simulation: why, when, what? terminology, definitions, frameworks and applications sandrijn van...

Simulation: Why, when, what?Terminology, definitions,

frameworks and applications

Sandrijn van Schaik, MD PhD

2015

UCSF Center for Faculty Educators & Kanbar Center for Simulation

Simulation: Why, when, what?

1. Define and describe simulation

2. Explain the rationale for using simulation in health professional education

3. List best practices for the use of simulation as an educational strategy

4. Find your way to various simulation resources at UCSF and beyond

Objectives

SIMULATION: WHY, WHEN, WHAT?

Simulation: Definition

• “To do or make something which looks real but is not real”– Dictionary.com

• “An educational modality with which the learner physically interacts to mimic an aspect of clinical care for the purpose of teaching or assessment”– Adapted from Cook et al. , Med Teach. 2013

SIMULATION: WHY, WHEN, WHAT?

Simulation modalities for HPE

• Mannequin-based simulation

• Standardized patients

• Partial Task Trainers

• Virtual Reality

• Mixed Modalities

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SIMULATION: WHY, WHEN, WHAT?

Mixed Modalities / Hybrid Simulation

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Combination of actors, partial task trainers and/or

simulation mannequins

SIMULATION: WHY, WHEN, WHAT?

Why Simulation?

• Patient Safety

• Learner Benefits

• Institutional Benefits

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Learning Assessment

SIMULATION: WHY, WHEN, WHAT?

Simulation for Patient Safety

• Avoid “practicing” on real patients

• Error reduction

• Optimize communication / teamwork

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SIMULATION: WHY, WHEN, WHAT?

Simulation to Benefit Learners

•Deliberate practice– Practice, received feedback, reflect,

practice again

•Practice in safe environment – Early practice of clinical skills

– High stakes, low volume events

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SIMULATION: WHY, WHEN, WHAT?

Simulation to Benefit Institutions

• Disaster preparedness

• Test (new) systems

• Uncover latent safety issues

• Reduced malpractice insurance

• Accreditation and other compliance issues

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SIMULATION: WHY, WHEN, WHAT?

SIMULATION: WHY, WHEN, WHAT?

Effective simulation: characteristics

1. Integration into curriculum

2. Feedback

3. Deliberate practice

4. Mastery learning

5. Range of difficulty levels

6. Clinical variation

7. Individualized learning

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SIMULATION: WHY, WHEN, WHAT?

Effective simulation: characteristics

1. Integration into curriculum

2. Feedback

3. Deliberate practice

4. Mastery learning

5. Range of difficulty levels

6. Clinical variation

7. Individualized learning

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SIMULATION: WHY, WHEN, WHAT?

Integration into Curriculum

• Simulation is one educational tool to get to the educational objectives of a curriculum

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Kern’s 6 steps to curriculum development

1. Problem identification

2. Needs Assessment

3. Goals and Objectives

4. Education Strategies

5. Implementation

6. Evaluation and Feedback

KernThe Johns Hopkins University Press 1998

SIMULATION: WHY, WHEN, WHAT?

Integration into Curriculum

• Simulation is most successful if related to other educational content and/or clinical experiences

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SIMULATION: WHY, WHEN, WHAT?

Simulation as educational strategy

• Is simulation the appropriate teaching modality to reach the educational objectives?

• Different types of simulation can be used for different educational objectives

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SIMULATION: WHY, WHEN, WHAT?

History taking

Communication skillsStandardized Patients

Hyb

rid s

imul

atio

n

Clinical reasoning

Clinical exam skillsMannequins

Teamwork

Resuscitation skillsTask trainers

Procedural skills

Effective simulation: characteristics

1. Integration into curriculum

2. Feedback

3. Deliberate practice

4. Mastery learning

5. Range of difficulty levels

6. Clinical variation

7. Individualized learning

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SIMULATION: WHY, WHEN, WHAT?

Feedback

• Often considered the most important aspect of simulation

• In scenario-based simulations, typically takes the form of “debriefing” – feedback with/among group of learners

• Effective feedback and debriefing require training and experience– Various approaches have been described

– Separate workshops dedicated to these topics

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SIMULATION: WHY, WHEN, WHAT?

Effective simulation: characteristics

1. Integration into curriculum

2. Feedback

3. Deliberate practice

4. Mastery learning

5. Range of difficulty levels

6. Clinical variation

7. Individualized learning

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SIMULATION: WHY, WHEN, WHAT?

Deliberate practice

• Practice followed by feedback and reflection, followed by focused repeated practice

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EricssonAcad Med 2004S70-S81

SIMULATION: WHY, WHEN, WHAT?

Effective simulation: characteristics

1. Integration into curriculum

2. Feedback

3. Deliberate practice

4. Mastery learning

5. Range of difficulty levels

6. Clinical variation

7. Individualized learning

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SIMULATION: WHY, WHEN, WHAT?

Mastery Learning

• Rigorous approach to competency-based education

• Different levels of mastery = different outcomes (or mastery standards) that learner needs to achieve at each level

• Requires clear bench marks with measurable outcomes

• Learner progresses through educational units of increasing level of difficulty

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SIMULATION: WHY, WHEN, WHAT?

