Category Archives: simulation

August 24, 2023 · 3:11 pm

What is Simulation? The question that caught me off guard!

I was having an exit interview meeting with one of my graduating simulation fellows, and he asked me an interesting question for his last day. He said, “Dr. Paul, what is simulation?” I thought this was perplexing after a year-long intense study of simulation with us at our Institute! It was quite insightful, though. One of his observations was that there are many ways to do simulations right. He had many experiences throughout the year, visiting other simulation centers, attending international meetings, and teaching with us at different facilities. He realized many different vantage points, missions, visions, and purposes for implementing healthcare simulation.

I took a deep breath, thought about it, and said, “Simulation is a methodology by which we re-create a portion of the healthcare delivery experience with a goal of education and/or assessment of people, groups of people, teams, and/or environments of care.” Then, I drew a rough sketch of my vantage point of simulation that divided into two major subgroups, including methods/modes on one side and primary purpose on the other. I recreated it in the accompanying figure.

Methods/Modes

I think of the methods or modes of simulation based on the primary simulator technology employed to generate the goals of an intended program. Of course, mixed modality simulations often incorporate a spectrum of technologies.

I don’t mean this list to be exhaustive by any stretch of the imagination, and some may argue an oversimplification. The general categories that come to my mind are as follows:

  1. High-technology manikins generally presents the form factor of an entire human being complemented with electronics, pneumatics, and computer equipment that helps the manikin represent various aspects of anatomy and or physiology. (As you have undoubtedly heard me opine in the past, the word FIDELITY does not belong in any descriptor of a simulator. It muddles the water and confuses the overall strategies associated with simulation, although it is a popular industry buzzword that has somehow worked its way into academic definitions inappropriately.)
  2. Low-technology manikins generally have the form factor of an entire human being but with significantly less electronics or infrastructure to allow physiologic or anatomic changes that occurred during the simulation encounter.
  3. Standardized people/patients, meaning live people playing various roles ranging from patients, family members, and other healthcare team members to help bring a simulation encounter to life.
  4. Task trainers represent a re-creation of a portion of the human being oftentimes created to accomplish goals of completing skills or procedures. Depending on the purpose, they may or may not have a significant amount of augmenting technology.
  5. Screen-based simulations are computerized case or situation representations of some aspects of patient care that change in response to the stimulus provided by participants.
  6. Role-play includes designs that utilize peers and/or select faculty to engage in a simulated conversation or situation to accomplish learning outcomes.
  7. Virtual reality/augmented reality are high technology recreations or supplements that re-create reality through the lens of a first-person engaging in some sort of healthcare situation and have the capacity to change in response to the stimulus provided by the participant or participants.

Primary Purpose/Goals

Again, looking at a given simulation’s primary purpose and goals will lead one to quickly find overlaps and that the categories did not exist in complete isolation. However, for this discussion, it helps to think of the different categories of intent.

Education

When I think of simulation programs primarily focusing on education, it comes down to helping participants gain or refine knowledge, skills, competence, or other measures that allow them to become better healthcare providers. In general, a teaching exercise. This can apply to simulation scenarios that are directed at one person, groups of people (all learning the same thing), or perhaps teams that have learning goals of competencies associated with the interaction between the groups of people similar to that that occurs in the care of actual patients in the healthcare environment.

Assessment

The simulation encounter is primarily designed as an assessment. This means there is a more formal measurement associated with the performance of the simulation, often employing scoring tools, with the primary focus of measuring the competency of an individual, groups of individuals, or similar to the above teams of individuals functioning as teams. Further, assessment can measure aspects of the environment of care and/or the systems involved in supporting patients and the healthcare workforce.  (For example, an in-situ code blue response simulation may measure the response of the local care team, the response of a responding team, the engagement of the hospital operator, the location and arrival of necessary equipment, etc.)

Research

There are many approaches to the use of modern healthcare simulation in research. At a crude level, I subdivided into looking at the outcomes of the simulation; meaning did the simulation encounter help to improve the participant’s performance? At the next level, you can evaluate if the simulation improves patient care.

