Healthcare Simulation in Practice

project.

Chapter 1

What is simulation?

Key points

   The terms simulation and fidelity are often misused and misunderstood

   There is often a fixation on the scenario and specifically the manikin

   Simulation is a process that includes numerous steps

   The goal of any simulation event should be effective learning and benefit to patient care and safety

   There is a need for facilitators to be educated and their skills developed in simulation theory and debriefing skills

   Facilitators need an awareness of how healthcare errors are caused and propagated

Over the last 50 years (DH 2011), there has been considerable interest in the use of simulation for healthcare education. Simulation was originally restricted to regional simulation centres for specific identified learners, often as a one-off event. Often the simulation was designed to teach clinical procedures. However, there is currently an explosion in simulation use within many different healthcare organisations. This chapter will look at what is understood by the term simulation. It will briefly mention the two main educational theories linked to simulation and discuss the concept of fidelity and realism. The different areas of simulation will be introduced and finally the subject of healthcare error will be mentioned.

The old medical education approach of ‘see one, do one, teach one’ (whilst learning on actual patients) has been described as inappropriate for the twenty-first century (Donaldson 2009) and has raised ethical questions about the use of patients as a training resource (Issenberg & Scalese 2008). Meanwhile, the reduction in teaching time and practice placements has increased the need for high-quality education. As the focus has shifted from the apprenticeship model to an outcome-based approach, simulation has been proposed as an ideal method of assessing competence.

Simulation can also be used to enhance the ad hoc nature of practice education and give all learners a standardised experience of rarer cases and incidents. Performing simulations in-situ, in the actual practice environment, allows for training of the extended team, including individuals who would not normally be the focus of more formal training. It has been found that such sessions can help detect organisational system-based risks in the clinical environment and reduce patient and institutional risk (Yajamanyam et al. 2012). Indeed, while serving as Chief Medical Officer, Sir Liam Donaldson called for simulation-based training to be fully integrated, resourced and supported by a skilled faculty to enable high-quality training (Donaldson 2009).

What is simulation?

One cannot describe how to fund, evaluate or train people to use simulation without first defining it. The prevailing confusion about the meaning of simulation is partly due to the lack of clear national simulation standards and strategies. There are also many different reasons that people may have for running simulations. The aim may be to recreate a rare or unfamiliar event so that individuals can develop experiential learning and become familiar with it. Alternatively, trainers may choose an event and repeat it a number of times so that students can learn through deliberate practice; or they may take a routine clinical event but focus on the team working and communication aspects, in an attempt to develop those particular skills. Simulation is a word that is often used and equally often misunderstood. It can actually involve a variety of different technologies and equipment (see Table 1.1, page 7). Figure 1.1 This is most people’s idea of healthcare simulation (a manikin in the Simulation Centre at North Manchester General Hospital) but it is by no means the only possible modality.

Figure 1.1

This is most people’s idea of healthcare simulation (a manikin in the Simulation Centre at North Manchester General Hospital) but it is by no means the only possible modality.

Part of the problem with establishing what is meant by simulation is the fact that people get fixated on the scenario (and specifically the manikin) and don’t always appreciate that simulation is a process with many interlinked stages that starts long before the simulation session and should continue far beyond it. David Gaba makes this point when he says ‘simulation is a technique, not a technology’ (Gaba 2004). A systematic review from the Best Evidence Medical Education (BEME) Collaboration identified 10 features that facilitators should be aware of and adopt when using simulation (Issenberg et al. 2005):

1   Feedback

2   Repetitive practice

3   Range of difficulty levels

4   Multiple learning strategies

5   Clinical variation

6   Controlled environment

7   Individualised learning

8   Defined outcomes/benchmarks

9   Simulation validity/realism

10 Curriculum integration.

Throughout this book, simulation is simply described as an attempt to ‘recreate a real life task, event or experience, providing a safe learning environment, for the acquisition of skills, knowledge, attitudes and behaviors’ (MacKinnon 2011). Note that this definition is deliberately broad, in order to be as inclusive as possible of all the different modalities of simulation. Actual patients have been included as a simulation modality, as there are times when patients are selected for training wards staffed by students or used in clinical examination training.

