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Healthcare Training in Simulated Environments

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Simulation

Introduction

“Clinical simulation is pretending for the purpose of improving behaviors for someone else's benefit (Kyle & Murray, 2008, p.xxiv).”

All respiratory therapists are trained to manage the airway of an unconscious patient. Endotracheal intubation is the most effective method of securing the airway but is a complex psychomotor skill requiring much practice. Historically, endotracheal intubation had been taught on patients, cadavers or animals, but this was not ideal. Mannequin training is one of the best options for instructing large numbers of students in a variety of skills (Gaiser, 2000) therefore the Respiratory Therapy program at TRU has adopted training on mannequins as a core component of their courses. Intubation trainers have been used for over 30 years (Good, 2003) but there is little published information on the relative merits of the available airway and intubation trainers. A variety of airway trainers with differing features are now commercially available from the low fidelity, part task trainer, that TRU respiratory therapy program utilizes, to the high fidelity, whole patient simulator that is becoming increasingly popular today.

Training health care practitioners in a simulated environment without actual patients is a potential method of teaching new skills and improving patient safety (Issenberg et al, 1999; Devitt et al, 2001; Lee et al, 2003). - pt safety

Simulations are defined as activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision-making, and critical thinking through techniques such as role-playing and the use of devices such as interactive videos or mannequins. A simulation may be very detailed and closely simulate reality, or it can be a grouping of components that are combined to provide some resemblance of reality. (Jeffries, 2005) - definition of simulation

Computer based simulations and part-task training devices can provide a certain degree of real-world application. These focus on specific skills or selected areas of human anatomy. High-fidelity patient simulators can provide real physical inputs and real environmental interactivity. To recreate all elements of a clinical situation, a full-scale or high fidelity simulation would be used. Costs of simulators will vary widely depending on purchasing costs, salaries, how faculty time is accounted for, and other factors. (Jeffries, 2005) - simulators, high fidelity, costs Modern technology, such as high fidelity simulation offers unique opportunities to provide the “hands-on” learning. High fidelity simulation offers the ideal venue to allow practice without risk and there are an infinite number of realistic scenarios that can be presented using this technology. As an example, life threatening cardiac arrhythmias can be simulated on a life like fully computerized mannequin. Monitors, identical to those used in the clinical situation can replicate the arrhythmia and corresponding changes in vital signs. The ‘patient' can be fully and realistically resuscitated with technical and pharmacological interventions. Viewing of videotaped performances allows personal reflection on the effectiveness of the case management. Morgan et al, 2006 - example of use of high fidelity sim.

High fidelity simulation provides a venue to teach and learn in a realistic yet risk free environment. The ‘patient' is represented by a computer-controlled mannequin who incorporates a variety of physiological functions (e.g. heart and breath sounds, pulse, end-tidal carbon dioxide). An instrumentation computer network can replicate situations likely to be encountered in an emergency room, critical care environment or operating room. A second person controls the mannequin and the monitors. The simulator mannequin will respond on an accurate way to induced physiologic or pharmacologic interventions. The ‘patient' will respond according to pre-set physiological characteristics (e.g. a young healthy adult or a geriatric patient with severe emphysema). In addition, the ‘patient' has the ability to speak, move his arm, and open and close his eyes and has pupils that can dilate and constrict. The simulation room can be set up to appropriately reflect the environment, either an emergency room, a recovery room, or a fully equipped operating room. Attached monitors respond to a medical intervention. Feedback from participants in the simulated environment has attested to the ‘realism' of the environment (Morgan & Cleave-Hogg, 2000). Morgan et al, 2006 - set up of HPS

A simulator replicates a task environment with enough realism to serve a desired purpose and the simulation of critical events has been used instructionally by pilots, astronauts, the military and nuclear power plant personnel (Gaba, 2004). The fidelity, or the “realness”, of simulations can vary in many ways, such as the use of simple case studies, utilization of human actors to present clinical scenarios, computer-based simulations, and the use of high-fidelity patient simulators that respond to real-world inputs realistically (Jeffries, 2005; Laerdal, 2008; Seropian, 2003). Recently, literature has described that using full-sized, patient simulators are a way of creating “life-like” clinical situations (Fallacaro & Crosby, 2000; Hotchkiss & Mendoza, 2001; Long, 2005; Parr & Sweeney, 2006). While simulation has been used by the aviation industry with flight training for years (Gaba, 2004), the use of a rudimentary human patient simulator in the health care field was first introduced in 1969 to assist anesthesia residents in learning the skill of endotracheal intubation (Abrahamson, Denson, & Wolf, 1969; Gaba & DeAnda, 1988). The more realistic human patient simulators were not created until 1988 and were used primarily to train anesthesiologists (Gaba, 2004).

Defining simulation in health care education

The literature on human patient simulation has tried to define several of the terms used in this study. However, there is no general consensus on many of these terms, including a debate on whether the simulator is a mannequin or a manikin (Gaba, 2006). One key term that requires specific definition for this study is high-fidelity mannequin-based patient simulator. The term “fidelity” is used to designate how true to life the teaching experience must be to accomplish its objectives (Maran & Glavin, 2003). Using this definition, fidelity becomes a scale where if given the objectives, a single piece of medical simulation equipment may be able to provide a “high-fidelity” experience for one objective but be “low-fidelity” for another objective. An example would be the insertion of a radial arterial catheter. If the objective were to only teach the psychomotor skills required for inserting the catheter, a relatively simple arterial blood gas access arm, part-task simulator would be adequate and provide a high-fidelity experience. But if the objective were expanded to include communication with the patient and members of the health care team, then the same device would suddenly become low-fidelity, as there is no feedback being delivered with catheter insertion and communication with the patient is not possible.

Beaubien & Baker (2004) noted that the term ‘fidelity' is frequently documented as a one-dimensional term that forces a static classification of simulation devices. Individuals with this view would have difficulty agreeing with the use of the terms as explained in the previous paragraph.

Maran and Glavin (2003) offered this definition: “Fidelity is the extent to which the appearance and behaviors of the simulator/simulation match the appearance and behaviors of the simulated system (p.23).”

