Welcome to Illuminating InSights, our blog interview series. Here, our team speaks with programs and professionals to learn about their experience in navigating various areas and topics related to healthcare training and education. This post highlights our time talking with Joe Goode, PHD, BA, MSN, CRNA, Associate Professor of Nurse Anesthesia at the University of Pittsburgh. His research interests include the use of health care simulation educational methodologies, which was the inspiration behind this interview.
Dr. Goode began by sharing his background and how he got started in the healthcare field:
Dr. Goode: The abbreviated version is that I didn't start in healthcare as a provider of any sort. My initial training was as a medical illustrator. I did that as part of my undergraduate work at the University of Michigan. At that time, medical illustration required an additional three years of graduate study, and I came home to work off some debt before I went to graduate school, as many people do. And I wasn't particular about where I was going to work. I had worked my entire time during undergrad in research labs. So I had some of that background and I landed in an institute, a research lab by chance, and they offered me a job. I took it. I stayed there for a while and then reconsidered my career. So that's the short version and decided I would go back to school. I became a nurse with the intent of becoming a nurse anesthetist. I started teaching shortly after I graduated, still working clinical, and then eventually went back and got my Ph.D.
In addition to sharing his own history, Dr. Goode also shared more about the University of Pittsburgh’s history when it comes to simulation education.
So, the University of Pittsburgh, the Department of Anaesthesia in particular, was one of the first anywhere in this country to start using simulation. Chairman Peter Winter, who the Winter Institute for Simulation, Education and Research (WISER) is named after, took a chance and spent a great deal of money at that time. This would have been back in the mid 90s, and spent a quarter of a million dollars on this patient simulator. It was going to go in this room and people were going to train with it. There was a lot of derision and people who weren't buying into it used to call it “big doll therapy” and didn't think highly of it. But there were a couple of visionaries and my colleague John O'Donnell was one of them. He was, at that point, already Director of our Nursing Anesthesia Program. I was one of his students.
Because Dr. Goode was a student training during the early years of simulation at the University of Pittsburgh, he has a really interesting perspective.
It made a difference getting practice with the simulator, but it also helped me learn in other ways. You’ve got to remember that this was in the early days of simulation, so we were learning as we were going. So to be a student going through that and then shortly afterwards transitioning to being an educator, it was an exciting time to be in healthcare; starting to understand what was working and what wasn't when teaching using simulation.
He also described his experiences and favorite aspects of being on the other side of simulation as an educator.
It's that moment of conceptualization when the person that you're training, whether it's an undergraduate, graduate student or even a practicing professional, when they get it right and you can see that on their face. Sometimes you get that in a lecture hall. But it's hard, right? It's usually a bigger room. Maybe there are 40 people in the room. Occasionally you can catch that as a group or maybe an individual that you see has really grasped the concept that you were trying to get across to them. But I think you see it a lot more in the simulation setting. I can't tell you how many times that we've talked about something in the lecture content and then we've gone to the simulation lab and we actually practice that thing or use that piece of equipment. You just see it and in their body language and on their face that they have now grasped the concept and that they understand. They'll oftentimes say that ‘I just didn't understand that concept until we came here and did this’. That's really an exciting moment to see when somebody catches on to what you're trying to teach them. So it's rewarding for the student, and I think it's really rewarding for the instructor as well to get that feedback; that I've gotten across what I wanted and what's important to get across to the student.
"You just see it and in their body language and on their face that they have now grasped the concept and that they understand."
While there are many fulfilling moments using simulation as an educator, there are also several challenges.
There's always a lack of time. As a health care educator, it's a combination, and I mostly work with graduate students, so they've already done their undergrad, they've worked as nurses primarily. I work as an educator in nurse anesthesia. So they have some experience at this point in time. Most of them have done a little bit of simulation, at least in undergrad. It would be really unusual if they hadn’t nowadays. But the one thing that's a challenge is to provide them with enough time in the simulation lab, though. What I mean by that is that we will schedule blocks of time and there are things that we need to accomplish, but we have 40 students coming in every year. So there's only so much time that you can delegate to a certain task that you're trying to train or a certain process that you're trying to get them used to.
An example that I can give you is, every fall we have a new cohort of students who start in our DNP program; they are brand new to anesthesia. We get them ready for their first clinical rotation in the operating room using simulation. Between the start of the term at the beginning of September and the time that they will start clinical in November, they receive approximately 60 hours of didactic content, and they will have somewhere around 50+ hours of associated simulation content that matches what they're learning in the classroom, all focused to get them ready for their first clinical rotation. What we do is a scaffolding process with the simulations during their first term. We start with simple, disassociated tasks that they're going to have to do. Maybe that's to get them more experienced with starting vascular access like intravenous catheters or arterial lines. Then we start with things like positioning patients on operating room tables, and the risks, and how you appropriately do that. Then we move on to basic airway management techniques, building scaffolding on top of these things. Finally, this culminates in what we call a mock induction, where they get assigned a theoretical patient on paper and they have to prepare an anesthetic management plan to safely put that patient to sleep to do what's called an induction of anesthesia and then work through a complication that may occur. That's sort of the culminating event for us as faculty to assess their performance, their thought processes in these scenarios, and make the decision about whether they're ready to go out into the clinical setting.
