Tag Archives: healthcare simulation

Beware of the Educational Evangelist!

beware educational evangelistThey are everywhere now days like characters in pokemon go. They seem to hang out in high concentration around new simulation centers.

You know the type. Usually they start off by saying how terrible it is for someone to give a lecture. Then they go on to espouse the virtues and values of student – centered education claiming active participation and small group learning is the pathway to the glory land. They often toss in terms like “flipped classroom”. And just to ensure you don’t question their educational expertise they use a word ending with “-gogy” in the same paragraph as the phrase “evidence-based”.

If you ask them where they have been in the last six months you find out that they probably went to a weekend healthcare education reform retreat or something equivalent…….

My principal concern with the today’s educational evangelist is that they are in search of a new way of doing everything. Often times they recommend complete and total overhauls to existing curriculum without regard to a true understanding of how to efficiently and effectively improve, and/or analyze the existing resources required to carry out such changes.

Further, the evangelist usually has a favorite methodology such as “small group learning”, “problem-based learning” or “simulation-based learning” that they are trying to convert everyone to through prophecy.

An easy target of all educational evangelist is the lecture, and often that is where the prophecy begins. They usually want to indicate that if lecture is happening, learning is not. As I discussed in a previous blog article lecture is not dead, and when done well, can be quite engaging and create significant opportunities for learning and is maximally efficient in terms of resources.

If you think about a critically it is just as easy to do lousy small group facilitation as it is to do a lousy lecture. Thus, the potential gains in learning will not achieve maximal potential. The difference is small group facilitation like simulation, generally take significantly more faculty resources.

The truth is the educational evangelist is a great person to have in and amongst the team. Their desire for change, generally instilled with significant passion are often a source of great energy. When harnessed they can help advance and revise curricula to maximize, and modernize various educational programs.

However, to be maximally efficient all significant changes should undergo pre-analysis, hopefully derived from a needs assessment, whether it is formal or informal. Secondly, it is worth having more than one opinion to decide the prioritization of what needs to be changed in a given curriculum. While the evangelist will be suggestive that the entire curriculum is broken, often times with a more balanced review you find out that there are areas of the curriculum that would benefit from such overhaul, and some aspects that are performing just fine.

When you begin to change aspects of the curriculum, start small and measure the change if possible. Moving forward on a step-by-step basis will usually provide a far better revised curriculum then an approach that “Throws out the baby and the bathwater”. Mix the opinions of the stalwarts of the existing curriculum methods with the evangelists. Challenge existing axioms, myths and entrenched beliefs like “Nothing can replace the real patient for learning….” If this process is led well, it will allow the decision making group to reach a considerably more informed position that will lead to sound decisions, change strategies, and guide investments appropriately.

So if you’re the leader or a member of a team responsible for a given curriculum of healthcare instruction and confronted with the educational evangelist, welcome their participation. Include them in the discussions moving forward with a balanced team of people have them strive to create an objective prioritization of the needs for change. This will allow you to make excellent decisions with regard to new technologies and/or methods that you should likely embrace for your program. More importantly you will avoid tossing out the things that are working and are cost efficient.

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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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Great Debriefing Should Stimulate Active Reflection

shutterstock_284271476_aDebriefing in simulation as well as after clinical events is a common method of continuing the learning process through helping participants garner insight from their participation in the activity. It is postulated and I believe, part of the power of this “conversation” when call debriefing is when the participant engages in active reflection. The onus is on the debriefer to create an environment where active reflection occurs.

One of the most effective ways to achieve this goal is through questions. When participants are asked questions regarding the activity being debriefed it forces them to replay the scenario or activity in their mind. I find it helpful to begin with rather open-ended broader questions for two reasons. The first is to ensure the participant(s) are ready to proceed. Secondly asking broader questions at the beginning such as “Can you give me a recap of what you just experienced?” Helps to force the participant to think about the activity in a longitudinal way. Gradually the questions become much more specific to allow the participant to understand cause and effect relationships between their performance in the activity and the outcomes of the case.

Another thing to consider is that when debriefing multiple people simultaneously, when a recollection of the activity is being recalled by one participant, the other participants are actively thinking about their own recognition of said activity. Thus active reflection is again triggered. It is quite natural for the other participants to not only be thinking about the activity, but actively forming their own thoughts in a comparison/contrast type of cognitive activity. During this period they are comparing their own recollection of the activity with the one of the person answering the initial question.

Question should be focused in a way that the debriefer is controlling the conversation through a structured pathway that allows the learning objectives to be met. Further, when one develops good debriefing habits through the use of questioning it limits the possibility of the debriefing converting into a ”mini – lecture”.

