Tag Archives: design

July 27, 2023 · 11:52 am

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Until next time, Happy Simulating!

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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.

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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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July 23, 2019 · 2:20 pm

5 Elements in My Approach to the Learning Contract in Simulation

In simulation-based education there is a relationship between the faculty of the program and the participants that is important during all aspects of simulation. The relationship has tenets of trust and respect that must be considered when designing as well as conducting simulations. I have heard this relationship referred to by a few titles such as psychological contract, fiction contract, learning contract, all of which are generally referring to the same thing.Smiling asian female vacancy candidate shaking hand with hr manager

Probably more important than the title, is what such a relationship embodies or focuses on. I view it as an agreement between two or more parties that acknowledges several aspects of simulation based programs and works to establish rules of engagement and principles of interactions between those involved.

In my practice of using simulation for clinical education I work a great deal with practicing professionals, who by in large are physicians. I generally adhere to five elements or premises over the course of interactions that I design as well as provide for the participants of my programs.

  1. Meaningful use of Your Time.

Acknowledging up front that participating in learning activities takes time away from their busy schedule. I assure them that the content of the program is carefully crafted to fill the needs of their learning cohort in the mostly timely way possible. I refer to refinements of the course that have occurred in response to feedback from prior participants to help increase the efficiency and effectiveness of the program.

  1. This is NOT real and that’s really ok!

During the orientation I am always careful to point out that not everything they are going to experience will look or feel real. I include the idea that things are “real-enough” to help us create a successful learning environment. I also let them know the things that may feel somewhat real during the simulation. Additionally, I emphasize that the “realness” is not the primary focus and point out that the learning and reinforcement of high-quality clinical practice is the ultimate outcome.

  1. We are not here to trick you.

I find that practicing professionals often come to simulation training endeavors with an idea that we design programs to exploit their mistakes. I assure them this is not the case. I am careful to include an overview of what they can expect during all phases of the learning. For example, when I am conducting difficult airway programs, I carefully orient them to every feature of the simulators airway mechanics before starting any scenarios. I also let them know that the cases associated with our scenarios are modeled after actual cases of clinical care. I explain that while we don’t model every detail of the case, that we work hard to design situations that provide opportunity to promote discussion and learning that would have or should have resulted from the actual case.

  1. Everyone makes mistakes. We are here to learn from each other.

At the most basic part of this element, I point out that WE all make mistakes and that is part of being human. I let them know that everyone is likely to make a mistake throughout the learning program. I carefully weave in the idea that it is far better to make mistakes in the simulated environment as opposed to when providing actual clinical care.

Further, I advance the idea that we can learn from each other. As everyone in clinical practice knows, there are many ways to do most things correctly. While this idea can be challenging because often people feel that “their way” is the correct way, I point out that with an open mind and professional, collaborative discussion we can share learnings with each other.

Contract Signing Concept

  1. We are here to help you be the best you can be.

Leveraging the idea that almost all practicing professional hold themselves to high levels of performance standards as well as the desire to improve can provide a powerful connection between the faculty and participants of a healthcare simulation program. I put forth this idea along with carefully tying in a review of the prior four elements. Further, I point out to them the opportunity to perfect the routine exists in our learning programs. I then pivot to highlight that some aspects of the program exist to practice and learn from situations that they may encounter infrequently that may have high stakes for the patient.

So, in summary, I believe the relationship between faculty members and participants of simulation-based education programs is multi-factorial and demands attention. Depending on the learners and the topics of the program, the elements that serve as the underpinning of the relationship may range from few to many, and moderate to significant in complexity.

In my simulation work providing clinical education that involves practicing physicians as participants, I pay close attention to the five elements described above throughout the design as well as the conducting of the learning encounters.

I invite you to reflect upon your approach to the development and maintenance of the relationship between your faculty and participants of your simulation efforts.

 

 

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July 23, 2018 · 11:08 am

The First Four Steps of Healthcare Simulation Scenario Design

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

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

4 Success Steps, business concept

Step One: Pick A Topic

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

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

Step Two: Define the Learner(s)

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

Step Three: Designing  the Learning Objectives

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

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

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

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

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

Step Four: Define the Assessment Plan

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

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

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

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

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

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

Until next time, Happy Simulating!

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May 8, 2018 · 4:25 pm

Don’t be Confused! Every Simulation is an Assessment

 

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

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

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

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

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

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

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

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

Until Next Time Happy Simulating!

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March 23, 2018 · 12:00 pm

Three Things True Simulationists Should NEVER Say Again

From Wiktionary: Noun. simulationist (plural simulationists) An artist involved in the simulationism art movement. One who designs or uses a simulation. One who believes in the simulation hypothesis.

Woman taping-up mans mouth

 

After attending, viewing or being involved in hundreds if not thousands of simulation lectures, webinars, workshops, briefings and conversations there are a few things that I hear that make me cringe more than others. In this post I am trying to simmer it down to the top three things that I think we should ban from the conversations and vocabularies of simulationists around the globe!

