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SimZones for Higher Education
25 Plays4 months ago
Professor Kate Morse and Dr Mary Fey join us to discuss the application of SimZones to the higher education context. We will discuss how SimZones can reduce learner cognitive load, scaffold learning and help to develop strategic faculty development plans.
Mary and Kate's article discussed in the podcast: Teaching, coaching, or debriefing With Good Judgment: a roadmap for implementing “With Good Judgment” across the SimZones | Advances in Simulation
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Transcript
Introduction to Simulation Happy Hour
00:00:52
Speaker
Simulation Happy Hour acknowledges the land and the waters from which you are listening today.
00:01:11
Speaker
Welcome to Simulation Happy Hour. Sit back, relax, and let's talk about all things sim. All right, welcome to another episode of Simulation Happy Hour.
00:01:24
Speaker
And returning again, which we're very excited about, is clinical professor um Kate Moss, who is the Assistant Dean for Experiential Learning and Innovation at Drexel University, and Mary Fay, who is the Associate Director of Applied Learning for Performance and Safety with the Centre for Medical Simulation.
00:01:45
Speaker
Welcome back. Thanks for having us back, Mouth. Thanks, Mel. And I'm joined with Kerry. How are you going, Kerry? Yeah. Hi, Mel. Great to be back here. And as I just said, last week I'm looking at you in the US and here you are back in Australia with our wonderful US colleagues. So fantastic. I know our US colleagues are virtual, but great to have them on board again.
00:02:10
Speaker
Love it. Absolutely. I am wearing my Washington DC jumper. So there we go. Oh, very nice. Okay. Well, I'm so excited about the topic today.
What is the SimZones Framework?
00:02:22
Speaker
So we're talking about SIM zones ah and in particular about applying it in different settings. So we all work in higher education. so We'll go to there, but initially, I guess for those people that aren't familiar with SimZones and what it is and how to apply it, Mary, I'm going to start with you. Can you help explain what SimZones is and where it originated?
00:02:48
Speaker
Sure. Happy to, Mel. So SimZones originated, came out originally from a children's hospital in Boston, and the the original paper was ah Chris Rusin, our colleague at CMS, and Peter Weinstock.
00:03:03
Speaker
um From there, and you know what really happened was Chris hadn't worked in healthcare care before. And then he came into healthcare care and was working as a simulation director at Children's National Medical Center.
00:03:15
Speaker
And he looked at the simulation that was going on and he thought, oh, there's different kinds of simulation that require differences in approaches and resources and faculty roles.
00:03:27
Speaker
And what is so blindingly obvious after you read the Simzones paper is just that. But I think the brilliance of Chris Rusin is that he sees patterns and he sees structures and he names them so it makes them accessible.
00:03:42
Speaker
And so that's really what Simzones is. It's a framework for a couple of
Understanding SimZones: Five Zones of Learning
00:03:47
Speaker
different things. It's a framework for the development of a simulation curriculum. It's a framework for thinking about resources needed by a simulation program. And it's very much, we're going to talk about this a little bit later, it's very much a framework for faculty development in thinking about what you need to train your faculty to be able to do to facilitate the different kinds of simulations.
00:04:09
Speaker
So that's kind of high level where SimZones came from. And so as Chris described the original zones, there are five of them. There are zones zero, one, two, three, and four.
00:04:21
Speaker
Very briefly, zone zero is instructor-less simulation or simulation that's done via some sort of an app or an online learning system where the students engage in some sort of educational activity and get some sort of feedback. So an example of that might be when students are practicing CPR and they get feedback from the mannequin about the rate and depth of their compressions. That would be a zone zero simulation activity.
00:04:50
Speaker
And then the zone one follows zone zero. And in zone one, a learner is practicing just an isolated context free skill. And so it might be something like, as I think about nursing programs, putting in a Foley catheter using a task trainer.
00:05:05
Speaker
So there's no story around it. There's no context. There's just a task trainer on a table and the student is working through just the psychomotor skills of like, where do I put my hand? How do I pick up this piece of equipment?
00:05:17
Speaker
Because what we're really thinking about there is how do we keep their cognitive load low at this point so that they can just get the skill piece down? And then once they've mastered the zone one level, then they can move on to zone two, or as we think of it now, they're ready to move into zone two because readiness planning is sort of another concept related to Zim zones that helps us think about, are the students really ready to progress?
00:05:41
Speaker
So after zone one, they move on to zone two. And so let's imagine if we keep the Foley catheter example, that now the students are in a more full-scale simulation where there's a patient that they're interacting with, maybe a family member. And at some point in the simulation, the decision is made that a Foley catheter has to go in.
00:05:58
Speaker
So now they have to put that Foley catheter in with all the contextual features around their patients. They have to explain things to families. They have to explain things to. It's not just a test trainer on a bed. Now it's a patient who's in a bed, you know, with limbs and all that, that they have to think about that zone too.
00:06:16
Speaker
Zone three then as Chris originally described it is zone three is when we start to think about how do we bring together the interprofessional team to give us opportunities for collaboration, but especially to help us explore what the challenges are in a given situation. Let's stick with the Foley catheter situation.
00:06:35
Speaker
Maybe the way we introduce complexity and the team into that is now the students have to collaborate with the interprofessional team to decide, is a Foley catheter appropriate?
00:06:46
Speaker
Could we just do an in and out catheter? When's that Foley going to get put in? How important is it? When does it come out? So you take into account now the larger issues around Foley catheters and their insertion.
