Realism and Fidelity How Important are They for Simulation Education

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Realism and Fidelity-How Important are They for
Simulation Education?

• Kristen Nelson, M.D.

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Disclosure

• Laerdal Foundation grant

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Objectives

• To introduce simulation as an educational
  methodology.
• To discuss how effective simulation can enhance
  learning.
• To define realism and fidelity in medical
  simulation.
• To discuss methods that can be incorporated into
  simulations to enhance realism.

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Definition of Simulation

• Replicates or imitates the real clinical
  environment
• Fidelity refers to correspondence to fact,
  reality
• May be achieved in many ways
• Environment/Location (in-hospital, OOH, specific
  type of room)
• Equipment
• Personnel/Team Components

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Why Simulation?

• Patient safety is paramount
• See one, do one, teach one is no longer
  accepted as the optimal way to learn
• Patient expectations of competency
• New technologies

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Benefits of Simulation for Learners

• Provides learning opportunities for repeated
  clinical exposures without patient harm
• Practice on plastic first (Hunt et al)
• Gives learners permission to fail
• Safe learning environment
• Experiential learning
• Reflection in action during simulation
• Reflection on action during critical review of
  experience

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Best Evidence Medical Education (BEME) Review-
Issenberg 2005

• Factors of simulation based education that
  influence effectiveness of learning
• Providing feedback
• Repetitive practice
• Curriculum integration
• Controlled environment
• Individualized learning
• Defined outcomes
• Simulator validity

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How Can Realism in Simulation Be Defined?

• Physical components
• Relational components
• Psychological components

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Physical Realism

• Environmental replication
• Room set-up identical vs in-situ
• Location of equipment (placement of drug box
  where it would be found normally)
• Equipment replication
• Using identical equipment
• Defibrillators, IO needles, IV pumps, etc
• Action replication
• Inserting an IO
• Discharging the energy from a defibrillator

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Relational Realism

• How actions relate to one another
• Pulse ox waveform is lost in unconscious
  patientpulselessnessinitiate CPR
• Actions have physiological consequences
• Pt in shock
• Action insert IO with rapid infusion of fluids
• Consequence re-establishment of perfusion

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Psychological Realism

• How individuals relate to one another
• Individual training/assessment
• Team training/assessment
• Is the emotion elicited similar to what would be
  seen in the actual setting

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Methods to Enhance Realism

• Establishing time constraints or using real time
• Use of confederates
• Use of standardized patients
• Use of audiovisual adjuncts
• Augmentation of mannequin
• Moulage
• Use of cold towel/ice just prior to simulation to
  mimic poor perfusion

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How Do You Create An Effective Simulation

• Define the learners- individual vs. team
• Define learning objectives
• Identify type of simulation (level of
  fidelity/realism) that best matches learning
  objectives
• Create and implement a curriculum for repetition
  of exercises- personnel, time, facilities,
  support, budget, barriers
• Evaluate stated objectives

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Simulation as a Tool

• Defining the purpose/objectives of session
  determines the tools you need
• Teaching/Education
• Training
• Evaluation/Competency
• Research

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Matching the Objective to the Equipment

• Computer-based
• the simulated exercise, problem solving,
  interaction and feedback is all driven by the
  interaction with a computer program
• Ex ACLS Heartcode, Laerdal Microsim

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Matching the Objective to the Equipment

• Low fidelity mannequins or partial task trainers
• Use to practice basic or component skills
• Most commonly used to teach a psychomotor skill

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Matching the Objective to the Equipment

• High-fidelity mannequin-based
• for complex team training or scenarios requiring
  integration of knowledge, attitudes, skills
• Usually based around a clinical scenario
• Instructor-driven vs computer-driven

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Fidelity in Simulation

• High Fidelity
• Actions have consequences
• Monitor interaction
• Learner assessment
• Chest rise
• Presence of pulse
• Communication
• what your assessment is
• Make time real

• Low Fidelity
• Actions dont have consequences
• Usually need instructor to define assessment
• No chest rise
• No pulse
• Communication
• what to do
• Make time real

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Example of Individual Learning

• Learners novice paramedics
• Objective IV or IO access
• Environment/simulation partial task simulator
• Evaluation proper insertion of vascular access
  device

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Example of Individual Learning

• Learners novice paramedics
• Objective Identification of patient that
  requires IO access
• Environment/simulation low vs high-fidelity
  mannequin
• Evaluation proper identification of sick
  patient, efficiency of IO insertion, etc

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Example of Team Training

• Learners novice and experienced paramedics
• Objective Identification of patient in shock
  that requires IO access and fluid administration
  (implementation of guidelines)
• Environment/simulation low vs high-fidelity
  mannequin

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Conclusions

• Simulation can be used
• - to diagnose deficiencies in health care team
• and individual performance
• - to test the effectiveness of interventions
• - as an educational tool to improve
  resuscitation
• knowledge and skills
• - as an evaluation tool for competencies

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References

• Scalese RJ, Obeso VT, Issenberg SB. Simulation
  Technology for Skills Training and Competency
  Assessment in Medical Education. J Gen Intern
  Med. 2007 23(Suppl 1) 46-49.
• Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL,
  Scalese RJ. Features and uses of high-fidelity
  medical simulations that lead to effective
  learning a BEME systematic review. Medical
  Teacher 2005 27 10-28.
• Ker J, Bradley P. Simulation in Medical
  Education. Association for the Study of Medical
  Education. Edinburgh ASME, 2007.
• Kern DE, Thomas PA, Howard DM, Bass EB.
  Curriculum Development for Medical Education A
  six step approach. Johns Hopkins University
  Press Baltimore, Maryland, 1998.
• Norcini, JJ. ABC of learning and teaching in
  medicine. BMJ 2003 326 753-755.
• Rethans JJ et al. The relationship between
  competence and performance implications for
  assessing practice performance. Med Educ 2002
  36 901-909.