A Focus on Simulation

Alyssa Haywoode

Date

January 3, 2024

Topics

Area of Expertise

Simulation-Based Education

Using manikins, simulated participants, virtual reality, and AI, the MGH Institute is teaching students to provide comprehensive patient care.

Simulation can be nursing students treating a manikin that has a heartbeat and working lungs.

Simulation can be physician assistant students working with simulated participants played by actors.

Simulation can be interprofessional teams of students utilizing virtual technology to strengthen clinical or communication skills.

But no matter its form, simulation at the MGH Institute always means building on fundamentals to achieve cutting-edge education and innovative approaches to train students, develop educators, and strengthen team-based care or research practice.

Suzan Kardong-Edgren, a simulation expert and an associate professor of health professions education within the IHP School of Healthcare Leadership, says 2009 was a touchstone for the field. That’s when she joined the research team behind a two-year, randomized national study examining whether clinical training hours for prelicensure nursing students could be replaced by simulation.

The question was a pressing one for the study’s sponsor, the National Council of State Boards of Nursing. Nursing programs were competing for limited numbers of clinical training rotations. When rotations could be secured, the experiences they offered were inconsistent.

The study was completed with nearly 700 nursing students from 10 schools around the U.S., and its findings broke new ground.

“What we found,” Dr. Kardong-Edgren says, “was that you could safely substitute up to 50% simulation for traditional clinical—if we used high-quality, vetted scenarios with trained faculty who used a consistent debriefing methodology.”

Involved with the major simulation organizations—including the Society for Simulation in Healthcare and the International Nursing Association for Clinical Simulation and Learning— Kardong-Edgren has one eye on strengthening simulation practices and one eye on simulation’s future, including virtual reality with video-game style headsets and haptic gloves.

“My ultimate goal?” she says with a wry smile. “High-quality simulation for all.” “Simulations are designed to be learning spaces where students can make mistakes, learn from them, and try again, so that they can improve their skills through deliberate practice,” says Rachel Pittmann, the assistant dean of interprofessional practice. “Having a safe environment and a rapport with faculty is critical to learning. And debriefing afterwards is where all that learning gels.”

Simulation plays a vital role for students just beginning their education, notes Meaghan Clapp, an instructor of physician assistant studies.

“We’ve incorporated more simulation experiences with manikins and actors to better prepare our first-year students for the clinical rotations they’ll be doing in their second year,” she says.

And for second-year students who are doing clinical rotations, the department has added simulations to supplement their training, too. “Over the last few years,” Clapp explains, “we’ve identified areas and competencies that students don’t encounter at clinical sites, so we’re using simulation to address this.”

Simulations can also involve people modeling real-world clinical experiences.

“Through the IHP’s nursing program, we had what we call gynecological teaching associates,” Clapp says, referring to the actors who stand in as patients, also known as simulated participants (SPs). “A few years ago, I worked with simulation participant program manager Tony Williams, and we were able to build a group of male teaching associates, so our students were able to learn about both female and male exams.”

Williams is an expert stage manager. He consults with faculty, juggles educational objectives, and recruits and trains SPs. Some of these actors are retired nurses, doctors, and physical therapists, or trained stage and screen actors. Others are newcomers who he trains from scratch.

Williams helps make simulations feel real enough to help students learn and experience the “Aha!” moments that will help them become better providers. One key achievement has been creating a diverse pool of actors to better simulate the patient pool that IHP graduates are likely to serve, especially patients whose first language is not English

“Traditionally, simulations invite students to guess what a patient’s diagnosis is,” Williams says. “But health care is much more comprehensive and has so many more elements, so we don’t just limit simulation to diagnostic procedures. We simulate conflict resolution, microaggressions, interprofessional education, and delivering bad news.

“We’re working toward a unified approach to healthcare simulation instead of being siloed and compartmentalized,” he continues. “We’re seeing more use of SPs across the Mass General Brigham system in continuing education programs and to train staff, helping current, experienced healthcare professionals to continue to grow and adjust to society’s needs.”

Meeting these needs is a crucial part of assistant professor of nursing Maureen Hillier’s simulation work, which stretches from classroom instruction to tackling tough social problems. Dr. Hillier, a certified healthcare simulation educator, brings her students to the Simulation Lab in the Shouse Building to learn about pediatrics, where care can be highly specialized to meet the needs of children of all ages who have different medical conditions.

In one simulation, the patient is a “baby,” a manikin with computer-generated symptoms. The baby’s parent is played by a convincingly anxious actor. Another simulation features a six-year-old boy, also a manikin, who is neurologically atypical. He’s a foster child, and he’s having trouble breathing.

