To successfully develop a simulation program, nursing faculty need a broad understanding of the tools available, the scope of their use, and the degree of their realism. With this information, faculty are better able to formulate a meaningful vision for their simulation programs.
In this article, we will review the different components of simulation and dispel the idea that they are discrete when, in fact, they are complementary. The concept of fidelity and the categories of simulation will be explained. Our goal is to provide needed background information on simulation and a framework for faculty interested in building a simulation facility.
Simulation has been used in the health care domain for more than 15 years (Bond, Kostenbader, & McCarthy, 2001; Cooper et al., 2000; Freeman et al., 2001; Gaba, Howard, & Fish, 2001; Gordon, Wilkerson, Shaffer, & Armstrong, 2001; Hjelm-Karlsson & Stenbeck, 1997; Kurrek & Fish, 1996; Mallow & Gilje, 1999; Marshall et al., 2001; Morgan, Cleave-Hogg, McIlroy, & Devitt, 2002). In the past 2 to 3 years, there has been an explosion in popularity. This popularity is multifactorial and driven, in part, by the acceptance of this teaching method by the two largest-volume markets for this tool: nursing and the military. The military’s use of simulation is understandable and correlates well with their exercise-based, experiential learning systems. Nursing has traditionally used forms of low-fidelity simulation to teach students at both the undergraduate and graduate levels, but until recently, simulation has remained expensive and time consuming. Few options and little breadth in the technology were available. However, in the past 2 years, several companies have introduced lower-cost alternatives with characteristics similar to the high-fidelity, high-cost models.
The increased use of simulation in nursing can be attributed to:
- The nursing shortage and the need to increase enrollment into nursing programs.
- A need to supplement limited numbers of clinical sites.
- Lower cost of simulation equipment.
- Emphasis on evidence-based practice and competencies.
- Acceptance of simulation as a useful tool.
- Increasing awareness of the need to address patient safety (Institute of Medicine [IOM], 2000).
- The ability of simulation to enhance clinical practice (Gaba, Fish, & Howard, 1994).
The challenges facing nursing include the rapid introduction of mixed-fidelity simulation products and the range of products available to a profession with limited information on simulation and related products. Simulation products have flooded the market during the past year. Although this would seem to be desirable, it actually presents nursing programs with an overload of products and concepts that are not backed by validation or expertise. Therefore, faculty purchase simulation equipment with little knowledge of how, when, and why to use it. This is due, in part, to a lack of useful literature and affordable consultation in the simulation domain.
This article is divided into two sections. The first discusses the concept of fidelity, a common term used in simulation. The concept will be defined and given context within the simulation domain. The second section addresses the three major categories of simulation: computer based simulation; task and skill trainers; and full-scale simulation. When combined with the concept of fidelity, this information will help faculty develop a functional, meaningful, and practical simulation facility.
The word fidelity is often used in the simulation domain to describe the accuracy of the system being used. Fidelity is defined as “precision of reproduction, the extent to which an electronic device, for example, a stereo system or television, accurately reproduces sound or images” (Encarta World English Dictionary, n.d.). Simulation attempts to achieve a high enough fidelity to convince users they are, in fact, using something that resembles what they would encounter in real life. In simulation, it is useful to divide fidelity into three categories: low, moderate, and high. The definitions are not strict, and often one simulation device can be used in both high and low fidelity capacities, depending on how it is used and for what purpose.
Low-fidelity simulators are often static and lack the detail and vitality of a living situation. They are useful for introducing and practicing psychomotor skills. However, they generally lack the realism or situational context to ensure students will be able to translate the experience into real-life situations. A good example of a low-fidelity simulator would be a foam intramuscular injection simulator. Administering injections not only requires technical skill but also relies heavily on interpersonal skills, which are difficult to demonstrate with a foam model.
A moderate-fidelity simulator offers more realism than a static, low-fidelity model. There are products from a variety of manufacturers that are good examples of moderate-fidelity simulators. They offer breath sounds, heart sounds, and pulse but may lack corresponding chest movement or functional eyes, which one would expect in a high-fidelity simulator. A comparison of two manikin-based simulators (i.e., Resusci-Anne™ and VitalSim™) would reveal that, although both are manikins, the former is a low-fidelity simulator, and the latter is a moderate-fidelity simulator. Moderate-fidelity simulators are useful as both introduction tools and tools for developing deeper understanding of specific, increasingly complex subject matter and competencies.
High-fidelity simulators produce the most realistic simulated-patient experiences. They include details that give the units personality and allow users to more closely identify with the unit as something they might actually encounter in real life. High-fidelity units must not only have the outward appearance of reality (cosmetic fidelity), but also react in realistic ways to student interventions (response fidelity).
These types of simulation units are the most costly. Manikin-based systems range in cost from $28,000 to more than $150,000. These manikins offer characteristics that we, as human beings, seek in our patients—they breathe, talk, and blink. All of these features add realism and bring students much closer to believing that what they are seeing and experiencing is real. Pulses and movement are also very compelling human features.
