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Neonatal
Neonatal Simulation
Neonatal Includes
Simulation
225+
Simulation A PRACTICAL GUIDE

full-color
images!
Editors: Lamia Soghier, MD, MEd, CHSE, FAAP, and

Beverley Robin, MD, MHPE, CHSE, FAAP A PRACTICAL GUIDE
D
eveloped by the leading experts in neonatal simulation, this innovative resource delivers
neonatal health care professionals and educators essential guidance on designing, developing,
and implementing simulation-based neonatal education programs.
The early chapters cover learning theory, fundamentals of scenario design, and simulation and the
Neonatal Resuscitation Program®. The later chapters cover specific applications of simulation in
A PRACTICAL GUIDE
neonatology and debriefing techniques.
This book guides the reader through scenario design, mannequins and task trainers, moulage,
simulation techniques, virtual simulations, mannequin adaptations needed to conduct specific
simulation procedures, debriefing methods, and more.
Step-by-step images guide the reader through how to adapt mannequins to simulate procedures and
how to replicate bodily fluids and conditions commonly encountered in newborns.
With 225+ color images, as well as plenty of helpful boxes and tables throughout, this book will be
useful to both novices and experts.
More than 30 chapters include
• In Situ Simulation
• Simulation and the Neonatal Resuscitation Program
• Mannequins and Task Trainers
• Boot Camps
• Debriefing in Simulation-Based Training in Neonatology
• Simulation Operations
Soghier • Robin
• And more...
For other neonatal resources, visit the American Academy of Pediatrics at shop.aap.org.
ISBN 978-1-61002-260-6
90000> EDITORS
Lamia Soghier, MD, MEd, CHSE, FAAP • Beverley Robin, MD, MHPE, CHSE, FAAP
9 781610 022606
AAP
NEONATAL_SIMULATION_final_spread.indd 1 2/22/21 9:20 AM

Neonatal
Simulation A PRACTICAL GUIDE
EDITORS
Lamia Soghier, MD, MEd, CHSE, FAAP • Beverley Robin, MD, MHPE, CHSE, FAAP
NeoSim.indb 1 2/21/21 12:13 PM

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The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care.
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First edition published 2021.
Printed in the United States of America
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ISBN: 978-1-61002-260-6
eBook: 978-1-61002-261-3
Library of Congress Control Number: 2018942267

III
Editors
Lamia Soghier, MD, MEd, CHSE, FAAP Beverley Robin, MD, MHPE, CHSE, FAAP
Associate Professor of Pediatrics Assistant Professor, Pediatrics
The George Washington University School of Medicine Director, Neonatal-Perinatal Medicine Fellowship Program
Medical Director, Neonatal Intensive Care Unit Rush University Medical Center
Children’s National Health System Chicago, IL
Washington, DC
Contributors
Anne Ades, MD, MSEd Marc Auerbach, MD, MSc
Professor of Clinical Pediatrics Associate Professor of Pediatrics and Emergency Medicine
Perelman School of Medicine at the University of Yale University School of Medicine
Pennsylvania New Haven, CT
Attending Neonatologist Chapter 7. Simulation for Infant Lumbar Puncture Training
The Children’s Hospital of Philadelphia Alana Barbato, MD
Philadelphia, PA Assistant Professor of Clinical Pediatrics
Chapter 11. Extracorporeal Membrane Oxygenation Division of Neonatal-Perinatal Medicine
Simulation Indiana University School of Medicine
Chapter 14. Boot Camps Indianapolis, IN
Catherine Allan, MD, FAAP Chapter 9. Simulating Neonatal Pericardial Effusion and
Medical Director, Cardiac Intensive Care Unit Cardiac Tamponade
Associate Program Director, Simulator Program G. Jesse Bender, MD
Boston Children’s Hospital NICU Medical Director
Boston, MA Mission Health System
Chapter 11. Extracorporeal Membrane Oxygenation Asheville, NC
Simulation Chapter 19. In Situ Simulations for Testing New Health Care
Christine Arnold, MS, RNC, CHSE Environments
Educator for Pursuing Excellence Angela D. Blood, MPH, MBA, CHSE-A
University of Rochester Medical Center Director, Curricular Resources
Rochester, NY Association of American Medical Colleges (AAMC)
Chapter 27. The Difficult Debriefing Washington, DC
Jennifer Arnold, MD, MSc, FAAP Chapter 1. Applications of Learning Theory in Simulation
Medical Director, Center for Medical Simulation and Renee D. Boss, MD, MHS
Innovative Education Associate Professor, Neonatology and Palliative Care
Johns Hopkins All Children’s Hospital Johns Hopkins University School of Medicine
St Petersburg, FL Baltimore, MD
Chapter 13. Simulation-Based Education for Parents and Other Chapter 20. Communication Skills in Neonatal Simulation
Home Caregivers of Infants With Technology Dependence
Steven Brediger, RRT-NPS
Michael-Andrew Assaad, MD, FRCPC, FAAP ECMO Educator
Associate Professor of Pediatrics Boston Children’s Hospital
Division of Neonatology Boston, MA
University of Montreal Chapter 11. Extracorporeal Membrane Oxygenation
Montreal, Quebec, Canada Simulation
Chapter 5. Simulation for Neonatal Airway Management
Christie J. Bruno, DO
Chapter 25. Blended-Method Debriefing With the PEARLS
Associate Professor of Pediatrics
Debriefing Framework
Neonatal-Perinatal Medicine Fellowship Training Program
Chapter 26. Co-debriefing in Neonatal Simulation
Director
Appendix B
Yale New Haven Children’s Hospital
New Haven, CT
Chapter 10. Neonatal Exchange Transfusion
Chapter 14. Boot Camps

IV CONTRIBUTORS
Melanie Burke, MRT (R) Christopher E. Colby, MD

Simulation Technician, Simulation Lab Professor of Pediatrics
Health Sciences North Mayo Clinic
Sudbury, Ontario, Canada Rochester, MN
Chapter 22. Moulage: The Special Effects Chapter 17. Telesimulation for Neonatal Resuscitation
Sabrina M. Butteris, MD Education and Training
Associate Professor, Department of Pediatrics Rita Dadiz, DO, CHSE, FAAP
University of Wisconsin School of Medicine and Associate Director of Pediatrics
Public Health Director, Neonatal Innovation and Safety Simulation
American Family Children’s Hospital Program
Madison, WI Division of Neonatology
Chapter 15. Simulation in Neonatal Global Health University of Rochester Medical Center
Bobbi J. Byrne, MD, FAAP Rochester, NY
Professor of Clinical Pediatrics Chapter 19. In Situ Simulations for Testing New Health Care
Division of Neonatal-Perinatal Medicine Environments
Indiana University School of Medicine Chapter 27. The Difficult Debriefing
Indianapolis, IN Maria Carmen G. Diaz, MD, FACEP, FAAP
Chapter 8. Neonatal Thoracentesis and Chest Tube Placement Clinical Professor of Pediatrics and Emergency Medicine
Simulation Sidney Kimmel Medical College of Thomas Jefferson
Chapter 9. Simulating Neonatal Pericardial Effusion and University
Cardiac Tamponade Philadelphia, PA
Chapter 18. In Situ Simulation Medical Director of Simulation
Appendix C Nemours Institute for Clinical Excellence
Appendix D Attending Physician, Division of Emergency Medicine
Douglas M. Campbell, MD, FRCPC Nemours/Alfred I. duPont Hospital for Children
Director of NICU, Medical Director of Allan Waters Family Wilmington, DE
Simulation Centre Program Chapter 13. Simulation-Based Education for Parents and Other
Department of Pediatrics Home Caregivers of Infants With Technology Dependence
University of Toronto Archana Dhar, MD
St Michael’s Hospital, Unity Health Toronto Associate Professor of Pediatrics
Toronto, Ontario, Canada UT Southwestern Medical School
Chapter 32. History of Neonatal Simulation Medical Director of Transport
Todd Chang, MD, MAcM Division of Pediatric Critical Care
Associate Director / Research Director, CHLA Las Madrinas Children’s Health Medical Center
Simulation Center Dallas, TX
Associate Fellowship Director, Division of Emergency Chapter 12. Extracorporeal Life Support Organization Training
Medicine and Education
Director of Research & Scholarship, Division of Emergency Walter Eppich, MD, PhD, FSSH
Medicine Professor and Chair of Simulation Education and Research
Vice Chair, Institutional Review Board Royal College of Surgeons of Ireland
Children’s Hospital Los Angeles Dublin, Ireland
Associate Professor of Pediatrics/Medical Education Chapter 25. Blended-Method Debriefing With the PEARLS
Keck School of Medicine Debriefing Framework
University of Southern California Chapter 26. Co-debriefing in Neonatal Simulation
Los Angeles, CA Jennifer L. Fang, MD, MS, FAAP
Chapter 30. Simulation Research Networks Assistant Professor of Pediatrics
Adam Cheng, MD Medical Director, Teleneonatology
Professor, Departments of Paediatrics and Emergency Division of Neonatal Medicine
Medicine Mayo Clinic
University of Calgary Rochester, MN
Calgary, Alberta, Canada Chapter 17. Telesimulation for Neonatal Resuscitation
Chapter 25. Blended-Method Debriefing With the PEARLS Education and Training
Debriefing Framework
Chapter 26. Co-debriefing in Neonatal Simulation

CONTRIBUTORS V
Heather M. French, MD, MSEd Elizabeth A. Hunt, MD, MPH, PhD

Associate Professor of Clinical Pediatrics Associate Professor
Perelman School of Medicine at the University of Department of Anesthesiology and Critical Care Medicine
Pennsylvania Johns Hopkins University School of Medicine
Philadelphia, PA Director, Johns Hopkins Medicine Simulation Center
Chapter 23. Simulation Training for Effective Resuscitation Baltimore, MD
Leadership Chapter 28. Rapid-Cycle Deliberate Practice
Appendix F Sarah Isaac, MEd, BHSc, BA
Janene H. Fuerch, MD Simulation Technician
Clinical Assistant Professor of Pediatrics Health Sciences North
Division of Neonatal and Developmental Medicine Sudbury, Ontario, Canada
Stanford University Chapter 22. Moulage: The Special Effects
Palo Alto, CA Priti Jani, MD, MPH
Chapter 31. Simulation-Based Research in Neonatology Assistant Professor of Pediatrics
Kristen M. Glass, MD Section of Critical Care Medicine
Associate Professor of Pediatrics The University of Chicago, Comer Children’s Hospital
Division of Neonatal-Perinatal Medicine Chicago, IL
Penn State Health Milton S. Hershey Medical Center Chapter 1. Applications of Learning Theory in Simulation
Penn State College of Medicine Lindsay Johnston, MD, MEd, CHSE, FAAP
Hershey, PA Associate Professor of Pediatrics
Chapter 10. Neonatal Exchange Transfusion Division of Neonatal-Perinatal Medicine
Megan M. Gray, MD Yale School of Medicine
Assistant Professor of Pediatrics New Haven, CT
Division of Neonatology Chapter 11. Extracorporeal Membrane Oxygenation
University of Washington Simulation
Seattle, WA Chapter 14. Boot Camps
Chapter 4. Mannequins and Task Trainers David O. Kessler, MD, MSc
Chapter 6. Umbilical Catheter Placement Vice Chair of Innovation for the Department of Emergency
Arika G. Gupta, MD Medicine
Assistant Professor of Pediatrics Associate Professor
Department of Pediatrics Columbia University Vagelos College of Physicians and
Division of Neonatology Surgeons
Northwestern University Feinberg School of Medicine New York, NY
Ann & Robert H. Lurie Children’s Hospital of Chicago Chapter 7. Simulation for Infant Lumbar Puncture Training
Chicago, IL Suzanne Lortie-Carlyle
Chapter 25. Blended-Method Debriefing With the PEARLS Manager, Simulation Lab
Debriefing Framework Health Sciences North / Horizon Santé-Nord
Chapter 26. Co-debriefing in Neonatal Simulation Sudbury, Ontario, Canada
Louis P. Halamek, MD, FAAP Chapter 22. Moulage: The Special Effects
Professor Lisa Mayer, RN, BSN
Division of Neonatal and Developmental Medicine Simulation Educator
Department of Pediatrics Riley Maternal and Newborn Health at Indiana University
Stanford University Health
Founding Director, Center for Advanced Pediatric and Indianapolis, IN
Perinatal Education (CAPE) Chapter 8. Neonatal Thoracentesis and Chest Tube Placement
Director of Neonatal Resuscitation, Attending Neonatologist Simulation
Lucile Packard Children’s Hospital
Tyler Montroy, A-EMCA, PCP
Palo Alto, CA
Simulation Technician
Chapter 3. Simulation and the Neonatal Resuscitation Program
Health Sciences North
Chapter 24. Debriefing in Simulation-Based Training in
Sudbury, Ontario, Canada
Neonatology: An Outcomes-Based Approach
Chapter 22. Moulage: The Special Effects
Chapter 31. Simulation-Based Research in Neonatology

