Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82

Figures & data

Table

Practice points

Simulation is increasingly being used in healthcare education to teach cognitive, psychomotor, and affective skills to individuals and teams. It is important to first determine the outcomes of using simulation and utilize these to guide its integration into the curriculum. Feedback is critical to effective learning using simulation, and should be guided by individual learning needs. Simulation allows for training in a controlled environment, with opportunities for deliberate practice and assessment. Simulation-based mastery learning, or SBML, significantly improves skills for all participants, and also leads to skill retention. Further research is needed in the areas of instructional design, outcomes measurement, and translational and implementation sciences in the context of simulation.

Table 1  Curriculum integration framework

Phase	Component	Examples/Comments
Plan	Develop a curriculum with expected outcomes	Cardiovascular system in medical school, the undergraduate nursing curriculum, or continuing education requirements for a given specialty
	Determine outcomes that are best addressed using simulation	Clinical skills, procedures, problem-solving, teamwork, etc.
	Determine the simulation to be used based on availability of resources and goals of teaching intervention	Full mannequin, task trainer, virtual reality, standardized patient, mixed-modality, etc.
	Determine mode of delivery for each intervention	Facilitator-led small group, peer-led, self-instruction
	Develop content for the simulation-based exercises	Cases, scenarios, skills lab
	Determine logistics and how faculty will be supported & trained	Faculty training session
	Establish how feedback will be incorporated and develop tools to aid in effective feedback	Verbal/written, formalized debriefing, incorporating videos, etc.
Implement	Implement the simulation-based educational exercises and new curriculum	Pilot test with sample group
	Troubleshoot any components as they arise during this phase, and address	Scenarios take longer than planned and more prompts are needed for learners to remain engaged
Evaluate	Evaluate effectiveness/assess learning outcomes	Assess skill performance, knowledge, attitudes, clinical impact, etc.
	Evaluate learner satisfaction	Evaluate simulation exercise, instructor/facilitator, feedback
	Evaluate instructor satisfaction	With process, teaching modality
Revise	Based on results of evaluation and new evidence, make revisions to simulation exercises or curriculum	As needed, continuous process

Box 1 Example: Emergency medicine residency curriculum

Binstadt et al. integrated simulation into a redesigned four-year emergency medicine residency curriculum (Binstadt et al. 2007). Their approach combined adult learning principles, medical simulation education theory, and standardized national curriculum requirements. They designed a complete set of simulation-based teaching modules covering emergency medicine, and integrated them into the Harvard-Affiliated Emergency Medicine Residency (HAEMR) curriculum.

They began by creating a comprehensive list of learning objectives mapping to the core content within each of the educational modules that needed to be covered. Next, a panel of experts from the residency program and the simulation center determined the best teaching methodology for each learning objective. Their teaching methodologies included large-group lecture, small-group seminar, self-directed learning or reading, partial-task simulation training, human patient simulation, and clinical teaching in the emergency department. Once they identified the modules with a strong simulation component, they developed “courses” focusing on a specific set of learning objectives. The courses were three hours long and the residents were divided into two groups based on residency year. Faculty members received objectives relevant to the topic area, a list of available resources and capabilities of the simulation center, and a template for designing the overall session and individual components.

Box 2 Example: Six-year medical school cardiovascular curriculum

The University of Dundee integrated cardiovascular simulation throughout its six-year medical education curriculum (Issenberg et al. 2003). The curriculum is vertically integrated, where students build and elaborate on what they have already learned during three phases or six years of training. The faculty incorporated a cardiopulmonary patient simulator (CPS) during three phases using multiple modalities, including large-group lecture, small-group facilitator-led sessions, and independent study. In the first phase, they used the CPS to demonstrate normal and abnormal physiological principles in a large-group lecture format. This served to acquaint students with normal structure and function and help them understand the relevance of the basic science educational components to the physical examination. It also served to build enthusiasm in the students for future clinical problems they would encounter. During the second phase (second and third years of training), they used the CPS for consolidating clinical skills training. The skills included heart sounds recognition, and precordial, arterial and jugular venous pulse examination. Faculty used the CPS in lectures, small-group sessions, and independent learning throughout a four-week cardiovascular block. During the third phase (experience of clinical practice), faculty used the CPS in the virtual hospital ward experience for the advanced clinical skills elective. They also used the CPS for assessment in the objective structured clinical examinations (OSCEs), where one of the stations required students to auscultate a simulated murmur.