Beyond the physical appearance of the manikin is the need to mimic real physiology and responses. The units must be able to realistically respond either automatically or manually to physical and pharmacological interventions. It is not necessary for these units to include the specific basis for the physiology, but rather to show the visible consequence of the physiology. High-fidelity manikin simulators achieve these increased levels of realism and serve as powerful teaching tools.
With good engineering, virtual reality systems can also be classified as high-fidelity simulators. People usually imagine virtual reality systems as involving glasses and futuristic technology. Although this is one type of virtual reality simulation, a more common form involves use of force-feedback (i.e., haptics). Haptics provide tactile simulation. For example, passing a needle through muscle has a different tactile quality that passing one through skin. These simulators frequently use sophisticated, three-dimensional graphics. Therefore, they offer visual and tactile fidelity. Response fidelity is also high in these units.
Virtual reality devices with varying degrees of quality are entering the market. They remain costly and have not yet been convincingly demonstrated to be effective in training students. This is particularly important given the cost per student for these devices, compared to low-fidelity simulators. For example, intravenous (IV) virtual reality devices, with all of their components, can cost as much as $30,000. It is safe to assume that the technology will only be pertinent to teaching for approximately 3 years because new and better technologies are constantly being developed. Such an expense would require justification prior to purchase in most institutions. An argument can be made that these devices, with their automation and reporting features, could replace much faculty time and, therefore, be a cost savings. However, we believe virtual reality systems should be cautiously purchased and used. No convincing evidence has demonstrated that becoming skilled with the use of virtual reality devices translates into better clinical performance or results. These tools are primarily intended to be used in conjunction with other clinical and simulated experiences.
Categories of Simulation
Computer-based simulation involves the use of software developed to simulate a subject or situation (Gilbart, Hutchinson, Cusimano, & Regehr, 2000; Nyssen, Larbuisson, Janssens, Pendeville, & Mayne, 2002). The software may be of low, moderate, or high fidelity, and can test many aspects of learning, such as skills, knowledge, and critical thinking. These systems are also convenient to use because students may have access to these programs outside of regular class hours, which gives them the ability to practice and learn independently. Tools have been developed that evaluate individuals for knowledge, skill, and critical thinking (Del Bueno, 2001).
More recently, software packages that include these elements, as well as the element of real time, have been introduced. These programs use underlying physiological models and expect students to care for a patient in a given situation in real time. The introduction of real time is important because it is a variable that is present in every clinical situation in which health care providers work. In addition, more sophisticated programs that provide not only real-time physiology, but also the ability to adapt the system to the type and level of student involved are entering the market.
Computer-based simulation systems are also evidence based. At the completion of each session, students have the opportunity to view a debriefing analysis and a review of their actions. This debriefing can also be reviewed as a group process or individually with a faculty member. The power of debriefing or facilitation of self-assessment and peer assessment cannot be overemphasized and will be discussed in more detail in the section below on full-scale simulation.
Unfortunately, computer-based systems are relegated to two dimensions, given that they are presented on a two-dimensional screen. Advances in graphics technology allow students to view images in what appear to be three-dimensional forms, which greatly enhances the experience by more closely mirroring what students can expect to encounter in real life. The likelihood of immersing students in an exercise is directly related to their belief that what they are seeing relates to the subject at hand. We also cannot ignore the “entertainment” value of a well-represented graphical situation.
These software-driven systems include many attractive features, and it is tempting to be lured by their sophisticated graphics and “wow” factor. However, they do have certain disadvantages that faculty should carefully assess and consider. A partial list of advantages and disadvantages to these systems is found in the Table, and some elements have been listed as both advantages and disadvantages, depending on the product and site. For example, regarding cost, some software-driven interactive programs to teach equipment competence cost more than $300,000 annually for a moderate-size hospital, but other programs may be based on a fixed, onetime, cost, making them more appealing and affordable.
Advantages and Disadvantages of Computer-Based Simulation Programs
Much of the software currently being developed uses a familiar Web-based format and provides an interface that is common and recognizable to students. We believe software-based simulation will overtake other forms of simulation as it develops more fully. This prediction is somewhat intuitive, given the portability and fewer physical constraints of such systems.
Computer-based simulation is not new, and the market is largely unregulated, with little validation supporting the products. Systems such as those offering advanced cardiac life support (ACLS) certification after successful completion have not been tested in any meaningful way to demonstrate that system users perform better, equal to, or worse than individuals who took a traditional ACLS course (Doyle, 2002). Convenience is often one of the major selling points of computer-based simulation, as health care systems and providers struggle to demonstrate competence and meet regulatory requirements. This is not to say that these systems do not have value, but rather that their value is not backed by substantive scientific validation or outcome data.
Task and Skill Trainers
Task and skill trainers (e.g., Resusci-Anne) are the most common type of simulation used today. These trainers are designed to allow students to hone skills (usually technical skills) and practice techniques related to a specific area. The training provided by and usefulness of the trainer are affected by its fidelity, but this does not mean that a low-fidelity trainer is not useful. Course objectives and goals will further guide the use of these products. For example, if the course objective is to introduce students to the proper insertion and handling of IV devices, then a low-fidelity IV arm will be more than sufficient.