VI CONTRIBUTORS
Ahmed Moussa, MD, MMed, FRCPC, FAAP Beverley Robin, MD, MHPE, CHSE, FAAP
Director, Center for Applied Health Sciences Education Assistant Professor, Pediatrics
(CPASS) Director, Neonatal-Perinatal Medicine Fellowship Program
University of Montreal Rush University Medical Center
Associate Professor, Departement of Pediatrics Chicago, IL
University of Montreal Chapter 2. Scenario Design
Neonatologist, CHU Sainte-Justine Chapter 19. In Situ Simulations for Testing New Health Care
Montreal, Quebec, Canada Environments
Chapter 5. Simulation for Neonatal Airway Management David L. Rodgers, EdD, EMT-P, NRP, FAHA
Appendix B Manager, Interprofessional Learning and Simulation
Allyson Norton, RN Penn State Health Milton S. Hershey Medical Center
Simulation Technician Hershey, PA
Health Sciences North Chapter 29. Simulation Operations
Sudbury, Ontario, Canada Taylor Sawyer, DO, MEd, CHSE-A
Chapter 22. Moulage: The Special Effects Director of Medical Simulation
Mark T. Ogino, MD, FAAP Associate Division Head for Education
Chief Partnership Officer Division of Neonatology
Neonatology Chief, Nemours Delaware Valley Associate Professor of Pediatrics
Nemours/Alfred I. duPont Hospital for Children Department of Pediatrics
Wilmington, DE Division of Neonatology
Clinical Professor of Pediatrics University of Washington School of Medicine, Seattle
Sidney Kimmel Medical College of Thomas Jefferson Children’s Hospital
University Seattle, WA
Philadelphia, PA Chapter 4. Mannequins and Task Trainers
Chapter 12. Extracorporeal Life Support Organization Training Chapter 6. Umbilical Catheter Placement
and Education Joo Lee Song, MD
Julie S. Perretta, MSEd, RRT-NPS, CHSE-A Assistant Professor of Clinical Pediatrics
Assistant Professor Division of Emergency and Transport Medicine
Anesthesiology and Critical Care Medicine Children’s Hospital Los Angeles
Johns Hopkins University School of Medicine Department of Pediatrics
Director of Education and Innovation Keck School of Medicine
Johns Hopkins Medicine Simulation Center University of Southern California
Baltimore, MD Los Angeles, CA
Chapter 2. Scenario Design Chapter 30. Simulation Research Networks
Chapter 28. Rapid-Cycle Deliberate Practice Theophil A. Stokes, MD
Appendix A Associate Professor of Pediatrics
Appendix G Uniformed Services University of the Health Sciences
Michael B. Pitt, MD, FAAP Bethesda, MD
Associate Professor of Pediatrics Chapter 20. Communication Skills in Neonatal Simulation
Division of Hospital Pediatrics Lillian Su, MD
University of Minnesota Clinical Associate Professor of Pediatrics
Minneapolis, MN Stanford University School of Medicine
Chapter 15. Simulation in Neonatal Global Health Medical Director of Simulation, Heart Center
Michael Roach, BScN, MN (c) Lucile Packard Children’s Hospital
Simulation Educator Palo Alto, CA
Health Sciences North Chapter 11. Extracorporeal Membrane Oxygenation
Sudbury, Ontario, Canada Simulation
Chapter 22. Moulage: The Special Effects Patricia E. Thomas, PhD, RN, NNP-BC, CNE
Shannon Poling, MEHP, RRT-NPS, CHSE Clinical Associate Professor
Simulation Educator College of Nursing
Johns Hopkins Medicine Simulation Center University of Texas at Arlington
Johns Hopkins University Arlington, TX
Baltimore, MD Chapter 16. Virtual Simulation
Chapter 28. Rapid-Cycle Deliberate Practice

CONTRIBUTORS VII
Rachel A. Umoren, MB, BCh, MS, FAAP Alexander Wood, BScN

Associate Professor of Pediatrics Simulation Technician, Simulation Lab
Division of Neonatology Health Sciences North
Department of Pediatrics Sudbury, Ontario, Canada
University of Washington Chapter 22. Moulage: The Special Effects
Seattle, WA Nicole K. Yamada, MD, MS, FAAP
Chapter 4. Mannequins and Task Trainers Clinical Associate Professor
Chapter 6. Umbilical Catheter Placement Division of Neonatal and Developmental Medicine
Chapter 16. Virtual Simulation Stanford University School of Medicine
Joanne Weinschreider, MS, RN Associate Director, Center for Advanced Pediatric and
Director of Simulation and Learning Resources Perinatal Education (CAPE)
School of Nursing Attending Neonatologist
Saint John Fisher College Medical Director, Neonatal Critical Care Transport Team
Rochester, NY Lucile Packard Children’s Hospital
Chapter 27. The Difficult Debriefing Palo Alto, CA
Elizabeth A. Wetzel, MD, MS Chapter 3. Simulation and the Neonatal Resuscitation Program
Assistant Professor of Clinical Pediatrics Marsha E. Yelen, MSN, RN
Division of Neonatal-Perinatal Medicine Director of the Standardized Patient Program
Indiana University School of Medicine Rush University Clinical Skills and Simulation Center
Indianapolis, IN Chicago, IL
Chapter 18. In Situ Simulation Chapter 21. Standardized Patients
Appendix C Appendix E
Appendix D

To Dr Halamek, founder of neonatal simulation, and to
all neonatal health care professionals and the patients
who benefit from their care

NeoSim.indb 10 2/21/21 12:13 PM
XI
Contents
Preface ............................................................................................................................................ XIII
1. Applications of Learning Theory in Simulation ........................................................................1
Priti Jani, MD, MPH, and Angela D. Blood, MPH, MBA, CHSE-A
2. Scenario Design .........................................................................................................................17

Julie S. Perretta, MSEd, RRT-NPS, CHSE-A, and Beverley Robin, MD, MHPE, CHSE, FAAP
3. Simulation and the Neonatal Resuscitation Program ............................................................33

Nicole K. Yamada, MD, MS, FAAP, and Louis P. Halamek, MD, FAAP
4. Mannequins and Task Trainers .................................................................................................45

Taylor Sawyer, DO, MEd, CHSE-A, FAAP; Megan M. Gray, MD; and Rachel A. Umoren, MB, BCh, MS, FAAP
5. Simulation for Neonatal Airway Management .......................................................................59

Ahmed Moussa, MD, MMEd, FRCPC, FAAP, and Michael-Andrew Assaad, MD, FRCPC, FAAP
6. Umbilical Catheter Placement..................................................................................................75

Taylor Sawyer, DO, MEd, CHSE-A, FAAP; Megan M. Gray, MD; and Rachel A. Umoren, MB, BCh, MS, FAAP
7. Simulation for Infant Lumbar Puncture Training ...................................................................85

David O. Kessler, MD, MSc, and Marc Auerbach, MD, MSc
8. Neonatal Thoracentesis and Chest Tube Placement Simulation ...........................................95

Lisa Mayer, RN, BSN, and Bobbi J. Byrne, MD, FAAP
9. Simulating Neonatal Pericardial Effusion and Cardiac Tamponade ...................................107

Alana Barbato, MD, and Bobbi J. Byrne, MD, FAAP
10. Neonatal Exchange Transfusion.............................................................................................121

Christie J. Bruno, DO, and Kristen M. Glass, MD
11. Extracorporeal Membrane Oxygenation Simulation ...........................................................127

Lindsay Johnston, MD, MEd, CHSE, FAAP; Anne Ades, MD, MSEd; Lillian Su, MD;
Steven Brediger, RRT-NPS; and Catherine Allan, MD, FAAP
12. Extracorporeal Life Support Organization Training and Education ...................................141

Archana Dhar, MD, and Mark T. Ogino, MD, FAAP
13. Simulation-Based Education for Parents and Other Home Caregivers of Infants
With Technology Dependence ...............................................................................................147
Jennifer Arnold, MD, MSc, FAAP, and Maria Carmen G. Diaz, MD, FACEP, FAAP
14. Boot Camps ..............................................................................................................................161

Anne Ades, MD, MSEd; Christie J. Bruno, DO; and Lindsay Johnston, MD, MEd, CHSE, FAAP
15. Simulation in Neonatal Global Health ...................................................................................181

Michael B. Pitt, MD, FAAP, and Sabrina M. Butteris, MD
16. Virtual Simulation ...................................................................................................................193

Rachel A. Umoren, MB, BCh, MS, FAAP, and Patricia E. Thomas, PhD, RN, NNP-BC, CNE
17. Telesimulation for Neonatal Resuscitation Education and Training ...................................209

Jennifer L. Fang, MD, MS, FAAP, and Christopher E. Colby, MD
18. In Situ Simulation ....................................................................................................................221

Elizabeth A. Wetzel, MD, MS, and Bobbi J. Byrne, MD, FAAP
NeoSim.indb 11 2/21/21 12:13 PM

XII CONTENTS
19. In Situ Simulations for Testing New Health Care Environments..........................................237

G. Jesse Bender, MD; Rita Dadiz, DO, CHSE, FAAP; and Beverley Robin, MD, MHPE, CHSE, FAAP
20. Communication Skills in Neonatal Simulation .....................................................................257
Theophil A. Stokes, MD, and Renee D. Boss, MD, MHS
21. Standardized Patients.............................................................................................................271

Marsha E. Yelen, MSN, RN
22. Moulage: The Special Effects ..................................................................................................287
Suzanne Lortie-Carlyle; Melanie Burke, MRT (R); Sarah Isaac, MEd, BHSc, BA; Tyler Montroy, A-EMCA,
PCP; Allyson Norton, RN; Michael Roach, BScN, MN (c); and Alexander Wood, BScN
23. Simulation Training for Effective Resuscitation Leadership ................................................313
Heather M. French, MD, MSEd
Introduction to Debriefing ...........................................................................................................329

24. Debriefing in Simulation-Based Training in Neonatology: An
Outcomes-Based Approach ..............................................................................................331
Louis P. Halamek, MD, FAAP
25. Blended-Method Debriefing With the PEARLS Debriefing Framework ........................345
Arika G. Gupta, MD; Michael-Andrew Assaad, MD, FRCPC, FAAP; Adam Cheng, MD; and
Walter Eppich, MD, PhD
26. Co-debriefing in Neonatal Simulation.............................................................................355
Michael-Andrew Assaad, MD, FRCPC, FAAP; Arika G. Gupta, MD; Walter Eppich, MD, PhD; and
Adam Cheng, MD
27. The Difficult Debriefing ....................................................................................................365
Christine Arnold, MS, RNC, CHSE; Joanne Weinschreider, MS, RN; and Rita Dadiz, DO, CHSE, FAAP
28. Rapid-Cycle Deliberate Practice .............................................................................................383
Julie S. Perretta, MSEd, RRT-NPS, CHSE-A; Shannon Poling, MEHP, RRT-NPS, CHSE; and
Elizabeth A. Hunt, MD, MPH, PhD
29. Simulation Operations ............................................................................................................397
David L. Rodgers, EdD, EMT-P, NRP, FAHA
30. Simulation Research Networks ..............................................................................................417
Joo Lee Song, MD, and Todd Chang, MD, MAcM
31. Simulation-Based Research in Neonatology.........................................................................425
Janene H. Fuerch, MD, and Louis P. Halamek, MD, FAAP
32. History of Neonatal Simulation..............................................................................................437
Douglas M. Campbell, MD, FRCPC
Appendix A.................................................................................................................................... 453
Appendix B .................................................................................................................................... 456
Appendix C .................................................................................................................................... 458
Appendix D ................................................................................................................................... 463
Appendix E .................................................................................................................................... 467
Appendix F .................................................................................................................................... 472
Appendix G ................................................................................................................................... 475
Index .............................................................................................................................................. 477
NeoSim.indb 12 2/21/21 12:13 PM

