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MALCOLM GLADWELL IN HIS BOOK "OUTLIERS" TALKS
ABOUT IN ORDER TO BE AN EXPERT, YOU NEED TO
PRACTICE SOMETHING FOR 10,000 HOURS.
NOW, WE TEACH A MYRIAD OF SUBJECTS AT
THE COMMUNITY COLLEGES.
ONE MAJOR SUBJECT, OVERARCHING SUBJECT, IS HEALTH CARE.
NOW, WHEN I THINK ABOUT IF I NEED ASSISTANCE FROM A
HEALTHCARE PROFESSIONAL, I WANT THEM TO HAVE
DEMONSTRATED MASTERY, BUT I REALLY DON'T WANT THEM
TO PRACTICE ON ANY OF YOU BEFORE THEY GET TO ME.
AND SO DR. JANINE HINTON IS GOING TO SHARE WITH US
HER EXPERIENCES AND HER RESEARCH IN USING
SIMULATIONS FOR STUDENTS TO PRACTICE WHAT THEY'RE
LEARNING IN NURSING.
SO PLEASE JOIN ME IN WELCOMING JANINE HINTON.
THANKS SO MUCH, JANINE.
THANK YOU FOR SHARING A FEW MINUTES WITH ME AND
LETTING ME SHARE WITH YOU HOW IMPORTANT HUMAN
PATIENT SIMULATION IS TO PROVIDING THE ARTIFICIAL
EXPERIENCE TO OUR LEARNERS TO MAKE THEM READY TO
TAKE CARE OF PATIENTS.
IT'S AN EMERGENCY.
YOU MUST DO SOMETHING NOW OR SOMEBODY'S GOING TO DIE.
BUT HOW ARE YOU GOING TO DO THIS RIGHT THE VERY
FIRST TIME WHEN YOU HAVE TO DO IT WHEN YOU HAVE
NEVER DONE IT BEFORE?
SIMULATION USING HIGH FIDELITY OR VERY
REALISTIC PATIENT SIMULATORS PROVIDES THE
OPPORTUNITY FOR LEARNERS TO PRACTICE THESE CRITICAL
SKILLS SO THEY ARE READY WHEN THEY ARE NEEDED.
THESE SIMULATORS ARE SERIES, BUT THEY'RE ALSO GREAT FUN.
THEY BREATHE. THEY TALK.
THEY COUGH. THEY GIVE BIRTH. THEY'RE BORN.
WE CAN EVEN MAKE THEM URINATE THE COLOR WE WANT
AT THE TIME WE WANT THEM ON DO IT.
IN 2009, CAPTAIN SULLY SULLENBERGER FAMOUSLY
LANDED THAT AIR BUS WITH 155 PEOPLE ON BOARD
INTO THE HUDSON RIVER.
HE'S NEVER LANDED A PLANE IN THE WATER BEFORE.
SO HOW DID HE DO IT?
FLIGHT SIMULATORS.
PILOTS SPEND YEARS AND HOURS AND FREQUENT
REACQUISITION OF THEIR SKILLS PRACTICING
DIFFERENT CONTINGENCIES IN DIFFERENT TYPE OF EMERGENCIES
SO THEY HAVE THE SKILLS AND THEY'RE READY TO GO.
IN ORDER TO BE ABLE TO DO SOMETHING, WE'VE GOT TO DO
THE THING THAT WE'RE TRYING TO LEARN HOW TO DO.
THIS IS THE SAME WITH HEALTHCARE PROVIDERS.
THEY NEED TO BE ABLE TO PRACTICE WHAT IT IS THEY
NEED TO DO AND THEY REALLY SHOULDN'T BE
PRACTICING ON REAL PEOPLE.
NEUROSCIENCE IS FASCINATING.
WE HAVE THIS MARVELOUS BRAIN PLASTICITY AND SO
PART OF LEARNING WHAT HAPPENS IS THERE'S
ACTUALLY CELLULAR CHANGES IN OUR BRAIN.
NEW CHANNELS ARE FORMED.
NEW LITTLE CONNECTIONS GROW AND THEY GET READY.
AND THE STRONGER THE STIMULUS THAT INITIATES
THOSE CHANGES, THE MORE LIKELY THAT LEARNING IS
GOING TO BE FAST AND EFFECTIVE AND MEMORABLE.
