Original article
doi: 10.1111/nup.12034
The nature of reality represented in high fidelity human patient simulation: philosophical perspectives and implications for nursing education Renee M. Dunnington* PhD RN *Associate Professor, School of Natural Science, Nursing, and Health, Capital University, Columbus, OH, USA
Abstract
Simulation technology is increasingly being used in nursing education. Previously used primarily for teaching procedural, instrumental, or critical incident types of skills, simulation is now being applied to training related to more dynamic, complex, and interpersonal human contexts. While high fidelity human patient simulators have significantly increased in authenticity, human responses have greater complexity and are qualitatively different than current technology represents. This paper examines the texture of representation by simulation. Through a tracing of historical and contemporary philosophical perspectives on simulation, the nature and limits of the reality of human health responses represented by high fidelity human patient simulation (HF-HPS) are explored. Issues concerning nursing education are raised around the nature of reality represented in HF-HPS. Drawing on Waks, a framework for guiding pedagogical considerations around simulation in nursing education is presented for the ultimate purpose of promoting an educative experience with simulation. Keywords: simulation, philosophy.
Humans have since the ancient Greeks concerned themselves with the nature and the apprehension of reality. Yet, the apprehension of reality is contingent upon the means through which it is made a manifest. Increasingly, the reality of human health conditions is represented through simulation as an integral part Correspondence: Dr Renee M. Dunnington, PhD, Department of Nursing, Capital University, 1 College and Main, Columbus, OH 43209, USA. Tel.: + 1 614 236 6703; fax: + 1 614 340 5829; e-mail: [email protected]
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of the education of health-care professionals. Yet, humans are more unique and complex than current simulation technology or technique represents (Turkle, 2004, 2007, 2009). The representation of reality in health-care simulation is worthy of analysis for the potential transformative impact of simulation on the development of health-care professionals and on health care in general. The purpose of this paper is to examine, through various philosophical lenses, the reality represented by high fidelity human patient simulation (HF-HPS) and to explore what it may
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mean to promote active construction of knowledge through simulation. Pedagogical issues that may promote a more educative experience with HF-HPS in nursing education are also discussed.
Simulation and the representation of reality Simulation may take many different forms and present with different technologies, techniques, or learning environments. High fidelity human patient simulation is an instructional technique that involves a technology comprised of a life-size human mannequin, monitors, and computer-driven programming that requires design, administration, and role play enactment of a dynamic clinical scenario. High fidelity human patient simulation has been praised for the potential to provide a realistic, authentic learning environment. This has led to a presumption of its superiority as a mode of instruction among healthcare educators and professionals. Much of the expectation of HF-HPS as a technology-mediated educational technique relies on the learner’s perception of being situated in a simulated yet authentic reality representing a clinical situation. Texture of representation What is the nature and extent of the reality represented in simulated forms? The representation of human beings and their health conditions through computer-programmed human simulators is qualitatively different from the natural essence of human beings. High fidelity human patient simulators are computer driven and bear the ‘epistemic texture’ (Gramelsberger, 2008, p. 84) of a mathematic script. Numeric language encodes an operational script of indices, formulas, and algorithms that process in accordance with a prescription of embedded theoretical rules (Gramelsberger, 2008). The inscription of scientific principles coded in a simulator allows a phenomenon to unfold in a dynamic, narrated scenario. Thus, with HF-HPS, the reality of natural human responses is deconstructed, and then reconstructed through a program that makes the intended health phenomena explicit through sequential, schematic representations
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and prepared redescriptions much as has been described with other forms of simulation (Latour & Woolgar, 1979/1986; Butler, 1999; Gramelsberger, 2008; Grüne-Yanoff & Weirich, 2010). The problem of simulation and representation of human health conditions is the texture of the representation. The appearance of the re-creation is seemingly real in its conceptualization; yet, the reproduction is decomposed in detail, seriated in process, and partial in its final objectification. The simulated human response is subject to the limit of the mathematical language of representation, a reality that is modelled to the extent that it is perceived or theoretically understood and transcribed (Butler, 1999; Gramelsberger, 2008; Grüne-Yanoff & Weirich, 2010) and to the extent that it is reconstructed upon the ideological, psychological, and axiological constitution of its designer. Authenticity in simulation related to human concerns is dependent on the degree that the theorized, programmed, and scripted events approximate the reality of natural living processes. Yet, humans are qualitatively different from mathematized machine representations. Humans have multiplicity and greater complexity. Human responses are less sequential, less predictable, more emergent, and more variable than current technology represents (Rettedal, 2000; Turkle, 2004, 2007, 2009). Humans have psychological, emotional, and spiritual domains that bear on their response to health and healing. Borrowing from Benjamin’s (1936/1968) notion of the ‘aura’ of an original in art, humans have an aura of unique essence of their being.These human dimensions are inadequately captured with mathematical inscriptions or narrated scenario events. Simulation is a causal reconstruction of natural human health responses; however, the living may defy a certain prediction or a fixed calculation (Turkle, 2007, 2009; Gramelsberger, 2008). Yet, with advancements in technology, HF-HPS is increasingly referential to the reality of the human health conditions that it represents. Current simulation technologies and techniques have been praised for their ability to replicate and amplify substantial aspects of the real clinical situation (Gaba, 2004). Simulation is recognized for its ability to provide an authentic but safe practice field for novice learners to
