Monthly Archives: April 2016

Learning from Simulation – Far more than the Debriefing

Most people have heard someone say “In Simulation, debriefing is where all of the learning occurs.” I frequently hear this when running faculty development workshops and programs, which isn’t as shocking as hearing this espoused at national and international meetings in front of large audiences! What a ridiculous statement without a shred of evidence or a realistic common sense approach to think it would be so. Sadly, I fear it represents an unfortunate instructor-centered perspective and/or a serious lack of appreciation for potential learning opportunities provided by simulation based education.LearningDuringSimulation2

Many people academically toil over the technical definitions of the word feedback and try to contrast in from a description of debriefing as if they are juxtaposed. They often present it in a way as if one is good and the other is bad. There is a misguided notion that feedback is telling someone, or lecturing to someone to get a point across. I believe that is a narrow interpretation of the word. I think that there are tremendous opportunities for learning from many facets of simulation that may be considered feedback.

Well-designed simulation activities hopefully provide targeted learning opportunities of which part of it is experiential, sometimes immersive, in some way. I like to think of debriefing as one form of feedback that a learner may encounter during simulation based learning, commonly occurring after engaging in some sort of immersive learning activity or scenario. Debriefing can be special if done properly and will actually allow the learner to “discover” new knowledge, perhaps reinforce existing knowledge, or maybe even have corrections made to inaccurate knowledge. No matter how you look at it at the end of the day it is a form of feedback, that can likely lead, or contribute to learning. But to think that during the debriefing is the only opportunity for learning is incredibly short-sighted.

There are many other forms of feedback and learning opportunities that learners may experience in the course of well-designed simulation based learning. The experience of the simulation itself is ripe with opportunities for feedback. If a learner puts supplemental oxygen on a simulated patient that is demonstrating hypoxia on the monitor via the pulse oximetry measurements and the saturations improve, that is a form of feedback. Conversely, if the learner(s) forgets to provide the supplemental oxygen and the saturations or other signs of respiratory distress continue to worsen then that can be considered feedback as well. The latter two example examples are what I refer to as intrinsic feedback as they are embedded in the scenario design to provide clues to the learners, as well as to approximate what may happen to a real patient in a similar circumstance.

With regard to intrinsic feedback, it is only beneficial if it is recognized and properly interpreted by the learner(s) either while actively involved in the simulated clinical encounter, and if not, perhaps in the debriefing. The latter should be employed if the intrinsically designed feedback is important to accomplishing the learning objectives germane to the simulation.

There are still other forms of feedback that likely contribute to the learning that are not part of the debriefing. In the setting of a simulated learning encounter involving several learners, the delineation of duties, the acceptance or rejection of treatment suggestions are all potentially ripe for learning. If a learner suggests a therapy that is embraced by the team, or perhaps stimulates a group discussion during the course of the scenario the resultant conversation and ultimate decision can significantly add to the learning of the involved participants.

Continuing that same idea, perhaps the decision to provide, withhold, or check the dosage of a particularly therapy invokes a learner to check a reference, or otherwise look up a reference that provides valuable information that solidifies a piece of information in the mind of the leaner. The learner may announce such findings to the team while the scenario is still underway thereby sharing the knowledge with the rest of the treatment team. Waaah Laaaah…… more learning that may occur outside of the debriefing!

Finally, I believe there is an additional source of learning that occurs outside of the debriefing. Imagine when a learner experiences something or becomes aware of something during a scenario which causes them to realize they have a knowledge gap in that particular area. Maybe they forgot a critical drug indication, dosage or adverse interaction. Perhaps there was something that just stimulated their natural curiosity. It is possible that those potential learning items are not covered in the debriefing as they may not be core to the learning objectives. This may indeed stimulate the learner to engage in self-study to enhance their learning further to close that perceived area of a knowledge gap. What???? Why yes, more learning outside of the debriefing!

In fact, we hope that this type of stimulation occurs on the regular basis as a part of active learning that may have been prompted by the experiential aspects provided by simulation. Such individual stimulation of learning is identified in the sentinel publication of Dr. Barry Issenberg et al in Vol 27 of Medical Teacher in 2005 describing key features of effective simulation.

So hopefully I have convinced you, or reinforced your belief that the potential for learning from simulation based education spans far beyond the debriefing. Please recognize that this statement made by others likely reflects a serious misunderstanding and underappreciation for learning that can and should be considered with the use of simulation. The implication of such short-sightedness can have huge impacts on the efficiency and effectiveness of simulation that begin with curriculum and design.