The next category is using simulation as a surrogate of the patient care environment but not measuring the effect of the simulation. For example, we might set up an ICU patient care environment for human factors experiments to figure out the ideal location of a piece of equipment, the tone of an alarm, the interaction of caregivers with various equipment, etc. Such an example of simulation often helps to determine optimal environments and systems of care in the primary planning stages or the remodeling of healthcare delivery processes and procedures.

So, the next time I orient an incoming simulation fellow, I will start with this discussion. I am thankful that my fellow who just graduated provided such a simple but deeply probing question to help wrap his arms around the various simulations he has been experiencing over the last year while he studied with us.

Having put some more thought into this, I think it’s a useful exercise for those of us in leadership positions within the simulation world; it is probably good to stop and think about this a couple of times a year to refresh, reset, and ensure that we are remaining mission-driven to our purpose.

Until next time, Happy Simulating!

Leave a comment

Filed under simulation

Tagged as , ,

August 8, 2023 · 11:07 am

HUMBLE: Six Traits That Will Make You a Better Simulation Educator and Lead Effective Debriefings

HUMBLE: Six Traits That Will Make You a Better Simulation Educator and Lead Better Debriefings

Excelling as a educator in the healthcare simulation field goes beyond just imparting knowledge; it requires a unique set of qualities that can truly make a difference in students’ learning experiences. The acronym HUMBLE focuses on six key traits that can help educators better design, facilitate, and lead more effective debriefings. These traits include Humility, Understanding, Mindfulness, Balance, Learning, and Engaging. In this blog post, I will delve into these traits and explore how they can enhance your abilities as an educator, ultimately leading to more impactful and engaging debriefing sessions.

H – Humility

This is one of my favorites and the most important in my humble opinion! Approaching teaching responsibilities in simulation from a perspective of humility goes a long way. Instructors, with humility, acknowledge that they don’t know everything and remain open to continuous learning. This attitude is also imparted to the participants, encouraging them to adopt the same approach throughout their careers.

An instructor who demonstrates humility creates a more approachable and non-threatening atmosphere, allowing students to feel comfortable admitting to and learning from their errors. This also contributes to a milieu that helps maintain a safe learning environment and a perspective of a level playing field that helps to allow participants of the simulation to share their thoughts. This, in turn, gives us as faculty a privileged glimpse into their thought processes. Interestingly, it is also well-known in business literature that leaders who demonstrate humility are often perceived as more credible and trustworthy.

U – Understanding

Understanding the fact that each participant of your simulation is a person that has their individual lives, challenges, successes, experiences, and strong and weak skills is key to understanding the fact that there are varying amounts of knowledge and/or abilities for the person to apply that knowledge in the simulated session. In other words, many factors contribute to why someone knows something or can apply knowledge in each situation. We should maintain an understanding that everyone has gaps in knowledge and attempt to remain nonjudgmental as to why those gaps exist.

M – Mindfulness

It is incredibly important that we are mindful of our presence during the simulation as well as the debriefing. Educators need to be attentive, focused, immersed, and committed to the learning objectives to expertly facilitate and then lead a high-quality debriefing that contributes to the learning outcomes. We need to work to identify tips and challenges that help maintain our mindfulness, focus, and attention during these activities.

While I am not suggesting a prescriptive approach, it is important to introspect and determine how you enhance your mindfulness associated with the simulation-based education process. For some, it means being well rested; for others, it means appropriately titrated doses of caffeine, and yet for others, exhaustive preparation the day before. Reflect on your performance by thinking about when your concentration may have waxed and waned and what you can do to improve. I find it particularly challenging to remain cognitively sharp throughout the entire series when running the same scenario repeatedly with different groups of learners!

B – Balance

Creating the mindset of balance in any one simulation session helps participants discover what they need to improve upon and what they did well in each simulation encounter. There is an old saying, “The negative screams, while the positive only whispers….. ” that I think you would agree applies when we are facilitating a simulation and about to go into the debriefing. If you think about it from the learner’s perspective, exploring a laundry list of their failures without recognizing the contributions that went well can be demoralizing and interfere with the faculty/participant relationship. While I’m not suggesting that we gloss over egregious errors, it is important to find a balance between those activities that went well and those that need improvement.

