July 1, 2010By Lance Baily

The Reality of Simulation

I have visited dozens of healthcare simulation labs across the US, and to be honest, the Simulation Users who understand the true power behind Simulation are few and far between.  Even some of the labs that have all the latest equipment, well- trained facilitators and support staff, and the biggest centers in the World are still inherently missing the real point of Healthcare Simulation.

Is the real purpose of an $80,000 manikin and a $1,000,000 Sim Lab to teach skills, or is the purpose much more significant?

Today I will discuss how and why Healthcare Simulation provides participants with the opportunity not only to learn about patient care, but more importantly, to grow their individual ability to manage complex healthcare situations.

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The Facilitator, aka the ‘Documentary Film-maker’

In great documentary filmmaking, a director’s real job is to capture footage that represents the reality of people in a given place, community or situation.   If the director has no relationship with this community, he/she  must spend time and energy building relationships in order to gain access to that inner world.  At very minimal s/he will have to convince someone to give permission for the subjects to be filmed.  Once a relationship has been built, the director will receive permission to bring a camera into an otherwise private affair.

When the  filmmaker develops a close and personal relationship with the subject, the subject will feel safe and will be willing to open up and reveal more.   The filmmaker will be able to ask deeper questions that might  otherwise be considered too personal.  With this depth of space in a relationship, a greater story is revealed through an unfiltered access into a subject’s normal reality.  In other words, access to record a delicate performance comes with the proven trust to honor the subject’s story and respect the retelling of that story.

While filmmakers have some choice with the selection of their documentary subject, facilitators of medical simulation have very little choice as to the learners in the session on a particular day.  Thus, those who debrief must take extra time and effort to create a safe space for learners to reveal their “performance.”

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Really Imagined

Respect is a key issue.  If a film director does not respect the subjects they are filming the shoot will end with frustration and emotion on both sides.  Likewise, a simulation facilitator must respect their students.

If you falter in front of the group and ‘lose your cool,’ you will reveal your judgment of their story and you would jeopardize the entire process.  In order to be a successful facilitator, you must be able to see the student’s perspective and not be judgmental.  Yes, learners will make but this is how the students learn..  I have heard several facilitators yell in the Sim lab control room, “I can’t believe this! I taught them better than that!”  The students would not make mistakes if they remembered and connected all the pieces of information we have sent their way.  Simulation is a way to help students connect the dots in a safe and stress free environment.

Your Risk vs. Their Reward

Some may think the prize of Simulation is knowledge gained, however, this is only a small part of the potential benefit simulation has to offer.   Knowledge is editable information that can change based on time and place .  Just look at how many reiterations general CPR has gone through in terms of “best practices” in the last fifty years. With the right education, almost everyone can be expected to pass a CPR test based on a lecture, hands-on workshop, manuscript, video presentation or audio recording.

The real reward from Simulation is the ability to change a learner’s behavior.  Why are behaviors more rewarding for learners to gain?  Think about it like this, would you rather hire a person for their knowledge or for their behavior?  With the right behavior almost any knowledge can be easily taught.  But even with the right knowledge, difficult behavior may prevent collaborative and heightened utilization of that knowledge (i.e. the know-it-all persona).

Behavior is much more difficult to transform because it is closely linked to a person’s sense of identity.  For instance, if a learner does not know the correct knowledge, the education/educators can ultimately be blamed and held responsible for that outcome. Conversely, there is no other person/place/thing that can easily be blamed for a learner’s inappropriate behavior.  If a learner exhibits a behavior that s/he learned a long time ago, they may continue that behavior even though they have new knowledge.

Of course, you can see how discussing someone’s behavior can quickly become a very touchy subject.  If someone close to a learner (like a parent) taught them an inappropriate behavior, the learner may associate requests to change that behavior as an attempt to alter their personal attachments, and thus their sense of self.  And so to have a conversation about a learner’s overall behavior, a facilitator must be willing to communicate at a much deeper level.

Educators/Supervisors more interested in the daily feeling of superiority gained from “I told you so” will find a transition into Healthcare Simulation challenging to say the least. Even thinking “I can’t believe they just did that” will chisel away at the dedication necessary to building trusting and respectful facilitator/learner relationships.

When facilitators can “believe the learner just did that”, then they can move on to more important questions such as “How do I help them to see an additional perspective?”  And those who have witnessed this shift in a learner’s perspective can attest that the reward is worth the wait.  “Watching a learner gain a higher awareness of themselves is beyond words” I have heard some Healthy Simulation Champions say.

How does Healthcare Simulation provide an opportunity to educate a learner about their behavior?

Being videotaped and analyzed in the workplace is not something many individuals are required to undergo.  It can be an uncomfortable process, even without the stress to perform adequately and professionally. Haven’t most of us found we sound and look different than we imagined when captured on video?  Add a potentially stressful situation and peer evaluation to the mix and you can have a seemingly risky situation on your hands.  However, when provided with a safe space, learners will be given an opportunity through Healthcare Simulation to witness themselves fully engage in a workplace situation, perhaps for the first time in their entire life.  When that happens, learners can be shocked to realize all of the elements of communication they have unconsciously let slide by their control.

How learners think they present themselves to fellow learners, classmates, coworkers, supervisors, subordinates, and patients versus how they actually present themselves can be two very different perspectives.  Video provides learners with an opportunity to see behaviors unfold that they potentially have never been made aware of or acknowledged before.  For instance if they grimace when looking at an infected wound, or roll their eyes when a certain supervisor enters the room, or tap their foot when a coworker is talking.  These are critical moments that will not come without providing learners a space to witness themselves without being judged.  Video will tell the truth, but only to those who are willing to acknowledge it!

In debriefing a simulation, the more developed a relationship with your learners the more trust they will give you to guide them to a path of self-discovery.  With experience, facilitators can educate learners that the camera is not a condemning prosecutor, but instead an impartial witness.  And when facilitators themselves offer the judge’s seat to the primary learner, then that individual is provided an opportunity to self educate themselves like never before.

A changed behavior never needs testing, as it is always present.  Watching this shift in understanding is not only the purpose of Medical Simulation but as well the real joy!

How can you provide the ultimate learning opportunity through Healthcare Simulation?

Videotape your own debriefings and sit down with a fellow facilitator to become aware of your own process.  Partaking in the video recording yourself will provide endless examples to you about your own imagined perspective of an engagement versus the expanded, impartial and more realistic perspective of that same session.  Then you too can be educated through expanded awareness of the process – and your behaviors will change right before your very eyes!

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