Tag Archives: training

5 Elements in My Approach to the Learning Contract in Simulation

In simulation-based education there is a relationship between the faculty of the program and the participants that is important during all aspects of simulation. The relationship has tenets of trust and respect that must be considered when designing as well as conducting simulations. I have heard this relationship referred to by a few titles such as psychological contract, fiction contract, learning contract, all of which are generally referring to the same thing.Smiling asian female vacancy candidate shaking hand with hr manager

Probably more important than the title, is what such a relationship embodies or focuses on. I view it as an agreement between two or more parties that acknowledges several aspects of simulation based programs and works to establish rules of engagement and principles of interactions between those involved.

In my practice of using simulation for clinical education I work a great deal with practicing professionals, who by in large are physicians. I generally adhere to five elements or premises over the course of interactions that I design as well as provide for the participants of my programs.

  1. Meaningful use of Your Time.

Acknowledging up front that participating in learning activities takes time away from their busy schedule. I assure them that the content of the program is carefully crafted to fill the needs of their learning cohort in the mostly timely way possible. I refer to refinements of the course that have occurred in response to feedback from prior participants to help increase the efficiency and effectiveness of the program.

  1. This is NOT real and that’s really ok!

During the orientation I am always careful to point out that not everything they are going to experience will look or feel real. I include the idea that things are “real-enough” to help us create a successful learning environment. I also let them know the things that may feel somewhat real during the simulation. Additionally, I emphasize that the “realness” is not the primary focus and point out that the learning and reinforcement of high-quality clinical practice is the ultimate outcome.

  1. We are not here to trick you.

I find that practicing professionals often come to simulation training endeavors with an idea that we design programs to exploit their mistakes. I assure them this is not the case. I am careful to include an overview of what they can expect during all phases of the learning. For example, when I am conducting difficult airway programs, I carefully orient them to every feature of the simulators airway mechanics before starting any scenarios. I also let them know that the cases associated with our scenarios are modeled after actual cases of clinical care. I explain that while we don’t model every detail of the case, that we work hard to design situations that provide opportunity to promote discussion and learning that would have or should have resulted from the actual case.

  1. Everyone makes mistakes. We are here to learn from each other.

At the most basic part of this element, I point out that WE all make mistakes and that is part of being human. I let them know that everyone is likely to make a mistake throughout the learning program. I carefully weave in the idea that it is far better to make mistakes in the simulated environment as opposed to when providing actual clinical care.

Further, I advance the idea that we can learn from each other. As everyone in clinical practice knows, there are many ways to do most things correctly. While this idea can be challenging because often people feel that “their way” is the correct way, I point out that with an open mind and professional, collaborative discussion we can share learnings with each other.

Contract Signing Concept

  1. We are here to help you be the best you can be.

Leveraging the idea that almost all practicing professional hold themselves to high levels of performance standards as well as the desire to improve can provide a powerful connection between the faculty and participants of a healthcare simulation program. I put forth this idea along with carefully tying in a review of the prior four elements. Further, I point out to them the opportunity to perfect the routine exists in our learning programs. I then pivot to highlight that some aspects of the program exist to practice and learn from situations that they may encounter infrequently that may have high stakes for the patient.

So, in summary, I believe the relationship between faculty members and participants of simulation-based education programs is multi-factorial and demands attention. Depending on the learners and the topics of the program, the elements that serve as the underpinning of the relationship may range from few to many, and moderate to significant in complexity.

In my simulation work providing clinical education that involves practicing physicians as participants, I pay close attention to the five elements described above throughout the design as well as the conducting of the learning encounters.

I invite you to reflect upon your approach to the development and maintenance of the relationship between your faculty and participants of your simulation efforts.




Filed under debriefing, design, simulation

Don’t Let the Theory Wonks Slow Down the Progress of Healthcare Simulation


Those of us in the simulation community know well that when used appropriately and effectively simulation allows for amazing learning and contributes to students and providers of healthcare improving the craft. We also know there is very little published literature that conclusively demonstrates the “right way to do it”.

Yet in the scholarly literature there is still a struggle to define best practices and ways to move forward. I believe it is becoming a rate limiting step in helping people get started, grow and flourish in the development of simulation efforts.

I believe that part of the struggle is a diversity of the mission of various simulation programs ranging from entry level students to practicing professionals, varying foci on individualized learning incompetence, versus and/or team working communications training etc. Part of the challenges in these types of scholarly endeavors people try to describe a “one-size-fits-all“ approach to the solution of best practices. To me, this seems ridiculous when you consider the depths and breadth of possibilities for simulation in healthcare.

I believe another barrier (and FINALLY, the real point of this blog post 🙂  is trying to overly theorize everything that goes on with simulation and shooting down scholarly efforts to publish and disseminate successes in simulation based on some missing link to some often-esoteric deep theory in learning. While I believe that attachments to learning theory are important, I think it is ridiculous to think that every decision, best practice and policy in simulation, or experimental design, needs to reach back and betide to some learning theory to be effective.