L – Limited, Lifelong Learning

This may be my second favorite! When conducting the debriefing, faculty should avoid trying to comment or debrief on every single thing in every scenario. It is important to remember that the journey of healthcare, whether in a simulated environment, attending lectures, attending workshops, or generating experiences by taking care of real patients, is a lifelong learning process. Each encounter along the way provides the potential for learning, albeit limited by the amount of cognitive transfer that can occur at a given time. During simulation, there is a natural tendency to want to cram everything into every scenario. I think this emanates from the fact that we are so excited about the simulation modality and get a small opportunity with each participant! Admittedly, I need to keep myself in check during such encounters. It’s important to think of the human brain as a sponge. Once it is saturated, the sponge cannot effectively take on more water.

E – Engagement

Engaging the learners in the conversation, as well as designing the scenarios to engage learners actively, is part and parcel of the basis of the idea that simulation, through active learning, is a high-quality opportunity. Think about this during the design process of your scenarios as well as the debriefings, insofar as how you assign roles, what your observers are required to do, and how you rotate people in and out of the scenario.

During the debriefing, remember that engaging your learners so that they are responding to the prompts you provide during the debriefing will elicit the responses. As the learners are engaged in the conversation, you can listen to their thought processes and make evaluations of the depth of their knowledge around a particular topic. Additionally, you can identify gaps that exist, either in knowledge or the application of knowledge, that can help them improve for the future. So often, when training others in debriefing, I observe faculty members dropping into a mode of “mini-lecture” during what is supposed to be a debriefing. This deviates from active cognitive engagement and sometimes transcends into (a well-intentioned) one-way conversation. It is important to remember that if your participants are not engaged, you are potentially squandering some of the learning opportunities. At a minimum, you are giving up the ability to hear what they are thinking.

In summary, as you continue to develop your skills as a healthcare simulation educator, I invite you to use HUMBLE as an acronym that helps to reflect upon positive traits, actions, and good guiding principles, that provide learners with an optimized environment for improvement.  I truly think that healthcare simulation educators have powerful opportunities for assisting with the transfer of knowledge, and experience and creating opportunities for reflection, and by being HUMBLE we can ensure a more effective and empathetic learning environment for all participants.

Until Next Time,

Happy Simulating!

Leave a comment

Filed under debriefing, simulation

Tagged as , ,

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!

Leave a comment

Filed under Curriculum, design, simulation

Tagged as , ,

May 26, 2023 · 1:17 pm

Simulation Professionals: Don’t let the Vocal Minority Get You Down!

The social psychologist Barbara Fredrickson coined the phrase, “The negative screams while the positive only whispers.” I don’t know about you, but this is extraordinarily true when reviewing course evaluations after simulation-based education programs!

Post-course evaluations are essential in measuring the program’s effectiveness and participant perceptions and are a tool to help with quality improvement initiatives. However, the feedback from vocal minorities can sometimes overshadow the opinions of the silent majority. After pouring blood, sweat, and tears into creating what you believe to be a successful simulation-based program, it can sometimes be a blow to your motivation when you receive negative evaluations.  At times the feedback can be pithy and personal and can sting.

Receiving negative feedback can be challenging for many reasons. First and foremost, it can feel like a personal attack on the hard work and effort you’ve put into a project or program. It’s natural to feel defensive or upset when someone criticizes something you’ve put so much time and energy into creating. Additionally, negative feedback can be difficult to process and use constructively. It’s easy to get caught up in the moment’s emotions and feel overwhelmed by the criticism. This can make it difficult to see the feedback as an opportunity for growth and improvement rather than a setback or failure.

This can be problematic as the feedback may not accurately represent the actual experiences of most participants, but it can certainly feel that way. It is also important to recognize the opportunities that come with critical feedback that could help you improve your program. It can help educators and course designers to identify areas for improvement and develop strategies for addressing these areas. Particularly when it is delivered constructively, and with a focus on improvement, negative feedback can be a powerful tool for enhancing the quality of simulation-based education programs and developing resilience in educators and learners alike. Critical feedback can help to identify areas for improvement, develop new strategies, and implement changes that can benefit future participants.

