Five Tips for Creating Hybrid Curricula for Simulation Based Learning

For the purposes of this discussion, we will assume that hybrid curriculums in simulation combine online educational materials in advance of on-site activities involving (in person) simulation into one curriculum.  

Why Hybrid?

There are things that we want the student to obtain knowledge on from a perspective of knowing things, or cognitively loading, for an upcoming education event. This often lends itself to carefully created on-line course work.

The in-person side of the equation is best used for when we want to see people doing things, particularly doing things with an understanding of the knowledge that they had already studied during the pre-work described above.  Combining these two facets, or hybrid learning, are some of the most efficient and effective designs for simulation programs.

Accompanying Video Discussion

Advantages

It allows students to be fully prepared from a knowledge perspective before the simulation encounters. This will allow you to conduct your simulation encounters at a much higher level by “raising the tide” of the knowledge of the learners in advance.  Such a design can potentially reduce unnecessary (costly) time in the simulation center. It also allows for students to assimilate the knowledge portion of your program at their own pace on their own time. Further, it helps to set the expectations of what the learners will need to incorporate when they participate in the simulations. Conducting the online portion as pre-work allows the student to seek out additional instruction mediums to help enhance their knowledge base understanding of the materials.

Disadvantages

Curriculum planning will require more effort. It’s more complicated than just deploying a simulation or just creating online education in isolation. You’re doing both! Combining the two which means that there is a time investment in creating the online materials that didn’t exist before we decided to move into a hybrid curriculum. There may be additional skills or resources needed associated with the creation of the materials and/or the administration of some sort of learning management system to make the online curriculum available to your learner population.

Students may not do the work online and prepare like they should before they come to your simulation center. Thus, you need to consider building incentives into the program that creates a compelling reason to do the work.

Tip 1: Begin with the End in Mind

Start with a detailed list of exactly what we want them to know and exactly what they want them to do. Yes, folks it is creating learning objectives, just like we’re designing simulations. Then carefully decide what is knowledge, what is skills and what is application of skills to help parse out which of the curriculum can benefit from on-line (pre) learning.  

Tip 2: Create High Quality Learning Materials

You want your students to take the online materials seriously. So, it is important to ensure they are of high quality, contribute to the learning, and not distracting. Not everything in your pre-learning needs to be Hollywood quality. Many people now do cell phone or mobile phone videos, and that’s fine! However, I want to caution you on the audio. You must make the audio or sound as good as the picture looks. If not, it is distracting, and your students may not take things seriously.

Tip 3: Create Active Learning for the Pre-Course Material

Try to create components of active learning in your online materials. Just because it’s online material and delivered asynchronously doesn’t mean there can’t be an active component. Resist the urge to simply regurgitate one of your old lectures and then toss it up online!

Find small opportunities to have them DO something. It might be as simple as asking them to write out a list of the steps of a procedure, drawing a diagram that they see on the screen, or maybe connecting social media so that they are communicating and learning from and/or with their peers. Lastly, having them taking an on-line assessment or quiz can serve as an effective tool.  

Tip 4: Ensure Learner Expectations and Consequences are Clear

Make sure your learners are clear on their responsibilities associated with the completion of the online materials, and what the consequences are if they don’t. Additionally, ensure the learners understand how the pre-course content is linked to the expectations that will be encountered when they arrive for the simulation sessions.

Some design examples include having the learners take a written pretest when they arrive at the simulation center and determine whether they have adequately prepared for the simulation or not. Other examples make it clear that they will be called on and expected to know the answers for the content contained in the pre-course materials.  It is important that we are fair to the student, with hybrid education, we need to ensure that the learner expectations and consequences are very clear.

TIP 5: Link Your Online Materials Directly to Your Simulations

Work to create an integrated continuum of learning that carries forward from the online materials through the expectations that the learners will encounter during the simulations. This can be emphasized through the direct inclusion of online materials into your simulation sessions. 

Consider including exact diagrams, exact pictures, exact phrases and themes utilized during the online learning during your face-to-face instruction. It might be in the form of a mini lecture. It might be audio/visuals that are incorporated during the debriefing process that can trigger in their mind the lessons that were learned from the online material and how it’s being applied to the simulation session learning outcomes.

Conclusions

The words online and hybrid can cause educators to become nervous because of the amount of work that’s involved as well as not understanding how to make those linkages between the pre-course materials and the simulation sessions. Admittedly, it is more work, but I would argue that the outcomes are far superior then either modality alone. Think of it as an investment. Things that can be moved to the online portion of hybrid design can prepare the learners so the valuable on-site time with the faculty can be conducted at a higher level.

I think that by incorporating good hybrid design with these tips, you will find that you will be creating exceptional learning environments for your students.

Until the next time, happy simulating!

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Simulation Training and Programs in Healthcare are Essential

It is important to remember that the primary constituents that are the primary beneficiaries of efforts involved in healthcare simulation are the patients that we serve. While simulation has existed for centuries, over the last several decades the case has been made that simulation efforts contribute significantly to the quality and safety associated with the delivery of healthcare.

Undoubtedly the pandemic has turned the world on its end. This includes the delivery of healthcare at the front lines as well as the education and assessment programs involving simulation that contribute to quality and safety. While the pandemic has had far reaching impact on all of us, one thing that has not changed is the need for patients to have access to the highest quality healthcare in the safest possible fashion. Simulation efforts around the world contribute mightily to this need.