XIII
Preface
In 2000, Louis P. Halamek, MD, FAAP, proposed a new approach to teaching neonatal resuscitation that capital-
ized on existing teaching models and incorporated simulation, such as that used by the military, aerospace, and
other high-risk industries. Through “NeoSim”—“hands-on” neonatal resuscitation training and postsimulation
debriefing—Dr Halamek brought this new paradigm—simulation-based education—to the field of neonatology.
Now, 20 years later, simulation-based education is the mainstay of the Neonatal Resuscitation Program® that
teaches thousands of health care professionals in more than 130 countries.
Over the years, simulation has been applied to many other aspects of education in neonatology, including
procedural skills training, competency assessment, and teamwork and leadership training. In more recent years,
simulation in neonatology has further expanded to include testing of new and existing health care environments,
educating families on the care of neonates with medical complexities, analyzing new medical devices, and even
conducting virtual simulations.
The impetus for creating Neonatal Simulation: A Practical Guide was 2-fold. First, we recognized that while
there are a variety of published adult and pediatric simulation books, none exist for neonatology. Thus, we wanted
to fill this void. Second, we wanted to make the innovative work of the neonatal simulation community easily
accessible to health professions educators, simulationists, researchers, and any other groups who can benefit from
its content—to enhance learning, patient care, and, ultimately, patient outcomes. The beginning chapters cover
learning theory, fundamentals of scenario design, and simulation and the Neonatal Resuscitation Program. The
later chapters cover specific applications of simulation in neonatology, and debriefing techniques. Images and
appendixes are included, where appropriate, to augment chapters, and central points at the end of each chapter
summarize content and offer a quick reference.
The book is a culmination of many hours of work by a growing interdisciplinary community of neonatal sim-
ulation experts who have shared their insights, research, and experience with us. We thank them immensely for
their dedication to the field and their willingness to share. We would especially like to thank the publishing team
at the American Academy of Pediatrics; in particular, we thank Alain Park, Barrett Winston, and Heather Babiar,
our editors, who believed in this project at its outset and supported us over the span of 3 years. Last, we would like
to thank all of you, who care for the tiniest of patients every day; we hope this book will help you teach and learn.
Lamia Soghier, MD, MEd, CHSE, FAAP

Beverley Robin, MD, MHPE, CHSE, FAAP
NeoSim.indb 13 2/21/21 12:13 PM

NeoSim.indb 14 2/21/21 12:13 PM
Chapter 1
Applications of Learning Theory

in Simulation
Priti Jani, MD, MPH, and Angela D. Blood, MPH, MBA, CHSE-A
Objectives
In this chapter, you will
1. Define learning theory and characterize its influence on the learner and the clinical environment.
2. Describe the unique context in which theories of adult learning are applied in simulation.
3. Appraise the diverse learning theories and determine their applications in simulation design.
Introduction
Adult learners, including neonatal health care professionals, learn in many different ways. No single learning
theory explains the entirety of a person’s development through experiencing simulation, whether it is experienced
as an instructional method or an assessment method. Considering an educational experience from multiple
learning theoretical perspectives may provide more than one explanation or interpretation for how and why
learning occurs. Neonatal simulation educators are best served not by an exhaustive review of all learning theories
but rather by a review of the most influential and relevant theories that can be applied to simulation. We present
multiple learning theories alongside examples of real-life health care scenarios to illustrate how understanding
the mechanism of learning can enhance neonatal health care professionals’ skills as simulation educators.
Background
Keeping neonatal health care professionals abreast of the latest clinical developments and helping them be able to
execute their clinical work to the highest standards are the responsibilities of the profession to patients, families,
and the public. With increased emphasis on patient safety, health care education must move away from the “see
one, do one, teach one” approach to hands-on, experiential methods, such as simulation, to develop and maintain
an excellent clinical workforce and, at the same time, minimize risk to patients.1 Because simulation can closely
replicate the clinical environment, its use as a teaching and assessment method is growing considerably. While it
is vital that neonatal simulation educators develop skills to design and facilitate simulation curricula, mimicry of
the clinical environment is only one of several important components. Successful simulation educators must also
understand how and why learning occurs, thereby arming themselves with the knowledge required to optimally
and efficiently develop curricula that will positively affect the clinical environment.

2 NEONATAL SIMULATION: A PRACTICAL GUIDE
For the purposes of this chapter, the targeted learners are trainees and neonatal health care providers (ie,
physicians, nurses, and other health care professionals). Although the fundamental principles of learning and
educational theory discussed here are applicable in a variety of settings, it is also important to note that learning
theories do not exist in a vacuum. They are informed by and evolve alongside the environment from which they
are born. Therefore, the social, political, and cultural contexts of the clinical environment may affect the degree
to which a specific theory holds true.
Past conceptualizations of learning were dominated by the belief that human behaviors are driven by inner
forces, needs, or impulses that are potentially operating below the level of consciousness. Today, we understand
that human behavior is influenced by the environment in which it exists. One prominent theory to support this
belief is social learning theory, which stresses the roles of observation, modeling, and reinforcement (whether for
good or for ill) that affect learning, describing individuals’ behaviors essentially as reactions to stimuli.2 Social
learning theory is therefore especially relevant in a clinical work environment such as a neonatal intensive care
unit (NICU), where health care professionals are constantly observing each other’s behavior, modeling their
behavior in response to their observations, and working toward rewards or avoidance of negative feedback.
While largely heterogeneous in their makeup, health care professionals have a common goal of providing
excellent patient care. This commonality advantageously positions the neonatal simulation educator because
they are not training undifferentiated adult learners, such as those in an undergraduate university program.
Rather, neonatal simulation educators are training health care professionals who have defined expectations and
similar clinical experiences and common goals.
What Is Learning Theory?

Learning theory is the reasoning behind the acquisition and development of knowledge, skills, and attitudes.
In this chapter, we define learning or educational theory as not only the acquisition and development of knowl-
edge, skills, and attitudes but also the appropriate application of theory toward the development of curricula.
Keeping both acquisition and application in mind is important to be able to ensure the correct use of resources,
the intended effect on learners, and the sustainability of the curricula. A lack of any of these factors can degrade
curricular sustainability via loss of institutional and learner support. To prevent this, it is important for the simula-
tion educator to have a comprehensive understanding of learning theory; thus, they can better
▶ Describe a problem in the clinical environment from an educational perspective.
▶ Address the needs of learners of different levels (trainees vs practicing health care professionals).
▶ Define goals and learning objectives for an educational activity.
▶ Design educational activities, including the selection of simulation modalities.
▶ Implement educational activities.
▶ Measure the effectiveness of educational activities.
To accomplish these goals, medical educators commonly use Kern’s 6-step approach to curriculum develop-
ment, which includes the following steps3: (1) problem identification and general needs assessment, (2) targeted
needs assessment, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) evaluation
and feedback.
Step 1. Problem Identification and General Needs Assessment

Problem identification and an associated needs assessment are critical because they provide the foundation
and rationale for the curriculum. The needs assessment focuses on the curricular objectives and evaluation
plan. Furthermore, it informs the intended impact of a curriculum, taking into account the current educational
approach to determine the ideal pathway toward achieving this effect.

CHAPTER 1. APPLICATIONS OF LEARNING THEORY IN SIMULATION 3
Step 2. Targeted Needs Assessment

The targeted needs assessment expands on the general needs assessment by determining the targeted learner
group and environment. It takes into account the prior experiences, learning preferences, and proficiencies of
the learner group. Similarly, it allows evaluation of the educational environment regarding existing curricula,
resources, and barriers.
Step 3. Goals and Objectives

A goal is the general educational objective, whereas an objective is specific and measurable. Objectives can pertain
to the learner, the process (measures of implementation), or the patient and health care outcomes. Learning
objectives should be based on Bloom’s taxonomy4 and can be subdivided into 3 categories: cognitive development
(knowledge), affective development (attitude and emotions), and psychomotor skills (manual or physical skills).
Step 4. Educational Strategies

It is essential to identify the objectives early during curriculum development. In doing so, the educator can put
into play the appropriate educational strategies, taking into account applicable learning theories. For example,
if the objective is for the learners to develop competency in umbilical catheter placement, the curriculum might
include video review and hands-on skills practice by using a task trainer, drawing on the work of Ericsson’s
principles of deliberate practice (discussed in the Deliberate Practice section later in this chapter).5
Step 5. Implementation
When developing a simulation-based curriculum, medical educators should carefully consider the approach to
implementation so that the resources are used efficiently and effectively to achieve the overarching goals and
objectives. In addition, they should consider the necessary institutional and administrative support, essential
resources, potential challenges and barriers, and details of curriculum administration.
Step 6. Evaluation and Feedback

Program evaluation should be considered by medical educators during the curriculum development phase
because it is critical to confirm that the learners achieve the learning objectives. Learner feedback and program
evaluation results guide curriculum revisions.
After the general needs assessment, the targeted needs assessment, the goals, the objectives, and the learner
characteristics are considered, learning theories are applied to develop the educational strategy. Simulation-based
medical education (SBME) is advantageous because it provides a surrogate for true experience. It garners the
benefit of this experience, while it affords for manipulation of the environment and the experience as needed for
effective learning.
Two learning theories related to skill acquisition (typically to psychomotor skill acquisition) and applicable to
simulation-based training are the Five-Stage Model of Skill Acquisition by Dreyfus6 and the Three Phases of Skill
Acquisition outlined by Fitts and Posner.7
Dreyfus Five-Stage Model of Skill Acquisition

The Dreyfus model of skill acquisition entails a progression through 5 levels to achieve expertise: novice, advanced
beginner, competence, proficiency, and expert/mastery.6
Novice
During the novice stage, the learner acquires knowledge about a task, free of context, and learns the rules that
guide the actions.6

Example: During their first Neonatal Resuscitation Program® course, an incoming, first-month
pediatrics resident is classified as a novice. They have not rotated in the NICU and have there-
fore never previously been in this environment, but they are given a set of rules to follow, based
on predetermined criteria: a description of the delivery room, when to call for help, steps of and
criteria for initiating mask ventilation, and so on.
Advanced Beginner
The advanced beginner stage is the period during which the learner begins to gain real-life experience and an
understanding of the context and setting. At this stage, from a removed and analytical standpoint, the learner
begins to identify “instructional maxims” (guiding principles) for actions.8
Example: One month into the clinical rotation in the NICU, pediatrics residents learn to
differentiate oxygen desaturations that require an intervention from those that do not. They do
so through pattern recognition; a transient desaturation or one with a poor waveform is likely
not clinically significant and can be observed, whereas a sustained desaturation with a good
waveform requires prompt intervention.
Competence
To achieve competence, the learner must meet the following 3 criteria: (1) engage in abundant experiences,
(2) develop emotional attachment to the task at hand, and (3) learn the guidelines that determine actions in
variable real-life situations.8 The emotional attachment and associated ownership of decisions made are essential
for progression from this competence stage to expert level.6
Example: By the second NICU rotation, pediatrics residents will have had multiple opportuni-
ties to provide mask ventilation during neonatal resuscitation. They will experience challenges
and errors (eg, an inability to establish a face mask seal, ineffective mask ventilation, provision
of mask ventilation at an inappropriate rate) and achieve successes (eg, mask ventilation produc-
ing good chest rise and resultant improvement in heart rate and oxygen saturations). From each
of these experiences, they will take away insights, opportunities for improvement, and principles
for guiding future actions. These understandings of the various paths that can be taken during
an oxygen desaturation (eg, equipment use, troubleshooting strategies, and decision-making)
will contribute collectively to the development of competence, as will the emotional investment
in learning and the recognition of the implications of performing ineffective mask ventilation.
Proficiency
When learners reach a level of proficiency, they are able to identify and categorize a problem, as well as to use
maxims to determine the appropriate course of action. Experience contributes to situational memory and pattern
recognition, which then serve to guide actions.8
Example: Whereas residents in the competence phase recognize a clinically significant oxy-
gen desaturation but are unable to pinpoint the exact cause (while being aware that there are
a variety of causes), residents in the proficiency phase identify the cause and use maxims to
determine the next path of action; if the cause is persistent apnea, they may choose to place an
endotracheal tube, whereas if the cause is chronic lung disease of prematurity, they may choose
to initiate noninvasive positive pressure ventilation (PPV).

