Nurse Education in Practice 15 (2015) 430e436

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Advanced life simulation: High-fidelity simulation without the high technology Trudy Dwyer a, *, Kerry Reid Searl a, 1, Margaret McAllister a, 2, Michael Guerin b, 3, Deborah Friel a, 4 a b

Central Queensland University, Rockhampton Campus, Australia Central Queensland Hospital and Health Service, Australia

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 13 May 2015

Simulation-based resuscitation education has emerged as a key to improving patient safety and numerous healthcare organisations have invested in high-fidelity simulation training centres. However, the high purchasing cost, limited portability, technical expertise and organisational skills required to coordinate these high-fidelity simulation centres are factors that limit their use as a wide-spread teaching and learning method. Creative innovation is required. The aim of this study was to pilot an inexpensive, portable, novel high fidelity humanistic simulation modality, for educating nurses and doctors in recognising and responding to the deteriorating patient. Analysis of five focus group discussions revealed the main theme of engagement in the simulation experience with three main subthemes of realism of the character, believability of the experience and being more connected. In conclusion, this innovative simulation modality offers a viable alternative for resuscitation training. © 2015 Elsevier Ltd. All rights reserved.

Keywords: Advanced life support Simulation learning Hybrid simulation High-fidelity simulation

Introduction Within hospitals patient adverse events such as a cardiac arrest or unplanned admissions to intensive care units are often preceded by a period where deterioration in the patient's condition has either gone undetected or not reported (Ludikhuize et al., 2011). Early detection of deterioration, initiating a timely response and effective action can save lives. In response to the identified need to improve patient safety, rapid response systems (RRS) have been developed and implemented worldwide (Committee on Quality of Health Care in America Institute of Medicine, 2001). RRS is a general term used to describe the various models of medical emergency response teams implemented to respond to the call to assess the deteriorating patients in the acute care setting (Committee on Quality of Health Care in America Institute of Medicine, 2001).

* Corresponding author. Tel.: þ61 749232180. E-mail addresses: [email protected] (T. Dwyer), [email protected] (K. Reid Searl), [email protected] (M. McAllister), [email protected] (M. Guerin), [email protected] (D. Friel). 1 Tel.: þ61 749309741. 2 Tel.: þ61 749309777. 3 Tel.: þ61 749276432. 4 Tel.: þ61 749306934. 1471-5953/© 2015 Elsevier Ltd. All rights reserved.

This system bypasses the traditional hierarchical approach to medical review, opting for a more horizontal approach to allow staff to access timely assistance when a patient's condition is deteriorating (Taenzer et al., 2011). The success of this system is dependent on the ability of staff to detect patient deterioration and respond in a timely and appropriate manner (Winters et al., 2013). Recent studies have demonstrated that education, experience and understanding of health professionals have an impact on the effective use of these response teams (Jones et al., 2009; LevettJones et al., 2012; Ludikhuize et al., 2012; Moola, 2012). Within Australia, approximately two-thirds of all hospitals provide regular simulation training for these emergency events (Australian Commission on Safety and Quality in Health Care, 2011). Over the last two decades, numerous health services have invested in hightechnology, high-fidelity simulation centres to address training needs. These centres typically offer training of specialised staff to develop and deliver advanced life support (ALS) and RRS training (Littlewood, 2011). Such centres offer numerous benefits for simulation training in patient safety events. They provide the opportunity to practice clinical skills and develop problem solving approaches to situations within a controlled, supportive and safe learning environment (Olejniczak et al., 2010). Nurses, doctors and paramedics report increased knowledge, self-confidence and selfefficacy following participating in these simulated resuscitation-