Healthcare simulation efforts are far reaching. Goals range from the education of future and current health care providers, assessing competency, to uncovering latent threats that exist that could possibly harm our patients. Our patients cannot afford significant delays or the halting of such programs and to do so would be a dereliction of our moral and ethical imperatives to keep patients safe.

At the beginning of the pandemic and continuing at present there seems to be a mad scramble to transfer learning to online activities, and/or suspend hands on simulation training. As simulation leaders and professionals, we need to ensure that our efforts are dedicated to planning the future, both far and near. For the near, foreseeable future that includes coexisting with the Covid virus. We must proceed forward with the conducting of our simulation-based programs in a way that is aligned with best practices of safety and prevention that is associated with the spread of the virus.

Reengineering our existing programs to accommodate for masks, appropriate PPE, social distancing where possible, aggressive cleaning policies and other such items are important part of the leadership process. As an example, going the extra mile and perhaps splitting one class into two to cut down the number of occupants in a given space maybe part of a reasonable curricular engineering solution. Reevaluating the effectiveness and efficiency of the hands-on part of the simulation and deciding if elements of the education could be adequately be covered online may be another part of the equation.

The far future and impact of the Covid related disruption(s) may bring us new technologies and enhanced ways to conduct simulations remotely. One could dream. Perhaps on-line coupled with enhanced virtual and/or augmented reality whilst practicing and learning with our colleagues! What is unreasonable is to think that all of the simulation specific training that we do can be hastily flopped online and converted to a zoom session! While it may have been an important urgent stop-gap transition task in February, do not mistake it as the long-term solution without careful evaluation and assessment.

Ensuring we are conducting our programs in the safest way possible with regard to the participants, the teaching faculty, as well as all of the staff and all humans associated with the simulation program required to support the effort is of paramount importance. This requires careful attention and significant leadership oversight whether we are teaching practicing professionals or students of health care programs. Our patients, the primary reason that we do simulation and those who have the most to lose if we don’t, are counting on us for the quality and safety associated with the healthcare they are receiving.

Simulation is not an optional, nice to have program. It is as essential as adequate staffing, ventilators, and fire alarm systems. It contributes significantly to the process that allows us to provide safe and high-quality care a most vulnerable population of people that we call patients.

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Cognitive Load Control and Scenario Design in Healthcare Simulation

As the design architects of simulation scenarios, we must remain cognizant of our ability to have influence over the cognitive load of those experiencing our simulations in the role of learners.

When caring for patients in real life, we expend cognitive energy in doing so to ensure we make the right decisions to provide the absolute best care for every patient. We engage in critical thought processes, that guide our interpretation of the enormous number of facts surrounding each patient so we can make further decisions to provide various therapies, or advice to the patient.

Headache brain in a clamp isolated grey background

When we design simulations for our learners, we are creating similar environments noted above that demand a significant amount of cognitive workload to be endured for the participant to successfully navigate the case and care the [simulated] patient. In addition, I argue that we are adding additional cognitive workload by subjecting someone to the simulated environment insofar as they are engaged in a conscious or perhaps subconscious pursuit of deciding what is simulated and what is not. I have previously written about this and dubbed it the cognitive third space of simulation.

Nonetheless, there is mental energy spent in the care of the patient as well as the interpretation of the simulation. We also must realize that our design choices inside of the scenario contribute to the adjustment of the cognitive load endured by the learner(s) associated with our simulations. It is important that we be deliberate in our design to ensure that we are allowing all involved to achieve the desired learning outcomes.

Some specific examples of this cognitive load influence may help to bring forth an understanding. Take a test result for example. If one looks in the electronic health record and sees the values reported for a simple test, like a basic metabolic profile (which consists of a sodium, chloride, potassium, CO2, BUN, creatinine and glucose) there is a certain amount of mental energy goes into the interpretation of the numeric data presented for each of the seven items of the basic metabolic profile. Some electronic health records may color-code the results to assist in the processing of normal versus normal, and some may not.

Such a decision involved in the human factors design of electronic health record actually influences the amount of cognitive spend on the interpretation of the given value. Further, as experienced clinicians are keenly aware, we must interpret the lab value in the context of the patient for whom the test has been ordered. What is normal for one patient, may not be normal for another. Thus, even in the interpretation of a simple test, there is a significant amount of cognitive process (critical thought) that should be applied.

How does this relate to simulation scenario design? We have the ability to engineer the scenario design to help the participants channel cognitive energy into those things that are important and away from those those things that are not. If we continue to run with the example of the basic metabolic profile as an example, we have choices on how said values are reported to the participants of our simulation.

We could have the participants look it up in the simulated electronic health record which takes time and cognitive processing as described above. We could give them a piece of paper or display the results on a screen demonstrating the seven values. This still takes significant cognitive processing to interpret the data. We could simply indicate that the basic metabolic profile result was “normal”.  This method significantly decreases the cognitive processing associated with the seven values of the basic metabolic profile and how it is to be interpreted into the context of the scenario. Also, one could make the argument that we are offering subtle, or perhaps not-so-subtle clues to the case that the basic metabolic profile is not a major part of what needs to be processed in the care of this particular patient.  

It is important to realize that all the examples above are viable options and there is not one that is superior to another. It is important that the decision is made during the design of the case that allows the participant(s) of the scenario to focus the appropriate cognitive spend on that which the designers of the scenario feel are most important. In other words, if it is part of the learning objectives that the participant should evaluate the actual values of the basic metabolic profile, then of course it would be appropriate to provide the requisite information at that level of detail. If, however, the results of the same test are perfunctory to the bigger picture of the case then one should consider a different mechanism of resulting values to the simulation participant.