Figure 1. The three Ps of feedback.

Box 3 Example of physiological and verbal feedback from the simulator

Simulation Scenario: Patient with asthma. O2 saturation: 89%, diffuse wheezes on pulmonary examination.

Trainee 1 appropriately assesses the patient and applies a nebulizer treatment → Simulator O2 saturation changes to 95% over 1 min, and wheezes diminish. Simulator states, “Thank you, I feel much better.”

Trainee 2 does not recognize bronchospasm and/or does not provide appropriate treatment → O2 saturation decreases to 80%, and simulator states, ”I can't breathe. I feel like I am getting worse.”

Box 4 Example of verbal and force feedback from endoscopic simulators

Feedback is provided in these task trainers by the reaction of tissue (e.g. resistance felt by operator), and the response of a patient experiencing discomfort (e.g. audible groans) if undue force or insufflation is applied.

Table 2  Plus/delta debriefing model example

Plus (+)	Delta (Δ)
Individual:	Individual:
– Introduced self to family	– Learn algorithms well to know next steps/correct treatment
– Used appropriate personal protective equipment	Team:
– Adequately assessed patient	– Clarify communication/cross check
– Made correct diagnosis	– Ensure roles are clearly defined to increase efficiency and decrease confusion
Team:	System:
– Team leader identified early	– Maintain and label equipment (decrease delay to treatment)

Scenario: A multidisciplinary team is asked to respond to a patient's room. The team finds a male patient in cardiac arrest with an initial rhythm of ventricular fibrillation. The patient's family is present in the room.

Box 5 Example: Knot tying

First-year medical students in a surgery interest group want to learn how to tie knots. One student has read an instruction manual and has repetitively practiced tying a one-handed knot incorrectly, because he had no feedback during his self-administered tutorial.

An alternative approach is to have students use blocks of wood, each with 2 parallel rubber tubes, and view a video of an instructor correctly tying knots. After the students view the video several times, the instructor observes their hand motions, pointing out what they are doing correctly and incorrectly. Each student then ties approximately 200 knots, and over the session, becomes competent in this skill. The instructor repeats the tutorial weekly for one month, focusing on increasing the students’ speed, while maintaining competence. This is an example of deliberate practice using a low-technology task training simulation with specific real-time feedback.

Box 6 Example: Performing colonoscopy

As a gastroenterology fellowship director, you are responsible for your fellows becoming skilled in performing a colonoscopy. You use a virtual colonoscopy task trainer and schedule Saturday mornings to teach the fellows the fundamentals of this skill. Prior to the practice session, fellows read about the procedure and watch videos of a skilled surgeon performing it.

During the session, you observe the fellows’ technique in reaching the cecum, visualizing the entire colon, and performing biopsies. At different times during the practice session, the virtual trainer provides feedback on how close the probe is to touching the colon wall. You provide real-time feedback on each aspect of the procedure, and allow for and encourage adjustments in the trainees’ techniques. This is an example of deliberate practice using a mid-level technology task training simulation that provides its own feedback along with that of the facilitator.

Box 7 Example: Radiograph interpretation

In certain circumstances, it is possible to incorporate deliberate practice without having an onsite expert providing feedback. Pusic et al. describe the use of learning curves to assess the deliberate practice of radiograph interpretations (Pusic et al. 2011). In this computer-based learning model, pediatric residents reviewed cases of ankle radiographs and had to characterize the films as either normal or abnormal. They were then given immediate feedback, comprised of a visual overlay indicating the region of abnormality (if any), and the final official radiology report. This teaching and testing digital case bank recorded learners’ answers, and generated longitudinal learning curves characterizing things such as a learner's accuracy. This is a novel form of deliberate practice that uses computer-generated feedback to enhance learning. Unlike the first two examples, in this case, there is no expert directly accompanying the learners, rather pre-programmed feedback.

Table 3  Process for developing a mastery learning intervention

Determine learning outcomes

What competencies should the learners master at the completion of the intervention?

⇩

Develop learning objectives based on the desired outcomes

⇩

Develop metrics (checklists/global rating scales)

These may be previously deviced, based on an expert model, based on existing national requirements/standards, or you may develop your own in consultation with experts (validity).

