How simulation, reflective practice and good judgement can be declined in the different SimZones.
In 2017 Roussin and Weinstock of Boston Children’s Hospital introduced the concept of SimZones to rationalize the simulation in healthcare (Roussin & Weinstock, 2017). The simulation zones are five.
Zone 0 involves the individual learners to assess their knowledge on one topic through a digital resource. In zone 1 a group of operators or trainees deepen a technical procedure with the guide of an instructor. Zone 2 concerns the multidisciplinary management of clinical situations: learners face a simulated clinical scenario with the guidance of an instructor. Role-playing is possible in this area. Zone 3 focuses on teamwork through high-fidelity environmental simulation. The most eligible choice is to involve a multidisciplinary group from the same reality. A facilitator manages the debriefing, preferably a strategic one. The objective is to stimulate change. Zone 4 uses the method of zone 3 in the healthcare environment. The guided debriefing of significant clinical events in each group leads to change.
The table shows the detailed classification of the simulation zones.
| Who | Individual learner | Partial team Trainees | Partial o full team | Full team, from one reality | Full team, from one reality |
| What | Self-assessment self-assessment Virtual reality e-learning | Session on an instructor-led technique. Pause for instruction | Simulated clinical situation with a standard patient, emergency training, with an instructor, no interruptions, single scenario, role play | Teamwork with a facilitator and stimulating change. | Reflection on teamwork with a facilitator and stimulation of change. |
| Where | without place | In situ, Simulation Room, Simulation Center | In situ, Simulation Room, Simulation Center | Simulation room, Simulation center, Single or multiple scenarios | In situ after a relevant clinical event |
| When | without time | Single or rotating practical session in a simulation course | Individual practical session | Simulation course | As soon as possible |
Reflective practice for simulation originated at Harvard University and the Massachusetts Institute of Technology (Rudolph et al., 2006). Through a cognitive, psychological and anthropological method, reflective practice helps to learn from lived experiences. Each of us produces in the mind a ‘fragment’ of reality, invisible to the outside world. he mind interprets sensory experience to make sense of reality. A diagnosis is a fragment of reality. Often in a working group, fragments of reality do not coincide between operators.
The consequence of fragment of reality is “action”. The action is visible to the outside world. Error, for better or worse, is the logical consequence of an action that stems from a subjective fragment of reality, which then turns out to be inadequate.
The ‘result’ is the synthesis of actions and fragments. The final effect is visible to the outside eye. In medicine, it could be the survival of a patient.
In a team, the connection between the actions of the group and the fragments of the individual workers explains the complexity of the results.
Reflection after the simulation helps to bring out the fragments of reality of each operator that led to the actions and the result. The path is backwards. The results are known to all while the fragments are not. New fragments and potentially new actions with better results than the previous ones emerge from the reflection. In essence, a change of the individual and the group is proposed.
Another fundamental element of reflective practice is “good judgment” (Rudolph et al., 2006)
The facilitators who experience a simulation with learners also produces their own fragments of reality that condition the approach to reflection.
The facilitator’s ‘judgmental’ approach is an attempt to bring out the error in the group from their own belief in reality. The effect on learners is unpredictable: shame, inadequacy, escape from the simulation experience, etc.
The ‘non-judgmental’ approach is inspired by Socrates’ method. The facilitator tries to bring out the error with open questions, without taking sides. The result is often confusion on the part of learners who do not understand what the facilitator is thinking and the ultimate goal of reflection.
The “good judgment” focuses on adult learning. Participants in the riflession after the simulation share their own fragments, whether they are learners or facilitators, to achieve a positive outcome. The simulation analyzes errors without negative consequences for operators, in an atmosphere of safety. The good judgment comprises three elements: attention and respect for learners, transparent communication about objectives, clear reflections on learners. In practice, it is an alternation between the facilitators’ ‘Assertion’ and the learners’ ‘Investigation’: the first ones present their view of the problem and then ask the latter ones for their opinion. There is no doubt about the starting point: the aim is a result shared by the group.
Good Judgment is suited to reflective practice in simulation zones.
In zone 1, the objective is ‘Teaching with Good Judgment’ (Fey et al, 2022). The trainers are experts in a procedure and their trainees aim to improve knowledge and practice. The trainer introduces the theory and objectives of the exercise; creates a safe climate, as it is a simulation environment; intervenes with breaks to correct inevitable errors; measures the improvement of practice in the learners.
In zone 2, the objective is ‘Training with Good Judgment’ (Fey et al, 2022). The trainer is a colleague who is an expert in the subject of the simulation. In zone 2, technical knowledge is tested by teamwork, eventually by role play. The trainer prepares the simulation experience; divides the roles between the learners; attends the simulation without breaks; clearly analyzes errors during the simulation with the Good Judgement method; and proposes a reflection on the group behavior.
In zone 3, the objective is ‘Debriefing with Good Judgment’ (Fey et al, 2022). Simulation reaches its highest expression. The trainers are expert facilitators in the debriefing technique: starting from the result of the simulation, they search with dialogue for the subjective fragments of each participant that determined the group’s objective actions and results. In the event of a negative result, the debriefer seeks change without humiliating the participants. The trainer has to express his doubts clearly and then hand the floor over to the learners. The debriefer avoids a climate of hostility between the participants.
In zone 4, the objective is similar to zone 3, i.e. ‘Debriefing with Good Judgment’. In this case, the difficulty is the reference to an event with colleagues personally involved. The debriefer’s human quality is the critical point to avoid a communication disaster. The debriefers must express their doubts clearly and let everybody have a say to make the change. No one should leave the debriefing with a sense of guilt or inadequacy.
in synthesis
– There are five simulation zones. A simulation course mixes simulation zones depending on the participants, training objectives, trainers, time, budget, devices. High-fidelity technology is not always indispensable. .
— Reflective practice helps to treasure lived experiences through a cognitive, psychological and anthropological method by bringing out the fragments of reality of each practitioner that led to the actions and outcome.
– The Good Judgement focuses on adult learning. Participants in the reflection after the simulation share their fragments, whether they are learners or facilitators, to achieve a positive outcome.
BIBLIOGRAPHY
Capogna G, Ingrassia PL, et al. Il debriefing dopo lo scenario di simulazione. Base e avanzato strategico Pearson 2021
Capogna G, Ingrassia PL, et al. Strategic Debriefing for Advanced Simulation Springer 2022
Fey MK, Roussin CJ, et al. Teaching, coaching, or debriefing With Good Judgment: a roadmap for implementing “With Good Judgment” across the SimZones. Adv Simul (Lond). 2022 Nov 26;7(1):39.
Roussin CJ, Weinstock P. SimZones: An Organizational Innovation for Simulation Programs and Centers. Acad Med. 2017 Aug;92(8):1114-1120
Roussin C, Sawyer T, Weinstock P. Assessing competency using simulation: the SimZones approach. BMJ Simul Technol Enhanc Learn. 2020 Sep 3;6(5):262-267.
Rudolph JW, Simon R, et al. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006 Spring;1(1):49-55.
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