I believe the Structured and Supported debriefing model created by my colleague Dr. John O’Donnell along with collaborators, provides the best framework by which to structure the debriefing. His use of the GAS mnemonic has effectively allowed the model to be introduced to both novice and expert debriefers alike and facilitate an easily learned structured framework into their debriefing work. We have been able to successfully introduce this model across many cultures and at least five different languages and have had significant success.

Worksheets, or job-aids with some example questions that parallel the learning objectives can be written on such tools prior to the scenario commencement. Supplementing the job aid with additional notes during the performance of the scenario can be helpful to recall the important points of discussion at the time of debriefing, and the preformed questions can serve as gentle reminders to the debriefer on topics that must be covered to achieve a successful learning outcome.

So a challenge to you is the next time you conduct a debriefing be thinking in the back of your mind how can I best force my participants to engage in active reflection of the activity that is bring debriefed. In addition, I would recommend that you practice debriefing as often as you can! Debriefing is an activity that improves over time with experience and deliberate practice.

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The Contract Essential to the Parties of Simulation

If you think about it an agreement needs to exist between those whom facilitate simulation and those who participate. Facilitate the purposes of this discussion is referring to those who create and execute simulation based learning encounters. Sometimes the agreement is more formal other times more implied. This phenomenon has been described in many ways over the yearsshutterstock_226296865 having been branded by such descriptors as fiction contract, psychological contract, or learning contract.

Why does this need to be the case? A contract or agreement is generally called for when two or more parties are engaging in some sort of collaborative relationship to accomplish something. Often times these type of contracts spell out the responsibilities of the parties involved. If you think about simulation at a high level the facilitator side is agreeing to provide learning activities using simulation to help the participant(s) become better healthcare providers. The participants are engaged at the highest level because they want to become better healthcare providers. While not trying to hold a comprehensive discussion, let’s explore this concept and the responsibilities of each party a bit further.

Facilitators are designing simulation activities with a variety of tools and techniques that are not perfect imitators of actual healthcare. They are crafting events for which the participant to a greater or lesser extent immerse themselves in, or at a minimum simply participate. Some of these activities are designed to contain diagnostic mystery, some demand specific knowledge, skills and attitudes be known or developed to successfully complete the program. Facilitators are also putting participants in situations that the must perform in front of others and that can create feelings of vulnerability. So all toll, the role of the facilitator comes with enormous responsibility.

Facilitators are also asking the participants to imagine part of what they are engaging in is a reasonable facsimile of what one may encounter when providing actual healthcare. Therefore another tenet of the agreement is that the facilitator will provide an adequate orientation to the simulation environment pointing out what is more and less real including the role that the participant may be playing and how their role interacts with the environment outside of the simulation, if at all. (I.e. define any communications that may occur during the simulation between the participants and the facilitator.

Facilitators trained in simulation know that mistakes occur sometimes due to a lack of knowledge, incorrect judgement or unrelated issues such as a poorly designed simulation. Facilitators thereby commit to not judge the participant in anything other than their performance during the simulation. While diagnostic conundrums are inevitable in many types of simulations the facilitator should not try to unnecessarily trick or mislead the participant in any way that is not directly contributing to helping the participant(s) improve. The facilitator must attempt to use the time of the participants wisely and responsibly.

The role of the participant shares responsibilities as a part of the agreement as well. Participants agree to a commitment to become better healthcare providers through continuous learning and improvement. This is inherent in a professional, but there are some likely good reasonsshutterstock_147464348 to remind participants of this important premise.

Participants must agree to the use of their time to participate in the simulation. The participants are also agreeing to an understanding that they know the environment of the simulation is not real, and that there will be varying levels of realism employed to help them perform in the simulation. But to be clear they agree to this tenet predicated on the trust that that facilitators are having the participant experience simulations that are relevant to what they do, with an underlying commitment to help them get better. In simulations involving multiple participants, they must also agree to similarly not judge others on what occurs in the simulation, as well as keeping the personal details of what they experience in the simulation confidential.

So in closing, successful simulation or other immersive learning environments require an agreement of sorts between those who create and execute the simulation based learning environments as well as those who participate in them. Each party brings a set of responsibilities to the table to help to ensure a rich learning environment with appropriate professional decorum and commitment to improvement. The agreements range from implicit to explicit, but when they exist and are adhered to will continue to allow the recognition of value that can arise from simulation to help improve the care ultimately delivered to our patients. After all, isn’t that our highest goal?

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Simulation Programs Should Stop Selling Simulation

SimforSaleWhatever do I mean? Many established simulation programs believe that their value is through creating simulation programs for people by which to attain knowledge, skills and/or perfect aspects of that needed to effectively care for patients. All of that is true, obviously. However, I believe that the true value of many established simulation programs is in the deep educational infrastructure that they provide to the institution with whom they may be affiliated. Whether that expertise is in the project management of educational design, educational design itself, the housing of the cadre of people who are truly interested in education, or the operational scheduling and support needed to pull off a major program, I believe these examples are the true understated value of many simulation programs.

