EU
WINTER 2019
UPDATE
CANADIAN PARAMEDIC PROGRAM USE OF REALISTIC SIMULATION IN EDUCATION (PURSE): A DESCRIPTIVE STUDY
by C. William Johnston, BA(Hons.), PCP
Alan M. Batt, MSc, PhD(c), CCP
USING FORMATIVE SCENARIOS TO REINFORCE EMS SKILLS AND BEHAVIOR ...AND MORE!
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CLINICAL EDUCATION TECHNOLOGY
IN THIS ISSUE National Association of EMS Educators 250 Mount Lebanon Boulevard Suite 209 Pittsburgh, PA 15234 Phone: 412-343-4775 Fax: 412-343-4770 www.naemse.org
2019 Board of Directors Bryan Ericson, M. Ed, RN, NRP, LP Board Chair Linda Abrahamson, MA, ECRN, EMT-P, NCEE Vice Board Chair Dr. Lindi Holt, PhD, NRP, NCEE Board Treasurer Dr. Nerina Stepanovsky, PhD, MSN, CTRN, PM Secretary
WHAT’S INSIDE
Rebecca Valentine, BS, NRP, NCEE, I/C Leaugeay Barnes, MS, NRP Dan Carlascio, NREMT-P, I/C
PAGE 3 NAEMSE NEWS PAGE 4 Membership Spotlight
Joe Grafft, MS, NREMT, EMS Mgr (Rt) Christopher Metsgar, MBA, BS Jill Oblak, MA, MBA, NRP Sahaj Khalsa, BS, NRP, NM, I/C
by NAEMSE Staff
Dr. William Robertson, DHSc, NRP
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PAGE 6
Using Formative Scenarios to Reinforce EMS Skills and Behavior
National Office Staff
by Todd Vreeland, MPA, NRP
Stephen Perdziola, BS Business Manager
Evaluation of the Elusive Effective Domain
Matt Whiting, BS Communications Coordinator, Editor, Designer
by John Spencer
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Erin Mihalsky Membership Coordinator
The Answer for Dyslexia?
Laurie Davin, AS Education Coordinator
by Doug Smith, CEO Platinum Educational Group
Jarred Kallmann Education Coordinator
PAGE 9 PURSE
by C. William Johnston and Alan M. Batt Reprinting Information
Interested in reprinting one of the articles you find in this publication? If so, please contact Matt Whiting via e-mail at matt@naemse.org or by phone at (412)343-4775 ext. 29
Submission Guidelines
Unsolicited submissions are welcomed. Members of the NAEMSE Publications Committee review Domain3 manuscripts. Acceptance of a manuscript for publication is contingent upon completion of the editing process.
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Manuscripts should be e-mailed to matt@naemse.org. Submit a cover letter with each manuscript indicating: Author name, credentials, title, and affiliation. A title letter should also be included disclosing any commercial associations that could post a conflict of interest. If you have an idea brewing that you’d like to submit, please contact us. We would be happy to discuss it. New authors are welcome and encouraged.
NAEMSE NEWS
NAEMSE NEWS NAEMSE RELEASES JOINT POSITION PAPER ON DEGREES FOR PARAMEDICS ABSTRACT The National Association of EMS Educators, the National EMS Management Association, and the International Association of Flight and Critical Care Paramedics believe the time has come for paramedics to be trained through a formal education process that culminates with an associate degree. Once implemented a degree requirement will improve the care delivered by paramedics and enhance paramedicine as a heath profession.
POSITION It is the position of the National EMS Management Association (NEMSMA), the National Association of EMS Educators (NAEMSE), and the InternationalAssociation of Flight and Critical Care Paramedics (IAFCCP), collectively known as “the associations” that the time has come for paramedicine to join the community of health professions that require a college degree. We believe that a two-year associate degree is the appropriate entry level of education for practitioners at the current paramedic level. In addition, we believe that paramedics involved in specialized practice, such as flight paramedics and community paramedics, among others, should be required to complete upper level undergraduate coursework up to and including a bachelor’s degree as a prerequisite to specialty certification. These requirements should apply to paramedics entering our profession and we recommend the EMS community within the United States enact such requirements by 2025.