The question that always, always, always comes up is: ‘Can I come back and practice on my own?’ That's a really hard thing for us to deal with and that's because of imprinting. You may have heard this concept before, but you know how you practice is how you're going to perform out in the clinical setting. So simulation is very powerful at imprinting practice patterns. The conundrum for faculty has been: Do you open the lab up and let them practice? Because if they're on their own, they may be practicing inappropriately and then they may be imprinting inappropriate processes and techniques. On the flip side, it's really hard to have faculty or even TA’s available all the time. It's expensive to staff and have access to the simulation facilities. There's liability involved, those sorts of things. So that's been a hard thing to deal with, and I'll tell you that traditionally we haven't allowed it and what we have tried to do is set up times where we might have faculty available for an hour or two to let students do some additional practice or have student instructors or teaching assistants available, but it's hard to arrange that stuff in the midst of a busy academic schedule.
"The question that always, always, always comes up is: ‘Can I come back and practice on my own?"
Dr. Goode also has a research background in simulation methodologies.
Typically, we think of the simulation as this thing that occurs, and then maybe we do a little bit of debriefing in the middle and then magically there's some change in practice out there in the real world. Anybody that thinks about this for any amount of time will realize that there are a lot of intervening things in between. That was my real interest and continues to be one of my interests.
Essentially, I did a three phase process for my doctoral research, including a historical analysis of simulation. I looked at simulation from the mid seventeen hundreds all the way through current times to look for trends and patterns and thoughts about simulation. Obviously, a couple of hundred years ago, things weren't very technologically advanced, but people were even then thinking about trying to find ways to replicate that in health care -- what particular anatomy, or learning how to do procedures on patients. So that was part of what I was going after. There was a lot of work with computer based training in nursing in the 60s. There's a trove of data there about that that sort of echoes what happened then later in the late 90s and early 2000s with simulation. My goal in doing that was to come up with a new theoretical model for simulation processes and then to test part of my own model. I use this mock induction process that I mentioned to you as a basis for my research. Essentially, I followed a cohort of our nurse anesthesia students through the first 17 weeks of their clinical rotation, and I wanted to see whether simulation made a difference in their initial preparation and then whether additional simulation would change the trajectory of their integration into their first rotation in clinical. Probably the most interesting thing I found was --I don't know that anybody else has documented this before, we're getting ready to publish this data -- it's the correlation between students' self-rating of their performance and how it tracked over time. Preceptors felt that our students were fairly well prepared and there was a big gap between what students felt. They didn't think they were as well prepared. Over time, however, those two trends came together and you could see that in ratings of individual tasks that they were being tracked on.
I think what it is, is that as you keep getting continual success, your confidence level goes up. That seems pretty simple, but it's not been documented yet, sort of quantitatively. The really interesting thing of the study and at first when I saw the data, I thought all my dissertation work was a failure! I brought half of the study group back midway through their first clinical rotation and ran them through simulation again, and it turned out there was absolutely no difference in the performance of the two groups over time.
I think the lesson learned is that a single one hour intervention in a setting like this is completely overwhelmed by the amount of learning in the clinical environment that they're getting. So it's really helped us as well because we had thought for many years about doing this, and we now realize that the bang for our buck, so to speak, is all about what we'd already been doing in that initial preparation. So if through simulation we can get these people up to a really high level in preparation for their first clinical rotation, which we seem to be able to do, then, then it's a win for us, right? They're going to be very well prepared. They're going to be accepted by the preceptors, and the preceptors are going to let them do more right off the bat. And, it's a win for the students as well.
Because of Dr. Goode’s simulation expertise, we wanted to hear his thoughts on our product.
The thing about the InSight Platform is that there are certain tasks, especially for our beginning students, where they will receive feedback on their performance. I think this is going to offer us the opportunity to open up the simulation lab to our students when faculty aren't available. My hope is that it can be sort of a turnkey kind of thing where they come in, maybe swipe their ID or something to get access, and then can have these modules where they can practice at a time that maybe is more convenient for them.
"I think this is going to offer us the opportunity to open up the simulation lab to our students when faculty aren't available."
One of the things that we always have to consider with graduate students, it's not like they're undergraduates on campus all the time. These are people who are a little older, usually in the twenty-five to thirty range, and they've got lives off campus. Their world isn't like the eighteen to twenty-two year old undergraduates. So sometimes, things like this may fit in better with their schedule.