To Err Is Human: The Value of Simulation in Pharmacy Education - Literature review Example

To Err Is Human: The Value of Simulation in Pharmacy Education. Traditionally, pharmacy education has thrived on didactic, oriented, and knowledge-based training. These methods, though essential, are not optimal because they fail to provide opportunities to develop skills in the practical identification and treatment of drug-related problems besetting the present-day practising pharmacist (Barzak, Ball and Ledger, 2001). The quality and effectiveness of traditional pharmaceutical training came under scrutiny with the report “To Err is Human” presented by the Institute of Medicine (IOM) in November, 1999 underscored the economic and clinical consequences of medication error and misuse (Bootman, 2005). The type of error is distinguished in this report as the error in execution and error in planned action. It identified drug-related morbidity or mortality as “the silent disease in America,” which the report stresses must be addressed by a new health education system that seeks to resolve the following identified weaknesses among students: (IOM, 2003 in Bootman, 2005) 1. Uneducated to work in teams for treatment of chronic disease; 2. Not trained to use and apply evidence-based information; 3. Unable to address diverse population; 4. Inability to analyze root cause of errors and quality problems; and 5. Lack of training in adequately using informatics in care of patients. Among the rules recommended by the IOM in these reports, they underscored the necessity for health care systems to be safe, evidence-based, and anticipatory – that is, proactive rather than reactive. For this reason, the report of the IOM in 2003 pronounced that “education for health professionals is in need of a major overhaul” because of its inability to address the imperatives earlier determined. These new directions are viewed by educators are indicative of the need of more effective directions for instruction. The relative effectivity of different methods of instruction are shown in the diagram following. It will be noted that lecture and reading yields an average retention rate of only 5% and 10% respectively, while practice by doing has a 75% average retention rate. Source: New Approaches to Improving Pharmaceutical Education Lecture Presentation. New directions that require simulation methods In 1993 The Pew Health Professions Commission report have charged pharmacy programs with the training students to communicate and interact in a multidisciplinary setting, in order to “engender a team approach to patient care.” This new direction encouraged an increased emphasis on developmental critical thinking, problem solving, and professionalism in pharmacy education. Additionally, a 2003 report in the Institutes of Medicine, “Health Professions: A Bridge to Quality” recommended stronger teamwork skills among healthcare professionals. This was supported by a recommendation by the Accreditation Council for Pharmacy Education (ACPE) in 2007, when they recommended greater stress on communications skills, patient safety, and interprofessional teamwork in the pharmacy curricula. This emphasis called for a non-traditional approach to instruction. (Fernandez, 2007) Simulated teaching is also used to address specific situations that require a more accurate, coordinated and expert response for lives to be saved. LaVelle and McLaughlin (2008) relate the experience of Health Partners, a group of nonprofit health care organizations comprised of ambulatory and urgent care clinics. The nursing leaders noted discomfort among their clinic staff while assessing and managing patients with emergent needs. There exist wide disparities in approaches, lack of familiarity with equipment, insufficiency of skills, and low confidence in handling emergency situations, especially during the occurrence of the two most common high-risk incidents – patients with chest pain and patients with anaphylaxis. In both situations, the clinic staff is required to render excellent assessment skills, psychomotor skills, critical thinking, and cohesive teamwork, enhanced by communication and confidence. Three concerns were noted which necessitated the use of simulation training: 1. Past traditional “skills days” and learning packets had not been particularly effective in improving staff competence and practices. 2. Despite “standardization,” the contents of code carts and pharmacy emergency drug boxes varied among clinics. 3. Roles and expectations needed to be clarified in order to improve communication and teamwork. Understanding Simulated Teaching Some training sessions using simulated techniques are targeted at particular situations. One example is a training program called The First Response: The First 10 Minutes, a two-phased, simulation-based education program designed to help improve the immediate care of patients with chest pain or anaphylaxis prior to the arrival of ambulance crews. A diagram highlighting the major components of the program is shown below, in order to provide a bird’s eye view of the use of simulated teaching technique (LaVelle & McLaughlin, 2008). Schematic of a Training Curriculum using Simulated Teaching Methods Standardized patient (SP) in Objective structured clinical examination (OSCE) (Adamo, 2003) and Human patient simulation (HPS) (Fernandez, 2007) are similar simulation models that make use of trained actors who simulate patients afflicted with certain disorders. In this method, a hallway of exam rooms, each occupied by a