Expert/Mastery
Experts rely heavily on intuition and memory when performing a task. They have a degree of experience that
facilitates an immediate recognition of a problem, as well as the path of action. In comparison to a learner who
is proficient, an expert has a greater repository of fine-tuned discriminations for similar situations.6
Example: When an intubated infant with a pneumothorax and indwelling chest tube experi-
ences desaturation with accompanying tachycardia, the nurse begins to ventilate by hand and
calls the resident into the room to help.
Proficient learners immediately look for chest rise and auscultate the chest. On hearing unilat-
eral breath sounds, they order radiography and request that the nurse provide suctioning. (They
also remember prior cases of desaturation that required suctioning and follow the standard
algorithms for an intubated patient with desaturation, such as the “DOPE” mnemonic [short for
dislodgement, obstruction, pneumothorax, equipment failure]).
On entering the room, experts notice the change in vital signs and the unilateral chest rise
and they intuitively check the chest tube mechanism for suction. They begin troubleshooting the
chest tube mechanism and ask the nurse to set up equipment for possible needle decompression
to relieve the reaccumulated pneumothorax.
Fitts and Posner Three Phases of Skill Acquisition

Fitts and Posner outline psychomotor skill acquisition in 3 phases: cognitive, associative, and autonomous.7
Cognitive Phase
In the initial stage of learning—the cognitive stage—the learner seeks to understand the procedure, experiments
with strategies, and performs inconsistently and without fluidity.
Example: When learning neonatal endotracheal intubation, beginning pediatrics residents
read about the procedure and review the anatomical structure of the neonatal airway and the
indications, contraindications, and risks of the procedure. They watch the senior fellow perform
the procedure in the NICU. By using a neonatal intubation task trainer, they practice the skill
and try various techniques; their performance is clumsy and they are intermittently successful.
Associative Phase
During the associative phase, the learner demonstrates the skill more efficiently and with more fluidity, compares
the performance with the desired outcome, and makes modifications accordingly; the skill becomes ingrained.
Example: Second-year neonatal-perinatal fellows are successful at neonatal endotracheal
intubation within the 30-second Neonatal Resuscitation Program guideline for most attempts.
When not successful, they analyze their performance to identify strategies to implement during
subsequent intubations. The fellow performs the procedure with more ease and fluidity, requir-
ing less concentrated attention than that required during the first year of training.
Autonomous Phase
In the final, autonomous phase, performance is fluid and the steps are performed without conscious awareness;
cognitive processes become implicit.
Example: Attending neonatologists quickly and efficiently complete neonatal endotracheal intuba-
tion, without thinking about the individual steps. When asked to explain the procedure, they miss
some of the steps because they are “second nature” and performed without conscious awareness.

Simulation and Team Performance

Medical care generally and emergency situations in particular require health care professionals to work collab-
oratively in interdisciplinary teams, with the goal of providing safe, quality patient care. Like teams in general,
health care teams face a number of challenges that include membership fluidity, with changes in team complement
between or during clinical events9; inadequate communication, especially traversing professional boundaries10;
siloed education, with potential lack of awareness of other team members’ training and skill sets11; and lack of
team-specific training.12 However, for effective team performance, teams must establish leadership, use closed-
loop communication, establish mutual trust, and develop a shared mental model.13 Simulation-based training has
been shown to enhance medical team performance.12,14 In the next section, we outline learning theories applied to
simulation, particularly to team training.
Adult Learning Theory

Knowles’ adult learning theory illustrates a common application of learning theory that applies to learning from
experiences in the real world, as well as simulation. Adult learning theory proposes that adults need certain ele-
ments for optimal learning. These include self-directed learning, contribution from prior experiences, and prob-
lem-solving in real-life contexts. Additionally, readiness and motivation to learn are essential.15 SBME provides
neonatal health care providers with the opportunities to apply their prior experiences to problem-solve in contexts
that mimic real-life.
Constructivist Learning Theory

Other theories demonstrate the parallels to learning between real life and simulation. Constructivist theory
postulates that learners use previous knowledge and experiences to construct new knowledge and that the new
knowledge is closely tied to the context in which it is constructed. Simulation creates a learning environment that
mimics real-life situations, thereby giving meaning and organization to new knowledge acquired and application
to real-life situations. Social constructivism highlights that learning is context and culture bound and that social
interactions are essential to learning and psychological safety.16 This is especially applicable to postsimulation
debriefing, during which discussion of learning points and team-led analysis occur. In line with constructivist
theory, simulation culture stresses the importance of a safe environment in which learners can work collabora-
tively and make mistakes without fear of judgment or reprimand.16
Situated Learning Theory

Situated learning theory, a component of social constructivism, emphasizes the interaction between the par-
ticipants (learners and instructors), the culture, and the environment, highlighting the importance of learning
situated in everyday contexts—those in which experiences typically occur.17 Described by Lave and Wenger,
situated learning includes communities of practice, wherein group members with shared goals participate in
collective learning, binding the group as a social entity.17 Such groups are typically composed of a core group of
seasoned members, with a larger proportion of newer, less experienced members. The less experienced members
learn through participation in the group, initially peripherally, becoming more experienced and therefore more
significant to the functioning of the group over time.17
Example: At the beginning of the rotation, the first-month pediatrics intern watches as the
interdisciplinary team resuscitates a neonate in the delivery room. During the following weeks,
the intern gradually participates in resuscitations, and, with coaching, provides effective PPV.

Toward the end of the rotation, the attending physician notices that the intern is no longer
reluctant to participate during resuscitations but is eager to stand at the head of the bed and
provide PPV, participating as a member of the interdisciplinary team.
Social Cognitive Theory

Social cognitive theory, coined by Bandura, is not a single theory but rather a collection of theories holding that
learning is shaped by dynamic and reciprocal cognitive, behavioral, and environmental factors.18 Furthermore,
learning occurs from observation, not merely through imitation but also through human agency—intentional
learning with the goal of changing behaviors. Bandura describes human agency with 4 elements: (1) intentionality
(intention to invest in learning), (2) forethought (anticipation of the envisioned goals and outcomes), (3) self-
reactiveness (choices made on the basis of perception of difficulty to achieve a specific goal and potential value
of the new knowledge), and (4) self-reflectiveness (metacognition, self-awareness, reflection, and self-regulation).19
Example: A team of clinicians participates in a real-life resuscitation event. After the event,
they participate in a clinical debriefing. Several opportunities for improvement are identified,
regarding role assignments and choreography. These prompt an intentional investment by all
to participate in simulation-based resuscitation activities. They recognize that the team will
benefit from simulated resuscitations, which will enhance patient care during future resuscita-
tion events. They accept that this process will take time and effort and understand that there is
value in participating in simulations to enhance the team’s performance. The self-reflection that
occurs during the debriefing and the identification of key gaps and lapses in teamwork translate
into the recognition of new approaches to role identification and code choreography during
future resuscitations.
Self-efficacy
Also described by Bandura, self-efficacy is an individual’s belief in their ability to perform a task or attain a
goal, and self-efficacy is fundamental to their actions.20 Not always accurate from a social cognitive theory
viewpoint, self-efficacy mediates cognitive advancement in 3 ways: (1) cognitive—self-assessment, preparation,
time management, and metacognition; (2) motivational—setting high goals and evaluating achievements; and
(3) affective—resilience, coping strategies, and the ability to manage stressors created by challenging situations.21
Self-efficacy is additionally influenced by observing others and receiving feedback and encouragement from
others. Collective efficacy refers to the unified ability of a group, which enables group achievement.21 Like self-
efficacy, a high level of perceived group efficacy leads to greater motivation, enhanced performance, and better
resilience regarding challenges.19
In developing simulation scenarios or sessions for team training, capitalizing on this aspect of human behavior
can be advantageous for fostering effective learning (for individuals and teams). Features to consider are
(1) using actual team members (as opposed to improvised teams) to allow for group practice and reflection,
and, wherever possible, including learners of different levels to allow for role modeling and to permit individual
learners to gain insight into their own actions; (2) developing realistic scenarios (based on actual patient events)
that appropriately heighten the participants’ physiological responses, with the intent of promoting engagement
and enhancing learning; (3) providing an opportunity to observe the feedback of other participants and facilitators
during debriefing; (4) getting input and feedback from team members and facilitators during debriefing; and (5)
allotting time for repetitive practice or a simple “redo” to provide additional opportunities for individuals and
teams to achieve the learning objectives.22

Experiential Learning Theory

Experiential learning theory, proposed by Kolb, highlights experiences (real or simulated) as promoters of learn-
ing.23 The assumptions are that learning, based on individual or group experience, is a continual process, with the
learner interacting with the environment, and that learning progresses with experiences and reflection on those
experiences. Furthermore, experiences are considered in the context of previous experiences. The 4-phase learning
cycle includes concrete experience, reflective observation, abstract conceptualization, and active experimentation
(Figure 1-1).23
Concrete
experience
Doing/having
an experience
Perception
continuum
Active Processing Processing Reflective
experimentation continuum Kolb’s continuum
observation
Planning/trying Learning
Reflecting/reviewing
out what you Cycle
on the experience
have learned
Perception
continuum
Abstract
conceptualization
Concluding/learning
from the experience
Figure 1-1. Kolb’s learning cycle.
The simulation activity is the concrete experience during which the learners actively participate by “doing.” The
subsequent 2 phases—reflective observation and abstract conceptualization—are the hallmarks of postsimula-
tion debriefing. The learners reflect on and analyze the experience, and through abstract conceptualization, they
develop new mental representations, modify existing ones, and consider actions for subsequent experiences. In the
active experimentation phase, learners apply the knowledge and skills to a new clinical (or simulated) experience,
followed by reflection on the experience, thus continuing the iterative learning cycle. The process can begin at any
phase of the cycle, and the learner must go through all 4 phases for effective learning to occur.
Example: Two pediatrics residents, a nurse, a neonatal-perinatal fellow, and a respiratory
therapist participate in a simulated neonatal resuscitation. The neonate has apnea, with poor
muscle tone. The team provides PPV but fails to notice that there is no chest rise. The neo-
nate’s heart rate decreases below 60 beats/min, and the fellow initiates chest compressions,
coordinated with ventilations. Chaos ensues, and the fellow, who is running the resuscitation,
continues chest compressions and orders the administration of epinephrine. The nurses prepare
the medication but are unsure of the dose. During the debriefing, the team members reflect on
the experience, and the instructor facilitates discussion related (1) to the importance of and the
methods for assessing the effectiveness of PPV; (2) to the corrective steps to be initiated when

PPV is ineffective; (3) to delegation, leadership, and the importance of the leader’s situational
awareness; (4) generally to the importance of clear and effective (closed-loop) communication
and specifically to medication dosing; and so on. The team has the opportunity to implement
the new knowledge and skills in a subsequent simulation (or actual clinical encounter), ideally
checking the effectiveness of PPV, providing corrective steps for ineffective PPV, and so forth.
Reflection-in-Action/Reflection-on-Action
Described by Schön, reflection-in-action and reflection-on-action are 2 additional principles that are applicable
to SBME.24 Reflection-in-action occurs when a person reflects (typically unexpectedly) on their own performance
during the performance. Then, as necessary, the individual applies knowledge or skill from previous experiences
to modify the current performance. Schön differentiates reflection-in-action from other types of reflective practice
because the effects on performance are immediate.
Example: The senior neonatal-perinatal fellow, while performing an endotracheal intubation,
notices that she cannot visualize the vocal cords because she is not exerting sufficient pressure
onto the laryngoscope handle. She modifies her technique and easily passes the endotracheal
tube through the neonate’s vocal cords.
In contrast, reflection-on-action is the retrospective review and analysis of actions with the goal of enhancing
subsequent performance. This is the premise of postsimulation debriefing.
Example: During simulation-based procedural skills training, the first-year neonatal-perinatal
fellow struggles with endotracheal intubation. Afterward, she reflects on her performance, and
together, she and the senior fellow identify strategies for her to implement during subsequent
practice.
Deliberate Practice
Described by Ericsson, deliberate practice (DP) is the purposeful, repetitive practice of cognitive or psychomotor
skills within a specific domain, combined with rigorous skill assessment and feedback that is specific, focused,
and ongoing.25 Applied to motivated learners, DP has been demonstrated to enhance performance in a variety of
domains.5 As described by McGaghie and Kristopaitis, DP has the following 10 features26:
1. Highly motivated learners who have good concentration
2. Well-delineated learning objectives or tasks
3. Appropriate degree of difficulty
4. Focused, repetitive practice
5. Rigorous and precise educational measurements
6. Immediate, illuminating feedback from instructors, simulators, and other leaders
7. Monitored learning experiences and strategies, error correction, and degree of understanding
8. Refined performance resulting from ongoing DP
9. Assessment to reach mastery performance; equal expected minimal outcomes; potentially varied learning
times
10. Advancement to a subsequent task or unit
Example: A group of new neonatology nurse practitioners participates in simulation-based
endotracheal intubation training. The lead instructor reviews the curricular objectives, outlines
the steps, and, on a neonatal mannequin, demonstrates the technique step by step. Thereafter, in
groups of 2, each led by an instructor, the learners practice endotracheal intubation on neonatal
mannequins. Each learner’s practice provides the opportunity for correction of deficiencies,

expert tips, and sharing of knowledge that is beneficial to all learners present. The learners
continue to practice, receiving ongoing focused feedback from instructors, with additional
demonstration by the instructor, as necessary. The learners incorporate instructor feedback as
they continue to practice, and they are also encouraged to monitor their own performances. As
practice continues, many of the psychomotor skills become automatic. Although the learners
initially spent time learning how to connect the laryngoscope blade to the laryngoscope handle,
open the mouth, and position the patient, these steps no longer contribute to the cognitive load,
and effortful practice focuses on other, more complex aspects of the procedure. Continued
practice leads to mastery of the skills of uncomplicated intubation (on a mannequin); however,
the duration of training to achieve mastery varies between the learners.
Mastery Learning
Mastery learning (ML), first described by Bloom, is a rigorous type of competency-based instruction in which
all learners are expected to attain the educational objectives before advancing to the next level of learning.4 ML
incorporates features of DP and highlights focused teaching, ongoing practice, and feedback with gradually
less coaching, aimed at achieving mastery performance. A key principle is that the time to achieve ML can vary
between learners.4 McGaghie and Kristopaitis describe the following 8 features of ML26:
1. Baseline assessment of learners
2. Clear, well-defined learning objectives of progressive difficulty
3. Educational activities (ie, skills practice, study) concentrated on attaining the learning objectives
4. Establishment of a minimum passing mastery standard (MPS) for each educational component
5. Formative evaluation with feedback to assess progress toward the MPS for each educational component
6. Continued practice or study until the MPS is attained
7. Advancement to the next level only when performance meets or exceeds the MPS
8. Uniform outcomes, but time to achieve an MPS can vary between learners
Example: Neonatal-perinatal medicine trainees must achieve mastery of the skills of neonatal
resuscitation early in their first year of training. Neonatal Resuscitation Program guidelines
outline the MPS for the didactic (online test) and e-simulation components, and validated
procedural checklists can be used to set an MPS for procedural skills performance. Baseline and
ongoing assessment can be accomplished in the simulated environment, where the trainees have
the opportunity to engage in DP until mastery is achieved through participation in multiple
scenarios and skills stations (with well-defined learning objectives) with increasing levels of
difficulty. Achievement of the mastery standard can be evaluated during simulations, by using
checklists, or during miniclinical evaluation exercises (individual stations or exercises during
which an expert observes and rates the learner).
Zone of Proximal Development

