My two cents on starting simulation program in a developing nation with limited resources.

Author: Asit Misra, MD, MEM

"My journey of healthcare simulation started on 20th October 2013 during “The International Emergency Medicine Teaching Course” at University of Maryland, Baltimore. During this course, I got formally introduced to the world of simulation-based education. After this short 1week faculty development course, I flew back to India thinking about how should I introduce simulation-based education in India at my institution during my 14-hour nonstop flight from New York to New Delhi. I was the new kid on the block having no idea of resources, money, technique, technology, space, and manpower requirement to start a simulation program. But I had a strong belief that it was not an impossible task.  One thing that I also learned from the teaching course was developing a niche in our career from Prof. Amal Mattu (one of the greatest Emergency Medicine teacher of this era) and his most important pearl was that “one should start working early and consistently towards developing a niche in his/her career”. I now know what my niche is going to be and that was Simulation in Healthcare Education.

I want to share the barriers and possible solutions one can face to start simulation program in a developing country by sharing the tips, which came across from my experience in the development of a 10000sqft Simulation Center in Northern India:

1) Believe in yourself: The first person you need to convince to start simulation is yourself. You need to believe that this is achievable and you can do it.

2) Figure out why you need simulation in your institution?

Perform a needs analysis and find out the areas of concern although you must understand simulation is not a solution for each and every problem you may come up with. Some examples for use of simulation are to improve learning outcomes, patient care outcomes, clinical error reduction, to improve system-based practice, assessment of team performance and team dynamics etc.

3) Identify the correct decision maker: The next person you need to convince is your Dean / Head of Education. Prepare a plan with achievable goals and objectives to present the concept before them.

4) Get your hands dirty: Get yourself involved to learn more about simulation, invest in your career and attend the short (week-long simulation faculty development workshops), read articles, books, listen to Simulation Podcast, become a member of Simulation Society. As quoted by Albert Einstein “You have to learn the rules of the game, and then you have to play better than anyone else.”

5) Make a team of like-minded people:  “If you want to go fast you may go alone but if you want to go further then you need to go together” by Prof. Michael Gordon (inventor of Harvey). You need to collaborate with those who want to participate in your project. You will need people to utilize the simulation-based education; as well you need people to teach. It also helps you to solve the manpower issues in the early phase of your simulation program.

6) Accept whatever space is allotted: Initially, it is wise to start in any place offered to start the simulation program. You can even start in-situ simulation if there is no space offered for the simulation.

7) Find out which modality of simulation suits your requirement: You can start simulation even by using standardized patients as well using the low-cost task trainers and low fidelity simulation). An all-inclusive approach is a good start and it helps to build your case. Do not overlook the training requirement for physicians, nurses, techs, students and other key departments of the hospital/institution (front office, security, etc.)

8) Connect with experts who are already working in the field of simulation in your region or abroad. Take some tips from them making the simulation curriculum and in simulation-based research.

9) Start slow and steady and then expand: Utilize the funds with caution while buying the simulation equipment. Show the utility of the simulation program in healthcare Education"

Living in All the Places No One Wants to Go

Author: Matthew David Charnetski, MSMS

I grew up in a small town in rural Iowa.  Attending undergraduate and thinking I wanted to become a physician; I was distracted by the rest of the planet.  Touching on each of the 7 continents, the sum total of my experiences (personally and professionally) took me from Antarctica to Kazakhstan.  Iowa, around the world three times and landing most recently in Northeast Arkansas as the Director of Simulation Learning.  From medicine to IT, simulation to education; decades of collected experiences created my simulation career as a simulation specialist, simulation educator, and program and curriculum director.

The Best Career I Never Wanted

Author: Melinda Ann Armstrong, RN, MSN, CHSE

Earning my MSN and becoming the lead faculty for a nursing fundamentals course in 2005 was the highlight of my career, or so I thought. I knew I wanted to teach nursing, while I was still a nursing student. After earning a BA in Business Administration and a successful ten year career in the banking industry, I chose to return to school earning my Diploma in Nursing, my BSN, and finally my MSN. I left a Neonatal Intensive Care Nursery to join the faculty at the school where I earned my nursing diploma, teaching with some of my greatest nursing heroes and mentors.