GRADUATE NURSES WILL COME BACK YEARS LATER AND I'VE
LONG FORGOTTEN THEY'RE PARTICULAR SIMULATION, BUT
THEY CAN TELL ME WORD FOR WORD WHAT HAPPENED,
WHAT THEY DID, AND WHAT I SAID TO THEM TOO.
THIS IS QUITE INTERESTING TOO.
WE KNOW THAT MEMORY IS VERY IMPORTANT TO LEARNING
AND THERE IS TWO MAJOR DIVISIONS OF MEMORY.
THERE'S THE DECLARATIVE WHERE I ANSWER A TEST
QUESTION OR WHERE CAPTAIN SULLY COULD SAY I CAN TELL
YOU HOW TO LAND A PLANE.
HE DIDN'T HAVE TIME TO TELL ANYBODY HOW TO LAND A PLANE.
HE NEEDED TO GET RIGHT INTO THE NON-DECLARATIVE
IMPLICIT MEMORY WHERE HIS SKILLS WERE, THE KNOWING
HOW TO DO SOMETHING.
NOTICE ALL THE DIFFERENT PARTS OF THE BRAIN THAT
ARE INVOLVED IN KNOWING HOW TO DO IT.
THESE ARE THE PARTS OF THE BRAIN THAT WE TARGET
THROUGH CLINICAL SIMULATION.
BETWEEN 210- AND 440,000 PEOPLE DIE IN OUR
HOSPITALS EVERY YEAR BECAUSE OF PREVENTABLE MEDICAL MISTAKES.
PREVENTABLE MEDICAL ERRORS ACCOUNT FOR THE THIRD
LEADING CAUSE OF DEATH.
HEART DISEASE IS FIRST.
CANCER IS SECOND.
AND THE THIRD ARE THOSE PREVENTABLE ERRORS.
THE NEWS DOESN'T GET ANY BETTER.
YOU ARE 10 TO 20 TIMES MORE LIKELY TO SUFFER
NONLETHAL HARM AS A RESULT OF MEDICAL MISTAKES.
HEALTH CARE IS VERY COMPLICATED.
THE GOAL OF EDUCATION IS TO PREPARE OUR LEARNERS
AND OUR HEALTHCARE PROFESSIONALS TO BE COMPETENT.
HERE WE A VERY HAPPY BIRTHING SIMULATOR WHO'S
PROBABLY GIVEN BIRTH FOR THE 10,000TH TIME.
THE BABY'S HAPPY.
IT'S THE SAME BABY SHE HAS OVER AND OVER AND OVER AGAIN.
AND THE STUDENT IS THRILLED BECAUSE MAYBE SHE
COULD HELP SOMEBODY DELIVER A REAL BABY.
BEING COMPETENT IMPLIES NO ERRORS, IF AT ALL POSSIBLE.
THIS IS A VIDEO OF FOUR SEMESTER STUDENTS WHO ARE
TEAM MANAGING A PATIENT WITH CARDIAC EMERGENCIES.
PLEASE LISTEN TO THE STATEMENT OF THE STUDENT
AT THE BEGINNING.
HER COMMENT IS CLASSIC OF WHAT WE HEAR FROM OUR LEARNERS.
WE JUST HAD CARDIAC AND, I MEAN, I FEEL LIKE I'M JUST
DROWNING IN -- YOU KNOW, YOU DON'T GET THIS UNTIL
YOU SEE THIS, UNTIL I DO IT, YOU KNOW.
IT'S BEEN THREE MINUTES.
OKAY. SO I'M GOING TO GO AHEAD AND SLAM THE 12 IN FOR US.
YOU MIGHT FEEL KIND OF FUNNY FROM THIS. OKAY?
READY. HERE WE GO. SLAM. QUICK PUSH.
THERE YOU GO. GOOD JOB.
12 IN. OKAY.
LOOKS LIKE WE'RE IN -- OKAY.
GO AHEAD AND START CPR.
GO AHEAD AND DROP THE HEAD OF THE BED NOW.
GET THAT ORAL AIRWAY GOING. START CPR.
JACE, I'M GOING TO NEED YOU RUNNING THAT
DEFIBRILLATOR FOR US, PLEASE.
