Krage and Erweteman (2015) identified a positive change in traditional teaching methods for the development of technical skills in anaesthesia from supervised practice to one learnt through simulation. Simulation allows learners to encounter rare clinical situations, such as a difficult airway, enabling them to gain practical experience before having to deal with high-risk situations in clinical practice with possibly no senior medical support immediately available (Lorello et al, 2014). Simulation is significant in improving both technical and non-technical skills in dealing with critically ill patients and ultimately patient safety (Fox-Robichaud and Nimmo 2007; Murphy et al, 2016; Peters et al, 2018; Jensen et al, 2019). Dieckmann et al (2007) noted that non-technical skills include teamwork, leadership, decision-making, situational awareness and, most importantly, effective communication. Greenland et al (2011) emphasised the importance of non-technical skills as well as technical competence in the management of the difficult airway. However, Jensen et al (2019) stated that high-fidelity simulation is costly and there remains a lack of evidence to support its impact on patient outcomes.
Cant and Cooper (2010) described high-fidelity simulation as a reproduction of a clinical scenario using a full-body computerised manikin, controlled by an operator who can effectively change physiological responses in line with the actions of the participant. The use of automated equipment allows participants to practise highly advanced practical skills, critically analyse teamwork skills and is one of the reasons why high-fidelity simulation is often preferred in crisis scenario training, such as the difficult airway. Krage and Erweteman (2015) discussed the importance of keeping the learner's outcomes as the focus of this training modality, rather than the realism of the simulation. They highlighted the positive impact that both feedback and debriefing play in its success. Ultimately, the advantages of simulation training are to reduce medical errors, increase patient safety and improve patient outcomes (Zhang et al, 2011), which are, in the end, the essence of everyday practice.
The Fourth National Audit Project of The Royal College of Anaesthetists and the Difficult Airway Society (NAP4) identified recurrent problems, including delayed recognition of critical events, inadequate provision of appropriately trained staff, and poor collaboration and communication within teams (Cook et al, 2011a; 2011b).
Aim
The main aim of this review was to explore the current research around the impact of interprofessional simulation-based team training in difficult airway management on team performance. The secondary objectives were to explore:
Design
A narrative review was carried out to effectively identify, appraise and synthesise previous studies to gain a further understanding of this clinical topic and as a rationale for further research. Ferrari (2015) described narrative reviews as a dynamic process that remains the foundation of clinical literature.
Literature search method
The following computerised databases were accessed to enable data collection for a search period between 2006 and 2016: CINAHL Complete, Biomedical Reference Collection: Comprehensive, and MEDLINE. A 10-year period was chosen to ensure the literature included was up to date and relevant. The Cochrane database and Centre for Reviews and Dissemination did not identify any studies relevant to this review. A search to identify unpublished studies was undertaken by scanning the Index of Theses at Queen's University Belfast, with no relevant studies identified. Bibliography and reference lists were reviewed for missing studies, and none were identified.
The key words used (plus variations in spellings etc) were: ‘Simulation’, ‘Simulation-based’, ‘Simulation training’, ‘Multidisciplinary’, ‘Multiprofessional’, ‘Interprofessional’, ‘Airway management’, ‘Airway emergency’, ‘Difficult airway management’, ‘Difficult airway’, ‘Can't Intubate Can't Ventilate’, ‘Can't Intubate Can't Oxygenate’. Key words were grouped into three linked subcategories. Group 1 terms focused on simulation, group 2 terms on interprofessional and multidisciplinary and group 3 terms concentrated on airway management. The subcategories were first combined using the Boolean logic term ‘OR’ before being put together with ‘AND’ to obtain the final number for the review. Language restrictions were applied to this review and only papers published in English were included.
Inclusion/exclusion criteria
Types of studies
This review included studies pertaining to interprofessional simulation training for difficult airway management in the acute environments in both adult and paediatric populations. All methods of study design such as quantitative, qualitative and mixed methods were included in this review. Pilot studies with significant population size and power of outcomes were also considered.
