Simulcast

9 - Put the Rubber to the Road - In Situ Simulation

Be open and honest with the team about the true objectives you are trying to achieve. When these are focused on doing better for the patient, people will join the ride.

Case:

You’ve been running fortnightly scenarios in the nearby simulation centre. These are part of the resident training program and from time to time may get a nurse or two along depending on how busy the department is. While well evaluated, you see the residents go back to the shop floor and struggle to apply any of the lessons that the group agreed had been take homes from the previous sim session. They can’t find equipment, struggle to coordinate the multidisciplinary team and seem much slower to achieve critical actions in the real resus. You approach the Department director and the nurse manager and suggest starting to conduct one of the sim sessions in the department in a real resus bay once a month. This is met with resistance, “we’re too busy theirs not enough staff or time”, “the staff have done mock codes before, they really disrupt things and they hated them”. You go back to your office and try to come up with how you will make this happen.

Welcome to Episode 5 of Simulcast. In this episode we discussed how moving some simulation efforts out of the lab and into the workplace can yield big benefits and get some tips on how to drive change management and make a sustainable in situ simulation program.

Our guest for episode 5 was Andrew Petrosoniak, an emergency physician and trauma team leader at St. Michael’s Hospital, and Assistant Professor in the Department of Medicine at the University of Toronto. Petro has a strong grounding in the sim lab, but is a vocal advocate for point of care or in-situ simulation. Petro is the taller, better looking, and all round more refined co-lead on TRUST, an in-situ simulation-based study examining design ergonomics, human factors and latent safety threats in trauma resuscitation. Petro and his colleagues have also recently published a great article on in situ sim in Emergency Medicine Australasia.

Through this episode we give a brief overview of in situ simulation, what can you get out of it that isn’t possible in the lab and how would you assess the functional alignment of in situ versus sim lab. We also look at some functional domains that can help better understand objectives for in situ sim.

We picked Petro’s brain about the TRUST study and try to answer the big question – how hard has the change management process been in bringing sim out of the lab and into the department?

More resources:

Spurr, Gatward, Joshi and Carley EMJ Article –Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments - http://emj.bmj.com/content/early/2016/03/11/emermed-2015-204845.full.pdf

A process tracking video from TRUST simulation - https://www.youtube.com/watch?v=itLtqAAwe_w&feature=youtu.be

8 - The Safe Container for Simulation

 In this episode we discuss psychological safety in simulation.  Harvard professor Jenny Rudolph, PhD joined us for the discussion, taking time out form her busy schedule as the Director of the Center for Medical Simulation in Boston. 

We considered this all too familiar case study…… 

You’re facilitating a sim session in your ED. The junior docs and the nurses arrive,  a few straggle in late. You do a nice RTR (Round the room) but everyone seems a bit anxious and they are shifting in their seats. You really want them to relax.  

“You shouldn’t be anxious guys, this is what you do every day”.  

They look more worried.  

“I mean these will be sick patients, but this is the place to stuff up, rather than with a real patient”.  

One of the docs looks like he might vomit.  

“and remember what happens here, stays here, no you tube videos from what we are recording” - as you attempt to lighten the mood. “Its not like this is a test, we really just want to make sure you’re ok to be on nights on your own……”  

“so relax….”  

Two of the participants dash off for a toilet break before you start. 

 

The podcast gave us a wonderful opportunity to delve deeper into the philosophy behind Jenny et al’s excellent article on Establishing a Safe Container for Learning in Simulation.  

Most of our learners are pretty apprehensive about participating in sim. As Jenny explained to us – some people ‘come to life’ on stage with an audience, but most of us feel a sense of psychological threat if we are doing things in front of others and perceive this as evaluative i.e. a test of some sort. We may not know how an individual will be predisposed to respond, but as facilitators we can help everyone feel more psychologically safe.  

