Purpose of Simulation Isn’t to Mirror Reality


The purpose of clinical simulation healthcare is not to mirror reality. The primary objective of the most commonly used simulation is to improve the performance of humans as it relates to caring for patients within the context of healthcare. Too many times we get lost in toiling over the details of trying to re-create a scenario as realistic as possible. This often leads to what I describe as invisible barriers to simulation insofar as design, perceived resource limitations, or operational realities limit the bandwidth that the simulation program is able to accomplish. It’s important to remember that the primary objective is not to simulate, but to educate. (Certain exceptions may apply to research projects, and human factors design elements, or other factors studying mimicking existing process flow etc.)

When we run a simulation we are not trying to convince the participant that it is real (because if they did think it was real they would likely be a little crazy J). What we need to do is create an environment that helps the participant feel as if there is some realistic comparison to the simulation to what they do when they are actually caring for patients. We need to enter into what is frequently referred to as a fictional contract or psychological contract that allows the participants to drop into their role as a normal care provider knowing that the simulation is artificial, but has value to their learning and their future practice.

Many, many decisions go into the design of simulation. Often times the specifics of the learning objectives and outcomes do not receive as much attention in the design phase as some of the other elements to try to create “perfect fidelity”.  In doing so we often unnecessarily add to the complexity of the scenario that may increase the setup time, the cleanup time, expose the scenario to the potential of technical failure. Further, we can actually confuse the participant as during the scenario they are constantly trying to assess what they are supposed to be interpreting as “real” versus that which is simulated.

So the next time you’re designing a scenario start with learning objectives, outcome objectives, and then answer the question, “what do I really need to provide to allow the potential participant, or participants” a general feeling of realistic sensation that will allow them to participate in a meaningful way.


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6 responses to “Purpose of Simulation Isn’t to Mirror Reality

  1. Andrew Spain

    Hmmm, will have to think more on the comments, but my first inclination is to agree…to a point. The purpose of education (to me) is to engender a change in the knowledge and/or behavior of the individual who is learning. As such, there is a great deal that can be done via the ‘mirroring’ of reality that will help to create those changes. For instance, the use of smells has been shown to create a lasting impact and improved memory of that which has been learned. So I suppose there is a balance in there somewhere. Certainly, just mirroring reality is not sufficient though. Loving how this is making me think!

    • Lori Lioce

      True Andrew. Great thought provoking, somewhat freeing conversation. We have swung over to the side of time consuming preparation to “mirroring” reality and collegial criticism of how many details are needed for “good” simulation. We don’t want “mirroring reality” to prohibit providing simulation, while ensuring enough reproducible fidelity to ensure objectives are met.
      I agree for immersion it is vital to reproduce the objective and subjective cues to immerse students and long-term learning. So yes, balance is the key.

  2. Edward Reesor

    I would have to disagree in that true higher level simulation allows the scenario to draw in the human factors that lead to critical failures. For a low level simulation that teaches tasks, you are correct. For high level simulation that challenges the student to perform those tasks without risking actual patient health, one has to challenge them in as real as situation as practicable, meaning you include smells, sounds, alarms and even temperature extremes. For example, a paramedic needs to be assessed on IV insertion before they can be allowed to practice in the real world. Apply a tourniquet, open the package, swab the area and insert the IV. Now do it at a simulated crash site where the patient is screaming and worried about their child, the family is frantic and over your shoulder, you are on the road surface. Those are the factors that can lead to critical failures. Using high level simulation, one has the ability to compress time and expose the students to those rare but necessary skills required for the job.

  3. Andrew Brown

    I can only agree to a point in that I agree with Edward, there is a fine line between too much detail and not enough detail to get buy in. Buy in is what helps get providers to act as they would so these human errors or misunderstandings can be addressed.

  4. I agree with some aspects of the comments in sofar as if “we want to assess paramedics ability to start an IV in the dark, we need to turn out the lights….”. We must always focus on the learning objectives of a given encounter. My point is broader and seeks to cause provactive thought into the desgin to avoid trying to carry the reality quotent to unecessary levels which can become a dowstream impediment to the success and proliferation of simulation.

    • Lori Lioce

      Absolutely agree – it is all about the learning objective. They should guide the entire simulated clinical experience and determine how many cues are needed.

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