Hillier’s students ask questions, make diagnoses, communicate with “family members,” and work with colleagues. Afterwards, students debrief, reflecting on what they did, what they learned, and what they might do differently.

“We can also make things happen in simulation classes that students may not encounter on their clinical rotations,” Hillier says, such as ensuring that every nursing student is exposed to conditions like dehydration and restricted airways.

“The biggest benefit is that there’s no risk of harming patients,” she says. “It’s a low-stakes learning environment that gives students the opportunity to become better.”

Nursing faculty watching students work with a simulated participant in the IHP's Simulation Lab. — Nursing faculty oversee students working with a simulated participant in the IHP's Simulation Lab, located in the Shouse Building.

Woman holding a virtual reality headset — A pilot study conducted by Assistant Professor Rebecca Inzana’s on using virtual reality headsets was well received by faculty.

Students talking with faculty member — Physician Assistant Studies Chair Josh Merson (left) debriefs PA students after a session with a manikin.

Simulation can also be used to expose students to what Hillier calls “low-frequency, highly acute events.” One example is the simulation she runs at Boston Children’s Hospital, creating a scenario where nurses can practice providing end-of-life care in the pediatric intensive care unit.

Hillier has started using simulation in her ethics class, creating an opportunity for students to grapple with course topics like informed consent. And thanks to funding from the IHP, she completed a year-long, National League for Nursing simulation fellowship in 2021. It was a deep dive into simulation and mentoring faculty members. Since then, she has worked with Jason Lucey, assistant dean of the School of Nursing’s advanced practice programs, to develop an opioid simulation that has been used with nurse practitioner students, which they shared at the International Nursing Association for Clinical Simulation in Learning.

In the entry-level Doctor of Occupational Therapy program, simulation is integrated with innovative student learning activities targeting the so-called “soft skills” of increasing trust, connections, and inclusion in client care. Assistant professor Cathy Leslie points to a quote from the Centers for Disease Control and Prevention: “Choosing to use jargon is an act of exclusion. Using clear communication advances health equity.”

In Leslie’s class, “Communication, Collaboration, and Therapeutic Modes,” students work through simulations with standardized patients to become better communicators. They learn to connect with patients whose problems include anger, concerns about suspected child abuse, depressive symptoms, and suicidal ideation.

“There is strong research showing the connections between healthcare providers’ use of effective health communication and patients’ health outcomes, safety, and participation as part of the healthcare team,” Dr. Leslie says. Providers who use plain language and other clear communication skills, she adds, can improve outcomes for patients who have low health literacy.

In her “Professional Reasoning” class, Emily Eddy, the entry-level OTD’s program director, includes simulations that weave together different settings and require students to interpret diagnostic information through the lens of justice, equity, diversity, and inclusion (JEDI).

Students consider the cultural and social contexts of clients’ lives, including education levels, socioeconomic status, and health insurance coverage, as well as patients’ access to food and transportation and whether they live in heat deserts.

“Students reflect in small groups and in the larger class on how the real-life facts of clients’ lives impact healthcare delivery and patient education,” says Dr. Eddy. “And we’ve adopted a modified version of the simulation Basic Assumption from the Center for Medical Simulation to read, ‘We believe everyone participating in simulation and debriefing activities at the IHP is intelligent, capable, and wants to improve.’”

Using Artificial Intelligence

“Define simulation,” Shuhan He asks.

An emergency medicine doctor and director of the Institute’s Healthcare Data Analytics program, Dr. He teaches a class in which he and his post-professional students explore the intersection of health care and artificial intelligence using case studies and scenarios.

“I think of data modeling as a simulation of reality,” he says. “We’re trying to extract meaningful insights from the data to improve care. For example, we know that septic shock can be a fatal disease, and every hour that we delay care, there’s a five to 10 percent increase in fatality, so it’s really important that we identify these cases earlier. And we can do that by using data to model real cases and understand where numbers are helpful and where they can be deceiving.”

Artificial intelligence helps by bringing the computing power to analyze healthcare data, while providers bring their ability to interpret that data and use it to improve care.

Simulation will also help providers function in remote health care, He says, by creating scenarios where students and providers can practice monitoring groups of patients they can’t see in person.

“Care has changed to be hybrid, remote, and digital,” He says. “And simulation has to reflect that reality.”

Rebecca Inzana, an assistant professor in the Center for Interprofessional Education and Practice, is focused on simulation-based education through the lens of virtual reality. Students and providers can actively learn by strapping a headset over their eyes, picking up handheld controllers, and administering care in bespoke simulated healthcare settings across the globe.

Inzana analyzed faculty perceptions of using virtual reality to meet interprofessional and JEDI learning competencies as part of her doctoral work in interprofessional learning and practice in health care at Lesley University in Cambridge.