As I have the good fortune to review a significant number simulation papers it is concerning to me to see many of my fellow reviewers shredding people’s efforts based on ties to learning theories, as well as their own interpretations on how simulation should be conducted. They have decided by reading the literature that is out there (of which there is very little, if any, conclusive arguments on best practices) has become a standard.

My most recent example is that of a paper I reviewed of a manuscript describing an experimental design looking at conducting simulation one way with a certain technology and comparing it to conducting the simulation another way without the technology. The authors then went on to report the resulting differences. As long as the testing circumstances are clearly articulated, along with the intentions and limitations, this is the type of literature the needs to appear for the simulation community to evaluate and digest, and build upon.

Time after time after time more recently I am seeing arguments steeped in theory attachments that seem to indicate this type of experimental testing is irrelevant, or worse yet inappropriate. There is a time and place for theoretical underpinnings and separately there is a time and place for attempting to move things forward with good solid implementation studies.

The theory wonks are holding up the valuable dissemination of information that could assist simulation efforts moving forward. Such information is crucial to assist us collectively to advance the community of practice of healthcare simulation forward to help improve healthcare globally.  There is a time to theorize and a time to get work done.

While I invite the theorist to postulate new and better ways to do things based on their philosophies, let those in the operational world, tell their stories of successes and opportunities as they are discovered.

Or perhaps it is time that we develop a forum or publication of high quality, that provides a better vehicle for dissemination of such information.

So…… in the mean time….. beware of the theory wonks. Try not to let them deter from your efforts to not only move your own simulation investigations forward, but to be able to disseminate and share them with the rest of the world!

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Filed under Curriculum, design, patient safety, return on investment

FIVE TIPS on effectively engaging adult learners in healthcare simulation

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Filed under Curriculum, design

Simulation Technicians – Part of the Critical Recipe of Success

SimTech.aJust about every successful simulation in the world has one thing in common. No its not a high fidelity design, great curricular integration or a fabulous debriefing. What is it then?????  Answer: There was a Simulation Technician involved. Sim Techs are crucial to the success of programs and are integral to any team using significant simulation. Sim Techs come in many varieties in terms of backgrounds, titles, and in some smaller programs, many share one of many responsibilities.

I do have a bias that I will disclose. I started my career as an Electronics Technician in the US NAVY. After nearly two years of Navy training I cut my teeth aboard an Aircraft Carrier, the USS John F Kennedy (CV-67). Now that was truly an immersive learning experience! USS.JFKAfter I screwed something up one day when we were off the coast of Libya in 1986, the Electronics Materials Officer called me in the office and said “Son, do I have to remind you where this boat is pointed?” me: “No Sir!”  him: “Now stop being a technician and join this team as a thinker.”

It is important to engage the Sim Tech in every aspect of the simulation. Too often they are thought of as “just a tech”, but this is a HUGE mistake. Engaged professional Sim Techs are capable of many things that can add value to your program beyond setting up, driving mannequins and cleaning up.

Sim Techs are capable of learning how to evaluate and SOldering.asort high quality simulation from that needing improvement, or good debriefing to less than good. Dare I say…. They can also be trained to conduct or participate in debriefings in very creative ways. Sim Techs interacting with your participants can help to alleviate anxiety and get ahead of problems before they occur. They can play a significant role in your quality improvement programs. After all, you have to imagine. They see a lot of simulation!

Sim Techs are highly capable at helping to orient faculty and help to get faculty functioning at a higher level. This may include how to operate A/V equipment, drive simulator, or reset a simulation room to be ready for the next group.

Engaged Sim Techs take pride in their work, become embedded into the effort and share in the pain when something doesn’t go as planned. This level of ownership will often help to transition a program into high reliability operation that has everyone beaming with pride.

The Sim Tech community as a whole harbors a huge supply of energy and creativity and love to participate in being a part of solutions. Whether its moulage, creating a special SimTech2.aenvironment, app, smell, video, visual cue, you can call upon the technical community to solve it.

It is encouraging to see a more professional approach to the workforce development of the simulation community. Achieving certification as a Certified Healthcare Simulation Operations Specialist (CHSOS) through the Society for Simulation in Healthcare (SSH), can be a great source of professional pride for the technician in addition to ensuring competence in several important areas that well trained technicians should have as a minimum.

I would highly recommend encouraging your technicians to take part in training, attending meetings with other techs and engaging in the available networking can pay off in great dividends.  Being current with their knowledge and being able to interact closely with vendors to not only know what is coming out down the pike, but sometimes being able to influence future products are other reasons to make a place in your budget for technician training. In addition to meetings such as the International Meeting for Simulation in Healthcare (IMSH), several high-quality specialty meetings have been created that dedicate a sole focus on technical training from the SSH as well as specialty organizations such as SimGHOSTS. High quality training programs are being offered by simulation centers both in person and on-line such as ours at WISER.

No Simulation Technician is “just a tech” unless the program leadership makes them that. Embrace your technicians. Nurture their professional development and status in and among the team. Push the envelope of their capabilities and creativity to expand into new roles and ownership of your simulation efforts. You will not only be thankful, but wonder why it took so long to realize this is a vital ingredient to the sauce of success of highly capable simulation programs!


