Category Archives: design

July 27, 2023 · 11:52 am

The Importance of the Psychological Contract in Healthcare Simulation: Six Fundamental Elements

Simulation is a powerful tool in healthcare education to enhance learning and improve patient outcomes. Through simulation-based learning encounters, participants can engage in hands-on experiences that mimic real-life situations, allowing them to develop critical skills and knowledge.

The success of healthcare simulation educational encounters relies on the participants and the facilitators who guide and support the learning process. Understanding the psychological contract that needs to exist between participants, facilitators, and content designers, is crucial in creating a positive and effective learning environment. In this blog post, we will explore the importance of this psychological contract and discuss strategies to enhance it, ultimately leading to enhanced learning and improved outcomes in healthcare simulation.

While most discussions of the psychological contract are in the context of facilitating a simulation in real time, some elements are critically important to consider during the design process associated with simulation-based education encounters. How we structure our briefings, pre-briefings, and course schedules can dramatically influence our relationship with the participants to enhance the learning potential in the simulated environment.  

I like to think of six essential elements when designing and facilitating simulations.

Professionalism: We agree to treat each other as professionals throughout simulation-based education encounters. The learner agrees to attempt to interact in the scenario as if they were taking care of an actual patient, and the simulation facilitator agrees that the scenario will be directed to respond with a reasonable facsimile of how an actual patient will respond to the care being delivered.

Confidentiality: The simulation program agrees to keep the performance assessment of participants confidential to the extent possible. The simulation participant should be apprised of the fate of any audio, video, or still photographic media generated from the simulation. If, by programmatic design, there is the intent to share any performance results, the participant should be aware of this before engagement in the program.

Time: The simulation facilitator commits to creating an environment of learning that respects the participant’s time. The simulation program commits to the intent that the simulation encounter and all associated time spent will help provide the participant with relevant, professional education and growth potential.

Realism/Deception: Both the participant and the facilitator acknowledge that the environment is not real and will contain varying degrees of realism. The simulation environment’s primary intent is to provide a reasonable facsimile of a healthcare encounter to serve as the background for the participant to demonstrate their clinical practice proficiency to the best of their knowledge in exchange for feedback that highlights areas of success and identifies areas of potential improvement. Our simulation-based scenario designs are modeled after actual patient encounters or close representations of cases that may occur within your practice domain. While the case may represent areas of diagnostic mystery or other unknowns, the scenarios are not designed to deceive or mislead the learner deliberately. The facilitator acknowledges there may be facsimiles of the simulation that may be misinterpreted by the learner as a matter of simulation scenario design limitations and will address them as appropriate, as they occur.

Judgment: While there will be an assessment of the learner’s performance to carry out effective feedback, it will be based upon known best practices, guidelines, algorithms, protocols, and professional judgment. No judgment will be associated with why a gap in knowledge or performance was identified. The facilitators agree to maintain a safe learning environment that invites questions, explorations, and clarifications as needed to enhance learning potential.

Humbleness: Healthcare is a complicated profession regardless of the practice domain. It requires the engagement of lifelong learners to learn and retain a significant amount of knowledge and skill. Additionally, there is a constant refinement of knowledge, best practices, and procedures. The facilitator acknowledges that they are imperfect and engage in the same lifelong learning journey as the participant.

While the descriptions associated with each element of the psychological contract in this post are more aligned with the engagement with senior learners or practicing professionals, it is easy to translate each category when working with students and other types of junior learners.

Educators and learners can establish a foundation of trust, collaboration, and active participation by understanding and embracing the tenants of psychological contracts in healthcare simulation. Careful consideration of these elements is beneficial during program design and when actively facilitating simulation-based learning encounters. This, in turn, enhances the learning outcomes, improves clinical practice, and prepares healthcare professionals to deliver high-quality care as they engage in real-world patient encounters and associated situations.

The next time you are designing or conducting simulation based education endeavors give careful consideration to the psychological contract!

Until next time, Happy Simulating!

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August 30, 2022 · 10:40 am

Sherlock Holmes and the Students of Simulation

I want to make a comparison between Sherlock Holmes and the students of our simulations! It has important implications for our scenario design process. When you think about it, there’s hypervigilance amongst our students, looking for clues during the simulation. They are doing so to figure out what we want them to do. Analyzing such clues is like the venerable detective Sherlock Holmes’s processes when investigating a crime.