Types of participants
Studies were included if they involved more than one health professional discipline. The review focused on interprofessional simulation training for post-qualification healthcare staff. Therefore, studies solely based on undergraduate students were excluded.
Types of interventions
Studies that carried out high-fidelity interprofessional simulation training for airway emergencies were included. Those studies that developed and evaluated their own interprofessional and simulation courses were also included in the review, as well as studies that collected data to analyse the benefits of simulation training.
Types of outcome measures
Studies that explored the effects of simulation training were included. The outcome measures specifically relevant for this review were those that evaluated performance, both technical and non-technical, ie teamwork, communication, participant confidence and those relating to patient outcomes, ie airway complications and intubation success rates. Outcomes that evaluated interprofessional simulation training using performance scores and participant survey evaluation were included.
Synthesis
No literature reviews were used within this research. Therefore, there were no results resynthesised, and authenticity was maintained. The included papers from the systematic search (Table 1) were analysed using a narrative synthesis approach, following PRISMA guidelines (Moher et al, 2009). The synthesis of the studies was designed to address the key learning outcomes of interprofessional simulation training in airway management, which includes performance, technical and non-technical skills, and patient outcomes. These key learning outcomes were used to provide the narrative structure and format for this article.
| Author(s), year, research design | Study aims |
|---|---|
|
Falcone et al (2008). Cincinnati, USA. |
To evaluate the effectiveness of a multidisciplinary trauma training programme on team performance for the first year of its implementation |
|
Figueroa et al (2013). Tennessee, USA. |
To determine if a multidisciplinary simulation-based team training results in improvements in teamwork, confidence, and communication among participants during paediatric post-cardiac surgery emergencies in a paediatric cardiovascular intensive care unit |
|
Kane et al (2006). Pennsylvania, USA. |
To evaluate implementation of standardised airway carts; development of an algorithm and training course to include manikin-based simulation; complications of intubation and rescue techniques identified from the development and implementation of a performance improvement airway tracking form |
|
Mark et al (2015). Baltimore, USA. |
To describe the development and implementation of the Difficult Airway Response Team (DART) programme. To summarise the characteristics of patients managed by the team in the first five years of operation |
|
Mehta et al (2013). London, UK. |
To devise and assess a multidisciplinary simulated course in training junior doctors for possible difficult airway scenarios |
|
Nishisaki et al (2010). Philadelphia, USA. |
To determine if just-in-time multidisciplinary simulation training refreshing intubation skills would improve resident's skills, as determined by first-attempt success rate and overall success rate in real intubations, without increasing tracheal intubation-associated events |
|
Nishisaki et al (2011). Philadelphia, USA. |
To evaluate the feasibility of implementing a newly developed simulation task-based scoring tool to evaluate the team performance during real tracheal intubations in a paediatric intensive care unit |
|
Nicksa et al (2015). San Francisco, USA. |
To explore whether high-fidelity simulations of high-risk clinical scenarios made a difference in junior residents' procedural and non-technical skills |
Findings
A total of 14 studies were extracted from the search, four of which were removed because they were duplicates of those already found. Two studies were removed because one, Nishisaki et al (2012), solely depicted the development of an instrument to measure participants' performance in simulation training and did not look at the outcomes of the interprofessional simulation itself. The second study by Joffe et al (2012) was removed because it did not pertain to interprofessional training and represented critical care medical staff only.
Eight studies were included in the final review (Figure 1). All studies utilised a quantitative methodology and ranged from 2006 to 2015, with seven coming from the USA and one from the UK. Half the studies pertained to the paediatric population and included the specialties of trauma, paediatric intensive care, and paediatric cardiac surgical intensive care. A pilot study was included in this review because of the significant population size and power of outcomes found.
