Teaching with Simulation

OPENING THE DOOR TO A NEW WORLD OF EDUCATION IN LATIN AMERICA

By ELIZABETH SINZ, MD, MED, ELIANA ESCUDERO, BSN, MED, DAVE RODGERS, EDD, KAREN VERGARA, BSN, NATACHA CRUDI and NADIR AYRAD

Abstract

Simulation Education has become one of the pillars of healthcare education. This manuscript describes the steps to bring healthcare simulation education to a new language and culture using Kern’s Curriculum model for curriculum development.

Introduction

Simulation has become an important tool over the past five decades, but it has been used for learning for much longer in all branches of healthcare education. In 1911, Mrs. Chase was developed to help nursing student education. Almost everyone has met Resusci Anne, a life-sized doll that was first introduced by the Laerdal Toy Company to help teach mouth-to-mouth ventilation for drowning victims. In 1969, Sim One, the first main frame computer-controlled simulator, was introduced to teach anesthesia students.

One of the biggest challenges for advancing healthcare simulation is the constant need for faculty development as more professionals utilize simulation for teaching due to the safety, effectiveness, and availability of this modality. Many educators are assigned the role without prior preparation or adequate training. There is little literature related to medical simulation in the Spanish language and very few courses available in Latin America to train all those who want to teach using this modality.

Simulation has been adapting to the educational needs of the institutions and participants. More and more educational institutions in Latin America have been creating their own simulation centers and gathering the proper equipment to cover all areas of the simulation from low fidelity to high fidelity. Technology undoubtedly has become an indispensable part of manikin simulation.

Penn State University has a long history using simulation for clinical education from undergraduate, graduate and post graduate levels. There is also a long history in the institution offering basic and advanced training for faculty involved in teaching with Simulation. Faculty anesthesiologist Dr. Bosseau Murray, an early innovator and leader in simulation-based learning, attended an early course for simulation instructors at the Center for Medical Simulation at Harvard in 1999 with Hershey surgeon Dr. Jerry Glenn. These courses were focused on training anesthesiologists to use simulation-based training for Crisis Resource Management (CRM). Nurse educators from Hershey, Sally Rudy and Tara Jankouskos, also attended a Harvard CRM course.

Dr. Murray and Sally Rudy then partnered to run weekly CRM courses for nurses, surgeons, and anesthesiologists. Their cases started with a patient (manikin) in trouble and the nurse entered the case to uncover the patient’s problem. When he or she called for assistance, a surgeon came to help, and that team worked together to manage the case. The patient would continue to deteriorate, and when additional help was needed, an anesthesiologist was sent to help, creating another team dynamic. After a few years of weekly CRM training in 2002, Dr. Murray created and delivered the first fully multiprofessional CRM Instructor Course with individuals from pediatrics, plastic surgery, nursing, emergency medicine, anesthesiology, and surgery.

The need to improve and grow as educators in Simulation has been one of the greatest passions of Dr. Elizabeth Sinz, anesthesiologist by profession and educator by heart. She joined Sally Rudy, neonatology nurse educator, and Dr. Margaret Wojnar, pulmonary medicine, to create the Penn State Hershey Simulation Instructor Course that is currently the cornerstone of simulation education in this institution (Sinz, et al).

Penn State Hershey Simulation Instructor Course

1. 2002 First Multiprofessional CRM Course (based on Harvard Center for Medical

Simulation Course) led by Dr. Bosseau Murray at Penn State Hershey

2. 2007 First Penn State Course led by Dr. Elizabeth Sinz (with advisory assistance from Harvard faculty) Multiprofessional (8 MDs, 6 RNs, 2 RTs, 1 PhD)

3. 2017 First Penn State Spanish Course in Santiago, Chile led by Dr. Angel

Diaz-Sanchez

Figure: Kern’s 6-Step Method of Curriculum Development (5) The most rewarding evaluation of the course so far is the continuous communication of the students who participated up to this day, Four years after the first course students in that first class continue to communicate, they share their work and experiences between them and even seek advice in the different platforms created at the time . Nothing better than seeing that their network works as we planned it .

The course was designed to convey key aspects of simulation for participants over five days. With important topics such as learning theory, curriculum development, and a lot of hands-on practice sessions with faculty supervision and orientation, the course gives a “jump start” to faculty who want to use simulation with their students in any discipline. At the end of the course the participants play the role of both student and instructor as they deliver and debrief a high-fidelity simulated case emphasizing teamwork and resource management. They also take turns as “meta-instructor” to introduce and practice giving and receiving peer feedback for continued improvement after the course. Over the years, the course has become an important part of the preparation to those who want to use the magnificent facilities that opened in 2010 for the Clinical Simulation Center at Penn State Hershey.

In 2014, the Clinical Simulation Center launched the Clinical Simulation Fellowship in its endeavors to continue growing the preparation in Simulation Education. I was the first fellow, having trained in anesthesia in Cuba and at that time in the process of validating my medical degree in US.

