Expanding - Northern Ontario School of Medicine

Transcription

adventures in simulation-based health
professional education in Northern Ontario
informatics innovations
expanding
simulation
Parry Sound, January, 2010 - Mathieu Seguin
adventures in simulation-based health
professional education in Northern Ontario
Editors: Rachel H. Ellaway, David Topps
Northern Ontario School of Medicine
Contributors: Jacques Abourbih, Sue Berry, Susan James,
Chris Kupsh, Suzanne Lortie-Carlyle, Karen Paquette,
Robert Rubeck and Roger Strasser
This work was funded by the Planning Simulation for Multi-professional Assessment Project
and the NOSM Informatics Research and Development Group (NIRD)
Photography: Mathieu Seguin, Rachel Ellaway, David Topps, Susan James; other sources annotated
© Northern Ontario School of Medicine, 2011, all rights reserved
expanding
simulation
table of contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Simulators and Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Simulation in Healthcare Education in Northern Ontario . . . . . . . . . . . . . . . . . . . . . . 13
Simulation for Dummies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Virtual Patients? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Operations: Simulation Activities at NOSM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Anesthesia Boot Camp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Midwifery Sims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Capability: Disasters and the NOSM CCC Retreat . . . . . . . . . . . . . . . . . . . . . . . . . 27
Moulage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Capacity: Pathways for Interactive Narrative Education . . . . . . . . . . . . . . . . . . . . . . 41
Exploring a PINE VP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
OpenLabyrinth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
VUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Research: Integrated Simulation: HSVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Sim Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Research: Virtual Worlds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Research: Haptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Sustainability: Opportunities and Challenges for NOSM . . . . . . . . . . . . . . . . . . . . . . 57
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5
NOSM Dean Roger Strasser acting
as a standardized patient at the CCC
retreat in Parry Sound in January 2010
Foreword
The Northern Ontario School of Medicine (NOSM) was established with a social accountability
mandate to contribute to improving the health of the people and communities of Northern Ontario
and a mandate to be to be innovative.
In this context, NOSM developed Distributed Community Engaged Learning (DCEL) as its
distinctive model of medical education and health research. This involves medical and health science
learners undertaking clinical education in a wide range of health service and community settings in
over 70 different locations across Northern Ontario.
DCEL emphasizes authentic learning in context and depends heavily on information communication
technology to support widely dispersed learners. In addition, DCEL relies on interdependent
partnerships between NOSM and communities, individuals and organizations in all parts of
Northern Ontario and beyond.
Simulation may be defined as the imitation of some real thing, state of affairs, or process. For clinical
education, simulation enhances hands-on practical learning in a controlled environment. Five years
ago, NOSM was the first medical school in Canada to have Harvey, a cardio-respiratory mannequin.
Already, Harvey seems “old hat” in the light of more recent developments in simulation presented
in this report.
“Expanding Simulation” reports a series of exciting simulation initiatives in which NOSM has played
a lead role, often in partnership with others in Northern Ontario and beyond. These initiatives
represent impressive examples of northern innovation and excellence in the context of limited
resources. I congratulate all the individuals and groups involved and encourage the continuation of
these outstanding innovations.
Dr. Roger Strasser
Dean and Professor
Northern Ontario School of Medicine
Introduction
professional education in Northern Ontario. Chapter
two describes the range of simulation activities carried
out as part of the educational programs run through
NOSM. Chapter three describes a simulation-intensive
three-day retreat for third-year NOSM undergraduate
students in January 2010. Chapter four describes the
Pathways in Interactive Professional Education Project
(PINE) that created 60 virtual patient cases on a variety
of northern healthcare topics. Chapter five describes
the development of a platform for multi-device, multisite integrated simulation activities. Chapter six
closes with a review of options and issues for ongoing
sustainable development of simulation capacity at
NOSM. A number of illustrations and descriptions of
simulation and simulators in Northern Ontario are also
provided.
“Simulations include devices, trained persons, lifelike
virtual environments, and contrived social situations
that mimic problems, events, or conditions that arise
in professional encounters.” (Issenberg et al, 2005)
The use of simulation is a safe and effective way of
training and assessing healthcare professionals with
particular strengths including the provision of meaningful
and constructive feedback on learner performance,
supporting repetitive practice, providing variation in the
difficulty and focus of clinical presentations, enabling
learners to try multiple strategies in controlled learning
environments, and supporting defined outcomes and
benchmarks (Issenberg et al, 2005).
The uptake of simulation for healthcare training has
been patchy in Northern Ontario. Patchy in terms of
investment, in terms of the forms of use, in terms of
the amount of use, in terms of the current and future
needs and in terms of how different subject areas
conceive of and use simulation. A common concern is
that, given the distribution, size and resources of the
universities and colleges in the north of the province,
the economies of scale are relatively poor and
therefore there is a need to work together to ensure the
quality and sustainability of simulation for healthcare
education. While the provincial government has funded
multi-institutional simulation support in Toronto it has
not so far made similar arrangements for the needs
of northern communities and those that serve them.
Despite the absence of funding, a loose consortium of
Northern Ontario institutions involved in simulation for
healthcare education has come together (the Northern
Ontario Simulation in Healthcare Network - NOSHN).
So far this has been an unfunded activity and has
largely focused on building a functional community of
practice across the participating organizations.
As with much of the innovative and critical work that
is carried out in the north of Ontario the innovation in
simulation-based education has been significant but
often disregarded or overshadowed by activities in
the south. One of the functions of this document is to
describe and share the innovative work carried out ‘up
here’ and to demonstrate not only the thinking but also
the skills and commitment to the use of simulation in
health professional education.
While we can show we have much in the way of practice
and ideas to share, we will inevitably continue to be
challenged by the geographical realities of Northern
Ontario that create challenges around achieving
critical mass, collaborating effectively with distant
partners and retaining quality and experienced staff.
We look therefore to opportunities to work with the
province and other collaborators so that we can share
and further develop capacity for simulation-based
learning. We need to ensure the ongoing supply of
safe, well-prepared and confident health professionals
to maintain the health of all of Ontario’s citizens.
This report is intended to serve both as a record of
the work that has been carried out in and around the
Northern Ontario School of Medicine (NOSM) and as
an indicator of future directions that it might take. The
report is arranged in six chapters. Chapter one presents
an overview of simulation provision for healthcare
Funding for this report was provided by the Northern
Interprofessional Collaborative for Healthcare Education
(NICHE) and the NOSM Informatics Portfolio.
9
Simulators and Simulation
Simulation in health professional education involves
representing a real-world situation in sufficient detail to
support meaningful training or assessment activities.
It does not usually require the simulation to creates
the illusion of reality, rather it requires that those
that are involved know that it is not real but behave
as if it were. More specifically simulation has three
dimensions; the creation of a semi-real situation (the
simulation environment including but not limited to
simulators), the definition or outline of some participant
activity within the situation and then the activity being
executed.
Although simulation can be carried out without any
props, it is typically better supported with some kind of
device or stand-in at least for the patient. A commonly
cited definition of ‘simulator’ is that it:
“usually refers to a device that presents a
simulated patient (or part of a patient) and
interacts appropriately with the actions taken by
the simulation participant” (Gaba, 2004)
There are many different patient-like simulators in
common use today including:
•
mannequins - these are full body representations
of human beings that range from highly
sophisticated high-fidelity machines that replicate
physiological and physical signs through to basic
non-interactive forms. NOSM has a mixture of
higher fidelity devices such as Laerdal’s SimMan
as well as the simpler Resusci Anne and a number
of pediatric mannequins including SimBaby.
•
part-task trainers - these represent just a part of
a patient for performing individual tasks. Examples
include an arm for practicing phlebotomy, a head
for practicing intubation or a female pelvis for
practicing gynecological examinations.
•
standardized patients - in essence actors
playing the role of a patient. Standardized patients
are trained to provide the same presentation of
a medical condition to all of the learners they
encounter.
This page: SimMan 3G (above) and an
airway part task trainer (below). Facing
page, clockwise from top left: SimBaby,
Resusci Anne, anesthetics machine,
simulated blood, defibrillator, wound
pads for mannequins, CentralLineMan
•
virtual patients - these are computer-based
representations of patient encounters. Virtual
patients can combine aspects of narrative and
games as well as medical simulation - see
separate section in chapter 4 on virtual patients.
•
‘medium as message’ simulators - these are
health informatics systems such as electronic
medical records, pharmacopeia and order entry
tools and PACS imaging platforms
•
paper cases and scenarios - such as those used
in problem-based learning and OSCE stations
We can think therefore about the simulator as an
artefact around which simulation activities can be
constructed so as to use some or all of the functionality
afforded by the simulator. A simulator may be used in
many different simulation activities, for instance a part
task trainer and a standardized patient may be used
together. As an example, consider a situation where
a learner has to perform a gynecological exam whilst
talking to the patient. The standardized patient would
be draped to make it seem that actor and part task
trainer were the same person.
Simulation activities typically start with a briefing on
the scenario to be negotiated followed by the learners
performing some kind of activity within the scenario.
No matter what kinds of simulator and simulation are
being used feedback is essential. Although feedback
might be given during the activity (for instance if it is
intended to be instructional), most scenarios withhold
feedback during the activity so as to retain the sense
of reality. Feedback therefore follows the activity
and typically involves participants first reflecting on
their own and each other’s performance followed by
constructive feedback from the tutor.
Although various forms of simulation have been part of
health professional education for many years, recent
improvements in simulator technologies and better
educational models have combined with the growing
need for well-prepared health professionals to place
simulation at the heart of healthcare professional
education, training and assessment.
Chapter 1
Simulation in Healthcare
Education in Northern Ontario
schools of nursing to purchase simulation equipment
to build simulation capacity at these schools. Using
this initial seed funding (two tranches of around $500k
per institution), each of the participating universities
and colleges were able to establish their own inhouse simulation centres that were well equipped
for their needs at the time. One of the expectations
of the funding initiative was that the recipients were
to ensure that use of these facilities was not just for
internal purposes but would also be shared with
collaborating communities and organizations. This
funding was instrumental in introducing high-fidelity
simulation to the region even though it was initially
only for nursing. None of the other professional groups
in the region had access to equivalent resources to
establish their own facilities at this time. Most of the
nursing programs have subsequently expanded the
application of their simulation facilities to other areas,
such as training paramedics.
Simulation is a rapidly growing component of the
training of healthcare professionals and ensuring that
they are safe and fit to practice. The expanding role of
simulation is reflected in the proliferation of simulation
centres at medical schools, hospitals and other training
organizations worldwide. However, simulation centres
are expensive to set up and maintain. Perhaps more
importantly, establishing centres creates challenges
for distributed medical education programs. Although
the Northern Ontario School of Medicine has
developed simulation facilities at its principal sites in
Sudbury and Thunder Bay its approach to distributed
healthcare education means that it needs to work
with partners across the province in order to provide
appropriate simulation facilities to all of its participants
and communities. This chapter reviews the current
state of simulation in health professional education
in Northern Ontario both to set the scene and as
the baseline for ongoing development in simulation
capacity in the region.
NOSM was preceded by two postgraduate education
centres supporting rural electives, residency and
other professional programs in the north (NOMP in
Thunder Bay and NOMEC in Sudbury - both merged
with NOSM in 2006). Although simulation was used
in some structured courses (like ACLS or PALS) and
in occasional preceptor-led sessions with the NOMP
and NOMEC residents it was on a distinctly ad hoc
basis. The Northern Ontario School of Medicine
opened its doors in 2005 as the faculty of medicine
at both Lakehead and Laurentian universities and a
not-for-profit corporation. Although its core facilities
are on the main Laurentian and Lakehead campuses
(Sudbury and Thunder Bay respectively) it has learners
and faculty across the region. Simulation was used
in the new MD program in the form of standardized
patients, part task trainers and mannequins although
the standardized patient program was (and continues
to be) the most fully developed activity. A simulation
Providers
Although the Northern Ontario School of Medicine
is the latest and largest dedicated healthcare
educational organization in the region there are many
other programs and courses for health professions.
At the time of writing three universities in the region
run healthcare professional programs: Lakehead
University in Thunder Bay, Laurentian University
in Sudbury and Nipissing University in North Bay.
There are also 6 colleges offering health professional
programs: Collège Boréal and Cambrian College in
Sudbury, Canadore College in North Bay, Northern
College in Timmins, Confederation College in Thunder
Bay and Sault College in Sault Ste Marie.
In 2003, the province of Ontario invested $10 million in
the Clinical Simulation Equipment Initiative that funded
13
Expanding simulation
participating institution. Two key factors emerged
from this activity; few centres were using their
simulation resources to their fullest extent and
there was great variation in extent and form of
use between partner institutions. Most institutions
identified the lack of personnel as their biggest
challenge, but also noted other challenges around
limited space, equipment and expertise. Concerns
were also raised about the ability of member
institutions being able to replace the equipment
originally purchased under the provincial funding
initiative.
program was created in 2008 within the Informatics
portfolio as part of an organizational review, but this
excluded simulated patients and the majority of the
part task trainer activity, which remained exclusively
within the undergraduate medical program. The
School acquired Laerdal SimMan 3G mannequins to
equip simulation centres in Sudbury and Thunder Bay
and has run many events and courses as described in
this report.
Networks
The other major investment by the province in simulation
involved $4.5M from the provincial government for
the Network of Excellence in Simulation for Clinical
Teaching and Learning (NESCTL), a simulation
network linking the Toronto Academic Health Science
Network and the Michener Institute for Applied Health
Science. Although NESCTL focused on Torontofocused activities and projects it was relaunched
as SimONE in December 2010 as the only ministryfunded simulation network in the province. There has
been some engagement with NESCTL by simulation
practitioners in Northern Ontario (mainly through
meetings and conferences sponsored by NESCTL)
but these activities are always in and around Toronto.
Following a number of discussions between different
simulation providers the Northern Ontario Simulation
for Healthcare Network (NOSHN) was established in
late 2007. Developed as a grassroots collaborative
network with no external funding or other support
NOSHN involved providers exploring ways of sharing
resources and ideas and supporting each other across
Northern Ontario. The network developed to include
all of the colleges and universities involved in health
professional education in Northern Ontario along with
the medevac provider ORNGE. Although there was
some initial hesitation about involving hospitals in the
network, it became clear that regional hospitals faced
the same kinds of problems as those experienced by
educational institutions and that several hospitals were
keen to work with the network. At the time of writing
three regional hospitals (Thunder Bay, Sudbury and
Sault Ste. Marie) have joined NOSHN. There were four
key foundational activities in establishing the network:
•
•
common policies were developed around sharing
equipment, scenarios and skills to allow personnel
and equipment to be used in different contexts.
This involved covering issues such as liability and
warranty for damage and how expenses such as
transporting equipment between sites would be
covered. For many members this was the first
time these kinds of issues had been considered.
•
a schedule of meetings and joint activities
was developed to promote and explore the
opportunities for collaborative working. A number
of collaborative sessions were run including a
‘Simulation for Dummies’ conference, moulage
and equipment sharing for the NOSM CCC retreat,
and the anesthesia boot camp for residents in
Sudbury. These activities are discussed later in
this report.
•
a shared online environment was set up at NOSM
for all members of NOSHN. A combination of wiki,
database, file server and object repository, the
platform has been used by members largely for
sharing ideas and materials.
There have been a number of benefits arising from
participation in this network:
an inventory was taken of the simulation resources
and the ways they were being used for each
14
•
regular peer communication and sharing of
ideas and news. This is particularly important
given the geographical challenges of the region
and the absence of a critical mass of simulation
professionals in any given organization.