The outcome measures for this narrative literature review were diverse regarding who, how and when outcomes were assessed. However, the studies were, in many ways, trying to explore performance using interprofessional simulation as a teaching method. Hence, it is difficult to segregate outcome measures because they are significantly intertwined. Performance is often subjective without a structured tool of measurement. Two studies measured the incidence of adverse events or airway management complications as performance measures from educational strategies, pertaining to the measurement of technical performance in the carrying out of tasks (Kane et al, 2006; Nishisaki et al, 2010). Five studies (Falcone et al, 2008; Nishisaki et al, 2011; Mehta et al, 2013; Figueroa et al, 2013; Nicksa et al, 2015) used validated tools (Gaba et al, 2001; Holcomb et al, 2002; Clancy 2007; Mishra et al, 2009) to assess performance; these were either modified or else the tool used was developed and validated by the authors (Nishisaki et al, 2012). Two of the studies used questionnaires to evaluate simulation as a teaching method (Mehta et al, 2013) and perception of increased non-technical skills (Figueroa et al, 2013) and confidence (Figueroa et al, 2013; Mehta et al, 2013). Only one study within this review explored overall team performance using a validated tool (Nishisaki et al, 2011), comprising both technical and non-technical skills domains (Table 1).
Discussion
This literature review highlights a deficit in empirical evidence of interprofessional simulation education in airway management. Simulation as a topic includes a broad scope of educational practice and exists within a wide variety of contexts. The variations lie within educational contexts, learner groups, and inconsistencies within the modes of simulation. All the studies within this review used immersive scenario-based simulation using high-fidelity manikins. Four key concepts emerged from the literature:
Debriefing
Debriefing is a theme that emerged from the primary literature review and even though it was not an element of simulation education that was under review, its position within this educational strategy was imperative (Falcone et al, 2008; Nishisaki et al, 2011; Figueroa et al, 2013; Johnston et al, 2018).
Seven of the eight studies discussed or referred to debriefing as an element of the simulation process, with Falcone et al, (2008), Mehta et al (2013) and Nicksa et al (2015) dedicating approximately 60% of time to the process. Falcone et al (2008); Nishisaki et al (2010), Nishisaki et al (2011) and Nicksa et al (2015) used videotaped simulation sessions as a debriefing facilitation modality to re-emphasise the importance of team communication, performance and relevant core principles for the management of an airway emergency. Falcone et al (2008), Nishisaki et al (2010), Mehta et al (2013) and Mark et al (2015) stated that a structured debriefing process was undertaken but failed to explain how the structure or process had been carried out.
Nishisaki et al (2011) stated that the simulation debriefing process was guided by the performance scale, illustrating a directed process. Figueroa et al (2013) described the goals of their debriefing process as an exploration of teamwork, communication, and efficacy during clinical scenarios. Gauging the familiarity of newly introduced algorithms, discussing emergency medical management and highlighting errors made was essential to this process (Figueroa et al, 2013). Both Figueroa et al (2013) and Mark et al (2015) found that debriefing had become a regular part of practice after every significant event and shift ‘huddles’ were encouraged in routine daily practice. Mehta et al (2013) discussed the course structure, in that both the scenario and debriefing were a lengthier process than the first simulation scenario and debriefing of the day. Mark et al (2015) failed to give any information in relation to debriefing; however, they supported Figueroa et al (2013) who strongly recommended a routine and effective debriefing process after real patient events.
Reflection
Nicksa et al (2015) illustrated the importance of participants' reflection within the feedback and debriefing process, dedicating the first 10 minutes of their debriefing process to this and, subsequently, facilitating discussion through which areas for further development needed to be highlighted. Both Hunt et al (2007) and Rudolph et al (2007) have strongly recommended continued reflective practice and identified this as crucial to experiential learning. A participant's ability to reflect on their performance gives rise to in-depth analysis and aids future behaviour development (Rudolph et al, 2008; Johnston et al, 2018). Reed (2015) has stipulated that it is through the reflective process after debriefing that the true lessons are learnt. Through feedback and reflection participants can take on board comments and recommendations to improve their future performance.
