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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.

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slide1

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

slide2

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

slide3

Objectives

  • 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.
slide4

Welcome

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

slide5

Video-based simulations

Three-dimensional static models

Virtual reality

Full-bodied manikin-based

Audio simulations

Task-specific simulators

Standardized patients

Written (paper) simulations

Animal models

Human cadavers

Computer-based clinical simulations

slide6

Video-based simulations

Three-dimensional static models

Virtual reality

Full-bodied manikin-based

Audio simulations

Task-specific simulators

Standardized patients

Written (paper) simulations

Animal models

Human cadavers

Computer-based clinical simulations

slide8

Gateway to Education – 2008 Symposium

Sept. 11, 2008, St. Louis, MO

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

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

Healthcare Simulation Strategies

Charleston, WV

slide9

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

slide10

The history of Patient Simulation

Patient simulation is not new!

Animal models for medical simulation have been used for over 2,000 years

slide11

The history of Patient Simulation

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

slide12

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

slide13

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..

slide14

The history of Patient Simulation

Computer-controlled patient simulators

1986 – Gainesville Anesthesia Simulator

1986 – MedSim Eagle

1969 - SimOne

1996 – METI HPS

2000 – Laerdal SimMan

1970 1980 1990 2000

slide16

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

slide17

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.

slide18

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).”

slide19

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).”

slide20

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).”

slide21

What is patient simulation?

“Simulations are createdexperiences 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).”

slide22

What is patient simulation?

“Simulations are createdexperiences that mimicprocesses 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 realexperiences 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).”

slide23

What is patient simulation?

Createdguided experiencesthat mimicreal-world processes or conditions to achieve educational goals

slide24

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.

slide25

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.

slide26

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.

slide27

Fidelity

Equipment/Physical

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

slide28

Fidelity

Equipment

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

Task

slide29

Fidelity

Equipment

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

Task

Environmental

slide30

Fidelity

Equipment

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

Task

Environmental

Psychological

slide31

Which is more important for most

learning events …?

12%

A high-fidelity simulator

88%

A high-fidelity environment

Dieckmann, P. (2008). How much realism is needed in medical simulation? Presentation at the International Meeting on Simulation in Healthcare, San Diego, Ca.

slide35

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

slide36

Learning Theory in Patient Simulation

There is no “Simulation Learning Theory”

But, simulation can benefit from broader learning theories

slide37

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.

slide38

Experiential Learning Cycle

Concrete

Experience

Observation

and Reflection

Testing implication of

concepts in new situation

Formation of abstract

concepts and

generalizations

slide39

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.

slide40

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.

slide41

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

slide42

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

slide43

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

slide45

Gateway to Education – 2008 Symposium

Sept. 11, 2008, St. Louis, MO

Break Time!

slide46

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

slide47

Objectives/Curriculum Integration

  • Science of Expertise
  • Types of Learning & Evaluation
  • Examples
slide48

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.

slide49

Objectives/Curriculum Integration

Advanced Beginner

Novice

Competent

Proficient

Expert

slide50

Objectives/Curriculum Integration

Advanced Beginner

Novice

Competent

Proficient

Expert

  • Prior knowledge lacking
  • Needs rules free of context – Cognitive Load
  • Difficulty with prioritization
  • Little situational awareness
  • Lacks communication skills
  • Vulnerable
slide51

Objectives/Curriculum Integration

Advanced Beginner

Novice

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
slide52

Objectives/Curriculum Integration

Advanced Beginner

Novice

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
slide53

Objectives/Curriculum Integration

Advanced Beginner

Novice

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
slide54

Objectives/Curriculum Integration

Advanced Beginner

Novice

Competent

Proficient

Expert

  • Clinical leadership (not administrative)
  • Has insight and vision
  • Can handle multiple complexities
slide55

Objectives/Curriculum Integration

  • Science of Expertise
  • Types of Learning & Evaluation
  • Examples
  • InitialLearning – 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
slide56

