SIMULATION AND THE ELECTRONIC HEALTH RECORD: MIND YOUR OBJECTIVES

There is a lot of disEHRandSim'cussion recently about incorporating electronic health record (EHR) into simulations. Which vendor? Which product? What features are needed? The disturbing thing about most of these discussions in my mind is that no one is talking about what they are trying to accomplish with the inclusion of electronic health records into the simulation environment.

What is the purpose of the EHR in it in a simulation? Is it simply to provide realism? If so, is the EHR that is implemented likely to be the one in the practice environment experienced by the student? Because if not, it is missing the mark likely adding confusion as well as increasing the orientation time necessary for a given simulation. Is the EHR supposed to provide crucial information that will help make healthcare decision during the simulation encounter? Is the entire simulation designed around an efficient query for specific information of a patient’s history? Are entries in the EHR made by the participants of simulation going to be analyzed for knowledge or critical thinking regarding a case? There are so many possibilities! I would argue however that integrating the EHR into the simulation simply for reality will likely be a colossal waste of time.

Much like any other component included in simulation the EHR should be included thoughtfully and carefully driven by needs analysis based on the learning objectives of the educational encounter. EHR technology can be overwhelming by itself to understand and navigate, combined with the fact that there are many different types of systems for different practice environments make it unwieldy to become expert in all brands, systems or examples.

Similarly, it if you have successful implementation of the EHR into your simulations I would recommend that you carefully decide for each and every simulating counter whether you need to include it or not. Again, this decision should rest upon the learning objectives and the intended educational outcomes of the event. Interacting with the EHR can be a time-consuming, frustrating part of the delivery of healthcare and it is up to the creator of the educational encounter to determine the usefulness and necessity of such integration.

The thoughtful use of EHR into select simulated encounters can significantly lead to increased observations of critical thought process, attention to detail, as well as overall understanding of the depth and breadth of understanding of a given case. Additionally it could serve as another avenue for assessment. If the integration of the EHR is predicated around these efforts and clearly the addition of the EHR component is both worthwhile and necessary. Additionally, simulations involving workflow and human factors can possibly benefit from such integration knowing that in today’s delivery of healthcare the interaction with the EHR is a daily reality.

I must close however with reminding the simulation community it is not our job to re-create reality, it is our job to create an innovative educational encounter from which we can form opinions to engage in discussions to help healthcare providers on their quest towards excellence.

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Unpacking of Expertise Contributes to Effective Simulation (Education) Design

shutterstock_188725688aPart of the challenge in creating any simulation-based learning encounter is the interactions that occurs with subject matter experts to serve as a source that helps to guide the design of the event. The challenge lies within the fact that as healthcare providers ascend to a position of expertise many of their thoughts and approaches to the clinical situation at hand undergo automaticity in terms of the way decisions are made or procedures are executed. No longer does an experienced surgeon think step-by-step on how to create a knot. They rely on muscle memory, experience and packaged expertise to complete the task. DeconstructionOfExpertiseSimilarly, a skilled diagnostician will often identify a clinical condition or stratification of the level of criticality of a patient seemingly by intuition that can occur in a brief encounter. But it is not luck or intuition. It is the honed art of observation combined with a stepwise knowledge stratification process combined with experience that has been integrated over time and bundled, or packaged, into what we call expertise.

Getting the experienced healthcare provider to unpack their expertise into tangible stepwise learning events can be the key to creating effective educational encounters. More simply put, aligning the mind of the expert to walk in the shoes of the novice and try to recall their own experiences as novices will help to create more effective learning counters. It is quite difficult for experts in areas of complex cognition or psychomotor skill areas (healthcare) to relate to the needs of the junior learner.  The junior learner who is on the journey to expertise has varying needs for granular application of individual pieces of learning along with the experience and mentoring that allows the connection of seemingly disparate small chunks of information into a fluid situation that allows for analysis and application of the final product (i.e. the delivery of healthcare).

This unpacking of expertise can effectively be carried out by ensuring that curricular activities address the need of learning and multiple stages of progress. Similarly, it is often a successful practice to combine several different individuals, perhaps with different vantage points with regard to levels of proficiency and even core expertise. This promotes a design environment that promotes a successful deconstruction of an expert situation into a series of tasks that require competence in component form, integration, practice and implementation. This is exceptionally true in healthcare where there is great variability in the process of acquiring information, analysis and affecting treatment that will be eventually rendered for a given patient for a given situation. I.e. in healthcare there are often times that there are many right answers.