Feedback and debriefing are vital to the learning process in simulated practice (Shinnick et al, 2011; Hubert et al, 2014; Figueroa et al, 2013; Reed, 2015). Salas et al (2008) discussed feedback and debriefing as a core principle of teamwork education and stated that behaviour-based analysis is imperative to aid future practice improvements. Rudolph et al's (2008) formative assessment model for post-simulation debriefing outlined several important points to keep in mind when carrying out debriefing, such as having specific, predetermined learning objectives.
Both Nishisaki et al (2011) and Figueroa et al (2013) used their performance assessment tools as tools for debriefing to assist with performance analysis, and this was carried out in Figueroa et al's (2013) study by trained physicians and nurse facilitators. Shinnick et al's (2011) study stated that debriefing is central to the acquisition of knowledge in the simulation process and thus warrants instructors to be mindful of this, ensuring the use of effective techniques and that sufficient time is provided.
Reed (2015) found that extensive literature exists that discusses the benefits of undertaking debriefing in simulation, yet few studies analytically evaluate the best method of debriefing. Waznonis (2014) called for a further look into debriefing to raise the profile of the importance of obtaining an effective, evidence-based method to assist those educators within practice. Post-event debriefs are vital to the improvement and advancement of team performance both in simulated and clinical practice and Murphy et al (2019) illustrate that the challenges faced in clinical practice often differ from those met during simulation training.
Measures of assessment and evaluation
The assessment and evaluation strategies for any educational approach are vital to its success (Ziv et al, 2007; Carlson et al, 2009). Crossingham et al (2012) suggested that many challenges and difficulties lie in the development of performance assessment tools in anaesthetic practice. Obstacles lie in the perceptions and subjectivity of the instructors with regards to their ideas of high-quality performance. The study (Crossingham et al, 2012) demonstrated the notion that inter-rater reliability in scoring methods do not necessarily translate as well to real patient-care situations as they may do in a simulated environment. This therefore raises questions about Nishisaki et al's (2011) study, whereby inter-rater reliability was calculated for two raters in the simulated environment only before observing real clinical performance. This ultimately questions the ability of the tools used to measure performance in simulation practice to be transferable to measure performance in the clinical setting (Nishisaki et al, 2010). In Nicksa et al's (2015) study, medical staff were the only professional group being assessed. Gillman et al (2016) suggested this approach was problematic because all participants' educational needs should be addressed in effective multidisciplinary team training.
Liaw et al's (2012) randomised controlled trial identified the thought-provoking discovery that no correlation exists between reported self-confidence and knowledge acquisition and actual increased clinical performance. This brings into question what exactly self-reporting participant data represent within surveys and questionnaires. Kirkpatrick's Four Level Training Evaluation Model (Munshi et al, 2015; Johnston et al, 2018) highlighted the importance of evaluating the educational impact of simulation training and its ability to transfer skills and behaviours learnt through simulation into clinical practice.
Nishisaki et al's (2011) study emphasised the necessity for the inclusion of both technical skills and non-technical skills to be assessed in the aim of enhancing overall clinical performance. Furthermore, Nishisaki et al (2012) stressed the importance that both individual and team technical and non-technical skills play in the effective airway management of a patient. Additionally, Hubert et al's (2014) study looked at third-year anaesthetists' compliance with a difficult airway algorithm with the post-test occurring by randomisation at 3, 6, or 12 months post-intervention. The study found 100% compliance with airway management guidelines post-test compared with 63% pre-test. This study showed no statistical differences in scores in the 3, 6, or 12 months post-test, which highlighted that it is important when discussing education to consider the length of time between courses that is necessary for the retention and maintenance of skills. The decline in skills, particularly those not used daily (difficult airway or surgical cricothyroidotomy), should be assessed when considering the frequency of simulated education. This reinforces the importance of devising a programme of sufficient length, quality and appropriate repetitions to ensure knowledge and skills, both technical and non-technical, are gained and maintained.
