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September 21, 2021 · 4:28 pm

Five Tips for Creating Hybrid Curricula for Simulation Based Learning

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

Why Hybrid?

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

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

Accompanying Video Discussion

Advantages

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

Disadvantages

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

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

Tip 1: Begin with the End in Mind

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

Tip 2: Create High Quality Learning Materials

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

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

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

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

Tip 4: Ensure Learner Expectations and Consequences are Clear

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

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

TIP 5: Link Your Online Materials Directly to Your Simulations

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

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

Conclusions

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

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

Until the next time, happy simulating!

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October 19, 2020 · 4:42 pm

Simulation Training and Programs in Healthcare are Essential

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

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

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

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

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

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

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

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

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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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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.

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May 7, 2020 · 1:16 pm

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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November 5, 2019 · 8:36 am

Simulation, Music, and Dancing

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

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

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

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

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

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

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

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

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

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

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

Compose, have people dance and help them get better!

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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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October 17, 2017 · 9:01 pm

True Systems Integration for Hospital Based Simulation Programs

Businessman is using tablet pc and selecting integrationHospital based simulation programs serve a different need than their counterparts housed in schools of medicine and nursing. The stakeholders, the mission, the program assessment and development of curriculum vary significantly. Not to over-generalize but the overall mission of the school focused simulation programs is based around having them integrated into the education processes that contribute to the development of successful students who will be called graduates. Many times, these students end up taking licensing, certifying or other high-stakes examinations that can serve as a convenient data set to assess the impacts of programs.

The mission of hospital, or health-system based programs can be more complex in terms of alignment within the organization. There is a myriad of possibilities within the healthcare delivery environment that can drive the objectives of simulation programs. Examples range from employee training and education; quality, safety or risk based; or perhaps focusing on facilities engineering perspectives. With all of these possibilities the potential strategies for measurement markers to evaluate the success of the program can become blurry, and at times harder to have ready access to the necessary information.

In an era of healthcare cost reductions that we are experiencing now in the United States and many other areas of the world there is significant pressure coming from many different sides to reduce costs and at the same time improve the quality of care. Thus, to prevail in this era of medicine any entity within healthcare delivery system that costs money to operate (like simulation programs) needs to ensure it is providing value to the hospital or system which supports it.

Determining such value can be very challenging. While there are a couple of examples in the literature of isolated value calculations (such as central line training) the utility of such reports is limited in isolation. In total they are only a minute part of the safety problems associated with the delivery of care in the hospital.

Determining the best value of a hospital based program can be achieved through a series of needs assessments that require the simulation leadership to establish relationships in the hospital leadership teams or C-Suites outside of folks involved in education. The true needs assessment comes from participating in a deep understanding of the existing problems, challenges, solutions and successes that the c-suite is incurring to execute the mission of the hospital. This information is often housed in offices of risk management, quality or patient safety.

Integration with the risk management team can better position the simulation program to understand the legal risks from errors and litigation that is currently facing the hospital. Identifying trends and subject matter that could benefit from simulation training can emerge.

Quality offices generally have significant amounts of information regarding the initiatives that the hospital should be, or is focusing on to better provide care to patients. Such initiatives are often based on measurement programs from payers (insurance companies, whether private of government such as Medicare) that result in significant financial risks and/or benefits for the organization. Thus, identifying simulation solutions that could benefit the initiative in some form or fashion can result in value creation for the program.

Patient Safety Offices (sometimes under, or aligned with quality offices) house much of the data on mistakes, small and large, and in some cases near misses, that are occurring in an institution. Such data will also have information on trends, as well as if there was harm transferred to the patient.

Access to this data over time can help to identify the true needs of organization, and help direct a value-based implementation of the simulation efforts. Importantly though, a careful analysis of this data can also help the simulation program recognize what is not likely to bring as much value to the organization.

Two things are important when considering such integration efforts. The first is, even though there is a new era of transparency emerging regarding patient safety, the information is sensitive. To achieve true integration the simulation program leadership needs to establish relationships across the organization. Ideally you desire not only access to the data, but also a presence that positions themselves closer to the core of the analysis and decision making. Many simulation programs remain peripheral to such processes and thus experience a contractor-vendor type of relationship instead of one more akin to an active partner. It takes time, trust and effort to develop such relationships.

Secondly, a dispassionate evaluation of the data that is achieved from the needs analysis is necessary with regard to properly interpreting the value provided by the simulation program. Many simulation programs are born of a passion to simulate, a passion of the first faculty members, and an attachment to legacy programs that have been running for years. For true alignment within an complex organization and surviving future value analysis initiatives (ie. Remaining supported and funded) a program needs to take a hard look at its existing programs and ensure they are pegged to the overall “true” needs of the institution at large.

