Transcript Document

Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
Medical Simulation:
Learning in Immersive
Environments
Michael Armacost, MA, NREMT-P
Banner Health Simulation & Innovation
Frederick, CO
David L. Rodgers, Ed.D., NREMT-P
Healthcare Simulation Strategies
Charleston, WV
Disclosure
Dr. Rodgers is a employed as a private curriculum and
instruction consultant. Laerdal Medical is one of his
clients.
Mr. Armacost has no disclosures
Objectives
Participants will be able to:
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Discuss the development of modern full-bodied manikin-based simulators to
its current state-of-the-art.
Differentiate between the meanings of low-, mid-, and high-fidelity simulation.
Explain the various types of simulation realism and how each impacts on the
learner.
Apply modern learning theory to simulation-based teaching.
Discuss a process to integrate a simulator into EMS curriculum.
Define the process of designing cases for simulation.
Discuss the role of simulation in team training and competency assessments.
Discuss several strategies to be used when facilitating a simulation session.
Welcome
What do you want to get out of
today’s program?
Video-based simulations
Virtual reality
Three-dimensional static models
Full-bodied manikin-based
Audio simulations
Task-specific simulators
Standardized patients
Written (paper) simulations
Animal models
Human cadavers
Computer-based clinical simulations
Video-based simulations
Virtual reality
Three-dimensional static models
Full-bodied manikin-based
Audio simulations
Task-specific simulators
Standardized patients
Written (paper) simulations
Animal models
Human cadavers
Computer-based clinical simulations
Full-bodied Manikin-based Simulation
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
From Beginnings to Stateof-the-Art: A Brief History of
Medical Simulation
David L. Rodgers, Ed.D., NREMT-P
Healthcare Simulation Strategies
Charleston, WV
The history of Patient Simulation
Other domains have used simulation
with success
First aviation simulator
developed in 1928 by
Edwin Link
1942 Link C-3 Simulator
The history of Patient Simulation
Patient simulation is not new!
Animal models for medical simulation have been used for
over 2,000 years
The history of Patient Simulation
First commercial manikin-based
simulator was introduced in
1911 – Mrs. Chase
The history of Patient Simulation
1960 – First manikin
specifically built for
resuscitation was
introduced – Resusci Annie
Asmund Laerdal and Bjorn Lind demonstrate
CPR on the original Resusci Anne
The history of Patient Simulation
1969 – SimOne developed as the first computer
controlled patient simulator
Abrahamson, S., Wolf, R. M., & Denson, J. S. (1969, October). A computer-based patient simulator
for training anesthesiologists, Educational Technology, 55-59..
The history of Patient Simulation
Computercontrolled
patient
simulators
1986 –
Gainesville
Anesthesia
Simulator
1986 –
MedSim
Eagle
1969 SimOne
1970
1980
1996 –
METI HPS
1990
2000 –
Laerdal
SimMan
2000
Questions?
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
Simulation Taxonomy:
Understanding Fidelity and
Realism in Patient Simulation
David L. Rodgers, Ed.D., NREMT-P
Healthcare Simulation Strategies
Charleston, WV
Simulation Terminology
The simulation literature has not
provided a consistent definition for
many of the terms vital to using
simulation.
Manikin vs. Mannequin
Gaba, D. (2006). What’s in a name: A mannequin by any other name would
work as well. Simulation in Healthcare, 1, 64-65.
What is patient simulation?
“Simulations are created experiences that mimic processes or
conditions that cannot or should not be experienced firsthand by a
student because of the student’s inexperience or the risk to the
patient (Morton, 1997, p. 66).”
“Simulation is a technique…to replace or amplify real experiences
with guided experiences that evoke or replicate substantial aspects
of the real world in a fully interactive manner (Gaba, 2004, p. i2).”
“Simulation is a generic term that refers to the artificial representation
of a real-world process to achieve educational goals via experiential
learning (Flanagan, Nestel, & Joseph, 2004, p. 57).”
What is patient simulation?
“Simulations are created experiences that mimic processes or
conditions that cannot or should not be experienced firsthand by a
student because of the student’s inexperience or the risk to the
patient (Morton, 1997, p. 66).”