We can do this through some practical steps - clarifying expectations, discussing confidentiality, and telling stories/ sharing our own fears and vulnerabilities. Establishing the fiction contract is important - as described in the ‘safe container’ paper, and building on work by Peter Dieckmann here.  (beware -  a deep dive into theory!) 

The fundamental mindsets (of learner and facilitator behind these steps need to be understood.  

Jenny described some key concepts in the area, starting with helping to shift our learners to a ‘growth mindset’ (see Carol Dweck’s TeD talk here) in response to the challenge of a simulation activity. 

The idea of positive regard is crucial. We have to truly respect our learners and their efforts, and we need to demonstrate that. Well intentioned words suggesting this respect can be easily undone with ‘guess what I’m thinking’ questions that might make learners feel manipulated or unfairly judged.   

So how do we know if we have achieved psychological safety for our sim participants?  

Its complex. 

Experts like Amy Edmonson (another TeD talk to watch) suggests that seeing supportive responses when one puts oneself on the line, such as by asking a question, seeking feedback, reporting a mistake, or proposing a new idea. 

Sounds like our aspirations for our work teams….?  Again, simulation practice parallels our real world healthcare practice. 

Thanks again to Jenny Rudolph for an illuminating podcast.

7 - Cognitive Load Theory Day 1 Sim Congress 2016

Day 1 – Cognitive Load theory with Michael Meguerdichia 

One of the highlights of attending conferences like the Australasian Simulation Congress is the opportunity to meet and learn from members of the international simulation community. Michael Meguerdichia (@mmegue01) is an emergency physician and is Medical Director at The Simulation Center Harlem in New York, part of the NY Health and Hospital Simulation Centers. He ran a workshop at the conference based on his recent BMJ STEL paper on cognitive load theory and the way we can improve knowledge transfer in simulation. There was standing room only at the workshop, and in the interview we talked about how this theory informs design and delivery of scenarios. 

 

6 - Adam Cheng Day 3 Sim Congress 2016

Day 3 – Debriefing and Faculty Development with Adam Cheng    

Adam Cheng’s (@DocChenger) work on healthcare simulation debriefing is prolific. He is Director of Research and Development, KidSIM Simulation Program at Alberta Children’s Hospital and Associate Professor, Department of Paediatrics at the University of Calgary in Calgary, Canada. We met up at the ASC where I discovered he is also a lovely and self-effacing gentleman. We talked about the PEARLs workshop he conducted at the conference and the lessons from his comprehensive keynote lecture on all things debriefing. Adam’s leadership in developing debreif2learn.org promises to connect and inform the global simulation debriefing community. 

5 - Jess Stokes-Parish Day 1 Sim Congress 2016

Day 1 – Pause and Discuss with Jessica Stokes-Parish 

Jessica Stokes-Parish (@j_stokesparish) was a co-convenor for the 2016 Australasian Simulation Congress. In this short interview on Day 1 we talked about the highlights of the conference so far, and her work on women speakers at conferences and women in STEM more generally. See also @WISSummit  on this topic.

4 - Getting Started in Simulation Research

Case
You’ve got your sim program up and running. The sessions are regular and you’ve managed to find a time when the doctors and nurses can both come. You’ve mastered the technical stuff well enough and you’ve run some cracker scenarios. Your debriefing is … well….. getting better….
During your performance review with your department head, she says that you really ought to be publishing some of this stuff – “it's great”, she says. “I’d like to see 1 or 2 papers from you in the next 12 months. And it would get admin off our backs if you could prove that the sim session are worth the money with some evidence”
You wander off excited at the possibilities. You really want to demonstrate the effect of your sims, and start planning an RCT where one group of registrars does a sim and the other group just does a paper case. You’re not sure what should be the outcome measure……..