A FEW COMPRESSIONS HERE.
WE'RE GOING TO GO THROUGH THIS FOR TWO MINUTES.
THE COMPRESSIONS ARE SUPPOSED TO BE ON THE OTHER SIDE.
YOU ARE SUPPOSED TO BE AIRWAY.
EITHER WAY.
I'M NOT GOING TO STOP.
GO, JASON. GO.
AND THEN YOU DO THE BAGGING JODY. OKAY?
LET'S PUT THE AIRWAY IN.
I NEED TO PUT THE PADS ON.
AIRWAY'S IN. GET THE PATCHES ON.
I'M GOING TO NEED YOU DOING THE PATCHES FOR ME.
27, 28, 29, 30.
ALL RIGHT.
IT'S BEEN TWO MINUTES.
LET'S JUST DO A PULSE CHECK HERE.
OKAY.
ALL RIGHT. LOOKS LIKE DEFIB.
GO AHEAD AND CHARGE UP TO 200 FOR ME.
CHARGING.
CLEAR, CLEAR, CLEAR, CLEAR.
CLEAR THE BED GUYS OFF THE BED. OKAY.
GOOD JOB.
OKAY. GO AHEAD AND CONTINUE CPR.
OKAY. YOU'VE DONE TWO SHOCKS NOW.
AND YOUR BED BOARD SEEMS TO BE SLIDING AWAY.
SOMEBODY ELSE WORK ON THAT FOR US RIGHT NOW.
ALL RIGHT.
HOLD ON.
IT'S BEEN TWO MINUTES. OKAY.
WE'RE GOING TO DO A PULSE CHECK.
IT LOOKS LIKE HE'S BACK.
LET'S SIT HIM UP A LITTLE BIT, GET THAT AIRWAY OUT.
LET'S GET HIM ON SOME OXYGEN.
JODY, COULD YOU GET ME A SET OF VITALS, PLEASE?
LET'S GET THAT BOARD OUT -- LET'S GET THAT BOARD
OUT FROM UNDERNEATH HIM HERE.
IT'S BEEN ON -- LET'S GO AHEAD AND PUT HIM ON FIVE LITERS.
YOU OKAY? YOU OKAY? THE PATIENT WAS OKAY.
THE STUDENTS REALLY DID A GREAT JOB.
THEY RECOGNIZED EARLY ON THAT THIS PATIENT HAD A
VERY SERIOUS SYMPTOMATIC SUPRAVENTRICULAR TACHYCARDIA
THAT NEEDED TO BE TREATED.
THEY SELECT ED THE APPROPRIATE DRUG.
THEY ALSO RECOGNIZED THAT THE PATIENT DIDN'T RESPOND
AS THEY WOULD HAVE LIKED TO THE DRUG AND DID GO
INTO CARDIAC ARREST AND THEN THEY ACTED AS A TEAM
AND THEY WERE ABLE TO MAKE HIM OKAY.
YOU CAN'T FIX SOMETHING IF YOU REALLY DON'T
KNOW HOW IT'S BROKEN.
WHAT IF CAPTAIN SULLY DIDN'T REALIZE THE RATE OF
DESCENT OF THAT PLANE?
WHAT IF HE FLEW TO LAGUARDIA AS HE WAS
DIRECTED TO MY AIR TRAFFIC CONTROL?
HE WOULD HAVE CRASHED INTO THE BUILDINGS OF THE CITY,
VERY DIFFERENT OUTCOME.
HEALTHCARE PROVIDERS MUST UNDERSTAND WHAT THE
HEALTH CRISIS IS WITH THEIR PATIENTS.
THEY HAVE TO UNDERSTAND WHAT THOSE HEALTH ISSUES ARE.
CAPTAIN SULLY OBVIOUSLY UNDERSTOOD THE SITUATION
WHEN THOSE GEESE FLEW IN AND KNOCKED OUT ALL
OF HIS ENGINES.
HE ACTUALLY HAD NEVER HAD AN ENGINE GO OUT IN
HIS ENTIRE CAREER AND NOW ALL OF THEM WERE OUT.
SITUATION AWARENESS IS A VERY CRITICAL THING FOR
AVOIDING ERRORS.
