Crossing the Line: Simulation and Boundary Areas

These are challenging times for the simulation community—times of uncertainty, of ferment, and of rapid growth. This instability reflects the realities of healthcare and healthcare education, where traditional approaches to training are no longer possible. By offering safe, learner-centered training, simulation occupies a central position. If simulation is to be fit for purpose, we need to elaborate an underpinning “theory of simulation. ” As well as establishing the scientific basis of our field, this will provide insight into the theoretical frameworks of related disciplines, helping learners and teachers to select the type of simulation which best meets their needs at a given moment. Effective simulation interweaves clinical practice, laboratory science, education, computer design and many other disciplines. This richness and diversity is a key strength, bringing creativity and innovation and presenting teachers and learners with a wide choice. Yet there is a danger that this very diversity may lead to fragmentation and a lack of overall direction. Without a coherent theory, it is easy to get lost in a confusion of beguiling but disparate fields. In this paper, I frame simulation as a conceptual space where many domains come into contact. Drawing on personal experience, observation and my reading of the literature, I argue that better understanding of these diverse realms will strengthen the theory-building process. I argue that the boundaries between domains are where creativity flourishes and where advances are to be found. I examine how such boundary areas may function and identify some difficulties which may be encountered in bridging areas of expertise. I have based this paper on an invited closing address at the IMMS conference in January 2006. I have written from a personal perspective, drawing on my background in clinical practice (as a surgeon and a primary care physician), in education (as a general practitioner trainer and a developer of training programs) and in research (as an academic with a particular interest in surgical simulation). BACKGROUND The landscape of clinical practice is being radically altered by external and internal forces. Changes in established models of healthcare delivery are being driven by changing patterns of care (with increasing emphasis on targets and service outcomes) and reduction in working hours (both in Europe and the United States). 1–3 Traditional service-based apprenticeship extending over many years is being supplanted by more focused, learner-centered programs aimed at achieving specific educational objectives in a much shorter time.4–10 The potential benefits of simulation are widely acknowledged, offering opportunities to practice repeatedly and in safety. Anesthesia-based team training and crisis resource management have led the move from task based practice to performing within authentic situations. Now patient-specific simulations are poised to create a whole new level of realism, using imaging and other data to provide authentic recreations of individual people. For many within healthcare, simulation is seen as a means of repeatedly practicing specific clinical tasks. Of course this is an important function, but it represents only a small part of simulation’s potential, and a task-focused philosophy can obscure the wider picture. If simulation is framed as a response to wider changes in the healthcare environment, a logical conclusion is that it should recreate as closely as possible the conditions of actual practice. These will include teamworking, leadership, crisis management, and many other elements. In this way, simulation can offer an alternative universe, where learners may safely experience issues which parallel those in real life. Seen from this viewpoint, simulation must provide not just a series of individual tasks, but rather a canvas upon which the elements of practice can be painted as required. Moreover, such environments should support that construction of professional identity which takes place within the clinical workplace through participation in communities of practice and of learning.11–13 In this sense, simulation is less of a physical reality than a conceptual space within which many activities can occur. To be effective, simulation must parallel its real world counterpart in a functional sense, even if it does not recreate reality in every detail. We must therefore examine the intersecting domains which relate to the various activities which simulation subsumes. These are illustrated by the issue of complexity. From the Department of Biosurgery and Surgical Technology, Imperial College London, London, UK. Reprints: Roger L. Kneebone (e-mail: r.kneebone@imperial.ac.uk). The author has indicated he has no conflict of interest to disclose. Copyright © 2006 by the Society for Simulation in Healthcare ISSN: 1559-2332/06/0103-0160