Vygotsky’s zone of proximal development (ZPD), initially used in reference to child development, has more recently
been applied to learners of all ages and refers to the area that is just beyond the learner’s actual developmental
level, representing a challenge that can be attained with assistance.27 This typically includes instructional scaf-
folding, through which the instructor assists the learner in advancing their ZPD. As the learner progresses, the
instructor reduces the support as it becomes unwarranted. Furthermore, the role of social interaction is important.
Engaging the learner with learners who are slightly more advanced (further into their own ZPDs) can assist in
advancing the learner’s ZPD. This type of near-peer teaching is advantageous to the learners and the peers them-
selves, who refine their own performances through teaching.28
NeoSim.indb 10 2/21/21 12:13 PM

Example: Determining a trainee’s ZPD and using near-peer teaching are typical in neonatal-
perinatal medicine training. When first-year fellows begin their training, the third-year fellows
assess the new fellows’ performances. On the basis of their individual experiences, the incoming
fellows’ ZPDs vary. The third-year fellows coach the first-year fellows at the bedside and during
simulation-based training, thus bringing the newcomers’ skills along in their individual ZPDs
and refining their own skills (and teaching) in the process.
Cognitive Load Theory

Cognitive load theory (CLT), developed by Sweller in the 1980s, emphasizes that when the amount of material
the working memory can process is overloaded, learning becomes compromised.29 This overload occurs because
working memory, which is responsible for conscious processing, analysis, and decision-making, temporarily stores
and manipulates the material but has very limited capacity and duration for new information.30 Thus, CLT plays an
important role in determining the ideal instructional strategies when medical educators are developing scenarios
or simulation-based curricula. Total cognitive load refers to the volume of material that the working memory can
process at any given time and comprises 3 types of cognitive load: intrinsic, extraneous, and germane.31
Intrinsic cognitive load refers to the inherent complexity of a task or scenario and the learner’s knowledge and
level of experience.30 This is an important consideration in developing simulation scenarios so that the task com-
plexity is at the appropriate learner level and not too far into, or beyond, the learner’s ZPD.
Example: Immersing a first-year pediatrics resident into a simulation scenario of a neonatal
hypoxic arrest secondary to a tension pneumothorax would represent a significant intrinsic
cognitive load on the learner, whereas immersing them into a scenario of a neonatal apnea that
necessitates mask ventilation would likely be more appropriate.
Extraneous cognitive load is the layout, design, and presentation of the educational sessions or simulation. The
extraneous cognitive load is determined by instructors (or instructional designers) and can be modified to
enhance learning.32 In fact, studies have shown that reducing extraneous cognitive load directly increases learning
across a variety of learning contexts and, most notably, for novice learners.33 Thus, a scenario for which superflu-
ous information, redundancy, or insufficient information is provided can increase extraneous cognitive load.
Example: A simulation scenario for which the learners (third-year medical students) receive the
patient information via a detailed printed patient information sheet and again at the beginning
of the scenario from a nurse (simulated participant) via a verbal handoff, with explicit, detailed
patient information, would likely represent a high extraneous cognitive load and overwhelm
the learners.
Additionally, environmental factors may contribute to extraneous cognitive load, in turn affecting learning. For
instance, an interdisciplinary neonatal resuscitation scenario conducted in an emergency department would
represent an environment that differs significantly from the typical environment in which a neonatal resuscitation
occurs. The noises associated with patient care and the patients themselves, as well as the lack of authentic neonatal-
specific equipment and poor “crowd control,” would increase the extraneous load, distract the learners (especially
those who are novices), and diminish the intended educational experience. Furthermore, because emotions can
contribute to extraneous load, when developing simulation sessions, educators should consider the emotional load
inherent in the scenario (eg, the death of a patient). Educators should also take into account any role portrayal and
the amount or degree of emotional display when incorporating actors (standardized participants), such as those in
hybrid simulations, so as not to overwhelm the participants and negatively affect learning.30
Germane cognitive load is a subset of intrinsic load that comprises the learner’s cognitive processing and the
amount of working memory devoted to learning a new skill or task and creating schemas. Thus, instructional
designers should consider and optimize the germane load, such that the simulation (or other educational exercise)
is of appropriate difficulty to challenge the learners, encourage critical thinking, and promote learning.
NeoSim.indb 11 2/21/21 12:13 PM

When designing scenarios and simulation sessions, educators and instructional designers should consider CLT
to create realistic situations that are conducive to and enhance learning.34 First, while chaotic emergency situations
can be reflective of the actual clinical environment, educators should consider the cognitive load and thus the
potential effect on learning. These types of situations are best suited to advanced learners and teams. For novice
learners, providing materials in advance, such as clinical algorithms or procedural checklists given a day or more
before the simulations, can decrease the extraneous cognitive load, as can embedding a standardized participant
in a health care professional role (eg, a nurse)35 to assist with unfamiliar equipment and suggest adherence to
protocols. In keeping with CLT, simulations (or procedural skills training) should be progressive, with learners
mastering simple tasks before moving on to those that are more complex and require integration of multiple skills.
One should also consider the fidelity of the simulation—the extent to which the simulation replicates “reality,”36
the environment (Does it accurately reflect the clinical environment? Is it too complex for the level of the learn-
ers?), the fidelity of the simulation activity (task trainer, mannequin, or standardized participant; Does using a
high-technology mannequin aid the learners, or does it provide too high of a cognitive load? Does the standard-
ized participant’s portrayal distract the learners by adding a significant cognitive load?), and the extent to which
the task reflects actual clinical practice (ie, What are the learner tasks, and do they align with the learner level of
training or experience? Should first-year neonatal-perinatal fellows perform pericardiocentesis, or should train-
ing begin with endotracheal intubation and umbilical catheter placement?). Lastly, informing learners that they
are expected to perform to the best of their abilities can decrease extraneous cognitive load by removing specific
performance-oriented goals.34
Debriefing
Essential to effective simulation-based learning is debriefing, which is covered in Chapter 24, Debriefing in
Simulation-Based Training in Neonatology: An Outcomes-Based Approach; Chapter 25, Blended-Method
Debriefing With the PEARLS Debriefing Framework; Chapter 26, Co-debriefing in Neonatal Simulation; and
Chapter 27, The Difficult Debriefing. This vital aspect of learning relies on reflective observation after a tangible
experience. Reflection during debriefing is considered an essential feature of SBME and is supported by numer-
ous learning theorists, as outlined in this chapter. Among them is Graham Gibbs, whose reflective cycle focuses
on “learning by doing.” Gibb’s model (Figure 1-2), in which there are 6 stages, can be applied to postsimulation
debriefing in the following ways37:
1. Description: a simple description of “what happened”
2. Feelings: a description of thoughts and feelings, without analysis
3. Evaluation: a discussion of events, including a review of what was effective and what was not
4. Analysis: making sense of the situation, in comparison with other experiences
5. Conclusion: drawing conclusions from what occurred; take-home learning
6. Action plan: actions for similar future experiences, including what learners will do differently next time
Learning Theory Takeaways

Simulation addresses many domains of learning in health care professions education—including the cognitive,
psychomotor, and behavioral domains—aimed at preparing health care professionals for providing safe and
effective patient care. As exemplified in this chapter, multiple learning theories can aid us in understanding how
simulation can promote effective learning. This is illustrated in the best evidence medical education report by
Issenberg and others.38 Undertaking an extensive review and synthesis of more than 100 peer-reviewed SBME arti-
cles published over a 34-year span, the researchers derived a list of 10 features and uses of simulation as a strategy
to support learning, which we summarize below (in italics).
NeoSim.indb 12 2/21/21 12:13 PM

Description
What
happened?
Action plan Feelings

If it arose again, What were
what would you thinking
you do? and feeling?
Evaluation
Conclusion
What was
What else
good and
could you
what needs
have done?
improvement?
Analysis
What sense
can you
make of the
situation?
Figure 1-2. Gibb’s reflective cycle.
Supported by several learning theories (Kolb, experiential learning; Gibbs, learning by doing; and Schön,
reflective practice), feedback is the single most important characteristic of SBME for effective learning. Feedback
allows learners to self-assess and evaluate their progress toward the acquisition and maintenance of skills. Second
to feedback, repetitive practice, backed by the theories of Ericsson (DP) and Bloom (ML), is noted to be a key
feature of SBME. Curricular integration of simulation-based activities is additionally an important factor, as is par-
ticipation in activities with progressive difficulty (eg, DP, ML), as well as clinical variation with the use of multiple
learning strategies, as appropriate to the learner level. Intrinsic to SBME, the researchers highlighted a controlled
environment in which learners can repetitively practice, reflect, and make mistakes (DP) without negative conse-
quences for themselves or for patients. Individualized learning was also noted to be an important factor; simulation
enables complex tasks to be separated into individual components, and as described by Bloom, learners progress
through various stages of learning at their own pace, toward the development of expertise and mastery (eg, DP,
ML). Finally, delineated outcomes (learning objectives), as appropriate to the learner level, and simulator fidelity—
the degree of realism—were also found to be important factors.
Summary
While there is a multitude of learning theories, this chapter serves to highlight a sample of those that are most
relevant to simulation as an instructional and assessment method. Learning theories have variable applications to
simulation-based education and assessment, and while multiple theories might be relevant, the applicability of any
given theory depends on a variety of factors that most importantly include the learning objectives, the targeted
learners, and the simulation modalities used. It is vital that educators and instructional designers consider applica-
ble learning theories when developing simulation curricula to promote optimal learning.
NeoSim.indb 13 2/21/21 12:13 PM