During the Fellowship I had the opportunity to present a workshop at the Global Meeting of Simulation in New Orleans 2015. As I met Spanish-speaking participants from numerous countries, it became apparent that there was a need for more education for instructors in Latin America.

I connected with well-known simulation personalities from Latin America to develop this project. Key simulation educators were invited to Hershey to complete the Penn State Sim Instructor Course. This group worked together to translate the course into Spanish in 2016 and developed all the resources to be able to bring the Instructor Course to Latin America. Educators from Mexico to Argentina were invited to attend a course that was able to integrate learning theory in a hands-on session with constructive feedback from the faculty.

Materials and methods

There is a lot of preparation and information-gathering for the faculty teaching the course. Each course is tailored to the needs of the participants and the facilities and equipment that they use with their students. For this reason, all materials and methods are in constant evolution.

Needs Analysis and Course Setup

Faculty for the course assess the needs of participants by reviewing a survey that is emailed ahead of time. We match their concerns with the material planned to be taught to assure that the course meets their needs. Participants are recruited from multiple professions to create a truly interprofessional participant group. This creates an environment where the participants can learn from each other as well as from the course faculty. This attention to the participants’ goals is intended to not only optimize the learning experience but also to demonstrate best practice for simulation-based training in healthcare.

Language

Our participants are from various countries of Latin America from Mexico in the North to Patagonia in Southern Argentina. One of our first challenges was coordinating the translations of all the documentation to a version of Spanish that would be understood in the same way by all the participants. To accomplish this goal, core course faculty from Cuba, Argentina, Chile, and Colombia who had completed the Penn State Simulation Instructor Course worked together to reach a consensus about the most neutral and understandable words and the most appropriate use of particular phrases.

We quickly realized that changing a course into another language is not simply the result of literal translation. The same word does not convey the same meaning from country to country, so it takes time and a lot of thinking about the different meanings for Spanish in all Latin American countries. We also found that some words do not need to be translated. For example, the word, “Debriefing” is better left in English since its translation to Spanish is far from the meaning intended in the course.

Participant input and the “One Minute Paper”

Not only is the “regular” course adapted ahead of time, but it can also be altered throughout the week. One tool for daily input is called the “one minute paper” and this is completed by participants at the end of every day. This document is on a card and has two questions; one question that focuses on what they found most useful or thought-provoking and the other to indicate what left them with more questions or was unclear. The faculty meet each day to review these cards as part of the planning for subsequent learning.

This method is described in the book The Reflective Practitioner [Ref-Schon]. The problems identified during the day are constantly discussed by the faculty, an action plan is developed and starts running immediately, and meta-debriefers (the more experienced faculty) are responsible for observing that changes have the desired effect. (4) This method is one way to assure that the material in the course is providing the learning desired by the participants.

Watchman

Another tool created for quality control of the course as well as to maintain the schedule for each particular activity is the watchman. The watchman is invited from the pool of students from previous courses that have an interest in becoming course faculty in the future. This role allows them to not

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Kern’s 6-Step Method of Curriculum Development

Step 1: Problem Identification:

Based primarily on discovering the problem in question or need, for this course the problem was the need for more available and affordable training for instructors in Latin America.

Step 2: Targeted Needs Assessment

For this step we relied on the knowledge of Latin American simulation experts. These individuals are recognized worldwide, and they were able to inform the development team about the situation around simulation education and faculty development from a variety of perspectives.

Step 3: Goals and Objectives

Our main goal was to take a successful course in the English language and transform it to meet the needs of the instructors in Latin America.

Step 4: Educational Strategies

Several strategic changes were made to adapt our regular course for this particular audience: - The course was restructured and shortened to be given over 3 ½ days instead of 5 days. - The course was organized to accommodate 24 participants by running duplicate hands-on sessions.

This allowed the size of the group to be expanded without diminishing the quality of the education. - The number of faculty teaching the course was doubled after appropriate training. - Didactic lectures and workshops were shortened to provide extra time for simulation and hands-on practice to be our primary teaching technique.

Step 5: Implementation

The course was implemented for the first time in May 2017 at the Simulation Center of the University Finis Terrae in Santiago de Chile. They provided the facilities, the simulation center and all the equipment needed to carry out the course. There was no cost to the Penn State Hershey Simulation Center since Penn State faculty used vacation time to attend and the South American Team paid for travel from the course charges.

Step 6: Evaluation

Evaluation occurs throughout the course as described above and is continuous and interactive. On the last day a comprehensive evaluation is completed including a question about how the participants plan to implement what they have learned in their teaching.

only see the course again, but to also see the course from within. This time around they have the chance to dissect all the activities and understand any topics or activities that were not clear when they took their course. Their role is to carefully observe everything that happens from the body language of students and faculty to the level of student engagement. They provide immediate feedback to faculty during student breaks, and they provide a summary to the students of the topics covered at the end of each day. Importantly, during the daily faculty debriefing, they provide feedback and suggestions to the faculty to help them improve. This role is designed to improve the course for the participants, improve the skills and awareness of the course faculty, and enhance the watchman’s understanding of the course and engage them in the process of continuous improvement so they are better prepared to eventually become course instructors.

