Pro's and Cons of Simulation in Healthcare

The advantages of simulation? 
Note... As I write this blog I am trying to keep the simulation theories to a high level before we delve into the individual strategies such as In-situ simulation, Augmented Reality and Virtual Reality simulation, Mixed Reality simulation, Computer Assisted simulation, and Immersive Interactive education.
In the previous blog post we have discussed the main academic arguments surrounding fidelity and suggested that within simulation fidelity is a subjective matter. 
We also reviewed the 3 MAIN COMPONENTS or aims of medical simulation - Equipment - Environment and Psychology. 


A couple of useful papers have outlined the benefits of simulation in healthcare and are summarised briefly below
Advantages (Moorthy, Vincent, & Darzi, 2005), (Brooks, Moriarty, & Welyczko, 2010)
Simulation allows participants to purposely undertake high-risk activities or procedural tasks within a safe environment without dangerous implications to themselves or their patients. 
( Often referred to as the canary in mineshaft theory).

• Simulation can improve participants skills and allow them to learn from error. 
• Learners are able to gain a greater understanding about the consequences of their actions and the need to reduce any errors and prevent them from happening again.

Simulation offers participative learning, and supports the teaching / learning of Adults.
Rather than sitting through a training lecture, trainees can practice what they have learnt, and quickly learn from any mistakes without serious implications.

• Learners address hands-on and thinking skills, including knowledge-in-action, procedures, decision-making, and effective communication. They can work as individuals or teams and thus allow for exploration of human factors and their interaction with their environment.
• Simulation based learning can be set up at appropriate times and locations, and repeated as often as necessary. It can be undertaken in-situ with minimal resources, or it can be undertaken in amazingly high technology simulation centres. 
• Simulation based learning can be customised to suit beginners, intermediates and experts, and adapted on the fly to cater for the learners ability. 
• Simulation has links to the educational theories of constructivism, experiential learning, Adult Learning (androgogy), social cognitive theory, (Bandura ) human factor education.
• Simulation can be seen to support the academic theories surrounding Brain Based Learning (to be discussed in a later article..)
• Simulation may - deepen the learning conversation, improve motivation, assist with the Novice to Expert by providing scaffolding and opportunities to develop an understanding from another participants perspective.
• Feedback can be given to learners immediately and allow them to understand exactly what went wrong / right and how they can improve. Debriefing tools - video feedback and peer review are all key features of this learning strategy.

Most importantly our learners don’t have to wait for a real situation to come up in order to learn. - This has spawned the concept of "stress inoculation training" which will also be discussed in a later article. Stress inoculation training is used widely in EMS and Military based education.
 Simulation based curricula have been developed in Nursing education and many traditional EMS education programmes have moved towards a blend of strategies - steadily seeing a removal of the traditional lecture based - force fed type of learning.
Disadvantages
Simulation is not always able to completely re-create real-life situations. And if the fidelity drops for just one second it can be very difficult to get the student back into the moment of suspended belief! 
Not all students / situations being created / tested by simulation are suitable for this methodology.
Some Simulators can be very expensive and require constant updates and maintenance.
It takes effort - 'lots of effort' to create meaningful experiences.
Many pieces of simulation equipment (Simulators, Monitors and other props) are reliant upon directly plugged in power sources, and are often not waterproof or easily transported, some are fragile.
Not every situation can be simulated. Most importantly we can only really simulate things that we know...
We cannot use simulation for example to test a new drug - still under trial... Never yet tested on humans - since such a simulation would not be able to predict every side effect to an unknown drug in an unknown patient population. We could of course simulate the delivery and other aspects of drug delivery.
The results and feedback are only as effective as the actual training provided, and the person / persons running the simulation: this is important since often too little emphasis is put onto the personal reflection, and peer review elements of a simulation event.
Our Staff running the simulator need to be trained on how to use the software and/or hardware and this takes up time and costs money. (Magician and Wand) They need to be clinically competent and able to understand the aspects of technical accuracy in order to feed back.
Gray (2002) suggests that "all simulation is pretend".. And students are never really subjected to the consequences for mistakes which may result in students under performing and not being fully engaged in the training, thus producing inaccurate results. 
Some students / participants can be unwilling to learn from their mistakes, whilst other students/ participants can be unwilling to engage, or may-not possess the ability to imagine.
Some students / participants get better at being tested - and some students/ participants learn how to play the 'simulation game' rather than how to treat real patients.
........As an overview - hopefully all of the content above obvious to everybody who runs a simulation...
So lets go a little further with how things are developing in the 21st century 
3d printing and new technologies have enabled the development of tissues and bones and the creation of affordable home made manikins and models.. these allow for clinicians themselves to become the ones building the models for simulation...
Some of the most challenging manikins are being built in peoples garages... the recent "wooky" intubation model and emisis system - The so called "Salad" system... are superb examples of how clinicians have made their own manikins - built because the lessons they can create are better than with they can achieve with more traditional tools.
It is becoming socially unacceptable to use human cadevers if other tools are available, and, it is becoming unacceptable to use animal models if other models are available.
We rarely see many of the "unusual" events that we used to see - Healthcare is improving to such in ways that some conditions are now rare - simulation can enable us to practice for the more unusual as well as the every day essentials to clinical practice.
The list of reasons to try and develop our simulation based strategies appears never ending, although the evidence that education via simulation really effects delivery of better care is still unfortunately lacking.
One key thing that many of the Modern Educators have learned is to make the learning event a fun but challenging process
Within the SMACC community we see amazing innovations presented every year - designed to teach the practical lessons essential to clinical practice.
In the next 'foundation of simulation' blog article - we will discuss Virtual and Augmented Realities - reviewing the technologies themselves and why 'headset and goggle based simulation' may have problems for healthcare education.
Sorry....I am heading off to the Middle East to review an amazing simulation facility - so next blog wont be until this time next week...
References
Brooks, N., Moriarty, A., & Welyczko, N. (2010). Implementing simulated practice learning for nursing students. Nursing Standard, 24(20), 41. Retrieved from http://go.galegroup.com.ezproxy.ecu.edu.au/ps/i.do?id=GALE%7CA219374229&v=2.1&u=cowan&it=r&p=AONE&sw=w&asid=46732320b5d0a6aec241ece3377893c9
Gray, W. D. (2002). Simulated Task Environments: The Role of High-Fidelity Simulations,Scaled Worlds, Synthetic Environments,and Laboratory Tasks in Basic and Applied Cognitive Research. Cognitive Science Quarterly, 2, 205-227.
Moorthy, K., Vincent, C., & Darzi, A. (2005). Simulation Based Training. British Medical Journal, 330, 493-494. doi:10.1136/bmj.330.7490.493
 Beaubien JM, Baker DP. The use of simulation for training teamwork skills in health care: how low can you go? Qual Saf Health Care. 2004;13: i51


For great Video Resources - follow Dr Tim - http://kidocs.org/talks-vids/
Previous article on paramedic competence - published online http://healthysimulation.com/2858/designing-prehospital-medical-simulation-scenarios/