http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(2): 110–115 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2013.869198
SPECIAL THEMED SECTION: HISTORICAL PERSPECTIVES
A history of simulation-enhanced interprofessional education Janice C. Palaganas1, Chad Epps2 and Daniel B. Raemer3 Harvard Medical School, Center for Medical Simulation, Boston, MA, USA, 2Department of Clinical and Diagnostic Sciences, University of Alabama Birmingham, Birmingham, AL, USA, and 3Massachusetts General Hospital, Center for Medical Simulation, Boston, MA, USA
Abstract
Keywords
This article explores the evolution and history of interprofessional education (IPE) using healthcare simulation (HCS). The evolution described here demonstrates an achievement of patient safety efforts as a consequence of the historical roots of healthcare and highlights HCS as a progressive method synergistic with IPE. This paper presents a descriptive review that covers the HCS and IPE literature, indicating factors that led to the use of HCS in IPE. Understanding the history of simulation-enhanced IPE provides healthcare educators with fertile ground to support future IPE. A number of benefits in using HCS to address common challenges to IPE are outlined, including natural relevance and engagement for learners, faculty attraction to its use, and the opportunity to explore socio-historical issues in teams. Several promising directions for future research are suggested.
Education, healthcare, history, interprofessional, mannequin, simulation
Introduction
History Received 1 August 2013 Revised 3 November 2013 Accepted 19 November 2013 Published online 27 December 2013
The intersection of histories of each profession, healthcare teams, organizations and individuals is duly emphasized now at a time when gaps in interprofessional teamwork are globally recognized as threats to patient safety. Patient outcome data and IPE efforts continue to increase awareness in ways that these gaps can no longer be ignored. Just as different healthcare professions, departments and programs have evolved over time to assist in filling patient care gaps (e.g. physician assistants were created due to a shortage of primary care physicians), the relatively new science of healthcare simulation (HCS) has evolved directly from these patient safety gaps and continues to evolve through achievements in interprofessional education (IPE). For the purposes of this discussion, healthcare simulation is defined as ‘‘a technique that uses a situation or environment created to allow persons to experience a representation of a real healthcare event for the purpose of practice, learning, evaluation, testing or to gain understanding of systems or human actions. HCS uses a simulator (e.g. mannequin, standardized patient, virtual or computer model, procedural model) as any representation used during training or assessment that behaves or operates like a given system and responds to the user’s actions’’ (Council for the Accreditation of Healthcare Simulation Programs, 2013, p. 46). Although both fields (IPE and HCS) have been in existence for over 40 years, research in the separate fields is relatively new, with publications increasing over the last decade. A review of how these two sciences merged into a field (Figure 1) and insight into findings seen today using HCS for IPE may capture a more fecund picture of interprofessional gaps that have resulted from the collective evolutions of healthcare professions and provide a medium to fill such gaps.
A healthcare team made up of practitioners, hospital staff, patients and family members, forms a complex web of rooted variables that contribute to the functioning of that team. These variables stem from two sources: the environment or organizational culture and the individuals that make up the team, specifically the knowledge, skills and attitudes of the individuals (Palaganas, 2012). Both sources are affected by their histories – the history of the organization and the history of each individual. Furthermore, these histories have been consequently influenced by the histories of each team role through socialization (e.g. acquired organizational hierarchy, social stereotypes through media) (Van Maanen & Schein, 1979). The increasingly complex needs of patients have driven each profession to become more sophisticated to meet these needs. Historical accounts of education in healthcare professions reveal that these developments toward professional sophistication have occurred in uniprofessional silos (Benner, Sutphen, Leonard, & Day, 2010; Cooke, Irby, & O’Brien, 2010; Donini-Lenhoff, 2008). The traditional process was to educate healthcare students within their own domain and expect them to possess the skills, knowledge and attitudes necessary to work together in healthcare teams (Institute of Medicine [IOM], 2001). Over time, it has become evident through hospital, patient safety, and risk management studies, statistics, and reports that this siloed approach has nurtured a culture of ineffective collaboration, resulting in patient care errors or near-errors that are attributed to poor communication and compromised teamwork and collaboration (World Health Organization [WHO], 2010). Healthcare educators have come to realize that healthcare professionals enter practice without the skills, knowledge and attitudes to effectively function in healthcare teams, creating impending and imminent gaps in patient care.