Developing

The course is structured according to the well-known Kern’s model for curriculum development. (5)

Outcomes/Results

Some of the key outcomes of developing and delivering this course were immediately apparent. The process of translation and the collaboration and discussion required to correctly capture the essential elements and intention in the course materials gave all members of the Latin American course faculty a much better understanding and intuition about the concepts and goals of the course. Even the American faculty leads developed a stronger perception of these concepts leading to improvements that were integrated into the Hershey course.

Coaching & Feedback was certainly one of the sessions that was initially controversial. During the first year many students and even the faculty confused coaching & feedback with evaluation. In training activities, we use coaching & feedback, making sure the student does not feel they are being “tested.” The main goal is for the student to learn, and the instructor is there to coach them to success with constructive feedback, using techniques such as deliberate practice. Many

faculty initially did not recognize this skill as both important and difficult, however as we drew more attention to this topic, the faculty and students discovered that these skills can be considerably improved with understanding and practice.

Some of our high-level or “meta-meta” instructors don’t speak the Spanish language. Nevertheless, they have a key supporting role for the instructors leading the different activities. They have been able to provide feedback by watching the level of engagement of the students and their participation in the different activities. Their detailed knowledge of every session in the course gives them a unique prospective; there is no doubt they can tell when details are not clear to the students, and this can impact their learning experience. (7)

The design of this course was a major departure from the usual way that faculty and students traditionally interact in Central America. There was some anxiety amongst the course developers that this method would not be well-received. It is not common to have a course with teachers from different specialties and different professions working together in the same time and place. Nevertheless, there is evidence of success in that subsequent courses have continued to use our multiprofessional approach. This has led to new partnerships that have extended beyond just the Simulation Instructor Course.

The most important indicator of success is that there have been continued courses that are spreading throughout portions of Latin America. For example, a group in Costa Rico that attended our first Latin American course has continued to conduct Simulation Instructor courses regularly and the use of simulation has markedly increased in this small country. Ongoing programs in Chile and Argentina are quite robust and several of the faculty from the original course are highly sought-after as speakers in national and international conferences on simulation education.

This process is also being used to translate the course into Portuguese. Several introductory sessions have been given there already, although progress was interrupted by the COVID pandemic that limited travel. Since a key part of course development is adaptability, the local leader of the course was able to create a hybrid learning strategy that included remote assistance and feedback from the US team with active learning and practice with peer feedback at the site. Many more courses are being offered with the same initial format that still allows for ongoing updates, improvements, and adaptations for the participants of the course.

Conclusion

In Latin America we encounter a strong outspoken and uninhibited group of learners that at times posed a challenge to the instructors. We learned that developing our Simulation Instructor Course for a different language and culture in Latin American countries provided benefits to our own faculty as we became more flexible and open to input from our students. Translating was more than simply changing English words to Spanish, and the impact was greater than simply telling them what we know. Just as in the US courses, every learner brings their own knowledge, attitudes, and experiences as well and their cultural background to the group. Bringing different professions together was an enriching experience for us as much as for the students in all courses we have taught. There is work to be done but the rewards are wonderful and ongoing.

Future Directions: Caminando al futuro.

Over the past year the Instructor Course was interrupted by the Worldwide Pandemic caused by the Coronavirus. Work is already underway to bring back the course as soon as the health conditions allow it. In addition, some remote learning has been surprisingly successful. The faculty continue to prepare and plan ahead so we can once again join our colleagues from Latin America to share our mutual love of simulation education. References 1. Cheng, Adam MD, FRCPC, FAAP; Grant, Vincent MD, FRCPC; Huffman, James MD, FRCPC; Burgess, Gavin MD, FRCPC; Szyld, Demian MD; Robinson, Traci RN; Eppich, Walter MD, MEd Coaching the Debriefer, Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: October 2017 - Volume 12 - Issue 5 - p 319-325 doi: 10.1097/SIH.0000000000000232 2. McGaghie, William C. PhD; Harris, Ilene B. PhD Learning Theory Foundations of Simulation-Based Mastery Learning, Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: June 2018 - Volume 13 - Issue 3S - p S15-S20doi: 10.1097/ SIH.0000000000000279 3. Schon, D. A. (1983). The Reflective Practitioner: How Professionals Think in Action. Basic Books, NY. 4. Sinz, Elizabeth; Rudy, Sally; Wojnar, Margaret; and Bortner Tammi (2014). “Teaching Simulation Literacy in Adult Healthcare Education: A Qualitative Action Research Study.” 5. Kern, D, E. (1998). “Curriculum Development for Medical Education: A six step approach. Baltimore: John Hopkins University Press.” 6. Brookfield, S. (2011). Teaching for Critical Thinking: Tools and techniques to help students question their assumptions. 7. Caffarella, R. & Daffron, S. (2013). Planning Programs for Adult Learners. San Francisco: Jossey-Bass.