SIMQ: Common Misconceptions About Simulations

From the Desk of Carol C. Dudding, PhD, CCC-SLP, CHSE

In this article we will be addressing some of the common misconceptions about simulations for clinical education.  We will exchange ideas with Lauren Mullen.  Lauren is the simulation lab director at James Madison University and has some important insights to share. 

The SimQ format, allows us to explore the technological as well pedagogical aspects of simulation for clinical education through the words of the experts.  It is anticipated that the audience will include university faculty, clinical educators and professionals, with interest in the use of simulations to enhance the clinical education of our students and practicing professionals. These articles are intended to address the needs of those considering the use of simulations, and those with varying levels of experiences.

Carol C Dudding, PhD, CCC-SLP, CHSE
Contributing Editor

SimQ: Common Misconceptions About Simulations

Lauren Mullen

Lauren, thank you for taking the time to address some of the common myths surrounding the use of simulations.  Tell us about yourself.

I am the lab director for the School of Nursing at James Madison University (JMU). I received both my bachelor’s and master’s degrees in nursing from JMU and am a Certified Healthcare Simulation Educator (CHSE).

Q.  How did you get involved in simulations? 

It began in 2008 during my graduate program.  It was before sim really took off. I mean simulation has been around since forever but it wasn’t until the mid-2000s when it began to be used more extensively in nursing education. I was working at another school as the director of the nursing program. I came to JMU as instructional faculty [member] and because of my specialization and expertise, this position of director of the simulation lab was created within the School of Nursing.  It was a perfect fit for me.

Q.  Tell us a bit about the JMU simulation facilities?

We are really fortunate to have over 7000 square feet of learning space dedicated to skills acquisition and health assessment.  Our new facility offers a 6-bed acute care and a 4-bed primary care learning environment.  Nursing students are able to enhance their skills in a life-like learning environment through practice-based, hands-on education.  The labs are equipped with low, moderate, and high-fidelity patient simulators from across the lifespan.  This allows students to be exposed to patient care scenarios that focus on pediatrics, medical/surgical, psychiatric, community health, and critical care.

As you know, we are really excited about our recently purchased high-tech newborn baby named Super Tory. We are also checking out some wearable technologies to allow a hybrid simulation experience. Maybe we can talk about that more later.     

Misconception #1: All simulations are created equal.

Simulations can take many forms: standardized patients, task trainers, manikins, computer-based simulations, and virtual reality. Each type of simulation varies in terms of cost, resources, technology and fidelity.  Briefly, standardized patients refer to the use of actors to portray the role of patients or caregivers in a consistent manner. Task trainers can be of high or low fidelity and allow the repeated practice of a specific skill. A well-known example of a task trainer is Rescusi-Annie to train in CPR. Manikins take the form of adults and/or children and vary in function. There are some extremely high tech manikins that can simulate bleeding, perspiration, and gas exchanges.  The pediatric manikins are able to change breathing rates and tone in response to oral feedings. Computer-based simulations are based on a gaming-technology, but are not meant to be for entertainment purposes. Some computer-based simulations are designed to allow users to demonstrate clinical decision making skills. An emerging area of simulations is in the area of virtual and/or augmented reality. As the name suggests, learners are able to interact with patients and/or each other in a created virtual world. Lastly, these forms of simulations can be mixed together such as combining the use of a standardized patient to serve as a family member for a digitized manikin.  The mixing of simulation types is also known as a hybrid approach.

Misconception​ #2: Simulations are expensive and require lots of money, dedicated space and resources.

The cost of a simulation varies according to the type of simulation employed.

For example, the going rate for a standardized patient (an actor to portray a patient) is approximately $15 per hour, but can vary in different geographic locations. Of course, you need to consider the total time necessary for training the standardized patient, the simulation time itself and any additional time required for evaluation, debriefing and follow-up.   

