Simulation Curriculum Development with a Scholarly Lens Yue Ming Huang, EdD, MHS Assistant Adjunct Professor Department of Anesthesiology David Geffen School of Medicine at UCLA Director of Operations, UCLA Simulation Center Mini Simulation User Network Conference West Coast University, North Hollywood, CA August 20, 2012

Disclosures I have no conflict of interest to disclose.

Agenda/Objectives Review educational principles for adult learners Review steps for curriculum development Describe considerations for scholarly dissemination Provide examples of published curricula and other resources

Getting to Know You Who is new to simulation (0-2 years), has 3-5 years, 6-10 years, >10 years of experience? Who is at a community college, nursing school, medical school, hospital-based simulation center, others? Who has had formal postgraduate training in education, e.g. Master/Doctorate in Education, Medical Education Fellowship, etc.? Who has experience publishing curriculum, educational tools, or simulation-based research?

Simulation as an Experience How many have been in the “hot seat” as a simulation participant/learner? If you have not, please do so

History of Experiential Learning “Experience is, for me, the highest authority. The touchstone of validity is my own experience. No other person's ideas, and none of my own ideas, are as authoritative as my experience... Neither the Bible nor the prophets -- neither Freud nor research --neither the revelations of God nor man -- can take precedence over my own direct experience.” from On Becoming a Person Carl Rogers, 1969

Educational Principles “We cannot teach another person directly; we can only facilitate his learning.” (Carl Rogers, 1969) An effective educational environment promotes significant learning if: 1) it is non-threatening or low-risk 2) facilitator can help learner differentiate his own perceptions through experiences

Adult Learning Theory (Malcolm Knowles 1978) Student centered and self-directed: Adult learners expect to have a say on what is taught, how they are taught, and how they are evaluated; Their feedback needs to be incorporated into program Experiential: Adults come with prior knowledge and learn best experientially Relevant: Adults need to know why they need to learn something and how they can apply new knowledge to their job/life. Problem-solving approach to learning Malcolm Knowles, 1913-1997, theory of andragogy (art/techniques of teaching adults) vs. pedagogy (teaching children), Harvard-Univ Chicago (MA, PhD)

Kolb’s Experiential Learning Cycle David Kolb, Professor of Organizational Behavior at Case Western Reserve University, is credited with launching the learning styles movement in the early seventies. According to Kolb (1984, 41), experiential learning has six main characteristics: * Learning is a continuous process grounded in experience. * Learning is best conceived as a process, not in terms of outcomes. * Learning involves transactions between the person and the environment. * Learning is a holistic process of adaptation to the world. * Learning requires the resolution of conflicts between dialectically opposed modes of adaptation to the world (learning is by its very nature full of tension). * Learning is the process of creating knowledge that is the result of the transaction between social knowledge and personal knowledge. Kolb D. (1984). Experiential learning: experience as the source of learning and development. Englewood Cliffs, New Jersey: Prentice Hall. Kolb D. (1999). The Kolb Learning Style Inventory, Version 3. Boston: Hay Group.

Discussions & Further Study Simulation Scenario Concrete Experience (Doing, feeling, experiencing) Deliberate Practice Active Experimentation (Applying, trying out what you learned) Guided Debriefing Reflective Observation (Reviewing, watching, reflecting) Simulation as part of the Experiential Learning Cycle Discussions & Further Study Abstract Conceptualization (Thinking, processing, learning)

Neuroscience Research Says… Learning engages the entire physiology The search for meaning occurs through “patterning” Emotions are critical to patterning Learning always involves conscious and unconscious processes Learning is enhanced by challenge and inhibited by threat

Circumplex of Emotions Optimal Activated State = Relaxed Alertness (low threat, high challenge) James Russell, prof of psychology at Boston College -under stress the indexing capacities of the brain are reduced and the brain’s short-term memory and ability to form permanent new memories are inhibited (cortisol vs. adrenaline/noradrenaline) -two types of stress “ one accompanied by a sense of pervasive threat related to a sense of helplessness and one accompanied by a sense of resolution or challenge “

6 Steps of Curriculum Design (Kern, 1998) Problem Identification and General Needs Assessment Needs Analysis of Targeted Learners Goals and Specific Measurable Objectives Educational Strategies Implementation Evaluation and Feedback Plan ahead with publication/dissemination in mind!

