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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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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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Lecture: It’s not Dead Yet

LectureNotDeadFellow simulationists, let’s get real. We should not be the enemy of lecture. Lecture is a very valuable form of education. What we should be campaigning against are bad lectures, and the use of lecture when it isn’t the best tool for the associated attempt at education.

We have all listened to lectures that were horrific and/or lectures presented by speakers who have/had horrific public speaking or presenting skills. But in essence a good lecture can be an incredibly efficient transfer of information. The one to many configuration that is in inherent in the format of lecture can lead to an amazing amount of materials covered, interpreted and/or organized by the presenter to raise the level of knowledge or understanding of the people in attendance.

Like anything else in education we need to stratify the needs of what we are trying to teach and create solutions by which to teach them. With regard to lecture as a tool, we need to find ways to engage the audience into active participation to enhance the comprehension, learning and attention of the participants. There are many tools available for this, some involving technology, some not. The onus is on the presenter to seek out techniques as well as technologies or creative ways to engage people in the audience into an active learning process.

I don’t think of simulation as an alternative, or better way to teach, then lecture. I view lecture and simulation as two different tools available to the educational design process to affect good learning. Much the same way that I would not say a screwdriver is a better tool than a pair of pliers.

Too many times at simulation meetings and in discussions with simulation enthusiasts I hear empirical lecture-bashings if it is old school, out-moded or something lacking value. During these conversations it becomes readily apparent that the person speaking doesn’t have full command of the fact that the main goal is education, not simulation, and that there are many ways to create effective learning environments.

Now lecture can get a bad rap deservedly. Go to a meeting and listen to a boring monotonous speaker drone on and read from their powerpoint slides while not even recognizing that there is an audience in front of them. Unfortunately that is still more common than not at many physician and nursing meetings. Or worse yet, in the new age of converting to flipped classrooms and on-line learning, people are taking the easy way out and moving videos of lectures and plopping them on-line and calling it on-line learning. How pitiful. How painful. The only thing I can imagine worse than a bad lecture in person, is a bad lecture on web based learning that I would have to suffer through.

So I still teach and lead workshops on helping people enhance their lecturing and presentation skills. In part because I continue to recognize that not only will lecture be around for a long time, it should be around for a long time because it CAN be incredibly powerful with the right preparation and in the right hands. Also I continue to recognize the value of seeing modern healthcare education efforts being carefully thought out to understand which tool is best for which phase of learning after careful evaluation of the intended learner group and the topic at hand.

We need to end the silo-like thinking of simulation is better than lecture and convert to a more outcomes oriented thought process that evaluates and implements the appropriate educational tool for the intended educational accomplishments.

So let’s commit to each other to never do a simulation that could be just effective as an engaging lecture, AND lets all agree to never do a lecture that sucks.

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Simulation can be Fun. And Serious.

shutterstock_286597808aI was recently energized by sitting in the back of one of our simulation rooms where two of my faculty colleagues were running simulations for some of Emergency Medicine Residents. They had prepared the session well and had clearly established a previously great and trusting relationship with the residents in a safe learning kind of way.

The residents seemed relaxed, smiling, and many were attending the session dressed in the likes of Khacki shorts, Teva’s and a Hawaiian shirt or two. During one of the scenarios the faculty member operating the simulator made a mistake and the “patient” took a turn for the worse when the correct treatment was ordered. He was on the other side of the glass and immediately said something funny about his mistake over the room speakers in a self-deprecating way. Everyone in the room was cracking up including the other faculty members, me, all of the team members and the resident observers. The simulation came to an end a few minutes later as the rest of the learning objectives were met

During the debriefing the faculty member called out his mistake once again to another round of snickers. Superficially it seemed that he was trying to be funny. Deeper I think he was level setting to ensure there wasn’t confusion of the change in status over the patient. Additionally he was ensuring to demonstrate the safe learning environment in so far as declaring that he was capable of making mistakes as well.

