Attribution-.

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NWSEN Simulation Faculty Development

Introduction to Simulation Training

NWSEN Simulation
Faculty Development
Simulation Faculty Development Programme
Acknowledgements

Thanks to
• Doogie Whitcombe (CMFT NHS)
• Leah Greene (MMU)
• Mark Hellaby (NHS HEE- North West)
• Reviewers from the faculty development working group and other individuals
• Nick Moseley (Moseley Multimedia Ltd)

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Course Menu
Select the Course Menu option buttons below to go to a section. Select the
Resources button to access additional documents and useful links.

Once you've finished the Tutorial, you can take the Assessment. The course will only
show as completed once you've passed the Assessment. You are required to achieve
80% in the assessment in order to pass.

• Tutorial

• Assessment
Learning objectives
After completing this module, you will be able to:

• Clarify the key terminology used in simulation

• Define the applications, key drivers and limitations of simulation
• Identify the entire simulation process
• Describe some advantages and disadvantages of simulation
• Recognise the range of simulation modalities.

Click on the Next Button to move on.

What is simulation?
Professor David Gaba, an American anaesthetist considered to be one of the fathers of
modern simulation practice, presented this definition of simulation.

Simulation is a technique - not a technology - to replace or amplify real

experiences with guided experiences that evoke or replicate substantial aspects
of the real world in an interactive manner - Gaba 2004

Note his emphasis on replicating real life experiences rather than the equipment we use.
This pictures shows a simulated patient working with students to deliver a high degree of
realism.
The scope of Simulation
Simulation is not just about training with manikins but should focus more on the
educational process. It can involve a variety of modalities as shown below, from
detecting organisational and system issues that could go unnoticed until there is a real
incident, to improving human factors in training staff how to work together as a multi
professional team - with opportunities to learn from mistakes.
What simulation achieves
Simulation can do much more than just teaching clinical skills.

Doing simulation in-situ, in the clinical environment, can help detect any issues
with the systems, policies and practices within an organisation that may not work.
Many system errors go unnoticed until there is a real incident. Conducting simulation in-
situ is a great way of picking up these embedded problems.

Human factors can be developed using simulation - not just people working with
people but also people working together with equipment in the organisation. Historically
in healthcare we've been very good at teaching people how to use equipment or follow
procedures but not been good at training people to work together as a multi professional
team. Simulation offers opportunities to develop multi professional education and allows
opportunities to learn from any errors. A team’s working behaviour can be successfully
developed using simulation.
The Simulation Process
Work on delivering a simulation starts long before the learners arrive. Designing and
delivering a simulation scenario involves the following process. Click on each step to
find out more.

Needs Analysis
The starting point is the needs analysis, where you determine what needs to be taught to
the learners and at what level; hence the learning outcomes are developed.

Scenario Development
Scenarios should be developed using a standardised framework or proforma as a peer-
reviewed evidence-based piece of work. Scenarios should be based on relevant
guidelines and standards and these should be clearly identified. Ideally scenarios should
be reviewed to ensure that they are clinically appropriate, to highlight any errors. For
example the pulse rate could be wrong for a condition.
Click here to see a sample scenario.
A simulation resource library with several hundred scenarios has been set up within the
NW to share these. Contact NWSEN for access to these scenarios.

Testing the scenario

The scenario is then tested and further developed over a period of time prior to being
delivered with a group of learners.
Course design
If you are building a course with several scenarios, you need to repeat this scenario
development process for each scenario and make sure that they all serve to underpin
the overall course learning outcomes.

Orientation
Orientation starts by introducing learners to the learning area and explaining why they
are there. Many learners arrive apprehensive because they don't understand what they
have to do.

Facilitation of the scenario

Facilitation differs from traditional teaching methods and involves knowing when to step
in and assist. It is important for the facilitator to set up a safe learning environment - we
will cover this in more detail later in this course.

Debriefing the scenario

After the scenario has been completed we then need to debrief it. Potentially no deeper
learning has occurred yet because the learners have perhaps carried out a series of
actions. During the debrief these actions are discussed and evaluated and turned into
learning opportunities. It is important to emphasise positive actions and identify and
discuss performance gaps.

In the past the focus has been around simply delivering the simulation scenario but now,
from an educational perspective, we understand the importance of debriefing - the
scenario is in fact an excuse to have a debrief.

