High Fidelity Simulation in Experiential Learning
Matthew Hogan; Olasehinde B. Adebayo; Salih Nela; and Shawn Silver
Description of Strategy
Kolb describes experiential learning (EA) as acquiring new knowledge through the transformation of an experience (2015). Experiential learning is said to be the link between work, education, and personal development. Therefore, it has found its place as an essential approach to ongoing and lifelong education in the settings of higher-level education, on the job practical competencies, and personal development through the fulfilment of career development opportunities (Kolb,2015). The stages of experiential learning are typically represented through Kolb’s Learning Cycle, which consists of concrete experience, reflective observation, abstract conceptualisation, and active experimentation (Mcleod, 2017). The concrete experience is a situation or experience which is new or is reinterpreted. The fact that it describes the concrete experience as one which could be reinterpreted demonstrates that Kolb’s Learning Cycle is a cycle. The experience can offer new learning and interpretation from the same or similar encounter (Mcleod, 2017). Reflective observation of concrete experience analyses the experience for importance or inconsistencies with current knowledge (Mcleod, 2017). Abstract conceptualisation involves developing innovative ideas and theories based on their reflection of the concrete experience and preparing to apply these to a new experience (AEE, n.d.). Finally, active experimentation involves incorporating these ideas and theories into new experiences, which help provide a deeper understanding of the world around them and influence future interactions with new experiences (AEE, n.d.). Reflective practices are best done under proper guidance and are crucial for learners in health profession education (Lundquist et al., 2020).
Medical simulation has become an important part of health profession education. It offers an opportunity to provide learners to work through Kolb’s Learning Cycle and engage in reflective practices under the guidance of trained and qualified facilitators (Lundquist, 2020). Gaba (2004) describes simulation as “a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” (p. 2). Medical simulations can then be categorised by their fidelity. Fidelity is described by Ker and Bradley (2014) as “the extent to which the appearance or/and behaviour of the simulation or simulator matches the appearance and behaviour of the real system” (p.177). The fidelity of the simulation can be looked at through different lenses. Rehman looks through the lenses of fidelity of equipment, environment, and psychological aspect (1995). Equipment fidelity describes the equipment’s likeness to reality (Ker & Bradley, 2014). Environmental fidelity is the realness of visual and other sensory cues (Ker & Bradley, 2014). Psychological is the likeness as perceived by the learner (Ker & Bradley, 2014). Hi or Lo fidelity is traditionally used to describe technical sophistication. However, it relates more to the simulation authenticity and should be looked at compared to the real world and community of practice (Ker & Bradley, 2014). High Fidelity Simulation provides a realistic and authentic experience. This provides “an effective means for developing skills, strengthening competency and reinforcing professional behaviours while not putting patients in harm’s way” (CAE Healthcare, 2017).
An essential component of medical simulation is the role of the facilitator. The facilitator is an instructor who can be seen as a director of a play who assists in learning through guidance of the simulation and discussion after the simulation (Roberts & Greene, 2010). Following a High Fidelity Simulation, a debriefing session takes place. It is the role of the facilitator to help the learners make sense of the learning which has taken place during the scenario (Roberts & Greene, 2010). Their role is to guide, explain, referee, coach and discuss. The Center of Medical Simulation describes the skills required for optimal debriefing, which are continuously evaluated. They are, establish an engaging learning environment, maintain an engaging learning environment, structure debriefing in an organised way, provoke interesting discussions, explore, and identify performance, and helps trainees achieve or sustain good future performance (2010). Without adequate facilitation and debriefing, the fidelity of the simulation may have little value. The true benefit of simulation lies in guiding the learners through reflective practice. Ker and Bradley (2014) explain that learners “can then begin to formulate concepts and hypotheses concerning the experience through discussion and individual reflection. Further experimentation with newly formed concepts and experiences can then lead to further reflection on experimentation” (p. 181)
Simulation can be used to facilitate learning across either the cognitive, affective, or psychomotor domains (Ker and Bradley, 2014). High Fidelity Patient Simulation is now being used to educate a variety of health care professionals. In High Fidelity Patient Simulation in Nursing Education: An Integrative Review, Weaver found that High Fidelity Patient Simulation benefits nursing students in terms of knowledge, value, and realism (Weaver, 2011). For the purposes of this assignment, we will review three environments where High Fidelity Simulations can be delivered. We will discuss simulation centres, mobile education programs and in-situ simulation.