•
shared training around simulation skills such as
mannequin operation, scenario writing, recipes
for blood and other fluids and bodily matter and
moulage.
Chapter 1 - Simulation in Healthcare Education in Northern Ontario
•
the ability as a group to leverage greater influence
over simulation vendors and suppliers.
as way of enhancing services to rural and remote
communities.
•
the ability to share scenarios, equipment and
sometimes even staff.
Northern Ontario is a large and profoundly distributed
environment with many challenges arising from
its geography, climate and its many languages
and cultures. The providers of health professional
education in the region have developed significant
capabilities in using simulation for teaching, learning
and assessment. Limited provincial support enabled
activity in a few areas but there remain many
challenges in running and sustaining efficient and
effective simulation programs in the region.
A number of common challenges were identified from
working as a network. Foremost among them was the
tendency for many institutions to acquire simulation
equipment before allocating space and designing the
programs that will use it. Furthermore, because of
this focus on setup, ensuring support for operational
expenses, such as replacing disposables and old or
damaged equipment, can be a problem where the
focus has been on capital rather than operational
budgets. Another common challenge follows from
the physical size of simulation equipment; sufficient
storage space is rarely provided. This is a particular
challenge in hospitals; when there is competition
for space and patient care takes precedence over
storage, particularly of educational resources.
Summary
Being able to bring simulation tools to health care
providers and educators in NOSM’s remote and rural
communities is a major challenge. NOSHN is one
way to develop the means to extend clinical simulator
training to a greater number of northern communities.
Supporting training in the local setting affords a safe
and non-threatening environment and allows service
provision to be maintained. There is clear need for
further research on the use of this type of training
Cambrian paramedics and NOSM
learners learn together on an
emergency mannequin scenario
Next Steps
The remaining chapters in this report illustrate some
of the ways in which simulation has been developed
and woven into the educational environment, many
of which have been enhanced through participation
of NOSHN members. However, although the
development of a bottom-up (unfunded) network has
strengthened relationships and enabled a certain level
of collaboration around simulation it cannot solve
all of the problems its members face and the future
of simulation for health professional education in
Northern Ontario remains uncertain. Investment in the
NOSHN network could be a major enabler for greater
collaboration around running simulation programs and
for developing the scholarship of simulation across
the network. It would also help to address the many
challenges faced in sustaining simulation activities
across Northern Ontario.
Simulation for Dummies
One of the earliest events arising from the collaboration
between member organizations of NOSHN was the
Simulation for Dummies symposium at Cambrian
College’s eDome in Sudbury. This one-day symposium
focused on making advanced simulation more
accessible to interprofessional teachers and learners,
and included presentations and interactive hands-on
workshops.
Canada, we were able to demonstrate the realities
of resuscitation, remotely controlled, right in front of
the audience. Three mobile eDome cameras provided
additional viewpoints. The fidelity of the scenario
was astounding, reinforcing key points, like the delay
between administration and the physiological effect of
intravenous drugs, even for this experienced team of
resuscitators.
The keynote speaker, June McDonald-Jenkins from
UOIT, gave a spirited presentation on how simulation
enhances interprofessional teamwork, which was
rounded off by a staged surprise crash code. A team
of paramedics was joined by a medical student and
an Emerg resident, as they wheeled their patient into
centre stage in the eDome. June, a former trauma
nurse, stepped right into the fray. Using the first
Laerdal SimMan 3G wireless mannequin available in
We took advantage of the eDome’s cutting edge
technical and videographic resources to create
valuable video teaching material for use in follow
up sessions. The highly interactive nature of the
symposium stimulated much discussion and
discourse, both during and between sessions. This
symposium was an excellent example of how well the
partner organizations in NOSHN play well together,
sharing resources, expertise and ideas.
Laerdal’s Dave Grant controls SimMan 3G wirelessly as the learners
battle to save their patient observed by eDome camera crews and
the meeting audience during megacode at NOSHN “Simulation
for Dummies” workshop, Cambrian eDome, Feb 2009.
Chapter 1 - Simulation in Healthcare Education in Northern Ontario
Virtual Patients?
A virtual patient is “an interactive computer simulation
of real-life clinical scenarios for the purpose of health
professions training, education, or assessment. Users
may be learners, teachers, or examiners” (Ellaway,
Candler et al. 2006). Virtual patients can help learners
integrate, contextualize, synthesize and apply multiple
educational dimensions in practice settings. They can
be made available on-demand and can be replayable
allowing learners to explore different decisions
and strategies. By the learner’s actions having
consequences virtual patients can support high levels
of immersion and user agency. The four main aspects
of virtual patients are:
•
schema VPs supporting learners in developing and
assessing patterns and schemas in professional
practice. These involve a repeated approach
to practice with different details each time that
demonstrates the efficacy of using the schema.
Typical schemas include history, examination,
investigation, diagnosis therapy (HEIDR) and
airway, breathing, circulation (ABC).
•
narrative VPs that allow the learner to explore
emotional, social and cultural dimensions of
practice letting them learn to deal with patient and
practitioner complexity, ambiguity, capriciousness,
and irrationality using characters and their motives.
•
game VPs involving formative or summative testing,
with scenarios that present opportunities to rate their
performance on different tasks. Essential aspects
include rules, and opportunities to win or lose.
•
simulation VPs that provide opportunities to practice
and/or be assessed in a real-world setting.
Essential aspects include critical decisions made/
not made, actions taken/not taken. These VPs
usually have smaller scope of action overall but
more detailed actions at key points.
As student access to patients becomes increasingly
limited (shorter hospital stays, more students, working
hour limits, and a growing need for assured curricula)
virtual patients can help to address this problem by
providing simple and flexible simulation activities.
The PINE Project website provides access to all
60 PINE VPs plus downloadable packages and the
VUE visualizations - http://pine.nosm.ca/pine
The Canadian Healthcare Education Commons
site has a section on virtual patients from across
the country - http://tinyurl.com/2clzeq9
The eVIP Project website has 320 virtual patients to
be played or downloaded in a number of languages
from multiple healthcare disciplines across Europe http://www.virtualpatients.eu
NOSM undergraduate learners deal
with a simulated trauma case
Chapter 2
Operations: Simulation
Activities at NOSM
and potentially difficult conversations. That these can
be overheard compromises the essential quality and
confidentiality of the learning experience, as well
as creating a disturbance for those working within
earshot. The lower levels of usage in Thunder Bay
have limited the impact of this issue but clearly do not
address it.
Introduction
Although this report concentrates on new and
innovative approaches to using simulation it is
important that we also set out the current operational
use of simulation at NOSM to put this innovative
work in context. This chapter describes the different
facilities and applications of simulation in NOSM’s
various education programs.
Residency Programs
Since opening in 2005 the School has established a
number of simulation resources and facilities. Student
labs were set up in both Sudbury and Thunder Bay,
principally for use by year 1 and 2 students in NOSM’s
MD program. Run by the School’s undergraduate
medical education (UME) portfolio these labs are largely
used for clinical skills and basic science laboratory
sessions for students in years 1 and 2. Simulation
activities focus on the use of part task trainers such
as phlebotomy arms, lumbar puncture trainers, arterial
blood gas arm trainers, and pelvic and rectal exam
trainers. NOSM also has a Harvey heart and lung
sound simulator at both the Sudbury and Thunder
Bay sites. Simulation laboratories were added in 2008
by the Informatics portfolio for use by any of NOSM’s
programs or partners, although uptake has been
largely by NOSM’s residency programs so far. These
labs are equipped with Laerdal SimMan 3Gs along
with SimMan 2s, SimBabys, ALS mannequins and a
range of adjunct equipment and resources. Although
control rooms were created to allow tutors to control
mannequins without being seen by learners funding
ran out before they were completed and the planned
closed circuit TV capability was not implemented. This
means that only the wireless 3G mannequins can be
controlled from the control rooms. Funding shortfalls
also meant that the Thunder Bay lab had soft partitions
rather than drywall isolating it from adjacent office
space. Simulation and debrief involves frank, noisy
NOSM has residency programs in family medicine
(with around 100 learners on-program at any one time)
along with specialty programs such as pediatrics,
surgery, community medicine, anesthesiology and
psychiatry (with 50 or so specialty residents at any
one time). Although the majority of learners’ time is
spent in the clinical workplace they do have regular
scheduled and structured educational sessions.
Depending on numbers a typical session will involve
residents either starting off with an interactive
presentation or a general briefing (to orientate them
and assist with knowledge transfer and review).
Learners then move on to the simulated cases and
simulators to rehearse their skills and knowledge.
Standardized patients are not used for these sessions
although discussions are underway to include some
residency training sessions especially for procedures
such as lumbar puncture, as well as obtaining
consent for such procedures and physician-patient
communication.
Emergency Medicine PGY3
Dr Kupsh started simulation-based teaching sessions
in 2008 with the Emerg PGY3s. Simulation sessions
were run once a month with the topic linked to their
problem-based learning sessions. For example, for a
19
Expanding Simulation
residents together) three times in the year (orientation
and two unified rounds, one each in Sudbury and
Thunder Bay).
PBL case on sports medicine involving a collapsed
marathon runner the simulation exercise represented
the runner using a mannequin to allow learners to
develop different strategies around resuscitation and
management of the case. On other occasions Dr
Kupsh has worked with the lead for the current block
to identify topics or skills that learners were struggling
with that could be addressed in the simulation
sessions.
Issues such as reduced stay times in hospitals and
the specialization within the environment mean that
opportunities for learners to get all of their learning
experiences on the wards was becoming increasingly
problematic. The development of these sessions was
therefore significantly enabled by the simulation labs at
NOSM by supporting viable alternatives to traditional
didactic methods.
Within the hour available for the session the handson simulated scenario ran for about twenty minutes
followed by thirty minutes of debriefing. Debriefing
involved two steps; one around ‘how did the medicine
of the case go?’ i.e. did the participants do the
appropriate things? The second was ‘how do they
function in terms of leading and working as part of
a team?’ Each participant was assigned a particular
role that persisted onto the debriefing. For instance,
the learner performing the role of the recorder would
be questioned along the lines of ‘it’s two years later,
we’re now in a court of law, can you defend yourself
on what’s written’ and so on.
The importance of these sessions was illustrated
when a PGY2 resident toward the end of their program
announced that they had never led a code. Simulation
allows program leads to make sure that their learners
have the appropriate experience and skills to deal
with these life and death situations. Although northern
residency programs have historically benefited
from relatively low numbers of learners and less
rigid hierarchies than in larger centres, as NOSM’s
programs grow this advantage may be reduced and
again simulation affords ways to maintain the quality
of the School’s programs.
Image from Ferdi’s World on Flickr used under a Creative Commons licence
The over arching goal is to developing the residents’
appreciation of the different tasks within a team so
that when they find themselves leading a team for
real they will be able to better manage the situation.
While the Sudbury Emerg residents receive a session
once every four weeks Thunder Bay Emerg residents
get less (on average four sessions a year) based on
how often Dr Kupsh can fly over to run them there.
There are also conjoint sessions (both east and west
Family Physician PGY1s and PGY2 Residents
The 60 Sudbury and 40 Thunder Bay Family Physician
PGY1s and PGY2s receive five 4-hour simulation
training sessions a year; topics change from year
to year but include rapid sequence intubation and
The Right Tools for the Job
“Although we use foam suturing pads, nothing beats real flesh when you’re
learning. We therefore use pigs’ feet (from the grocery store) for suturing
practice as they approximate the skin on a human’s back. We also use turkeys
when we’re putting in chest tubes. Although we have the trainer model it
doesn’t quite get that feeling of going through layers of tissue. We put a half
collapsed balloon inside the thoracic cage so learners have to make the cut
through the layers of tissue between the ribs to get to the thoracic cavity
and that approximates the feel much better than the plastic model. Although
mannequin manufacturers say you can put a chest tube in it’s not real enough
for me so I pair the mannequin with the turkey simulator. Similarly, starting
an IV on 3G can be problematic so I have a part task trainer right by the
mannequin. You can’t give any medication until you have the IV started and
if you can’t start the IV then here’s the EZ-IO right next to it.” Dr Chris Kupsh
20
Chapter 2 - Operations: Simulation Activities at NOSM
a static model. We are addressing this by adapting
hybrid methods such as attaching task trainers to
standardized patients (or their tutors) to make the
scenarios more challenging and real. The costs
associated with using standardized patients are not
insignificant but the learning benefits are significant.
Not every student is going to be able to perform every
task at every station so tutors switch roles around
between stations. This ensures that everyone gets to
be both participant and observer.
airway, electrocardiogram and chest x-ray, casting,
codes and resuscitations and miscellaneous
procedures (including suturing, EZ-IO, c-spine,
x-rays). These sessions employ a mix of task trainers,
biological materials and mannequins with learners
moving through a number of stations. For instance,
there are four stations for the airway session; normal
airway, advanced airway and two scenarios with
learners spending an hour at each station. ‘Codes
and resuscitations’ involves two circuits of three
stations; pediatric resuscitation, adult resuscitation
and a trauma. However, because of the lack of tutors
in Thunder Bay there are sometimes fewer stations.
These sessions are designed and run by Dr Kupsh
with different ER physicians acting as tutors for each
station. The selection of topics is matched to the
College of Family Physicians’ list of procedures that
family practitioners should be able to deal with.
These sessions are also being strengthened through
including mannequin-based scenarios once the
basic skills have been learned so as to practice them
in a more meaningful context. For instance, an ALS
mannequin that breathes and has a pulse can be
used to teach around an airway that learners can both
observe and actually assess.
NOSM has developed a substantial standardized
patient (SP) program with more than seventy individuals
on its books. Standardized patients are actors that
have been trained to simulate particular conditions. In
order to match the actor to the case they range from
children to seniors and with both males and females.
At the time of writing SPs are mainly used in phase 1
of the undergraduate curriculum, in OSCE exams and
occasionally on contract for postgraduate exams for
the Medical Council of Canada.
Evaluation of these sessions shows that residents value
these sessions and would like to have more. Currently
Dr Kupsh writes up the objectives, the cases and the
delivery guides for the learning activity coordinators
in Thunder Bay and Sudbury as well as leading the
sessions. An extra hour session was added in 2010
where groups of five PGY2 residents are put through
a range of resuscitation scenarios using SimMan 3G or
2G mannequins (depending on the scenario). However,
this is limited by available resources and the logistics
organizing sessions, particularly in Thunder Bay.
In any given week thirty or so SPs are called in to the
School. OSCEs typically involve 24 SPs over multiple
circuits. The use of SPs in phase 1 is essentially for
learning basic communication, interviewing and
examination skills as part of the regular Structured
Clinical Sessions. Training time for an SP depends
on the case - a simpler case involves around 30
minutes of preparation, a more difficult case about
an hour. Higher stakes events such as OSCE stations
can require even more time to ensure consistency
across multiple sessions so that learners have the
same opportunity and the same details are expressed
consistently.
MD Program
The 4-year NOSM MD program involves two years
of mixed preclinical and community learning (largely
located in either Sudbury or Thunder Bay), followed
by a year-long comprehensive community clerkship
and a final year of specialty clerkships. Simulation is
currently used in clinical skills sessions in years 1 and
2 and again to a lesser extent in year 4.
First and second year students encounter
standardized patients in their SCS (structured clinical
skills) sessions and they also, depending on the lab,
work with a range of task trainers. The current SCS
format involves learners receiving a one-hour lecture
followed by practical work with the part-task trainers.