IN 88% OF ACCIDENTS WHERE HUMAN ERROR WAS PART OF THE BLAME,
THE PROBLEMS HAD TO DO WITH SITUATION AWARENESS.
HEALTHCARE PEOPLE, PILOTS, THEY'RE WELL-MEANING.
THEY WANT TO TAKE CARE OF OTHERS.
THEY DON'T MEAN TO MAKE MISTAKES, BUT THEY COULD
EASILY MISUNDERSTAND THE SITUATION THAT THEY ARE IN.
SITUATION AWARENESS: THE PERCEPTION OF THE ELEMENTS
WITHIN A VOLUME OF SPACE AND TIME, THE COMPREHENSION
OF THEIR MEANING, AND THE PROJECTION OF WHERE
THEY'RE GOING TO BE IN THE NEAR FUTURE.
WE HAVE BEEN SUCCESSFULLY USING ENDSLEY'S MODEL OF
SITUATION AWARENESS TO HELP EQUIP OUR NURSING
STUDENTS WITH SITUATION AWARENESS SKILLS TO HELP
THEM TO AVOID, TRAP, AND REDUCE MEDICAL ERRORS.
WE'VE FOCUSED THEIR SKILL BUILDING PRIMARILY ON THAT --
THOSE THREE LEVELS OF SITUATION AWARENESS.
PERCEPTION. COACHING THEM.
WHAT DO THEY NEED TO LISTEN TO?
WHAT SHOULD THOSE LUNG SOUND LIKE OR NOT SOUND LIKE?
WHAT ABOUT THOSE VITALS AND LABS?
COMPREHENSION, LEVEL TWO.
WHEN WE PUT THIS PUZZLE ALL TOGETHER, WHAT DOES IT MEAN?
AND THEN THREE, PROJECTING THE FUTURE THAT HELPS
GUIDE THEIR DECISIONS.
WHAT KIND OF INTERVENTIONS NEED TO BE DONE?
AND THEN THEY NEED TO HAVE TO BE ABLE TO PERFORM
THOSE SKILLS AS WELL.
THIS IS A PICTURE OF A FIRST SEMESTER NURSING
STUDENT NAVIGATING THROUGH AN ERROR TRAPPING
SIMULATION IN OUR PREVIOUS SIMULATION LAB.
SHE HAD TO FIGURE OUT THAT THE PATIENT'S BLOOD
PRESSURE WAS TOO LOW TO RECEIVE HER NEXT DOSE OF A
BLOOD PRESSURE LOWERING MED.
SHE NEEDED TO BE ABLE TO COMMUNICATE TO THE DOCTOR.
AND MAGGIE COULD CARE LESS.
MAGGIE WAS WORRIED HER POODLE FLUFFY WAS AT HOME.
SHE WAS GOING TO DESTROY THE CARPET.
AND WHO CARES WHAT HER BLOOD PRESSURE WAS?
WE HAVE EVIDENCE THAT SUPPORTS THAT THIS TYPE OF
SIMULATION ACTUALLY IMPROVES PERFORMANCE.
THE FREQUENCY OF MITIGATING OR TRAPPING
POTENTIAL MEDICAL ERRORS INCREASED.
PERFORMANCE INCREASED AND SO DID SITUATION AWARENESS.
AS PART OF SOME OTHER WORK THAT WE'VE DONE AND BEING
ABLE TO FIGURE OUT MEASURES, DIRECT OBSERVATIONAL
MEASURES OF COMPETENCE IN LICENSED
NURSES AND THIS HAS BEEN A PARTNERSHIP WITH THE STATE
BOARD OF NURSING IN ASU.
WE FOUND SOMETHING SURPRISING IN OUR LAST
ROUND OF DATA ANALYSIS.
WE HAD 201 VIDEO RECORDED SIMULATION TESTS THAT WERE
EACH EVALUATED BY A MINIMUM OF THREE NURSING EXPERTS.
THE NUMBER ONE PREDICTOR OF COMPETENCE WERE THOSE
NURSES WHO REPORTED THAT THEY FREQUENTLY
PARTICIPATED IN CLINICAL SIMULATION.
THIS WAS A SIMPLE TYPE OF DEMOGRAPHIC QUESTION THAT
WE DIDN'T REALIZE WAS GOING TO BE SUCH A STRONG
INDICATOR OF THE STRENGTH OF SIMULATION.
