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informatics innovations
expanding
simulation
adventures in simulation-based health
professional education in Northern Ontario
Parry Sound, January, 2010 - Mathieu Seguin
informatics innovations
expanding
simulation
adventures in simulation-based health
professional education in Northern Ontario
Editors: Rachel H. Ellaway, David Topps
Northern Ontario School of Medicine
Contributors: Jacques Abourbih, Sue Berry, Susan James,
Chris Kupsh, Suzanne Lortie Carlyle, Karen Paquette,
Robert Rubeck and Roger Strasser
This work was funded by the Planning Simulation for Multi-professional Assessment Project
and the NOSM Informatics Research and Development Group (NIRD)
Photography: Mathieu Seguin, Rachel Ellaway, David Topps, Susan James; other sources annotated
© Northern Ontario School of Medicine, 2010, all rights reserved
table of contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Simulators and Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Simulation in Healthcare Education in Northern Ontario . . . . . . . . . . . . . . . . . . . . . . 13
Simulation for Dummies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Virtual Patients? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Operations: Simulation Activities at NOSM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Anesthesia Boot Camp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Midwifery Sims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Capability: Disasters and the NOSM CCC Retreat . . . . . . . . . . . . . . . . . . . . . . . . . 27
Moulage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Capacity: Pathways for Interactive Narrative Education . . . . . . . . . . . . . . . . . . . . . . 41
Exploring a PINE VP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
OpenLabyrinth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
VUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Research: Integrated Simulation: HSVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Sim Challenge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Research: Virtual Worlds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Research: Haptics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Sustainability: Opportunities and Challenges for NOSM . . . . . . . . . . . . . . . . . . . . . . 57
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5
NOSM Dean Roger Strasser acting
as a standardized patient at the CCC
retreat in Parry Sound in January 2010
The Northern Ontario School of Medicine (NOSM) was established with a social accountability
mandate to contribute to improving the health of the people and communities of Northern Ontario
and a mandate to be to be innovative.
In this context, NOSM developed Distributed Community Engaged Learning (DCEL) as its
distinctive model of medical education and health research. This involves medical and health science
learners undertaking clinical education in a wide range of health service and community settings in
over 70 different locations across Northern Ontario.
DCEL emphasizes authentic learning in context and depends heavily on information communication
technology to support widely dispersed learners. In addition, DCEL relies on interdependent
partnerships between NOSM and communities, individuals and organizations in all parts of
Northern Ontario and beyond.
in this report.
a lead role, often in partnership with others in Northern Ontario and beyond. These initiatives
represent impressive examples of northern innovation and excellence in the context of limited
resources. I congratulate all the individuals and groups involved and encourage the continuation of
these outstanding innovations.
Dr. Roger Strasser
Dean and Professor
Northern Ontario School of Medicine
Introduction
“Simulations include devices, trained persons, lifelike
virtual environments, and contrived social situations
that mimic problems, events, or conditions that arise
in professional encounters.” (Issenberg et al, 2005)
The use of simulation is a safe and effective way of
training and assessing healthcare professionals with
particular strengths including the provision of meaningful
and constructive feedback on learner performance,
supporting repetitive practice, providing variation in the
learners to try multiple strategies in controlled learning
benchmarks (Issenberg et al, 2005).
The uptake of simulation for healthcare training has
been patchy in Northern Ontario. Patchy in terms of
investment, in terms of the forms of use, in terms of
the amount of use, in terms of the current and future
needs and in terms of how different subject areas
conceive of and use simulation. A common concern is
that, given the distribution, size and resources of the
universities and colleges in the north of the province,
the economies of scale are relatively poor and
therefore there is a need to work together to ensure the
quality and sustainability of simulation for healthcare
education. While the provincial government has funded
multi-institutional simulation support in Toronto it has
not so far made similar arrangements for the needs
of northern communities and those that serve them.
Despite the absence of funding, a loose consortium of
Northern Ontario institutions involved in simulation for
healthcare education has come together (the Northern
Ontario Simulation in Healthcare Network - NOSHN)
but so far this has been an unfunded activity and has
largely focused on building a functional community of
practice across the participating organizations.
This report is intended to serve both as a record of
the work that has been carried out in and around
the Northern Ontario School of Medicine and as an
indicator of future directions that it might take. The
report is arranged in six chapters. Chapter one presents
an overview of simulation provision for healthcare
professional education in Northern Ontario. Chapter
two describes the range of simulation activities carried
out as part of the educational programs run through
NOSM. Chapter three describes a simulation-intensive
three-day retreat for third-year NOSM undergraduate
students in January 2010. Chapter four describes the
Pathways in Interactive Professional Education Project
(PINE) that created 60 virtual patient cases on a variety
the development of a platform for multi-device, multi-
site integrated simulation activities. Chapter six
closes with a review of options and issues for ongoing
sustainable development of simulation capacity at
NOSM. A number of illustrations and descriptions of
simulation and simulators in Northern Ontario are also
provided.
As with much of the innovative and critical work that
is carried out in the north of Ontario the innovation in
often disregarded or overshadowed by activities in the
south. One of the reasons for preparing this document
is to broadcast and share the innovative work carried
out ‘up here’ and to demonstrate not only the thinking
but also the skills and commitment to the use of
simulation in health professional education.
While we can show we have much in the way of
practice and ideas to share we will inevitably continue
to be challenged by the geographical realities of
Northern Ontario that lead to problems in achieving
critical mass, collaborating effectively with distant
partners and retaining quality and experienced staff.
We look therefore to opportunities to work with the
province and other collaborators so that we can share
and further develop capacity for simulation-based
learning. We need to ensure the ongoing supply of
maintain the health of all of the province and not just
those in the south.
Funding for this report was provided by the Northern
Interprofessional Collaborative for Healthcare Education
(NICHE) and the NOSM Informatics Portfolio.
9
Simulators and Simulation
Simulation in health professional education involves
support meaningful training or assessment activities.
It does not usually require the simulation to creates
the illusion of reality, rather it requires that those
that are involved know that it is not real but behave
dimensions; the creation of a semi-real situation (the
simulation environment including but not limited to
activity within the situation and then the activity being
executed.
Although simulation can be carried out without any
props, it is typically better supported with some kind of
device or stand-in at least for the patient. A commonly
“usually refers to a device that presents a
simulated patient (or part of a patient) and
interacts appropriately with the actions taken by
the simulation participant” (Gaba, 2004)
There are many different patient-like simulators in
common use today including:
mannequins - these are full body representations
of human beings that range from highly
physiological and physical signs through to basic
non-interactive forms. NOSM has a mixture of
as well as the simpler Resusci Anne and a number
of pediatric mannequins including SimBaby.
- these represent just a part of
a patient for performing individual tasks. Examples
include an arm for practicing phlebotomy, a head
for practicing intubation or a female pelvis for
practicing intimate examinations.
- in essence actors
playing the role of a patient. Standardized patients
are trained to provide the same presentation of
a medical condition to all of the learners they
encounter.
This page: SimMan 3G (above) and an
airway part task trainer (below). Facing
page, clockwise from top left: SimBaby,
Resusci Anne, anesthetics machine,
pads for mannequins, CentralLineMan
- these are computer-based
representations of patient encounters. Virtual
patients can combine aspects of narrative and
games as well as medical simulation - see
separate section in chapter 4 on virtual patients.
- these are
health informatics systems such as electronic
medical records, pharmacopeia and order entry
tools and PACS imaging platforms
- such as those used
in problem-based learning and OSCE stations
We can think therefore about the simulator as an
artefact around which simulation activities can be
constructed so as to use some or all of the functionality
afforded by the simulator. A simulator may be used in
many different simulation activities, for instance a part
task trainer and a standardized patient may be used
together. As an example, consider a situation where a
learner has to perform an intimate exam whilst talking
to the patient. The standardized patient would be
draped to make it seem that actor and part task trainer
were the same person.
the scenario to be negotiated followed by the learners
performing some kind of activity within the scenario.
No matter what kinds of simulator and simulation are
being used feedback is essential. Although feedback
might be given during the activity (for instance if it is
intended to be instructional), most scenarios withhold
feedback during the activity so as to retain the sense
of reality. Feedback therefore follows the activity
their own and each other’s performance followed by
constructive feedback from the tutor.
Although various forms of simulation have been part of
health professional education for many years, recent
improvements in simulator technologies and better
educational models have combined with the growing
need for well-prepared health professionals to place
simulation in the heart of healthcare professional
education, training and assessment.
Education in Northern Ontario
Chapter 1
Simulation in healthcare education is a rapidly
growing aspect of preparing the next generation of
professionals and ensuring the current generation is
have proliferated at medical schools, hospitals and
other training organizations worldwide. However,
simulation centres are expensive to set up and
maintain. Perhaps more importantly, establishing
centres is questionable for distributed medical
education programs. Although the Northern Ontario
School of Medicine has developed simulation facilities
at its principal sites in Sudbury and Thunder Bay
its approach to distributed healthcare education
means that it needs to work with partners across the
province in order to provide appropriate simulation
facilities to all of its participants and communities.
This chapter reviews the current state of simulation
in health professional education in Northern Ontario
both to set the scene and as the baseline for ongoing
development in simulation capacity in the region.
Although the Northern Ontario School of Medicine
is the latest and largest dedicated healthcare
educational organization in the region there are many
other programs and courses for health professions.
At the time of writing three universities in the region
in Sudbury and Nipissing University in North Bay.
There are also 6 colleges offering health professional
programs: Collège Boréal and Cambrian College in
Sudbury, Canadore College in North Bay, Northern
College in Timmins, Confederation College in Thunder
Bay and Sault College in Sault Ste Marie.
In 2003, the province of Ontario invested $10 million
in the Clinical Simulation Equipment Initiative that
funded schools of nursing to purchase simulation
equipment so as to establish simulation capacity at
these schools. Using this initial seed funding (two
tranches of around $500k per institution), each of the
participating universities and colleges were able to
establish their own in-house simulation centres and
labs that were quite well equipped for their needs
at the time. One of the expectations of the funding
initiative was that the colleges were to demonstrate
that the use of these facilities was not just internal to
the college but also to be shared with collaborating
communities and organizations as a condition of
the refresh phase. The funding was instrumental in
though it was only for nursing learners. None of the
other professional groups in the region had access
nursing programs have subsequently expanded the
application of their simulation facilities to other areas,
such as training paramedics. See the appendix at the
end of this chapter for more details on the facilities
and capacity for each of these institutions.
Two postgraduate education centres supporting rural
electives, residency and other professional programs
in the north (NOMP in Thunder Bay and NOMEC in
Sudbury) were merged with NOSM in 2006. Although
simulation was used in some structured courses
sessions with their residents it was on a distinctly ad
hoc basis. The Northern Ontario School of Medicine
opened its doors in 2005 as simultaneously the faculty of
campuses (Sudbury and Thunder Bay respectively)
it has learners and faculty based across the region.
Simulation was used in the form of simulated patients,
part task trainers and mannequins although only the
13
simulated patient program involved substantial activity
from the outset. A simulation program was created
in 2008 within the Informatics portfolio as part of an
organizational review, but this excluded simulated
patients and the majority of the part task trainer
activity, which remained exclusively within the control
of the undergraduate medical program. The simulation
equip simulation centres in Sudbury and Thunder Bay
and have built networks and run a series of events to
build capacity as well as providing simulation facilities
to the School’s programs, a number of which are
described in subsequent chapters.
The other major investment by the province in simulation
involved $4.5M from the provincial government for
the Network of Excellence in Simulation for Clinical
network linking the Toronto Academic Health Science
Network and the Michener Institute for Applied Health
Toronto-focused activities and projects it recently
took on a role of representing simulation in Ontario
as a whole, although without a mandate from those it
would represent. There has been some engagement
(mainly through meetings and conferences sponsored
but quite independently and largely unacknowledged
outside the region, a simulation network came
together in Northern Ontario. Following a number of
discussions between different simulation providers the
Northern Ontario Simulation for Healthcare Network
(NOSHN) was established in late 2007. Developed as
a grassroots collaborative network with no external
funding or other support NOSHN involved providers
exploring ways of sharing and supporting each other
across Northern Ontario. The network grew quickly
to include all of the colleges and universities involved
in health professional education in Northern Ontario
there was some initial hesitation about involving
hospitals in the network, it became clear that regional
hospitals faced the same kinds of problems as those
experienced by educational institutions and that
several hospitals were keen to work collaboratively
in the area of simulation. At the time of writing three
regional hospitals (Thunder Bay, Sudbury and Sault
Ste. Marie) have also joined NOSHN.