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based sessions (Buckley and Gordon, 2011; Delasobera et al., 2010; van Schaik et al., 2011). In a 2011 study of medical-surgical nurses (n ¼ 38) found that immersive high-fidelity simulation, combined with traditional classroom education, improved nurses' perceptions of their ability to respond to the deteriorating patient (Buckley and Gordon, 2011). The authors reported that responding in a systematic manner; assertive skills, airway management and clinical handover were the skills that participants reported the greatest level of improvement. However, these training centres that use complex technological human patient simulators have also been criticised for their lack of clinical realism, high establishment and maintenance costs, and the need for ongoing training experts (Littlewood, 2011; Thidemann €derhamn, 2013; Zendejas, 2013). Additionally, health care and So workers describe difficulties engaging with manikins and express performance anxiety in the simulation learning environment (Fernandez et al., 2009; Hunziker et al., 2012). These issues are particularly important given the substantial resources directed to the development and sustainability of high-fidelity simulation environments (Littlewood, 2011; Zendejas, 2013). Furthermore, while simulation training has been shown to increase awareness of factors impacting on quality care, particularly effective team work and communication (Merchant, 2012; Wehbe-Janek et al., 2012; Wynn et al., 2009) there is limited evidence of its influence on improving clinical actions and outcomes. In relation to RRS training, research is needed to understand what impact simulation training has on the effectiveness of the first responder. The first person to identify deterioration in a patient is vital for triggering RRS and for influencing better patient outcomes. If simulation is to be effective in RRS, it needs to impact positively on the thinking and actions of the first responder. An important challenge for educators is to develop simulation experiences that are easily portable, cost effective, and efficient in time to set up and mimic realism for the learners leading to deep level learning and enhancement of clinical reasoning and clinical actions. The aim of this study is to pilot an inexpensive, portable, novel high fidelity humanistic simulation modality, for educating nurses and doctors in recognising and responding to the deteriorating patient.

general objective, but will interact spontaneously with learners, depending on the questions they ask or the actions they take (Fig. 1). An extension of this humanistic simulation experience has been to create a way for learners to learn advanced resuscitation techniques as well as remembering that the patient is at the centre of the health care intervention, and needs to be respected, considered and assisted. Too often when learners experience resuscitation a disembodied part is practised on, or only mechanical proficiency is learned. The team became aware of the opportunity of combing the Mask-Ed™ (KRS Simulation) approach with another simulation technique which would potentially enhance the realness of the

Humanistic simulation Within a regional Australian University, our team has created various simulation learning experiences that utilise innovative simulation where role play with a humanistic focus is combined with simulation learning. The simulation technique, termed MaskEd™ (KRS Simulation) requires the expert educator to wear realistic silicone masks and body suits and to take on the persona of a particular patient who themselves have a carefully constructed history which enables them to be a platform for teaching and learning (McAllister et al., 2013). Learners are asked to engage with the patient, assisting him or her through a health care experience, in this case, serious health deterioration. Instead of the patient being an actor, or perhaps a real consumer, the role play involves an educator with insight into the patient experience, in role. The hidden educator is able to capture teachable moments and direct the learning experience whilst in the persona of a patient. The interaction that follows involves a three way interplay between the learner, the patient and the hidden educator. The educator needs to be knowledgeable about the content and skills being learned and discussed and may subtly guide learners to ask more probing and effective questions so that the ‘patient’ is effectively assisted. Additionally, the technique is designed around the use of totally realistic props so that learners can suspend the disbelief that often happens when manikins or actors seem unrealistic. The role play experience is also only semi-scripted, that is the educator has a


Fig. 1. Mask-Ed™ (KRS Simulation).


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simulation experience in a resuscitation scenario. The hybrid approach would see Mask-Ed™ (KRS Simulation) being combined with ALSi (iSImulate Pty Ltd) a patient simulation technology that is relatively low cost ( The ALSi simulator monitor simulates advanced life support monitors and aims to be interactive, realistic, easy to use, versatile, portable and affordable. The system consists of two iPads that communicate with each other. One is customised to look like a portable cardiac monitor and defibrillator (Fig. 2). The second becomes the control centre for the educator who can then produce various cardiac conditions to appear on the screen of the first iPad, allowing learners to identify, diagnose and respond. The team designed a hybrid simulation scenario to combine the highly humanistic approach of Mask-Ed™ (KRS Simulation) with the highly technical ALSi. It involved the educator dressed and role playing a deteriorating patient, the monitor shows a common cardiac rhythm disturbance should trigger the decision to call the rapid response team. Learners included a range of health professionals including ward nurses, ALS nurses and doctors. Learners worked in teams of three to five multi professional staff reflecting the different levels of personnel generally involved in a rapid response protocol. At the commencement of the scenario the first responder received a verbal handover of information regarding the patient's condition and a copy of the person's medical records (Fig. 3). The paper will next report on the findings of a qualitative study to evaluate the impact of the learning experience on participants.

