P and Ahmed K (2015) Simulation-Based Ureteroscopy Training: A Systematic ReviewJournal of Surgical Education, 10.1016/j.jsurg.2014.07.003, VOL. 72, NO. 1, (135-143), Online publication date: 1-Jan-2015. Sea J and Sundaram C (2015) Urologic Surgery Training Using Computer-Assisted Simulators Advances in Image-Guided Urologic Surgery, 10.1007/978-1-4939-1450-0_19, (243-263), . Vallas C, Alexiou K, Alexandrou A and Economou N (2015) Different forms of laparoscopic training: Review and comparisonΜορφές λαπαροσκοπικής εκπαίδευσης.ανασκόπηση και συγκρίσειςHellenic Journal of Surgery, 10.1007/s13126-014-0157-2, VOL. 86, NO. 6, (337-346), Online publication date: 1-Nov-2014. Seitz C and Fajkovic H (2019) Training in ureteroscopy for urolithiasisArab Journal of Urology, 10.1016/j.aju.2013.08.010, VOL. 12, NO. 1, (42-48), Online publication date: 1-Mar-2014. Marchi D, Esposito M, Gentile I and Gilio F (2014) Laparoscopic Cholecystectomy: Training, Learning Curve, and Definition of Expert Laparoscopic Cholecystectomy, 10.1007/978-3-319-05407-0_11, (141-147), . Nagendran M, Gurusamy K, Aggarwal R, Loizidou M and Davidson B (2013) Virtual reality training for surgical trainees in laparoscopic surgeryCochrane Database of Systematic Reviews, 10.1002/14651858.CD006575.pub3 Schlickum M, Felländer-Tsai L, Hedman L and Henningsohn L (2012) Endourological simulator performance in female but not male medical students predicts written examination results in basic surgery Scandinavian Journal of Urology, 10.3109/00365599.2012.693538, VOL. 47, NO. 1, (38-42), Online publication date: 1-Feb-2013. Al-Kandari A (2013) Difficulties in Endourologic Training Difficult Cases in Endourology, 10.1007/978-1-84882-083-8_32, (315-325), . Krambeck A, Gettman M and de Cógáin M (2013) Surgical Simulation Ureteroscopy, 10.1007/978-1-62703-206-3_39, (443-451), . Chummun K, Burke J, O'Sullivan R and Prendiville W (2011) The influence of a 'take home' box trainer on laparoscopic performance for gynaecological surgeonsGynecological Surgery, 10.1007/s10397-011-0720-6, VOL. 9, NO. 3, (303-308), Online publication date: 1-Sep-2012. Arora S, Undre S and Kneebone R (2012) Simulation and Training in Minimally Invasive Surgery Simulation Training in Laparoscopy and Robotic Surgery, 10.1007/978-1-4471-2930-1_4, (31-38), . Ahmed K, Zakri R, Rowland S, Joyce A, Challacombe B, Dasgupta P and Khan M (2011) What is the current status of revalidation in urology?BJU International, 10.1111/j.1464-410X.2011.10375.x, VOL. 108, NO. 8, (1248-1253), Online publication date: 1-Oct-2011. Schreuder H, van Hove P, Janse J, Verheijen R, Stassen L and Dankelman J (2011) An "Intermediate Curriculum" for Advanced Laparoscopic Skills Training with Virtual Reality SimulationJournal of Minimally Invasive Gynecology, 10.1016/j.jmig.2011.05.017, VOL. 18, NO. 5, (597-606), Online publication date: 1-Sep-2011. Sarker S and Delaney C (2010) Feasibility of self-appraisal in assessing operative performance in advanced laparoscopic colorectal surgeryColorectal Disease, 10.1111/j.1463-1318.2010.02271.x, VOL. 13, NO. 7, (805-810), Online publication date: 1-Jul-2011. Ahmed K, Jawad M, Abboudi M, Gavazzi A, Darzi A, Athanasiou T, Vale J, Khan M and Dasgupta P (2011) Effectiveness of Procedural Simulation in Urology: A Systematic ReviewJournal of Urology, VOL. 186, NO. 1, (26-34), Online publication date: 1-Jul-2011. Corona R, Verguts J, Binda M, Molinas C, Schonman R and Koninckx P (2011) The impact of the learning curve on adhesion formation in a laparoscopic mouse modelFertility and Sterility, 10.1016/j.fertnstert.2011.04.057, VOL. 96, NO. 1, (193-197), Online publication date: 1-Jul-2011. Olweny E and Pearle M (2011) Update on Resident Training Models for UreteroscopyCurrent Urology Reports, 10.1007/s11934-010-0169-6, VOL. 12, NO. 2, (115-120), Online publication date: 1-Apr-2011. Lendvay T, Rosen J and Hannaford B (2011) Telerobotics: Its Future in Clinical Application Pediatric Robotic and Reconstructive Urology, 10.1002/9781444345292.ch44, (314-327), Online publication date: 22-Mar-2011. Arora S, Lamb B, Undre S, Kneebone R, Darzi A and Sevdalis N (2010) Framework for incorporating simulation into urology trainingBJU International, 10.1111/j.1464-410X.2010.09563.x, VOL. 107, NO. 5, (806-810), Online publication date: 1-Mar-2011. Sarker S, Maciocco M, Zaman A and Kumar I (2010) Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment toolThe American Journal of Surgery, 10.1016/j.amjsurg.2009.10.025, VOL. 200, NO. 3, (334-340), Online publication date: 1-Sep-2010. Schout B, Ananias H, Bemelmans B, D'Ancona F, Muijtjens A, Dolmans V, Scherpbier A and Hendrikx A (2009) Transfer of cysto-urethroscopy skills from a virtual-reality simulator to the operating room: a randomized controlled trialBJU International, 10.1111/j.1464-410X.2009.09049.x, VOL. 106, NO. 2, (226-231) Ahmed K, Jawad M, Dasgupta P, Darzi A, Athanasiou T and Khan M (2010) Assessment and maintenance of competence in urologyNature Reviews Urology, 10.1038/nrurol.2010.81, VOL. 7, NO. 7, (403-413), Online publication date: 1-Jul-2010. Sarker S, Kumar I and Delaney C (2010) Assessing Operative Performance in Advanced Laparoscopic Colorectal SurgeryWorld Journal of Surgery, 10.1007/s00268-010-0486-4, VOL. 34, NO. 7, (1594-1603), Online publication date: 1-Jul-2010. Schout B, Hendrikx A, Scheele F, Bemelmans B and Scherpbier A (2009) Validation and implementation of surgical simulators: a critical review of present, past, and futureSurgical Endoscopy, 10.1007/s00464-009-0634-9, VOL. 24, NO. 3, (536-546), Online publication date: 1-Mar-2010. White M, DeHaan A, Stephens D, Maes A and Maatman T (2009) Validation of a High Fidelity Adult Ureteroscopy and Renoscopy SimulatorJournal of Urology, VOL. 183, NO. 2, (673-677), Online publication date: 1-Feb-2010. Schout B, Muijtjens A, Hendrikx A, Ananias H, Dolmans V, Scherpbier A and Bemelmans B (2010) Acquisition of flexible cystoscopy skills on a virtual reality simulator by experts and novicesBJU International, 10.1111/j.1464-410X.2009.08733.x, VOL. 105, NO. 2, (234-239), Online publication date: 1-Jan-2010. Gamboa A and McDougall E (2010) Training Implications for Stone Management Urinary Tract Stone Disease, 10.1007/978-1-84800-362-0_48, (577-587), . Connors J, Sacks D, Black C, McIff E, Stallmeyer M, Cole J, Rowley H, Wojak J, Mericle R, Murphy K and Cardella J (2009) Training Guidelines for Intra-arterial Catheter-directed Treatment of Acute Ischemic Stroke: A Statement from a Special Writing Group of the Society of Interventional RadiologyJournal of Vascular and Interventional Radiology, 10.1016/j.jvir.2009.10.005, VOL. 20, NO. 12, (1507-1522), Online publication date: 1-Dec-2009. Connors J, Sacks D, Furlan A, Selman W, Russell E, Stieg P and Hadley M (2009) Training, Competency, and Credentialing Standards for Diagnostic Cervicocerebral Angiography, Carotid Stenting, and Cerebrovascular InterventionJournal of Vascular and Interventional Radiology, 10.1016/j.jvir.2009.04.003, VOL. 20, NO. 7, (S292-S301), Online publication date: 1-Jul-2009. Van Herzeele I, Aggarwal R, Malik I, Gaines P, Hamady M, Darzi A, Cheshire N and Vermassen F (2009) Validation of Video-based Skill Assessment in Carotid Artery StentingEuropean Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2009.03.008, VOL. 38, NO. 1, (1-9), Online publication date: 1-Jul-2009. Laguna M, de Reijke T and de la Rosette J (2009) How far will simulators be involved into training?Current Urology Reports, 10.1007/s11934-009-0019-6, VOL. 10, NO. 2, (97-105), Online publication date: 1-Mar-2009. Gurusamy K, Aggarwal R, Palanivelu L, Davidson B and Gurusamy K (2009) Virtual reality training for surgical trainees in laparoscopic surgery Cochrane Database of Systematic Reviews, 10.1002/14651858.CD006575.pub2 Undre S, Arora S and Sevdalis N (2009) Surgical Performance, Human Error and Patient Safety in Urological SurgeryBritish Journal of Medical and Surgical Urology, 10.1016/j.bjmsu.2008.11.004, VOL. 2, NO. 1, (2-10), Online publication date: 1-Jan-2009. Stone M and B Virtual in Urology, Schout B, Hendrikx A, Scherpbier A and Bemelmans B Update on Training Models in A Systematic Review of the between and Urology, VOL. NO. 6, Online publication date: de la Rosette J, Laguna M, J and P Training in Urology, VOL. NO. 5, Online publication date: Lendvay T, P, Sweet R and C validation of a virtual-reality of Robotic Surgery, VOL. 2, NO. 3, Online publication date: Gurusamy K, Aggarwal R, Palanivelu L and Davidson B Systematic review of randomized controlled on the of virtual reality training for laparoscopic Journal of Surgery, VOL. NO. 9, Online publication date: G, J, G, J, Pearle M, Sweet R and McDougall E Surgical Simulation: A Urological of Urology, VOL. NO. 5, Online publication date: Aggarwal R, T, K, T and Darzi A and of Surgical Skills in the of Surgery, VOL. NO. 2, Online publication date: D and J Advances in of VOL. 34, NO. 3, Online publication date: Gurusamy K, Aggarwal R, Palanivelu L, Davidson B and Gurusamy K Virtual reality training for surgical trainees in laparoscopic surgery Cochrane Database of Systematic Reviews, S, G, J, A and A Management by Gynecology, VOL. NO. 6, Online publication date: V, J, C, S, K, J, A, J, J and R From the to the Surgical The for of the on of Surgical Research, VOL. NO. 1, Online publication date: C, D, L, J and Gettman M (2018) The of Medical Simulation in American Urological Training An Assessment by of Urology, VOL. NO. 1, Online publication date: C and S Simulation in . B, E, B, B, V, J, Pearle