It is also important to remember that most participants with positive experiences may not feel the need to provide feedback. In contrast, those who have negative experiences may be more inclined to do so. So, I challenge you to go back and look at the designs of your course evaluation tools. It’s important to remember that the silent majority can be an important ally in the success of your program. By actively seeking out their feedback and insights, you can ensure that your program is meeting the needs of all participants, not just the most vocal. I’m not suggesting that we ignore the critical feedback; we just must find a way to balance it into a healthy model that contributes to resilience.

Developing a growth mindset is essential for developing resilience for those running simulation programs. It involves embracing challenges and staying motivated even when things get tough. Instead of seeing failures and setbacks as signs of inadequacy, individuals with a healthy mindset view them as opportunities for growth and learning. One powerful tool I use is remaining patient-centric in the decisions made regarding our simulations. Thinking about the downstream benefits that help raise the quality-of-care patients receive because of our efforts helps to keep my eye on the ball.

Lastly, remember that we can’t be all things to all people. While we remain excited and recognize the power of simulation-based education, not everyone will share our enthusiasm. As we move forward, remember that we can learn from the naysayers and the people unhappy that they are required to participate in some of our programs. Try to avoid the negative screaming in your ear, and you mistakenly believe that it represents the majority opinion. Stay focused on the idea that patients will benefit from our efforts, and many participants likely perceive value from our efforts.

Leave a comment

Filed under Curriculum, simulation

Tagged as , , ,

April 25, 2023 · 12:22 pm

When Simulation Is NOT the Answer: Own It!

Obviously, we are happy that simulation has become a popular method of education in healthcare. Simulation can provide a hands-on approach to learning that allows participants to experience real-life situations in a safe and controlled environment.

However, while simulation has many benefits, it’s not necessarily the best option for every type of education.  When we engage simulation as a modality, it is relatively complex, expensive and resource intensive compared to other educational methodologies. That all being said we all know at times it is an irreplaceable methodology that allows education, competency assessment, as well as system assessment information to be utilized in the improvement of healthcare.  The key is to have a stratification process/policy in place to evaluate opportunities to decide when simulation is the optimal deployment tool.

As leaders and managers of simulation programs we are charged with creating the return on investment for our programs. We are entrusted by the people who provide our funding to be good stewards of the investment and ongoing operational support of the simulation efforts.  It is up to us to hold the keys to the vault that we call simulation so that it gets engaged, deployed and/or utilized in the fashion that generates the expected outcomes with the highest amount of efficiency and effectiveness.

In short, don’t simulate because you can, simulate because you need to!

As your simulation center becomes a more recognized resource within your institution, there will often be an increase in request for services.  As this occurs it is critically important that leaders of programs are ensuring that the simulations are bringing value. 

For example, if someone wants you to do simulation training for an entire unit to rule out a new simple policy or procedure change, do not just say yes.  Instead, create a framework that advises the requester if simulation is the best modality.

When contemplating the value of simulation as a modality, I think it is best to go back to the creation of learning objectives for anticipated scenarios.  I always like to say that if you do knowledge, skills, and attitudes (KSA) analysis of your learning objectives and they all come up with K’s, you should reevaluate whether simulation is the best method.

Web-based education including courses, videos, lectures, or assigned reading may accomplish the same objectives as your planned simulation.  If this is the case, as a leader in simulation it is important that you recognize this and recommend modalities other than simulation.  It will likely save your organization time and money.  More importantly, it may increase the credibility of your advice and reputation moving forward as a problem solver for the institution as well as someone who is fiscally responsible.  Over time it can be valuable for a simulation program to enjoy a reputation of “the solution deployment” expert, not simply the “simulation” expert.

It is important to remember that the true value we provide is in the end-result of creating higher quality healthcare along with a safer environment for patients.  In this day and age, it has become increasingly important that our engagement is thoughtful, prudent with cost considerations in mind.  While we are all passionate about simulation, leaders of the future will garner success through a lens of efficiency and effectiveness in the programs that we deploy.