involved only this group. The deterioration simulation scenario was conducted in both the high-fidelity simulation laboratory and in situ on the clinical area. In situ simulation is described as simulation that takes place in the clinical environment (Walker et al., 2013). Procedure Focus group discussion was chosen as the most appropriate method for data collection when little is known about the phenomenon and expansion is important (Rasika, 2012). Further, the purposeful discussion generated explored the stakeholder's opinions, perspectives and provided feedback on the novel simulation modality. Data collection continued until observations and narratives became saturated and further focus groups became unnecessary (Rasika, 2012). Audio and video recording of the scenarios and focus group discussions allowed the researchers to listen, monitor and observe interactions to create an understanding of the topic, the social dynamics and social interactions between participants (Doody et al., 2013). Ethical considerations The research received full approval from the appropriate Health Service District Human Research Ethics Committee (HREC). Participants were provided with an explanation of the purpose of the research (written and verbal) and advised that participation was voluntary.


Data analysis

A qualitative exploratory study was designed and conducted to pilot test this innovative hybrid simulation approach to responding to the deteriorating patient. A qualitative exploratory framework was considered appropriate for this study as it provided the opportunity to examine the simulation experience from the perspective of the learner. Typically exploratory qualitative research is chosen when there is little known or documented about the topic under investigation (Dwyer et al., 2014).

The conversations and observations from the focus group sessions were audio and video recorded and transcribed. Interpretation of the data elicited from participants occurred as an iterative process (Creswell, 2009) commencing with watching the videos and listening to the audio recordings of data. Next, transcripts were read to obtain a sense of the data as a whole and identify emerging patterns and insights. The frequently emerging themes that provide a focus for the whole picture were coded to best reflect the participants' descriptions. Significant phrases were extracted to best reflect the participants' experiences with the novel simulation modality. Peer checking occur to ensure trustworthiness with themes with differences being discussed and recoded as necessary.

Study setting and participants Participants invited to inform this research consisted of registered nurses, medical students and medical doctors who attend the standard advanced life support (ALS) training. Convenience/purposive sampling was chosen as these health care providers were best placed to provide the required information and thus sampling

Findings Participant narratives were evaluated to ascertain their perceptions of this high fidelity humanistic, low technical and highly portable approach to simulation as a modality for recognising and responding to the deteriorating patient. A total of five focus groups were conducted, comprising of 5e10 participants per group. Results from the study emerged from the main theme of engagement in the simulation experience with three main subthemes including realism of the character, believability of the experience and more connected. All sub themes were interrelated and the major theme of engagement was inherent within each sub theme. In essence all were dependent upon each other. For example the engagement could not occur without the realism of the character. The realism of the actual experience was dependent on the character and the learning was because the participants were immersed in the realism (See Fig. 4). Engagement

Fig. 2. ALSi monitor iPad. From: used with permission.

The engagement of participants in the simulation experiences was immediate. Whilst some participants spoke about the shock of

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Fig. 3. Example of scenario.

‘At first I thought it was a [real] patient.’ Even though participants recognised that the experience was a simulation and the character was in fact the educator, the level of engagement continued. Because of the spontaneous and ongoing interaction between the educator and learners, participants remained engaged and were excited about what might happen next as reflected in these comments about the experience: ‘ … this is awesome’ ‘it [the simulation]was really cool’ Fig. 4. Theme and subthemes.

Further, when participants saw the mask and props being donned, the engagement was still apparent. As summed up by one participant. what they had come into, it was the fact that they believed the event was real that made such an impact, as reflected in the following comments: ‘The masks were absolutely brilliant. I walked in and knew we were doing the scenario and then I saw this person and thought “… oh my God there is a patient in here’

‘It ran beautifully. The minute you put on the mask everybody's attitude changed in the room, including ours. We all got excited because you could see you slipped straight into character. You could see the [the responders'] response straight away dealing with a patient, as opposed to dealing with a teacher in a mask. Then everyone reacted immediately and treated you exactly as they should … the moaning … the lack of pillow, the


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interventions that all happen in the real life situation e it came alive - so yes, it went really well.’

Realism of the character Participant's all spoke of the realism of the character and the authentic human response. ‘It's brilliant, it's a lot better and a lot more life-like e you've got the whole thing, the sweating. You could believe it was real, a real person.’