A few moments later the residents were engaged in a debriefing using the Structured and Supportive Debriefing Model and the GAS tool. During the debriefing many topics were covered ranging from teamwork, the initial care and stabilization of the patient, to aberrancies in the electrical system of the heart leading to wide complex tachycardia that can mimic ventricular tachycardia.

A few minutes later the debriefing was wrapped up expertly by the faculty member. Another scenario ensued with a new group of residents and again, unplanned, something funny happened. Again laughter, then back to work, then the end. Debriefing commenced. During the second debriefing led to a discussion of how cyanide poisoning interacts with cellular metabolic pathways of the P450 cytochrome system and the therapeutics that should be considered to save the patient’s life. During the conversation a few light hearted comments by residents created more laughing.shutterstock_261594212a

I sat back thinking….. this is really fun…….There they are dressed in their tevas and shorts…..Learning of all things…… imagine that. This is truly patient-centric simulation. Innovative education occurring in a comfortable atmosphere helping these future emergency physicians perfect their diagnostic, therapeutic and leadership skills. They don’t need to be in scrubs, shirts and ties or wearing hospital badges to optimize this learning opportunity. They are not going to show up to work in the hospital wearing shorts and tevas. They are professionals. You know what? They are in fact adult learners being treated as adults.

I was a bite envious of my faculty colleagues having creating this amazingly relaxed environment where the residents felt comfortable to speak up, right or wrong in front of each other and faculty members alike.  In fact they were encouraged to explore during the cases. And they were learning. Learning new concepts or at least reviewing topics and learning objectives that were appropriate for their training program.

Guys and gals dressed as if they were going to a picnic, learning from each other, laughing and feeling free to explore and demonstrate their knowledge, skills and attitudes for the purpose of improving. Were they not taking it seriously? Cytochrome P450 and conduction aberrancies sure sounded serious to me, as did the discussion of teamwork and leadership.

Sometimes I think we can easily take ourselves too seriously in the simulation world. While I would be the first to argue there are times to do just that, I am reminded that there are times when it is not the case. People seem to be so caught up in defining rules of how things should and shouldn’t be done in simulation encounters that sometimes I observe huge opportunities to find new and interesting ways in which we can engage learners in their prime. I think that these faculty members new their participants well and designed amazing learning opportunities for them that included some of the power of simulation.

After all, we are not trying to simulate reality, we are trying to use simulation to create a milieu that will enhance our ability to carry out learning and assessment objectives that will eventually influence the care that is delivered by the healthcare system.

It was a great day for me, simulation and especially for future patients!

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Why Waste Time Learning On Real Patients?

MannequinMammalsOkay, admit it, this title will be challenging for some. Although the converse of the question is what some of the naysayers say about simulation. What’s the real deal? The real deal is learning from real patients is an invaluable part of the healthcare education experience. At the risk of alienating some we must think of the real patient experience as a “tool” in the educational toolbox. But there are many tools in the toolbox!

We must also recognize the value of learning in the simulated environment as an additional tool in the toolbox. When we have many different tools by which to complete a goal, going through the risks and benefits of each will help us make the proper decisions to allow us to proceed with the most efficiency and effectiveness in our educational endeavors.

When I observe aspects of examples of learning in the clinical environment I become easily frustrated with seeing examples of colossal amounts of time wasted while waiting for some nugget of education to randomly appear in the clinical environment. Paramedic and nursing students working in the clinical environment that are changing bed linens over and over again are clearly being used as a service to someone and not functioning in a capacity that is enhancing their clinical learning. Similarly interns that may be on a specialty care service that are dictating their 30th discharge summary of the month are probably being used more in a service capacity than one in an environment that enhances their education.

Some of the advantages of simulation include being able to structure the learning environment so that the time can be accounted for in a more robust fashion that helps to ensure that valuable learning opportunities are presented, encountered or participated in. Additionally the ability to do and re-do exist in the simulated environment, where as in most cases this is not possible in the actual clinical care environment.  This is important to enhance and create programs of mastery learning with incorporated deliberate practice. And this applies whether we are talking about individual expertise or that of groups of people working on collaborative goals in team training environment. Additionally, in many simulation program designs there is much closer oversight of what a learner or groups of learners is/are accomplishing in the simulated environment when compared to the oversight that occurs in most clinical learning environments.

