Do No Harm – It's More Than a Promise

While the phrase, “First, do no harm,” does not appear, as such, in the Hippocratic Oath, it is widely accepted as one of the significant principles under which physicians, and, by extension, others in the healthcare field operate in the practice of medicine.

With few exceptions, those who pursue careers in healthcare, do so from a sincere desire to help others in achieving, maintaining and recovering an appropriate level of physical and mental health. While some clinical interventions can be temporarily painful or unpleasant, there is no intent by the care provider to inflict pain or discomfort on a patient.

FIRST DO NO HARM, by BENJAMIN SCHWARTZ ,  New Yorker Cartoons

FIRST DO NO HARM, by BENJAMIN SCHWARTZ, New Yorker Cartoons

For some of the more routine clinical activities, it takes more than a lack of intent to keep from inflicting unnecessary pain, it takes practice, practice and more practice. And, not just any practice - it takes realistic practice.

For example, take the skill of drawing blood or starting an IV. These are a fairly straight forward activities requiring the clinician to safely insert a needle into the vein of a patient. It is a task covered early in clinical training, but is it practiced as often or as realistically as we believe? Many of us have experienced the real pain and discomfort some providers unintentionally cause when drawing blood or starting an IV.

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Now, some might say it’s “just” a bruise, but in fact, a bruise is an injury producing an area of discolored skin due to the rupturing of the underlying blood vessels. For many it may be “just” uncomfortable and unsightly, but depending on the patient and other medical variables, it may pose a real danger or at least complicate other elements of the patient’s health.

To make good on their commitment to “Do No Harm,” clinical learners and practitioners alike must attain and maintain their hands-on skills to ensure they do not hurt the patient in the process of delivering the care they need.

It was for that very reason ReaLifeSim products were created. ReaLifeSim’s wearable IV training simulator permits students to conduct safe, repeated, realistic practice on a live people (SP’s, volunteers, or each other) to build both the competence and confidence necessary to “do no harm.”

Photo credit: ENA2018

Photo credit: ENA2018

Repetition

When you first start doing something, you focus on the mechanics.

In healthcare, we need repeated practice to move our skills to mastery. And, not just any practice will do - it must be high quality, perhaps perfect realistic practice.

In sports, baseball for example, that could mean swinging the bat over and over and over until you develop the proper mechanics to consistently hit the ball.

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For more than a century, neuroscientists have recognized the existence of “automatism,” which is the ability to perform complicated actions without conscious thought or intention. C. Bergland, https://www.psychologytoday.com/us/the-mysterious-neuroscience-learning-automatic-skills

Automaticity can be achieved by practicing with increasing memory load meaning, purposefully add distractions to your training regimen. It’s about making a newly learned skill a part of who you are, as opposed to just a thing you can do. B. Hardy, https://www.fastcompany.com/how-to-learn-a-new-skill-well-enough-to-do-it-automaticall

Providing the practice and repetition necessary to perfect new clinical skills and develop critical thinking in a safe, observable environment are just some of the many benefits of clinical simulation education.

Providing tools for realistic practice experiences for task training and advanced scenarios is what we do. ReaLifeSim wearable vascular access training simulators - durable, adaptable, portable.

Photo credit: Disaster Medical Solutions

Photo credit: Disaster Medical Solutions

Photo Credit: Pocket Nurse & ENA2018

Photo Credit: Pocket Nurse & ENA2018

How do YOU choose new products?

Most responses will likely include (in no particular order):

  • function,

  • interoperability,

  • realism,

  • durability & maintenance,

  • and of course, budget.

Recommendations from peers and demonstrations at conferences may also influence the decision maker.

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The choices seem limitless with VR and AR and AI and Mixed Reality and Fidelity to fit every need!

Can it still be argued that real practice on real people is the best way to develop real competence and real confidence?

Perhaps it’s best when the two are blended….

"Simulation specialists who add the human component to the simulated experience were found to make the simulated environment more realistic and consequently more conducive to learning caring behaviors." Ward et al., Int J Nurs Clin Pract 2017, 4: 257 https://doi.org/10.15344/2394-4978/2017/257

How can we provide simulated learning on real people without risking injury? This was a problem we decided to solve when we created ReaLifeSim wearable vascular access training simulators.

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Worn by real people to encourage provider-patient communication and add the human dimension, they can also be used as an “add-on” to high-cost high-fidelity manikins for enhanced function and extended sustainability so as not to have to damage costly equipment for routine skills.

