High-Fidelity Patient Simulation: a Descriptive White Paper Report

HIGH-FIDELITY PATIENT SIMULATION: A DESCRIPTIVE WHITE PAPER REPORT by David L. Rodgers, EdD, NREMT-P June 2007 3501 MacCorkle Ave. SE #120 Charleston, WV 25304 www.sim-strategies.com 304.444.1078 [email protected] Copyright 2007 – David L. Rodgers i HIGH-FIDELITY PATIENT SIMULATION: A DESCRIPTIVE WHITE PAPER REPORT Background 1 Development of Manikin-Based Patient Simulation Technology 4 Definitions 13 Cost versus Benefit 16 What is Simulation 18 Why Use Simulation 24 - Growth of Medical Knowledge 25 - Changes in Medical Education 26 - Patient Safety 30 - Realism 37 - Patient Availability 39 - Student Availability 41 - Standardization and Replication 41 Effectiveness of Simulation as a Teaching Tool 42 Simulation and Short Course Programs 49 Student Perceptions of Manikin-based Simulation 52 - Acceptance 52 - Confidence 54 - Leaner Satisfaction 56 - Patient Perceptions 58 Limitations of Simulation 58 Simulation in Nursing Education 62 Simulation and Team Training 66 Simulation Learning Theory 70 - Constructivism 73 - Experiential Learning and Reflective Thought 77 - Adult Learning Theory 84 - Novice to Expert Continuum 87 - Brain-based Learning 91 - Social Cognitive Theory 96 Motivation 96 Affective Domain 100 Summary 105 References 110 ii Summary The introduction of high-fidelity manikin-based simulation into the healthcare provider education curriculum represents a significant shift in healthcare provider education. While the use of simulation in more primitive forms has been found in healthcare education for many years, recent improvements in technology have created highly realistic simulators capable of very high levels of fidelity – to the point that it is often possible to “suspend disbelief” in the learning environment, making the situation appear to be quite real. There are many drivers currently in place that are pushing the use of simulation in the learning environment. These include: The growth of medical knowledge – The ever increasing body of medical knowledge presents new challenges to curriculum planners. Educators must find new ways of accommodating this volume of knowledge in the curriculum. Changes in medical education – Calls for increased accountability and outcomes measurement are being voiced in medical, nursing, and allied health education. Education practices and curricula that have been in place for decades must change to meet new demands for improving learner outcomes. Patient safety – It is no longer acceptable to use patients as primary learning models for healthcare provider students. Simulation offers a suitable alternative to allow student learning and initial demonstrations of competence to take place in a patient-free environment. Realism – Technology has advanced to the point where simulation at relatively high levels of fidelity has become affordable for many healthcare education organizations. Patient availability – Improvements in care in the clinical environment have reduced the numbers of many types of patient cases making what were once iii commonly seen diseases or events much more rare. This has led to a reduced opportunity for students to be exposed to these patient conditions during clinical training. Simulation can serve as a replacement for many of these conditions and augment the clinical experience. Student availability – Increasing learning demands combined with schedule restrictions have limited the availability for many student populations. Simulation offers an opportunity to program a student’s learning activity with greater efficiency. Standardization and replication – With the pressures for improved learner outcome measurements, simulation offers the capability to create standardization in evaluation by providing consistent replication of patient cases. While the body of peer-reviewed literature evidence on the efficacy of high-fidelity manikin-based simulation is still relatively young, what has been reported has demonstrated that simulation is a viable learning strategy in healthcare provider education. However, much of this data is limited to knowledge and skill acquisition in the learning environment. There is still relatively very little data available on how well manikin-based simulation learning transfers to the clinical environment. Still, based on research showing the ability of students to meet learning objectives with higher degrees of success with manikin-based patient simulation, simulation has considerable face validity. Other research has shown high-fidelity manikin-based patent simulation has been received well by learners. Research has demonstrated simulation has high degrees of acceptance among learners and that learners have felt highly satisfied with their simulation learning experience, even more so than learners who did not have simulation available for use. Learners’ confidence in their ability is also higher when the learning environment includes high- fidelity patient simulation. iv While no one theory can explain or predict outcomes in patient simulation, as a learning strategy, high-fidelity manikin-based simulation is bolstered by several learning theories. Education theories that have a role in explaining how simulation works include: Constructivism – Originating with the works of John Dewey and moving forward to other theorists such as Piaget and Vygotsky, the basic premise of constructivism is that learners each have a unique knowledge base and rebuild that knowledge based on new information. Three tenets of constructivism that have relevance to simulation are: o Each person brings his or her own unique experience and knowledge set to the situation. Simulation allows learners to pull from their own frame of reference and apply themselves to the situation. Each learner has the potential to approach the situation in their own manner. o Learning occurs through active exploration when an individual’s knowledge does not fit the current experience. Simulation offers the opportunity to push learners past their current knowledge level and see new areas where knowledge may be lacking. o Learning requires interaction within a social context. A fundamental function of manikin-based simulation is the team approach to patient care. Whether it is a single- or multi-disciplinary team in the simulation, effective interaction with team members is often a requirement for success in simulation. Experiential Learning – Based on concepts presented by Kurt Lewin and David Kolb, experiential learning theory (ELT) is frequently mentioned in the simulation literature as a leading learning theory that supports simulation learning. There are two primary components for ELT to be effective. First is an active experience in which the learner interacts with the learning environment. Simulation provides this immersive v experience very well. However, the experience itself is not where the learning occurs. Learning happens in the second component, a reflective process that reviews the actions of the experience and identifies areas for improvement. The process then continues in a cycle that builds on each experience and reflective action. Adult Learning Theory – Developed from concepts presented by Eduard Lindemann and Malcolm Knowles, adult learning theory centers on six assumptions that make andragogy (the teaching of adults) different from pedagogy (the teaching of children). All six assumptions can be observed in patient simulation. These assumptions are: o Adults have an intrinsic need to know o Adults have self-responsibility o Adults have a lifetime of experiences o Adults have an innate readiness to learn o Adults have a life-centered orientation to learning o Adults have internal motivators Brain-based Learning – One relatively new learning theory that has received very little attention in the simulation literature is brain-based learning (BBL). This learning theory examines how the brain learns. Several theorists are still actively contributing to building this learning theory. One BBL concept that is very applicable to patient simulation is Renate and Geoffrey Caine’s three essential elements for learning. They stated three elements were necessary for learning: o Relaxed alertness – Learners must be alert to new challenges, but not so much so that fear (including fear of failure) interferes with the learning process. Simulation represents a safe environment for learners to face new challenges without the fear of patient harm. vi o Orchestrated immersion in complex experiences – The instructor creates an immersive simulation experience with specific objectives. o Active processing of experience – Similar to the reflective thought process found in experiential learning, learners must process the experience to identify areas for improvement. High-fidelity manikin-based patient simulation is an essential learning tool in healthcare provider education at all levels. With a combination of multiple drivers and a growing body of evidence showing positive learner outcomes, patient simulation will be a key part of the healthcare provider education curriculum. However, as simulation technology advances, users must be cautious to use the technology as part of a coordinated curriculum that emphasizes learning outcomes and not just the use of technology. vii HIGH-FIDELITY PATIENT SIMULATION: A DESCRIPTIVE WHITE PAPER REPORT Background Technology has become an important part of many classrooms. Health professions education is no different. One relatively recent technology in the health professions classroom is the use of high-fidelity manikin-based

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