Video version of this post

This has important implications for our scenario design work because many times, we get confused with the idea that our job is to create reality when in fact, it is not that at all our job. As simulation experts, our jobs are to create an environment with the reality that is sufficient to allow a student to progress through various aspects of the provision of health care. We need to be able to make a judgment and say, “hey, they need some work in this area,” and “hey, they’re doing good in this area.”

To accomplish this, we create facsimiles of what they will experience in the actual clinical environment transported into the simulated environment to help them adjust their mindset so they can progress down the pathway of taking care of those (simulated) patient encounters.

We must be mindful that during the simulated environment, people engage their best Sherlock Holmes, and as the famous song goes, [they are] “looking for clues at the scene of the crime.”
Let’s explore this more practically.

Suppose I am working in the emergency department, and I walk into the room and see a knife sitting on the tray table next to a patient. In that case, I immediately think, “wow, somebody didn’t clean this room up after the last patient, and there’s a knife on the tray. I would probably apologize about it to the patient and their family.”

Fast forward…..

Put me into a simulation as a participant, and I walk into the room. I see the knife on the tray next to the patient’s bed, and I immediately think, “Ah, I’m probably going to do a crich or some invasive procedure on this patient.”

How does that translate to our scenario design work? We must be mindful that the students of our simulations are always hypervigilant and always looking for these clues. Sometimes when we have things included in the simulation, we might just have there as window dressing or to try to (re)create some reality. However, stop to think they can be misinterpreted as necessary to be incorporated into the simulation by the student for success in their analysis.

Suddenly, the student sees this thing sitting on the table, so they think it is essential for them to use it in the simulation, and now they are using it, and the simulation is going off the tracks! As the instructor, you’re saying that what happened is not what was supposed to happen!

At times we must be able to objectively go back and look at the scenario design process and recognize maybe just maybe something we did in the design of the scenario, which includes the setup of the environment, that misled the participant(s). If we see multiple students making the same mistakes, we must go back and analyze our scenario design. I like to call it noise when we put extra things into the simulation scenario design. It’s noise, and the potential for that noise to blow up and drive the simulation off the tracks goes up exponentially with every component we include in the space. Be mindful of this and be aware of the hypervigilance associated with students undergoing simulation.

We can negate some of these things by a good orientation, by incorporating the good practice into our simulation scenario design so that we’re only including items in the room that are germane to accomplishing the learning objectives.

Tip: If you see the same mistakes happening again and again, please introspect, go back, look at the design of your simulation scenario, and recognize there could be a flaw! Who finds such flaws in the story?  Sherlock Holmes, that’s who!

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June 6, 2022 · 12:05 pm

5 Tips to Improve Interrater Reliability During Healthcare Simulation Assessments

One of the most important concepts in simulation-based assessment is achieving reliability, and specifically interrater reliability. While I have discussed previously in this blog every simulation is assessment, in this article I am speaking of the type of simulation assessment that requires one or more raters to record data associated with the performance or more specifically an assessment tool.

Interpreter reliability simply put is that if we have multiple raters watching a simulation and using a scoring rubric or tool, that they will produce similar scores. Achieving intermittent reliability is important for several reasons including that we are usually using more than one rater to evaluate simulations over time. Other times we are engaged in research and other high stakes reasons to complete assessment tools and want to be certain that we are reaching correct conclusions.

Improving assessment capabilities for stimulation requires a significant amount of effort. The amount of time and effort that can go into the assessment process should be directly proportional to the stakes of the assessment.

In this article I offer five tips to consider for improving into rate of reliability when conducting simulation-based assessment

1 – Train Your Raters

The most basic and overlooked aspect of achieving into rate and reliability comes from training of the raters. The raters need to be trained to the process, the assessment tools, and each item of the assessment that they are rendering an opinion on. It is tempting to think of subject matter experts as knowledgeable enough to fill out simple assessments however you will find out with detailed testing that often the scoring of the item is truly in the eye of the beholder. Simple items like “asked medical history” may be difficult to achieve reliability if not defined prior to the assessment activity. Other things may affect the assessment that require rater calibration/training such as limitations of the simulation, and how something is being simulated and/or overall familiarity with the technology that may be used to collect the data.

