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TheIntersectionofEthics,Education,andSimulation:ExploringDifficult
Issues
AaronW.Calhoun,MDChair,SSIHResearchCommitteeAssociateEditor,SimulationinHealthcareDirector,SPARCProgram
Outline
• EmergingEthicalIssuesinSimulation• DeathofaSimulator:HelporHindrancetoLearning
• DeceptionasanEducationalMethodology:IsItAlways(orEver)Wrong?
Disclosures
• AaronW.Calhoun- Co-investigatoronHealthResourcesandServicesAdministration(HRSA)targetedissuesgrant
EthicalIssuesinSimulation
• “Insimulation,yougettoplaywithpeople’smindsforagoodcause…”– Aretherelimits?–Whatarethey?– Howdowemakegooddecisions?
• Currentlyfacingseveralethicalissueswithoutclearanswer
EthicalIssuesinSimulation
• DeathinSimulation?– Isitappropriate?– Ifso,whenandwithwhom?
• DeceptioninSimulation?– Isitappropriate?– Ifso,whenandwithwhom?
• Thesequestionsarecurrentlygeneratingagreatdealofdiscussioninthesimulationcommunity
VS
WhatisDeath,Exactly?
• Soundslikeanoddquestion,buttherearemanywaysamannequincandie…
• Leighton’sTaxonomy– ExpectedDeath-Bothfacilitatorsandlearnersareawarethemannequinwilldie
– UnexpectedDeath - Facilitatorsknowbutlearnersdonot
– DeathduetoActionorInaction-Completelyunplanned.Facilitatorsdecidetoletmannequindiebasedonlearneractions
LeightonK:Deathofasimulator.ClinicalSimulationinNursing2009;5(2):e59-62
WhatisDeath,Exactly?
• Soundslikeanoddquestion,buttherearemanywaysamannequincandie.
• Leighton’sTaxonomy– ExpectedDeath-Bothfacilitatorsandlearnersareawarethemannequinwilldie
– UnexpectedDeath - Facilitatorsknowbutlearnersdonot
– DeathduetoActionorInaction-Completelyunplanned.Facilitatorsdecidetoletmannequindiebasedonlearneractions
LeightonK:Deathofasimulator.ClinicalSimulationinNursing2009;5(2):e59-62
SimulatedDeath:WhatWeKnow
• AddingEmotionalStressorstoTraininginSimulatedCardiopulmonaryArrestEnhancesParticipantPerformance.– 25studentvolunteersrandomlyassignedtocontrolvsintervention
– Actorsscriptedtoaddstresstocardiacarrestscenariofor“intervention”group
– Addingemotionalstressorstosimulationenhancedlearneranxiety(measuredbymaxheartrate[120vs95]andStateAnxietyInventoryscores[35vs28],toolrange20-80)
– Addedstressalsoimprovedpracticalcompetencyscores(32.5/40vs25/40)sixmonthslater
DeMaria S,etalAddingEmotionalStressorstoTraininginSimulatedCardiopulmonaryArrestEnhancesParticipantPerformance.MedicalEducation.44(10):1006-1015
SimulatedDeath:WhatWeKnow
• TheImpactofSimulatedPatientDeathonMedicalStudents’StressResponseandLearningofACLS– 26studentsparticipatinginanAHAACLScourse– Studentsthenengagedinahigh-fidelitysimulationscenariorandomizedtodeathvssurvivalconditions
– 6monthfollow-upsimulationinwhichACLSskillswereassessed
– Allparticipantshadhigherheartrate(32bpmdiff),DHEA(97pg/mldiff),andsalivarycortisol(0.115ug/mldiff)
– Heartratesignificantlyhigherindeathgroup(29.2bpmdiff)– Nodifferenceinskillat6months
DeMaria S,etalTheImpactofSimulatedPatientDeathonMedicalStudent’sStressResponseandLearningofACLS.MedTeach2016Jul;38(7):730-737
SimulatedDeath:WhatWeKnow
• DeathDuringSimulationTraining:FeedbackfromTrainees– 63physiciansand175airmedicalteammemberscompletedQIsurveysregardingtheirperceptionsofdeathinthesimulatedenvironment
– Participantsinsimulationswithunexpecteddeathdidnotfinditdistracting
– Participantsexpectedthesimulatortodieifthiswasanappropriateoutcome
– Participantsstronglydisagreedthatstudentsshouldbeexemptfromsimulateddeath
– Participantsdidnotfeelthatitwouldgeneratereluctancetoengageinfutureactivities
Phrampus P,etalDeathDuringSimulationTraining:FeedbackFromTrainees[abstract].In:InternationalMeetingonMedicalSimulation:2005;Miami(FL)SocietyforTechnologyinAnesthesia:2005p95,Abstractsnr16.