There are several structured method of Hierarchical Task Analysis (HTA) in the literature that are used in various forms in many different industries. The essential underlying element of the HTA is the breaking down complicated situations into their component forms. This is a method that while time-consuming, can lead to effective strategies to build learning platforms, and in particular help guide the creation of assessment tools in simulation to help promote formative step-wise learning toward expertise. While this discussion is focusing on simulation, conceptually this applies to all aspects of education design in healthcare that will likely help us increase the efficiency and effectiveness of our programs.  After all isn’t simulation a subset of healthcare education? Now there’s a concept worth remembering!

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Extra Cognitive Processing Associated With Simulation – The Cognitive 3rd Space

This is a concept I’ve observed over the years. In the design and conducting of simulation we as facilitators and faculty members develop a shared mental model in what we see in a simulated environment, how we act in a simulated environment, aCognitiveGuynd how we anticipate that our trainees will act in the simulated environment.

Embedded in the latter assumption is what I call the cognitive 3rd space of simulation. Conceptually this refers to the fact that participants of simulation in healthcare have a background thought process that is continuously assessing what they are seeing in the simulated environment and trying to decide what the facilitators are trying to indicate with the presence, and sometimes absence, of the various pieces of equipment, clinical finding replicas, and other accoutrements of the environmental stimulus associated with simulation. In other words there is a continuous background thought process trying to figure out is this that I am seeing supposed to be simulated or not.

In the real clinical environment where healthcare providers are gathering data from interviews, observations, physical examinations, test results etc. that feed into the eventual analysis which leads to a decision-making plan. This cognitive 3rd space associated with simulation is the fact that this continuous reconciliation of “what are they trying to simulate for me?” question that is continuously active in the mind of the trainees during simulation encounter in addition to the traditional process of data gathering analysis and treatment planning associated with the provision of real healthcare.

The degree of which a participant manages this third space is multifactorial and relates to many things including experience in the simulated environment, the orientation, the environment itself, their own confidence as well as the degree of buy-in that they have for the overall experience.

Reconciling this requires us to make a conscious understanding that when we provide stimulus in the simulated environment it may or may not be interpreted by the participant of simulation in the same way that it was intended. Helping to control the potential variation and confusion that can result from this is embedded into the design of our simulations, briefings and orientation, equipment selection and the interactions that go on between participants and facilitators of simulation events.

A variant to this also relates to the environmental set up of the simulation space. Participants are often focusing on “clues” in the surroundings of the simulated clinical environment. For example, if they notice an intubation set up on the bedside tray table they may think “this scenario requires an intubation.” While in the simulation they may or may not perform an intubation in the patient as a result of the observation, however this thought process or separate thread of thought is extramural to the normal cognitive processing that might go on in caring for a real patient.

As designers of simulations we must work to ensure that try to keep this interpretive grey zone minimized. This often runs afoul of the desire for many who try to recreate reality and go onto to develop the theatrics of simulations with clever remedies that may actually introduce further confusion into the mindset of the participant. The result may be an impediment in the ability to evaluate the performance in terms of the ability of the decisions to translate to the real care environment.

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The True Value of Simulation into the Future: Assessment. Still.

I recently had the honor of delivering the keynote address at the Annual Meeting of the Association for Simulated Practice in Healthcare (ASPiH) in Nottingham, England. ASPiH has established itself as the simulation association for the United Kingdom and is certainly one of the premiere societies in all of Europe dedicated to simulation. I was asked to talk about incorporating simulation into the assessment of professional practice. The development of the talk gave me a good bit of time to introspect, reflect and consider many of the possibilities.

One thing that became clear in my mind though is a reinforcement of thoughts that the true value over time that will provide the necessary return on investment for simulation is assessment. The ability for simulation to provide opportunity to assess the competency of individuals whether they are completing undergraduate programs leading to a certificate, degree, or some sort of license in healthcare, or they are practicing professionals on the front line is critical to the future of healthcare as well as the community of simulation.

The next decade of global healthcare in the developed world will shift to have tremendous focus on improving quality, value and safety like no other era in the past. Multiple factors are driving this agenda ranging from a demand from the public to improve healthcare as well as a continually rising expectation in excellence, a realistic need to lower the cost of care, the gathering of transparency of quality and safety data just to name a few. Improving the demonstration of clinical competence amongst individuals as well as teams is linked to each and every effort to improve care. Yet despite hundreds of years of evolution of the teachings of healthcare professions we still have not yet developed widespread, valid, reliable performance exams that evaluate the application of knowledge.