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Margaret Bearman (@margaret_bea) was our special guest for this month’s episode. She is the course convenor of the Grad Cert in Clinical Simulation at Monash University in Melbourne, and Deputy Director of the NHET sim program (listen also to our Pause and Discuss on this program)

Margaret’s first piece of advice was to read widely; to think about how our scholarly work can contribute to ‘the research conversation’. This means we can see what others have done, how they did it, and where the gaps and new questions are. Margaret credited the concept of this conversation to Lorelei Lingard, who has also a written wonderful series on academic writing well worth reading for budding manuscript authors.

 

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The journals recommended were:

• Simulation in Healthcare
• BMJ STEL – Simulation and Technology Enhanced Learning
• Advances in Simulation (See Editor in Chief Debra Nestel’s expert opinion piece in this months’ Simulcast journal club)
• Clinical Simulation in Nursing

Plus general health professional education journals like The Clinical Teacher

Various experts / research summits have also resulted in publications on current opportunities and priorities in healthcare research ( and here)

Acquiring and refining research skills was the next recommendation. Our ‘positivist’ world view (think hypothesis testing, RCTs etc) that many clinicians share may not prepare us well for all the methods that are needed for the current research questions in healthcare simulation. Those interested might consider looking at approaches like realist evaluation.

A range of strategies was suggested including courses (including broader health professional educational research skills), mentors and collaboration, using library resources, and conference workshops/ sessions (like this one by William McGaghie planned for Sim Health in September this year).

Margaret also shared some of her current work as an example of the elements of putting a research project together. Thanks again to Margaret Bearman for such an insightful and informed perspective.

3 - Eppich Debriefing

Debriefing is a social event – wisdom from Walter Eppich

 

Case

Ellen felt anxious walking into the debrief room.

The ED team had just finished an in situ simulation where the focus was on rapid sequence intubation (RSI) in head injury, and using the new intubation checklist. This was the third sim session in a series the department had agreed to run following 3 patient cases where significant desaturation occurred during intubation attempts.

Ellen thought they’d done OK but had recognized a lot of the usual ‘bad habits’ that frankly irked her when she worked on the floor with these guys – no nasal prong O2, a pretty vague conversation about who was going to actually do the tube, and low level grumbles about the time it takes to do the checklist. She was particularly disappointed that those things had come up in the last sim, and that a couple of the nurses had participated in that previous sim. “How can we actually get this into their heads?” she thought.

Entering the debrief room, Ellen knew what she wanted to bring up, but felt her stress level rising. Reactions first, she thought, and then facts. What would be a good advocacy inquiry question? What else did they say in that debriefing course…..? …….Should she let the learners dictate the topics?

And she knew that the ED consultant who was in the scenario was not a big fan of sim, and anticipated he might be difficult. His performance is probably off limits for today, she thought.

Deep breath.

“OK guys that was great. Well done”……..

 

In this episode of Simulcast we were delighted to talk with Walter Eppich (@LearnThruTalk). Walter is a paediatric emergency physician from Chicago, and Associate Professor of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine. He is Principal Faculty, Harvard Center for Medical Simulation (@MedSimulation), and a PhD Candidate, School of Health Professions Education, Maastricht University, Netherlands. He has published prolifically in the area of simulation debriefing.

Walter shared some general thoughts on debriefing, including ‘’letting go’’ of the idea that we must have a strong hand on the debrief, the importance of translating lessons to real practice, and the idea that participants also need to take responsibility for the process and success of the debrief. This last concept is embodied in his article with Adam Cheng (@DocChenger) on Learner Centered Debriefing, this month’s Simulcast Journal Club article.

He made the point that many of our options/ models for debriefing are more similar than they are different, as illustrated in his own blended approach, described in his PEARLs paper.

Walter then gave us a practical step by step guide to how he would approach Ellen’s debriefing case, and included additional thoughts on previewing topics, ensuring psychologic safety (see also landmark work by Amy Edmonson here), and using a strategy like the Center for Medical Simulation ‘Basic Assumption’ to maintain that positive regard for learners. He emphasized that debriefing is a social event, and one of a number of examples of learning conversations that are his passion. This is especially relevant as more simulation educators engage in debriefing after in situ scenarios, where there is an existing relationship between participants and debriefers.

