Integrating Low-Fidelity Desktop Scenarios into the High- Fidelity Simulation Curriculum in Medicine and Aviation.

Integrating Low-Fidelity Desktop Scenarios into the High- Fidelity Simulation Curriculum in Medicine and Aviation. Matthew J W Thomas University of South Australia matthew.thomas@unisa.edu.au Abstract. The pursuit of efficiency in training systems design whilst simultaneously maximising transfer of training and the depth of training outcome presents a number of challenges for the curriculum designer. The recent developments in low-cost desktop simulation and training have the potential to offer much to the simulation-based curriculum. There exists considerable research evidence suggesting that low-fidelity simulation can achieve high levels of transfer of training, without the organisational burden of costs associated with the use of high-fidelity simulators. Similarly, research has suggested that there is not a simple direct relationship between fidelity and learning outcome in the simulation-based training environment. Within both the medical and aviation training settings, the learner s experience of high-fidelity simulation is typically through complete immersion in brief, stressful and complex scenarios. These sporadic forays into the simulation-based training environment frequently require a level of cognitive engagement with the simulated task that can impact on the potential for learning to take place. Indeed, it could be suggested that high-fidelity simulation provides only the experiential component for a learning process that actually begins well prior to the simulation and the majority of learning actually takes place during the post-simulation debrief and subsequent reflection on action. This paper explores the potential of low-fidelity desktop simulation as an integrated element of the overall simulation-based curriculum, and as a wrap-around for high-fidelity simulation. The paper provides a series of examples to illustrate an integrated curriculum, and highlights areas in which both efficiencies and enhancements might be achieved. 1. INTRODUCTION: ONGOING SKILL DEVELOPMENT AND MAINTENANCE The requirement to continually develop and maintain proficiency is a crucial aspect of quality assurance and safety in high-risk industries such as aviation and medicine. While initial training is designed to provide the necessary skills and professional competence to perform a specific task, there remains a need to regularly update knowledge and skill as well as practice essential tasks. The development and maintenance of expertise in any domain requires extensive, sustained practise in a manner which embeds self-awareness, performance monitoring and critical reflection[1]. This is indeed perhaps most important in relation to any changes in operational practice or in areas such as emergency or abnormal operations where an individual might not be exposed to critical events during the normal everyday course of work. The role of high-fidelity simulation in ongoing skill development and maintenance is already well established in aviation, and becoming more and more so in the field of medicine. standards for proficiency, a set number of check and training activities must be undertaken annually. Typically, an organisation will develop a training curriculum that is shaped directly in response to the regulatory requirements and, more often than not, training is carried out only to the statutory minimum requirement [2]. To illustrate such a curriculum, Figure One provides a syllabus outline for recurrent training in a hypothetical commercial airline. 1.1 Aviation Within the commercial aviation environment the standard approach to skill development and maintenance involves an annual cycle of proficiency checks and ongoing recurrent training. Structured around national regulations governing the minimum technical components of the syllabus and minimum performance Figure 1: Syllabus Outline of Annual Recurrent Check and Training for a Commercial Airline

For the commercial airline, the high-fidelity full flight simulator typically carries the bulk of the training load[3]. In the example above, more than half the annual check and training activities occur during full flight simulation. Furthermore, all the check and training activities are assessable, with failure leading to the removal of the individual from normal duties until a sufficient level of proficiency is demonstrated. Accordingly, the individual learner s experience of highfidelity simulation in this check and training environment is one of significant stress due to the highjeopardy nature of the curriculum context. Furthermore, the types of events encountered during simulation-based training and the demands on individual performance are frequently well beyond the realms of everyday experience. One possible weakness of these approaches to skill development and maintenance is that they can adopt an over-emphasis on the evaluation of proficiency (checking) at the expense of ongoing skill development (training). 