Tag Archives: healthcare simulation

August 18, 2015 · 2:56 am

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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May 6, 2015 · 6:28 pm

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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April 8, 2015 · 7:44 pm

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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October 16, 2014 · 5:51 pm

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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February 4, 2014 · 6:02 pm

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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November 20, 2013 · 2:55 pm

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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September 6, 2013 · 11:40 am

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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