“Simulation is a technique…to replace or amplify real experiences
with guided experiences that evoke or replicate substantial aspects
of the real world in a fully interactive manner (Gaba, 2004, p. i2).”
“Simulation is a generic term that refers to the artificial representation
of a real-world process to achieve educational goals via experiential
learning (Flanagan, Nestel, & Joseph, 2004, p. 57).”
What is patient simulation?
“Simulations are created experiences that mimic processes or
conditions that cannot or should not be experienced firsthand by a
student because of the student’s inexperience or the risk to the
patient (Morton, 1997, p. 66).”
“Simulation is a technique…to replace or amplify real experiences
with guided experiences that evoke or replicate substantial aspects
of the real world in a fully interactive manner (Gaba, 2004, p. i2).”
“Simulation is a generic term that refers to the artificial representation
of a real-world process to achieve educational goals via experiential
learning (Flanagan, Nestel, & Joseph, 2004, p. 57).”
What is patient simulation?
“Simulations are created experiences that mimic processes or
conditions that cannot or should not be experienced firsthand by a
student because of the student’s inexperience or the risk to the
patient (Morton, 1997, p. 66).”
“Simulation is a technique…to replace or amplify real experiences
with guided experiences that evoke or replicate substantial aspects
of the real world in a fully interactive manner (Gaba, 2004, p. i2).”
“Simulation is a generic term that refers to the artificial representation
of a real-world process to achieve educational goals via experiential
learning (Flanagan, Nestel, & Joseph, 2004, p. 57).”
What is patient simulation?
“Simulations are created experiences that mimic processes or
conditions that cannot or should not be experienced firsthand by a
student because of the student’s inexperience or the risk to the
patient (Morton, 1997, p. 66).”
“Simulation is a technique…to replace or amplify real experiences
with guided experiences that evoke or replicate substantial aspects
of the real world in a fully interactive manner (Gaba, 2004, p. i2).”
“Simulation is a generic term that refers to the artificial representation
of a real-world process to achieve educational goals via experiential
learning (Flanagan, Nestel, & Joseph, 2004, p. 57).”
What is patient simulation?
Created guided experiences that mimic
real-world processes or conditions to
achieve educational goals
Fidelity
“Fidelity is the extent to which the
appearance and behaviour of the
simulator/simulation match the
appearance and behaviour of the
simulated system (p. 23).”
Maran, N. J., & Glavin, R. J. (2003). Low- to high-fidelity simulation - A
continuum of medical education? Medical Education, 37 22-28.
Fidelity
Low-fidelity simulators are focused on single skills
and permit learners to practice in isolation.
Medium-fidelity simulators provide a more realistic
representation but lack sufficient cues for the learner
to be fully immersed in the situation.
High-fidelity simulators provide adequate cues to
allow for full immersion and respond to treatment
interventions.
Yaeger, K. A., Halamek, L. P., Coyle, M., Murphy, A., Anderson, J., Boyle, K., et al.
(2004). High-fidelity simulation-based training in neonatal nursing. Advances in
Neonatal Care, 4, 326-331.
Fidelity
a “system that presents a fully interactive
patient and an appropriate clinical work
environment (p. i5).”
Gaba, D. (2004). The future vision of simulation in health care. Quality and
Safety in Health Care, 13, i2-i10.
Fidelity
Equipment/Physical
Over 365 facilities in 48
states/provinces in the US
and Canada, Germany,
Brazil, and Japan are
participating in the
NRCPR.
Fidelity
Equipment
Task
Over 365 facilities in 48
states/provinces in the US
and Canada, Germany,
Brazil, and Japan are
participating in the
NRCPR.
Fidelity
Equipment
Task
Environmental
Over 365 facilities in 48
states/provinces in the US
and Canada, Germany,
Brazil, and Japan are
participating in the
NRCPR.
Fidelity
Equipment
Task
Environmental
Psychological
Over 365 facilities in 48
states/provinces in the US
and Canada, Germany,
Brazil, and Japan are
participating in the
NRCPR.
Which is more important for most
learning events …?
