Journal Club February 2021 _ Functional Task Alignment

Introduction :  

Welcome to simulcast journal club! Each month we discuss an article on simulation and discuss it with colleagues around the world.  Every comment is valued and appreciated, we hope you join us in our ongoing virtual community of practice. 

Title :  “Functional Task Alignment 

The Article : 

Hamstra S, Brydges R, Hatala R et al. Reconsidering Fidelity in Simulation-Based Training. Academic Medicine 2014;89:387-392. doi:10.1097/acm.0000000000000130 

Discussion :  

As simulation has matured as a specialty, our thinking around ‘fidelity’ has grown too.  While many of us remain quite concerned about realism and achieving psychological immersion from our participants, this article from Hamstra in 2014 challenges that notion and introduces a relatively new term : ‘functional task alignment’. 

We invite you to explore the article and consider just how important realism is to you, and let us know whether this article challenged your preconceptions! 

About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.

23 thoughts on “Journal Club February 2021 _ Functional Task Alignment

  • Victoria Brazil

    Hey Ben
    Really important issue for those of us trying to design simulations that foster engagement, and for those of us trying to have debreifng conversations that aren’t dominated by lamentations …..’well of course the mannikin wasn’t very realistic’.

    Personally i like the idea of abandoning the term fidelity as it is now so confusing as to what is meant when used.
    Trouble is .. ‘functional task alignment’ doesn’t have an easy ring to it … 🙂 .. and requires a fair depth of understanding to …….”focus on functional correspondence between the simulator and the applied context”

    At risk of dodging the main issue… I am surprised at the size of ‘realism gaps’ that sim participants will manage if adequately prepared and pre-briefed. I remember doing a scenario with Jesse ( Spurr) as an SP who was having procedural sedation for his simulated ankle dislocation. When he developed (simulated) laryngospasm in the scenario, the team quickly managed the airway on the airway head manikin the bed besdide his (real) head. They didn’t miss a beat. A lesson for me in the effective pre-briefing that he had done before the case. (I was still a little nervous)

    Couple of shout outs to friends of simulcast doing work in this area – to Jess Stokes Parish and her ‘expert opinions on the authenticity of moulage paper –
    and to Sarah Janssens and others in developing a ‘realism assessment questionairre’ –

    Keen to hear others thoughts

    • Ben Symon

      Thanks Vic!
      I feel less strongly about abandoning fidelity, even though I agree it’s just confusing and non specific in a lot of settings now.
      I guess for me I still find the concepts of conceptual/emotional/physical realism useful when considering diagnostically where learners have disengaged from a simulation. I think you make a great point that functional task alignment isn’t catchy, although I do feel very clever when I say it, so maybe that’s helpful?

      Functional Task Alignment to me is a really useful term when I think about designing and running a sim in particular, and the introduction of the concept has really helped me focus not just the mannequin or SP I’m going to work with, but strong thoughts about the very specific tasks I want the team to rehearse as well, and making sure as much as possible my sim is haiku’d down to its most essential, unmissable parts.

      I guess in that way, it makes me think about how important nomenclature is to the way we approach a problem.

  • Dan Hufton

    Thanks for the link Ben, an interesting article, I agree the term fidelity can be confusing.

    As the authors elude to, I’m not sure a dichotomous separation of physical resemblance and functional task alignment are helpful I think the two are more linked. Moulage used correctly has a really important role (the meningococcal rash, the burn) can really aid immersion and therefore are key to task alignment (will def check out Jess Stokes Parish work).

    The article (whilst not explicitly saying) I feel focuses mostly on mannikin based simulation. I wonder how we apply these concepts to simulated pt scenarios? I wonder if particularly with these scenarios a concept of EMOTIONAL connection (“fidelity”) is a key feels like a combination of the physical and communication/acting. I can imagine Jesse’s acting skills (and understanding of the underlying learning outcomes) helped and emotional engagement with his laryngospasm that then overcomes switch to the airway mannikin.

