Aaron William Calhoun, Elaine Sigalet, Rebekah Burns and Marc Auerbach
© Springer International Publishing Switzerland 2016
V. J. Grant, A. Cheng (eds.), Comprehensive Healthcare Simulation: Pediatrics, Comprehensive Healthcare Simulation, DOI 10.1007/978-3-319-24187-6_13 A. W. Calhoun ()
Department of Pediatrics, Division of Critical Care, University of Louisville School of Medicine, Kosair Children’s Hospital, Louisville, KY, USA
e-mail: [email protected] E. Sigalet
Department of Education, Sidra Research and Medical Center, Doha, Qatar
e-mail: [email protected] R. Burns
Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle, WA, USA e-mail: [email protected]
M. Auerbach
Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
e-mail: [email protected]
Simulation Pearls
1. The healthcare education process spans a wide contin- uum, with each phase possessing unique characteristics and challenges.
2. Simulation has been demonstrated to be an effective tool for addressing the challenges at each level of the healthcare education continuum, including the teaching of basic knowledge, teamwork, procedural skills, attitudes, and team performance constructs such as communication skills.
3. Simulation is an ideal venue for introducing stakehold- ers to the concept of interprofessional (IP) education. It provides an opportunity for them to learn from, with, and about each other as they learn to work effectively together to manage pediatric illness.
4. Future developments in simulation across the healthcare education continuum should focus on improving learner transitions between educational phases.
Introduction
Educational needs change considerably as learners progress from undergraduate to graduate educational environments and then from graduate to the ongoing professional educa- tion that occurs during clinical practice. Despite advances in curricula design and instructional methods, medical, nursing, and other students in healthcare programs perform a significant fraction of their education in preclinical set- tings using didactic sessions, small group discussions, and problem-based learning to acquire and master new knowl- edge and skills. As they graduate, however, this environment changes. At this phase, emphasis is on delivery of care in an IP context, but given the pace at which new knowledge is generated, ongoing educational processes are still needed to assure that practitioners can maintain a current knowledge base and skill set. While clinicians often rely on conferences and other continuing professional development (CPD) ac- tivities for this education, studies indicate that these methods often have little impact [1].
Medical students are required to go through an additional transitional phase of residency (and possibly fellowship edu- cation) that exists between these two environments. Increased supervision and decreased autonomy, however, may lead to residents feeling unprepared for the transition to independent practice [2]. Furthermore, in the graduate medical environ- ment, they experience more stringent time constraints due to both the demands of clinical practice and government man- date while still being expected to maintain their role as learn- ers [3]. Scheduling issues may become even more a barrier as graduates transition into the independent practitioner role.
Salient differences between these environments are graphi- cally depicted in Fig. 13.1.
Given these challenges, technology-enhanced education- al modalities, such as e-learning and simulation, are being increasingly relied upon to assist learners in transitioning between these environments [4]. In particular, simulation- based educational methodologies have been utilized across the spectrum of medical education [3, 5]. In this chapter,
we describe the use of simulation to address the educational needs of diverse groups of learners and the science behind the implementation of various strategies in the hopes of allowing educators to more effectively engage with their learners.
The structure of the chapter includes a discussion of:
• Pediatric simulation in undergraduate education
• Pediatric simulation in graduate medical education
• Pediatric simulation in CPD
• Pediatric IP simulation across the education continuum
• A consideration of the research needs and future peda- gogical directions of simulation-based education (SBE) across the healthcare education continuum
Initial discussion in each area will focus on both the science of simulation as it has been applied to the specific problems inherent to each level of education. We will then discuss pro- gram implementation, both within and across these domains.
It is our hope that this chapter will inform readers as to what is known and enhance their ability to address educational is- sues that transcend the domains presented.
Undergraduate Education
The paradigm shift in undergraduate health professional ed- ucation from a traditional apprenticeship model to a compe- tency-based model has led to many programs integrating the basic sciences with clinical sciences early in training [6]. As a result, students must be prepared to interact in the clinical environment at an earlier phase in their training. Programs are accountable for this change and need to ensure that new curricula are designed to address these goals. Educators must
understand the theory of skill acquisition so they can develop learning objectives appropriate to novices. In particular, stu- dents require earlier experience with deliberate practice. De- liberate practice, or mastery-based learning theory, refers to an instructional method where learners continue to rehearse the application of knowledge or a specific task in a mentored setting until mastery is achieved [7]. Simulation potentiates this technique by providing a standardized educational envi- ronment where the skill in question can be practiced as many times as the learner’s assigned educational time and need al- lows. Deliberate practice-based simulations require students to be attentive, reflect on performance, and repeat actions until they feel confident and demonstrate a specified level of competence [8]. This design gives students the opportunity to increase their confidence and level of competency before being asked to interact with real patients.