In the past, simulation centres were often developed for specific health care professions. Today, a common model of simulation centre is a multi-disciplinary model that can provide simulation services to a variety of health care professions, including physicians, nurses, respiratory therapists, and paramedics (Horley, 2016). In addition to providing an opportunity for single profession skills and simulation practice, these centres also offer an opportunity for integrated multi-disciplinary simulation (Boet, 2014). The Clinical Learning Resource Centre (CLRC) on the University of Saskatchewan campus is an example of an inter-disciplinary simulation training centre (University of Saskatchewan, 2021).
The exact layout of a simulation centre will depend on the health care professions that the centre serves. A multi-disciplinary simulation centre will typically feature mock-ups of the following: standard patient care rooms, emergency room and intensive care unit spaces and operating room suites (Horley, 2016). To facilitate the various stages of the simulation, process the centre can also include debriefing spaces, communication rooms, break or meal facilities and storage space. Depending on the type of mannequins and other simulation equipment being used, there may also be a requirement to store medical gases on the site of the simulation centre (Horley, 2016).
Rural nurses and other health care providers often practice in settings with limited access to continuing education resources (Smith, 2020). To help address this, mobile education services have become more prevalent over the last several years. In 2020 Premkumar and colleagues studied the feasibility of delivering mobile simulation to family practice anaesthetists in rural Saskatchewan. Although they found that there was a significant expense to delivering the program, they also found that the program was effective at bringing continuing medical education to rural practitioners (Premkumar et al., 2020). In 2012 Pena and colleagues studied the delivery of a mobile surgical education program in South Australia. They found that the use of a mobile simulation unit to deliver surgical training was feasible (Pena, 2012). In western Canada, the Shock Trauma Air Rescue Service (STARS) has delivered a mobile simulation-based education program for the last twenty years. The program provides specialised critical care training to various health care professionals (STARS, 2021). The STARS mobile education unit is set up with a mocked-up patient care space as well as a control room. The unit also features adult and paediatric high-fidelity simulation mannequins (STARS, 2021).
Over the last decade, in-situ simulation has become a more common delivery method for High Fidelity Simulation education. Petrosoniak and colleagues defined in-situ simulation as “a point of care training strategy that occurs within the patient care environment involving actual healthcare team members, provides additional benefits to centre-based simulation” (Petrosoniak et al., 2016). In-situ simulation allows healthcare providers, often while practicing in multi-disciplinary teams, to manage complex patient simulation within the care environment. In-situ simulation is particularly appealing to emergency health care providers due to the varying shift patterns, the need for specialised equipment and the complex and chaotic environments in which they often practice (Petrosoniak et al., 2016). Some of the potential challenges of delivering in-situ simulation include interfering the patient care, ensuring staff availability, and ensuring the ‘sim’ medications and fluids do not become mistaken for standard medication stock (Petrosoniak, 2016).
High-fidelity simulation has been proven to help the learners learn skills in a safe environment, transfer these skills to the clinical setting with increased confidence, improve psychological stability and clinical efficacy in medical treatment without risking patient safety. Below are listed strengths of HFS:
- What makes High Fidelity Simulation so useful is its ability to simulate realistic clinical situations and settings with no risk to the security of patients (Medley and Horne, 2005, Peteani, 2004)
- Simulation creates experiential learning, which has been shown to assist learners with the integration of content that’s necessary for safe and effective clinical practice (Medley & Horne, 2005).
- The use of high-fidelity simulation provides students with different learning styles opportunities to internalise and apply new information (Fountain and Alfred, 2009).
- Nursing research has documented simulations that equip learners with skills that may be directly transferred to the clinical setting led to increased self-confidence (Jeffries, 2007; Johnson, Zerwic, & Theis, 1999; Peterson & Bechtel, 2000).
- High-fidelity simulation enables multiple learning objectives to be achieved during a realistic and secure context for people (MHCV Presado, 2018).