There were four key foundational activities in getting
the network started:
an inventory of the simulation resources and the
ways they were being used for each participating
institution - see appendix to this chapter. Two key
factors emerged from this activity; few centres
were using their simulation resources to their fullest
extent and there was great variation in extent and
form of use between partner institutions. Most
biggest challenge, but also noted other challenges
around limited space, equipment and expertise.
common policies were developed around
equipment and knowledge sharing to allow
personnel and equipment to be employed in
different contexts. This needed to address issues
such as liability and warranties for damage as well
as how expenses such as transporting equipment
between sites would be met. For many members
been considered.
a schedule of meetings and joint activities
was developed to promote and explore the
opportunities for collaborative working. A number
of collaborative sessions were put together
including a ‘Simulation for Dummies’ workshop
at Cambrian College, moulage and equipment
sharing for the NOSM CCC retreat (see Chapter
2), and the anesthesia boot camp for residents in
Sudbury. A Simulation Users Network (MiniSUN)
meeting is being planned by the NOSHN partners
on remote simulation teaching.
a shared online environment was set up at NOSM
for all members of NOSHN. A combination of wiki,
platform was easy to setup and maintain and has
proved popular amongst the members for sharing
ideas and materials.
14
Expanding simulation
regular peer communication and sharing of
ideas and news, particularly important given the
geographical challenges of the region
cross training around simulation skills such as
recipes and moulage
the ability as a group to leverage greater control
over simulation vendors
the ability to share scenarios, equipment and
sometimes even staff
In discussion amongst members a number of common
was the tendency to acquire simulation equipment
the programs that will use. Furthermore, because of
the focus on setup, ensuring the means to provide for
operational expenses, such as replacing disposables
and old or damaged equipment, can often be
overlooked. Another common challenge follows from
space is rarely provided. This is a particular challenge
in hospitals; when there is competition for space and
patient care takes precedence.
Summary
Being able to connect simulation tools with health
care providers in NOSM’s communities is a major
challenge. NOSHN is one way to develop the means
to extend clinical simulator training to these northern
communities. Supporting training in the local setting
affords a safe and non-threatening environment and
allows service provision to be maintained. There is
clear potential to conduct further research on the use
of this type of training as way of enhancing services to
rural and remote communities.
Northern Ontario is a large and profoundly distributed
environment with many challenges arising from diverse
weather, languages and cultures. The providers of
health professional education in the region have
provincial support has boosted this in a few areas but
there remain many challenges in sustaining simulation
in the region.
The remaining chapters in this book illustrate
some of the ways in which simulation has been
expanded, enhanced and woven into the educational
environment, many of which have been enhanced
through participation of NOSHN members. However,
although the development of a bottom-up (unfunded)
network has strengthened relationships and opened
up options for collaboration around simulation it cannot
solve all of the problems its members face and the
future of simulation for health professional education
in Northern Ontario is still uncertain. Investment in the
NOSHN network would be a major enabler for greater
collaboration around running simulation programs and
for developing the scholarship of simulation across
the network. It would also help to address the many
challenges faced in sustaining simulation activities
across Northern Ontario.
Cambrian paramedics and NOSM
learners learn together on an
emergency mannequin scenario
Simulation for Dummies
One of the earliest events arising from the collaboration
between member organizations of NOSHN was the
Simulation for Dummies symposium at Cambrian
College’s eDome, Sudbury. This one-day symposium
focused on making advanced simulation accessible to
interprofessional teachers and learners, and included
presentations and interactive hands-on workshops.
The keynote speaker, June McDonald-Jenkins from
UOIT, gave a spirited presentation on how simulation
enhances interprofessional teamwork. We staged a
surprise interruption by having a crash code arrive
mid-sentence. A team of paramedics was joined by
a medical student and an Emerg resident, as they
wheeled their patient into centre stage in the eDome.
June, a former trauma nurse, unexpectedly stepped
wireless mannequin available in Canada, we were able
to demonstrate the realities of resuscitation, remotely
Laerdal’s Dave Grant controls SimMan 3G wirelessly as the learners
battle to save their patient observed by eDome camera crews and
the meeting audience during megacode at NOSHN “Simulation
for Dummies” workshop, Cambrian eDome, Feb 2009.
controlled by wireless, right in front of the audience.
Three mobile eDome cameras provided additional
key points, like the delay from administration to effect
of most intravenous drugs, even for this experienced
team of resuscitators.
We took advantage of the eDome’s excellent
capacity and expertise, with cutting edge technical
and videographic resources. The eDome team were
able to create some valuable video teaching material
that has been useful in follow up sessions. The highly
interactive nature of the symposium stimulated much
discussion and intercourse, both during and between
sessions. This symposium was an excellent example
of how well the partner organizations in NOSHN
play well together, sharing resources, expertise and
valuable spaces.
Virtual Patients?
A virtual patient is “an interactive computer simulation
of real-life clinical scenarios for the purpose of health
professions training, education, or assessment. Users
may be learners, teachers, or examiners” (Ellaway,
Candler et al. 2006). Virtual patients can help learners
integrate, contextualize, synthesize and apply multiple
educational dimensions in practice settings. They can
be made available on-demand and can be replayable
allowing learners to explore different options and
strategies. By learner actions having consequences
they can support high levels of immersion and user
agency. The four main aspects of virtual patients are:
schema VPs supporting learners in developing and
assessing patterns and schemas in professional
practice. These involve a repeated approach
to practice with different details each time that
Typical schemas include history, examination,
investigation, diagnosis therapy (HEIDR) and
airway, breathing, circulation (ABC).
narrative VPs that allow the learner to explore
emotional, social and cultural dimensions
of practice thereby dealing with complexity,
ambiguity, capriciousness, irrationality using
characters and their motives.
game VPs involving formative or summative testing,
where the scenario presents an opportunity to rate
performance. Essential aspects include rules, and
opportunities to win or lose.
simulation VPs that provide opportunities to practice
and/or be assessed in a real-world setting.
Essential aspects include critical decisions made/
not made, actions taken/not taken. These VPs
usually have smaller scope of action overall but
more detailed actions at key points.
As student access to patients gets harder (shorter
hospital stays, more students, working hour limits, and a
growing need for assured curricula) virtual patients can
Check the websites on the right for examples.
The PINE Project website provides access to all
60 PINE VPs plus downloadable packages and the
VUE visualizations - http://pine.nosm.ca/pine
The Canadian Healthcare Education Commons
site has a section on virtual patients from across
the country - http://tinyurl.com/2clzeq9
The eVIP Project website has 320 virtual patients to
be played or downloaded in a number of languages
from multiple healthcare disciplines across Europe -
http://www.virtualpatients.eu
NOSM undergraduate learners deal
with a simulated trauma case
Operations: Simulation
Activities at NOSM
Chapter 2
19
Although this publication concentrates on new
and innovative approaches to using simulation it is
important that we also set out the current operational
use of simulation at NOSM to put these new forms in
some kind of context. This chapter will describe the
different facilities and applications of simulation in
NOSM’s various education programs.
Since opening in 2005 the School has established a
number of simulation resources and facilities. Student
labs were set up in both Sudbury and Thunder Bay
principally for use by year 1 and 2 students in NOSM’s
MD program. Run by the School’s undergraduate
medical education (UME) portfolio these labs are used
for both clinical skills and basic science laboratory
sessions for students in years 1 and 2. Simulation
activities are largely around the use of part task
trainers such as phlebotomy arms, lumbar puncture
trainers, arterial blood gas arm trainers, and pelvic
and rectal exam trainers. NOSM also has a Harvey
heart and lung sound simulator at both Sudbury and
Thunder Bay. Simulation laboratories were added in
2008 by the Informatics portfolio for use by any of
NOSM’s programs or partners, although uptake has
been largely by NOSM’s residency programs so far.
range of adjunct equipment and resources. Although
control rooms were created to allow tutors to control
mannequins without being seen by learners funding
ran out before they were completed and the planned
CCTV was not implemented. This means that only the
separate space. Funding shortfalls also meant that the
Thunder Bay lab only has partitions rather than drywall
and debrief involves frank, noisy and potentially
can be overheard compromises the essential quality
of safety for the learners, and to a lesser extent the
tutors, as well as creating a disturbance for those
usage in Thunder Bay have limited the impact of this
issue but clearly do not address it.
NOSM has residency programs in family medicine
(with around 100 learners on-program at any one
time) as well as specialties such as pediatrics, surgery,
community medicine, anesthesiology and psychiatry
(with 50 or so specialty residents at any one time).
Although the majority of learners’ time is spent in the
clinical workplace they do have a number of scheduled
and structured educational sessions.
Depending on numbers a typical session will involve
residents either starting off with an interactive
and assist knowledge transfer and reprise) and then
moving on to the simulated cases and simulators
to rehearse their skills and knowledge. Currently
standardized patients are not used for these sessions
although discussions are underway to expand what
is pretty much an exclusively UME activity to include
some residency training sessions especially for
miscellaneous procedures such as lumbar puncture
encompassing consent and communication issues.
Dr Kupsh started simulation-based teaching sessions
once a month with the topic linked to their problem-
20
on sports medicine involving a collapsed marathon
runner the simulation exercise replicated the runner
using a mannequin to allow learners to develop and
test strategies around resuscitation and management.
On other occasions Dr Kupsh would consult with the
lead for the current block to identify topics or skills that
learners were struggling with that could be addressed
in the simulation sessions.
Within the hour available each simulation session ran
for about twenty minutes followed by thirty minutes
‘how did the medicine of the case go?’ i.e. did they do
the appropriate things? The second was ‘how do they
function in terms of leading a team, being a helper,
and working as part of a team?’ Each participant had a
particular role. For instance for the role of the recorder
questions would be asked along the lines of ‘it’s two
years later, we’re now in a court of law, can you defend
yourself on what’s written’.
A key part of this is developing the residents’
appreciation of how hard the different tasks are within
team for real they will be able to manage the situation
better. While the Sudbury residents receive a session
once every four weeks Thunder Bay residents get, on
average, four sessions a year based on how often Dr
sessions (both east and west residents together) three
one each in Sudbury and Thunder Bay.
enabled by the creation of the simulation labs at
NOSM along with growing problems with traditional
approaches to teaching and learning. Issues such as
reduced stay times in hospitals and the specialization
within the environment mean that opportunities for
learners to get all of their learning experiences on the
wards is increasingly problematic.
A key episode for Dr Kupsh was when one of her soon
code. She realized then the importance of making sure
learners have the appropriate experience and skills
to deal with these life and death situations. Although
northern residency programs have historically
less rigid hierarchies than in larger centres, as NOSM’s
programs grow this advantage may be reduced.
The 60 Sudbury and 40 Thunder Bay Family Physician
training sessions a year; topics change from year to
year but include rapid sequence intubation and airway,
electrocardiogram and chest x-ray, casting, codes
and resuscitations and miscellaneous procedures
(including suturing, EZ-IO, c-spine, x-rays). These
sessions employ a mix of task trainers, biological
materials and mannequins and are based around a
number of stations. For instance, there are four stations
for the airway session; normal airway, advanced airway
Expanding Simulation
learning. We therefore use pigs’ feet (from the grocery store) for suturing
practice as they approximate the skin on a human’s back. We also use
turkeys when we’re putting in chest tubes. Although we have the trainer
model it doesn’t approximate that feeling of going through layers of tissue.
We put a half collapsed balloon inside the thoracic cage so learners have
to make the cut through the layers of tissue between the ribs to get to the
thoracic cavity and that approximates the feel much better than the plastic
model. Although mannequin manufacturers say you can put a chest tube in
it’s not real enough for me so I pair the mannequin with the turkey simulator.
Similarly, starting an IV on 3G can be problematic so I have a part task
trainer right by the mannequin. You can’t give any medication until you have
the IV started and if you can’t start the IV then here’s the EZ-IO right next to
it.” Dr Chris Kupsh
Image from Ferdi’s World on Flickr used under a Creative Commons licence
21
and two scenarios and learners spend an hour at each
station. For ‘codes and resuscitations’ there are two
circuits of three stations; pediatric resuscitation, adult
resuscitation and a trauma. However, because of the
lack of tutors in Thunder Bay they are sometimes
limited to fewer stations. These sessions are designed
and run by Dr Kupsh with an ER physician acting as
tutors for each station. The selection of topics for
these sessions is matched to the College of Family
Physicians list of the procedures they expect family
practitioners to be comfortable with.
The residents respond very well to these sessions
and would like to have more. However, this is limited
by available resources and the logistics organizing
sessions, particularly in Thunder Bay. Currently Dr
Kupsh writes up the objectives, the cases and the
delivery guides for the learning activity coordinators
in Thunder Bay and Sudbury as well as leading the
sessions. An extra hour session was added in 2010
The 4-year NOSM MD program involves two years of
pre-clinical work largely located in either Sudbury or
Thunder Bay, followed by a yearlong comprehensive
clerkships. Simulation currently features to an extent
in clinical skills sessions in years 1 and 2 and again in
some specialist clerkships in year 4.