A common misperception in the design of healthcare simulation scenarios is to try to re-create the realistic environment of the clinical atmosphere. While this is always a tempting choice, it is not without consequences. It comes from the mistaken belief that the goal of simulation scenarios is to re-create reality. Modern, successful simulationists need to recognize this outmoded, immature thought process.

In the context of a case where the basic metabolic profile is not significantly important that we should not design the “dance” (scenario) to include the steps of looking in the electronic health record and making determinations of the values associated with the test. It is a waste of time, and more importantly a waste of cognitive processing which is already artificially increased by the participant being involved in the simulation in the first place. It is in my opinion a violation of the learner contract between faculty and students.

While I am focusing on a simple example of a single test, I hope that you can imagine that this concept extrapolates to many, many decisions that are made in the scenario design process. For example, think about a chest x-ray. Do you result a chest x-ray as “normal”, “abnormal” or otherwise during the run time of the scenario? Or do you show an image of a chest x-ray and have your participants interpret the image? One answer is not superior to the other. It is just critically important that you evaluate what is best for the cognitive load of the learners involved in your scenario and how the decision relates to the details of the learning objectives you wish to achieve during the course of the simulation activity.

In moderate to complex cases associated with healthcare simulation the designer of the simulation, or architect, has a responsibility to craft the scenario to accomplish the learning objectives that are intended. In many scenarios, hundreds of decisions are made in terms of how participants extract data from the experience to incorporate into their performance of the simulation. It is critically important that as the designers of such learning events that we remain cognizant of the cognitive load placed upon our learner(s) that is associated with the normal care of patients, as well as the extra that is imposed upon them from participating in a simulation-based case.

Many of the decisions that we incorporate into the design of our scenarios have significant influence over this cognitive load, and the mental energy participants will spend to engage in the participation. We need to understand the impact of our choices and be deliberate with our design decisions to enhance the overall simulation-based learning process efficiency and effectiveness.

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Where do we Debrief?

Selecting the location to conduct the debriefing after a simulation is a decision that often has many variable. Sometimes there are limited choices and the choice is dictated by what is available, or what space holds the technology that is deemed essential to the debriefing. Other times there is deliberate planning and selection.

This short video explores some of the basics of how such decisions are made and some of the pros and cons associated with the final choices.

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Exploring the Elements of Orientation and (Pre)Briefing in Simulation Based Learning Design

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I want to explore a little bit about orientation and (pre)briefing(s) associated with simulation based education design concepts. The words are often tossed about somewhat indiscriminately. However it is important to realize they are both important elements of successful healthcare simulation and serve distinct purposes.

When we look in the Healthcare Simulation Dictionary, we find that the definition of Orientation is aligned with an overview preparation process including “… intent of preparing the participants.” Examples include center rules, timing and the simulation modalities.

On the other hand, according to the same dictionary the definition of the word Briefing includes “An activity immediately preceding the start of a simulation activity where participants receive essential information about the simulation scenario….”

I look at orientation as the rules of engagement. I like to think of orientation linked to the overall educational activity in total. Some essential components include orientation to the simulation center, the equipment, the rules, and the overall schedule for the learning activity.

At a somewhat deeper level of thought I think the orientation is linked to the learning contract. What do I mean by that?

I think it is essential that we as the faculty are establishing a relationship with our learners and begin to establish trust and mutual respect. To that end, we can use orientation to minimize surprises. Adult learners do not like surprises!

We need to have the adult learner understand what they can expect. I always orient the learners as to what will feel real, and I am similarly honest with them about what will not feel real. If they will be interacting with a computerized simulator for example, I orient them to the simulator before the start of the program.

In the simulation world we throw around words like debriefing, scenario and task training. To clinical learners these terms may be unfamiliar, or have different contexts associated with them. This for example, can cause anxiety and during the orientation we need to walk them through the experience they are about to embark upon.

Some factors can influence the amount and depth of the orientation. Variables such as the familiarity your participants have with simulation, your simulation center, and your simulation-based encounters. For example, learners who come to your center on the monthly basis probably need less total orientation than those who are reporting for the first time. Learners familiar with the fact that debriefings occur after every simulation may already be acclimated to that concept, but people coming to the sim center for the first time may not be aware of that at all.

Participants just meeting you for the first time they might need a little bit more warming up and that an come in the form of orientation. Overall though it is not just about telling them what’s going on, as it is using the opportunity toward earning their trust and confidence in the simulated learning encounter(s) and the value associated to them as a professional.

BriefingGraphic3Switching the focus to the brief, briefing or (pre)briefing. The briefing is more linked to the scenario as compared to the orientation. The briefing should focus on the details of the case at hand introducing components of information that allow one to acclimate to what they going to need to accomplish during the simulation. What is their role and goals in this scenario they are about to embark upon? If you are going to ask people to play different roles then they are in real life, it is very important that this fact is crystal clear in the briefing.

I think that the briefing should also bring the context to the healthcare experience. It is important to orient the learner for the impending encounter what they are to perceive and think of as real as they are experiencing what is in the simulation. You as a simulation faculty may think that it is obvious that a room in your simulation center is an ICU bed. The participant may not and deserves clarity prior to the start of the simulation so they do not feel like they are being tricked or duped. During the briefing the statement “You are about to see a patient in the ICU…..” can remove such ambiguity.