M, S and J (2018) A Prospective Study Validating the Acquisition of System Skills Using a Computer Based Virtual Reality Surgical of Urology, VOL. NO. 5, Online publication date: C, W and G Technology for and Urologic of VOL. NO. 3, Online publication date: E, K and R Virtual reality ureteroscopy simulator as a tool for assessing endourological Journal of Urology, VOL. 13, NO. 7, Online publication date: S, D and S A of the of and virtual reality VOL. 32, NO. 4, Online publication date: O, M, C, A, R, Seitz M, B, R, A and C virtual reality simulator for of lower VOL. NO. 6, Online publication date: E, G, K, L, D, Pearle M and J Assessment of basic human performance predicts performance of American Journal of Surgery, VOL. NO. 6, Online publication date: A, L, de la A, R, D, S and C Simulation training in urologic Urology Reports, VOL. 7, NO. 2, Online publication date: L, P, A, J, P, D and G Surgical of Surgery, VOL. NO. 3, Online publication date: S, J, C, B, R, D, A and K Simulator assessment of of Vascular Surgery, VOL. NO. 1, Online publication date: M and R Training on Models in Urology, VOL. NO. 3, Online publication date: S, P, A, J and T A study of skills in virtual and Endoscopy, VOL. 19, NO. 2, Online publication date: Connors J, Sacks D, Furlan A, Selman W, Russell E, Stieg P and Hadley M Training, Competency, and Credentialing Standards for Diagnostic Cervicocerebral Angiography, Carotid Stenting, and Cerebrovascular VOL. NO. 1, (26-34), Online publication date: Connors J, Sacks D, Furlan A, Selman W, Russell E, Stieg P and Hadley M Training, Competency, and Credentialing Standards for Diagnostic Cervicocerebral Angiography, Carotid Stenting, and Cerebrovascular InterventionJournal of Vascular and Interventional Radiology, VOL. 15, NO. 12, Online publication date: Connors J Training, Competency, and Credentialing Standards for Carotid in Vascular and Interventional Radiology, VOL. 7, NO. 4, Online publication date: R, T, P, S and R (2018) of Urology, VOL. NO. 5, Online publication date: K, L, M, C, J and M (2018) A of Urology, VOL. NO. 2, Online publication date: E, S, K, R, E, R and K (2018) A of Urology, VOL. NO. 1, Online publication date: and G Advances in and in of VOL. NO. 1, Online publication date: (2018) of Urology, VOL. NO. 1, Online publication date: 2002 by American Urological Association, Author JAMES D. WATTERSON by this DARREN T. BEIKO by this JAMES K. KUAN by this JOHN D. DENSTEDT with and by this All

Simulation in Healthcare premiered in 2006 providing a forum for educators, researchers, clinicians, and developers to publish their scholarly work in an emerging arena, representing the intersection of simulation and healthcare. Under the leadership of Dr. David Gaba, the founding editor-in-chief (EIC), the journal has enjoyed tremendous success. It is the most revered peer-reviewed journal of its kind and one of the most successful accomplishments of our society. During Dr. Gaba's tenure, the journal was accepted for indexing by PubMed in 2008. Author interest in publishing surged, requiring an increase from 4 to 6 issues per year in 2010. The journal received its first Thomson Reuters Journal Impact Factor rating of 2.036 in 2011. At present, Simulation in Healthcare is the official journal for 21 national, international, and professional associations or societies. The journal is now in its 11th year and published its first special theme issue in April. This is a remarkable record of achievement by any measure and one in which all members of our society can take pride. We owe Dr. Gaba a debt of gratitude and wish him much success in his future endeavors. I am humbled and honored to succeed Dr. Gaba as the second EIC of this prestigious journal. I come into this role with a different background than my predecessor. I am a human factors psychologist by profession. Human factors psychology is a synthesis of psychology and engineering. It is a discipline concerned with how to improve individual or team performance by creating a better fit between humans and their technology, with an emphasis on training, assessment, safety, and better design of tasks and equipment. Initially, I studied aviation and military simulation systems but shifted my focus toward healthcare around 2003. I knew that simulation provided a safe means to study human fallibility and improve human resilience in other high-risk domains and believed that healthcare was no exception. Since then, I have been fortunate to conduct research and collaborate with clinicians and healthcare providers from many different specialties including: anesthesiology, dermatology, emergency medicine, family medicine, interventional radiology, nursing, obstetrics and gynecology, oncology, pediatrics, sonography, surgery, as well as physician's assistants and standardized patients. Most important, in my new role as EIC, I am supported by an outstanding and distinguished team of associate editors, editorial board members, and peer reviewers whose expertise spans a diverse spectrum of clinical and technical specialties. I am also grateful to have the sage council of Dr. Gaba who will remain on the editorial board as founding EIC. In addition to healthcare simulation, I am also involved in the training and education of simulation professionals. My university recognizes the pervasive and multidisciplinary nature of modeling and simulation and established an interdisciplinary steering committee with representatives from every college. I currently serve as chair of this steering committee, which is tasked with managing and guiding the pedagogical concerns of modeling and simulation across the university, including 8 modeling and simulation certificate programs in business; computer science; education; health sciences; international studies; math; modeling, simulation, and visualization; and human factors. SIMULATION IN HEALTHCARE Who Are We and Who Do We Want to be? The journal is “growing up.” We have entered our teen years. As children become adolescents, they begin to do more exploring, take more risks, and try to gain a better understanding of themselves. The psychologist, Erik Erikson, argued that adolescents often go through an identity crisis.1 They begin to ask questions about who they are, where they belong, how they fit in, and what they want to be. Those who are successful at resolving the issues surrounding their identity have greater confidence in themselves and are better prepared to enter adulthood. Perhaps, this is a good time to take measure of “who we are” and “who we want to be.” Who Are We? Well, we can be defined largely by what we publish. To do some introspection, I reviewed the last 3 full years of the journal (2013–2015), a representative snapshot of who we are now. I categorized the content by type of article, country of origin, primary themes, clinical specialty addressed, expertise level targeted, and the primary type of simulation addressed. During this interval, we published 169 articles. Empirical investigations account for 46% of articles published, the largest percentage. The next largest category is technical reports accounting for 17% of the content. Commentary, reviews, special articles, editorials, letters to the editor, and case scenarios, each account for 5% to 8% of the content. Most (61%) of the content originates in the United States or includes US authors, but we are indeed an international journal. Authors from Canada (11%), Australia (6%), Denmark (4%), and the United Kingdom (4%) constitute the next largest contributors, but we had authors from 21 other nations. Classifying the topics of the articles is a little more challenging; however, a reasonable set of themes is shown in Table 1. This is not a rigorous classification scheme, and the themes are not necessarily mutually exclusive, but it does convey a general picture. Articles on assessment, education/training, and technology account for approximately 63% of our content. This number increases to 84% if articles on validation, teams, human factors issues, simulation theory, and patient safety are added to the count. By contrast, articles on medical knowledge, patient outcomes, and patient care account for only a small fraction of our content, approximately 6%.TABLE 1: Classification of Themes Published (2013–2015)Turning to clinical specialty, most of our content addresses anesthesiology (16%). Emergency medicine, general medicine, and surgery, each account for 11% of the articles, followed by nursing (10%), pediatrics (9%), and obstetrics and gynecology (8%). Other specialties with more than 1 article during this period include cardiology, EMTs/paramedics, internal medicine, and radiology. Approximately 76% of the articles address practicing clinicians and residents. The remainder focuses on students or expertise at multiple levels. Only 1 article employed patients as their primary participants. Approximately 50% of the articles address mannequin or physical model simulators. The next largest percentage (17%) addresses standardized patients or actors. Research on virtual reality (VR), hybrid systems, or multiple formats accounts for 26% of the articles. However, we have occasionally published articles on animal models, cadavers, and center or hospital operations. In sum, we publish a lot of research on how to use simulation for training and assessment, ways to improve the simulation experience for learners, and methods for developing and evaluating new simulation systems. In some respects, our identity seems to have a strong human