“I was curious about how we at the IHP could leverage technology to address clinical learning in the context of the pandemic and in the larger context of challenges finding clinical placement sites,” she says. “Virtual reality is still evolving, but it’s being used in medicine and nursing education, as well as in first responder and military training. So, is there an interest and opportunity to use this technology for learning across all health professions?”

Inzana wanted to know if virtual simulations could add to the toolbox of educational approaches thoughtfully addressing JEDI and interprofessional learning goals. To find out, she applied for and won a grant from the Association of Schools Advancing Health Professions to fund a pilot study of IHP faculty members’ perceptions of virtual reality.

Faculty participated in two virtual reality scenarios: a pediatric emergency room case treating a child and family of color, and a community health scenario in a temple in Bangladesh.

“The faculty entered the simulations in interprofessional groups,” Inzana says. “They immersed themselves in the virtual environments, engaged with avatars representing patients and family members, made clinical decisions, and functioned as a team.”

The results: faculty were impressed. They agreed that virtual reality simulations could be useful in meeting their interprofessional learning and JEDI objectives for students.

“There’s also the potential to be free of geographical limitations,” Inzana says. “As long as there is reliable Wi-Fi, you can have faculty and learners participating from anywhere.”

“We’re going beyond the typical uses of simulation in preparing health professional trainees for practice,” Dr. Reamer Bushardt, the IHP’s provost and vice president for academic affairs, says about simulation’s role in educating students at the Institute and the faculty’s trailblazing work in this space.

“We consider the complexities that exist within the practice environment and the nuances of effective interpersonal communication. We are preparing students for success both as independent practitioners as well as members of healthcare teams. Our approach includes helping students learn to connect with individuals and their families during their worst or happiest moments. We also want our students to be able to see how systems and practices can harm some individuals or groups, while unfairly advantaging others, then be prepared to do something to address inequities.”

Educating Educators

Janice Palaganas is an international figure in simulation who has helped shape the field. Now, as a professor of health professions education, she spends much of her time thinking about how simulation-based education can expand at the IHP beyond her teaching and scholarship commitments.

Dr. Palaganas and Kardong-Edgren, her department colleague, are busy conducting sweeping research on a broad range of topics, including virtual simulation, distance simulation, the impact of COVID-19 on simulation, and styles of debriefing.

One key strategy, Palaganas says, is creating more ways for simulation practitioners to collaborate, share knowledge, and put that knowledge into action. To foster this at the IHP and across Boston, Palaganas is forming the Research on Experiential-Based Education Lab, or REBEL.

“The focus of the lab is studying simulation modalities, and which ones are more effective for different learning objectives,” she says, noting they are looking to collaborate with clinical partners who would work with students and run simulations in patient care settings, called in-situ simulations.

Faculty in the HPEd department are committed to educating educators utilizing a wide range of learning modalities, doing it through its PhD, master’s, and certificate programs, all of which have simulation tracks.

One HPEd student, Dawn Wawersik, first encountered simulation when she served in the Navy, and then fell in love with the field as a clinical nurse educator.

“After that, COVID-19 happened, which was a great opportunity to get my PhD,” Wawersik recalls. She enrolled at the IHP specifically to work with Palaganas and Kardong-Edgren.

For her dissertation, Wawersik looked at the individual values and organizational factors that affect error reporting. Her finding: “You’re never going to move error reporting very far along without boosting students’ moral courage.”

That raised a basic question: Can moral courage be taught? To find out, Wawersik did a qualitative study, surveying nursing faculty. Her findings were that courage could be woven into the curricula. She then created a simulation where nursing students would find an error, to see if they would report it.

“They did report,” Wawersik says. “They did have moral courage. But the times that they spoke up the most were when they trusted their instructor. It really comes down to trust and risk perception. And what I perceive as a risk is different than what you perceive as a risk. So, organizations have to ask how they can address that.”

Wawersik, Palaganas, and several other colleagues recently published these findings in the Journal of Healthcare Leadership.

Thanks to her IHP experience, Wawersik decided to combine her passion for simulation and educating educators, becoming the executive director of the Interprofessional Simulation Institute at Nova Southeastern University in Florida.

Now, as an alum and a colleague, Wawersik’s ideas and work help organically expand the IHP’s simulation community, which is part of Palaganas’ long-term plan.

Palaganas attends workshops and conferences with her students. She supports them to make presentations, doing dry runs beforehand and debriefings afterwards.

“I want students to be prepared so that their light can shine. The most exciting part of this work for me is positioning my students as leaders”—which, she notes, is also an ideal way to ensure a bright future for the many faces of simulation in healthcare.