The challenge with any simulation is to confuse it with the real thing. That is, to buy into the scenario, to get the heart rate up just a little, to simulate a stressful situation we want to practice responding well to. But is there a danger in confusing the real thing with exercises? In making the exercise the real thing?
In the 2022 movie, White Noise, the town has to evacuate. They arrive at the designated reunification point.
Jack Gladney (Adam Driver), pointing to the armband of the aid worker assessing his risk from exposure to the ‘toxic airborn event’, says, “What does SIMUVAC stand for?”
Aid worker: “It’s short for Simulated Evacuation, a new state program they’re battling over funds for.”
“But this evacuation isn’t simulated, it’s real.”
“Well we know that, but we thought that we could use sim as a model.”
“Are you saying you saw the chance to use the real event in order to rehearse the simulation?”
“We took it right to the streets.”
“How’s it going?”
“The insertion curve isn’t as smooth as we’d like. We don’t have our victims laid out where we’d want them if this was an actual simulation. You have to make allowances for the fact that everything you see tonight is real.”
Simulations as simulacrums
Simulacrum and simulate have the same word origin. The former, simply defined, is an image or a representation. But it has deeper connotations.
"...the simulacrum is essentially the copy of a copy, that is to say, the copy of something that is not itself an original... On this view of things, anything deemed to be an original idea or object is in fact a mirage, an optical illusion of the same order as back-projection in cinema." (Oxford Reference, simulacrum).
There is definitely a cinematic quality to simulations I have been involved in. And that isn't an indictment. In medicine and science, we work in a world of copies, models, and, even, fiction. Some (philosophers) consider models a type of fiction, since they are not something concrete, but a representation, an abstraction.
“…when Bohr introduced his model of the atom he introduced a fictional object of the same kind as the object Conan Doyle introduced when he invented Sherlock Holmes...What makes a work a fiction is not its falsity (or some ratio of false to true claims): neither is everything that is said in a novel untrue (Tolstoy’s War and Peace contains many true statements about Napoleon’s Franco-Russian War), nor does every text containing false claims qualify as fiction (false news reports are just that, they are not fictions). The defining feature of a fiction is that readers are supposed to imagine the events and characters described, not that they are false...” (Stanford Encyclopedia of Philsophy, Models of science).
That sounds about right when it comes to simulations, imagining disasters and patients, sometimes with the help of some makeup and moaning. Baudrillard is the philosopher credited with developing this deeper meaning of simulacrum, of criticizing simulation in religion, politics, and modern life in general, if I understand him (which I'm not sure I do). Simulation, he thought, takes the beauty out of the difference between real and imagined, “the magic of the concept and the charm of the real." We should replace 'charm' with 'horror' or 'destruction' if we’re talking about disasters. The simulation makes things sterile and reproducible. “It is nothing more than operational.” (Stanford, Baudrillard selected readings).
And there's the advantage with simulations, making things operational. Operationalization is a worthy pursuit.
Operationalization
What should we be measuring? What should we be improving? These are the questions behind operationalization. "To operationalize a concept is to identify those variables in terms of which the phenomenon…can be accurately observed" (Verheul, Dückers, 2020).
Objectives and methods need to align. If the simulation does not fit the objectives (or if there are none, or too many, or too vaguely defined), the simulations may be "unsuitable" or even "counterproductive" (Peach, Hornyak, 2003). Defining those objectives in disaster response is usually left to common sense, which, without belabouring the point with quotes from Einstein, Voltaire, or Deadpool, I'll just suggest that common sense is highly prone to bias.
Shhh. My common sense is tingling.
-Deadpool
While this is no easy task in disaster research, it is possible. See the study by Verheul and Dückers, 2020, for example. And simulation is the application of operationalization. So if we are to make simulations or exercises useful, we need to look closely at our objectives.
Ritualism
We assume that we learn something from exercises. Otherwise, why would we do them? The way that studies commonly measure learning is by either doing a pre- and post-exercise knowledge test or by asking people if they feel more prepared after doing an exercise. By those measures, educational events are effective. But if you do more exercises and look at the points for improvement that result, do these change? If participants are learning, there should be a change in the deficiencies identified. That's the methodology used by Verheul and colleagues (2018). They found the benefit not so obvious.
I'm not saying we shouldn't do hospital exercises. As said Dr. Kollek. "While we don't know if doing exercises means you're prepared, it's definitely true that not doing any exercises means you're not prepared" (CEEP Journal Club podcast, Jan 2024). Whether our exercises improve our preparedness as individuals, teams, and institutions depends on targeting the right things and having the right objectives for the right methods. Otherwise we're just going through the motions.
References
Standford, Baudrillard selected readings. https://web.stanford.edu/class/history34q/readings/Baudrillard/Baudrillard_Simulacra.html).
Verheul ML, Dückers ML. Defining and operationalizing disaster preparedness in hospitals: a systematic literature review. Prehospital and disaster medicine. 2020 Feb;35(1):61-8.
Peach EB, Hornyak MJ. What are simulations for?: Learning objectives as a simulation selection device. InDevelopments in Business Simulation and Experiential Learning: Proceedings of the Annual ABSEL conference 2003 (Vol. 30).
Verheul ML, Dückers ML, Visser BB, Beerens RJ, Bierens JJ. Disaster exercises to prepare hospitals for mass-casualty incidents: does it contribute to preparedness or is it ritualism?. Prehospital and disaster medicine. 2018 Aug;33(4):387-93.
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