standardized patient with a uniquely challenging condition, is designed to bear remarkable similarity to the actual environment. The use of SPs augments the OSCE as an assessment event, by facilitating teaching and learning as an addition to assessment. While SPs were originally introduced by Howard Barrows in the 1960s, the practice only began to gain impetus in 1993 after its recommendation by the Association of American Medical Colleges’ Consensus Conference on the Use of Standardized Patients in the Teaching and Evaluation of Clinical Skills. Since then a number of diverse roles has brought about a confusing number of descriptors such as programmed patients, prepared patients, trained patients, standard patients, standardized patients, actors, pseudo-patients, and patient instructors. At present, though, the commonly used terms are simulated patient and standarized patient. (Adamo, 2003) Adamo (2003) defines a simulated patient encounter as one that includes any medical encounter conducted for purely educational purposes that may or may not utilized the simulator’s personal medical history. A standardized patient is one who exhibits consistent content of verbal and behavioural responses by the SP to stimulus provided by the student or examinee. A standardized patient encounter is a simulated patient encounter, but a simulated patient encounter is not necessarily standardized. An individual standardized patient or SP undergoes the following preparation: 1. An SP is typically selected on the basis of gender, body habitus, previous surgeries, past medical history, and when relevant, level of education and/or language. 2. The SP is matched to a case requirement and trained to reliably portray and recall accurately the details of what is said and done in an actual medical encounter. 3. The SP may also undergo training to be able to provide an accurate, written, and objective report through the use of checklists. 4. The SP can be trained to provide patient-centered, subjective rating and description evaluation of the examinee’s behaviour, as a basis for constructive post-encounter feedback to the student. Computer-Assisted Simulation Training Methods The use of Personal Digital Assistants (PDAs) in a Clinical Simulation Laboratory Course was investigated by Austin and Koehn (2004), as to the role and value of personal digital assistants, or PDAs, together with the ePocreates® software program in clinical simulation courses in pharmacy education. In the study, students were equipped with standard pharmacy reference textbooks together with a Palm Pilot® with ePocrates freeware version. During the clinical simulation course, the students interviewed standardized patients and were expected to consult tertiary references for assistance in interviewing, assessment, and patient management activities. The result of the study showed that the students observed demonstrated purposeful selective us of PDAs, but more frequently and consistently showed preference for text-based references. The exception to this general observation, however, was during circumstances wherein they believed text references would be outdated, or wherein they were to specifically identify their own information need. When students experienced ambiguity in their information need, they preferred the visual scanning that access to textbooks provided. Thus it was concluded that PDAs may complement textbooks in a clinical simulation environment, but are not seen to replace them. The small screen limits text-scanning ability and students in a high knowledge-uptake stage of professional development found greater utility in using textbooks. The use of Problem-Based Learning (PBL) and Computer-Assisted Learning (CAL) are two modes of teaching being explored at school of pharmacy. CAL refers to any learning method that is assisted by the integrated use of computers. PBL, on the other hand, is a “method of learning (or teaching) that emphasises (a) the study of a clinical case either real or hypothetical, (b) small group discussion, (c) collaborative independent study, and (d) hypothetical educative reasoning (Schmidt, 1993 in Barzak, Bal & Ledger, 2001). In this sense, PBL may be seen as the genus classification of training methods to which simulation is a species. As to these methods, Barzak, Ball and Ledger (2001) have assessed that PBL has the advantage over traditional approaches in that it has a greater relevance to the practice of pharmacy, it has the ability to promote the retention and application of knowledge, and it encourages self-directed life-long learning. It is prone, however, to some disadvantages such as higher costs in both resources and staff time. CAL, on the other hand, aims to bridge the gap not covered by traditional methods and PBL. The study recommends the increased and enhanced use of PBL, and CAL where applicable. Among the more recent computer-aided methods and devices for pharmaceutical simulated training is SimMan, a computerized patient simulator. SimMan was developed by Laerdal Medical Corporation at a cost of $30,000, and was specially intended for 91W military medical training. “He” is currently being used by the 89th Regional Readiness Command, headquartered in Wichita, Kansas, and is classified as military occupation specialty. The picture above (source: Army Reserve Magazine) shows the SimMan in use during simulated training. The SimMan, while computer aided, is human in form and is programmed with features that allow it to be programmed for different scenarios, and different symptoms. This