History of healthcare simulation
Correspondence: Janice C. Palaganas, Harvard Medical School, Center for Medical Simulation, 100 First Avenue, Building 39, Fourth Floor, Boston 02129, MA, USA. E-mail: [email protected]
While patient and human anatomy models have appeared since ancient healthcare practice, healthcare simulation in its modern form stems from parallel technological and developmental advancements in aviation training, computer science and
20 14
J Interprof Care Downloaded from informahealthcare.com by Nyu Medical Center on 05/13/15 For personal use only.
1
DOI: 10.3109/13561820.2013.869198
J Interprof Care Downloaded from informahealthcare.com by Nyu Medical Center on 05/13/15 For personal use only.
healthcare education. Developments in HCS were generated from simulation knowledge and educational theory from each of these fields and originated in the specialized areas of obstetric training, nursing training (Mrs. Chase, PLATO, and Kruse infant dolls), resuscitation training (ResusciÕ -Anne), anesthesia training (Sim One), and medical (Harvey), physiological, and pharmacological (GasManÕ >) diagnostic training (Cooper & Taqueti, 2004; Denson & Abrahamson, 1969; Goddu, 2004; King, 2001; Price, 1939; Rizzolo, 2013). While initial developments appeared to have occurred independently within each of these areas, quality patient care seemed to be the impetus for all of the original healthcare simulators (Figure 2). These simulators spurred new products, new
Figure 1. Interprofessional education and healthcare simulation. IPE and HCS evolved as separate sciences and have naturally overlapped into a merged field. This merged area is the focus of this article and is referred to as ‘‘the field’’.
History of simulation-enhanced IPE
111
concepts, new prospects, and, hence, new motivations through the solicitation and sharing of creativity and feedback from users and clinicians. Eventually, all of the original healthcare simulators facilitated changes in healthcare education toward an improvement in patient safety (Cooper & Taqueti, 2004). One paramount advance in HCS was the integration of human factors research into crisis resource management (CRM) simulations (Gaba, 1997). Originally adapted from aviation, i.e. crew resource management, healthcare CRM is an approach to managing critical situations in a healthcare setting. CRM training develops communication skills and emphasizes the role of human factors, e.g. interprofessional relationships and hierarchy, fatigue, expected or predictable perceptual errors, different management styles and organizational cultures in high-stress, high-risk environments (Gaba, Howard, Fish, Smith, & Sowb, 2001; Helreich, Merritt, & Willhelm, 1999). This training began an era of formal IPE using HCS (Cheng, Donoghue, Gilfoyle, & Eppich, 2012). Socio-historical issues (e.g. imbalances of power, gender, hierarchy, status, professional divisions) complicate learning processes in interprofessional learning (e.g. Bunderson & Reagans, 2011; Irvine, Kerridge, McPhee, & Freeman, 2002). Existing interprofessional education and learning literature tend to overlook the pervasiveness of social hierarchy on learning outcomes (Barr, Koppel, Reeves, Hammick, & Freeth, 2005; Holtman, Frost, Hammer, McGuinn, & Nunez, 2011; Reeves et al., 2010; Sims, 2011). IPE literature has suggested some social effects on learning, including the influence of social context on the individual level (Le´gare´ et al., 2011), gender differences in attitudes toward IPE (Curran, Sharpe, Forristall, & Flynn, 2008), and the influence of attitudes of other team members on
Figure 2. Evolution of modern day healthcare simulation-enhanced IPE. This is a list of notable historical simulation and healthcare team training efforts by earliest identified date of reference. Efforts have increased over the past decades with advances continuing today. While simulators, environments, communities of knowledge and team training emerged in different healthcare fields, quality patient care seemed to be the impetus for each development (Bauman, 2013; Carayon, 2012; Cooper & Taqueti, 2004; Denson & Abrahamson, 1969; Gaba, 1997; Gilmer, 1960; Goddu, 2004; IOM, 1972; Issenberg et al., 1999; Jantsch, 1947; King, 2001; McConaughey, 2008; Price, 1939; Rizzolo, 2013; Rosen, 2013; Slone & Lampotang, in press).
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J. C. Palaganas et al.
