Ten databases were identified as the sources to be used to search for appropriate papers to support this research. The previously identified query was used to search each database. Before the query was ran, a basic query was tested for each database to confirm the unique interpretation of Boolean logic by each database. As a result of this test, the syntax of each query was sometimes modified to produce consistent results. The citations from the result set of each query were saved using the feature of each database to allow for the archiving of each result set. Each database was searched based upon Title, Abstract and Author keywords as defined by the individual database.
The title, abstract and when necessary the full paper was reviewed to determine if the paper met the inclusion criteria. During phase two, each paper was read in its entirety to ensure that all inclusion criteria was met to arrive at the final result set shown in Table
1. Multiple reviews of each paper through the lens of the inclusion criteria produced the results found in column 4 of Table
1. It should be noted that a number of the papers that did not fit the inclusion criteria are referenced in this paper as they inform the landscape of health care education using High Fidelity simulators and standardized patients. The nine papers identified are marked in the references section with an asterisk.
Table 1Result-set size for each database for each search phase
IEEE | 9 | 2 | 0 |
ACM | 14 | 3 | 0 |
Science Direct | 53 | 9 | 2 |
Springer Link | 740 | 4 | 1 |
Scopus | 361 | 15 | 4 |
PubMed | 245 | 2 | 0 |
Web of Science | 166 | 1 | 0 |
CINAHL | 424 | 3 | 2 |
Cochrane Library | 78 | 0 | 0 |
EMBASE | 286 | 0 | 0 |
Total | 2376 | 39 | 9 |
Health care disciplines represented in past research
Of the initial 39 papers from phase one, many health care disciplines were represented covering a broad spectrum of health care areas. However, as can be seen from Table
2, the majority of the papers focused on nursing education.
Table 2Health care disciplines represented
Child rehabilitation | 1 | 0 |
Physiotherapy | 1 | 0 |
Nursing education | 11 | 3 |
Emergency medicine | 2 | 0 |
Disaster medicine | 2 | 0 |
Neo-natal care | 1 | 0 |
Physician training | 8 | 1 |
Trauma team training | 1 | 0 |
Ultrasonography | 1 | 1 |
Psychiatry | 1 | 0 |
Paramedic training | 1 | 1 |
Acute care training | 1 | 0 |
Midwifery | 2 | 1 |
Haemodialysis | 1 | 1 |
Military physician training | 1 | 0 |
Other | 1 | 1 |
Pharmacy training | 2 | 0 |
Not applicable | 1 | 0 |
Total | 39 | 9 |
For each review phase the authors identified the health care discipline in which the paper and associated research was focused upon. From the Table
2 it can be seen that Nursing Education was the focus of the largest single percentage of studies identified in phase 1 (28%) with Physician Training being the next largest at 21%. The other disciplines were represented in just one or two papers, positioning physician and nursing training as representing almost half of the phase 1 papers (Table
3). The final nine papers selected for this systematic literature review were as follows:
Table 3Final paper selection
Wearable simulated maternity model: Making simulation encounters real in midwifery | 2019 | Midwifery | Andersen, P., Downer, T., O’Brien, S., & Cox, K |
Tracheostomy Overlay System: An Effective Learning Device Using Standardized Patients | 2015 | Nursing Education | Cowperthwait, A. L., Campagnola, N., Doll, E. J., Downs, R. G., Hott, N. E., Kelly, S. C., … Buckley, J. M. |
An easy-to-build, low-budget point-of-care ultrasound simulator: from Linux to a web-based solution | 2017 | Ultrasonography | Damjanovic, D., Goebel, U., Fischer, B., Huth, M., Breger, H., Buerkle, H., & Schmutz, A. |
Avstick: An Intravenous Catheter Insertion Simulator for Use with Standardized Patients | 2018 | Nursing Education | Devenny, A., Lord, D., Matthews, J., Tuhacek, J., Vitlip, J., Zhang, M., … Cowperthwait, A |
Advancing renal education: hybrid simulation, using simulated patients to enhance realism in haemodialysis education | 2015 | Haemodialysis | Dunbar-Reid, K., Sinclair, P. M., & Hudson, D. |
Expanding the Fidelity of Standardized Patients in Simulation by Incorporating Wearable Technology | 2017 | Nursing Education | Holtschneider, M. E. |
Quantitative Approach Based on Wearable Inertial Sensors to Assess and Identify Motion and Errors in Techniques Used during Training of Transfers of Simulated c-Spine-Injured Patients. | 2018 | Paramedic Training | Lebel, K., Chenel, V., Boulay, J., & Boissy, P. |
Hybrid Simulation in Teaching Clinical Breast Examination to Medical Students | 2019 | Nursing Education | Nassif, J., Sleiman, A.-K., Nassar, A. H., & Naamani, S. |
High Fidelity Patient Silicone Simulation: A qualitative evaluation of nursing students’ experiences. | 2012 | Nursing Education | Reid-Searl, K., Happell, B., Vieth, L., & Eaton, A. |
Table three outlines the final nine papers selected as the outcome of the systematic literature review. It is interesting to note, yet not surprising, that the majority of the papers were published within the last 3 years, an indication of the novelty of this approach. In alignment with table two, one should also note that the majority of papers represent the nursing education field.