But, it can and will be even better:

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“If people would realize how important it is to exploit those aspects of reality that cannot yet be replicated in VR, then we'd be much further ahead in healthcare sim than we are.  Now, take the techniques shown here and add the VR for simulating different training contexts, as we're doing with our Mixed Reality Medical Emergency Response Team trainer and you have a real recipe for success.” Bob Stone, Director, Human Interface Technologies Team at University of Birmingham (UK), credit for above image.

Real practice on real people may always play an important role in developing and maintaining hands-on and interpersonal skills, but advances in clinical simulation are challenging that premise every day.

My "Realism in Clinical Scenarios" Soapbox…

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As recently as in the past few months, I again observed a mock emergency response scenario, and I kid you not - they taped/wrapped IV tubing to the manikin arm saying, “IV started”.

I’m a veteran emergency nurse and educator, an inventor of wearable vascular access products, and I am “a tough stick” when it comes to IVs. That said, here we go…

That kind of limitation, the lack of realism, extends the gap between what we prepare them to do and what they will actually experience regardless of their status as soon-to-be new providers or salty old veterans.

That simple omission feels awfully close to a “pretend you started the IV” situation and we DO NOT PRETEND in clinical simulation.

“In the simulation, it is important to make a simulation experience as real as possible.  This is accomplished primarily by having the students perform the task and not just pretend to do it,” shared S. Howard, Ph.D., RN, CHSE, in “Increasing Fidelity and Realism in Simulation”, 2018, LWW.com.

C. Kroboth, NRP, CCEMT-P, LT, Fairfax County Fire and Rescue adds, “Don’t cut corners here; it’s nearly impossible for students to “imagine” or “pretend” that certain stimuli are present in the simulation when they’re not. Take advantage of all the resources at your disposal using simulated smells, moulage, and even recorded sounds, so that these sensory elements are familiar when they encounter them in the field.”

Of course, there’s always an exception, like when the provider is in a hospital/clinic setting scenario and the patients would have established IVs … but not in an external emergency or disaster situation. The percentage of the population walking around with an established IV is, I’m sure, quite small.

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To be fair - I must also include a sincere thank you to those of you who consistently try to maintain the highest level of realism in scenarios - you know who you are.

There are a variety of wearable products to increase the clinical realism of SPs (our ReaLifeSim products would be some of them), plus manikins that can be programmed to do nearly everything.

Let’s keep it real people - so we don’t do a disservice to those we’re teaching.

Emotional Resilience

Traumatic stress. Compassion stress. Physical stress. Social stress.

Regardless of their place on the responder spectrum of care, everyone from hospice nurse to combat medic can become victims, affected by the incidents to which they respond, day in and day out.

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It’s been said that people in other careers dream about retirement while First Responders just dream of surviving. The environmental stressors and trauma routinely confronted by medical professionals and emergency responders affect their emotions, decisions and actions and we are doing better to prepare the next generations of providers.

From “The Importance of Emotional Resilience for Staff and Students in the ‘Helping’ Professions: Developing an Emotional Curriculum”, L. Grant, Prof of Social Work and G. Kinman, Prof of Occupational Health Psychology, Univ of Bedfordshire, “Educators need to prepare students for the realities of caring work and encourage them to be assertive in seeking out the support they require to protect their own wellbeing, to advocate for working conditions which optimize the wellbeing of their patients and clients.”

The summer conferences are providing a variety of clinical challenges from simulated complicated childbirths to simulated mass casualty scenes taken from the headlines.

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Realism in clinical simulation practice is helping them to identify what they feel and why they are feeling it - in a safe environment, supported by facilitators, instructors, and peers.  

We must continue to provide effective learning experiences that are immersive - simulating a “real-life” situation that can engage the learners’ senses, emotions, thinking, and behavior.

ReaLifeSim Debuts Their Vision of the Future at the 9th Annual Serious Games & Virtual Environments Arcade & Showcase IMSH2019

AR Visualization Combined with
Human-Centered Wearable Design

The DISRUPTIVELY INNOVATIVE Team at ReaLifeSim is pushing the boundaries of traditional clinical simulation education, AGAIN, with their NEW unique Mixed Reality IV Training.

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Their new Augmented Reality ReaLifeSim IV Training system (AR-RLS) uses the wearable ReaLifeSim hybrid simulation IV Trainer, real-time digital information integrated into the individual’s visual environment, and a tablet or smart phone.