NATIONAL EMS COURSES NAEMSE continues to bring its heralded EMS instructor course to all corners of the country. If you have never attended, you can reserve your spot online. If you’re an instructor, spread the good news to your colleagues in the EMS community. The following is a complete listing of some of our upcoming SPRING courses:
INSTRUCTOR COURSE I Memphis, TN: January 18-20, 2019 r 12-14, 2014 Fire DepartHeld in partnership with Memphis Held in partnership with Louisville ment Training Center Metro EMS Las Vegas, NV: February 8-10, 2019 Held in partnership with North American Rescue Wichita Falls, TX: March 8-10, 2019 Held in partnership with Vernon College Erlanger, KY: March 29-31, 2019 Held in partnership with St. Elizabeth Training & Education Center Gulfport, MS: April 12-14, 2019 Held in partnership with AMR Turners Falls, MA: April 26-28, 2019 Held in partnership with Community 911
INSTRUCTOR COURSE II Georgetown, TX: January 25-26, 2019
Held in partnership with Williamson County EMS
Virginia Beach, VA: March 22-23, 2019 Held in partnership with Tidewater Community College Belleville, IL: April 5-6, 2019 Held in partnership with Memorial Hospital
To read the full position paper, please visit: www.naemse.org For more information, please visit
NAEMSE.ORG
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NAEMSE MEMBER SPOTLIGHT
NAEMSE MEMBER
SPOTLIGHT Hometown Kailua, Hawai’i
Current Employer/s Kapi’olani Community College Job Title/s Paramedic Program Director
MARK KUNIMUNE Job Scope Oversee 3 paramedic program sites. Responsible for accreditation, curriculum development, field instructor trainings, and clinical instruction. Hardest Job Aspect? Working to get faculty, administrators, and agencies to a;; be on the same page. Most Rewarding Job Aspect? Seeing the lightbulbs going off in student’s heads. Working with dedicated field instructors. Why Did You Join NAEMSE? I joined NAEMSE to build a network of EMS educators throughout the country to learn and share ideas. NAEMSE Activies/Participation Co-Chair of the Cultural Competence Committee. Personal Hobbies Surfing, playing Hawaiian music, bike riding, creating things for the grandkids. Who Would Play You In a Movie? McGyver What is Your Refrigerator Never Without? Dark chocolate.
ORDER THE PREMIERE EMS EDUCATION TEXTBOOK TODAY!
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USING FORMATIVE SCENARIOS TO REINFORCE EMS SKILLS AND BEHAVIOR
Using Formative Scenarios to Reinforce EMS Skills and Behavior by Todd Vreeland, MPA, NRP EMS Consultant
Unlike past education where instructors provide all the information and developed content, scenarios provide an opportunity to flip the classroom and involve students. Start by giving your students a specific skill or behavior that needs to be evaluated, and have them develop a formative scenario with specific objectives. The formative scenario worksheet that was used at the NREMT Scenario Development Workshops was created by UCLA paramedic students who modified an existing document. The Formative Scenario Worksheet clearly outlines the objectives in the Background Information, material needed for Scene Preparation, Dispatch and Patient Assessment, Patient History, as well as expected interventions and what changes should occur in the simulated patient condition based on the care provided. Student created formative scenarios require student to research the specific skill or behavior to develop a realist scenario. While initial scenarios may need additional input from instructors, students will quickly learn how to create realistic scenarios.
Realistic formative and summative scenarios are how we in EMS education fulfill the mantra, “Train like we fight.” Formative scenarios reinforce the learning process with perfect practice by providing frequent and accurate feedback to ensure automatic delivery of the skills (NREMT, 2015). Summative scenarios are used to evaluate a student’s ability to incorporate these isolated skills into overall patient care and scene management (NREMT, 2015). This repetitive perfect practice during the formative phase of education coupled summative evaluation helps students train to be better providers. Formative scenarios are the initial step to incorporate scenarios into EMS education. At first glance, creating all the formative scenarios needed may seem like a daunting task, but there are several resources available. The National Association of EMS Educators and the National Registry of Emergency Medical Technicians have sample scenarios and templates available on their websites. While these scenarios are rough drafts, with modification and validation at the local level, they provide a useful starting point.