FREQUENT PARTICIPATION AND SIMULATION WAS MORE
PREDICTABLE OF COMPETENCE THAN THEIR YEARS OF
EXPERIENCE, THEIR LICENSOR, THEIR ADVANCED EDUCATION,
OR THEIR CERTIFICATIONS.
WE SUSPECT THAT THIS HAS SOMETHING TO DO WITH THE
FACT THAT IN SIMULATION THERE'S SUCH A FOCUS ON LEARNING.
THERE IS AN ABILITY TO DEBRIEF AND THEN YOU HAVE
TO WATCH THE VIDEO AFTERWARDS.
I KNOW I'VE HAD TO CHANGE SOME HABITS THAT I SAW ON
VIDEO THAT I WAS QUITE SURPRISED.
SIMULATION TECHNOLOGY IS VERY EXPENSIVE AND LABOR
INTENSIVE, BUT WE VALUE HUMAN LIFE AND WE WANT TO
BE ABLE TO TAKE CARE OF THE PEOPLE WHEN WE'RE
CALLED TO DO THAT.
THESE ARE INSTRUCTORS TRAINING TO THE INSIDES.
THE GUTS OF THE SIMULATOR.
ONE DAY WE HAD A TOUR AND PEOPLE WERE ASKING ME,
"ARE THEIR INSIDES REAL TOO?"
AND I WAS THINKING, "WELL, NO, BECAUSE THERE'S
WIRES AND COMPUTERS.
AND TO MAKE THEM URINATE ON COMMAND, THEY HAVE TO
HAVE WIRES THAT GO TO THE BLADDER.
AND, NO, THEY'RE NOT LIKE REAL PEOPLE INSIDE.
THEY'RE FULL OF SPEAKERS AND STUFF."
BUT THESE INSTRUCTORS ALSO HAVE TO LEARN THE SCIENCE
OF EXPERIENTIAL LEARNING.
THEY KEEP UP-TO-DATE ON BEST PRACTICES AND WE
CONTINUE TO HELP OUR STUDENTS TO BUILD THOSE
HABITS THAT THEY NEED.
HOW ARE YOU GOING TO DO SOMETHING RIGHT WHEN IT'S
NEEDED RIGHT NOW, WHEN YOU HAVEN'T DONE IT IN A LONG TIME?
WE HAVE THIS PROBLEM.
WELL, THEY ALL LEARNED THAT LAST SEMESTER.
THEY ALL PASSED IT THEN, BUT WHY CAN'T THEY DO IT NOW?
SKILLS DECAY OR DETERIORATION.
OUR BRAINS LOSE THOSE CONNECTIONS THAT WE BUILT
IF WE DON'T USE THEM.
SO SOME KIND OF SAD NEWS ON CPR.
90 DAYS AFTER YOUR CERTIFIED, YOU PROBABLY
CAN'T DO IT ANYMORE.
IN A STUDY OF HEALTHCARE PROVIDERS, WITHIN 6 TO 12
MONTHS, IT'S LIKE THEY NEVER LEARNED IT.
THE GOOD NEWS IS THOUGH WITH REPEATED RECERTIFICATION
YOU LEARN FASTER AND YOU DO REACQUIRE THOSE SKILLS.
SO WE NEED TO HAVE PRACTICE.
AND SO ANDERSON DID FIND THAT EVEN COMPARING A
COUPLE PEOPLE WHO HAD JUST BEEN CERTIFIED JUST A FEW
DAYS AGO TO SOMEONE WHO'S BEEN RECERTIFIED MULTIPLE
TIMES, THEIR REPETITION DID PROVE TO BE BETTER.
HERE'S A GROUP OF PARAMEDICS.
THEY'VE COME IN TO REFRESH THEIR SKILLS.
SO LET'S TAKE A WATCH.
JUST KEEP THEM CONTINUOUS WHILE WE INNOVATE.
DO I NEED TO GET THE THIRD ROUND OF EPI READY?
YEAH, PLEASE. TUBES DOWN. ALL RIGHT.
OKAY. 26 AT THE LIPS. OKAY.
WELL, LET'S CHECK REAL QUICK.
CAN I ANALYSES?
GO AHEAD.