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gain competence with risky procedures or high stress patient care situations. Simulation has also been a formidable solution to the shortage of clinical placements and access to uncommon procedures. The substitution of simulation for a portion of human contact in nursing education and across other health-care disciplines is also an emerging trend. The potential of learning transfer to the real patient care context is the greatest expectation of HF-HPS. It is this potential impact on health care that bears further examination of the reality represented and produced by simulation. Deception or mimesis Historical, philosophical, and theoretical views on simulation may lend insight into the experience of reality represented through simulation. Simulation was first made explicit through art. Plato clearly rejected art as a simulation of truth. He considered the representation of reality in the images of art as being ‘at the third remove from reality’, the mere ‘representation. . .of an apparition’ (The Republic). Plato’s verdict was that the image itself was a deceptive illusion of a representation that was only a reflection of something that was not the real thing. Yet, an opposing perspective is seen from Plato’s student, Aristotle. Aristotle described the principle of mimesis as the noble function of art. For Aristotle, the goal of art was to most adequately represent reality (Poetics). In his view, from mimesis and the experience of the simulated representation of drama, humans could draw knowledge and experience. The reality represented in art could give a necessary distance for humans to identify and respond to that which they recognize but may not have experienced in life (Poetics). Here, the fundamental concern relates to the consequence of representing reality through a simulated form such as art. From Plato’s perspective, simulation leads to deception through an experience that does not adequately represent the real. From Aristotle’s view, mimesis leads to knowledge and experience of the real that is gained through the experience with a simulated form. Henceforth, the Aristotelian view, the aim to gain knowledge and experience of reality through simulation, has remained a dominant influence from the Renaissance to the Modern era
(Hansli, 2008). This is also evident in the increasing adoption of simulation technology across disciplines. Mechanical reproduction Benjamin (1936/1968) theorized on the mechanical reproduction of art. He asserted that the sphere of authenticity is outside technical reproducibility and that the quality of the original’s presence is always diminished in the object that is reproduced. He conceptualized the essence of the real form as the ‘aura’ of the original. This concept lends explanation to the impact of mechanical reproduction of human beings through HF-HPS. Mechanical reproduction through a computer-operated script detaches the original from its unique human essence and produces a diminished reproduction that is devoid of the human aura of natural existence. This theorization suggests that nursing education mediated by simulated human forms such as computerized mannequins may alter sense perception and transform students’ ultimate interpretation of the natural human essence. This raises questions of how the interaction with the mechanical reproduction of human beings may mobilize or shift the learner’s capacity for human connection or perspective on human vulnerability or human value. Paradoxical simulacrum Baudrillard (1983) referred to the transformation of perception from a simulated form of reality as the paradox of simulation. Baudrillard’s (1983) paradox was that ‘reality is immediately contaminated by its simulacrum’ (p. 149). The truth is miniaturized in the production of a representation that is derived from mere intelligible ideas, miniature units, and matrices of the real. The problem is that through the process of representation, ‘only the simulacrum exists’ (Baudrillard, 1983, p. 149). In other words, the object and the substance of the real form disappear and the simulation becomes the dominant scheme. The simulation becomes the only realization or perception of truth in relation to the represented form. The very definition of the real becomes that of which it is possible to give an equivalent reproduction. . . . At the limit of this process of reproductibility, the real is not only what
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can be reproduced, but that which is already reproduced. The hyperreal. (Baudrillard, 1983, p. 146)
If the simulation becomes the dominant perception of what is real, then, how may sense making be altered by the medium of simulation? Simulation may produce its own reality while representing something different and diminished from the original that may persist as the dominant perception in the mind of the participant. Simulation transforms perception by its own reality, the hyperreal that becomes the persistent conceivable form (Baudrillard, 1983; Butler, 1999). So, simulation is not simply representation; simulation is an epistemic phenomenon that persists in object realization. Authenticity of simulation, then, becomes the fundamental concern when training health-care professionals using mechanical forms. Departures from or misrepresentations of the real phenomenon may become the actual phenomena understood and retained. Such re-creations of reality by simulation, if misrepresented, bear implications on learning transfer to live human care particularly if the reality of the actual situation differs from the representation of the situation in the simulation. Poietic enframing Heidegger was fundamentally concerned with man (humans) and the nature of Being. While not addressing simulation directly, his theory related to technology lends insight into the potential of simulation technology to mediate on the apprehension of the reality of natural human beings. In Heidegger’s (1954/1977) view, technology is a mode of bringing forth reality, a mode of revealing that which in nature presents itself. Heidegger (1954/1977) asserted that technology structures and enframes the reality it reveals, entrapping and destining the manifestations of truth and the fullness of being. Harkening back to the Greeks, Heidegger (1954/1977) elaborated on the essence of technology as more than a mere means but as a way of revealing. He characterized the essence of technology as poiesis, bringing forth in a manner of revealing only that which is gathered together in advance (Heidegger, 1954/1977). The issue here is that enframing mediates on the relationship of the perceiver to all that is natural. In
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Heidegger’s (1954/1977) view, the enframing of reality destines the aspects of reality that are revealed by technology and conceals what is unconcealed of the real phenomenon. So what is unconcealed of the real form may no longer concern humans as an object or quality of the real, leaving an illusion that the enframed representation encountered in simulation is the only existent construct of the reality perceived. Yet, Heidegger (1954/1977) in other writing also offered insight into the potential of simulation to open up more meaningful experience. Heidegger espoused the notion that objects exist in the world in four connected ways through earth, sky, mortals, and divinities. Warnick & Waddington (2004) suggested that when the connectedness of these fourfold elements are gathered into a single interpretation, such as with simulation, a richer experience and closeness to the natural world can be revealed. As to Gaba’s (2004) point cited earlier, HF-HPS may potentially amplify the real experience of human conditions. In this light, the design of HPS scenarios with regard to the fourfold elements of the natural world may allow the learner to experience a fuller nature of a given human condition than generally theorized as possible of simulation. Hyperreality Similarly, Borgmann (1992) expressed plural perspectives on the interface of technology and the nature of reality. For Borgmann (1992), technology in its hyperfine and hypercomplex design offers the potential for the generation of an experience with an artificial reality that ‘surpasses . . . [the] natural reality in brilliance, richness, and pliability’ (p. 83). Like Baudrillard (1983), Borgmann (1992) termed this, ‘hyperreality’. But, while Borgmann (1992) described that hyperreality may bear encyclopaedic completeness in the varieties of potential experience, he also asserted that as a pliable form, hyperreality enables an experience with unlimited flow of time. The experience is both disposable and discontinuous while exerting no real force of connection, interaction, or effect. The hyperreal is indifferent to the context and orientation of the natural world. In contrast, reality is commanding and continuous with a connection of the person with the natural world (Borgmann, 1992).