    We have recently started using some mask Ed (high physical resemblance silicone mask) for some of our SP scenarios particularly there is one scenarios about managing a delirious older person and capacity assessment that was always a tricky balance to get across to the actors (they generally looked the part – high physical resemblance – but were variable in acting performance – therefore functional task alignment/learning objectives lost). Now we used an educator in a mask. The physical resemblance here I think is really important – the participants treat this person very differently from how they would treat a 30-40yr old educator because they look the part but the functional task alignment is maintained because the educator behind the mask can keep the balance of acting and understands the learning objectives.

    As Vic comments it is amazing what participants will accept/overlook where prebriefed appropriately. I would love to hear other peoples prebriefing aids to help immersion? I generally do an orientation to what the mannikin can/can’t do, for example, where to listen for lung/heart sound (if important) and what they sound like. What other pre brief pearls do people have?

    I think separating physical resemblance, functional task alignment, emotion, psychological safety are tricky as they all play a role in the overall immersion felt by the participants. Reminds me of what Vic said in a previous podcast when talking about RCTs in sim and trying to prove “better”. Instead of thinking higher “fidelity” is better we should look at the realism needed to achieve immersion: what elements? where?, for who? and for what outcomes?

    • Eve Purdy

      I do agree with Dan that our fixation with fidelity may have shifted us as a community towards a more mannekin-based practice. I remember vividly the degree engagement I felt when I was involved in a scenario with a simulated patient rather than a mannekin for the first time in residency…I then found myself reflecting on why it took so long for that to happen (4 years into a 5 year residency with weekly simulation-based education). When I broached the question, I was told it was because of cost…do you know how many simulated patient hours you can buy for a “high fidelity mannekin”???? Lots.

      Now I realize part of my frustration with this reality was from a fundamental problem with the functional task alignment. A mannekin with an arrhythmia that I needed to cardiovert wasn’t really at all aligned with what my real job is in the emergency department in that situation…speaking to someone, reading between the lines, managing risk with them, acknowledging their worries….fundamental aspects of the job were just not attended to. It worked in early residency when I was just trying to remember the ACLS algorithm but not when I was more senior and trying to master the nuances of doing this right…..hopefully this new lexicon will help our community get it right more often!

    • Ben Symon

      Hi Dan,
      Thanks for your comments as always!
      I share some affection with you about emotional, conceptual and physical fidelity, so I’m torn about this one even though I love every paragraph of this article.
      You mentioned that all of these aspects contribute to immersion, and it makes me wonder how essential immersion is to sim?
      When I play with my 6 yr old and we decide a piece of paper is a brontosaurus, he doesn’t engage with it any worse than if I buy an expensive realistic toy. I think maybe we’re very good at making these social contracts to agree what isn’t real is real.
      With regards to your question about pre briefing tips, one technique I use is to specifically de-emphasise the realism and point out that this is a skills rehearsal to get better at a specific task. As such we have enough here to learn, even if it doesn’t look exactly the same as your workspace.

      • Dan Hufton

        Thanks Ben. Useful tip on the prebrief thank you.

        I wasn’t sure about using the word “immersion” as I think that sometimes means different things to different people to – similar to fidelity. I don’t think of immersion as being the participant thinks it’s real but they get enough of a sense this simulation episode is a ‘concrete experience’ to reflect on in the debrief.

        If you have great trust (i.e with a 6yr old) that physical fidelity can be minimal but the immersion is there (I’m sure the brontosaurus piece of paper also has audiologic fidelity too!! Would love to hear that😀) .

        Whereas a different group will need a different cocktail recipe: of trust, physical, emotional and functional alignment for it to feel enough like a ‘concrete experience’ that pushes them round the kolb cycle to reflect, build and learn from it?

  • Eve Purdy

    Dear Ben,

    At risk of being on a complete tangent, I am mostly going to admire this article for the way the research was conducted and written.

    Clearly, the authors set out with a different goal than what they presented. The envisioned systematic review and metanalysis of simulation fidelity never came to fruition…instead what we are left with is an elegant reflection. A piece that we get to chew on and debate with our friends. Personally, I think this is far more valuable. A good example of when a narrative review (technically ‘lower’ in the hierarchy of evidence) can be superior…Specifically, I found the way results were presented to be hearteningly relatable.

