Training on Demand: A Solution to Clinical Education Through Simulation

TECHNOLOGY AND EDUCATION

Sean Guinane, MS, PA-C; Laura Molloy, MMS, PA-C, Philadelphia College of Osteopathic Medicine, Department of Physician Assistant Studies, Philadelphia, Pennsylvania Introduction One of the greatest struggles facing physician assistant (PA) education programs is the availability of clinical training sites. PA programs often compete for educational space that may otherwise be occupied by medical students. The number of newly developed PA programs has also caused competition for sites within the profession. As programs struggle to find and maintain an adequate number of high-quality clinical sites, students may also experience clinical rotations that do not provide the best environment and experience to help them develop their professional persona. Imminent reformation of the US health care system is expected to bring an influx of new patients. Providers will have a difficult time meeting the demands of the millions requiring services without compromising safety and a high level of care. Though efforts are underway to increase the number of health care providers, the training of these providers requires clinical training capacity for them. Improved clinical education for PAs and other health professions students is necessary to fully realize the goals of health care reform. Clinical simulation offers a partial solution to the shortage of clinical sites for current PA students and for the increasing number of new PA programs. Simulation takes many forms. Human actors posing as patients can help students with their history taking and physical examination skills. Part-task simulators provide practice in specific patient procedures or tasks, ranging from uncomplicated plastic models for venipuncture 32

or airway intubation, to more complex ultrasound-guided catheter placement trainers. High-fidelity simulators are electronically controlled mannequins or life-like models that are capable of reproducing physiologic functions. Finally, computer-based, virtual-reality simulators allow trainees to practice skills requiring hand-eye coordination while mastering anatomy and becoming familiar with the handling of instruments. High-fidelity simulators are the focus of this article. Programs have embraced the use of simulation in preclinical education, yet clinical education has remained limited to traditional bedside learning. The value of learning from patients cannot be replaced. But given the limited availability of sites and high variability of student experiences, clinical education should be supplemented and enhanced with the use of simulation.

Feature Editor’s Note: Physician assistant educators should be aware of the growing complexity and capability of simulation in teaching students as clinical rotations and encounters become scarcer. Simulation with new technology allows for consistent teaching and assessment of skills in a resourcelimited environment. — Allan Platt, MMSc, PA-C Sean Guinane can be reached at [email protected].

Requirements for Supervised Clinical Practice PA education is regulated through the accreditation process of the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). Specifically, accreditation standards acknowledge that a program may “remain creative and innovative in program design and the methods of curriculum delivery and evaluation.”1 Simulation is underutilized in clinical education, despite it being a creative and innovative modality. The ARC-PA standards advise that programs should use licensed health care providers as preceptors; the standards also state that those not licensed in the area of instruction

The Technology and Education feature is intended as a forum for the presentation and discussion of technology in PA programs and education generally. Appropriate submissions include articles related to uses of technology in the classroom, web-based platforms, distance learning, and products and programs. Articles describing the effect of new technologies on student behavior and learning are also welcome. Features should be submitted to journal staff at jpae@PAEA online.org. 2013 Vol 24 No 4 | The Journal of Physician Assistant Education

Training on Demand: A Solution to Clinical Education Through Simulation

may precept students after evaluation by program faculty.1 To this end, use of a simulation-trained clinician with specialty-trained clinician guidance can satisfy the requirements of this standard.

Current State of Simulation in Education The use of simulation currently in PA education has mostly been limited to didactic education. Use of part-task simulators, such as model arms on which an intravenous line may be placed or a small pad of simulated skin that may be closed with sutures or staples, provide excellent opportunities for students to practice early in their education and remain focused on the presented task. As the student advances in his or her education, however, it is important to remove the focus provided by a simulator and allow the student to create his or her own focus by way of the patient interaction. For this, part-task simulators are inadequate and a full-bodied, high-fidelity simulation patient is preferred. While some institutions may have these tools available, they are not commonplace and are less likely to be used to augment clinical practice experiences. Simulation has the ability to improve patient care through objective, reproducible, standardized assessments of provider competency. In the medical education setting, simulation provides skills training in an environment in which students can make mistakes without the fear of harming patients. Simulation can be used to evaluate competence, decreasing the chance of errors while performing technical procedures in the clinical setting. The ability to control the simulation setting allows researchers to evaluate the effect the simulation has on patient outcomes. There is robust evidence depicting how skills attained in the simulation lab can translate to performance outcomes. A recent meta-analysis reviewed 20 years of research comparing traditional clinical

education with simulation-based education using deliberate practice. The review found that students with simulation and deliberate practice had higher levels of goal achievement than those with traditional education.2 Deliberate practice enables a motivated learner to repeatedly perform a task with continued feedback and an opportunity for correction. This allows the trainee to receive feedback and soon experience the task again, whereas in traditional clinical education, an opportunity to complete the task may not present again to allow the trainee to apply the corrective feedback. Through simulation-based education and deliberate practice, the learner is given the greatest opportunity to master a skill before moving to another task. This is particularly useful in procedure-laden rotations, such as surgery or emergency medicine. Similarly, education through simulation allows an on-demand experience for the learner, when traditional clinical education would require the learner to wait for an opportunity to present itself. While not technically challenging, examination of the male or female reproductive structures requires experience with both professional demeanor and familiarity with technique. The sensitive nature of these exams generally prohibits frequent practice among students, which has often led to these exams generally being considered a skill for mastery during the clinical education of a PA student. Two studies found that the use of simulated examination before reproductive examination on a person improved skill and decreased anxiety in trainees.3,4 Anxiety can be a significant barrier to learning. By decreasing the anxiety about exam technique, the examination may be a better learning opportunity for the student. This is further supported by data from a program implemented by advanced practice nursing students. The already-experienced nursing students used simulated patients to enhance diagnostic