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Stop by the EMSEd Hands-on Experience booth at and participate in a brief formative scenario that reinforces a specific clinical objective. You will be shown a completed Formative Scenario Worksheet like the one used at the NAEMSE/NREMT Scenario Development Workshops. The EMSEd formative scenario for the Hands-on Experience is designed for basic life support (BLS) or advanced life support (ALS) providers, and all are encouraged to participate regardless of their experience. References: 1. National Registry of Emergency Medical Technicians (2015), 2015 Paramedic Psychomotor Competency Portfolio (PPCP), Retrieved from nremt.org.
EVALUATION OF THE ELUSIVE AFFECTIVE DOMAIN
EVALUATION OF THE ELUSIVE AFFECTIVE DOMAIN by John Spencer, Customer Support Manager, Lead Medical Educator Cognitive, Psychomotor, and Affective are the three domains of learning that we must evaluate as instructors. The cognitive domain focuses on knowledge and is easily evaluated using quizzes and tests. The psychomotor domain focuses on the use of motor skills and can be evaluated by standard skills testing. What about the affective domain? This domain focuses on things like motivation, attitudes, perceptions and core values. As instructors, we are required to objectively evaluate our students’ affect; however, many instructors find it difficult to evaluate a student on what many consider to be subjective criteria. The key to an objective affective evaluation is to evaluate often, use an objective assessment tool and to create opportunities that allow the instructor to observe the student for identified behaviors. It is suggested that instructors evaluate their students’ affect at least twice during a program, once at the midpoint and again at course completion. This is acceptable, but may not be a best practice in longer programs, as it does not provide the student with consistent feedback on opportunities for growth. Affective evaluations provided monthly would provide them with more consistent feedback and allow for a more accurate measurement of their growth. The assessment tool is very important. Most instructors are probably utilizing an affective evaluation tool designed to measure a student’s professional behavior in eleven key areas. These areas are integrity, empathy, self-motivation, appearance and personal hygiene, self-confidence, communications, time management, teamwork and diplomacy, respect, patient advocacy, and careful delivery of service. Each of these areas should have examples of professional behaviors to be observed and then the student is marked as either being “competent” or “not yet competent.” These forms often provide an area for instructor comments on areas that are marked as “not yet competent.”
An example of such a form can be found on the NHTSA website. Such forms are an acceptable assessment tool to use, but they can be viewed as critical and often do not provide the student with feedback for growth in their areas of weakness. Adjusting the scoring system to reference the student’s behavior, instead of labeling them as “competent” or not, helps to make the evaluation more palatable and can even increase the objectivity of the assessment. A system that scores the student based on how often the professional behaviors are observed can achieve this goal while still measuring the student’s competency. An example of such a scoring system could be to score the student using a scale of Always, Sometimes, or Not Observed. For each area that receives a score below “Always”, the instructor should provide examples of when the student failed to demonstrate the professional behavior. The student should then be allowed to write down an action plan outlining how they will work to improve in these areas. This process also helps to increase the objectivity of future evaluations. Having an objective assessment tool is essential, but the instructor must also have opportunities to observe for the professional behaviors. The students should be informed that they are constantly being evaluated on their affect in all areas of the program. The instructor can observe for the professional behaviors during didactic time by observing students during group work and discussions. The affective domain can also be evaluated during psychomotor skills time by observing how the students work together to master skills. This is also a great time to run scenarios and simulations to observe the students as they interact with simulated patients. Evaluations completed by clinical preceptors can also be used by instructors as they complete the affective evaluations. Evaluating the student’s affect is an essential part of the education process. It helps to guarantee that only those students that possess professional behaviors become a part of our industry and provide compassionate care to the patients that they encounter.
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THE ANSWER FOR DYSLEXIA?
The Answer for Dyslexia? by Doug Smith, CEO Platinum Educational Group, Medical Educator
Dyslexia is a specific reading disability due to a defect in the brain’s processing of graphic symbols. It is a learning disability that alters the way and is typithe brain processes written material cally characterized by difficulties in word recognition, spelling, and decoding. Dyslexia is not linked to intelligence. While teaching a paramedic class about 14 years ago I encountered a student who provided me with a great educational opportunity. She was attending this program and seemed far more knowledgeable than the other students. Not long into the program I asked her why she was attending as she demonstrated a good grasp on the material already. She indicated this was her third full paramedic program. She had taken her first paramedic program a few years past and failed the State Examination after the maximum number of attempts. She then attended another full paramedic program. During this time, the State had switched to the National Registry and she again failed after the maximum number of attempts. Hence the reason she was attending this program. When I asked her what she thought was the cause of her previous failures (clearly the problem was not due to a lack of motivation) she indicated she had the reading disability of dyslexia.
