Replacing Practicum Time With
Immersive Simulations…. Can,
or should it be done?
Norbert Werner
The Game Plan
• Discuss the need for filling experiential gaps
in the clinical practicum experience
• Highlight the NAIT Paramedic program and
their experience with embedding simulation
within the clinical practicum
• An open discussion and sharing of other SIM
experiences, both good and bad….
A Few Important Questions…
1. Are our learners at an appropriate level of
competence/preparedness upon graduation and able to
function independently in today’s healthcare environment?
Field-ready performance level
Entry-level performance
Textbooks
Classroom instruction
Training load
Part-task simulation
Mentoring
The real thing
Immersive simulation
Curriculum
(Kyle 2008)
2. How do we address and close the current
experiential gaps that exist in our apprenticeship
model in the clinical practicum?
Theory-Practice gap
Practicum experiential gaps
Extending practicum not the
solution
Cannot guarantee specific patient
presentations with “time and
chance”
First time experiences high-risk for
patient and student
Initial skills,
knowledge,
and attitudes
Realistic
Simulation
Real clinical
care/practicum
2. How do we address and close the current
experiential gaps that exist in our apprenticeship
model in the clinical practicum?
Paramedics + Hallways =
Experience? NO!
Experiential curve in 1993
compared to today…
3. Are we creating reflective practitioners in our
learners? Does the clinical setting allow for reflection to
occur?
4. Do we authentically assess our learners in a
contextual, simulated setting before a real patient
setting?
Risk of non-authentic assessment: Incompetence in the “real
world”
5. Are our graduates ready to work in an interdisciplinary, or inter-professional team environment?
• Inter-D Teams
• Teams expected to
work in
teams….training
together.
One possible solution…
Replacement of clinical time with simulation,
or should we say…
Filling the gaps of clinical time with simulation?
A different emphasis and agenda
A case example…
• NAIT Paramedic Program Pilot March 2010
• First 48 hours of clinical/practicum now a SIM Week Event
• Identified experiential gaps (i.e. call management)
• 20 pre-determined immersive simulations
• Clinical and non-clinical (CRM, Human Factors, IPE)
Twenty SIMs in four days focusing on…
•
High-acuity/low
frequency events
•
Assessment of
performance
•
High-risk or dangerous
•
Teamwork/IPE/CRM
•
Core competency (bread
and butter)
•
Reflective practice
•
Deep learning
•
Active/engaged
experiential learners
•
•
Critical thinking/decisionmaking
Context-based learning
In preparation for research…
Pre and post student survey themes:
1. Perception of “readiness to practice”
2. Perception of SIM-based learning
3. Attitudes toward replacement of clinical time with SIM
If I was starting my practicum TODAY, I would be ready
to:
A few examples…
Knowledge
Low High
Experience
Low High
Confidence
Low High
Take the lead in running a cardiac arrest
1 2 3 4 5
1 2 3
4 5
1 2 3 4 5
Take the lead in managing a MCI
1 2 3 4 5
1 2 3
4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3
4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3
1 2 3 4 5
Provide leadership to a 1 2 3 4 5
pre‐hospital team during a medical crisis.
Take the lead in managing a high‐risk pregnancy
Communicate effectively during a critical event.
Take the lead in managing a difficult airway 4 5
My Perception of Simulation-Based Teaching and
Learning…
A few examples…
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Doing SIM outside of the lab/classroom setting makes my experience more realistic and relevant
1
2
3
4
5
Based on my previous experience, SIM is a valid representation of clinical practice
1
2
3
4
5
I currently feel ready for my final practicum and feel that this SIM week is a waste of my time
1
2
3
4
5
A realistic work setting is important in SIM
1
2
3
4
5
I am open to role‐play another persona/healthcare discipline within a simulation scenario
1
2
3
4
5
I feel more stressed in SIM than I would on my practicum 1
2
3
4
5
SIM can fill the clinical gaps that may exist in my practicum (i.e. rare events, high‐risk situations, etc.)