00:06:57
Speaker
And then Zone four is actually learning from real life. So technically not simulation, but we think about that more as clinical learning, but still with coaching and feedback that goes on as it would in any sort of workplace learning, workplace assessment environment.
00:07:13
Speaker
So that's sort of the big view of what the SimZones is.
Application of SimZones in Higher Education
00:07:17
Speaker
And I know what you want to talk about next. And so I'm just going to say, and so, you know, as Kate and I started to think about what does this mean for higher education? Is it the same?
00:07:25
Speaker
we started to realize that there were some important differences. So the basic structure still stands, but the nuances within the different zones, I think are a little bit different within the academic environment.
00:07:37
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Great. Thank you. I know at CMS, so that was from, originated within the healthcare care context. So hospital-based simulation.
00:07:48
Speaker
Right. I know you've thought about this within your courses at CMS, so which is not hospital-based. It's classroom and in the sim lab.
00:08:01
Speaker
So how are you applying it in a course? You want me to take this one, Kate, and keep going? Sure. And then I'll add on the nuances of how I've incorporated into yeah the master's course on simulation.
00:08:17
Speaker
Okay, great. So, you know, as I mentioned before, SimZones is really all about readiness. It's about ensuring that our students are ready to be in the learning situation that we're putting them in.
00:08:28
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And so it's really thinking about, you know, what do they need to just know? Because there's basic knowledge you have to know before you can do something. So what do they have to know? That's kind of that zone zero space.
00:08:41
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And then we start to introduce the skills gradually and add more context as we go across the zones. And so in our week-long instructor training course at CMS, as many people may know, we're generally, what we're focusing on is teaching people how to facilitate and debrief simulations.
00:08:57
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And so within debriefing, there's the structure of the talk, there's the conversational strategies we use. And so as we do it in the week-long course, we have a didactic module that might be about using advocacy inquiry.
00:09:12
Speaker
And so there is zone zero training, and that is what we tell them about advocacy inquiry, why it works, what's the structure of it. There's zone one training then is we might put up a picture and say, create an advocacy inquiry question around this picture. So there's no context.
00:09:27
Speaker
There's no pressure. They're just looking at something and trying to arrange the words. Then we move them up to a zone two training where we show them a video with some students in a simulation. And now they have to ask the question to a human being. We'll have someone else in the course play the person in the play, the character in the video.
00:09:44
Speaker
And they have to now do an advocacy and inquiry question to a real person and hear an answer. That's um sort of their zone two training. And then we move them up further in complexity by having them then debrief a simulation.
00:09:58
Speaker
using advocacy inquiry within the structure of a four-phase debriefing conversation. And so that's how it is throughout the course with regard to conversational strategies, with regard to structuring a four-phase debriefing discussion, and even a little bit around assessment, which we do some in the course. But it's really all about what do they need to do Have them get a little bit of ah practice with it in a decontextualized way with no pressure.
00:10:25
Speaker
Increase the cognitive load now by putting some context around it. and then increase the complexity even more by putting them into a realistic situation. So we structure the course according to the sim zones too.
00:10:37
Speaker
Thank you. And when you were talking, there's so many underpinning theories to that. Like it's all about constructivism and, you know, zone of proximal learning. Proximal, it's a gosky. Ponditive load theory. And so, yeah, that structure is underpinned by a lot of educational theory.
00:10:57
Speaker
Yeah. yeah I have to agree with you. Absolutely. And I, you know, I think one of the most important ones you mentioned, Mel, is cognitive load. You know, and I've seen that play out in nursing education a lot when people are not thinking about it and they drop students into full-scale simulation when they haven't had time to really nail down the component parts of it. And then the students freeze and get a deer in the headlights and the faculty can't understand why this, why can't they just do this? Well,
00:11:26
Speaker
because their cognitive load is too high and they just can't think. And so I think that's why the idea of readiness and making sure that students are ready to move into the next zone is critical. So yeah, I think cognitive load is hugely important there.
00:11:41
Speaker
Thanks. and And Mary, just a double click on that.
Teaching Strategies and Cognitive Load Theory
00:11:45
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I fully agree. The cognitive load cannot be underestimated. And I think hand in hand with that goes the idea of skill decay.
00:11:54
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because I think that is such a challenge in higher education. You know, someone is taught a skill, whether it's putting in a Foley catheter, to use Mary's example, and fundamentals nursing. And then there's the magical thinking that happens that people are, everybody's getting to do this in clinical practice, which we know is highly variable.
00:12:16
Speaker
And then when they come now to do it in a simulation, in a zone two simulation with contextual elements, a higher cognitive load, they've lost that skill because they weren't, you know, for an expert to lose a skill, we we have a slightly slower slope, but for a novice gaining a skill, they have a quite a rapid,
00:12:38
Speaker
you know, two to three, but two months, they're gone. It's gone. You know and they sort of, I always tease them, they have hotel memory. You know, somebody new comes in, somebody old has to leave because they get so much information.
00:12:51
Speaker
So if there's no contextual practice, it's not that in their long-term memory to go back to it. I think SimZones is so helpful to be able to say to faculty, how do you know the learners are ready to be in this sim? And they're like, oh, well, they learned this skill.
00:13:11
Speaker
Great. When was that? oh it was back in fundamentals. Okay. And now we're like three semesters away from that. And when did they deliberately get to practice that with feedback?
00:13:25
Speaker
Right. Oh, yeah. So do that and then come to SIM and then your learners are not going to be stuck in, as Mary said, you know, deer in the headlights, overwhelmed, feeling like they're not going to be unsuccessful.