Another critical briefing point is to clarify the faculty-student engagement rules that should be expected during the scenario runtime if it was not covered in the orientation. There are many correct ways to conduct simulation scenarios. There are varying levels of interaction between faculty members running the simulation and the learners that are participating. This should be clarified before the scenario starts.

For example, are you going to let the learners ask questions of the of the faculty member during the simulation? Or not? This should be upfront and covered in the briefing, and perhaps even aspects of that in the orientation.

While not a requirement I think that parameters associated with time expectations are always good to give in a briefing. For example stating “You are going to have 10 minutes in the scenario to accomplish X,Y and Z, and then we will have a ten minute debriefing before the next scenario.”

Remember our adult learners don’t like surprises! I always use the briefing before a scenario to remind the participant(s) that afterward we are going to have a debriefing. I remind them of that so that they know that they should collect her thoughts and ideas and be ready to have this discussion. Secondly, I am saying in any unspoken way, that if they are uncomfortable about something, or have questions, that there will be an opportunity for discussion during the debriefing. (In other words, your sort of giving some control back to the learner…. Helping to build the trusting relationship.)

Some of the variations of the briefing are similar to that of the orientation mentioned above. People who are more familiar to simulation, your particular programs, your style, may require slightly less of a briefing than others. Additionally, if you are running multiple scenarios as part of a simulation-based course, after the first couple of scenarios you will find that the briefing can be shortened as compared to the beginning of the day.

So, in summary, orientation and briefings are different elements of simulation-based learning that are useful for different things that will contribute to the success of your simulations.

Think of orientation linked to the bigger picture and the learner contract that contributes to making the relationship comfortable between the participants and the faculty. The orientation is the rules of engagement and orientation to the technology and being explicit as to what is to be expected of the participant. Think of the briefing as linked more to the scenario roles, goals, and introduction to patient and environment information to help the participant mentally acclimate to what they are about to dive into.

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Simulation, Music, and Dancing

Many of you know of my crazy thoughts and ideas to try to connect things together with contrasts and comparisons to help people understand concepts and ideas. Well…. Here goes another one of them!Dance

I find that people continuously struggle with understanding the true relationship of the scenario (defined as the collective information, tools, and techniques that are presented to participants of simulations) to the outcomes of the simulation. The confusion arises from the fact that people get inappropriate messaging during the formative times of their simulation careers.

People gain the idea that the scenario must be as real as possible, or perfect mimic some aspect of real life in healthcare in order to be effective instead of recognition that the sole purpose is to create a script and stage that allows participants to perform. Some people believe that the overall goal of simulation is to recreate reality. The sad part is, those misguided thoughts often lead to over-production of the scenario and that the scenario is the primary focus of the activity. This can lead to the unintended consequences of increasing the workload of the simulation relative to the value of performance improvement and/or introduce confusion to the participants of the scenario.  Neither of which are desirable.

It occurred to me recently that a terrific analogy can be made by evaluating the relationship of music, to competitive dance. As it turns out the scenario is simply the music.

Thinks about it. When a dancer or group of dancers are going to compete, a number of things must be in place. First, there is an understanding that the dance will be carried out with the playing of music. The activity will last a certain length of time, involve one or more people who are supposed to do certain things at certain times and that various details will be assessed or evaluated along the way. At times the evaluation maybe be structured to focus on improvement (formative) and perhaps feedback is shared along the way (deliberate practice preparing for a competition), while other times may it may be a high-stakes evaluation (summative) resulting in only a score (the actual competition).

Now let’s focus on the music. What is its purpose in a dance competition? If you think about it, the music providers the framework or backdrop against which the dancing activity occurs. It helps to coordinate the tone, the tempo, and the activities associated with the dance. If the objective is to assess a pair of dancers doing a waltz, then a waltz is played. So the learning objective would read, at the conclusion of this five minute activity, the participants will demonstrate the ability to perform a waltz. If we wanted to evaluate a Latin dance, we would play Latin music and have an appropriate assessment criterion by which to guide the improvement of the activity.

While it is technically possible for the assessment to occur in the absence of the music, it would be awkward for the participants and the evaluators as well. Further, a piece of music may be specifically chosen to encourage a certain dance move that would facilitate the evaluation of the activity, let’s say a twirl or a flip. If we needed to evaluate or score how well one performed a flip, a flip would need to occur during the dance.

When using the methods of simulation in the healthcare world, we need to see people dance. The dance we need to see is often a complex one involving the delivery of healthcare, but it is a dance none the less involving specific movements, communications, and other activities toward a specific goal There are times that we need to see individuals dance, other times teams.

If we are to evaluate a certain element of healthcare, then we must have carefully composed the music that propagated the desired activity to have occurred during the dance. As they dance, we perform an assessment with a goal of helping them improve through various feedback mechanisms. Such feedback may occur through active reflection and facilitated discussion (debriefing), self-reflection, peer to peer engagement, or perhaps in the delivery of a more formal score in the case of summative feedback.

The bigger point is, the scenario is constructed and executed (composed) to provide the background milieu to form the basis of the dance, i.e. have participants perform the activity that we wish to assess. We choose different types [of music] to play that is concordant with the activity we wish to evaluate. At times we play a tune that accentuates the evaluation of critical thinking skills, perhaps the performance of a complex skill, or maybe one that allows a whole team to dance together requiring teamwork that will benefit from feedback.