12%
A high-fidelity simulator
88%
A high-fidelity environment
0
10
20
30
40
50
60
70
80
90
100
Dieckmann, P. (2008). How much realism is needed in medical simulation? Presentation at the
International Meeting on Simulation in Healthcare, San Diego, Ca.
Same simulation
device, but completely
different learning
experiences
Suspension of disbelief
Questions?
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
Learning Theory and
Simulation: Knowing the
“Why” Behind Your
Teaching
David L. Rodgers, Ed.D., NREMT-P
Healthcare Simulation Strategies
Charleston, WV
Learning Theory in Patient Simulation
There is no “Simulation Learning Theory”
But, simulation can benefit from broader
learning theories
Experiential Learning Theory
Dominant learning theory in simulation
David Kolb – Chief proponent
Based on Kurt Lewin’s Experiential
Learning Cycle
Kolb, D. A. (1984). Experiential Learning: Experience as the Source of
Learning and Development. Prentice-Hall, Englewood Cliffs, NJ.
Experiential Learning Cycle
Concrete
Experience
Testing implication of
concepts in new situation
Formation of abstract
concepts and
generalizations
Observation
and Reflection
Adult Learning Theory
Adults have an intrinsic need to know
Adults have self-responsibility
Adults have a lifetime of experiences
Adults have an innate readiness to learn
Adults have a life-centered orientation to learning
Adults have internal motivators
Knowles, M., Holton, E., III, & Swanson, R. (1998). The adult learner (5th
ed.). Woburn, MA: Butterworth-Heinemann.
Brain-based Learning
• Three key instructional techniques for
Brain-Based Learning:
 Orchestrated immersion in complex experience
 Relaxed alertness
 Active processing
Caine, R. N. & Caine, G. (1994). Making Connections. Addison-Wesley,
Menlo Park, CA.
Brain-based Learning
• Three key instructional techniques for
Brain-Based Learning:
 Orchestrated immersion in complex experience
 Relaxed alertness
 Active processing
Learning environments designed to
fully immerse students in the learning
experience
Brain-based Learning
• Three key instructional techniques for
Brain-Based Learning:
 Orchestrated immersion in complex experience
 Relaxed alertness
 Active processing
Eliminate fear in the classroom while
also maintaining a challenging
educational climate
Brain-based Learning
• Three key instructional techniques for
Brain-Based Learning:
 Orchestrated immersion in complex experience
 Relaxed alertness
 Active processing
Allow time for the student to process
and internalize new information
Questions?
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
Break Time!
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
It’s All About Objectives:
Integration of Simulation
into Your Curriculum
Michael Armacost, MA, NREMT-P
Banner Health Simulation & Innovation
Frederick, CO
Objectives/Curriculum Integration
• Science of Expertise
• Types of Learning & Evaluation
• Examples
Objectives/Curriculum Integration
• Science of Expertise
Prior Knowledge and Learning
Novice to Clinical Expert
All knowledge is based upon what you
already know. The more you know –
the easier learning and instruction will
be.
Objectives/Curriculum Integration
Novice
Advanced
Beginner
Competent
Proficient
Expert
Objectives/Curriculum Integration
Novice
Advanced
Beginner
Competent
Proficient
 Prior knowledge lacking
 Needs rules free of context – Cognitive Load
 Difficulty with prioritization
 Little situational awareness
 Lacks communication skills
 Vulnerable
Expert
Objectives/Curriculum Integration
Novice
Advanced
Beginner
Competent
Proficient
 Uses checklist (think NR skill sheets)
 Trusts technology over patient
 Critical thinking is used more often
Disengagement with patient, family, environment
 Beginning of effective communication techniques
 Recognizes patient deterioration
Expert
Objectives/Curriculum Integration
Novice
Advanced
Beginner
Competent
Proficient
Expert
 Critical thinking and situational awareness demonstrated
 Present an effective report to a health care provider
 Questions technology based on patient presentation
 Begins to apply best practices
Objectives/Curriculum Integration
Novice
Advanced
Beginner
Competent
Proficient
 Incorporates best practices into patient care
 Ethical decision making becomes important
 Sees self as patient advocate
Professional behavior
Experiences provide strong framework for practice
Expert
Objectives/Curriculum Integration
Novice
Advanced
Beginner
Competent
Proficient
 Clinical leadership (not administrative)
 Has insight and vision