1. Simulation will never replace learning from real patients!: Of course it wont! That’s not the goal. In fact, in some aspects simulation offers some advantages over learning on real patients. And doubly in fact, real patients have some advantages too! STOP being apologetic for simulation as a methodology. When this is said it is essentially deferring to real patients as some sort of holy grail or gold standard against which to measure. CRAAAAAAAZY……   Learning on real patients is but one methodology by which to attack the complex journey of teaching, learning and assessing the competence of a person or a team of people who are engaged in healthcare.  All the methodologies associated with this goal of education have their own advantages, disadvantages, capabilities and limitations. When we agree with people and say simulation will never replace learning from real patients, or allow that notion to go unchallenged, we are doing a short service to the big picture of creating a holistic education program for learners. See previous blog post on learning on real patients. 

2. In simulation, debriefing is where all of the learning occurs!: You know you have heard this baloney before. Ahhhhhhhhhhhhh such statements are purely misinformed, not backed up by a shred of evidence, kind of contrary to COMMON SENSE, as well as demeaning to the participants as well as the staff and faculty that construct such simulations. The people who still make this statement are still stuck in a world of instructor centricity. In other words, “They are saying go experience all of that…… and then when I run the debriefing the learning will commence.” The other group of people are trying to hard sell you some training on debriefing and then make you think it is some mystical power held by only a certain few people on the planet. Kinda cra’ cra’ (slang for crazy) if you think about it.

When one says something to articulate learning cannot occur during the simulation is confirming that they are quite unthoughtful about how they construct the entire learning encounter. It also hints at the fact that they don’t take the construct of the simulation itself very seriously. The immersive experience that people are exposed to during the simulation and before the debriefing can be and should be constructed in a way that provides built in feedback, observations, as well as experiences that contribute to a feeling of success and/or recognition of the need for improvement. See previous blog post  on learning beyond debriefing

3. Recreation of reality provides the best simulation! [or some variant of this statement]: When I hear this concept even eluded to, I get tachycardic, diaphoretic, and dilated pupils. My fight or flight nervous system gets fully engaged and trust me, I don’t have any planning on running. 😊

[disclaimer on this one: I’m not talking about the type of simulation that is designed for human factors, and/or critical environmental design decisions or packaging/marketing etc. which depend upon a close replication to reality.]

This is one of the signs of a complete novice and/or misinformed person or sometimes groups of people! If you think it through it is a rather ludicrous position. Further, I believe trying to conform to this principle is one of the biggest barriers to success of many simulation endeavors. People spent inordinate amounts of time trying to put their best theatrical foot forward to try to re-create reality. Often what is actually occurring is expanding the time to set up the simulation, expanding the time to reset the simulation and dramatically increasing the time to clean up from the simulation. (All of the after mentioned time intervals increase the overall cost of the individual simulation, thereby reducing the efficiency.) While I am a huge fan of loosely modeling scenarios off of real cases in an attempt to create an environment with some sense of familiarity to the clinical analog, I frequently see people going to extremes trying to re-create details of reality.

We have hundreds and thousands of design decisions to make for even moderately complex scenarios. Every decision we make to include something to try to imitate reality has the potential to potentially cause confusion if not carefully thought out. It is easy to introduce confusion in the attempts to re-create reality since learners engage in simulation with a sense of hyper-vigilance that likely does not occur in the same fashion when they are in the real clinical learning environment. See previous blog post on cognitive third space.

If you really think about it the simulation is designed to have people perform something to allow them to learn, as well as to allow observers to form opinions about the things that the learner(s) did well, and those areas that can be improved upon. Carefully selecting how a scenario unfolds, and/or the equipment that is used to allow this performance to occur is part of the complex decision-making associated with creating simulations. The scenario should be engineered to exploit the areas, actions, situations or time frames that are desired focal points of the learning and assessment objectives.  Attention should be paid to the specifics of the learning and assessment objectives to ensure that the included cache of equipment and/or environmental accoutrements are selected to minimize the potential of confusion, create the most efficient pathway that allows the occurrence of the assessment that contributes improving the learning.

Lastly, lets put stock into the learning contract we are engaging in with our learners. We need to treat them like adult learners. (After all everybody wants to throw in the phrase adult learning principles…. Haha).

Let’s face it: A half amputated leg of a trauma patient with other signs and symptoms of hemorrhagic shock that has a blood-soaked towel under it is probably good enough for our adult learners to get the picture and we don’t actually need blood shooting out of the wound and all over the room. While the former might not be as theatrically sexy, the latter certainly contributes to the overall cost (time and resource) of the simulation. We all need to realistically ask, “what’s the value?”

While my time is up for this post, and I promised to limit my comments to only three, I cannot resist to share with you two other statements or concepts that were in the running for the top three. The first is “If you are not video recording your scenarios you cannot do adequate debriefing”, and the second one is “The simulator should never die.” (Maybe I’ll expand the rant about these and others in the future 😉).

Well… That’s a wrap. I’m off to a week of skiing with family and friends in Colorado!

Until next time,

Happy Simulating!

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August 23, 2017 · 8:20 pm

Recreating Reality is NOT the goal of Healthcare Simulation

Discussing the real goals of Healthcare Simulation as it relates to the education of individuals and teams. Avoiding the tendency to put the primary focus into recreating reality, and instead providing the adequate experience that allows deep reflection and learning should be the primary focus. This will help you achieve more from your simulation efforts!

 

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April 25, 2016 · 1:03 pm

Learning from Simulation – Far more than the Debriefing

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

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

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

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

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

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

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

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

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

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

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

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April 4, 2016 · 4:00 pm

Simulation Curriculum Integration via a Competency Based Model

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

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

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

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

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

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

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

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

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

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

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

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

 

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