Words By Ciara Laybutt, Mitchell Trethowan, Alexander Zeng
Simulation-based training has played a fundamental role in paramedic education since its early inception (1). Paramedicine simulation involves techniques that are designed to replicate clinical and operational situations. Hogg et al. showed that adverse clinical outcomes were more commonly associated with human factors, such as clinical decision making, rather than poor technical knowledge. Simulation therefore provides a tangible opportunity for paramedicine students to experience the real-time pressures of the out-of-hospital environment, which assists with the development of students’ decision-making, clinical skills, and critical thinking without compromising patient safety (2–4). Additional research has found high fidelity simulation to provide notable improvements in human factors such as leadership skills, teamwork, situational awareness, communication, and clinical decision making and reasoning (2,5–7). Another advantage of simulation is the ability to manipulate the participants’ level of immersion, which can range from the classroom environment to three-sixty-degree visual projection (5,6,8). Three-sixty-degree projection in this setting is defined as the employment of a four-wall projector system to simulate a multitude of environments that a paramedic may experience in real world practice (9).
Historically, paramedicine simulation has largely remained low fidelity (10). This is expected to change as the paramedicine profession continues to evolve, and further technological advancements are made.
This critical reflection will review a recent experience of paramedicine students in an immersive high fidelity simulation environment. It will also discuss and how high-fidelity simulation could be used to enhance the education of student paramedics.
Six paramedicine students from a Queensland university were invited to attend a high- fidelity simulation centre, consisting of a three-sixty-degree augmented environment. This included audio-visual immersion with temperature and lumen control, as well as state-of-the-art patient simulators, and professional actors and props. The students’ previous experience involved simulation training within a controlled workshop environment consistent with many undergraduate programs in Australia.
A three-sixty-degree image was projected around the students, which simulated an entirely different environment. In a typical classroom simulation setting, practicing students would be surrounded by assessors, observing students, and objects not relevant to the scenario. A typical classroom simulation would also not utilise or have access to temperature control and sound effects.
Immersive high-fidelity simulation is rapidly evolving the way in which medical professionals are trained, particularly in emergency medicine fields. A review of the literature found that the use of high-fidelity simulations in education is supported across multiple healthcare disciplines, including paramedicine. McKelvin and McKelvin found that while it is essential to gain a foundational skill set using conventional training, there is also a need for immersive simulation to ensure deeper learning and readiness for the workforce. In the context of emergency services, high-fidelity simulation has been shown to improve initial student performance (11). The simulations’ realism prompted a more student-led scenario which allowed students to be more engaged with the situation and focused on their actions (12). High-fidelity simulations in nursing education have also been shown to develop a range of clinical qualities, such as, knowledge retention, learner satisfaction, and confidence. This is particularly important when simulating low frequency, high acuity cases (4,8,13,14).
An intense war zone simulation was portrayed as a realistic night-time incident, incorporating low light, smoke, simulated gunshots, and two actors with critical injuries including upper limb amputation and blast trauma.
It was observed that the high-fidelity scenario caused changes in the students' pragmatic thinking processes when compared to standard classroom scenarios. Participants recall how scenarios performed in the classroom setting were generally less impactful, immersive, and time critical, and therefore, taken less seriously. However, in the high-fidelity simulation, plans that were formed outside the room were quickly forgotten, triaging of patients was misunderstood and procedures became rushed which impeded their effectiveness. It is known that providing care in critical events results in sympathetic stimulation and associated stress, contributing to increased medical errors, compromised patient safety, and changes in clinician mental and physical health (15,16). Behavioural and cognitive efforts to reduce internal and external demands from a stressful encounter forms part of the individual’s ability to cope, ultimately leading to the individual being able to manage, deal with, and respond appropriately to stressful situations (17). Overall, students were satisfied with their efforts but cognisant of areas of improvement. Each simulation also had a targeted group debriefing that added to the richness of the experience.
From a student’s perspective, immersion in a realistic setting enabled the consolidation of specific skills and knowledge, which in turn resulted in the development of confidence in clinical practice (2).
Students involved came to appreciate the importance of maintaining a systematic clinical approach as well as the ability to remain adaptable when adversities arise. Acknowledging the techniques employed by students to mitigate the stress that accompanies the role (e.g. teamwork, effective communication, breathing techniques, situational awareness) was paramount in assessing the value of high-fidelity simulations. Exposing students to high fidelity simulations enabled better preparation for their upcoming clinical placements and professional practice. Exposure to such environmental conditions and adversities, including high temperatures, loud sound effects, and dimmed lighting, challenged students' critical thinking skills and clinical decision making. Studies have demonstrated that skills performed and practiced within high-fidelity simulated environments improve skill retention and medical knowledge (18,22). Although students were observed by lecturers and peers externally during the simulation, there was no interaction between parties and students were completely autonomous in their decision making. This challenged student’s decision-making skills whilst removing the power imbalance when assessors are physically present in the room. Another consideration is the significant time and financial cost of implementing these high-fidelity simulations into medical training. Despite this, clearly high-fidelity simulation offers major benefits for students and should be more widely integrated into emergency medical training (10,19).
When developing education models for paramedicine students, one of the primary objectives is to equip and prepare students for the challenges that they may experience in the real world. The anecdotal and empirical evidence reviewed in this article indicates that the use of high-fidelity, immersive simulations in the training of student paramedics has the potential to yield major benefits. The realistic environment created simulated real-world stressors and challenged the students’ systematic approach and clinical knowledge. Students also reported feeling better prepared for clinical placement and professional practice (8,19,23). The experience highlighted the importance of mastering fundamental skills and employing healthy coping strategies to mitigate stress (16).
Moving forward, it is clear high-fidelity simulation offers significant benefits for the development of paramedicine students and warrants further research and implementation into paramedicine programs.
Many thanks to Sean O’Loughlin, a paramedic and educator in high-fidelity simulation at the Emergency Australia High Fidelity Training and Simulation Centre in Brisbane. He was instrumental in providing the opportunity for the students to experience a full immersive high-fidelity simulation. Many thanks to Monique Hatchman, a technical officer at Griffith University who worked with Sean to provide this opportunity
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