SimulatedDeath:WhatWeKnow
• TraineePerspectivesonManikinDeathDuringMockCodes– 62pediatrictraineessurveyedregardingmockcodeparticipation
– 59(95%)surveyreturnrate,42%ofwhichhadwitnessedadeathduringasimulation
– Traineesfounditrareandunexpectedwhenthemannequindied,equatingitwithinadequateresuscitation
– Traineesfoundmannequindeathtobeasignificantstressor,butthoughtitbeneficial
– Traineesdidnotthinka“deathdisclosure”priortothesimasneeded
Lizotte MH.TraineePerspectivesonManikinDeathDuringMockCodes.Pediatrics.July2015;136(1):e93-e98
SimulatedDeath:WhatWeKnow
• DeathofaManikin:AdverseEffectonLearningandMechanisms– Prospectiveinterventionon116medicalstudents– Randomallocationto“death”or“nodeath”groups– Moreemotionalstressandsadnessmeasuredimmediatelyafterthesession
– Highercognitiveloadmeasuredimmediatelyafterthesession(7.63/9vs7.25/9)
– 3monthslater,studentsinthe“death”groupwerelesslikelytonavigateasimilarsituationsuccessfully(70.9%vs86.9%
FraserK,etalDeathofaManikin:adverseEffectonLearningandMechanisms[Abstract].In:Chest2011;140(4)
SimulatedDeath:WhatWeKnow
• TheEmotionalandCognitiveImpactofUnexpectedSimulatedPatientDeath– Furtherdataderivedfromsamestudy– Oddsratioof0.37(95%CI,0.14-0.95)ofbeingrated“competent”atthefollow-upsimulationforthoseexposedtomannequindeath
FraserK,etalTheEmotionalandCognitiveImpactofUnexpectedSimulatedPatientDeath:ARandomizedControlledTrial.Chest.May2014;145(5):958-963
SimulatedDeath:Whatweknow
• First,DoNoHarm:UsingSimulatedPatientDeathtoEnhanceLearning– LettertotheeditorregardingDeMaria study– Concernedthatsomeofthedatafromthatstudy(particularlycommentsfromnursesreferringblameforthe“death”tothephysicians)indicatederosionofthecollaborativeenvironment
– Expressesconcernthatsimulateddeathisoftennotgroundedinsoundethicalprinciplesthatpromotenon-punitiveeducationalculturesandinter-professionalcollaboration
– Advisedthatsimulateddeathonlyoccurwhenitisanexplicitpartofthelearninggoals
Bruppacher HR,etalFirst,DoNoHarm:UsingSimulatedPatientDeathtoEnhanceLearning.MedEduc 45(3):317-318
SimulatedDeath
• Studiesaddressdifferent(perhapsunrelated)questions
• Resultsnoteasytocorrelate
• Whatneedstobedonetounifyourapproach?