⇩

Determine minimum passing score using appropriate standard-setting methods (e.g., Angoff, Hofstee)

⇩

Ensure rater training and calibration

⇩

Use the rating instrument in a pilot to determine reliability

Make any necessary changes

⇩

Conduct simulation-based educational intervention with deliberate practice and feedback

⇩

Perform a clinical skills evaluation using developed checklist

Participants must meet pre-determined minimum passing standard (MPS)

⇩

Participants who do not meet MPS should engage in additional deliberate practice until they can achieve MPS

Box 8 Example: Lumbar puncture training for internal medicine residents

Barsuk and colleagues used a simulation-based mastery learning intervention to train internal medicine residents in lumbar puncture (LP) (Barsuk et al. 2012). The intervention group was composed of 58 Post Graduate Year-1 (PGY-1) internal medicine residents. They developed and validated a 21-item checklist that was scored dichotomously – done correctly or done incorrectly. They also performed a pilot test to determine reliability. The minimum passing score (MPS) was determined as a mean of the Angoff and Hofstee standard setting methods.

Before the intervention, participants answered baseline questions and rated their procedural confidence. They underwent a clinical skills examination using the checklist. They then completed an educational session featuring a New England Journal of Medicine procedure video on lumbar puncture, an interactive LP demonstration, and deliberate practice with directed feedback. The residents then underwent a post-test using the same checklist and were expected to meet or surpass the MPS. Residents who did not achieve the MPS engaged in additional deliberate practice and were retested until the MPS was reached. The group of internal medicine residents was then compared to PGY 2–5 neurology residents who had been trained using standard clinical experience and training. The internal medicine residents who had undergone the simulation-based mastery learning intervention significantly outperformed the neurology residents who had not received the intervention.

Box 9 Example: Laparoscopic inguinal hernia repair training for surgical residents

Zendejas et al. implemented a simulation-based mastery learning intervention to train PGY 1-5 surgical residents in laparoscopic, totally extraperitoneal (TEP) inguinal hernia repair (Zendejas et al. 2011). The residents were randomized to regular clinical practice and instruction, or the mastery learning intervention.

The mastery learning curriculum consisted of supervised practice sessions using a TEP task trainer and standard laparoscopy equipment. Participants practiced on the simulator until they demonstrated mastery, defined as reduction and successful repair of indirect and femoral hernias using mesh in less than two minutes in two consecutive attempts. The standard was determined by taking the average time that it took five experienced laparoscopic surgeons to repair both hernias. All residents were assessed on subsequent TEP laparoscopic repairs in the operating room. Residents randomized to the mastery learning group performed the procedure faster, with better operative performance scores and fewer complications.

Box 10 Example: Laparoscopic skills

Imperial College of London has developed a graduated laparoscopic training curriculum that has learners progress through three levels of several tasks as proficiency is achieved (Aggarwal et al. 2006). At the easy level, learners perform 12 tasks twice on the same day in two sessions that are more than one hour apart. At the medium level, learners repeat the 12 tasks (at a more difficult pace) twice on the same day in two sessions that are more than one hour apart. At the hard level, learners practice two tasks (manipulate diathermy and stretch diathermy). They perform these for a maximum of two sessions per day, the sessions being greater than one hour apart. Learners complete training when the following levels of proficiency (in two of the most difficult tasks) are achieved on two consecutive sessions:

• Right hand economy of movement <2.0

• Left hand economy of movement <2.0

• Total error score <150

• Time taken <25 s

Box 11 Example: Cardiac bedside skills

The University of Miami developed a multi-year cardiac bedside skill curriculum in which the difficulty of each task increases with each stage of training.
Cardiac Finding: A simulator presents a fourth heart sound at the apex.
Level	Population	Tasks	Example
1	1st year medical student	Identify finding	“I hear a fourth heart sound.”
2	2nd year medical student	Correlate finding with underlying patho-physiology	“This fourth heart sound is caused by an increased after-load on the left ventricle.”
3	3rd year medical student	Generate a differential diagnosis	“Possible causes are aortic stenosis, hypertension, etc.”
4	2nd year internal medicine resident	Make a management decision	“Order an EKG, consult a specialist, and initiate medical therapy.”