However, we have observed a fall off in attention once
learners have performed the tasks once or twice on
In year 4 MD learners get simulation training as
part of their emergency medicine rotation. The four
students in each rotation have a 3-hour weekly
session addressing topics such as airway, chest
x-ray, suturing and casting. For example, one session
allowed learners to rotate through four abnormal
21
Anesthesia
Boot Camp
Family Practice Anesthesiologists (FPAs) face
numerous challenges, often outside the support of a
tertiary center: infrequent exposure to crises, limited
availability of support from colleagues, limited access
to professional development, all compounded by a
short training schedule (typically 1 year). Most FPAs
will return to rural, or underserviced areas and serve
as local expert leaders in crisis management and
resuscitation for a diverse range of patients, including
children, elders, and pregnant patients. This can create
significant anxiety in handling sporadic crises. FPA
training programs must adequately prepare trainees
for the unique situations they will face in Northern
Ontario. Intense courses like crisis management
“boot-camps” have been shown to be successful in
other specialty programs in building confidence as
well as technical skills.
The aim was to allow learners to develop team
leadership skills and to practice acute medicine prior
to real-life crises. The goal was to provide trainees
with a safe learning environment in order for them
to develop an appreciation of the spectrum of their
profession, learn valuable procedural and crisis
management skills, expand on their knowledge of
physiology as it relates to anesthesia, reflect on their
personal experiences and develop their own personal
learning objectives for the future.
Different sessions were set up for each day of the
week-long course. These included interactive lectures,
task training sessions, and multiple simulation
sessions with high-fidelity simulators (with a minimum
of 4 cases per day). Residents were also asked to fill
out a journal page each evening to consolidate their
learning objectives, help manage stress and identify
process issues. Individual debriefings were carried out
every second day and an overall debriefing was done
with each trainee on the last day.
Feedback from the learners at the end of the course
was very positive: “Lots of experience in a short
period of time – it would have taken months or years
to encounter these cases” “Things will stick” “The
trouble with doing normal uneventful anesthesia is
that you don’t learn to be scared” “Repeat this at the
end of the year”.
This Boot Camp was the result of collaboration
of Faculty from the Anesthesia, Critical Care and
Emergency Departments at Sudbury Regional Hospital
(HRSRH) as well as the IT department at NOSM and a
Simulation Fellow from Ottawa. The first 3 days took
place at NOSM and the last 2 days were held in the
Operating Rooms at the HRSRH and involved NOSM
and Ottawa FPA residents. In view of the success of
this week, we have had expressions of interest from
Queen’s, McMaster, Western and Toronto for their FPA
programs as well as their Anesthesia FRCP programs.
Support for this event was provided by the AHCS AFP
Innovation Fund. Although there are clear benefits the
ability to provide this type of experience regularly is
severely limited by a lack of regular funding.
Dr C Kupsh and Dr R Anderson
Chapter 2 - Operations: Simulation Activities at NOSM
activities in addition to its MD and residency programs
further reflecting how multiprofessionalism is part of
the School’s identity. Simply throwing learners from
different professions together is not the answer. For
instance mixing undergraduate nursing students
with residents doesn’t work well because of the
difference in their levels of experience. It would be
more appropriate therefore to combine senior nurses
with residents. The other challenge with IPE is making
sure that one group’s interests are not pursued to the
detriment of other participants. For example, although
some ACLS courses have developed an IPE dimension,
less experienced learners need extra tuition to make
sense of the program while more experienced learners
disengage from the more basic material.
behaviour stations that involve managing four different
patients at once, for trauma stations the learners work
on a SimMan 3G patient management problem. Unlike
residents who can usually manage the case without
tutor intervention, undergraduate learners require
more support and direction.
Challenges
Because simulation teaching expertise has tended to
be concentrated in Sudbury learners in the northeast
receive a more regular diet of simulation based training
and assessment than those in the northwest. Dr Kupsh
runs sessions whenever she is in Thunder Bay but this
is infrequent and it is a costly way to provide simulationbased education in this location.
There have been a number of IPE simulation courses
run using simulation involving NOSM teachers and
learners, including:
An attempt to address this issue for residents in
Thunder Bay involved setting up an extra simulation
room at the medical school with an ALS mannequin, a
VitalSim and an airway kit to allow residents to run their
own ACLS scenarios. However, none of the Thunder
Bay residents have made use of it. One major reason
is the absence of an expert tutor to give feedback and
validate learner performance.
In Sudbury, because of the large numbers of residents
and limited space in the simulation lab many sessions
are run in the nearby undergraduate labs. The numbers
of residents also require two circuits of three stations
in an afternoon. Even then this can involves 6-7
learners per group. Sessions have been further split
into morning and afternoon diets to help address this
problem but logistics remain a significant challenge.
Interprofessional Education (IPE) and Simulation
NOSM is one of Canada’s smallest medical schools
operating over one of its largest regions. This creates
significant challenges in providing tutors and clinical
experience. NOSM makes use of a number of different
professional groups to support its programs with a
strong focus on interprofessional education. NOSM
has also depended on collaborations with more
established institutions and programs as it builds out
its programs and facilities. NOSM’s partnerships with
Ontario’s new Family Health Teams are clear indicators
of this interprofessional learning environment. It should
be noted that NOSM has a number of other educational
•
TNCC (Trauma Nursing Core Curriculum) course
was designed for and run by nurses to learn
basic trauma management. This provided an
opportunity for interprofessional working and Dr
Kupsh and her colleagues arranged for the course
to use both NOSM mannequins and her PGY3
emerg residents to enhance the sessions. Not
only did this enrich the course it also allowed for
work around teamworking and leadership
•
The ALARM course is offered by the SOGC (Society
of Obstetricians & Gynecologists of Canada).
Susan James of the Laurentian midwifery program
arranged for her midwifery students to go through
the course and offered additional spots for
NOSM residents and labour and delivery nurses
from Sudbury Regional Hospital. About half of
the activities are simulation-based (including the
assessments at the end) and SOGC brings in all
their own simulation equipment.
Conclusions
Simulation is currently being used in many ways
across NOSM’s programs but this use is uneven and
led by just a few individuals. A strategic approach
is required to align needs and resources as well as
develop capacity among NOSM’s faculty and its many
partners.
23
Midwifery Sims
Laurentian, Ryerson and McMaster universities jointly
run the Ontario Midwifery Education Program. Susan
James, the Director of the Laurentian University
School of Midwifery talks about her use of simulation:
“Teaching and practice of clinical skills takes place both
before and throughout midwifery practice placements.
The approach varies, but the overall objective is to
provide students with both quality and quantity of
practice. For some skills, simulated models provide
excellent beginning competence. For example, being
able to first practice venipuncture on a simulated arm
provides the student with a quasi-realistic experience
without the fear of puncturing a live arm.
While birth simulators such as Noelle can provide
experience with the labour and birth process, the
usefulness of this simulator is limited. Noelle is heavy
and can really only give birth in the “stranded beetle”
position. Using the obstetrical manikins allows the
student the opportunity to practice “catching” in any
position and over the same period of time that it takes
for Noelle to give birth once, several students can
have an opportunity to practice the midwife role. In
addition, the student who takes the role of the birthing
woman must negotiate the baby through the birth
canal. She learns the importance of the mechanisms
of labour – how the baby needs to flex its head and
rotate through the various diameters to fit through the
pelvis. The manikins are also well suited to teaching
approaches to emergency births such as shoulder
dystocia, breech, undiagnosed twins and cord
prolapsed/presentation.
An important role of simulation in the midwifery
program is for practicing approaches to care where
the situations are relatively rare and may be seldom
encountered in practice or in situations where the
consequences of inappropriate actions are life
threatening. Simulation allows students to experiment
with options, see what might happen if they try
something that they have not yet seen in practice and
to see what the roles of other care providers might be
in the same situation.
Mothers of Invention
Many skills can be learned and practiced using low
cost simulation models. Foam rubber, sponges and
balloons can be used creatively as reasonably realistic
models. A kitchen sponge and a balloon along with
some yellow tinted water can be used to practice
female catheterization. A water filled balloon inside an
obstetrical manikin can be used to practice amniotomy.
Some balloons can be filled with meconium or blood
tinted water to up the ante; moving the student into
a management role in addition to the basic skill
acquisition. High density foam blocks can be easily
crafted into perineal suturing models. Markers or paint
can be used to create the anatomical landmarks and
layers. This option does not pose the risks of some of
the simulators that use harder materials where needle
breakage can be a real and regular problem.
Collaboration
The PINE virtual case studies introduce a variety of
simple to complex cases where the student assumes
a primary care management role. If the student makes
a non-life threatening “error,” the case studies, like in
real life, provide additional choices for the student to
compensate for the error. If the error is life-threatening,
the case study ends and the student is invited to start
over. The ability to learn from making errors in a safe
environment is a valuable addition to the curriculum.
The ALARM course organized by the Society of
Obstetricians and Gynecologists of Canada (SOGC) is
a component of the third year midwifery curriculum and
included family medicine residents and practitioners,
nurses and midwifery students. The goal is to use a
combination of lecture and case study simulation to
practice interdisciplinary approaches to obstetrical
emergencies. Not only do participants learn from the
“expert faculty,” they learn from one another and learn
to trust the expertise of each professional in the group.
Susan James, Director Laurentian
University Midwifery Education Program
“participants were able to triage and manage mass
casualty patients according to large group learning
and Skill Station instruction and to transfer that
knowledge to event-based performance”
Chapter 3
Capability: Disasters and the
NOSM CCC Retreat
NOSM Comprehensive Community Clerkship
The Comprehensive Community Clerkship (CCC)
makes up the third year of the Northern Ontario School
of Medicine’s MD program:
“this mandatory longitudinal integrated clerkship
involves students living and learning in 12 large
rural or small urban communities outside Sudbury
and Thunder Bay for the full academic year”
(Strasser et al, 2009)
All of the learners from the distributed CCC sites come
together once a year along with their teachers and CCC
support staff for a retreat. In 2010, the CCC retreat
took place in Parry Sound, a town on Georgian Bay
in the northeast corner of Lake Huron. In addition to
the NOSM medical students the retreat also involved
Canadore College’s first-year nursing students on
placement in Parry Sound. Other invited participants
included local high school students along with local
dignitaries and senior staff from the medical school.
NOSM has two main sites
at Thunder Bay and Sudbury
(circles) and a number of CCC
sites (diamonds) at Parry Sound, North
Bay, Temiskaming Shores, Timmins, Sault
Ste Marie, Huntsville and Bracebridge,
Sioux Lookout, Kenora, Fort Frances,
Kapuskasing and Dryden.
Tabletop exercise
The Disaster Theme
The retreat started with a tabletop exercise that got
learners and preceptors working in groups of eight or
so to respond to a series of questions and challenges
arising from the simulated disaster scenario. The
narrative provided involved a multiple vehicle accident
on Highway 69 during the upcoming G8 meeting in
nearby Huntsville. Multiple injuries, limited resources,
personnel problems and media intrusion were
presented and responses sought from the participants.
A panel of experts gave their initial responses to the
situation and then each group worked to devise
answers to strategic questions that were interspersed
with ethical questions to the audience as a whole - see
the sample of questions below. An electronic audience
response system was used to solicit and display
answers for a series of ethical questions with feedback
The 2010 CCC retreat was designed with a strong
instructional component around a common theme
of disaster response and management. This theme
was selected to form a united context for exploring
clinical, social, organizational and interprofessional
dimensions of practice. This disaster theme was a
topic that is not addressed in the small regional CCC
teaching sites or in the mainstream curriculum.
The pursuit of a disaster scenario theme was greatly
enhanced by the participation of Don Brisbane, a Parry
Sound EMS professional with significant experience in
training hospital teams to deal with mass casualty and
disaster planning scenarios. The event consisted of a
series of activities building on this scenario.
27
provided by one or more of the expert panelists along
with reflections from the audience. These sessions
were designed to be ice breakers among groups of
learners who had not necessarily met before as well
as an introduction to the issues involved with the
disaster response theme.
morning following a similar model to that run in the
‘Simulation for Dummies’ meeting - see page 14.
Students were called out from the audience along
with a preceptor to work on saving this patient. All
of the participants then gave feedback on managing
the situation. Emphasis was placed on discussing the
experiences of working with a mannequin as a prelude
for the following mass simulation exercise.
The morning of the second day involved a series
of presentations and workshops around the CCC
and the NOSM undergraduate program. A ‘surprise’
emergency resuscitation session was run late in the
Mass Simulation Exercise
The rest of the CCC retreat was given over to a mass
simulation exercise organized around eight stations.
Learner groups mixed NOSM medical students and
Canadore nurses. Each group was rotated through
a series of simulation stations dealing with practical
issues associated with emergency response medicine.
The topics covered were EMS/communications (two
half stations), shock, airway management, triage,
fracture, mental health/ virtual triage (two half stations),
C-spine, and obstetrics with flat baby.
Example Tabletop Exercise Questions
Large numbers of armed security staff, members of
the international press and political aids are gathering
on the hospital grounds. Hospital staff can not get to
the hospital. Things are getting tense. Emergency is
swamped and another wave of patients are expected
any minute.
1. Upon notification of this mass casualty incident, what
immediate actions should be taken by the hospital staff?
Each station took 35 minutes and each group
completed four stations on the Friday afternoon and
the other four on the Saturday morning. All stations
were highly interactive, requiring learners to develop
and practice hands-on skills in dealing with the various
challenges they were presented with. A wide range of
simulation modalities were used including simulated
patients (actors with make-up), mannequins, video
games and role-play.
2. What general medical support will be in the most
urgent demand? What additional services of a specialized
or exceptional nature will be required that your facility
lacks?
3. At what point does your hospital stand up its Incident
Command System and begin making preparations for
special emergency medical routines?
28
4th floor
The West Parry Sound
Health Centre was extremely
generous with their time
and resources. A whole
floor of the hospital along
with several rooms on other
floors were given over to the
mass simulation exercise.
Obstetrics
8
7
C-Spine
elevator
washrooms
Shock
2
Airway
3
entrance
Comms
1B
Triage
Fracture
Moving groups of learners
between stations could have
led to confusion and loss of
time. We designed a flow
through the available space
- with stations sequenced so
that learners would travel the
minimum distance between
each step and to travel only
in the one direction - the
diagram shows the location
of the stations and the
flow path between them.
control
4
5
6A
Mental
1A
Virtual Triage
6B
washrooms
elevator
rest area
1st floor
29
EMS
Moulage
Moulage is literally ‘moulding‘ from the French and
involves using makeup and other devices to simulate
injuries to humans or mannequins. Several stations
at the CCC retreat involved moulage of some kind, in
particular the EMS station. NOSM didn’t have anyone
with moulage skills in-house at the time of the CCC
retreat so Karen Paquette from Cambrian College was
engaged as the moulage artist for the retreat.
Using make-up from Ben-Ney, Karen Paquette
created a scene composed of casualties from a bus
accident, using fake blood and flesh tone wax to create
everything from bruises to simulated severed limb
wounds, which were then to be assessed by students.
The visual effects added realism to the trauma patients
of the EMS station. Make up was applied to faces for
bruising and to make the skin look dusky. Hematoma
was created by using a combination of painted flesh
tone and bruise coloring which was added over top.
Vaseline was then applied under the skin to further
create swelling necessary for visual and tactile effect.
Protruding bone was created using a combination
of flesh tone wax and old chicken bones and by
combining a little bruise color and blood would then
give the effect of a compound fracture. In order to
create a severed limb effect, Karen used an old shirt
with a ripped arm, lots of blood and a simulated
severed arm strap attached to the person’s side.