factors foundation with a healthcare focus. We address a fairly broad range of clinical specialties but tend to publish perhaps most in areas where the simulation systems are more plentiful and have histories that reach further back. Finally, most of what we publish originates in the United States, but nearly 40% of our content comes from outside the United States or includes international authors. Who Do We Want to be? As we look ahead, we want to continue doing what we do well. One of the strengths of the journal is its diversity: diversity of topics published, specialties addressed (clinical, instructional, and technical), varieties of simulation, and membership among the associate editors and editorial board. We want to continue to attract submissions from across the broad spectrum of healthcare simulation. New developments and rigorous research in one application or specialty area informs the entire community. We want to maintain diversity among the ideas and opinions we publish. We also want to continue to encourage diversity within the editorial and reviewing processes of the journal. Another strength of the journal is our roster of international partners. Although we are the official journal for many national associations, we do not receive many articles from members of these associations. Our international partners are a tremendous resource for the healthcare simulation community and the journal, and we need work harder to encourage their participation. Introspection can be critical, so we must also think about areas where we could do better. One important area concerns the impact of simulation on patients. In their 2011 review, McGaghie et al2 described 3 phases of translational science research. The first phase (T1) focuses on science that moves basic laboratory findings into the clinical research paradigm (eg, do theories of education and training predict outcomes in simulation research?). In the second phase (T2), results from clinical research are evaluated for their effects on patients. What is the impact of results obtained in simulation studies on patient outcomes and do they inform clinical practice? The last phase (T3) addresses science aimed at greater public health concerns. What can be done to improve prevention or better manage the health needs of the population? As noted previously, much of the content we publish is at the T1 level. Although much research is still needed at the T1 level, it is time to begin looking beyond our simulation centers and take on the challenge of translational studies at the T2 and T3 levels. We should not shy away from material that originates outside of healthcare that has meaning for our community. Lessons learned in other domains with a history of simulation can be invaluable to a community that is still young. For example, the military and other high-risk domains often describe simulations as live, virtual, and constructive.3 According to this classification scheme, live simulations are those in which real people operate real equipment. In virtual simulations, real people interact with simulated systems (ie, physical or virtual models). Constructive simulations are qualitatively different. They represent software specifically developed to simulate people (agents) interacting within simulated systems. Many in our healthcare simulation community are familiar with live and virtual forms of simulations that incorporate mannequins, part-task trainers, VR systems, and standardized patients. To date, there has been less interest in constructive simulations; however, there is great potential for these types of systems. They can be used to model the delivery of healthcare services, inform providers and administrators about the potential impact of policies, and incorporated into live and virtual simulation scenarios to enhance the environmental and operational context. Furthermore, we need to embrace the power that simulation offers beyond training providers. In many other high-risk domains, simulation is the conduit through which technological advances are evaluated. In aviation, new hardware and software are often evaluated in flight simulators and test aircraft before seeking US Federal Aviation Administration approval. This approach is beginning to gain acceptance in healthcare as simulation centers work with medical device manufacturers to provide context-based user evaluations of equipment before seeking US Food and Drug Administration approval. Change is inevitable. To the extent that change can be better managed with simulation, it can provide smoother and safer transitions that serve the healthcare community and the patients. For example, Ventre and coworkers4 conducted in situ simulations to evaluate the operational readiness of a children's hospital obstetric unit before it opened. Over the course of several days, they uncovered multiple deficiencies in equipment, staffing, and communication and were able to have them addressed before accepting patients. Technological changes on the horizon are coming faster and will have profound effects on patient care and healthcare. Consider VR. The delivery of games, entertainment, and information via VR systems is now becoming commercially viable. A wide variety of choices are available from moderately expensive systems specifically designed for developers and enthusiasts to systems for less than US $100 that can be coupled to a smart phone. The potential for offering providers and patients VR content and simulations is unprecedented, and they will soon expect it. Ultrasonography is another example. Portable and even handheld systems allow clinicians to evaluate their patients rapidly and more thoroughly. Ultrasonography is becoming pervasive and is now being incorporated into undergraduate medical curricula.5 Although it is debatable whether portable ultrasonography systems will replace the stethoscope as a diagnostic tool,6 it is clear that the technology is creating a great need for simulation-based training systems. Several commercial simulation systems are currently available, and it is likely that the genuine ultrasonography systems will continue to develop in parallel with simulation systems. Perhaps most important, the robots are rising. They are not limited to vacuums in our homes. Google's driverless cars have been tested on the roads since 2012. Artificial intelligence in software based on algorithms and neural networks allows you to talk to your phone and directs your attention to items that should appeal to you when surfing the Internet. Cybathon 2016, the first Olympic competition for people with physical impairments and their robotic-assisted prosthetics, will be held in Zurich this October. Many in the healthcare community may be familiar with robot-assisted surgery (eg, the da Vinci Surgical System by Intuitive Medical, Inc); however, these systems are actually telerobotic systems that require a human to operate them. By contrast, researchers have reported on an autonomous robotic system for soft tissue surgery driven by a plenoptic 3-D, near-infrared fluorescent imaging system and a suturing algorithm derived from surgeons.7 Their initial results showed better performance of the robotic system over expert surgeons using a robot-assisted system. An autonomous surgical system is qualitatively different from a telerobotic system because most of the authority over its actions has been delegated to the system. In other high-risk domains such as aviation, the advantages of automated systems are often accompanied by well-documented opportunities for human error.8 Simulation has played an important role in revealing potential unintended consequences of highly autonomous systems and will be critical for evaluating automated systems in healthcare. Finally, let's not lose sight of the fact that what we do matters. In the April 2016 issue of this journal, we published a set of 6 articles and 2 editorials on a special theme: the management of highly communicable diseases. The articles address a range of uses of simulation to educate workers on the spread of disease, how to prepare for an outbreak, lessons learned from exercising protocols and their implications for safety, as well as several case scenarios for readers interested in conducting exercises in their own institutions. One could argue that this collection of articles represents the journal at its finest. The work transcends any specialty area or any specific simulation method. It provides state-of-the-art information that has meaning for healthcare providers, workers, and patients across the globe. It can be considered T3-level research that informs the greater public. Although we cannot predict where and when another outbreak will occur, we have provided a starting place for people to turn for information when the next outbreak does occur. CONCLUSIONS In his inaugural editorial, Gaba said, “A new journal is a work in progress.”9 We may be a little older, but that has not changed. There is still work to be done. Thus, I invite all of you to participate in the next phase of our history. Act like teenagers. Explore new applications for simulation. Question the status quo. Make new friends and reach out to other healthcare and simulation communities. Simulate the future to guide the present. Be fearless in your ideas for using simulation to improve healthcare. Send us your best work. Give us your feedback. Volunteer to review articles. Most importantly, help continually reaffirm our identity: Simulation in Healthcare, the finest journal of its kind.

