Simulation

Introduction
Simulation is a step in the circle of learning that follows knowledge acquisition, skills
proficiency and decision making learning. It is a technique, rather than just a technology that
promotes experiential and reflective learning.

Definitions of simulation

Simulations have been defined as an operating representation of central features of reality as an

attempt to give appearance and/or to give the effect of something -Barton (1970)

Simulation is a method whereby an artificial or hypothetical experience is created that engages the
learner in an activity that reflects real-life conditions but without risk-taking consequences of actual
situations.
-Rystedt and Lindstrom (2001)

Purposes of simulation

 To help students practice decision-making and problem solving skills and to develop human
interaction abilities in a controlled and safe-setting.
 By means of active involvement in a simulation exercise, a game, or a role-playing situation,
the student achieves cognitive, affective and psychomotor outcomes.
 Students have a chance to apply principles and theories they have learned and to see how
and when these principles work.

Stages of simulation

There are three stages of simulation namely:

1. Brief/Pre-brief
2. Scenario
3. Debrief

Experientlal Experientlal Reflective learning

learning learning

Briefing Simulatior Debrief reflection with

why and the real highest potential for learning
how Situaton

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Brief/Pre-brief

Briefing is a foundational part of the simulation experience that helps to prepare and orient learners
to the simulation experience. It promotes experiential learning. The pre-brief also introduces
learners to the concept of simulation, orients them to the simulation environment, equipment, and
embedded participants. The facilitator discloses learning objectives of the simulation scenario,
establishing a fiction contract (expectation setting for performance) with learners, providing logistic
details about the session, and pledging to respect the learners. It allows for confidentiality and
create psychologically safe environment for the learners which will enable to optimize their
experience in the simulation lab.

Scenario

A scenario is an outline or model of the simulated sequence of events that can be used for an
exercise or to support scenario-based training. It can be written as a narrative or depicted by an
event timeline. Simulation scenarios are designed to assess, educate, and help learners to self
identify gaps in their understanding of material or application of knowledge. It provides the context
for the simulation based on actual or potential situations and includes the objectives, target
population, description and progress of the situation, actions expected from the students.

Debriefing

"Debriefing is the heart and soul of simulation based training"

Post-event debriefings in healthcare are defined as an after-event discussion regarding performance
and thought processes of the team during the scenario to promote reflective learning and improve
clinical performance.
It is a facilitated or a guided reflection in the cycle of experiential learning. Debriefing should be
based on the pre-set learning outcomes. 80% of learning takes place in this phase. It should allow
for progression through the identified phases of debrief-reaction, analysis and summary. A
psychologically safe environment must be established in debriefing stage. It allows people to share
and reflect their feelings, assumptions and opinions. This further helps in discussing difficult topics.

Reactions Analysis Summary

Stages of debriefing

Reactions Analysis Summary

Clear the air and guide the This is the bulk of the debrief. Review what happened, what
initial discussion Spending time to understand was discussed and try to apply
"what happened and deeper it to the context
meaning into why it
happened"
Questions like"So how did you Try to understand the frame of You could say something like"

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feel this case went mind of participants, their Let us identify some take home
mental models points from this case for future
practices"

Goals of the Debrief

 To enable the participants to become aware of their reactions during a crisis.

 To help them develop tools for evaluating and analyzing their reactions.
 To effect a positive change in their behavior.

Advantages of Debriefing

 Clarify learning points.

 Introduce key issues to participants for further dialogue.
 Insight into strategies and processes that lead to good results, not just results themselves.
 Participants can begin to develop their own evaluative skills for future critical events.

Steps of Simulation Process [Designed by Goldstein and Pfeiffer (1983)]

The steps of the simulation process include:

 Experience
 Sharing
 Processing
 Generalization
 Application.

Experience
This stage involves experiencing or simulating the particular problem or situation. Four or five
participants are selected and each one of them should identify their own purpose of the exercise
and its ultimate goal.
Sharing
The second stage involves participants sharing their experiences after the exercise is concluded.
Members are encouraged to share both their observations of what, when and how they felt about
the activities or events. Often the feelings are important to reveal their comments about
objective events.
Processing
This stage involves processing the information gathered during the sharing stage. Unlike
sharing, which is done in small groups, this is generally accomplished with all the participants.
The goal of this step is to identify commonly shared experiences or perceptions and to identify

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 common themes among the group members.
Generalization
In this stage, the teacher guides the group into drawing broad implications from the experience
and resulting discussion. This is the most important phase of the entire process, and if left out,
the learning will appear incomplete.
Application
The final stage of the process is to help the participants to apply the new generalization to future
situations. Overall application phase is designed to give the participants a chance to apply the
new concepts, feelings and ideas in real-life situation.

Requisites for a good simulation process:

A successful simulation process should meet the following criteria:

 Active involvement of all the students.