Hybrid simulation is a growing form of simulation in health care education. Today, the primary form of simulation is the use of full body mannequins or high fidelity simulators. These types of simulators present to the student a technology based representative of a human body/person that would allow the student to conduct invasive procedures in which the mannequin would ‘respond’. However, this approach lacks in the realism which may be required to encourage student to patient interaction. Hybrid simulations generally fall into the category of a worn device such as a sleeve or chest plate that allows for invasive procedures, a silicon overlay to present to the student a particular look or feel or wearable sensors that are used in conjunction with other technology to provide feedback to the student. A novel yet inexpensive approach to hybrid simulation was fashioned by researchers at the University of the Sunshine Coast, Queensland, Australia. The Wearable Simulated Maternity Model, for example, provides a cost-effective and realistic alternative that, when worn by simulated patients, enhances fidelity and student ability to practice performing physical examinations (*Andersen et al.,
2019).
Researchers at the University of Delaware developed a tracheostomy overlay system (TOS) that is worn by the patient to allow students to conduct tracheostomy suctioning and wound care (*Cowperthwait et al.,
2015). Cowperthwait believes that tracheostomy suctioning is an important skill nurses as well as family members need to know (*Holtschneider,
2017). The current practice of suctioning a plastic manikin does not translate to real life, whereas a wearable simulator enables valuable feedback, feedback which a manikin cannot provide (*Holtschneider,
2017). Cowperthwait believes that this feedback is critical in increasing learner competency while at the same time preparing both staff and family members for patient reactions when tracheostomy suctioning is being performed (*Holtschneider,
2017).
The TOS was developed by an interdisciplinary team of faculty and students from three departments (engineering, nursing, and theatre) to address the limitations of using a standardized patient in simulation. The TOS sits over the actor’s torso, aesthetically representing a chest and throat with an inserted tracheostomy tube. This overlay system allows nursing students to perform tracheostomy care, assessment and suctioning on a live patient. The actor is able to respond accordingly to abnormal suctioning or too much faceplate pressure/manipulation based upon cues provided by sensors within the TOS that can be felt by the actor (*Cowperthwait et al.,
2015).
The TOS is worn by a human actor with the intent to improve the procedural techniques of students that are practicing assessment and care of a patient with a tracheostomy (*Cowperthwait et al.,
2015). The current use of standardized patients in simulation has been proven to be an effective way to increase scenario realism; however, there are many limitations to the type of injury or illness that can be assigned to standardized patient cases (*Cowperthwait et al.,
2015). The use of medical lines on a standardized patient for example is not practical; however some high-fidelity mannequins have the capability to receive a medical line in various parts of their anatomy. However, these mannequins lack the ability to interact with the caregiver and elicit the necessary emotions and body language that a real patient would naturally present to the care-giver.
Another approach found in the literature of hybrid simulation is to outfit the standardized patient with a wearable sleeve which would allow the student to perform invasive procedures such as inserting an IV into the arm that could be leveraged for various healthcare training scenarios. This approach was used by a group of researchers at the University of Delaware and similarly by a group of researchers from Australia. A second group of researchers, also from the University of Delaware, used a wearable sleeve to develop Avstick, an Intravenous Catheter insertion simulator for use with standardized patients (*Devenny et al.,
2018). This device allows the nurse trainee to perform an intravenous catheter insertion on a live patient without causing harm or stress to the patient. Whereas Dunbar-Reid et al. used the wearable sleeve to enhance realism in haemodialysis training (*Dunbar-Reid et al.,
2015). This wearable sleeve simulator allowed a standardized patient to be ‘dialysed’.