SBE also facilitates planned experiences to support cur- riculum delivery via timely exposure, in a controlled edu- cational environment, and with enhanced mechanisms for student feedback [9]. This approach gives learners an op- portunity to experiment with clinical practice, facilitating conceptualization of principles supporting best practice in healthcare delivery [10]. The element of facilitator control is an important facet of SBE. Educators make decisions about what type of experiences will support the learning objectives and the required level of complexity to facilitate learning for a specific group or individual [9]. This approach can move the learner along the continuum of competency from entry to graduation in a more efficient manner by creating a bridge between classroom learning and the clinical environment without creating risk to real patients and families [11].
Undergraduate Graduate Ongoing
Clinical Time
Educational Time
Learning Environment Learning Environment Learning Environment
• Predominantly classroom and small-group
• Some clinical exposure
• Typically single- discipline
• Clinically focused
• Interprofessional
• Little opportunity for focused educational time
• Predominantly clinical
• Interprofessional
• Substantial mentoring
• Substantial lecture and classroom time Fig. 13.1 The spectrum of
educational environments in health care. This figure depicts the relationships between edu- cational and clinical time within the undergraduate, graduate, and continuing professional develop- ment environments. As learners progress from preclinical educa- tion to graduate education and finally to practice, the relative balance between educational and clinical time shifts substantially.
Common educational method- ologies used in each phase have been included.
State of the Science
The past four decades have seen an explosion of publica- tions in SBE, from two publications in 1972 to almost 1200 publications today [12, 13]. Most of the literature focuses on undergraduate medical and nursing education, though a limited number of articles exist providing scientific sup- port for the effective use of simulation in the education of allied health professions such as physiotherapy and phar- macy [14, 15]. This suggests that institutions, faculty, and stakeholders are committing resources to simulation in undergraduate health professional education. The majority of these studies focus on curriculum development, assess- ment, and strategies for addressing technical skill acquisi- tion. In a recent systematic review, 19 studies noteworthy for the rigor of their research designs were identified [16].
The majority of these studies focused on technical skills, with three also addressing nontechnical skills [17–19]. In all but one study, assessment of the curricula supported an increase in student knowledge [16]. Only one of these stud- ies, however, focused on the technical skill needed to effec- tively manage pediatric illnesses [19]. Unfortunately, little research has examined skill transfer to actual patient care in medical education. However, in undergraduate nursing education there is good evidence to support the efficacy of curricula that transfers to clinical practice. Noteworthy is a recently published study that examined the impact of re- placing a percentage of clinical practice with SBE. Results show that SBE can replace up to 50 % of clinical practice in North America in undergraduate nursing programs with no significant impact on student performance as measured by the national nursing exam scores (national council licensure examination, NCLEX). Importantly, there was no adverse effect on the transition to real practice settings measured at 6 months after graduation [20]. This is the first known study to achieve this level of outcome in undergraduate SBE. In addition to knowledge and procedural skills, criti- cal thinking may be improved with SBE. Although there are few studies that evaluate the effectiveness of this ap- proach, what can be found is encouraging. One study of 237 nursing students noted a significant improvement in critical thinking after engagement with simulation-based coursework [21].
Simulation may also overcome barriers to engagement that can be experienced when educational programs are over- ly reliant on didactic teaching and assessment of knowledge.
A study examining perceptions of traditional medical edu- cation curricula uncovered that many students feel checked out or intellectually disengaged in classroom sessions and believe that their time was better spent memorizing knowl- edge for an upcoming test [22]. This suggests that some programs are still reliant on knowledge-based assessments and may need a greater focus on the application of knowl-
edge to adequately prepare undergraduate students for the demands of the clinical environment. A number of studies in the field of undergraduate nursing education also support this. A recent meta-analysis in undergraduate nursing edu- cation demonstrated the effectiveness of SBE in improving attitudes, knowledge, and skills, as well as the application of these to actual practice [23]. The study did reveal, however, that there is a paucity of pediatric focused simulation-based curricula.
Overall, the existing literature supports the use of careful- ly constructed simulation-based educational opportunities in the preparation of students for the demands of real practice, and that these interventions can result in good knowledge transfer to the real environment. Given that required clini- cal rotations often reach capacity, particularly for nursing students, simulation appears to offer a viable alternative for undergraduate learners [24].