00:13:41
Speaker
And your conversations are not going to be task oriented because they're good at the task. And they're looking at the more, you know, contextual elements of what are they noticing? what How are they interpreting information? You know, we're talking about nursing, what are they interpreting? What are they anticipating?
00:13:59
Speaker
Versus, hey, i i we're going to spend the debrief talking about hey how you hung blood. yeah Important, but not really what you necessarily want to get out of that debrief. yeah So I think that simple question of SimZones being able to say to faculty, how do you know learners are ready to be in this zone?
00:14:22
Speaker
it It can be transformative to them because they're like, oh, yeah. yeah i Oh, yeah. but guess that really was in year one.
00:14:34
Speaker
Yeah. Then let's practice that before they come so they can now apply it in context and we can talk about the bigger things about prioritization of care.
00:14:45
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Call it for help, you know, whatever the contextual elements are. I love that. What do you think, Kerry? I love that concept about readiness for practice.
00:14:56
Speaker
It so makes sense. It so makes sense. And it's it to me, it's ah it's a great way of scaffolding that learning as well. So, yeah, fabulous.
00:15:09
Speaker
Kerry-Ann, that is like such an important word because I think like that sometimes because curriculum in higher education is so jam-packed.
00:15:21
Speaker
We don't really scaffold and take a skill and then put it in context of, well, what does it look like in, you know, maternal child health? What does it look like in acute care? What does it look like in community care?
00:15:38
Speaker
And we forget to scaffold it in different contexts and make it, you know, more complex, more nuanced. And that's what I think really helps people be ready for practice. Yeah.
00:15:50
Speaker
and I know, Kate, that we've spoken about. Yeah, go, Kerry. but i think ah You know, I think there's a real risk of when we get caught up with skill sets where students are actually in a simulation lab practicing actual tasks where sometimes those tasks can be quite simplistic that,
00:16:15
Speaker
I've often said to students, I've got actually teach primary school children these skills. You know, there is nothing really difficult about it. But what separates you from ah primary school child to registered nurse?
00:16:28
Speaker
It is about that critical thinking. It is about that next layer. And so I really love that whole concept, you know, recently where I'm working, with we're doing this I do, we do, you do approach.
00:16:41
Speaker
in the simulation context where, you know, we're seeing students progress through that that task but then starting to overlay. Now, unless you are in a curriculum where you can see what is happening in other units, you can often lose that scaffolding. You can often see that skills just get repeated or they remain at a basic level without adding that that layer of complexity where we bring in the clinical reasoning, where we bring in that critical thinking. So i really love this and, you know, potentially how this could be transparent in a curriculum so that other unit coordinators can
00:17:24
Speaker
in courses can see what is happening in this unit, what then needs to be brought into this next unit. I just love that scaffold approach that this can bring.
00:17:36
Speaker
Yeah, thanks, Kerry. Yeah, go ahead, Mel. i was I'm going to jump to you soon, but I think that whole transparency. So one thing we've done... where I work is each sim lead in each discipline, I've asked them to matrix their simulation-based curriculum and matrix them to the sim zones. And so everyone can see within their own discipline what simulation is occurring across curriculum and across the years and what sim zone it is.
00:18:11
Speaker
And so it it really allows you to see, well, over one year, are we increasing in complexity, let alone over the three-year course, are we increasing in complexity?
00:18:23
Speaker
And overwhelmingly, i know we found that in one discipline, it was basically all majority was zone one. And so, you know, then it's around, okay, well, what are we doing to be experts then in zone one?
00:18:40
Speaker
Like, are we all teaching the same? Are we all using an evidence-based framework to teach skills? Are we all or know how to give action-orientated feedback? Are we?
00:18:51
Speaker
And the answer was no. So that's the work that you can really target and improve how we deliver curriculum using the zones. But I've kind of jumped ahead because, Kate, I think we've jumped over the bridge, but just to bring it back, what are the key differences using the SIM zones in higher ed to health-based SIM?
00:19:18
Speaker
Sure. And listen, I think that this is still yeah you know a work in in progress as we we apply it in the higher education model. And I think you know zone zero is zone zero. What has to stay in front of that is requisite knowledge because in the professional side, you know there's a reasonable
Challenges in Applying SimZones
00:19:40
Speaker
assumption. People have passed board exams and those kinds of things. So they come with some requisite knowledge.
00:19:46
Speaker
But we're oftentimes... That's a core piece of what we do, particularly in undergrad and then as people are transitioning to advanced practice. So requisite knowledge, zone zero remains an automated ah feedback that we may not be there in the moment, but we've designed the learning activity where they get to apply and get automated feedback.
00:20:09
Speaker
And I think that the The zone one, oftentimes I think of our fundamental labs and our skill labs in all health professions.
00:20:19
Speaker
And the the shift is recognizing the sometimes occasional magical thinking that if we've taught it in a fundamental lab, they all, you know they've mastered it and they They haven't because they're not at mastery then. They're just developing and they might be able to demonstrate in a lab context, but it's not competence. And I think we're learning, particularly in in the States, as we sort of wrestle with competency-based curriculum, that that, you know, they may have the skill, which is a skill checklist, but they might not have, as Carrie Ann talked about, like the knowledge and the attitudes to go around that, like,
00:21:05
Speaker
When would you put a Foley catheter in versus a straight cath? What concerns do you have about this particular patient based on their medical history and their anatomy and all those kinds of things?
00:21:18
Speaker
And that doesn't happen in fundamentals. And then zone two for us in academia, I have to say we have to become so enamored with the role of pause and discuss in zone two.