To achieve a burn wound, she used molding wax which
created pockets for blistering and then added blood
and KY gel to make the area look like it was seeping
blood. Our “cast” of characters not only looked the
part, but also played the part well.
Moulage for head trauma,
pallor and a severed limb
are applied (top to bottom
right) and the moulaged
EMS patients ready to go
(below) with Karen centre
Chapter 3 - Capability: Disasters and the NOSM CCC Retreat
following a bus accident that involved government
dignitaries. Participants learned ethical tactics and
techniques to manage the media to convey accurate
information, sustain credibility, and build favorable
public perception.
Station 1: Emergency Medical Services (EMS)
Led by Parry Sound EMS lead Guy Harris this halfstation was run in two halves in a divided room.
The first half introduced basic concepts in triage
and second half allowed learners to practice their
new found skills with standardized patients playing
the part of accident victims with a variety of injuries
(see moulage panel opposite). The sessions on the
Friday afternoon involved NOSM’s Dean and several
Associate Deans as the standardized patients.
Learning points:
1. Have a media plan in place BEFORE a crisis occurs
2. If you are the designated spokesperson, take time
to gather your key messages. It is okay to tell a
reporter you will call him or her back.
Learning points:
3. Speak in “headlines” – offer the conclusion first,
briefly and directly, and then back it with facts or
proof points.
1. Safety First: If You Don’t Know ... Don’t Go!
2. First EMS personnel on scene should not start
treatment: establish the number of patients,
establish the number of ambulances required and
establish which allied agencies are required.
4. Use interview bridges to regain control of an
interview: “what’s really important here is…”, “the
thing to keep in mind is…”, “let me tell you what I
do know…”, “let’s look at it from a broader/different
perspective…”, “another way to approach it is…”
3. Establish a Command Post and designate: Site
Coordinator, Triage Officer, Ambulance Treatment
Officer, Ambulance Traffic Control Officer.
5. Trust and Credibility = the Communication
of Caring, Empathy, Competence, Expertise,
Honesty, and Commitment.
4. Initiate Triage: Assess ABCs and assign a triage
tag to everyone.
5. Establish a Holding Area: Arrange triaged patients
to corresponding holding area matching there tag
color to area color.
Station 3 Shock
Run by Drs Jacques Abourbih and Laurel Snyder
this full station was designed to introduce learners
to high fidelity simulator technology and then to
evaluate team performance in an exercise involving
the resuscitation of a trauma patient. Initially learners
and observers were briefed about the expectations
for the performance and were then shown a video of
the same scenario performed by an interprofessional
team. Learners were then instructed to resuscitate
the mannequin. Performance Evaluation comprised
3 components: debriefing team members with tutor
and peer feedback followed by a reflective exercise
around individual and team performance.
6. Transport by Priority: Red first, Yellow second,
Green third and Blue last.
7. Use the mnemonic EMCA (Emergency Medical Care
Assistant): E - Environmental safety, M -Mechanism
of injury, C - # of Casualties, A - Allied agencies
required, P - Protective equipment required.
Station 2 Communications
Run by NOSM Director of Communications Kim
Daynard this half station provided media training
to learners, particularly with respect to how best to
respond to media inquiries and conduct themselves
in media interviews during a crisis situation. In this
station, learners were provided with a particular
scenario to discuss in which a television reporter
demands comments with respect to a woman’s claim
that she and her new born baby were “kicked out of
the hospital to make room of a bunch of rich, fat cats”
Learning points:
1. Appreciate that effective team work improves
outcome in high stake, critical medical situations
2. Appreciate
the
importance
of
effective
communication between members of the team
31
3. Understand the importance of rapid assessment
of ABC’s in a critically ill patient
4. Recognize the symptoms and signs of hypovolemic
shock
5. Recognize the importance of effective hemostasis,
and fluid resuscitation , and when the patient
is ready to transfer to the OR for definitive
management
Station 4 Airway Management
Run by Dr Chris Kupsh and Dr. Brad Hunkin this full
station focused on learning how to assess an airway,
recognizing when you’re getting into difficulty, and how
to intervene. The station involved a brief introduction to
the SimMan 3G followed by a discussion of the most
common causes of airway obstruction and the steps
one needs to take to alleviate this problem. Learners
were then taught a series of skills including oral and
nasal airway insertion as well as the life-saving skill
of bag-mask ventilation. If time permitted, further
discussion included particulars about intubation
(indications, size and type of tube to use, etc). There
were two learners allocated to each task trainer or
mannequin that rotated around four activities within
the station. Three doctors from the community worked
with Dr Kupsh to provide one-on-one coaching.
Learning points:
1. ABCs - A stands for airway and comes first in the
assessment of a patient.
2. Simple measures (such as a chin lift or jaw thrust)
can be very effective.
3. Airway patency during initial assessment does
not mean that the airway will stay that way ...
conditions can progress. Anticipation of the
clinical course is critical!
4. Airway patency does not assure adequate
ventilation as it requires adequate function of
lungs, chest wall and diaphragm.
5. Knowing how to bag-mask ventilate is life saving!
Dr Kupsh (centre) with
learners and observers
at the Airway Station
A mannequin is treated
at the Shock Station
Dr Smyth leading the
Fracture Station
Station 5 Triage
Station 7 Mental Health
This full station was led by Dr. Redmond and Pattie
Farris and involved learners being taught how to triage
a patient and then processing a series of patients with
simulated injuries to practice these triage skills.
Station 6 Fracture
Led by Patricia Savage RN this half-station involved
team role play with written character prompts chosen
by random selection by each member of the team.
Students were provided with a brief overview of what
to expect in the session and the main learning objective
of being able to delineate the difference between
Critical Incident Debriefing and Crisis Assessment.
The scenario involved a team of doctors and nurses
from a hospital unit where one of the team members
and his children had died suddenly and unexpectedly
under suspicious circumstances. Each member of the
team assumed and developed their randomly chosen
character and the tutor led the initial Critical Incident
Debrief. The team discovered individual needs,
including one or two high risk situations in individual
group members which led to applying principles of
practice for crisis assessment.
This full station involved learners working with Dr Smyth
on identifying different kinds of fractures and selecting
the appropriate strategy for dealing with them. Skills
covered included interpreting radiology, different
casting and splinting techniques and recognizing and
dealing with any complications arising from fractures
and associated injuries.
Pat observed: “Most learners handled the role play
well. The group aptly discussed the issue of team
dynamic and individual personality styles and its’
effect on communication, both positive and inhibitive.
They were also able to reflect on the impact of personal
history and experience and how this influences
thinking and behaviour. As the day passed, the groups
Learning points:
1. Describe basic triage.
2. Define the purpose and value of triage.
3. Understand the unique nature of Emergency
patients.
4. Demonstrate an understanding of triage skills
5. Describe the full triage process.
33
Station 9 C-Spine
reflected growth in teamwork inasmuch as the first
groups to participate demonstrated more cohesion
within their own disciplines and later in the day, after
having been through other stations, there was more
intraprofessionalism being demonstrated.”
Run by Dr Peter Hutten-Czapski this full station
focused on learning how to assess C-Spine X-rays
used to evaluate trauma patients. The station involved
a quick introduction to the Canadian C-Spine rules
followed by a quick didactic systemic approach to
reading the C-Spine film. By repetition of review of
normal and abnormal films by each in the group (with
the others reviewing silently) the learners immediately
put the didactic approach into practice.
Learning points:
1. To understand how Critical Incident Intervention
and Crisis Intervention are different.
2. To recognize that Mental Health and Mental Illness
are parts of a continuum of functioning.
Station 10 Obstetrics with Flat baby
3. To understand the critical points which require
assessment in suicidal ideation.
This full station was divided into two sub stations
which were separate but educationally linked. On
entering the room, the students were immediately split
into two groups that alternated stations.
4. To be introduced to the Mental Status Assessment.
5. To understand when and how to make a referral to
a Schedule 1 Psychiatric facility.
The Shoulder Dystocia Station was run by Dr James
Goertzen and was designed to give learners an
opportunity to learn the practice skills for managing
an infant delivery with shoulder dystocia. The station
started with a short presentation outlining the manual
steps for a normal delivery, along with physiological
and anatomical information on what shoulder dystocia
is, how it is recognized, what the impact can be on
the mom and the baby, and the procedural steps
to manage this situation. Learners were then taken
through a practical scenario approximately 3-5 times
allowing them to take on different roles. A nurse
educator assistant managed the model while Dr
Goertzen coached the learners, gave feedback and
corrected steps along the way. Participants were
given a handout at the end of the station as a reminder
and follow-up.
Station 8 Virtual Triage
This half-station was led by Dr Rachel Ellaway and
employed a virtual patient case developed by Dr
David Topps and Dr Ellaway that presented learners
with a road traffic accident scenario where they had to
manage three patients. Following a ‘choose your own
adventure’ model (see Chapter 4) learners working
in groups of 2-4 had to try and save as many of the
patients as they could. By working in teams and
discussing which of the available paths they were
going to take learners were able to explore critical
issues in triage and disaster management.
Learning points:
Learning points:
1. You don’t need to be working in an emergency
room to get involved in a triage situation.
1. Shoulder dystocia is a common unpredictable
obstetrical emergency and be prepared to manage
shoulder dystocia at all obstetrical deliveries.
2. If you have the opportunity, keep checking all of
your patients - situations can change rapidly.
2. Shoulder dystocia occurs with the impaction of
the fetal anterior shoulder against the maternal
symphysis pubis.
3. Visually dramatic injuries or patient distress are
not necessarily good indicators of survivability.
4. Don’t give up on a course of action that you know
needs to be followed through.
3. Effective management of shoulder dystocia
requires multiple members of a health team to
utilize a systematic approach.
5. Concentrate on saving those you can.
34
technical lead Aaron Wright. The disaster planning
session was led by local EMS and planning expert
Don Brisbane. There were also many clinicians and
other health professionals involved in running stations,
both from Parry Sound and from across the rest of
the province including some who traveled several
thousands of kilometres to be at the retreat.
4. HELPERR: call for Help, Evaluate for episiotomy,
eLevate legs, P - external manual suprapubic
pressure, Enter vagina and rotate shoulders,
Remove posterior arm, Roll the patient to her
hands and knees
The Flat Baby Station was run by Dr Marc Blayney
and started with a review of the key steps of infant
resuscitation focusing on preparation, equipment,
key steps to follow using the NRP framework. He
then went through the scenario several times with the
students supporting them in the process.
Debrief and feedback expert Mary Salisbury was
commissioned to lead the closing feedback session
as well as evaluate the stations, assist in feedback
and to generate a report on the strengths and
weaknesses of the retreat as a whole. Simulated
patients (human actors) were drawn from the NOSM
staff and local volunteers. Some were given makeup
and simulated injuries (see page on moulage) while
others participated ‘as is’ - see triage station. There
were many other volunteers from the local hospital
who acted as Guides (one per group of students),
Floaters (to help with the two split stations and spell
the Guides when they needed a break) and Door
Managers (the door between the hospital and the long
term care centre was card controlled so a volunteer
was stationed at this door manage access). The
West Parry Sound Hospital staff provided the venue
along with arranging for volunteers to come in, and
providing storage space, security staff and so on. The
core simulation team (Kupsh, Lortie-Carlyle, Paquette,
Wright and Ellaway) did the station set up and tear
down as well as acquiring equipment and transporting
it to and from Parry Sound.
Learning points:
1. Newborns are different, the resuscitation process
is not.
2. Initial Steps in Newborn resuscitation are simple
and life saving
3. Apnea in newborn is most often due to HYPOXIA
4. Bradycardia in newborns is often due to HYPOXIA
5. ABCD: Airway, Breathing, Circulation, Drugs.
Debrief
At the end of the retreat on the Saturday a 90-minute
debriefing session was conducted involving the station
leads working with Mary Salisbury, a professional
training consultant who was invited to watch and
participate in the whole event as an evaluator and
feedback expert for both the learners and the retreat
as a whole. Ms Salisbury elected to follow one student
group through a series of stations and then to locate
herself at the one station (shock) to observe the
remaining groups passing through the station. She
was also present as an observer for the rest of the
retreat including the tabletop exercises and the staged
resuscitation event.
Logistics
In order to successfully execute the simulation exercise
there were extensive discussions and planning
meetings which began three months before the event
with the Parry Sound and NOSM teams. With both
teams committed, coordination began with a formal
initial request by Dr. Strasser to physicians asking for
their involvement to lead or assist in a skills station.
This request also asked for a time frame, specific
equipment needs and patients requirements which
helped shape the outline of the exercise. There were
a number of steps required in leading up to the event:
Multiple Roles and Responsibilities
The CCC retreat involved many individuals undertaking
many roles. Clearly there were learners (year 3 NOSM
and year 1 Canadore) as well as a number of organizers
including Dr Sarah Strasser for the retreat as a whole,
simulation sessions lead Dr Rachel Ellaway, simulation
sessions coordinator Suzanne Lortie-Carlyle and
•
35
Regular meetings were held with station leads,
community representatives and NOSM staff. Two
face-to-face meetings were held in Parry Sound
radios and T-shirts identifying them as guides. All
information was provided in a volunteer package.
A tour of the station circuit was also given to the
volunteers before starting each day.
to map out the space available so as to identify
the location for each station and the way learners
would flow between them. These discussions also
identified and secured a locked area for overnight
storage of the NOSM simulation equipment,
clarification of issues and roles with local catering
and maintenance teams and times and means for
access to different parts of the building.
•
•
•
A tracking system was created included applicable
details in identifying leads/assistants, and details
such as required consumables, teaching support,
handouts and running time, etc. Central to this was
the skills station outline that was also provided to
the learners in their information package.
Much of the equipment used needed to be
transported from Sudbury. A cargo van was hired
to transport the two SimMan 3G mannequins, the
Noelle birthing simulator (on loan from Cambrian
College) as well as the tripods, computers,
disposables and many other items required. An
inventory list proved invaluable both for planning
and packing purposes. Individual stations had
their own boxes of consumables and other items
based on the lists submitted by leads.
•
Dedicated briefing times were allocated to inform
teams (prior to start) on set up, floor plan and
circuit of hospital, including briefing station leads.
•
A dedicated meeting space and time was
provided for volunteers to discuss details such
as schedules, groups, stations, maps, two-way
Tight timelines are always a challenge and good
communication was essential. Each team member
was given a two-way radio and along with a
separate team member to call out the starting
point, two minute warnings and the final call outs
to move the groups from station to station.
2) Most NOSM staff left with the students after the
final feedback session. This left the simulation team
to clear up for the whole retreat. In future we would
clarify roles and responsibilities and directly assign
staff for general clean up. The time required for set up
and tear down was also underestimated.
Equipment was set up and tested on the day
before the stations started to identify and fix any
technical bugs and timing issues. Equipment was
then left in a semi-ready state (mannequins on
stretchers) in the locked storage area to allow for
transport down to the station areas.
On the day each station was set up with a flip
chart identifying the station and lead(s) along with
the consumables in their appropriate boxes.
•
1) Volunteers unfamiliar with using two-way radios
missed some messages. In future two-way radios
would be placed at stations instead of with volunteers.
An itemized list was sent to the learners asking
them to bring a stethoscope, watch, indoor
shoes, etc. to avoid additional packing and loss of
equipment. Most but not all complied.
•
Learner briefing at the start of skills stations
rotation: explaining the outline of the skills stations,
tight time frame, guide availability, evaluations,
washroom locations and break time provided in
the learner package. Helpful to mention the guide
will be with them to move the group from one
station to the next quickly.