So, the next time you are composing your scenario, give careful consideration to the moves that you desire to evaluate. The music that plays should allow/encourage your dancers to perform the steps and activities that will be evaluated and turned into useful information to facilitate improvement.

Compose, have people dance and help them get better!

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Five Pearls for Debriefing 

Sharing some practical considerations to help you with your debriefing efforts!

 

Shell with a pearl

1. Before you begin attend to learner readiness 

Before you begin ensuring the emotional readiness of your learners will be a huge benefit. Learning during a debriefing can be enhanced by reducing distractions. Such distractions can occur from many possible origins. If learners are particularly stressed, angry or perhaps sad after simulation experience it is best to let them process their emotions or otherwise emotionally and mentally prepare themselves to be able to focus on the content of the debriefing. So, taking a few minutes to observe, or perhaps even directly asking, “Are you ready?” may go a long way. Also, another tool that I use after a stressful simulation is to just acknowledge that there may be stress with a statement such as “Wow. That looked stressful. Are you guys ready to talk about it?” 

2. During the debriefing, listen to the learners, analyze their thoughts and understanding 

A structured debriefing should provide the opportunity to listen to learners. This allows the debriefer to analyze if the learners have a command of the facts and understanding of the intended learning associated with the simulation. It is easy to become impatient with the process and start telling the learners what they need to know. Once this occurs, it is difficult to assess what the learners do know and understand. As you listen to learners during the debriefing think about what you need to ask next, or where you need to take the conversation to be able to analyze the next area of content you wish to explore during the debriefing. So another tip is shift your thoughts to how can I discover if my learners know….. as opposed to the normal transmittal of information that comes from thinking I need to tell them X, Y and Z so that they understand. 

3. What went right is as important as what went wrong 

There is a saying that the negative screams and the positive whispers. This could not be truer when it comes to debriefing. It is far easier to remember what people did wrong during a scenario, then what they did right. But if you sit back and think about it, they are equally as important. Learners leaving a debriefing understanding that they did correctly and why it was correct, paired with an understanding what they did wrong and why it was wrong is critically important for improvement to occur. If the right things are not debriefedit may be that they were done out of habit or luck and that the learners don’t understand it at all! Or worse yet, they could be perceived as unimportant. So a good tip is to jot some noted down of things that went correctly during a scenario. Trust me, you’ll remember all those mistakes which will be screaming! 

4. Keep the debriefing focused 

A challenge for anyone conducting a debriefing is to keep things focused. Learners love to talk about what learners want to talk about. However, it’s important as the facilitators of the conversation that we have the learners talking about what they need to be talking about. What learners need to be talking about should be driven by the learning objectives of the scenario. This direction needs to come from the debriefer. There is a delicate relationship that exists between the learners and the debriefer so carefully thinking about how to maintain this but being able to gently nudge the conversation back to the right pathway is a skill worth concentrating on. A tip is to develop some scripts that you are comfortable using when such nudging need to occur.  

Consider this example, “I agree that the exact dosage of the medication is critically important, but for this scenario and debriefing we are tasked with focusing on the effectiveness of the communications within the team. So, who can give me an example of effective communications that occurred during the scenario?”  

 5. Bring out summary/take home points 

Every simulation has a plethora of opportunities for learning. It is the job of the debriefer to ensure that the primary learning objectives of the simulation are covered. During complicated cases or cases with multiple learning objectives it is possible to cover a lot of ground along with many topics and facts during the time when you are analyzing the learners grasp of the content. It is important to close with summary points that are crucial take home messages. This can be challenging for some, and often turns into a mini lecture. And remember when you start lecturing to the learners, you are sacrificing the ability to ensure understanding where the learner is at that point and time. Concluding or beginning the wrap up of the debriefing by asking leaners to give one or two things that they think went well during the scenario along with what they would  change next time can be an effective probe into understanding that the learners took away the big learning messages. It also serves as the time to allow you to shape the discussion with further questions that drive home the intended take away points. Always think to yourself what are the two or three things that I want them to remember most from this experience a month from now. 

Well that’s is for now. Remember debriefing gets better with practice, feedback and experience. So, get out there, debriefget some feedback and debrief again! 

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5 Elements in My Approach to the Learning Contract in Simulation

In simulation-based education there is a relationship between the faculty of the program and the participants that is important during all aspects of simulation. The relationship has tenets of trust and respect that must be considered when designing as well as conducting simulations. I have heard this relationship referred to by a few titles such as psychological contract, fiction contract, learning contract, all of which are generally referring to the same thing.Smiling asian female vacancy candidate shaking hand with hr manager

Probably more important than the title, is what such a relationship embodies or focuses on. I view it as an agreement between two or more parties that acknowledges several aspects of simulation based programs and works to establish rules of engagement and principles of interactions between those involved.

In my practice of using simulation for clinical education I work a great deal with practicing professionals, who by in large are physicians. I generally adhere to five elements or premises over the course of interactions that I design as well as provide for the participants of my programs.

  1. Meaningful use of Your Time.

Acknowledging up front that participating in learning activities takes time away from their busy schedule. I assure them that the content of the program is carefully crafted to fill the needs of their learning cohort in the mostly timely way possible. I refer to refinements of the course that have occurred in response to feedback from prior participants to help increase the efficiency and effectiveness of the program.

  1. This is NOT real and that’s really ok!

During the orientation I am always careful to point out that not everything they are going to experience will look or feel real. I include the idea that things are “real-enough” to help us create a successful learning environment. I also let them know the things that may feel somewhat real during the simulation. Additionally, I emphasize that the “realness” is not the primary focus and point out that the learning and reinforcement of high-quality clinical practice is the ultimate outcome.

