Requisitos DE PUNTOS Y PORCENTAJES (60 PUNTOS)

The next subtype of fidelity to consider in relation to the impact on learner self-efficacy is environmental fidelity. As described earlier, there are different ways of defining this, but the

focus for this work will be on the physical representation of the training environment, as this is what was discussed by some of the interviewees. The following discussion will summarise the attitudes that learners had towards environmental fidelity and its importance.

Although the simulator itself is termed “high fidelity” for its ability to interact with the learners and respond to their actions, the environments in which STAT and SMART are conducted are not intended to be accurate representations of clinical areas. This is partly because of the different clinical backgrounds of the learners - it would be impossible to create a simulated clinical area that reflected the working environment of all the participants. The learning environment is also set-up to include all the learners who are observing the simulated task, not just the learner who is participating in a particular scenario. This has advantages from a training point of view, as all the learners can be involved and ask questions. However, it could be argued that this detracts from the immersive realism of the situation:

“I think you possibly take it more seriously if it's not in front of a big group of people. I know that sounds a bit daft - you still take it seriously when you are being watched, but you don't have those people in your sight; you can just sort of look at it and you put yourself as if it's real. You can pretend it's real and just go with it, whereas when you're being watched it's a little but different.” (Nurse 10; 20:36)

Nurse 10 describes how the presence of her fellow learners in the same room when she is participating in a simulated scenario serves to remind her of the artificial nature of what she is doing and makes it harder for her to temporarily suspend disbelief and to pretend that she is in a clinical role. The incorporation of peer observation and feedback is recognised as being helpful in the acquisition and development of new knowledge and skills (Lincoln and McAllister, 1993), although in the case of high-fidelity simulation it has the potential to distract from the simulated task, thereby potentially negatively impacting on the

psychological fidelity. This phenomenon has been reported previously, although qualitative studies of learners’ perceptions of peer observation suggest that even if a learner is being observed remotely rather than having their peers watching on in the same room, the

knowledge that they are being watched by their peers creates a feeling of anxiety which may affect their performance (Melluish et al., 2007). There may be no way around this without observing a learner without their consent, which would certainly be unethical. It is possible that individual personalities and characteristics of learners may make them more or less likely to be able to ignore or overcome the awareness of being watched, but there was not enough

relevant data in this study to comment on this. However, it seems as though the awareness of being observed (which, in the case of STAT and SMART, is contributed to by the presence of other learners in the room) is not the only factor that separates simulation from reality. One of the other nurses expressed the opinion that the physical appearance of the room is unlikely to make her forget the she is in an artificial environment, and whilst this is in the forefront of her mind, she instinctively focuses her thoughts on what she needs to do to “pass” or succeed in the scenario.

“It’s nothing like real life. For all that it's set up like a hospital bay, the difference is you have to think about things thoroughly, whereas on the ward or in A&E you just do things, and you just know to do things. You've got your routine of how to assess a patient, and with the simulation you're constantly re-thinking and re-checking: have I done everything, have I missed something? Because you know you're being assessed on it, whereas in practice you just doing it and you know that you've done everything. You don't question yourself at all.” (Nurse 9; 20:29)

Despite the effort to improve environmental fidelity by trying to accurately re-create a hospital environment, it does not disguise the fact that she is being trained and assessed. To an extent, overcoming this is never going to be possible, as learners will always be aware that they are being trained, even if that training were to take place in their own clinical

environment. Although being in a more familiar environment may make the accomplishment of certain tasks easier due to the practicalities of knowing what equipment was available and where it is stored etc., the suggestion is that the degree of environmental fidelity will never mask the fact that the scenario isn’t real. This mirrors the comments made about the fidelity of the simulator itself, suggesting a ‘reality barrier’ that is created through the conscious awareness that the training environment, no matter how realistic the appearance, is not a real- life environment.

“Obviously in the simulator room you don't do things you would in practice, you do things kind of in practice by instinct really and kind of get on and do it, and in the Sim room you're aware that people are watching you and that it was a simulated scenario so it was just different to practice.” (Nurse 8; 14:57)

The responsibility therefore appears to lie with the learner to shift their focus from “passing the test” to trying to act as they would in real life. This seems to rely on a degree of

metacognition, with the learners having to try and look beyond the immediate situation and try to consciously relate their actions to their clinical roles. Note that Nurse 8 had never

participated in high-fidelity simulation previously, and it is unsurprising that she was preoccupied with the immediate simulated task as learning how to engage with that was the immediate priority for her. However, Nurse 5, another simulation novice, felt that there would be little extra advantage in a more realistic setting:

“Interviewer: If we'd have mocked up an entire A&E department and put the simulator in there, just to increase the sense of a realistic environment, would it have made a difference? Nurse: Not hugely, I don't think. It would have maybe made it a bit more realistic, but I don't think that would have made a huge impact.” (Nurse 5; 18:12)

Earlier comments from Nurse 5 had suggested that she felt there would be an advantage to having a real person as the simulated patient due to the added realism. However, she does not attach the same importance to the visual representation of the clinical environment. Other learners who did have prior experience of simulation-based training also felt that the

simulated patient, as the main focus of the scenario, was more important than the appearance of the room in which the simulation took place:

“It doesn't really matter. You're focused on what you're doing with the patient, so it doesn't really matter that they've got the curtains up or a pretend defib in the background or whathaveyou. It doesn't really matter - for me, anyway.” (Nurse 9; 24:05)

All the other nurses who were used to simulation-based training echoed this feeling. In terms of trying to create a realistic and immersive simulated environment, the overriding opinion was that, as with the simulator itself, there is probably a minimum standard that needs to be reached to give the learners enough of a link to the clinical world, but beyond that there seemed to be little extra benefit:

“I don't think it's as important as the mannequin itself, and the scenario that you're given. I think it would be a lot of work to do all that - to make it. I think it's quite realistic what you've got at the minute - the trolley and the monitor and all the props like the oxygen and things like that to actually run through the scenario and actually do things as you go, and have an assistant to help you if you need. I don't think it needs to be any more in depth for the scenario for the training.” (Nurse 4; 22:10)

The use of props that come into play during the scenarios, such as the patient monitor and oxygen mask, are equally as important, if not more so, than the appearance of the room according to this nurse. These are all physical objects which learners can use to interact with the simulated patient (and the scenario), and which they are used to using in real life. They

help to form associations between the two environments, which in turn can make learners perceive the learning process to be more effective.