J Interprof Care, 2014; 28(2): 110–115
individual learning (Curran, Sharpe, Flynn, & Button, 2010). The critical role of socio-historical factors in collaborative practice can be more evident and are often highlighted in HCS debriefings (Blum et al., 2004; Calhoun, Boone, Miller, & Pian-Smith, 2013; Kobayashi et al., 2006; Pian-Smith et al., 2009; Streiff et al., 2011; van Soeren et al., 2011). The ability to make apparent these issues that are often hidden in other forms of IPE provides a new advantage of leveraging HCS for IPE – an advantage that has yet to be further explored (Sharma, Boet, Kitto, & Reeves, 2011).
Eduardo Salas refers to as a ‘‘national obsession’’ with team training (Salas, Burke, & Cannon-Bowers, 2000, p. 339). There was an increased focus on team training with the use of MedTeams (McConaughey, 2008) in the early 2000s and the release of TeamSTEPPS (Health and Human Services Department, Agency for Healthcare Research and Quality, 2008) in 2006. In 2010, the World Health Organization published a framework for action on IPE, domains for competencies were developed (Canadian Interprofessional Health Collaborative, 2010; Interprofessional Education Collaborative Expert Panel [IPECEP], 2011a), and more detailed competencies under the domains were established (IPECEP, 2011b). Sponsored by the Josiah Macy Jr. Foundation, representatives from 22 professional healthcare organizations gathered at the 2012 Interprofessional Education and Healthcare Simulation Symposium to build upon the work of IPECEP’s domains (2011a) and competencies (2011b) by coming to consensus on how HCS can further the field of IPE (Wilhaus et al., 2012).
Simulation also has a long, informal and undocumented history as a natural human behavior ranging from imitative play, gaming, to war tactic training. These types of simulation activities often include more than one person with differing roles, knowledge, skills and attitudes. These human behaviors, sometimes observed through child’s play, imply a natural human tendency toward simulating team performance. An extensive literature review of published and gray literature revealed the first documented IPE and HCS initiative published in 1947 and focused on inter- and trans-disciplinary education (Palaganas, 2012). The manuscript by Jantsch (1947) did not use the specific words ‘‘interprofessional education’’ or ‘‘simulation’’, but exemplified simulation-enhanced IPE because the students learned with, from, and about each other. Jantsch describes the use of trained actors (modern day standardized healthcare providers) to facilitate role-play activities between professions. Simulation-enhanced IPE emerged in the 1950s and presented as computerized simulations for sociology, psychology, behavioral sciences and organization theory. The literature broadened in the 1960s, possibly as a result of a surge in human factors studies (Gilmer, 1960; IOM, 1972). As early as the 1960s, teamwork and collaboration were commonly referred to as the ‘‘future of healthcare delivery’’ (Henry, 1974, p. 11) – a phrase still used today when describing IPE. Healthcare team training appeared in the 1980s with MedTeams (McConaughey, 2008) and crisis resource management training in anesthesia simulations (Gaba, 1997). A steep incline of simulation-enhanced IPE (Figure 3) began in the early 1990s and continues today. In the last 1990s, the Institute of Medicine (1999) published To Err is Human. The following year began a new wave of what
Healthcare simulation as a natural hub for interprofessional education The history of HCS and simulation-enhanced IPE illustrates a natural merging of the fields. Over time, with contributions from multiple professions, healthcare simulation has acquired features that are advantageous over other educational techniques, leading to its growth. Some of these attractive features are: a close resemblance to actual clinical practice; more objective simulator scores (assessment); the ability to assess psychomotor skills; more relevant feedback; learner identification of educational needs; the ability to vary conditions; and student motivation to practice specific tasks (Pugh, 2008). The safe container established by HCS not only protects the actual patient, it also creates an environment in which learners can safely make mistakes and learn from them with decreased fear and anxiety, thus increasing the learning threshold. According to the literature review conducted by Issenberg, McGaghie, Petrusa, Gordon, and Scalese (2005) under the Best Evidence Medical Education (BEME) Collaboration, a filtered set of 109 studies from 1969 to 2003 identified 10 consistent features and uses of high-technology simulators that lead to effective learning. These features are beneficial to the development of every healthcare professional and include:
800 700 Number of Publica ons
J Interprof Care Downloaded from informahealthcare.com by Nyu Medical Center on 05/13/15 For personal use only.
