Simulation in Healthcare
The simulated clinical experience in nursing education: a historical review
The benefits of training nurses' technical competences in a simulated environment were perceived early, before executing them for the first time on a real person. The industry itself helped through the creation of not always realistic anatomic models, but which systematically attended to the schools' needs in this area. The delivery mannequin (Figure 4), which Mme Coudray created as early as in the 18th century, is part of the collection at the Flaubert Museum of the History of Medicine (CHU - Hôpitaux de Rouen) and evidences professionals' need to have a model for training in this specific area.
Six factors led to the emergence of simulation as we know it today: the social requirement for safety and quality in health care, the need to renew health professionals' education, ethical considerations, technological advances, professional inexperience and constantly changing practice environments and contexts(2,9).
Safety and quality in health
Errors in health in general (and not just medical errors) are possible, frequent and have multiple causes. Health organizations' strategic and operational policies, the organization of work and services, available resources and materials may have a positive or negative impact on error events. Patient safety is increasingly valued, pertinent and current. It is estimated that between 10% and 20% of hospitalized patients are victims of adverse events and that a significant number of deaths occur due to health professionals' errors, almost half of which would be avoidable(15). The quality of care delivery is another current element and health organizations make huge efforts in this respect, which demands knowledge and competences with a view to calm, timely, safe and high-quality interventions in a wide range of situations, contributing to minimize errors.
The education of health professionals
Today, knowledge and technologies proliferate exponentially, demanding new forms of knowledge transfers and a pro-active attitude from teachers and students. Health professionals' and specifically nurses' education is a factor closely connected with quality and patient safety(16). It is through theoretical and practical training that nurses remain updated, mobilize knowledge for practical contexts and perform practices centered on each patient and based on scientific and current evidence. Some traditional teaching models, on the opposite, still incorporate practical learning on patients only, with many students, lack of uniformity and opportunities in the teaching-learning process, so that students get different experiences and their education displays gaps, resulting in nursing care that is more centered on organizations and processes and not always truly scientific.
The ethical-legal justification
It is mainly through emerging concerns with care humanization and the assertion of bioethical and legal thinking that some of the strategies used for decades in students' learning of technical procedures start to be reconsidered and questioned, mainly those procedures in which the other person (patient or fellow student) is the practical learning object(3).
Centered on the dignity and integrity of human beings and on the avoidance of equipment, it is assumed that, whenever the development and training of a technique are possible in a simulated context, it is illegitimate to perform an invasive procedure first on a person in the context of health teaching and learning. This idea is reinforced if we consider that the vulnerability of disease processes makes it difficult for ill people to practice their autonomy, which compromises their ability to refuse an intervention a student will perform. The need to inform patients that it is the first time the student is performing a technical procedure is another source of strong anxiety for both, which makes it necessary to adapt teaching strategies to ethical and legal precepts(3,4).
Current information and communication technologies permit high-quality distance education, provide interactive software and make available realistic materials and models, besides simulators that are not only anatomically similar to a human being, but are also able to give physiological reactions to interventions made that are very close to actual reactions. Also, they provide "human" responses, as an instructor can answer the student's questions and inquiries(17,18). A school that intends to be updated, innovative and future-oriented uses the potential of current technologies to stimulate competency development in its students.
Nurses' excessive mobility and turnover, besides many teams' young age, are determining factors of immaturity and professional inexperience. In many job contexts, the Nursing team consists of a set of young workers, as a result of the large number of retirements in the last decade and successive changes in education programs. In many teams, there are no expert nurses to serve as leaderships in care management and in permanent education and improvement processes. Low wages, precarious job conditions and low professional acknowledgement in society have caused discouragement in nurses. This stimulates neither self-education nor the search for excellence.
Practice environments and contexts in constant change
Today's hospitals (and their respective clinical contexts) have gone through significant changes. At more complex units, there are patients who were considered incurable until some years ago, and patients are present at secondary and palliative care wards that were transferred to distinguished units until some years ago. Patients are discharged increasingly early. Outpatient and minimally invasive surgeries are preferred. In this context, students or nurses, whether in clinical practice or education, can develop several clinical practices, throughout their education process or professional life, without the opportunity to experience different situations over a long time period, increasing the probability of error when one of these takes place for the first time.
Other factors are the recent changes in the health units' management paradigm, which are strongly concerned with costs, productivity and resource rationalization.