Silicon is another common material used by researchers to re-produce parts of the body to either present to the learner visual cues or tactile surfaces to assess. A group of researchers from CO University Australia developed the persona of a simulated patient complete with a personal and medical history. This simulated patient was then ‘brought to life’ by the professor who donned life-like silicone props which represented face, hands and torso. The professor, in character, interacted with the students and answered questions as the patient, and posed new questions for the students to consider and to guide the discussion (*Reid-Searl, Happell, Vieth, & Eaton,
2012). Similarly, researchers from Universities in Lebanon and the United States co-developed a hybrid teaching model in which clinical breast exams were conducted on a standardized patient wearing a silicone breast simulator jacket (*Nassif, Sleiman, Nassar, & Naamani,
2019). This silicon prop presented to the learner a silicon based breast with integrated lesions, which allowed the learner to conduct a clinical breast exam that realistically represented a live patient.
Remote sensors are another common element of hybrid simulation. These sensors are strategically placed on various parts of the body of the standardized patient. The sensors are then integrated with external technology to provide the learner with some form of electronic feedback that becomes part of the learning scenario. Researchers from the Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, at the University of Freiburg, developed a more affordable and accessible hybrid training approach to deliver hands on training in point of care ultrasound systems, which are often used for the initial clinical assessment of critically ill patients. Researchers developed an HTML browser-based ultrasound simulation application based upon the original Linux based version developed by Kulyk and Olsynski in 2011. This application reads inputs from sensors that are attached to standardized patients (*Damjanovic et al.,
2017). Similarly, Canadian researchers explored the use of wearable inertial sensors to assess and identify motion and errors in techniques used during transfers of simulated c-spine injured patients. These wearable sensors provided the trainees with objective feedback along with a three dimensional model of the performed move, providing specific areas of improvement for future transfer attempts.
Lessons learned from hybrid simulations identified in the literature review
A common theme identified in the literature as it relates to hybrid simulation is the improvement in trainee-patient interaction as a result of having a human actor as part of the simulation. This compared to simulations based upon mannequins alone, where students often raised concerns about the lack of realism of the simulation due to the lack of interaction with a ‘real person’. This lack of interaction is significantly overcome by the use of standardized patients as they can speak and readily display nonverbal behavior in reaction to what learners do and say (*Holtschneider,
2017).
Cowperthwait et al. for example found that the use of the tracheostomy overlay system demonstrated significantly more positive clinical interactions than the mannequin based scenario (*Cowperthwait et al.,
2015). In addition to an increased amount of positive patient interactions, students who trained with the tracheostomy overlay system self-corrected their behavior considerably more than those who trained with the mannequin (*Cowperthwait et al.,
2015). A similar result was seen by Dunbar-Reid et al. who used hybrid simulation in haemodialysis education. This simulation enabled participants to practice clinical skills relative to renal patient care while simultaneously developing communication skills while interacting with the human actor (*Dunbar-Reid et al.,
2015). Researchers found that the hybrid simulation approach delivered enhanced realism and therefore provided a more authentic learning context without putting real patients at risk (*Dunbar-Reid et al.,
2015). The renal-specific hybrid-based simulation approach provided students with an authentic, patient centered environment that allowed instructors to assess student’s technical and interpersonal competencies.
Similarly, Devenny et al. found that by using Avstick, an Intravenous Catheter Insertion Simulator, trainee-patient communication, procedure explanation, patient reassurance, question asking, and general patient interaction, showed a significant increase as compared to the same group being trained using a mannequin (*Devenny et al.,
2018). Researchers concluded from these results that the wearable IV trainer, Avstick, is as effective as a mannequin for improving student self-efficacy and is superior to training with a mannequin as it relates to improving student interaction with the patient during clinical encounters. Indeed, anecdotal evidence clearly showed that students were much more willing to respond to and engage in conversation with a human actor wearing the Avstick than with a ‘static representation of a human patient’ (*Devenny et al.,
2018).
Other hybrid simulation studies showed similar positive results. However, not all results were tied to communications. Reid-Searl et al. found that the use of silicon props worn by a standardized patient, in this case the professor, took students out of their comfort zone which in turn reduced their fear and increased their self-confidence, which the students felt better prepared them for future clinical placements (*Reid-Searl et al.,
2012). During the debriefing, students described how this simulation experience helped them to build confidence in their ability to work with real human beings in the workplace thus reducing some of their fears of this inevitable reality (*Reid-Searl et al.,
2012). Indeed, many of the participants described the simulation as taking them ‘out of their comfort zone’ and forcing them to actively engage with the patient (*Reid-Searl et al.,
2012). One of the obvious advantages of this approach was the reduction of risk in using a human actor vs a real patient, this significantly reduced the fear of harming the patient through inappropriate actions or behaviour. The researchers concluded that these findings highlight important considerations for nursing education around active learning, reducing anxiety and encouraging students to regard patients as real human beings rather than focusing primarily on symptoms and techniques (*Reid-Searl et al.,
2012). Similarly, Nassif et al. found that hybrid simulation using silicon breast jackets produced significantly higher lesion reporting, identification of malignant features, and accurate location identification as compared to the traditional teaching methods (*Nassif et al.,
2019). Indeed, students in the hybrid simulation group indicated, through satisfaction surveys, that they were more likely to recommend hybrid simulation for teaching clinical breast examination, that hybrid simulation helped develop confidence in the clinical setting and that the hybrid simulation helped to integrate the theory of a clinical breast examination with the practice (*Nassif et al.,
2019).