Simulation is often initially viewed as a tool to teach clinical procedures. However, the above definition demonstrates that it can be used not only to develop knowledge and skills but also to focus on attitudes, ways of behaving and their development. Thus, the same scenario can be used for a number of different learning outcomes. In recent years, there has been considerable interest in the use of simulation for inter-professional education, with a particular focus on patient safety (Gough et al. 2012). Innovative simulation sessions are increasingly being used to develop a greater awareness of how to recognise and prevent patient harm incidents and the human factors that can contribute to them.

Educational theories and simulation

The two main educational theories associated with simulation-based education are experiential learning (constructivism) and deliberate practice (behaviourism). David Kolb (1983) described the experiential learning cycle and recognised that learners have preferred learning styles. He described a cycle, where a learner experiences an event (concrete experience), then reflects on the event (reflective observation), forms new views (abstract conceptualisation) and finally puts these views into practice (active experimentation). Peter Honey and Alan Mumford (Honey & Mumford 1982) adapted Kolb’s experiential model and assigned four different learning styles to the cycle: activist (concrete experience), reflector (reflective observation), theorist (abstract conceptualisation) and pragmatist (active experimentation). They then developed a questionnaire to identify individuals’ learning style(s), based on the assumption that every learner has a preferred style or styles.

Each simulated learning event has elements that engage with these different learning styles, whether in the scenario, debriefing or subsequent scenario where learning is put into action. Experiential learning is described as a form of constructivism, in which learners construct their understanding of the world through their interaction with it, by means of a process of assimilation and accommodation (Bradley & Postlethwaite 2003). The central tenet of constructivism is that learning is an active process in which the lecturer acts as a guide or facilitator (Tam 2000). Because simulation is now recognised as taking a constructivist approach, we refer to those who guide the scenario or debriefing as facilitators.

Deliberate practice, in which the learner repeats a task and receives rigorous assessment and specific feedback, aims to achieve better skills performance (Duvivier et al. 2011), which becomes fluent and instinctive (Weller et al. 2012). Often, the task is a cognitive or psychomotor one (Grant 2012). There is also an emphasis on motivation and feedback (Castanelli 2009), which aligns it more to behaviouristic theory, where a positive behaviour is rewarded and any action is a learnt behaviour.

Fidelity and simulation

Fidelity (in relation to simulation) is another word that is often misused or not fully understood. It is also multi-dimensional (Beaubien & Baker 2004) and originates from descriptions of aircraft flight simulators. The term fidelity refers to how closely the simulation imitates the real-life event. Whilst imitation is the aim, it is not clear what level of fidelity is required to achieve authenticity (Bland et al. 2011).

As already stated, a simulation requires far more than just a manikin. Whilst simulation hardware is part of the process, it is by no means the whole story. With aircraft simulators, the air crew interact directly with technology and the same equipment can therefore be used in a simulator to recreate a very realistic cockpit environment. However, healthcare staff interact with people (not just equipment), and a manikin is never a perfect representation of a patient. Manikins may be described as low fidelity (for instance, a part task trainer such as a cannulation arm), medium fidelity (for example, a resuscitation manikin, perhaps with ECG and other physical parameters) and finally high fidelity (such as the very realistic human patient simulators, which can breathe, blink, sweat and react physiologically to drugs and events). As we have seen, it is not just the fidelity of the manikin that gives a simulation defined fidelity. Yet the two are often equated in research and published literature. Does a low-fidelity manikin only allow a low-fidelity simulation? Does a high-fidelity manikin always ensure a high-fidelity simulation? The answer is ‘Clearly not’.

Equipment, environment and psychology can also have varying degrees of fidelity. For instance, how far does the simulation mirror the actual environment and equipment the learner would normally work with (Berragan 2011)? Environmental fidelity includes the physical layout, the provision of other supporting equipment, and the test results that would normally be available. Psychological fidelity involves the extent to which learners believe in the scenario and whether they feel it is a realistic equivalent to an actual clinical episode.

I have to say, because of the misuse, confusion and inconsistency surrounding the term ‘fidelity’, it is not a word I often use. Gaba (2004) and others have suggested terms that better describe elements of a simulated event but these are not in widespread use.

Table 1.1: Different types of simulation

Realism and simulation

True immersive simulation occurs when we recreate the complete environment so accurately that learners cannot distinguish it from reality. It is unusual to achieve this completely within a healthcare setting (Hotchkiss et al. 2002). This is partly because of the limitations of the equipment used and also because the learners usually know that they are attending a simulation. The aim is to create a safe environment in which students are permitted to make errors.