I never "worry" about action, but only about inaction -Winston Churchill to General Dill, December 1940 This issue of the Journal sees the publication of 2 articles that focus on the ethical issues in conducting simulation involving different types of challenging and stressful scenarios. Corvetto and Taekman1 provide a review addressing very important issues such as under what circumstances should instructors allow the simulated patient to "die" and, when this is allowed to happen, how should it be handled in debriefing? Calhoun et al2 describe the use of simulation, to present cases in which clinicians need to "challenge the hierarchy" to seek the optimal care of the simulated patient, without the participants being aware that this is in fact the main intended learning objective of the scenario. Both articles describe simulations that can be very demanding on the psyche of the participants. To put these articles in context and to flesh out further some of the thorny issues, they are accompanied by 2 editorials. The first is by an intensivist and ethicist, Robert Truog, MD, and a psychiatric nurse, clinical psychologist and psychology researcher, Elaine Meyer, PhD, RN.3 Their editorial masterfully articulates a number of issues of great import that are raised in the published articles—most especially about the potential risks of involvement to participants in simulations that deal with psychologically challenging themes. In the present editorial, I have a few additional comments and perspectives. I am in complete agreement with Truog and Meyer on 3 points as follows: first, that it is vital to appropriately consider the psychological effects on participants in simulation; second, that not enough discussion of these issues has taken place in our field and certainly not in the pages of any journal; and third, that we who conduct simulations have a duty to our participants and ourselves to act with the best interests of the participants and of patients and their families as we do this work. Concerning "death scenarios," Corvetto and Taekman as well as Truog and Meyer nicely lay out that a variety of factors may come into play when deciding whether and how to allow the simulated patient to die. All agree that "death" can be appropriate in some situations but less appropriate—even unwise—in others. All agree that issues of prebriefing and debriefing of such occurrences is highly important. Yet, how much advance warning that the simulated patient might "die" continues to be a matter of debate. Clearly, for those who are naïve to simulation and for early learners in health care—for whom a patient death may be a never-experienced but a much feared event—advance preparation seems warranted. On the other hand, I believe that for those with considerable experience in realistic clinical simulations and/or for those in high-acuity clinical domains who routinely wield invasive therapies or who deal with acutely decompensating patients, it may well be within their clinical sphere for a (simulated) patient to die, even quite unexpectedly or despite their best efforts at resuscitation. For such learners, I worry that providing advance warning does not replicate an important reality of actual clinical work. I worry that clinicians who might have to deal with such occurrences with real patients will not be prepared for the emotional shock that they will experience and will not act optimally either in the management of the "arresting" patient or in the disclosure and discussion of the tragic adverse events to the patient's family. I would like to have them experience this shock in well-conducted simulations and debriefings so that they are better prepared when it happens for real. Thus, worrying about both the well-being of the simulation participant and that of patients and families seems appropriate. Corvetto and Taekman as well as Truog and Meyer articulate this balance well. Even more question are raised about the use of simulation for psychologically demanding situations involving challenging the hierarchy. Here, although Calhoun et al thoroughly articulate their concerns and their rationales for conducting such simulations, the issues are addressed even more critically by Truog and Meyer. Clearly, they worry about the effect of such scenarios on the psyche of the participants—especially when they are presented without advance warning. Among other things, they worry that the self-esteem and personhood of a participant might be damaged, conceivably irreparably, in scenarios for which a failure to effectively challenge the orders of a senior clinician leads to apparent catastrophe for a patient. I also see this as a valid worry, at least in principle. Simulation can be a very powerful tool. For years, I have quipped that in simulation "we are allowed to mess with peoples' heads, for a good cause," but perhaps, the depth of this power is not fully recognized—even by those with considerable experience with the technique—and therein lies a valid caution. Both Calhoun et al as well as Truog and Meyer reference or discuss the famous Milgram obedience experiments.4,5 (Modern reprints of Milgram's book5 are available.) In the prototypical example, subjects were encouraged by a white-coat clad experimenter to administer apparently real, painful, and dangerous electrical shocks as punishment to what they thought were other individuals who gave wrong answers to a test of learned material. Unbeknownst to the experimental subjects, this was a complete simulation because there were no individuals actually being shocked. This situation is vastly different from health care simulation because subjects in the Milgram experiments really thought that they were harming a real human being, whereas in health care, simulation subjects know that no human patient is being harmed. In a fascinating virtual reprise of the Milgram experiments, a group of British researchers in 2006 described6 a similar experiment but where the "individual being shocked" was clearly a virtual reality avatar and not a person. Despite this fact, subjects showed various subjective and objective signs of psychological discomfort, even as most "administered" the full program of shocks to the error-prone avatar. The key lessons from the Milgram obedience experiments and the virtual reality update remain. Human beings are highly vulnerable to manipulation by situational, organizational, and interpersonal factors that can cause them to do things that they might otherwise consider unthinkable. Even the transference into the virtual, without any deception, does not discharge the emotional content of such activities. Perhaps, an even more relevant "infamous experiment" to consider is the Stanford Prison Experiment, conducted approximately 41 years ago and only a few kilometers away from where I now write this editorial. The description and results of this experiment were published in 1973,7,8 but it is discussed in great detail in a fascinating recent book by the principal investigator, Stanford professor of psychology (now emeritus) Phillip Zimbardo (for more information on this experiment, visit http://www.prisonexp.org).9 His work has had huge impacts in social psychology and most recently in coming to grips with the shocking revelations of, among other things, the prisoner abuse by American military and civilian personnel in the Abu Gharib prison in Iraq. In a nutshell, the Stanford Prison Experiment looked at how volunteers who were randomly assigned to be either prisoners or guards would act based on these role assignments during a rather low-technology simulation of a medium security prison. Within an astonishingly short period, people assigned to be guards assumed increasingly worrisome behaviors typically attributed to guards, including an evolving culture of control and humiliation. Conversely, those assigned to be prisoners developed different sorts of behaviors commonly seen in prisons, ranging from collaboration with the system to outright rebellion to serious withdrawal, depression, and likely suicidal ideation. From a modern perspective, it is clear that the experiment was flawed and risky in design and lacked many critical safeguards. It is believed by many that it should never have been conducted even had there been better protections for subjects. However, like from the Milgram experiments, the key lesson for health care simulation from the Stanford Prison Experiment is that human beings very rapidly respond to social cues in both real and simulated situations and quickly take on the mantle of the roles assigned to them. This makes every one of us vulnerable to having our behavior modified powerfully by such circumstances. Certain kinds of simulations "mess with subjects' heads" more than others. For these types especially, we are quite right to be worried. That then begs the question. How much should we be worried? About what in particular? For all health care simulations? For all learner populations? For all kinds of scenarios? Perhaps most importantly, how do we balance our worries about the risks of discomforting participants or even harming them versus our worries about inaction failing to address the suboptimal clinical performance and behavior that we are typically trying to improve through simulation education and training? Unlike the Stanford Prison Experiment, most clinical simulations are not conducted just to study the participants but rather to teach them something. Some simulations aim to teach skills needed in life-critical patient care situations. Calhoun et al, Truog and Meyer, and I all recognize that the "challenge the hierarchy" simulations are targeting an important clinical issue within health care, just as it was found to be a problem in other domains of high intrinsic hazard (eg, aviation, maritime, nuclear power). Several infamous and many more not so famous accidents have had this issue at their roots. In health care, we know that real patients have been and still are being harmed when team members do not challenge apparently mistaken decisions made by others, usually those higher in the hierarchy. This is not a conjecture or just an academic proposition—it is a serious problem that many of us have witnessed first hand or in postcase reviews. Thus, scenarios that replicate such situations are thought to be appropriate to familiarize clinicians with such circumstances and to exercise their abilities to recognize them and take appropriate action to protect the patient by challenging the leader's decisions if they seem to be dangerous. There seems little disagreement that it is appropriate to use simulation to probe or teach about these issues. However, there is some disagreement as to how this should be done and what lines should not be crossed. Truog and Meyer argue that deception took place in the study of Calhoun et al because the senior clinician gave instructions that he would not typically give in that clinical situation. They worry that