Effective simulation: characteristics

1. Integration into curriculum

2. Feedback

3. Deliberate practice

4. Mastery learning

5. Range of difficulty levels

6. Clinical variation

7. Individualized learning

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SIMULATION: WHY, WHEN, WHAT?

Effective simulation: characteristics

1. Integration into curriculum

2. Feedback

3. Deliberate practice

4. Mastery learning

5. Range of difficulty levels

6. Clinical variation

7. Individualized learning

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SIMULATION: WHY, WHEN, WHAT?

Individualized learning

• Learners are active participants, not passive bystanders

• Can be challenging for larger groups of learners

• Different models to engage multiple learners in simulation– Rotating or shared “active” roles

– Observation roles with specific tasks

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SIMULATION: WHY, WHEN, WHAT?

Two more aspects to consider…

1. Controlled environment/psychological safety: learners can make, detect and correct errors without adverse consequences

2. Simulator validity or fidelity: the degree of realism the simulator provides

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SIMULATION: WHY, WHEN, WHAT?

Fidelity of simulation

SIMULATION: WHY, WHEN, WHAT?

Fidelity – useful concept?

Replace term fidelity with• Physical resemblance

– Should get less emphasis (no evidence that it improves learning by itself)

• Functional task alignment– functional properties of the entire simulation context

that align with learning objectives

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Hamstra et alAcad Med2014

SIMULATION: WHY, WHEN, WHAT?

Dimensions of Fidelity

• Equipment Fidelity– Highest with physiology-based mannequins (realistic

responses to interventions such as O2, medications)

• Environmental Fidelity– Highest with in-situ simulation (takes place in the

actual clinical setting)

• Psychological Fidelity– Highest if the participants forget the situation is not

real. Dependent on instructor/actor

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BeaubienQual Saf Health Care 2004

SIMULATION: WHY, WHEN, WHAT?

SIMULATION: WHY, WHEN, WHAT?

Simulation for Assessment

• Standardization

• Direct observation

• Video recording / multiple observers

• Feedback from standardized patients

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Learning Assessment

SIMULATION: WHY, WHEN, WHAT?

Assessment and simulation

• Checklist vs global rating scales

• Bench marks / milestones

• Self assessment / peer assessment?

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SIMULATION: WHY, WHEN, WHAT?

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SIMULATION: WHY, WHEN, WHAT?

Framework for Simulation as Educational Strategy

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Simulation Activity

Script

Patient

Environment

Instructors

Learner

Equipment and Tools

Preparation

Assessment & Feedback

SIMULATION: WHY, WHEN, WHAT?

Example: Standardize Patient exercise

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History & Clinical Exam Practice

Patient Script (PMH, HPI, Symptoms)

Actor/Standardized

Patient

Clinical Exam Room Faculty

observers/simulation staff (video)

Medical Student

Stethoscope and BP cuff

Instructions

ChecklistFeedback

SIMULATION: WHY, WHEN, WHAT?

Example: Mannequin-based activity

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Resuscitation team training

Scenario outline

Mannequin

Operating Room Technicians

ConfederatesFacilitator

OR team members

Crash cartMedications

(pre) brief

Assessment toolDebriefing

SIMULATION: WHY, WHEN, WHAT?

Example: Procedure training

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Phlebotomy Training

Steps of the procedure

Partial task trainer

Environment

Instructor

Nursing student

NeedlesSyringes

ChecklistFeedback

SIMULATION: WHY, WHEN, WHAT?

Content knowledge

Simulation = Preparation

There are many factors that can impact learning

• SP activity:– Need to select and train actors; create checklists and

detailed instruction materials

• Mannequin activity:– Technicians need to know how the mannequin

should respond to various learner actions; create a scenario thinking about different paths

• Procedure activity:– Instructors need to know the trainers, and best

practices for procedural training (demonstrate, break down into step, practice with feedback)

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SIMULATION: WHY, WHEN, WHAT?

Teach for UCSF Simulation Certificate

• Certificate program offered to current and future faculty at UCSF and affiliated institutions

• Series of workshops, simulation is one of several certificates offered

• Details see: http://meded.ucsf.edu/radme/Teach-for-UCSF

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SIMULATION: WHY, WHEN, WHAT?

Resources

• UCSF Kanbar Center for Simulation– Visit the website: http://meded.ucsf.edu/simulation

– Visit the instructor resources on the CLE: go to moodle.ucsf.edu and search for Kanbar or click the link on the kanbar website

– Email kanbar@ucsf.edu

• Society for Simulation in HealthCare– http://www.ssih.org/

• California Simulation Alliance– https://www.californiasimulationalliance.org/

CSACollaboratives.aspx

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SIMULATION: WHY, WHEN, WHAT?

References

• Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82. Motola Y et al; Medical Teacher 2013;35 (10):e1511-e1530

• Comparative effectiveness of instructional design features in simulation-based education: systematic review and meta-analysis. Cook DA et al; Medical Teacher 2013;35(1):e867-98.

• Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Ericsson K; Academic Medicine, 2004;79(10):S70-80

• A critical review of simulation-based mastery learning with translational outcomes. McGaghie WC; Medical Education 2014;48(4):375-85.

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SIMULATION: WHY, WHEN, WHAT?

Questions?

• kanbar@ucsf.edu

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