In conclusion, healthcare simulation is an important tool for education and patient safety, but it is not always the best tool. Simulation program managers and leaders should consider the specific learning outcomes they hope to achieve and carefully consider which educational modality is most appropriate for their learners. By doing so, they can ensure that they are providing the best possible, most cost-efficient training for their staff and ultimately improving patient outcomes.

Remember: Don’t simulate because you can, simulate because you need to!

Let me know what you think in the comments! If you enjoyed this post, please let me know by liking it, or subscribing to my Blog!

Until next time,

Happy Simulating!

Leave a comment

Filed under Curriculum, return on investment, simulation

Tagged as , ,

January 19, 2023 · 9:00 am

Not Every Simulation Scenario Needs to Have a Diagnostic Mystery!

It is quite common to mistakenly believe that there needs to be a diagnostic mystery associated with a simulation scenario. This could not be further from the truth.

Sometimes it arises from our clinical hat being confused with our educator hat (meaning we let our view of the actual clinical environment become the driving factor in the design of the scenario.) We must carefully consider the learning objectives and what we want to accomplish. One of the powerful things about simulation is that we get to pick where we start and where we stop, as well as the information given or withheld during the scenario.

Let us take an example of an Inferior Wall Myocardial Infarction (IWMI). Let us imagine that we desire to assess a resident physician’s ability to manage the case. Notice I said to manage the case, not diagnose, then manage the case. This has important distinctions on how we would choose to begin the scenario. If the objectives were to diagnose and manage, we might start the case with a person complaining of undifferentiated chest pain and have the participant work towards the diagnosis and then demonstrate the treatment. Elsewise, if we were looking to have them only demonstrate proficiency in the management of the case, we may hand them an EKG showing an IMWI (or maybe not even hand them the EKG) and start the case by saying, “your patient is having an IWMI” and direct them to start the care.  

What is the difference? Does it matter?

In the former example of starting the case, the participant has to work through the diagnostic conundrum of undifferentiated chest pain to come up with the diagnosis of IWMI. Further, it is possible that the participant does not arrive at the proper diagnosis, in which case you would not be able to observe and assess them in the management of the case. Thus, your learning objectives have become dependent on one another. By the way, there’s nothing wrong with this as long as it is intended. We tend to set up cases like this because that is the way that the sequencing would happen in the actual clinical environment (our clinical hat interfering). However, this takes up valuable minutes of simulation, which are expensive and should be planned judiciously. So, my underlying point is if you deliberately are creating the scenario to see the diagnostic reasoning and treatment, then the former approach would be appropriate.

The latter approach, however, should be able to accomplish the learning objective associated with demonstrating the management of the patient. Thus, if that is truly the intended learning objective, the case should be fast-forwarded to eliminate the diagnostic reasoning portion of the scenario. Not only will this save valuable simulation time it will also conceivably lead to more time to carefully evaluate the treatment steps associated with managing the patient. Additionally, it will eliminate the potential of prolonged simulation periods that do not contribute to accomplishing the learning objectives and/or get stuck because of a failure to achieve the initial objective (in this case, for example, the diagnosis.)

So, the next time you make decisions in the scenario’s design, take a breath and ask yourself, “Am I designing it this way because this is the way we always do it? Am I designing it this way because this is the way it appears in the real clinical environment?”

The important point is that one is asking themselves, “How can I stratify my design decisions so that the scenario is best crafted to accomplish the intended learning objectives?” If you do, you will be on the road to designing scenarios that are efficient and effective!

Leave a comment

Filed under scenario design, simulation

Tagged as , ,

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!

1 Comment

Filed under Curriculum, design, scenario design, simulation

Tagged as , ,

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.

Leave a comment

Filed under Curriculum, design, scenario design, simulation, Uncategorized

May 22, 2020 · 3:00 pm

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.

Leave a comment

Filed under Curriculum, debriefing, simulation, Uncategorized

Tagged as ,

May 7, 2020 · 1:16 pm

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

AdobeStock_119412077

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.

Leave a comment

Filed under Curriculum, scenario design, simulation, Uncategorized

Tagged as ,