    “However, we found it impossible to code this feature with high reliability. List 1 illustrates some of our frustrations as we struggled to achieve consensus…..We attempted to define, refine, clarify, subcategorize, and implement this term during our review, but to no avail. Despite several attempts to clarify our definitions, we were never able to consistently recognize fidelity between or even within raters.”

    We could use more of this candour and warmth in the presentation of scientific results. I will try to bring some to mine the next time I write.

    • Benjamin Symon

      Agreed, I think this is a fantastic point. I really appreciate how you continue to move the conversation about research away from a concrete ‘this type is better than that type’ and towards measuring the impact of any research, whatever the format, on how it helps us grow as a specialty. Thanks Eve!

  • Chris Speirs

    Hi Ben,
    Being at the novice end of my sim career, this article highlights a few points I had never really considered. I’m not sure I had particularly strong beliefs about fidelity, but when pressed I’d probably have assumed more is better. This article, and some of the excellent comments below, really highlight the need to ask why we are doing the exercise in the first place.

    I think regardless of how good your mannikin is, no one really believes it’s a real patient. There is always going to be some element of a ‘social contract’. I would acknowledge that a better mannikin probably does increase immersion of participants but I often wonder just by home much. I suspect the additional value is disproportionally less than the additional cost, effort and trade off against other methods (for example an SP).

    I particularly liked the example of the brontosaurus. This correlates quite nicely to the example Vic uses about switching from SP to mannikin mid sim. I believe if the pre-brief is done well, this change will be done seamlessly and the participants would barely even acknowledge the change. However, I do acknowledge that we are quite spoilt in that our participants are seasoned sim veterans who are largely unphased by the sim room. Perhaps this is a function of an experienced group of learners and what I am witnessing would be quite different with a team of new sim learners.

    Finally, I might finish by returning to my initial point – I think the why is very important. What are our learning objectives and what is the best way to achieve these outcomes? I sometimes ponder whether the increased fidelity is for the participants or for us as simulation educators merely because we think the extra toys, make up, or noise is cool. Sometimes that’s probably as good a reason as any.

    • Ben Symon Post author

      Thanks Chris! It’s great to hear from you again. I’m glad this article had a big impact on you, and you’re not alone! Moving on from the specifics of it, it’s just a really powerful reframe about what our purpose is. As you say, the Why, is very important.

  • Qaasim Dollie

    I must admit when I started reading it I thought the article would focus primarily on defining fidelity, review the literature and then compare it to other disciplines. I totally agree with Eve that they definitely set out on the standard meta-analysis path, hit a road block when they attempt to code fidelity get terribly frustrated and end up reflecting on their research and true focus of simulation education. The sample of comments (List 1) from the authors is absolute gold. I can completely relate to their frustrations when starting out a literature review with the best intentions then being overwhelmed by data and completely losing focus on what my question was in the first place.

    • Benjamin Symon

      Thanks for joining us Qaasim! Sounds like this is a shared challenge for you? What sort of research are you doing?

  • Ruth-Ellen Marks

    Thank you for sharing the article, Ben. My experience with simulation thus far has been mostly through emergency medicine simulation, both as a participant and facilitator in our departmental education as well as teaching medical students at university.

    I noticed that the article used the original term ‘simulator fidelity’ (redefined by the authors as ‘physical resemblance’) primarily to refer to the appearance of the mannequin or tissue being simulated. It then based its recommendations for change upon the idea that this is less relevant than the functional correspondence between the simulator and the applied context. I feel that in our context in emergency medicine, and certainly in our own simulation department, the concept of ‘simulator fidelity’ has just as much to do with the realism with which a patient’s changing physiology and other clinical indicators are communicated and the ability of a simulated resuscitation team to intervene in these, as the appearance of the mannequin itself. Thus, ‘simulator fidelity’ in our context would include elements such as the realism of the simulated patient monitoring system, the voice from the ceiling communicating the patient’s responses, and the actor on the other end of phone calls to simulated interdepartmental colleagues. Simulator fidelity would also include elements such as ability to draw up medications and use procedural kits realistically.

    This observation still does fit with the authors’ central hypothesis. which is that mannequin appearance is less important than identifying the elements of the task central to the primary teaching objective. I would observe that by focusing on important areas of the simulation other than the appearance of the mannequin in our local context, we are already practicing ‘functional task alignment’, i.e. ensuring there is functional correspondence between the simulator and the applied clinical context.