- Considering that these mannequins have a high level of realism, they also contribute to the evaluation of the student’s competencies in a very robust way (McCallum, 2007). High fidelity simulators are used at the CLRC for the CanNASC (Canadian National Anesthesia Simulation Curriculum) practical examination of Anesthesia Residents.
- During the simulation, students are exposed to different situations which will occur in a hospital or our community setting, providing them with opportunities to mobilise skills in customer appreciation, make decisions, communicate, add a team, and manage the care of a simulated patient (Foronda C, 2013).
- The use of high-fidelity human simulation might positively impact a high level of cognitive skill and clinical skill acquisition (Jīn Lee, 2015).
- Based on a meta-analysis, which was conducted of 26 controlled trials, with a complete of 2,031 nursing students, the utilisation of high-fidelity human simulation tended to have beneficial effects on cognitive and psychomotor domains of learning. In an analysis of cognitive outcomes, the weighted average effect size across studies was −0.97 for problem-solving competency, −0.67 for critical thinking, and −2.15 for clinical judgment. The effect size for clinical competence of the psychomotor domain was −0.81 (Jīn Lee, 2015).
- One study confirmed the effect of high-fidelity simulation in medical education through enquiry. It has been confirmed that simulation education can affect anxiety and confidence in clinical performance and improve psychological stability and clinical efficacy in medical treatment. This has confirmed the importance of clinical practice education using high-fidelity simulation in improving the clinical competency of physicians, which is directly connected to patient safety (JH Yu, 2021).
- High Fidelity Simulation provides opportunities for repeated practice on a manikin, largely avoiding the moral concerns of practicing on real patients and potentially risking their safety (BA Klein, 2018).
As with every method, HFS has some weaknesses, which are more related to the high financial cost to establish and maintain these centres and the training of the teachers to design adequate clinical scenarios and learning objectives. Below are listed weaknesses of HFS:
- It requires a significant amount of time and energy to teach and train the teachers, as well as to prepare clinical scenarios and design learning objectives (MHCV Presado, 2018).
- Significant initial cost (Issenberg et al., 1999) and ongoing funding after the initial investment are also required to maintain a simulation program, which includes the need for sustaining equipment and continued training of personnel (Landeen et al., 2015).
- Negative transfer of training is said to occur when students learn something incorrectly or are unable to apply what they have learned in a simulation to a real-world situation (Fritz et al., 2008).
Opportunities in High Fidelity Simulation are the beneficial external elements or factors that could be derived from HFS by an organisation (Sincy,2016). For example, in medical education, Au et al. (2016) sees HFS as an opportunity for students and practitioners to carry out clinical scenarios using computer programmed mannequins by offering users real-life interaction for professional excellence. As such, the opportunities with HFS includes.
- Organisations can prepare simulated scenarios to address identified organisation learning needs and performance gaps.
- HFS creates opportunities that can help organisations improve practice through the knowledge derived from the various scenarios designed to meet learning needs (Medley & Horne, 2005; Wetzel et al., 2013; Boet et al., 2014).
- HFS training can promote healthcare personnel in continuing personal professional development (Wetzel et al., 2013).
- To an organisation, it can help promote self-directed personal learning in patient care and clinical skills
- Safety is prime to organisational operations, in healthcare HFS can help promote safe patient practice (Medley & Horne, 2005)
- It offers real-time feedback such that there is an opportunity for leaders to plan for the future of organisational improvement through the HFS scenarios
- HFS offers simulators the opportunity to make mistakes with the scenario’s setup, receive timely feedback that can help avert disastrous outcomes if such scenarios were to be carried out in real-life situations
- Opportunity to learn through interprofessional participation and group discussion.
