I asked our sim lab director for comments on this question and her response is: "Currently our use of low fidelity simulation is not focused on workplace events.

We generally refer to low fidelity simulators as task trainers which students utilize these for student practice opportunity for select interventions and skills such as injections, IV initiation, catheterization, wound care. Faculty are encouraged to include a case study type description of a potential client as a way to introduce and expand clinical decision making around the particular skill completed on the task trainer. Some questions may be related to cultural considerations, gender, or age, all elements which should be taken into consideration.

Our work with students and work place events occurs with use of the high fidelity manikins and scenarios which involve small groups of students 2-3 working through a clinical situation which requires integration of information, clinical decision making, provision of care- which can involve the need to work with other health care team members. We have found that existing scenarios that usually come with the system are a good starting point and the physiological changes that are a part of the program do reflect clinical changes seen in patients. We usually add context and specifics that we feel support the student learning when we build our cases.

The different perspectives of care provided can sometimes arise when students are working in groups and may be centered around the “how” should we do this, and we have seen that the approach taken may be very reflective of the clinical experiences and setting the students are in. We spend a fair amount of time during the debriefing of the simulation encouraging the participants to bring forth their different perspectives- allowing time for others to develop an understanding of what occurred, and why things happened in a given way- reflecting on how it might be done differently. We approach debriefing using an inquiry based approach- Can you help me understand why you approached the situation this way- or I noticed that this occurred can you assist us un understanding what you thinking at that moment- trying to see things from many different frames.

We have had our students participate in a high tech scenario at the Alberta Children’s Hospital which does bring together nursing, medical, and respiratory students- with a large focus on team (interprofessional) communication and interaction.

Pat Morgan R.N. M.S.N.

Director of Clinical Simulation Learning Center

University of Calgary

Calgary, Alberta Canada

I think it depends what medical discipline you are in. Croskerry and Graber have spent time looking at cognitions and analysis of events with regard to critical incidents, as well as practice in emergency medicine. I have just spent four years exploring cognition and decision making in obstetric care looking at both intrinsic and extrinsic factors. This includes cognition, situation awareness; systems and human factors so takes it into a functionality within a broader context. I have a lot of references in these areas if you interested/

Sharon

Bryce another thought here, there was an RCT done on this very thing too with regard to the SaFE study in the SW of England where they looked at high fidelity v low fidelity v basic training with regard to Obstetric emergency drills and a module within this was looking at team skills, including communication, situation awareness etc that I was involved with. There has also been work done in Bristol in anaesthesia. Again would be happy to share the references with you.

Sharon

You might find this paper useful for designing scenarios to complement the learner group:

Bush MC, Jankouskas TS, Sinz EH, Rudy S, Henry J, Murray WB. A method for designing symmetrical simulation scenarios for evaluation of behavioral skills. Simulation in Healthcare 2007;2(2):102.

Also this one:

Beaubien JM, Baker DP. The use of simulation for training teamwork skills in health care: how low can you go? Quality & Safety in Health Care 2004;13 Suppl 1:i51-6.

Warm regards,

Robyn

I currently run a mobile simulation program that travels to 10 hospitals in southeastern NC. I utilize low fidelity simulators (task trainers) in conjunction with high fidelity simulators. Although my audience focus is mainly nursing staff, I also assist in training residents and allied health care providers. Consider the following scenario for emergency care: A patient arrives with a traumatic injury, driven in by friends. If the simulator does not allow for intravenous access, someone on the team must establish venous access using the skill trainer before fluid resuscitation can commence. According to the training audience, you can use low fidelity simulators quite effectively in the demonstration of patient transfer safety, demonstration of proper CPR techniques, etc. It really depends on the equipment you use and the objectives you set for the student.