Non-technical skills and patient safety
Murphy et al (2016) stressed that the complexity of modern-day health care largely depends on effective multidisciplinary teamwork. Like most of the studies in this review, Rosen et al (2008) and Hsu et al (2015) strongly recommended simulation-based team training to enhance teamwork skills, effective communication skills and ensure effective learning (Nishisaki et al, 2010; Figueroa et al, 2013; Armenia et al, 2018; Jensen et al, 2019; Murphy et al, 2019). Difficult airway scenarios require high-level collaboration and teamwork to effectively manage such dynamic and unpredictable patient situations (Figueroa et al, 2013; Murphy et al, 2016). Falcone et al (2008) referred to the aviation profession in highlighting that clear and efficient team functioning is imperative in the effort to reduce errors and increase safety in a high-paced, stressful working environment. Salas et al's (2008) review brought to light eight key elements of team work education, which centred on ensuring content relevance for participants (echoed by Shapiro et al (2008) and Nishisaki et al (2010)) and to increase the chance of the transferability of new skills to everyday practice.
Communication
Figueroa et al (2013) and Mehta et al (2013) found that simulation had a positive effect on team members' mutual respect and the appreciation given to their roles, which in turn enhanced team communication. However, Raemer et al (2016) showed the ability to speak up comes from intricate relationships between the individual factors of those involved, ie personality, the organisational culture, fear of repercussions, perceived disloyalty in the hierarchical structure, and the suspected ineffectiveness in speaking up because of being ignored. They concluded that organisational culture and effective communication require more than an educational strategy, calling for a change in organisational culture to facilitate its development as the norm in practice (Kane et al, 2006; Raemer et al, 2016). Further, Murphy et al (2019) identified the importance of psychological safety in order to speak up within a team to identify concerns or clarify information to ensure successful teamwork, although they stated that this remains a challenge to team members due to fear of conflict or appearing incompetent to their peers. The first author (MC) believes that education, through interprofessional simulation, is a good place to start to effectively make changes to organisational culture and team behaviours.
Culture
The hierarchical culture and lack of free moving communication channels between the medical and nursing staff were contributing factors in the case of Elaine Bromiley, who died following difficulties encountered in managing her airway during a routine operation (McClelland and Smith, 2016) and detrimental to interprofessional decision-making (Murphy et al, 2016). Both Kane et al (2006) and Falcone et al (2008) highlight the importance of instilling a culture of change to engage all members of the team in striving for improvements, through increased openness and communication. The Francis (2013) report is a perfect example of the huge impact organisational culture has on the standards of care and the workings of an institution. Further emphasis on the Nursing and Midwifery Council's (NMC) (2018)Code and empowerment of staff in displaying such vital patient safety behaviours are imperative to enhance practices,. The creation of a positive change culture, founded upon patient-centred standards of care, cannot be underestimated in the effort to make continuous improvements to practice. Further efforts must be carried out to promote non-technical skills and foster an environment where staff are able to speak up, thus ensuring better care and increased safety for patients.
Human factors and teamwork
Cooper et al's (1978) qualitative research found that human factors played a huge part in errors in anaesthesia. The results were deemed so essential to the discipline that they were re-published 24 years later (Cooper et al, 2002). This 1978 study clearly illustrated the advantage of using critical incident analysis through qualitative interviews as an effective way to explore human errors, which were present in 82% of critical incidents examined. Inadequate information, distractions, and unfamiliarity with equipment and processes were highlighted as major causes of anaesthetic errors. Nishisaki et al (2010) suggested that improved multidisciplinary performance may have played a vital role in the non-occurrence of intubation events, clearly highlighting the importance of competent and effective teamwork in such high-risk circumstances. This is reiterated by both Falcone et al (2008) and Figueroa et al (2013) who emphasised the necessity of effective coordination, communication and a shared mental model in optimising patient safety.