While this post is not representative of all the possible strategies to integrate a simulation program, it is meant to give insight into a few examples of possibilities, and articulate the depth of the relationships that should be developed.

 

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August 1, 2017 · 8:02 pm

Operational Realities and Simulation Program Design for Practicing Professionals

Doctor Instructing Nurses In Hospital RoomAs educators involved in the design of simulation based activities we like to have a clear understanding of what we are trying to accomplish in a given educational encounter. We often talk about beginning with a needs analysis to determine what will bring most impact. We ideally design learning objectives that are well matched to our intended participants. We execute scenarios and debrief them expertly covering all the relevant topics. While this is an idealized workflow for the development of a simulation encounter, it doesn’t always translate to reality when we attempt to execute a program. Our success may be in the ability to creatively adapt our educational program to the realities of the environment and situations that it will be conducted.

One reason that such a discordance can occur is that we fail to consider operational realities into the design of our educational gems. The adage of trying to stuff 8-pounds of learning into a 5-pound bag is well known. It also seems to be a constant struggle in the design of simulation programs where there is often an urgency to “teach them everything they need to know.” However, such attempts can put students, faculty members, and programs at disadvantages. This can come from many different perspectives ranging from failing to accomplish the intended learning goals, erosion of confidence in the program, the faculty, as well as hampering the ability of the program to make change as designed and/or desired.

Considering operational realities of simulation program design are critically important when creating programs that are aimed at the training of practicing professionals. In particular, when designing those programs that may interrupt or be embedded into the normal workflow of the caring of actual patients.

Let’s consider the design of a program that provides a mock-resuscitation scenario conducted impromptu in an ICU that the unit nurses, physicians and respiratory therapists (RT) will participate.

During our needs assessment and our expert opinions of the design of an educational encounter we may imagine many things that need to be covered during the debriefing for a specific topic. Such topics may include the demonstration of knowledge of the therapeutics that the patient needs from the nurse, the physician, the RT, the assessment of the patient, further testing needed, communication, teamwork and so on.

First off, is the obvious. Operational parameters should be built-in to provide criteria for a go/no-go decision for the scenario. While in this day and age all healthcare units are busy, it is not advisable ethically, or operationally from a patient safety perspective, to divert healthcare resources to a training activity if the target unit is already overwhelmed. Such decisions are ideally achieved in advance during the program design phase through a collaborative discussion involving the simulation and the clinical unit manager. They are best defined in advance depending on the overall educational and improvement goals.

The obvious next consideration is the time that is available. This includes time for the scenario as well as the debriefing. Carefully considering the needs of the learners as well as the dynamics of the operational realities is particularly important. Additionally, factoring in how the scenario is embedded into the overall curriculum is critical.

For example, is this a scenario that is once and done? Meaning that the participants will not likely encounter any further simulations until next year. Or is this a recurring educational effort in this ICU where we will have repeated engagement with the care providers over time. This could have significant bearing on the length of time you spend in various topics during the debriefing.

Continuing with our above example of the ICU resuscitation scenario it is common to have much less time than anticipated to conduct the debriefing. Design considerations should include a prioritization of learning topics that adapt to the operational reality. For example, imagine there is a fifteen-minute period of time that occurs after the scenario for debriefing and then everyone scampers off back to work. Let’s pretend there are learning objectives SPECIFIC to nursing care, physician care and care provided by respiratory therapy. Then there are learning objectives around communication and team work that cut across the disciplines. We would want to design the debriefing discussion to focus on those topics that are multidisciplinary and would maximally benefit from a group discussion.

Thus, in this case, it would likely do a disservice to the domain specific objectives or learning points by trying to artificially shorten each one AND then also try to cover communications and teamwork. (In other words, none of the objectives get covered very well.) We may be better off focusing on the communication and teamwork while the nurses, physicians and therapists are all still in attendance as that would likely give the biggest bang for the buck for that operational circumstance.

Having achieved successful accomplishment of the communications and teamwork objectives we now need to turn our creative curricular designing efforts to the domain specific learning objective. This is why it is critical for simulation educators to think more-broadly and realize that they are healthcare educators that use simulation as part of a learning method.