Central Points
▶ Adult learning theory proposes that for optimal learning to occur, adult learners need to be motivated to learn,
possess self-direction, have prior experiences from which to draw, and problem-solve in real-life contexts.
▶ Constructivist learning theory and social cognitive learning theories emphasize the role of context in learning,
thus paralleling real-life learning to learning that occurs during simulations.
▶ Grounded in the learning theories of Kolb (experiential learning), Schön (reflective practice), and Gibbs (learn-
ing by doing), feedback is the single most effective characteristic of SBME for learning.
▶ Educators and instructional designers should appraise various learning theories and apply those that are most
pertinent to simulation curricula design, to be able to optimize learning outcomes.
References
1. Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond “see one, do one, teach one”: toward a different training paradigm.
Postgrad Med J. 2009;85(1003):244–249 PMID: 19520875 https://doi.org/10.1136/qshc.2007.023903
2. Bandura A. Social Learning Theory. General Learning Press; 1971. Accessed December 16, 2020. http://www.asecib.ase.ro/
mps/Bandura_SocialLearningTheory.pdf
3. Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education: A Six-Step Approach. 2nd ed.
Johns Hopkins University Press; 2009
4. Taxonomy of Educational Objectives: The Classification of Educational Goals. David McKay Co Inc; 1956. Bloom BS, ed.
Cognitive Domain; handb 1
5. Ericsson KA, Charness N, Hoffman RR, Feltovich PJ, eds. The Cambridge Handbook of Expertise and Expert Performance.
Cambridge University Press; 2006 https://doi.org/10.1017/CBO9780511816796
6. Dreyfus S. The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24(3):177–181 https://doi.org/10.1177/
0270467604264992
7. Fitts PM, Posner MI. Human Performance. Brooks/Cole Publishing Co; 1967
8. Peña A. The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective. Med Educ Online. 2010;
15(1):4846 https://doi.org/doi:10.3402/meo.v15i0.4846
9. Tannenbaum SI, Mathieu JE, Salas E, Cohen D. Teams are changing: are research and practice evolving fast enough? Ind
Organ Psychol. 2012;5(1):2–24 https://doi.org/10.1111/j.1754-9434.2011.01396.x
10. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communica-
tion in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):i85–i90 PMID: 15465961 https://doi.org/10.1136/
qshc.2004.010033
11. Galloway SJ. Simulation techniques to bridge the gap between novice and competent healthcare professionals. Online J
Issues Nurs. 2009;14(2)
12. Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: a critical
review. Acad Med. 2010;85(11):1746–1760 PMID: 20841989
13. Salas E, Sims DE, Burke CS. Is there a “Big Five” in teamwork? Small Group Res. 2005;36(5):555–599 https://doi.org/
10.1177/1046496405277134
14. Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, et al. Pediatric resident resuscitation skills improve after “rapid
cycle deliberate practice” training. Resuscitation. 2014;85(7):945–951 PMID: 24607871 https://doi.org/10.1016/
j.resuscitation.2014.02.025
15. Huang HM. Toward constructivism for adult learners in online learning environments. Br J Educ Technol. 2002;33(1):
27–37 https://doi.org/10.1111/1467-8535.00236
16. Ker J, Bradley P. Simulation in medical education. In: Swanwick T, ed. Understanding Medical Education: Evidence, Theory
and Practice. The Association for the Study of Medical Education; 2010:175–192
17. Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge University Press; 1991 https://doi.org/
10.1017/CBO9780511815355
18. Bandura A. Social-learning theory of identificatory processes. In: Goslin DA, ed. Handbook of Socialization Theory and
Research. Rand McNally; 1969:213–262
19. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52(1):1–26 PMID: 11148297 https://
doi.org/10.1146/annurev.psych.52.1.1
20. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice Hall; 1986
NeoSim.indb 14 2/21/21 12:13 PM

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of Insects get their living off this industrious creature. Another bee,
Stelis nasuta, breaks open the cells after they have been completely
closed and places its own eggs in them, and then again closes the
cells with mortar. The larvae of this Stelis develop more rapidly than
do those of the Chalicodoma, so that the result of this shameless
proceeding is that the young one of the legitimate proprietor—as we
human beings think it—is starved to death, or is possibly eaten up as
a dessert by the Stelis larvae, after they have appropriated all the
pudding.
Another bee, Dioxys cincta, is even more audacious; it flies about in

a careless manner among the Chalicodoma at their work, and they
do not seem to object to its presence unless it interferes with them in
too unmannerly a fashion, when they brush it aside. The Dioxys,
when the proprietor leaves the cell, will enter it and taste the
contents; after having taken a few mouthfuls the impudent creature
then deposits an egg in the cell, and, it is pretty certain, places it at
or near the bottom of the mass of pollen, so that it is not
conspicuously evident to the Chalicodoma when the bee again
returns to add to or complete the stock of provisions. Afterwards the
constructor deposits its own egg in the cell and closes it. The final
result is much the same as in the case of the Stelis, that is to say,
the Chalicodoma has provided food for an usurper; but it appears
probable that the consummation is reached in a somewhat different
manner, namely, by the Dioxys larva eating the egg of the
Chalicodoma, instead of slaughtering the larva. Two of the
Hymenoptera Parasitica are very destructive to the Chalicodoma,
viz. Leucospis gigas and Monodontomerus nitidus; the habits of
which we have already discussed (vol. v. p. 543) under Chalcididae.
Lampert has given a list of the Insects attacking the mason-bee or
found in its nests; altogether it would appear that about sixteen
species have been recognised, most of which destroy the bee larva,
though some possibly destroy the bee's destroyers, and two or three
perhaps merely devour dead examples of the bee, or take the food
from cells, the inhabitants of which have been destroyed by some
untoward event. This author thinks that one half of the bees' progeny
are made away with by these destroyers, while Fabre places the
destruction in the South of France at a still higher ratio, telling us that
in one nest of nine cells, the inhabitants of three were destroyed by
the Dipterous Insect, Anthrax trifasciata, of two by Leucospis, of two
by Stelis, and of one by the smaller Chalcid; there being thus only a
single example of the bee that had not succumbed to one or other of
the enemies. He has sometimes examined a large number of nests
without finding a single one that had not been attacked by one or
other of the parasites, and more often than not several of the
marauders had attacked the nest.
It is said by Lampert and others that there is a passage in Pliny

relating to one of the mason-bees, that the Roman author had
noticed in the act of carrying off stones to build into its nest; being
unacquainted with the special habits of the bee, he seems to have
supposed that the insect was carrying the stone as ballast to keep
itself from being blown away.
Fig. 20—Anthidium manicatum, Carder-bee. A, Male; B, female.
The bees of the genus Anthidium are known to possess the habit of
making nests of wool or cotton, that they obtain from plants growing
at hand. We have one species of this genus of bees in Britain; it
sometimes may be seen at work in the grounds of our Museum at
Cambridge: it is referred to by Gilbert White, who says of it, in his
History of Selborne: "There is a sort of wild bee frequenting the
garden-campion for the sake of its tomentum, which probably it turns
to some purpose in the business of nidification. It is very pleasant to
see with what address it strips off the pubes, running from the top to
the bottom of a branch, and shaving it bare with the dexterity of a
hoop-shaver. When it has got a bundle, almost as large as itself, it
flies away, holding it secure between its chin and its fore legs." The
species of this genus are remarkable as forming a conspicuous
exception to the rule that in bees the female is larger than the male.
The species of Anthidium do not form burrows for themselves, but
either take advantage of suitable cavities formed by other Insects in
wood, or take possession of deserted nests of other bees or even
empty snail-shells. The workers in cotton, of which our British
species A. manicatum is one, line the selected receptacle with a
beautiful network of cotton or wool, and inside this place a finer layer
of the material, to which is added some sort of cement that prevents
the honied mass stored by the bees in this receptacle from passing
out of it. A. diadema, one of the species that form nests in hollow
stems, has been specially observed by Fabre; it will take the cotton
for its work from any suitable plant growing near its nest, and does
not confine itself to any particular natural order of plants, or even to
those that are indigenous to the South of France. When it has
brought a ball of cotton to the nest, the bee spreads out and
arranges the material with its front legs and mandibles, and presses
it down with its forehead on to the cotton previously deposited; in this
way a tube of cotton is constructed inside the reed; when withdrawn,
the tube proved to be composed of about ten distinct cells arranged
in linear fashion, and connected firmly together by means of the
outer layer of cotton; the transverse divisions between the chambers
are also formed of cotton, and each chamber is stored with a mixture
of honey and pollen. The series of chambers does not extend quite
to the end of the reed, and in the unoccupied space the Insect
accumulates small stones, little pieces of earth, fragments of wood
or other similar small objects, so as to form a sort of barricade in the
vestibule, and then closes the tube by a barrier of coarser cotton
taken frequently from some other plant, the mullein by preference.
This barricade would appear to be an ingenious attempt to keep out
parasites, but if so, it is a failure, at any rate as against Leucospis,
which insinuates its eggs through the sides, and frequently destroys
to the last one the inhabitants of the fortress. Fabre states that these
Anthidium, as well as Megachile, will continue to construct cells
when they have no eggs to place in them; in such a case it would
appear from his remarks that the cells are made in due form and the
extremity of the reed closed, but no provisions are stored in the
chambers.
The larva of the Anthidium forms a most singular cocoon. We have

already noticed the difficulty that arises, in the case of these
Hymenopterous larvae shut up in small chambers, as to the disposal
of the matters resulting from the incomplete assimilation of the
aliment ingested. To allow the once-used food to mingle with that still
remaining unconsumed would be not only disagreeable but possibly
fatal to the life of the larva. Hence some species retain the whole of
the excrement until the food is entirely consumed, it being, according
to Adlerz, stored in a special pouch at the end of the stomach; other
Hymenoptera, amongst which we may mention the species of
Osmia, place the excreta in a vacant space. The Anthidium adopts,
however, a most remarkable system: about the middle of its larval
life it commences the expulsion of "frass" in the shape of small
pellets, which it fastens together with silk, as they are voided, and
suspends round the walls of the chamber. This curious arrangement
not only results in keeping the embarrassing material from contact
with the food and with the larva itself, but serves, when the growth of
the latter is accomplished, as the outline or foundations of the
cocoon in which the metamorphosis is completed. This cocoon is of
a very elaborate character; it has, so says Fabre, a beautiful
appearance, and is provided with a very peculiar structure in the
form of a small conical protuberance at one extremity pierced by a
canal. This canal is formed with great care by the larva, which from
time to time places its head in the orifice in process of construction,
and stretches the calibre by opening the mandibles. The object of
this peculiarity in the fabrication of the elaborate cocoon is not clear,
but Fabre inclines to the opinion that it is for respiratory purposes.
Other species of this genus use resin in place of cotton as their

working material. Among these are Anthidium septemdentatum and
A. bellicosum. The former species chooses an old snail-shell as its
nidus, and constructs in it near the top a barrier of resin, so as to
shut off the part where the whorl is too small; then beneath the
shelter of this barrier it accumulates a store of honey-pollen, deposits
an egg, and completes the cell by another transverse barrier of resin;
two such cells are usually constructed in one snail-shell, and below
them is placed a barricade of small miscellaneous articles, similar to
what we have described in speaking of the cotton-working species of
the genus. This bee completes its metamorphosis, and is ready to
leave the cell in early spring. Its congener, A. bellicosum, has the
same habits, with the exception that it works later in the year, and is
thus exposed to a great danger, that very frequently proves fatal to it.
This bee does not completely occupy the snail-shell with its cells, but
leaves the lower and larger portion of the shell vacant. Now, there is
another bee, a species of Osmia, that is also fond of snail-shells as a
nesting-place, and that affects the same localities as the A.
septemdentatum; very often the Osmia selects for its nest the vacant
part of a shell, the other part of which is occupied by the Anthidium;
the result of this is that when the metamorphoses are completed, the
latter bee is unable to effect its escape, and thus perishes in the cell.
Fabre further states with regard to these interesting bees, that no
structural differences of the feet or mandibles can be detected
between the workers in cotton and the workers in resin; and he also
says that in the case where two cells are constructed in one snail-
shell, a male individual is produced from the cell of the greater
capacity, and a female from the other.
Osmia is one of the most important of the genera of bees found in

