Increasing fidelity and realism in simulation for nursing students

Levels of Fidelity

• Low fidelity simulation: Used to build 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: Used to build 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: Used to build 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.

Types of Fidelity

• 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, Bruny©, 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).

What is Realism in 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). 

Engagement in simulation as a product of the dimensions of simulation and fidelity (Choi, et al., 2017)

Simulation and 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.

On-Campus Clinical and Control

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?

References:

Abe, K., Cleland, J., Rethans, J. (2013) Simulated patients in medical education. Oxford Medicine Online. Doi 10.1093/med/9780199652679.001.0001

Alexander, A., Brunye, T., Sidman, J., Weil, S., (2005). From gaming to training: A review of studies on fidelity, immersion, presence, and buy-in and their effects on transfer in PC-Based simulations and games.Â

Choi W, Dyens O, Chan T, Schijven, M., Lajoie, S., Mancini, M., Dev, P, Fellander-Tsai, L., Ferland, M. Kato, P., Lau, J., Montonaro M., Pineau J., Aggarwal, R. (2017). Engagement and learning in simulation: recommendations of the Simnovate Engaged Learning Domain Group. BMJ Simulation and Technology Enhanced Learning 2017;3: S23-S32.Â

Dieckmann, P., Gaba, D., Rall, D., (2007). Deepening the theoretical foundations of patient simulation as social practice. Simulation in Healthcare 2 (3) 10.1097/SIH.0b013e3180f637f5

Hayden, J., Smiley, R., Alexander, M., Kardong- Edgren, S., & Jeffries, P.R. (2014). The NCSBN national simulation study: Replacing clinical hours with simulation in pre-licensure nursing education. Journal of Nursing Regulation, 5 (2), 61-64.doi:10.1016/S21558256 (15)303355Â

International Nursing Association for Clinical Simulation and Learning [INACSL], (2013). Standards for best practice: Simulation.  Retrieved from www.inacsl.org/i4a/pages/index.cfm?pageid=3407

Miller, G. (1990). The assessment of clinical skills/competence/performance. Academic medicine, 65 (9)

Meakim, Boese, Decker, Franklin, Gloe, Lioce, Sando, Borum (2013) Standards of Best Practice: Simulation Standard I: Terminology. Clinical Simulation in Nursing. doi: 10.1016/j.ecns.2013.04.001

Munshi, F., Lababidi, H., Sawsan, A., (2015). Low-versus high-fidelity simulation in teaching and assessing clinical skills. Journal of Tiabah University Medical Sciences 10 (1). Doi 10.1016/j.tumed.2015.01.008Â

Noel, D., Stover, S., & McNutt, M. (2015). Student perceptions of engagement using mobile-based polling as an audience response system: Implications for leadership studies. Journal of Leadership Education, 14(3), 53-70. doi:10.12806/V14/I3/R4

Rudolph, J. Simon, R., Raemer, D. (2007). Which reality matters? Questions on the path to high engagement in healthcare simulation. Simulation in Healthcare 3 (3) doi: 10.1097/SIH.0b013e31813d1035

3 levels of fidelity

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).

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).