In regards to wearable sensors, Lebel et al. found that the use of motion sensors affixed to standardized patients allowed researchers to provide more specific, quality feedback to learners enabling them to more easily correct emergency rolling techniques performed on c-spine injured patients. Researchers found that the use of wearable inertial sensors provided instructors with objective data to provide personalized feedback during training and could be further employed to provide a complete training solution by directly embedding the inertial sensors into mannequins (*Lebel, Chenel, Boulay, & Boissy,
2018).
Damjanovic et al. also showed that the use of embedded sensors can be useful in emergency medical situations. This hybrid simulation approach demonstrated that a robust ultrasound simulator can be fabricated for a fraction of the cost of commercially available solutions, making this a novel approach for ultrasound education in developing countries. Additionally, this technology may be applied in situations where a casualty surge is experienced, as point of care ultrasound has been shown to aid in the management of mass casualties, such as those experienced during the Boston bombings. Due to the solutions low cost and lack of required hardware, as the solution is primarily a software solution, researchers felt that this design could be easily employed in blended learning environments facilitating the savings of time and resources.
Through the use of the Wearable Simulated Maternity Model, Andersen et al. found that students enjoyed the authentic immersive approach to midwifery simulation using real people to practice clinical and communication skills, rather than inanimate objects such as manikins or part task training models (*Andersen et al.,
2019). Indeed, the Wearable Simulated Maternity Model has shown that a simple to implement simulation experience can be designed that provides a high-fidelity simulation at a very low cost (*Andersen et al.,
2019). This model was fabricated using readily available yet inexpensive materials (*Andersen et al.,
2019). Anderson et al. found that despite the ‘low budget’ production, the implementation of this model in a student simulation scenario showed a notable impact on student learning and engagement (*Andersen et al.,
2019).
A significant, yet often overlooked advantage of hybrid simulation is the ability to incorporate diversity into our simulation scenarios (*Holtschneider,
2017). Indeed, a problem identified by Cowperthwait is that many of the manikins currently on the market have Caucasian features but have black skin, which is not realistic (*Holtschneider,
2017). Alternatively, hybrid simulation models allow the standardized patient to be whoever they are, allowing the educator to use a diverse population, allowing them to speak for themselves (*Holtschneider,
2017).
Future research direction
The general theme of this research was the question of how health care education can be enhanced through the use of wearable technology and human actors. To completely answer this question more longitudinal research is required to understand how hybrid simulation techniques enable health care workers to perform their duties more effectively in the field as compared to training based upon high fidelity simulators or standardized patients only.
Additionally, more work is required to better understand, and indeed maximize the way in which standardized patients can provide appropriate verbal feedback to learners to help them improve communication skills and how this focus on communication can promote a patient-centered care model (*Holtschneider,
2017). However, this ‘appropriate’ verbal feedback may not come naturally to the standardized patient. Indeed, Cowperthwait et al. found that during the tracheostomy care scenario standardized patients did not know how to appropriately react to suctioning that was too deep unless they were properly trained (*Holtschneider,
2017). This training came in the form of interviews with former tracheostomy patients, allowing the standardized patients to hear firsthand the patients’ thoughts, feelings, and emotions (*Holtschneider,
2017). More work is required to explore the impact of various approaches to standardized patient training, and how this training is reflected in the fidelity of the simulation and thus the long term efficacy of the learner.
In her work with the University of Delaware, Cowperthwait discovered that it is not only the learner that benefits from the use of standardized patients, but the standardized patients themselves (*Holtschneider,
2017). Through the simulation scenarios, Cowperthwait found that standardized patients have become better patient advocates when they and their family members receive health care (*Holtschneider,
2017). This insight opens opportunity for further research to better understand the depths and types of reciprocal benefits of using standardized patients during simulation scenarios and its impact on the broader patient care environment (*Holtschneider,
2017).
Finally, the use of wearable devices opens up many avenues for learners to practice critical care interventions. More work is required to explore what other intervention based procedures can be simulated using a hybrid simulation model (*Holtschneider,
2017).