Program Implementation
As is evident from the breadth of the literature discussed above, simulation-based programs have already found wide- spread acceptance in the undergraduate nursing and medi- cine contexts. In 2011, the Association of American Medical Colleges conducted a survey on the prevalence of simula- tion at the medical school level [25]. According to this study, 92 % of participating medical schools used simulation in some way, and 86 % of associated teaching hospitals also used simulation. This finding is also supported by a national survey of pediatric clerkship directors completed in 2012 [26]. In this study, 89 % of 72 responding clerkship directors reported using simulation in some form. These surveys indi- cate that SBE has already achieved an overwhelming preva- lence at the undergraduate level, and mastering this means of delivering educational curricula will likely continue to pay dividends well into the future.
When incorporating simulation into undergraduate edu- cation, it is important to follow established steps in curri- cula design [9]. The first step is problem identification. Who are the learners (profession, phase in training program, and current level of experience) and what do the learners need to know and do? Step two is a needs analysis. Are there specific needs of the learners that you need to understand before developing learning objectives? In step three, learn- ing objectives are developed based on information from the needs analysis or educational program leaders. Objectives should challenge the learner’s cognitive entry behaviors but not overwhelm the learner. Engaging simulation as a learning modality is appropriate when the learner achieve- ment of the learning objectives would benefit from deliber- ate practice or the theory of experiential learning. Scenario development is the curriculum content, the first step of the
educational strategy detailed in step four. For less experi- enced learners, a simpler scenario intended to teach basic paradigms of care in a distraction-free environment may be best. Although high environmental fidelity is often held out as the ideal, this must be balanced with the increased cogni- tive load produced by such environments. Excessive cogni- tive load has been associated with diminished retention of knowledge (Chap. 1) [27]. For more experienced learners, however, higher environmental fidelity may be desired, as this will allow for a more realistic experience that may trans- late more readily to the clinical environment. Additionally, in this phase it is necessary to be sure that adequate per- sonnel, equipment, and space exists to efficiently move the large groups of learners through their required coursework.
Step five is implementation. A related consideration is how far the case should progress toward a negative outcome, as a number of recent articles have been published focusing on emotionally difficult scenarios that suggest mitigating the impact of these cases to undergraduate learners may be best [28–31]. The last step is feedback and evaluation. Faculty need to make a judgment about the efficacy of the curricu- lum. Did the learners achieve the learning objectives and if not, why not? This information should be used to revise the curriculum before delivering it to another cohort of learn- ers. Stand-alone simulation centers, unless directly associ- ated with the academic training center, provide capacity for engaging simulation; however, there are usually financial implications for the program that must be planned for in the early phases of curricula design.
Postgraduate Education
The application of simulation-based educational methodolo- gies to pediatric postgraduate training has been widespread, and, correspondingly, has produced a robust literature [32].
One telling study sought to quantify the number of pediat- ric emergency medicine programs that incorporated high- fidelity simulation into their routine training activities. A total of 66 programs throughout the USA and Canada were surveyed. Of the 51 programs that responded, 63 % were using high-fidelity simulation to teach a broad array of skills including management of medical emergencies, procedural skills, and medical decision-making [33]. The past decades have also seen the development of simulation boot camps designed to train incoming interns and fellows in an attempt to avoid the July effect, seen as novice trainees begin to fill new patient care roles [34]. Programs of this nature have been described for internal medicine and pediatric critical care medicine [34, 35]. They have been shown to be logi- cally feasible and to result in improved clinical performance and trainee confidence [34].
State of the Science
A number of publications focus on the application of high-fi- delity simulation to resuscitation training. This is not surpris- ing, given the roots in airline crew resource management and the correlation between the skills needed in that environment with those required during a medical crisis (Chap. 4) [36].
Studies have demonstrated the positive effect of simulation training on team performance, timeliness of essential pro- cedures, resuscitation team self-perception and confidence, and hospital survival rates for pediatric arrests [37–39]. Sev- eral studies have also addressed the addition of a deliberate practice educational methodology to team training [38, 40].
This technique has been used to good effect in simulated en- vironments and should be strongly considered when devel- oping curricula. [35, 40–42].
Another area in which simulation has found particular ap- plicability to postgraduate pediatric education is in the do- main of procedural skills (see Chap. 11) and sedation. Given current work-hour restrictions, it is becoming increasingly difficult for pediatric residents to obtain adequate practice with crucial procedures [43–45]. Simulation is becoming a growing modality used to fill this gap [46]. One common procedure that has been extensively studied is lumbar punc- ture (LP), with data suggesting that performance skills can be significantly improved using simulation-based training methodologies, though it is less clear how many sessions are needed to effect this change [47–49]. LP skills have also been shown to transfer between the simulated and real envi- ronments [49]. Another procedure that has been extensively investigated is endotracheal intubation, a procedure that is both critical and high risk. Simulation-based training has been demonstrated to significantly improve airway team in- terpersonal interactions, intubation success rates, and to de- crease time to successful intubation among trainees [50–52].