TheImportanceofTheoreticalFrameworks
• Notonlyistherelimiteddata,thereisnouniformlyacceptedwaytoapproachtheissue
• Theoreticalframeworkshelpusorganizeourdataandourquestionsaboutthedata,allowingustoarriveatmoreconsistentanswers
AQualitativeResearchStudy…
Focusgroupscomposedoffellows,residents,and
nursesthathadexperiencedsimulated
death
Transcriptswereanalyzedby3coders
Triangulatedusingagroundedtheory
approachtogeneratealistofrelevantthemes
Themesorganizedintoaframeworkdepicting
relationships
Surveywasgeneratedusingframework
Surveyelectronicallydistributedtoallfellows,residents,nurses,andRTs
Surveyanalyzedusingmixedmethodsapproach
Resultsusedtomodifythetheoreticalframework
ThemesfromOurLearners
1. Learnerpreparationandsuspensionofdisbeliefduringsimulation
2. Differencesinemotionalresponsebetweenrealandsimulateddeath
3. Effectsofsimulateddeathonfutureemotionalengagementwithlearningactivities
4. Learnerself-perceptionandperceptionbyteamregardingdeficits
5. Impactofdebriefingonemotiveresponsetothesimulation
6. Impactofdebriefingonlearnerknowledgeandskills7. Knowledgeretentionandpracticechangescausedby
mannequindeath
1:LearnerPreparation
andSuspensionofDisbelief
MannequinDeath
2:DifferencesinEmotionalResponse
betweenRealandSimulated
Death
3:EffectofSimulatedDeath
onFutureEmotional
EngagementinLearningActivities
4:LearnerSelf-perceptionandPerceptionbyTeamRegardingKnowledgeandSkillDeficits
5:ImpactofDebriefingon
EmotiveResponsetotheSimulation
6:ImpactofDebriefingtheKnowledgeandSkillsLearnedDuringtheSimulation
7:EffectofMannequinDeathonKnowledge
RetentionandPracticeChange
APilotModeloftheEffectofMannequinDeathDuetoLearnerActionorInactionontheLearner’sEducationalExperience
LearnerReactiontoSubsequentSimulationSessions
LearnerExperience
andKnowledge
fromPreviousSimulationSessions
Tripathy S,etal.WhentheMannequinDies:CreationandExplorationofaTheoreticalFrameworkUsingaMixedMethodsApproach.SimulationinHealthcare.June2016;11(3):149-156
Theme: Study:2:DifferencesinEmotionalResponseBetweenRealandSimulatedDeath
• NickersonM,etal.SimulationPhilosophyandPractice:SimulatorPatientDeathvs Survival
3:EffectsofSimulatedDeathonFutureEmotionalEngagementinLearningActivities
7:PerceivedEffectofMannequinDeathinKnowledgeRetentionandPracticeChanges
• Phrampus P,etal.DeathDuringSimulationTraining:FeedbackFromTrainees
• Phrampus P,etal.PerceptionsofExperiencingSimulatedDeath
5:ImpactofDebriefingonEmotiveResponsetotheSimulation
7:PerceivedEffectofMannequinDeathinKnowledgeRetentionandPracticeChanges
• FraserK,etal.DeathofaManikin:AdverseEffectonLearningandMechanisms
• Lizotte MH.TraineePerspectivesonManikinDeathDuringMockCodes
6:ImpactofDebriefingonKnowledgeandSkillsLearned
7:PerceivedEffectofMannequinDeathinKnowledgeRetentionandPracticeChanges
• DeMariaS,etal.Addingemotionalstressorstotraininginsimulatedcardiopulmonaryarrestenhancesparticipantperformance
• FraserK,etal.TheEmotionalandCognitiveImpactofUnexpectedSimulatedPatientDeath:ARandomizedControlledTrial
• Lizotte MH.TraineePerspectivesonManikinDeathDuringMockCodes
ExternalExperienceandValidation
• ParallelstudyconductedatLurieChildren’sHospital
• Educationalphilosophyexcludingmannequindeathduetoactionorinaction
• Externalrescueprovidedinallcaseswherethisotherwisewouldoccur
• Afterafriendlydebateatthesimulationconference…
AParallelStudy
• Similarqualitativemethodology• 3physicianand3nursefocusgroups• Essentiallyconfirmedthemes• Additionalthemenoted…– Effectofactionsusedtomitigatedeathonperceptionsoffidelity
• Thisthemecouldonlyhavearisenatacenterwheremannequindeathisprevented
• Modelmodifiedtoincludeadditionalthemeaswellasimplieddecisionpoint
1:LearnerPreparation
andSuspensionofDisbelief
MannequinDeath?