Box 12 Example: Cardiac murmur interpretation

At the University of Miami, educators use simulation to demonstrate the range and variations of common cardiac murmurs (Gordon et al. 2007). For example, the various presentations of mitral regurgitation are simulated, linked to the underlying anatomic defect of the mitral valve apparatus.
Mitral valve apparatus defect	Mitral regurgitation characteristic(s)
Calcified mitral valve annulus	Combined mitral regurgitation and stenosis
Ruptured chordae tendineae	Short, early systolic murmur heard at apex
Valve degeneration from rheumatic fever	Holosystolic murmur heard at apex
Dilated left ventricle from cardiomyopathy	Holosystolic murmur with third and fourth sounds
Papillary muscle dysfunction from ventricular aneurysm	Crescendo-decrescendo systolic murmur at apex radiating anteriorly
Systolic anterior movement from hypertrophic cardiomyopathy	High pitched, crescendo murmur

Box 13 Example: Orotracheal intubation

At the University of Utah, educators have developed a curriculum to train novice learners to perform orotracheal intubation (Thomas et al. 2010). They incorporated the following difficult airway attributes and determined the eventual success rates of the learners. The difficult airway features to which learners were exposed included:

• Cervical immobilization

• Trismus (difficulty opening mouth)

• Pharyngeal obstruction

• Using a straight blade

• Laryngeal spasm

• Tongue edema

Box 14 Example: Patient sedation in a dental office

At the University of Colorado, dentists developed a curriculum to teach crisis management during complications that may result during local anesthesia and sedation procedures (Tan 2010). They developed cases that reflect the possible range of serious problems that may occur in a dental office. These included:

• Anaphylaxis

• Laryngospasm during procedural sedation

• Sedative medication overdose

• Multiple drug interaction with resultant cardiac arrhythmia

Figure 2. Steps in developing an individualized learning program.

Table 4  Teamwork competency model

Team competency	Definition
Team leadership	The ability to direct and coordinate the activities of other team members, assess team performance, develop team knowledge, skills and abilities, motivate team members, plan and organize, and establish a positive atmosphere.
Mutual performance monitoring	The ability to apply appropriate task strategies to develop common understandings of stress, skills and the environment external to the team itself.
Backup behavior	The ability to anticipate other team members’ needs through knowledge about their responsibilities.
Adaptability	The ability to adjust team strategies and alter the course of action based on information gathered from the environment through the use of backup behavior and reallocation of intra-team resources.
Team orientation	An attitude characterized by a propensity to take others’ behavior and input into account during group interaction, and the belief in the importance of team goals over individual members’ goals.
Shared mental models	The shared understanding that team members hold.
Mental trust	The shared belief that team members will perform their roles and protect the interests of their teammates.
Closed-loop communication	The exchange of information between a sender and a receiver.

Table 5  Principles of team training

Principle	Content
1. Identify critical teamwork competencies and use these as a focus for training content.	– Teamwork is a complex process with many relevant types of knowledge, skills, and attitudes.
	– Teamwork focuses on leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation.
	– Examples are crew resource management, team-building, and cross-training programs.
2. Emphasize teamwork over task work, design for teamwork to improve team processes.	– Because of scarce time and availability for training, there is a tendency to include elements of both task work and teamwork into training sessions.
	– Most effective team training programs that improve team processes focus only on teamwork.
3. One size does not fit all. Let the team-based learning outcomes desired, and organizational resources, guide the process.	– Effective team training is guided by educational science.
	– Teamwork is more than knowledge; it also includes behavior and attitudes.
	– For effective team training, a mix of traditional methods of instruction (lecture), modeling/demonstration, and practice or simulation should be utilized.
4. Task exposure is not enough. Provide guided, hands-on practice.	– Effective team training also entails guided, hands-on practice.
	– High-fidelity simulation and role-playing are the most-utilized practice training methods.
5. The power of simulation. Ensure training reflects work environment.	– Effective training creates an environment in which trainees go through the same mental processes they will utilize on the job.
	– Simulation-based training offers opportunities for trainees to implement and practice skills in environments similar to what they will experience on the job.
	– Key to effective use of simulation-based training is to create realistic scenarios that trainees will or could potentially encounter on the job.
6. Feedback matters. It must be descriptive, timely, and relevant.	– Feedback can include both outcome-based and behavior-based information.
	– Feedback is usually in the form of a debriefing during which trainees discuss their own performance with the help of a facilitator.
7. Go beyond reaction data. Evaluate clinical outcomes, learning, and behaviors on the job.	– Training must be evaluated to measure learning outcomes and to determine program effectiveness.
	– Methodological approach to training evaluation (e.g., Kirkpatrick four-level typology) should be implemented (Kirkpatrick 1996).
8. Reinforce desired teamwork behaviors. Sustain through coaching and performance evaluation.	– The behaviors targeted during training must be reinforced on the job.
	– To promote the transfer of teamwork competencies targeted in training to the job environment, teamwork behaviors should be incorporated into coaching and mentoring sessions, as well as performance evaluation.