such deception can be perceived as a betrayal of trust by simulation participants. They suggest that we should never present situations where, without previous warning to participants, an actual or apparent respected clinician purposefully yet surreptitiously insists that a clinician or team during a simulated case should adopt a seriously mistaken diagnosis or course of action. They believe that the risk of harm to learners and of a breach of trust between teacher and pupil is too high and that such situations should be performed only if the learners are briefed ahead of time that the scenario will involve such a situation. I am not convinced that the study of Calhoun et al used deception—at least not beyond that of simulation in general, which uses the simulated "as if" to represent an analog to the real thing. Clearly, in the kinds of simulation scenarios discussed in the study of Calhoun et al, everyone understands that this is not a real patient care situation. I accept a worry about the learners' psyches, but I worry more that a requirement to always prebrief participants about a scenario's objectives could seriously undermine the learning, meaning, and impact of such scenarios. It is one thing to execute sound behaviors when you know what is coming. It is another to do so either in real life or in a simulation where one is not forewarned. Of course, this balance can differ depending on many factors. For early learners (eg, students), the balance seems to me to favor prebriefing and even full presentation that challenging authority is the main point of the scenario. For experienced personnel, including most house staff, I would argue that such prewarning might prevent them from experiencing the important reality that there are natural barriers to speaking up, even when the (simulated) consequences are grave. It is not so easy to recognize or counter such tendencies when they crop up unexpectedly. One factor in the study of Calhoun et al was that the role of the respected attending physician giving inappropriate orders was played by an actual attending physician who is much respected and beloved. Would things have been less risky to the participants' psyches if it had been a total stranger clearly playing a role? How much trouble do participants have in separating an actor-in-role from a real clinician in such settings? How much does it bother them when there is a discordance? How much value might there be in coming to grips with the fact that even beloved respected clinicians can occasionally actually be mistaken and insistent, as they too—like anyone—can be affected by stress, fatigue, illness, prescription medications, or other vagaries of life? Another factor to consider is the particular combination Calhoun et al used of a scenario about challenging authority coupled with an outcome of patient death. As discussed in detail by Corvetto and Taekman, there can be huge emotional baggage of patient death scenarios. When coupled with a non-predisclosed "challenge the authority" scenario, is this just too much? If so, too much for which learner populations? Could the same point about challenging the hierarchy be made with the simulated patient critically ill but not dead? Like so many issues in this sphere, there exist very few, if any, data about participant opinion, emotion, learning, or transfer of skill to actual patient care. Clearly, more empirical work is needed about these issues, so that we can judge the degree to which our worries are founded in participants' actual perceptions and concerns. These data, along with continued thoughtful scholarly discussion of the issues, can guide our profession to find the optimal approaches to maximize learning and optimize care for patients and families, while minimizing the risk to the psyche of participants. Some might argue that we already know enough about this topic to have "standards" promulgated by an organization like the Society for Simulation in Healthcare. I worry about taking such drastic steps. Given the extreme diversity of simulation applications, with many unique combinations of factors, I am skeptical that any meaningful and fair standards could be drafted. However, I suggest that there are general principles upon which our entire community can agree: Instructors must think hard about the ethical and psychological aspects of what they are doing both in advance and in the moment. Instructors should design and conduct simulations in ways that take into account the vulnerabilities of the learner population. During prebriefing, instructors should discuss and disclose relevant psychologically challenging components of simulation scenarios when it is possible to do so without adversely affecting the learning objectives. During debriefing, instructors should disclose any deception or scripting of scenario outcome or confederate behavior, so that learners may understand what transpired and why the scenario was conducted as it was. Instructors for simulations that are likely to evoke strong emotions and psychological response from participants should be highly experienced and fully prepared to deal with the issues raised. Instructors should consider routine follow-up with all participants after such simulations are conducted and should certainly follow-up if there is any indication of a significant psychological impact from the experience. Instructors should consider establishing referral linkages with professionals who can evaluate and treat individuals who are troubled by the simulation.

In this issue of Simulation in Healthcare, there are two papers discussing important issues facing the simulation community at a critical juncture in the development of simulation in healthcare. A full manuscript1 describes an independent organization—Advanced Initiatives in Medical Simulation (AIMS)—that can be considered a "cousin" to the SSH, whereas a meeting report2 describes the 2006 Simulation Summit that the leadership of the Society for Simulation in Healthcare (SSH) convened in November 2006. We must disclose that SSH is the professional society that publishes this Journal. One author of this editorial is the founding and current President of SSH; the other author is a founding member of the SSH Board of Directors and currently an ex officio member of the SSH board. Furthermore, are both current or former board members of AIMS. Still, even looking beyond our biases, it is fair to say that the recent activities of these two organizations represent important milestones in the evolution of simulation as a core component in the revolutionary effect that simulation is having on healthcare education and safety in the United States. Although SSH is an international society, the focus of its SUMMIT was on North American stakeholders. AIMS is specifically focused on US policymakers, although AIMS activities have participants from other countries. The SSH Summit was a chance to take stock of where the field of simulation in healthcare is today and where SSH wants to be in the future, in the context of where we have been. Twenty years ago, there was frequent use of simple part-task trainers (eg, cardiopulmonary resuscitation mannequins, intravenous arms). Standardized patient (actors) exercises, although started in the early 1960s and developed extensively in the 1980s, did not themselves become widespread until the 1990s. In 1990, there were only a few pockets of technological simulation in a narrow spectrum healthcare domain. Today, technological simulation is in widespread use and growing rapidly in many different fields and in locations throughout the world. Part-task trainers and standardized patient simulations are also commonly used, sometimes in various combinations with each other or with technological simulators. When some of us first started our mannequin-based simulation work in the mid- to late 1980s, we believed that simulation would become important to healthcare over the following decade. Now as we are into our third decade of simulation work, we realize that we are still in the early phases of the decades-long process of embedding simulation into the fabric of healthcare. A number of observers—mostly those with a technological or entrepreneurial bent—have asked: "What is the next big invention in simulation?" With a broader view they might ask: "What is the next big step for simulation?" We would contend that while there is abundant need for technology development to make simulation devices of greater veracity and for more applications, the biggest step for simulation going forwards will not be technological, but will be organizational. That is, even with today's technologies there is an enormous amount that can be accomplished with simulation that is not being done because the institutional mechanisms for providing it are immature. Still, we think it is now clear that the organizational tide is beginning to turn significantly. The evidence is represented by the following list of events that have occurred in the last couple of years: The US Food and Drug Administration has started to require simulation-based training for physicians wanting to deploy a specific carotid stent.3 The American College of Surgeons has begun an accreditation program for skills centers (specifically dealing with simulation). The American Council for Graduate Medical Education Surgery Residency Review Committee has decided to begin requiring simulation-based for simulation-based training of surgical residents. The American Society of Anesthesiologists has established a permanent Committee on Simulation Training and will "approve" simulation programs that demonstrate merit. The American Board of Anesthesiologists has decided to make simulation training one mandatory component of the every 10-year maintenance of certification in anesthesiology (MOCA) program for diplomats receiving initial certification from 2007 onwards. AIMS not only conducts a yearly symposium and Capitol Hill exhibition linking the simulation community to policymakers, but it has also begun to advocate model legislation that would authorize and fund multiple programs in simulation totaling over $50 million in the first fiscal year and such sums as may be necessary beyond that. The International Meeting on Medical Simulation (IMSH) meeting is expecting >1000 registrants; its postgraduate course on creating simulation centers rapidly filled to capacity with a substantial waiting list; the meeting has multiple tracks, dozens of workshops, and more than 70 peer-reviewed research abstracts. The number of companies providing simulation products and supporting components or services (such as audiovisual systems) continues to grow. An interesting development is that a large provider of aviation simulation services (including building and operating training centers and the production of simulators) has recently disclosed its intent to enter the healthcare simulation market with multiple business approaches including