simulation and skills training: a new way to teach and … · 2018-04-24 · 4/17/2018 3 mnhpc 28th...

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MNHPC 28th Annual Conference | April 8-10, 2018 www.mnhpcconference.org

Simulation and Skills Training: A New Way to Teach and Practice

“High-Stakes” End of Life Skills

Naomi Goloff, MD FAAP, Anne Woll, MS, Erik Norbie

University of Minnesota


All planners, presenters, and authors have disclosed relevant relationships with commercial interests and have no conflicts of interest to report… but wish that they did.

Disclosures


1) Understand how simulation and skills-based training can be applied to teaching end of life (EOL) care

2) Identify 1-2 opportunities to use simulation and skills-based training for your learners

Objectives

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Who has experience with simulations (aside from BLS, ACLS, etc)?

Who has participated in a simulation focused on EOL care?

Questions ...


Training for End of Life Care


Despite a need for practice and competency in pediatric EOL care, there is a lack of:

• Recognition of technical complexity of EOL care skills

• Formal Training

• Opportunities to practice and receive feedback

• Training with colleagues and other care providers

• Criteria to assess level of competency

The Need

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Participant Characteristics

Number (n=17) of participants that have:

Participated in an end-of-life discussion with a pediatric patient and/or family of a pediatric patient.

17 (100%)

Led an end-of-life discussion with a pediatric patient and/or family of a pediatric patient.

12 (70.6%)

Participated in an extubation at end of life with a pediatric patient.

14 (82.4%)

Led an extubation at end of life with a pediatric patient. 10 (58.8%)


Participant Characteristics

N=17 Don’t know

None A little Some A great

deal

I have had good modeling from attendings on how to provide end of life care.

3 (17.7%)

14 (82.4%)

I have had specific training (i.e., formal teaching or observation) in providing end of life care.

1 (5.9%) 5 (29.4%) 9 (52.9%) 2 (11.8%)

I have had training (i.e., formal teaching or observation) in responding to patients' and families' psychosocial needs.

6 (35.3%) 8 (47.1%) 3 (17.7%)


Examples of EOL care skills

The Need

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Examples of EOL care skills

• Medication dosing and escalation

• Anticipatory guidance

• Withdrawal of life sustaining treatment

• Communication techniques

• Navigating care decisions and disagreements

• EOL ethics

• And...

The Need

0 2 4 6 8 10 12 14 16

Strongly Agree

Agree

Disagree

Strongly Disagree

Don't Know

I feel confident about my ability to lead a

conversation about a terminal prognosis.

I feel confident about my ability to prepare a

patient's family for end of life decisions.

I feel confident about my ability to make

collaborative decisions about withdrawal of life-sustaining treatment.

I feel confident about my ability to address difficult

questions (e.g., pain, process of dying, etc.)honestly and compassionately.

I feel confident about my ability to give

anticipatory guidance about end of life.

I feel confident about my ability to order

medications for an extubation at end of life.

I feel confident about my ability to manage

symptoms during an extubation at end of life.

Overall, I feel confident about my ability to provide

end of life care to patients.

Self-Reported Confidence (Pre Workshop)


EOL care not always specified in guidelines for physician training (ACGME, AAP) e.g. Neonatology EPA

Yet EOL skills are necessary in Neonatal Intensive Care Unit (NICU)

In 2016-2017, our hospital had 259 total deaths, 114 of which were infants (44%).

Current Guidelines

Neonatology EPA (AAP)

https://www.abp.org/subspecialty-epas#Neonatology

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Of the EOL “skill training” that does happen, it typically occurs in lectures and at the bedside

• Lectures have limitations (similar to resuscitation training)

• Bedside experiences may be infrequent and limited to observation

• Is this really skill training?

Traditional Training


I was never taught how to perform a compassionate extubation. My attending just sent me in and told me that I would be fine. I spent weeks afterward dreaming of this, and wondering if I had done a good job.

- pediatric ICU fellow

“ ”


My husband and I wondered why they gave us so much time ‘memory making’ with our daughter before she went to surgery. We did not understand that we were preparing for the end of her life.

- parent

“ ”

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Zoya Palliative Care Memorial Fund

As a physician, I know how much time we spent practicing resuscitation. But we do not practice care at EOL. How much better care would be if we did. We want to help make that happen with this fund.

