Simulation is an educational and training technique used to introduce students to real-world situations while performing high-risk skills in a safe environment.1 Medical simulation use began in the 1960s with Resusci-Annie, created by Laerdal.2,3
High-fidelity simulation was introduced as a teaching and assessment tool in medical education during the early 1990s.1 The demand for high-fidelity simulation was driven by the need to decrease the acquisition time for surgeons to learn minimally invasive surgical techniques.2 Since then, high-fidelity simulation has been used in other specialties, such as nursing,4 anesthesia,1 and emergency medicine.1 Although these simulators offer a high-quality clinical educational and assessment experience, other factors to consider are cost and the time required to learn the software.
Simulators are categorized as low-, medium-, and high-fidelity5 based on their affinity to represent reality.5 An example of a low-fidelity simulator is Resusci-Annie.3,5 The SAM II Student Auscultation Manikin by Cardionics is a medium-fidelity simulator that has features with breath, bowel, and heart sounds but lacks eye and chest movement along with the ability to talk.5,6 The iStan from CAE Healthcare is a high-fidelity simulator that is a whole body manikin with computers and software designed to simulate the physiological progression of medical conditions.5,7 High-fidelity simulators can cry, talk, blink, and have chest movement during respiration.5 The computer software allows the simulator to give feedback to interventions, either manually or automatically.5
High-fidelity simulation can provide athletic training students with an opportunity to practice clinical decision-making and refine clinical skills in a controlled learning environment.4 According to the National Athletic Trainers' Association's Athletic Training Education Competencies, fifth edition, students need to demonstrate the ability to integrate learned skills and decision-making by completing clinical integrated proficiencies.8 Clinical integrated proficiencies should be performed on actual patients in real time. However, barriers exist in clinical education preventing this experience from occurring. Management techniques in the educational domain of acute care of injury and illness are used to manage low-frequency conditions that are high risk (potentially life-threatening).9 Cardiopulmonary resuscitation,9 automated external defibrillator use, and airway adjuncts are examples of low-frequency, medium-high risk injury management skills. While students are learning and practicing these skills, simulated scenarios would be appropriate educational tools to assess their proficiency.8 Other barriers to real-time evaluation of clinical integrated proficiencies include preceptor role strain and a lack of replicability to ensure athletic training students are all exposed to the same quality of educational experience.4 The pros and cons of using high-fidelity simulation are listed in Table 1.
Pros and Cons of Using High-Fidelity Simulation
High-fidelity simulators are valuable instructional tools in a clinical skills course1 for students to learn and demonstrate a primary/secondary survey and monitor basic body functions (eg, blood pressure, respiration rate, pulse rate, and heart sounds).1,8 A good use of high-fidelity simulators for students is to acquire and assess knowledge and skill in the acute care of injury and illness domain by demonstrating a primary/secondary survey, demonstrating a head to toe examination, and monitoring vital signs, including pulse rate, heart rate, respiration rate, blood pressure and auscultation (Figure 1), and airway adjuncts. Practice recognition/management skills of illnesses and conditions that fall under the acute care of injury and illness domain include shock/anaphylactic shock, sudden cardiac arrest, asthma attacks, toxic drug overdose, closed head injury (skull fracture and subdural and epidural hematomas), cervical spine trauma, open and closed fracture (Figure 2), fail chest, exertional sickling, seizures, hypothermia/frostbite (Figure 3), and diabetic emergencies.
Conducting auscultation on simulator. Normal and abnormal heart, lung, and bowel sounds can be heard.
A forearm compound fracture can be simulated. The following skills can be assessed: how to conduct a primary/secondary assessment along with controlling bleeding, splinting, shock management, and head to toe examination.
Frostbite to the fingers can be simulated.
These simulators have the ability to simulate realistic physiological signs and symptoms of medical conditions in scenarios of sudden cardiac arrest, asthma attacks, anaphylactic shock, toxic drug overdose, and shock.8 For example, in a simulated clinical presentation of anaphylactic shock, the patient is staged so that athletic training students can see the physiological signs of anaphylactic shock while the pre-programmed scenario is displayed on the classroom projector screen. As the scenario unfolds, the athletic training students see the decline of vital signs on the classroom projector screen and kinesthetically experience the same decline while monitoring the patient simulator. During this exercise, the course instructor discusses appropriate interventions for anaphylactic shock, including an epinephrine auto-injector trainer used by the athletic training students on the patient simulator as part of the intervention. Once the athletic training students correctly administer the auto-injector, the instructor can manually progress the simulation to show what occurs when epinephrine is given as the software simulates the physiological response to the epinephrine intervention. The same simulation can be run to demonstrate what can go wrong if the intervention is delayed and anaphylaxis is left to progress.