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and therapeutic abilities.5 This use of simulated patients also underscores the benefit of simulation-based education in treating a patient through a holistic approach, rather than limiting training and assessment to procedural tasks alone.

Implementation and Adoption into Clinical Education The opportunities for innovation and creativity in simulation training are boundless. Included here is one recommendation on how simulation may be incorporated into supervised clinical practice for PA students. Implementation efforts should include consideration of a suitable space and facilities, recruitment and training for a simulation engineer, case development including additional faculty time commitment, and changes to the current structure of supervised clinical practice to include the simulation experience. High-fidelity simulators require dedicated space, unlike their part-task simulator counterparts. In addition to the simulated patient room, space is necessary for the simulator engineer. Optimally, this would be an adjacent room, though the engineer may operate the controls from within the same space. Space comes at a cost, and the expense of implementing a high-fidelity simulation program has been poorly documented in research.6 One panel estimates the cost of high-fidelity simulators to be as high as $200,000, with additional costs for space renovation and audiovisual equipment leading to a project that can cost up to $1 million.7 While this space has capability for use in more than one health care educational program and the potential to generate revenue, initial cost may present the greatest obstacle for inclusion in PA education. Simulation engineers play an integral role in the delivery of a simulated experience. The engineer is responsible for the behind-the-scenes operation of the simu33

Training on Demand: A Solution to Clinical Education Through Simulation

lated mannequin and is typically trained by the device manufacturer. The capabilities of the simulator may be adjusted during the course of the educational experience, and the engineer’s role is to guide these adjustments to meet the needs of the faculty facilitator. In simple cases, the simulator engineer may be the only guide, providing technical support and enabling deliberate practice to occur. Training for clinical instructors is available from myriad facilities, including manufacturers and medical institutions. These trainings are designed to provide the faculty with the basics of simulation education theory and aid in development of cases to guide learning. To meet the needs of students and the ARC-PA Standards, it is necessary to recruit clinicians from specialty areas to help with case development. Working in concert with the simulation engineers, program faculty and specialty practice clinicians will spend numerous hours to fully develop the simulated case. In order to allow PA students to synthesize and apply the new information, fully developed cases must include a patient history, physical exam findings, diagnostic test results, and defined criteria for procedure performance. Cases must also include simulated responses for erroneous student interventions, such as delivery of an incorrect medication. Software for simulators often includes cases that may be used as provided, or modified to meet existing goals and objectives; however, the instructor must be familiar with the programming of the case so she or he can anticipate teaching moments during the simulated encounter. While simple cases may be prepared in a relatively short time, complex cases will require several days or weeks to fully develop and test before deployment to students in a simulated encounter. With high-fidelity simulated patients, abnormal exam findings may be programmed in a variety of body regions, with skilled simulation faculty creating additional 34

findings beyond the simulator’s function (see Table 1). In addition to the programmable exam findings, the high fidelity simulator will respond to interventions by students, such as a slowed heart rate and altered rhythm, with administration of the appropriate cardiovascular drug. A skilled simulation faculty and staff will allow additional findings to be developed, such as simulating crepitus with cellophane under palpated skin or padding in extremities to resemble edema. In addition to significant investments of space, money, personnel, and time, faculty and staff must also consider how these simulated cases will be delivered to students in supervised clinical practice. With robust cases and sufficient staffing, replacing half of the current time on a given clinical experience may be reasonable. This will enable current preceptors to teach twice as many students in the already established time frame of a program. For example, consider an emergency medicine preceptor currently training two students during a 6week period. Two students may rotate

with this preceptor for 3 weeks while two additional students are in simulation encounters for 3 weeks. After 3 weeks, the two groups of students will trade places, doubling the number of students trained by this preceptor (see Figure 1). With challenges to find high-quality clinical educators in a variety of disciplines, this approach may allow for program growth despite reduced clinical educators, or allow for preceptor attrition without necessitating reduction in program size.