Can handle multiple complexities
Expert
Objectives/Curriculum Integration
• Science of Expertise
• Types of Learning & Evaluation
• Examples
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Initial Learning – Original Learning – EMT-B Initial Course
Refresher Learning – Practice and Tuning – EMT-P Refresher
Continuing Education – New Skills for the Old Dog – King Airway
Competency Assessment – Shut up and Show Me - Testing
Objectives/Curriculum Integration
• Science of Expertise
• Types of Learning & Evaluation
• Examples
 Initial Learning – Original Learning – EMT-B Initial Course
Objectives/Curriculum Integration
• EMT-Basic Initial Course - Example
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Vital Signs & orientation to the simulator (no scenarios)
Airway and breathing
Trauma & Patient Assessment
Medical & Patient Assessment
Altered Mental Status
Many others “typical”
Objectives/Curriculum Integration
• EMT-Basic Initial Course – Lessons Learned
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Focus on novice and advanced learner levels
Do not teach/practice task level skills in simulation
Patience (yours and theirs)
Cognitive load – making them cry is not a good outcome
Small group instructors – scripts, training, gags
It takes two (Driver and Facilitator)
Over the manikin debriefing vs. real debriefing
Objectives/Curriculum Integration
• Science of Expertise
• Types of Learning & Evaluation
• Examples
 Initial Learning - EMT-B Initial Course
 Refresher – EMT-P Refresher Course
Objectives/Curriculum Integration
• EMT- Paramedic Refresher - Example
How would you integrate simulation into your course?
PM Objectives?
Practice Analysis
Objectives/Curriculum Integration
• Science of Expertise
• Types of Learning & Evaluation
• Examples
 Initial Learning - EMT-B Initial Course
 Refresher – EMT-P Refresher Course
 Continuing Education – King Airway
Objectives/Curriculum Integration
• King Airway Continuing Ed - Example
How would you integrate simulation into your course?
 Task training
 Simulation training
 Competency
Questions?
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
Instructional Design for
Simulation: Designing
Branching Scenarios and
Creating Cases
Michael Armacost, MA, NREMT-P
Banner Health Simulation & Innovation
Frederick, CO
Instructional Design
•
•
•
•
Instructional Principles
Staff preparation
Environment
Scenario design
Instructional Design
Instructional Principles
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New K&S is built on prior knowledge (experience)
Hard work, frustration and pain (experience)
Learn by doing (experience)
Expectation failure (sweet spot)
Context and learning through stories (experience)
Reflection, self and coached
“For the things we have to learn before doing
them, we have to do them.” Aristotle
Instructional Design
•
•
•
•
Instructional Principles
Staff preparation
Environment
Scenario design
Instructional Design
Staff Preparation
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First, lets admit we teach how we were taught
Change is hard
We want our students to succeed
Letting people fail, is novel behavior for most instructors
Facilitation is a skill (new)
Driving is a skill (new)
Debriefing is a skill (new)
“I love the smell of neurons in the sim room!”
Instructional Design
Staff preparation (cont)
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Coaching and instruction
Facilitating and instruction
Using simulation to teach those who simulate
Standards of practice
Instructional Design
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•
•
•
Instructional Principles
Staff preparation
Environment
Scenario design
Instructional Design
Environment
 Suspending disbelief
 Too little vs. too much
 When technology gets in the way
“Simulation is mostly smoke and mirrors!” David Gaba
Instructional Design
•
•
•
•
Instructional Principles
Staff preparation
Environment
Scenario design
Instructional Design
Scenario Design
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Audience
Objectives
Stories
Branching
Failure and death (the ultimate bad branch)
Programming the beast
Testing, testing and more testing
Instructional Design
Objectives
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Don’t kill the patient
Diagnosis
Patient assessment
Problem solving
Communications
Teamwork
Situational awareness
Integrate new procedure, tool, etc.
Focus
Instructional Design
Scenario Design
C
Home State
C
Failure
C
Completion
C
Instructional Design
Programming
Stages of the Program
TIME
1.
2.
3.
4.
5.