Practical examinations in the form of group and individual simulations can also be used to assess student proficiency. The group simulation would involve an equipment-laden patient who sustains cervical spine trauma. In this simulation, athletic training students work as part of a team to provide care to the patient simulator. The individual simulation would involve any of the other acute care of injury and illness skills taught throughout the course but all athletic training students will experience the same individual simulation to ensure uniformity. All simulations are treated like an examination, but during the individual simulations other athletic training students are not present in the room. Each group and individual simulation involves the background of the patient, an injury video, simulation completion (which is videotaped), and a debriefing following the simulation. The debriefing process is a critical element of the simulation process. This is a time for athletic training students to discuss their strengths and how they may improve future performance and refine clinical skills. If time permits, athletic training students should be allowed to complete the simulation a second time. After the debriefing, athletic training students complete a clinical simulation experience evaluation form. The form is used to assess how athletic training students feel the clinical simulation experience assisted them in meeting course learning objectives outlined in the course syllabus.
Before deciding to pursue simulator use in clinical education, programs should investigate other allied health care programs at their institution that may already be using high-fidelity simulators. Other programs would include nursing, physical therapy, and medical school programs. This would be a great way to pool resources and participate in interprofessional education.
- Doherty-Restrepo JL, Tivener K. Current literature summary: review of high-fidelity simulation in professional education. Athl Train Educ J. 2014;9:190–192. doi:10.4085/0904190 [CrossRef]
- Rosen K. The history of medical simulation. J Crit Care. 2008;23:157–166. doi:10.1016/j.jcrc.2007.12.004 [CrossRef]
- Laerdal. Patient simulators, manikins & more. Available at: http://www.laerdal.com/us/nav/36/Patient-Simulators-Manikins-More. Accessed May 15, 2016.
- Palmer E, Edwards T, Racchini J. High-fidelity simulation meets athletic training education: an innovative collaborative teaching project. Athl Train Educ J. 2014;9:96–100. doi:10.4085/090296 [CrossRef]
- Al-Elq A. Simulation-based medical teaching and learning. J Fam Community Med. 2010;17:35–40. doi:10.4103/1319-1683.68787 [CrossRef]
- Cardionics the Heart of Auscultation. SAM II, the student auscultation manikin. Available at: http://www.cardionics.com/sam-ii-the-student-auscultation-manikin.html. Accessed 2015.
- CAE Healthcare. Patient simulators. Available at: http://caehealthcare.com/eng/patient-simulators/. Accessed 2015.
- National Athletic Trainers' Association. Athletic Training Educational Competencies, 5th ed. Dallas, TX: National Athletic Trainer's Association; 2011.
- Tivener KA, Gloe DS. The effect of high-fidelity cardiopulmonary resuscitation (CPR) simulation on athletic training student knowledge, confidence, emotions, and experiences. Athl Train Educ J. 2015;10:103–112. doi:10.4085/1002103 [CrossRef]
Pros and Cons of Using High-Fidelity Simulation
Give students the chance to refine clinical skills used to manage rare/catastrophic conditions in a controlled learning environment.
More realistic resemblance to reality compared to lower fidelity simulators.
Replicability to ensure students are being exposed to the same educational experience.
If the student makes a mistake, the simulator can be “rebooted” and the scenario repeated.
Decrease preceptor role strain.
Tool used by athletic training professionals to measure proficiency with clinical integrated proficiencies.
Tool used by athletic training professionals to integrate technology in the classroom.
Allow students to work individually or as part of a group.
Initial cost of high-fidelity simulator.
Cost of yearly maintenance is $7,000.00 to $8,000.00 depending on type of simulator and includes on-site visit from technician and cost of replacement parts.
Require time to complete the simulation (30 to 60 min/per scenario), for the educator to learn the software and how to create scenarios, and for the students to learn and practice with the simulator prior to testing.
Designated classroom space for the simulator.