center design, center operations, curriculum development, and (eventually) simulator production. As detailed in the meeting report, the summit assembled representatives from a large number of organizations who recognize this as a pivotal time for the future of simulation in healthcare. Granted, there is some selection bias of those organizations that chose to attend the meeting (and similarly the biases of those who chose to complete the SSH survey described in the report). The main themes of the deliberations in the meeting clearly revolved around the organizational issues of the wider-spread adoption of simulation and the delineation of where and how it can best be used. In particular, the discussions centered on: The need for common standards and metrics The need for coordination and oversight of disparate efforts The desire for partnerships between the simulation community and other organizations The need to align and regularize regulatory mandates and funding streams for simulation development and use The need to engage the public about the need for and benefits of simulation Important drivers for the adoption of simulation, and the organizations that will implement the evolving mandates for its use have been delineated over the last few years.4,5 A key role has been identified for the professional societies of the simulation community. SSH has emerged as the leading professional society by virtue of its large (more than 1,000) and growing multidisciplinary membership, its sponsorship of the equally burgeoning IMSH meeting, and (if we may say so) its publication of an outstanding peer-reviewed Journal. Although a professional society has no line authority, the mere existence of a multidisciplinary society is evidence to policymakers that simulation has gone beyond the stage of a fad among healthcare techno-geeks. Perhaps the most important role is to provide the multidisciplinary neutral forum for deliberations about simulation by other organizations that represent driving forces or implementing bodies. The SSH Summit represents one example of this role, where the Society acted as the convener of multiple organizations who might never have come together for any purpose, and least of all to discuss simulation. As central as SSH will be, Dawson et al. articulate the limitations of a 501(c)3 professional society (like SSH) to directly influence policymakers. AIMS—which is designated as a 501(c)6 "trade organization"—has a wider scope to specifically promote legislative and regulatory changes, at either the federal or state level. The synergies between these organizations are clear. In other industries, such as aviation or nuclear power, many of the enabling processes of mandates, coordination, standardization, and oversight of implementation are conducted by government through legislation and by centralized regulator (in the United States, the Federal Aviation Administration for aviation or the Nuclear Regulatory Commission for nuclear power). In US healthcare, the story will almost certainly be different. Whereas in aviation there is only the single federal regulator, healthcare in the United States has over 50 jurisdictions (the 50 states and various federal healthcare systems including those in the Department of Defense and Department of Veterans Affairs). In each jurisdiction the authority is typically distributed between organizations representing different disciplines or components of the healthcare system. Federal institutions like the Food and Drug Administration (FDA) regulate the drugs and devices used, but not the practice of healthcare. Similarly, although federal payers (such as the Centers for Medicare and Medicaid Services) control much of the flow of money in healthcare, they have weak control over many elements of practice such as training or certification of clinicians as individuals or teams. Add to the mix the approximately 8,500 hospitals, 140 medical schools, and over 1,000 nursing schools—all of which have disparate voluntary oversight in the form of accrediting bodies, societies, and collaborations—and the analogy to the aviation or nuclear power industry further weakens. Thus, in healthcare (especially in the United States) we can expect a much more mixed organizational model for the adoption of simulation with a patchwork of organizations providing de facto regulation rather than de jure regulation. In such a setting, the simulation community itself should—in fact, must—take a leading role in helping to find a meaningful structure to achieve the community's long-term goal of using simulation to achieve safer patient care. Thus, the SSH Strategic Summit reported herein can be expected to be the first of many activities for SSH as convener and generator of common ground, while AIMS will continue its focus on promoting simulation to "officialdom." The members of the Society—the primary readers of this Journal—should support both organizations in these endeavors and be prepared to lend their assistance on committees and projects to bring the simulation community's leadership role to maximum fulfillment.

Welcome to the inaugural preview issue of the new journal Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. The Society for Medical Simulation (SMS) was established in January 2004 to represent the rapidly growing group of educators and researchers who use a variety of simulation techniques for education, testing, and research in health care. The membership is united by its desire to improve performance and reduce errors in patient care using all types of simulation including task trainers, mannequin-based patient simulators, virtual reality, and standardized patients. SMS is a broad-based, multidisciplinary, multispecialty, international society with ties to all medical specialties, nursing, allied health paramedical personnel, and industry. Why a new journal? Simulation is a cross-cutting technique with applications in multiple domains and disciplines of healthcare, and for diverse purposes. The intellectual arena of simulation brings together scholars and practitioners from the clinical world, the world of education and testing, and the world of computer science and technology. The target populations for simulation activities are increasingly multidisciplinary. Thus, traditional journals within healthcare are typically too narrow in focus to optimally serve the needs of the simulation community, and do not represent the field to the rest of the scholarly world. Simulation in Healthcare will be the first and premiere journal dedicated to publishing on the use of simulation for education, training, performance assessment, and research in health care. As such, the core areas of interest for the journal will include (but are not necessarily limited to): Immersive and simulation-based training, and education and/or performance assessment, for diverse target populations, domains of healthcare, professional disciplines of healthcare, levels of experience, types of knowledge or skill, types of simulation, etc. Research about simulation techniques and technologies, the pedagogy of simulation, and the influence of cognitive science on the use of simulators Research that uses simulation techniques as a tool to study such things as human performance of clinicians and teams, cognitive science of clinicians and teams in clinical environments, human machine interactions in clinical environments Review papers and theoretical pieces about: The “science” of simulation, such as computer science, haptics, mathematical modeling, alrgorithms, hardware Cognitive science and human factors issues of human performance in healthcare environments that are of relevance to simulation for education, training, testing, or research Pedagogy, including instructional design, experiential learning Health policy or organizational structure and behavior or related to the application, adoption, and use of simulation in the health care industry Psychometrics of performance assessment and testing Laboratory reports and case descriptions of specific techniques or scenarios to make the conduct of simulations more effective or practical Book reviews, letters to the editor, and calendars of upcoming events of interest to Society members I am proud to serve as the founding Editor-in-Chief for Simulation in Healthcare. I have been conducting research on simulation since 1986 and have published numerous papers in this area. Like many other pioneers in simulation, I can attest to the difficulty then, and even now, in being understood by editors and reviewers steeped in biomedical knowledge, but not in the intricacies of “building” ersatz human beings, training diverse (and sometimes unruly) clinicians, and assessing performance in scenarios meant to replicate some of the most stressful and emotionally challenging of clinical situations. We have assembled an outstanding multidisciplinary and international Editorial Board with diverse representation from many different domains and disciplines of healthcare. From the Editorial Board, we have chosen four eminently qualified individuals to serve as Associate Editors. All of the members of the Editorial Board are experts in different aspects of simulation in healthcare. In addition, we have assembled a cadre of highly qualified peer-reviewers, who along with the Editorial Board will be responsible for a publication that is rigorous in its peer-review, mindful of the unique challenges of research and scholarship on simulation, and dedicated to advancing the field with new knowledge and understanding. We pledge that the review process for submitted manuscripts will be fair, thorough, and timely. We strive for a balance of articles that are scientifically sound, innovative, and fresh. We look forward to publishing our new journal, and hope that the readers equally look forward to reading each issue avidly as it is released. In this preview issue, we are pleased to present three fully peer-reviewed papers. Already at this early stage, we see a hint of the diversity of topics and disciplines that will be represented in the journal. Although all three of these papers deal with “patient simulation,” they relate to different learner populations (medical students or residents), different patient populations (neonates or adults), and to different aspects of simulation (pedagogy versus mathematical modeling). Each adds important pieces to the understanding and advancement of simulation in healthcare. Submitted papers currently under review cover an even wider set of topics and domains. A new journal is a work in progress. The Editorial Board will seek feedback not only from the Board of its parent Society and the Society’s members, but also from the wider readership we seek to establish. Thus, we encourage all of you to help us craft the finest publication possible by letting us know your thoughts about the current and future direction for Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare.