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Hyperrealities such as simulation may engender different experiential forces between the hyperreal and the real. Natural human experiences are evocative in nature. Human conditions and interactions carry a force to emotionally connect, overwhelm, and transcend. This force may touch the heart and stir the soul. Lacking real human essence to connect and evoke, then as Borgmann (1992) might suggest, HF-HPS may mediate on the learner’s conception of real human essence and generate an indifferent and unencumbered perception of the natural human condition.Yet, Borgmann (1992) also suggested that technology may engender a more focal and brilliant experience of the reality represented in simulation. However, he also predicted that the experience of artificial reality would remain discontinuous, bounded, and disconnected, leading to shallow experiences that are indifferently understood. Therefore, HF-HPS may well provide brilliant, rich, and pliable experiences. Yet, these experiences may also promote numbness and disconnection from the essence of the human condition. Comparative representation An analysis of the work of Deleuze (1969/1990) would support a contrasting view of the experience of a reality through simulation. Deleuze’s (1969/1990) theory of identity and difference maintained that the world is both represented and replicated in a variety of ways and that simulacra are not necessarily inferior to the reality that they represent. He argued that simulation bears close association to the original; therefore, the simulacrum is worthy of representation and capable of bearing insights contained within the original that inspired its construction (Deleuze, 1969/1990). In contrast to Baudrillard (1983), for Deleuze (1969/1990), the simulacrum flaunts a privileged and superior position over the original. The simulation bears direct connection to the original and holds power as it stands in difference. From the Deleuzian point of view then, both the association with the original and the difference in relation are important connections between the real and the simulated form. Deleuze (1969/1990) argued that in nature, there exist only differences between all things of natural sameness. Therefore, to grasp reality
is to apprehend difference (Deleuze, 1969/1990). From this point of view, the differences between HF-HPS and human reality may be productive to an end. High fidelity human patient simulation may offer multiple and varied formations on the human condition and iterative opportunities to experience and to apprehend, allowing the learner to appreciate the variety of potential human response patterns. The experience of human conditions represented in simulation may also stand in such dramatic contrast to the real of which it is compared, that real human experiences may seem augmented and more evocative in their nature, enabling the learner to experience a deeper connection. Virtual transformation Turkle’s (2004, 2009) work offers a grounded and contemporary discourse about human-machine interactions that raises a different point. She proposed that the explicit, immersive, and engaging nature of simulation makes its reality difficult to doubt (Turkle, 2009). An echo to Baudrillard’s (1983) concept of the hyperreal, Turkle (2009) explained that the virtual transforms the real into a more real thereby making it hard to acknowledge what lies beyond, or what is absent from within. Simulation precludes a sense of scepticism that allows the simulation to replace the original with a diminished and decontextualized alterity. Turkle’s (2009) work provides evidence of this paradoxical effect. Turkle (2009) reported that simulation encouraged learners to premature closure, unconsidered work, and acceptance of the simulation as fait accompli (Turkle, 2009). Thus, simulation may change or redefine how learners think (Turkle, 2009) and come to know reality. Faculty surveyed in Turkle’s (2009) work reported that students learning by computer simulation needed to realize the shortcomings contained within the simulation. Yet, to question the certitude of simulation requires a disconnection between the real and the unreal as well as referential knowledge and experience from which to critically judge the potentialities beyond. Students, by experience, are not in such a position. Immersion in simulation requires suspension of disbelief, making it difficult to be simultaneously ‘doing and doubting’ (Turkle, 2009, p. 8) in an
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increasingly authentic simulated learning dimension. Learning mediated by HF-HPS may need to be recontextualized and supplemented with referential wisdom regarding the possibilities that lie beyond the limit of the simulation exercise. This is particularly important in relation to natural phenomenon and the complexity and variability of human health responses.
Implications for nursing education concerning the reality represented in simulation The analysis here is not meant to diminish or overestimate the contribution of HF-HPS in health care or its present or potential utility in nursing education. Simulation has a long history of effectiveness as a learning tool across a variety of applications around human enterprises. The increasing authenticity in the technology and the need to employ HF-HPS to assure competency and patient safety command its use. Yet, the representation achieved in scenario-based HF-HPS may not teach all that need be known. The contradiction and paradoxical effects theorized between the real and the technological representation of the reality of the human condition make it important to put the use of simulation in, as Turkle (2004) has suggested, a particular place.Therefore, the potentialities and the limitations of HPS require pedagogical consideration. Dewey (1938/1981) espoused that educative experiences are those held under highly specialized conditions in specialized environments. He elaborated on the nature of experiences with the notion that experiences can fail to be educative and be, instead, miseducative. Waks’ (2001) interpretation is that the Dewian framework of mis-educative experiences is fourfold. This includes experiences that induce insensitivity to subsequent experiences; experiences leading to mechanical response patterns; experiences of immediate pleasurableness; and experiences that are fragmentary or split from subsequent experience. These categories clustered into a twofold framework are used here to examine HF-HPS in light of the nature of reality that it may represent. Pedagogical considerations that may increase the potential for
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more educative learning experiences with HF-HPS in nursing education are explored. Mechanical response patterns and insensitivity to subsequent experiences The application of simulation in nursing and healthcare applications over the past 20 to 30 years and prior to the more recent evolution of computerized HF-HPS has been largely aimed at training of discrete, technical, procedural, and psychomotor skills, and for advanced life support or crisis management training (Issenberg et al., 2005; Bradley, 2006; Nehring & Lashley, 2010). Practice of invasive procedures such as resuscitation or catheterization on inanimate simulators ensures patient safety until novice practitioners achieve competence in the mechanical operations of dangerous or life-saving procedures. These simulations, while being framed around natural human conditions, represent a reality that is procedural, operational, instrumental, linear, or sequential, representing a less dimensional, interactional, or contextual nature. Such instrumental concerns are amenable to the schematic representation given by the epistemic texture of mathematical code (Gramelsberger, 2008) inherent in computerized high fidelity simulators. The type of learning in this context is also mechanical where systematic and mechanical learner response patterns would be desired. The difference now is that the use of simulation in nursing education has moved beyond instrumental and operational skills training to other contexts. High fidelity human patient simulation is being applied to learning human health-care concerns including interpersonal or therapeutic communication, perception of multisystem health status, cue recognition, diagnostic reasoning, prioritization, clinical judgment, and a variety of other nursing interventions (Rauen, 2001; Wong & Chung, 2002; Bearnson & Wiker, 2005; Lasater, 2007; Radhakrishnan et al., 2007; Kuiper et al., 2008; Sleeper & Thompson, 2008). Such contexts are less producible in the linear, sequential texture represented in computerized mannequins or scripted scenarios. Human responses are complex, indefinite, emergent, and contextual. There are inconsistencies, delays, and accelerations inherent in and across human conditions.