Walter is also part of an exciting new simulation debriefing project with Adam Cheng and others – follow @Debrief2Learn for updates on the launch of website of same name

We’ll be hearing more from Walter on those learning conversations soon, but in the meantime enjoy his practical wisdom on the podcast.

More on debriefing from the #FOAMed blogosphere

https://www.aliem.com/2014/simlife-em-challenge/

http://injectableorange.com/2013/07/debriefing-careful-you-dont-just-give-carrot-a-little-stick-is-sometimes-needed/

http://stemlynsblog.org/good-to-talk-debrief-in-the-emergency-department/

http://intensivecarenetwork.com/radford-vandyke-simulation/

https://emsimcases.com/2015/06/30/debriefing-techniques-the-art-of-guided-reflection/

https://www.aliem.com/2014/improving-debriefing-skills-pathways-grid/

2 - Australasian Sim Congress with Julian van Dijk

2 - Pause & Discuss:

The Australasian Simulation Congress with Julian Van Dijk 

 

Collaboration is vital for successful sim programs, and yet we often work in isolation from fellow simulation enthusiasts. The Australasian Simulation Congress is a great opportunity for those of us in this part of the world to learn, to network, and to be inspired in our simulation work. It’s a joint effort for SimHealth (folks like us in healthcare), and Sim Tect (amazing simulation people from aviation, engineering, human factors, manufacturing and more) 

Big name guest speakers include Adam Cheng (@docChenger), a debriefing guru from Alberta, Canada. Look out for his new online project debreif2learn.com going live soon. Also speaking are Carrie Hamilton from the UK and William McGaghie from Chicago, USA.  

It’s on in Melbourne from Monday 26th September to Thursday 29th September, and we spoke to Julian Van Dijk (@julianvandijk2), the Sim Health conference convenor, about what to expect. 

 

 

1 - The future vision of simulation in health care. Are we there yet?

You have been asked to develop a five-year strategic plan for simulation services in your hospital. Through your literature review you recall an article by David Gaba, ‘The future vision of simulation in healthcare’. All your dreams have been answered. In 2004 Gaba mapped the dimensions of organisational applications of simulation. You are thrilled to find his projection of two possible histories viewed from 2025; one optimistic – simulation integrated into the very fabric of health care; and one pessimistic – lamenting the abject failure of simulation to progress past and ad-hoc expensive education luxury. Now your challenge lies in which history rings most true in 2016 and how do we move forward for the next five years? 

 

In 2016, the term ‘simulation’ covers a wide range of activities - procedural skills, team training, quality improvement, mannequins, simulated patients, virtual reality and much more. And yet healthcare simulation remains inaccessible, badly delivered or simply failing to live up to promise in many contexts. 

To kick off our first episode of Simulcast, Jesse and I decided to tack a step back and look at the ‘state of the art’ of healthcare simulation in 2016. We used David Gaba’s landmark paper - The future vison of simulation in health care from 2004 - as a starting point.  

David Gaba is one of the grandfathers of healthcare simulation. Trained as a biomedical engineer, a pilot and then as an anaesthesiologist, he brought a unique vision to how to train better for the work we do in healthcare.  

When he wrote this paper in 2004, healthcare simulation was in its infancy, and mostly delivered around expensive mannequins in dedicated simulation centres. I had just done my first Crisis Resource Management (CRM) course as a participant at Monash simulation that same year, and was an immediate convert to the possibilities. 

In the podcast we look at the clarity Gaba offered us in that paper - how to think about the dimensions for healthcare simulation delivery – the technology used, the participants, the learning objectives, the environment of delivery. 

But he also offered us two future visions of simulation for 2025. One is optimistic – in which healthcare sim is embedded and integrated with care, training and quality improvement. The alternate vision is one in which simulation never really ‘made it’.  

We bring our own biases and hopes to the discussion…..