2 – Modify Your Assessment Tool

Modifications to the assessment tool can enhance interrelated reliability. Sometimes it can be extreme as having to remove an assessment item because you figure out that you are unable to achieve reliability despite iterative attempts at improvement. Other less drastic changes can come in the form of clarifying the text directives that are associated with the item. Sometimes removing qualitative wording such as “appropriately” or “correctly” can help to improve reliability. Adding descriptors of expected behavior or behaviorally anchored statements to items can help to improve reliability. However, these modifications and qualifying statements should also be addressed in the training of the raters as described above.

3 – Make Things Assessable (Scenario Design)

An often-overlooked factor that can help to improve indurated reliability is make modifications to the simulation scenario to allow things to be more “assessable”. We make a sizable number of decisions when creating simulation-based scenarios for education purposes. There are other decisions and functions that can be designed into the scenario to allow assessments to be more accurate and reliable. For example, if we want to know if someone correctly interpreted wheezing in the lung sounds of the simulator, we introduced design elements in the scenario that could help us to gather this information accurately and thus increase into rater reliability. For example, we could embed a person in the scenario to play the role of another healthcare provider that simply asks the participant what they heard. Alternatively, we could have the participant fill out a questionnaire at the end of the scenario, or even complete an assessment form regarding the simulation encounter. Lastly, we could embed the assessment tool into the debriefing process and simply ask the participant during the debriefing what they heard when I auscultated the lungs. There is no correct way to do this, I am trying to articulate different solutions to the same problem that could represent solutions based on the context of your scenario design.

4 – Assessment Tool Technology

Gathering assessment data electronically can help significantly. When compared to a paper and pencil collection scheme technology enhanced or “smart” scoring systems can assist. For example, if there are many items on a paper scoring tool the page can sometimes become unwieldy to monitor. Electronic systems can continuously update and filter out data that does not need to be displayed at a given point in time during the unfolding of the simulation assessment. Simply having previously evaluated items disappear off the screen can reduce the clutter associated with scoring tools.

5 – Consider Video Scoring

For high stakes assessment and research purposes it is often wise to consider video scoring. High stakes meaning pass/fail criteria associated with advancement in a program, heavy weighting of a grade, licensure, or practice decisions. The ability to add multiple camera angles as well as the functionality to rewind and play back things that occurred during the simulation are valuable in improving the scoring accuracy of the collected data which will subsequently improve the interrater reliability. Video scoring associated with assessments requires considerable time and effort and thus reserved for the times when it is necessary.

I hope that you found these tips useful. Assessment during simulations can be an important part of improving the quality and safety of patient care!

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Thanks and until next time! Happy Simulating.

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July 7, 2020 · 2:57 pm

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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July 23, 2019 · 2:20 pm

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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August 15, 2018 · 12:00 pm

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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July 23, 2018 · 11:08 am

The First Four Steps of Healthcare Simulation Scenario Design

How can you make your scenario design process more consistent and efficient? One way is by following a step-by-step method to create your masterpieces!

In this post I cover the first four steps of a proven scenario design process.
There are four core steps that must be done in order. After the first four are accomplished you can branch out and be a little bit more variable in your approach to scenario design.

4 Success Steps, business concept

Step One: Pick A Topic

Picking a topic may seem like common sense but there is a lot to think about.

In healthcare simulation we have many topics to choose from. But in step one we want to a little bit specific and figure out that the major topic is that will be covered. We may be cover the teaching of physiologic, diagnostic or treatment where people are going to be making critical decisions, ordering medications, and other therapy, or perhaps our primary focus going to be on team training, teamwork, communications, team leadership. You get to pick!

Step Two: Define the Learner(s)

This is really important because in order to go to the next step which is designing the learning objectives we have to understand our learner population. For example, what do you expect of a fourth-year medical student what you expected them in terms of being able to evaluate and treat a simulated patient that is complaining of chest pain? Now contrast that to if your learners are medical students that are in the second year of medical school and haven’t had any clinical experience. In other words, we can take the same topic but as applied to two different populations, our expectations and what we are going to be evaluating from them is very different.