Stiegler et al (2012) observed anaesthetic emergency simulated scenarios for evidence of errors in non-technical skills and found failures in the ability to consider other possibilities in 79.5% of simulation scenarios, lack of situational awareness and task fixation (61.5%) and the lack of situational awareness to call for senior help (53.8%). We already know from the literature (Cook et al, 2011a; 2011b) that high instance of failures in human factors exists in our healthcare practices. The high occurrence of such failures found in simulated practice raises the question of the extent to which human factor failures are present in everyday anaesthetic patient care and the consequences these have for patient safety.
Flin et al (2013) continued the work from NAP4 (Cook et al, 2011a; 2011b): 12 anaesthetists, who reported to the NAP4, were interviewed to identify how human factors contributed to the reported events. From these interviews, a high incidence of poor situational awareness, time and staff pressures and personal pressures, ie stress and hunger, were noted. This study reiterated the failures identified by Stiegler et al (2012) and illustrated that all events demonstrated deficiencies in human factors. This is in stark contrast to the NAP4 findings (Cook et al, 2011a; 2011b), which may have underestimated the part human factors play in major airway complications. Christian et al's (2006) prospective observational study looked at factors within the theatre setting that have the potential to influence or affect the safety of the patient. This research, along with that of Murphy et al (2019), exposed communication breakdowns and the loss of information in transfer to be the most concerning for patient safety, which reflects the need for further non-technical skills training in practice.
Hunt et al (2007) and Murphy et al (2019) outlined the features of enhanced team functionality, which include well-established communication strategies (reiterated by Christian et al (2006)), vital leadership and followership abilities and the ability to adapt to a dynamic environment. Mehta et al (2013), like Hunt et al (2007) and Murphy et al (2019), stressed the importance of a shared vision between all members of a highly skilled interprofessional team. In the first author's (MC) experience, it is evident that high-quality leadership is an essential non-technical skills that is central to the quality of the functionality of the team. Hunt et al (2007) made the crucial point that, for leadership to be effective, information should be openly transferable between the leader and team members, which requires an environment in which members of the team feel able to speak up, as discussed by Raemer et al (2016), ultimately enhancing patient safety. Mehta et al (2013) emphasise that, like technical skills, non-technical skills can deteriorate over time. Therefore, regular simulation training that focuses on enhancing participants' non-technical skills regarding leadership, teamwork, situational awareness, and communication, allows for superior crisis training. Greenland et al (2011) and Cook and MacDougall-Davis (2012) emphasised that to ensure crisis airway management is effective training should be regular, up-to-date and applicable.
Patient outcomes
In the first author's experience (MC), change is often initiated only after a critical event has occurred. Figueroa et al (2013) effectively demonstrated that multidisciplinary teams are often not adequately prepared for high-acuity, time-critical circumstances in practice. All the studies included in this review gave strong rationales for conducting their research: these related to poor patient outcomes, adverse incidents and frequently observed suboptimal emergency care, all of which had been encountered in practice. In addition, both Kane et al (2006) and Mark et al (2015) identified several problems that provided the rationale for carrying out their studies. These problems included ineffective communication strategies, lack of training, unclear roles within the multidisciplinary team during events and an outdated paging system.
Equipment and expertise
Unreliable access to difficult airway equipment, variable access to clinicians trained or skilled in performing airway procedures, and lack of familiarity with specialised airway equipment were also serious deficits highlighted (Kane et al, 2006). All staff present in the management of a patient's airway should be familiar with and competent to use a full range of airway devices (Kane et al, 2006; Mellanby et al, 2014). Mehta et al (2015) provided a strong rationale for the development of the Difficult Airway Response Team (DART) course, which included three airway-related fatalities encountered in the 2 years prior to the course development. This study stated that no airway-related fatalities were reported in the 2-year period during which the course was in progress.