-parent/physician

“

”


A New Approach to End of Life Training


• Could a simulation-based workshop provide effective training and practice for “high-stakes” EOL skills?

• What would this workshop involve?

• How will we know if it is effective?

The Genesis

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• Provide instruction to fellows using a skills-based workshop to practice EOL care

• Provide an immersive experience for fellows to practice integrating EOL skills

• Bring together a diverse learning community around EOL care

• Pilot an educational experience to inform future EOL care training

Project Goals


A University of Minnesota partnership to co-create an educational experience between:

• Clinical Experts in Pediatrics and Palliative Care

– Physicians (NICU, PICU, Heme Onc, Palliative Care)

– Nurse Practitioners (Palliative Care)

– Registered Nurses (PICU, Palliative Care)

– Social Work

• Parent Advisors

• IERC and AHC Simulation Center

Collaboration


Our team of simulation professionals:

• Provides resources for clinical skills education, simulations, and interprofessional education

• Serves learners in programs across the Academic Health Center and the surrounding professional healthcare workforce

• Supports the spectrum of simulation modalities: standardized patients (SPs), full-body mannequins, task trainers, and hybrid simulation

IERC and AHC Simulation Center at the U of M

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Delivery of terminal diagnosis in adults

• Internal Medicine Residents

• Heme Onc Fellows (Regions)

EOL Skills Training Using Simulation

EOL (adult) planning discussions

• Surgery Residents

• Palliative Care Faculty/Preceptors

• Global Health Program

• Rural Physician Associate Program (MS3)

Communication skills training at the University of Minnesota:


Why Simulation Makes Sense


“A strategy in which a particular set of conditions are created or replicated to resemble authentic situations that are possible in real life…to promote, improve, or validate a participant’s performance.”

What is simulation?

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• Simulation is an active learning process

– Experience real emotions and learner engagement

– Practice higher-order skills—beyond just ‘doing’

– EOL care requires nuanced skills uniquely applied to each situation (i.e. creating)

Skill Development through Simulation Creating

Evaluating

Analyzing

Applying

Understanding

Remembering

Bloom’s Taxonomy, Revised Anderson, L. (2001)


“An expert is a person who has made all the mistakes that can be made in a very narrow field.”

Neils Bohr

Simulation: A Safe Place for Mistakes


Types of skills

• Frequency/risk:

– Commonly occurring challenges

– High-risk / low-incidence situations

• Level:

– Basic skills

– Advanced, highly-nuanced skills

When to use Simulation

Objectives

• Teaching:

– Introduce skills

– Practice and develop skills

• Assessment:

– Assess skill proficiency

– Demonstrate competency

• Scholarship:

– Share work

– Develop protocols or best practices

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Simulation allows you to create the educational opportunity needed:

• Isolating skills (e.g. dosing for symptom management, extubation at EOL)

– New skills—gain comfort, experience success

– Familiar skills—repeated practice helps develop expertise (Ericsson, 2004)

• Integrating skills (e.g. EOL family conference)

– Reflects the demands of professional practice

– The challenge is greater than the sum of its parts

Deliberate Design


Debriefing is key:

• Allows trainees to reflect on their performance

• Reveals thought processes (or ‘frames’)

– Reinforce effective frames

– Develop alternative mental models

– Change future actions and results

• Debriefing is the reason for the simulation

Changing Future Performance

Frames Actions Results

Debriefing leads to new frames

Debriefing changes later actions

Rudolph, JW, et al. (2007)


Workshop Design

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Workshop At-A-Glance

40 minutes 35 minutes 35 minutes 35 minutes 35 minutes 40 minutes

Group 1

Pre-briefing

Bedside Consult

Family Conference

Skills Station

Debriefing

Group 2 Family Conference Bedside Consult

Group 3

Skills Station

Bedside Consult

Family Conference

Group 4 Family Conference Bedside Consult


• Case Series

• Facilitated by faculty

• Standardized RN

Skills Station


Bedside Consult

Immersive Scenarios

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• “What will happen if we keep Russell like this, asleep and on the breathing machine?”

• “Are we giving up on him?”

• “How long will he live for after the ventilator is off?”

• “Will he be in pain?”

Examples of Question Prompts


Family Conference

Immersive Scenarios


• “How do people make this decision? If we stop dialysis or chemo aren’t we causing her death?”