    I thought focusing on the ‘physical resemblance’ concept applied much more to the ideas about surgical simulator fidelity that they were using in their examples.

    My other observation was that we don’t even need full ‘experiential simulator fidelity’ (with all the elements I described above) in order to achieve every learning objective. I experienced this last week, when I was able to use four short airway scenarios with very low ‘physical resemblance’ and malfunctioning monitoring equipment to achieve learning objectives regarding planning and practicing for various difficult airway situations. This again supports the authors’ hypothesis that functional task alignment should be the ultimate goal, rather than perfection in terms of the mannequin or scenario.

    The most valuable statement in the article, I felt, reminded us as educators to ask ‘What are we going to teach?’ as the first question, rather than ‘How will we use the existing platform to teach this skill?’ This is a reminder to us that simulation is not always the best tool to achieve a learning objective, and that we must always practice a learner-centred approach and look for opportunities to engage our learners in principles of active learning.

    • Ben Symon Post author

      Thanks Ruth! I think the article reads well about the nomenclature of fidelity, but is also a useful call to focus on what our educational intent truly is. The breakdown you mention of simulator fidelity reminds me of the way Rudolph et al defined it in Establishing a Safe Container. Did that resonate with you?

  • Sonia Sahni

    I believe that the article raises some very valid points with regards to shifting our focus away from the traditional concept of simulation fidelity. There is much to be said that making a simulation as realistic as possible does not necessarily maximise learning outcomes. I would even extend this to say that by attempting to make a simulation as realistic as possible (but of course falling short) we are alienating certain participants who feel that they cannot engage as “it’s not real life”. Perhaps even shifting towards a more skills-based simulation approach which focuses not on making a situation as close to reality as possible but focuses on learning a specific task may remove a lot of participant anxiety and improve learning opportunities. The cup and straw is a perfect example of this. The shift from physical resemblance to functional task alignment would definanantly help in focusing on the individual needs of our participants.

    For example, a way this could be implementing in the obstetrics department is with a post-partum haemorrhage simulation. Rather than focusing on the broader aspect of a post-partum haemorrhage, perhaps honing-in on the individual skill sets required. Perhaps focusing on how to perform an adequate fundal massage would engage participants who both have a lot of clinical knowledge on how to perform as well as new medical staff who have minimal knowledge. I feel this would remove the daunting experience of focusing on multiple aspects of a PPH and improve participant engagement. It would also allow participants with a thorough skill set to teach more junior staff members from their clinical experiences.

    I definitely agree that more than structural fidelity it is important to match the learner’s needs. I feel that a successful simulation session is one where the participant has walked away feeling that they have either learnt something from the session or that they have solidified their understanding or perhaps shared their knowledge and assisted the learning of a colleague.

    • Ben Symon Post author

      Thanks Ruth, I think the point you raise : by working hard to make a sim appear realistic we reinforce the notion that physical realism is important to learning, and thus potentially culturally reinforce our own problem!
      A recent example for me : we are currently piloting a sim about caring for a child after they die. The design emphasis was not on the communication buy instead on the practical aspects of death that are not often rehearsed. (E.g. dressings, equipment removal, bathing, memory boxes). But instinctively when we piloted it, educators generate an authentic, intensively emotional experience (such as using a hyper realistic 3d modelled mannequin) to the point that the emotion was inhibiting the actual learning. We’ve gotten good at creating authentic, supposedly transformative learning experiences. But in the words of Jeff Goldblum from that great scientific documentary “Jurassic Park” : Your Scientists Were So Preoccupied With Whether Or Not They Could, They Didn’t Stop To Think If They Should.