Objectives/Curriculum Integration

  • Science of Expertise
  • Types of Learning & Evaluation
  • Examples
  • InitialLearning – Original Learning – EMT-B Initial Course
slide57

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”
slide58

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
slide59

Objectives/Curriculum Integration

  • Science of Expertise
  • Types of Learning & Evaluation
  • Examples
  • InitialLearning - EMT-B Initial Course
  • Refresher – EMT-P Refresher Course
slide60

Objectives/Curriculum Integration

  • EMT- Paramedic Refresher - Example

How would you integrate simulation into your course?

slide63

Objectives/Curriculum Integration

  • Science of Expertise
  • Types of Learning & Evaluation
  • Examples
  • InitialLearning - EMT-B Initial Course
  • Refresher – EMT-P Refresher Course
  • Continuing Education – King Airway
slide64

Objectives/Curriculum Integration

  • King Airway Continuing Ed - Example

How would you integrate simulation into your course?

  • Task training
  • Simulation training
  • Competency
slide66

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

slide67

Instructional Design

  • Instructional Principles
  • Staff preparation
  • Environment
  • Scenario design
slide68

Instructional 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

slide69

Instructional Design

  • Instructional Principles
  • Staff preparation
  • Environment
  • Scenario design
slide70

Instructional 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!”

slide71

Instructional Design

Staff preparation (cont)

  • Coaching and instruction
  • Facilitating and instruction
  • Using simulation to teach those who simulate
  • Standards of practice
slide72

Instructional Design

  • Instructional Principles
  • Staff preparation
  • Environment
  • Scenario design
slide73

Instructional Design

Environment

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

“Simulation is mostly smoke and mirrors!” David Gaba

slide74

Instructional Design

  • Instructional Principles
  • Staff preparation
  • Environment
  • Scenario design
slide75

Instructional Design

Scenario Design

  • Audience
  • Objectives
  • Stories
  • Branching
  • Failure and death (the ultimate bad branch)
  • Programming the beast
  • Testing, testing and more testing
slide76

Instructional Design

Objectives

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

Focus

slide77

Instructional Design

Scenario Design

C

Home State

C

Failure

Completion

C

C

slide78

Instructional Design

Programming

Stages of the Program

  • Stable state
  • Initial presentation
  • Branch #1 – Patient unchanged
  • Branch #2 - Patient deteriorates (death spriral ?)
  • Branch #3 - Patient improves

Driving on the fly – Experience required

TIME

slide79

Instructional Design

  • Instructional Principles
  • Staff preparation
  • Environment
  • Scenario design
slide81

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

slide82

TEAM/CRM

  • Crisis Resource Management & Simulation
  • Using simulation for competency assessment
slide83

TEAM/CRM

  • Crisis Resource Management & Simulation
  • Using simulation for competency assessment
slide84

TEAM/CRM

Crisis Resource Management & Simulation

  • Crew Resource Management (CRM)
  • Anesthesia Crisis Resource Management (ACRM)
  • Crisis Resource Management (CRM)
slide88

TEAM/CRM

Example #1

slide89

TEAM/CRM

Example #2

slide90

TEAM/CRM

Characteristics of good team environment in a medical

high-stakes environment

  • 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
slide92

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.
slide93

TEAM/CRM

  • Crisis Resource Management & Simulation
  • Using simulation for competency assessment
slide95

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

slide96

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.

slide97

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

slide98

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

slide99

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 Healthcare1(1): 49-55.

slide100

Reflection/Debriefing

Demonstration & Practice

slide102

Gateway to Education – 2008 Symposium

Sept. 11, 2008, St. Louis, MO

Lunch!

slide103

Contact Information

Michael Armacost, MA, NREMT-P

Banner Health Simulation & Innovation

970.203.6704

Michael.armacost@BannerHealth.com

BannerHealthInnovations.org

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

Healthcare Simulation Strategies

304.444.1078

dave.rodgers@sim-strategies.com

www.sim-strategies.com