1. Simulation: Why, when, what? Terminology, definitions, frameworks and applications Sandrijn van Schaik, MD PhD 2015 UCSF Center for Faculty Educators & Kanbar Center for Simulation

2. 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?

3. 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?

4. Simulation modalities for HPE Mannequin-based simulation Standardized patients Partial Task Trainers Virtual Reality Mixed Modalities 4 SIMULATION: WHY, WHEN, WHAT?

5. Mixed Modalities / Hybrid Simulation 5 Combination of actors, partial task trainers and/or simulation mannequins SIMULATION: WHY, WHEN, WHAT?

6. Why Simulation? Patient Safety Learner Benefits Institutional Benefits 6 SIMULATION: WHY, WHEN, WHAT?

7. Simulation for Patient Safety Avoid “practicing” on real patients Error reduction Optimize communication / teamwork 7 SIMULATION: WHY, WHEN, WHAT?

8. 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 8 SIMULATION: WHY, WHEN, WHAT?

9. Simulation to Benefit Institutions Disaster preparedness Test (new) systems Uncover latent safety issues Reduced malpractice insurance Accreditation and other compliance issues 9 SIMULATION: WHY, WHEN, WHAT?

11. 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 11 SIMULATION: WHY, WHEN, WHAT?

12. 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 12 SIMULATION: WHY, WHEN, WHAT?

13. Integration into Curriculum Simulation is one educational tool to get to the educational objectives of a curriculum 13 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 Kern The Johns Hopkins University Press 1998 SIMULATION: WHY, WHEN, WHAT?

14. Integration into Curriculum Simulation is most successful if related to other educational content and/or clinical experiences 14 SIMULATION: WHY, WHEN, WHAT?

15. 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 15 SIMULATION: WHY, WHEN, WHAT? History taking Communication skills Standardized Patients Hybrid simulation Clinical reasoning Clinical exam skills Mannequins Teamwork Resuscitation skills Task trainers Procedural skills

16. 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 16 SIMULATION: WHY, WHEN, WHAT?

17. 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 17 SIMULATION: WHY, WHEN, WHAT?

18. 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 18 SIMULATION: WHY, WHEN, WHAT?

19. Deliberate practice Practice followed by feedback and reflection, followed by focused repeated practice 19 Ericsson Acad Med 2004 S70-S81 SIMULATION: WHY, WHEN, WHAT?

20. 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 20 SIMULATION: WHY, WHEN, WHAT?

21. 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 21 SIMULATION: WHY, WHEN, WHAT?

22. 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 22 SIMULATION: WHY, WHEN, WHAT?

23. 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 23 SIMULATION: WHY, WHEN, WHAT?

24. 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 24 SIMULATION: WHY, WHEN, WHAT?

25. 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 25 SIMULATION: WHY, WHEN, WHAT?

26. Fidelity of simulation SIMULATION: WHY, WHEN, WHAT?

27. 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 27 Hamstra et al Acad Med2014 SIMULATION: WHY, WHEN, WHAT?

28. Dimensions of Fidelity Equipment Fidelity –Highest with physiology-based mannequins (realistic responses to interventions such as O 2, 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 28 Beaubien Qual Saf Health Care 2004 SIMULATION: WHY, WHEN, WHAT?

30. Simulation for Assessment Standardization Direct observation Video recording / multiple observers Feedback from standardized patients 30 SIMULATION: WHY, WHEN, WHAT?

31. Assessment and simulation Checklist vs global rating scales Bench marks / milestones Self assessment / peer assessment? 31 SIMULATION: WHY, WHEN, WHAT?

32. 32 SIMULATION: WHY, WHEN, WHAT?

33. Framework for Simulation as Educational Strategy 33 Script Patient Environment Instructors Learner Equipment and Tools Preparation Assessment & Feedback SIMULATION: WHY, WHEN, WHAT?

34. Example: Standardize Patient exercise 34 Patient Script (PMH, HPI, Symptoms) Actor/Standar dized Patient Clinical Exam Room Faculty observers/simulati on staff (video) Medical Student Stethoscope and BP cuff Instructions Checklist Feedback Checklist Feedback SIMULATION: WHY, WHEN, WHAT?

35. Example: Mannequin-based activity 35 Scenario outline Mannequin Operating Room Technicians Confederates Facilitator Technicians Confederates Facilitator OR team members Crash cart Medications Crash cart Medications (pre) brief Assessment tool Debriefing Assessment tool Debriefing SIMULATION: WHY, WHEN, WHAT?

36. Example: Procedure training 36 Steps of the procedure Partial task trainer Environment Instructor Nursing student Needles Syringes Needles Syringes Checklist Feedback Checklist Feedback SIMULATION: WHY, WHEN, WHAT? Content knowledge

37. 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) 37 SIMULATION: WHY, WHEN, WHAT?

38. 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-UCSFhttp://meded.ucsf.edu/radme/Teach- for-UCSF 38 SIMULATION: WHY, WHEN, WHAT?

39. Resources UCSF Kanbar Center for Simulation –Visit the website: http://meded.ucsf.edu/simulationhttp://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.edukanbar@ucsf.edu Society for Simulation in HealthCare –http://www.ssih.org/http://www.ssih.org/ California Simulation Alliance –https://www.californiasimulationalliance.org/CSAColl aboratives.aspxhttps://www.californiasimulationalliance.org/CSAColl aboratives.aspx 39 SIMULATION: WHY, WHEN, WHAT?

40. 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. 40 SIMULATION: WHY, WHEN, WHAT?

41. Questions? kanbar@ucsf.edu 41