First and second year students have standardized
patients in their SCS (structured clinical skills)
sessions and they also, depending on the lab, work
with task trainers. The current format is learners get
a one-hour talk and then they go and work with the
trainers. However, there is a fall off in attention once
they have done the skill once or twice on a static
model. At present we are starting to attach the task
trainers to standardized patients (or attach to the
Tutors for the lab as they are already booked to be
there) so as to make it more challenging and real. The
costs associated with using standardized patients are
every student is going to be able to do everything at
each station but tutors switch roles around between
stations. This ensures that everyone gets to be both
participant and observer.
Tutors are also beginning to expand these sessions
by including mannequin-based scenarios once the
basic skills have been learned so as to practice them
mannequin that can breathe and have a heart rate can
be used to talk about an airway that learners can look
at it and actually assess.
NOSM has also developed a substantial standardized
patient (SP) program with more than seventy
individuals on its books. Standardized patients are
actors that have been trained to simulate particular
conditions. In order to match the actor to the case
they range from children to seniors and include males
and females. At the time of writing SPs are used in
phase 1 of the undergraduate curriculum, in OSCE
exams and occasionally on contract for postgraduate
exams for the Medical Council of Canada.
In any given week thirty or so SPs are called in to the
School. OSCEs typically involve 24 SPs over multiple
circuits. The use of SPs in phase 1 is essentially for
learning basic communication, interviewing and
examination skills as part of the regular Structured
Clinical Sessions. Training time for an SP depends on
the case - a simpler case around 30 minutes, a more
as OSCE stations also require more time for training
to ensure consistency across multiple sessions so
learners all have the same opportunity and the same
details are expressed consistently throughout
In year 4 students get simulation training as part of
their emergency medicine rotation. The four students
in each rotation have a weekly 3-hour session involving
working on tasks addressing topics such as airway,
chest x-ray, suturing and casting. For example, in one
session learners rotate through interactive PowerPoint
sessions for abnormal behaviour managing four
different patients at once, and for the trauma stations
problem. Unlike residents who can usually manage the
case without tutor intervention undergraduate learners
require more support and direction.
Chapter 2 - Operations: Simulation Activities at NOSM
Anesthesia
Boot Camp
Family Practice Anesthesiologists (FPAs) have
numerous challenges, often outside the support of
the tertiary care center: infrequent exposure to crises,
limited availability of colleague support, limited access
to professional development, all compounded by a
short training program (1 year). Most FPAs will return
to rural, or underserviced areas and serve as local
expert leaders in crisis management and resuscitation
for a diverse range of patients, including pediatrics,
anxiety in handling sporadic crises. FPA training
programs must adequately prepare trainees for the
unique situations they will face in Northern Ontario.
Intense courses like crisis management “boot-camps”
have been very successful in other specialty programs.
The aim was to allow learners to develop team
leadership skills and to practice acute medicine prior
to real-life crises. The goal was to provide trainees
with a safe learning environment in order for them
to develop an appreciation of the spectrum of their
profession, learn valuable procedural and crisis
management skills, expand on their knowledge of
personal experiences and develop their own personal
learning objectives for the future.
In order to accomplish these goals, different sessions
were set up each day. These included interactive
lectures, task training sessions, simulation sessions
journal page each evening to consolidate their learning
objectives, manage stress and identify process issues.
was done with each trainee on the last day.
of experience in a short period of time – it would have
taken months or years to encounter these cases”
“Things will stick” “The trouble with doing normal
uneventful anesthesia is that you don’t learn to be
scared” “Repeat this at the end of the year”.
This Boot Camp was the result of collaboration
of Faculty from the Anesthesia, Critical Care and
Emergency Departments at HRSRH as well as the IT
department at NOSM and a Simulation Fellow from
the last 2 days were held in the Operating Rooms
at the HRSRH and involved NOSM and Ottawa FPA
residents. In view of the success of this week, we have
had expressions of interest from Queen’s, McMaster,
Western and Toronto for their FPA programs as well
as their Anesthesia FRCP programs. Support for this
event was provided by the AHCS AFP Innovation
safety the ability to provide this type of experience
regularly is severely limited by lack of regular funding.
Dr C Kupsh and Dr R Anderson
23
Because Dr Kupsh is based in Sudbury learners in
the northeast receive a more regular diet of simulation
based training and assessment than those in the
northwest, largely due to the absence of a trained and
enthusiastic preceptor to design and lead sessions
and to make use of the available simulator resources
has meant that there is far less simulation-based
education. Dr Kupsh runs sessions whenever she is in
Thunder Bay but this is both an infrequent and costly
way to provide simulation-based education.
As an attempt to address this issue for residents
an extra simulation room was set up at the medical
VitalSim and an airway kit to allow residents to run
of this opportunity none of the Thunder Bay residents
have made use of it. One major reason is the absence
of an expert tutor to give feedback although it could
be argued that senior learners should be developing
more autonomous forms of learning.
In Sudbury, because of the large numbers of residents
and limited space in the simulation lab many sessions
are run in the nearby student lab space, which means
coordinating these sessions with the times when the
lab is being used by UME. The numbers also require
two circuits of three stations in an afternoon and even
then this involves 6-7 learners per group and that still
taxes the available resources. Sessions have been split
into morning and afternoon diets to help address this
NOSM is a relatively small medical school that
operates over a vast area. There are therefore
experience. NOSM makes use of a number of
different professional groups to support its programs.
NOSM being a new organization has also depended
on working with more established institutions and
programs as it builds out its programs and facilities.
The School’s community and primary focus also points
to working with the many professions found in these
environments. NOSM’s partnerships with the new
family health teams are clear indicators of this kind
of interprofessional learning environment. It should be
noted that NOSM has a number of other educational
activities in addition to its MD and residency programs
and as such multiprofessionalism is part of the
School’s identity. Simply throwing learners from
different professions together can be problematic.
For instance mixing nursing students with residents
doesn’t work well because of the difference in levels of
experience. It would be more appropriate to combine
senior nurses with residents. The other problem with
IPE is you have to make sure that one group’s interests
are not served to the detriment of other participants.
an IPE dimension but less experienced learners need
extra tuition to make sense of the program while more
experienced learners may be bored by the more basic
material.
There have been a number of IPE courses using
simulation along with NOSM teachers and learners:
TNCC (Trauma Nursing Core Curriculum) course
is designed for nurses and run by nurses to
learn basic assessment systems. Dr Kupsh saw
an opportunity for interprofessional working
and arranged for the course to use both NOSM
enhance the sessions. Not only did it enrich
the course it also allowed for work around
teamworking and leadership
had all her midwifery students going through the
course and she offered spots for NOSM residents
and some of the labour and delivery nurses from
Sudbury Regional Hospital. This gave a good mix
of learners from different backgrounds. About half
of the activities are simulation-based (including
all their own simulation equipment.
Simulation is used in many aspects of NOSM’s
programs but this use is uneven and led by just a few
individuals. A strategic approach is required to align
needs and resources as well as develop capacity
among NOSM’s faculty and its many partners.
Chapter 2 - Operations: Simulation Activities at NOSM
Midwifery Sims
run the Ontario Midwifery Education Program. Susan
School of Midwifery talks about her use of simulation:
“Teaching and practice of clinical skills takes place both
before and throughout midwifery practice placements.
The approach varies, but the overall objective is to
provide students with both quality and quantity of
practice. For some skills, simulated models provide
excellent beginning competence. For example, being
provides the student with a quasi-realistic experience
without the fear of puncturing a live arm.
While birth simulators such as Noelle can provide
experience with the labour and birth process, the
usefulness of this simulator is limited. Noelle is heavy
and can really only give birth in the “stranded beetle”
position. Using the obstetrical manikins allows the
student the opportunity to practice “catching” in any
position and over the same period of time that it takes
for Noelle to give birth once, several students can
have an opportunity to practice the midwife role. In
addition, the student who takes the role of the birthing
woman must negotiate the baby through the birth
canal. She learns the importance of the mechanisms
pelvis. The manikins are also well suited to teaching
approaches to emergency births such as shoulder
dystocia, breech, undiagnosed twins and cord
prolapsed/presentation.
An important role of simulation in the midwifery
program is for practicing approaches to care where
the situations are relatively rare and may be seldom
encountered in practice or in situations where the
consequences of inappropriate actions are life
threatening. Simulation allows students to experiment
with options, see what might happen if they try
something that they have not yet seen in practice and
to see what the roles of other care providers might be
in the same situation.
Many skills can be learned and practiced using low
cost simulation models. Foam rubber, sponges and
balloons can be used creatively as reasonably realistic
models. A kitchen sponge and a balloon along with
some yellow tinted water can be used to practice
obstetrical manikin can be used to practice amniotomy.
tinted water to up the ante; moving the student into
a management role in addition to the basic skill
acquisition. High density foam blocks can be easily
crafted into perineal suturing models. Markers or paint
can be used to create the anatomical landmarks and
layers. This option does not pose the risks of some of
the simulators that use harder materials where needle
breakage can be a real and regular problem.
The PINE virtual case studies introduce a variety of
simple to complex cases where the student assumes
a primary care management role. If the student makes
a non-life threatening “error,” the case studies, like in
real life, provide additional choices for the student to
compensate for the error. If the error is life-threatening,
the case study ends and the student is invited to start
over. The ability to learn from making errors in a safe
environment is a valuable addition to the curriculum.
a component of the third year midwifery curriculum and
included family medicine residents and practitioners,
nurses and midwifery students. The goal is to use a
combination of lecture and case study simulation to
practice interdisciplinary approaches to obstetrical
emergencies. Not only do participants learn from the
“expert faculty,” they learn from one another and learn
to trust the expertise of each professional in the group.
Susan James, Director Laurentian
University Midwifery Education Program
“participants were able to triage and manage mass
casualty patients according to large group learning
and Skill Station instruction and to transfer that
knowledge to event-based performance”
Capability: Disasters and the
NOSM CCC Retreat
NOSM has two main sites
at Thunder Bay and Sudbury
(circles) and a number of CCC
sites (diamonds) at Parry Sound, North
Bay, Temiskaming Shores, Timmins, Sault
Ste Marie, Huntsville and Bracebridge,
Sioux Lookout, Kenora, Fort Frances,
Kapuskasing and Dryden.
Chapter 3
The Comprehensive Community Clerkship (CCC) is
the third year of the four-year Northern Ontario School
of Medicine medical degree program:
“this mandatory longitudinal integrated clerkship
involves students living and learning in 12 large
rural or small urban communities outside Sudbury
and Thunder Bay for the full academic year”
(Strasser et al, 2009)
All of the learners in the CCC come together each year
for a retreat along with many of their teachers and
support staff at one of the CCC sites. In 2010, the CCC
retreat took place in Parry Sound, a town on the east
Huron. The 2010 CCC retreat was designed to have a
strong instructional component with a common theme
of disaster response and management. This theme
was selected to form a united context for working with
clinical, social, organizational and interprofessional
dimensions of practice. In addition to the 55 NOSM
medical students the retreat also involved 25 of
placement in Parry Sound. Other invited participants
included local high school students along with local
dignitaries and senior staff from the medical school.
A common theme for the retreat of disaster
management was chosen both as a way of creating
a common thread across most if not all of the
the opportunity afforded by having a critical mass of
learners and staff together to tackle a topic that is not
addressed in the small regional CCC teaching sites or
in the mainstream curriculum.
The pursuit of a disaster scenario theme was greatly
enhanced by the participation of Don Brisbane a Parry
in training hospital teams to deal with mass casualty
and disaster planning scenarios. Don developed a
nearby Huntsville involving a multiple vehicle pile-
up with diplomats, security teams, protestors and
members of the press corps as casualties. The event
consisted of a series of activities building on this
scenario.
This involved learners and preceptors working in
groups of eight or so to respond to a series of questions
and challenges arising from a simulated disaster
scenario. The narrative provided involved a multiple
27
vehicle accident on highway 69 during the upcoming
limited resources and other factors such as personnel
problems and media intrusion were presented and
responses sought from the participants. A panel of
experts gave their initial responses to the situation
and then each group worked to devise answers to
strategic questions that were interspersed with ethical
questions to the audience as a whole - see the sample
of questions below. An electronic audience response
system was used to solicit and display answers for
a series of ethical questions with feedback provided
by one or more of the experts present along with
designed to be ice breakers among groups of learners
who had not necessarily met before (NOSM medical
students, Canadore nurses and a number of invited
guests) as well as an introduction to the issues
involved with disaster response.
The morning of the second day was involved with a
series of presentations and workshops around the
CCC and engagement with the NOSM undergraduate
program. A ‘surprise’ emergency resuscitation session
was run late in the morning following the same
model as that run in the ‘Simulation for Dummies’
meeting - see page 14. Students were called from the
audience along with a preceptor who gave feedback
on managing the situation along with the simulation
leader, an emergency physician. Emphasis was also
put on discussing the experiences of working with
a mannequin as a prelude for the following mass
simulation exercise.
The rest of the CCC retreat was given over to a mass
simulation exercise organized around eight stations.