 Clarity: The decisions made should be based on the clear consequences and causes of the
simulation process and resulting discussion.
 Feasibility: It measures the cost in terms of materials, space, and time against outcomes.
 Repeatability and reliability: These qualities are important because it is essential that
simulation be repeated with the same degree of reliability relative to its outcome. This
will improve the accuracy of learning as well as the credibility of the simulation process.

Role of the teacher in simulation

The teacher has an important role to organize session for students on pertinent skill to be learnt
through simulation:

Planning: It begins with choosing or developing an appropriate simulation that will meet course
objectives. Textbooks or library books should be pointed out to students so that they can prepare for
the simulation.
Teacher is also responsible for preparing the environment. When planning a simulation it is
very important if the learning experience is made to resemble real life as much as possible but in a
non-threatening way. The activity should challenge the decision-making ability of the learner. This
can be done by the imposition of:
- Time constraints
-Provision of realistic levels of tension
-Use of actual equipment or other important features in the environment in which the specific skills
will be performed.
Facilitating: After introducing the activity the teacher may take a backseat but she must be vigilant
and alert to guide the students who are trying to find their way through a difficult problem and
encourage creative thinking and act as an information resource or a facilitator.

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Characteristics of simulations

 Mirror real situations while providing control over extraneous variables that might interfere
with learning.
 Provide a mix of experiences that can be replicated for successive learners.
 Provide a safe environment in which learning has priority over patient care or system
demands.
 Focus on application rather than uncertain recall of knowledge.
 Provide immediate feedback on performance.

Uses of simulation

Simulation in healthcare offers many benefits:

 Simulations are used to synthesize cognitive, psychomotor and or affective content in the
analysis and solution of real life problems.
 Simulations provide opportunities for the practice of problem-solving and decision-making
as well as psychomotor and interactive skills, within a controlled, low-risk setting.
 A wide variety of clinical conditions can be simulated in controlled environments to produce
standardized experiences. With simulation, students and providers can gain experience with
various types of patients and cases they may not often encounter during their rotations and
shifts. This is particularly significant for training to manage emergency situations.
 Simulation technique can be used to achieve many learning objectives.
 Simulation can help nursing students gain skill in applying the nursing process.
 Learn to solve problems efficiently with minimal wasting of time and resources.
 In the acquisition of communication skills, e.g. students can put themselves in the shoes of
others (patients, families, coworkers, supervisor, and physicians) and learn something about
these people's feelings and how to interact effectively with them. They get immediate
feedback about how they affect other people learning communication.
 Decision making skills can be fostered via simulation, e.g. if the results are undesirable, one
can back track and look at the factors that led them to a poor decision. The instructor and
classmates (if a group is involved) can help the students to gain insight.
 Simulation technique can be applied to the learning of psychomotor skills, e.g. when
students practice skills in college lab using mannequins and hospital type equipment, they
are involved in a patient care simulation.
 According to Hertel and Millis, 2002; Simulation allows faculty members to take specific
information such as a client's personal characteristics; health information; family
components; and physical, mental, and emotional state-and weave it into a real-life scenario
that enhances a student's comprehension of the material because it is meaningful.
 Used to evaluate the student learning and competence.
eg Written exams have been developed in a simulation format to test the application of
knowledge.

Types of simulations

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Model simulation:
-Example: Manikins
-Typical use: Demonstration practical
-Uses: Pelvic manikins, CPR manikins
Oral simulation:
-Example: Problem based

- Typical use: Case discussions

-Use: Classroom discussion on problem-solving
Written simulation

-Example: Paper and pencil latent image

-Typical use: Teach knowledge assessment

-Use: Patient management diagnosis

Simulated patients:
-Example: Trained actor role play
- Typical use: Teach interpersonal skills
-Use: Simulated burns patient

Hybrid simulation:
-Example: Combination of standardized patients and part-task trainer.
-Typical use: Demonstration practical

Computerized simulation:
Example: Microcomputer
Typical use: Teach cognitive skills/problem
Uses: Clinical management, solving

Types of Simulation Equipment

Many types of simulation equipment are available to nurse educators. Models range from
equipment that teaches a simple, single skill (e.g. inserting an intravenous access into an arm,
assessing vital signs, such as heart, lung, and bowel sounds) to very advanced, realistic
equipment that can simulate reality-based scenarios in a clinical setting, such as an intensive
care unit. Fletcher (1995) described the term "fidelity" as the degree of accuracy depicted by the

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 simulation, compared to the real experience. Whereas static or low fidelity models are useful for
practice and testing of specific skills, high-fidelity models challenge students to make clinical
decisions based on data obtained from assessments and interventions. 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.

