Resuscitation 93 (2015) A3–A4

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Resuscitation journal homepage: www.elsevier.com/locate/resuscitation

Editorial

High-fidelity in simulation education: Only a part of the answer

One of the most important underpinnings of simulation education is the ability of instructors and centers to create a milieu where learners can ‘suspend disbelief’, permitting them to act in a manner that most accurately reflects the way they would act with a real patient. The use of so-called ‘high-fidelity’ mannequins and simulators is one widespread method whereby this can be attempted. While abundant studies have shown that learners’ affective responses to these simulators are favorable,1,2 research on their measurable impact on learning is more varied. In the current issue of Resuscitation, Cheng et al.3 present the results of a particularly rigorous analysis of published literature examining the specific impact of high-fidelity physical features of mannequins on educational outcomes among learners in life support courses. The study represents a summary of a worksheet from the 2015 Consensus on Science of the International Liaison Committee on Resuscitation (ILCOR), a periodic exhaustive review of published evidence on resuscitation science with which much of the readership of Resuscitation is probably very familiar. As described in the article, the review occurs as a series of PopulationIntervention-Comparison-Outcome (‘PICO’) questions, permitting exclusive focus on a single factor influencing the outcomes of interest. The scientific rigor of the ILCOR methodology is self-evident and its output represents the basis for resuscitation guidelines all over the world.4 Beyond the detailed summary of the ILCOR review for this focused topic, the authors are to be commended for dedicating content in the manuscript to looking past the focused findings of the review and contextualizing them in a broader sense with respect to life support educational methodology in general. In this article, high fidelity was defined as “those that provide physical findings, display vital signs, physiologically respond to interventions (via computer interface) and allow for procedures to be performed on them”. Authors concluded high physical fidelity manikins have a moderate beneficial effect on skills performance at course conclusion. A large heterogeneity existed across studies, which is not surprising given the challengingly broad spectrum of learners, interventions, and contexts represented in this literature. Reasons for the heterogeneity are likely many, including misalignment of the nature and degree of physical fidelity to outcome assessment (e.g., assessment of leadership skills is not so much sensitive to whether the simulator has a voice or not). The authors comments also highlight the fact that heterogeneity might also arise from diverse quality in debriefing or instructional design, elements that are as important as mannequin fidelity and are just as difficult to control for, if not more so.

http://dx.doi.org/10.1016/j.resuscitation.2015.05.004 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.

It should be obvious that ‘fidelity’ means different things to different people in different care areas. For example, an ECMO simulation has relatively little need of physical fidelity in the simulated patient, depending rather on environmental and conceptual fidelity prompting responses in learners. These types of fidelity, on the other hand, are likely of little help to a paramedic, whose ‘environment’ for resuscitation could be a hotel lobby, a football field, etc.; here physical fidelity may be of more paramount importance. As educators, we are faced with the need to take a finite set of life support courses and educational devices and make the learning relevant and appropriate for all of these learner groups. Consider the current Basic Life Support guidelines recommendation for starting chest compressions: if a victim is unresponsive and has apnea or agonal breathing, a rescuer should begin chest compressions.5,6 It follows that it would be desirable – for learners at every level – for a mannequin to be able to simulate the difference between being ‘lifeless’ and having ‘signs of life’.7 Given that all patient simulators, high- or low-fidelity, are in fact mannequins that move very little and only ‘vocalize’ when equipped with microphones that a facilitator can operate, a learner’s inference about a simulator being ‘lifeless’ invariably necessitates a substantial degree of disbelief suspension. How does one simulate this distinction more effectively? And how do we reconcile this shortcoming in fidelity in one of the most fundamental immediate judgments about a victim’s condition we expect rescuers – including laypeople – to make accurately? This challenge falls to two groups of people. First, life support instructors must continue to design and implement combinations of physical and situational fidelity in their training settings that makes suspension of disbelief possible for all learners. Secondly, technology in simulator design and manufacturing must continue to innovate means by which to convey these elusive observable findings, whether directed at laypeople (‘lifeless’ versus ‘alive’) or healthcare providers (mentation, hypoperfusion, color, etc.). The closing section of the article clearly discusses the need for incorporating studies supporting high-fidelity mannequin use in a bigger picture. Simply using high-fidelity mannequins alone is not enough; the commensurate need exists for optimal instructional design, proper alignment of the nature and degree of fidelity to learning outcomes, competency standards for life support instructors, and consistent structured debriefing sessions in order to maximize the impact of simulation education. Perhaps an analogy can be drawn here to a fundamental psychomotor skill that comprises a ubiquitous learning objective of life support

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Editorial / Resuscitation 93 (2015) A3–A4

courses – that of high-quality cardiopulmonary resuscitation, where no single task is enough, but rather paying simultaneous attention to a composite of elements (‘push hard, push fast, release completely, minimize interruptions, avoid hyperventilation’) is necessary to truly do the best job possible. Viewed in this light, it should not be surprising that a single ILCOR ‘PICO’ question fails to truly give us the answer.

6. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S685–705. 7. Donoghue AJ, Durbin DR, Nadel FM, Stryjewski GR, Kost SI, Nadkarni VM. Perception of realism during mock resuscitations by pediatric housestaff: the impact of simulated physical features. Simul Healthc 2010;5:16–20.

Aaron Donoghue a,b,∗ Division of Critical Care Medicine, Children’s Hospital of Philadelphia, PA, United States b Division of Emergency Medicine, Children’s Hospital of Philadelphia, PA, United States a

Conflict of interest statement The authors have no relevant conflicts to disclose. References 1. Halamek LP, Kaegi DM, Gaba DM, et al. Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics 2000;106:E45. 2. Mundell WC, Kennedy CC, Szostek JH, Cook DA. Simulation technology for resuscitation training: a systematic review and meta-analysis. Resuscitation 2013;84:1174–83. 3. Cheng A, Lockey A, Bhanji F, Lin Y, Hunt EA, Lang E. The use of high-fidelity manikins for advanced life support training – a systematic review and metaanalysis. Resuscitation 2015;93:142–9. 4. Morley PT, Atkins DL, Billi JE, et al. Part 3: evidence evaluation process: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81:e32–40. 5. Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S862–75.

Akira Nishisaki Division of Critical Care Medicine, Children’s Hospital of Philadelphia, PA, United States ∗ Corresponding author at: Division of Emergency Medicine, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19004, United States. E-mail address: [email protected] (A. Donoghue)

5 May 2015

High-fidelity in simulation education: Only a part of the answer.

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