Unlike LP, however, the literature on skill transfer is mixed [52, 53].
Finally, a number of publications have addressed the area of communication skills training in pediatrics (see Chap. 23).
Skills that have been taught in the postgraduate environment using simulation include the delivery of difficult news, com- munication surrounding medical error, and conflict resolu- tion both within the medical team and between the team and patient family members [54–61]. While some of these studies are descriptive in nature, many have shown positive improvements in learner confidence, perceived skill, and qualitative measures of emerging conversational themes that could be traced to the intervention [54, 58, 60]. IP team communication in graduate medical education has also been addressed using simulation. In particular, crisis team com- munication and communication regarding errors have been addressed [28, 38, 62]. Some factors, such as the effect of hierarchy and authority gradients on medical errors during
crises, can be difficult to address without recourse to medical simulation [28, 62].
Program Implementation
It is clear that a great deal of research has been performed with regard to graduate level simulation in pediatrics, with value demonstrated in a myriad of ways. Still, the practical issues of how such a program can be implemented remain. Many graduate level simulation programs opt to use a freestanding simulation center affiliated with their institution, and, if such is available, this can be an excellent approach. If, however, such a program is not available, or is available but requires a prohibitive transit time, then other options exist. One tech- nique is the creation of an in-hospital simulation suite [63, 64]. Such an approach has been successfully adopted by a number of institutions, and requires the conversion of one or more clinical beds into part-time or full-time simulation spaces. While still potentially costly, this approach effec- tively removes the distance issue from the equation. Having a simulation program on-site can significantly enhance the ease at which IP activities can be conducted, as it is often much more difficult to free nursing staff from clinical duties than it is to generate resident educational time [63, 64]. One exemplar program that has adopted this strategy reported an initial construction cost of $290,000, and ongoing costs of approximately $67,875 per year [63].
As space is at a premium in many hospitals such a strat- egy may not work at many institutions. For those in this situ- ation, adopting an in situ approach may be the most cost and
space effective. In situ simulation refers to the use of simula- tion equipment in functional clinical space to achieve an im- promptu educational environment (see Chap. 12) [65]. While sometimes used in an unannounced fashion to perform sys- tems testing, it is also possible to use in situ methodology to develop graduate level simulation programs that require no permanent educational space. Using this approach, simula- tors are placed on mobile carts that allow for easy transport to different clinical domains, and sessions are scheduled based on predicted space availability [64, 66]. Such programs are often more cost-effective as there is no need for large-scale infrastructure. One program reported an initial startup cost of
$128,921, and ongoing yearly costs of $11,695 for the first 2 years of operation [64]. Current operational data shows that this program presently conducts approximately 360–370 simulation sessions per year with 440–420 education hours provided. In situ programs do have their limitation, such as the possibility of session cancellation due to capacity issues necessitating the need to identify backup spaces in which to conduct simulations. Still, this approach offers a means by which graduate medical programs with little space and financial support can conduct SBE. Table 13.1 depicts the strengths and weaknesses of each approach.
At present, curricula are frequently developed locally, which can lead to significant divergence and a concurrent need for standardization. Here, reference to national guide- lines such as the Accreditation Council for Graduate Medical Education Milestones Project (in the USA), can be of use, as these provide a global framework to which curricula can adhere [67]. Despite this anchor, however, the temptation will always be present to develop material without reference
Table 13.1 A comparison of different approaches to graduate medical simulation
Off-site simulation center On-site simulation center In situ program Benefits Resource-rich Lack of transit time makes learner
attendance easier Lower startup and ongoing costs Often easy to schedule sessions Easy scheduling Lack of transit time makes learner
attendance easier Low cancellation rate Easy to organize interprofessional
sessions Easy to organize interprofessional
sessions
Ease of audiovisual recording Low cancellation rate High environmental fidelity Possible ease of audiovisual recording
(site-specific) Drawbacks Location and resulting transit time can
make attendance difficult Costly to build and maintain Higher cancellation rate due to lack of required space
Can be difficult to organize interprofes-
sional sessions Requires adequate clinical space Higher cancellation rates due to compet- ing clinical demands
Costly to build and maintain Dependence of audiovisual recording on
portable devices Lower environmental fidelity
This table lists the strengths and benefits of different simulation program operational structures as they pertain to graduate level simulation.
Off-site and on-site simulation centers as well as in situ approaches are included