Yaeger et al (2004) broke fidelity down into three general classifications: low-medium-and high-fidelity and explained that low-fidelity simulators are focused on single skills and permit learners to practice in isolation while medium fidelity simulators provide more realism but lack sufficient cues for the learner to be fully immersed in the situation. High-fidelity simulators, on the other hand, provide adequate cues to allow for full immersion and respond to treatment interventions.

For the purposes of this study, the following definitions will be used:

1. High-fidelity patient simulator - A full-bodied mannequin that replicates human body anatomy and physiology, is able to respond to treatment interventions, and is able to supply objective data regarding student actions through debriefing software.

2. Low-fidelity simulator - A part task trainer or a full-bodied mannequin that replicates human anatomy, but does not have physiologic functions (including spontaneous breathing, palpable pulses, heart and lung sounds, and voice capabilities), does not have a physiologic response to treatment interventions, and does not have a debriefing software system.

Use the next two statements at the beginning of other sections on simulation:

* “Simulation is a training and feedback method in which learners practice tasks and processes in lifelike circumstances using models or virtual reality, with feedback from observers, peers, actor-patients, and video cameras to assist improvement in skills (Eder-Van Hook, 2004, p.4).”

* “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).”

When we are looking at the use of high-fidelity patient simulators in health professions education, we have to be aware of and not confuse the simulator with the simulation. As Gaba (2004) described, “Simulation is a technique - not a technology (i2).” The mannequins or other devices are only part of the simulation. Dutta, Gaba and Krummel (2006) noted a gap in the research literature, stating, “A fundamental problem in determining the effectiveness of surgical simulation has been an inability to frame the correct research question. Are the authors assessing simulation or simulators (p.301)?”

Simulation has many applications. The teaching of psychomotor skills seems an obvious use for simulation but there are other areas that simulation can be utilized effectively. Rauen (2004) listed several areas in addition to psychomotor skill training where simulation has been used. Her list included teaching theory, use of technology, patient assessment and pharmacology. Rauen (2004) notes that the “emphasis in simulation is often on the application and integration of knowledge, skills, and critical thinking (para 3).”

History and Development of Simulation in Healthcare education

The history of simulation in healthcare has been well documented by several authors including Bradley (2006), Cooper and Taquito (2004), Gaba (2004) and Rosen (2004) and began with the use of models to help students learn about anatomical structures. Although the use of mannequins as the simulation model is relatively new (Bradley, 2006), simulation using animals as models dates back over 2000 years. Mannequins were utilized as models in obstetrical care as early as the 16th century (Ziv, Wolpe, Small, & Glick, 2003). The more modern medical simulators originated in the 1950s with the development of a part-task trainer called ‘Resusci-Anne' that revolutionized resuscitation training (Bradley, 2006; Gaba, 2004). Part-task trainers are meant to represent only a part of the human anatomy and will often consist of a limb or body part or structure. These low fidelity modesl were developed to aid in the technical, procedural, or psychomotor skills, such as venipuncture, catheterization and intubation (Kim, 2005), allowing the learner to focus on an isolated task. Some models provide feedback (visual, auditory or printed) to the learner on the quality of their performance (Bradley, 2006; Good, 2003).

Another general classification of patient simulators that combines some of the elements of both three-dimensional models and task-specific simulators is partial or part task simulators (Kyle & Murray, 2008). Issenberg, Gordon, Gordon Safford, and Hart (2001) used the term procedure skills simulator for this type of device. Maran and Glavin (2003) stated, “part-task trainers are designed to replicate only part of the environment (p.24).” and replicate anatomy and physiology of a single portion of the human body. As described by Beubien and Baker (2004), the skills taught with part task simulators “segment a complex task into its main components (p. i53).” Rather than creating complex scenarios commonly done with high fidelity patient simulation, part task trainers permit students to focus on individual skills instead of more comprehensive situations. Examples would be an arm with vascular structure to teach arterial blood gas procedures or a head with upper airway anatomy to practice advanced difficult airway procedures.

The second wave of modern simulation, with the development of full-scale, computer controlled, mannequin based patient simulators started in the 1960's with the development of Sim One (Bradley, 2006; Gaba, 2004; Good, 2003). SimOne had many of the features found on the high-fidelity mannequin-based patient simulators used today. SimOne was quite lifelike, and fitted with a blood pressure cuff and intravenous port. SimOne was able to breath, it had a heartbeat, temporal and carotid pulse and a blood pressure (Abrahamson, 1997).

Patient simulators have become very sophisticated over the years and now allow a wide range of invasive and non-invasive procedures to be performed on them, as well as enabling teamwork training (Davis, Buono, Ford, Paulson, Koenig and Carrison, 2006). When they are set up in a simulated and realistic environment, they are often referred to as high-fidelity simulation platforms (HFSP) or human patient simulators (HPS) (Kim, 2005). Components of the human patient simulator (HPS) include a mannequin and computer hardware and software. The HPS has characteristics expected in patients such as a pulse, heart and lung sounds, and blinking eyes with reactive pupils. The mannequin also supports invasive procedures, such as airway management, thoracentesis, pericardiocentesis and catheterization of the bladder (Laerdal, n.d.).

Medical Education Technologies, Inc. (METI) introduced the Human Patient Simulator (HPS) in 1996. It has subsequently followed with PediaSim in 1999, a simulator utilizing the HPS software but scaled down to mimic a child. In 2005, BabySim was introduced.

While being the first to enter the market with a full-bodied mannequin for patient simulation purposes in resuscitation with the Resusci Anne in 1960, Laerdal Medical did not introduce a high-fidelity patient simulator until 2000 with the introduction of SimMan. This device does not possess all the high-level functionality of METI HPS, but does provide adequate fidelity for many medical emergency situations. The Laerdal Medical SimMan also differs from the others in that it does not operate on mathematical models for simulator responses. Instead, it operates on instructor controls combined with script-based control logics. The Laerdal Medical SimMan patient simulator is the device to be used in this study. Details of the simulator's functions are found in appendix ____.