Table 6  Team strategies and tools to enhance performance and patient safety (Team STEPPS) for medical and nursing students

Robertson and colleagues adapted the Team Strategies and Tools to Enhance Performance and Patient Safety (Team STEPPS) for use as an educational intervention for medical and nursing students (Robertson et al. 2010).
Component	Content
Needs analysis	– Despite the importance of teamwork and communication, these critical skills are not taught in health professions education.
	– Philosophy at both medical and nursing school is to teach and concurrently develop a culture around the importance of interprofessional teams and their role in the provision of patient-centered care.
Instructional methodologies	– Lecture followed by small-group problem-solving sessions, including interactive play, medical simulations, and review of video vignettes.
	– Standard debriefing process to lead the discussions focused on the use or absence of teamwork skills.
Simulation modules	– High-fidelity simulation and incorporation of crisis resource management training.
Implementation	– Half-day workshop for all first-year nursing students and third-year medical students.
	– Facilitators from the academic and clinical setting attended a two-hour training session.
Assessment and evaluation	– 12-item teamwork knowledge test on leadership, situation monitoring, mutual support, and communication (Hobgood et al. 2010).
	– 14-item Collaborative Healthcare Interdisciplinary Relationship Planning (CHIRP) scale for attitude assessment (Hobgood et al. 2010).
	– 17-item self-rating of the video vignettes using the Team Skills Checklist Video Rating (Hobgood et al. 2010).
	– 15-item training satisfaction survey from the Medical Team Training Program Evaluation Tool (Baker et al. 2006).
Example. Guise et al. developed a mobile obstetric emergency simulation and team training program. The mobile unit has the advantage of being practical, given the expense of simulation equipment, the time required for staff to develop educational materials and simulation scenarios, and the need to have a standardized program to promote consistent evaluation across sites (Guise et al. 2010). The system was successful in developing new skills, maintaining infrequently used clinical skills, and uncovering latent safety threats in the clinical setting.
Component	Content
Needs analysis	– Involved stakeholders in development, making the curriculum short, engaging, accessible, and clinically important, with a high perceived return on investment.
	– Obstetric emergencies, such as shoulder dystocia, postpartum hemorrhage, and eclampsia, were chosen because their time-critical nature makes communication and teamwork issues apparent.
Instructional methodologies	– Evidence-based clinical didactics, followed by teamwork skills training using SBAR (situation, background, assessment, and response), transparent thinking, and directed and closed-loop communication.
Simulation modules	– High-fidelity simulation using a mobile cart.
Implementation	– On-site schedule of 2.5 h for each visit.
	– Two emergency simulation scenarios were run, with facilitated team debriefing followed by a standardized clinical didactic session.
Assessment and evaluation	– Identification of latent quality and safety issues conducted by researchers through a thematic checklist (Baker et al. 2006).
Example. Rosen and colleagues developed an event-based approach to designing simulation scenarios and measurement tools for training and assessing teamwork skills in emergency medicine residents (Rosen et al. 2008b).
Component	Content
Needs analysis	– Training in teamwork skills in emergency medicine residency programs is very important due to the complex and time-pressured nature of patient care in emergency medicine.
	– A single encounter with a new and unknown patient in a chaotic and emotionally charged environment makes establishing rapport with the patient extremely difficult.
Instructional methodologies	– Event-based approach to training, to systematically link the content of training scenarios and measurement tools to the teamwork competencies being trained (Fowlkes et al. 1998).
Simulation modules	– High-fidelity simulation and incorporation of crisis resource management training.
Implementation	– Choose a clinical situation capable of meeting the learning goals.
	– Explicitly defined knowledge, skills, and attitudes necessary for effective performance in given clinical context.
	– Define expected behaviors associated with critical events, and create opportunities to perform, with triggers that elicit performance being trained.
Assessment and evaluation	– Create behavioral checklists using critical events and targeted responses.
	– Determine causes of effective and ineffective performance.
	– Use products of performance diagnosis to make decisions about what feedback to provide and what future training is needed.