I am wrapping up utilizing a simulated clinical scenario - which will be viewed on line by a large cohort for a research project. The scenario counts on the observer to identify elements of group interaction and report. Its not perfect - but has tremendous utility and scale ( we are enrolling over 150 healthcare practitioners ). So to specifically answer your questions: I believe we are trending toward group interaction and at least in my current research , it is a virtual replication of real clinical scenario. Hope this helps

I have provided In-Situ training for residents and nurses in L&D, and perform scenarios with full OR teams and ED staff. I do have high fidelity simulators for use in involved scenarios, but they are not needed for OR fire drills and team communication skills. Obviously, looking at interaction is an important aspect of simulated training use, another is to assure practitioners maintain excellent assessment and critical thinking skills.

Hi Sharon,

I am a law enforcement trainer and attempt to apply the current state of HF knowledge to my courses. Any info that you have that you believe would apply to my domain would be greatly appreciated. You can reach me at: [email protected].

Thanks to all,

Pappy

I asked our sim lab director for comments on this question and her response is: "Currently our use of low fidelity simulation is not focused on workplace events.

We generally refer to low fidelity simulators as task trainers which students utilize these for student practice opportunity for select interventions and skills such as injections, IV initiation, catheterization, wound care. Faculty are encouraged to include a case study type description of a potential client as a way to introduce and expand clinical decision making around the particular skill completed on the task trainer. Some questions may be related to cultural considerations, gender, or age, all elements which should be taken into consideration.

Our work with students and work place events occurs with use of the high fidelity manikins and scenarios which involve small groups of students 2-3 working through a clinical situation which requires integration of information, clinical decision making, provision of care- which can involve the need to work with other health care team members. We have found that existing scenarios that usually come with the system are a good starting point and the physiological changes that are a part of the program do reflect clinical changes seen in patients. We usually add context and specifics that we feel support the student learning when we build our cases.

The different perspectives of care provided can sometimes arise when students are working in groups and may be centered around the “how” should we do this, and we have seen that the approach taken may be very reflective of the clinical experiences and setting the students are in. We spend a fair amount of time during the debriefing of the simulation encouraging the participants to bring forth their different perspectives- allowing time for others to develop an understanding of what occurred, and why things happened in a given way- reflecting on how it might be done differently. We approach debriefing using an inquiry based approach- Can you help me understand why you approached the situation this way- or I noticed that this occurred can you assist us un understanding what you thinking at that moment- trying to see things from many different frames.

We have had our students participate in a high tech scenario at the Alberta Children’s Hospital which does bring together nursing, medical, and respiratory students- with a large focus on team (interprofessional) communication and interaction.

Pat Morgan R.N. M.S.N.

Director of Clinical Simulation Learning Center

University of Calgary

Calgary, Alberta Canada

I am particularly interested in researching effectiveness of simulation in relation to learning outcomes in mental health. The reality is that we have to use scenarios, exemplars and vignettes because you cannot 'guarantee' a student witnessing such a clinical event in practice. From my experience so far, analysis, evaluation and de-briefing are all useful tools for drawing out critical thinking and perspective rather than the quality of the scenario itself. However, mental health is very grey and non-linear so scenarios and other simulation methods need to be much more analytical regarding responses and predictable outcomes. Can anyone else share their experiences and need for simulation in MH and why??

Great contributions to the conversation by all. @Robyn, thank you for the references. @Sharon, I am interested in reading more about your work.

Equipping people for the workplace is an ongoing challenge. Key to the efficacy of simulation for whole events seems to be the quality of face to face conversation. Future simulation design will need to better connect people across complex tasks.

That is, moving from action (time based tasks) and interaction (impact of individuals and teams on operations) to better understand transactions (how people make sense of an event within its operating system). I am following John Dewey and Arthur Bentley (1949) in 'Knowing and the Known' here. Do we need a human centred taxonomy or terminology that will explain human behavior in simulation settings?

The fidelity (how realistic) and validity (how well the target environment is represented) of different approaches to role and context (how people recognize what is going on) during a simulated event warrants greater study in healthcare... Do you agree?