The eight learner groups mixed NOSM medical
students and Canadore nurses and rotating each
group through a series of simulation stations dealing
with practical issues associated with emergency
response medicine. The stations provided were EMS/
communications (two half stations), shock, airway
management, triage, fracture, mental health/ virtual
28
Expanding Simulation
Large numbers of armed security staff, members
of the international press and political aids are
gathering on the hospital grounds. Hospital staff
can not get to the hospital. Things are getting
tense. Emergency is swamped and another wave
of patients are expected any minute.
what immediate actions should be taken by the
hospital staff?
2. What general medical support will be in the
most urgent demand? What additional services of
a specialized or exceptional nature will be required
that your facility lacks?
3. At what point does your hospital stand up its
Incident Command System and begin making
preparations for special emergency medical
routines?
29
4th floor
1st floor
EMS
Shock
Comms
Airway
elevator
washrooms
entrance
rest area
Mental
Triage
Fracture
Virtual Triage
1A
1B
2
3
4
5
6A
6B
control
C-Spine
Obstetrics
elevator
washrooms
7
8
Moving groups of learners
between stations was an
obvious point of potential
confusion and loss of time.
Flow was maintained by
available space - stations
were sequenced so as
to let learners travel the
minimum distance between
each step and to travel only
in the one direction - the
diagram shows the location
of the stations and the
The West Parry Sound
Health Centre was extremely
generous with their space,
time and resources. Virtually
along with a number of
given over to the mass
simulation exercise.
Moulage
Moulage is literally ‘moulding‘ from the French and
involves using makeup and other devices to simulate
injuries to humans or mannequins. Several stations
at the CCC retreat involved moulage of some kind, in
particular the EMS station. NOSM didn’t have anyone
with moulage skills in-house at the time of the CCC
retreat so Karen Paquette from Cambrian College was
engaged as the moulage artist for the retreat.
Using make-up from Ben-Ney, Karen Paquette
created a scene composed of casualties from a bus
everything from bruises to simulated severed limb
wounds, which were then to be assessed by students.
The visual effects added realism to the trauma patients
of the EMS station. Make up was applied to faces for
bruising and to make the skin look dusky. Hematoma
tone and bruise coloring which was added over top.
Vaseline was then applied under the skin to further
create swelling necessary for visual and tactile effect.
Protruding bone was also created using a combination
combining a little bruise color and blood would then
give the effect of a compound fracture. In order to
create a severed limb effect, Karen used an old shirt
with a ripped arm, lots of blood and a simulated
severed arm strap attached to the person’s side.
To achieve a burn wound, she used molding wax which
created pockets for blistering and then added blood
blood. Our “cast” of characters not only looked the
part, but also played the part well.
Moulage for head trauma,
pallor and a severed limb
are applied (top to bottom
right) and the moulaged
EMS patients ready to go
(below) with Karen centre
triage (two half stations), C-spine, and obstetrics with
completed four stations on the Friday afternoon and
the remaining four on the Saturday morning. All stations
were highly interactive, requiring learners to use or
develop hands-on skills in dealing with the challenges
they were presented with. A wide range of simulation
modalities was used that included simulated patients
(actors with make-up), mannequins, onscreen serious
games and role-play.
station was run in two halves in a divided room. The
second half allowed learners to practice their new
found skills with standardized patients playing the part
of accident victims with various injuries (see moulage
panel opposite). The sessions on the Friday afternoon
involved NOSM’s Dean and several Associate Deans
as the standardized patients.
Learning points:
1.
2. First EMS personnel on scene should not start
treatment: establish the number of patients,
establish the number of ambulances required and
establish which allied agencies are required.
3. Establish a Command Post and designate: Site
4. Initiate Triage: Assess ABCs and assign a triage
tag to everyone.
5. Establish a Holding Area: Arrange triaged patients
to corresponding holding area matching there tag
color to area color.
6.
7. Use the mnemonic EMCA (Emergency Medical
Care Assistant): E - Environmental safety, M
-Mechanism of injury, C - # of Casualties, A -
Allied agencies required, P - Protective equipment
required.
Run by NOSM Director of Communications Kim
Daynard this half station involved providing media
training to learners, particularly with respect to how
best to respond to media inquiries and conduct
themselves in media interviews during a crisis situation.
In this station, learners were provided with a particular
scenario to discuss in which a television reporter
demands comments with respect to a woman’s claim
that she and her new born baby were “kicked out of
the hospital to make room of a bunch of rich, fat cats”
following a bus accident that involved government
dignitaries. Participants learned ethical tactics and
techniques to manage the media to convey accurate
information, sustain credibility, and build favorable
public perception.
Learning points:
1. Have a media plan in place BEFORE a crisis occurs
2. If you are the designated spokesperson, take time
to gather your key messages. It is okay to tell a
reporter you will call him or her back.
3.
proof points.
4. Use interview bridges to regain control of an
interview: “what’s really important here is…”, “the
thing to keep in mind is…”, “let me tell you what I
do know…”, “let’s look at it from a broader/different
perspective…”, “another way to approach it is…”
5. Trust and Credibility = the Communication of
Caring/Empathy, Competence/Expertise, Honesty,
and Commitment.
this full station was designed to introduce learners
evaluate team performance in an exercise involving
the resuscitation of a trauma patient. Initially learners
and observers were briefed about the expectations
for the performance and were then shown a video of
the same scenario performed by an interprofessional
31
Chapter 3 - Capability: Disasters and the NOSM CCC Retreat
the mannequin. Performance Evaluation comprised
around individual and team performance.
Learning points:
1. Appreciate that effective team work improves
outcome in high stake, critical medical situations
2. Appreciate the importance of effective
communication between members of the team
3. Understand the importance of rapid assessment
of ABC’s in a critically ill patient
4. Recognize the symptoms and signs of hypovolemic
shock
5. Recognize the importance of effective hemostasis,
Run by Dr Chris Kupsh and Dr. Brad Hunkin this full
station focused on learning how to assess an airway,
to intervene. The station involved a brief introduction to
common causes of airway obstruction and the steps
were then taught a series of skills including oral and
nasal airway insertion as well as the life-saving skill
of bag-mask ventilation. If time permitted, further
discussion included particulars about intubation
(indications, size and type of tube to use, etc). There
were two learners allocated to each task trainer or
mannequin that rotated around four activities within
the station. Three doctors from the community worked
with Dr Kupsh to provide one-on-one coaching.
Learning points:
1.
assessment of a patient.
Dr Kupsh (centre) with
learners and observers
at the Airway Station
Expanding Simulation
2. Simple measures (such as a chin lift or jaw thrust)
can be very effective.
3. Airway patency during initial assessment does
not mean that the airway will stay that way ...
conditions can progress. Anticipation of the
4. Airway patency does not assure adequate
ventilation as it requires adequate function of
lungs, chest wall and diaphragm.
5.
This full station was led by Dr. Redmond and Pattie
Farris and involved learners being taught how to triage
a patient and then processing a series of patients with
simulated injuries to practice these triage skills.
Learning points:
1. Describe basic triage.
3. Un ders tand the un ique natu re of Emer genc y pat ient s.
4. Demonstrate an understanding of triage skills
5. Describe the full triage process.
This full station involved learners working with Dr Smyth
on identifying different kinds of fractures and selecting
the appropriate strategy for dealing with them. Skills
covered included interpreting radiology, different
casting and splinting techniques and recognizing and
dealing with any complications arising from fractures
and associated injuries.
team role play with written character prompts chosen
by random selection by each member of the team.
Students were provided with a brief overview of what
to expect in the session and the main learning objective
of being able to delineate the difference between
The scenario involved a team of doctors and nurses
from a hospital unit where one of the team members
and his children had died suddenly and unexpectedly
A mannequin is treated
at the Shock Station
Dr Smyth leading the
Fracture Station
33
Chapter 3 - Capability: Disasters and the NOSM CCC Retreat
under suspicious circumstances. Each member of the
team assumed and developed their randomly chosen
character and the tutor led the initial Critical Incident
Debrief. The team discovered individual needs,
including one or two high risk situations in individual
group members which led to applying principles of
practice for crisis assessment.
Pat observes: “Most learners handled the role play
well. The group aptly discussed the issue of team
dynamic and individual personality styles and its’
effect on communication, both positive and inhibitive.
thinking and behaviour. As the day passed, the groups
groups to participate demonstrated more cohesion
within their own disciplines and later in the day, after
having been through other stations, there was more
intraprofessionalism being demonstrated.”
Learning points:
1. To understand how Critical Incident Intervention
and Crisis Intervention are different.
2. To recognize that Mental Health and Mental Illness
are parts of a continuum of functioning.
3. To understand the critical points which require
assessment in suicidal ideation.
4. To be introduced to the Mental Status Assessment.
5. To understand when and how to make a referral to
a Schedule 1 Psychiatric facility.
This half-station was led by Dr Rachel Ellaway and
employed a virtual patient case developed by Dr
David Topps and Dr Ellaway that presented learners
manage three patients. Following a ‘choose your own
adventure’ model (see Chapter 4) learners working
in groups of 2-4 had to try and save as many of the
patients as they could. By working in teams and
discussing which of the available paths they were
going to take learners were able to explore critical
issues in triage and disaster management.
Learning points:
1.
room to get involved in a triage situation.
2. If you have the opportunity, keep checking all of
your patients - situations can change rapidly.
3. Visually dramatic injuries or patient distress are
not necessarily good indicators of survivability.
4. Don’t give up on a course of action that you know
needs to be followed through.
5. Concentrate on saving those you can.
Run by Dr Peter Hutten-Czapski this full station
focused on learning how to assess C-Spine X-rays
used to evaluate trauma patients. The station involved
a quick introduction to the Canadian C-Spine rules
followed by a quick didactic systemic approach to
the others reviewing silently) the learners immediately
put the didactic approach into practice.
This full station was divided into two sub stations
which were separate but educationally linked. On
entering the room, the students were immediately split
into two groups that alternated stations.
The was run by Dr James
opportunity to learn the practice skills for managing an
infant delivery involving shoulder dystocia. The station
started with a short PowerPoint presentation outlining
the manual steps for a normal delivery, physiological
and anatomical information on what shoulder dystocia
is, how it is recognized, what the impact can be on
the mom and the baby, and the procedural steps
through a shoulder dystocia scenario approximately
3-5 times allowing students to take on different roles
in the management team. A nurse educator assistant
learners, gave feedback and corrected steps along
the way. Participants were given a handout at the end
of the station as a reminder and follow-up.
34
Expanding Simulation
Learning points:
1. Shoulder dystocia is a common unpredictable
obstetrical emergency and be prepared to manage
shoulder dystocia at all obstetrical deliveries.
2. Shoulder dystocia occurs with the impaction of
the fetal anterior shoulder against the maternal
symphysis pubis.
3. Effective management of shoulder dystocia
requires multiple members of a health team to
utilize a systematic approach.
4.
pressure, Enter vagina and rotate shoulders,
Remove posterior arm, Roll the patient to her
hands and knees
The was run by Dr Marc Blayney
and started with a review of the key steps of infant
resuscitation focusing on preparation, equipment,
key steps to follow using the NRP framework. He
then went through the scenario several times with the
students supporting them in the process.
Learning points:
1. Newborns are different, the resuscitation process
is not.
2. Initial Steps in Newborn resuscitation are simple
and life saving
3.
4.
5. ABCD: Airway, Breathing, Circulation, Drugs.
At the end of the retreat on the Saturday a 90-minute
leads and Mary Salisbury, a professional training
consultant who was invited to watch and participate in
the whole event as an evaluator and feedback expert
for both the learners and the retreat as a whole. Ms
Salisbury elected to follow one student group through
a series of stations and then to locate herself at the
one station (shock) to observe the remaining groups
passing through the station. She was also present
during the rest of the retreat including the tabletop
exercises and the staged resuscitation event.
many roles. Clearly there were learners (year 3 NOSM
and year 1 Canadore) as well as a number of organizers
including Dr Sarah Strasser for the retreat as a whole,
simulation sessions lead Dr Rachel Ellaway, simulation
technical lead Aaron Wright. The disaster planning
session was led by local EMS and planning expert
Don Brisbane. There were also many clinicians and
other health professionals involved in running stations,
both from Parry Sound and from across the rest of
the province including some who traveled several
thousands of kilometres to be at the retreat.
Debrief and feedback expert Mary Salisbury was
commissioned to lead the closing feedback session
as well as evaluate the stations, assist in feedback
and to generate a report on the strengths and
weaknesses of the retreat as a whole. Simulated
patients (human actors) were drawn from the NOSM
staff and local volunteers. Some were given makeup
and simulated injuries (see page on moulage) while
others participated ‘as is’ - see triage station. There
were many other volunteers from the local hospital
Floaters (to help with the two split stations and spell
Managers (the door between the hospital and the long
term care centre was card controlled so a volunteer
was stationed at this door manage access). The
West Parry Sound Hospital staff provided the venue
along with arranging for volunteers to come in, and
providing storage space, security staff and so on. The
Wright and Ellaway) did the station set up and tear
down as well as acquiring equipment and transporting
it to and from Parry Sound.