Aside from high-fidelity mannequin based patient simulators, there are many other types of simulation used in healthcare provider education and training. Collins and Harden (1998), Issenberg, Gordon, Gordon, Safford, and Hart (2001), and Ziv, Small and Wolpe (2000) discussed several other forms of simulation. The list includes animal models, human cadavers, written simulations, audio simulations, video-based simulations, three dimensional or static models, task specific simulators and virtual reality simulation. (Add VR reference?) Perhaps the next step in the evolution of health care teaching modalities is virtual reality (VR) simulation. Commercial VR simulators now exist to teach various trauma skills (Kaufman & Liu, 2001). In a study of the effectiveness of using a VR bronchoscopy simulator, students quickly learned the skills needed to perform a diagnostic bronchoscopy at a level that was equal to those who had several years of experience (Colt et al, 2001).

Simulation has been used for many years in the aviation and nuclear power industries and other highly complex working environments in which the consequences of error are costly (Bradley, 2006). A simulator designed to mimic the anesthesia patient was first developed in 1988, and since then, the number of hospitals and universities buying simulators for educational purposes is increasing (Henrichs, Rule, Grady and Ellis, 2002). The human patient simulator is used in health care education because it is a high-fidelity instrument that provides both educators and students with a realistic clinical environment and an interactive “patient” (Feingold, Calaluce and Kallen, 2004).

The cost of simulation is related to the level of fidelity and the technology being used. For high fidelity patient simulators, purchase costs can range from $30,000 for the Laerdal Medical SimMan or the METI ECS to over $200,000 for the METI HPS. Optional equipment available for these simulators can make the purchase costs even higher. In addition to the simulator, it is important to create a learning environment that replicates real-world settings, complete with appropriate medical equipment. Halamek et al. (2000) stated, “The key to effective simulation-based training is achieving suspension of disbelief on the part of the subjects undergoing training, ie, subjects must be made to think and feel as though they are functioning within a real environment (para 15).” Creating this environment adds additional costs to setting up a simulation-based medical education program.

Advantages of using simulation in health care education

Patient simulation of all types, including high-fidelity patient simulation, is becoming more common in many aspects and levels of healthcare provider education (Good, 2003; Issenberg, McGaghie et al., 1999; leblond, Russell, McDonald et al, 2005). The reasons behind the increased use of patient simulation include the advancement of medical knowledge, changes in medical education, patient safety and ethics. For new healthcare providers it is also important to consider the changing student demographic, as today's students are more comfortable with technology. Issenberg, McGaghie et al. (1999) pointed out several advantages to the use of patient simulators, stating “Unlike patients, simulators do not become embarrassed or stressed; have predictable behavior; are available at any time to fit the curriculum needs; can be programmed to simulate selected findings, conditions, situations, and complications; allow standardized experience for all trainees; can be used repeatedly with fidelity and reproducibility; and can be used to train both for procedures and difficult management situations. (p. 862)”.

Advancement of medical knowledge

Medical knowledge is continually growing with new tests, medications, and technologies that all bring about innovative understandings and expertise. The problem with educating health care providers with this new knowledge is that their curriculum is of a finite length therefore innovation in the curriculum is needed in order to prepare future health care providers. Issenberg, Gordon, Gordon, Stafford, and Hart (2001) made the following comments:

“Over the past few decades, medical educators have been quick to embrace new technologies and pedagogical approaches… in an effort to help students deal with the problem of the growing information overload. Medical knowledge, however, has advanced more rapidly than medical education…Simulation technologies are available today that have a positive impact on the acquisition and retention of clinical skills. (p.16)

Changes in medical education

Healthcare provider education has typically been taught using a lecture/apprenticeship model (McMahon, Monaghan, Falchuk, Gordon, & Alexander, 2005) that relies on observation and repetition (Eder-Van Hook, 2004). Halamek et al. (2000) noted the traditional model of medical education has three components: the learner performs a reading of the literature, the learner observes others with greater experience, and then the learner develops hands-on experience. This is the traditional medical model of education that has been in use for over 2,000 years (Current state report on patient simulation in Canada, 2005).

In relation to the traditional model, Issenberg, Gordon, Gordon, Stafford and Hart (2001) observed, “This process is inefficient and inevitably leads to considerable anxiety on the part of the learner, the mentor, and at times the patient (p. 19).” McMahon, Monaghan, Flachuk, Gordon, and Alexander (2005) stated this model “is inefficient in promoting the highest level of learned knowledge, as reflection and metacognition analysis occur independently, often without guidance and only after extended periods of time when students are able to piece together isolated experiences (p. 84-85).” Customarily, this format is often referred to as the “See one, do one, teach one” model of medical learning (Brindley, Suen & Drummond, 2007; Eder-Van Hook, 2004; Gorman, Meier, & Krummel, 2000; Yaeger et al., 2004).

Halamek et al. (2000) identified several problems with the current medical education model which includes; 1. Reading of the literature does not produce competency. More active rather than passive participation in the learning experience is needed; 2. Learners may have difficulty determining if their model for observation is a good or poor model. Just because the model may be senior does not mean they are competent. 3. The variability of experiences in the apprenticeship model is high, therefore learners' experiences will not be equal, and 4. Many training settings do not fully represent the complexity of the real world resulting in an inability of the learners to adequately practice their decision-making skills in a “real” environment.

Yaeger et al (2004) reinforced these points stating that healthcare education rely on two fatally flawed assumptions. The first assumption is that all clinical role models are effective and skilled, and all behaviors demonstrated by these role models are worthy of replication. The second assumption is that the end of the training period implies that a trainee is competent in all the skills necessary for successful clinical practice (Yaeger et al, 2004). Yaeger (2004) also noted that in the apprenticeship model, there is a need for a preceptor but this preceptor may not have the necessary skills to be an effective educator.

Patient safety

A predominant theme in many discussions of high-fidelity simulation is the concept of patient safety. In the education of healthcare providers, there are sometimes conflicting goals. As Friedrich (2002) commented in quoting Atul Gawande, “medicine has long faced a conflict between ‘the imperative to give patients the best possible care and the needs to provide novices with experiences' (p. 2808).” When looking at the broader topic of medical simulation, the concept of patient safety is a frequently mentioned subject (Bradley, 2006; Cleave-Hogg & Morgan, 2002; Ziv, Ben-David, & Ziv, 2005).