Feedback from the participants and observers on the
day was very positive, which we attribute to three
key factors; robust planning, strong communication
and great team work. With a plan of action everyone
knew their assigned roles and felt confident in their
contribution. However, there were some wrinkles:
Hospital organization details:
•
•
3) Given the number of participants in the final
feedback session (nearly 100 with learners, faculty
and staff) it was hard to directly involve more than a
few individuals. Using an audience response system
is one way to evaluate skills stations and participate in
the debriefing of such a large group.
4) Some of the larger stations (in terms of simultaneous
activities and participants) proved difficult to manage.
We would seek to have additional assistants to help at
stations with larger number of participants.
Evaluation
36
Although only 27% of the learners submitted a
response those that did evaluated most aspects very
highly - see Table 1. There was a lower score regarding
the time available for each station and the amount of
adaptability to individual needs. The highest score
was accorded to the statement asking for more
opportunities to use simulation.
A number of parallel evaluation streams were
undertaken as part of the CCC retreat including
reviewing the whole program for CME purposes and
a parallel activity for internal quality assurance. The
simulation part of the retreat was also evaluated:
•
participant evaluation - questionnaires were issued
to participants during the simulation stations to
capture their opinions and experiences.
•
observer evaluation - senior NOSM staff sat in
with a number of station activities to review the
dynamics and quality of the teaching.
•
external evaluation - this was undertaken by the
debriefing lead Mary Salisbury and involved her
holistic interpretation of the retreat both as an
observer and as the feedback expert.
Free text responses were also highly positive with
participants particularly valuing the hands-on and
clinical learning aspects of the retreat, not least
because they had expected (and in some cases
feared) a more didactic and less practical set of
experiences. Other strong positives included the
opportunity for interprofessional learning with mixed
groups of medical students and nurses and access to
skills and issues they would not have encountered in
the normal run of their training. It should be stated that
the retreat was expensive to run (although less than
Participant Evaluation
The goals and objectives for the session as a whole were clear.
4.21
The goals and objectives for the stations were clear.
4.21
I was able to actively participant the stations.
4.39
I was provided with appropriate feedback from my tutors.
4.25
I was provided with appropriate feedback from my peers.
4.09
There was suitable range of different clinical encounters
4.43
The stations were forgiving of any errors I made
4.35
The stations were well paced and well structured.
4.38
The stations were rushed or otherwise short on time.
3.29
The stations addressed practical skills well.
4.22
The stations addressed professional issues well.
4.25
The stations addressed ethical issues well.
4.04
The stations were adaptable to my needs.
3.77
The stations provided some benchmarking on performance.
4.17
The stations were realistic and believable.
4.55
The stations were appropriate to my current level of training.
4.55
The stations were relevant to my future practice.
4.61
The use of mannequins was an important element.
4.56
The use of actors was important element.
4.64
I want more opportunity to use simulation.
4.65
Table 1: participant evaluation of the simulation sessions - scores range from 1 (lowest) to 5 (highest),
response rate of 27%
37
in previous years) with the planning and execution of
the simulation activities requiring the most effort and
arguably providing the greatest value to the learners.
The external reviewer, Mary Salisbury, provided a
report based on her interpretations and evaluations of
the retreat. Some observations include: “Skill Stations
were varied, lively and interesting. In their brevity they
made their point and held the interest of participants
evidenced by the fact teams were as equally interested
in the Communication Skill Station as they were in the
Shock Station. The Mental Wellness Station while
the most sober station generated questions that were
deeper and the most reflective. “
Observer Evaluation
Observers moved between stations and groups
and made notes of their observations based on a
framework that identified Learning Climate, Control
of Session, Communication of Goals, Promoting
understanding and retention, Evaluation, Feedback,
and Promoting Self-Directed Learning (Skeff, 1988).
An example of the observations made are shown in
the aggregate report in Table 2.
“Skill Station Masters, were integral to learning and
they, themselves, performed as instruments of learning.
They provided the resources necessary to ensure ...
success as evidenced by teams easily suspending
their disbelief in the simulation experience, eagerly
Educational Category
Observed Behaviours
Learning Climate: Stimulation:
Students engaged and constantly learning by doing. Maximum respect of
Learner Involvement: Respect/
instructor and colleagues observed. All learners very much involved. Time
Comfort, Admission of Limitations
for all to practice skills, Orientation clear direction, Invited students to be
active participants. Creates safe environment by allowing students to
make errors and correcting them supportively. Everyone was comfortable.
Slightly too many learners for resources at station. Clarity of language
Control of Sessions:
Very much so – good leadership. Made sure to cover topic without hurrying. Offer
Leadership Style, Focus of
of assistance, presence: 1 guiding, 1 answering. Gentle thoughtful prepared.
Session, Pace of Session.
Controlled session well, moved at good pace to maintain interest, helped maintain
focus, forced students to stay on topic. Engaging style. Hands on re: pulse.
Communication of Goals:
Did clearly at beginning. Immediately presented learning goals to
Establishment of Goals,
students, reiterated goals throughout. Good intro of station team.
Expression of Goals,
Negotiation of Goals
Understanding & Retention:
Clearly organized, didn’t allow digression, kept learners on track, encouraged
Organization of Material,
student participation. Brief presentation – expandable information. Clear,
Clarity, Emphasis, Fostering
organized approach, easy for students to follow. Students involved
Self-Assessment
hands on throughout. Good emphasis on importance for future practice.
Each student had chance to perform e.g. intubation tube.
Evaluation: Observation
Instructor constantly asked questions in a positive learner orientated way.
of Learners, Questioning,
Students were comfortable in answering. Accepted feedback even if they
Fostering Self-Assessment
were wrong. Questioned. Embedded questions. Observed students completing
skills actively, provided correction and feedback. Non judgmental. Positive
at all times. Excellent back and forth between students and teachers.
Feedback: Minimal Feedback,
A lot of feedback was provided giving learners increasing confidence in their
Behavioral Feedback,
clinical skills. Good use of models . Provided great feedback, verbal and
Interactive Feedback
interactive throughout. Excellent coaching of physical skills. Excellent hands on.
Self-Directed Learning:
Good motivation, excellent resources. Interactive resource, peer collaboration.
Motivation, Resources
Encouraged student to continue observing those skills. Get familiar with equipment.
Table 2: observer evaluation for Station 6: Airway Management
38
resources, problem solving, decision making and
healthcare delivery capabilities.
engaging with all needed resources with materials,
available and readily at hand. Skill Station Masters
provided the directions and objectives of engagement
in a clear concise manner as well as coaching,
encouraging or mentoring participants to success as
evidenced by the need for teams to ask few questions
of clarification yet able to act on the Station directions
to achieve the objectives.“
2. Post retreat observations and feedback specific
to learner performance “back home” should be
gathered. These data also help to identify the
impact of new knowledge and skills on patient
outcomes over time. This data would also support
future planning of retreat themes and needed skill
development and skills practice.
Recommendations
3. An advanced Shock and Airway Station should
be added to subsequent retreats. Obtaining
a “deeper drill” into the knowledge and skill
requirements is critical to the proper functioning
of providers in community-based settings. The
CCC retreat provided a fail-safe learning setting
to grow participant skills and critical thinking over
time; to reinforce skills, tools, and strategies that
are foundational to safe care in remote settings.
Medical learners want to learn medicine in ways that
are accessible, meaningful and useful. Didactics are
of limited utility in meeting these needs. By providing
opportunities for developing practical skills in nearreal contexts and working in multi-professional teams
the 2010 CCC retreat transformed what had been
seen as a distraction from the learning process to one
that fundamentally contributed to and enhanced it.
The organisers have recommended therefore:
•
that all events involving learners, and in particular
group events like the CCC retreat, involve
substantial practical and educational dimensions
that are complementary to and augmenting of
their mainstream program experiences
•
that simulation in its many forms is an extremely
powerful heuristic and should be used more widely
and improve learning and assessment
•
that interprofessional experiences are highly
valuable and an important (although often
neglected) aspect of healthcare education
•
that feedback and evaluation are a fundamental
part of the experience and should be planned and
implemented as such
•
that the logistics and planning of such events is
well supported and attention is paid to the flow
and structure of events both from procedural and
cognitive perspectives
•
that learning is a fundamental part of everyone’s
experience in such an event and opportunities to
develop and learn are afforded to all
4. Course evaluations are critical to program
accreditation and the retreat is well positioned in
this regard. Planning should consider the need for
additional data and analysis relative to perception,
attitude and performance data. Since attitude data
are also prediction data, information in this regard
might assist NOSM faculty in leveraging learning
opportunities for large groups of diverse learners
specific to IPE and community engagement.
Summary
In the end around 60 learners took part (some were
unable to travel due to weather problems - January in
Northern Ontario can be harsh and unpredictable) and
they each received 3 hours of the tabletop exercise
and 6 hours of the simulation stations. This equates
to 540 participant hours in simulation training over
the 3-day retreat. The experience changed everyone
involved.
Mary Salisbury, the evaluation and debrief consultant
had a number of her own recommendations:
1. Teams
should
be
structured
to
maximize
39
Chapter 4
Capacity: Pathways for
Interactive Narrative Education
(nursing) to create a series of open and freely available
virtual patients, presenting both the core and the more
idiosyncratic aspects of experienced practice.
Background
Katherine Montgomery (2006) observed that:
“in medicine, narrative is essential for the transfer
of clinical knowledge and insight gained from
practice. The clinical case history not only provides
a means of working out and remembering what is
best to do for a given patient but also captures
experience and presents It to its audience. As
a result, case narrative is the primary, vicarious
means of shaping clinical judgment for new
learners and experienced practitioners alike”
There were many reasons expressed by participants
for getting involved in PINE including:
Despite the primacy of narrative in medical education,
its overt use still gives pause to practitioners rooted
in a positivist scientific tradition. This paradox of
narrative in healthcare has, at least in part, meant that
its structured use in education is still in its infancy.
Narrative therefore remains a rich area for discovery
and exploration in support of healthcare education.
One area that is increasingly making use of structured
narrative is that of ‘virtual patients’, defined as an:
•
Opportunities for curriculum innovation and
development
•
Addressing dominance of southern and urban
settings in teaching materials
•
Opportunities for faculty and interprofessional
development
•
Curiosity in exploring a novel approach to
educational practice
PINE made extensive use of existing tools allowing
for a focus on case and educational development.
The tools used were OpenLabyrinth (an open source
and web-based virtual patient authoring, runtime and
analysis toolset) and VUE (a free topic mapping tool) see panel for more information both tools.
“interactive computer simulation of real-life clinical
scenarios for the purpose of medical training,
education, or assessment” (Ellaway et al, 2006)
The primary goal of the project was to create at least
60 virtual patients across a number of disciplines
with targets of 20 in medicine, 15 in midwifery, 15
in interprofessional topics and 10 in nursing. The
selection of these topics represented the areas of
interest and expertise of the project leads in the
participant different institutions, and the numbers
were negotiated based on the anticipated capacity
of the available authors. The first step was therefore
to recruit a mixture of teaching staff from the lead
institutions and a number of associated healthcare
professionals with an interest in education as case
authors who were then invited to a series of authoring
workshops. In the end more than eighty authors
(almost none of whom had authored a virtual patient
This chapter describes the Pathways for Interactive
Narrative Education Project that developed a series of
free and open virtual patient cases using interactive
narrative as the primary instructional model. The virtual
patients were all designed to enable learners of many
levels to explore the many aspects of practice across
multiple disciplines in contemporary healthcare. The
Project was a collaboration between the Northern
Ontario School of Medicine (also leading in medicine
and interprofessional topics), Laurentian University
(midwifery & nursing), McMaster University (midwifery
and physiotherapy) and Confederation College
41
Exploring a PINE VP
“We all learn from salient examples and pithy
narratives; we remember these much more than
lecture content. When creating the PINE virtual patient
(VP) library, we encouraged teams of interprofessional
authors to base cases on key points arising from their
own remembered experiences.
One notable case, Gail’s Dilemma, was grounded in just
such a real life case. It tells the harrowing story of how an
initially simple traffic accident quickly transformed into
a life and death race, pushing the rural caregiver team
to their limits, struggling with limited resources. Playing
the case, some students initially ask why the narrative
describes local relationships and small town trivia, but
quickly realize these factors have real impact on their
decisions as caregiver. Navigating the case teases out
cognitive and problem solving elements, not easily
addressed through other educational approaches. Each
decision has a consequence. Getting it right during the
frantic ambulance run determines Gail’s outcome, just
as on the day it happened.
Simple multimedia elements (daughter’s anxious
voice, paramedics’ scribbled transcript, economical
online at http://pine.nosm.ca/mstartnode.asp?mapid=184
pop-up avatars) add dimensions to the case, while
keeping production costs low. Plain text narrative still
conveys a great story – but the plain face disguises the
underlying challenge. Learners’ progress is tracked
at every step, as Gail’s shock and blood pressure
teeter between life and death and they can, but not
necessarily will, save her.
After slaving for hours, crafting a great presentation or
workshop, many teachers are reticent to simply give
it away and naturally wish to protect our intellectual
property. Welcome to the Creative Commons!
This free (as in beer, Nelson Mandela and, most
importantly, lawyer-free) method is easily understood,
legally enforceable and provides graduated levels of
control that are more practical than plain copyright,
yet more flexible than public domain. These are
best explained on the excellent web site but most
teachers will be satisfied with BY-NC-SA, meaning:
give attribution (BY), non-commercial use only (NC)
and share-alike (SA). We have found that, with
SA, if you give a little, you get a lot including good
feedback, thanks and suggestions - we all benefit.”
David Topps
Chapter 4 - Capacity: Pathways for Interactive Narrative Education
5. Fleshing out the narrative content for each node and
revising the pathways and steps as needed to develop
a well paced and structured learning experience.
before) were involved in seven workshops and thirteen
small group authoring sessions. Workshop facilitators
were trained in the use of the VUE tool (see separate
panel) for capturing the case narratives and in thinking
structurally and educationally about the case narrative,
guiding and challenging the authors to do the same.
Trained facilitators worked with up to three authors at
a time (larger groups either led to disagreement, nonproductive discussion, or domination by one or two
individuals). Each workshop involved:
Post-workshop editing of the cases was undertaken
to pick up any structural errors and to find ways of
improving the pacing and flow. The VUE maps were
then uploaded to OpenLabyrinth to create a new
virtual patients.
Each virtual patient was then edited to fit the
presentation model of OpenLabyrinth and gaming and
multimedia elements were added such as counters,
rules, images, avatars and skins (visual layouts).
Each virtual patient scenario was then tested (and
if necessary adjusted) to ensure it ran as expected.
Authors were next given the chance to review and
suggest changes and these were combined into
a second editorial pass. Once these steps were
complete the virtual patient was published to the PINE
website in three forms:
1. Identifying learning objectives to be addressed
2. Identifying a suitable outline narrative to act as a
vehicle for expressing the objectives
3. Defining a series of linked nodes that represent key
steps through the narrative (the ‘critical story path’)
4. Rendering these nodes and links using the VUE
tool and adding alternative branches and paths to
represent credible (but often mistaken or less than
optimal) decision paths the learner could take
PINE workshops
43
rules to the narrative pathways giving each decision
amplified consequences. These consequences are
represented by a few simple constructs within the
OpenLabyrinth engine:
1. running live from the PINE server
2. the original VUE map for download
3. a MedBiquitous Virtual Patient content package
for download
•
Counters: these consist of one or more variables
representing a tangible quantity (time, money,
drug dose, vital signs etc.) or intangible quantity
(morale, general health, reputation etc.) that can
be changed by the learners’ decisions. The value
of any counter can be changed at any decision
point. One or more rules can be set to trigger when
a counter got to a certain value and these rules
could then jump to a new node. For instance, one
rule could advance the learner once a counter got
above a certain level, or it could take them back
to an earlier point in the narrative or terminate the
activity altogether (such as when a patient died or
a resource such as time or money ran out).