Realistic. Interactive. Immersive. Augmented Reality. Mixed Reality.

AR-RLS provides a realistic platform to work under the pressure of practicing while experiencing the influence human factors on hands-on and interaction communication skills.

AR-RLS software runs as an app for easy updates. The AR component helps students to better comprehend spatial relationships, deepen knowledge, and strengthen patient care in a highly interactive virtual and physical environment.

AR and safe hands-on skills practice on a SP (or manikin) with authentic haptic, visual, and interactive feedback are combined in this mixed reality learning environment.

How does this benefit learners and enhance the quality of care?

Augmented reality (AR) is no longer a tool used only in the gaming world or entertainment sector. It’s an innovative tool with the capacity to mitigate safety risks and help save lives in the healthcare industry. Numerous studies indicate AR is useful because it helps the healthcare learner to understand spatial relationships and concepts, to acquire skills and knowledge, to strengthen cognitive-psychomotor abilities, and to shorten their learning curve and prolong learning retention.

This mixed reality experience, integrating and overlays virtual elements over the real world. On our new IV Trainer, AR takes the form of 3D images visible to the user on the tablet or smartphone. The wearable AR-RLS helps educators effectively provide multi-modal strategies in clinical simulation skills training and “real life” scenario-based, inter-professional education during which learners safely experience the influence of human factors. It increases subjective attractiveness by providing students with authentic simulated experiences.

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Advocating for Patient Safety is Job 1 at ReaLifeSim

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We’re pleased and proud to share ReaLifeSim was one of 33 companies nominated worldwide as a Patient Safety Advocate and acknowledged by the staff at Medical Training Magazine in their Patient Safety Advocacy issue. The issue was released today and will be distributed during the International Meeting on Healthcare Simulation 2019 conference in San Antonio, TX. Click HERE to link directly to the feature.

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Patient safety experts agree communication and teamwork skills are essential for providing quality care. “When all clinical and non-clinical staff collaborate effectively, health care teams can improve patient outcomes, prevent medical errors, improve efficiency and increase patient satisfaction. Health care teams that communicate effectively and work collaboratively reduce the potential for error, resulting in enhanced patient safe- ty and improved clinical performance.” (https://bit.ly/2CTCwaD).

In the world of healthcare, more emphasis is being placed on training in human factors routinely provided to staff, similar to other safety-critical industries. Case studies, role plays and realistic simulated practice, for example, are used to improve emotion regulation, reflective ability, emotional intelligence and empathy.

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With ReaLifeSim and VetReaLifeSim, learners safely practice hands-on clinical skills working with a live person or a live animal (veterinary care), relating to them as they would in a real-life situation, promoting a heightened sense of “presence” and emotional connection. Clinical students safely practice their hands-on skills to a level of competence, while simultaneously relating to the “patient” as a real person in a way that communicates confidence and inspires trust from the patient. The improved communication skills benefit and improve clinical team communication.

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We designed ReaLifeSim because it was needed in our clinical education environments. We needed a better way to "train the way you treat". ReaLifeSim is continuously redefining clinical simulation training using state of the art IoT and cloud technology to provide the opportunity for learners to safely experience the influence of human factors. After working with ReaLifeSim or VetReaLifeSim, learners and providers report they are more competent and confident, helping them to feel more comfortable communicating with their patients - which can contribute to reduced preventable medical errors, reduced time to treatment, and increased patient satisfaction.

Healthcare Simulation Week Kicks off TODAY!

Today is the beginning of Healthcare Simulation Week 2018. This week celebrates all those who design, build, test, sell and use the ever-widening variety of simulation products to educate, train, practice and ultimately deliver safe, high quality healthcare with competence, confidence, efficiency and effectiveness to those who need it.

While simulation is a “hot topic” in healthcare today, it has been around in some form for many years, even with such rudimentary efforts as practicing injections using an orange or a semi-rigid block of material that mimicked skin density.

Today, the confluence of advances in materials science, miniature wireless electronics, robotics, computer-driven software programs, virtual and augmented reality devices have produced an incredible array of hardware and software products bringing clinical students and practitioners alike very life-like experiences in their training scenarios.

The end goal of all this effort - improved patient outcomes – is very much worth celebrating. ReaLifeSim, LLC salutes the Society for Simulation in Healthcare and all those working in the healthcare simulation field.

Author- James Benson, CCO, B&G Educational Innovations

#HcSimWeek18 #healthcare #simulations #ReaLifeSim  #patientsafety 

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