• Perspectives on Safety
  • Published March 2006

What Does Simulation Add to Teamwork Training?


Let?s take as a given that improving the ability of individuals and teams to function “as a team” is important in health care, especially in highly dynamic clinical environments.(1) How can this best be accomplished? In a comprehensive approach to teamwork training, there is a need to convey knowledge about teamwork, develop skills of teamwork, and enhance attitudes concerning teamwork.(2) Didactic training may address knowledge and can influence attitudes, but to fully develop skills and alter attitudes, experiential training is likely to be the most effective. Thus, given the complexity of the topic, it is likely that multiple approaches will be necessary to maximize learning and transfer to real patient care. Moreover, it is also likely that no single course or exercise can change such complex behaviors permanently?only long-term repetitive training and practice, combined with solid reinforcement of the principles and skills in the actual work environment, has any chance of developing new and optimal teamwork patterns that become deeply ingrained in the work culture.

Salas and colleagues (1,2) have articulated a set of principles concerning teamwork training (many of which are summarized in the Table, column 1). A critical component of these principles is that training in teamwork should include guided hands-on practice with feedback. It is very important that participants have a chance to actually “deploy” the skills being taught, not just to talk about them. Such “practice” might be accomplished using a spectrum of activities, perhaps some as simple as verbal exercises or role-playing. However, role-playing away from the context of the work is often “sterile” and doesn?t really capture the complexity of teamwork situations in the real world. Moreover, teamwork is not used as an isolated skill during real patient-care work; it is interleaved with many other cognitive and psychomotor demands of the clinical situation. In many settings (such as in the OR, the ICU, or the ED), one has to simultaneously make clinical decisions, perform procedures, and interact with team members. Doing this is not easy, and integrating all these skills optimally takes practice.

I propose that only simulations of various sorts that involve the key dynamic of the environment can provide such practice in any credible fashion. Neither classroom work nor intensive coaching in real settings can fully probe the complexities of real interpersonal and patient care situations, and they are unlikely to provide life-long challenge to experienced clinicians and teams. Simulation in this context is a technique (not a technology) to replicate enough aspects of the real world to engage participants sufficiently to probe and exercise their behaviors and actions when working in a team setting.(3) A spectrum of simulation (Box) approaches can be used with a continuum of advantages and disadvantages.(4) “In-situ” simulation drills can be carried out in actual work settings, but these are not always available, are not fully controllable or instrumented, and the drills can be disruptive to (or aborted by) the requirements of actual patient care. Simulation courses in dedicated simulation centers can replicate key parts of the clinical environment with full control, are heavily instrumented for recording and replay of simulation scenarios, and allow guaranteed scheduled time for training that is not interrupted by patient care. “Virtual worlds” on the computer can involve single users or even multiple participants interacting over a network–they may be especially useful for more frequent precursor and refresher training to extend the scope of “hands-on” simulation-based teamwork scenarios. Regardless of the modality, the content and design of the training exercises is critical. As Beaubien and Baker (4) point out: “High fidelity simulations can enhance the perceived realism of well designed team training programs, but cannot compensate for poorly designed ones.”

Simulation, which need not be ruinously expensive (see Box), has a proven track record of engaging trainees and experienced clinicians alike. Besides the usual advantages of simulation for training in health care (5,6), simulation has particular advantages for teamwork training, in that it:

  • Involves participants in clinically challenging situations that link directly to their previous work experience;
  • Provides scenarios of known and specific challenge to teamwork skills;
  • Provides opportunities for cross-role understanding and even cross-training and practice in the work of different roles;
  • Facilitates reflection on practice by the team through a shared review of what transpired in the simulation scenario; and
  • Provides scheduled time for such exercises, with specially trained teaching faculty.

In conducting team-oriented simulation-based training, there are two general approaches, each of which has advantages and disadvantages. One is to conduct “single-discipline” training, (we call this training crews to work in teams). This approach takes participants from only one discipline (eg, anesthesiologists) but provides scenarios that involve all the relevant other crews, played either by hired personnel (ie, circulating nurse), instructors (for surgeons), or the participants themselves (scrub tech). The advantages of this approach are as follows:

  • It allows concentration on specific skills and knowledge for each specific crew, including material that may be of little relevance to other crews;
  • It targets disciplines whose work can be simulated with appropriate fidelity (for example, as of now, the technical aspects of open surgery cannot be simulated adequately);
  • It simplifies the logistical and political considerations of training only one discipline at a time; and
  • Generic training on teamwork can be provided to health care personnel who do not work in fixed crews or teams.

The other approach is “combined-team training,” where all members of the team, from several different crews (eg, surgeons, nurses, anesthesiologists), undergo training together as a team. Combined team training allows for more natural team interactions and reinforces understanding across disciplines. It can be most effective when a specific group of individuals actually do work together as a dedicated team. However, combined team training cannot as readily achieve some of the goals listed above for training crews to work in teams, and it can be difficult to organize from a logistical standpoint. These two approaches are complementary methods to improve decision-making and teamwork skills, and I believe that the ideal techniques of simulation-based teamwork-oriented training would be a sequence of both of these approaches.