Low-fidelity Simulators
Low-fidelity simulators are often less in detail and vitality of a living situation. In introducing
and practicing psychomotor skill, they generally lack the realism. A good exampleof a low
simulator would be a foam intramuscular injection simulator. Administering injections not only
requires technology skill but also relies heavily on interpersonal skills, which are difficult to
demonstrate with a foam model.
Moderate-fidelity Simulators
A moderate-fidelity simulator offers more realism than a static, low-fidelity model. 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. Moderate-fidelity
simulators are useful as both introduction tools and tools for developing deeper understanding
of specific, increasingly complex ubject matter and competencies.

High-fidelity Simulators
High-fidelity simulators produce the most realistic simulated patient experiences. They
include details that give the units personality and used 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.
High-fidelity models are often life-size mannequins with features such as palpable pulses,
visible respirations, measurable blood pressure and pulse oximetry, vocal sounds, open orifices,
and minimal movement, all programed by computer. Through interface with the computer, the
data emitted from the mannequin will change based on student interventions and decisions. A
faculty member can manually control the computer or small subprograms can be stored and
programed into the scenario.

For example, a stored subprogram may alter blood pressure and heart rate in response to
administration of a specific medication. These small programs are unlimited in scope and use.
Educators need to:
- Determine the content best taught through simulation.

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 - Determine the learning objectives
- Replicate reality as closely as possible through the environment and equipment
- Use video equipment to record the activities for later use in debriefing conferences
- Conduct a debriefing conference, which is a time for participants and observers to engage in
group discussion and learning-based on the actions taken by the participants. Rationales for
clinical decisions can be discussed, suggestions for alternative actions made, feelings related
to the situation shared, and mistakes identified. During the debriefing session, only selected
portions of the videotape should be shown to make the desired point. Instructors should
focus on the exact actions taken and evaluate the communication and interaction between
participants.

Hybrid Simulation.

This type of simulation is defined as a type where two or more simulation types are
combined to produce a more realistic simulation experience. A typical example is the use of
portable devices by standardized patients, where students are able to perform certain
procedures while interacting with a real person. For example, a standardized patient may fix
a suture training model (cushion) on his/her arm, where the trainee can suture a wound;
thus, while giving the trainee the opportunity to obtain informed consent, explain the
procedure, etc.

Learning Objectives of the Simulation Process

The simulation procedure is commonly used to:

- Develop highly complex cognitive skills, such as decision-making, evaluating and

synthesizing
- Impact positively on the learner's values, beliefs and attitudes
- Induce feelings of empathy in the minds of the students.
- Sharpen human relation skills and communication skills
- Unlearn negative attitudes or behavior.

Advantages of simulation

 It actively engages learners in the application of knowledge and skills in realistic situations.
 Simulation establishes a setting where theory and practice can be combined.
 Dynamic framework.
 Bridging the gap to reality.
 It provides an integrated view as well as vehicle for free interdisciplinary communication.
 Decision making skills into action. It develops various skills in children in increasing difficulty
order.

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 Controlled teaching assignments are possible for students. Teachers obtain experiences which
are realistic and thus they become critical.
 It is useful in promoting transfer of learning from the classroom to the clinical setting.
 The controlled setting of the simulations makes it possible to have consistency in learning
experiences from learner to learner.
 Simulations permit applications of theory to practice when access to clinical settings is limited
or impossible.
 Students can receive feedback on the appropriateness of their action during simulation.
 It provides participants to deal with the consequences of their actions.
 Students can learn without harming the patient.

Disadvantages of simulation

 Simulations are time consuming. Simulation cannot be devised in a fraction of time.

 Mechanisms for feedback of data may require the use of sophisticated materials.
 Costs of development and reproducing a simulation may not be recovered even with repeated
use.
 The simulation limits aspects of reality situations.
 Learners may not find the simulation relevant to their situation.
 Simulation cannot be made in all subjects of the
curriculum.
 Simulation technique can be overused.
 It is possible that emotions may be aroused to an undesirable degree, especially in role playing.
 Requires specific skills on the part of the teacher to use simulation technique as method of
teaching, hence not every instructor feels comfortable using simulation technique.
 The process and outcomes of simulation may not always be predictable.
 Craftsmanship is required for local construction.

Conclusion
During the discussion we covered about what is simulation and types of simulation
and uses of simulation in nursing education. Advantages and disadvantages also discussed. Through
simulation the students will get great exposure to the content what they studied. It is best used to
improve the skills.
Bibliography
1. Sodhi, Kaur Jaspreet. Comprehensive text Book of Nursing Education. 2 nd edition. Jaypee
Publication. Page: 75 -77
2. R Sudha. Nursing Education principles and concepts.2nd edition. Jaypee publication.
Page :97-99
3. B sankaranarayanan. B Sindhu. Learning and Teaching NURSING. Jaypee publications.
4. Konstantinos Koukourikos, Areti Tsaloglidou. Simulation in Clinical Nursing Education. Acta
Informatica Medica. v.29(1); 2021 Mar