Purpose, learning, fidelity and transfer are constructs found in the wider literature on simulation. They were chosen to provide a framework for this study, partly because they surfaced frequently during comments by students of dentistry on the “Phantom Head” simulation, but also because a review of the simulation literature suggests that each of these different constructs is an important component of the simulation environment.
This study identifies interdependence between them. Examples of this include an implied relationship between standardisation in the preclinical laboratory and inappropriate rule learning; links between poor physical fidelity and inadequate learning seen in the use of plastic teeth, and participant requests for more realistic soft tissues on “Phantom Heads”; or the suggestion that clinical overlays to “Phantom Head” exercises would help make them more clinically relevant.
Authenticity as a unifying construct linking purpose, learning, fidelity and transition
The purpose of this section of the chapter is to explore the relationships between
purpose, learning, fidelity and transition. The study appears to show a unifying theme of authenticity. Although authenticity itself is a poorly defined concept, it does contribute to our understanding of these relationships. For example, some student participants observed that it was difficult to think of their “Phantom Heads” as though they were real patients, but that when the same phantom heads were taken into the clinical setting, working on them felt more authentic. But why should this be the case?
One relationship between authenticity and learning is documented by Herrington et al. (2003), who comment on the significance of “[t]he capacity of authentic learning settings to
187 promote students’ willing suspension of disbelief”, suggesting that they can enhance “the effectiveness of a range of learning settings”. In the previous chapter I suggested another possibility; a mark of authenticity is the degree to which a learning setting promotes implicit learning. These possibilities are not exclusive, but the question of how they might link learning, purpose, fidelity and transition needs exploration.
It is easy to understand why the concept of “willing suspension of disbelief” could promote psychological fidelity. Medical simulation continually strives for more realism, for example in the complexity of physiological modelling available on medical
mannequins, or the use of moulage to simulate patient injuries. The psychological impact of a simulation appears to be important in preparing the student to deal with reality; for example a high level of physical fidelity may have the effect of teaching the student to minimise their psychological reaction to injury. This may be important in helping the student subsequently in providing patient care with less danger of cognitive overload.
It is also easy to visualise under certain circumstances, a relationship between transition and authenticity. Using the metaphor of transition as boundary crossing, we can see that a managed transition allows the student to encounter barriers sequentially rather than simultaneously, reducing step size and its associated cognitive load. Without a doubt some of these barriers are procedural, and the managed transition is instrumental in teaching students the relevant procedures. But as important is the psychological transition required to treat a real patient.
In both settings mentioned above, authenticity doubtless enables the student to willingly suspend disbelief. But I suggest that it also provides the student with implicit learning
188 opportunities that may otherwise not have occurred, so that both have a place in
cultivating the authenticity of the learning setting.
While the purpose of simulation is to provide an authentic learning setting for the student, there exists a degree of tension between authenticity and simulation. For example, student participants in this study all recognised the “Phantom Head” itself as a simulation. There appeared to be very little “willing suspension of disbelief” relating to work on the “Phantom Head” itself and, while there were many opportunities for implicit learning, these were limited to one aspect of clinical activity which was itself distorted by standardisation. As one participant commented “Nothing can prepare you for it [treating a patient]. Not properly”. From the point of view of both psychological fidelity and implicit learning, it would seem that the nature of simulation imposes limits on authenticity.
Nevertheless within those limits dental educators have a responsibility to prepare the student as well as possible for restorative clinical activity, so how could we improve the authenticity of preclinical teaching? Students in the study made some suggestions, such as using clinical overlays, but these are unlikely to be sufficient in themselves. Perhaps an answer can be found in computer gaming because, in most cases, these succeed by virtue of their immersive nature. As Gee (2007, p1)points out “designers face and largely solve an intriguing educational dilemma… : how to get people, often young people, to learn and master something that is long and challenging--and enjoy it, to boot”. This is the challenge for those involved in preclinical dental education: to involve our students, to motivate them to learn, and to simulate preclinical restorative dentistry in a way that makes the transition to patient care safer for the patient and easier for the student. We
189 have been using the “Phantom Head” for 100 years, but we are still not providing as effective a simulated environment as that which PC game designers have managed in far less time.