Much of the incentive behind the focus on patient safety relates back to the Institute of Medicine 2000 report To Err is Human: Building a Safer Health system (Kohn, Corrigan, & Donaldson, 2000). This study reported over 44,000 people and possibly up to 98,000 people die each year in United States hospitals from medical errors. The total annual cost of these errors is between $17 billion and $29 billion. Even more alarming is the fact that these findings represent only the hospital sector of the healthcare system. The number of lives affected would be even higher if other parts of the healthcare system were included such as long term care facilities and Emergency Medical Services. In its summary of recommendations, the report specifically mentions simulation as a possible remedy, stating “…establish interdisciplinary team training programs for providers that incorporate proven methods of team training, such as simulation (p.14).”

In Canada, it was estimated there were 70,000 preventable adverse events in Canadian hospitals with an estimate of deaths associated with those errors ranging from 9,000 to 24,000 (Current state report on patient simulation in Canada, 2005). The Canadian Patient Safety Institute supports the use of simulation as a means of improving patient safety in Canadian hospitals. In the conclusion of its report on patient simulation, the institute stated:

Growing awareness of adverse events in Canadian hospitals, combined with increasing emphasis on patient safety, has changed the traditional “learning by doing” approach to healthcare education. Anecdotal evidence reveals the promising potential of simulation to fundamentally change the way healthcare professionals practice and further hone their skills, interact across disciplines, and manage crisis situations. (Current state report on patient simulation in Canada, 2005, p.23)

Ethical perspective

One of the strongest statements made regarding the ethical perspective of simulations was presented by Ziv, Wolpe, Small and Click (2003). Under the title “Simulation-Based Medical Education: An Ethical Imperative”, the authors presented an argument that not using simulation was more than just an education issue, it was an ethical issue. As they report, there is often an over reliance on vulnerable patient populations to serve as teaching models when other resources exist that would provide adequate and possibly, more superior replacements.

The education of healthcare providers requires a balancing act between providing the best in patient care while also providing learning opportunities for the healthcare professions student (Friedrich, 2002). To protect patient safety, actual patient contact is often withheld in the healthcare provider learning process to a later period in their education.

One of the principle reasons patient simulation is being indicated as a partial remedy for the medical errors crisis is its ability to impact on a particularly vulnerable time in the learning process. As Patow (2005) cited, the “learning curve” faced by many healthcare professions students is a source of medical errors. He continued, stating that the realism of many of the currently available simulators is quite high and allows for procedures to be practiced to mastery prior to being tested on real patients. But simulations offer much more than just practice. Since medical errors often result from ineffective processes and communication, simulation allows teams “to reflect on their own performance in detailed debriefing sessions” (Patow, 2005, p.39). This opportunity to review, discuss, and learn from the simulation is an important step in the learning process.

The use of patient simulation in the training of healthcare providers is not limited to new students. There is also a need to maintain education in the health professions and simulation can be utilized effectively in this area as well (Ziv, Small & Wolpe, 2000). As in other reports, Ziv, Small and Wolpe (2000) restated the shortcomings of the traditional model and explained that simulation was not just for the beginner but also for the expert who is expected to “continuously acquire new knowledge and skills while treating live patients (p.489).” These authors feel simulation, when used across the range of health professions education, can make an impact on patient safety by removing patients from the risk of being practiced upon for learning purposes.

Gaba (2004) pointed out there are also many indirect impacts of patient simulation on patient safety. These areas of impact include improvements in recruitment and retention of highly qualified healthcare providers, facilitating cultural change in an organization to one that is more patient safety focused, and enhancing quality and risk management activities.

A final point on patient safety is the ability to let healthcare providers make mistakes in a safe environment. In real patients, preceptors step in prior to the mistake being beyond the point of recoverability or if the mistake occurs (particularly for those healthcare providers who are not longer students), there is a very limited instructive value to the case.

Ziv, Ben-David, and Ziv (2005) stated, “Total prevention of mistakes, however, is not feasible because medicine is conducted by human beings who err…[Simulation Based Medical Education] may offer unique ways to cope with this challenge and can be regarded as a mistake-driven educational method (p.194).” They continued stating that Simulation Based Medical Education is a powerful learning experience for students and professionals where “students are permitted to make mistakes and are provided with the opportunity to practice and receive constructive feedback which, it is hoped, will prevent repetition of such mistakes in real-life patients. (p.194)”.

Ethical Use of Simulation (incorporate these paragraphs into previous on pt safety)

Health care educators, whether from nursing, respiratory therapy, or medicine, find themselves in similar situations in deciding how to teach patient management to their students. Bioethicists have long condemned the use of real patients as training tools for physicians (Lynoe, Sandlung, Westberg, & Duchek, 1998). Unfortunately there have been times in which the student learning has occurred to the detriment of patients (Lynoe et al, 1998). However, with the advent of high-fidelity human patient simulation approaches to learning, it may be time to adopt this method of instruction in the development of interprofessional education.

The Institute of Medicine (IOM) recently issued a report on medical errors and recommended the use of interactive simulation for the enhancement of technical, behavioural and social skills of physicians (Kohn, Corrigan & Donaldson, 1999). Numerous accounts are found in the medical literature touting the use of human patient simulation in the education of health care personnel at all levels, from student to attending physicians. Patient simulation is used for training personnel in several areas of medical care such as trauma, critical care, surgery and anaesthesiology, mainly due to the extensive skill required to perform adequately the procedures and techniques relevant to these areas. Several researchers have demonstrated the effectiveness of simulation in the skill development of medical personnel (Morgan et al, 2003; Lee, Pardo, Gaba, Sowb, Dicker, Straus, et al., 2003; Hammond, Bermann, Chen & Kushins, 2002). In areas with low technology, such as internal medicine and in acute care areas providing less procedural skills but greater decision making requirements, the use of simulation in the education of its clinicians has progressed (Ziv, Wolpe, Small & Glick, 2003). Despite the growing support for the use of simulation in health care education, there is not yet enough evidence to support its use.