Filed under Uncategorized

Insitu Mock Codes Evaluate People Readiness and System Readiness – An Important Patient Safety Tool

CombinedTeamandEvaluationOver the last 20 years WISER has conducted hundreds of unannounced mock code evaluations at hospitals directly associated with our health system. Additionally we have assisted others with conducting and reporting on this important patient safety activity in hospitals both in the US and outside. As it is true in most things in simulation there is no binary answer on right versus wrong in the way simulation is carried out.

In situ mock codes bring a unique perspective that allows all of the effectiveness of simulation based education to be combined with human factors and systems testing that are crucial to ensure higher levels of patient safety for the increasingly ill patients who are being cared for in hospitals around the world. This is a patient population that is at well documented great risk for harm from errors that occur resulting from a myriad of causes ranging from human error to poorly design systems.

Mock codes in hospitals bring crucial insight into the care delivery that occurs episodically in high tempo, high stress unplanned situations in our hospitals. They can identify areas of deficiency that are not readily apparent. (Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes; Hunt et al. Pediatrics. 121(1):e34-43, 2008). We can gain unique perspectives such as where do we need to place AED’s? Is the hospital operator handling code requests in the most expedient fashion? Where in the hospital should responders respond from? It is these important system data points that can be understood from mock code data generation that are impossible to gain conclusive evidence from in the simulation lab, or in those mock codes that personnel know are of the simulated variety.

While we are able to do undeniable powerfully effective training in our simulation labs, it is the mock code and other insitu activities that help to bring true facts to factor into decisions that evaluate and ultimately improve patient safety. Do mock codes have the ability to lead to unintended harm or further error if not carefully planned carried out and monitored? Of course they do, and they must be regarded as such. But mopping the floor of the hospital also carries forth the increased possibility of hip fractures, yet it is a required element of infection control and with appropriate precautions and guidelines we make every attempt to minimize this potential risk.

Those of us in healthcare who are directly involved in the care of patients as well as those who have roles in system oversight of the direct care of patients recognize that with every intervention, every therapy and every procedure there are risks and benefits. The same goes for the training we provide. The fact that someone in a simulation center may get shocked by a defibrillator or stuck by a needle during simulation training are potential harms that may occur secondary to the use of simulation based education. So we recognize these risks through failure mode effect analysis, learning from others at meetings such as the International Meeting for Simulation in Healthcare (IMSH), remaining informed by current literature and implementing solutions that attempt to minimize these risks.

While Raemer does a wonderful job of pointing out some of the potential possibilities of potential hazards associated with mock codes (Ignaz Semmelweis Redux?; Sim Healthcare 9:153-155, 2014), this personal opinion piece does not actually include an overall analysis of risk vs. benefit. Nor does he present any data that combines evaluation of training programs, professional readiness and systems design with a quantitative deliverable that allows such an assessment. With the latter information properly collected and analyzed those of us involved in designing future care delivery systems through policy, investments in training, staffing and equipment will be better prepared to make a difference in the safety of patients.

The reference to the Owen article is baffling. (Unexpected Consequences of Simulator Use in Medical Education: A Cautionary Tale; Sim Healthcare 9:149-152, 2014). Professor Owen authored a remarkably elegant piece in this month’s SIH journal that was inappropriately titled in my opinion. The title seems to be one that attempts to be provocative in an ability to gain ones attention in the simulation world.  (That part was effective I must admit, as I read the article immediately.) However the article and its title implies that the use of simulation CAUSED untoward outcomes in patients. From a root cause perspective in the information presented in the article, that is NOT THE CASE. The poor outcomes were associated with the lack of hand hygiene and the lack of knowledge associated with proper hand cleaning and infection transmission. It is analogous to saying that an automobile striking a pedestrian is the fault of the car.

I would estimate real codes occur in our healthcare system (of 20 hospitals/care facilities) roughly 50 times per day. So if we simply take 50 codes per day that is 18,250 codes per year. This is not a rare critical event; this is a common critical event that we still have much to learn about from a training perspective as well as a systems design perspective. We all know there are delays and errors associated with codes in general. My colleagues and I reported an enormous amount of medication administration errors during observations of REAL CODES (Medication errors during medical emergencies in a large, tertiary care, academic medical center; Resuscitation. 83(4):482-7, 2012 Apr) and that is just one element in the complex environment of actual codes.

Despite reams of paper trails, and gigabytes of data in the vaults of patient safety and risk management reports in the offices of hospitals, we still have very little insight into the actual root causes of the epidemic of harm to patients that occurs during hospitalization. The mock code, with its associated risks and POTENTIAL complications is an important tool in the armamentarium of patient safety probes that will ultimately save lives.


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Simulation and the Future of Customized Continuing Education for Practicing Professionals

Click Here to Watch the Video on YouTube

I posted a new video on the WISER You Tube channel describing how simulation can fit into a futuristic model of customizing a pathway of continuing education for practicing healthcare professionals. The model incorporates the utilization of healthcare system quality, safety and risk data. A provocative thought to move us down a road to help imoprove replace the time honored, yet inefficient system of continuing education that exists currently.


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November 13, 2013 · 7:50 pm