constructivismexplains how knowledge is constructed when information comes into contact with existing knowledge that has been developed by experiences

Simulation in Health Professions Education: F r o m T h e o r y t o I m p l e m e n t a t i o n

Adam Dubrowski, PhD

“Country doctors feel uncomfortable with adhering to standards of care felt mandatory by consultants in the city. An occasional rapid sequence intubation is not enough to maintain proficiency in the procedure. Yet rural physicians working in under-staffed settings cannot easily maintain skills because they can’t leave their communities.”

The country doctor’s lamentTia Renouf, MD Can J Rural Med 2005; 10 (3)

Low frequencyHigh stakes

Just in-timeJust in-place

Pre-hospital Care

Primary Care

Community Hospital

University/Tertiary Hospital

Low Frequency simulation for training

Pre-hospital Care

Primary Care

Community Hospital

University/Tertiary Hospital

Development

Implementation

Silo

Hub and spoke

Methods and tools to merge the gap between the development and the implementation of simulation, leading to a hub-and-spoke model

Iterative

DesignWujec (2011)

Pre-hospital Care

Primary Care

Community Hospital

Tertiary Hospital

MRC

D e v e l o p m e n t O f C o m p l e xI n t e r v e n t i o n s

Campbell, et al (2000) BMJ.16;321(7262):694-6.

MRC

D e v e l o p m e n t O f C o m p l e xI n t e r v e n t i o n s

CIPPP r o c e s s b a s e d

d e v e l o p m e n t

Stufflebeam & Shinkfield (2007)Campbell, et al (2000) BMJ.16;321(7262):694-6.

Grand Mid-range Micro

Why use theories in qualitative research? Scott Reeves et al. BMJ 2008; 337 (3) 631

Cognitive Load

Theory (CLT)

Sweller, 1988; van Merrienboer and Sweller, 2010

Kurahashi et. al. 2011

Practice: Trained SkillsTest

WrittenTest

1 week rest

No practice: Novice

Kurahashi et. al. 2011

Skills Test: Expert Opinion

05

10152025

Written Test: Score

05

1015

2025

TrainedNovice Novice

TrainedNovice Novice

Kurahashi et. al. 2011

Reducing the complexity of the

learning environment

reduces cognitive load and improves

handling and learning novel

information.Sweller, van Merrienboer and Paas, 1998

A number of studies suggest skills learned in simulation

improve

McGaghie 2011, Gurusamy 2008, Nestle 2011

A number of studies suggest skills learned in simulation

can transfer to the clinical

setting

Sturm 2008, Grancharov 2009, Seymour 2002, Barusk 2009a, Park 2007, Wahidi

2010

simulation worksHow and why

Need research focuses on instructional design

[…] is the practice of creating "instructional experiences which make the acquisition of knowledge and skill more efficient, effective, and appealing."

Merrill et al., 1996

Instruct iona l Des ign

Clinical technical skills are a subset of

psychomotorskills

Psychomotor

Psychomotor

P h y s i c a l p r a c t i c e

R e p e t i t i v e V a r i a b i l i t yM a s s e d v s D i s t r i b u t e dF e e d b a c k

Wolpert,et al.(2001), Rizzolatti et al. (2001), Calvo-Merino et al. (2005)

Observational practice

Ins t ruct ionsModel ingSoc ia l Network ing

Campbell, et al (2000) BMJ.16;321(7262):694-6.

Moulton et al., Ann Surg. 2007

Optimal schedules

Moulton et al., Ann Surg. 2007

1 2 3 4 1 month

1 2 3 41 weekrest

1 month

distributed practice

massed practice

1 31 31 31 31 2 4

T

T

Transfer

distributedmassed

Exp

ert

O

pin

ion

30

20

10

0 Pre-test

Microsurgical drill

Post-test

Rat

Transfer

Moulton et al., Ann Surg. 2007

simulationInstructional designoptimizes

Representat ions o f Ac t ions

Carroll & Bandura (1990), Bandura et al. (1974), Beek & Lewbel (1995)

 “Psychomotor learning is …. outside the domain of

online learning.”

Newton, G., Introduction to Developing Online Electrical Course Ware. 1999 

P r e p a r a t i o n

Instruction

Instruction & Networking

Traditional Collaborate

PDFs + Video Networked Spot-the-difference

Observe

Spot-the-difference

P r e T e s t

W o r k s h o p

P o s t T e s t

Research: Current

Future: Preparation

Contro

l

Obser

vatio

nal P

ract

ice

OP an

d EN

05

10152025

Traditional Observe Collaborate

Post-

Test

Glo

bal R

ati

ng

s

Research

Social (Ed) netwroking improves learning during the workshop

Conclusion

Campbell, et al (2000) BMJ.16;321(7262):694-6.

MalawiI s s i m u l a t i o n n e e d e d ?

CIPPP r o c e s s b a s e d

d e v e l o p m e n tStufflebeam & Shinkfield (2007)

A mother’s journeyNiranjan Kissoon, MD Pediatr Crit Care Med 2010 Vol. 11, No. 4 Co n t e x t

DistrictHospital

District Health Centre

Community Hospital

Tertiary Hospital

W h a t i s d o n e w e l l

A healthcare worker journeyCo n t e x t

DistrictHospital

District Health Centre

Community Hospital

Tertiary Hospital

W h a t i s d o n e w e l l

W h a t n e e d s t o b e d o n e

A healthcare worker journeyCo n t e x t

DistrictHospital

District Health Centre

Community Hospital

Tertiary Hospital

W h a t i s d o n e w e l l

W h a t n e e d s t o b e d o n e

A healthcare worker journeyCo n t e x t

S i m u l a t i o n

DistrictHospital

District Health Centre

Community Hospital

Tertiary Hospital

E T A T

Univ

ers

ity level

Emergency TriageAssessment & TreatmentIn p u t s

DistrictHospital

District Health Centre

Community Hospital

Tertiary Hospital

Univ

ers

ity levelETAT: Instructional

DesignP r o c e s s

E T A T + +

E T A T

Instructional Design

Univ

ers

ity levelETAT: Instructional

DesignP r o c e s s

DistrictHospital

District Health Centre

Community Hospital

Tertiary Hospital

HIV

HBB

ETAT

ETATHBBHIV

HIV

HBB

ETAT

Different programsSimilar system “journey”Similar strengths (Inputs) Similar weaknesses (Processes)All connected to the University

University as the hub (Train the Trainer)

University as the hub (Train the Trainer)

DistrictHospital

District Health Centre

Community Hospital

Tertiary Hospital

Is this unique to Malawi?

“Country doctors feel uncomfortable with adhering to standards of care felt mandatory by consultants in the city. An occasional rapid sequence intubation is not enough to maintain proficiency in the procedure. Yet rural physicians working in under-staffed settings cannot easily maintain skills because they can’t leave their communities.”

The country doctor’s lamentTia Renouf, MD Can J Rural Med 2005; 10 (3)

MRC

D e v e l o p m e n t O f C o m p l e xI n t e r v e n t i o n s

CIPPP r o c e s s b a s e d

d e v e l o p m e n t

Stufflebeam & Shinkfield (2007)Campbell, et al (2000) BMJ.16;321(7262):694-6.

Adam Dubrowski, PhDadam.dubrowski@gmail.com

Home District Centre

District Hospital

Regional Hospital

Tertiary Hospital

Home Pre-hospital care

Primary Care

Community Hospital

Tertiary Hospital

UniversityTrain the Trainer

Context Input Process Product