Simulation Research in Medical Education

In 1998, Ali, Cohen, Gana & Al-Bedah studied the differences in performance of senior medical students in an Adult Trauma Life Support (ATLS) course. This course uses simulated scenarios to both teach and evaluate students' performance in trauma situations. The students were divided into three groups; 32 medical students completed a standard ATLS course, 12 students audited the course (without participating in the sessions or taking the written exam) and a control group of 44 matched students who had no exposure to ATLS. Of note is that some participants from all three groups were doing clinical hours in trauma hospitals during this study while others were not. The participants were observed while managing the standardized (live) patient in simulated trauma and non-trauma scenarios. The participants' management of the sessions was scored on a standardized checklist of 30 to 40 items with weighted scores for each. The results revealed that students trained in ATLS programs that used simulated scenarios, achieved the highest scores, while the students who audited the sessions for the ATLS scored lower. However, those who had no ATLS training scored the lowest for trauma-related scenarios. Performance in the non-trauma related scenarios were similar for the three student groups. The effect of students doing clinical hours in hospital of varying trauma focus on the results was not discussed. This study is significant because many respiratory therapists and nurses who work in critical care areas are required to take ATLS and related simulation-based training sessions and this study demonstrated that participant performance improved after completing the training sessions.

Morgan, Cleave-Hogg, McIlroy & Devitt (2002) examined 144 fourth-year medical student's participation in either video-assisted or simulator-assisted learning facilitated by a faculty. Simulator performance pre- and post-tests were administered to both groups. After the pre-test was completed, participants were randomly assigned to either video or human patient simulator groups. Each simulated educational session lasted 1.5 hours and was followed by a 3-hour break in which students participated in an educational session of the opposite type (video groups was in a patient simulated session and the simulated group was in a video session). After the break, participants repeated the original simulated educational session. A statistically significant improvement in the written post-test scores was obtained in both groups (p<0.001), however, there was no statistically significant difference (p<0.296) between the students taught by use of either the video-assisted or simulator teaching approaches. There was also no significant improvement in students' performance in the second simulated session. Both video and simulator types of faculty-facilitated educational approaches apparently offered a valuable learning environment.

Results of these studies demonstrate that simulation has a positive effect on the skill performance of participants. However because these studies used different methods of instruction and evaluation, the ability to generalize these findings to a particular method of instruction is limited.

Simulation in Respiratory Therapy Education

There is a large amount of literature and studies that focus on the use of simulation in the education of nurses however, a search of the literature produced five articles that mention simulation, either low, medium or high fidelity, in the education of respiratory therapists. An article by Rodehorst et al (2005) was the only study with human patient simulators in education that included respiratory therapists. Nargozian (2004) reports that there is no information that exists as to the relative effectiveness of different didactic teaching modalities such as listening to a lecture, viewing videotape or using computer software programs. In the teaching of airway management skills, the learning process usually involves progression from didactic lessons to skills training on inanimate models to supervised clinical practice. However, the ‘see one, do one, teach one' model is no longer acceptable in medical education (Nargozian, 2004) because of the increased attention to patient safety that has led to a search for alternate teaching methods for skills training.

Two studies of allied health professionals illustrate that over the course of a year, cognitive knowledge did not decrease but mechanical skills did deteriorate (Bishop et al, 2001). Another study revealed that feedback on skill maintenance was still not enough to prevent skill loss and that feedback and training was needed to maintain skills (Kovacs et al, 2000). These studies suggest that there may be an optimal timeframe for review to maintain skills.

What is simulation? (This seems to be the same as “development” - perhaps incorporate in section History & Development of sim?)

Simulations are defined as activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision-making, and critical thinking through techniques such as role-playing and the use of devices such as interactive videos or mannequins. A simulation may be very detailed and closely simulate reality, or it can be a grouping of components that are combined to provide some semblance of reality. (Jeffries, 2005) - definition of sim

Computer based simulations and part-task training devices can provide a certain degree of real-world application. These focus on specific skills or selected areas of human anatomy. High-fidelity patient simulators can provide real physical inputs and real environmental interactivity. To recreate all elements of a clinical situation, a full-scale or high fidelity simulation would be used. Costs of simulators will vary widely depending on purchasing costs, salaries, how faculty time is accounted for, and other factors. (Jeffries, 2005) - defines part task trainer, high fidelity

Modern technology, such as high fidelity simulation offers unique opportunities to provide the “hands-on” learning. High fidelity simulation offers the ideal venue to allow practice without risk. There are an infinite number of realistic scenarios that can be presented using this technology. As an example, life threatening cardiac arrhythmias can be simulated on a life like fully computerized mannequin. Monitors, identical to those used in the clinical situation can replicate the arrhythmia and corresponding changes in vital signs. The ‘patient' can be fully and realistically resuscitated with technical and pharmacological interventions. Viewing of videotaped performances allows personal reflection on the effectiveness of the case management. Morgan et al, 2006 - put with advantages?

High fidelity simulation provides a venue to teach and learn in a realistic yet risk free environment. The ‘patient' is represented by a computer-controlled mannequin who incorporates a variety of physiological functions (e.g. heart and breath sounds, pulse, end-tidal carbon dioxide). An instrumentation computer network can replicate situations likely to be encountered in an emergency room, critical care environment or operating room. A second person controls the mannequin and the monitors. The simulator mannequin will respond on an accurate way to induced physiologic or pharmacologic interventions. The ‘patient' will respond according to pre-set physiological characteristics (e.g. a young healthy adult or a geriatric patient with severe emphysema). In addition, the ‘patient' has the ability to speak, move his arm, and open and close his eyes and has pupils that can dilate and constrict. The simulation room can be set up to appropriately reflect the environment, either an emergency room, a recovery room, or a fully equipped operating room. Attached monitors respond to a medical intervention. Feedback from participants in the simulated environment has attested to the ‘realism' of the environment (Morgan & Cleave-Hogg, 2000). Morgan et al, 2006 - put with advantages?

