The 3 P’s of Simulation

Simulation can be defined as an “assortment of activities that represent actual or conceivable situations that may be encountered within a real-world environment.”¹ Simulation requires learners to experience a contrived environment to gain knowledge and master psychomotor skills. Learning experts Alice and David Kolb have thoroughly described the value of experiential education and its varied applications (e.g., service learning, problem-based learning, and simulation). They espouse that it is thinking, coupled with doing, that promotes deeper and longer-lasting learning than thinking alone.²  

The Kolbs demonstrated evidence that experiential learning is an effective learning strategy.³ It is worth noting that experiential learning is not always a hands-on psychomotor experience—it can be a lecture or settings. However, this article will focus on hands-on experiences. 

The Kolbs give their name to an experiential learning cycle based on the idea that deep learning takes place when there is a concrete experience (i.e., something is done), reflection on what was done, understanding of what was done, and a change (in behavior) based upon what was done. Learning is more likely to occur when associated with doing, because learners can interact with the event and take time to reflect upon it.³ 

Simulation has been used to teach and assess mastery for some time. It was used to teach and evaluate piloting skills in the early years of aviation.⁴ Initial flight training was conducted using tools that provided little realism and scant feedback. For example, those first flight simulators were made from stripped-down planes (frames without engines) tethered to a fixed point. 

As technology advanced, the amount and depth of feedback given to trainees improved. Advances in simulator designs included more responsive controls, video screens, and onboard computers. Components were added to provide a real-world feel for complex maneuvers.^1,5 Flight simulation is now a commonly used training tool by the airline industry.⁶ 

Experiential Learning in EMS 

Support for experiential learning in EMS education has steadily grown since at least the 1980s. Early adopters were limited to manikins that only provided basic feedback, if any. For example, CPR manikins used in the 1970s and early 1980s provided little feedback and could not be programmed to respond in any particular way. Intravenous cannulations were practiced using simulated detached arms. Childbirth training was relegated to only slightly realistic-looking manikins that could not truly simulate a birth.

Manikins and other simulation equipment became more realistic in the 1990s and 2000s. Innovations included wireless systems that allowed scenarios to be run outside of labs, as well as better feedback. For example, manikins could present blocked airways, 12-lead EKGs could be acquired, and bowel and heart sounds could be generated. 

By the 2010s popular high-fidelity manikins incorporated RFID chips, allowing them to automatically respond to actions taken by caregivers. For example, when a learner injected a medication into the manikin, the chip allowed the manikin to know which medication was administered, and the simulator reflected expected physiological changes without actions by the educator. Some high-fidelity models could mimic the abdominal (uterine) contractions of childbirth, display pupillary changes, present complex airway problems, and exhibit seizures. 

Use of newer, high-fidelity simulation tools has improved the training of individuals and teams.⁴ However, improvements in how well simulators represent our patients are still needed. While realistic-looking minority representation can be found with a few manufacturers, too many either do not offer diverse choices or simply paint a Caucasian manikin so it looks darker. It is up to customers to keep the pressure on manufacturers to do better.⁷

Knowing that simulation is useful and will be a part of healthcare education for the foreseeable future means educators need to do it well. I offer this framework for putting simulations into practice.

3 P’s of Simulation 

Prepare

One of the best ways to increase the effectiveness of a simulation is to put time into it before the day you plan to use it. This means thinking through:

• Who is your audience?
• What are your goals?
• Is your lab capable of doing what you want?
• Have you prepared a contingency if things don’t work?
• What are your expectations?

Who is your audience?

For most EMS programs the audience will be students learning to be paramedics, advanced EMTs, EMTs, or emergency medical responders. Other programs will include non-EMS healthcare providers and lay persons. Regardless of the audience, your simulations must be tailored to the students’ scope of practice. If you have a mixed group, attempt to incorporate all the fields represented into each scenario. 

You must match your expectations with your students’ abilities and scopes of practice. I find it easiest to write the scenario to the highest level of care allowable by the team, then grade team members to their level of care. This means I only need one rubric, and it can account for each team member’s participation.

What are your goals?

Your goals are the things you want to accomplish by having students participate in the simulation. For example, do you want them to have a slow-paced learning experience? Is the simulation to be conducted in real time? Is it a test? Will students be team members or leaders? Will you use distractors or a laboratory setting? Are students expected to perform as novices, experts, or in between? Your goals need to be clearly stated. Creating a rubric for grading will help the students know how they will be assessed and help you evaluate them consistently. 