History of simulation-enhanced interprofessional education
600 500 400 300 200 100 0
SPECIAL THEMED SECTION: HISTORICAL PERSPECTIVES
A history of simulation-enhanced interprofessional education Janice C. Palaganas1, Chad Epps2 and Daniel B. Raemer3 Harvard Medical School, Center for Medical Simulation, Boston, MA, USA, 2Department of Clinical and Diagnostic Sciences, University of Alabama Birmingham, Birmingham, AL, USA, and 3Massachusetts General Hospital, Center for Medical Simulation, Boston, MA, USA
Abstract
Keywords
This article explores the evolution and history of interprofessional education (IPE) using healthcare simulation (HCS). The evolution described here demonstrates an achievement of patient safety efforts as a consequence of the historical roots of healthcare and highlights HCS as a progressive method synergistic with IPE. This paper presents a descriptive review that covers the HCS and IPE literature, indicating factors that led to the use of HCS in IPE. Understanding the history of simulation-enhanced IPE provides healthcare educators with fertile ground to support future IPE. A number of benefits in using HCS to address common challenges to IPE are outlined, including natural relevance and engagement for learners, faculty attraction to its use, and the opportunity to explore socio-historical issues in teams. Several promising directions for future research are suggested.
Education, healthcare, history, interprofessional, mannequin, simulation
Introduction
History Received 1 August 2013 Revised 3 November 2013 Accepted 19 November 2013 Published online 27 December 2013
The intersection of histories of each profession, healthcare teams, organizations and individuals is duly emphasized now at a time when gaps in interprofessional teamwork are globally recognized as threats to patient safety. Patient outcome data and IPE efforts continue to increase awareness in ways that these gaps can no longer be ignored. Just as different healthcare professions, departments and programs have evolved over time to assist in filling patient care gaps (e.g. physician assistants were created due to a shortage of primary care physicians), the relatively new science of healthcare simulation (HCS) has evolved directly from these patient safety gaps and continues to evolve through achievements in interprofessional education (IPE). For the purposes of this discussion, healthcare simulation is defined as ‘‘a technique that uses a situation or environment created to allow persons to experience a representation of a real healthcare event for the purpose of practice, learning, evaluation, testing or to gain understanding of systems or human actions. HCS uses a simulator (e.g. mannequin, standardized patient, virtual or computer model, procedural model) as any representation used during training or assessment that behaves or operates like a given system and responds to the user’s actions’’ (Council for the Accreditation of Healthcare Simulation Programs, 2013, p. 46). Although both fields (IPE and HCS) have been in existence for over 40 years, research in the separate fields is relatively new, with publications increasing over the last decade. A review of how these two sciences merged into a field (Figure 1) and insight into findings seen today using HCS for IPE may capture a more fecund picture of interprofessional gaps that have resulted from the collective evolutions of healthcare professions and provide a medium to fill such gaps.
A healthcare team made up of practitioners, hospital staff, patients and family members, forms a complex web of rooted variables that contribute to the functioning of that team. These variables stem from two sources: the environment or organizational culture and the individuals that make up the team, specifically the knowledge, skills and attitudes of the individuals (Palaganas, 2012). Both sources are affected by their histories – the history of the organization and the history of each individual. Furthermore, these histories have been consequently influenced by the histories of each team role through socialization (e.g. acquired organizational hierarchy, social stereotypes through media) (Van Maanen & Schein, 1979). The increasingly complex needs of patients have driven each profession to become more sophisticated to meet these needs. Historical accounts of education in healthcare professions reveal that these developments toward professional sophistication have occurred in uniprofessional silos (Benner, Sutphen, Leonard, & Day, 2010; Cooke, Irby, & O’Brien, 2010; Donini-Lenhoff, 2008). The traditional process was to educate healthcare students within their own domain and expect them to possess the skills, knowledge and attitudes necessary to work together in healthcare teams (Institute of Medicine [IOM], 2001). Over time, it has become evident through hospital, patient safety, and risk management studies, statistics, and reports that this siloed approach has nurtured a culture of ineffective collaboration, resulting in patient care errors or near-errors that are attributed to poor communication and compromised teamwork and collaboration (World Health Organization [WHO], 2010). Healthcare educators have come to realize that healthcare professionals enter practice without the skills, knowledge and attitudes to effectively function in healthcare teams, creating impending and imminent gaps in patient care.