•
Conditionals: these are rules that specify that
certain nodes can not be accessed before other
predefined nodes had been visited. For instance,
a learner may be required to review all of the
evidence before proceeding or they might need to
order some tests before they can see the results.
•
Random paths: these are when only one of a
number of options is randomly or semi-randomly
preselected. For instance, there might be a
weighting reflecting the prevalence of a certain
condition or a case may simply play out differently
each time a learner works their way through it.
PINE Cases
The 60 PINE cases were highly varied in terms of
intended purpose (teaching, revision, assessment),
size (from 21 to 313 nodes) and level of difficulty (from
advanced student to lay audiences) as well as subject
area. Exemplar cases include:
•
“Too Many Homers in Springfield” involved taking
the role of a dietitian challenged with improving
the health of her community in a town with high
levels of obesity, smoking and drinking.
•
“Gail” and “Mad Dog” drew upon real experiences
of rural physicians dealing with cases that go
beyond the purely clinical. In “Gail” the learner
faced having to save a colleague who was involved
in a road traffic accident and “Mad Dog” required
the learner to help a disturbed patient in a stand
off with the police.
•
“Northern Hike” and “Brokeback Trapline”
dealt with issues in wilderness medicine where
preparation and improvisation would be required
of the learner to save friends and others whilst in
the backwoods of Northern Ontario.
•
“Timing is Everything” involved the learner playing
a midwife who must get her client to the hospital
but who doesn’t make it and has to assist in the
birth by the roadside.
•
Open Educational Resources
The finished cases were made available as free
resources that were open for adaptation by anyone
wishing to do so. To manage this process, the PINE
Project used the Creative Commons AttributionNoncommercial-Share-Alike 2.5 Canada License.
Creative Commons (http://creativecommons.org) is
an internationally adopted framework for licensing
materials somewhere between full copyright and
public domain. The use of this particular Creative
Commons license meant that PINE materials are
free to be used and reused by anyone, anywhere as
long as they give attribution, don’t commercialize
the materials and they pass on the same licensing
conditions to any derivatives that may be created.
“Lackadaisical Larry” and “Nurse Nancys of
the North” involved learners reflecting on their
educational environment. “Larry” was about
a failing student who badly needed help while
“Nancys” was about conflict and resolution in
small-group learning.
Gaming Elements
In addition to the narrative, learners were given more
control over the flow of the case and opportunities to
develop strategies for problem solving by adding game
44
OpenLabyrinth
OpenLabyrinth is a web-based system for creating
and running virtual patients. The system allows users
to create a virtual patient activity as a sequence of
nodes or pages that are connected directly or via the
execution of user-defined rules. In effect, each page
or step in the case narrative is represented by a node,
and the case can advance by the learner selecting
from the available options linked from each node.
An OpenLabyrinth virtual patient can therefore be
represented as a decision tree. This can be enhanced
by using counters to track and control how a case
unfolds as well as avatars representing characters in
the case and quizzes and questions.
OpenLabyrinth supports the MedBiquitous/ANSI
virtual patient standard for importing and exporting
cases from other systems. It can also import and
export VUE format files. OpenLabyrinth has been
made available as open-source software and is
currently used by a number of institutions worldwide.
http://groups.google.com/group/openlabyrinth
VUE
The Visual Understanding Environment (VUE) is an
Open Source project based at Tufts University. The
VUE project is focused on creating flexible tools for
managing and integrating digital resources in support
of teaching, learning and research. VUE provides a
flexible visual environment for structuring, presenting,
and sharing digital information.
A VUE concept map comprises of a series of boxes
each representing a concept or a part of a concept.
Relationships between topics are created using links
between the boxes.
VUE can be used to create and/or edit OpenLabyrinth
decision trees by creating boxes to represent case
narrative nodes and the links between them. Although
VUE supports many other features only the boxes
(converted to nodes), text in the boxes/nodes and
the links (between nodes) will be imported, everything
else will be ignored.
http://vue.tufts.edu
A selection of splash screens from PINE virtual patients
Discussion
By making such a declaration, and by providing the
materials in an open data standard format, they can
be safely used and reused, adapted and changed and
aspects used in other applications with impunity so
long as the conditions of license are followed.
Resources are key to any kind of educational
development and were a significant concern for the
PINE Project, in particular the time taken to develop a
case. Experience showed that the time commitment
per case varied quite significantly (correlating for
instance with the number of counters and rules as well
as nodes) but a typical breakdown would be along the
lines of:
It was important for the project to take this approach
both to meet educators’ needs to tailor and align
materials with their local needs and contexts, and to
ensure that any liabilities and obligations regarding
the use and repurposing of the project materials
were clearly addressed for the benefit of the greatest
number of users. This was implemented as a briefing
and consent form that signed over any work they
conducted for the Project under a Creative Commons
licence. Authors also committed to not use any
previously copyrighted, unconsented or confidential
additional material.
• Workshop time – 9 hours (3 people - 3 hours each)
• Post workshop work up – 3-8 hours
• First editorial – 1 hour
• Gaming and multimedia – 5-10 hours
• Review and second editorial – 3 hours
A number of instances have already come up where
teachers wanting to repurpose a PINE virtual patient
were able to do with impunity because of the Creative
Commons licensing. It is anticipated that, since the
materials are freely available that more use and reuse
is going on than we know of.
• Final production and publishing – 4 hours
Total production time ranged from 25 to 35 hours at
a cost of ~$1,000 to $1,500 per PINE virtual patient
(based on the rates used in the project). This was
significantly lower than costs that have been identified
46
Chapter 4 - Capacity: Pathways for Interactive Narrative Education
act and react within the simulation activity.
for virtual patient development elsewhere (Huang,
Reynolds and Candler, 2007) although the amount
of clinical expert input was perhaps less than in
previously reported studies.
However, despite its many successes the PINE Project
was limited in a number of ways:
Although the main purpose of the PINE Project was the
development of the 60 virtual patient cases, there was
also a less explicit but possibly more important faculty
development and capacity building in the participant
organizations. With more than eighty authors involved
in seven workshops and other authoring sessions
right across the province the project was successful
not only in raising the profile of virtual patients but also
in developing basic skills in their creation for all those
involved.
Although the impact of the project will take some
time to fully emerge, one notable early example was
the uptake of PINE virtual patients by the Ontario
Midwifery Education Consortium (involving Laurentian,
McMaster and Ryerson universities). OMEC had a
common multi-site program and had redesigned the
third year of their 4-year program at the same time
as the PINE project was being run. The use of PINE
virtual patients enabled their students to:
•
Experience a range of standardized patient
encounters, to do so online and to have the results
of their work available for their tutors to analyze
and provide feedback across a wide range of
clinical and professional issues.
•
Experience relatively rare clinical situations (those
that learners may not see during the four years
of the program) that nonetheless are critical to
ensuring safe practice.
•
Experiment with the consequences of their
decisions in ways that are impossible in real-life
practice. In particular, they can make ‘mistakes’
that would rarely if ever be permitted in a real
clinical learning setting and then be able to go
back to re-try the case study and see where they
went wrong and why.
•
The focus was on the development of virtual patients
rather than their implementation, use or evaluation.
This reflected the funder’s focus on content
generation and the short timescale of the Project.
•
Although it was written in to the Project plan the
use of advanced and experimental media such as
techniques and from graphic novels, video and
radio proved too complicated to realise given the
time and resources available.
•
The extended use of reporting on learner
behaviour within a virtual patient was not explored.
OpenLabyrinth generates reports after a learner
session but the development and testing of an
expert interpretation was not pursued again due
to resource constraints.
Conclusions
The medium of virtual patients is a rich and engaging
way to work with complex narrative and game-like
learning activities. By using free tools, developing simple
but effective approaches to design and development,
and engaging a wide range of authors, the PINE Project
was able to develop a wide range of online educational
activities with a limited budget and in a short period
of time. The Project was also able to build capacity in
the development and use of virtual patients in many
healthcare education institutions across Ontario.
The future sustainability of the materials generated by
PINE is unknown. However, athough OpenLabyrinth
is still a living system the provision of the cases in a
downloadable and interoperable format ensures
longevity.
Acknowledgements
The PINE Project was funded by Inukshuk Wireless
between October 2008 and October 2009 with
additional funding provided by the NOSM IPE Program
and the hard work by the great many contributors to
the Project. All sixty PINE cases are available online
from http://pine.nosm.ca/PINE
These are common benefits cited for simulation in
healthcare education and as such virtual patients can
more easily be seen as one modality among many in
the simulation field. The difference between virtual
patients and other modalities is partly in what is being
simulated and partly in how the learner is expected to
47
A camera array view of a mannequin
during a Sim Challenge session
Chapter 5
Research: Integrated
Simulation: HSVO
on leading the project as a whole, educational and
simulation experience, distance, rural and remote
education and particular focus on virtual patients,
data standards and specifications and evaluation.
Simulation Silos
Simulation has come to form an essential part
of healthcare education but despite the many
modalities currently in use (such as mannequins,
part-task trainers, virtual patients etc.) there is little
or no integration between these tools and systems.
This constrains their users to somewhat siloed and
disconnected ways of working, which in turn limits
the utility of simulators and the return on (substantial)
investment in them.
There is clearly an unmet challenge regarding how
simulation devices can be integrated into ‘simulation
continua’ (Ellaway, Kneebone et al, 2009). The
challenge of multiple independent and isolated
simulation devices is not a new one. There are several
technical standards for simulation coordination such
as the High Level Architecture (HLA) but these are
both complicated and expensive to implement and
contain much non-negotiable military content.
The HSVO Project grew out of a conversation while
walking in the woods (while avoiding the bears) near
Sioux Narrows in 2007 between Drs Ellaway and
Topps and Kevin Smith. The vision was for a simple,
adaptable and extensible platform that would allow for
different simulators to be integrated and controlled by
a common and remote service to allow them to create
and run simulation activities that spanned multiple
devices and multiple locations.
Project Team
A team was assembled to create a ‘network enabled
platform’ with funding from CANARIE Inc (Canada’s
research network provider) for two years:
•
•
The Communications Research Centre (CRC) in
Ottawa brought skills in high speed networking,
virtual networks and lightpaths (high capacity
point to point connections) and multimodal video
conferencing.
•
The National Research Centre (NRC) IIT laboratory
in Fredericton NB had previously developed a
system for launching web applications on a single
computer. This tool was redeveloped as the hub
for the HSVO Platform.
•
McGill University contributed through two teams.
The Shared Reality Lab developed a series of
camera arrays allowing remote users to select from
a number of real and computer interpolated views
of a single scene (such as a surgical procedure).
They also developed a connection interface for
the Laerdal SimMan 3G mannequin. The Arnold
and Blema Steinberg Medical Simulation Centre
was involved as simulation experts and the testing
environment for simulation devices and activities.
•
Innovations in Learning in California provided highspeed network access to stereoscopic anatomical
images and a physiologic simulator.
•
iDeal Consulting involved a number of ex-CRC
and ex-NRC leaders acting in a consultative and
visioning role across the Project.
A number of other individuals and organizations were
also involved including Cork University in Ireland and
the University of Wisconsin. The HSVO Project was
funded by CANARIE for two years from 2008 to 2010
to create a network-enabled platform for integrating
The Northern Ontario School of Medicine was the
lead (through Lakehead University) with a focus
49
and supporting research into distributed simulation.
learners remotely observe an autopsy or an operation.
Using a camera array they dynamically select and
share different points of view. Visuals are rendered
responding to steps in the procedure or requests from
the tutor (push) or from the students (pull).
Use Cases
The authoring and execution of scenarios potentially
consisting of multiple interacting devices and users
across multiple locations was the primary rationale
for the Project with particular applications using
mannequin, virtual patient and visualization devices
of various kinds. In order that the Project could
coordinate the educational and clinical requirements
for the platform with its design and implementation
the HSVO Project developed two main use cases:
In supporting these two use cases the Project identified
three major challenges to be addressed in the Project:
Challenge 1: Standardized Control
Simulators are highly heterogeneous with no standard
way of controlling, communicating or otherwise
expressing or exposing their data or functionality. The
first challenge was to find a way to standardize the way
that different simulation devices could communicate
and be controlled. This was addressed within the HSVO
Project by the creation of a messaging specification
to standardize the expression and transport of
commands, reports and other data between
simulation devices. A ‘bus interface’ middleware layer
was developed to use this specification for translating
between any given device’s functionality and the
Use Case 1: Active Participation. Groups of learners
at multiple locations work through clinical scenarios
that start with an on-screen virtual patient activity. At
predefined points the path taken by different learners
or the values of counters embedded in the virtual
patient trigger the platform to move data (such as the
simulated patient’s vital signs) and then the locus of
activity to a high fidelity human mannequin.
Use Case 2: Active Observation. A group of
50
Chapter 5 - Integrated Simulation; the HSVO Platform
HSVO platform and accommodating functionality not
natively supported by its device.
consisting of a robotic mannequin and a number
of computers and adjunct equipment such as
radio-tagged ‘drugs’ and other interventions.
Challenge 2: Device Heterogeneity
Simulators and the activities they support are
profoundly heterogeneous. While some devices allow
their scenarios to be pre-defined, these scripts are
highly device specific. There was therefore a need to
create a common activity definition format to allow for
multi device activities to be authored and executed
using the HSVO platform. This was addressed by the
utilization and further development of an integration
and control tool called SAVOIR (Service-oriented
Architecture for a Virtual Organization’s Infrastructure
and Resources) that could simultaneously control
multiple devices, sessions and activities, as well as
the authoring of activities and the presentation of data
and communication services between participants.
There is currently no standardization of the technologies
or techniques for implementing simulation tools and
services. The HSVO platform therefore needed to be
technology- and context-independent allowing for
any programming language and network technology
to connect and integrate with the platform. The open
source ‘MULE’ Enterprise Service Bus was used to
provide a technologically agnostic framework for the
input and output of HSVO messages and different
teams deliberately used different programming tools
to test its technical portability.
•
3D visualization using the Remote Stereo Viewer
(RSV) and VolSeg tools (www.digitalanatomy.org)
to support stereoscopic and volumetric data sets.
•
Physiologic algorithms represented by a
mathematical model of hypovolemic shock. This
involves setting starting conditions after which the
patient will bleed out in a certain time. The model
changes based on different kinds of user actions.
Developing Scenarios
The HSVO platform provides a web-based authoring
tool for creating scenarios that are made up of one
or more services, the configuration for each service
and the rules that define the sequence of activities.
For instance, a simple hypothetical scenario could
involve learners starting off working through a
screen-based simulation and depending on whether
they make a critical decision the activity switches to
another device such as a mannequin for resuscitation
(for a bad choice) or further instruction (for a good
choice). Scenarios can include multiple instances of a
particular service such as OpenLabyrinth with different
labyrinths running in different sites.
3. Devices as Services
Specific services and resources used included:
•
Camera arrays consisting of user-selected real
and virtualized camera views. These arrays were
developed specifically for the project.