The realism of the character also became a point of discussion, with participants comparing other modalities of simulation. For example participants spoke about the difference with the use of role play where the educator dressed up is still visually present to the learner. ‘it is more like a real patient, it took away [the teacher's] identity, it made you treat [the situation ] more realistically … I had more buy-in.’

Believability of the experience The human-like responses were also identified as one aspect that made the participants feel as though they had to communicate with the person. There was no longer a manikin, but rather a real person with real responses. As participants stated: ‘With the sim man you can't ask them to respond, but with this (mask ed character) … you can ask them and they are talking to you and you can tell them what's going on. I think it's more realistic and helps you to communicate’. ‘ … the moaning was a fabulous teaching technique … ’ The realism resulted in participants focusing on the patient and this had a flow on effect of reducing the anxiety that had previously been experienced in other simulation scenarios.

The believability of the experience was another relevant aspect to the engagement. Not only did the participants believe in the character through the props and his genuine mannerisms and human responses, but also the context of the situation. In this simulation, the surrounding equipment, the noises and the environment seemed real. ‘ … it was sort of a shock … you're not used to seeing such a thing, but it sort of made everyone aware that you are working with electricity.’ ‘it was so much better than the manikin - so many times [say in a simulation] ‘I'm going to give the such and such drug’ but not actually do it. Doing it [in this experience] is so much more real.’

‘I wasn't as anxious as I was this morning with the dolls [mannequins].’

In conventional resuscitation simulation approaches there is a tendency for both the lecturer and the learner to focus on the series of time-critical steps required in a protocol. For example,

Participants also reported that the level of realism made them take the simulation experience more seriously, an important element in learning. As one participant reported;

‘it always worries me that in ALS we falsify the time by not putting in the drip … by not actually doing it.’

‘Well you kind of feel like oh this could be a real person because they were symptomatic and so they would take it more seriously’

In this scenario, participants felt that the whole experience was more akin with reality. A participant commented:

Participants further expressed that talking to an actual person was easier than simulating the conversation with the mannequin. Talking to the mannequins had the potential to erode confidence, as one participant noted: ‘I have to remember to explain to the manikin all the way through, I feel stupid talking to an inanimate object.’ The reality of the character appeared to facilitate immersion in scenario with the participants reporting increased personal confidence that facilitated the demonstration of behaviours that aligned more closely with their actually behaviour in the clinical. ‘I suppose just thinking about it clinically, you have to give more specific instructions like, ‘put your head forward’ … ‘move your arm for me’ and it actually happens instead of just being a mannequin. And then how to explain things as well, dealing with an emotional response.’ and ‘I think it makes you deal with your own emotions, if you have got somebody who is distressed, you've got to put on your professional hat and have to be very controlled because they do look like they are going to die and you have to control that.’

‘You pretty well do this [the experience] in real time … and get the feel for the urgency of the situation.’ Watching and experiencing the outcome of their individual actions first-hand was particularly valuable. As one person noted: ‘I think it makes you deal with your emotions, if you have someone who is distressed … and they look like they are going to die … ’

More connected The data also revealed that learners found that the experience helped them to practice the skills in a way that still allowed them to communicate and connect with the human being. In other simulation approaches this had not been easy to do. As an experienced medical educator noted, there was less stop/starting in this approach and participants were able to work smoothly through an event from beginning to end. This uninterrupted flow is possibly related to both the learners' and educator's immersion in the simulation. The communication, and the plot continued and it was not appropriate to stop and reflect mid-way. Doing it through this humanistic simulation provided significant benefits, according to participants.

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‘You actually become less task orientated’ ‘You became more patient orientated’ ‘It was easier to see the person’ One participant recalled a part of the experience, when all the learners were overly focused on the monitor, and almost failed to notice the patient beginning to roll off the trolley because no one was attending to their stability. ‘We were all focused on the treating the monitor instead of the patient … [it reminded us of] the importance in future of treating the patient’. Another participant, an experienced educator, also stated, ‘I didn't believe [it would work] until I experienced it - it actually changes your mindset on what you are dealing with … I learned from it. We got a lot out of it.’