Simulation programs tend to attract a variety of people who are truly interested in education. While I don’t think that everyone who is passionate about teaching in healthcare needs to be an educational expert, I do believe that it is important that we have people involved in the development and deployment of innovative education who are truly interested in teaching. Many hospitals and universities rely on personnel to conduct their education programs that are subject matter experts, but may or may not have desire, interest or satisfactory capabilities needed for teaching.

Many people who are passionate about teaching in healthcare have a particular topic or two that they like to teach about, but lack the skills of critical analysis, and deeper knowledge of educational design principles to help them parse their education efforts into the appropriate methods to create maximal efficiency in the uptake of the subject matter.  This very factor is likely why we still rely on good old-fashioned lecture as a cornerstone of healthcare education whether we are evaluating that from the school perspective, or the practicing healthcare arena. Not that I believe there is anything wrong with lecture, I just believe that it is often overused, often done poorly, and often done in a way that does not encourage active engagement or active learning between the lecturer in the participant’s.

Simulation programs are often the water cooler in many institutions around which people that are truly interested in and may have some additional expertise in an education will tend to congregate. The power of this proximity creates an environment rich for brainstorming, enthusiasm for pushing the envelope of capabilities, and continuous challenge to improve the methods by which we undertake healthcare education.

Simulation programs that have curricular development capabilities often have project management expertise as well as operational expertise to create complex educational solutions. This combination of skills can be exceptionally valuable to the development of any innovative education program in healthcare whether or not simulation is part of the equation.

Many times healthcare education endeavors are undertaken by one or two people who quickly become overwhelmed without the supporting infrastructure that it takes to put on educational activities of a higher complexity than a simple lecture. Often times this supporting technology or set of resources resides inside the walls of “simulation centers” are programs. By not providing access to these para-simulation resources to the rest of the institution, I argue that simulation programs are selling themselves short.

If you consider the educational outcomes from a leadership perspective (i.e. CEO, Dean etc.), They are much less concerned about how the educational endeavor occurred, but far more focused on the outcomes. So while there are many topics and situations that are perfect for simulation proper, we all know there is a larger need for educational designs with complexity larger than that of a lecture that may not involve simulation.

If a given simulation program partners with those trying to create complex educational offerings that don’t directly involve simulation, but are good for the mission of the overall institution with whom they are aligned, it is likely going to endear, or create awareness for the need for continuing or expanding the support of that particular program by the senior leadership team.

If you sit back and think about it, isn’t that an example of great teamwork?

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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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Running Scenarios “On-the-Fly” is Like Typing PowerPoint Slides in Front of a Live Audience

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Could you imagine sitting at a lecture at a meeting and the presenter was typing the information to create the slides while theydelivered the lecture? I believe it would be maddening, particularly if the person didn’t type very well!  Well folks, that is akin to what you are doing when you run your SimMan scenarios “on the fly”. Actually it is likely worse. I am writing this post in the context of SimMan because that is the system of which I have the most hands on expertise, but this story applies to almost all of the commonly available computerized patient simulators available at the present time.

Begin by asking your self, why do I create a PowerPoint to use during my presentation ahead of time, instead of in front of an audience? The answer is because you want to pre-populate, or preprogram frames of information grouped together to help your audience understand what is going on. The information that you are likely pre-populating your slides with is likely to complex, or at least too cumbersome to type out in front of the audience. In addition, you likely save your PowerPoint presentation so you can use it again and deliver the same or similar presentation with some consistency, I would ask you to realize, that this same thought process could be applied to the preprogramming of the simulator presentation during a scenario.

When you use a computerized simulator during a scenario, you are asking the participant to look at the frames of information that you are presenting to them. The individual vital signs, perhaps a sound or some other visual aid may all be part of what you want them to see. They begin to interpret your story usually in the context of a clinical situation requiring their interpretation, analysis and treatment or decisions.

As you allow the story to evolve in response to their actions or inactions, the simulator may changes states. For instance, in response to a proper treatment, you may want the vital signs to improve. Think of this as when you want to tell something different in your presentation you witch to another PowerPoint slide. Why? Because you want to present the next frame of information to the audience.SimMan

No matter where I travel in the world there is a common theme that I hear regarding SimMan scenarios. That is to say that people say “we tried programming and that didn’t work, so now we do run them on the fly.” When I ask for more details the story is usually the same. Participants always do things that we aren’t expecting and we need to “take over” is a common response. There is a feeling that when you are in a preprogrammed scenario as a simulator operator that you are trapped. Guess what? This feeling may be valid depending on the style of programming that is employed.

Also think of it from a different angle, one of my previous blog post points out the complexity of vitals sign changes that need to change during a course of worsening hypoxia. I argue that it is essentially impossible to change everything in the same way every time a scenario is run. So in essence, you lose the ability to generate consistency in running your scenarios. This consistency, or reliability is important to achieve when using scenarios as assessments.