Virtual and computer-based simulations have different cost structures and may or may not require dedicated equipment. For example, Simucase is offered for an individual yearly subscription price that most find quite reasonable. The use of virtual reality for training in an academic environment is emerging. Special virtual viewing equipment, such as goggles, may be required. However, as in all things, the cost is likely to come down and the technology become more accessible with time.

Now of course, a fully functioning simulation lab, similar to what is available at larger Schools of Nursing and medical colleges, is going to require a considerable investment of money, expertise, space and resources.  But of course, it isn’t necessary or likely that all allied health programs will have their own dedicated sim lab. But that doesn’t mean that the faculty and students don’t have access to the manikins and/or sim labs on campus.

If you have access to these resources, there are a number of costs to consider. An initial cost to develop simulation experiences depends on many factors.  During the planning phase, it would be prudent to consider 1) number of learners 2) equipment needs 3) desired level of fidelity 4) operational resources. Even after a simulation is developed, there are costs associated with consumable products utilized during simulation.  The bulk of costs associated with simulation will be for simulation technology and equipment as well as a simulation operator to program and run the simulations.  High fidelity manikins range in cost from $6K-$85K.  Lower priced manikins elicit basic life-like characteristics, while the higher cost manikins have advanced capabilities that help increase fidelity during the simulation experience.  More importantly, educators can apply the standards of best practice with regard to simulation with lower cost options so long as sound simulation methodology is used. 

Misconception #3: There is little evidence to support the use of simulations.

A landmark study published by the National Council of State Boards of Nursing (NCSBN) in 2014 demonstrated that up to 50% of high-quality simulation may be utilized to replace traditional clinical hours across pre-licensure nursing curricula (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014).  In addition to being an effective strategy for developing critical thinking in students, simulation has also been shown to increase confidence in students prior to entering the clinical setting.  There are a number of other studies, including a meta-analysis by Cook and colleagues (Cook et al., 2011), that fully support the use of simulation for student and workforce training.  Refer to the references provided below for more details.

Q.  Let me add that there is research specific to the use of sim in Communication Sciences and Disorders and Occupational Therapy. While a comprehensive list of research is available elsewhere, there are a few key studies that support the use of various forms of standardized patients as a viable instructional strategy (Hill, Davidson, & Theodoros, 2013; Zraick, 2012).  Studies on the use of part-task trainers (Benadom & Potter, 2011) and high-fidelity manikins (Estis, Rudd, Pruitt, & Wright, 2015), indicate that CSD students increase in comfort levels and foundational knowledge for working with a variety of different disorder groups. Similarly, virtual simulations have been used to augment hands-on training of wheelchair skills for occupational therapy students, and have resulted in improved self-efficacy and discussion about technique (Chard, 1997; Baird et al., 2015). 

Misconception #4: Students hate simulations.

I have found that students LOVE simulation!  Students report that simulation experiences challenge them to think on their own, develop prioritization and teamwork skills, and expose them to more diverse patient situations in which to make critical patient care decisions.  Facilitators who foster a “safe space” observe more engaged learners willing to self-discover their own skills and abilities without risking patient safety.  Students often tell me that they love knowing they can make and learn from their mistakes using simulations in a safe environment.  They report an increase in confidence after completing simulations.  

Carol: We too have found that our SLP masters students are eager to engage in simulations and find the experiences very worthwhile.

Misconception​ #5: Simulations can be completed without any assistance from an instructor and/or facilitator.

This is, in part, a myth. Some instructors believe that they can assign students a simulation, much like a written case study, to be turned in as an assignment. This defies what is known about best practices in simulations.  They need be based on specific learning objectives and use appropriate educational strategies.  For example, it is widely accepted that simulations are more than the technology employed. A quality simulated learning experience is comprised of the pre-brief, the simulation experience and a debriefing.

Misconception​ #6: Most student learning occurs during the simulation experience itself.