  1. We are not here to trick you.

I find that practicing professionals often come to simulation training endeavors with an idea that we design programs to exploit their mistakes. I assure them this is not the case. I am careful to include an overview of what they can expect during all phases of the learning. For example, when I am conducting difficult airway programs, I carefully orient them to every feature of the simulators airway mechanics before starting any scenarios. I also let them know that the cases associated with our scenarios are modeled after actual cases of clinical care. I explain that while we don’t model every detail of the case, that we work hard to design situations that provide opportunity to promote discussion and learning that would have or should have resulted from the actual case.

  1. Everyone makes mistakes. We are here to learn from each other.

At the most basic part of this element, I point out that WE all make mistakes and that is part of being human. I let them know that everyone is likely to make a mistake throughout the learning program. I carefully weave in the idea that it is far better to make mistakes in the simulated environment as opposed to when providing actual clinical care.

Further, I advance the idea that we can learn from each other. As everyone in clinical practice knows, there are many ways to do most things correctly. While this idea can be challenging because often people feel that “their way” is the correct way, I point out that with an open mind and professional, collaborative discussion we can share learnings with each other.

Contract Signing Concept

  1. We are here to help you be the best you can be.

Leveraging the idea that almost all practicing professional hold themselves to high levels of performance standards as well as the desire to improve can provide a powerful connection between the faculty and participants of a healthcare simulation program. I put forth this idea along with carefully tying in a review of the prior four elements. Further, I point out to them the opportunity to perfect the routine exists in our learning programs. I then pivot to highlight that some aspects of the program exist to practice and learn from situations that they may encounter infrequently that may have high stakes for the patient.

So, in summary, I believe the relationship between faculty members and participants of simulation-based education programs is multi-factorial and demands attention. Depending on the learners and the topics of the program, the elements that serve as the underpinning of the relationship may range from few to many, and moderate to significant in complexity.

In my simulation work providing clinical education that involves practicing physicians as participants, I pay close attention to the five elements described above throughout the design as well as the conducting of the learning encounters.

I invite you to reflect upon your approach to the development and maintenance of the relationship between your faculty and participants of your simulation efforts.

 

 

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Filed under debriefing, design, simulation

Education may NOT be the Return on Investment Value of Healthcare Simulation

Its January 2019 and I am flying to San Antonio, Tx to attend the International Meeting for Simulation in Healthcare. While traveling (in coach) I cannot help but to ponder where we are in simulation and where we are going. While I feel that simulation has a bright future and will earn a deservedly important role in healthcare it feels as if it is taking longer then it should.

In my overly simplistic view of simulation I envision two primary user groups. Those who utilize simulation to teach students of various healthcare professions (schools) and those who use simulation to somehow improve the quality of the delivery of healthcare. The latter of which likely includes education of individuals as well, but more of the ilk of practicing healthcare professionals and those in the apprentice phases of training such as resident physicians.

For the purpose of this post, I will be focusing on simulation efforts associated with healthcare delivery. Toward the end, I will circle back to the “school” environment again.

As healthcare dollars for the delivery of healthcare continue to be under more pressure and harder to come by there is great interest in controlling spending and increasing vigilance by corporate overlords on money being spent on investments. Investments or capital purchases are under higher levels of scrutiny than ever before. Simulationists must bear in mind that simulation is an investment, or at the least a capital expense for healthcare systems. This realization is accompanied by the stark reality that whatever you want to purchase for your simulation efforts whether it be a single simulator, or a suite of training equipment is competing against other “things” also associated with the delivery of care. Pesky things such as CT Scanners, ultrasound machines, laproscopic surgical equipment for the operating room or dialysis machines.

Why pesky? From my view as a simulation and safety leader I am envious. I am flat our jealous that it is so easy for the purchasers of the above listed examples, it is so easy for them to justify their return on investment (RPOI). Huh? What’s that? In simple terms the ROI is the business term and calculations that allow spreadsheet drivers to determine how much profit an investment of dollars in a “thing” will bring back to the

Perhaps looking at an overly simplistic explanation will help. Let’s say somFemale patient undergoing MRI - Magnetic resonance imaging scaneone wants to put in a new CT Scanner. The costs of the scanner and installation, maintenance, staffing, and operational expenses are calculated. Then how much can be charged for each scan, how many scans can be done by the hour, and how many hours per day the scanner will be running calculates the revenue that the new CT scan will bring in. After the install is paid for, all of the rest of the revenue coming in once the expenses are deducted is profit. Thus at least when justifying the new CT scanner a requester of funds will create a fancy business proposal with colors and graphs that show money flowing in as a result of the purchase after a given period time. Purchase approved!

Now let’s take a typical cost justification scenario discussion between a simulationist (sim) and a Chief Finance Officer CFO of a healthcare system:Corporate Bean Counting

Simulationist (Sim): I’d like $250,000 to buy a simulator.

CFO: How is that going to make us more money?

SIM: To educate people and make them smarter and reduce mistakes?

CFO: We have lots of smart doctors and nurses working here. You should be reducing mistakes anyway.

SIM: There is a study showing a reduction of central line infections saves money.

CFO: Save who money? We still make money when the patient is in the hospital. And besides, your not asking for central line simulator.

SIM: But insurers are not going to pay for errors and hospital acquired infections anymore

CFO: Maybe not. We still make money when the patient is in the hospital. What’s your return on investment for this doll?