2:DifferencesinEmotionalResponse
betweenRealandSimulated
Death
3:EffectofSimulatedDeath
onFutureEmotional
EngagementinLearningActivities
4A:LearnerSelf-perceptionandPerceptionbyTeamRegardingKnowledgeandSkillDeficits
5:ImpactofDebriefingon
EmotiveResponsetotheSimulation
6:ImpactofDebriefingtheKnowledgeandSkillsLearnedDuringtheSimulation
7:EffectofMannequinDeathonKnowledge
RetentionandPracticeChange
FinalModeloftheEffectofMannequinDeathDuetoLearnerActionorInactionontheLearner’sEducationalExperience
LearnerReactiontoSubsequentSimulationSessions
LearnerExperience
andKnowledge
fromPreviousSimulationSessions
4B:EffectofActionsUsedtoMitigateDeathonPerceptions
ofFidelity
Yes
No
MannequinDeath:ContributingFactors
• Effectofstressonlearning• Effectoffidelityonlearning• Effectoffidelityonfutureexpectations• Roleoflearnerexperience
Stress:TheYerkes-DoddRelationship
LowStress HighStress
HighPerformance
LowPerformance
LowComplexityActivities
HighComplexityActivities
Yerkesetal.TheRelationofStrengthofStimulustoRapidityofHabitFormation.JournalofComparativeNeurologyandPsychology.18:459–482
Fidelity
NoCasesEndinDeath
AllCasesEndinDeath
HighPerformance
LowPerformance
1:1CorrelationwithLearnerAction
EffectonFutureExpectations
• Inpractice,ouractions(evenwhentechnicallycorrect) donotalwaysresultinsurvival
• Doesa1:1correlationbetweenstudentactionsandsurvivalgiveafalseimpressiontostudents?
• Doesa1:1correlationaugmentfuturepsychologicalstressbycausinglearnerstoinvariablyequatedeathandfailure?
Lizotte MH.TraineePerspectivesonManikinDeathDuringMockCodes.Pediatrics.July2015;136(1):e93-e98
SomeCurrentData
• SPARCSimulationProgramroutinelyallowsformannequindeathduetoactionorinaction
• InternationalSimulationDataRegistry(ISDR)queriedforallSPARCProgramdeaths
• 41/242(17%)simulatedcardiacarrestsinSPARCProgramendindeath
• 30%averagerateofdeathduringpediatricresuscitation(1.7xgreater)
Bhanjietal.SurvivalRatesFollowingPediatricIn-HospitalCardiacArrestsDuringNightsandWeekends.JAMAPediatrics.2017.171(1):39-45
EffectonFutureExpectations
NoCasesEndinDeath
AllCasesEndinDeath
HighPerformance
LowPerformance
1:1CorrelationwithLearnerAction
Isamore“realistic”deathratebetterlongterm?
VS
EffectofExperience
• Experiencelevelofthelearner/learnergroupmayhaveoppositeeffect
• Whilethedataismixed,manysuggestthatdeathduetoactionorinactionshouldbeavoidedattheundergraduatelevel
CalhounAW,Pian-SmithMC,Truog RD,Gaba DM,MeyerEC.DeceptionandSimulationEducation:Issues,Concepts,andCommentary.SimulationinHealthcare.June2015;10(3):163-169.