A simulator replicates a task environment with enough realism to serve a desired purpose and the simulation of critical events has been used instructionally by pilots, astronauts, the military and nuclear power plant personnel (Gaba, 2004). The fidelity, or the “realness”, of simulations can vary in many ways, such as the use of simple case studies, utilization of human actors to present clinical scenarios, computer-based simulations, and the use of high-fidelity patient simulators that respond to real-world inputs realistically (Jeffries, 2005; Laerdal, 2008; Seropian, 2003). Recently, nursing literature has described that using full-sized, patient simulators are a way of creating “life-like” clinical situations (Fallacaro & Crosby, 2000; Hotchkiss & Mendoza, 2001; Long, 2005; Parr & Sweeney, 2006). While simulation has been used by the aviation industry with flight training for years (Gaba, 2004), the use of a rudimentary human patient simulator in the health care field was first introduced in 1969 to assist anesthesia residents in learning the skill of endotracheal intubation (Abrahamson, Denson, & Wolf, 1969; Gaba & DeAnda, 1988). The more realistic human patient simulators were not created until 1988 and were used primarily to train anesthesiologists (Gaba, 2004). - put with history & development

Advantages of simulation (Seems to be the same as “purpose of using sim from additions to chpt 2. Perhaps leave as subtitle - advantages?)

Many advantages to using simulation are reported in the literature. Some of these include: a) presentation of uncommon critical scenarios in which rapid responses are required; b) participation in situations in which errors are allowed to reach their conclusion and students are allowed to see the results of their mistakes; c) encouragement of multidisciplinary team approaches to the management of patient problems; and d) development of procedural skills without risk to patients (Morgan, Cleave-Hogg, DeSousa, & Tarshis, 2003). The benefit of using simulations in education is to expose the student to high risk, low occurrence “critical events”, and practice in a safe environment, incurring no harm to a “real patient” (Chopra et al, 1994). Until recently, computerized mannequins could not realistically re-create the health care setting or offer real world scenarios (Issenberg et al, 2005). Recent advances in technology have greatly enhanced the capability of human patient simulators (HPS) to duplicate the types of scenarios that students are likely to encounter in clinical practice. Further, they can safely practice decision-making skills in a controlled environment. Although these advantages support the use of simulation, some say there are disadvantages.

Barriers to simulation

One of the major limitations of implementing an HPS-based curricular component is cost. While the hardware and technology are expensive, the faculty time required is even more so. To truly provide a complete experience, faculty members are required to provide direct observation and feedback. Debriefing sessions are extremely critical to the learning process and are routinely cited as the most important part of the entire simulation session (Issenberg et al, 2005). They are also very time consuming. (Fernandez et al, 2007)

Another limitation is the lack of existing data to support the need for simulation-based training. While HPS and teamwork training have a great deal of face validity, few studies offer any solid proof of training advantages over more traditional methods. This makes it difficult to justify the costs mentioned above and difficult to know how to best implement this technology. (Fernandez et al, 2007)

Lack of Realism

Others have also commented on the lack of realism in some areas, including the feel of the skin, skin colour, and skin temperature (Euliano, 2000; Good, 2003). The lack of realism may not apply to only the simulation device. Morton (1997) commented on the ability of the environment to be recreated, saying:

…. Simulation is constrained by the degree it can mimic reality. The fast-paced, high-stress environment of a critical care unit is difficult to simulate. As a result, there is no assurance that the learner will make a smooth transition of knowledge from the simulated situation to the actual clinical environment. (p.67)

Kneebone, Scott, Darzi, and Horrocks (2004) warned against an over reliance on simulation as being a replacement for actual clinical experience. Simulation competence may lead to overconfidence on the part of the learner creating a dangerous situation when the learner takes those skills to the clinical area. They stated, “There is also a danger that simulation may become an end in itself, disconnected from the professional practice for which it purports to be a preparation (p.1099).” Gilbart, Hutchison, Cusimano, and Regehr (2000) support this viewpoint as 100% of their simulation-based learners felt confident about their ability to provide care while only 83% of a comparison group felt confident, despite finding there was no significant difference in either group to provide adequate patient care. However, it could not be determined if this was a matter of overconfidence in the simulator group or under confidence in the comparison group.

Technical issues

One problem with high-fidelity mannequin based patient simulators is that they are mechanical. Breakdowns do occur. Henrichs, Rule, Grady and Ellis (2002) noted some dissatisfaction with breakdowns in their study of health care providers' experience with simulation sessions.

Cost

Cost remains an issue with simulation courses as the purchase of the simulators, equipping the simulation room, providing maintenance, and training faculty and staff still remains relatively high (Dent, 2001; Euliano, 2001; Farnsworth, Egan, Johnson & Westensko, 2000; Good, 2003; Nehring, Ellis, & Lashley, 2001).

Lack of data to support

While there has been a fair amount of research conducted on simulation as a teaching strategy in healthcare provider education, more needs to be done (Bradley, 2006; Hotchkiss & Mendoza, 2001). Just as evidence-based medicine has become an expectation in patient care, evidence-based education is becoming a higher priority in many healthcare provider curriculums. Once such manifestation of this movement is the Best Evidence Medical Education program (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005). One issue that creates problems for simulation-based education research is the small sample size of many studies (Bradley, 2006). Other authors (Beubien & Baker, 2004; J. cooper & Taqueti, 2004) also suggest more research is required, particularly research that shows improvements in patient safety. Another issue regarding simulation research is the inability to establish matching findings. Gilbart, Hutchison, Cusimano, and Regehr (2000) noted this as they reviewed the literature regarding transference of skills from simulation to the real world clinical environment.

Limited number of users

Nehring, Ellis, and Lashley (2001) also noted the limited number of learners that could utilize the simulator at one time as a barrier. Simulation-based education limits activities to small groups or possibly even single learners. Other formats such as lecture, demonstration, or web-based instruction can allow for larger groups or more simultaneous users.

Faculty development

Good (2003) stated that faculty development may be a problem (Jeffries too). As in many areas of education, faculty staffing and work requirements are stretched. Teaching with simulation requires a whole new skill set that many faculty members do not currently have. In addition to the teaching techniques required (such as debriefing) there is the technology to learn. While many simulation centers employ simulation technicians to manage this aspect, this is not universal and the faculty member may be called upon to manage the technology. Feingold, Calaluce, and Kallen (2004) and Nehring, Ellis, and Lashley (2001) also reported faculty concerns that simulation would require additional time and resources beyond their normal teaching responsibilities.

