Simulation Learning

There is inconsistent and variable terminology used within simulation literature, among professions, and across geographic locations, which can create confusion among both facilitators and participants using SBE. You will note these variations in terminology within the guide and in the associated resources.

This guide was designed for individuals both in an educational setting and a clinical practice setting, and therefore participants are from a variety of backgrounds.

• The term facilitator describes those who facilitate SBE, including educators, instructors, faculty, simulationists, debriefers, etc. 
• The term participant describes individuals participating in SBE, including learners, students, etc.
• The term simulation-based education describes all simulation-based experience or activities that occur in healthcare simulation.

Simulation is composed of 3 components:

• prebrief 
• simulated activity
• debrief.

Each of these components is guided by evidence-informed best-practice standards and will be explored in subsequent sections of this guide. In the preparation and planning stage, facilitators are required to engage in multiple activities prior to the delivery of a simulated experience. These include:

• conducting a needs assessment
• developing the simulated case scenario
• securing resources (e.g., personnel, space, equipment, etc.)

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Standards of best practice are present in most areas in healthcare and within all healthcare professions. Standards of best practice are generally formed and agreed upon by experts in a specific field or on a specific topic. They are guidelines on the best way of doing something.

The Healthcare Simulation Standards of Best practice™ (HSSOBP™) serve as a guide for integrating evidence-informed best practices in simulation-based education within academia, clinical practice and research (Watt et al., 2021). These standards were previously referred to as the International Nursing Association of Clinical Simulation and Learning (INACSL) Standards.

HSSOBP™ are designed to be relevant across all healthcare professions and in all simulation-based activities, regardless of the setting. They consist of 10 standards and a glossary of terms. Each article explains the standard, the background information that underpins the standard, and the criterion required to meet it (Watt et al., 2021). You will be introduced to many of these standards throughout various sections in this guide. The HSSOBP™ provides literature to support best simulation practices for the following individual standards:

• Professional Development
• Prebriefing: Preparation and Briefing
• Simulation Design
• Facilitation
• The Debriefing Process
• Operations
• Outcomes and Objectives
• Professional Integrity
• Sim-Enhanced IPE (Sim-IPE)
• Evaluation of Learning and Performance
• Simulation Glossary

(Watt et al., 2021)

Other commonly used standards that guide simulation-based education include:

• The Association of Standardized Patient Educators (ASPE) Standards of Best Practice
• The Society for Simulation in Healthcare (SSH) Accreditation Standards
• The Association for Simulated Practice in Healthcare (ASPiH) Standards for Simulation-Based Education
• The National Nursing League (NLN) Jeffries Simulation Framework

Healthcare simulation is guided by the Healthcare Simulationist Code of Ethics, which highlights key aspirational values for the practice of simulation:

• Integrity
• Transparency
• Mutual respect
• Professionalism accountability
• Results orientation

Psychological safety in SBE refers to an explicit or implicit feeling that participants are comfortable participating, sharing thoughts, speaking up, and discussing mistakes without fear of repercussion or embarrassment. SBE involves interpersonal risk-taking (Lioce et al, 2020). Learners are more likely to participate when they feel psychologically safe. It allows them to embrace vulnerability and being uncomfortable which can enhance their learning.

Watch:

  Building a Psychologically Safe Workplace

TEDx Talks,2014.

In simulation-based education, learners require:

• information on prerequisite knowledge and skills for the simulation
• orientation to both space and equipment
• clear learning objectives that link the simulation both to the objectives and to relevant clinical practice
• information on the process of simulation (prebrief, simulation, debriefing and reflection on practice)

Creating a ‘safe container’ for learning also includes establishing a fiction contract with the learners, attending to logistical details, and both declaring and enacting a commitment to respecting learners and showing concern for their psychological safety (Rudolph, Raemer, & Simon, 2014). Specific strategies to promote psychological safety will be discussed throughout this guide.

Purdy and colleagues (2022) expand on the idea of the ‘safe container’ to recognize that facilitators cannot ensure a safe environment for all participants in every situation, despite best efforts. Prior simulation and past life experiences, personal attributes and behaviours, and confidence levels influence how participants react and feel during simulation.

We should note that we cannot ensure that all participants feel psychologically safe. Facilitators should not present the simulation environment as an all-inclusive, safe space. To do so can worsen the impacts on participants who do not feel psychologically safe. Facilitators must also be prepared to address safety concerns. This may include: 

• Implementing a ‘safe word’ for any participant to use to halt the simulation if they are feeling unsafe, distressed or in the event of an emergency. For example, a safe word may be deployed in the event of an emergency to indicate that it is not part of the simulation, or if a participant feels unsafe or distressed because of the SBE activity content.
• Applying policies and procedures related to code of conduct and safety in the workplace.
• Being aware of other resources that participants may need to access, such as counselling services or employee assistance programs.

Fidelity refers to the extent to which various aspects of simulation combine to imitate reality (Lavoie et al., 2020). Fidelity may also be referred to as realism or authenticity. When designing a Simulation-Based Experience (SBE), an appropriate fidelity (level of realism) should be identified to meet the learning objectives/outcomes. Higher fidelity does not equate to better learning.

Types of Fidelity

Fidelity includes physical, conceptual, and psychological dimensions (Lavoie et al., 2020; Campbell et al., 2023). All three aspects work together to enhance realism and participants' engagement.

• Physical/Environmental Fidelity: The degree to which the experience replicates the appearance of a real-life situation. Physical fidelity includes the modality (e.g., standardized patient or patient simulator/mannikin), the equipment, related props, embedded participants, and the use of moulage. Examples include in-situ versus simulation lab setting, using equipment that matches that of the clinical environment, or using moulage to enhance realism.
• Conceptual Fidelity: Ensures that the simulation scenario makes sense and is realistic. For example, the vital signs and lab results reflect the diagnosis presented in the scenario.
• Psychological/Emotional Fidelity: The extent to which the simulation scenario evokes underlying emotions, feelings, beliefs, and self-awareness in the learners. Examples include the use of realistic conversation with family members and patients, time pressures, and competing priorities. (Watts et al., 2021)

Levels of Fidelity (realism)

• Low fidelity simulations lack components that can make them feel like real-world situations. Examples include the use of partial task trainers or static manikins to perform tasks or skills, or unfolding case-studies for table-top discussions.
• Moderate fidelity simulations are more realistic than low fidelity, but less than high fidelity options. Examples include using manikins that produce heart sounds, bowel sounds, and lung sounds to assist learners with solving problems, performing skills (such as IV insertions, injections, nasogastric tube insertion, tracheostomy suctioning and Foley catheter insertions) and making decisions.
• High fidelity simulations are the most realistic. Examples include using complex manikins (full body computerized manikins) or standardized patients to provide increased realism. High fidelity manikins or patients may respond verbally to learners and interventions. This allows learners to develop communication and problem-solving skills.