So why aren’t more people using simulation for assessment? The answer is complicated. I believe part of it is the assess-o-phobia that I have mentioned in a previous blog posts. Next, defining measures of clinical performance is in general, difficult. In my opinion to develop assessment tools in simulation is much harder than any other facet involved in the creating of simulation scenarios and associated learning programs. This presents a formidable barrier. Lastly, there is a pervasive discomfort felt by many people associated with creating assessment tools that would assign a “grade” or something similar to a simulation.

It is rather interesting with the comfort that we deal out a written examination often times made up of multiple choice questions that we have developed either personally or with groups of people and use it as a knowledge assessment tool. While I’m not disputing the ability of the written test to serve as an assessment of knowledge, the striking thing is the contrast in the discomfort to developing such a measurement tool for simulation, or even actual clinical operations or provision of care of real patients.

Some people profoundly advocate simulation should be used for assessment because it is not appropriate tool, and others feel that it violates the safe learning environment. I think as we shift to a patient centric approach to simulation we should be able to create a reduction in this reluctance that allows assessment forward. In fact, I always find it interesting to point out to people during debriefing training programs, particularly those that are vocal against concepts of assessment, and let them realize that when they watch a simulation and then conduct and/or facilitated briefing they have actually already performed assessment in their minds. The very items that they have formed an opinion on, or “assessed” will play a part in the educational strategy that should ultimately reinforce what participants did well and encourage change in the areas where deficiencies were noted that will lead to an effective debriefing and the accomplishment of learning objectives.

Allowing participants to demonstrate competence could be one of the most important parts of the value equation for simulation. Manager and leaders of healthcare providing institutions are grappling with ways to improve quality and significantly improve patient safety all over the world. A patient centric approach to simulation would certainly suggest that as well.

This inevitably will help us in making stronger arguments for the case for simulation. At the moment many people try to sell the idea of simulation to their leadership. This creates thoughts and visions of expensive investments in technology and the daily pains of leaders. If we shift the point of focus point our sales pitch pivots to the selling of the concept of excellence, improved patient care, and safer patient care it will far better align with the pain points of those running healthcare systems. That becomes harder to deny!

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Ebola and Fidelity

hazmat_shutterstock_135522821_aThose of you who are used to my normal musings and rants against perfecting the “fidelity” and realism used in simulations might be surprised to hear me speak of examples of simulations where perfect/near perfect fidelity does matter.

Various association social forums are abuzz with people talking about simulations involving personal protective equipment in the light of the current unfolding of the Ebola crisis. It is important to differentiate this type of simulation and recognize the importance of re-creating the aspects of the care environment that is the subject of the education in the most highly realistic way available. In this case we are probably talking about using the actual Personal Protective Equipment (PPE) equipment that will be used in the care of the patient suspected of Ebola at any given facility.

This is a high-stakes simulation where the interaction with the actual equipment that one will be using in the care environment is germane to a successful outcome of such interaction. In this case the successful outcome is keeping the healthcare worker safe when caring for a patient with a communicable disease.  More broadly this falls under the umbrella of simulation for human factors.

Human factors in this context being defined as “In industry, human factors (also known as ergonomics) is the study of how humans behave physically and psychologically in relation to particular environments, products, or services.” (source: searchsoa.techtarget.com/definition/human-factors)

Other examples of when human factors types of simulation are employed are in areas such as product testing, equipment familiarization objectives, environmental design testing. So for instance if we are evaluating the number of errors that occurs in the programming of a specific IV pump in stressful situations, it would be important to have the actual IV pump or a highly realistic operational replica of the same. This is in contrast to having the actual IV pump used in a hospital for scenario focused on an acute resuscitation of the sepsis patient, but not specifically around the programming of the IV pump. The latter example represents more of when the IV pump is included more as a prop in the scenario versus that of the subject of the learning objectives and inquiry on the safety surrounding its programming.

So yes world, even I fully believe that there are some examples of simulations where a re-creation of highly realistic items or elements is part and parcel to successful simulations. The important thing is that we continuously match the learning objectives and educational outcomes to those elements included are simulations so that we continue to be most efficient and efficacious in our designs of simulation-based education encounters. What I continue to discourage is a simple habit of spending intense time and money in highly realistic re-creations of the care environment when they are not germane to the learning objectives and educational outcomes.

