medical simulation: learning in immersive environments michael armacost, ma, nremt-p banner health...

Medical Simulation: Learning in Immersive Environments

Michael Armacost, MA, NREMT-PBanner Health Simulation & InnovationFrederick, CO

David L. Rodgers, Ed.D., NREMT-PHealthcare Simulation StrategiesCharleston, WV

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

DisclosureDisclosure

Dr. Rodgers is a employed as a private curriculum and instruction consultant. Laerdal Medical is one of his clients.

Mr. Armacost has no disclosures

ObjectivesObjectives

Participants will be able to:

• 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.

WelcomeWelcome

What do you want to get out of today’s program?

Full-bodied manikin-based

Video-based simulations

Audio simulations

Computer-based clinical simulations

Written (paper) simulations

Standardized patients

Human cadavers

Animal models

Three-dimensional static models

Task-specific simulators

Virtual reality

Full-bodied manikin-based

Video-based simulations

Audio simulations

Computer-based clinical simulations

Written (paper) simulations

Standardized patients

Human cadavers

Animal models

Three-dimensional static models

Task-specific simulators

Virtual reality

Full-bodied Manikin-based SimulationFull-bodied Manikin-based Simulation

From Beginnings to State-of-the-Art: A Brief History of Medical Simulation

David L. Rodgers, Ed.D., NREMT-PHealthcare Simulation StrategiesCharleston, WV

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

The history of Patient SimulationThe 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 SimulationThe 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 SimulationThe history of Patient Simulation

First commercial manikin-based simulator was introduced in 1911 – Mrs. Chase

The history of Patient SimulationThe 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 SimulationThe 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 SimulationThe history of Patient Simulation

1969 - SimOne

1986 – MedSim

Eagle

1986 – Gainesville Anesthesia Simulator

1996 – METI HPS

2000 – Laerdal SimMan

1970 1980 1990 2000

Computer-controlled patient simulators

Questions?

Simulation Taxonomy: Understanding Fidelity and Realism in Patient Simulation

David L. Rodgers, Ed.D., NREMT-PHealthcare Simulation StrategiesCharleston, WV

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

Simulation TerminologySimulation 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? 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? 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? 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? 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? 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? What is patient simulation?

Created guided experiences that mimic real-world processes or conditions to achieve educational goals

FidelityFidelity

“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.

FidelityFidelity

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 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.

Over 365 facilities in 48 states/provinces in the US and Canada, Germany, Brazil, and Japan are participating in the NRCPR.

Equipment/Physical

FidelityFidelity

Over 365 facilities in 48 states/provinces in the US and Canada, Germany, Brazil, and Japan are participating in the NRCPR.

Equipment

Task

FidelityFidelity

Over 365 facilities in 48 states/provinces in the US and Canada, Germany, Brazil, and Japan are participating in the NRCPR.

Equipment

Task

Environmental

FidelityFidelity

Over 365 facilities in 48 states/provinces in the US and Canada, Germany, Brazil, and Japan are participating in the NRCPR.

Equipment

Environmental

Psychological

Task

FidelityFidelity

Which is more important for mostlearning events …?

A high-fidelity simulator

A high-fidelity environment

12%

88%

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?

Learning Theory and Simulation: Knowing the “Why” Behind Your Teaching

David L. Rodgers, Ed.D., NREMT-PHealthcare Simulation StrategiesCharleston, WV

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

Learning Theory in Patient SimulationLearning Theory in Patient Simulation

There is no “Simulation Learning Theory”

But, simulation can benefit from broader learning theories

Experiential Learning TheoryExperiential 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 CycleExperiential Learning Cycle

Concrete Experience

Testing implication ofconcepts in new situation

Observation and Reflection

Formation of abstractconcepts and

generalizations

Adult Learning TheoryAdult Learning Theory

Adults have an intrinsic need to know

Knowles, M., Holton, E., III, & Swanson, R. (1998). The adult learner (5th ed.). Woburn, MA: Butterworth-Heinemann.

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

Adults have self-responsibility

Brain-based LearningBrain-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.

• 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 LearningBrain-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 LearningBrain-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

Brain-based LearningBrain-based Learning

Questions?

Break Time!

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

It’s All About Objectives: Integration of Simulation into Your Curriculum

Michael Armacost, MA, NREMT-PBanner Health Simulation & InnovationFrederick, CO

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

Objectives/Curriculum Integration Objectives/Curriculum Integration

• Science of Expertise• Types of Learning & Evaluation• Examples

Objectives/Curriculum Integration Objectives/Curriculum Integration

• Science of ExpertisePrior Knowledge and LearningNovice 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 Objectives/Curriculum Integration

NoviceAdvanced Beginner Competent Proficient Expert

Objectives/Curriculum Integration Objectives/Curriculum Integration

NoviceAdvanced Beginner Competent Proficient Expert

Prior knowledge lacking

Needs rules free of context – Cognitive Load

Difficulty with prioritization

Little situational awareness

Lacks communication skills

Vulnerable

Objectives/Curriculum Integration Objectives/Curriculum Integration

NoviceAdvanced Beginner Competent Proficient Expert

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

Objectives/Curriculum Integration Objectives/Curriculum Integration

NoviceAdvanced 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 Objectives/Curriculum Integration

