Expanding - Northern Ontario School of Medicine
Transcription
Expanding - Northern Ontario School of Medicine
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 informatics innovations 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 Expanding Simulation 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 Expanding Simulation 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 Chapter 3 - Capability: Disasters and the NOSM CCC Retreat 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 Expanding Simulation 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 Chapter 3 - Capability: Disasters and the NOSM CCC Retreat 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 Expanding Simulation 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 Chapter 3 - Capability: Disasters and the NOSM CCC Retreat 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 Expanding Simulation 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 Chapter 3 - Capability: Disasters and the NOSM CCC Retreat 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 Expanding Simulation 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 Expanding simulation 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 Expanding simulation “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 Expanding simulation 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 informatics innovations 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