Step 1. Problem Identification and General Needs Assessment Identify the problem or educational gap What is the current approach (who is doing what, when, how, resource limitations) What is the ideal approach Ideal – current approach = general assessment

Step 2. Needs Analysis of Targeted Learners Who are the learners, level of training, previous experience, current performance, learning styles/preferences What are barriers or enabling/reinforcing factors What are the available resources to this group (simulation, faculty, clinical experiences) Use multiple ways to obtain info/needs assessment

Needs Assessment Methods Informal discussions Questionnaires/Surveys Interviews Focus groups Observations Tests Literature review Available documents – ACGME, Joint Commission, national board research Include different sites Other ideas?

Scholarly Work for Steps 1 & 2 Systematic review of literature Needs assessment report Assessment tool Keep in mind: Is there a need? A gap in the literature? Clinical significance? Has it been done before? Am I contributing something new? Is it generalizable? Is it innovative and compelling?

Step 3. Goals and Objectives Review types (learner, process, outcome) and levels of objectives Learning domains: cognitive, psychomotor, affective Review Bloom’s Taxonomy of educational objectives Write SMART (specific, measurable, achievable, relevant, timely) objectives Ask this question: Who will do what and how much/how well by what time (when)?

Bloom’s Taxonomy of Educational Objectives

Learning, Mastery & Expertise Proficient Competent Advanced Beginner Novice George Miller Miller’s Model of Assessment 1990 Dreyfus & Dreyfus Model of Skills Acquisition 1988

Essential Components of a Learning Objective Behavior/Skill: need to be specific and observable Condition: under what circumstances is this behavior achieved; are tools/assistance allowed? Standard: what is an acceptable level of performance; by what criteria is the behavior measured against?

Step 4. Educational Strategies Use multiple educational methods and match methods to objectives Review/discuss pros/cons of different methods Choose methods that are feasible in terms of resources Consider different simulation options Other interactive methodologies (games, ARS, engaging exercises etc.)

Simulation Methods Screen-based virtual patients Role plays Standardized patients Artificial models, procedural task trainers Virtual reality simulators Full body computerized simulators Hybrid simulation Group learning projects Games and other engaging activities

Scholarly Work for Steps 3 & 4 Creation/description of a new educational tool or method Simulation scenarios Theoretical/comparative paper on the merits of educational processes or tools

Step 5. Implementation Consider resources: personnel, time, facilities, funding/costs Administration and operations Piloting, phasing-in, full implementatoin

Step 6. Evaluation and Feedback Identify users and use (formative, summative), resources for evaluation, questions to ask, evaluation design Choose/construct measurement method – address reliability, validity, bias Ethical concerns Data collection and analysis Result reporting

Kirkpatrick’s Levels of Evaluation Level 1: Reaction – How did learners perceive the course, the process? Satisfaction surveys Level 2: Learning – What knowledge and skills were gained? Written tests, demonstrations, checklists Level 3: Behavior - What are the observable practice changes, transfer of learning from lab to job? Field evaluations, observations Level 4: Results - What are the tangible outcomes (return in investment, cost reduction, improved quality, increased production/efficiency,decreased complications, etc.)

Indicators of Deep Understanding Performance in Multiple Contexts Ability to Question Able to ask the right questions Know how to find the answers Know what to do with the answers Appropriate Performance in Unexpected Situations

Scholarly Work for Steps 5 & 6 Research study Descriptive study of curriculum implementation Cost effective analysis report Assessment tool Keep in mind: Get IRB and funding early Document each step in detail, keep notes Consult with education and research experts Collaborate

Curriculum Maintenance and Enhancement Continuous quality assurance methods for improvement Faculty development Resource allocation Management of change Scholarly activity by learner and faculty

12 Tips for Effective Short Course Design Assess the clinical problem. Determine learning outcomes. Use evidence-based medicine to develop content. Identify resources. Select teaching strategies for active learning. Select teaching strategies that foster reflection. Use passive strategies sparingly to ensure a common knowledge base. Create an individualized needs or pre-course assessment. Prepare teachers. Commitment to change and evaluation. Provide a 2–3 month post-course reflective exercise. Use data in an iterative way. Lockyer et al, Medical Teacher 2005

6 Steps of Curriculum Design Problem Identification and General Needs Assessment Needs Analysis of Targeted Learners Goals and Specific Measurable Objectives Educational Strategies Implementation Evaluation and Feedback

Where to Publish? Simulation in Healthcare journal Medical education journals (see list at http://www.med.uottawa.ca/aime/eng/journals.html): Academic Medicine, Medical Education, Medical Teacher, Teaching and Learning, Advances in Health Sciences, Journal of Nursing Education, Nurse Education Today, Nurse Educator, etc. Clinical specialty journals: watch for calls for Education issues MedEdPortal – curriculum, case scenarios, tutorials, facilitator guides