So the next time you are incorporating simulation into your education endeavor, sit back and think of all of the potential during which learning may occur. Of course the debriefing in one such activity during which we hope learning to occur. Thinking beyond the debriefing and designing for the bigger picture of potential learning that can be experienced by the participants is likely going to help you achieve positive outcomes from your overall efforts.

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Simulation Curriculum Integration via a Competency Based Model

Process_Integration.shutterstock_304375844One of the things that is a challenge for healthcare education is the reliance on random opportunity for clinical events to present themselves for a given group of learners to encounter as part of a pathway of a structured learning curriculum. This uncertainty of exposure and eventual development of competency is part of what keep our educational systems time-based which is fraught with inefficiencies by its very nature.

Simulation curriculum design at present often embeds simulation in a rather immature development model in which there is an “everybody does all of the simulations” approach. If there is a collection of some core topics that are part and parcel to a given program, combined with a belief, or perhaps proof, that simulation is a preferred modality for the topic, then it makes sense for those exposures. Let’s move beyond the topics or situations that are best experienced by everyone.

If you use a model of physician residency training for example, curriculum planners “hope” that over the course of a year a given first year resident will adequately manage an appropriate variety of cases. The types of cases, often categorized by primary diagnosis, is embedded in some curriculum accreditation document under the label “Year 1.” For the purposes of this discussion lets change the terminology from Year 1 to Level 1 as we look toward the future.

What if we had a way to know that a resident managed the cases, and managed them well for level one? Perhaps one resident could accomplish the level one goals in six months, and do it well. Let’s call that resident, Dr. Fast. This could then lead to a more appropriate advancement of the resident though the training program as opposed to them advancing by the date on the calendar.

Now let’s think about it from another angle. Another resident who didn’t quite see all of the cases, or the variety of cases needed, but they are managing things well when they do it. Let’s call them Dr. Slow. A third resident of the program is managing an adequate number and variety, but is having quality issues. Let’s refer to them as Dr. Mess. An honest assessment of the current system is that all three residents will likely be advanced to hire levels of responsibilities based on the calendar without substantial attempt at remediation of understanding of the underlying deficiencies.

What are the program or educational goals for Drs. Fast, Slow and Mess? What are the differences? What are the similarities? What information does the program need to begin thinking in this competency based model? Is that information available now? Will it likely be in the future? Does it make sense that we will spend time and resources to put all three residents through the same simulation curriculum?

While there may be many operational, culture, historical models and work conditions that provide barriers to such a model, thinking about a switch to a competency based model forces one to think deeper about the details of the overall mission. The true forms of educational methods, assessment tools, exposure to cases and environments, should be explored for both efficiency and effective effectiveness. Ultimately the outcomes we are trying to achieve for a given learner progressing through a program would be unveiled. Confidence in the underlying data will be a fundamental necessary component of a competency based system. In this simple model, the two functional data points are quantity and quality of given opportunities to learn and demonstrate competence.

This sets up intriguing possibilities for the embedding of simulation into the core curriculum to function in a more dynamic way and contribute mightily to the program outcomes.

Now think of the needs of Dr. Slow and Dr. Mess. If we had insight combined with reliable data, we could customize the simulation pathway for the learner to maximally benefit their progression through the program. We may need to provide supplement simulations to Dr. Slow to allow practice with a wider spectrum of cases, or a specific diagnosis, category of patient, or situation for them to obtain exposure. Ideally this additional exposure that is providing deliberate practice opportunities could also include learning objectives to help them increase their efficiencies.

In the case of Dr. Mess, the customization of the simulation portion of the curriculum provide deliberate practice opportunities with targeted feedback directly relevant to their area(s) of deficiency, ie a remediation model. This exposure for Dr. Mess could be constructed to provide a certain category of patient, or perhaps situation, that they are reported to handle poorly. The benefit in the case of Dr. Mess is the simulated environment can often be used to tease out the details of the underlying deficiency in a way that learning in the actual patient care environment is unable to expose.

Lastly, in our model recall that Dr. Fast may not require any “supplemental” simulation thus freeing up sparse simulation and human resources necessary to conduct it. This is part of the gains in efficiencies that can be realized through a competency -based approach to incorporating simulation into a given curriculum.

Considering a switch to a competency based curriculum in healthcare education can be overwhelming simply based on the number of operational and administrative challenges. However, using a concept of a competency based implementation as a theoretical model can help envision a more thoughtful approach to curricular integration of simulation. If we move forward in a deliberate attempt to utilize simulation in a more dynamic way, it will lead to increases in efficiencies and effectiveness along with providing better stewardship of scarce resources.

 

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