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Life is conditional, spontaneous, and transcendent. Much of the human essence, evocative connection, variability, and complexity remain unaccounted for with current computerized representations of human simulator technology or within the scope of what is possible with scenario design and instructional facilitation. The importance here, as Waks (2001) suggested, is that preselected problems in simulations call for preselected responses that might lead to mechanical responses that may drastically reduce the sensitivity demanded and response flexibility needed. This is especially true when compared to natural experiences that are more complex, emergent, and contextual. Students may learn through simulation to respond in rote and mechanical ways or fail to recognize variable or unique human responses upon transfer to real human encounters. Students, when presented with the real human situation, may fail to contextualize relevant human factors lacking in the simulated representation. In this sense, if pedagogically unaccounted for, HF-HPS could result in a mis-educative experience related to human concerns that are beyond the instrumental or to human circumstances that are beyond the limits of simulated representations.Therefore, a more educative outcome may be reached if faculty challenge students to think and reflect beyond the limit of the simulation to other potential variations, contexts, or complexities that may present in the live patient care situation. Fragmentary linkage and immediate pleasurableness The aura (Benjamin, 1936/1968) of human essence bears a connection to the natural physical world and is transcendent to the spiritual domain. Human interactions bind persons together with a force that is intimate and emotionally evocative. This force inspires a sense of passion, empathy, and awe in the nurse– patient interaction related to human health concerns. The nature and substance of human existence in the world are commanding and encumber in the nurse a sense of duty to aid, comfort, and protect. Yet, Borgmann (1992) suggested that there is a clear difference in the experiential force between the real and the hyperreal as experienced with simulation. Natural
forces like human encounters call together a totality and connection of a person in the world. Yet hyperrealities such as human simulation display fragmentary linkage in that they are indifferent to a context, discontinuous, and inconsequential because they carry no real force beyond the simulated situation. Simulations are contrived and disconnected from the real. In the sense that simulation is like a game, the experience of simulation is both fragmentary and unbounded (Borgmann, 1992). In simulation, the scenario can be repeated and the consequence undone. The experience eliminates the risk that would burden and connect the nurse to eminent consequences of the natural world. The reality of HF-HPS is pleasurable, inconsequential, and evocatively shallow. High fidelity human patient simulation disburdens the nurse from the tensional problematic normally present in the reality of human patient encounters. Simulation fails to overwhelm and transcend. On this account, HF-HPS could also be mis-educative for lacking the evocative force to induce a sense of responsibility, accountability, and clinical agency. It might also fail to inspire a sense of empathy in the present or connection to the human essence that would be encumbered on the nurse in real human patient encounters. On the contrary, the experience of simulation may also engender a sense of immediate pleasurableness, meaning a sense of satisfaction or contentment among participants. The concern for immediate pleasurableness (Waks, 2001) of HF-HPS is that simulation may have the tendency to fulfil the senses and to satisfy the learner to its own end. As a scenario unfolds, a reality is made a manifest.The learner experiences this reality although the substance and the boundary of its representation, without the experience or the referent to know what is left, are unrevealed. As Heidegger (1954/1977) suggested, technology, or in this case HF-HPS, may enframe what is experienced and becomes known. Also, as Turkle (2009) concluded, students may lack necessary distance to doubt or the critical stance to question what else may go beyond. This has particular implication when recognizing that the situation of the simulation, as Baudrillard (1983) suggested, may become a reality of its own being, a hyperreal, and not simply something recognized as a lesser symbolic representation.
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What is experienced in the context of HF-HPS will likely stick in the minds of the participants. To the degree that what is represented in the simulation has fidelity to the real clinical situation, then the experience stands to be highly educative. However, there is risk of a mis-educative experience when errors of conditions, processes, or procedures go unacknowledged or uncorrected in simulation. The unrevealed error could become the reality that the learner perceives as correct and later transfers to the live clinical situation. This has particular significance for educators during design, facilitation, and debriefing of simulations. Educators must assure that mis-educative perceptions from simulations are acknowledged and stand corrected to safeguard against errors or departures of fidelity from becoming real errors applied to patient care.
Conclusions and recommendations Multiple sociopolitical factors continue to propel the adoption of HF-HPS as an integral component in the education of nurses and other health-care professionals. The substitution of simulation for part of the educational experience with live human clinical care is also increasingly gaining momentum. In light of recent trends propelling the instructional use of HF-HPS, a philosophical and theoretical examination of the reality represented in simulation is assistive to a better understanding of the limits of authenticity and the nature of reality that simulation may produce.According to Kozma (1991), ‘[the] capabilities of a particular medium, in conjunction with methods that take advantage of these capabilities, interact with and influence the ways learners represent and process information, and may result in more or different learning’ (p. 179). This analysis has provided insights applicable to pedagogical considerations to guide the application of HF-HPS towards its most educative end. The analysis of the reality represented in HF-HPS supports that faculty consider engaging a pedagogical approach that moves beyond the instrumental application of HF-HPS to one that is more contextual. While authenticity is taken for granted in health-care simulations, limited attention has been given to the learner experience of the reality of the human condi-
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tion through its representation by HF-HPS. Research is also needed to answer important questions around issues of reality and representation in HF-HPS in order to support pedagogical development and to increase the efficacy of teaching and learning with HF-HPS in such a way that would promote learning outcomes that transfer to the complex, variable, and emergent human context. Work in this direction would increase the educative value of HF-HPS and assist to position HF-HPS in nursing education in its most relevant place.
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Hansli T. (2008) Parrhasius’s curtain: visual simulation’s mimesis and mediality. In: Simulation: Presentation Technique and Cognitive Method (eds A. Gleiniger & G. Vrachliotis), pp. 13–27. Birkhauser, Boston. Heidegger M. (1977) The Question Concerning Technology and Other Essays (tr. W. Lovitt). Harper & Rowe Inc., New York (Original work published in 1954). Issenberg S.B., McGaghie W.C., Petrusa E.R., Gordon D.L. & Scalese R.J. (2005) Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher, 27(1), 10–28. Kozma R.B. (1991) Learning with media. Review of Educational Research, 61(2), 179–211. Kuiper R., Heinrich C., Matthias A., Graham M.J. & Bell-Kotwall L. (2008) Debriefing with the OPT model of clinical reasoning during high fidelity patient simulation. International Journal of Nursing Education Scholarship, 5(1), Article 17. Lasater K. (2007) High-fidelity simulation and the development of clinical judgment: students’ experiences. The Journal of Nursing Education, 46, 269–276. Latour B. & Woolgar S. (1986) Laboratory Life: The Construction of Scientific Facts. Princeton University Press, Princeton, NJ (Original work published in 1979). Nehring W. & Lashley F. (2010) High-Fidelity Patient Simulation in Nursing Education. Jones and Bartlett Publishers, Boston. Plato (2006) The Republic (tr. R.E. Annen). CTL, New Haven, Connecticut.