In order to successfully execute the simulation exercise
there were extensive discussions and planning
meetings which began three months before the event
with the Parry Sound and NOSM teams. With both
35
Chapter 3 - Capability: Disasters and the NOSM CCC Retreat
teams committed, coordination began with a formal
initial request by Dr. Strasser to physicians asking for
their involvement to lead or assist in a skills station.
equipment needs and patients requirements which
helped shape the outline of the exercise. There were
a number of steps required in leading up to the event:
Regular meetings were held with station leads,
community representatives and NOSM staff. Two
face-to-face meetings were held in Parry Sound
to map out the space available so as to identify
the location for each station and the way learners
storage of the NOSM simulation equipment,
and maintenance teams and times and means for
access to different parts of the building.
A tracking system was created included applicable
details in identifying leads/assistants, and details
such as required consumables, teaching support,
handouts and running time, etc. Central to this was
the skills station outline that was also provided to
the learners in their information package.
Much of the equipment used needed to be
transported from Sudbury. A cargo van was hired
Noelle birthing simulator (on loan from Cambrian
College) as well as the tripods, computers,
disposables and many other items required. An
inventory list proved invaluable both for planning
and packing purposes. Individual stations had
their own boxes of consumables and other items
based on the lists submitted by leads.
An itemized list was sent to the learners asking
them to bring a stethoscope, watch, indoor
shoes, etc. to avoid additional packing and loss of
equipment. Most but not all complied.
Hospital organization details:
Equipment was set up and tested on the day
technical bugs and timing issues. Equipment was
then left in a semi-ready state (mannequins on
stretchers) in the locked storage area to allow for
transport down to the station areas on the day.
chart identifying the station and lead(s) along with
the consumables in their appropriate boxes.
A dedicated meeting space and time was
provided for volunteers to discuss details such
as schedules, groups, stations, maps, two-way
radios and T-shirts identifying them as guides. All
information was provided in a volunteer package.
A tour of the station circuit was also given to the
volunteers before starting each day.
rotation: explaining the outline of the skills stations,
tight time frame, guide availability, evaluations,
washroom locations and break time provided in
the learner package. Helpful to mention the guide
will be with them to move the group from one
station to the next quickly.
Tight timelines are always a challenge and good
communication was essential. Each team member
was given a two-way radio and along with a
separate team member to call out the starting
to move the groups from station to station.
Feedback from the participants and observers on the
day was very positive, which we attribute to three
key factors; robust planning, strong communication
and great team work. With a plan of action everyone
contribution. However, there were some wrinkles:
1) Volunteers unfamiliar with using two-way radios
missed some messages. In future two-way radios
would be placed at stations instead of with volunteers.
2) Most NOSM staff left with the students after the
to clear up for the whole retreat. In future we would
clarify roles and responsibilities and directly assign
staff for general clean up. The time required for set up
and tear down was also underestimated.
feedback session (nearly 100 with learners, faculty
and staff) it was hard to directly involve more than a
36
Expanding Simulation
few individuals. Using an audience response system
is one way to evaluate skills stations and participate in
4) Some of the larger stations (in terms of simultaneous
We would seek to have additional assistants to help at
stations with larger number of participants.
A number of parallel evaluation streams were
undertaken as part of the CCC retreat including
reviewing the whole program for CME purposes and
a parallel activity for internal quality assurance. The
simulation part of the retreat was also evaluated:
participant evaluation - questionnaires were issued
to participants during the simulation stations to
capture their opinions and experiences.
observer evaluation - senior NOSM staff sat in
with a number of station activities to review the
dynamics and quality of the teaching.
external evaluation - this was undertaken by the
holistic interpretation of the retreat both as an
observer and as the feedback expert.
Although only 27% of the learners submitted a
response those that did evaluated most aspects very
highly - see Table 1. There was a lower score regarding
the time available for each station and the amount of
adaptability to individual needs. The highest score
was accorded to the statement asking for more
opportunities to use simulation.
37
Chapter 3 - Capability: Disasters and the NOSM CCC Retreat
Table 1: participant evaluation of the simulation sessions - scores range from 1 (lowest) to 5 (highest),
response rate of 27%
The goals and objectives for the session as a whole were clear. 4.21
The goals and objectives for the stations were clear. 4.21
I was able to actively participant the stations. 4.39
I was provided with appropriate feedback from my tutors. 4.25
I was provided with appropriate feedback from my peers. 4.09
There was suitable range of different clinical encounters 4.43
The stations were forgiving of any errors I made 4.35
The stations were well paced and well structured. 4.38
The stations were rushed or otherwise short on time. 3.29
The stations addressed practical skills well. 4.22
The stations addressed professional issues well. 4.25
The stations addressed ethical issues well. 4.04
The stations were adaptable to my needs. 3.77
The stations provided some benchmarking on performance. 4.17
The stations were realistic and believable. 4.55
The stations were appropriate to my current level of training. 4.55
The stations were relevant to my future practice. 4.61
The use of mannequins was an important element. 4.56
The use of actors was important element. 4.64
I want more opportunity to use simulation. 4.65
Free text responses were also highly positive with
participants particularly valuing the hands-on and
clinical learning aspects of the retreat, not least
because they had expected (and in some cases
feared) a more didactic and less practical set of
experiences. Other strong positives included the
opportunity for interprofessional learning with mixed
groups of medical students and nurses and access to
skills and issues they would not have encountered in
the normal run of their training. It should be stated that
the retreat was expensive to run (although less than
in previous years) with the planning and execution of
the simulation activities requiring the most effort and
arguably providing the greatest value to the learners.
Observers moved between stations and groups
and made notes of their observations based on a
understanding and retention, Evaluation, Feedback,
An example of the observations made are shown in
the aggregate report in Table 2.
Mary Salisbury provided a report based on her
interpretations and evaluations of the retreat. Some
Educational Category Observed Behaviours
Students engaged and constantly learning by doing. Maximum respect of
instructor and colleagues observed. All learners very much involved. Time
for all to practice skills, Orientation clear direction, Invited students to be
active participants. Creates safe environment by allowing students to
make errors and correcting them supportively. Everyone was comfortable.
Slightly too many learners for resources at station. Clarity of language
Control of Sessions:
Session, Pace of Session.
Very much so – good leadership. Made sure to cover topic without hurrying. Offer
Controlled session well, moved at good pace to maintain interest, helped maintain
focus, forced students to stay on topic. Engaging style. Hands on re: pulse.
Did clearly at beginning. Immediately presented learning goals to
Understanding & Retention:
Organization of Material,
Clarity, Emphasis, Fostering
Self-Assessment
Clearly organized, didn’t allow digression, kept learners on track, encouraged
student participation. Brief presentation – expandable information. Clear,
organized approach, easy for students to follow. Students involved
Each student had chance to perform e.g. intubation tube.
Evaluation: Observation
Fostering Self-Assessment
Instructor constantly asked questions in a positive learner orientated way.
Students were comfortable in answering. Accepted feedback even if they
were wrong. Questioned. Embedded questions. Observed students completing
skills actively, provided correction and feedback. Non judgmental. Positive
at all times. Excellent back and forth between students and teachers.
Feedback: Minimal Feedback,
Behavioral Feedback,
Interactive Feedback
interactive throughout. Excellent coaching of physical skills. Excellent hands on.
Motivation, Resources
Table 2: observer evaluation for Station 6: Airway Management
38
Expanding Simulation
observations include: “Skill Stations were varied,
lively and interesting. In their brevity they made their
point and held the interest of participants evidenced
by the fact teams were as equally interested in the
Communication Skill Station as they were in the Shock
Station. The Mental Wellness Station while the most
sober station generated questions that were deeper
“Skill Station Masters, were integral to learning
and they, themselves, performed as instruments of
learning. They provided the resources necessary to
ensure Station success as evidenced by teams easily
suspending their disbelief in the simulation experience,
eagerly engaging with all needed resources with
materials, available and readily at hand. Skill Station
Masters provided the directions and objectives of
engagement in a clear concise manner as well as
coaching, encouraging or mentoring participants to
success as evidenced by the need for teams to ask
Station directions to achieve the objectives.“
Medical learners want to learn medicine in ways that
are accessible, meaningful and useful. Didactics are
of limited utility in meeting these needs. By providing
opportunities for developing practical skills in near-
real contexts and working in multi-professional teams
the 2010 CCC retreat transformed what had been
seen as a distraction from the learning process to one
that fundamentally contributed to and enhanced it.
The organisers have recommended therefore:
that all events involving learners, and in particular
group events like the CCC retreat, involve
substantial practical and educational dimensions
that are complementary to and augmenting of
their mainstream program experiences
that simulation in its many forms is an extremely
powerful heuristic and should be used more widely
and improve learning and assessment
that interprofessional experiences are highly
valuable and an important (although often absent)
aspect of healthcare education
that feedback and evaluation are a fundamental
part of the experience and should be planned and
implemented as such
that the logistics and planning of such events is
and structure of events both from procedural and
cognitive perspectives
that learning is a fundamental part of everyone’s
experience in such an event and opportunities to
develop and learn are afforded to all
Mary Salisbury, the evaluation and debrief consultant
had a number of her own recommendations:
1. Teams should be structured to maximize
resources, problem solving, decision making and
healthcare delivery capabilities.
2.
to learner performance “back home” should be
gathered. These data also help to identify the
impact of new knowledge and skills on patient
outcomes over time. This data would also support
future planning of retreat themes and needed skill
development and skills practice.
3. An advanced Shock and Airway Station should
be added to subsequent retreats. Obtaining
a “deeper drill” into the knowledge and skill
requirements is critical to the proper functioning
of providers in community-based settings. The
CCC retreat provided a fail-safe learning setting
to grow participant skills and critical thinking over
time; to reinforce skills, tools, and strategies that
are foundational to safe care in remote settings.
4. Course evaluations are critical to program
accreditation and the retreat is well positioned in
this regard. Planning should consider whether
there is a need for additional data and analysis
relative to perception, attitude and performance
data. Since attitude data are also prediction data,
information in this regard might assist NOSM
faculty in leveraging learning opportunities for
and community engagement.
Summary
In the end around 60 learners took part (some were
unable to travel due to weather problems - January in
Northern Ontario can be harsh and unpredictable) and
they each received 3 hours of the tabletop exercise
and 6 hours of the simulation stations. This equates
to 540 participant hours in simulation training over the
3-day retreat. The experience changed us all.
39
Chapter 3 - Capability: Disasters and the NOSM CCC Retreat
Capacity: Pathways for
Interactive Narrative Education
Chapter 4
Katherine Montgomery (2006) observes that:
“in medicine, narrative is essential for the transfer
of clinical knowledge and insight gained from
practice. The clinical case history not only provides
a means of working out and remembering what is
best to do for a given patient but also captures
experience and presents It to its audience. As
a result, case narrative is the primary, vicarious
means of shaping clinical judgment for new
learners and experienced practitioners alike”
Despite the primacy of narrative in medical education,
its overt use still gives pause to practitioners rooted
narrative in healthcare has, at least in part, meant that
its structured use in education is still in its infancy.
Narrative therefore remains a rich area for discovery
and exploration in support of healthcare education.
One area that is increasingly making use of structured
narrative is that of the virtual patient is an:
“interactive computer simulation of real-life clinical
scenarios for the purpose of medical training,
education, or assessment” (Ellaway et al, 2006)
This chapter describes the Pathways for Interactive
Narrative Education Project that developed a series of
free and open virtual patient cases using interactive
narrative as the primary instructional model. The virtual
patients were all designed to enable learners of many
levels to explore the many aspects of practice across
multiple disciplines in contemporary healthcare. The
Project was a collaboration between the Northern
Ontario School of Medicine (also leading in medicine
(midwifery & nursing), McMaster University (midwifery
and physiotherapy) and Confederation College
(nursing) to create a series of open and freely available
virtual patients, presenting both the core and the more
idiosyncratic aspects of experienced practice.
There were many reasons expressed by participants
for getting involved in PINE including:
Opportunities for curriculum innovation and
development
Addressing dominance of southern and urban
settings in teaching materials
Opportunities for faculty and interprofessional
development
Curiosity in exploring a novel approach to
educational practice
PINE made extensive use of existing tools allowing
for a focus on case and educational development.
and web-based virtual patient authoring, runtime and
analysis toolset) and VUE (a free topic mapping tool)
see panel for more information both tools.