EffectofExperience
NoCasesEndinDeath
AllCasesEndinDeath
HighPerformance
LowPerformance
1:1CorrelationwithLearnerAction
Isamore“forgiving”approachneededforthelessexperienced?VS
TheFinalEquation…
(Stress)+∫(Experience)(Fidelity)=?–Intheend,thedecisionisacomplexrelationalcalculus–Likesomanythingsinmedicine,thecorrectanswerisprobably“itdepends…”
PracticalImplications
• Learnerexperienceandpotentialpsychologicalafter-effectsmatterwhenapproachingemotionallydifficultsimulations
• Learnersalsoseemtowanttoexperiencetheoutcomeoftheiractions,especiallyinasafeenvironment
• FutureQuestions:– Whatleveloftrainingisappropriateforcertainexperiences?
– Isourcurrentglobaleducationalculturetooprotective?
– Whatarethelong-termpositiveandnegativeeffectsofdifferenttypesofmannequindeath
DeceptionandScience
• LaserInterferometerGravitationalWaveObservatory(LIGO)
• Thegoal:Todetectevidenceofgravitationalwaves
• “Falsepositive”signalsroutinelyinsertedintosystemtotestinstrumentandscientists
• Donetomitigatethebiastowardconfirmingapositivesignal
• Scientistsbeing“deceived”…CollinsH.Gravity’s Kiss. MITPress 2017
DeceptionandSociety
• LasVegasPoliceinvestigationofthekillingof2homelessmen
• Mannequinplacedatlocationofmurdersasdecoy
• Feb23at3am:Suspectapproachedthesceneandstruckmannequin’sheadrepeatedlywithahammerconcealedwithinapizzabox
• Subsequentlyarrestedforcarryingaconcealedweapon
• Cannot,ofcourse,makemurderaccusation
http://ktla.com/2017/03/07/to-catch-thrill-killer-vegas-cops-set-up-sleeping-mannequin/
DeceptioninSimulation,ACaseStudy…
• Asimulated sixyearoldpatientwithahistoryofrenalfailurebythenameofRodneySmithisadmittedtotheICUforfrequentPVC’s
• HewasinitiallybroughttotheEDwithanewcomplaintofchestpainand“racingheart”thatbeganfourhoursago
• Accordingtothefamilyhehasmissedhislastseveralperitonealdialysispassesduetoequipmentmalfunction
• SuddenlythepatientdevelopspulselessventriculartachycardiaandCPRisinitiated
• CallfromEDtolearnergroupimmediatelythereafterrevealingaserumpotassiumof12
TheConfederate
• Dr.MarkMcDonaldarrives• Intensivist,NortonChildren’sHospitalMedicalDirector
• Doubleagent!• Dr.McDonaldordersapotassiumphosphatebolus
• Residentandnurseconfirmandadministerit
• Patientbecomesasystolic…
IsThisUnethical?
• Goalofthecaselaudable:teachinghowtoappropriatelychallengehierarchy
• Alegitimateclinicalissue• Thedeceptionwasneededtocreaterealism
• Butwasitreally?• Thoughthismayseemself-evident,somemedicalethicistsdisagree
• Currentlythefocusofanongoingdebateinthesimulationcommunity
WhatConstitutesDeception?
ExamplesofDeceptioninSimulation
Aconfederatefromoutsidethelearnergroup joinstheteamduringasimulationandintentionallymakesinappropriatemedicaldecisionsduringthecase
Simulationfacultyintentionallyplacefaultyequipmentwithin thesimulatedenvironmentinawaythatwouldbeunexpectedtolearners
Theoutcomeofthesimulated caseisintentionallydecoupledfromtheactionsofthelearnergroup inawaythatisinconsistentwiththegroundrulesofthecase.
NestedSpectraofDeception…
Aconfederatefromoutsidethelearnergroup joinstheteamduringasimulationandintentionallymakesinappropriatemedicaldecisionsduringthecase
Simulationfacultyintentionallyplacefaultyequipmentwithin thesimulatedenvironmentinawaythatwouldbeunexpectedtolearners
Theoutcomeofthesimulated caseisintentionallydecoupledfromtheactionsofthelearnergroup inawaythatisinconsistentwiththegroundrulesofthecase
NotDeceptive
HighlyDeceptive
NotDeceptive
NotDeceptive
HighlyDeceptive
HighlyDeceptive
DeceptioninSimulation:WhatDoWeKnow?