Radhakrishnan K., Roche J.P. & Cunningham H. (2007) Measuring clinical practice parameters with human patient simulation: a pilot study. International Journal of Nursing Education Scholarship, 4(1), Article 8. Rauen C.A. (2001) Using simulation to teach critical thinking skills. You can’t just throw the book at them. Critical Care Nursing Clinics of North America, 13(1), 93–103. Rettedal A. (2000) When reality is difficult to simulate. European Journal of Anaesthesiology, 17, 515–526. Sleeper J.A. & Thompson C. (2008) The use of hi fidelity simulation to enhance nursing students’ therapeutic communication skills. International Journal of Nursing Education Scholarship, 5(1), Article 42. Turkle S. (2004) The Second Self: Computers and the Human Spirit. MIT Press, Cambridge, MA. Turkle S. (2007) Authenticity in the age of digital companions. Interaction Studies, 8(3), 501–517. Turkle S. (2009) Simulation and Its Discontents. MIT Press, Cambridge, MA. Waks L.J. (2001) Computer mediated experience and education. Educational Theory, 51(4), 415–432. Warnick B. & Waddington D. (2004) The gathering: an ethical and educational criterion for educational technology. Educational Technology, 44(5), 24–32. Wong T.K.S. & Chung J.W.Y. (2002) Diagnostic reasoning processes using patient simulation in different learning environments. Journal of Clinical Nursing, 11, 65–72.
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doi: 10.1111/nup.12034
The nature of reality represented in high fidelity human patient simulation: philosophical perspectives and implications for nursing education Renee M. Dunnington* PhD RN *Associate Professor, School of Natural Science, Nursing, and Health, Capital University, Columbus, OH, USA
Abstract
Simulation technology is increasingly being used in nursing education. Previously used primarily for teaching procedural, instrumental, or critical incident types of skills, simulation is now being applied to training related to more dynamic, complex, and interpersonal human contexts. While high fidelity human patient simulators have significantly increased in authenticity, human responses have greater complexity and are qualitatively different than current technology represents. This paper examines the texture of representation by simulation. Through a tracing of historical and contemporary philosophical perspectives on simulation, the nature and limits of the reality of human health responses represented by high fidelity human patient simulation (HF-HPS) are explored. Issues concerning nursing education are raised around the nature of reality represented in HF-HPS. Drawing on Waks, a framework for guiding pedagogical considerations around simulation in nursing education is presented for the ultimate purpose of promoting an educative experience with simulation. Keywords: simulation, philosophy.
Humans have since the ancient Greeks concerned themselves with the nature and the apprehension of reality. Yet, the apprehension of reality is contingent upon the means through which it is made a manifest. Increasingly, the reality of human health conditions is represented through simulation as an integral part Correspondence: Dr Renee M. Dunnington, PhD, Department of Nursing, Capital University, 1 College and Main, Columbus, OH 43209, USA. Tel.: + 1 614 236 6703; fax: + 1 614 340 5829; e-mail: [email protected]
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technology,
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education,
nursing
of the education of health-care professionals. Yet, humans are more unique and complex than current simulation technology or technique represents (Turkle, 2004, 2007, 2009). The representation of reality in health-care simulation is worthy of analysis for the potential transformative impact of simulation on the development of health-care professionals and on health care in general. The purpose of this paper is to examine, through various philosophical lenses, the reality represented by high fidelity human patient simulation (HF-HPS) and to explore what it may
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mean to promote active construction of knowledge through simulation. Pedagogical issues that may promote a more educative experience with HF-HPS in nursing education are also discussed.
Simulation and the representation of reality Simulation may take many different forms and present with different technologies, techniques, or learning environments. High fidelity human patient simulation is an instructional technique that involves a technology comprised of a life-size human mannequin, monitors, and computer-driven programming that requires design, administration, and role play enactment of a dynamic clinical scenario. High fidelity human patient simulation has been praised for the potential to provide a realistic, authentic learning environment. This has led to a presumption of its superiority as a mode of instruction among healthcare educators and professionals. Much of the expectation of HF-HPS as a technology-mediated educational technique relies on the learner’s perception of being situated in a simulated yet authentic reality representing a clinical situation. Texture of representation What is the nature and extent of the reality represented in simulated forms? The representation of human beings and their health conditions through computer-programmed human simulators is qualitatively different from the natural essence of human beings. High fidelity human patient simulators are computer driven and bear the ‘epistemic texture’ (Gramelsberger, 2008, p. 84) of a mathematic script. Numeric language encodes an operational script of indices, formulas, and algorithms that process in accordance with a prescription of embedded theoretical rules (Gramelsberger, 2008). The inscription of scientific principles coded in a simulator allows a phenomenon to unfold in a dynamic, narrated scenario. Thus, with HF-HPS, the reality of natural human responses is deconstructed, and then reconstructed through a program that makes the intended health phenomena explicit through sequential, schematic representations
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and prepared redescriptions much as has been described with other forms of simulation (Latour & Woolgar, 1979/1986; Butler, 1999; Gramelsberger, 2008; Grüne-Yanoff & Weirich, 2010). The problem of simulation and representation of human health conditions is the texture of the representation. The appearance of the re-creation is seemingly real in its conceptualization; yet, the reproduction is decomposed in detail, seriated in process, and partial in its final objectification. The simulated human response is subject to the limit of the mathematical language of representation, a reality that is modelled to the extent that it is perceived or theoretically understood and transcribed (Butler, 1999; Gramelsberger, 2008; Grüne-Yanoff & Weirich, 2010) and to the extent that it is reconstructed upon the ideological, psychological, and axiological constitution of its designer. Authenticity in simulation related to human concerns is dependent on the degree that the theorized, programmed, and scripted events approximate the reality of natural living processes. Yet, humans are qualitatively different from mathematized machine representations. Humans have multiplicity and greater complexity. Human responses are less sequential, less predictable, more emergent, and more variable than current technology represents (Rettedal, 2000; Turkle, 2004, 2007, 2009). Humans have psychological, emotional, and spiritual domains that bear on their response to health and healing. Borrowing from Benjamin’s (1936/1968) notion of the ‘aura’ of an original in art, humans have an aura of unique essence of their being.These human dimensions are inadequately captured with mathematical inscriptions or narrated scenario events. Simulation is a causal reconstruction of natural human health responses; however, the living may defy a certain prediction or a fixed calculation (Turkle, 2007, 2009; Gramelsberger, 2008). Yet, with advancements in technology, HF-HPS is increasingly referential to the reality of the human health conditions that it represents. Current simulation technologies and techniques have been praised for their ability to replicate and amplify substantial aspects of the real clinical situation (Gaba, 2004). Simulation is recognized for its ability to provide an authentic but safe practice field for novice learners to