The primary goal of the project was to create at least
60 virtual patients across a number of disciplines
with targets of 20 in medicine, 15 in midwifery, 15
in interprofessional topics and 10 in nursing. The
selection of these topics represented the areas of
interest and expertise of the project leads in the
participant different institutions, and the numbers
were negotiated based on the anticipated capacity
to recruit a mixture of teaching staff from the lead
institutions and a number of associated healthcare
professionals with an interest in education as case
authors who were then invited to a series of authoring
workshops. In the end more than eighty authors
(almost none of whom had authored a virtual patient
41
Exploring a PINE VP
“We all learn from salient examples and pithy
narratives; we remember these much more than
lecture content. When creating the PINE virtual patient
(VP) library, we encouraged teams of interprofessional
authors to base cases on key points arising from their
own remembered experiences.
such a real life case. It tells the harrowing story of how an
a life and death race, pushing the rural caregiver team
to their limits, struggling with limited resources. Playing
the case, some students initially ask why the narrative
describes local relationships and small town trivia, but
quickly realize these factors have real impact on their
decisions as caregiver. Navigating the case teases out
cognitive and problem solving elements, not easily
addressed through other educational approaches. Each
as on the day it happened.
Simple multimedia elements (daughter’s anxious
voice, paramedics’ scribbled transcript, economical
pop-up avatars) add dimensions to the case, while
keeping production costs low. Plain text narrative still
conveys a great story – but the plain face disguises the
teeter between life and death and they can, but not
necessarily will, save her.
After slaving for hours, crafting a great presentation or
workshop, many teachers are reticent to simply give
it away and naturally wish to protect our intellectual
This free (as in beer, Nelson Mandela and, most
importantly, lawyer-free) method is easily understood,
legally enforceable and provides graduated levels of
control that are more practical than plain copyright,
best explained on the excellent web site but most
and share-alike (SA). We have found that, with
SA, if you give a little, you get a lot including good
David Topps
online at http://pine.nosm.ca/mstartnode.asp?mapid=184
before) were involved in seven workshops and thirteen
small group authoring sessions. Workshop facilitators
were trained in the use of the VUE tool (see separate
panel) for capturing the case narratives and in thinking
structurally and educationally about the case narrative,
guiding and challenging the authors to do the same.
Trained facilitators worked with up to three authors at
a time (larger groups either led to disagreement, non-
productive discussion, or domination by one or two
individuals). Each workshop involved:
1. Identifying learning objectives to be addressed
2. Identifying a suitable outline narrative to act as a
vehicle for expressing the objectives
3.
steps in progressing through the narrative (the ‘critical
story path’)
4. Rendering these nodes and links using the VUE
tool and adding alternative branches and paths to
represent credible (but often mistaken or less than
optimal) decision paths the learner could take
5. Fleshing out the narrative content for each node and
revising the pathways and steps as needed to develop
a well paced and structured learning experience.
Post-workshop editing of the cases was undertaken
virtual patient.
multimedia elements were added such as counters,
rules, images, avatars and skins (visual layouts).
Each virtual patient scenario was then tested (and if
necessary adjusted) to ensure it ran as expected.
Authors were then given the chance to review and
suggest changes and these were combined into a
second editorial pass.
Once these steps were complete the virtual patient
was published to the PINE website in three forms:
PINE workshops
Chapter 4 - Capacity: Pathways for Interactive Narrative Education
43
1. running live from the PINE server
2. the original VUE map for download
3. a MedBiquitous Virtual Patient content package
for download
The 60 PINE cases were highly varied in terms of
intended purpose (teaching, revision, assessment),
advanced student to lay audiences) as well as subject
area. Exemplar cases include:
the role of a dietitian challenged with improving
the health of her community in a town with high
levels of obesity, smoking and drinking.
of rural physicians dealing with cases that go
faced having to save a colleague who was involved
the learner to help a disturbed patient in a stand
off with the police.
“Northern Hike” and “Brokeback Trapline”
dealt with issues in wilderness medicine where
preparation and improvisation would be required
of the learner to save friends and others whilst in
the backwoods of Northern Ontario.
“Timing is Everything” involved the learner playing
a midwife who must get her client to the hospital
but who doesn’t make it and has to assist in the
birth by the roadside.
a failing student who badly needed help while
small-group learning.
In addition to the narrative, learners were given more
develop strategies for problem solving by adding game
rules to the narrative pathways giving each decision
represented by a few simple constructs within the
Counters: these were a combination of one or more
variables representing a tangible (time, money,
drug dose, vital signs etc) or intangible (morale,
general health, reputation etc) factor affected by
the learners’ decisions. The value of any counter
could be changed at any decision point. One or
more rules could be set to trigger when a counter
got to a certain value and these rules could then
jump to a new node. For instance, one rule could
advance the learner once a counter got above
a certain level, or it could take them back to
an earlier point in the narrative or terminate the
activity altogether (such as when a patient died or
a resource such as time or money ran out).
Conditionals: these were rules that specify that a
certain node could not be accessed before certain
other nodes had been visited. For instance,
a learner may be required to review all of the
evidence before proceeding or they might need to
order some tests before they can see the results.
Random paths: these are when only one of a
number of options is randomly or semi-randomly
preselected. For instance, there might be a
condition or a case may simply play out differently
each time a learner works their way through it.
cases as free resources that were open for adaptation
by anyone wishing to do so. To manage this process,
the PINE Project used the Creative Commons
Attribution-Noncommercial-Share-Alike 2.5 Canada
http://creativecommons.
org) is an internationally adopted framework for
licensing materials somewhere between full copyright
and public domain. The use of this particular Creative
Commons license meant that PINE materials are
free to be used and reused by anyone, anywhere as
long as they give attribution, don’t commercialize the
materials and pass on the same licensing conditions
to any derivatives that may be created. By making
44
Expanding Simulation
OpenLabyrinth
and running virtual patients. The system allows users
to create a virtual patient activity as a sequence of
nodes or pages that are connected directly or via the
or step in the case narrative is represented by a node,
and the case can advance by the learner selecting
from the available options linked from each node.
represented as a decision tree. This can be enhanced
by using counters to track and control how a case
unfolds as well as avatars representing characters in
the case and quizzes and questions.
virtual patient standard for importing and exporting
cases from other systems. It can also import and
made available as open-source software and is
currently used by a number of institutions worldwide.
The Visual Understanding Environment (VUE) is an
Open Source project based at Tufts University. The
managing and integrating digital resources in support
of teaching, learning and research. VUE provides a
and sharing digital information.
A VUE concept map comprises of a series of boxes
each representing a concept or a part of a concept.
Relationships between topics are created using links
between the boxes.
decision trees by creating boxes to represent case
narrative nodes and the links between them. Although
VUE supports many other features only the boxes
(converted to nodes), text in the boxes/nodes and
the links (between nodes) will be imported, everything
else will be ignored.
http://groups.google.com/group/openlabyrinth
http://vue.tufts.edu
VUE
such a declaration, and by providing the materials
in an open data standard format, they can be safely
used and reused, adapted and changed and aspects
used in other applications with impunity so long as the
conditions of license are followed.
It was considered to be important for the project
to take this approach both from the recognition of
educators’ needs to tailor and align materials with
their local needs and contexts, and to ensure that
any liabilities and obligations regarding the use and
repurposing of the project materials were clearly
form that signed over any work they conducted for
the Project under a Creative Commons licence. They
also committed to not use any previously copyrighted,
A number of instances have already come up where
teachers wanting to repurpose a PINE virtual patient
were able to do with impunity because of the Creative
Commons licensing. It is anticipated that, since the
materials are freely available that even more use and
reuse is going on than we know about.
Economics are key to any kind of educational
PINE Project, in particular the time taken to develop a
case. Experience showed that the time commitment
instance on the extent of counters and rules as well as
nodes) but a typical breakdown would be:
The total production time ranged from 25 to 35
hours at a cost of ~$1,000 to $1,500 per PINE virtual
patient (based on the rates used in the project). This
A selection of splash screens from PINE virtual patients
46
(Huang, Reynolds and Candler, 2007) although the
amount of clinical expert input was perhaps less than
in previously reported studies.
Although the overt purpose of the PINE Project was the
development of the 60 virtual patient cases, there was
also a less explicit but possibly more important faculty
development and capacity building in the participant
organizations. With more than eighty authors involved
in seven workshops and other authoring sessions
right across the province the project was successful
in developing basic skills in their creation for all those
involved.
Although the impact of the project will take some
time to fully emerge, one notable early example was
the uptake of PINE virtual patients by the Ontario
McMaster and Ryerson universities). OMEC had a
common multi-site program and had redesigned the
third year of their 4-year program at the same time
as the PINE project was being run. The use of PINE
virtual patients enabled their students to:
Experience a range of standardized patient
encounters, to do so online and to have the results
of their work available for their tutors to analyze
and provide feedback across a wide range of
clinical and professional issues.
Experience relatively rare clinical situations (those
that learners may not see during the four years
of the program) that nonetheless are critical to
ensuring safe practice.
Experiment with the consequences of their
decisions in ways that are impossible in real-life
practice. In particular, they can make ‘mistakes’
that would rarely if ever be permitted in a real
clinical learning setting and then be able to go
back to re-try the case study and see where they
went wrong and why.
healthcare education and as such virtual patients can
more easily be seen as one modality among many in
patients and other modalities is partly in what is being
simulated and partly in how the learner is expected to
act and react within the simulation activity.
However, despite its many successes the PINE Project
was limited in a number of ways:
The focus was on the development of virtual
patients rather than their implementation, use or
content generation and the short timescale of the
Project.
Although it was written in to the Project plan the
use of advanced and experimental media such as
techniques and from graphic novels, video and
radio proved too complicated to realise given the
time and resources available.
The extended use of reporting on learner
behaviour within a virtual patient was not explored.
session but the development and testing of an
expert interpretation was not pursued again due
to resource constraints.
The medium of virtual patients is a rich and engaging
way to work with complex narrative and game-like
learning activities. By using free tools, developing
simple but effective approaches to design and
development, and engaging a wide range of authors,
the PINE Project was able to develop a wide range of
online educational activities with a limited budget and
in a short period of time. The Project was also able to
build capacity in the development and use of virtual
patients in many healthcare education institutions
across Ontario.
The future sustainability of the materials generated by
is still a living system the provision of the cases in
a downloadable and interoperable format ensures
longevity.
The PINE Project was funded by Inukshuk Wireless
between October 2008 and October 2009 with
additional funding provided by the NOSM IPE Program
and the hard work by the great many contributors to
the Project. All sixty PINE cases are available online
from http://pine.nosm.ca/PINE
Chapter 4 - Capacity: Pathways for Interactive Narrative Education
47
A camera array view of a mannequin
during a Sim Challenge session
Research: Integrated
Chapter 5
Simulation has come to form an essential part of
healthcare education but despite the many modalities
currently in use (such as mannequins, box trainers,
virtual patients etc) there is little or no integration
between these tools and systems. This limits their
users to somewhat siloed and disconnected ways
of working, which in turn limits the availability of
simulators and the return on (substantial) investment.
There is therefore an unmet challenge regarding
how simulation devices can be integrated into
‘simulation continua’ (Ellaway, Kneebone et al, 2009).
The challenge of multiple independent and isolated
simulation devices is not a new one. There are several
technical standards for simulation coordination such
both complicated and expensive to implement and
contain much non-negotiable military content.
The HSVO Project grew out of a conversation while
walking in the woods (while avoiding the bears) near
Sioux Narrows in 2007 between Drs Ellaway and
Topps and Kevin Smith. The vision was for a simple,
adaptable and extensible platform that would allow for
different simulators to be integrated and controlled by
a common and remote service to allow them to create
and run simulation activities that spanned multiple
devices and multiple locations.
A team was assembled to create a ‘network enabled
platform’ with funding from CANARIE for two years:
The Northern Ontario School of Medicine was the
on leading the project as a whole, educational and
simulation experience, distance, rural and remote
education and particular focus on virtual patients,
The Communications Research Centre (CRC) in
Ottawa brought skills in high speed networking,
virtual networks and lightpaths (high capacity
point to point connections) and multimodal video
conferencing.
The National Research Centre (NRC) IIT laboratory
in Fredericton NB had previously developed
SAVOIR, a system for launching web applications
on a single computer. This tool was redeveloped
as the hub for the HSVO Platform.
camera arrays allowing remote users to select from
a number of real and computer interpolated views
of a single scene (such as a surgical procedure).
They also developed a connection interface for
and Blema Steinberg Medical Simulation Centre
was involved as simulation experts and the testing
environment for simulation devices and activities.
speed network access to stereoscopic anatomical
images and a physiologic simulator.
iDeal Consulting involved a number of ex-CRC
and ex-NRC leaders acting in a consultative and
visioning role across the Project.
A number of other individuals and organizations were
also involved including Cork University in Ireland and
the University of Wisconsin. The HSVO Project was
funded by CANARIE for two years from 2008 to 2010
to create a network-enabled platform for integrating
and supporting research into distributed simulation.