Different simulation devices are connected through
a ‘bus interface’ that translates between what the
device can do and what the platform can do. Multiple
services can be connected to the HSVO network hub
(SAVOIR) over a common message bus implemented
using Enterprise Service Bus (ESB) technologies. This
allows for other devices to be added as new services
to extend the platform as long as they have some
controllable features. A software development kit was
created to support the creation of new bus interfaces.
Challenge 3: Device Agnosticism
•
•
Simulations based around narrative and gaming
components (virtual patients) using OpenLabyrinth,
a free and open source virtual patient toolset. Any
kind of virtual patient design can be rendered and
integrated using this web-based toolset. As such
it represents other services including learning
management and assessment systems
Once created a scenario definition can be saved for
later use and reuse. A session is created by taking a
predefined scenario and adding start and end times
along with the participants and the network locations
or ‘endpoints’ where the different parts of the scenario
Human patient simulators in the form of
mannequins were represented by using Laerdal’s
SimMan 3G, an untethered physical simulator
51
Sim Challenge
The whole point of the HSVO platform is that it
is used and there was therefore a need for it to be
evaluated in use by real learners and teachers. The
HSVO ‘Sim Challenge’ was created to engage tutors
and learners in using the HSVO platform in a variety
of different settings. This involved creating a series
of sessions that involved multiple sites in a variety of
simulation activities. So far Sim Challenge has run 9
sessions across 4 sites (Sudbury, Ottawa, Montréal,
Cork) running for more than 14 hours and involving 21
teachers and more than 80 learners over its duration.
The sessions have employed many different designs
and have been received with great enthusiasm by
both learners and tutors:
“It was fascinating working with the HSVO platform
extending the capability of simulation devices –
making dummies smarter! The HSVO network enabled
platform provides access to scarce resources, such
as large volume anatomic or image libraries, or
high performance compute clusters. By interlacing
simulation modalities, making best use of where each
one shines, we provided rich yet highly distributed
educational environments.
Initially running cases was very complex, monitoring
27 windows, feeling like a traffic controller on an
aircraft carrier. The team refined the interfaces, hiding
the complexity, and making it accessible to regular
clinical teachers. Making best use of the platform
therefore requires imaginative script writing, with
realistic scenarios and challenging cases. Although
this can be time consuming the actual process is
being continually refined and streamlined. Learner
engagement was phenomenal even across multiple
sites and at throughout occasionally lengthy scenarios.
Bookending task trainers and expensive mannequins
with cheap resources, like Disney does for their
amusement park rides to extend the experience, makes
much better use of expensive simulation resources.”
HSVO clinical tutor
A mixture of HSVO services (top), the surgical
camera array at McGill Simulation Centre (above),
adjusting the SimMan mannequin (below), the
HSVO Project team (bottom).
Chapter 5 - Integrated Simulation; the HSVO Platform
will be rendered. One scenario can be used multiple
times to create different sessions. During runtime, the
workflow engine runs the predefined session, sampling
the state of the different services involved, evaluating
any rules in the scenario, and issuing commands to
different services to change their state (such as start,
stop or exchange data). While physical devices are by
definition location specific (such as the mannequin or
camera array) online devices can be launched in many
locations.
a definitive description of the breadth and depth of
the ways in which the platform can be used has yet
to be developed. However, there are a number of key
applications that the platform is able to support:
1. Distributed participants – learners, tutors or
technicians are located in different locations and
interact through multiple services.
2. Distributed services – services and resources
used by the services (such as datasets and
configuration files) are located at different nodes
across the network. For example, the RSV service
application can sit on a server in Ottawa while
pulling data from a server in Sunnyvale, California
and presenting it to a user in Thunder Bay.
The HSVO Platform in Use
The Northern Ontario School of Medicine and McGill
University’s medical school have healthcare education
and training responsibilities for the greater part of
Ontario and Quebec respectively with a combined
landmass of over 2 million square kilometers.
Although distributed healthcare education is clearly
an ongoing requirement for all professions and at
all levels in remote and rural communities, there are
many challenges in bringing high quality activitybased education to them. The ability to locate some
devices in communities and provide access to others
remotely through an integrated learning environment
such as the HSVO platform is clear. Not only can
learners remain in their communities allowing clinical
services to be maintained but these teams can learn
and develop together and with other teams, and a
distributed community of professional learning and
development can be built and sustained.
3. Integrated services – services can share parameter
values. For instance, the same virtual patient may
be realized on multiple services by exchanging the
same vital signs between services even if services
present them or use them in different ways.
Discussion
The challenge of simulation integration, at least at the
technical level is addressed through the development
and use of the HSVO network-enabled platform.
Middleware, logic, rules, messages and an extensible
connector framework make the platform highly
adaptable and extensible for adding services and
creating new and innovative scenarios and sessions.
Furthermore, the use of a simple hub-based model
addresses the needs of healthcare educators and
those of developers building services connected to the
platform. The messaging model has been designed to
be very simple and adaptable
The HSVO platform has been used to allow groups
of geographically distributed learners to come
together around different activities and simulation
tools. For instance, one activity involved teams
of learners from the Universities of Ottawa and
Cork to compare management decisions and their
outcomes in a simulated patient case to explore
clinical reasoning and the many differences in the
healthcare systems in Canada and Eire. Another
activity was more competitive between learners from
NOSM and McGill around their management of an
emergency case involving the disclosure of some but
not all the information available to each team. In both
cases the learners used simulation tools along with
communication tools (such as web conferencing).
HSVO allows web devices to be coordinated, to talk to
each other, to control each other, to use services from
elsewhere, to use each other as services. This means
that instructors and learners can have access to any
services and devices at any time and location thereby
supporting both scheduled and on demand practice
or instruction. In use the platform is proving to be both
engaging and useful with many new kinds of activities
and forms of working in simulation education and
training arising from the platform’s affordances.
See the HSVO Project website for more information:
www.hsvo.ca
The full capabilities and forms of use are under
investigation at the time of preparing this paper so
53
Research: Virtual Worlds
Virtual worlds are computer-generated synthetic
spaces complete with lighting, gravity, props and
many other reflections of (more or less) reality. Their
users work through one or more avatars, characters
that they control to act on their behalf. Although they
are similar to immersive computer games the critical
difference is that there is no intrinsic plot or rationale
for the virtual world; it is up to its users to decide what
they want to do there.
The ‘Lakehead University Virtual Centre for Advanced
Research in Teaching and Training’ project (LUVCARTT)
was funded by the Canada Foundation for Innovation
(CFI) and brought together a number of virtual world,
hapto-visual and educational tools and platforms as
part of a common integrated research platform. A
key part of this was the creation of a dedicated island
within Second Life called ‘Nossum Island’ (see pictures
from the island below). The island was created with
a number of buildings (hospital, family health team
clinic, lecture theatres) as well as social spaces such
as a tepee and a set of cabins in the treetops.
Simulation-specific development included the creation
of a holodeck (based on the holodeck in Star Trek this
is a space into which virtual objects can be projected)
that connected to the OpenLabyrinth virtual patient
engine to create and control interactive simulation
activities for multiple avatars within the Second Life
environment. Called ARIADNE this toolset could
translate between Second Life and OpenLabyrinth
events and change the Second Life environment
accordingly. For instance, clicking on a patient may
start an examination of them or get them to lie down.
The net result is a relatively low cost immersive
environment that can be used for a range of purposes.
The only limitations are a) the amount of available
computing power to run Second Life and b) the
limitations in control and subtlety within the world.
Various views of Nossum Island (left) and the ARIADNE platform (right)
Research: Haptics
such procedures. The haptic feedback means that
teacher and learner can sense surfaces and densities
as they manipulate the controls. The dual controls are
Internet-based, enabling remote specialty mentoring,
even over vast distances. Additional features, such as
simulated “x-ray-vision” so that novice learners can
see as well as feel deep tissue structures, facilitate
graduated learning. Precise metrics on vectors and
forces allow truly objective assessment, which was
previously impossible through tutor observations.
Some important clinical procedures such as lumbar
punctures, joint injections, or endometrial biopsies
cannot be taught or learned by observation – there
is little to see; it’s all about feel. Compounding this
challenge, the teacher cannot even lay a guiding
hand on the learner’s hand without spoiling the
proprioceptive and tactile sensation for both learner
and teacher, never mind the additional patient
discomfort caused. Assessment of progress or
competence in performing such procedures tends to
be subjective, indirect and inaccurate. In a distributed
medical education environment, personnel skilled in
teaching these procedures are often not available
and cannot feasibly be moved from community to
community.
We encountered challenges with limited servo-motor
feedback in certain dimensions, resolvable with
additional engineering model work; and with finding
a widely accessible and cost effective programming
library. These problems are soluble and this project
has great potential for revolutionizing remote teaching
of key clinical procedures across remote and rural
communities.
We developed a dual control haptic simulator, using
affordable and robust components, along with some
anatomically accurate 3D models, to teach and assess
The OMNI haptic controller, the model flow diagram
and several views of the spinal tap model in use
55
Operation! probably the first medical
simulator any of us encountered
Chapter 6
Sustainability: Opportunities
and Challenges for NOSM
rely exclusively on bedside encounters. Simulation
can augment the learners’ exposure to cases to
counter this reduced access to real patients in the
patients they do see.
Introduction
The previous chapters have painted a rich picture
of the many different forms of simulation being
developed and used at the Northern Ontario School of
Medicine. In doing so, we have also sought to identify
the limitations and challenges faced in building and
sustaining a comprehensive simulation program
in a northern, rural and remote region. This chapter
reprises these issues to identify opportunities for
building a more sustainable and long-term approach
to using simulation to benefit NOSM’s learners, its
faculty and the many communities it serves.
•
Learner access to patients in tertiary centres is
falling as new techniques significantly cut hospital
stays. There are new and changing roles such as
nurse practitioners and paramedics who are taking
on tasks previously carried out by physicians.
Learners who only work with a preceptor will enjoy
a shrinking range of experiences. Furthermore,
some procedures are infrequent but essential for
learners to master, such as central line placement,
intra-osseous infusions or compromised airway
management. Yet again, relying on chance
encounters and presentations is too unreliable in
providing these essential learning experiences.
Simulation allows learners to develop skills that
might be unavailable through bedside practice.
•
The Case for Simulation
NOSM, like most other North American schools,
follows an apprenticeship model of clinical learning,
the core of which involves learners working directly
with their clinical preceptors. Although NOSM has
particular strengths in providing such experiences, the
apprenticeship model on its own is less than optimal
in developing skilled and safe approaches to practice.
Reasons for this include:
•
Bedside learning must always place the patient
first. Although this promotes good models of care,
it is intrinsically limited and variable in meeting the
needs of learners. Simulation, by being learnercentric, can ensure structured and adaptable
learning experiences that best meet learners’
needs.
Although NOSM has been able to provide highquality clinical experiences in its early years, as
its programs grow there will likely be increasing
competition for practical experience, further
exacerbating the other challenges noted here.
Simulation is a powerful and adaptable educational
modality for augmenting and accommodating
gaps and limitations of bedside teaching and
learning. It also helps learners to develop
confidence in a range of stressful circumstances
through structured rehearsal and feedback.
•
Learner access to particular encounters is limited
to those patients presenting at any given time.
Such presentations vary by season, location
and general variations in population health. With
accreditation frameworks requiring greater levels
of assurance regarding the spread and quality of
learner encounters, it is increasingly impractical to
The use of simulation in medical education has grown
substantially in the last decade, not just in the range
and sophistication of simulators, but also in supporting
the development of effective practice and an evidence
base for such work. The systematic review conducted
by Issenberg et al (2005) distils this down to a few key
points:
57
“The research evidence is clear that high-fidelity
medical simulations facilitate learning among trainees
when used under the right conditions”
“The evidence also shows that simulation-based
medical education complements, but does not
duplicate, education involving real patients in genuine
settings. Simulation-based medical education is best
employed to prepare learners for real patient contact.
It allows them to practice and acquire patient care
skills in a controlled, safe, and forgiving environment.
Skill acquisition from practice and feedback also
boosts learner self-confidence and perseverance,
affective educational outcomes that accompany
clinical competence.” Issenberg et al, 2005, p26
This same review distils ten critical conditions for
effective use of simulation:
1. Provide feedback during the learning experience
with the simulator
2. Learners should repetitively practice skills on the
simulator
3. Integrate simulators into the overall curriculum
5. Adapt the simulator to complement multiple
learning strategies
More recently simulation has been considered as part
of a larger learning continuum. Following this model,
we can move from purely bedside encounters to
learning specific skills to practising in fully simulated
environments before transferring to the clinical
environment – see figure below:
6. Ensure the simulator provides for clinical variation
(if available)
Educational Value
4. Learners should practice with increasing levels of
difficulty (if available)
7. Learning on the simulator should occur in a
controlled environment
As with most other simulation programs, the feedback
from learners who have been involved in NOSM’s
simulation activities has been very positive. But
indicators of success come from more than just
satisfaction ratings. Both learners and teachers have
been forthright in their recognition of the power of the
hands-on experience:
8. Provide individualized (in addition to team) learning
on the simulator
9. Clearly define outcomes and benchmarks for the
learners to achieve using the simulator
“you can talk about airway management all you want
in a presentation but until someone actually lays hands
on a nasal airway … you can describe how to put it in
all you want but until someone puts one in there’s no
comparison. You have to have a hands-on component.
10. Ensure the simulator is a valid learning tool
The place of simulation in the wider educational
context is also clarified:
A progressive use of simulation in healthcare professional education (after Ellaway et al, 2009)
58
Chapter 6 - Sustainability: Opportunities and Challenges at NOSM
other learners, and (for simulation modalities that
provide them) more objective metrics. For example,
the OpenLabyrinth virtual patient engine has very
detailed metrics on every action each learner makes
and its relation to the instructional objectives. Laerdal’s
SimMan 3G also provides a very precise real-time log
of every event and action registered by the mannequin
during a scenario.
Bag-valve-mask is described in every book but go
ahead and do it. You cannot do that on a theoretical
basis, you have to have hands-on and that’s where task
trainers and the mannequins come into play” (NOSM
clinical skills tutor)
Finding the appropriate degree of fidelity or
verisimilitude is an important aspect of implementing
simulation sessions. There are some aspects that
are important to reproduce, especially when dealing
with altered time perceptions in crisis management
situations. But ‘appropriate’ is the key word here;
learners are well able to supply a sufficient level of
‘suspension of disbelief’. Furthermore, higher levels
of fidelity do not always create greater learning.
For example, one of the most emotionally and
pedagogically powerful virtual patient cases used
widely around the world, the Sarah Jane case, uses
plain text to portray its narrative. High-tech is not
always the answer, for example Dr Kupsh uses
pigs’ feet and turkeys in some clinical skills sessions
because their tactile qualities are better than those of
man-made trainers.
These logs can be essential when learners dispute
the feedback provided, which is surprisingly common
as we are all too often ‘sure’ that we did something
when we actually only thought of doing it. Video
recording provides another objective log in this regard
but integration with other metrics is more useful.
Current data integration systems such as B-Line
can be expensive for what they provide. The NOSM
simulation group has been working on more practical
and cost-effective approaches to this challenge. See
Chapter 2 for further details on this work.
Capacity
The activities described in this publication have
demonstrated value and great potential for educational
impact. However, while the NOSM inventory of
simulation equipment is now reasonably filled and
there is a growing use of the facilities, maintenance
activity has fallen to just a few clinical faculty. Not
only can this lead to faculty burnout, it is also costly
compared to paying staff rates for such services. This
is exacerbated by the School’s simulation champions
being almost exclusively located in Sudbury. Thunder
Bay, despite having the physical resources, has very
little on-the-ground simulation activity.