Europe, and is remarkable for the diversity of instinct displayed in the
formation of the nests of the various species. As a rule they avail
themselves for nidification of hollow places already existing;
choosing excavations in wood, in the mortar of walls, and even in
sandbanks; in several cases the same species is found to be able to
adapt itself to more than one kind of these very different substances.
This variety of habit will render it impossible for us to do justice to
this interesting genus within the space at our disposal, and we must
content ourselves with a consideration of one or two of the more
instructive of the traits of Osmia life. O. tridentata forms its nest in
the stems of brambles, of which it excavates the pith; its mode of
working and some other details of its life have been well depicted by
Fabre. The Insect having selected a suitable bramble-stalk with a cut
extremity, forms a cylindrical burrow in the pith thereof, extending the
tunnel as far as will be required to allow the construction of ten or
more cells placed one after the other in the axis of the cylinder; the
bee does not at first clear out quite all the pith, but merely forms a
tunnel through it, and then commences the construction of the first
cell, which is placed at the end of the tunnel that is most remote from
the entrance. This cavity is to be of oval form, and the Insect
therefore cuts away more of the pith so as to make an oval space,
but somewhat truncate, as it were, at each end, the plane of
truncation at the proximal extremity being of course an orifice.
Fig. 21.—Osmia tricornis, ♀. Algeria.
The first cell thus made is stored with pollen and honey, and an egg
is deposited. Then a barrier has to be constructed to close this
chamber; the material used for the barrier is the pith of the stem, and
the Insect cuts the material required for the purpose from the walls of
the second chamber; the excavation of the second chamber is, in
fact, made to furnish the material for closing up the first cell. In this
way a chain of cells is constructed, their number being sometimes as
many as fifteen. The mode in which the bees, when the
transformations of the larvae and pupae have been completed,
escape from the chain of cells, has been the subject of much
discussion, and errors have arisen from inference being allowed to
take the place of observation. Thus Dufour, who noted this same
mode of construction and arrangement in another Hymenopteron
(Odynerus nidulator), perceived that there was only one orifice of
exit, and also that the Insect that was placed at the greatest distance
from this was the one that, being the oldest of the series, might be
expected to be the first ready to emerge; and as the other cocoons
would necessarily be in the way of its getting out, he concluded that
the egg that was last laid produced the first Insect ready for
emergence. Fabre tested this by some ingenious experiments, and
found that this was not the case, but that the Insects became ready
to leave their place of imprisonment without any reference to the
order in which the eggs were laid, and he further noticed some very
curious facts with reference to the mode of emergence of Osmia
tridentata. Each Insect, when it desires to leave the bramble stem,
tears open the cocoon in which it is enclosed, and also bites through
the barrier placed by the mother between it and the Insect that is
next it, and that separates it from the orifice of exit. Of course, if it
happen to be the outside one of the series it can then escape at
once; but if it should be one farther down in the Indian file it will not
touch the cocoon beyond, but waits patiently, possibly for days; if it
then still find itself confined it endeavours to escape by squeezing
past the cocoon that intervenes between it and liberty, and by biting
away the material at the sides so as to enlarge the passage; it may
succeed in doing this, and so get out, but if it fail to make a side
passage it will not touch the cocoons that are in its way. In the
ordinary course of events, supposing all to go well with the family, all
the cocoons produce their inmates in a state for emergence within a
week or two, and so all get out. Frequently, however, the emergence
is prevented by something having gone wrong with one of the outer
Insects, in which case all beyond it perish unless they are strong
enough to bite a hole through the sides of the bramble-stem. Thus it
appears that whether a particular Osmia shall be able to emerge or
not depends on two things—(1) whether all goes well with all the
other Insects between it and the orifice, and (2) whether the Insect
can bite a lateral hole or not; this latter point also largely depends on
the thickness of the outer part of the stem of the bramble. Fabre's
experiments on these points have been repeated, and his results
confirmed by Nicolas.
The fact that an Osmia would itself perish rather than attack the
cocoon of its brother or sister is certainly very remarkable, and it
induced Fabre to make some further experiments. He took some
cocoons containing dead specimens of Osmia, and placed them in
the road of an Osmia ready for exit, and found that in such case the
bee made its way out by demolishing without any scruple the
cocoons and dead larvae that intervened between it and liberty. He
then took some other reeds, and blocked the way of exit with
cocoons containing living larvae, but of another species of
Hymenoptera. Solenius vagus and Osmia detrita were the species
experimented on in this case, and he found that the Osmia
destroyed the cocoon and living larvae of the Solenius, and so made
its way out. Thus it appears that Osmia will respect the life of its own
species, and die rather than destroy it, but has no similar respect for
the life of another species.
Some of Fabre's most instructive chapters are devoted to the habits

and instincts of various species of the genus Osmia. It is impossible
here to find space even to summarise them, still more impossible to
do them justice; but we have selected the history just recounted,
because it is rare to find in the insect world instances of such self-
sacrifice by an individual for one of the same generation. It would be
quite improper to generalise from this case, however, and conclude
that such respect for its own species is common even amongst the
Osmia. Fabre, indeed, relates a case that offers a sad contrast to the
scene of self-sacrifice and respect for the rights of others that we
have roughly portrayed. He was able to induce a colony of Osmia
tricornis (another species of the genus, be it noted) to establish itself
and work in a series of glass tubes that he placed on a table in his
laboratory. He marked various individuals, so that he was able to
recognise them and note the progress of their industrial works. Quite
a large number of specimens thus established themselves and
concluded their work before his very eyes. Some individuals,
however, when they had completed the formation of a series of cells
in a glass tube or in a reed, had still not entirely completed their tale
of work. It would be supposed that in such a case the individual
would commence the formation of another series of cells in an
unoccupied tube. This was not, however, the case. The bee
preferred tearing open one or more cells already completed—in
some cases, even by itself—scattering the contents, and devouring
the egg; then again provisioning the cell, it would deposit a fresh
egg, and close the chamber. These brief remarks will perhaps suffice
to give some idea of the variety of instinct and habit that prevails in
this very interesting genus. Friese observes that the variety of habits
in this genus is accompanied as a rule by paucity of individuals of a
species, so that in central Europe a collector must be prepared to
give some twenty years or so of attention to the genus before he can
consider he has obtained all the species of Osmia that inhabit his
district.
As a prelude to the remarks we are about to make on the leaf-cutting

bees of the genus Megachile it is well to state that the bee, the
habits of which were described by Réaumur under the name of
"l'abeille tapissière," and that uses portions of the leaves of the
scarlet poppy to line its nest, is now assigned to the genus Osmia,
although Latreille, in the interval that has elapsed since the
publication of Réaumur's work, founded the genus Anthocopa for the
bee in question. Megachile is one of the most important of the
genera of the Dasygastres, being found in most parts of the world,
even in the Sandwich Islands; it consists of bees averaging about
the size of the honey-bee (though some are considerably larger,
others smaller), and having the labrum largely developed; this organ
is capable of complete inflection to the under side of the head, and
when in the condition of repose it is thus infolded, it underlaps and
protects the larger part of the lower lip; the mandibles close over the
infolded labrum, so that, when the Insect is at rest, this appears to be
altogether absent. These bees are called leaf-cutters, from their
habit of forming the cells for their nest out of pieces of the leaves of
plants. We have several species in Britain; they are very like the
common honey-bee in general appearance, though rather more
robustly formed. These Insects, like the Osmiae, avail themselves of
existing hollow places as receptacles in which to place their nests.
M. albocincta frequently takes possession of a deserted worm-
burrow in the ground. The burrow being longer than necessary the
bee commences by cutting off the more distant part by means of a
barricade of foliage; this being done, it proceeds to form a series of
cells, each shaped like a thimble with a lid at the open end (Fig. 22,
A). The body of the thimble is formed of large oval pieces of leaf, the
lid of smaller round pieces; the fragments are cut with great skill from
the leaves of growing plants by the Insect, which seems to have an
idea of the form and size of the piece of foliage necessary for each
particular stage of its work.
Fig. 22—Nidification of leaf-cutting bee, Megachile anthracina. A, one

cell separated, with lid open; the larva (a) reposing on the food; B,
part of a string of the cells. (After Horne.)
Horne has given particulars as to the nest of Megachile anthracina

(fasciculata), an East Indian species.[30] The material employed was
either the leaves of the Indian pulse or of the rose. Long pieces are
cut by the Insect from the leaf, and with these a cell is formed; a
circular piece is next cut, and with this a lid is made for the
receptacle. The cells are about the size and shape of a common
thimble; in one specimen that Horne examined no less than thirty-
two pieces of leaf disposed in seven layers were used for one cell, in
addition to three pieces for the round top. The cells are carefully
prepared, and some kind of matter of a gummy nature is believed to
be used to keep in place the pieces forming the interior layers. The
cells are placed end to end, as shown in Fig. 22, B; five to seven
cells form a series, and four or six series are believed to be
constructed by one pair of this bee, the mass being located in a
hollow in masonry or some similar position. Each cell when
completed is half filled with pollen in the usual manner, and an egg is
then laid in it. This bee is much infested by parasites, and is eaten by
the Grey Hornbill (Meniceros bicornis).
Megachile lanata is one of the Hymenoptera that in East India enter
houses to build their own habitations. According to Horne both sexes
take part in the work of construction, and the spots chosen are
frequently of a very odd nature. The material used is some kind of
clay, and the natural situation may be considered to be the interior of
a hollow tube, such as the stem of a bamboo; but the barrel of a gun,
and the hollow in the back of a book that has been left lying open,
have been occasionally selected by the Insect as suitable. Smith
states that the individuals developed in the lower part of a tubular
series of this species were females, "which sex takes longer to
develop, and thus an exit is not required for them so soon as for the
occupants of the upper cells which are males." M. proxima, a
species almost exactly similar in appearance to M. lanata, makes its
cells of leaf-cuttings, however, and places them in soft soil.
Fabre states that M. albocincta, which commences the formation of

its nest in a worm-burrow by means of a barricade, frequently makes
the barricade, but no nest; sometimes it will indeed make the
barricade more than twice the proper size, and thus completely fill up
the worm burrow. Fabre considers that these eccentric proceedings
are due to individuals that have already formed proper nests
elsewhere, and that after completing these have still some strength
remaining, which they use up in this fruitless manner.
The Social bees (Sociales) include, so far as is yet known, only a

very small number of genera, and are so diverse, both in habits and
structure, that the propriety of associating them in one group is more
than doubtful; the genera are Bombus (Fig. 331, vol. v.), with its
commensal genus or section, Psithyrus (Fig. 23); Melipona (Fig. 24),
in which Trigona and Tetragona may at present be included, and
Apis (Fig. 6); this latter genus comprising the various honey-bees
that are more or less completely domesticated in different parts of
the world.
In the genus Bombus the phenomena connected with the social life
are more similar to what we find among wasps than to what they are
in the genus Apis. The societies come to an end at the close of the
season, a few females live through the winter, and each of these
starts a new colony in the following spring. Males, females and
workers exist, but the latter are not distinguished by any good
characters from the females, and are, in fact, nothing but more or
less imperfect forms thereof; whereas in Apis the workers are
distinguished by structural characters not found in either of the true
sexes.
Hoffer has given a description of the commencement of a society of

Bombus lapidarius.[31] A large female, at the end of May, collected
together a small mass of moss, then made an expedition and
returned laden with pollen; under cover of the moss a cell was
formed of wax taken from the hind-body and mixed with the pollen
the bee had brought in; this cell was fastened to a piece of wood;
when completed it formed a subspherical receptacle, the outer wall
of which consisted of wax, and whose interior was lined with honey-
saturated pollen; then several eggs were laid in this receptacle, and
it was entirely closed. Hoffer took the completed cell away to use it
for museum purposes, and the following day the poor bee that had
formed it died. From observations made on Bombus agrorum he was
able to describe the subsequent operations; these are somewhat as
follows:—The first cell being constructed, stored, and closed, the
industrious architect, clinging to the cell, takes a few days' rest, and
after this interval commences the formation of a second cell; this is
placed by the side of the first, to which it is connected by a mixture of
wax and pollen; the second cell being completed a third may be
formed; but the labours of the constructor about this time are
augmented by the hatching of the eggs deposited a few days
previously; for the young larvae, having soon disposed of the small
quantity of food in the interior of the waxen cell, require feeding. This
operation is carried on by forming a small opening in the upper part
of the cell, through which the bee conveys food to the interior by
ejecting it from her mouth through the hole; whether the food is
conveyed directly to the mouths of the larvae or not, Hoffer was
unable to observe; it being much more difficult to approach this royal
founder without disturbing her than it is the worker-bees that carry on
similar occupations at a subsequent period in the history of the
society. The larvae in the first cell, as they increase in size,
apparently distend the cell in an irregular manner, so that it becomes
a knobbed and rugged, truffle-like mass. The same thing happens
with the other cells formed by the queen. Each of these larval
masses contains, it should be noticed, sister-larvae all of one age;
when full grown they pupate in the mass, and it is worthy of remark
that although all the eggs in one larval mass were laid at the same
time, yet the larvae do not all pupate simultaneously, neither do all
the perfect Insects appear at once, even if all are of one sex. The
pupation takes place in a cocoon that each larva forms for itself of
excessively fine silk. The first broods hatched are formed chiefly, if
not entirely, of workers, but small females may be produced before
the end of the season. Huber and Schmiedeknecht state that though
the queen provides the worker-cells with food before the eggs are
placed therein, yet no food is put in the cells in which males and
females are produced. The queen, at the time of pupation of the
larvae, scrapes away the wax by which the cocoons are covered,
thus facilitating the escape of the perfect Insect, and, it may also be,
aiding the access of air to the pupa. The colony at first grows very
slowly, as the queen can, unaided, feed only a small number of
larvae. But after she receives the assistance of the first batch of
workers much more rapid progress is made, the queen greatly
restricting her labours, and occupying herself with the laying of eggs;
a process that now proceeds more and more rapidly, the queen in
some cases scarcely ever leaving the nest, and in others even
becoming incapable of flight. The females produced during the
intermediate period of the colony are smaller than the mother, but
supplement her in the process of egg-laying, as also do the workers
to a greater or less extent. The conditions that determine the egg-
laying powers of these small females and workers are apparently
unknown, but it is ascertained that these powers vary greatly in
different cases, so that if the true queen die the continuation of the
colony is sometimes effectively carried on by these her former
subordinates. In other cases, however, the reverse happens, and
none of the inhabitants may be capable of producing eggs: in this
event two conditions may be present; either larvae may exist in the
nest, or they may be absent. In the former case the workers provide
them with food, and the colony may thus still be continued; but in the
latter case, there being no profitable occupation for the bees to
follow, they spend the greater part of the time sitting at home in the
nest.
Supposing all to go well with the colony it increases very greatly, but
its prosperity is checked in the autumn; at this period large numbers
of males are produced as well as new queens, and thereafter the
colony comes to an end, only a few fertilised females surviving the
winter, each one to commence for herself a new colony in the
ensuing spring.
The interior of the nest of a bumble-bee (Bombus) frequently