Step Three: Designing  the Learning Objectives

This is where you want to go into detail, great painstaking detail, about what you’re trying to accomplish with the simulation scenario. It is very important to take time on this step. Many people tend to gloss over this step which can create confusion later.

Let’s take a topic example. Let’s say asthma in the emergency department. When you think about asthma in the emergency department there could be many sub topics or areas from which to choose. It could be focused on competence of managing a minor asthma attack, or it could be a first-ever asthma attack, or it could be management of chronic asthma, or it could be major could be a life-threatening situation.

Carefully consider what do we want this learner group that we have defined in step two. Do you want them to diagnose? To treat? To critical compare and contrast it to other cases of shortness of breath in an acute patient? You get to choose!

Perhaps we want to focus on the step-by-step history presentation or the physical exam or maybe we want to see the learners perform treatment. Or maybe we want to see the overall management or the critical thinking that goes on for managing asthma in the emergency department. There are many possibilities, largely driven by your intended learner group demographics.

So, in other words were taking the big topic of asthma and we are going to cone it down to answer the question of what exactly we want our learners to accomplish by the end of the scenario. We can’t just assume that what is supposed to happen in the real clinical environment will or should happen in the simulation environment. That rarely works. We actually want to later engineer the story and situation to allow us to be able to focus on the learning objectives.

Step Four: Define the Assessment Plan

How are you going to assess that each objective defined in step three was accomplished? That is the fundamental thought process for step four.

What are you going to be watching for when you the creator of this simulation scenario are watching the participants do their thing? What are you going to be focusing your attention on that you’re going to bring into the debriefing? What are you picking up on that you might be filling out assessment tools?

Define your assessment plan with specificity of what you’re looking for. This is different than designing the assessment tools that could come later. Or perhaps not at all. It is important that you remember every simulation is an assessment of sorts. See Previous Blog Post on this!

This doesn’t mean that every simulation needs assessment tool like a checklist, rating scale or formal grading scheme. It simply is referring to consideration of how to focus the facilitating faculty member, or teacher, or whatever you call them, who are observing the simulation. Remember, that to help the learner(s) of the simulation get better, the faculty need to be focused on certain things to ensure that the goals of the scenario are accomplished for our selected learner group, associated with the topic we chose in step one.

Lastly, what I want to point out to you is that you should notice something missing. The story!

The story comes later. Everybody wants to focus on the story because the story is fun. It’s often related to what we do clinically. It’s replicating things that are fun that brings in the theatrics of simulation! But what we really want to do is bring the theatrics of simulation to cause the actors on the stage (the participants) to so some activity. This activity gives us the situation to focus our observations on the assessment of the performance. This in turn allows us to accomplish the learning objectives of the scenario and help the participants improve for the future!

Until next time, Happy Simulating!

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May 8, 2018 · 4:25 pm

Don’t be Confused! Every Simulation is an Assessment

 

Recently as I lecture and conduct workshops I have been asking people who run simulations how often they do assessments with their simulations. The answers are astounding. Every time there are a few too many people reporting that they are performing assessments less than 100% of the time that they run their simulations. Then they are shocked when I tell them that they do assessments EVERY TIME they run their simulations.

While some of this may be a bit of a play on words there should be careful consideration given to the fact that each time we run a simulation scenario we must be assessing the student(s) that are the learners. If we are going to deliver feedback, whether intrinsic to the design of the simulation, or promote discovery during a debriefing process, somewhere at some point we had to decide what we thought they did well and identify areas for needed improvement. To be able to do this you had to perform an assessment.

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Now let’s dissect a bit. Many people tend to equate the word assessment with some sort of grade assignment. Classically we think of a test that may have some threshold of passing or failing or contribute in some way to figure out if someone has mastered certain learnings. Often this may be part of the steps one needs to move on, graduate, or perhaps obtain a license to practice. The technical term for this type of assessment is summative. People in healthcare are all too familiar with such types of assessment!

Other times however, assessments can be made periodically with a goal of NOT whether someone has mastered something, but with more of a focus of figuring out what one needs to do to get better at what they are trying to learn. The technical term for this is formative assessment. Stated another way, formative assessment is used to promote more learning while summative assesses whether something was learned.

