Some of the biggest constraints to widespread simulation training are cost, expertise and access. There is a limit to the number of centres needed to provide immersive simulations, the ‘real’ experience in mock clinical areas with all the appropriate equipment, manikins and faculty. One group has tried to address these issues by identifying the key aspects of the different clinical environments (e.g. the operating theatre or intensive care unit) that are needed for learning and then replicating these in a portable environment that can be set up in a short space of time and a small area. This is ‘distributed simulation’ (DS) (Kneebone et al., 2010), where inflatable, portable simulations can be erected in places of work and immersive simulations can be run. In addition to providing more easily accessible training, this kind of technology is much cheaper.
Tang et al. (2013) describe the key components of DS as:
- a self-contained, immersive environment which can be closed off from its surroundings
- providing the minimum necessary ‘cues’ to recreate a realistic clinical context – e.g. sounds (conversation, monitor sounds), equipment, people
- simple, user-friendly recording and playback equipment, often using mobile devices
- practical, lightweight, portable components which can be put up quickly by a small team
- flexibility to recreate various settings according to requirements.
An important element of the success of distributed simulation, or other simulation activities involving limited amounts of ‘kit’ are the concepts of ‘selective attention’ and ‘working memory’. DS does not reproduce all the elements of the real setting, but selects and recreates the features that provide key cues for the participants to maintain a working ‘reality’. Kneebone (2010) calls this the ‘circles of focus’. For example, if training a surgeon to carry out a new laparoscopic technique in a DS theatre setting, the central cues and focus would be around the part of the body being operated on (operative field) and the highest fidelity would be on the anatomy, physiological responses and the technical equipment being used. As we move away from the centre of the concentric circles, other cues would be provided to maintain the reality of a theatre (theatre noises, some equipment, scrub and circulating nurses, anaesthetist, etc.) but there would be no need to include cues from outside the limited environment.
The increasing emphasis on the ability to bring the simulation to the learner rather than learners having to travel to a centre has also been replicated by other initiatives. These include ‘man in a van’ (‘Simvan’), where the equipment is mobile and simulation is taken to the learner, and ambulances which are set up as real ambulances, but are learning facilities which go to different locations. However, such developments need trained faculty to travel with the equipment.