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Beware of Some of the Costs of Fidelity and Simulation

Fidelity is a concept that is often not thought about in detail and can contribute to being a barrier in the adoption simulation. It is also one of the most misused words in simulation, and can unnecessarily contribute to raising the costs and complexities of simulations. It can results in a significant desire to make every attempt to re-create the reality of the patient care environment without consideration of the necessity related to accomplishing the learning objectives. This has tremendous implications. Trying to overdo fidelity can cause unnecessary set up time, cleanup time, and therefore add significant costs and inefficiencies to accomplishing a simulation-based encounter. This is not to suggest tat we shouldn’t consider planning for elements that help create a more realistic presentation f what we are trying to simulate, it is just suggesting caution that each element be carefully considered for necessity and overall impact to the entire scenario including costs.BloodyMess

This set of costs is very concerning because they are in a category of what I consider add to the hidden barriers of simulation. This arises from imbedding elements of simulations in to the design that contribute to the complexity, overall costs and don’t add to the educational outcomes.

Furthermore, attempts at trying to re-create fidelity can often add confusion for the simulation participants in trying to interpret what it is that is being simulated. As I have discussed previously, there is no such thing as suspension of disbelief. Participants of simulations are constantly having to interpret their environment. Since they are engaged in a simulation they are always hyperaware of the fact that some things are simulated and some things are attempts at creating normalcy. The take-home message is that the learning objective should be carefully considered to determine what aspects of a corresponding actual situation needs to be simulated in the laboratory environment.

A careful orientation of the learner along with describing the capabilities and limitations of the simulation will engage the participant in a way that you could accomplish the learning objectives with a minimal amount of work placed into recreating the fidelity of the situation. This is particularly true of trying to re-create the environment, physical exam findings or situation that a patient is likely to be found in when compared to an actual clinical encounter.

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Clinical Bedside Teaching Can Benefit from “Simulation Style Debriefing”

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I recently had a great opportunity to do bedside teaching in the REAL Emergency Department of Wan Fang Hospital, which is one of the major teaching hospitals of Taipei Medical University in Taipei, Taiwan where I hold an appointment as a Visiting Professor.

It is amazing to realize the similarities between bedside teaching usual actual patients and the learning that can be facilitated through effective structured communications that encourage reflective learning. Yes, indeed those of you not so subtly reading between the lines recognize I am saying that I was implementing classic debriefing methods to help facilitate learning critical thought process while utilizing the experience of real patients.

We did case discussions of two actual patients with junior and senior level medical students. We reviewed case details, patient examination, hypothesis testing, clinical testing and diagnosis. During the two hour sessions I was relying upon the structured and supporting debriefing model (GAS Model) to facilitate the discussion.

The GAS model is one of the most common methods of simulation used throughout the world and was created by my Colleague Dr. John O’Donnell of WISER and University of Pittsburgh School of Nursing, Chair of the Department of Nurse Anesthesia in conjunction with the American Heart Association. 

In recent years John, I, and others have discovered the advantages of using “simulation style” structured debriefing used in the clinical teaching setting. The model encourages active reflection and self discovery through a structured model supported by supplemental learning materials and focusing on the participants readiness to learn.image[1]

Implementing the GAS Model during this exciting, but challenging opportunity to actualize bedside clinical teaching in an environment with participants who do not speak English as a primary language was hugely successful for the students judging by the feedback that I have received.

The model of debriefing can be expanded and contracting for varying levels of complexity and molded to support any learning encounters that benefit from active reflection with a goal of prompted discovery. It is easily learned through structured education sessions and workshops.

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Feedback – More Than Just Debriefing

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Too often in the designs of scenarios for simulation there is a lack of attention to the fact that there are many forms of feedback that occurs during a simulation than the debriefing. Debriefing is certainly an important part of any learning encounter, but in reality represents only one type of feedback.

As you think about sources of feedback I ask you to be both creative and attentive. I like to think of feedback in two broad categories, intrinsic and extrinsic. The latter being the more commonly thought of mechanisms such as debriefings, video reviews, and simulator log file reviews etc. with the former being the topic of this post.

What I find to be of significant interest as it related to the design of scenarios is the feedback that occurs intrinsically. That is clues, or changes that occur during the scenarios that are available to the participant to incorporate in their understanding of how their decisions, treatments, or lack thereof, are affecting the statues of the patient.