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(Here came my first opportunity to be educated.) I recall asking what letters she reversed and she said none, her problem was that she saw the rivers on the pages. I was surprised and asked what she meant. She pointed out where the spaces lined up and formed “rivers” on the page. I then saw them clearly at this point as well. I indicated that if she had a documented reading disability the Registry would make a compensation by allowing her additional time. She informed me she knew this but the additional time was not beneficial as she could concentrate and have the rivers go away but as soon as she started to read again they would reappear. It was at this point she offered me lesson number 2, telling me she was “Purple”. I had no clue what she was talking about and asked her to explain. She informed me that her color had been identified as purple and that if she would be allowed to place a purple transparency over her test the “rivers” would disappear and she would be able to effectively read the items. I asked her about how common the color issue was with dyslexics and she indicated it was quite common. I told her I did not think the Registry would allow a purple transparency but purple colored glasses should not present a problem. If needed, she could ask a doctor for a prescription. I put her on a roster to take the exam, she obtained the purple sunglasses and passed the Registry on the first attempt. After further research, I have learned that many dyslexics can have their reading challenge mitigated with the use of color and that everyone has a unique color that works for them. The transformation happens instantaneously like putting on a set of appropriate corrective glasses. Based on research article I read this apparently does not work for everyone however, I have anecdotally not discovered anyone where this has not worked. I have encountered many a person who was as bewildered as I initially was with this information from people who even are learning disability experts who work for educational institutions and were unaware of this color correction. If you search “Dyslexia Colored” online, you will find products that are reasonably affordable ($21.95 for colored overlays). You will also find articles that dispute this theory, however, I have found that it has helped many. References: 1. National Registry of Emergency Medical Technicians (2015), 2015 Paramedic Psychomotor Competency Portfolio (PPCP), Retrieved from nremt.org.
THE NATIONAL EMERGENCY MEDICAL SERVICES EDUCATOR CERTIFICATION
The National Emergency Medical Servcies Educator Certification (NEMSEC)
New year, new locations! The National Emergency Medical Services Educator Certification (NEMSEC) is in full swing for 2019. Throughout the year, we will be continually adding more host locations for the NEMSEC exam. To kick off the new year, the NEMSEC exam will be coming to:
Thursday, January 17, 2019 Memphis, Tenessee Sunday, February 10, 2019 Las Vegas, Nevada FOR MORE INFORMATION AND REGISTRATION, VISIT
http://naemse.org/page/nemseccourse
NEW LOCATIONS FOR 2019!
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Learn more at Laerdal.com Laerdal Medical. All rights reserved. 18-17125 | Educator Update | www.naemse.org 910©2018
CANADIAN PARAMEDIC PROGRAM USE OF REALISTIC SIMULATION IN EDUCATION
Canadian Paramedic Program Use of Realistic Simulation in Education (PURSE): a descriptive study by C. William Johnston, BA(Hons.), PCP and Alan M. Batt, MSc, PhD(c), CCP BACKGROUND Literature suggests that simulation-based learning is an important modality in medical education. Although there is a large body of evidence in other medical fields, there has been little reported evidence of simulation use in paramedic education. This study aimed to report patterns of simulation use in paramedic programs across Canada. METHODS This was a cross-sectional survey of Primary Care and Advanced Care paramedic programs across Canada. An online questionnaire was distributed to all identified paramedic program coordinators in Canada. RESULTS Of the 44 invitations sent, 20 complete responses (45%) were received and analyzed. Paramedic programs reported they own or have access to a wide range of simulation resources. The majority of programs (85%) agreed that simulation directly impacted patient care but only 60% trained faculty on how to design and facilitate simulation. Only 3 programs (15%) reported using simulation as a supplement or to augment training, typically skill-based clinical hours. Standardized patients are underused in simulation. Typical barriers reported to simulation implementation were cost, time, and availability of resources CONCLUSION Simulation based learning has become an important aspect of multiple health care professions. As the paramedic profession continues to develop, it is important that initial paramedic education incorporates simulation effectively. Faculty education surrounding inexpensive and effective ways to incorporate simulation will likely increase use of simulation in paramedic programs. Future research should investigate how simulation in paramedic education impacts patient outcomes.