SIM: We are buying the simulator to train people to work together better. To work as highly functional interdisciplinary teams.

CFO: Right. We have lots of smart doctors and nurses working here. You should be reducing mistakes anyway. They are smart enough to work as teams. They do it every day.

SIM: But we can make the teams work better and make people enjoy working together more and improve patient care.

CFO: People like working here. You should be improving patient care. Where is the proof that simulation is needed to train teams AND that team training improves patient care?

SIM: The airlines have been doing it for years.

CFO: Where is the proof that airline simulation improves the airlines?

SIM: everybody just knows. It makes sense. And planes don’t crash as much as they used to.

CFO: Hospitals don’t burn down either. You know, we bought the new CT Scanner last year, and we have been able to make money on it. Its just like radiology predicted in their purchase proposal. Let me think about your request and I’ll get to you.

While the above scenario is somewhat tongue in cheek, sadly, I think it is closer to real life then many simulations we conduct. The fact of the matter is the true ROI of simulation is buried in nuances, potential opportunities, mired by anecdotal enthusiasm with a scant amount of hard-core evidence that provides the black and white spreadsheet numbers that make the bean counters excited.

It is upon us to figure out ways to describe the ROI of simulation more coherently, accompanied by facts and figures that make a difference to the leaders of healthcare systems. Let me give you a hint……. It aint about education.

We must transcend long hold belief and common assumption that the value of simulation is the education. I think the realization and yet unlocked true potential of simulation remains ties up in the ability to assess. It is tough to pivot from thinking that simulation is primarily an education methodology. But I encourage you to do so. Now before you get your hair on fire and leave me nasty comments, I’m not suggesting that we abandon simulation which we know to be an incredibly powerful education platform/modality. I just believe it you think it the main power is education first and foremost its becomes difficult to strategically plan, document, and provide leadership in other directions.

I think in the healthcare delivery space a more powerful argument that can contribute to the ROI of simulation is to harness the ability of simulation to identify the best deployment of judicious resources. So, what does this mean? Stop teaching with simulation? No, of course not.

Focusing more on the use of simulation as an assessment and surveillance tool can help to create bigger value. When teaching with simulation, conducting assessments of what people or perhaps units are doing well, what they are struggling with in a more quantitative way can help to identify the true needs of the organization. Understanding the local struggle and perhaps what the local community is not struggling with allows for a smarter utilization strategy for simulation.

Now before the heads pop off of the safe learning environment people, I’m not Stressful girl with exploded headsuggesting we need to turn every simulation into a summative performance assessment and give passing and failing grades that will ruin peoples lives. However consideration should be given to the gathering of data to show improvement is critically important as you do all of your great education work. After you collect the data is a systematic way have the courage to abandon what participants always do well on, focus or increase in the areas of greatest improvements.

Carefully collect the data if you use your simulation activities for on-boarding. Don’t ask if they liked the simulation. That’s not the data you need for your ROI justifications. Can you shorten aspects of on-boarding through the use of simulation? Showing credible evidence that nursing on-boarding can be shortened by x number of days or weeks through the strategic and judicious use of simulation will bring music to the ears of the bean counting crew who don’t fancy paying for the training of people when they could be working.

Other thoughts…. Using simulation as an evaluation tool in a human factors applications can assist other departments in increasing efficiency, and improving throughput. Think about the importance of that. What????? Not your cup of tea? Think back a few paragraphs on calculations leading to justifying the need for the new CT Scanner.

Carefully documenting that simulation trained anesthesiologists, CRNA’s , endoscopists and surgeons for example may shorten OR time which means more surgeries can occur, which generate lots of revenue is part of the ROI that should be in capital letters. This is the data that matters for the ROI justifications.

In-situ programs can give valuable feedback to hospital safety and quality leaders to demonstrate volatilities in the system with regard to both process, staffing, human performance etc. It can also demonstrate where the strengths lie. If there is unnecessary training going on where the strengths lie, then redeploy or readjust to the actual needs of your system. Additionally, formulating such relationships with the quality and safety leaders of your institution and letting them know of you true capabilities that are more then making people happy and smarter through education, can win you some powerful allies in the corporate leadership suites.

Lastly circling back to the schools……. Looking past the education benefits of simulation to use it as a tool to create data that can lead to information the underpins significant change, cost savings, and allocations of precious resources (people and money) will do you well. With the exception of more students,  I  don’t think it is likely that windfalls of money are coming your way either…….

So is you are carefully assessing you simulation efforts and activities in a thoughtful manner, you can help to reduce redundancy, unnecessary training intervals, or repetitions and on and on. Doing less of that which is ineffective save money. Saving money is a variable of the ROI that your CFO will pay attention to.

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Filed under assessment, hospital, return on investment, simulation

Beware of Simulation Posers!

You may be a simulation poser if you say or do three or more of the following things…..

1. You say something like “In simulation all of the learning occurs during the debriefing.”
Appraisal: Not true. You are lying, uniformed, or not creative.
Not even close. If you believe this you are not paying attention to other learning opportunities that participants of simulation can avail themselves to. Think about the status changes of a simulator in response to proper or improper treatment. Think about participant to participant potential interactions. Think about the potential for instructor participant interactions that may contribute to learning. The potentials are practically limitless! For more see this blog post.