Correlation of Simulation Training to Health Care Delivery As previously described, simulation permits students and providers to train in a controlled environment that does not affect patient safety. Trainees can learn from their mistakes and not only perform a skill, but master it. Limited exposure to rare medical conditions or complex procedures during one’s training can occur for a variety of reasons but lessens the opportunity for practice. Simulation introduces students to abnormal findings they may not see on clinical

Table 1. Select Physical Exam Capabilities of a Simulated Patient System Eyes

Functions Alter pupillary response, alter blink rate, tear production

Vascular

Pulse grade adjustable or absent at multiple sites, bleeding, peripheral and central venous access

Cardiac

Multiple heart sounds with altered intensity based on location of auscultation, alter heart rate, pericardiocentesis, defibrillation

Lungs

Adventitious sounds, absence of sounds controlled by lobe, alter respiratory rate, airway obstruction by tongue edema or laryngospasm, endotracheal intubation, chest tube placement, needle decompression

Abdomen

Various bowel sounds controlled by region, vomit fluid, nasogastric intubation

Urinary

Interchangeable genitals with urinary catheter placement and urinary output

Neuromuscular

Convulsion

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Training on Demand: A Solution to Clinical Education Through Simulation

rotation. Learning through simulation can be customized for beginners to advanced practitioners. Effective patient care is the direct result of the training that the medical and health professions staff receives. Education that includes simulation-based training improves the provider’s technical skills and enhances knowledge of complex clinical situations by allowing for deliberate practice of skill acquisition and improvement. In one meta-analysis, the authors compared simulation-based medical education with deliberate practice to traditional clinical education in order to assess clinical skill acquisition. Findings of this analysis revealed the superiority of technology-enhanced simulation training for skills for myriad surgical and emergency procedures.6 There is significant evidence that patient outcomes are improved as a result of the application of skills learned through simulation training. Simulation has been shown to reduce bloodstream infections in patients receiving central line placement.8,9 Yudkowsky et al reveal that practicing on virtual simulators improves residents’

ability to perform catheter placement in the brain to facilitate the drainage of cerebrospinal fluid.10 Improved patient outcomes related to obstetrical and gynecological procedures point to simulation training as the reason as well.11,12 Findings such as these translate into patient care and should affect changes to clinical education.

Future of Simulation in PA Education

same standards that have previously been established continue to be met. Eventually, this will provide both educational benefits to the student, experiential benefits to the patients for whom these new providers will care, and additional costeffective resources to the expanding health system in the United States.

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Of 181 accredited PA programs, 29 recently joined the effort to educate future PAs, with nearly twice as many in the accreditation application process.13,14 Rapid growth of the profession must be met with rapid growth of clinical training sites. Unfortunately, efforts for this have not yielded results, and programs struggle to find clinical learning opportunities for students. With data to support the benefit of simulation-based education in other health professions, it is imperative that PA programs begin to blend traditional and simulation-based clinical education experiences. Frequent data analysis will be required to ensure the

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4. Figure 1. Doubling Clinical Capacity of a Preceptor with Simulation Supplementation Current: 1

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Accreditation Review Commission on Education for the Physician Assistant. Accreditation Standards for Physician Assistant Education: Fourth edition. 2012. http://www.arc-pa.org /documents/Standards4theditionwithcla rifyingchanges9.2013%20FNL.pdf. Accessed November 3, 2013. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011;86(6): 706-711. Loveless MB, Finkenzeller D, Ibrahim S, Satin AJ. A simulation program for teaching obstetrics and gynecology residents the pediatric gynecology examination and procedures. J Pediatr Adolesc Gynecol. 2011;24(3):127-136. Pugh CM, Iannitelli KB, Rooney D, Salud L. Use of mannequin-based simulation to decrease student anxiety prior to interacting with male teaching associates. Teach Learn Med. 2012;24 (2):122-127. Jeffries PR, Beach M, Decker SI, et al. Multi-center development and testing of a simulation-based cardiovascular assessment curriculum for advanced practice nurses. Nurs Educ Perspect. 2011;32(5):316-322. Zendejas B, Wang AT, Brydges R, Hamstra SJ, Cook DA. Cost: The missing outcome in simulation-based medical education research: A systematic review. Surgery. 2012;153(2):160176. Jha AK, Duncan BW, Bates DW. Simulator-based training and patient safety. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical 35

Training on Demand: A Solution to Clinical Education Through Simulation

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Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med. 2009;169(15):14201423. Burden AR, Torjman MC, Dy GE, et al. Prevention of central venous catheter-related bloodstream infections: Is it time to add simulation training to the prevention bundle? J Clin Anesth. 2012;24(7):555-560.

10. Yudkowsky R, Luciano C, Banerjee P, et al. Practice on an augmented reality/haptic simulator and library of virtual brains improves residents’ ability to perform a ventriculostomy. Simul Health Care. 2013;8(1):25-31. 11. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008;112(1):14-20. 12. Robertson B, Schumacher L, Gosman G, Kanfer R, Kelley M, DeVita M. Simulation-based crisis team training for multidisciplinary obstetric providers. Simul Health Care. 2009;4(2):77-83.

13. Accreditation Review Commission on Education for the Physician Assistant, Inc. Accredited entry-level programs. 2013. http://arc-pa.net/acc_programs/. Accessed November 3, 2013. 14. Accreditation Review Commission on Education for the Physician Assistant. Applicant programs. 2013. http://www. arc-pa.com/provisional_acc/applicant_ programs.html. Accessed November 3, 2013.

2013 Vol 24 No 4 | The Journal of Physician Assistant Education