in turn creates different reactions among the trainees. The reactions are recorded within the memory of the attached computer, and can thereafter be printed out at any time for review and evaluation by individual soldiers, thereby providing them immediate feedback. If a soldier does not perform an procedure property, the computer automatically adjusts SimMan’s response, even to the point of stopping breathing in sufficiently serious situations. (Army Reserve Magazine, u.d.) Whatever the patient simulator method or device, different patient simulators incorporate a range of technical features. Grant, McNeil and Luo (2008) explored the different features considered by students to be the most valuable, and which may be less valuable in achieving specific educational objectives. In the outcome, those features most highly rated were vital sign display, interactive voice, chest rise, and palpable pulse. The feature with the lowest ratings included abnormal breath sounds, pre-recorded voice, IV arm, and heart tones. Rated by more than one-third of the student-respondents as distracting, not useful, or uncertain if useful were heart tones, abnormal breath sounds and pre-recorded voice. Thus in the design and construction of automated patient simulators, the features most highly rated or seen as most useful should be further developed by manufacturers, and those rated most poorly or considered least useful should be eliminated. Usefulness as Instructional Tools The learning outcome of experiential learning fostered by simulation techniques is seen by Apampa, Rai and Branch (2009) to fall within two general categories. These are: 1. Experience. The student gains invaluable hands-on experience through: a. Developing an understanding of the relationships between pharmacy staff patients, customers and the health care team b. Demonstrating knowledge and understanding when dealing with patients c. Exploring and reflecting on complaints handling in practice 2. Professionalism. The student also gains an insight into the profession though: a. Demonstrating appropriate communication skills in practice b. Demonstrate a knowledge of skills required for lifelong learning c. Develop an understanding of standards within pharmacy practice. The use of simulation with immediate debriefing is supported by the principles of adult education, which espouse the following principles: Adults often learn more effectively when they can participate in interactive environments Immediate feedback during debriefings is more valuable than delayed feedback Consistent messages and standardized protocols reduce ambiguity and variation in practice Concrete applications increase learner engagement and retention of information People learn from their mistakes and, with simulation, mistakes can be allowed to lad to natural consequences without harming actual patients (LaVelle & McLaughlin, 2008) Furthermore, Apampa, Rai and Branch (2009) stated that experiential learning brought about by observation, simulation and participation was effective due to its adherence to the theory by David Kolb on the dynamics of learning, which is graphically depicted in the following diagram. The diagram shows the important interrelationships among the concrete experience, reflective observation, abstract conceptualization, and active experimentation which underlie experiential learning, as depicted by Kolb’s theory.   LaVelle & McLaughlin (2008) revealed some medication “lessons learned” in their study of simulated training for patient safety in ambulatory care. Some of these lessons are the following, hereunder quoted: • Since most pharmacists and nurses are outpatient-based and unfamiliar with the administration of emergency medications, the corrective action plan must have “hard stops” to reduce the risk of medication errors. • Despite overall excellent relationships with the physicians, nurses sometimes did not question them when they requested an incorrect medication or dose during scenarios. Whether this reluctance was due to the clinic hierarchy or nurses’ insecurity, several actions (e.g., “pause for the cause,” practice “assertion language”) and an understanding of the responsibilities involved in being on a high-performance team are needed. • Vigilance is critical, even when medications and supplies have been “standardized.” The variability that occurs naturally when large numbers of staff are spread over multiple sites should trigger frequent, routine examinations of code carts and pharmacy drug boxes by clinical experts who can quickly spot potential problems. Except for purchasing additional wheelchairs and reinstalling overhead speakers in some clinics, most of the suggested corrective actions were both inexpensive and relatively easy to implement. In addition to the above lessons learned, the HealthPartners experience, as a secondary but nevertheless important outcome, identified forty patient safety concerns and their corresponding corrective action plans, thereby improving the standardization and expertise of clinical personnel during emergency situations, and improving their team communication and confidence in addressing these cases. It was generally agreed that these forty safety concerns would not have been discovered had the training not been held in situ. (LaVelle & McLaughlin, 2008) Benefits and Limitations of Simulated Teaching Advantages of simulated teaching. Fernandez, Parker, Kalus, Miller & Compton (2007) sought to determine the effectiveness and student acceptance of using a human patient simulation (HPS) training