MedEdPortal Examples Ragsdale L, Gutman D, Kobayashi L. Geriatric Emergency Medicine Curriculum Using High Fidelity Medical Simulation. MedEdPORTAL; 2010. Available from: www.mededportal.org/publication/3168 Acton R, Schmitz C, Chipman J, Reihsen T, Gilkeson J, Groth S, et al. University of Minnesota Surgical Clerkship Simulation Skills Curriculum and Instructor Guide. MedEdPORTAL; 2010. Available from: www.mededportal.org/publication/7948 Chakraborti C. A Simulation-Based Curriculum For 4th Year Medical Students During An Internal Medicine Acting Internship. MedEdPORTAL; 2009. Available from: www.mededportal.org/publication/1687 Motz L, Lloyd B, Donato A, Chaudhary A, Kaliyadan A, Stavarski D, et al. Interdisciplinary Curriculum and Simulation Cases for Teaching Leadership and Communication to Medical Rapid Response Teams. MedEdPORTAL; 2012. Available from: www.mededportal.org/publication/9145 Brown C, Gephardt G, Lloyd C, Swearingen C, Boateng B. Teaching Palliative Care Skills Using Simulated Family Encounters. MedEdPORTAL; 2011. Available from: www.mededportal.org/publication/8507

Example Curricular Papers Fernandez GL et al. Boot Camp: Educational Outcomes After 4 Successive Years of Preparatory Simulation-Based Training at Onset of Internship. J Surg Educ 2012 Mar-Apr;69(2):242-8. Binstadt ES et al. A comprehensive medical simulation education curriculum for emergency medicine residents. Ann Emerg Med. 2007 Apr;49(4):495-504, 504.e1-11. Norman J. Systematic review of the literature on simulation in nursing education. ABNF J. 2012 Spring;23(2):24-8. Hudson D, Dunbar-Reid K, Sinclair PM. The incorporation of high fidelity simulation training into hemodialysis nursing education: part 2--a pictorial guide to modifying a high fidelity simulator for use in simulating hemodialysis. Nephrol Nurs J. 2012 Mar-Apr;39(2):119-23. Rhodes HA. Simulation in Kansas practical nursing programs. J Pract Nurs. 2011 Fall;61(3):10-3.

References Kern DE et al. Curriculum Development for Medical Education: A Six-Step Approach. Johns Hopkins University Press, 1998. Lockyer J, Ward R, Toews J. Twelve tips for effective short course design. Med Teach. 2005 Aug;27(5):392-5. Seropian MA et al. An Approach to Simulation Program Development. Journal of Nursing Education. 2004 Apr;43(4):170-4. Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005 Mar-Apr;26(2):96-103.

Web Resources UW collaborative website: http://collaborate.uw.edu/educators-toolkit/scenario-building-library.html-0 Society for Academic Emergency Medicine scenario library: http://www.emedu.org/simlibrary/default.aspx?AspxAutoDetectCookieSupport=1

Nursing Simulation Resources Simulation Innovation Research Center (NLN): http://sirc.nln.org/ California Institute for Nursing and Healthcare (CINH) Simulation Alliance: http://www.cinhc.org/programs/simulation/ Scenario Libraries: Kansas State Board of Nursing:http://www.ksbn.org/cne/SimulationScenarioLibrary.htm Montgomery College: http://cms.montgomerycollege.edu/nursingsims/ Massachusetts Dept of Higher Ed:http://www.mass.edu/currentinit/Nursing/Sim/Scenarios.asp

Hot Topics Interprofessional team training simulation curriculum Train-the-trainer (faculty/instructor development) Assessment with simulation

More to Consider How do I get buy-in for simulation training? What are my available resources/funding opportunities? What is already in the literature and available online? How do I incorporate technical and non-technical behavioral skills (e.g. leadership and communication skills training)? How many simulation sessions/scenarios do I need to achieve objectives? Realistically/logistically, how often/how many can learners come to the simulation center?

More to Consider How can I incorporate more independent simulations since I do not have enough faculty to teach? What do I need to consider for limited space and scheduling? How do I get all my faculty trained to teach in this curriculum? How do I add a competency/evaluation component to a course that has been primarily instructional? What approach should I take when I have to follow a national standardized curriculum?

Questions? Yue Ming Huang, EdD, MHS Email: yhuang@mednet.ucla.edu