Binstadt ES, Walls RM, White BA, Nadel ES, Takayesu JK, Barker TD, Nelson SJ, Pozner CN. A comprehensive medical simulation education curriculum for emergency medicine residents. Ann Emerg Med 2007; 49: 495–504

 PubMed Web of Science ®Google Scholar

Issenberg SB, Pringle S, Harden RM, Khogali S, Gordon MS. Adoption and integration of simulation-based learning technologies into the curriculum of a UK undergraduate education programme. Med Educ 2003; 37(Suppl 1)42–49

 PubMed Web of Science ®Google Scholar

Pusic M, Pecaric M, Boutis K. How much practice is enough? Using learning curves to assess the deliberate practice of radiograph interpretation. Acad Med 2011; 86: 731–736

 PubMed Web of Science ®Google Scholar

Barsuk JH, Cohen ER, Caprio T, Mcgaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents' lumbar puncture skills. Neurology 2012; 79: 132–137

 PubMed Web of Science ®Google Scholar

Zendejas B, Cook DA, Bingener J, Huebner M, Dunn WF, Sarr MG, Farley DR. Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: A randomized controlled trial. Ann Surg 2011; 254(3): 502–509

 Web of Science ®Google Scholar

Aggarwal R, Grantcharov T, Moorthy K, Hance J, Darzi A. A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skills. Am J Surg 2006; 191: 128–133

 PubMed Web of Science ®Google Scholar

Gordon MS, Issenberg SB, Ewy GA, Feldner JM, Waugh RA, Gessner IH, Safford RE, Brown DD, Rich S, Gordon DL, et al. Harvey, The Cardiopulmonary Patient Simulator – Learner Manual. University of Miami Press, Miami, FL 2007

 Google Scholar

Thomas F, Carpenter J, Rhoades C, Holleran R, Snow G. The usefulness of design of experimentation in defining the effect difficult airway factors and training have on simulator oral-tracheal intubation success rates in novice intubators. Acad Emerg Med 2010; 17: 460–463

 PubMed Web of Science ®Google Scholar

Tan GM. A medical crisis management simulation activity for pediatric dental residents and assistants. J Dent Educ 2010; 75: 782–790

 Web of Science ®Google Scholar

Kirkpatrick DL. Evaluation of training. Training and Development Handbook2nd, RL Craig. McGraw-Hill, New York, NY 1996

 Google Scholar

Robertson B, Kaplan B, Atallah H, Higgins M, Lewitt MJ, Ander DS. The use of simulation and a modified TeamSTEPPS curriculum for medical and nursing student team training. Sim Healthcare 2010; 5: 332–337

 PubMed Web of Science ®Google Scholar

Hobgood C, Sherwood G, Frush K, Hollar D, Maynard L, Foster B, Sawning S, Woodyard D, Durham C, Wright M, et al. Teamwork training with nursing and medical students: Does the method matter? Results of an inter-institutional, interdisciplinary collaboration. Qual Saf Health Care 2010; 19: 1–6

 Google Scholar

Baker DP, Day R, Salas E. Teamwork as an essential component of high-reliability organizations. Health Serv Res 2006; 41: 576–598

 Web of Science ®Google Scholar

Guise JM, Lowe NK, Deering S, Lewis PO, O'haire C, Irwin LK, Blaser M, Wood LS, Kanki BG. Mobile in situ obstetric emergency simulation and teamwork training to improve maternal-fetal safety in hospitals. Jt Comm J Qual Patient Saf 2010; 36: 443–453

 PubMedGoogle Scholar

Fowlkes JE, Dwyer DJ, Oser RL, Salas E. Event-based approach to training (EBAT). Int J Aviat Psychol 1998; 8: 209–221

 Web of Science ®Google Scholar