presents a very irregular appearance; this is largely owing to the fact
that these bees do not use the cells as cradles twice, but form others
as they may be required, on the old remains. The cells, moreover,
are of different sizes, those that produce workers being the smallest,
those that cradle females being the largest, while those in which
males are reared are intermediate in size. Although the old cells are
not used a second time for rearing brood they are nevertheless
frequently adapted to the purposes of receptacles for pollen and for
honey, and for these objects they may be increased in size and
altered in form.
It may be gathered from various records that the period required to

complete the development of the individual Bombus about
midsummer is four weeks from the deposition of the egg to the
emergence of the perfect Insect, but exact details and information as
to whether this period varies with the sex of the Insect developed are
not to be found. The records do not afford any reason for supposing
that such distinction will be found to exist: the size of the cells
appears the only correlation, suggested by the facts yet known,
between the sex of the individual and the circumstances of
development.
The colonies of Bombus vary greatly in prosperity, if we take as the
test of this the number of individuals produced in a colony. They
never, however, attain anything at all approaching to the vast number
of individuals that compose a large colony of wasps, or that exist in
the crowded societies of the more perfectly social bees. A populous
colony of a subterranean Bombus may attain the number of 300 or
400 individuals. Those that dwell on the surface are as a rule much
less populous, as they are less protected, so that changes of
weather are more prejudicial to them. According to Smith, the
average number of a colony of B. muscorum in the autumn in this
country is about 120—viz. 25 females, 36 males, 59 workers. No
mode of increasing the nests in a systematic manner exists in this
genus; they do not place the cells in stories as the wasps do; and
this is the case notwithstanding the fact that a cell is not twice used
for the rearing of young. When the ground-space available for cell-
building is filled the Bombus begins another series of cells on the
ruins of the first one. From this reason old nests have a very irregular
appearance, and this condition of seeming disorder is greatly
increased by the very different sizes of the cells themselves. We
have already alluded to some of these cells, more particularly to
those of different capacities to suit the sexes of the individuals to be
reared in them. In addition to these there are honey-tubs, pollen-
tubs, and the cells of the Psithyrus (Fig. 23), the parasitic but friendly
inmates of the Bombus-nests. A nest of Bombus, exhibiting the
various pots projecting from the remains of empty and partially
destroyed cells, presents, as may well be imagined, a very curious
appearance. Some of the old cells apparently are partly destroyed
for the sake of the material they are composed of. Others are formed
into honey-tubs, of a make-shift nature. It must be recollected that,
as a colony increases, stores of provisions become absolutely
necessary, otherwise in bad weather the larvae could not be fed. In
good weather, and when flowers abound, these bees collect and
store honey in abundance; in addition to placing it in the empty pupa-
cells, they also form for it special receptacles; these are delicate
cells made entirely of wax filled with honey, and are always left open
for the benefit of the community. The existence of these honey-tubs
in bumble-bees' nests has become known to our country urchins,
whose love for honey and for the sport of bee-baiting leads to
wholesale destruction of the nests. According to Hoffer, special tubs
for the storing of pollen are sometimes formed; these are much taller
than the other cells. The Psithyrus that live in the nests with the
Bombus are generally somewhat larger than the latter, and
consequently their cells may be distinguished in the nests by their
larger size. A bumble-bees' nest, composed of all these
heterogenous chambers rising out of the ruins of former layers of
cells, presents a scene of such apparent disorder that many have
declared that the bumble-bees do not know how to build.
Although the species of Bombus are not comparable with the hive-
bee in respect of the perfection and intelligent nature of their work,
yet they are very industrious Insects, and the construction of the
dwelling-places of the subterranean species is said to be carried out
in some cases with considerable skill, a dome of wax being formed
as a sort of roof over the brood cells. Some work even at night. Fea
has recorded the capture of a species in Upper Burmah working by
moonlight, and the same industry may be observed in this country if
there be sufficient heat as well as light. Godart, about 200 years ago,
stated that a trumpeter-bee is kept in some nests to rouse the
denizens to work in the morning: this has been treated as a fable by
subsequent writers, but is confirmed in a circumstantial manner by
Hoffer, who observed the performance in a nest of B. ruderatus in his
laboratory. On the trumpeter being taken away its office was the
following morning filled by another individual The trumpeting was
done as early as three or four o'clock in the morning, and it is by no
means impossible that the earliness of the hour may have had
something to do with the fact that for 200 years no one confirmed the
old naturalist's observation.
One of the most curious facts in connection with Bombus is the

excessive variation that many of the species display in the colour of
the beautiful hair with which they are so abundantly provided. There
is not only usually a difference between the sexes in this respect, but
also extreme variation within the limits of the same sex, more
especially in the case of the males and workers; there is also an
astonishing difference in the size of individuals. These variations are
carried to such an extent that it is almost impossible to discriminate
all the varieties of a species by inspection of the superficial
characters. The structures peculiar to the male, as well as the sting
of the female, enable the species to be determined with tolerable
certainty. Cholodkovsky,[32] on whose authority this statement as to
the sting is made, has not examined it in the workers, so that we do
not know whether it is as invariable in them as he states it to be in
queens of the same species. According to Handlirsch,[33] each
species of Bombus has the capacity of variation, and many of the
varieties are found in one nest, that is, among the offspring of a
single pair of the species, but many of the variations are restricted to
certain localities. Some of the forms can be considered as actual
("fertige") species, intermediate forms not being found, and even the
characters by which species are recognised being somewhat
modified. As examples of this he mentions Bombus silvarum and B.
arenicola, B. pratorum and B. scrimshiranus. In other cases,
however, the varieties are not so discontinuous, intermediate forms
being numerous; this condition is more common than the one we
have previously described; B. terrestris, B. hortorum, B. lapidarius
and B. pomorum are examples of these variable species. The
variation runs to a considerable extent in parallel lines in the different
species, there being a dark and a light form of each; also each
species that has a white termination to the body appears in a form
with a red termination, and vice versa. In the Caucasus many
species that have everywhere else yellow bands possess them
white; and in Corsica there are species that are entirely black, with a
red termination to the body, though in continental Europe the same
species exhibit yellow bands and a white termination to the body.
With so much variation it will be readily believed that much remains
to be done in the study of this fascinating genus. It is rich in species
in the Northern hemisphere, but poor in the Southern one, and in
both the Ethiopian and Australian regions it is thought to be entirely
wanting.
The species of the genus Psithyrus (Apathus of many authors)
inhabit the nests of Bombus; although less numerous than the
species of the latter genus, they also are widely distributed. They are
so like Bombus in appearance that they were not distinguished from
them by the earlier entomologists; and what is still more remarkable,
each species of Psithyrus resembles the Bombus with which it
usually lives. There appear, however, to be occasional exceptions to
this rule, Smith having seen one of the yellow-banded Psithyrus in
the nest of a red-tailed Bombus. Psithyrus is chiefly distinguished
from Bombus by the absence of certain characters that fit the latter
Insects for their industrial life; the hind tibiae have no smooth space
for the conveyance of pollen, and, so far as is known, there are only
two sexes, males and perfect females.
Fig. 23—Psithyrus vestalis, Britain. A, Female, x 3⁄2; B, outer side of
hind leg.
The Bombus and Psithyrus live together on the best terms, and it
appears probable that the latter do the former no harm beyond
appropriating a portion of their food supplies. Schmiedeknecht says
they are commensals, not parasites; but it must be admitted that
singularly few descriptions of the habits and life-histories of these
interesting Insects have been recorded. Hoffer has, however, made
a few direct observations which confirm, and at the same time make
more definite, the vague ideas that have been generally prevalent
among entomologists. He found and took home a nest of Bombus
variabilis, which contained also a female of Psithyrus campestris, so
that he was able to make observations on the two. The Psithyrus
was much less industrious than the Bombus, and only left the nest
somewhat before noon, returning home again towards evening; after
about a month this specimen became still more inactive, and passed
entire days in the nest, occupying itself in consuming the stores of
honey of its hosts, of which very large quantities were absorbed, the
Psithyrus being much larger than the host-bee. The cells in which
the young of the Psithyrus are hatched are very much larger than
those of the Bombus, and, it may therefore be presumed, are formed
by the Psithyrus itself, for it can scarcely be supposed that the
Bombus carries its complaisance so far as to construct a cell
specially adapted to the superior stature of its uninvited boarder.
When a Psithyrus has been for some time a regular inhabitant of a
nest, the Bombus take its return home from time to time as a matter
of course, displaying no emotion whatever at its entry. Occasionally
Hoffer tried the introduction of a Psithyrus to a nest that had not
previously had one as an inmate. The new arrival caused a great
hubbub among the Bombus, which rushed to it as if to attack it, but
did not do so, and the alarm soon subsided, the Psithyrus taking up
the position in the nest usually affected by the individuals of the
species. On introducing a female Psithyrus to a nest of Bombus in
which a Psithyrus was already present as an established guest, the
latter asserted its rights and drove away the new comer. Hoffer also
tried the experiment of placing a Psithyrus campestris in the nest of
Bombus lapidarius—a species to which it was a stranger;
notwithstanding its haste to fly away, it was at once attacked by the
Bombus, who pulled it about but did not attempt to sting it.
When Psithyrus is present in a nest of Bombus it apparently affects

the inhabitants only by diminishing their stores of food to so great an
extent that the colony remains small instead of largely increasing in
numbers. Although Bombus variabilis, when left to itself, increases
the number of individuals in a colony to 200 or more, Hoffer found in
a nest in which Psithyrus was present, that on the 1st of September
the assemblage consisted only of a queen Bombus and fifteen
workers, together with eighteen specimens of the Psithyrus, eight of
these being females.
The nests of Bombus are destroyed by several animals, probably for

the sake of the honey contained in the pots; various kinds of small
mammals, such as mice, the weasel, and even the fox, are known to
destroy them; and quite a fauna of Insects may be found in them; the
relations of these to their hosts are very little known, but some
undoubtedly destroy the bees' larvae, as in the case of Meloe,
Mutilla and Conops. Birds do not as a rule attack these bees, though
the bee-eater, Merops apiaster, has been known to feed on them
very heavily.
The genera of social bees known as Melipona, Trigona or Tetragona,

may, according to recent authorities, be all included in one genus,
Melipona. Some of these Insects are amongst the smallest of bees,
so that one, or more, species go by the name of "Mosquito-bees."
The species appear to be numerous, and occur in most of the
tropical parts of the continents of the world, but unfortunately very
little is known as to their life-histories or economics; they are said to

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Neonatal Simulation A Practical Guide

1st Edition Lamia M Soghier Beverley

Healthcare Simulation Research A Practical Guide Debra

Equine Neonatal Medicine 1st Edition David M. Wong

Textbook of Neonatal Resuscitation 7th Edition Gary M

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Healthcare simulation : a guide for operations

Simulation A PRACTICAL GUIDE

Editors: Lamia Soghier, MD, MEd, CHSE, FAAP, and

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Melanie Burke, MRT (R) Christopher E. Colby, MD

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Heather M. French, MD, MSEd Elizabeth A. Hunt, MD, MPH, PhD

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NeoSim.indb 6 2/21/21 12:13 PM

Rachel A. Umoren, MB, BCh, MS, FAAP Alexander Wood, BScN

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2. Scenario Design .........................................................................................................................17

3. Simulation and the Neonatal Resuscitation Program ............................................................33

4. Mannequins and Task Trainers .................................................................................................45

5. Simulation for Neonatal Airway Management .......................................................................59

6. Umbilical Catheter Placement..................................................................................................75

7. Simulation for Infant Lumbar Puncture Training ...................................................................85

8. Neonatal Thoracentesis and Chest Tube Placement Simulation ...........................................95

9. Simulating Neonatal Pericardial Effusion and Cardiac Tamponade ...................................107

10. Neonatal Exchange Transfusion.............................................................................................121

11. Extracorporeal Membrane Oxygenation Simulation ...........................................................127

12. Extracorporeal Life Support Organization Training and Education ...................................141

14. Boot Camps ..............................................................................................................................161

15. Simulation in Neonatal Global Health ...................................................................................181

16. Virtual Simulation ...................................................................................................................193

17. Telesimulation for Neonatal Resuscitation Education and Training ...................................209

18. In Situ Simulation ....................................................................................................................221

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19. In Situ Simulations for Testing New Health Care Environments..........................................237

21. Standardized Patients.............................................................................................................271

Introduction to Debriefing ...........................................................................................................329

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Lamia Soghier, MD, MEd, CHSE, FAAP

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Applications of Learning Theory

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What Is Learning Theory?

Step 1. Problem Identification and General Needs Assessment

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Step 2. Targeted Needs Assessment

Step 3. Goals and Objectives

Step 4. Educational Strategies

Step 6. Evaluation and Feedback

Dreyfus Five-Stage Model of Skill Acquisition

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