This issue of Simulation in Healthcare sees the publication of its first peer-reviewed dedicated supplement to the Journal. This supplement provides 11 seminal monographs on different topics and aspects of “Simulation Research,” resulting from the Society for Simulation in Healthcare (SSH) Research Summit that immediately preceded the January 2011 International Meeting on Simulation in Healthcare. The Summit was organized and run roughly along the lines of a National Institutes of Health (NIH) Consensus Conference, as described by the NIH Consensus Development Program (CDP – see http://consensus.nih.gov/aboutcdp.htm for more information about the model promulgated by the NIH CDP). Ten topics were defined for the Summit, and experts in the field were recruited to be workgroup leaders for each. Each workgroup prepared a presummit working paper; presented the key elements at the Summit; deliberated with Summit attendees in breakout groups (ranging in size from 15 to 150 people); and then incorporated feedback from the groups, the plenary discussions, and postsummit scholarship into final versions of these monographs. These articles thus represent the best thinking by some of the Society's best people, bolstered by the collective wisdom of others with experience and interest in simulation research. We are pleased to provide these detailed monographs and a synthesis by the Summit organizers. The supplement should stand alone as a milestone document in the field. My goal in this editorial is not to recapitulate either the synthesis or the material in the monographs but to highlight the importance of this work and to encourage everyone in the field of simulation in healthcare to start thinking strategically about the future of simulation research. The Summit reviewed the state of the field in a variety of aspects of research about simulation or using simulation as a tool. It follows on an Utstein-style experts workshop on research priorities that was held last year in Europe, convened jointly by the Society in Europe for Simulation Applied to Medicine and SSH, the results of which were summarized in the June 2011 issue of this Journal.1 Most of the workgroups in the SSH Summit (and from the Utstein-style meeting) identified major gaps in the research base that need to be filled to move the field forward most productively and to best inform the public and policy makers about the relevant roles of simulation in health care. That there are gaps in the literature comes as no shock. First, there has only been a relatively short time of research, development, and implementation of simulation techniques to healthcare. Although some elements of simulation go back decades, and simulation use and research much as we know it today started 25 years ago, only the last 5 to 10 years have seen rapid growth in its use and an explosion in published simulation research. Second, simulation research is hard. As an educational intervention, simulation is almost always more labor-intensive than “usual practice.” Access to the learner population is often as difficult as is providing the simulator, space, and trained instructors to do the teaching. Simulators themselves, although no longer incredibly expensive, are not cheap. Providing experienced personnel to operate simulators and conduct simulation-based training or clinical interventions is expensive. Finally, although it is possible to measure some relevant outcomes in studies of modest size, many important questions may take much larger and longer studies, the funders for which have yet to be found. Among the many cogent messages to come from, the Summit is a call for more rigorous research. The Journal itself has been raising the bar as to what constitutes publishable research; purely descriptive studies or studies with weak outcome measures rarely measure up unless they report something that is highly novel. One influential result of the Summit is a detailed articulation of simulation research as “translational science” with phases of translation analogous to those promulgated for traditional biomedical research linking laboratory “bench to bedside.” Various articulations of levels of translational research have been promulgated2,3 (Translational Research Working Group, National Cancer Society, http://www.cancer.gov/researchandfunding/trwg/TRWG-definition-and-TR-continuum) and their applicability to education research was noted by William McGaghie.4 Of note, the T-level definitions differ widely between the various sources cited earlier in the text. The monograph by McGaghie et al5 from the Summit describes three levels of simulation translational research: T1 (measurements in the educational laboratory), T2 (patient care practices), and T3 (improved patient and public health), and at the workshop, they also discussed a level of treatment value or cost savings (T3—cost-effectiveness). Some translational research paradigms describe even higher levels: —T4 (dissemination—can it be done by others?) T5 (adoption—will others use it?) and T6 (population health impact). As documented in the Summit monograph, only a few studies at T2 and T3 levels or beyond have been performed. The report calls for programs of simulation research at these levels rather than being satisfied with the T1 level or below. Yet, such translational research will remain difficult to conduct. Many of the most important questions at T2 and beyond may require determining whether institutions can systematically provide better patient care and outcomes when they provide comprehensive, continuous training for healthcare providers as individuals, teams, and work units, across all disciplines and domains, linked to performance assessment and process change, executed over a long period of time.6–8 This is what we have come to expect from simulation in high-hazard industries such as commercial aviation, albeit they cannot prove—with T3 level evidence—that simulation saves lives or airplanes, in part because pilots would be unwilling to be in the control group. Hence, we have a hard but necessary road ahead, and obtaining the needed resources to travel this road will not be easy. The Research Summit opens the door to views of the next phases of the simulation endeavor. The findings summarized in the Supplement provide a basis for the coming years, and this document should be read and disseminated widely. In the future, it is likely that we will need to mobilize yet larger resources to provide more definitive answers to the big questions about simulation. As we do so, we will need to articulate more fully the key themes and questions and to demonstrate the linkage between them and our projects. In the coming months, I shall have more to say about how we might organize to bring the visions of the Summit to fruition and to convince policy makers of the need to fund the long-term research agenda.

This study aimed to evaluate the training outcomes and early transfer of ultrasound to the clinical environment of a simulation-based longitudinal ultrasound training program for critical care physicians in a single-center intensive care unit. We designed a simulation-based longitudinal ultrasound training for emergency and intensive care residents. The course lasts for 6 months per session, including theoretical classes, practice with simulators and real human models, learning of critical care ultrasound processes and protocols, and finally clinical application. A total of 164 physicians have received training through this program. We evaluated learner satisfaction, theoretical knowledge and practical performance both before and after training, as well as process-based indicators of clinical application and transfer of ultrasound skills into the clinical environment. Across all 10 survey items, 81.3% to 100% of trainees responded "agree" or "strongly agree," with the highest ratings observed for the usefulness of theoretical courses and the relevance of content to clinical work. Post-training assessments showed significant improvements in theoretical examination (median difference=24, 95% CI [23.3, 26.6], W=13,366), abnormal image interpretation (median difference=36, 95% CI [32.7, 36.7], W=13,041), and operational skills (median difference=30, 95% CI [28.7, 31.3], W=13,366) (all P<0.05). Median scores significantly improved post-training compared with baseline: clinical case assessment scores increased from 48 (IQR: 38, 55) to 76 (IQR: 72 to 84); case analysis from 11 (IQR: 8 to 15) to 21 (IQR: 17 to 26); and image interpretation from 4 (IQR: 2 to 7) to 16 (IQR 13 to 18) (all P<0.05). During clinical practice, a total of 956 critical care ultrasound examinations were performed. Of these, 415 examinations (43.41%) provided additional diagnostic clarification. Overall, 789 examinations (82.53%) generated ultrasound findings that supported, refined, or contextualized ongoing diagnostic assessment or clinical decision-making. Our longitudinal ultrasound training program strengthens foundational knowledge and enhances clinical application of critical care ultrasound. However, this single-center study lacks a comparator arm and long-term patient outcome evaluation. Future multicenter studies should validate these findings, compare training methodologies, and assess the impact of critical care ultrasound on patient morbidity and mortality.

BACKGROUND: Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic. METHODS: The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic. FINDINGS: Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021. INTERPRETATION: Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades. FUNDING: Bill & Melinda Gates Foundation.

Healthcare professionals often hesitate to participate in team-based simulation activities because of perceived psychological risk, which can undermine learning, collaboration, and innovation. Psychological safety-defined as a shared belief that the team is safe for interpersonal risk-taking-is critical in healthcare simulation but remains understudied in the Indian context. This study aims to assess baseline perceptions of psychological safety and explore barriers and enablers within interprofessional simulation teams in South India. We employed an explanatory sequential mixed-methods design. In the quantitative phase, 127 healthcare professionals (doctors, nurses, and paramedics) participated in an online survey using Edmondson's Psychological Safety Questionnaire. We analyzed psychological safety scores in relation to team familiarity, profession, and seniority. In the qualitative phase, we purposively sampled participants with high and low psychological safety scores for focus group discussions. Thematic analysis was conducted to identify key barriers and enablers. Psychological safety scores were higher among teams with familiar members, nurses, and junior team members. Conversely, lower scores were reported among paramedics, unfamiliar teams, and both senior and junior-most members. Team familiarity showed a significant positive association with psychological safety. Thematic analysis revealed 6 main themes with various subthemes for barriers: Internalized Hierarchy, Fear of Judgment, Knowledge Deficits, Facilitator Behavior, Silencing Mechanisms, Role Confusion. Two main themes with various subthemes for enablers included Facilitation that Builds Trust and Structure and Clarity. Unique local barriers included debriefing in English (a non-native language), physician-only facilitators, and challenges experienced by introverted participants. Team familiarity and facilitator skill sets are vital to promoting psychological safety in interprofessional simulation. To address contextual barriers in resource-limited and hierarchical settings, interventions should include inclusive faculty development, diverse facilitation teams, tailored debriefing based on personality traits, and use of the local language during debriefing. These findings contribute to the broader global understanding of psychological safety by offering insights from a previously underrepresented setting.