DON'T CHARGE IT YET.
AGAIN. OKAY. GO AHEAD.
VENTILATION SHOWING UP THE ROUTE.
SHOWING WHAT?
YEAH. HE'S VENTILATING ALMOST.
ALL RIGHT.
OKAY. GO AHEAD AND SECURE THAT TUBE.
LET'S MARK WHERE IT'S AT.
26 AT THE "T".
OKAY.
WE'RE GOING TO CHECK RHYTHM.
THIRD ROUND OF EPI COMING. OKAY.
AFTER YOU GET THAT EPI THEN ON THE NEXT ROUND OF CPR,
CAN I HAVE YOU GUYS SWITCH? YEAH.
GOOD. THAT'S BETTER ON THE COMPRESSIONS, I THINK.
70, 80. COMPRESSION RATE 132.
OKAY. SLOW IT DOWN JUST A LITTLE.
THIRD ROUND EPI ON BOARD.
THAT'S THREE MILLIGRAM AND THREE EPIS ON BOARD.
5, 4, 3, 2, 1.
OKAY.
IT'S BEEN ANOTHER TWO MINUTES.
OKAY. WE HAVE A SHOCKABLE RHYTHM.
CLEAR THE PATIENT.
EVERYBODY CLEAR.
CLEAR.
PLEASE GET OFF THAT BLOW BAG AND MOVE WAY.
OKAY. SHOCKED. GO AHEAD.
AGAIN, CONTINUE COMPRESSIONS.
WE DON'T HAVE ANYMORE EPIS.
OKAY.
NEXT 100 COMPRESSIONS WE'RE GOING TO CHECK AGAIN.
AT THIS POINT, WE'LL GO AHEAD AND PREPARE THE PATIENT.
SO THESE GENTLEMEN WERE WORKING THROUGH A SCENARIO
WHERE THEY WERE CALLED TO A LONG-TERM CARE FACILITY
WHERE THE PATIENT HAD NOT BEEN SEEN FOR SEVERAL HOURS.
IT WASN'T A PLACE WHERE YOU TYPICALLY WOULD CHECK
ON PEOPLE OFTEN AND SO THE PATIENT WAS FOUND DEAD.
THEY NEEDED TO COME IN, WORK ON RESUSCITATING HIM
AND THEN GET HIM TO A HIGHER FACILITY.
ONE OF THE LOVELY THINGS ABOUT THESE SIMULATORS IS
THEY DO COUNT HOW FAST THEY COMPRESS.
SHOULD HAVE BEEN 100 A MINUTE, NOT TOO WORRIED IF
HE'S GOING TOO FAST, BUT, YOU KNOW, A 132 IS
PROBABLY A LITTLE BIT MUCH.
IT TELLS US IF THEY'RE GETTING OXYGEN IN ALL PARTS
OF THEIR LUNGS, TELLS US IF THEIR PLACEMENT IS CORRECT.
SO WE JUST CAN CALL IN THERE.
THEY CALL IT THE VOICE OF GOD COMING OVER THE
SPEAKER AND GIVING THEM SOME FEEDBACK.
THERE WE GO.
SO IN ORDER TO BE ABLE TO DO SOMETHING THAT WE NEED
TO DO SOON, WE BETTER PRACTICE IT SOON.
AND IF WE NEED TO DO IT AGAIN LATER, WE NEED TO
KEEP DOING IT SO THAT WE'RE READY.
OUR HUMAN PATIENT SIMULATORS REALLY DON'T
MIND IF WE MAKE MISTAKES.
THEY DON'T CARE IF WE STOP ISN'T THE MIDDLE OF AN
EMERGENCY PROCEDURE AND HAVE A LONG DISCUSSION
ABOUT ALTERNATIVE TREATMENTS.
THEY DON'T MIND IF WE STOP AND ANSWER A SERENDIPITOUS
QUESTION FROM A STUDENT THAT LEADS US ON AN
EXPLORATORY PATHWAY OF MORE INFORMATION THAT THAT
STUDENT NEEDS TO KNOW RIGHT NOW.
OUR HUMAN PATIENTS CANNOT TOLERATE THAT.
THEY NEED US TO BE READY.
THANK YOU FOR LETTING ME SHARE THIS WITH YOU.