Is your lab capable of doing what you want?

Simulation labs fall within a wide range of complexity. A simple lab might be a room with a low-fidelity manikin on the floor. The lack of realistic surroundings, like furniture or vehicles, will require students to imagine and verbalize key aspects of the scenario. This low-fidelity setup can work, and it is by far the cheapest way to go. However, the lack of a real-world situation will make the simulation less valuable. Inexpensive props can add a sense of realism to your scenarios. 

You can increase the value of the lab experience by recording students’ performance using a video camera or even smartphone. Some simulation systems include high-quality recording equipment. Recordings should be considered protected information under FERPA (the Family Educational Rights and Privacy Act) and securely maintained. 

If you can move up to a mid-fidelity simulation system, the manikins will provide students with a variety of realistic and programmable vital signs and you with meaningful feedback. A typical mid-fidelity manikin will allow students to see chest rise and fall, feel pulses, hear breath sounds, initiate IVs, and deliver electrical therapy. Such manikins may cost $1,000–$15,000. 

High-fidelity simulation systems allow students to experience more realistic physiological parameters, like vital signs that react to the student’s actions, and provide in-depth feedback. This increase in realism is accompanied by an increase in cost: Some of these models cost more than $50,000. 

Have you prepared a contingency if things do not work?

If your lab is designed for low-fidelity simulations, you are less likely to experience software and hardware glitches. With high-fidelity simulations, there in is an increased chance for problems. These include Wi-Fi connectivity, the need for last-minute software updates (for manikins, simulated monitors, laptops), and having adequately charged batteries.

Some simulators function as their own mesh networks, so they connect to each component, while others work with your agency’s open Internet connection. Other devices require a secure wireless or hard-wired (LAN) Internet connection. Because of security concerns, you may need your agency to grant permission for the simulator to connect to your network. 

When using high-fidelity manikins, it is strongly recommended to check for software updates on a regular basis. Give yourself enough time to download, install, and test any changes. This can take more than an hour each time. Hopefully your program has someone dedicated to managing your simulation lab space; this person will ensure updates are installed before your lab session. 

If you do not have a lab manager and equipment crashes during a class, you need a backup plan. If you are lucky enough to have duplicates, you could simply swap your manikin with a comparable one. If that is not an option, you can step down to a simpler manikin. If that manikin cannot produce the data you intended, you could instead use a free-standing monitor that displays vital signs as if they were coming from a patient. Lastly, you could ask learners to pretend they can see and hear the parameters you intended the manikin to produce. This option is least desirable because it fails to provide realism and reinforces the bad behavior of having students repeatedly asking you for answers instead of assessing the patient. 

What are your expectations?

Goals and objectives clarify your expectations of students’ behavior. To measure that behavior, it helps to have a standardized assessment tool. Examples can be found through professional organizations and colleagues, or you can create your own. Whichever you use, the template for your assessments should include the information you would expect to see on a patient care report and expected changes based upon treatments. You will need to describe the scene, the patient’s chief complaint, vital signs, expected treatments and outcomes for those actions, and critical errors. 

There will be times when learners make choices you never saw coming.  These decisions may lead the patient’s condition in a direction for which you had not prepared.  Remain flexible and able to incorporate these actions into the unexpected pathway. 

Play

After the preparation it’s time to help the learners engage with the scenario. A simulation should last between 10–20 minutes. It’s best to adhere to the adage “crawl before you walk and walk before you run.” In this context it means learners should go through their first simulations slowly and methodically. Give them room to make mistakes and the grace to be forgiven. An educator can help guide leaners by offering structured comments during the scenario, known as facilitation. More facilitation will be done during early simulations than in later ones. 

Encourage students to focus on the manikin or standardized patient, rather than the instructor, for information. If there are data not available from the simulation system’s equipment, the educator can call it out from the sideline. But remember, the more you do this, the more the student will depend upon you and not develop their own habit of focusing upon the patient.  