NoviceAdvanced Beginner Competent Proficient Expert

Incorporates best practices into patient care

Ethical decision making becomes important

Sees self as patient advocate

Professional behavior

Experiences provide strong framework for practice

Objectives/Curriculum Integration Objectives/Curriculum Integration

NoviceAdvanced Beginner Competent Proficient Expert

Clinical leadership (not administrative)

Has insight and vision

Can handle multiple complexities

Objectives/Curriculum Integration Objectives/Curriculum Integration

• Science of Expertise• Types of Learning & Evaluation• Examples

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 Objectives/Curriculum Integration

• Science of Expertise• Types of Learning & Evaluation• Examples

Initial Learning – Original Learning – EMT-B Initial Course

Objectives/Curriculum Integration Objectives/Curriculum Integration

• EMT-Basic Initial Course - Example

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 Objectives/Curriculum Integration

• EMT-Basic Initial Course – Lessons Learned

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 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 Objectives/Curriculum Integration

• EMT- Paramedic Refresher - Example

How would you integrate simulation into your course?

PM Objectives?PM Objectives?

Practice AnalysisPractice Analysis

Objectives/Curriculum Integration 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 Objectives/Curriculum Integration

• King Airway Continuing Ed - Example

How would you integrate simulation into your course?

Task training Simulation training Competency

Questions?

Instructional Design for Simulation: Designing Branching Scenarios and Creating Cases

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

Michael Armacost, MA, NREMT-PBanner Health Simulation & InnovationFrederick, CO

Instructional DesignInstructional Design

• Instructional Principles• Staff preparation• Environment• Scenario design

Instructional DesignInstructional Design

Instructional Principles

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 DesignInstructional Design

• Instructional Principles• Staff preparation• Environment• Scenario design

Instructional DesignInstructional Design

Staff Preparation

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 DesignInstructional Design

Coaching and instruction Facilitating and instruction Using simulation to teach those who simulate Standards of practice

Staff preparation (cont)

Instructional DesignInstructional Design

• Instructional Principles• Staff preparation• Environment• Scenario design

Instructional DesignInstructional Design

Suspending disbelief Too little vs. too much When technology gets in the way

Environment

“Simulation is mostly smoke and mirrors!” David Gaba

Instructional DesignInstructional Design

• Instructional Principles• Staff preparation• Environment• Scenario design

Instructional DesignInstructional Design

Audience Objectives Stories Branching Failure and death (the ultimate bad branch) Programming the beast Testing, testing and more testing

Scenario Design

Instructional DesignInstructional Design

Don’t kill the patient Diagnosis Patient assessment Problem solving Communications Teamwork Situational awareness Integrate new procedure, tool, etc.

Objectives

Focus

C

C

CC Completion

Failure

Home State

Scenario Design

Instructional DesignInstructional Design

Instructional DesignInstructional Design

Stages of the Program

1. Stable state2. Initial presentation3. Branch #1 – Patient unchanged4. Branch #2 - Patient deteriorates (death spriral ?)5. Branch #3 - Patient improves

Driving on the fly – Experience required

Programming

TIME

Instructional DesignInstructional Design

• Instructional Principles• Staff preparation• Environment• Scenario design

Questions?

Added Value of a Simulator: TEAM/CRM Training and Using Simulation for Competency Assessment

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

Michael Armacost, MA, NREMT-PBanner Health Simulation & InnovationFrederick, CO

TEAM/CRMTEAM/CRM

• Crisis Resource Management & Simulation• Using simulation for competency assessment

TEAM/CRMTEAM/CRM

• Crisis Resource Management & Simulation• Using simulation for competency assessment

TEAM/CRMTEAM/CRM

Crew Resource Management (CRM) Anesthesia Crisis Resource Management (ACRM) Crisis Resource Management (CRM)

Crisis Resource Management & Simulation

TEAM/CRMTEAM/CRM

Example #1

TEAM/CRMTEAM/CRM

Example #2

TEAM/CRMTEAM/CRM

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

Characteristics of good team environment in a medical high-stakes environment

CompetencyCompetency

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.

Competency Assessment and Simulation

TEAM/CRMTEAM/CRM

• Crisis Resource Management & Simulation• Using simulation for competency assessment

Questions?

Debriefing 101

Michael Armacost, MA, NREMT-PBanner Health Simulation & InnovationFrederick, CO

David L. Rodgers, Ed.D., NREMT-PHealthcare Simulation StrategiesCharleston, WV

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

Reflection/DebriefingReflection/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/DebriefingReflection/Debriefing

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

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

Reflection/DebriefingReflection/Debriefing

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

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

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/DebriefingReflection/Debriefing

Demonstration & Practice

Questions?

Lunch!

Gateway to Education – 2008 SymposiumSept. 11, 2008, St. Louis, MO

David L. Rodgers, Ed.D., NREMT-P

Healthcare Simulation Strategies

304.444.1078

dave.rodgers@sim-strategies.com

www.sim-strategies.com

Contact InformationContact Information

Michael Armacost, MA, NREMT-P

Banner Health Simulation & Innovation

970.203.6704

Michael.armacost@BannerHealth.com

BannerHealthInnovations.org