Academic Life in Emergency Medicine (ALiEM)

Some resources just stand out in their innovation, quality and delivery, and Academic Life in Emergency Medicine (ALiEM) has to be one of the best for education. This organisation is part of the free open access to medical education (#FOAMed) movement, so its all accessible. It shows if you don’t have access to journals, books or higher education, that the online world can still help supplement your education theory and development with peer reviewed resources. Take a look at the incubator project, is this the start of challenging the traditional education pathways? If the doctors can do it, surely nurses can be inspired to create a community of learning away from the traditional sources of knowledge and make learners as co-designers and change the agility in knowledge translation and evidence based practice?

Academic Life in Emergency Medicine (ALiEM)

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eBook of the ALiEM blog series available for review and to join the peer review process.

Community of practice approach to learning networks.

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“The ALiEM Faculty Incubator Project is a year-long professional development program for educators, which enrolls members into a mentored digital community of practice. This small, 30-person, exclusive community will stoke the fires of creative engagement through mentorship and collaboration. We aim to strengthen your educational skills and produce tangible works of scholarship. Our goal is to construct a curriculum, delivered to you in a closed digital platform, and help you launch and accelerate your career development.”

Lacking in academic integrity I hear you say, take a look at the publication list around learning, education and social media from their team.

 

Follow the @ALiEMteam on Twitter.

 

 

 

The Role of Debriefing in Simulation-Based Learning. 

Journal Club Article: Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125.

Purpose

Determining what is important in the aspects of debriefing within simulation based learning.

Background

The importance of remembering the adult learner, and all the experience they bring through knowledge, assumptions and feelings. Active participation and leveling (#Heutagogy) of the traditional hierachies between teacher and learner are part of the adult learning philosophy. The adult learner is seen as self-directed, motivated and learns from meaningful and work related education that can applied in workplace.

“Adults learn best when they are actively engaged in the process, participate, play a role, and experience not only concrete events in a cognitive fashion, but also transactional events in a emotional fashion. The learner must make sense of the events experienced in terms of their own world” (pg. 115).

“The concept of reflection on an event or activity and subsequent analysis is the cornerstone of the experiential learning experience.” (pg. 116).

Origins of debriefing in simulation were from critical stress incident debriefing and to do this in a timely manner post incident, with the aim to stimulate group cohesion and empathy.

The Debriefing Process

  • Supportive climate; open, sharing, honest, free to learn.
  • Environment of trust; the pre-brief to explain the purpose of the simulation and what is to be expected.
  • The roles of debriefer and those to be debriefed.

Models of Debriefing

The aim of the debrief is to make sense of the event. The structure of the simulation may be:

  1. Experience the event,
  2. Reflect on the event,
  3. Discuss the event with other participants,
  4. Learn and modify behaviour learnt from the experience.

Objectives

As ever match learning such as the debriefing to the learning objectives. Allow emergent and evolving learning that occurs throughout the simulation process. “Two main questions:

  1. Which pieces of knowledge, skills, or knowledge are to be learned?
  2. What specifically should be learned about each of them?”

Role of The Facilitator

The facilitator will be a Co-learner in the simulation with the aim to guide and direct, rather than a traditional lecture based authoritarian approach. Debriefing is a skill and requires training and development. Resources such as the support from experts to guide and develop are important in developing simulation skills.

Debriefing 

Dismukes & Smith (2017) describe three levels of facilitation:

  1. High: High level facilitation actually requires low level of involvement from the facilitator. “Participants largely debrief themselves with the facilitator outlining the debriefing process and assisting by gently guiding the discussion only when necessary, and acting as a resource to ensure objectives are met” (pg 119).
  2. Intermediate: “An increased level of instructor involvement may be useful when the individual or team requires help to analyze the experience at a deep level, but are capable of much independent discussion” (pg 119).
  3. Low: “An intensive level of instructor involvement may be necessary where teams show little initiative or respond only superficially” (pg 120).

Summary 

The debrief is described as ” the heart and soul of the simulation”.

Resources

Dismukes, R. K., & Smith, G. M. (2017). Facilitation and debriefing in aviation training and operations. Routledge.

Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125.

Lederman, L. C. (1991, July). Differences that make a difference: Intercultural communication, simulation, and the debriefing process in diverse interaction. In Annual Conference of the International Simulation and Gaming Association, Kyoto, Japan (pp. 15-19).

Petranek, C. (1994). A maturation in experiential learning: Principles of simulation and gaming. Simulation & Gaming25(4), 513-523.