Please don’t misunderstand; I am not trying to diminish the value of learning on real patients in the clinical environment. I am merely stating that there are pros and cons, limitations and capabilities of all different modalities of learning as we bring people along the journey of what it takes to become a practicing healthcare professional. It is one that is complex that requires multiple repetitions from different vantage points, perspectives, as well as opportunities for learning. Carefully evaluating those opportunities, the resources that are available in a given program are important concepts to ensure that we continue to improve the health care education for creating tomorrow’s healthcare providers.

Those who are in the capacity of creating new curriculum or revamping and revising old, would do well to think broadly about the needs of the learner, the level of learner and what would be optimal exposure to create the most efficient and effective learning at that point in time. We need to begin to challenge the existing status quo so that we can truly move forward in revising healthcare education to continue to allow people to achieve excellence.

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Are Routine Pre-and Post Simulation Knowledge Tests Ethical? Useful? To whom?

shutterstock_77554009X_aDisclaimer (before you read on): This post is not referring to research projects that have been through an institutional review board or other ethics committee reviews.

What I am actually referring to is the practice of many simulation programs that do routine written pre-test, followed by written posttest to attempt to document a change in the learner’s knowledge as a result of participating in the simulation. This is a very common practice of simulation programs. It seems the basis of such testing would be to eventually be able to use the anticipated increase in knowledge as a justification for the effectiveness of the simulation-based training.

However we must stop and wonder if this ethical? I believe as described in some of my previous posts that there is a contract that exists between participants of simulation encounters, and those who are the purveyors of such learning activities. As part of this contract we are agreeing to utilize the time of the participating in a way that is most advantageous to their educational efforts that help them become a better healthcare provider.

With regard to pretesting, we could argue from an educational standpoint that we are going to customize the simulation education to help tailor of the learning to the needs of the learners as guided by the results of some pretest. I.e. using to pretesting some sort of needs analysis fashion. But this argument requires that we actually used the results of said pre-test in this fashion.

The second argument and one that we embark upon in several of the programs of which I have designed is that we are assessing the baseline knowledge to evaluate the effectiveness of pre-course content, or pre-course knowledge that participants are programs to do either complete or possess prior to coming to the simulation center.  I.e.  A readiness assessment of sorts. In other words the question being is this person cognitively prepared to engage in the simulation endeavors that I am about to ask them to participate in.

Finally another argument from an educational standpoint for pretesting could be made that we would like to point out to the participants of the simulation areas of opportunity to enhance their learning. We could essentially say that we are helping the learner direct where they will pay close attention and focus on during the simulation activities or participation in the program. Again this is predicated on the fact that there will be a review of the pretest answers, and/or at least feedback to the intended participants of the simulation program on the topic areas, questions or subjects of which they did not answer the questions successfully.shutterstock_201601739-a

The posttest argument becomes a bit more difficult from an ethical perspective outside of the aforementioned justification of the simulation-based education. I suppose we could say that we are trying to continue to advise the learner on areas that we believe there are opportunity for improvement and hopefully inspire self-directed learning.

However my underlying belief is if we look at ourselves in the mirror, myself included, we are trying to collect the data over time so that we can perform some sort of retrospective review and hopefully uncover there was a significant change in pretest versus posttest testing scores that we can use to justify our simulation efforts in whole or in parts.

This becomes more and more concerning if for no other reason than it can lead to sloppy educational design. What I mean is if we are able to ADEQUATELY assess the objectives of a simulation program with a given pair written tests, it is likely more knowledge-based domain items we are assessing and we always have to question is simulation the most efficient and effective modality for this effort. I.e. if this is the case may be every time I give a lecture I should give a pre-and posttest (although this would make the CME industry happy) to determine the usefulness of my education and justify the time of the participants attending the session. Although in this example if I was lecturing and potentially enhancing knowledge, perhaps one could argue that a written test is the correct tool. However the example is intended to put out the impracticality and limited usefulness of such an endeavor.