What is the problem? The Trainees? The Operator? The Software? The Programmer? I would submit that the software systems that accompany most patient simulator these days are quite sophisticated with very deep capabilities. Most of us only learn them superficially at best. Further, those who take classes usually learn from a representative of the company who sold the equipment and there style of programming often doesn’t match reality.

Well the first lessen is participants ALWAYS do something unexpected, or at least almost always. So therefore if your scenario programming STYLE boxes you into a corner when the unexpected happens, you should change your ways, not abandon the work!

One of the best ways to get started with a comfort zone of using programmed scenarios is to use the software to create your initial set of vitals. If you think about it, just setting vitals alone causes a significant amount of task loading at the beginning of the scenario. If a patient is in shock, you would likely at a minimum, change the heart rate, pulse rate, resp rate, oxygen sats, End tidal CO2 and on and on. All of this if of course depending on the complexity and depth of clinical information you are trying to control for a given scenario.

I think of the example above every time I get to drive my wife’s car. I sit in the drivers seat and push a button labeled ‘[Driver] 2’. When I do this, the seat moves, backwards, reclines slightly, the steering wheel moves away from me and down a bit, and the mirrors adjust to where I had them previously. Brilliant! Pushing one button set so many things that I may have to adjust manually. This saves time and ensures a consistency in my experience when driving her car.

The properly pre-programmed scenario offers you quick set up (like my wife’s car), flexibility, consistency in presentation, ways to deal with unexpected, and maybe most importantly, helps allow you to observe the scenario more closely and worry about the simulator less.

This can be accomplished through an increased understanding of what the software can do, and a realistic application to your scenario objectives. Start by unlinking your changes in the vital signs or condition changes to the events playing out in front of you. Create menu items that have the simulator presentation get worse or get better, that you can trigger based on what you think should be happening based on the action or inactions of the participant(s).

Think about taking some small steps into embracing the pre-programmed scenario into your armamentarium of simulation tools. Do yourself a favor and take a simulator programming course from someone who is not a hardware company rep. Done properly, I promise you it will expand your capabilities as a simulation educator. It will also allow more flexibility in your scenario designs and increase the consistency when you run a given scenario.

Lastly, changes in the simulator condition is just part of the power of the software that you already own if you have a Laerdal Simulator. There is so much more to talk about in trying to convince you of the power that lurks inside your SimMan! I haven’t even begin to cover other technological assistance that can help with debriefing accuracy, structure and consistency, automating data collection and on and so much more!

With just a small investment in time and perhaps an adjustment to style, you can significantly boost the productivity of your Simulation program.  So fear no more, take the deep dive and learn more………

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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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Simulation is NOT the GOAL! – Shocking to some…..Important for us all!

We must continue to be mindful that the goal of healthcare simulation is not the simulation itself. It is easy to be enamored with the ability to re-create aspshutterstock_88037848_aects of the healthcare environment with equipment that is fun to work with and makes the participant go “WOW!!!!” It is also fun to surprise participants from time to time and experience the joy of seeing a participant or group achieve an “ahaaaa” moment created by one of our simulations.

However fun, useful, exciting and relevant the situation; the simulation is not the ultimate goal. This concept must be in the back of every successful simulation faculty member. The goals of the activity are driven by the objective and assessment tools that the simulation is designed to accomplish. The ultimate goal is better trained and more confident healthcare providers of all levels!

Whether you are considering what simulation equipment to purchase, designing the audio and visual systems, data collection or floor plans of a new program, it will serve you well to continue to focus on the mission. Many times the ability to recreate fanciful renditions of highly complex situations takes over as the chief aim and end up costing more money and consuming more resources then may be necessary. The mission that is detailed enough to allow a drill-down to the learning objective level to help guide the procurements sensibly.

I can not tell you how many times we have had a well meaning faculty member see a fancy simulator at a national meeting and then return home to want to purchase one. Then as we take the time to analyze the goals of what the goal of the education that the faculty member is setting out to accomplish, we find that the newest, fanciest, whiz-bang simulator is necessary after all. Often times a lesser-cost piece of equipment will suffice.

Don’t get me wrong, I still get excited every year on exhibit hall floors seeing the new technology becoming available for our profession and ostensibly designed to benefit healthcare providers and patients for the future. But we must keep that enthusiasm under control to be able to make objective decisions on the types of purchases we make and the designs we create.

Similarly the designs of our scenarios including what we include and exclude should go though a similarly rigorous evaluation process. There is no sense making a scenario more complicated to set up, execute and break down unless each element contributes directly to the learning objectives.shutterstock_133235459_a

This will allow us to hit the bull’s eye with effectiveness and efficiency in the use of simulation into the future. That will help us toward the real goal!

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