Implementing SBME into residency education programs comes with many challenges. Among the primary barriers to SBME implementation in the EM residency program at the AUB were faculty time and training. A study by Acton et al. showed an 86% increase in faculty load between the academic year 2006 and 2010 which was largely attributed to implementing a new simulation curriculum as well as participating in multi-institutional simulation-based research projects16. Similarly, a study on simulation–based education in EM postgraduate training programs in Canada found that faculty time and training were the major obstacles to simulation implementation17.
Models for implementing successful SBME curricula in faculty rich environments have been previously described18. Dagnone et al. discussed the importance of supporting faculty simulation champions who received supported education time and trained additional faculty over several years to assist in simulation instruction when developing comprehensive SBME courses19, however this can be challenging in environments with limited faculty resources. Takahashi et al. revealed a positive correlation between the number of simulation faculty and the degree of simulation-based education implementation20.
Little has been described regarding strategies to implement SBME curricula in programs with limited faculty resources. This posed a significant barrier to pilot curriculum development, implementation and sustainability at our site and would likely be a barrier to those wishing to incorporate SBME into their own resource limited programs. Among suggested solutions for reducing faculty time spent on simulation is using a shared case banks for simulation curricula1. However, even when provided cases, our faculty spent an average of 2 hours to prepare for a given scenario each month, including time to program the scenario, test run the equipment, gather supplies and review relevant updates in clinical guidelines. If the curriculum was to be evaluated as we did, an additional hour of faculty time was needed to distribute, collect, and analyze evaluation data for each session. For each 2-hour block of simulation teaching time, faculty found that they dedicated close to 5 hours of total teaching time even with the use of pre-existing cases: 2 hours were spent to prepare for the simulation event, 2 hours to facilitate the simulation session, and 1 hour to complete evaluation. This significant time commitment should be accounted for when programs begin incorporating SBME elements into their existing curricula.
For those educators entirely new to simulation, SBME also requires significant faculty onboarding given the complexity and variability of both high and low technology simulators and the many established methods of participant debriefing. Even with Dagnone et al.’s faculty champions, the curriculum described required 2–3 faculty a year and the time support to attend weeklong training sessions at simulation centers of excellence. This model required 6 years to fully develop and is not feasible for most residency programs who desire to add SBME to their existing education curricula.
For those programs with limited educator time, we found that incorporating SBME into pre-existing education conference time greatly increased curricular feasibility. By adapting existing weekly resident education conferences to include SBME, we were able to increase resident engagement with the curriculum, reduce time for curriculum administration activities (i.e. scheduling) and capitalize on previously protected faculty time. For those programs struggling to increase protected educator hours, identifying opportunities to replace didactic or small group learning with experiential learning could increase SBME without requiring faculty to come in during non-clinical hours.
Another way to reduce faculty time for SBME is to reduce simulation activity set-up time. The availability of a simulation technician or education coordinator who will help prepare and set up the sessions can then free up the faculty’s time making her/him more available to focus on the teaching. Educators can also plan to run a scenario several times in a row to take advantage of preparation time. In our revised curriculum, this meant shortening the simulation-based activities (40-min each) to allow for more repetitions (3) so that all residents could rotate through a simulated experience on a given day. In addition, while one group was undergoing the simulation, the 2 others did other educational activities, so the educational experience was maximized.
Given the desirability of simulation-based curricula and the time-intensive nature of SBME, we believe that more recommendations are needed to help simulation-based educators advocate for appropriate protected time. Basic guidelines regarding educator preparation time for simulation-based activities could help programs create more feasible simulation curricula. Experienced simulation-based educators should include anticipated faculty time when publishing SBME curricula or cases to help set realistic expectations. Finally, the development of needs assessment tools to identify relevant equipment, personnel, time, and space could provide educators with a more accurate picture of available resources.