1
2
3
4
5
A picture is worth a gazillion words…
Some examples of SIM Week…
“Ped” in the pool…
VHR: Atypical AMI outside fitness area
Cardiac Arrhythmia on the Ice
“Delirium? Dementia? Hmmm……”
Bone CA/Pain Management/Family Support:
Clinical and non-clinical objectives…
High-acuity-low frequency:
Post-partum Haemorrhage and NRP
High-risk situations: Too much crack!
Rare events: Pediatric pain management in a
racquetball court…
Inter-professional education in the dental environment
Crisis Management
6 y/o trauma code in parking lot
Real EMS unit
Resuscitation “on the move”
No backup
Green partner
Equipment malfunction...Oh my!!!
Hybrid SIM (SP and Mannequin)
AMI in President’s Office
Decision-Making and Cancellations:
“Just the flu”………..or hypokalemia?”
DNR-End of Life…
No DNR paperwork
present?
What to do!?
Conflict resolution with a
rural physician
Assertiveness
Professionalism
The classic MCI
Pre and post-survey mean scores on “readiness to
practice”
If I was starting my practicum TODAY, I would be ready to:
Knowledge
Pre
Post
Take the lead in running a cardiac arrest
Mean 3.89
4.21
score
Provide leadership to a pre‐hospital team during a medical crisis.
Knowledge
Pre
Mean 3.42
score
Take the lead in managing a high‐risk pregnancy
Experience
Pre
Post
Confidence
Pre
Post
2.05
3.05
Experience
Mean 3.68
score
Take the lead in managing a difficult airway Knowledge
Mean score
4
Confidence
Post
Pre
Post
Pre
Post
3.84
2.74
3.37
2
3.84
Knowledge
Pre
3.21
Experience
Confidence
Post
Pre
Post
Pre
Post
3.84
2.21
2.68
3
3.58
Experience
Confidence
Pre
Post
Pre
Post
Pre
Post
3.95
4.11
2.05
2.84
3
3.84
Pre and post-survey mean scores on perception of
SIM-based learning
Strongly disagree
1
Disagree
Neutral
Agree
2
3
4
During a simulation, I often feel that I am experiencing “the real thing”.
Pre
Post
Mean Score
2.16
3.63
Simulation does NOT feel real to me.
Mean score
Pre
3.37
Post
1.95
Strongly agree
5
In my experience, simulation scenarios feel/felt real.
Pre
Post
Mean score
2.26
4.21
Take the lead in a pediatric resuscitation
Knowledge
Pre Post
Mean 3.58 4.05
score
Experience Confidence
Pre Post Pre Post
1.53 2.53 2.53 3.58
Replacing some practicum time with simulation can add efficiency to my learning
Pre
Post
Mean Score 2.74
4.37
Mean Score
Simulation increases my level of experience as a practitioner.
Pre
Mean score
3.05
Doing SIM outside of the lab/classroom setting makes my experience more realistic and relevant
Pre
Post
Mean score
3.32
4.53
Post
4.21
I learn by observing others in simulation.
Pre
2.26
Post
4.21
Implications-Post Survey Feedback
• Realistic context is important to the learner
• Some were LESS confident after SIM Week. Why?
Authentic assessment uncovered competence issues
• Strong student support for replacement of SOME clinical
time with realistic SIM
• Transfer of experiential learning in SIM to real practice
evident: ongoing student testimonials
Other NAIT programs
replacing clinical time…
Respiratory Therapy (RT):
Up to eight weeks of SIM in
lieu of clinical
• Diagnostic Medical
Sonography (DMS)
Program
• Two weeks of practicum,
maybe more?
• Others?
Summary: “Take-aways…”
1. Addressing clinical capacity is important, but emphasis
and motivation should be on pt safety and filling the
experiential learning gaps of practicum
2. SIM is just one teaching strategy; use wisely
•
•
Multi-modality approach
Golden thread throughout curriculum, not just practicum
3. High-quality SIM and DEBRIEFING paramount if it is
to replace real pt care
•
•
Watch out for “good enough” SIM philosophy
Transfer of learning linked to relevance and realism
Thanks!
norbertw@nait.ca
780-378-5368