As mentioned earlier, the debriefing is part of the simulation experience. In fact, research has shown that the debriefing is where most student learning occurs. The facilitator/instructor observes student performance during a simulation. They may or may not elect to provide feedback during the simulation as it is observed by the facilitator.  During the debrief, the facilitator guides students through their performance using reflection and feedback.  The process of learning during debriefing has cognitive, behavioral, and environmental effects when students are faced with similar situations in the future.  If you are considering using simulations, I strongly encourage you to review debriefing strategies and have a plan in place for how your debriefing will occur.

Carol: Sounds like we may need to dedicate an article to the topic of debriefing.

Misconception​ #7:  Nursing and medical faculty prefer to conduct their own simulations, without other disciplines being involved.

I have found this to be one of the most concerning myths. That nursing and medicine are territorial and will not allow others to use their facilities. That has not been my experience at all. We welcome the opportunity to collaborate and I encourage anyone who is interested in simulations to seek out opportunities within your network to find other professionals who are using simulations and try to collaborate.  At my university, using simulations across programs helps us in meeting our mandates for interprofessional education and practice.  Simulations seem to make a great deal of sense in the area of interprofessional education, so I hope this misconception of programs not wanting to collaborate with one another can be put to rest for good.

Carol: I know the simulation center at the University of South Alabama is an excellent example of a sim center focused on interprofessional education. There is some great research coming out of that lab…including the work of Julie Estis, CCC-SLP.  Here is the link if interested to learn more https://www.southalabama.edu/centers/simulation/ or check out the SIMQ that Julie Estis completed in the course library.

Misconception​ #8:  Watching a video of a voice client and discussing during class is an example of a low fidelity simulation.

This is the kind of statement that makes me nervous. When I hear this it sounds to me that someone is looking for a “quick fix” to a problem. As you know by now, quality simulations are constructed to allow for interactive, hands-on learning. In order for this to qualify as simulation, all stages of a simulation would need to be included.  In addition, simulation involves the student in the decision-making process.

In all aspects of our professional lives, we need to have adequate training and knowledge before endeavoring to implement simulations within our curriculums.

Misconception​ #9:  High tech simulations (digitized manikins) offer improved learning as compared to a lower fidelity simulation such as standardized patients (actors).

Sorry to repeat myself but simulation is more than a technology. This is a good time to introduce the concept of fidelity.  Fidelity is the degree to which the simulation replicates reality.  While high fidelity manikins are more realistic and life-like, a standardized participant represents the highest degree of fidelity because it is a real person. A low –tech simulation, such as practicing placement of a Foley catheter using a part task trainer placed on a desk or table, can be more effective than a poorly developed simulation using a $60,000 manikin with simulated urine output.  For the optimal learning experience you need to consider the objectives of the simulation and select the most appropriate type of simulation that will meet the learning objectives you are targeting.  

Misconception​ #10:  There is no set of standards for simulations. Everyone can do what they think is necessary.

The International Nursing Association for Clinical Simulation and Learning (INACSL) leads the development and dissemination of best practice with regard to simulation.  INACSL publishes and updates the Standards of Best Practice: Simulation each year and is the guiding framework for sound simulation development in nursing programs nationally and internationally.  It's accessible online and is a must-have resource.

Misconception​ #11:  All students receive an individual grade for their participation in simulations.

There are three types of evaluation during simulation based experiences: formative, summative, and high stakes.  It is more common for simulation to be formative where students are progressing toward meeting learning outcomes or course objectives.  Grades are not typically assigned here.  When assigning a score to participant performance, factors such as using a reliable instrument in the context of a theoretically based method of evaluation, using unbiased raters or observers, and providing learners with clear expectations and objectives must be considered.  A simulation may be summative in that a student must demonstrate an expected level of skill and performance before “passing.” You may see grades assigned in the context of a course. The high stakes aspect refers to something known as an OSCE. It stands for an Objective Structured Clinical Examination.  Many health professions require that practitioners successfully demonstrate skills as part of an OSCE in order to practice.