Lack of Realism

Another drawback noted by Greenberg, Loyd, and Wesley (2002) is that despite technological advances in simulator fidelity, simulators do not convey “humanness (p.1109).” Simulators are cold and plastic in appearance and even with the capability for a human voice to be generated via microphone and speaker, there are limits to how real the devices can seem. To counteract this deficit, Greenberg, Loyd, and Wesley devised a program where standardized patients are incorporated into the scenario and utilized up until the point actual procedures start. Kneebone et al. (2002) developed similar systems with part-task simulation.

Dehumanizing of Health care

Issenberg, McGaghie et al. (1999) pointed one other area of concern for simulation technology. They commented that there is some fear that technology will dehumanize health care. Simulation technology removes the health professions student from interacting with the patient and decreases total time spent with real patients. These authors felt that simulation training served the patient's best interest by placing a better-prepared clinical student at the bedside. Ziv, Wolpe, Small and Glick (2003) agreed with this point, stating, “Although over reliance on technological medicine may sometimes be a threat to humanistic care, the proper use of simulation technology has the potential to enhance humanistic training in medicine (p.786).”
Barriers to simulation (or limitations?) (Use as intro paragraph for barriers?)

A few disadvantages to using high-fidelity human simulation have been identified in the literature. The most frequently mentioned disadvantage is the heightened sense of awareness by participants of the possibility of an uncomfortable, simulated clinical event (Seropian, 2003). Another disadvantage is that some participants have difficulty suspending their disbelief during the session and therefore do not respond as honestly to the simulated situation as they might in an actual situation (Seropian, 2003). It is also difficult to simulate improved patient outcomes accurately since in real patient situations, numerous confounding factors are present, that are not present in the simulation (Ashish, Bradford, & Bates, 2001).

Costs

One of the greatest barriers to using high-fidelity human simulation discussed in the literature is the cost of the simulators and the simulation centers built to house them. Costs range from $20,000 for medium-fidelity human simulation models to $200,000 for high-fidelity simulator (Ashish, Bradford & Bates, 2001). The costs related to the maintenance, the planning of an appropriate instructional space, and the training and practice of faculty members regarding the use of simulation technology also have to be considered (Feingold et al, 2004; Seropian et al., 2004; Ziv et al, 2000). If a simulation center is created, the cost can be as great as $1,000,000 depending on the amount of equipment and human resources are included.

Faculty training

Faculty need appropriate training to learn the software and understand how to implement this technology into the curriculum with the students (Jeffries, 2005; Steinert, 2005) because a major barrier to the incorporation of simulation in education is the lack of proper faculty training (Jeffries, 2005; Ziv et al, 2000). An appropriate vision and business plan outlining the costs and use for simulation needs to be completed before purchasing the equipment (Seropian et al, 2004). Additional research must be conducted that examines the cost benefit ratio (Ziv et al, 2000) with respect to the integration of simulation into the curriculum. Seropian (2004) suggests considering the following administrative issues when implementing simulation as an education tool, in addition to developing an appropriate vision and business plan prior to the purchase of simulators: curriculum development, curriculum integration, scenario writing, scheduling, equipment, cost of disposable supplies, audiovisual aids, simulation specialist, and a debriefing facilitator. For most health care programs, the cost prohibits the ability to deliver such experiences.

In a study evaluating student and faculty perceptions regarding the use of HPS, researchers found that while 100% of the faculty agreed that the skills learned during the simulation would be transferable to a real clinical setting, only half of the students agreed (Feingold et al, 2004).

Simulation and Team Training (or IPE?) (needed?or incorporate in collaborative learning or collaboration?)

Simulation offers an opportunity to more effectively practice and evaluate team leadership as it allows the instructor to step back from the teaching scenario and allow the team to function in a more independent manner.

Reviewing learning teams in general, Kayes, Kayes, and Kolb (2005) summarized several negative behaviors that tended to surface in groups. These included:

* Over reliance on a single dominant person as team leader,

* Tendencies to resort to groupthink where individual members allow their independent thought to conform to the group, even when the group decision is wrong, such as making riskier or more conservative decisions than individuals would have made alone,

* Diffusion of responsibility in which individual members of the group shirk responsibility thinking that someone else will assume that responsibility, and

* Social loafing where individual group members loose motivation creating a situation in which the group's results are less than what the individual results could have been.

It is this team approach that must be addressed to have a substantial impact on patient safety and healthcare outcomes. As Hamman (2004) noted in comparing aviation incidents with adverse medical events, it is typically not a single individual or a piece of equipment that fails. It is more typically a team that fails. Training at this level has to involve more than just focus on the individual. Whole teams must be evaluated. As Hamman observed, in healthcare, training is focused at the individual with the intent of making that individual a better clinician. Henriksen and Moss (2004) stated that, “Health care providers work together, but are trained in separate disciplines. Few receive training in teamwork (p.i1).” Integrating the individual and his or her knowledge into the more complex interactive requirement is not the focus of most healthcare education programs. Hamman (2004a) created a five-step process for developing team simulations in medicine:

1. Identify team topics and subtopics, linking performance indicators to objectives.

2. Select incidents to simulate, preferable from a data set of real events

3. Identify objectives and the observable behaviors that will indicate their completion as tracked by a validated assessment instrument.

4. Test the simulation scenario with at least two different expert teams and confirm validation of the assessment instrument.

5. Modify and finalize the simulation based on expert team feedback and deliver simulation scenario to its intended audience.

(This portion is in the wrong place, should be with experiential learning)

Experiential learning in teams can be credited to Kurt Lewin in his work in the 1940s (Kayes, Kayes, & Kolb, 2005). For teams, reflection is an important process for improving team function. Kayes, Kayes, and Kolb (2005) cited principles that have they deduced from a review of research on experiential learning in teams in general.