00:21:33
Speaker
And I know this like gives Chris shivers because we're like, well, it's an early zone too, because their cognitive load when they come into the sim lab is so high.
00:21:44
Speaker
You know, when you put them in and they're seeing a patient and the patient is telling them what's going on, the beeps and whistles, the alarms are going off. And even if they have the right answer, their cognitive load so high, they can't access that thinking.
00:21:58
Speaker
But you pause the sim, you come in as faculty and you say to them, so what are you noticing? And they're like, blah, blah, blah. And they're telling you all this great thing. And you're like, that's fantastic. but and And they will say to you, but i I was stuck. But now when all that contextual nose goes away, you can either like massage their thinking a little bit or amplify that they're on the right path.
00:22:22
Speaker
keep going, clinton you know continue on, and now I'm gonna turn on all those contextual elements again. But that pause and that coaching, deliberate coaching, I think is so powerful for them. And in many ways, in my mind, reflects clinical life because I would never and never left my students by themselves in a complex situation.
00:22:45
Speaker
Like I'd let them go so far and then I'd be like, okay, like what's going on? What are you thinking? But I would never like let them do it. So that zone two, I think is very powerful for us. And we really in under our undergrad only have one, what I would consider a zone three simulation, which is a disaster simulation. And we still have a coach in the room, which is one of us as an embedded charge nurse that's there to coach. And we might coach more heavily if they're sort of struggling and we might coach a little lighter if they're
00:23:20
Speaker
doing really well, but they always have that that sort of security of of someone. So they're not in there all by themselves. I think where we struggle and where we want, like what's our really big opportunity is that zone three around interprofessional conversations, which is challenging. And then zone four is in my mind in higher education is clinical practice.
00:23:48
Speaker
So I want to touch on that soon because I know we've had lots of discussions around that and I've got an example of what I think Sim-based Zone 4 is.
When to Use Feedback or Debriefing?
00:23:59
Speaker
But before we jump to that, Mary, can you help us explain one thing I really like about Sim Zones because it helps people kind of guide the faculty on what kind of feedback or conversations yeah and when, like what is the difference between feedback coaching and debriefing, which could be its own session in itself, but can you help explain that?
00:24:23
Speaker
Yeah. So, and Mel, you know, as you know, we, Kate and I were were authors on a paper that talks about teaching, coaching, and debriefing with good judgment. So taking those strategies of teaching versus coaching versus debriefing and embedding or embedding them with good judgment values in that, with good judgment being the method of debriefing taught at the Center for Medical Simulation.
00:24:47
Speaker
All right, now I've already lost track of your original question. It's like, what are the differences? What are the differences between these? And when, kind of. You might pull that out. Here's where SimZones really helps us.
00:24:58
Speaker
Zone one, like super clear what the learners are expected to do, very limited in like how much of that extra critical thinking goes on around it. And ah the instructor's stance in zone one is a stance of understanding that the learners just don't know how to do this thing. And that's why they're there.
00:25:22
Speaker
So you give them some zone zero learning before they come to the lab. And then when they're there in the lab, you're just going to tell them what to do. So when you see them struggling with whatever, you know how nursing students are with getting the Foley catheter kits open and everything sterile, you know.
00:25:39
Speaker
That is not the time for the instructor to stand there and go, Sue, look at what you're doing. What are you doing now? Because how would they know? So this is the time to go stop, look at your hand.
00:25:51
Speaker
Your bare hand is touching what needs to be sterile. Do you see that? Yes. Okay. Back up a couple steps. Let's do it again. That's zone one. Yeah. Zone two is where we move into coaching. And the difference between a teacher and a coach is when you're teaching, everybody kind of gets the same thing because they're all at ground zero, right?
00:26:10
Speaker
But they all leave zone one with a sort of baseline level of skill. But in zone two, this is where individual idiosyncrasies start to pop up. you know, let's stick with our Foley.
00:26:22
Speaker
So in zone two, there may be some students who still struggle with sterile technique. Okay, then we're going to coach them on that. There may be other students, they got that sterile technique down pat, but they do not know how to talk to patients.
00:26:33
Speaker
So we need to coach those students on that. And so coaching is very much dealing with those idiosyncratic challenges that come up as people's skills start to develop. And When you're in a coaching context, it is still really important to be super clear with what's going on with the learner. Hey, you know, I see you opening the Foley catheter kit and putting things on non-sterile surfaces.
00:26:57
Speaker
You know, I'm really concerned that the patient is going to end up with urinary tract infection. If you do this, here's what I think would work better for you. Make a suggestion and then say to the learner, how does that sound? Do you think you can do that? Check in with them if they're on the same page. Yes.
00:27:12
Speaker
Okay, back up and do it again. Anytime you're coaching, having your students redo after they get the feedback is super important because I can tell them what to do and go, does that make sense to you? And they'll be like, yeah, Dr. Faye, that's great.
00:27:23
Speaker
and they have no idea what I'm talking about. So we always want to give them a ah chance to do it again. So that's coaching. And then debriefing is more of an exploratory conversation. What were the challenges? What made this hard for you? What were you trying to accomplish and how did you get derailed? So it's a little more in my mind, like a little more of an abstract conversation where we're we're debriefing because now we're really exploring team dynamics, individual dynamics, biases, prejudices, what we saw, what we didn't see.
00:27:51
Speaker
So it's more kind of open as opposed to teaching and coaching where I'm trying to like accomplish one thing. debriefing is a little looser, I guess is a word for debriefing.
00:28:02
Speaker
But, you know, I think it is super important to point up and Kate and I've had this conversation with Chris many times. There's really not a super bright line, ah especially between zone two and zone three.
