Medical Training Magazine Interviews:

Carol F. Durham

MTM: If medical error is the third leading cause of death in the US what could and should be done to correct this?

Carol Durham: I believe this is true and it is troublesome that this number is not decreasing even after the increased awareness brought by the IOM 1999 report. We need to recognize that all components of healthcare including education are a part of this problem. We need to examine the way we are teaching to determine what we are not doing that is allowing this dismal outcome for our patients. It is certainly not intent or desire because I believe all who enter healthcare intend to help people and to make a difference not to do harm.

We (in education/academia) need to collaborate with practice and industry partners to co-produce what is needed in education and to create the tools needed to deliver that education.

MTM: What do you see as the three biggest changes in nurse education in the next five years?

CD: Enhancing nurses’ ability to be systematic in gathering data, noticing the data that is applicable as relevant to what needs to be noticed. Recognizing the significance of patterns.

Equipping nurses and other healthcare providers to be a part of changes needed in healthcare systems. We have focused on training nurses in the technical skills required for being a nurse and have importantly focused on the holistic care of the patient. This is a foundation and important to being a nurse. Howev- er, we have to expand our view of what is needed to be a highly functioning nurse in today’s complex healthcare system. We have to teach nurses systems think- ing and equip them with ways they can impact system functions. We need to empower nurses to be a part of the prob- lem solving team around healthcare is- sues from the bedside to the board room. Simulation provides the platform for rehearsing how to develop and re ne being a part of the change leadership team – sometimes being the leader but at all times having their voices heard. Simulating crucial conversations, leadership challenges and providing opportunities for learners to identify and problem solve challenges to patient care both at the individual and the system level.

Creating meaningful interprofessional education experiences for all learners. Deming (1993) in his work around profound knowledge or knowledge for improvement challenges us to improve the quality of our work. Quality improvement has been the focus in healthcare for a long time. In light of the staggering number of preventable deaths from healthcare errors we have begun to focus on patient engagement and involving patients in the co-production of their health. It is no longer acceptable to tell patients and families what they need to do but rather request to come alongside them to co-produce their health. This means we have to move from the mindset of asking patients “What is the matter with you?” so that we can “treat it” or “ x it” to asking “What matters to you and your family?” so that patients and families, communities etc. can co-produce desired health outcomes. Simulation lends itself to this for patients, families, and caregivers. We are just beginning to use simulation as a training modality for patients.

In order to advance co-production of health and healthcare services, it is essential that the educational system for healthcare professionals be viewed through a co-production lens. We have to engage our learners in similar conversations about what matters to them and how their education can assist them to obtain what is important to them. We need to create education systems that allow learners to be partners in the co- production of their education. We have to guard against simulation being a one and done kind of experience where we teach in old ways with a new methodology. Rather we have to re-envision education using simulation as a way to partner with learners to address what matters to them such as being a compe- tent and con dent practice-ready prac- titioner. As an example, in addition to applying the knowledge of how to care for a patient experiencing a myocardial infarction (heart attack) we also need to assist the learner to uncover knowledge gaps, enhance problem solving by notic- ing and interpreting patterns of change in patients that foreshadow catastrophic events.

Now that simulation has become embedded in many healthcare programs, we need to continue to explore ways to maximize its utilization.(Deming, W. E. (1993). The new economics for industry, government, education. MIT Press)

MTM: What changes need to be made in nursing education, healthcare regulations and the healthcare system to improve patient safety?

CD: Develop stronger and valued partnerships between all three with active engagement in co-production of healthcare education.

Examine our educational outcome measures that bring us closer to our real outcome quality and safe patient care. MTM: How can simulation be used more effectively for assessment?

CD: We use simulation to evaluate teamwork and collaboration and communication which we feel is important to improving patient care.

MTM: ‘Training decay’ is a well known phenomenon within the training industry; pilots are assessed as to capability twice a year as a result. With the projected shortage of healthcare professionals, what can be done to improve training at all levels?