Many of you might be saying, what are you talking about???? Ha!!! Now on to my favorite part which is providing concrete examples to help explain myself further.  Let’s say you are simulating a pelvic fracture case with hypotension and shock. The vitals’ of the high technology simulator that you may be using for the case would likely show tachycardia and hypotension etc. Now lets say the participant(s) place a pelvic binding device and give a unit of blood. You may include changes in the vitals appearing on the monitor that indicated that there was mild to moderate improvement of the patient. Perhaps the tachycardia would decrease and the blood pressure may improve over a set period of time.

During the design process of the scenario many people may create the changes in the vitals thinking they are mimicking reality of what may occur.  More importantly I think those involved in the design of the scenario should realize that the changes in the vitals referred to above are a source of important intrinsic feedback. The participants should be able to make the observations and decide they are helping the patient to improve.

This can be powerful feedback that links together successful performance with particular behaviors or decisions that were made. It is self-discovery, it will help to guide further care and decisions if the scenario continues. If the designer of the scenarios recognizes this intrinsic feedback in the design phases, additional creative solutions can be implemented to reinforce the learning.

While my pelvic fracture example shows a positive change tin the patient based on correct actions, the converse example could be true if incorrect care is being rendered. Consider that if you have a heart attack case with hypotension and the patient is administered aspirin and nitroglycerin. You would likely worsen the shock from a physiological perspective. Seeing this change will provide intrinsic feedback to the learners(s).

This is not to say that it all has to do with fancy feedback from high technology simulators. The same could be accomplished with showing a worsening EKG on paper if treatment is incorrect or delayed, or conversely showing and improving EKG for the right treatment given within the appropriate time.

Approaching feedback from a deliberate perspective can be helpful in reinforcing learning. It should be recognized as a design tool and carefully integrated into the core deign of any scenario. Debriefing can be linked to these feedback areas in the scenario. This can provide valuable links or areas ripe for discussion to assist in accomplishing the learning objectives.

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Insitu Mock Codes Evaluate People Readiness and System Readiness – An Important Patient Safety Tool

CombinedTeamandEvaluationOver the last 20 years WISER has conducted hundreds of unannounced mock code evaluations at hospitals directly associated with our health system. Additionally we have assisted others with conducting and reporting on this important patient safety activity in hospitals both in the US and outside. As it is true in most things in simulation there is no binary answer on right versus wrong in the way simulation is carried out.

In situ mock codes bring a unique perspective that allows all of the effectiveness of simulation based education to be combined with human factors and systems testing that are crucial to ensure higher levels of patient safety for the increasingly ill patients who are being cared for in hospitals around the world. This is a patient population that is at well documented great risk for harm from errors that occur resulting from a myriad of causes ranging from human error to poorly design systems.

Mock codes in hospitals bring crucial insight into the care delivery that occurs episodically in high tempo, high stress unplanned situations in our hospitals. They can identify areas of deficiency that are not readily apparent. (Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes; Hunt et al. Pediatrics. 121(1):e34-43, 2008). We can gain unique perspectives such as where do we need to place AED’s? Is the hospital operator handling code requests in the most expedient fashion? Where in the hospital should responders respond from? It is these important system data points that can be understood from mock code data generation that are impossible to gain conclusive evidence from in the simulation lab, or in those mock codes that personnel know are of the simulated variety.

While we are able to do undeniable powerfully effective training in our simulation labs, it is the mock code and other insitu activities that help to bring true facts to factor into decisions that evaluate and ultimately improve patient safety. Do mock codes have the ability to lead to unintended harm or further error if not carefully planned carried out and monitored? Of course they do, and they must be regarded as such. But mopping the floor of the hospital also carries forth the increased possibility of hip fractures, yet it is a required element of infection control and with appropriate precautions and guidelines we make every attempt to minimize this potential risk.

Those of us in healthcare who are directly involved in the care of patients as well as those who have roles in system oversight of the direct care of patients recognize that with every intervention, every therapy and every procedure there are risks and benefits. The same goes for the training we provide. The fact that someone in a simulation center may get shocked by a defibrillator or stuck by a needle during simulation training are potential harms that may occur secondary to the use of simulation based education. So we recognize these risks through failure mode effect analysis, learning from others at meetings such as the International Meeting for Simulation in Healthcare (IMSH), remaining informed by current literature and implementing solutions that attempt to minimize these risks.