If you are using multidisciplinary teams, assign roles accordingly. Teams might consist of varied groups from EMS, respiratory therapy, clinical lab, and nursing programs. Also consider reaching out to nontraditional roles like chaplains. A team made up of disparate jobs can enhance a collective ability to consider what to do and how to adapt.⁸ 

Ponder

The ponder (aka debriefing) happens immediately after the simulation.⁸ It should be bidirectional and last as long as the scenario. Some students may enjoy the stress of a high-intensity simulation. Others may feel overly scrutinized and exceptionally stressed.⁸ This stress can lead to a cumulative effect that impacts the student’s ability to learn. 

Be sure beginning learners know errors are not a big deal and you will shepherd them through the process.⁹ Creating a sense of “psychological safety” will increase information sharing, social comfort within the group, and willingness to take risks. When learners do things wrong, be kind and take the time to correct them. Guide students to a deeper understanding of the right actions and provide tips to improve their performance.¹⁰ 

During the debrief, I recommend using the approach of asking: 

• How do you think you did?
• What could (would) you do differently?
• What was your rationale for your decisions?
• What does the group think? 

Then offer your feedback, ending on a positive note.

Summary

Simulation is a vital element of teaching future EMS professionals. Regardless of the complexity of the equipment, a simulation space must be designed to allow lots of realistic hands-on practice. Low-fidelity systems are unlikely to suffer last-minute failures but will provide learners with limited realism and feedback. High-fidelity systems provide significantly more realism and robust feedback, but operators require training and technology support. The most effective simulation programs have full-time dedicated operators. 

For all systems, you must prepare the simulations using a standardized format; this will help ensure you have the information needed to run the scenario. Check equipment before the simulation for functionality. Practice scripts before using them with learners. Encourage learners to feel comfortable and see the simulation lab as a safe space for making mistakes. 

Use feedback as a tool to correct misunderstandings and mistakes. Feedback sessions should be lengthy, especially during the early stages. They may become shorter as students achieve increasing levels of mastery. Simulations will be a great tool to maximize the success of your learners. The three P’s represent a solid strategy for using them to their fullest.  

References 

1. Wiggins LL, Sarasnick J, Siemens NG. Using Simulation to Train Medical Units for Deployment. Mil Med, 2019 Dec; 185(5): 341–5. 

2. Kolb A, Kolb D. Experiential Learning Theory as a Guide for Experiential Educators in Higher Education. Experiential Learning & Teaching in Higher Education, 2017 Jun; 1(1): 7–44.

3. Kolb DA. Experiential Learning Theory and The Learning Style Inventory: A Reply to Freedman and Stumpf. Academy of Management Review, 1981 Apr; 6(2): 289–96.

4. Hamman W. The Complexity of Team Training: What We Have Learned from Aviation and Its Applications to Medicine. Qual Saf Health Care, 2004 Oct; 13(Suppl 1): i72–i79.

5. Koonce JM, Bramble WJ Jr. Personal computer-based flight training devices. Int J Aviation Psych, 1998; 8(3): 277–92.

6. Jones C, Jones P, Waller C. Simulation in Prehospital Care: Teaching, Testing and Fidelity. J Paramedic Practice, 2013 Aug; 3(8): 430–4.

7. Hunter S. The Education Bridge: How Culture-Based Narratives Improve EMS Learning. J Emerg Med Serv, 2005 Sep; 30: 58–67.

8. Coggins A, De Los Santos A, Zaklama R, Murphy M. Interdisciplinary clinical debriefing in the emergency department: an observational study of learning topics and outcomes. BMC Emerg Med, 2020; 20: 79.

9. Lateef F. Maximizing Learning and Creativity: Understanding Psychological Safety in Simulation-Based Learning. J Emerg Trauma Shock, 2020 Jan–Mar; 13(1): 5–14.

10. Lombardi K. Applying Experiential Learning Theory to Medical Simulation. Educator Update, National Association of EMS Educators, 2015 Fall; https://issuu.com/naemse/docs/fall15issuenew1.

Sidebar: The Three P’s

Prepare—Identify your audience, goals, and expectations. Configure your learning environment. Devise a contingency plan for unexpected problems.

Play—Facilitate gradually more challenging scenarios. Encourage students to focus on the manikin or patient, not the instructor. Assign team roles as needed.

Ponder—Conduct a thorough yet encouraging debriefing in which information is openly shared. Offer your own feedback.

Sandy Hunter, PhD, NRP, is an assistant professor in the Department of Emergency Medical Science at Wake Technical Community College in Raleigh, N.C.