INTRODUCTION Paramedics are routinely required to treat patients in austere environments with limited resources. These environments are constantly changing and can create significant challenges for the practicing paramedic. Often in these new environments, paramedics are required to perform critical and time sensitive interventions that have high potential benefit to patients.1 However, due to the unpredictable nature of paramedic practice, these clinical encounters are typically low volume in nature. This becomes particularly relevant during paramedic student transition to clinical practice, such as during internship or preceptorship phases. To better prepare students for these low-volume, high-risk situations, paramedic education often prioritizes exposing paramedic students to these experiences during their initial education.2 An effective method for providing an alternative to clinical exposure to these encounters is simulation. Simulation in the context of health professional education, is a complex modality and not just a technology. It helps to expose participants to realistic patient care encounters with the intention of eliciting realistic responses.3 This is accomplished through immersion of participants, by recreating or replicating aspects of the real world in a context that is both effective for the learner and safe for the patient.3,4 This approach allows learners to repetitiously practice approaches to clinical encounters, while benefiting from instructor and peer feedback.4,5 As simulation use has increased in healthcare, numerous additional technologies have been developed specifically for this purpose. This transition to advanced technologies in healthcare has demonstrated consistent improvements in student knowledge, skills, and behaviours. Technology use in healthcare simulation has also been associated with positive improvements in patient outcomes, although these are smaller effects than in other areas measured. An abundance of literature exists on the benefits of simulation use in the training, education, and maintenance of competency in medical and nursing education.6 There is however little data investigating the use of simulation in paramedic education. A recent study by McKenna et al. (2015) examined the use of simulation in paramedic education in the United States.7 This study demonstrated that although simulation is used widely throughout paramedic education in the U.S, there is significant variability in how, and how often it is used by individual programs.7 Paramedic education in the U.S. is very different compared to paramedic education in Canada. Although there are differences between provinces, in Canada, generally speaking, paramedics complete a minimum of one year of education, with the majority completing two years at an
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To inspire educational excellence CANADIAN PARAMEDIC PROGRAM USE OF REALISTIC SIMULATION IN EDUCATION
accredited college. This then entitles individuals to write various provincially administered exams, and once licenced or certified, to work for an ambulance service as a Primary Care Paramedic. Additional qualifications may be earned by completing additional education. Given the differences between paramedic education in the U.S. and in Canada, a gap exists in the literature regarding the use of simulation and simulation equipment in paramedic education in Canada. OBJECTIVE AND RATIONALE The purpose of this study was to examine physical inventory, and patterns of simulation used in paramedic education programs across Canada. By understanding the current status of simulation use in paramedic education, we can recommend targeted improvements to the educational process to improve the use of simulation in paramedic education, ultimately better preparing paramedics and benefiting patients. Our review of the literature highlighted that there are a large number of factors involved in simulation. We identified four key areas: 1. Inventory available, whether owned or shared 2. Inventory used, how often and for what purpose 3. Aspects of “fidelity” used in simulations 4. Barriers to simulation use and the replacement (if any) of clinical education with simulation METHODS Participants This was a cross-sectional census survey of paramedic education programs in Canada. We generated a list of paramedic programs across the country, through provincial ministry websites, the Paramedic Association of Canada, and online searches of college and training institution websites. A list of program coordinator contacts was compiled for all identified programs. The final list comprised 44 paramedic programs across Canada. These programs represented individuals from Ontario, New Brunswick, Nova Scotia, Newfoundland, Quebec, Alberta, Manitoba, Saskatchewan, and British Columbia. This study received ethical approval from the Research Ethics Board at Fanshawe College (protocol no. 16-0307-1). Instrument The survey instrument was developed after completion of a comprehensive literature review to investigate these four distinct areas of simulation. Each of the questions provided participants with the opportunity to provide additional discussion if desired. The questions were reviewed by a panel of paramedic educators to ensure questions elicited the desired information. Input from the authors of the US-based ‘SUPER’ study (McKenna et al. 2015) was also sought.7 Questions were revised