History of healthcare simulation
Correspondence: Janice C. Palaganas, Harvard Medical School, Center for Medical Simulation, 100 First Avenue, Building 39, Fourth Floor, Boston 02129, MA, USA. E-mail: [email protected]
While patient and human anatomy models have appeared since ancient healthcare practice, healthcare simulation in its modern form stems from parallel technological and developmental advancements in aviation training, computer science and
20 14
J Interprof Care Downloaded from informahealthcare.com by Nyu Medical Center on 05/13/15 For personal use only.
1
DOI: 10.3109/13561820.2013.869198
J Interprof Care Downloaded from informahealthcare.com by Nyu Medical Center on 05/13/15 For personal use only.
healthcare education. Developments in HCS were generated from simulation knowledge and educational theory from each of these fields and originated in the specialized areas of obstetric training, nursing training (Mrs. Chase, PLATO, and Kruse infant dolls), resuscitation training (ResusciÕ -Anne), anesthesia training (Sim One), and medical (Harvey), physiological, and pharmacological (GasManÕ >) diagnostic training (Cooper & Taqueti, 2004; Denson & Abrahamson, 1969; Goddu, 2004; King, 2001; Price, 1939; Rizzolo, 2013). While initial developments appeared to have occurred independently within each of these areas, quality patient care seemed to be the impetus for all of the original healthcare simulators (Figure 2). These simulators spurred new products, new
Figure 1. Interprofessional education and healthcare simulation. IPE and HCS evolved as separate sciences and have naturally overlapped into a merged field. This merged area is the focus of this article and is referred to as ‘‘the field’’.
History of simulation-enhanced IPE
111
concepts, new prospects, and, hence, new motivations through the solicitation and sharing of creativity and feedback from users and clinicians. Eventually, all of the original healthcare simulators facilitated changes in healthcare education toward an improvement in patient safety (Cooper & Taqueti, 2004). One paramount advance in HCS was the integration of human factors research into crisis resource management (CRM) simulations (Gaba, 1997). Originally adapted from aviation, i.e. crew resource management, healthcare CRM is an approach to managing critical situations in a healthcare setting. CRM training develops communication skills and emphasizes the role of human factors, e.g. interprofessional relationships and hierarchy, fatigue, expected or predictable perceptual errors, different management styles and organizational cultures in high-stress, high-risk environments (Gaba, Howard, Fish, Smith, & Sowb, 2001; Helreich, Merritt, & Willhelm, 1999). This training began an era of formal IPE using HCS (Cheng, Donoghue, Gilfoyle, & Eppich, 2012). Socio-historical issues (e.g. imbalances of power, gender, hierarchy, status, professional divisions) complicate learning processes in interprofessional learning (e.g. Bunderson & Reagans, 2011; Irvine, Kerridge, McPhee, & Freeman, 2002). Existing interprofessional education and learning literature tend to overlook the pervasiveness of social hierarchy on learning outcomes (Barr, Koppel, Reeves, Hammick, & Freeth, 2005; Holtman, Frost, Hammer, McGuinn, & Nunez, 2011; Reeves et al., 2010; Sims, 2011). IPE literature has suggested some social effects on learning, including the influence of social context on the individual level (Le´gare´ et al., 2011), gender differences in attitudes toward IPE (Curran, Sharpe, Forristall, & Flynn, 2008), and the influence of attitudes of other team members on
Figure 2. Evolution of modern day healthcare simulation-enhanced IPE. This is a list of notable historical simulation and healthcare team training efforts by earliest identified date of reference. Efforts have increased over the past decades with advances continuing today. While simulators, environments, communities of knowledge and team training emerged in different healthcare fields, quality patient care seemed to be the impetus for each development (Bauman, 2013; Carayon, 2012; Cooper & Taqueti, 2004; Denson & Abrahamson, 1969; Gaba, 1997; Gilmer, 1960; Goddu, 2004; IOM, 1972; Issenberg et al., 1999; Jantsch, 1947; King, 2001; McConaughey, 2008; Price, 1939; Rizzolo, 2013; Rosen, 2013; Slone & Lampotang, in press).