Stable state
Initial presentation
Branch #1 – Patient unchanged
Branch #2 - Patient deteriorates (death spriral ?)
Branch #3 - Patient improves
Driving on the fly – Experience required
Instructional Design
•
•
•
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Instructional Principles
Staff preparation
Environment
Scenario design
Questions?
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
Added Value of a Simulator:
TEAM/CRM Training and
Using Simulation for
Competency Assessment
Michael Armacost, MA, NREMT-P
Banner Health Simulation & Innovation
Frederick, CO
TEAM/CRM
• Crisis Resource Management & Simulation
• Using simulation for competency assessment
TEAM/CRM
• Crisis Resource Management & Simulation
• Using simulation for competency assessment
TEAM/CRM
Crisis Resource Management & Simulation
 Crew Resource Management (CRM)
 Anesthesia Crisis Resource Management (ACRM)
 Crisis Resource Management (CRM)
TEAM/CRM
Example #1
TEAM/CRM
Example #2
TEAM/CRM
Characteristics of good team environment in a medical
high-stakes environment
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Team formation and positive team climate
Establish team leadership
Solve conflicts constructively
Communicate and share your mental models
Coordinate task execution
Cross-monitor your teammates
Share workloads and be true to your performance limits
Apply problem-solving strategies
Improve team skills
Competency
Competency Assessment and Simulation
The cost of not doing it are too high.
The groundwork is done.
You have to able to demonstrate it.
It wont involve a #2 pencil.
It wont be an oral station.
Simulation principles can provide a safe, economical method
to repeatedly measure people doing stuff.
 We need to change our culture around competency.
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TEAM/CRM
• Crisis Resource Management & Simulation
• Using simulation for competency assessment
Questions?
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
Debriefing 101
Michael Armacost, MA, NREMT-P
Banner Health Simulation & Innovation
Frederick, CO
David L. Rodgers, Ed.D., NREMT-P
Healthcare Simulation Strategies
Charleston, WV
Reflection/Debriefing
To be complete, a simulation needs to be more
than just the experience. Debriefing following a
simulation experience provides the opportunity
for reflection on actions.
This is where the real learning occurs
Schon, D. A. (1983). The Reflective Practitioner: How Professionals Think in
Action. Basic Books, NY.
Reflection/Debriefing
Do…
• Set the expectation for learner participation
• Guide the session to the extent necessary to achieve the debriefing
objectives
• Adjust facilitation to the level needed to engage the learner to the
maximum extent possible
• Draw out quiet learners
• Ensure that all critical points are covered
• Integrate instructional points as needed into the learners’ discussion
• Reinforce positive aspects of the learners’ behavior
McDonnell, L. K., Jobe, K. K., & Dismukes, R. (1997). Facilitating LOS Debriefings: A Training Manual: National
Aeronautics and Space Administration, NASA Technical Memorandum 112192, DOT/FAA/AR-97/6
Reflection/Debriefing
Don’t …
• Lecture and have the debriefing become an instructor-centered session
• Give your own analysis and evaluation before the learner has
completed their analysis
• Give the perception that only your perceptions are important
• Interrupt learner discussion
• Interrogate – be positive when discussing problems
• Have a rigid agenda
• Shortchange high-performance learner by cutting sessions short
McDonnell, L. K., Jobe, K. K., & Dismukes, R. (1997). Facilitating LOS Debriefings: A Training Manual: National
Aeronautics and Space Administration, NASA Technical Memorandum 112192, DOT/FAA/AR-97/6
Rudolph, J., R. Simon, et al. (2006). "There's no such thing as "nonjudgmental
debriefing: A theory and method for debriefing with good judgment." Simulation in
Healthcare 1(1): 49-55.
Reflection/Debriefing
Demonstration & Practice
Questions?
Gateway to Education – 2008 Symposium
Sept. 11, 2008, St. Louis, MO
Lunch!
Contact Information
Michael Armacost, MA, NREMT-P
Banner Health Simulation & Innovation
970.203.6704
[email protected]
BannerHealthInnovations.org
David L. Rodgers, Ed.D., NREMT-P
Healthcare Simulation Strategies
304.444.1078
[email protected]
www.sim-strategies.com