00:28:14
Speaker
So Kate and I are always kidding saying, oh, there's a zone 2.5. Because sometimes you think you're moving into a zone 3 sim, but you get there and you find out that your learners are still struggling with a more fundamental aspect of whatever the challenge is. And you need to sort of back up and do a little bit of coaching.
00:28:30
Speaker
That's totally fine. Sometimes you're in a zone 2 and you're like, oh, gosh, they totally missed this. I need to back up and do a little bit of zone 1 practice. before I can confidently move them into zone two. And so there's not always a bright line and it's not always forward progress. Sometimes you realize because of the learners you have with you, you need to back up and do a little touch on a previous zone just to get everybody ready to go.
00:28:54
Speaker
Thank you. Kate.
00:28:58
Speaker
i I love how Mary is describing that. And I often think and talk to faculty about the idea of, you're scheduled, you know, you think you're doing ah a little bit of a zone two sim, so you're going to be coaching, coaching, coaching.
00:29:13
Speaker
And you coach and the learner is not able to sort of course correct. And to me, then like my little internal rule in my head is if I've said something a couple of times, then I'm coaching on the wrong thing.
00:29:30
Speaker
Like either but i'm I'm making a judgment about what might be getting in their way in that zone, And I'm coaching and saying, look, don't do this, do this, and here's why. So I'm giving direct at coaching, but they're not doing it. So there's you know something that they're seeing. So then that's where i i see those faculty, particularly in clinical practice who are out with the learners in real life, being able to go, okay, I've coached you twice. We're sort of stuck in the same loop.
00:29:59
Speaker
i help me understand what's going on here for you because I'm coaching you on the wrong thing. So i I see like this sort of nuanced when in expert faculty practice of being able to go, okay, coaching is not working.
00:30:16
Speaker
It's not about the learner. It's about how I'm coaching. So now I'm going to explore to try and understand and better target my coaching to help you get better. Whereas I think historically where we might yeah sort of start that, you know, ladder of inference going, well, the learner's not listening. The learner's not going to be able to do this. When in fact we're coaching on the wrong thing and they're internally going, yeah, I know that piece I'm stuck over here, but they're not being able to articulate that. So I think that's the, like, to me, that is, was a big shift for me to be able to go, Oh, wait a minute. I've coached and coached and it's not working.
00:30:57
Speaker
I need to figure out what's going on here. Easy to say, hard to do, you know, for all of us because you sort of get caught in that coaching loop. But that's such an important point. Like you take it out of the sim lab and look about feedback in general. You might give learners feedback, feedback, feedback, and the behavior isn't.
00:31:18
Speaker
changing. So then we do need to switch to an exploratory kind of frames based approach, like what is driving those actions that I'm not seeing? And they might not yet understand.
00:31:32
Speaker
Right, right. So it may not be that they're just not listening. Yeah. Yeah. And as an educator, you can get caught in that loop. Why aren't you doing what I tell you? And, you know, if you can't sort of take that breath and go, wait a minute, I must be missing something. And to me, that's the basic assumption, but which, you know, is easy to talk about. But that's what it really matters when you can sort of go, OK, wait a minute, I must be missing something here.
00:32:00
Speaker
Yeah, and I think, Kerry, that might be hard to do when there's 30 students in the class, like the cognitive load for you, right? Like, who have I said that to and when and how many times?
00:32:11
Speaker
Yeah, I guess that's the ah support our faculty need to do. they They need training and support and mentorship in that space to get to that. Well, right, and I'm guessing, Kerry-Ann, in that classroom setting, and if somebody is stuck,
00:32:29
Speaker
Like how much do you work with them to help them get unstuck without making them feel like they're, you know, you're sort of not targeting them, but you're, you know, it's potentially uncomfortable for them.
00:32:43
Speaker
And, you know, i think you've hit a pretty important point there because one of the challenges we face in the Australian context is many, many faculties have anything from 18 students per one facilitator in a classroom to potentially 32 students with two facilitators.
Educators' Challenges and Support Strategies
00:33:01
Speaker
Now, the challenge also lies in the fact that many of our classroom lab spaces may have clinicians that are coming in overseeing the students who may not necessarily be au fait with some of the principles around simulation. So
00:33:20
Speaker
It might be that one person who is experienced in simulation working with another less experienced clinician who's come in because of their expertise in the clinical side of things, but not necessarily the teaching side of things.
00:33:35
Speaker
So herein lies a challenge. And how is it that you move past that?
00:33:41
Speaker
these are ongoing challenges for us in simulation in the Australian context. I'm speaking from my experience, not necessarily everyone else's, but no, I think it's pretty universal.
00:33:55
Speaker
Yeah. All right. Thank you for that. i would, yeah, such an important discussion. And I think, Yeah, one that needs to continue to happen, I think. And hopefully, you know, people listening to this, it may trigger conversations within their own organisations and faculty.
00:34:15
Speaker
I would love to go. Sorry, just one more thing. I think this is a really great opportunity for us to be thinking about when we're catering for clinical laboratory situations where we've got clinicians in there and perhaps a more experienced academic, of how we can establish frameworks that make it a KISS approach, you know, keep it simple approach, even though there's complexities in it. But if we remove the almost the difficulty in what people perceive as what simulation is, which often
00:34:55
Speaker
moves them away from actually participating in SIM because they think, oh I'm going to miss this. or And I remember even the early days of being introduced into debrief thinking, oh, my gosh, that is so hard. There are so many elements to debrief. I don't think I'm going to be able to do it.