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after discussion with the panel and reviewed again prior to distribution of the survey. The survey consisted of a mix of 38 multiple-choice and open-ended questions that were divided into five sections: program demographics, simulation equipment inventory, simulation equipment use, fidelity in simulation, and perceptions of simulation use in education. Simulation equipment was divided into the same categories as previous studies. Equipment was categorized as task trainers (e.g., IV arm; airway head); manikins-simple (e.g., CPR manikin); manikins-intermediate (e.g., with airway, IV, ECG); manikins-advanced (fully programmable); standardized/simulated live patients; computer-based (games, scenarios); and virtual reality (3D or complex computer-generated images) or haptic (create kinesthetic or tactile perception) simulation.7 All participants were asked if they incorporated different types of fidelity into their simulations. These ‘types’ of fidelity were referenced from the Paramedic Association of Canada’s National Occupational Competency Profile 2, and are outlined as follows: • Procedural fidelity – performing actual procedures such as IV initiation, injections, airway management; • Physiological fidelity – changes in patient conditions including vital signs throughout the simulation; • Interpersonal fidelity – interactions with partners, bystanders, family members, etc.; • Environmental fidelity – placing the simulations in the actual environment or as close as they can using the constraints of the space available. The survey was created on LimeSurvey, an open-source survey administration tool. It was distributed via email with a unique single-use token login to ensure only invited recipients were able to respond. The survey remained active for a three month period between March and June of 2016, with reminder emails sent to participants twice throughout this period. Participation was voluntary, and the participants were instructed that they could leave the survey at any time. It was made clear to participants that no program identifiable data would be disclosed at any stage. Analysis Anonymized data were exported from the LimeSurvey platform into SPSS 20 (IBM Corporation) for statistical analysis. Incomplete responses and respondents who declined to consent were excluded. The data were coded in preparation for analysis, and descriptive statistics were conducted. RESULTS At the end of the study period 20 responses from educators across Canada had been received. This represents a 45%
To inspire educational excellence CANADIAN PARAMEDIC PROGRAM USE OF REALISTIC SIMULATION IN EDUCATION
response rate. The majority of responses (n=15, 75%) came from Ontario based paramedic program coordinators. This result was expected due to the fact that Ontario has a significantly higher number of paramedic programs in comparison to other provinces in Canada. The majority of respondents represented programs which were two years in length (n=14, 70%); responses were also received from programs that were shorter than two years (n=5, 25%) and longer than two years in duration (n=1, 5%). The majority of programs (n=15, 75%) had greater than 30 students enrolled in their programs during each class. The majority of programs within Canada are taught at the Primary Care Paramedic level and this represented the majority of respondents (n=18, 90%). Responses were also received from Advanced Care and Critical Care program coordinators, in both land and air ambulance services (n=9, 45%). Some program coordinators are responsible for both PCP and ACP level courses, therefore the total number of programs represented exceeds the number of individual survey responses. Simulation resources The majority of program coordinators indicated that their programs owned, or had access to, task specific trainers (n=18, 90%). These include items such as intubation and airway manikins as well as IV arms and simulated trainers for any specific tasks. The majority of programs owned, or had access to, simple manikins (n=17, 85%) and intermediate manikins (n=18, 90%), which allow for procedures such as IV access and airway manoeuvres to be performed. A total of 16 programs (80%) owned, or had access to, fully programmable, or what are typically defined as “high fidelity� adult manikins. Nine (45%) programs had access to standardized adult patients in their education curriculum, while five (24%) had access to computer based simulation, and four (20%) had access to virtual reality simulation. One program indicated it owned no simulation equipment, but had access. Over 70% of programs had spaces designated for
simulation and simulation based learning. Consistently, respondents reported greater access to simulation equipment and trainers that was modelled after adult patients compared to other patient populations. The higher the complexity of the simulation equipment the less likely the programs were to have it. Sixteen (84%) programs had access to basic neonatal manikins while only seven (35%) had access to advanced programmable neonatal manikins. No programs had access to neonatal simulated patients. Programs reported higher access to paediatric advanced manikins (n=9, 45%) but reported similar use of standardized patients with only two (10%) having access to standardized paediatric patients. Only three programs (15%) had access to older adult specific manikins or advanced programmable manikins, and only two programs (10%) reported using standardized older adult patients. Simulation Use During skills training, task specific trainers were consistently used (n=19, 95%). Intermediate manikins and advanced programmable manikins were also used regularly (n=16, 80%; n=12, 60% respectively). Nine of the programs (45%) reported frequent use of standardized patients. Only one program (5%) reported consistent use of virtual reality simulation. Programs did report less use of task trainers (n=15, 75% vs n=19, 95%) and more use of simulated patients (n=11, 55% vs n=9, 45%) for assessment purposes. No programs reported using virtual reality simulations for student progression and only one program reported using computer based simulations. The majority (n=14, 70%) of programs used a non-mobile simulated ambulance space regularly for student training. Less programs (n=10, 50%) regularly used a simulated ambulance which allowed students to drive. Seventeen (85%) of the programs reported having components of the curriculum as mandatory, and many of the programs reported that every skill and laboratory component had a simulation aspect. Only three programs (n=3, 15%) used simulation as a direct replacement for clinical experience. These programs replaced airway management, certain practical skills, and IV management clinical experience with simulation. Programs reported similar equipment use for examinations used to progress students to the next semester or semester equivalent, including graduation and preceptorship.