Misconception​ #12: Simulations are best for providing students with practice before actually seeing a live patient.

This is partially true. Simulations are certainly used for practice before seeing a live patient. However, there are other uses within the educational and workforce settings. Simulations are a suitable replacement for direct care clinical experiences.  Programs can utilize simulation in a variety of ways prior to or after seeing live patients.  Introductory simulations help students get a feel for real patient interactions.  These types of simulations help faculty identify areas for strengthening prior to live patient interactions.  Some simulations are aimed at developing critical thinking skills while others are simply to gain competency with psychomotor skills that are integral to patient care.  Readiness for practice simulations are associated with transition to practice for students entering their chosen profession. We are focused on pre-service training, but simulations are also used in the workforce to train on aspects of patient care and teamwork.  For example, simulations can be used by practicing professionals as a way for maintaining skills and competency assessments.  

Misconception​ #13:  Most simulations are commercially available for purchase by the college/university.

This is a myth in that most simulations are developed through collaboration between clinical educators and instructors. There are some commercially available scenarios available through manufacturers of manikins but often require some in-house modifications.

Misconception​ #14: Simulations are not effective in teaching interprofessional team skills.

Interprofessional simulations are one of the most powerful tools used by simulationists in developing interprofessional team skills.  INACSL has included Simulation-Enhanced Interprofessional Education (Sim-IPE) in the most recent publication of simulation standards.  Exposure to other professions during simulation allow students to gain an understanding of the roles, responsibilities, and communication process of the interprofessional team.  This understanding is critical to providing optimal care to patients with complex healthcare needs.

Misconception​ #15:  Simulation experiences can replace all hands-on clinical learning.

Simulations are meant to augment traditional direct care clinical hours.  In some states, simulation can replace up to 50% of direct hours for nursing students.  There is value in both direct and simulation hours, which is why most states allow some type of simulation to replace direct care hours. 

I will add that speech-language pathology students are permitted to count simulations for up to 20% of clinical clock hours. Occupational Therapy students will be able to fulfill some initial experiential learning opportunities through the use of virutal simulated environments, according to the 2018 accreditation standards. 

Carol:  Thanks Lauren for your time and expertise. It no doubt gives us an important perspective as allied health fields move further into the use of simulations. The remaining myths are focused on CSD, so why don’t I take it from here.

For OT, AOTA's Accreditation Council for Occupational Therapy Education (ACOTE) has added the terms simulated environments as a means to meet Level I fieldwork requirements in section C.1.9. Level I Fieldwork of the 2018 ACOTE Standards and Interpretive Guide (effective July 31, 2020). All are encouraged to read the implementation language carefully to ensure compliance.    

Thanks Carol. I look forward to continuing our work together. And we never did get to discuss wearable manikins. Let’s save that for a later discussion.

Misconception​ #16:  Simulations are new to Communication Sciences and Disorders within the last 5 years.

Simulations have been around in the medical and nursing arena for more than 150 years. As mentioned, the use of simulations really began to take off in those disciplines with the advent of new technologies in the 2000’s.  While there has been a growing interest in the use of sims within CSD within the last 5 years, research in our field goes back to Syder in 1996, and Zraick and colleagues in 2002 and 2003 in reporting the effective use of standardized patients.  

Misconception​ #17:  Students in speech-language pathology cannot count time spent in simulation towards clinical clock hours, required by ASHA.

Most readers are aware that in 2016, ASHA’s Council for Clinical Certification (CFCC) in Audiology and Speech-Language Pathology made changes to the implementation language for Speech-Language Pathology Standard V-B to allow up to 20% of the required 375 direct clinical hours to be obtained through simulation.

Misconception​ #18:  All programs must provide students in speech-language pathology clinical clock hours through simulation.