module, with a focus on the development of interdisciplinary team skills. Participating students undertook a simulated case of an acutely ill patient with hypertensive emergency, performing a history and physical examination. Then working as a team, they made treatment recommendations to the nursing and physician staff members. After the exercise, they underwent a facilitated debriefing session and completed satisfaction surveys on the effectiveness of the session. In the resulting assessment, it was determined that over 98% of the students indicated that they gained material learning that was relevant to their current studies. When asked to compare the simulation exercise with student lectures, 90% of the students indicated that they learned clinical patient care better through the use of the HPS mannequin in simulated patient scenarios. The study concluded that HPS-based learning provides realistic training experience in imparting clinical knowledge and interpersonal teamwork skills. Furthermore, the experience proved to be enjoyable and satisfying as well as relevant to their practice. For certain topics, simulation-based training provides a better vehicle for instruction than traditional lecture formats, and therefore would be useful in supplementing and enhancing current pharmacy curriculum, filling gaps where they exist. In a survey conducted by Apampa, Rai and Branch (2009), students were asked to rate their overall experiential learning experience (observation, simulation and participation, the pharmaceutical care given, the preceptors who acted as their teacher and practitioner, and the staff at the placement site. The results of the survey testify to the effectiveness of an integrated experiential learning program, as shown below. It will be noted that experiential learning was rated by 91% of the student-respondents as relevant to their degree program in pharmacy, while 94% of these students have come to consider pharmaceutical care as a professionally rewarding experience because of the training undertaken. High-fidelity simulations of patient scenarios have successfully promoted critical thinking and staff teamwork in various branches of health care. (LaVelle & McLaughlin, 2008) Disadvantages of using simulation techniques. One of the challenges using the same SPs for frequent and/or numerous events is to maintain the SP as portraying a non-expert patient. SPs who have gone many physical examination sessions tend to voluntarily progress through a physical sequence, which inadvertently prompts the student being assessed. The veteran SP gains a familiarity with effective clinical skills, and may be tempted to assume the role of teacher and to speak from that viewpoint. For instance, second-year students conducting their physical examination for the first time tend to let the patient’s legs dangle unsupported at the edge of the examination table. The SP is property trained to say, “My legs really hurt in this position,” but seasoned SPs may tend to break their role and say, “You don’t want to forget to support your patient’s legs,” which breaks his role as patient and assumes the role of instructor. (Adamo, 2003) Preferences for the different types of simulation models Most students, this writer included, prefer the use of specialized patients (SP) or human patient simulation (HPS), and preferably in situ (onsite) are preferred by majority of students. In the choice of specialized patients, the students indicated a preference for community volunteers vis-à-vis course instructors or student peers (Gallimore, George, & Brown, 2008). Their expressed reasons was the greater similarity with real-life situations, and the simulation procedure feels more credible, engendering a greater feeling of confidence among the students during the execution of their theory-learned procedures. The only drawback is when the specialized patients have acted as such for a long time, and, as pointed to previously in this paper, tend to act as teachers rather than patients. Secondary to the use of human patient simulation is an appreciation for the SinMan or similar type of training method. The use of a non-human patient is particularly attractive to the students who are newly being exposed to practical methods and techniques for experiential learning, inasmuch as they have apprehensions or embarrassment about making mistakes when dealing with live, human, simulated patients. The use of a robot or similar inanimate tool which, however, could imitate accurate human reactions is useful until such students have practiced sufficiently to confidently “examine” and “treat” humans. The drawback is, of course, if the mechanized tool exhibits the distracting and non-useful features earlier described, which in future simulation training products should be minimized, re-designed, or eliminated altogether. REFERENCES Adamo, G 2003 Simulated and standardized patients in OSCEs: achievements and challenges 1992-2003. Medical Teacher, vol. 25, no. 3, May, pp. 262-270 Apampa, B; Rai, A; & Branch, C 2009 Pharmacy Education: What is the value of experiential learning? Powerpoint lecture. Medway School of Pharmacy. Accessed 3 November 2009 from http://www.healthlinks-events-bpc2009.co.uk/presentations/B%20Apampa%20%20Manchester%20presentation%20final.pdf Benefits of a teaching certificate program for pharmacy residents. 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Building rural heath care teams through interprofessional simulation-based education. 10th National Rural Health Conference Read More