As we continue to attempt to create arguments for the value of simulation and overcome the hurdles that are apparent as well as hidden, I think that we owe it to ourselves to decide whether such ROUTINE use of pre-and post-testing is significantly beneficial to the participants of our simulation, or are we justifying the need to do so on the half of the simulation entity. Because we owe it to our participants to ensure that the answer reflects the former in an honest appraisal.

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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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Simulation Can Be the Model Flipped Classroom

FlippedClassroomSimulation can be utilized in a manner that is consistent with the current recognition of the gains and benefits of “The Flipped Classroom”. Essentially the flipped classroom that many educators are talking so much about is an engagement of the students that is different than traditional models. Historically learner show up to lectures to learn about a new topic and then are assigned homework to reinforce the concepts. In the model of the flipped classroom, the students are provided with tools such as lectures, video examples, resources, reading lists that introduce the topic and allow a cognitive exploration BEFORE coming to class. Then they show up to the face-to-face activity and instead of hearing a lecture from the professor are engaged in higher levels of cognitive processing regarding the topic. These higher levels could be conducting experiments, experiential learning, exploration, group discussions debating a topic, or perhaps engaging in scholarly debate on the merits.

Imagine education surrounding a topic that involves pre-learning such as web-based education, video reviews, or other activities that either introduce a new topic or perhaps refresh the cognitive underpinnings of the subject matter. Then have the learners come together in a face-to-face environment and engage in experiential learning through simulation of various sorts that may include mannequin based simulation, partial task training workshops or content review discussions. It seems like the ultimate combination.

Interestingly, as I have been reading more about the Flipped Classroom I realize that we have been utilizing these concepts for many years in Simulation in particular with our programs aimed at training residents and practicing professionals. At my center (WISER) many of our courses are created with just that type of overall education strategy. Our Simulation Information Management System (SIMS) houses over 125 courses many which have extensive online materials for subject matter review prior to the actual simulation day. Subject materials may be pre-recorded lectures, PowerPoints, screen based simulations, videos demonstrating correct performance for example. Some courses even perform pre-tests before the actual simulation encounter to ensure that the cognitive preparation has been completed.

Intuitively it is easy to understand the advantages. The face-to-face time that students spend together in conjunction with faculty members is generally the most expensive time of the education. So it seems that we should be creating activities that maximize the effectiveness of the precious face-to-face time. Now the technology is no longer a barrier for the dissemination of information we can appeal to various learner types and styles, as well as keep the face-to-face time for much higher-levels of engagement. Thinking about it from a Kirkpatrick model we can move the reaction and learning levels to a more efficient off-site, self-paced exploration and learning, and then maximize the time the face-to-face environment with faculty to achieve higher levels of knowledge acquisition and expertise such as behaviors and results.

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Kirkpatrick Model of Training Evaluation

During the learning and reaction phases the learners can obtain the materials at their own pace and perhaps have a choice of methods by which to achieve the cognitive learning objectives. This increases the efficiency as learners who are mastering the material more quickly can move along to more advanced topics, and those who need a little more time, or need to review several times over have the ability to do so.

During the face to face sessions simulations scenarios can provide a deeply immersive learning environment for learners, and then this can be augmented by rich interactive discussion with faculty members as well as peers as continual mastery of the materials are recognized. The experiential learning offered by simulation can help to demonstrate the student’s mastery of the material from a cognitive perspective as well as demonstrate the ability to apply to real-world or near real world settings and circumstances.

This combination of cognitive priming or preparation with the experiential immersive process seems right to apply to the healthcare education environment. Recognizing that simulation, mannequin based simulation in particular, can be an expensive time-consuming endeavor; we need to ensure that we are maximizing the overall outcome of the educational experience.

Thus I argue simulation can be the Model Flipped Classroom and provide significant return on investment for topics that are appropriately bundled in the fashion described.

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