In 2006 I was approached by the Dean of Nursing, who asked me if I’d like to explore creating a nursing simulation lab at our school. Happily putting the “fun” in nursing fundamentals, I declined. This scenario repeated itself twice, before the Dean’s inquiry became a directive and I was informed that I would, indeed, be joining him on his exploration into the world of healthcare simulation. Knowing nothing about this modality, I began reading, studying, and visiting simulation labs and product vendors. Still a little skeptical, I told myself this was just a “Dean-directed project” and not my career trajectory. After assisting the Dean with grant writing and partnering with the neighboring hospital, a patient simulation lab was designed, built, and opened. I was named the Simulation Lab Coordinator, while continuing to act as lead faculty for my beloved nursing fundamentals course. Eventually I began to think of this lab as “my” lab and the simulators as “my” patients. I was even named a “METI Sim Mentor” by one of the major equipment vendors. We grew, adding simulation sessions for both the school and the hospital. I added staff and equipment and space. I eventually bid farewell to nursing fundamentals and was promoted to “Director of Nursing Labs”.

As I reflect upon my now over 10 years of healthcare simulation education experience I smile when I remember how adamant I was when telling my Dean I wanted no part of the wonderful world of simulation. How very fortunate I am that he could see the “closet simulationist” living inside me and pushed me headlong into this career. I have enjoyed attending conferences, giving presentations, and mentoring others in this field. In 2012 I earned my Certified Healthcare Simulation Educator designation and continue to hold it as one of my greatest accomplishments. I’ve worked in simulation labs in academic institutions and hospital systems in two different states and networked with countless individuals from around the world. I joke that “all my patients are plastic, and I like it that way”, but actually that is really close to the truth! I have been richly blessed and am thankful the best career I never wanted.

Creating A Real Disaster On A Budget

Author: Ms. Keondra Rustan, MSN, RN

This story details an experience that I had doing a disaster drill of a bomb threat using the criminal justice department, local fire department, and nursing department. It had the premise of a bomb being sent to an employee at a corporate office and being set off. The fire department helps in the rescue of the individuals at the site, the criminal justice department was to investigate the scene for the culprits, and finally, the nursing department was to triage and treat the victims.

I was first approached of this problem by the director of the criminal justice department. It was short notice and we did not have the budget for supplies. I had been experimenting with things that I found online with gelatin and decided that I was able to tackle the challenge. I moulaged approximately 10 humans and 3 manikins on a budget of $20. I was able to simulate the smell of blood by boiling rusty nails in food colored water with corn syrup. We overturned desks and made the rooms look messy and had people lay under and around the debris to be rescued and we had the nurses (nursing students) set up a disaster tent outside to triage the victims and get them treated appropriately. It was a great learning experience for everyone. All parties enjoyed it and the debrief afterwards was very thorough. Each department met their learning objectives.

Where There’s a Will, There’s a Way – Custom-Building of A/V Systems to Deliver High Fidelity Manikin-Based Simulation on Site

Author: Ms. Bronwyn Reid McDermott

Healthcare simulation is at an early stage of development in Ireland with many Universities and training programmes yet to incorporate Simulation Based Education (SBE) into their curricula. Most Hospitals and Universities do not have dedicated simulation facilities. Furthermore, the availability of simulation technicians with Audio/Visual (A/V) experience and skills is non-existent and dedicated funding for SBE is not available. The Irish Centre for Applied Patient Safety and Simulation (ICAPSS) is a unique simulation centre located within a large teaching hospital and providing SBE to all healthcare students and professionals. The Centre is on the grounds of University Hospital Galway (UHG) in a 1930s Art Deco building which was formerly a nurses’ home and is listed on the National Inventory of Architectural Heritage.