Thatcher, D. C., & Robinson, M. J. (1985). An introduction to games and simulations in education. Hants: Solent Simulations.

Teamwork and team training in the ICU: Where do the similarities with aviation end?

Journal Club Article: Reader, T. W., & Cuthbertson, B. H. (2011). Teamwork and team training in the ICU: Where do the similarities with aviation end?Critical care15(6), 313.

Background

Comparing the lessons learnt and development of team training approaches in the aviation industry to the complex needs of the Intensive Care Unit (ICU). The importance of teamwork and the coordination of behaviours in terms of patient care provided and subsequent outcomes. Higher levels of doctor-nurse collaboration improve safety and mortality rates. The recognised importance of poor communication which has been identified as a factor in medical error.

Team input and team processes = team output

  • Teamwork

“Team skills are important for maintaining safety in both domains, as multidisciplinary teams must work effectively under highly complex, stressful, and uncertain conditions. ”

  • Active & Latent Failures

“team-related ‘active failures’ (for example, failures to communicate the proximity of nearby aircraft) and ‘latent failures’ (for example, lack of team training, poor ergonomic design, and organizational culture) that influence behavior and error in the cockpit.”

  • Decision Making Under Stress

“Techniques include exposing teams to high-stress situations, training pilots to facilitate team discussions before and after stressful team activities, and cross-training aircrew team members to understand the demands and needs of one another’s role. Teams are trained in a multidisciplinary environment…….”

  • Hierarchical Team Structures

The ability to understand other roles, so in stressful events still work together as a team and negative behaviours and attitudes don’t effect performance.

  • Environmental Factors

“Fatigue and stress are known to negatively influence performance in the ICU, and non-technical factors such as team communication, situation awareness, and decision making frequently underlie error.”

Developing a workplace culture based upon safety requires supporting and valuing staff in the high risk environment of ICU, with models of training and supervision that focuses not only on the norms of practice (normative) and educative training, but on restorative and supportive resources to improve stress and burnout, and aid personal development.

Keywords: Intensive Care Unit; Team Performance; Human FactorsTeam Training; Aviation Industry; Cognitive Load; Situation Awareness.

Relevant additional resources around some of the themes identified in this articles to aid collaborative educational teamwork:

 

 

 

The Rise of eSports

eSports 

Moving from the bedroom to filling out stadiums, welcome to eSports. Think this is just a hobby? Think again. With increasing sponsorship and media interest, this a rising sporting extravaganza. Take a read of this great review on the atmosphere and experience attending an eSports event by MishManners.

A little About eSports 

FIFA Interactive World Cup

 

The following is a list of eSports resources and tournaments.

ESPN. (2018). eSports.

FIFA.com (2018). FIFA eWorld Cup 2018.

MishManners. (2018). Australia takes Esports to the Next Level. Hackathon Queen.

Red Bull eSports. (2018). eSports.

Wikipedia. (2018). eSports.

Wikipedia. (2018). Lists of eSports leagues and tournaments.

From the Premier League, Manchester City and West Ham United have signed up an eSports player as member of their squad to represent them in eSports competitions.

 

The Celebrity Millionaires of Competitive Gaming

 

Resus Days

Practice Saving Lives While Playing a Game

Resus Days is a resuscitation game to help healthcare professionals practice some quick-thinking needed for care of cardiopulmonary emergencies. Using gamification to deliver a simulation game for cardiopulmonary resuscitation. Check the below resources, the first level is free to try it out.

The Blurb

Rehearse life-saving decision-making in a fun, game environment. Resus Days is a simulation game for healthcare professionals to practice some quick-thinking needed for care of cardiopulmonary emergencies. You are the team leader in the resuscitation team. Your task is resuscitate the patient until he is back to a normal heart rhythm (normal sinus rhythm). The game includes 7 levels covering cardiac arrest, bradycardia, tachycardia, and simulated megacode. The first level (cardiac arrest) is free to play. If you like it, an in-app purchase will unlock six additional levels.

Keywords: #resuscitology #gamification

The game homepage is: https://resusdays.com

 

 

 

Gaming Addiction: Disorders Due to Addictive Behaviours

As education continues with an increasingly e-learning approach to delivery, its worthwhile to consider some of the precautionary aspects. Gamification and social media may enhance and offer different learning opportunities but the potential to create or exacerbate disorders due to addictive behaviours from gaming addiction, will need to be considered when delivering the e-learning approach and consideration of the well-being of students. Patterns of gaming behaviour when interfering with normal daily activities, and any changes in physical or psychological health will need to be monitored.