Evaluation of the learning event

Because this is an educational process, evaluation of the learning event is critical and
must be conducted routinely.
This should be a higher level of evaluation that covers more than whether learners
enjoyed the session. Ideally we need to know if learners have actually changed their
clinical practice for the better.
Fidelity or Realism?
In the context of simulation, fidelity has several meanings and is a misused and
misunderstood term.

Typically, the term fidelity is used to describe the fidelity of the simulation scenario but
also the fidelity of the simulation manikin.

Click on each option button to find out more.

Fidelity of the simulation scenario

This is often described as being made up of a number of different elements and is often
described as:
• Manikin fidelity - how real the manikin/piece of equipment is
• Environmental fidelity - how real the environment is.
• Psychological fidelity – how real the level of stress is that learners are experiencing

Manikin Fidelity
Is typically described as low, medium and high where low fidelity is a part task trainer or
static manikin and high fidelity is a computerised human patient simulator.
Issues with fidelity
The term fidelity can confuse and mislead because:

• It is taken from the aircraft industry

• The manikin fidelity is not fixed but reflects what the manikin is being used for
• There is a false assumption that low fidelity is worse than high fidelity
• There is a false assumption the manikin fidelity equates to simulation fidelity
• There is no evidence that increasing fidelity increases learning
• We are ignoring the learner buy-in and suspension of disbelief - it doesn’t need to be
that real.

Perhaps the term realism is a safer term to use.

Fidelity and educational outcome

The higher the fidelity, the higher the educational outcomes.

Is this statement true or false? Select an option and then click on the Submit
button.

• True

• False
Stepwise approach to simulation
It’s good to use the following stepwise approach when developing a skill or behaviour.

Select the option button for each step for more information.

Check first that the required knowledge is present using e-Learning, a tutorial, or
question and answer session.

Use a part task trainer in an abstract setting – for example if you are teaching
someone how to inject you would get them to use a part task trainer (an isolated arm)
that gives them the opportunity to understand how to manipulate equipment and use it
effectively.

Use a part task trainer in a contextual environment – for example attach the arm to a
real person so that not only do they have to manipulate the equipment they also have to
interact with a real person, explain things and get consent.

Use a patient simulator or standardised patient with environmental emersion – for

example during a simulation so they additionally gain an understanding of when to do
the skill in context as part of the treatment process.
Miller's pyramid
The stepwise approach aligns quite nicely to Miller's pyramid Reference 1.01, a
medical educational model.

Click on each option button to find out how.

Does - doing it competently.

Shows how - doing it with a real person

Knows how - is starting to put the equipment together

Knows – has the foundational knowledge

Best place to run a simulation
Where's the best place to run a simulation?
Click on each location to see the pros and cons.

In-situ
In-situ in the clinical area is the ultimate in environmental fidelity, with the real equipment
and the real team. It is the best place to see organisational and process issues that may
not be apparent elsewhere. The downside is that you could be in a busy clinical area
where there are other distractions and you are limited in the amount of time you have.
The simulation could also be cancelled if there are other clinical emergencies or staffing
issues.

Designated learning area – on site

This is very useful for doing more formal sessions where learners know that they are
going to be involved for 1/2 day or a full day. However, often you have to create a
pseudo team rather than a real team and staff are often ‘cherry-picked’ for attendance so
we rarely have access to the whole team.
Regional simulation facility
If available this will include experts in various fields including educational theory and
clinical practice. However, environmental and psychological fidelity suffers, as delivery
tends to be with much more generic equipment that may not be the equipment used by
learners in their own organisations.
Advantages of simulation - Question
What are of the advantages of simulation training?

List your ideas in the box below and then click on the Submit button, then click
Next to compare your list with ours.
Advantages of simulation
My advantages of simulation

Compare our list of advantages with yours:

• There shouldn't be any risk to a real patient

• Uncommon scenarios can be presented at will
• Multi-factorial problems can occur - clinical or management problems
• The same scenario can be delivered in a valid way repeatedly so that different
learners will have the same experience
• Errors can be allowed to evolve. In a clinical practice somebody would have to
stop it whereas in a simulation you can actually allow errors to evolve and carry on
as part of the learning opportunity
• Scenarios can be frozen if required - you can stop scenarios and discuss them.
Video feedback as part of the learning process can be very powerful
• In-situ simulation can test clinical systems to help develop systems and
processes within an organisation
Disadvantages of simulation
These are some of the disadvantages of simulation:

• It's not and never will be entirely real – learners need to think through how they
would have reacted in the real situation
• It doesn't remove the need for quality educators. This is often overlooked by the
people responsible for funding this who may think that a very expensive manikin will
do all the teaching by itself
• It is faculty and resource heavy
• Hyper-vigilance and simulator-itis - Learners come expecting things to go wrong
in a way they wouldn't do in real life
• You need to be careful you don't just train people to respond to manikins rather
than real patients
• In-situ training can be inefficient - some simulations may have to be cancelled
because staff can't attend or the clinical area is busy
• You have to be very careful you don't effect the real clinical area. Patients’
relatives may not know it's a simulation
• You can't guarantee the release of staff and educators to take part
The learning environment
In a simulation, learners need to be comfortable that they are in an environment where
they can express their thoughts and concerns.

Is this statement true or false? Select an option and then click on the Submit
button.

• True

• False
Safe learning environment
Here are ways of making sure that the simulation is a safe learning environment
before it starts:

• Make sure learners have the basic knowledge so when they arrive they don't feel
they are going to be tested on something new
• Introduce the session so that learners understand exactly what they are expected
to do. Explain that their role will be to respond as they do in clinical practice. If
necessary, give a demonstration or orientation to the equipment including the
manikin. Some equipment may be unfamiliar to learners
• Establish ground rules - for example that you have to respect people's opinions
even if you don't agree with them and the importance of confidentiality
Image copyright:
Manchester Metropolitan University, 2015

Safe learning environment - continued

Here are ways of making sure you have a safe learning environment during the
simulation and debrief session:

• Make it clear that it’s ok within the simulation if learners make mistakes since
this provides positive learning opportunities that can be reflected on and learnt from -
potentially this will prevent them from making the same mistake in clinical practice.
• Have more than one learner in a scenario - one person on their own reinforces the
feeling of being assessed.
• In the debrief, stress that this is a safe learning environment where we want them
to talk to us openly and work together to build an action plan that helps with
developing safe practices. It’s important they feel involved in this process.
• Having multiple scenarios or repeating the same scenario means that if learners
know that they have not done very well in one scenario they can have another go
and do better in the next one.
Section end
That ends this Introduction to simulation.

You have had the opportunity to clarify the key terminology used in simulation,
define the applications, key drivers and limitations of simulation and identify the
entire simulation process.

You should also now be able to describe some advantages and disadvantages of
simulation and recognise the range of simulation modalities.

In the next section we’ll look at educational theory and simulation training.
Course Assessment
This assessment is made up of 5 questions. 4 questions must be answered correctly
to achieve the pass score of 80%.

If you answer any question wrongly during the assessment you won’t have the chance to
try it again.

Once you've started, select the correct option or options for each question and then
click on the Next button to confirm your choice and move on to the next question. You
will be given feedback for each question you answer to consolidate your learning.

If you don’t pass the assessment, you can review the course and take the assessment
again later.

Click on the Next button to start the assessment.

Question A
Select one option and then click on the Next button to continue.

Which of the following is true about the term fidelity?

(Select one of the following options)

• Demonstrates how the more expensive equipment is the greater the learning

• Only describes the manikin

• Explains the realness of the voice of the manikin

• Is a confusing and misused term

Question B

Select one option and then click on the Next button to continue.

Simulation is which one of the following?

(Select one of the following options)

• Only about manikins

• A technology

• An educational modality used for a spectrum of activities

• Only used for teaching skills

Question C
Select one or more options and then click on the Next button to continue.

A benefit of in-situ simulation is

(Select all that apply)

• It uses the real team

• It is run in the real environment

• It tests real systems

• It can be used for continual improvement

Question D
Select one or more options and then click on the Next button to continue.

When simulation is delivered in a formal simulation area (designated simulation area)

which of these is true?

(Select all that apply)

• It is easier to run longer sessions than in-situ

• The team may not be the real clinical team

• It is the best place to test systems and process

• It is only used for teaching procedures

Question E
Select one or more options and then click on the Next button to continue.

As part of the learners orientation to the simulation the facilitator should do which of the
following?

(Select all that apply)

• Demonstrate the equipment

• Establish ground rules

• Explain the simulation process

• Discuss local housekeeping