Learning culture
Simulation team training has been shown to positively impact on patient outcomes through reduced complications, the reduction of time to surgical intervention (Dunning et al, 2009) and improved transfer times to definitive care (Murphy et al, 2019). Nishisaki et al (2010) and Nishisaki et al (2011) analysed complications of intubations and incidence of tracheal intubation-associated events (TIAE) as a performance measure of their simulation education. They concluded, however, that team simulation training was not effective in significantly improving technical skills in intubation success, although noted no increase in unwanted TIAEs. Both Murphy et al (2016) and Abir and Mhyre (2017) emphasised the value of reviewing adverse patient outcomes in order to instil a learning culture, identify patterns of systems failure and highlight areas for development in non-technical skills, including teamwork, communication and decision-making, factors highlighted by Mark et al (2015). Patient outcomes in emergency airway management situations are a good indicator of effective team practices, providing that enough information is collected to efficiently explore all aspects of the situation. Careful research planning is then required in the future to explore the links between interprofessional team training and improved patient outcomes effectively.
Limitations
Narrative reviews are often challenged due to their rigour and robustness when compared with systematic reviews. This review has followed the PRISMA guidelines to present the selected papers and applied double-blind peer review of papers identified to improve rigour in the design.
Conclusion
This review highlights the benefits of interprofessional simulation training as a method of teaching high-risk and infrequent clinical airway emergencies without exposing patients to risk (Nishisaki et al, 2010; Nishisaki et al, 2011; Mehta et al, 2013). The operating department environment is a highly complex, technology-enhanced area that requires effective collaboration to competently manage dynamic and unpredictable critical situations in practice (Cousley and Martin 2016; Murphy et al, 2016; Armenia et al, 2018). Falcone et al (2008) referred to the aviation profession and the use of crew resource management in highlighting that clear and efficient team functioning is imperative in the effort to reduce errors and increase patient safety in a high-paced and stressful working environment. Further research into how simulation education is assessed and the transferability of airway management and non-technical skills into clinical practice would give strength to this educational method to reduce errors and increase safety (Jensen et al, 2019).
Although the benefits of this training modality are apparent (Nishisaki et al, 2011; Figueroa et al, 2013; Mehta et al, 2013; Murphy et al, 2016; Murphy et al, 2019), there remains a distinct lack of empirical evidence and significant gaps in contemporary literature to validate its place in team training (Murphy et al, 2016; Jensen et al, 2019). Although Lioce et al (2015) outlined guidance for simulation design, further exploration into what simulation and debriefing approaches best encourage the acquisition and retention of knowledge and skills is required to achieve their full potential. Crosby (2011) and Frerk et al (2015) emphasised the importance of regular practised responses of emergency airway plans and algorithms to the reduction of errors and adverse patient outcomes. It is evident that teamwork, communication, and other non-technical skills are essential and highly valuable to collaborative patient care, and the available literature indicates that interprofessional simulation training is the most effective way to enhance team performance and maintain skills. Hubert et al (2014) strongly suggested that both technical and non-technical skills are transferable from simulated practice to real-life practices. Further investigations into the transferability of clinical skills have been recommended by several studies within this review (Falcone et al, 2008; Nishisaki et al, 2010; Nishisaki et al, 2011). Future studies that look at the transferability of airway management skills into clinical practice, the development of non-technical skills and the effects on patient outcomes are vital to the evolution of simulation education (Zoric and Savoldelli, 2015).
This narrative review demonstrated that perioperative practitioners need to become proactive in educational strategies to enable staff to develop and enhance skills in infrequently encountered situations such as the difficult airway. It is imperative that those on the frontline know what is expected of them when infrequent situations arise. A positive working environment and good multidisciplinary team communication are needed to gain the maximum benefit from simulation education.