World Health Organisation: International Classification of Diseases (ICD)

Disorders due to addictive behaviours from gaming addiction:

“Gaming disorder is defined in the draft 11th Revision of the International Classification of Diseases (ICD-11) as a pattern of gaming behavior (“digital-gaming” or “video-gaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences” (WHO, 2018).

 

Symptoms to monitor:

  • impaired control over gaming (frequency, intensity, duration)
  • increased priority given to gaming
  • continuation or escalation of gaming despite negative consequences

Gamification

Some questions around gaming:

  • Keen gamer or problem with addiction, at what point is too much and does age/maturity need to be factored into the guidelines?
  • How does a sensible mix of connectivity with social media, gaming, work and social time look?
  • The developing technology such as augmented reality (AR), simulation technology and virtual reality (VR). How will they be introduced and controlled?

A quick Google Scholar search using ‘gaming addiction’ shows there are plenty of research papers on this topical subject.

References

Petry, N. M., & O’brien, C. P. (2013). Internet gaming disorder and the DSM‐5Addiction108(7), 1186-1187.

Woodward, A. (2018). The World Health Organization Identifies Gaming Disorder as a Mental Health Condition. Futurism.com

World Health Organisation. (2018). Gaming Disorders.

 

 

 

Simulation Resources To Follow

Simulation is a key component of nursing and healthcare training, and the knowledge base is continually increasing with research publications, conferences, online and social media resources. To aid knowledge translation, the nurse educator needs to embrace a global network of resources not just confined to local knowledge. To keep current on simulation focused research, here are some resources that may help (no conflict of interest to report). As ever please add any suggestions of other resources you know about in the comments section at the bottom of this post and I will update the below resource list.

This post supplements the recent Journals For The Nurse Educator To Follow  and these journals will also include simulation research.

Simulation Focused Journals

Online & Social Media Resources

Clinical Reasoning Cycle

Book Club: Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Clinical Reasoning Cycle

Define reasoning as “the process by which nurses (and other clinicians) collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process”.

“Clinical reasoning is often confused with the terms ‘clinical judgement’, ‘problem solving’, decision making’ and ‘critical thinking’. While in some ways these terms are similar to critical reasoning, clinical reasoning is a cyclical process that often leads to a series or spiral of linked clinical encounters” (pg.4 Levett-Jones, 2013).

Stages of the Clinical Reasoning Cycle

  1. Consider the patient
  2. Collect cues/information
  3. Process information
  4. Identify problems/issues
  5. Establish goals
  6. Take action
  7. Evaluate outcomes
  8. Reflect on process and new learning

Why is this book important?

For nurse training and education delivery, the stages of clinical reasoning can be incorporated into training sessions to discuss the clinical judgments and decision making during a care intervention and applying the ‘nursing process’.  Simulated nursing environments are an ideal educational approach to challenge clinical decision making and clinical reasoning skills. Nurses are the constant presence on the ward level, providing the monitoring and making judgments form the clinical reasoning encounters every shift over a patients hospital journey. Responding to complex and time critical events requires sophisticated abilities which expand further than pure theoretical knowledge, such as assessing and responding to clinical deterioration.

In the current economic drive for cost cutting measures across healthcare (nurses make up the majority of the healthcare workforce, so are often seen as a costly element), the drive to replace with lower skilled, trainees and eventually robots are factors for the nursing profession to consider. Nurses need to be able to understand and explain the role they play and have a voice to raise the profile of what it entails to be a nurse and the efficacy of such skills to maintain levels of care and safety.

Summary

Thinking on the go and decision making are skills to develop over time and with experience but need to be incorporated into nurse training. Nurses with effective clinical reasoning skills have a positive impact on patient outcomes (School of Nursing and Midwifery Faculty of Health, 2009). It’s important to remember, during all this consideration of the patient and reflective process that you (the nurse) are human and as such wont get everything correct all the time.

References

Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Alfaro-LeFevre, R. (2015). Critical Thinking, Clinical Reasoning, and Clinical Judgment E-Book: A Practical Approach. Elsevier Health Sciences.

Interprofessional Ambulatory Care Unit. Clinical Reasoning User Manual. Edith Cowan University.

School of Nursing and Midwifery Faculty of Health (2009) Clinical Reasoning Instructor Resources. University of Newcastle.

Peyton’s 4 Step Approach for Skills Teaching

We have all either delivered or been on the end of a “see one, do one” or “do one, teach one” approach to learning, often delivered in simulation with the aim for skill development. But maybe we should add another two-steps into the approach and follow Peyton’s four-step method. To aid the processing of information (learning) and then apply this new knowledge in context (situational awareness) the four-stage technique can be utilised.