In 2015, a portion of the upper floor of this building was renovated to cater for an emerging demand for SBE. The initial repurposing of this building posed a number of challenges. A combination of structural and resource limitations led to the development and installation of a custom A/V system, allowing the centre to deliver Hi Fidelity Manikin Based simulation to both undergraduate and postgraduate learners. An iterative approach is used to refine and develop this system as the centre and technology evolves and as the ICAPSS team gain an improved understanding of learner needs and technological advances.

Following a recent “Paediatric Drills” session delivered by ICAPSS and the paediatric team at UHG, staff at the centre were asked to deliver a similar session at Temple Street Children's University Hospital (CUH). This is an acute national paediatric hospital located in Dublin, Ireland, that cares for more than 150,000 children per year. Paediatric SBE in particular, is in its infancy in Ireland. A small number of training hospitals deliver low fidelity SBE on an ad-hoc basis, driven by trainers with international experience. However, there is increasing interest in paediatric simulation in Ireland, amongst both pediatric trainers and trainees. The planned opening of a state of the art National Children’s Hospital in Dublin in 2020 has accelerated the interest in paediatric SBE which is now seen as a “must have” in any modern healthcare facility.

CUH has no dedicated simulation facilities and it was proposed that the simulation take place in an empty ward which was due to be refurbished over the coming months. The hospital itself is a Victorian Building, the former mansion of the Earl of Bellomont, which was repurposed as an infirmary in the mid-1800s. Similar to UHG, there were both structural challenges and limited financial resources. An initial assessment of the site was carried out by ICAPSS staff to determine the feasibility of delivering a high-fidelity simulation session. Over a number of weeks, the ICAPSS custom A/V system was adapted to facilitate for mobile simulation. The lessons and skills learned by the ICAPSS A/V technician during our own refurbishment and continuous upgrading were fundamental to the success of this project. The empty ward was adapted to allow a patient room to host the simulator and the adjoining the nurses’ station to perform as a control room. A large patient room was converted for feedback and debriefing with projection of a live A/V feed. The cost of this adaptation was approximately $80.00.      

A total of 13 trainees participated in the paediatric drills day in CUH. Post training day evaluations showed that 100% of trainees agreed or strongly agreed the training was relevant to their stage of learning, would impact positively on their future clinical practice and that more of this type of training is required.

An increasing demand for SBE in Ireland where SBE is in its infancy and under resourced, requires novel and unique solutions. These examples demonstrate the specialist skills required of A/V technicians and how perseverance, commitment and innovation.

https://www.dropbox.com/s/1fmy7upp46zf84r/Short%20clip.mp4?dl=0

From Content Expert to Novice Educator: The First Year Learning Cliff

Author: Narcy Maneja Foraker

My life has been filled with "happy accidents". I received my Master's in Nursing Education through OHSU in June of 2017, signed a full-time year long faculty contract to teach in simulation. This was everything I wanted and had no idea what this world had in store for me.

I learned one-way of simulation. Simulation is suppose to be like this... or so I thought. The current lead simulation faculty member and I were left trying to put a fractured model together when we had no idea what we were looking at. Before I knew it three months later and my lead faculty member was turning in their resignation and I was now, by default, the new lead.

Currently, I am still "repelling" off of my learning cliff. Thankfully, I found a strong anchor and belay to help me on my descent and my story will reveal what I have learned and will continue to learn.

A Non-Clinician in a Clinical World: A Journey into Healthcare Simulation

Author: Kati Maxkenzie, Masters of Science in Healthcare Simulation, BFA

"I never knew what I wanted to do when I grew up. The only inclination I had ever had was maybe to be a paramedic or a drama teacher. Neither of these were serious thoughts just something I thought I might like. When it can to school, I was involved in everything except the academic work. I was part of every club, you could rarely find me in class but you would easily find me teching the drama productions or organizing a fundraiser. So when it came to applying for university, I wasn’t interested. So while all my friends went off to higher education, I stayed working my job in retail and dabbled in assisting local theatre groups.

Within a year, I was traveling the world, still not knowing what I wanted to do when I grew up. After living abroad, working in retail and theatre, I decided it was time I bit the bullet and committed to a career. So off I went to university to get my Bachelor of Fine Arts Degree with a Major in Drama and a Minor in Education. A Drama Teacher I would be. Or so I thought.