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gain competence with risky procedures or high stress patient care situations. Simulation has also been a formidable solution to the shortage of clinical placements and access to uncommon procedures. The substitution of simulation for a portion of human contact in nursing education and across other health-care disciplines is also an emerging trend. The potential of learning transfer to the real patient care context is the greatest expectation of HF-HPS. It is this potential impact on health care that bears further examination of the reality represented and produced by simulation. Deception or mimesis Historical, philosophical, and theoretical views on simulation may lend insight into the experience of reality represented through simulation. Simulation was first made explicit through art. Plato clearly rejected art as a simulation of truth. He considered the representation of reality in the images of art as being ‘at the third remove from reality’, the mere ‘representation. . .of an apparition’ (The Republic). Plato’s verdict was that the image itself was a deceptive illusion of a representation that was only a reflection of something that was not the real thing. Yet, an opposing perspective is seen from Plato’s student, Aristotle. Aristotle described the principle of mimesis as the noble function of art. For Aristotle, the goal of art was to most adequately represent reality (Poetics). In his view, from mimesis and the experience of the simulated representation of drama, humans could draw knowledge and experience. The reality represented in art could give a necessary distance for humans to identify and respond to that which they recognize but may not have experienced in life (Poetics). Here, the fundamental concern relates to the consequence of representing reality through a simulated form such as art. From Plato’s perspective, simulation leads to deception through an experience that does not adequately represent the real. From Aristotle’s view, mimesis leads to knowledge and experience of the real that is gained through the experience with a simulated form. Henceforth, the Aristotelian view, the aim to gain knowledge and experience of reality through simulation, has remained a dominant influence from the Renaissance to the Modern era
(Hansli, 2008). This is also evident in the increasing adoption of simulation technology across disciplines. Mechanical reproduction Benjamin (1936/1968) theorized on the mechanical reproduction of art. He asserted that the sphere of authenticity is outside technical reproducibility and that the quality of the original’s presence is always diminished in the object that is reproduced. He conceptualized the essence of the real form as the ‘aura’ of the original. This concept lends explanation to the impact of mechanical reproduction of human beings through HF-HPS. Mechanical reproduction through a computer-operated script detaches the original from its unique human essence and produces a diminished reproduction that is devoid of the human aura of natural existence. This theorization suggests that nursing education mediated by simulated human forms such as computerized mannequins may alter sense perception and transform students’ ultimate interpretation of the natural human essence. This raises questions of how the interaction with the mechanical reproduction of human beings may mobilize or shift the learner’s capacity for human connection or perspective on human vulnerability or human value. Paradoxical simulacrum Baudrillard (1983) referred to the transformation of perception from a simulated form of reality as the paradox of simulation. Baudrillard’s (1983) paradox was that ‘reality is immediately contaminated by its simulacrum’ (p. 149). The truth is miniaturized in the production of a representation that is derived from mere intelligible ideas, miniature units, and matrices of the real. The problem is that through the process of representation, ‘only the simulacrum exists’ (Baudrillard, 1983, p. 149). In other words, the object and the substance of the real form disappear and the simulation becomes the dominant scheme. The simulation becomes the only realization or perception of truth in relation to the represented form. The very definition of the real becomes that of which it is possible to give an equivalent reproduction. . . . At the limit of this process of reproductibility, the real is not only what
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can be reproduced, but that which is already reproduced. The hyperreal. (Baudrillard, 1983, p. 146)
If the simulation becomes the dominant perception of what is real, then, how may sense making be altered by the medium of simulation? Simulation may produce its own reality while representing something different and diminished from the original that may persist as the dominant perception in the mind of the participant. Simulation transforms perception by its own reality, the hyperreal that becomes the persistent conceivable form (Baudrillard, 1983; Butler, 1999). So, simulation is not simply representation; simulation is an epistemic phenomenon that persists in object realization. Authenticity of simulation, then, becomes the fundamental concern when training health-care professionals using mechanical forms. Departures from or misrepresentations of the real phenomenon may become the actual phenomena understood and retained. Such re-creations of reality by simulation, if misrepresented, bear implications on learning transfer to live human care particularly if the reality of the actual situation differs from the representation of the situation in the simulation. Poietic enframing Heidegger was fundamentally concerned with man (humans) and the nature of Being. While not addressing simulation directly, his theory related to technology lends insight into the potential of simulation technology to mediate on the apprehension of the reality of natural human beings. In Heidegger’s (1954/1977) view, technology is a mode of bringing forth reality, a mode of revealing that which in nature presents itself. Heidegger (1954/1977) asserted that technology structures and enframes the reality it reveals, entrapping and destining the manifestations of truth and the fullness of being. Harkening back to the Greeks, Heidegger (1954/1977) elaborated on the essence of technology as more than a mere means but as a way of revealing. He characterized the essence of technology as poiesis, bringing forth in a manner of revealing only that which is gathered together in advance (Heidegger, 1954/1977). The issue here is that enframing mediates on the relationship of the perceiver to all that is natural. In
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Heidegger’s (1954/1977) view, the enframing of reality destines the aspects of reality that are revealed by technology and conceals what is unconcealed of the real phenomenon. So what is unconcealed of the real form may no longer concern humans as an object or quality of the real, leaving an illusion that the enframed representation encountered in simulation is the only existent construct of the reality perceived. Yet, Heidegger (1954/1977) in other writing also offered insight into the potential of simulation to open up more meaningful experience. Heidegger espoused the notion that objects exist in the world in four connected ways through earth, sky, mortals, and divinities. Warnick & Waddington (2004) suggested that when the connectedness of these fourfold elements are gathered into a single interpretation, such as with simulation, a richer experience and closeness to the natural world can be revealed. As to Gaba’s (2004) point cited earlier, HF-HPS may potentially amplify the real experience of human conditions. In this light, the design of HPS scenarios with regard to the fourfold elements of the natural world may allow the learner to experience a fuller nature of a given human condition than generally theorized as possible of simulation. Hyperreality Similarly, Borgmann (1992) expressed plural perspectives on the interface of technology and the nature of reality. For Borgmann (1992), technology in its hyperfine and hypercomplex design offers the potential for the generation of an experience with an artificial reality that ‘surpasses . . . [the] natural reality in brilliance, richness, and pliability’ (p. 83). Like Baudrillard (1983), Borgmann (1992) termed this, ‘hyperreality’. But, while Borgmann (1992) described that hyperreality may bear encyclopaedic completeness in the varieties of potential experience, he also asserted that as a pliable form, hyperreality enables an experience with unlimited flow of time. The experience is both disposable and discontinuous while exerting no real force of connection, interaction, or effect. The hyperreal is indifferent to the context and orientation of the natural world. In contrast, reality is commanding and continuous with a connection of the person with the natural world (Borgmann, 1992).
