medical simulation: learning in immersive environments michael armacost, ma, nremt-p banner health...
Post on 19-Dec-2015
221 views
TRANSCRIPT
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
www.sim-strategies.com
Contact InformationContact Information
Michael Armacost, MA, NREMT-P
Banner Health Simulation & Innovation
970.203.6704
BannerHealthInnovations.org