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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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Suspension of Disbelief is So Yesterday – Lets Think About a Great Movie Encounter

The concept of “suspension of disbelief” was orginally attirubuted to a poet/philospher in the 1800’s with regard to creating works of fiction to be interpreted by readers. When I first started in healthcare simulation back in 1997 it was told to me that we needed to create an environment where there is a suspension ofdisbelief so that the participants will believe that they are in the actual health care environment and perform accordingly. I drank the coolaid, I thought that is what we were to do. Today when I reflect on this notion it seems a bit crazy when it is inerpreted to mean that we are designing simulations to make participants forget they are in the simulated environment.

Certainly we don’t want health care professionals to actually think they are in the real clinical environment when they engage in simulation.  We want to create an evironment where they can perform aspects of what they do when they are taking care of real patients so that we can form an opinion to help them improve. This ocurrs through feedback,  assessment and debriefing methods as well as other innovative learning and assessment strategies.  I think we need to think of it more as a “fiction contract” which I believe was a term coined by Peter Dieckmann of Copenhagen which has always resonated with me. (At least he was the first person i heard use it in that concept, shutterstock_130674926and he a brilliant mind in simulation as well as a friend.  So barring any information to the contrary, i’ll leave it attributed to him for the time being 🙂 )

A good metaphor would be to think of it more like the intellectual engagement of going to see a great movie. The movie goer buys a ticket and enters into a contract (of sorts) with the producers of the film and perhaps the movie theater involving a belief  that the money they are spending will allow them to see something that is not quite real, but is a reenactment of something real, and  perhaps they will be participating in it emotionally and psycologically, but they never thought it was real.  However, the value to the participant is in the movie metaphor would be the entertainment provision.  So in essence the “deal” is summarized by the fact that they are entering into an unofficial agreement that says I will provide you $15 to buy the movie ticket, and you will provide me two hours of entertainment. 

I think there are strong analogies between that and the way we should approach healthcare simulation relationship between participants and the simulation providers. We need to create environments where the participants trust us so that they will engage psycologically and emotionally in the simulated environment  in exchange for the valuable use of their time to help them improve as a healthcare provider. 

I think that if we shift the focus so that we are not trying to create a “suspension of disbelief”, it will allow us to better create the environment necessary for effective healthcare simulation. That is that we realize we’re not trying to recreate everything to do with reality in healthcare, we’re just trying to recreate that which allows the participant to engage in a way that they might when they are actually taking care of patients. I think it is particularly important to be direct in letting the participant know that not everything we do in simulation will mimic their realistic practice environment. If we are honest with this orientation and apporach, I believe it causes less constrenation on the part of the participant who is in an environment where some things seem real and some things do not.

Participants are often experiencing a sense of  internal “conflict” when interpreting what the see, hear and experience in the simulation, wondering is this supposed to be part of the simulation or not? I am of the opinion that they are more likely to reconcile this with us if we are frank, open and honest about the intent and expectations of the simulation. This is in contrast to simply asking them to “pretend this is all real” conceptually describing the mantra of suspension of disbelief.

Through this bilateral agreement we enter into a fiction contract or a trust contract that says, on the participant’s side, I will engage in this activity in exchage for the trust that you are making valuable use of my time and helping me become a better healthcare professional.  On the simulation provider side of the agreement it goes something like this: “we will create an educational program using aspects of simulation, which some parts will feel realistic and some will not, but we commit to you that this will be a valuable use of your time with tust, dignity, respect and professionalism. We will attempt to help you get better as a healthcare provider.”  Isn’t that what we’re all trying to accomplish? To me this seems more plausible than asking professionals to suspend the disbelief and interpret the entire simulation as “real”………

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Purpose of Simulation Isn’t to Mirror Reality

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The purpose of clinical simulation healthcare is not to mirror reality. The primary objective of the most commonly used simulation is to improve the performance of humans as it relates to caring for patients within the context of healthcare. Too many times we get lost in toiling over the details of trying to re-create a scenario as realistic as possible. This often leads to what I describe as invisible barriers to simulation insofar as design, perceived resource limitations, or operational realities limit the bandwidth that the simulation program is able to accomplish. It’s important to remember that the primary objective is not to simulate, but to educate. (Certain exceptions may apply to research projects, and human factors design elements, or other factors studying mimicking existing process flow etc.)

When we run a simulation we are not trying to convince the participant that it is real (because if they did think it was real they would likely be a little crazy J). What we need to do is create an environment that helps the participant feel as if there is some realistic comparison to the simulation to what they do when they are actually caring for patients. We need to enter into what is frequently referred to as a fictional contract or psychological contract that allows the participants to drop into their role as a normal care provider knowing that the simulation is artificial, but has value to their learning and their future practice.

Many, many decisions go into the design of simulation. Often times the specifics of the learning objectives and outcomes do not receive as much attention in the design phase as some of the other elements to try to create “perfect fidelity”.  In doing so we often unnecessarily add to the complexity of the scenario that may increase the setup time, the cleanup time, expose the scenario to the potential of technical failure. Further, we can actually confuse the participant as during the scenario they are constantly trying to assess what they are supposed to be interpreting as “real” versus that which is simulated.

So the next time you’re designing a scenario start with learning objectives, outcome objectives, and then answer the question, “what do I really need to provide to allow the potential participant, or participants” a general feeling of realistic sensation that will allow them to participate in a meaningful way.

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