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HealthSeptember 19, 2018

Increasing fidelity and realism in simulation for nursing students

Written by: Sheri Howard, Ph.D., RN, CHSE

Fidelity in simulation is key for a successful transition from nursing education to clinical practice. Watching students grow and learn using simulation-based learning to develop critical thinking skills, decision-making skills, and have those “light bulb moments" is one of the most rewarding parts of being a nurse educator.

Simulation-based learning in nursing education

Simulation-based learning occurs in a safe environment where structured activities, that represent actual or potential situations, facilitate learners’ development of knowledge, skills, and attitudes. Simulation is being used in nursing education more than ever before and is an attempt at replicating reality to help students practice and learn in a safe environment. In healthcare education, simulation tries to replicate some of the essential aspects of a clinical situation so that the situation may be more readily understood and managed when it occurs in clinical practice. Bridging the gap between didactic (classroom) and clinical areas (practice) are needed for students to develop the knowledge, skills, and attitudes needed to succeed in the clinical arena.

Nurse educators are struggling to meet the dynamic needs of a complex health care system that is seeing patients with extremely high acuity. Simulation-based education strategies can be applied to structure learning experiences to any area a student needs improvement or needs to develop competency. The struggle with recreating these experiences can be with realism and fidelity in a simulation. The simulation must be realistic, and therefore more believable, in order for the students to learn. 

Four qualifiers for simulation in clinical training

The National Council of State Boards of Nursing released the results of a landmark study in 2014. The study identified four qualifiers, that when used, indicated that up to 50% of the traditional clinical time could be successfully replaced with simulation. Fidelity and realism are a large part of ensuring that high-quality simulation is being used in nursing education.

1 - The use of International Nursing Association for Clinical Simulation and Learning (INACSL) standards for best practices

2 - Trained simulation faculty

3 - High quality simulation

4 - Rigorous structured reflective debriefing.

What is fidelity in simulation?

Fidelity refers to how closely a simulation imitates or amplifies, reality. Miller (1990) indicated that action, or what a person does, is built upon their knowledge, competence, and performance. As a student increases knowledge, competence, performance and action, the level of fidelity is increased in a simulation experience. The higher the fidelity, the more a student does and therefore the more opportunities there are for learning.

3 levels of fidelity

Low fidelity simulation builds knowledge

The simulations in this category will feel the least real to the learner. These can include static models and two-dimensional displays. These can also be task trainers designed for specific task or procedures such as IV arms or CPR manikins.

Mid fidelity simulation builds competence

These simulations are more realistic and allow more opportunities for learning. Examples would be full body manikins that mimic patients by having breath sounds, bowel sounds, and heart sounds, and allow students to perform procedures such as IV insertions, Injections, NG tube insertion, tracheostomy suctioning and Foley catheter insertions.

High fidelity simulation builds performance and action

These simulations are the most realistic and maximum interaction of learners in an environment that closely resembles reality. These are full body computerized manikins that replicate the anatomy and physiology of a real patient. Many of these manikins have the ability to talk which allows students to develop communication and problem-solving skills. High fidelity manikins also have the capability to run pre-programmed scenarios.

3 types of fidelity in simulation

  • Conceptual fidelity: Ensures that the scenario makes sense. Is the lab work or medications consistent with the signs and symptoms the patients are exhibiting? Subject matter experts should be used to review sceneries to maximize conceptual fidelity (Rudolph et al., 2007; Dieckmann et al., 2007).
  • Physical fidelity: The degree to which the simulator duplicates the appearance and feel of the real system (Alexander, Brunyé, Sidman, & Weil, 2005).
  • Emotional or Psychological fidelity is the extent in which a simulation can duplicate or capture the real task by using a simulated task and make the student feel as if it is real (Munshi, Lababidi, Alyousef, 2016).
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What is realism in nursing simulation?

Realism is defined as representing things or situations in a way that is accurate or true to life.  In the simulation, it is important to make a simulation experience as real as possible. This is accomplished primarily by having the students perform the task and not just pretend to do it. The word pretends should be strictly prohibited in all simulation labs. Pretend is defined as to give the false appearance or to represent falsely. If one pretends to be sick, that would only consist of lying in bed, but when an illness is simulated, there are actual signs and symptoms of the illness.

Simulation is not pretended and students should be doing a task and not pretending to do one. If the simulation calls for an insertion of an IV and for a medication to be given IV push, then the students should start an IV and push the medications. Stating that you would do something and actually doing it is two entirely different experiences. It is also important that students actually chart what they are doing. This can be done using a paper chart where students write out a narrative of what they did for the patient or by using a product such as Lippincott DocuCare that teaches the students to critically think about documentation while using an electronic medical record.