00:35:11
Speaker
But then someone gives you an overlay of a framework that, hey, just do it like this. So I'm thinking in these sim zones, how great it would be to have some sort of framework that allows us to see it really transparently in curriculum, that it's not too hard, that it's, and again, you know, I want to push that opportunity for our listeners to think, have a go, you know, look at things in a simplistic way that can make a difference for our learners.
00:35:42
Speaker
um Yeah. You know, Carrie-Ann, I think that the teaching, coaching and debriefing with good judgment paper, we tried to keep it really practical. and i And that actually gives like examples of what a conversation might sound like in each zone.
00:35:56
Speaker
And so that might be something that you might find helpful. And I would also say that, you know, I don't know to what degree this is possible there, but I certainly advocate for this in the US that anybody who's teaching our learners in simulation, they've got to have some kind of orientation to how this all works.
00:36:12
Speaker
Or else what we end up with is clinicians who are coming into the lab and they don't feel confident in what they're being asked to do. And I think many times people who have the potential to be great teachers,
00:36:24
Speaker
sometimes get discouraged early on because we throw them into situations that they're not ready for. So let's think about what zone one, zone zero, zone two training for clinical adjuncts that might be coming in to help us. And it doesn't have to be extensive.
00:36:38
Speaker
And herein lies hearing life a major difference in that in Australian context, again, I'm only speaking from my experience, we do not need to have simulation qualification to be teaching inside a simulation context.
00:36:54
Speaker
You know, yeah, so, you know, how are we preparing our educators with those principles? And the other challenge lies in the casualisation of staff.
00:37:06
Speaker
Yes. you know, that you're bringing in staff members here for one semester and then they're off. Yeah. you know and then they're often being employed from the point of week one without necessarily that time to prepare them. So we have challenges that I think this probably echoes many academics across across the country and maybe the US.
00:37:32
Speaker
And the world. Kate. Yeah, I would, Carrie-Anne, I think that's a universal challenge of, you know, the constant dilemma or tension is time.
00:37:49
Speaker
You know, everyone's busy. Everyone's teaching a lot of credits. the the What you call casual, we would mostly call adjuncts or clinical faculty, they're hired just, you know, kind of a just-in-time approach.
00:38:02
Speaker
And part of that hire is not a week of orientations. So how do we provide that like zone zero, zone one training, at least a little bit of zone two, where they're getting some feedback and coaching from an expert to help them feel comfortable and kind of develop their own style and think about how does that sound like them? Because they're going to sound different to whoever's coaching them.
00:38:31
Speaker
I think that's a real tension. and legitimizing that teaching in simulation is different.
00:38:43
Speaker
It's a different skill set. yeah Yeah. I think one way I've tried to tackle this is, yes, get each discipline to kind of matrix a simulation in their curricula.
Faculty Development and SimZones
00:38:58
Speaker
Then we can see where different units lie in the sim zones. And then ah kind of created SimZone kind of faculty development plan looking at what are the kind of modes and modalities and methods of Sim used in that zone.
00:39:19
Speaker
What tools of an in an organization we have that they need to get orientated to. And then what are some faculty development activities we could do? So, for example, Zone Zero, independent practice, the skills really is around kind of How do we, I guess that's it's a technical kind of zone where you might use independent CPR mannequins or VR ah headsets or things like that. We also have at my organization SimCapture for Skills, so students can independently film their practice and do peer-to-peer assessment or self-assessment.
00:40:07
Speaker
And so then what are the relevant faculty development? Well, it's around, I guess, orientation and familiarization to these technologies, ensuring they know how to operate it and they know how to pre-brief it and and provide feedback.
00:40:21
Speaker
So then you go into zone one and it's around task trainers or, you know, mannequins, online scenarios, again, virtual reality.
00:40:33
Speaker
We have simulated EMR as part of the tools, SimCapture for skills, virtual reality, and these part task trainers. So do the faculty know how to manage that those resources, how to design and deliver skills-based zone one activities?
00:40:53
Speaker
Do they know how to teach a skill using an evidence-based framework like Patons? Do they know the difference of the type of feedback? Is it feedback? Is it coaching?
00:41:05
Speaker
How do they manage those feedback conversations? How do they pre-brief and maintain psychological safety for technical skills? and so And then you can go up through the zone. So it really helps you map and think. And if if in this particular unit you're focused on zone two,
00:41:26
Speaker
well, then you know you need to focus your faculty development on zone two. Don't worry about all the rest. Just get them good at that zone. Better have an understanding of the prior zones.
00:41:39
Speaker
So it really helps you prioritise what faculty in what unit at what level in the curricula needs what training. And it makes something that's quite overwhelming, I think, down to bite-sized pieces.
00:41:56
Speaker
Right. Yeah. I love that. And I think, i I don't know if we've like sort of morphed into one human being, Mel, but that's where we've gotten to proposal wise, because I had a proposal for faculty development that was sort of all encompassing. And they're like, yeah, that's lovely.
00:42:13
Speaker
It's never going to work. like You know, we people can't. So we did. Okay. So if you're going to be a skills, if you're going to be a zone one faculty and that's where you live, then we're going to teach you,
00:42:25
Speaker
So we've sort of made it modular so that people can, you know, depending on where you teach, you would then access those those skills and and, you know, attend that faculty development. And I think it's a pretty similar approach without, I love your deliberateness in matrixing and get it. Like, I think that is so revealing for faculty.
00:42:50
Speaker
Oh, Because they don't often get to like have that pause and actually really reflect on where am I teaching? what am i What's my priorities here? Because I think people are you know so busy that that gives them that opportunity. So I love that you've done that. And I think that's the right approach is that module.