• Verylittleliteraturearisingfromthemedicaleducationcommunity
• Mostvaluableinformationcomesfromthefieldofpsychology
• Significantfocusontherolethatdeceptionhasplayedinpastpsychologicalresearch– The“infamous”MilgramExperiment– TheStanfordPrisonExperiment
TheMilgramExperiment
• 1961- YalepsychologistStanleyMilgram begana“study”oftheeffectsofpainonmemory
• Recruitedvolunteerswhothenwereaskedtoadministerelectricshockstolearnerswhentoldbyaproctor
• Shocksquicklyescalatedbyproctortopotentiallylethalvoltages
• Inreality,Milgramwasstudyingvolunteerobedience…
PerryG.BehindtheShockMachine.TheNewPress2012
DistinctionsinDeception
• Deception“Within”vsDeception“About
DeceptionWithin
MutuallyAcceptableEducationalPurpose
Another,UndisclosedPurpose
DeceptionAbout
Kelman HC.HumanUseofHumanSubjects:TheProblemofDeceptioninSocialPsychological Experiments.PsychologicalBulletin1967;67(1):1-11.
DistinctionsinDeception
• Deception“Within”vsDeception“About
DeceptionWithin
MutuallyAcceptableEducationalPurpose
Another,UndisclosedPurpose
DeceptionAbout
Kelman HC.HumanUseofHumanSubjects:TheProblemofDeceptionInSocialPsychological Experiments.PsychologicalBulletin1967;67(1):1-11.
AnApproach…
• Answertothequestionismultifactorial
• Learner,Faculty,EducationalMaterial,andInstitutionalEnvironmentareallpotentialfactors
• Perhapsmoresignificantly,therelationshipbetweenthesefactorsisalsoimportant…
AnExample
• Aresidentlearnerentersasimulationinwhichdeceptionisemployed
• Boththeresidentandthesessionfacultyhaveadequateexperiencetoengageintheemotionallychallengingsituation
• But…theresidentandfacultyalsojusthadaparticularlynegativeinteractiononroundsthatmorning
• Theuseofdeceptionmaynotbewiseinthiscircumstance
AFrameworkForEmotionallyDifficultSimulations
InstitutionalEnvironment
ScenarioStructure
SessionGoal
FacultyBackground
LearnerBackground
EducationalIntent
CalhounAW,Pian-SmithMC,Truog RD,Gaba DM,MeyerEC.DeceptionandSimulationEducation:Issues,Concepts,andCommentary.SimulationinHealthcare.June2015;10(3):163-9.
PracticalImplications
• Again,learnerexperiencematters,asdothepotentialpsychologicalafter-effects
• Nomanorwomanisanisland• Educationisfundamentallyrelational,andourrelationshipswithourlearnersisasignificantfactorintheeffectivenessofourtraining
• Theultimateansweronthequestionofdeception’slegitimacyislikelytobe“itdepends”
IntotheFuture…
• Currentlydesigningamixedmethodsstudyintendedtoexploretheusageofdeceptionwithinthesimulationcommunity– Rangeofdefinitions– Spectrumofapproaches– Decisionmakingprocessregardinguse
• Ultimategoalistocreateamorerobustfoundationforfutureresearch
Summary
• MannequinDeathduetoActionorInactionandtheroleofdeceptivetechniquesarecurrentareasofethicaldebateinthesimulationcommunity
• Whilesomedataexistsregardingmannequindeath,thereislittlepublishedregardingdeception
• Answerswillnotbesimple,andlikelydependonindividuallearnerandfacultyexperienceandrelationships
• Moreworkisneeded…