In HFS, threats are the condition that poses a negative effect on achieving the goal (Sincy, 2016). Some threats of HFS in EA include:
- Dormant safety threats that can be embedded in HFS includes errors in equipment design and poor management of equipment (Wetzel et al., 2013)
- The health field with medical education is ever dynamic. As such, the use of technology to promote experiential learning in medical education could be faced with a constant need to change practice for conformity with the changing technological devices (Patow, 2005)
- High-fidelity simulation equipment and the budgetary need to train personnel can be expensive (Kim et al., 2016)
Tales from the Field
“STARS has provided high-fidelity simulation-based education to participants in its STARS Academy program for the last fifteen years. The STARS academy is a five-month program the provides critical care and transport medicine education to participating physician nurses and paramedics (STARS, 2021). High Fidelity Simulation in the STARS Academy is used for several of the functions described by Ker and Bradley, including training teams in crisis resource management, the management of complex clinical situations and for performance assessments (Ker and Bradley, 2014). The high-fidelity simulation within the academy program allows participants to practice clinical and non-clinical skills in a realistic environment without any risk to a patient. In my experience working as a member of the facilitation team with the STARS Academy, I have witnessed first-hand the benefits of high-fidelity simulation.” –Matthew Hogan
“As a participant, I had an introduction to simulation through nursing education utilising low fidelity simulation. This included training arms for venipunctures, pelvic manikins for urethral catheterisation, sterile bundles, and urinary catheter bundles. This gave me an opportunity to familiarise myself with the anatomy and equipment which I had learned about in textbooks. Under the guidance of an educator, any clarifications needed would be made. I would be able to practice the skills without having to expose my patients to a risk of injury, infection, or embarrassment.
My first experience with High Fidelity Simulation was with the STARS education bus. As a novice nurse, I had limited exposure to critically and injured patients. I had some education and exposure to these patients but had never reflected on the cases to take away learning. During the simulation, we did some interventions which caused the patient to deteriorate. During the debrief, the facilitator guided the group towards answering the questions as to why they deteriorated. Through that exposure to a high fidelity environment, including mannequins, environment, medication, I was able to conceptualise the teaching points of the scenario and apply them easily to the real-world setting. The simulation will be forever engrained in my memory, and I always think about it when applying interventions to critically ill patients.” -Shawn Silver
“High Fidelity Simulation has been the most used teaching method in my career as an educator. I remember my first simulation session as a facilitator using Sim Man 3G simulator, in 2008, with a group of doctors and nurses in a Megacode Station of ACLS. As they started asking me questions about the conditions of a patient, I told them to ask a patient because he could talk. They looked at me in disbelief, but on the following question, I activated the vocal response of a manikin using a tablet, saying: I had never had pain like this before, and they were shocked. One of the nurses said: “Wow, I cannot believe that this damn dummy really talks”. I asked them to treat him as a real patient and try to help him as you would help your patient in ER. During debriefing, everyone expressed their shocking surprise moment, hearing responses from the manikin and having vitals changing in a monitor in real-time as they were managing the case.
High Fidelity Simulation is the backbone of medical education for medical students and residents at the Clinical Learning Resource Center, University of Saskatchewan. There is a persistent dedication of the educators at the College of Medicine (undergraduate and postgraduate) to design high-quality scenarios, matching educational goals and objectives for all levels of learners. Simulations are done with high realism of clinical situations, designed to help learners perform different skills, manage different clinical conditions and improve team communication skills. We have witnessed so many surprise reactions and “wow” moments from the learners of all levels. I remember the reaction of the R5 Anaesthesia Resident after he saw smoke coming from the Endotracheal Tube during Anaesthesia Fire Simulations stating: “In my Anaesthesia training I have seen so much cool stuff during simulations, but it would never cross my mind that you will be able to generate smoke coming from the manikin through ET tube. That was such real and unbelievable.” – Salih Nela
“My first experience with high fidelity simulation was at the University of Regina. During one of the nursing courses laboratory sessions. It was an experience that I have lived to remember to date. The scenario provided me was a patient going through a hypovolemic shock. No one told me the patient situation. The only thing I had was the patient, health records, situation that brought the patient to the hospital, laboratory results, vital signs, and the patient list of medications. Been my first time with high fidelity simulation, I was confused. After some moments of deep relaxation, I was able to understand the situation I was dealing with fully, and I provided care for my patent holistically. Something that made this experience stands out is that everything I did, both right and wrong, at this first High Fidelity Simulation, I still remember everything to date. It is a very good experience that is difficult to forget.” –Olasehinde Adebayo
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