This is a myth. In fact, programs are discouraged from incorporating sims into the curriculum without proper training for both faculty and students and resources. As in any endeavor, administrative support and infrastructure are keys to success.  Before implementing simulations it is strongly recommended that programs complete proper training and develop an implementation and debriefing plan.

Misconception​ #19:  Programs must have a faculty member, like Lauren, dedicated to carrying out simulations within a program.

This is another one of those myths that is a barrier to implementing simulations within CSD programs. In most cases, there are 1 or 2 faculty members (clinical and/or academic) with an interest in simulations that work together in small and big ways to incorporate simulations into their instruction.  

Misconception​ #20:  Simulations are the answer to all the problems facing speech-language pathology programs.

You know the answer to this one. Simulations are another instructional strategy to assist students in learning the requisite knowledge and skills in a safe learning environment. Sims offer students hands-on practice that is repeatable. They also support the development of professional skills such as communication, teamwork and clinical decision making. While there is evidence to support their use, and students love them, they are but another tool for student training.

References

2018 Accreditation Council for Occupational Therapy Education Standards and Interpretive Guide (Effective July 31, 2020). American Journal of Occupational Therapy, 72, (supplement 2). doi:10.5014/ajot.2018.72s217

Baird, J. M., Raina, K.D., Rogers, J.C., O’Donnell, J., Terhorst, L., & Holm, M. B. (2015). Simulation strategies to teach patient transfers: Self-efficacy by strategy. American Journal of Occupational Therapy, 69(Suppl. 2), 6912185030. http://dx.doi.org/10.5014/ajot.2015.018705

Benadom, E. M., & Potter, N. L. (2011). The use of simulation in training graduate students to perform transnasal endoscopy. Dysphagia,26, 352–360. https://doi.org/10.1007/s00455-010-9316-y

Chard, G. (1997). Should Occupational Therapists use Simulation Exercises? Using Wheelchair Training an an Example. British Journal of Occupational Therapy, 60(4), 161-166.

Cook, D. A., Hatala, R., Brydges, R., Szostek, J. H., Wang, A. T.,Erwin, P. J., & Hamstra, S. J. (2011). Technology-enhanced simulation for health    professions education: A systematic review and meta-analysis. Journal of the American   Medical Association, 306(9), 978–988.

Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association. (2013). 2014 Standards for the Certificate of Clinical Competence in Speech-Language Pathology. Retrieved Feb 13, 2018 from http://www.asha.org/Certification/2014-Speech-Language-Pathology-Certification-Standards/.

Estis, J. M., Rudd, A. B., Pruitt, B., & Wright, T. (2015). Interprofessional simulation-based education enhances student knowledge of health professional roles and care of patients with tracheostomies and Passy-Muir® valves. Journal of Nursing Education and Practice, 5(6), 123–128. https://doi.org/10.5430/jnep.v5n6p123

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBSN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S4–S41.

Hill, A. E., Davidson, B. J., & Theodoros, D. G. (2013). The performance of standardized patients in portraying clinical scenarios in speech-language therapy. International Journal of Language and Communication Disorders, 48(6), 613–624 https://doi.org/10.1111/1460-6984.12034

Syder, D. (1996). The use of simulated clients to develop the clinical skills of speech and language therapy students. European Journal of Disorders of Communication, 31(2), 181–192. https://doi.org/10.3109/13682829609042220

Zraick, R. (2002). The use of standardized patients in speech language pathology. SIG 10 Perspectives on Issues in Higher Education, 5, 14–16. https://doi.org/10.1044/ihe5.1.14

Zraick, R., Allen, R., & Johnson, S. (2003). The use of standardized patients to teach and test interpersonal and communication skills with students in speech-language pathology. Advancesin Health Sciences Education, 8, 237–248.

Zraick, R. I. (2012). A review of the use of standardized patients in speech pathology clinical education. International Journal of Therapy and Rehabilitation, 19(2), 112–118.