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Hyperrealities such as simulation may engender different experiential forces between the hyperreal and the real. Natural human experiences are evocative in nature. Human conditions and interactions carry a force to emotionally connect, overwhelm, and transcend. This force may touch the heart and stir the soul. Lacking real human essence to connect and evoke, then as Borgmann (1992) might suggest, HF-HPS may mediate on the learner’s conception of real human essence and generate an indifferent and unencumbered perception of the natural human condition.Yet, Borgmann (1992) also suggested that technology may engender a more focal and brilliant experience of the reality represented in simulation. However, he also predicted that the experience of artificial reality would remain discontinuous, bounded, and disconnected, leading to shallow experiences that are indifferently understood. Therefore, HF-HPS may well provide brilliant, rich, and pliable experiences. Yet, these experiences may also promote numbness and disconnection from the essence of the human condition. Comparative representation An analysis of the work of Deleuze (1969/1990) would support a contrasting view of the experience of a reality through simulation. Deleuze’s (1969/1990) theory of identity and difference maintained that the world is both represented and replicated in a variety of ways and that simulacra are not necessarily inferior to the reality that they represent. He argued that simulation bears close association to the original; therefore, the simulacrum is worthy of representation and capable of bearing insights contained within the original that inspired its construction (Deleuze, 1969/1990). In contrast to Baudrillard (1983), for Deleuze (1969/1990), the simulacrum flaunts a privileged and superior position over the original. The simulation bears direct connection to the original and holds power as it stands in difference. From the Deleuzian point of view then, both the association with the original and the difference in relation are important connections between the real and the simulated form. Deleuze (1969/1990) argued that in nature, there exist only differences between all things of natural sameness. Therefore, to grasp reality
is to apprehend difference (Deleuze, 1969/1990). From this point of view, the differences between HF-HPS and human reality may be productive to an end. High fidelity human patient simulation may offer multiple and varied formations on the human condition and iterative opportunities to experience and to apprehend, allowing the learner to appreciate the variety of potential human response patterns. The experience of human conditions represented in simulation may also stand in such dramatic contrast to the real of which it is compared, that real human experiences may seem augmented and more evocative in their nature, enabling the learner to experience a deeper connection. Virtual transformation Turkle’s (2004, 2009) work offers a grounded and contemporary discourse about human-machine interactions that raises a different point. She proposed that the explicit, immersive, and engaging nature of simulation makes its reality difficult to doubt (Turkle, 2009). An echo to Baudrillard’s (1983) concept of the hyperreal, Turkle (2009) explained that the virtual transforms the real into a more real thereby making it hard to acknowledge what lies beyond, or what is absent from within. Simulation precludes a sense of scepticism that allows the simulation to replace the original with a diminished and decontextualized alterity. Turkle’s (2009) work provides evidence of this paradoxical effect. Turkle (2009) reported that simulation encouraged learners to premature closure, unconsidered work, and acceptance of the simulation as fait accompli (Turkle, 2009). Thus, simulation may change or redefine how learners think (Turkle, 2009) and come to know reality. Faculty surveyed in Turkle’s (2009) work reported that students learning by computer simulation needed to realize the shortcomings contained within the simulation. Yet, to question the certitude of simulation requires a disconnection between the real and the unreal as well as referential knowledge and experience from which to critically judge the potentialities beyond. Students, by experience, are not in such a position. Immersion in simulation requires suspension of disbelief, making it difficult to be simultaneously ‘doing and doubting’ (Turkle, 2009, p. 8) in an
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increasingly authentic simulated learning dimension. Learning mediated by HF-HPS may need to be recontextualized and supplemented with referential wisdom regarding the possibilities that lie beyond the limit of the simulation exercise. This is particularly important in relation to natural phenomenon and the complexity and variability of human health responses.
Implications for nursing education concerning the reality represented in simulation The analysis here is not meant to diminish or overestimate the contribution of HF-HPS in health care or its present or potential utility in nursing education. Simulation has a long history of effectiveness as a learning tool across a variety of applications around human enterprises. The increasing authenticity in the technology and the need to employ HF-HPS to assure competency and patient safety command its use. Yet, the representation achieved in scenario-based HF-HPS may not teach all that need be known. The contradiction and paradoxical effects theorized between the real and the technological representation of the reality of the human condition make it important to put the use of simulation in, as Turkle (2004) has suggested, a particular place.Therefore, the potentialities and the limitations of HPS require pedagogical consideration. Dewey (1938/1981) espoused that educative experiences are those held under highly specialized conditions in specialized environments. He elaborated on the nature of experiences with the notion that experiences can fail to be educative and be, instead, miseducative. Waks’ (2001) interpretation is that the Dewian framework of mis-educative experiences is fourfold. This includes experiences that induce insensitivity to subsequent experiences; experiences leading to mechanical response patterns; experiences of immediate pleasurableness; and experiences that are fragmentary or split from subsequent experience. These categories clustered into a twofold framework are used here to examine HF-HPS in light of the nature of reality that it may represent. Pedagogical considerations that may increase the potential for
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more educative learning experiences with HF-HPS in nursing education are explored. Mechanical response patterns and insensitivity to subsequent experiences The application of simulation in nursing and healthcare applications over the past 20 to 30 years and prior to the more recent evolution of computerized HF-HPS has been largely aimed at training of discrete, technical, procedural, and psychomotor skills, and for advanced life support or crisis management training (Issenberg et al., 2005; Bradley, 2006; Nehring & Lashley, 2010). Practice of invasive procedures such as resuscitation or catheterization on inanimate simulators ensures patient safety until novice practitioners achieve competence in the mechanical operations of dangerous or life-saving procedures. These simulations, while being framed around natural human conditions, represent a reality that is procedural, operational, instrumental, linear, or sequential, representing a less dimensional, interactional, or contextual nature. Such instrumental concerns are amenable to the schematic representation given by the epistemic texture of mathematical code (Gramelsberger, 2008) inherent in computerized high fidelity simulators. The type of learning in this context is also mechanical where systematic and mechanical learner response patterns would be desired. The difference now is that the use of simulation in nursing education has moved beyond instrumental and operational skills training to other contexts. High fidelity human patient simulation is being applied to learning human health-care concerns including interpersonal or therapeutic communication, perception of multisystem health status, cue recognition, diagnostic reasoning, prioritization, clinical judgment, and a variety of other nursing interventions (Rauen, 2001; Wong & Chung, 2002; Bearnson & Wiker, 2005; Lasater, 2007; Radhakrishnan et al., 2007; Kuiper et al., 2008; Sleeper & Thompson, 2008). Such contexts are less producible in the linear, sequential texture represented in computerized mannequins or scripted scenarios. Human responses are complex, indefinite, emergent, and contextual. There are inconsistencies, delays, and accelerations inherent in and across human conditions.