As part of our overall design of the goals for the entire learning activity, perhaps we could email the nursing specific protocols or highlights of the intended learning to the nurses after the event. Or perhaps direct them toward a brief on-line learning encounter specific to the goals of the scenario. We could do the same for the physicians and the RT’s. The content in this case would be tailored specifically toward the care providers and will likely seem more relevant to the recipient.

I am of the opinion that once the care team experiences the simulation they will be more receptive to and engaged in the downstream feedback that they may receive after the encounter (meaning simulation and debriefing) is completed.

I believe this is true particularly if the information is specific to the practice domain, succinct, relevant, and tied directly to the simulation activity. Their participation in the simulation likely helps them to realize areas needed for self-improvement as well as an overall heightened engagement in the learning process. Contrast this thought to the education motivation, or lack thereof, that is realized through a list of mandatory on-line training programs that one gets assigned annual as part of a regulatory requirement. (Can you say annual torture?)

So, as you move forward be sure to consider operational realities and try to remain nimble on creative ways to accomplish the learning. It may be different then your initial vision of the activity. Simulation education creators should engage collaboratively with operational leaders particularly if the encounters are embedded into the mix of healthcare operations.

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April 26, 2017 · 2:51 am

Simulation Technicians – Part of the Critical Recipe of Success

SimTech.aJust about every successful simulation in the world has one thing in common. No its not a high fidelity design, great curricular integration or a fabulous debriefing. What is it then?????  Answer: There was a Simulation Technician involved. Sim Techs are crucial to the success of programs and are integral to any team using significant simulation. Sim Techs come in many varieties in terms of backgrounds, titles, and in some smaller programs, many share one of many responsibilities.

I do have a bias that I will disclose. I started my career as an Electronics Technician in the US NAVY. After nearly two years of Navy training I cut my teeth aboard an Aircraft Carrier, the USS John F Kennedy (CV-67). Now that was truly an immersive learning experience! USS.JFKAfter I screwed something up one day when we were off the coast of Libya in 1986, the Electronics Materials Officer called me in the office and said “Son, do I have to remind you where this boat is pointed?” me: “No Sir!”  him: “Now stop being a technician and join this team as a thinker.”

It is important to engage the Sim Tech in every aspect of the simulation. Too often they are thought of as “just a tech”, but this is a HUGE mistake. Engaged professional Sim Techs are capable of many things that can add value to your program beyond setting up, driving mannequins and cleaning up.

Sim Techs are capable of learning how to evaluate and SOldering.asort high quality simulation from that needing improvement, or good debriefing to less than good. Dare I say…. They can also be trained to conduct or participate in debriefings in very creative ways. Sim Techs interacting with your participants can help to alleviate anxiety and get ahead of problems before they occur. They can play a significant role in your quality improvement programs. After all, you have to imagine. They see a lot of simulation!

Sim Techs are highly capable at helping to orient faculty and help to get faculty functioning at a higher level. This may include how to operate A/V equipment, drive simulator, or reset a simulation room to be ready for the next group.

Engaged Sim Techs take pride in their work, become embedded into the effort and share in the pain when something doesn’t go as planned. This level of ownership will often help to transition a program into high reliability operation that has everyone beaming with pride.

The Sim Tech community as a whole harbors a huge supply of energy and creativity and love to participate in being a part of solutions. Whether its moulage, creating a special SimTech2.aenvironment, app, smell, video, visual cue, you can call upon the technical community to solve it.

It is encouraging to see a more professional approach to the workforce development of the simulation community. Achieving certification as a Certified Healthcare Simulation Operations Specialist (CHSOS) through the Society for Simulation in Healthcare (SSH), can be a great source of professional pride for the technician in addition to ensuring competence in several important areas that well trained technicians should have as a minimum.

I would highly recommend encouraging your technicians to take part in training, attending meetings with other techs and engaging in the available networking can pay off in great dividends.  Being current with their knowledge and being able to interact closely with vendors to not only know what is coming out down the pike, but sometimes being able to influence future products are other reasons to make a place in your budget for technician training. In addition to meetings such as the International Meeting for Simulation in Healthcare (IMSH), several high-quality specialty meetings have been created that dedicate a sole focus on technical training from the SSH as well as specialty organizations such as SimGHOSTS. High quality training programs are being offered by simulation centers both in person and on-line such as ours at WISER.

No Simulation Technician is “just a tech” unless the program leadership makes them that. Embrace your technicians. Nurture their professional development and status in and among the team. Push the envelope of their capabilities and creativity to expand into new roles and ownership of your simulation efforts. You will not only be thankful, but wonder why it took so long to realize this is a vital ingredient to the sauce of success of highly capable simulation programs!

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