Discussion There has been enormous growth in the use of hightechnology, high-fidelity simulation for learning and teaching within the resuscitation domain. At the same time, there is continuing criticism of the lack of realism because of the disjointed nature of structured simulation where practise is interspersed with actions and reflections and with manikins that are inert and inanimate (Hunziker et al., 2012; Perkins, 2007). In such scenarios learners risk disengagement and possibly do not learn as much as when they are fully immersed in the scenario (Perkins, 2007). When they feel they are being watched and critiqued their anxiety can become a barrier and thus selfconfidence will not flourish (Ludikhuize et al., 2011). The multidisciplinary learning and believable aspects of in-situ resuscitation training observed in the current study have been reported by others (Lighthall et al., 2010; Walker et al., 2013). In our study it was the interplay between the patient, educator and learner, and engagement with the humanistic simulation that extended the learner experience. The closer the stimulation technology and environment mimic real life events the more likely the learned behaviour is to be transferred to the clinical setting (Merchant, 2012). The findings of this study indicate that this innovation, because of its humanistic nature of the simulation, developed technical as well as communication skills, and full engagement with the human being (patient), and thus may be described as authentic learning. Further, the experience appeared to reduce performance anxiety because learners were engaged in the scenario and interacted with the character as if they were a real patient, and thus were prompted to respond in ways closer to a clinical context. This realism or humanistic nature of the simulation used in this study enhanced the meaningfulness of the learning experience for the RRT members. Indeed psychology research postulates that when simulation experiences are memorable and comparable with real life situations, should a similar event occur in clinical practice (ie cardiac arrest), learners can consciously or subconsciously remember scenarios they have encountered in training and accurately recall successful behavioural strategies (Reader and Cuthbertson, 2012). While health care organisations are accessing high-fidelity simulation training centres to prepare staff for emergency response situations. These centres remain underutilised because barriers such as space, cost, mobility of staff and training of instructors (Merchant, 2012; Nagle et al., 2009; Wood, 2010). The


proximity of simulation to ‘real life’ learning and assessment may be, mistakenly based on the premise that the more expensive or higher engineering fidelity simulation centres equate to greater authenticity and translation into improved learning outcomes (Norman et al., 2012; Salas et al., 2013). Authenticity actually equates to a more meaningful learning experience and a greater the transferability of skills to other situations. High technology procedural trainers potentially focus on the procedure and doing and largely ignore the emotional stress of the environment. The humanistic nature of the simulation used in the current study transferred the learners focus from the monitors and procedures to the patient; listening to the patient and responding patient feedback. Limitations of the study There are some methodological limitations of the study. Whilst the study involved a small number of participants, who were not randomly assigned and there were no conditions of control, it is not possible to generalise the findings. Nonetheless, the qualitative comments indicate that the experience was more authentic than simulations that involve inanimate patients and unrealistic events. Because the simulated learning experience used in the current study is portable, requiring relatively inexpensive props and the educator's own skills clinical knowledge, such learning could take place in situ, increasing its accessibility and broadening multidisciplinary team participation. In smaller regional centres, this is important. Since cardiac arrests occur anywhere, any time, it is also important that staff do not only learn the technique in an artificial simulated environment that utilise mannequins as patients. This scenario can be played out in a car park, the outpatient department or anywhere. Being able to operate in situ also means that the process-related safety issues, such as speaking clearly, checking with each other that messages have been sent and received accurately, can be addressed. As Shearer (2013) reminds us, these communication issues are commonly where errors are made and thus effective simulations address the patient safety trigger points for it to be valuable and relevant for clinicians and for patients. Failure to recognise the deteriorating patient and trigger prompt intervention leads to serious adverse effects and increased patient mortality. This simulation strategy is one creative way to address this global health concern. Conflict of interest The authors report potential conflict of interest as author Kerry Reid-Searl is the developer of Mask-Ed™ (KRS Simulation). The use of the two devices was at the discretion of the authors undertaking the study. The manufacturers of the product ALSi had no input to the study or the writing of the article. Funding No funding was received for the study. Acknowledgement Both Mask-Ed™ (KRS Simulation) and ALSi have been used with permission.  Mask-Ed™ (KRS Simulation): industry-and-partnerships/professional-development-courses/ cphe/mask-ed-krs-simulation.  ALSi:


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Advanced life simulation: High-fidelity simulation without the high technology.

Simulation-based resuscitation education has emerged as a key to improving patient safety and numerous healthcare organisations have invested in high-...
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