The level of realism must be determined as well as the type of simulation that is being used. Is this a unit specific simulation? If so, the specific equipment used in each area should be used for that simulation. The medications and supplies that are specific to the clinical unit should be used as well. Is the simulation being held in a simulation lab or is it an in-situ simulation? An in-situ simulation takes place in the actual work environment, using the equipment and supplies that are used in these areas. This area could include the emergency room, operating room, labor, and delivery or on a pediatric unit. An in-situ simulation allows for the most realism because it occurs in the actual unit.

Manikin or simulated patient?

Another question to ask is whether this will be a simulation involving a manikin or will a Simulated Patient (SP) be used? An SP is an actor that participates in the simulation as the patient or family member. These can be professional actors, students, faculty, or volunteers that receive special training to simulate symptoms or problems that a real patient might have.

“SPs are lay people who are trained to portray a patient with a specific condition in a realistic way, sometimes in a standardized way (where they give a consistent presentation that does not vary from student to student). Simulated or standardized patients are now almost ubiquitous in modern medical education programs. Their use is firmly based in theories of medical education including experiential learning, deliberate practice, and situated learning. SPs are central to teaching and assessment in undergraduate, postgraduate, and continuing education across many different educational contexts and cultures. SPs can be used for teaching and assessment of consultation, clinical and procedural skills—in simulated teaching environments or in-situ. They are involved in a range of teaching and learning: from simple communication skills to highly skilled advanced communication; from systems-based examination to complex hybrid simulations. All SPs play roles but SPs have also been used successfully to assess learner performance and give feedback” (Abe, Cleland & Rethans, 2013).

Choi, et al.(2017) used the below illustration to show the connection between simulation, fidelity, and realism and how this can increase the engagement of students. The more engaged students are the more opportunities they have for learning. Nurse educators should remain vigilant to find ways to stimulate the engagement of students through creative means (Noel, et al., 2015).  

Simulation and nursing student engagement

Words are very important and nurse educators should be mindful of the words they use. Often universities refer to a hospital experience and a simulation experience as two different things. A suggestion to improve the realism of simulated experiences would be to call it “on campus clinical” and “off-campus clinical”. This sends a message to the students that the experiences they have in the simulation lab are comparable to those experienced in a hospital.  Many times, a well-designed on-campus clinical can be more beneficial to students because these can be designed to give the students an experience they may not get at an off-campus clinical experience. One thing that is lacking at a clinical site is control.

Educational control during nursing clinicals

When students are in the hospital, many times instructors do not have much control. Instructors may or may not be in control of the patients that the students are assigned to and even if the instructor does have some input into that decision, that too could change by the time the student arrives.

Educators have control over the simulation. This includes what disease patients’ exhibit, what complications the patient develops, and which students are assigned to take care of that patient and what it is that we want them to do.

Another area of control is the simulation space. Nurse educators should make every effort to ensure that the room and mannequin are as realistic as possible. One way to accomplish this is by using moulage. Moulage is a French word for “casting or molding” is the art of creating lifelike substances (injuries, wounds, or fluids) to assist in providing shock desensitization, realism, and, training techniques to simulation. Because so much of nursing assessment is based on sensory experiences- what is felt, seen, heard and smelled, increased realism provides the missing link to the story.

Tips for increasing fidelity and realism in simulation

  1. Use The National Council of State Boards of Nursing Qualifiers when designing a simulation. Fidelity and realism are a large part of ensuring that high-quality simulation is being used.
  2. Choose the level and type of fidelity that is appropriate for the simulation as well as the appropriate scenario to maximize student learning.
  3. Pre-brief students
    1. Simulation is a learning exercise, not a punitive evaluation
    2. Instruct students to act exactly like a real-life setting
    3. Give students a report at the beginning of the scenario and instructions that charting must be completed – like at a hospital (off-campus clinical). 
  4. Give a few minutes after report for the students to plan as a team before starting the scenario.
  5. Have the manikin operator, who is the voice of the mannequin; give “hints” if the student is really struggling. 
  6. Make it as real as possible. Use equipment used in the clinical setting. Never, Never, Never use the word pretend in simulations.
  7. Utilize moulage when possible. Use sounds, smells, and visual components to make it real for the students.  Remember, a picture is worth a thousand words-paint the picture for your students.
  8. Ask yourself if the simulation is helping your students learn the important concepts of the course, and are you allowing them to put those concepts into action?

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