Hi Bryce absolutely but there is research out there about the limitations of heathcare high and low fidelity simulations and how they are good for procedural factors. However, humans beings and human individual response patterns when the situation is real and the emotional decision making factors, including loss of situation awareness, is difficult to simulate. This is often due to HCPs knowing that they are mannequins and the outcome result not being real is impossible to recreate with the element of a consciousness that knows it is not for real. e.g can never fully simulate a full post-partum haemorrhage to its full extent and therefore the full emotional effect on decision making and their interaction within the systems. Simulations are good for the procedures without the 'human cognitive element ' to a certain extent.

With regard to studying how individuals within healthcare recognise what is fully going on is what we are researching here at the University of Gloucestershire; looking at fire fighters; medicine and military within the context of situation awareness and decision making. Part of this includes the role of simulations, low and high fidelity, and then looking at this in real time within the workplace.

Simulations absolutely have a good part to play as part of the training and updating process, but in terms of preparation within a real emergency or general working practices, there is a gap between the two. The human factor aspect tends not to be included or trained within these simulations, as Croskerry refers to them as 'cognitive dispositions to respond' which become the difference between good decisions and poor ones often.

Sharon

At Florida Atlantic University we use high and low fidelity simulation to train nursing students, to train interprofessional teams of nursing and medical students, and to conduct research. I have just published in the Feb issue of the Journal of Hospice & Palliative Nursing the results of our using simulation to help nursing students to care for persons who are dying and distraught family members. The objectives were not "doing" but reflective "being with" the patients.

Ladd, Hickman, Grimley, Touhy (2013). Teaching end-of-life nursing using simulation. Journal of Hospice & Palliative Nursing,15(1), 41-51. doi: 10:1097/njh.0b013e3182651f6

Thank you Charlotte. I will look the paper up. I'm particularly interested in the reflective component. There should also be plenty of interest here at the University of Western Sydney in the School of Nursing, where palliative care is a research area.

Natalie, I worked with a group of researchers to use and evaluate some novel simulations with groups of MH practitioners in relation to near misses and IP team practices. They included instructor led debriefing but largely driven by the insights from the groups. I can put you in touch with them if you want to email me: [email protected]

Having opened our college simulation center, I will say that low fidelity is all we had to start. I am hoping my low fidelity you are asking about the mannequins with only vital signs? The scenarios we do start with two things: the objective of the simulation (ie teamwork, collaboration, etc) and the objective of the scenario (ie review skills, assessment, etc). Then the scenario is free wheeled with the instructor running the scenario allowed to take it any direction the students go. For example: the scenario is a pt with chest tube (leaking) however she also has GT, COPD and Foley with issues. The objective: find leak and call a rapid response. Must students ignore the chest tube thinking that the vital signs are all pointing to COPD (they give nebulizer treatments, extra oxygen, etc). Eventually the team (4 students) get the objective. I was once told by an individual I met at a conference who said: the simulation is only as good as the scenario. You can have a piece of wood in the bed as a mannequin, the scenario would still drive the experience. I also feel that the more realistic through creative moulage you can make the scenario a worthy training experience.

Alice, I love the spontaneity. We don't get to 'design' our clinical experiences in real time clinical work so why should simulation scenarios with students be any different. I agree with you about the scenario not the technology being the driver. If low fidelity is all we do, so long as the scenario permits free play and adaptation, then we have achieved much. I also like they way your students have to choose from a number of potential clinical issues. Prioritization is a key skill in assessing the deteriorating patient. Thank you for sharing.

The scenario is written with the specific student programs in mind and around a situation where collaborative communication as well as skill sets from each student iis requires. With an overlap of skill sets, students are required to efficiently determine which student provides which skills.  The debriefing is a review by the students of what went well, what were the issues, what additional info was needed what might have been done differently. Discussion also includes both ethical and legal roles of the students' profession.