While Raemer does a wonderful job of pointing out some of the potential possibilities of potential hazards associated with mock codes (Ignaz Semmelweis Redux?; Sim Healthcare 9:153-155, 2014), this personal opinion piece does not actually include an overall analysis of risk vs. benefit. Nor does he present any data that combines evaluation of training programs, professional readiness and systems design with a quantitative deliverable that allows such an assessment. With the latter information properly collected and analyzed those of us involved in designing future care delivery systems through policy, investments in training, staffing and equipment will be better prepared to make a difference in the safety of patients.

The reference to the Owen article is baffling. (Unexpected Consequences of Simulator Use in Medical Education: A Cautionary Tale; Sim Healthcare 9:149-152, 2014). Professor Owen authored a remarkably elegant piece in this month’s SIH journal that was inappropriately titled in my opinion. The title seems to be one that attempts to be provocative in an ability to gain ones attention in the simulation world.  (That part was effective I must admit, as I read the article immediately.) However the article and its title implies that the use of simulation CAUSED untoward outcomes in patients. From a root cause perspective in the information presented in the article, that is NOT THE CASE. The poor outcomes were associated with the lack of hand hygiene and the lack of knowledge associated with proper hand cleaning and infection transmission. It is analogous to saying that an automobile striking a pedestrian is the fault of the car.

I would estimate real codes occur in our healthcare system (of 20 hospitals/care facilities) roughly 50 times per day. So if we simply take 50 codes per day that is 18,250 codes per year. This is not a rare critical event; this is a common critical event that we still have much to learn about from a training perspective as well as a systems design perspective. We all know there are delays and errors associated with codes in general. My colleagues and I reported an enormous amount of medication administration errors during observations of REAL CODES (Medication errors during medical emergencies in a large, tertiary care, academic medical center; Resuscitation. 83(4):482-7, 2012 Apr) and that is just one element in the complex environment of actual codes.

Despite reams of paper trails, and gigabytes of data in the vaults of patient safety and risk management reports in the offices of hospitals, we still have very little insight into the actual root causes of the epidemic of harm to patients that occurs during hospitalization. The mock code, with its associated risks and POTENTIAL complications is an important tool in the armamentarium of patient safety probes that will ultimately save lives.

 

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Is Death Not Safe?

deadSimManToeTag_aAll of the discussion on the Sim Connect Community networking site of the SSH inspired me to expound a little on the topic of death during simulation.

A number of years ago we had a poster at IMSH reporting our results of a survey given to 224 professionals (Emergency Physicians, Flight Paramedics and Flight Nurses) who attended courses that had some scenarios that ended in death depending on how the cases were managed. Overall 48% of them had experienced death during the courses. These were courses that did not include objectives on death, family/patient communications or teamwork. Thus, there was no focus on the death during the debriefing.   PDF of Poster

They were asked a series of questions about experiencing death during the simulations. The four main conclusions that we reported were: 1) Participants disagreed that simulated death was distracting to the learning environment; 2) Participants strongly disagreed that students in their respective fields should be exempted from simulated death; 3) Participants strongly disagreed that experiencing simulated death would create a reluctance to participate in further simulation training; 4) Participants disagreed that a separate disclosure about the possibility of simulated death was necessary. On further analysis there was no difference in the perceptions of those who experienced simulated death and those who had not.

Bear in mind these are all practicing professionals and all from a high-acuity emergency profession. But, none the less this was their collective opinion. So maybe at times we should slow down and ask the participants their impression. I think many people take the phrase “safe learning environment” to extremes and try to make absolute rules that are very broad sweeping and thus become rate limiting steps in creating effective education.

Do I think that death in simulation is appropriate for all learners? Absolutely not! In the case of the learners participating in the courses we studied, it was the collective opinion of the subject matter experts involved in the design of the courses that it was appropriate. But importantly, it was a deliberate decision as part of the course design.

While there is significant passion, emotions, urban myths and beliefs surrounding this topic, like most things in simulation I think there is no one correct answer. I believe that those who profess to know “THE” way to do simulation and are unyielding in there methodology or offerings should be viewed with skepticism and doubt.

When programs carefully evaluate who their learners are, make realistic expectations, understand what is needed of the learner to provide the best patient care possible, remains attentive to the general emotional well being of the participants, and deliver the learning with well trained facilitators, I believe they are providing PATIENT CENTRIC SIMULATION. A concept which I believe is the most useful of all to the global healthcare community and will result in higher quality patient care.

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