Health SecurityVol. 18, No. 4 CommentaryA Social and Behavioral Research Agenda to Facilitate COVID-19 Vaccine Uptake in the United StatesEmily K. Brunson, Monica Schoch-Spana, and on behalf of the Working Group on Readying Populations for COVID-19 VaccineEmily K. BrunsonAddress correspondence to: Emily K. Brunson, PhD, Associate Professor, Department of Anthropology, Texas State University, 601 University Dr, San Marcos, TX 78666 E-mail Address: [email protected]Search for more papers by this author, Monica Schoch-SpanaSearch for more papers by this author, and on behalf of the Working Group on Readying Populations for COVID-19 VaccinePublished Online:19 Aug 2020https://doi.org/10.1089/hs.2020.0106AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited byWhy healthcare providers are not vaccinated? A qualitative study during the COVID-19 pandemic in Iran13 October 2023 | BMC Primary Care, Vol. 24, No. 1American Singles' Attitudes Toward Future Romantic/Sexual Partners' COVID-19 Vaccination Status: Evidence for both Vigilance and Indifference in a National Sample18 May 2023 | Sexuality & Culture, Vol. 27, No. 5Investigating the Reasons for the Unwillingness to Get Vaccinated against COVID-19 in the General PopulationThe Open Public Health Journal, Vol. 16, No. 1Effect of knowledge, social and religious factors effecting the intention of Muslims in Pakistan to receive COVID-19 vaccination: mediating role of attitude towards COVID-19 vaccination2 June 2022 | Journal of Islamic Marketing, Vol. 14, No. 7In‐home healthcare worker COVID ‐19 vaccination awareness, access, and acceptability—An online focus group study15 December 2022 | Journal of the American Geriatrics Society, Vol. 71, No. 5COVID-19 vaccination acceptance among community members and health workers in Ebonyi state, Nigeria: study protocol for a concurrent-independent mixed method analyses of intention to receive, timeliness of the intention to receive, uptake and hesitancy to COVID-19 vaccination and the determinants15 December 2022 | BMJ Open, Vol. 12, No. 12Psychosocial Determinants of COVID-19 Vaccination Intention Among White, Black, and Hispanic Adults in the US1 October 2021 | Annals of Behavioral Medicine, Vol. 56, No. 4The Early-Term Adverse Effects in Healthcare Personnel after CoronaVac Vaccination15 March 2022 | Journal of Contemporary Medicine, Vol. 12, No. 2"On the last day of the last month, I will go": A qualitative exploration of COVID-19 vaccine confidence among Ivoirian adultsVaccine, Vol. 40, No. 13COVID-19 vaccine confidence projectJournal of the American Pharmacists Association, Vol. 62, No. 1Ending the Pandemic: How Behavioural Science Can Help Optimize Global COVID-19 Vaccine Uptake22 December 2021 | Vaccines, Vol. 10, No. 1Racial/ethnic disparities in intent to obtain a COVID-19 vaccine: A nationally representative United States surveyPreventive Medicine Reports, Vol. 24Hesitancy Prevalence and Sociocognitive Barriers to Coronavirus Vaccinations in Nigeria30 December 2021 | European Review Of Applied Sociology, Vol. 14, No. 23Agent Based Model of Anti-Vaccination Movements: Simulations and Comparison with Empirical Data21 July 2021 | Vaccines, Vol. 9, No. 8Acquiring favorable attitudes based on aversive affective cues: Examining the spontaneity and efficiency of propositional evaluative conditioningJournal of Experimental Social Psychology, Vol. 95Communicating With Vaccine-Hesitant Parents: A Narrative ReviewAcademic Pediatrics, Vol. 21, No. 4Preparing for SARS-CoV-2 Vaccines in US Immigrant Communities: Strategies for Allocation, Distribution, and CommunicationAmerican Journal of Public Health, Vol. 111, No. 4Evidence-Based Strategies for Clinical Organizations to Address COVID-19 Vaccine HesitancyMayo Clinic Proceedings, Vol. 96, No. 3Factors Influencing COVID-19 Vaccination Demand and Intent in Resource-Limited Settings: Based on Health Belief Model1 June 2021 | Risk Management and Healthcare Policy, Vol. Volume 14 Volume 18Issue 4Aug 2020 InformationCopyright 2020, Mary Ann Liebert, Inc., publishersTo cite this article:Emily K. Brunson, Monica Schoch-Spana, and on behalf of the Working Group on Readying Populations for COVID-19 Vaccine.A Social and Behavioral Research Agenda to Facilitate COVID-19 Vaccine Uptake in the United States.Health Security.Aug 2020.338-344.http://doi.org/10.1089/hs.2020.0106Published in Volume: 18 Issue 4: August 19, 2020Online Ahead of Print:July 24, 2020 TopicsCOVID-19COVID-19 vaccine PDF download

Clinical reasoning is fundamental in kinesiology education, but its assessment remains a challenge. The Script Concordance Test (SCT) is a tool for assessing reasoning under conditions of uncertainty. This study assesses the feasibility of using the SCT to evaluate clinical reasoning in kinesiology students and gathers preliminary validity evidence for its application in simulation-based education. An observational analytic study with a pretest and posttest design was used. Fifty-two kinesiology students participated in 7 simulated tele-rehabilitation scenarios in neurokinesiology, cardiorespiratory rehabilitation, and musculoskeletal rehabilitation. SCTs were administered before and after the simulations to measure changes in reasoning. The Wilcoxon signed-rank test and Cohen's effect size (d) were used to evaluate differences in scores. Three of the 7 SCTs met reliability criteria (Cronbach's &#x3b1; > 0.7). Postsimulation SCT scores significantly improved (P = 0.021), with a small effect size (Cohen's d = 0.22). A new Script Concordance Simulation Index was developed, showing high discriminatory ability (AUC = 0.989) between student reasoning categories. The SCT can be utilized as a tool to evaluate clinical reasoning in kinesiology students within simulation-based education. Our study contributes to the generation of evidence supporting the feasibility and potential validity of the SCT in this context. The Simulation Script Concordance Test Index introduces an innovative approach to tracking cognitive trajectories after simulation. Future studies should provide additional evidence to strengthen the validity of the SCT in simulation-based education, and by deepening the understanding of the reasoning that underlies students' decision-making changes.

The lack of reliable tools for measuring implementation processes and outcomes weakens confidence in study findings and strategy effectiveness. This study aimed to gather validity evidence for the previously published Implementation Quality Rubric for Simulation (IQR-SIM) from 2 sources: response process and internal structure. The IQR-SIM is structured into 3 phases of implementation, each divided into themes. Within these themes are items representing actionable steps for effective implementation. It employs a 3-point rating scale (1, 2, and 3), along with nonscored options "don't know/can't assess" and "not applicable." Semistructured interviews were conducted to collect detailed program descriptions from international simulation centers. Three trained raters evaluated these interview-derived implementation data using the IQR-SIM. The frequency of using the scores and the nonscored options was calculated to evaluate rater use of the scale. Inter-rater reliability was assessed to examine variability in ratings, while internal consistency reliability was analyzed to determine whether all items measured the same construct. Twenty simulation-based programs from 7 international simulation centers participated. Phase 1 (stakeholder engagement and context exploration) had the highest proportion of fully accomplished items (54.6% received a rating of 3/3). Theme 1b (Obtaining buy-in from relevant stakeholders) was predominantly rated as fully accomplished (68.3%). Item 9 (planned for human resource needs) received the highest proportion of rating 3/3 (83.3%). Internal consistency reliability was good (Cronbach alpha=0.85). Inter-rater reliability analysis showed a moderate intraclass correlation coefficient (ICC=0.57). ICC values between raters ranged from 0.39 to 0.52. Multisite validity evidence regarding the response process and internal structure of the IQR-SIM was established, supporting its use in evaluating the implementation quality of simulation-based programs. The study demonstrates that the IQR-SIM can be applied across diverse simulation centers and program types, enhancing its broad use for implementation evaluation.