Patient care scenarios provide an opportunity for learners to apply classroom material and isolated skill practice in realistic situations. The NREMT now requires paramedic students to demonstrate competency in scenarios that cover a variety of topic areas over the course of the program, and the new NREMT Psychomotor Competency Exam includes a patient care scenario [1]. Scenarios can also be used to engage learners in continuing education to cover required competency areas, implement new protocols or roll out new equipment.
Unfortunately scenarios are often run with unclear objectives and little pre-planning, which impairs learning and leaves both facilitators and learners frustrated. Whether scenarios include high-fidelity simulation equipment, task trainers or patient actors, here are 10 tips to run an effective patient care scenario:
1. Set scenario goals and objectives.
Start planning scenarios with a goal of what you want learners to understand or be able to do afterwards. Goals of a scenario may be for EMT students to identify and treat a condition they just learned about, for paramedic students to manage a complicated scene and patient presentation at the end of their program or for working paramedics to improve resuscitation team dynamics.
After identifying goals, determine what critical interventions that team members must perform in order to be successful. For example, critical interventions for a patient having an asthma attack may include the team members introducing themselves to the patient, administering albuterol within five minutes and initiating transport within 15 minutes. Get input from multiple people when identifying goals and objectives for a scenario; this establishes consistent expectations for each group participating in the scenario and inter-rater reliability.
2. Match the level of scenario complexity with the level of the participants.
Scenarios should build on the participants’ prior knowledge and expect them to apply that knowledge in a new situation. Set goals that push the participants’ level of competence, but do not exceed it. Develop scenarios for novice learners with a few learning objectives and straightforward patient presentations and gradually increase the complexity of patient care and scene dynamics in future scenarios. Make sure learners have demonstrated competency in any isolated skills, like intravenous access, before they are expected to perform them in a scenario [1].
3. Set up a realistic scene.
Design ways to make the scenario more like the field. Set up props such as walkers, commodes and empty liquor bottles in a classroom or take a field trip and run scenarios in a station kitchen, bunk room, day room, bathroom, office or vehicle. Moulage patients or show pictures of injuries as learners assess body areas and give the simulated patient a real prescription medication bottle. Add safety hazards such as simulated weapons, capped syringes, tripping hazards or dim lighting and play sound clips of radio noise or traffic in the background. Move patients on real stretchers and stair chairs to an out-of-service ambulance and give a handoff report to an a simulated emergency department nurse.
4. Do a dry run with equipment and actors.
Equipment failure is a distraction that detracts from the scenario’s learning objectives. Turn all electronic equipment on, check batteries and test Wi-Fi or Bluetooth connections. Manually check anything on a simulator that participants will be expected to find on a physical exam and have a backup plan for anything that may fail.
Actors in the scenario who go off script also derail learning objectives. Brief everyone involved in the scene about the goals and objectives of the scenario and how they should interact with learners. Run through the scenario beforehand and make sure the simulated patient knows how they should respond to any treatment.
5. Create an environment where learners feel safe making mistakes.
Performance anxiety in scenarios is an issue for students and EMS professionals at all experience levels. Team members who trust each other and trust the facilitator perform better and learn more from the scenario, while fear of punitive criticism compromises the scenario’s educational value [2, 3]. Encourage participants to go past their comfort level and experiment. Emphasize that the scenario is an opportunity for group members to learn from each other’s strengths and weaknesses, to learn from mistakes and to improve patient care.
6. Orient learners to the equipment.
Explain how participants should perform a physical exam and any invasive skills before starting the scenario, such as actually checking for a blood pressure versus asking for one, or starting an IV on a task trainer next to a patient versus verbalizing one. Allow participants to practice performing a physical exam on any simulation equipment. Learners will get the most value from the scenario by actually doing as much of the assessment and treatment as time and resources allow.
7. Communicate expectations for roles in the scenario.
Before the scenario, designate a team leader who is responsible for scene management, patient assessment and treatment decisions, and designate team members to perform tasks delegated by the team leader. Make sure team members understand their scope of practice, certification level and when, or if a team member can question a decision by the team leader. Team members should always be empowered to question a decision or procedure if they believe there is a safety threat.
8. Plan for the scenario to go off track.
Think about where the participants may get stuck or make an error that shifts the scenario away from the learning objectives, such as a team leader misdiagnosing a patient with anaphylaxis as having an asthma attack. Scenario participants should be allowed to figure out as much as possible on their own, though a scenario should always stop for a safety threat to the team or to the patient. The most appropriate intervention from the facilitator depends on the group’s baseline competency level and the amount of time available. Some options to do this include:
- Have the patient decompensate at a predetermined time if the correct treatment is not administered.
- Have the simulated patient prompt the team leader, such as “the last time this happened, my throat swelled up and they gave me a shot in my leg.”
- Allow the team leader to call medical control.
- Pause and rewind by asking the team leader what they know so far about the patient, fill in any knowledge gaps or missed assessment findings and resume the scenario.
9. Find a way to get everyone involved.
Avoid down time for participants between scenarios. Have any extra people act as bystanders or help assess the scenario, or have them wait in another room to receive a radio or patient hand-off report.
10. Let participants do most of the talking after the scenario.
Most learning from a scenario happens during the discussion afterwards when participants reflect on the experience and connect it to learning objectives. Instead of a rapid-fire critique of what went well or poorly in the scenario, facilitate a discussion with a debriefing model such as GAS – gather, analyze and synthesize.
Let the participants defuse how they feel about the experience, guide them through discussing what happened in the scenario, compare what happened in the scenario with the learning objectives and review key points to take away from it [3]. Be sure to budget enough time for debriefing – it may take longer than the actual scenario.
To get the most value from patient care scenarios, set learning objectives that are appropriate for participants and consider all logistics needed for the scenario to run smoothly. Clearly communicate expectations and create an environment that fosters safety and trust among participants.
References
1. National Registry of Emergency Medical Technicians. 2015 Paramedic Psychomotor Competency Portfolio Manual. Retrieved from: https://www.nremt.org/rwd/public/document/paramedic-portfolio
2. Fraser K, Ayres P, Sweller J. Cognitive Load Theory for the Design of Medical Simulations. Simulation in Healthcare 10:295-307, 2015) DOI:10.1079SIH.0000000000000097
3. Levine A, DeMaria S, Schwartz A, Sim A (eds). The Comprehensive Textbook of Healthcare Simulation (2014) New York: Springer