  • Darragh Shields

    Hi Ben,
    Thanks for sharing this article. Like previous commentators have mentioned, higher fidelity is often incorrectly associated with better simulation and often refers to the mannequin as opposed to the simulation. When reading this article, I was reminded of a previous podcast when the “uncanny valley” was mentioned- where the improved structural fidelity at point leads to discomfort for the learner. I think when we run simulations we do naturally try to ensure best functional task alignment (like Vic, I think a more catchy term is required for it to be embraced). Fundamentally when your simulation is well matched to your learning objectives and the participants are aware of the Learning objectives from the outset makes best simulation. I think that in the time that this article was published (2014)the Sim community has embraced some of the concepts discussed..
    I really liked the concept of educators acting as SPs and wearing an appropriate mask- good Hybrid simulations with SPs and mannequins are likely to give best results.
    Really love the podcast and now that I have “caught up” with the back catalogue look forward to listening in the future.

    • Ben Symon Post author

      Thanks Darragh! Any ideas for a catchy term? I think that fidelity is such a hard term to quit because it’s so familiar and instinctive.

      • Darragh Shields

        Hi Ben,
        Agree, but fidelity means different things to different people which can add to the confusion and high=good/low=bad!! A catchy term is difficult but it’s down to the “Immersion” of the Learner!!

  • Susan Eller

    Hello Ben,

    Wow – some great conversation regarding the article thus far.

    I agree with Vic and others that the term fidelity is confusing. I have never truly liked that term, as to me fidelity aligned with realism. Many of my simulation colleagues tended to equate higher fidelity either with higher technological features or “structural fidelity”. As Dan and others have responded to this post, I also deal with SPs who often provide a higher degree of fidelity when dealing with communication, physical assessment, and professionalism issues. As Eve points out, the authors discussion of the difficulties of coding/clarifying a definition for “fidelity”was well written and engaging.

    I appreciated that they brought Kuhn into the discussion by saying that disagreements in terminology represent an early phase in the development of the field. My inner geek went deeper down that rabbit hole. It may be an oversimplification, but to me Kuhn described the cycles of science starting with “normal science”, than progressing to anomalies that disrupt the current status quo and lead to revolution since the new ideas are incommensurate with the old model. So – if fidelity does not accurately describe the educational dimension that we are striving for, why hasn’t the term functional task alignment become more common place? I note that the article came out in 2014, but I have not heard any discussions of this change outside of journal club. How much of evolving terminology is changing the habits/culture of simulation-based educators, and how much of this is that the term also doesn’t adequately represent the phenomenon?

    Personally, the term does not resonate with me, as functional task alignment sounds reductionist. Suggesting that structural fidelity can be replaced with physical resemblance does not seem to capture some of the more elusive areas of the spectrum that are achieved with realism sufficient enough to be functional, yet not provoking the uncanny valley. It may just be the way the semantics of the terms landed on me.

    So who among this wicked clever group can come up with the “catchy” phrase that captures the art of matching the conceptual/emotional/physical realism with the applied context in simulation-based education?

  • Derek Louey

    Hi Ben,

    Now that I starting to really dig deep into my Masters, I love these kind of articles which again challenge many of the words we so loosely use in MedEd. ‘Fidelity’ is what Lingard refers to as a ‘god-term’, a rhetorical device that is frequently used, assumed to be plainly self-evident, but upon further examination has very little empiric data to explain it. But has this article just substituted one god-term for another? Whether we substitute fidelity as possessing structural/physical resemblance for a functional one, we encounter another conceptual problem in sim design. What do we mean by ‘functional task alignment’? What exactly is the task for which competence is being sought and how does this map to the task being demonstrated or practiced in the sim? I could imagine that performing a simple skill such as performing a laparoscopic suture would require a fairly basic setup. There is a 1:1 relationship. However, how does this work with more complex or cognitive tasks e.g. attempting to mobilise an organ as the laparoscopic field suddenly gets filled with blood and the anaesthetist is frantically and noisily trying to resuscitate the patient. What would be the minimal elements in the sim that would facilitate a surgeon’s ability in the true scenario. Ultimately, sim is a make-believe, schematic of the real world. The pedagogical assumption is that the stripped down, controlled version (just enough to maintain structural or function fidelity that allows mapping of technical and cognitive skills) but not so complex or feature rich (that risks cognitive overload and impaired learning), we allow for transfer of learning. Do we now need a theory of ‘alignment’?



    LINGARD, L., 2009. What we see and don’t see when we look at ‘competence’: notes on a god term. Advances in Health Sciences Education, 14(5), pp. 625-628.

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