1.2 Medicine A similar, though far less regulated, approach to ongoing skill development and maintenance has developed in recent times in the field of medicine. The various colleges of general practice and individual specialities have each developed Professional Development or Continuing Education programs as important aspects of overall Quality Assurance in their professional disciplines. For instance, the Australian and New Zealand College of Anaesthetists have developed the Maintenance of Professional Standards Program (MOPS) to structure ongoing skill development and maintenance. This program is designed to foster continuing scholarship in order to maintain a high standard of clinical practice in all anaesthetists[4]. The program outlines the minimum requirements for annual training and professional development activities in a range of areas. Participants in the program are required to gain a minimum number of points through engaging in activities such as clinical audits, self-directed learning activities, conference attendance and participation in simulation-based training activities. The role of simulation in ongoing skill development and maintenance for medical specialists is a relatively new element of the field. However, preliminary indications suggest that much can be gained from the utilisation of high-fidelity simulation. For instance, patient simulators have a unique role to play in helping practising clinicians learn to recognise and treat infrequently occurring and often highly complex clinical problems[5]. As demonstrated in the Figure Two, the high-fidelity Human Patient Simulator can play a role across a continuum from normal procedures to rare and critical events. Furthermore, the Human Patient Simulator can be utilised in the development of both technical and non-technical skills. Figure 2: The role of the Human Patient Simulator A typical scenario for use within a high-fidelity patient simulator training session might involve one or more clinical crises which the participants must resolve to ensure patient safety and the best possible clinical outcome. Again, as with the aviation simulation-based training environments, the scenarios utilised in these forms of advanced clinical training frequently demand high-workload levels and produce large amounts of stress for participants. Accordingly, while the simulation itself provides a sound experiential basis for learning to take place, the overall curriculum context needs to be carefully managed in order to maximise the opportunities for learning. 2. OPPORTUNITIES FOR LEARNING IN CURRENT SIMULATION-BASED TRAINING SYSTEMS Maximising the opportunity for learning presents a significant challenge facing the design of training systems that offer both a cost-effective and sufficiently comprehensive approach to skill development and maintenance. Simulation-based training is perceived as primarily experiential in nature and avoids the common criticism that learning is restricted to the presentation and demonstration of information at the expense of hands-on knowledge and skill development[6]. Fundamental to the instructional framework of simulation-based training is the quest for realism, and considerable efforts are consistently made to enhance physical, functional and task fidelity[2, 7]. However, due to the compact nature of simulation-based training and the frequently high-workload and stressful nature of the scenarios presented to the participants, it can be argued that simulation-based training programs may not be providing the most valuable opportunities for learning from an instructional perspective. Within both the medical and aviation training settings, the learner s experience of high-fidelity simulation is typically through complete immersion in brief, stressful and complex scenarios. These sporadic forays into the simulation-based training environment frequently require a level of cognitive engagement with the simulated task

that can impact on the potential for learning to take place. Indeed, it could be suggested that high-fidelity simulation provides only the experiential component for a learning process that actually begins well prior to the simulation and the majority of learning actually takes place during the post-simulation debrief and subsequent reflection on action. 2.1 Events of Instruction An essential component of our understanding of learning involves the recognition that learning progresses through a systematic series of processes. These events of instruction have been described by Gagné as: 1) gaining attention; 2) informing learner of objectives; 3) stimulating recall of prior knowledge; 4) presenting the stimulus material; 5) providing learner guidance; 6) eliciting performance; 7) providing feedback; 8) assessing performance; and 9) enhancing retention and transfer [8]. Learning potential is maximised where each of these nine events of instruction are all present and appropriately sequenced. Within a simulation-based curriculum for ongoing skill development and maintenance, the emphasis is typically placed on events six to eight, in which a complex scenario is presented to the participants, who are then required to manage the event to the best-possible outcome. The expectation is that events one to five will occur prior to the simulator session through self-study processes and a facilitated pre-simulator session briefing. Feedback frequently occurs after performance has been assessed, (not ideal for maximising learning), and enhancing retention is achieved through post-session debriefing and subsequent reflection-on-action by the participants. While the experiential nature of simulation-based training is an obvious benefit to learning, its potential must be maximised with a greater emphasis placed on the essential events of instruction which occur pre- and post- the simulator-based events. 