Figure 1: Access to simulation resources
Simulation Fidelity Fourteen (70%) of the programs provided students with the opportunity to participate in high-fidelity simulation.
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One program reported moving away from high-fidelity exercises due to cost outweighing benefit. Physiological and procedural were the main types of fidelity incorporated into simulation exercises (n=18, 90%). Environmental fidelity was the least frequently incorporated (n=14, 70%).
clinician skill.8,9 If this tool is only used for evaluation or assessment, then the benefit of simulation is potentially missed. It is vital that the use of simulation as an evaluation tool shifts to the use of simulation as an educational tool.
Perceptions Seventeen respondents (85%) agreed or strongly agreed that simulation is an important aspect of paramedic education. Sixteen (80%) agreed or strongly agreed that simulation experience has a direct impact on patient outcomes. Ten (50%) believed that they were using the right amount of simulation in their programs.
Among the barriers to simulation implementation, a commonly identified theme was the lack of educational resources for educators to assist them in facilitating simulation based education. One respondent specifically mentioned that they were unable to get dedicated faculty with specific training on programmable manikins. Additional barriers identified included: a lack of physical space, a lack of time to perform simulations, and cost. These findings again echo findings of McKenna et al. (2015), which surveyed paramedic education programs in the United States, as well as Jeffries (2008) which investigated nursing education programs.7,10
Nine (45%) believed that they could incorporate more simulation into their programs. All agreed or strongly agreed that simulation was an effect method of assessment for determining progression in their programs. Twelve (60%) reported specific training for the faculty in simulation design and execution. Ten (50%) reported that their faculty had received training in how to use programmable advanced manikins. DISCUSSION These results indicate that paramedic programs across Canada have access to, or own, a large variety of equipment for simulation. The respondents reported utilizing the equipment in a wide variety of ways. Task trainers were much more frequently used (95%) than intermediate (80%), advanced programmable manikins (60%), or simulated patients (45%). Programs were much less likely to have dedicated advanced manikins for neonatal, pediatric, or older adult populations. This is consistent with the findings of McKenna et al. (2015) in US paramedic programs.7 Although task trainers are important learning tools for clinical skills, and were identified as the most commonly used simulation equipment by respondents, they represent the lowest aspect of the fidelity spectrum, and their use should ideally be limited to initial procedural skill learning. The use of task trainers can be effective in learning the stepwise conduct of a procedure; however, even when used for this limited purpose, not all task trainers are equal, and some provide a better student experience than others. Many of the programs used simulation, but simulation equipment use tended to focus around assessment. Testing in a high fidelity environment is an effective way to model if students are ready to progress to clinical and field experiential learning placements. However, this use should not overshadow the use of simulation throughout the educational process. Simulation-based education has been demonstrated across a variety of health professions education as an effective tool to improve patient-outcomes and
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Most of these barriers to simulation are based on a technology-centred view of simulation. In general, health care education programs seem to focus on the technology aspect of simulation while ignoring the importance of instructor preparation. Hamstra et al. (2014) suggest that advancing technology should be used as an adjunct to simulation rooted in transfer of learning, learner engagement, and suspension of disbelief.11 Many of these goals can be accomplished without the use of expensive technology and equipment. Focusing on non-technology based simulation will allow for simulation to be further integrated into paramedic curriculum, while maintaining the same benefits. An area where most programs seemed to struggle was with environmental fidelity and placing simulations in environments that were similar to actual environments in which patient care takes place. Many of the programs reported very little use of standardized patients in their education compared to the use of manikins. Standardized patients are important for the development of communication skills in students. Ryoo et al. (2013) demonstrated that communication skills were increased with simulated patient use over high fidelity manikins.12 Simulated patient interaction is also shown to decrease anxiety in nursing students when entering into clinical environments 13. Many paramedic patient interactions involve minimal patient care skills interventions, or procedures, but involve a large communication component. By incorporating simulation with standardized patients training can focus on the important communication skills. These interactions can also ease student anxiety helping better prepare them for a transition to “real-life� patients in a clinical setting. The use of simulated patients can however be costly and was a reported barrier to their use in paramedic programs.