CD: Healthcare needs to become a high reliability organization such as aviation and nuclear power plants. We need to move away from the mentality of er- rors happen, after all we are human and examine how these industries – who involve humans have more reliable op- erations and outcomes. So using just in time training or refreshing of skills as a normal expectation can help to mitigate the inevitable training decay.

MTM: What training tools, techniques do you use in simulation to ensure that your trainees are proficient to care for patients? How often are their skills tested?

CD: We have skill testing every 2-3 weeks in the beginning and then each semester subsets of skills are assessed.

MTM: How important is team training and communication in patient care?

CD: These skills are the crux of improving patient care. If you examine the Joint Commission sentinel event data across decades, communication continues to be a leading cause. Communication is much harder than expected and we assume we know how to do it but we do not. We have to level the playing eld so that each professional is valued for the skills and perspectives they bring to the care of the patient.

MTM: What are the best methods for team training?

CD: Training on the concepts of team such as TeamSTEPPS and then creating repetitive immersive experiences where interprofessional learners and or practitioners are required to care for simulated cases together and then debriefing on teamwork, collaboration and communication. We need to truly prepare learners to be ready for practice including collaboration.

MTM: Do you have a view of the value of simulation to nurse education? How could the simulation industry help improve training, care and results?

CD: Nursing educators need to consider industry as partners. Collaborating allows each to bring their expertise educational theory and solution development. Without communication each cannot know what the other has to offer nor can the issues/problems be identified so that effective and efficient solutions can be devised.

Healthcare educators cannot be content with what they did last year but ever evolving how they teach the essen- tial components of their profession. They need to model evidenced based practice and also use a variety of strategies to allow the learners to not only be exposed to the information but also be able to integrate the knowledge, skills and attitudes necessary to make them a competent and compassionate practitioner.

MTM: INACSL developed Standards of Best Practice to advance the science of simulation, share best practices, and provide evidence based guidelines for implementation and training. What im- pact do you think these standards have had on nurse education and the use of simulation? What impact do you hope they will have in the future?

CD: The INACSL Standards of Best Practice: SimulationSM have expanded and helped to standardize how people think about the implementation of simulation. The standards are being more widely adopted. We are hoping that each program using simulation will nd these standards a viable guide for their simulation programs.

MTM: How will the above impact outcomes?

CD: Provide standards to evaluate the quality of simulations. Boards of Nurs- ing and others can use the INACSL Standards of Best Practice: SimulationSM to evaluate simulation experiences and programs.

MTM: As a member of the Global Network for Simulation in Healthcare (GNSH) what do you feel will be the main contributions it will make to provide better training?

CD: GNSH uniquely provides an opportunity for simulation leaders, simulation associations/organization leaders, industry partners and some key stakeholders to dialogue about healthcare education/training using simulation pedagogy. Networking with global colleagues allows all to learn with, from and about simulation and healthcare worldwide. Through this opportunity we discover we are more similar than different. By leveraging this opportunity to be together to network, engage in discourse around the challenges in healthcare and how simulation can assist in improving outcomes further educates all who participate.

The work across the last three years has been invaluable to examine the return on investment of simulation and create strategies to more effectively communication with those who are instrumental in using simulation as a strat- egy to improve healthcare outcomes. Notably, Michael Seropian has been a steadfast leader that has helped to shape and implement the mission and vision of GNSH. MTM


Dr. Carol Fowler Durham integrates excellence in teaching with long ex- perience in practice and scholarship to improve the ways faculties prepare the future nursing workforce. As a member of the RWJF’s Quality and Safety Education for Nurses (QSEN) project, she developed simulation-based educational experiences that reflect cutting-edge pedagogy. Dr. Durham has made significant and sustained contributions in IPE and is a leader in preparing faculty to integrate quality and safety into their curriculum and their teaching.

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