Pratt and Sachs argue that simulation is unproven, possibly unnecessary, and replaceable with intensive coaching of clinicians during and after real patient care activities. Yet, simulation is clearly a critical tool in the conduct of teamwork training. It is a linchpin of training in nearly all high-hazard industries and in all high reliability organizations. Even in these arenas, where individual and team performance are assessed on a regular basis, it has been difficult to acquire unequivocal evidence that teamwork training or simulation saves lives. It will be yet more difficult to develop such evidence in health care. In fact, the real questions about simulation and team training in health care are about the efficacy of the strategy of comprehensive long-term training and reinforcement, not about any single technique or course. Answering these questions probably awaits large-scale and long-duration adoption of the strategy by one or more major health care entities, with assessments spanning a long time horizon. Studies of such efforts will provide valuable information, but the health care professions should not wait for unequivocal proof before continuing to expand the use of simulation as a core part of teamwork training for all the benefits it can provide.

David M. Gaba, MD
Professor of Anesthesia; Associate Dean for Immersive and Simulation-based Learning
Stanford University
Staff Anesthesiologist; Director, Patient Simulation Center of Innovation
VA Palo Alto Health Care System


Back to Top

1. Salas E, Dickinson T, Converse S, Tannenbaum S. Toward an understanding of team performance and training. In: Swezey RW, Salas E, eds. Teams: Their Training and Performance. Norwood, NJ: Ablex Publishing Corporation; 1992.

2. Salas E, Burke CS, Cannon-Bowers JA. What we know about designing and delivering team training: tips and guidelines. In: Kraiger K. Creating, Implementing, and Managing Effective Training and Development: State-of-the-Art Lessons for Practice. San Francisco, CA: Jossey-Bass; 2002.

3. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13(suppl 1): i2-i10.
[ go to PubMed ]

4. Beaubien JM, Baker DP. The use of simulation for training teamwork skills in health care: how low can you go? Qual Saf Health Care. 2004;13(suppl 1):i51-i56.
[ go to PubMed ]

5. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology. 1988;69:387-394.
[ go to PubMed ]

6. Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience. Simul Gaming. 2001;32:175-193.


Back to Top Inexpensive Simulation?
The fidelity of a simulation activity is more related to the overall conduct of the scenario than to the specific capabilities of the patient “simulator.” Thus, team-oriented simulations do not necessarily require expensive simulation systems. For situations such as a clinic or ward where the exercise wouldn?t necessarily recreate acute illness or need invasive therapies to be executed, “standardized patient” actors (either trained lay-people or clinician volunteers) can be the best simulator. In fact, in some clinical practice settings, surreptitious standardized patients are slipped into a clinic schedule as a check of quality. For other clinical purposes, verbal simulation or drills without any simulator (or with only a passive mannequin) might be sufficient.
Too much “make believe” can fail to engage clinicians, however, and in many settings a fully interactive patient simulator will be needed to provide credible and challenging clinical work for individuals and teams. Where in-situ simulation can be conducted, no separate facility is required. Medium-capability fully interactive patient simulators are now available from several manufacturers for approximately $35,000, far lower than the cost of many pieces of clinical equipment that sit unused in the hospital. The video gear needed to capture an in-situ exercise in the real work environment can be as simple as a camcorder and a tripod, replaying from the camera to a TV set on the ward. Including accessories such as additional microphones or hard disk recording and replay adds only a few thousand dollars at most. All the equipment can be amortized over several years. The largest “costs” of doing good teamwork training (of any kind) are not the hardware, but rather (i) the “faculty time” of those engaged in developing and running the training (for team simulations, instructors need special training and experience in post-scenario debriefing), and (ii) the time of the training participants. Still, learning and maintaining critical teamwork skills should best be seen as a requirement of high-quality care, and thus an appropriate “cost of doing business” that directly or indirectly may have a positive return on investment over the long-term.


Back to Top
Table. Principles of Teamwork Training and How They Are Handled in Simulation-Based Teamwork-Oriented Curricula

Principles of Teamwork Training (1,2)

How These Are Handled in Simulation-Based Teamwork-Oriented Curricula

Teamwork is a necessary skill for optimum results

Many types of simulation-based training, whether of single-discipline crews or combined-teams, is heavily teamwork oriented

Teamwork includes a complex set of cognitive and behavioral skills and attitudes

The readings, lectures, and group exercises preceding simulations purposefully addresses these skills

Instructional strategies are tailored to the types of individuals and teams

Simulation-based teamwork-oriented training is tailored to health care individuals, crews, and teams in specific domains

Team-based task analysis is a powerful starting point

Many disciplines have not conducted a formal task analysis; however, most of the leaders of simulation-based teamwork training are themselves subject matter experts sensitive to the relevant tasks

Training should be designed to facilitate information presentation, demonstration, guided practice, and feedback

Simulation-based teamwork courses typically incorporate multiple modalities of didactic, group-work, practice, and feedback

Opportunities for guided hands-on practice should be built into training

Complex simulation scenarios provide this opportunity; guidance is provided both by team members during scenarios and by expert debriefers afterwards

Pre-practice education is an important component of teamwork training

Various textbooks, readings, course briefings, and familiarizations accomplish this

Training can be delivered through various proven strategies

Simulation-based courses typically provide multiple modalities of didactic, group-work, practice, and feedback, but rely heavily on simulation scenarios as a proven strategy

Timely feedback is critical to allow team members to adjust their knowledge

Feedback is provided during group-work exercises and discussions and during the detailed debriefings after each simulation scenario

Team performance measurement is a part of successful team training

Methods to measure individual and team non-technical performance in health care have been developed, but their use in actual training sessions has been limited


View Related Point-Counterpoint

Back to Top