49
The authoring and execution of scenarios potentially
consisting of multiple interacting devices and users
across multiple locations was the primary rationale
for the Project with particular applications using
mannequin, virtual patient and visualization devices
of various kinds. In order that the Project could
coordinate the educational and clinical requirements
for the platform with its design and implementation
the HSVO Project developed two main use cases:
Use Case 1: Active Participation. Groups of learners
at multiple locations work through clinical scenarios
that start with an on-screen virtual patient activity. At
or the values of counters embedded in the virtual
patient trigger the platform to move data (such as the
simulated patient’s vital signs) and then the locus of
Use Case 2: Active Observation. A group of
learners remotely observe an autopsy or an operation.
Using a camera array they dynamically select and
50
Expanding simulation
share different points of view. Visuals are rendered
responding to steps in the procedure or requests from
the tutor (push) or from the students (pull).
three major challenges to be addressed in the Project:
Simulators are highly heterogeneous with no standard
way of controlling, communicating or otherwise
expressing or exposing their data or functionality. The
that different simulation devices could communicate
and be controlled. This was addressed within the HSVO
to standardize the expression and transport of
commands, reports and other data between
simulation devices. A ‘bus interface’ middleware layer
between any given device’s functionality and the
HSVO platform and accommodating functionality not
natively supported by its device.
Simulators and the activities they support are
profoundly heterogeneous. While some devices allow
multi device activities to be authored and executed
using the HSVO platform. This was addressed by the
utilization and further development of an integration
and control tool called SAVOIR (Service-oriented
Architecture for a Virtual Organization’s Infrastructure
and Resources) that could simultaneously control
multiple devices, sessions and activities, as well as
the authoring of activities and the presentation of data
and communication services between participants.
There is currently no standardization of the technologies
or techniques for implementing simulation tools and
services. The HSVO platform therefore needed to be
technology- and context-independent allowing for
any programming language and network technology
to connect and integrate with the platform. The open
provide a technologically agnostic framework for the
input and output of HSVO messages and different
teams deliberately used different programming tools
to test its technical portability.
Simulations based around narrative and gaming
a free and open source virtual patient toolset. Any
kind of virtual patient design can be rendered and
integrated using this web-based toolset. As such
it represents other services including learning
management and assessment systems
Human patient simulators in the form of
consisting of a robotic mannequin and a number
of computers and adjunct equipment such as
radio-tagged ‘drugs’ and other interventions.
51
Camera arrays consisting of user-selected real
and virtualized camera views. These arrays were
3D visualization using the Remote Stereo Viewer
(RSV) and VolSeg tools (www.digitalanatomy.org)
to support stereoscopic and volumetric data sets.
Physiologic algorithms represented by a
mathematical model of hypovolemic shock. This
involves setting starting conditions after which the
patient will bleed out in a certain time. The model
changes based on different kinds of user actions.
Different simulation devices are connected through
a ‘bus interface’ that translates between what the
device can do and what the platform can do. Multiple
services can be connected to the HSVO network hub
(SAVOIR) over a common message bus implemented
using Enterprise Service Bus (ESB) technologies. This
allows for other devices to be added as new services
to extend the platform as long as they have some
controllable features. A software development kit was
created to support the creation of new bus interfaces.
The HSVO platform provides a web-based authoring
tool for creating scenarios that are made up of one
For instance, a simple hypothetical scenario could
involve learners starting off working through a
screen-based simulation and depending on whether
they make a critical decision the activity switches to
another device such as a mannequin for resuscitation
(for a bad choice) or further instruction (for a good
choice). Scenarios can include multiple instances of a
labyrinths running in different sites.
later use and reuse. A session is created by taking a
along with the participants and the network locations
or ‘endpoints’ where the different parts of the scenario
will be rendered. One scenario can be used multiple
times to create different sessions. During runtime, the
the state of the different services involved, evaluating
Sim Challenge
The whole point of the HSVO platform is that it
is used and there was therefore a need for it to be
evaluated in use by real learners and teachers. The
HSVO ‘Sim Challenge’ was created to engage tutors
and learners in using the HSVO platform in a variety
of different settings. This involved creating a series
of sessions that involved multiple sites in a variety of
simulation activities. So far Sim Challenge has run 9
sessions across 4 sites (Sudbury, Ottawa, Montréal,
Cork) running for more than 14 hours and involving 21
teachers and more than 80 learners over its duration.
The sessions have employed many different designs
and have been received with great enthusiasm by
both learners and tutors:
“It was fascinating working with the HSVO platform
extending the capability of simulation devices –
making dummies smarter! The HSVO network enabled
platform provides access to scarce resources, such
as large volume anatomic or image libraries, or
high performance compute clusters. By interlacing
simulation modalities, making best use of where each
one shines, we provided rich yet highly distributed
educational environments.
Initially running cases was very complex, monitoring
the complexity, and making it accessible to regular
clinical teachers. Making best use of the platform
therefore requires imaginative script writing, with
realistic scenarios and challenging cases. Although
this can be time consuming the actual process is
engagement was phenomenal even across multiple
sites and at throughout occasionally lengthy scenarios.
Bookending task trainers and expensive mannequins
with cheap resources, like Disney does for their
amusement park rides to extend the experience, makes
much better use of expensive simulation resources.”
HSVO clinical tutor
A mixture of HSVO services (top), the surgical
camera array at McGill Simulation Centre (above),
adjusting the SimMan mannequin (below), the
HSVO Project team (bottom).
any rules in the scenario, and issuing commands to
different services to change their state (such as start,
stop or exchange data). While physical devices are by
camera array) online devices can be launched in many
locations.
University’s medical school have healthcare education
and training responsibilities for the greater part of
Ontario and Quebec respectively with a combined
landmass of over 2 million square kilometers.
Although distributed healthcare education is clearly
an ongoing requirement for all professions and at
all levels in remote and rural communities, there are
many challenges in bringing high quality activity-
based education to them. The ability to locate some
devices in communities and provide access to others
remotely through an integrated learning environment
such as the HSVO platform is clear. Not only can
learners remain in their communities allowing clinical
services to be maintained but these teams can learn
and develop together and with other teams, and a
distributed community of professional learning and
development can be built and sustained.
The HSVO platform has been used to allow groups
of geographically distributed learners to come
together around different activities and simulation
tools. For instance, one activity involved teams
of learners from the Universities of Ottawa and
Cork to compare management decisions and their
outcomes in a simulated patient case to explore
clinical reasoning and the many differences in the
healthcare systems in Canada and Eire. Another
activity was more competitive between learners from
emergency case involving the disclosure of some but
not all the information available to each team. In both
cases the learners used simulation tools along with
communication tools (such as web conferencing).
The full capabilities and forms of use are under
investigation at the time of preparing this paper so
the ways in which the platform can be used has yet
to be developed. However, there are a number of key
53
applications that the platform is able to support:
1. Distributed participants – learners, tutors or
technicians are located in different locations and
interact through multiple services.
2. Distributed services – services and resources
used by the services (such as datasets and
across the network. For example, the RSV service
application can sit on a server in Ottawa while
pulling data from a server in Sunnyvale, California
and presenting it to a user in Thunder Bay.
3. Integrated services – services can share parameter
values. For instance, the same virtual patient may
be realized on multiple services by exchanging the
same vital signs between services even if services
present them or use them in different ways.
The challenge of simulation integration, at least at the
technical level is addressed through the development
and use of the HSVO network-enabled platform.
Middleware, logic, rules, messages and an extensible
connector framework make the platform highly
adaptable and extensible for adding services and
creating new and innovative scenarios and sessions.
Furthermore, the use of a simple hub-based model
addresses the needs of healthcare educators and
those of developers building services connected to
designed to be very simple and adaptable
HSVO allows web devices to be coordinated, to talk to
each other, to control each other, to use services from
elsewhere, to use each other as services. This means
that instructors and learners can have access to any
services and devices at any time and location thereby
supporting both scheduled and on demand practice
or instruction. In use the platform is proving to be both
engaging and useful with many new kinds of activities
and forms of working in simulation education and
training arising from the platform’s affordances.
See the HSVO Project website for more information:
www.hsvo.ca
Research: Virtual Worlds
Virtual worlds are computer-generated synthetic
spaces complete with lighting, gravity, props and
users work through one or more avatars, characters
that they control to act on their behalf. Although they
are similar to immersive computer games the critical
difference is that there is no intrinsic plot or rationale
for the virtual world; it is up to its users to decide what
they want to do there.
was funded by the Canada Foundation for Innovation
(CFI) and brought together a number of virtual world,
hapto-visual and educational tools and platforms as
part of a common integrated research platform. A
key part of this was the creation of a dedicated island
from the island below). The island was created with
a number of buildings (hospital, family health team
clinic, lecture theatres) as well as social spaces such
as a tepee and a set of cabins in the treetops.
of a holodeck (based on the holodeck in Star Trek this
is a space into which virtual objects can be projected)
engine to create and control interactive simulation
environment. Called ARIADNE this toolset could
accordingly. For instance, clicking on a patient may
start an examination of them or get them to lie down.
The net result is a relatively low cost immersive
environment that can be used for a range of purposes.
The only limitations are a) the amount of available
limitations in control and subtlety within the world.
Various views of Nossum Island (left) and the ARIADNE platform (right)
55
Research: Haptics
Some important clinical procedures such as lumbar
punctures, joint injections, or endometrial biopsies
cannot be taught or learned by observation – there
is little to see; it’s all about feel. Compounding this
challenge, the teacher cannot even lay a guiding
hand on the learner’s hand without spoiling the
proprioceptive and tactile sensation for both learner
and teacher, never mind the additional patient
discomfort caused. Assessment of progress or
competence in performing such procedures tends to
be subjective, indirect and inaccurate. In a distributed
medical education environment, personnel skilled in
teaching these procedures are often not available
and cannot feasibly be moved from community to
community.
We developed a dual control haptic simulator, using
affordable and robust components, along with some
anatomically accurate 3D models, to teach and assess
such procedures. The haptic feedback means that
teacher and learner can sense surfaces and densities
as they manipulate the controls. The dual controls are
Internet-based, enabling remote specialty mentoring,
even over vast distances. Additional features, such as
simulated “x-ray-vision” so that novice learners can
see as well as feel deep tissue structures, facilitate
graduated learning. Precise metrics on vectors and
forces allow truly objective assessment, which was
previously impossible through tutor observations.
We encountered challenges with limited servo-motor
feedback in certain dimensions, resolvable with
a widely accessible and cost effective programming
library. These problems are soluble and this project
has great potential for revolutionizing remote teaching
of key clinical procedures across remote and rural
communities.
and several views of the spinal tap model in use
simulator any of us encountered
Sustainability: Opportunities
and Challenges for NOSM
Chapter 6
57
The previous chapters paint a rich picture of the many
different forms of simulation being developed and
used at the Northern Ontario School of Medicine.
In doing so, we have also sought to identify the
limitations and challenges faced in building and
sustaining a comprehensive simulation program
in a northern, rural and remote region. This chapter
reprises these issues to identify opportunities for
building a more sustainable and long-term approach
faculty and the many communities it serves.
NOSM, like most other North American schools,
follows an apprenticeship model of clinical learning,
the core of which involves learning directly from clinical
preceptors. Although NOSM has particular strengths
in providing such experiences, the apprenticeship
model on its own is less than optimal in developing
skilled and safe approaches to practice for a number
of reasons:
Bedside learning must always place the patient
it is intrinsically limited and variable in meeting the
needs of learners. Simulation, by being learner-
centric, can ensure structured and adaptable
learning experiences that best meet learners’
needs.
to those patients presenting at any given time.
Such presentations vary by season, location
and general variations in population health. With
accreditation frameworks requiring greater levels
of assurance regarding the spread and quality of
learner encounters, it is increasingly impractical to
rely exclusively on bedside encounters. Simulation
can augment the learners’ exposure to cases to
counter this reduced access to real patients in the
patients they do see.
stays. There are new and changing roles such as
nurse practitioners and paramedics who are taking
on tasks previously carried out by physicians.
a shrinking range of experiences. Furthermore,
some procedures are infrequent but essential for
learners to master, such as central line placement,
intra-osseous infusions or compromised airway
encounters and presentations is too unreliable in
providing these essential learning experiences.
Simulation allows learners to develop skills that
might be unavailable through bedside practice.
Although NOSM has been able to provide high-
quality clinical experiences in its early years, as its
programs grow there will be increasing competition
for practical experience, further exacerbating
the other challenges noted here. Simulation is
a powerful and adaptable educational modality
for augmenting and accommodating gaps and
limitations of bedside teaching and learning. It also
of stressful circumstances through structured
rehearsal and feedback.
Simulation has grown substantially in the last decade,
not just in the range and sophistication of simulators,
but also in developing effective practice and an
evidence base for such work. The systematic review
conducted by Issenberg et al (2005) distils this down
to a few key points:
medical simulations facilitate learning among trainees
when used under the right conditions”
This same review distils ten critical conditions for
effective use of simulation:
1. Provide feedback during the learning experience
with the simulator
2.
simulator
3. Integrate simulators into the overall curriculum
4.