By the end of my degree, I had many years of retail management experience and I had founded a successful community theatre group. I was all ready to pursue a career as a Drama Educator when something unexpected happened. I fell in love with an American. So before long I found myself living in California.

Once here, it wasn’t long before I stumbled across someone who was in involved in this thing called simulation. When they started talking about this thing called simulation, I would smile and nod having no clue what they were talking about. Then one Sunday evening, I received a phone call from them declaring that they “had found a career for me”. They encouraged me to attend this thing called ‘IMSH’ that was in San Francisco that week. So clueless, off I went.

I will never forget the moment she took me over to the vendor hall and asked for a demonstration. Next thing I knew, I was catching a baby that was being birthed out of a robot. It was the single most weirdest and coolest moment of my life. I was sold; I finally knew what I wanted to be when I grew up, a simulationist.

I had a rich history in operations, education, and technology but on my resume there was no through-line to link these skills. So simulation became that through line. I pursued my Masters in Healthcare Simulation and applied for every entry-level job I could.

Just after my 2nd IMSH, I had landed a job as a sole Simulation Specialist working 0.8 FTE at a hospital-based center. By my 3rd IMSH, I had written the business case to become 1.0FTE and by my 4th IMSH, I had created enough business to have justified a full-time Sim Tech and been promoted to Simulation Center Manager. Having just attended my 5th IMSH, I have just transitioned to managing a brand new hospital-based center in Oakland, CA, obtained my CHSOS, have presented at several local and international conferences, and have encouraged other non-clinicians to either become or grow as simulationists.

I would say, hands down, my biggest hurdle that I have had to overcome has been being a non-clinician in healthcare. First when I interview with clinicians, they are often extremely hesitant with my non-healthcare background. Even now, after 3 years working experience and a Masters, that hesitation can surface. However, I would also say this is also one of my biggest strength. I am able to come at problems in a way that clinicians have never considered. I find once they are able to see that I understand their world and that I am working to better it, that they are extremely willing to partner. As I like to say, they are the experts in their field of healthcare and my expertise is the methodology of simulation. I have found my passion in healthcare simulation where it takes my experience of operations, hands-on learning, and technology and puts it into action to help create a safer environment in healthcare. I love the community is from all walks of life and is willing to share their journey to help someone"

Simulation: Inventing my own success

Author: Ms Nanci Barone, MSN, RN

My success in simulation education began on June 2, 2010. While driving home from work that Wednesday evening and 2 blocks from my house my career changed forever because of a careless driver. My car was struck, the airbags deployed, and my right arm shattered. As an operating room nurse I knew as soon as I looked down at my right arm that this was not good. My shattered arm required a surgical procedure to repair the damage leaving me with 2 plates and 14 screws in my right forearm. Initially I thought I would be able to return to work in the 6-8 weeks that it would take for the bones to heal, unfortunately that was not the case. I spent many months in physical therapy trying to get my right hand to work again. After 6 months in physical therapy I realized that I would not be able to return to my much-loved career as an operating room nurse.

Nursing offers so many opportunities so when I was unable to return to the operating room I knew this would be a time for me to recreate my nursing career. Instead of thinking of this as a barrier I thought about nursing and asked myself what I most liked about being a nurse. Was it caring for patient’s? Was it working with a team of other healthcare professionals? Was it sharing my knowledge with all of the students I came into contact with while working? It was challenging to pick one thing, but I knew as a nurse I loved teaching, so I decided that the best option for me would be to return to school for a master’s degree in nursing education. While attending Villanova University I was introduced to a new concept, something I had never heard of before, simulation. Immediately I realized what a powerful tool simulation was and made it my goal to learn as much as I could from that point forward.