2. You claim there is a magic ratio of simulation time to debriefing time. “for every 15 minutes of simulation you must debrief for 45 minutes…. Etc.”
Appraisal: Rubbish.
No such thing exists. In fact if you think about this it is utterly ridiculous given the number of variables that exist that may potentially influence the debriefing time. Things like the topic, number of learners, experience level of the learners, number of faculty, experience of the faculty and on and on. Just stop saying it and the perception of your (simulation) IQ will raise by 10.

3. You espouse that during simulation encounters the students and faculty must be separated by something like a glass wall.
Appraisal: Lack of creative thinking.
While there are a lot of god reasons to design simulations that physically isolate the faculty from the participants, there are as many compelling reasons to have faculty in the same room at even at times interact ……. (agghhhast) with the participants. Think about the possibilities. Faculty side by side with students could engage in coaching and formative assessment or more easily conduct pause and discuss or pause and reflect type of learning encounters that can be more awkward when on the other side of the wall!

4. You say the simulator should never die during a simulation.
Appraisal: Wrong
‘Nuff Said on this one.

5. Simulations must have every aspect designed to be as real as possible.
Appraisal: Simply Crap.
Trying to create the ultra real environment can lead to increased time to set up, clean up and otherwise make the simulation less efficient. Worse yet creating a lot of simulated artifact can actually lead to increased confusion. How? Read this blog post on the cognitive third space of simulation. Simulations should be designed and outfitted to provide enough realism that enables the accomplishing of learning objectives. Everything else is a waste of time, money and/or people resources (ironically the same things you probably say that you don’t have enough of).

6. You say during simulations participants must/will suspend disbelief.
Appraisal: Ridiculous.
Out of the other side of your mouth you probably babble about adult learning theory……
If we are educating seriously smart adults, we don’t want them to think the plastic simulator is real. Seriously. I like to think of a more mature understanding of the situation that gives the participates a bit more credit for their lifetime of cerebral accomplishments. How about a message like…. “We have created this learning encounter using simulation for you so we can work together to help you become a better healthcare provider. Some of what you are going to experience will seem realistic and some will not. But we promise to make the best use of your time, treat you with dignity and respect, as we help you learn and practice.” Now that’s how adults talk. (Mic drop)

7. You claim one debriefing model is far superior to another. Or one has been validated.
Appraisal: Crap that gets sold at debriefing training programs.
If you are saying this, you probably don’t use a structure to your debriefing, don’t believe in learning objectives, or you only know one model of debriefing.
Truth is there are a bunch of good debriefing models in existence. You would do well to learn a few. Different models of debriefing are like tools in the toolbox. Some are good for certain topics, learners and situations and some for others.

8. You state that you should always use video while debriefing.
Appraisal: Industry sponsored rubbish.
You have drank some serious kool-aid, have had the wrong mentor, or an improper upbringing if you believe this. Further, if your make your participants watch the entire simulation on video, you should receive a manicure with a belt sander. Lastly if you say you use the video to solve disputes about what a student did or didn’t do, you may be hopeless.
Video can be a tool that can be strategically used to enhance debriefings at times. But more often video playback gets used as a crutch to make up for a lack of quality debriefing skills and to fill time.
There is also a misguided belief that students want to watch their videos. They don’t. They hate it. They think they look fat and their hair doesn’t look good.
Harnessing the power of a good debriefing is hard work and requires skill. But active reflection and guiding students towards a self-discovery of what they did well and what they need to change for the future is serious active learning. The more you can do that, the more the learning will occur. Watching a video of a simulation is like watching a bad movie. I always find it fascinating that simulation programs will spend a fortune putting in a video system that could film a Hollywood movie, but wont invest even a fraction of that cost into development of the faculty.

9. You use the terms “High and Low Fidelity Simulations” when you are referring to the use of a high technology simulator in your simulations.
Appraisal: You are feeding into the biggest industry sponsored word there is. In fact, the word fidelity is so perverse it should be banned. See additional blog post here on banning the “F” word.
The highest fidelity human simulator I know is a real person playing the role of a standardized or simulated patient. Everything else is overall, lower fidelity.
Seriously folks….. Somewhere along the way industry labeled a couple of simulators high fidelity because they had a feature or two that approximated that of a human. The label stuck and continues to perpetuate great confusion throughout the community of simulation, in practice and in the literature as well. Some centers even name their room like this!!!

Sadly, this crazy definition even made its way into the simulation dictionary of the Society for Simulation in Healthcare (which is otherwise excellent I might add). Do high technology simulators have some very cool and very useful high-technology features? Absolutely! But real like a person, ie high fidelity? Not so much.

The next time you think your SimMan or HPS is a high-fidelity simulator try doing a knee exam and compare it to a real person. Better yet, lock yourself in a room with either or both of them, and hold a 30-minute conversation. Then send me a note to the how the fidelity strikes you.

10. You tell your institution you will make a profit with your new simulation center.
Appraisal: Your setting yourself up for trouble
It just doesn’t happen very much. Everyone has a “business plan” and tries to justify the costs and appeasing finance people with rows and rows of imagined potential revenue sources that often include internal and external components. Somehow, some way, they just never seem to all pan out. Most simulation programs are a cost center to the institution to whom they are sponsored by. They are an important investment, but not a profit motivated investment for the institution. It is far better to focus on the value statement that you are brining to your institution(s) then to trying to convince your boss’s boss that the institution will get rich off of your program. Focusing on the value you produce that is aligned with your institutions mission may help you grow support for your program and as well as help you keep your job a little bit longer.

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Filed under Curriculum, debriefing, design, simulation