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Life is conditional, spontaneous, and transcendent. Much of the human essence, evocative connection, variability, and complexity remain unaccounted for with current computerized representations of human simulator technology or within the scope of what is possible with scenario design and instructional facilitation. The importance here, as Waks (2001) suggested, is that preselected problems in simulations call for preselected responses that might lead to mechanical responses that may drastically reduce the sensitivity demanded and response flexibility needed. This is especially true when compared to natural experiences that are more complex, emergent, and contextual. Students may learn through simulation to respond in rote and mechanical ways or fail to recognize variable or unique human responses upon transfer to real human encounters. Students, when presented with the real human situation, may fail to contextualize relevant human factors lacking in the simulated representation. In this sense, if pedagogically unaccounted for, HF-HPS could result in a mis-educative experience related to human concerns that are beyond the instrumental or to human circumstances that are beyond the limits of simulated representations.Therefore, a more educative outcome may be reached if faculty challenge students to think and reflect beyond the limit of the simulation to other potential variations, contexts, or complexities that may present in the live patient care situation. Fragmentary linkage and immediate pleasurableness The aura (Benjamin, 1936/1968) of human essence bears a connection to the natural physical world and is transcendent to the spiritual domain. Human interactions bind persons together with a force that is intimate and emotionally evocative. This force inspires a sense of passion, empathy, and awe in the nurse– patient interaction related to human health concerns. The nature and substance of human existence in the world are commanding and encumber in the nurse a sense of duty to aid, comfort, and protect. Yet, Borgmann (1992) suggested that there is a clear difference in the experiential force between the real and the hyperreal as experienced with simulation. Natural
forces like human encounters call together a totality and connection of a person in the world. Yet hyperrealities such as human simulation display fragmentary linkage in that they are indifferent to a context, discontinuous, and inconsequential because they carry no real force beyond the simulated situation. Simulations are contrived and disconnected from the real. In the sense that simulation is like a game, the experience of simulation is both fragmentary and unbounded (Borgmann, 1992). In simulation, the scenario can be repeated and the consequence undone. The experience eliminates the risk that would burden and connect the nurse to eminent consequences of the natural world. The reality of HF-HPS is pleasurable, inconsequential, and evocatively shallow. High fidelity human patient simulation disburdens the nurse from the tensional problematic normally present in the reality of human patient encounters. Simulation fails to overwhelm and transcend. On this account, HF-HPS could also be mis-educative for lacking the evocative force to induce a sense of responsibility, accountability, and clinical agency. It might also fail to inspire a sense of empathy in the present or connection to the human essence that would be encumbered on the nurse in real human patient encounters. On the contrary, the experience of simulation may also engender a sense of immediate pleasurableness, meaning a sense of satisfaction or contentment among participants. The concern for immediate pleasurableness (Waks, 2001) of HF-HPS is that simulation may have the tendency to fulfil the senses and to satisfy the learner to its own end. As a scenario unfolds, a reality is made a manifest.The learner experiences this reality although the substance and the boundary of its representation, without the experience or the referent to know what is left, are unrevealed. As Heidegger (1954/1977) suggested, technology, or in this case HF-HPS, may enframe what is experienced and becomes known. Also, as Turkle (2009) concluded, students may lack necessary distance to doubt or the critical stance to question what else may go beyond. This has particular implication when recognizing that the situation of the simulation, as Baudrillard (1983) suggested, may become a reality of its own being, a hyperreal, and not simply something recognized as a lesser symbolic representation.
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What is experienced in the context of HF-HPS will likely stick in the minds of the participants. To the degree that what is represented in the simulation has fidelity to the real clinical situation, then the experience stands to be highly educative. However, there is risk of a mis-educative experience when errors of conditions, processes, or procedures go unacknowledged or uncorrected in simulation. The unrevealed error could become the reality that the learner perceives as correct and later transfers to the live clinical situation. This has particular significance for educators during design, facilitation, and debriefing of simulations. Educators must assure that mis-educative perceptions from simulations are acknowledged and stand corrected to safeguard against errors or departures of fidelity from becoming real errors applied to patient care.
Conclusions and recommendations Multiple sociopolitical factors continue to propel the adoption of HF-HPS as an integral component in the education of nurses and other health-care professionals. The substitution of simulation for part of the educational experience with live human clinical care is also increasingly gaining momentum. In light of recent trends propelling the instructional use of HF-HPS, a philosophical and theoretical examination of the reality represented in simulation is assistive to a better understanding of the limits of authenticity and the nature of reality that simulation may produce.According to Kozma (1991), ‘[the] capabilities of a particular medium, in conjunction with methods that take advantage of these capabilities, interact with and influence the ways learners represent and process information, and may result in more or different learning’ (p. 179). This analysis has provided insights applicable to pedagogical considerations to guide the application of HF-HPS towards its most educative end. The analysis of the reality represented in HF-HPS supports that faculty consider engaging a pedagogical approach that moves beyond the instrumental application of HF-HPS to one that is more contextual. While authenticity is taken for granted in health-care simulations, limited attention has been given to the learner experience of the reality of the human condi-
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tion through its representation by HF-HPS. Research is also needed to answer important questions around issues of reality and representation in HF-HPS in order to support pedagogical development and to increase the efficacy of teaching and learning with HF-HPS in such a way that would promote learning outcomes that transfer to the complex, variable, and emergent human context. Work in this direction would increase the educative value of HF-HPS and assist to position HF-HPS in nursing education in its most relevant place.
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