Closing the gaps found when evaluating our programs
and experiences is a key expectation of the LCME
ED-2 directive. Simulation can help to address some
of these needs. But simulation cannot do this alone;
it is important to integrate such experiences with real
patient care as noted by Issenberg et al.
One of the core principles that the NOSM simulation
group has been promoting is that of mixed modality
simulation. It has been observed that there are
valuable educational facets that can be addressed
by using combinations of simulation modality, e.g.
standardized patients along with task trainers, virtual
patients along with high-performance mannequins
(Kneebone, 2003). Not only does this afford more
varied use of simulation resources, it gets us closer to
the ideal of a continuum of simulation connecting to
bedside practice.
For a simulation facility to be viable and useful, it
requires a dedicated member of staff who manages
the lab, takes care of the equipment, sets up, does the
booking, cleans up, makes sure equipment doesn’t
disappear and so on. It is also important to develop
a cadre of preceptors who are comfortable as well
as capable with using simulation modalities in their
teaching. This is a significant faculty development
issue around creating a core group of keen teachers,
who can then champion these activities and model
them to their peers. None of this is free; these factors
depend on the ongoing financial and operational
support of the host institution.
Debriefing and feedback are critical elements in
simulation, no matter which modality of simulation
is used. This may involve as much time as the
simulation itself. Feedback should also look at
process issues, not just the clinical content, especially
in an interprofessional environment. Feedback can
be based both on direct observation by the tutor and
59
integration. While the MD program uses standardized
patients and task trainers in phase 1 and the
occasional mannequin session in phases 2 and 3, it is
not particularly well integrated with the curriculum at
present. NOSM’s residency programs make greater use
of simulation but this remains largely bottom-up and
preceptor-led and could benefit from a more strategic
approach to its integrated use. The Continuing Health
Professional Education (CHPE) portfolio recently
appointed an interprofessional simulation lead and
have been running an interprofessional simulation
program of training events and as such are already
taking a more integrated approach. A strategic review
of NOSM’s approach to simulation has recently been
commissioned by the three educational portfolios to
address issues of alignment and integration.
A common concern for most simulation centres is
lack of space and NOSM is no exception to this
rule. Innovative approaches should be explored in
conjunction with our NOSHN partners. Modular,
mobile, and hybrid approaches to simulation have seen
some success in other regions, for instance a mobile
simulation unit is run by ORNGE (Ontario’s medivac
organization) in Northern Ontario. Such approaches
would certainly be able to extend simulation services
to many of NOSM’s communities but would still be
dependent on a core simulation program within the
School.
Extending our simulation activities out to our
communities holds great promise but raises further
practical issues such as security, insurance and liability
when taking simulation equipment out of the lab and
on the road. Policies covering these issues need to be
agreed between all parties involved before engaging
in any exchange or off-site activities. Participants in
the NOSHN network are exploring this area but clearly
more work needs to be done to support meaningful,
open and assured ways of collaborating around
simulation. On-site security is also an issue. The
simulation centre inventory includes expensive and
hard to replace equipment as well as expired (nonnarcotic) medications, recycled for teaching purposes
that can still pose a safety risk in the wrong hands.
Given the regular loss of disposables and small items
of equipment following simulation sessions, the need
for dedicated centre managers is even greater.
There has also been significant integration through
community engagement, with the development of the
Northern Ontario Simulation for Healthcare Network
(NOSHN) and the work it has subsequently supported.
Research and development projects have also been
critical to developing capacity and energy around
simulation although translation into practice has been
limited so far. However, most of the work so far has
focused on Sudbury and there remains much work to
be done in building capacity in the west. The scope
of simulation development should also be expanded
to include all NOSM teaching sites such as the CCC
sites (Timmins, Kenora, Sault Ste Marie etc).
As the interest in and applications of simulation
grow within the School the next logical step is to
develop a strategic plan for simulation that involves
all stakeholders. Such a plan would target available
resources on key strategic initiatives as well as
establishing a core program around which these
initiatives would be sustainable.
Integration
Despite the growing need for simulation, its uptake at
NOSM has been patchy and has suffered from a lack
of cohesive effort between portfolios. For instance,
significant purchases were made in 2005 and 2006
to establish an inventory of simulation equipment.
But much of this equipment lay in storage until it
was unpacked and deployed by the newly-formed
NOSM simulation group in 2009. Change is shown in
the growing collaboration between portfolios. As an
example, this publication was partly funded by CHPE
and involves contributions from the undergraduate,
postgraduate and informatics portfolios as well as
faculty from human and clinical sciences.
Investment
Benefits compared to costs and the return on
investment (ROI) from simulation is the balancing
factor here. Although there are a great many benefits
arising from the use of simulation, they clearly come
at a cost. A key part of taking a strategic approach
to simulation at NOSM is analysing the returns on
the investment made, which in turn requires regular
evaluation and program review.
Educationally the key issue is that of curriculum
60
Chapter 6 - Sustainability: Opportunities and Challenges at NOSM
A common concern for simulation programs is
that although there can be quite generous funding
for equipment purchase there is often insufficient
subsequent support for the operation and routine
maintenance of these resources. While infrastructure
capital funding has been relatively generous during
NOSM’s startup phase, support for operations has
subsequently been somewhat leaner. There may be
some opportunity for cost recovery around particular
courses and programs such as the various mandatory
life support courses. But given the logistic challenges of
Northern Ontario, we should careful about the degree
to which this is viable. Many CME offices across the
country have found that, while cost recovery is often
feasible, turning a regular profit is much harder.
The Way Forward
The Ontario government has provided targeted funding
for simulation over the last ten years for both the
northern nursing programs and the Toronto teaching
hospitals. The former investment has benefited the
School to an extent through its creation of simulation
centres in our partner colleges and universities and
has created a solid ground for the NOSHN network.
The latter has had limited impact outside the hospital
network at which it was originally targeted. NOSM has
made capital investments in equipment and facilities
but is only now taking a strategic approach to the
integration of simulation into its programs.
The many projects and activities described in this
publication demonstrate that NOSM has made a strong
but uneven start in using simulation in support of its
educational programs. Despite the many successes
reported in this publication, there is still much to do to
create a sustainable NOSM simulation program. Key
factors in pursuing this goal include:
Investment in simulation can be both easy and hard.
Easy in as much as physical simulators and the
simulation environment can be very visible (compared
say to online simulators) and therefore offer significant
PR and donation opportunities as well as a focus for
institutional activities. The challenges over funding
come from within and without. Within simulation the
case is still being made as to how it can be best used
and what the best approaches to running cost effective
and sustainable simulation programs are. Evaluation
and research therefore remain essential components
of simulation operations. The external challenge
comes from the transitional status of simulation in the
eyes of accreditors and funding agencies. Although
the case for simulation has been well made, it is
not required in the same way say as it is required in
the airline industry for safe practice. Until simulation
becomes mandatory its status and the argument for
investing in it remains an area of contention.
•
Apprenticeship is insufficient on its own as a way
of developing future health professionals
•
Trained and enthusiastic clinical faculty are in very
short supply in general and particularly so in some
locations
•
Dedicated staff are required to make the most of
the simulation labs and facilities
•
Opportunities to use simulation must be extended
to all of the communities NOSM serves
•
Curriculum integration is somewhat lacking but
beginning to be addressed
•
Evaluation and review is an essential part of
program development
•
Although a simulation network can initially be
developed relatively cheaply, it needs support to
be much more than a forum for discussion
•
External funding is important in developing an
appropriate simulation program for NOSM and its
many partners and stakeholders
Conclusions
The Northern Ontario School of Medicine remains
committed to the highest standards in health
professional education and training and simulation
is a key part of fulfilling that goal. This publication
has demonstrated a wide range of simulation
activity ranging from operations to research at many
educational levels and across multiple programs
and professions. While there is much innovation and
hard work, a more strategic approach to simulation is
required and indeed this process has already begun. It
is hoped that in years to come that this work described
will form a strong foundation for a more robust and
aligned approach to simulation in the north of Ontario.
61
62
References
Begg, M., Ellaway, R., Dewhurst, D., Macleod,
Kuhl, F., Weatherly, R., Dahmann. “Creating Computer
H. (2007). “Transforming Professional Healthcare
Simulation Systems: An Introduction to the High Level
Narratives into Structured Game-Informed-
Architecture”, Prentice Hall, Upper Saddle River, NJ, 1999.
Learning Activities.” Innovate 3(6).
Montgomery, K. (2006). How Doctors Think:
Ellaway, R., Candler, C., Greene, P., Smothers, V.
clinical judgment and the practice of medicine.
(2006). An Architectural Model for MedBiquitous
New York, Oxford University Press
Virtual Patients. Baltimore, MD, MedBiquitous.
Poulton T, Conradi E, Kavia S and Round J:
Ellaway R, Topps D, Lachapelle K, Cooperstock J:
The replacement of ‘paper’ cases by interactive
Integrating Simulation Devices and Systems. Medicine
online Virtual Patients in Problem-Based Learning
Meets Virtual Reality 17 2009. J. Westwood, S. Westwood,
(PBL). Medical Teacher 2009; 31(8): 752-758.
R. Haluck et al. (Eds), Amsterdam, IOS Press: pp88-90.
Riley, R. Ed. “Manual of Simulation in Healthcare”,
Ellaway R: Apples and Architraves: a Descriptive
Oxford University Press, Oxford, UK, 2008.
Framework for e-Learning Research.
Round, J., Conradi, E., Poulton, T., Ellaway, R. (2009).
Medical Teacher 2009; 32(1): 95-97.
“Training staff to create simple interactive Virtual
Ellaway, R. and Masters, K. (2008). “AMEE Guide 32:
Patients, the Impact on a medical and healthcare
e-Learning in medical education Part 1: Learning, teaching
institution.” Medical Teacher 31(pp764-769).
and assessment.” Medical Teacher 30(5): pp455-473.
Skeff KM. Enhancing teaching effectiveness
Ellaway R, Kneebone R, Lachapelle K, Topps D: Connecting
and vitality in the ambulatory setting. J Gen
and combining simulation modalities for integrated teaching,
Intern Med. 1988;3(2 suppl):S26–S33.
learning and assessment. Medical Teacher 2009; 31(8): 725-
Spencer, B and Liu S. “Modelling the Sharing of Resources
731.
across Collaborative Sessions”. APSCC, 2008, pp813-818
Gaba D: The future vision of simulation in health care.
Strasser, R., J. Lanphear, et al. (2009). “Canada’s
Quality and Safety in Health Care 2004; 13: 2-10.
New Medical School: the Northern Ontario School
Huang G, Reynolds R, Candler C: Virtual
of Medicine: Social Accountability Through
patient simulation at US and Canadian medical
Distributed Community Engaged Learning.”
schools. Acad Med. 2007; 82(5): 446-51.
Academic Medicine 84(10): pp1459-1464.
Issenberg B, McGaghie W, Petrusa E, Gordon D,
Wu, J . M Savoie, S Campbell, H Zhang “A network
Scalese R: Features and uses of high-fidelity medical
management tool for resource-partition based layer 1
simulations that lead to effective learning: a BEME
virtual private networks.” Int. J. Network Mgmt 19, Wiley
systematic review. Medical Teacher 2005; 27(2): 10-28.
InterScience, Hoboken, NY, 2009, pp139–152
63
Acknowledgements
HSVO Project: Jeff Blum, Martin Brooks, Scott
Campbell, Jeremy Cooperstock, Bryan Copeland,
Cristina Dalroti, Parvati Dev, Bruno Emond, LeRoy
Heinrichs, Justin Hickey, Bobby Ho, Michael Kirlew,
Kevin Lachapelle, Sandy Liu, Jordan MacDonald,
Kapildev Misra, Aaron Moss, Adriana Olmos, Swaroop
Patnaik, Alison Peek, René Richard, Mark Richards,
Roger Sanche, Michel Savoie, Steve Senger, George
Shorten, Kevin Smith, John Spence, Bruce Spencer,
Haijian Sun, Craig Symington, Yonghua You, Hanxi
Zhang, Aislinn Joy, Michael Kirlew
Dave Clarke, Cathy Coulson, Julie Corey, Liz Darling,
Jonelle Demers, Sandra Dewsberry, Patti Dickieson,
Irene Erickson, Elaine Foster-Seargeant, Loretto
Friere, Lissa Gagnon, Lisa Giguère, Manavi Handa,
Judith Horrigan, Eileen Hutton, Shirleen Hudyma,
Sharon Jaspers, Susan James, Heather JessupFelcioni, Kristen Jessiman, Irene Koren, Terry Koivula,
Chris Kupsh, Maureen LaCroix, René Lapierre, Anne
Malott, Bryan MacLeod, Helen McDonald, MaryEllen McCooeye, Patty NcNiven, Joanne Mellan, Rob
Mellan, Barb Morrison, Lisa Morgan, Heather NeilsonClayton, Kirsten Pavelich, Andreanne Pinet, Laura
Piccinin, Louise Poirier Benoit, Sally Prystanski, Erin
Puhalski, Maurianne Reade, Shelia Renton, Anne
Robinson, Judy Rogers, Tara Rollins, Anita Sabados,
Catherine Schroeder, Lorie Shimmell, Yvonne St.
Denis, Denise Taylor, Bronwen Thomas, Edan Thomas,
Lynne Thibeault, Maureen Topps, Joyce Tryssenaar,
Vicki Van Wagner, Debra Walker, Karline WilsonMitchell and Richard Witham
PINE Project: Jacques Abourbih, Michelle Addison,
Elizabeth Allemang, Cindy Backen, Ren Barrett, Susan
Bailey, Mike Bédard, Nicole Bennett, Janet Binette,
Leslee Blatt, Andrea Boyd, Catherine Boudreau,
Kirsty Bourret, Lorraine Carter, Amée Charbonneau,
Bob Chaudhuri, Pilar Chapman, Teri-Lynn Christie,
NOSHN: Karen Paquette, Fran Rose, Teri-Lynn
Christie, Janet Binette, Kristen Jessiman, Robert
Bentzen, Dan Draper, Barb Morrison, Jocelyne Bédard,
Johanne Carbonneau, Johanne Messier-Manne, Judy
Rantala, Lynne Thibeault, Lise Bonin, Nicole Ranger,
René Lapierre, Roger Pilon, Yvonne St Denis
We would like to thank the following for their input and
support for the work described here
At the Northern Ontario School of Medicine: Suzanne
Lortie-Carlyle, Chris Kupsh, Aaron Wright, Jacques
Abourbih, Kelley van den Broek, Sue Berry, Judy
Baird, Bob Rubeck, Danielle Bélanger and lastly Roger
Strasser reviewing the manuscript and providing the
foreword.
Parry Sound, January, 2010 - Mathieu Seguin
65
Simulation has been shown to be a safe and effective way
of training and assessing healthcare professionals with a
number of key strengths including the provision of meaningful
and constructive feedback on performance, supporting
repetitive practice, providing variation in difficulty and clinical
presentation, enabling multiple strategies and controlled
learning environments, supporting defined outcomes and
benchmarks and high validity. A common challenge is that the
geography and resources available require providers to work
together to ensure the quality and sustainability of simulation
for healthcare education. This report discusses both the
simulation operations and the innovative work carried out in
and around the Northern Ontario School of Medicine and its
partners to demonstrate the thinking, skills and commitment
to its use in health professional education.
NOSHN
NIRD
NOSM Informatics
Research & Development

Expanding - Northern Ontario School of Medicine

Transcription

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