2.2 Incongruence in Existing Programs Common to the ongoing skill development and maintenance programs in both medicine and aviation is the possibility that individual instructional events remain incongruent facets of a disparate curriculum. One essential aspect of effective curriculum design is the proper integration of simulation-based training with everyday work experiences and other forms of ongoing training [9]. Not only must each curriculum component embed each of the nine events of instruction, but each component must also be aligned with an overall instructional objective and integrated into a coherent instructional program in order to maximise learning. A typical annual curriculum might include individual components such as: 1) a Computer-Based Training (CBT) package introducing a new piece of technology; 2) a face-to-face workshop on team dynamics; 3) a highfidelity simulation session involving a complex nonnormal event; and 4) a classroom session explaining new emergency procedures. In this instance there can often be a lack of alignment between the content of CBT training, simulation-based training, and the operational requirements of the task. In order to maximise learning potential, each of these elements of the overall curriculum must be integrated into an aligned instructional program. The opportunity exists to conceptualise Gagné s events of instruction not only in relation to discrete instructional events, but also more broadly across a whole curriculum framework. Through the expansion of this framework to include a whole of curriculum focus, it is possible to work towards an integrated curriculum in which learning potential is maximised. 3. THE INTEGRATED CURRICULUM The outcome of any simulation-based training is a product not only of the technology involved, but rather the overall curriculum in which the simulator-based training is embedded is perhaps more important in determining educational quality. An ideal situation might be one in which low-fidelity desktop devices and high-fidelity simulators are employed as complementary elements of an integrated curriculum. Figure 3: The optimal use of low-fidelity and highfidelity instructional devices. If we adopt an approach that wraps low-fidelity desktop scenarios around the intense instructional use of highfidelity simulation, integration can assist in maximising learning potential. As demonstrated in Figure 3, the use of low-fidelity desktop scenarios can greatly assist in the early events of instruction that are typically underemphasised in simulation-based training.

3.1 Example One: Introduction of New Procedures in Commercial Aviation The first example of an integrated curriculum structure that wraps low-fidelity desktop scenarios around highfidelity simulation involves the introduction of new flight-deck operating procedures in the commercial aviation setting. Typically, the introduction of new procedures such as a new company standard noiseabatement takeoff profile, would involve self-study of the relevant changes to procedures in the Flight Operations Manual, a pre-simulator briefing, and an evaluation of competence in a cyclic simulator session. While this traditional approach is most likely adequate, a number of potential problems can be manifested. For instance, potential problems can arise from inadequate integration of the new procedure with the natural complexity of normal operations such as multi-crew teamwork, changed demands on situation awareness, and the timing of other tasks such as communication with Air Traffic Control. In order to avoid such problems and maximise learning potential, the use of low-fidelity desktop scenarios have significant potential. In this instructional situation, a low-fidelity desktop training package could be developed, which provides a number of demonstrations of the new procedure and also the opportunity for trainees to practice the procedure in a low-fidelity real-time environment prior to the highfidelity simulation environment. Such an approach can maximise the learning potential in a number of important ways. First, the desktop scenarios could present trainees with a behavioural model of the new procedure that assists in company standardisation. Through taking advantage of the advanced multimedia capabilities of current desktop computing, it is possible to provide modelled behavioural cues through the integration of video into the desktop scenario. Secondly, the desktop scenarios could introduce the operational complexities found in the normal work environment. The provision of multiple pathways through the inclusion of various decision-points into the scenario, would allow for exploratory modes of learning in which the outcomes of various decisions provide meaningful feedback within the context of an authentic learning task. Thirdly, such operationally realistic learning tasks can assist in the integration of technical knowledge with non-technical skills such as communication and support functions, and workload prioritisation involved in the management of competing operational requirements. Accordingly, increasing levels of task-realism can still be achieved within an overall low-fidelity architecture. Finally, the desktop scenarios could assist trainees with the development of a coherent understanding of the new procedure through practice of the new procedure in a range of operational contexts, and at varying levels of difficulty. Accordingly, when the trainee is required to demonstrate competence with the new procedure in the high-fidelity simulator environment, they have already had the opportunity to explore the operational implementation of the procedure in a variety of contexts. Figure 4: Example Desktop Scenario: A simple Internet-based self-study package designed to be used prior to Line Oriented Flight Training (LOFT) scenario in the full-flight simulator. As illustrated in the example above, it is currently possible to create sophisticated desktop-scenarios, designed and delivered with existing Internettechnologies, that provide significant benefit to the early stages of Gagné s events of instruction. 