When things can get even more confusing is when assessment activities can have components or traits of both types of assessment activities. None the less, what is less important then the technical details is the self-realization and acceptance of simulation faculty members that every time you observe a simulation and then lead a debriefing you are conducting an assessment.

Such realization should allow you to understand that there is really no such thing as non-judgmental debriefing or non-judgement observations of a simulation-based learning encounter. All goal directed debriefing MUST be predicated upon someone’s judgement of the performance of the participant(s) of the simulation. Elsewise you cannot provide and optimally promote discovery of the needed understanding of areas that require improvement, and/or understanding of the topic, skills, or decisions that were carried out correctly during the simulation.

So, if you are going to take the time and effort to conduct simulations, please be sure and understand that assessment, and rendering judgement of performance, is an integral part of the learning process. Once this concept is fully embraced by the simulation educator greater clarity can be gained in ways to optimize assessment vantage points in the design of simulations. Deciding the assessment goals with some specificity early in the process of simulation scenario design can lead to better decisions associated design elements of the scenario. The optimizing of scenario design to enhance “assess-ability” will help you whether you are applying your assessments in a formative or summative way!

So, go forth and create, facilitate and debrief simulation-based learning encounters with a keen fresh new understanding that every simulation is an assessment!

Until Next Time Happy Simulating!

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January 29, 2018 · 6:18 pm

Don’t Let the Theory Wonks Slow Down the Progress of Healthcare Simulation

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Those of us in the simulation community know well that when used appropriately and effectively simulation allows for amazing learning and contributes to students and providers of healthcare improving the craft. We also know there is very little published literature that conclusively demonstrates the “right way to do it”.

Yet in the scholarly literature there is still a struggle to define best practices and ways to move forward. I believe it is becoming a rate limiting step in helping people get started, grow and flourish in the development of simulation efforts.

I believe that part of the struggle is a diversity of the mission of various simulation programs ranging from entry level students to practicing professionals, varying foci on individualized learning incompetence, versus and/or team working communications training etc. Part of the challenges in these types of scholarly endeavors people try to describe a “one-size-fits-all“ approach to the solution of best practices. To me, this seems ridiculous when you consider the depths and breadth of possibilities for simulation in healthcare.

I believe another barrier (and FINALLY, the real point of this blog post 🙂  is trying to overly theorize everything that goes on with simulation and shooting down scholarly efforts to publish and disseminate successes in simulation based on some missing link to some often-esoteric deep theory in learning. While I believe that attachments to learning theory are important, I think it is ridiculous to think that every decision, best practice and policy in simulation, or experimental design, needs to reach back and betide to some learning theory to be effective.

As I have the good fortune to review a significant number simulation papers it is concerning to me to see many of my fellow reviewers shredding people’s efforts based on ties to learning theories, as well as their own interpretations on how simulation should be conducted. They have decided by reading the literature that is out there (of which there is very little, if any, conclusive arguments on best practices) has become a standard.

My most recent example is that of a paper I reviewed of a manuscript describing an experimental design looking at conducting simulation one way with a certain technology and comparing it to conducting the simulation another way without the technology. The authors then went on to report the resulting differences. As long as the testing circumstances are clearly articulated, along with the intentions and limitations, this is the type of literature the needs to appear for the simulation community to evaluate and digest, and build upon.

Time after time after time more recently I am seeing arguments steeped in theory attachments that seem to indicate this type of experimental testing is irrelevant, or worse yet inappropriate. There is a time and place for theoretical underpinnings and separately there is a time and place for attempting to move things forward with good solid implementation studies.

The theory wonks are holding up the valuable dissemination of information that could assist simulation efforts moving forward. Such information is crucial to assist us collectively to advance the community of practice of healthcare simulation forward to help improve healthcare globally.  There is a time to theorize and a time to get work done.

While I invite the theorist to postulate new and better ways to do things based on their philosophies, let those in the operational world, tell their stories of successes and opportunities as they are discovered.

Or perhaps it is time that we develop a forum or publication of high quality, that provides a better vehicle for dissemination of such information.

So…… in the mean time….. beware of the theory wonks. Try not to let them deter from your efforts to not only move your own simulation investigations forward, but to be able to disseminate and share them with the rest of the world!

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January 9, 2018 · 2:48 am

FIVE TIPS on effectively engaging adult learners in healthcare simulation

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