• “I’m worried I’ll regret making this decision.”

• “There are so many tubes…how can we possibly do this at home?”

• “If we stop dialysis, how long will she have?”

Examples of Question Prompts

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What We Learned


Confidence Survey

0 2 4 6 8 10 12 14 16 0 2 4 6 8 10 12 14 16

Don’t Know

Strongly Disagree

Disagree

Agree

Strongly Agree

Pre Workshop Post Workshop

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• Fellows recognized the need for and were appreciative of this workshop and continued practice

• Differing perceptions of patient-centered care between fellows and SPs / Observers (e.g. menu of care options)

• Challenges of finding language

• Gaps in knowledge (e.g. Hospice)

• Impact of workshop order (skills station vs. immersive simulations)

Workshop Impact: Themes


• Refresher workshops for repeated practice and to prevent skill decay

• Sessions to address knowledge gaps

– Hospice Information

– “Everything you ever wanted to ask a parent”

• Adding interprofessional partners for subsequent iterations

• Study the impact

Next Steps


EOL Simulation-Based Training at Your

Organization

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• Identify resources

– Collaboration partners

– Local simulation resources

– ASPE, SSH

• Variations on a theme

• Fidelity

Strategies for Broader Implementation


What are ways you can adapt / modify this kind of workshop for your organization?

Reflection


It dawned on me... It is an honor to give someone the ‘right’ death the same way it is a privilege to give someone a ‘right’ birth.

- Bedside RN speaking about first experience with longtime patient who had died

“ ”

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?

Questions


Anderson, L. W., Krathwohl, D. R., Airasian, P., Cruikshank, K., Mayer, R., Pintrich, P., ... & Wittrock, M. (2001). A taxonomy for learning, teaching and assessing: A revision of Bloom’s taxonomy. New York. Longman Publishing. Artz, AF, & Armour-Thomas, E.(1992). Development of a cognitive-metacognitive framework for protocol analysis of mathematical problem solving in small groups. Cognition and Instruction, 9(2), 137-175.

Brock, K. E., H. J. Cohen, B. M. Sourkes, J. J. Good and L. P. Halamek (2017). "Training Pediatric Fellows in Palliative Care: A Pilot Comparison of Simulation Training and Didactic Education." J Palliat Med 20(10): 1074-1084.

El Sayed, M. F., M. Chan, M. McAllister and J. Hellmann (2013). "End-of-life care in Toronto neonatal intensive care units: challenges for physician trainees." Arch Dis Child Fetal Neonatal Ed 98(6): F528-533.

Ericsson, K. A. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine, 79(10), S70-S81.

Gillan, P. C., S. Jeong and P. J. van der Riet (2014). "End of life care simulation: a review of the literature." Nurse Educ Today 34(5): 766-774.

References


Henner, N. and R. D. Boss (2017). "Neonatologist training in communication and palliative care." Semin Perinatol 41(2): 106-110.

Hope, A. A., S. J. Hsieh, J. M. Howes, A. B. Keene, J. A. Fausto, P. A. Pinto and M. N. Gong (2015). "Let's Talk Critical. Development and Evaluation of a Communication Skills Training Program for Critical Care Fellows." Ann Am Thorac Soc 12(4): 505-511.

Lamba, S., L. S. Tyrie, S. Bryczkowski and R. Nagurka (2016). "Teaching Surgery Residents the Skills to Communicate Difficult News to Patient and Family Members: A Literature Review." J Palliat Med 19(1): 101-107.

Lu, A., D. Mohan, S. C. Alexander, C. Mescher and A. E. Barnato (2015). "The Language of End-of-Life Decision Making: A Simulation Study." J Palliat Med 18(9): 740-746.

Meyer, E. C., M. D. Ritholz, J. P. Burns and R. D. Truog (2006). "Improving the quality of end-of-life care in the pediatric intensive care unit: parents' priorities and recommendations." Pediatrics 117(3): 649-657.

Rudolph, J. W., Simon, R., Rivard, P., Dufresne, R. L., & Raemer, D. B. (2007). Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology clinics, 25(2), 361-376.

References

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Naomi Goloff

[email protected]

Anne Woll Erik Norbie

https://www.simulation.umn.edu/

simulation and skills training: a new way to teach and … · 2018-04-24 · 4/17/2018 3 mnhpc 28th...

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