3.2 Example Two: Anaesthesia Crisis Resource Management The second hypothetical example of an integrated curriculum structure that wraps low-fidelity desktop scenarios around high-fidelity simulation is that of Anaesthesia Crisis Resource Management (ACRM). Traditionally, an ACRM course involves a half- or whole-day training program that utilises high-fidelity simulation in the development of non-technical skills such as decision-making, communication and group interaction, situation awareness, and error management. Preparation prior to immersion in the high-fidelity simulation is typically minimal and might involve only a brief introduction to ACRM principles in a presession briefing. In this instructional situation, low-fidelity desktop scenarios offer what is likely to be an effective mechanism by which trainees can be introduced to the underlying principles involved with ACRM and are able to engage with complex decision-making and group management scenarios. Particularly through the use of a case-study or problem-based learning approach, lowfidelity desktop simulation has the potential to maximise learning. For example, trainees can be exposed to a sequence of events within a critical clinical situation such as cardiac arrest. The desktop scenario can present the trainee with a range of realistic cues including representation of the patient s physiological status through a simple simulation of the standard aural and visual cues available

in the operating room in relation to heart-rate, blood pressure, airway and breathing, oxygen saturation and other parameters. With the inclusion of a series of decision-points where the trainee must identify pertinent information and choose from a range of alternate actions, the desktopscenario can provide an authentic task that can be explored outside the time-critical and high-stress environment of the high-fidelity Human Patient Simulator. As the low-fidelity simulation can be designed to be responsive to the decisions made by the trainee, the trainee can thus become familiar with the use of ACRM strategies prior to immersion in the highfidelity simulation environment. Accordingly, it is suggested that learning will be maximised through an integrated curriculum that wraps low-fidelity desktop scenarios around high-fidelity simulation. The key elements of the desktop-scenario which provide an advantage over the typical print-based pre-training package include: 1) increased task-realism; 2) scenario development which is responsive to learner input; 3) realistic aural and visual cues; 4) enhanced feedback; and 5) learner support and adaptation to learner needs. Together, and as an integrated element of the simulation-based curriculum, low-fidelity desktop scenarios can provide an opportunity to maximise learning potential and increase the efficacy and efficiency of high-fidelity simulation. 3. Smallwood, T. (2000) The Airline Training Pilot. 2nd ed. Ashgate: Aldershot, UK. 4. ANZCA (2002) Maintenance of Professional Standards: Program Manual. Australian and New Zealand College of Anaesthetists: Melbourne, Australia. 5. Good, M.L. (2003). "Patient simulation for training basic and advanced clinical skills," Medical Education, vol. 37 no. Suppl. 1, pp. 14-21. 6. Merrill, M.D. (2002). "First Principles of Instruction," Educational Technology Research and Development, vol. 50 no. 3, pp. 43-59. 7. Thomas, M.J.W. (2003) "Operational Fidelity in Simulation-Based Training: The Use of Data from Threat and Error Management Analysis in Instructional Systems Design", in Proceedings of SimTecT2003: Simulation Conference. Simulation Industry Association of Australia: Adelaide, Australia. pp. 91-95. 8. Gagné, R.M. (1985) The Conditions of Learning and Theory of Instruction. 4th ed. Holt, Rinehart and Winston: New York, NY. 9. Maran, N.J. & Glavin, R.J. (2003). "Low- to high- fidelity simulation - a continuum of medical education?," Medical Education, vol. 37 no. Suppl 1., pp. 22-28. 4. CONCLUSIONS AND AREAS FOR FUTURE RESEARCH This paper has presented a brief analysis of the structure of current high-fidelity simulation curricula and a critique of the opportunities for learning embedded within typical ongoing skill development and maintenance programs. In response to difficulties with maximising the opportunities for learning within such curricula, examples of how low-fidelity desktop scenarios can be integrated into the high-fidelity simulator curriculum as a powerful wrap-around designed to increase cost-efficiency and maximise the overall learning potential. This paper has highlighted the need for empirical investigation of the potential of such wrap-around desktop-scenarios in relation to training efficiency in high-fidelity simulation and transfer of training potential of this approach to curriculum design. REFERENCES 1. Guest, C.B.; Regehr, G.; & Tiberius, R.G. (2001). "The life long challenge of expertise," Medical Education, vol. 35 no., pp. 78-81. 2. Macfarlane, R. (1997) "Simulation as an instructional procedure", in Designing instruction for Human Factors training in aviation, G.J.F. Hunt, Editor. Ashgate: Aldershot, UK. pp. 59-93.