00:43:13
Speaker
Everybody's not going to be good at everything. Because if they just live in one space and you know zone one is simulation, than be a fabulous zone one simulationist.
00:43:27
Speaker
Yeah. Yeah. I love it. So I thought I might, because this may generate some conversation, particularly as we go up the zones. I wanted to love to give an example from occupational therapy. They do an immersive simulation week that is actually their clinical
Immersive Simulation in Occupational Therapy
00:43:47
Speaker
placement.
00:43:47
Speaker
Mm-hmm. So they do this particular placement in simulation. And so over the course of the week, they do different activities, which hopefully scaffold up to the summative assessment.
00:44:02
Speaker
So I was thought it would also be a good example of maybe what different things look like in the zones. So for zone zero they do classroom content at the start of the week.
00:44:16
Speaker
So what they do is they watch a client interview on a video, and then in class evaluate that performance and complete their own kind of reflective exercise on what they saw, maybe identify their own learning needs, where the gaps were. So that's kind of that prerequisite knowledge.
00:44:42
Speaker
Then zone one is peer-to-peer practice with feedback using their summative assessment rubric to guide the feedback conversations. So it's still formative assessment.
00:44:54
Speaker
So they do a client interview peer-to-peer and do documentation of that interview. And they practice a phone call to a physician to report the assessment findings.
00:45:07
Speaker
So they're assessed on really professional behavior, self-management, communication, effective information gathering, and identification of the client's needs.
00:45:19
Speaker
So this is kind of more feedback. Coaching.
00:45:24
Speaker
And then in zone two, which is around Wednesday, they bring in paid actors as simulated participants. And so now they do these interview rehearsals with the SPs, with immediate faculty and SPs.
00:45:44
Speaker
feedback via like a mini debrief. And then they rewatch a video of their own performance and self reflect. So again, reflect against the summative assessment items.
00:45:58
Speaker
Now zone three, and I love your thoughts if this is zone three, but they do a student led mini case conference. where they discuss the client's interview results and they collectively think about a proposed rehabilitation plan that needs to involve other health professionals.
00:46:20
Speaker
And then they get feedback and coaching on that discussion. And then zone five, and this is where Chris and I may differ in opinion, zone four, sorry, zone four,
00:46:36
Speaker
is high they do a high stakes assessment, simulation based assessment. Now, high stakes being they use the exact same assessment rubric as what they would out on clinical placement.
00:46:49
Speaker
So it's no different. And they must pass this assessment as they would a clinical placement to continue on in the course. So,
00:47:01
Speaker
For all intents and purposes, it is their placement. They get summative assessed with the placement tool. So I know in the original SimZones for the healthcare care context, it is in real the real world environment.
00:47:18
Speaker
Here they can't do placement in the real world environment for a number of reasons. So they've had to simulate it and it is their placement. Thoughts? So, you know, um I'm going to say that my initial reaction is something that i had to come around to, which is just because the numbers are higher doesn't mean it's better.
00:47:47
Speaker
And what I mean by that is we always think that it always has to go zone zero, zone one, zone two, zone three, zone four, or else we didn't do the whole thing. Not true.
00:47:58
Speaker
Anybody who is a pre licensure student rarely does his own three, rarely, because zone three is really about people who know how to do the skill. And now we're exploring what are the challenges it's for the experience ED team who does a resuscitation.
00:48:15
Speaker
Well, they know how to do resuscitations, but in this particular same, there were particular challenges. And now we explore those challenges. So. The big difference between zone two and zone three is in zone two, there is an absolute, you did it right, you did it wrong.
00:48:29
Speaker
In zone three, it's, well, it wasn't exactly what we were looking for, what got in your way. So there's a difference between those two. And so I'm going to say that what you call the zone three isn't.
00:48:43
Speaker
It's a zone 2.5. tim And I'm with Chris. Zone four is applied learning in the real workplace. So even though you're using exactly the same rubric, I don't think that makes that a zone four.
00:48:55
Speaker
Now, having said that, I'm dying to know what Kate's going to say because... The zones is a theory. It's a framework. It's not black and white, you know. So everything I just said comes from my understanding of the sim zones and how it gets applied. And we are very much still exploring what this means in the academic space.
00:49:14
Speaker
So in zone two, what is different than to zone three of just doing ah frames-based debrief that's focusing on behaviors and attitudes and teamwork as opposed to skill? i I think it comes down to zone three is really intended for experienced clinicians who really don't need to buff up their skills a whole lot.
00:49:43
Speaker
They just need to explore the challenges. which is a given situation. Whereas a zone two, are still not they're not super expert with their skills and there's a right way and a wrong way to do it. And we are still in the role in a zone two of observing them to see if they got it right or got it wrong.
00:50:00
Speaker
And in zone three, it's a little bit different. It's grayer. Yeah. It's grayer. I'm thinking of 2.5. like the two point Right. And that's why I think there's gradations in zone two. And a lot of what we do in the undergraduate world doesn't ever really get beyond zone two. And I think about our disaster sim, which has ethical dilemmas around, do you continue doing CPR on someone you know in a in a disaster?
00:50:29
Speaker
They're in the emergency room. So you know they would have been black tagged if they were in the field. And do you really put these? So there's not really a right or wrong you know, you can argue both sides of the fence around the ethical dilemmas of, you know, resuscitating, not resuscitating.
00:50:46
Speaker
And they're, there i think that's a little grayer and To me, that is like a 2.75 because we got a coach in the room.