For teams to learn, some form of intervention is required. Natural development is an unreliable way to improve performance (Kayes, Kayes, & Kolb, 2005). Simulation offers a “programmed team learning experience (Kayes, Kayes, & Kolb, 2005, p.350)”. For experiential learning to work for team development and acquisition of new knowledge, four components must be in place for team members, with one component for each of the four segments of the experiential learning cycle. Team members must be…

* Involved and committed to the team and its purpose and who are creating new knowledge and identifying challenges (concrete experience).

* Engaging in reflection and conversation about the team's experiences and making observations to ensure that all available knowledge has been addressed (reflective observation).

* Thinking critically about how the team works and coming up with new theories, devising plans, models, and placing abstract events into coherent and simple explanations (abstract conceptualization)

* Making decisions, taking action, and experimenting with various approaches and strategies for problem solving (active experimentation) (Kayes, Kayes, & Kolb, 2005, p.350)

Learning Theory that Bridges Simulation & IPE (collaborative, experiential, reflection, constructivisit)

Experiential Learning theory

The ability to transfer theoretical knowledge and apply this in a practice setting leads to the attainment of knowledge according to the Theory on Experiential Learning (Kolb, 1984). The traditional methods of teaching in a lecture format, with the instructor sharing facts with the students is perhaps not the best teaching method for health care professions such as respiratory therapy or nursing (Kolb, 1984). The learners need to be able to apply these abstract classroom concepts during a practical learning experience in order to enhance cognitive development. According to the theory, learning is enhanced when students are actively involved in gaining knowledge through experience with problem solving and decision-making, and active reflection is integral to the learning process (Kolb, 1984). Education is a result of experience (Dewey, 1997).

Experiential learning

Collaborative, cooperative, or social learning is closely linked to experiential learning, but most authors in IPE consider them to be distinct (Barr et al., 2005; D'Eon, 2005). D'Eon (2005) suggests that collaborative learning provides the structure and experiential learning the process. The context for experiential learning - a team of students working collaboratively on a case study, for example - provides the opportunity for IPE to occur. Learning in this sense is best conceived of as a process, not as a product or an outcome; and this approach to education suggests that the insights and skills acquired by the participants in an interprofessional experience are the learning itself. (clark, 2006)

Experiential learning is also a conflict-filled process, and out of the conflict comes the development of insight, understanding and skill (Kolb, 1984). Different health care professionals or students come into the interprofessional learning experience with different learning styles and ways of interacting with the world around them, related both to personal and to professional factors. According to experiential learning theory, these styles exist along two sets of polarities: i. Concrete experience (CE) - “feeling” - versus abstract conceptualization (AC) - “thinking”, and ii. Active experimentation (AE) - “doing” - versus reflective observation (RO) - “watching”. Of relevance to IPE, Kolb (1984) has found that the science-based professions usually exhibit high competency levels in AC and AE, while those in the human service area (e.g., social work) typically evidence high levels in CE and RO. (clark, 2006)

Learning as a process must include all of these elements. Learners must be able to participate in new experiences (CE), reflect on and observe their experiences from different perspectives (RO), create concepts that integrate their observations into logical theories (AC), and use these theories to make decisions and solve problems (AE). In the process of learning, the participant moves successively through these modes to create a learning cycle that integrates feeling, watching, thinking, and doing - a cycle that is virtually identical to the plan (P), do (D), study (S), and act (A) PDSA cycles promoted by quality improvement approaches (Barr et al., 2005). (clark, 2006)

The implications of experiential learning theory for IPE relate to the fact that learning is a continuous process grounded in experience, no an outcome. Practically speaking, this means that students learning to work as an interprofessional team should expect to work collaboratively either in real clinical situations and settings or on realistic case studies and problem-based learning experiences that mimic or reproduce “real world” situations such as simulations (D'Eon, 2005). (clark, 2006)

How a task is to be approached by the group, the actual steps that a group might follow in the process of working through learning tasks, is best described by what we know as experiential learning. D'Eon (2005)

Experiential learning is learning that takes place as a result of an encounter with an experience that is planned by instructors within a course, program or curriculum (Kolb, 1984). Beginning with an experience, students first plan a response to the situation and then they carry out their plans and implement their solution. The cycle continues to an observation or data-collection stage and finally on to reflection and the creation of general rules and principles. This simple cycle is the process that will help students approach and learn from experiences they encounter. D'Eon (2005)

The experience could be a paper case, a simulated patient encounter, or a real-life event during a rotation of some kind that they must successfully manage in some way. The experiences should also vary in complexity. Stage one is planning what they will do, what investigations or management they will attempt first. It depends on the nature of the case and the objectives for learning and can be determined entirely by the instructors or in part by the students as in some form of self-directed learning. Stage two is carrying out the plan, engaging in the management, doing the investigations etc. For paper cases it may simply mean letting the instructor know what the plan is. Stage three is making note of the outcomes of the interventions undertaken by the learners and others. In what way did the solutions/action work? For whom and how long did they work? These are some of the key questions that could be asked to determine the success of the actions implemented in Stage two but formulated in Stage one. The information can come from the environment, the patient, the students themselves and/or the instructors/supervisors. Finally, in Stage four, the students reflect on the information gathered in Stage three and the situation and consider what they might do in the future when a similar situation is encountered - they generalize. D'Eon (2005)

Experiential learning cycle: plan, act, observe, reflect

Stage one: Plan what to do as a result of the situation presented in the experience

Stage two: Act. Put the plans into action. Try out the solutions generated in Stage one.

Stage three: Observe and gather data on the effect of the action taken.

Stage four: Reflect and generalize. Determine what was learned and what could be done better next time. D'Eon (2005)

Reflection

The process of reflection is a cognitive process that can be enhanced through a structured learning activity. Kolb's theory has been used many times in education to explain the need for the incorporation of practice into a curriculum. The theory also provides a framework for the use of human patient simulation as students are able to apply their knowledge to the care of a simulated patient within a safe environment, which will lead to the improved gaining of knowledge. The debriefing experience used with students after the HPS experience directly mirrors the importance of reflection as an integral part of the learning process. It is during this experience that students can cognitively and purposefully think about the learning experience so that those abstract principles learned in the classroom can become concrete as a result of their application (Schon, 1991)

Schon (1991) argues that although profe


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