112
J. C. Palaganas et al.
J Interprof Care, 2014; 28(2): 110–115
individual learning (Curran, Sharpe, Flynn, & Button, 2010). The critical role of socio-historical factors in collaborative practice can be more evident and are often highlighted in HCS debriefings (Blum et al., 2004; Calhoun, Boone, Miller, & Pian-Smith, 2013; Kobayashi et al., 2006; Pian-Smith et al., 2009; Streiff et al., 2011; van Soeren et al., 2011). The ability to make apparent these issues that are often hidden in other forms of IPE provides a new advantage of leveraging HCS for IPE – an advantage that has yet to be further explored (Sharma, Boet, Kitto, & Reeves, 2011).
Eduardo Salas refers to as a ‘‘national obsession’’ with team training (Salas, Burke, & Cannon-Bowers, 2000, p. 339). There was an increased focus on team training with the use of MedTeams (McConaughey, 2008) in the early 2000s and the release of TeamSTEPPS (Health and Human Services Department, Agency for Healthcare Research and Quality, 2008) in 2006. In 2010, the World Health Organization published a framework for action on IPE, domains for competencies were developed (Canadian Interprofessional Health Collaborative, 2010; Interprofessional Education Collaborative Expert Panel [IPECEP], 2011a), and more detailed competencies under the domains were established (IPECEP, 2011b). Sponsored by the Josiah Macy Jr. Foundation, representatives from 22 professional healthcare organizations gathered at the 2012 Interprofessional Education and Healthcare Simulation Symposium to build upon the work of IPECEP’s domains (2011a) and competencies (2011b) by coming to consensus on how HCS can further the field of IPE (Wilhaus et al., 2012).
Simulation also has a long, informal and undocumented history as a natural human behavior ranging from imitative play, gaming, to war tactic training. These types of simulation activities often include more than one person with differing roles, knowledge, skills and attitudes. These human behaviors, sometimes observed through child’s play, imply a natural human tendency toward simulating team performance. An extensive literature review of published and gray literature revealed the first documented IPE and HCS initiative published in 1947 and focused on inter- and trans-disciplinary education (Palaganas, 2012). The manuscript by Jantsch (1947) did not use the specific words ‘‘interprofessional education’’ or ‘‘simulation’’, but exemplified simulation-enhanced IPE because the students learned with, from, and about each other. Jantsch describes the use of trained actors (modern day standardized healthcare providers) to facilitate role-play activities between professions. Simulation-enhanced IPE emerged in the 1950s and presented as computerized simulations for sociology, psychology, behavioral sciences and organization theory. The literature broadened in the 1960s, possibly as a result of a surge in human factors studies (Gilmer, 1960; IOM, 1972). As early as the 1960s, teamwork and collaboration were commonly referred to as the ‘‘future of healthcare delivery’’ (Henry, 1974, p. 11) – a phrase still used today when describing IPE. Healthcare team training appeared in the 1980s with MedTeams (McConaughey, 2008) and crisis resource management training in anesthesia simulations (Gaba, 1997). A steep incline of simulation-enhanced IPE (Figure 3) began in the early 1990s and continues today. In the last 1990s, the Institute of Medicine (1999) published To Err is Human. The following year began a new wave of what
Healthcare simulation as a natural hub for interprofessional education The history of HCS and simulation-enhanced IPE illustrates a natural merging of the fields. Over time, with contributions from multiple professions, healthcare simulation has acquired features that are advantageous over other educational techniques, leading to its growth. Some of these attractive features are: a close resemblance to actual clinical practice; more objective simulator scores (assessment); the ability to assess psychomotor skills; more relevant feedback; learner identification of educational needs; the ability to vary conditions; and student motivation to practice specific tasks (Pugh, 2008). The safe container established by HCS not only protects the actual patient, it also creates an environment in which learners can safely make mistakes and learn from them with decreased fear and anxiety, thus increasing the learning threshold. According to the literature review conducted by Issenberg, McGaghie, Petrusa, Gordon, and Scalese (2005) under the Best Evidence Medical Education (BEME) Collaboration, a filtered set of 109 studies from 1969 to 2003 identified 10 consistent features and uses of high-technology simulators that lead to effective learning. These features are beneficial to the development of every healthcare professional and include:
800 700 Number of Publica ons
J Interprof Care Downloaded from informahealthcare.com by Nyu Medical Center on 05/13/15 For personal use only.
History of simulation-enhanced interprofessional education
600 500 400 300 200 100 0