As graduation approached I was able to start work as a simulation facilitator at Widener University. During this time, I sought out opportunities to expand my knowledge of simulation. I joined the Philadelphia area Simulation Consortium and attended their annual meetings. Through this organization I was able to learn from other simulationists and expand my knowledge. While working as an adjunct clinical instructor at The University of Pennsylvania, Temple University, Neumann University and Widener University I started incorporating simulation into my teaching.  I attended local conferences that focused on interprofessional simulation activities. All of this experience led me to my current position; Director for Simulation and Clinical Skills at Thomas Jefferson University, College of Nursing. During my initial interview my membership in The Philadelphia Area Simulation Consortium stood out as a positive attribute. I started to realize all of my hard work and dedication may provide me with the opportunity to work in my dream job.

My teaching dream did come true I joined the faculty at Thomas Jefferson University College of Nursing in June 2016, 6 years after the car accident that changed my life. Since joining the faculty I have attended IMSH twice, the second time I was selected as a presenter in a rapid-fire session. I have been selected to share my work on simulation in our nursing foundations class as a podium presenter at the annual Philadelphia area Simulation Consortium meeting. I have also been selected to present that work at the 2018 QSEN conference.

Let Your Goals Be Greater Than Your Considerations

Author: Brennan Snow

"I started working at B-Line Medical in early 2008 and right away the company mission struck a chord with me, but it wasn't until late 2012 where I found an opportunity to make a difference on a much larger scale than had been present initially.

Late in 2012 I arrived in the office for a company meeting. Typically, these meetings included general information to be disseminated to the group at large concerning internal company matters. This particular day, we had a guest speaker; Dr. Meaney, who had come to thank us for providing critical equipment for a pilot program he developed: The Saving Children’s Lives Program.

During his presentation, I learned that a large portion of the infant mortality he’d traced was not caused by lack of funding, but instead due to a failure to treat preventable causes of death. Through his program, the cost of training a BLS/PALS/PEARS trained healthcare worker, which he refers to as a “lifesaver”, totaled a mere $75.00!

This made an impression on me, as it seemed like a mechanism to create a huge and lasting impact. After all, how many patients does a single nurse or ”lifesaver” care for during their career, and how many could we create at such a low cost if we tried?

At that time I was in a band that was pretty active in our area. I texted my bandmates to ask when they could meet up. When we met, I told them all about the SCL Program and mission, and we decided as a group to host a concert to raise money for the cause.

We spent the next few weeks reaching out to musicians willing to donate their talent, and a venue kind enough to donate space. The newly formed B-Line Medical Charitable Fund matched 100% of what we raised, and everything raised was given to the SCL Program. That first year we raised over $5,100, thus sponsoring the training of over 68 “lifesavers”!

I kept in touch with Dr. Meaney after the event, and learned that “of [the initial] participants in the pilot program, 40% attempted life-saving interventions once a month, but only 28% ever had training.” Further, he noted, “targeting effective management of acute illness (i.e. pneumonia and diarrhea) in resource limited settings could save millions of children’s’ lives each year.”

In spite of identifying the need effectively, we were facing funding challenges.  While the program appeared to be addressing the proficiencies necessary to reduce those specific mortality statistics, we were not receiving the in-country governmental support sufficient to continue or expand our efforts. This was indeed a problem, as bureaucracy can move slowly (and often does), and immediate action was needed to keep this program going.

Working near the Embassy of Botswana in DC, I took the opportunity to request an audience with the Ambassador. Upon my arrival, and subsequent to the funny looks I received when making my request, I explained that I and did not want anything. After a thorough checking of my references, I assured my audience that the program was doing great work, and that if it did not receive greater support soon, then it would cease to exist. They listened, analyzed me and the proposal, and said they’d speak with the Ambassador. Finally, a breakthrough!

A few weeks later, I was able to get Dr. Meaney into the Ambassador’s office, at which point the Ambassador asked Dr. Meaney, “Ok, what’s on your wishlist”? Shortly after, the program received the greater support we’d been hoping for and Dr. Meaney was given access to the entire Kweneng district, and was tasked with training all of the healthcare workers in that district in BLS/PALS/PEARS.

We hosted another Music In Action concert later in 2015. Again with the bands donating their time, the venue donating their space, and volunteers assisting in any way possible, we raised $12,000, and created another 60 “lifesavers”! At this point, of the 200+ program participants, 128 had been sponsored by the Music In Action benefit concerts.