5. Adapt the simulator to complement multiple
learning strategies
6. Ensure the simulator provides for clinical variation
(if available)
7.
controlled environment
8. Provide individualized (in addition to team) learning
on the simulator
9.
learners to achieve using the simulator
10. Ensure the simulator is a valid learning tool
The place of simulation in the wider educational
“The evidence also shows that simulation-based
medical education complements, but does not
duplicate, education involving real patients in genuine
settings. Simulation-based medical education is best
employed to prepare learners for real patient contact.
It allows them to practice and acquire patient care
skills in a controlled, safe, and forgiving environment.
Skill acquisition from practice and feedback also
affective educational outcomes that accompany
clinical competence.” Issenberg et al, 2005, p26
More recently simulation has been considered as part
of a larger learning continuum. Following this model,
we can move from purely bedside encounters to
environments before transferring to the clinical
As with most other simulation programs, the feedback
from the learners who have been involved in NOSM’s
simulation activities has been very positive. But
indicators of success come from more than just
satisfaction ratings. Both learners and teachers have
been forthright in their recognition of the power of the
hands-on experience:
“you can talk about airway management all you want
in a presentation but until someone actually lays hands
on a nasal airway … you can describe how to put it in
all you want but until someone puts one in there’s no
comparison. You have to have a hands-on component.
Expanding simulation
58
A progressive use of simulation in healthcare professional education (after Ellaway et al, 2009)
Bag-valve-mask is described in every book but go
ahead and do it. You cannot do that on a theoretical
basis, you have to have hands-on and that’s where task
trainers and the mannequins come into play” (NOSM
clinical skills tutor)
verisimilitude is an important aspect of implementing
simulation sessions. There are some aspects that
are important to reproduce, especially when dealing
with altered time perceptions in crisis management
situations. But ‘appropriate’ is the key word here;
‘suspension of disbelief’. Furthermore, higher levels
For example, one of the most emotionally and
pedagogically powerful virtual patient cases used
widely around the world, the Sarah Jane case, uses
plain text to portray its narrative. High-tech is not
always the answer, for example Dr Kupsh uses
pigs’ feet and turkeys in some clinical skills sessions
because their tactile qualities are better than those of
man-made trainers.
Closing the gaps found when evaluating our programs
ED-2 directive. Simulation can help to address some
of these needs. But simulation cannot do this alone;
it is important to integrate such experiences with real
patient care as noted by Issenberg et al.
One of the core principles that the NOSM simulation
group has been promoting is that of mixed modality
simulation. It has been observed that there are
valuable educational facets that can be addressed
by using combinations of simulation modality, e.g.
standardized patients along with task trainers, virtual
patients along with high-performance mannequins
(Kneebone, 2003). Not only does this afford more
varied use of simulation resources, it gets us closer to
the ideal of a continuum of simulation connecting to
bedside practice.
simulation, no matter which modality of simulation
is used. This may involve as much time as the
simulation itself. Feedback should also look at
process issues, not just the clinical content, especially
in an interprofessional environment. Feedback can
be based both on direct observation by the tutor and
other learners, and (for simulation modalities that
provide them) more objective metrics. For example,
detailed metrics on every action each learner makes
of every event and action registered by the mannequin
during a scenario.
These logs can be essential when learners dispute
the feedback provided, which is surprisingly common
as we are all too often ‘sure’ that we did something
when we actually only thought of doing it. Video
recording provides another objective log in this regard
but integration with other metrics is more useful.
can be expensive for what they provide. The NOSM
simulation group has been working on more practical
and cost-effective approaches to this challenge. See
Chapter 2 for further details on this work.
The activities described in this publication have
demonstrated value and great potential for educational
impact. However, while the NOSM inventory of
there is a growing use of the facilities, maintenance
activity has fallen to stipendiary clinical faculty. Not
only does this result in faculty burnout, it is also costly
compared to paying staff rates for such services. This
is exacerbated by the few champions being almost
exclusively located in Sudbury. Thunder Bay therefore,
despite having the physical resources, has very little
on the ground simulation activity.
For a simulation facility to be viable and useful, it
requires a dedicated member of staff who manages
the lab, takes care of the equipment, sets up, does
the booking, cleans stuff, makes sure equipment
doesn’t disappear and so on. It is also important to
develop a cadre of preceptors who are comfortable
with using simulation modalities in their teaching. This
teachers, who can then champion these activities
and model them to their peers. None of this is free;
operational support of the host institution.
59
Chapter 6 - Sustainability: Opportunities and Challenges at NOSM
A common issue for most simulation centres is lack of
space and NOSM is no exception to this rule. However,
rather than clamouring for more on-site space, better
use could and should be made of existing space.
Other innovative and collaborative approaches
should be explored in conjunction with our NOSHN
partners. Modular, mobile, and hybrid approaches to
simulation have seen some success in other regions,
(Ontario’s medivac organization) in Northern Ontario.
Such approaches would certainly be able to extend
simulation services to many of NOSM’s communities
but would still be dependent on a core simulation
program within the School.
Extending our simulation activities out to our
communities clearly holds great promise but raises
further practical issues such as security, insurance
and liability when taking simulation equipment out
of the lab and on the road. Policies covering these
issues need to be agreed between all parties involved
before engaging in any exchange or off-site activities.
Participants in the NOSHN network are exploring this
area but clearly more work needs to be done to support
meaningful, open and assured ways of collaborating
around simulation. On-site security is also an issue.
The simulation centre inventory includes expensive
and hard to replace equipment as well as expired (non-
narcotic) medications, recycled for teaching purposes
that can still pose a safety risk in the wrong hands.
of equipment following simulation sessions, the need
for dedicated centre managers is even greater.
Despite the growing need for simulation, its uptake at
NOSM has been patchy and has suffered from a lack
of cohesive effort between portfolios. For instance,
to establish an inventory of simulation equipment.
But much of this equipment lay in storage until it
was unpacked and deployed by the newly-formed
NOSM simulation group in 2009. Change is shown in
the growing collaboration between portfolios. As an
example, this publication was partly funded by CHPE
and involves contributions from the undergraduate,
postgraduate and informatics portfolios as well as
faculty from human and clinical sciences.
Educationally the key issue is that of curriculum
integration. While the MD program uses standardized
patients and task trainers in phase 1 and the occasional
mannequin session in phases 2 and 3, it is not
particularly integrated with the curriculum at present.
NOSM’s residency programs make greater use of
simulation but this remains largely bottom-up and
approach to its integrated use. The Continuing Health
Professional Education (CHPE) portfolio recently
appointed an interprofessional simulation lead and
have been running an interprofessional simulation
program of training events and as such are already
taking a more integrated approach. A strategic review
of NOSM’s approach to simulation has recently been
commissioned by the three educational portfolios to
address issues of alignment and integration.
community engagement, with the development of the
Northern Ontario Simulation for Healthcare Network
(NOSHN) and the work it has subsequently supported.
Research and development projects have also been
critical to developing capacity and energy around
simulation although translation into practice has been
limited so far. However, most of the work so far has
focused on Sudbury and there remains much work to
be done in building capacity in the west. The scope
of simulation development should also be expanded
to include all NOSM teaching sites such as the CCC
sites (Timmins, Kenora, Sault Ste Marie etc).
As the interest in and applications of simulation
grow within the School the next logical step is to
develop a strategic plan for simulation that involves
all stakeholders. Such a plan would target available
resources on key strategic initiatives as well as
establishing a core program around which these
initiatives would be sustainable.
Investment
investment (ROI) from simulation is the balancing
arising from the use of simulation, they clearly come
at a cost. A key part of taking a strategic approach
to simulation at NOSM is analysing the returns on
the investment made, which in turn requires regular
60
Expanding simulation
evaluation and program review.
A common concern for simulation programs is that
there can be quite generous funding for equipment
the operation and routine maintenance of this same
equipment. While infrastructure capital funding has
been relatively generous during NOSM’s startup
phase, support for operations has subsequently been
somewhat leaner. There may be some opportunity
for cost recovery around particular courses and
programs such as the various mandatory life support
courses. But given the logistic challenges of Northern
Ontario, we should careful about the degree to which
has found that, while cost recovery is often feasible,
The Ontario government has provided targeted funding
for simulation over the last ten years for both the
northern nursing programs and the Toronto teaching
School to an extent through its creation of simulation
centres in our partner colleges and universities and
thereby a solid ground for the NOSHN network. The
latter has had limited impact outside the hospital
network at which it was originally targeted. NOSM has
made capital investments in equipment and facilities
but is only now taking a strategic approach to the
integration of simulation into its programs.
Investment in simulation can be both easy and hard.
Easy in as much as physical simulators and the
simulation environment can be very visible (compared
PR and donation opportunities as well as a focus for
institutional activities. The challenges over funding
come from within and without. Within simulation the
case is still being made as to how it can be best used
and what the best approaches to running cost effective
and sustainable simulation programs are. Evaluation
and research therefore remain essential components
of simulation operations. The external challenge
comes from the transitional status of simulation in the
eyes of accreditors and funding agencies. Although
the case for simulation has been well made, it is
not required in the same way say as it is required in
the airline industry for safe practice. Until simulation
becomes mandatory its status and the argument for
investing in it remains an area of contention.
The many projects and activities described in this
publication demonstrate that NOSM has made a strong
but uneven start in using simulation in support of its
educational programs. Despite the many successes
reported in this publication, there is still much to do to
create a sustainable NOSM simulation program. Key
factors in pursuing this goal include:
of developing future health professionals
Trained and enthusiastic clinical faculty are in very
short supply in general and particularly so in some
locations
Dedicated staff are required to make the most of
the simulation labs and facilities
Opportunities to use simulation must be extended
to all of the communities NOSM serves
Curriculum integration is somewhat lacking but
beginning to be addressed
Evaluation and review is an essential part of
program development
Although a simulation network can initially be
developed relatively cheaply, it needs support to
be much more than a forum for discussion
External funding is important in developing an
appropriate simulation program for NOSM and its
many participants and stakeholders
The Northern Ontario School of Medicine remains
committed to the highest standards in health
professional education and training and simulation
has demonstrated a wide range of simulation
activity ranging from operations to research at many
educational levels and across multiple programs
and professions. While there is much innovation and
hard work, a more strategic approach to simulation is
required and indeed this process has already begun. It
is hoped that in years to come that this work described
will form a strong foundation for a more robust and
aligned approach to simulation in the north of Ontario.
61
Chapter 6 - Sustainability: Opportunities and Challenges at NOSM
62
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Acknowledgements
We would like to thank the following for their input and
support for the work described here
At the Northern Ontario School of Medicine: Suzanne
Abourbih, Kelley van den Broek, Sue Berry, Judy
Baird, Bob Rubeck, Danielle Bélanger and lastly Roger
Strasser reviewing the manuscript and providing the
foreword.
HSVO Project: Jeff Blum, Martin Brooks, Scott
Campbell, Jeremy Cooperstock, Bryan Copeland,
Heinrichs, Justin Hickey, Bobby Ho, Michael Kirlew,
Kapildev Misra, Aaron Moss, Adriana Olmos, Swaroop
Patnaik, Alison Peek, René Richard, Mark Richards,
Shorten, Kevin Smith, John Spence, Bruce Spencer,
Zhang, Aislinn Joy, Michael Kirlew
PINE Project: Jacques Abourbih, Michelle Addison,
Elizabeth Allemang, Cindy Backen, Ren Barrett, Susan
Bailey, Mike Bédard, Nicole Bennett, Janet Binette,
Jonelle Demers, Sandra Dewsberry, Patti Dickieson,
Judith Horrigan, Eileen Hutton, Shirleen Hudyma,
Sharon Jaspers, Susan James, Heather Jessup-
Felcioni, Kristen Jessiman, Irene Koren, Terry Koivula,
Ellen McCooeye, Patty NcNiven, Joanne Mellan, Rob
Puhalski, Maurianne Reade, Shelia Renton, Anne
Robinson, Judy Rogers, Tara Rollins, Anita Sabados,
Denis, Denise Taylor, Bronwen Thomas, Edan Thomas,
Vicki Van Wagner, Debra Walker, Karline Wilson-
Mitchell and Richard Witham
Christie, Janet Binette, Kristen Jessiman, Robert
Bentzen, Dan Draper, Barb Morrison, Jocelyne Bédard,
Johanne Carbonneau, Johanne Messier-Manne, Judy
65
Parry Sound, January, 2010 - Mathieu Seguin
informatics innovations
Simulation has been shown to be a safe and effective way
of training and assessing healthcare professionals with a
number of key strengths including the provision of meaningful
and constructive feedback on performance, supporting
presentation, enabling multiple strategies and controlled
benchmarks and high validity. A common challenge is that the
geography and resources available require providers to work
together to ensure the quality and sustainability of simulation
for healthcare education. This report discusses both the
simulation operations and the innovative work carried out in
and around the Northern Ontario School of Medicine and its
partners to demonstrate the thinking, skills and commitment
to its use in health professional education.
NOSHN NIRD
NOSM Informatics
Research & Development