Peyton’s Four-Step Approach: 

1. “The teacher demonstrates the skill at his normal pace without any comments (Demonstration)

2. The teacher repeats the procedure, this time describing all necessary sub-steps (Deconstruction)

3. The student has to explain each sub-step while the teacher follows the student’s instructions (Comprehension)

4. The student performs the complete skill himself on his own (Performance)” (Nikendei et al, 2014).

There are clearly defined instructional steps to guide educator and student. Provides small group or a 1:1 teacher:student ratio for successful instructional training in skills learning sims.

Keywords: Simulation; skills labs; 4-step; experiential learning; technical skills.

References

Bullock, I., Davis, M., Lockey, A., & Mackway-Jones, K. (Eds.). (2015). Pocket Guide to Teaching for Clinical Instructors. John Wiley & Sons.

International Clinician Educators (ICE) Blog. (2017). Effective teaching of technical skills requires more than see one do one. KeyLime podcast No. 142. ICE blog.

Münster, T., Stosch, C., Hindrichs, N., Franklin, J., & Matthes, J. (2016). Peyton’s 4-Steps-Approach in comparison: Medium-term effects on learning external chest compression–a pilot studyGMS journal for medical education33(4).

Nikendei, C., Huber, J., Stiepak, J., Huhn, D., Lauter, J., Herzog, W., … & Krautter, M. (2014). Modification of Peyton’s four-step approach for small group teaching–a descriptive study. BMC medical education14(1), 68.

Walker, M., & Peyton, J. W. R. (1998). Teaching in theatre. Teaching and learning in medical practice. Rickmansworth, UK: Manticore Europe Limited, 171-180.

Wang, T. S., Schwartz, J. L., Karimipour, D. J., Orringer, J. S., Hamilton, T., & Johnson, T. M. (2004). An Education Theory–Based Method to Teach a Procedural Skill. Archives of dermatology140(11), 1357-1361.

 

 

The Stress Curve (Yerkes and Dodson Law)

Background History

“Yerkes-Dodson law from 1908 to the present. In its original form, the law was intended to describe the relation between stimulus strength and habit-formation for tasks varying in discrimination difficultness. But later generations of investigations and textbook authors have rendered it variously as the effects of punishment, reward, motivation, drive, arousal, anxiety, tension or stress upon learning, performance, problem-solving, coping or memory; while the task variable has been commonly referred to as difficulty, complexity or novelty, when it is not omitted altogether” (Teigen, 1994).

Stress Curve By Yerkes and Dodson 1908

OriginalYerkesDodson

Pressure & Performance

There are four main influencers related to pressure and performance:

  1. Skill Level.
  2. Personality.
  3. Trait Anxiety.
  4. Task Complexity.

The perception of stress from the individual can trigger the innate fight or flight response.

For The Educator

  • Remember stress can be both a negative and positive experience. This stress theory can link to ’emotional intelligence’ of the individual, well-being and potential for burnout.
  • Simulation sessions can be set up to challenge the learner along the stress curve. The educator must be aware of how they can positively or negatively influence the learners experience.
  • The environment can also impact on stress and perceived threats (culture, unsafe workplace such as violence).
  • For the educator. the question when to challenge the learner and when to step back is very difficult and will require regular review and feedback from the learner and the wider nursing team. Its good to provide a challenge, with the required supports but dropping the learner into an unsupported situation may backfire and effect confidence. Also learners (nurses) are people and have personal lives and so sometimes private life issues means the level of stress the person is experiencing renders learning negligible. This is the time to step off the learning curve, give an extension and put supports in place and to regroup at an appropriate time. Provide a personal approach to learning, not one fitted around traditional university semester timetables.

Keywords: Resilience, mindfulness, stress curve; burnout; Yerkes and Dodson Law.

References

Gibbons, C., Dempster, M., & Moutray, M. (2008). Stress and eustress in nursing students. Journal of Advanced Nursing, 61(3), 282-290.

Intensive (2017) Training for Stress.

Selye, H. (1956). The stress of life.

Teigen, K. H. (1994). Yerkes-Dodson: A law for all seasons. Theory & Psychology, 4(4), 525-547.

Watson, R., Gardiner, E., Hogston, R., Gibson, H., Stimpson, A., Wrate, R., & Deary, I. (2009). A longitudinal study of stress and psychological distress in nurses and nursing students. Journal of Clinical Nursing, 18(2), 270-278.

Wikipedia (2017) Yerkes-Dodson Law.