Tag Archives: healthcare simulation

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


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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