00:50:57
Speaker
Like we're not good. I know, which is just, but say Chris is like having all of a sudden a migraine because they can't always. And oftentimes we coach them to stop. like And by asking provocative questions of how long have you been doing this? You know, I'm worried about the resources. You've got four people here. You got more patients coming in.
00:51:18
Speaker
So like we're pushing them to make a decision. and and sometimes we're making the decision for them. Versus at the graduate level, I think about the zone.
00:51:33
Speaker
and i think about the zone three we do with them around an impaired colleague. And they're already professional nurses. You know, they're experienced ICU nurses who are back learning how to be nurse anesthetists.
00:51:48
Speaker
And yet this impaired colleague thing is a, it's hard. It's, it's, there's not, you know, do you, don't you, when do you, what are the signs, symptoms, you know, where's patient safety, where's professional response. It's a little more nuanced than,
00:52:08
Speaker
um Then they and like the the field, you gave the right drug at the right time. Right. Like that's a, yeah, like here's the dose. Don't, you know, don't give 10 milligrams of morphine. People aren't going to breathe.
00:52:22
Speaker
So I think that becomes the struggle. And i I think we've gone around and around trying to think about like zone four for us in higher education is clinical practice. And I know Mary, you've coached me around,
00:52:38
Speaker
the, um like the safety guards are different in clinical practice than they are in simulation. Even if you're holding them to the same rubric, we don't have the same safety rails in simulation that have to exist in clinical practice. Like when you coached me around that, I was like,
00:53:03
Speaker
Yeah, I can see that.
00:53:07
Speaker
Like i very I might take that clinical person and say, hey, you need some more coaching based on what happened in SIM, but nothing bad's going to happen if they make a med error.
00:53:20
Speaker
Yeah.
00:53:23
Speaker
Interesting. are we doing, Mallory? Are we helping make that make sense in your mind? It's hard. No, I'm getting that. It's about this. Yeah. Yeah. I'm getting there. So zane zone two can be high stakes.
00:53:40
Speaker
Oh, absolutely. Yeah, yeah. Absolutely. Excellent. yeah And I think, too, I think of zone four as real clinicians solving clinical problems.
00:53:53
Speaker
You know, like for example, hey, we had a resuscitation. All these things didn't go so well. And now they're solving that clinical problem that happened in real life.
00:54:06
Speaker
And Mary, course, correct me if I'm like off in La La Land. and they're you And they might then use simulation to solve that problem, but they're focused on solving clinical problems. And when our students are out in clinical, you know, the stakes are certainly higher.
00:54:22
Speaker
And yet, and this may be a difference in the States, they're not left to their own devices. You know, there's always going to be a a clinical faculty supervising them, particularly at the undergrad level and at the graduate level, it would be ah preceptor.
00:54:43
Speaker
Yeah. And I think back to your point, you know, the the zones go both ways. So I think what I'd like to see in zone four in real clinical practice is our facilitators getting taught how to do frames-based debriefing and coaching. Because often if someone fails a skill, if they've passed that skill in uni, it's not often...
00:55:11
Speaker
the actual technical skill that they're unable to do in real clinical practice. It's all the context and everything all yeah around it. And so sending them back to uni to redo the competency is not fixing the right thing.
Integrating SimZones Beyond the Sim Lab
00:55:27
Speaker
And it would save a whole lot of work and paperwork and learning plans if we knew how to explore and understand what was going on for that learner in that moment and in that context. It's not always knowledge and technical skill.
00:55:43
Speaker
Yeah. Yeah. 100% agree. And yeah, hundred percent ah great and I think about the power of post, um post what we would call post-conference, which, yeah you know, those debriefing tools of being able to facilitate and dive in deeper around things that happened and understanding what might have got in the way of that learner of being able to demonstrate, you know, what we've determined is the right thing.
00:56:12
Speaker
or Or expanding their thinking around generalizing and applying of, well, what if it was in this slightly different context? Would that change what you did?
00:56:23
Speaker
Would that change your approach? What if the cultural context was different? Would that change what you did with that patient? And how, you know, sort of that challenging reflection piece, like to me, i think we don't always...
00:56:42
Speaker
consistently leverage those post-conference conversations in a way that could help people. agree. Yeah. And you know I think that highlights that you know all of this thinking around what stage is my learner at and how do I facilitate this learning experience that belongs everywhere, not just in the simulation lab. you know And when you're talking about like zone one simulations, Mel, they don't have to happen in a sim lab. They can happen in a classroom.
00:57:09
Speaker
You know, you think about teaching therapeutic communication SBAR. You can do zone one, zone two in a classroom. Yeah, yeah. So I think all facilitators in an ideal world, you know, would be skilled in facilitating learning conversations across the continuum.
00:57:29
Speaker
Excellent.
Conclusion and Future of SimZones
00:57:30
Speaker
Well, an amazing discussion and we could keep going, but I think we've, um the cognitive load... of us and our listeners in view and respect of constructivism.
00:57:45
Speaker
We might pause there, but super interesting conversation and yeah, more discussions to have, particularly in the higher education context. And I know, you know, we're thinking about trying to put something out to support SimZones in that context. So watch this space hopefully, but Thank you all. Thank you, Kerry. Thank you, Mary. Thank you, Kate.
00:58:10
Speaker
Great to see you guys. We'll get to have happy hour in person. um Real happy hour. Yeah. We'll come to you.
00:58:23
Speaker
Brilliant. The bubbles are on go Excellent. Great to see you again, Kerry-Ann. Likewise. Thank you. bye Thank you, guys.