To inspire educational excellence CANADIAN PARAMEDIC PROGRAM USE OF REALISTIC SIMULATION IN EDUCATION
LIMITATIONS The subjects of this study were entirely Canadian paramedic program coordinators, with the mjaority based in the province of Ontario. As there are significant differences between Canadian paramedic education programs and international paramedic education programs, these results may not be generalizable to paramedic training programs in other nations. Additionally there are significant differences in program length, program goals, and resource availability within individual provinces, and between provinces across Canada. Our study only received responses from only 45% of paramedic programs in the country. Although the survey completion email was sent to the program coordinator of each paramedic program, there is no way to ensure that only program coordinators completed the survey. It is possible that how faculty use simulation equipment is not always communicated to the program coordinator. We did not investigate the use of simulation by base-hospitals or other licensing bodies. CONCLUSIONS The majority of Canadian paramedic education programs use simulation throughout the program. The area that most programs seemed to struggle was with environmental fidelity and placing simulations in environments that are similar to where paramedics practice is essential in developing competent graduates. Even though simulation equipment is often available, many program coordinators feel that significant barriers exist to their ideal use of simulation. Future research should consider further examination of these barriers. Some of these barriers could potentially be addressed with education packages which may help educators to prepare simulation resources before the class that are cost effective, timely, and meet educational objectives. Future research should also consider investigating simulation use during continuing education, both by certifying bodies and by paramedic services.
4. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005; 27: 10–28. 5. Cook DA, Hamstra SJ, Brydges R, et al. Comparative effectiveness of instructional design features in simulation-based education: Systematic review and meta-analysis. Med Teach 2013; 35: e867–e898. 6. Mcgaghie WC, Issenberg SB, Barsuk JH, et al. A critical review of simulation-based mastery learning with translational outcomes. Medical Education 2014; 48: 375–385. 7. McKenna KD, Carhart E, Bercher D, et al. Simulation Use in Paramedic Education Research (SUPER): A Descriptive Study. Prehospital Emerg Care 2015; 3127: 1–9. 8. Zendejas B, Brydges R, Wang AT, et al. Patient outcomes in simulation-based medical education: A systematic review. Journal of General Internal Medicine 2013; 28: 1078–1089. 9. Kennedy CC, Cannon EK, Warner DO, et al. Advanced airway management simulation training in medical education: a systematic review and meta-analysis. Crit Care Med 2014; 42: 169–78. 10. Jeffries PR. Getting in S.T.E.P. with simulations: simulations take educator preparation. Nurs Educ Perspect 2008; 29: 70–73. 11. Hamstra SJ, Brydges R, Hatala R, et al. Reconsidering fidelity in simulation-based training. Acad Med 2014; 89: 387–92. 12. Ryoo EN, Ha EH, Cho JY. [Comparison of learning effects using high-fidelity and multi-mode simulation: an application of emergency care for a patient with cardiac arrest]. J Korean Acad Nurs 2013; 43: 185–93. 13. Kameg KM, Szpak JL, Cline TW, et al. Utilization of standardized patients to decrease nursing student anxiety. Clin Simul Nurs 2014; 10: 567–573.
REFERENCES 1. McCann L, Granter E, Hassard J, et al. Where next for the paramedic profession? An ethnography of work culture and occupational identity. Emerg Med J 2015; 32: e6.3-e7. 2. Paramedic Association of Canada. National Occupational Competency Profile for Paramedics. 2011. 3. Gaba DM. The future vision of simulation in healthcare. Simul Healthc 2007; 2: 126–135.
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