Task trainers vary in their fidelity. They range from low-fidelity manikins and IV arms to moderate-fidelity ob-gyn pelvic task trainers to high-fidelity virtual reality trainers. All of these trainers likely have a role in skill teaching. One well-executed study involving surgical residents who were training to perform laparoscopic procedures using a moderate-fidelity trainer showed benefit in decreasing time to “competence” in the use of laparoscopic equipment in real patients (Seymour et al., 2002).
Task trainers fall into several distinct, but at times related, categories:
- Plastic-based, nondynamic trainers.
- Plastic-based dynamic trainers.
- Virtual reality trainers with low-fidelity haptics.
- Virtual reality trainers with high-fidelity haptics.
Before these trainers can be applied to different course programs, faculty need to understand their limitations. Training using these tools can be performed in groups, as well as in the absence of a faculty member. The latter method is less preferable, given the value of an experienced clinician in such a teaching environment. Task trainers’ various degrees of fidelity can also be used to the advantage of a course. Different skill trainers can be introduced incrementally as students’ skills and confidence mature. With each new trainer the focus may stay the same or change, but can revolve around the same course objective or competence.
For example, in one session, students may begin with a static IV arm and learn the basics of handling needles and IV catheters. They can learn the sequencing of inserting an IV and the importance of preparedness. Students can then move to a virtual reality trainer that provides the haptic feedback of inserting an IV, using a realistic, graphic, screen-based interface. In this session, students refine their sequencing skills and gain an appreciation of the “feel” of inserting an IV. The virtual reality program may also provide students with some limited interpersonal communication, taking the situation from impersonal to personal and patient centered. After completing this stage, students can then learn how to assemble IV bags and tubing and attach them to IVs they have placed in static IV arms. In this example, students have learned several aspects of the core subject of IV insertion and management. Curricula with such a structure supports the idea of spiral teaching (Harden & Stamper, 1999), in which various teaching methods and foci are used to integrate acquisition of skills, clinical judgment, and knowledge.
Although using task trainers is appealing, faculty must remember there is little data to support their applicability to clinical practice (Pittini et al., 2002). It is intuitive that the more practice students get, the more likely they are to succeed. Therefore, most U.S. medical residencies and programs are based on the concept of apprenticeship, in which trainees are exposed to clinical situations repeatedly. The ultimate expectation is that trainees will be able to manage any given situation on their own through this “practice-and-learn” model. Task trainers are not real and, thus, may have limited usefulness as a standalone teaching method, unless coupled with other trainers or other teaching methods, including clinical experience. Students who learn to intubate on a plastic head reach a learning plateau because the training device is plastic and has only anatomical fidelity. High-fidelity simulations and clinical exposure must follow each training session.
Full-scale simulation is probably the most recognized form of simulation in health care. Full-scale simulation attempts to recreate all of the elements of a situation that are perceptible to students (Holzman et al., 1995; Seropian, 2003). This type of simulation can involve real people, real physiology, real interaction, real actions, and realistic responses and reactions. The environment is made to resemble the intended environment as closely as possible in order to immerse students in an experience that is the closest we can come to real life. With full-scale simulation, students must act at a higher level and must call on myriad cognitive and technical skills during the scenario. The scenario can be a simulation of a crisis or of noncritical physiology, requiring students to respond in an appropriate way.
Full-scale simulation is inherently unpredictable. Students’ actions and reactions cannot be predicted, and therefore, this method requires considerably more resources and skill than other forms of simulation. Actors, props, and other environmental elements must be considered and used when appropriate. Interpersonal interaction is also a key component of this form of simulation. The interaction may be between colleagues or with the patient alone. The physiology is often dynamic and must be responsive to the actions of the students and other people in the scenario. The scenarios are usually recorded and broadcast live to peers of the same training group.
This method is usually manikin based but can also include standardized patients and role play. High-fidelity role play is not new and has been used in nursing education for many years. Discussion of the use of standardized patients and role play is beyond the scope and intent of this article, but these forms of full-scale simulation introduce (among other things) elements of human interaction and communication, areas recognized as critical for safe patient care (IOM, 2000).
The fidelity of manikin-based simulation must be high, both in appearance and response. The simulation unit is more costly, but students tend to prefer this experience to others. Students’ preference is multifactorial but has much to do with their need to address their underlying fear, lack of confidence, and lack of exposure to clinical situations. After using this type of simulation, students will likely feel more prepared.
Full-scale simulation often involves debriefing after a scenario (Hertel & Millis, 2002; Lederman, 1992; Steinwachs, 1992). In the debriefing process, students are allowed to self-assess, as well as receive peer assessment in the presence of a skilled facilitator. The debriefing uses a video recording of the scenario to initiate discussion, and the key learning objectives are culled from the session. Debriefing is very constructive but can also be psychologically traumatic for certain individuals or when used improperly. The debriefing process should be respected, and quality debriefing must always be a priority.
The advantage of full-scale simulation is that it facilitates three types of learning in approximately 1 hour:
- Scenario participants learn by realistic experience.
- Individuals watching the live broadcast learn as observers (virtual “flies on the wall”).
- When scenario participants and observers gather as a group, they all learn by sharing their experiences in group discussion.