This article suggests the construct of medical simulation education in the air medical industry can integrate principles of crew resource management by training in the same environments that flight crews function. The multidisciplinary crew-centered approach to designing simulation education can improve overall crew performance and reinforce safety in daily operations. This concept is far from novel and has a proven track record in the aviation industry, but air medical medicine can benefit from this proven system as well.
In an article titled “Teams, Leaders, and Organizations: New Directions for Crew-oriented Flight Training,”1 Hackman states that “it is the team, not the aircraft or the individual pilot, that is at the root of most accidents and incidents.” Simulation in aviation has a long history, dating back to early decades of the industry. With cockpit or crew resource management (CRM) becoming a staple of the air medical industry, we find ourselves on the precipice of using simulation to teach the foundational concepts of CRM. Consistent with Hackman’s statement, medical errors in the air medical industry may be caused by system errors and a breakdown in team functions.
It is important to acknowledge that all air medical team members are adults and, therefore, adult learning theory becomes relevant and potentially influential; it is, in fact, referenced frequently in current “educational simulation” literature. Respected adult education theorists include Jean Piaget, John Dewey, D.A. Kolb, Malcolm Knowles, and many others; although each theorist has their respective tenets, there appears to be a shared commonality to the science behind adult learning and education. It is generally accepted that adults operate on the following common principles:
1. Adult education takes place through interplay of real lifeactions and conditions.
2. Adults bring with them a set of unique ideas based ontheir unique experiences.
3. Adults learn in several domains including psychomotor,cognitive, and affective domains.
4. Each of these domains can be isolated and usually arepresented as such.
5. An “overlap” of these domains promotes a more universal learning experience.
6. The full effect of learning can be absorbed more fullythrough an active reflection of the learning event.
Educators can integrate CRM principles when applicable and design simulations to promote the same. Foundationally, it is a multidisciplinary team of paramedics, nurses, respiratory therapists, and occasionally physicians that comprise the medical crew. By adding communication specialists and pilots to complete the full team composition, educators can begin to better understand their simulation construct. Integration of the full crew configuration and recreation of realistic environments will further strengthen CRM principles. The Institute of Medicine acknowledges in its report “To Err is Human” that “most care delivered today is done by teams of people, yet training often remains focused on individual responsibilities, leaving practitioners inadequately prepared to enter complex settings . . . the ‘silos’ created through training and organization of care impede safety improvements.”2
Implementing Simulation in Air Medical Training: Integration of Adult Learning Theory
David Matics, MS
When using a team-based approach to design and deliver simulation, the educator should be aware of several intrinsic tendencies among team learning events. Kayes et al3 identified the following summation of team-based learning challenges that educators and designers of team-based simulations should be aware of: 1) overreliance on the most dominant person within the team; 2) a tendency to resort to conforming to the overall group ideas, even when the group is wrong; 3) shirking responsibilities because of thinking that “someone else will do it”; and 4) social daydreaming in which 1 or more members lose interest in the process, thus decreasing team effectiveness.4
Entire teams should be integrated in the delivery of care much like the real-life environment dictates. As such, it is the evaluation of the team rather than the individual that must occur. Henriksen and Moss5 state that, “Health care providers work together, but are trained in separate disciplines. Few receive training in teamwork.” The following recommendations of Hamman6 for creating these team-based constructs are suggested in his 5-step process: 1) identify team topics and subtopics, linking performance indicators to objectives; 2) select incidents to simulate, preferably from a data set of real events; 3) identify objectives and the observable behaviors that will indicate their completion as tracked by a validated assessment instrument; 4) test the simulation scenario with at least 2 different expert teams and confirm validation of the assessment instrument; and 5) modify and finalize the simulation based on expert team feedback and deliver the simulation scenario to its intended audience.
Emphasis on the second bullet point is relevant to this discussion. Air medical agencies typically conduct a systematic and recurrent chart review; the recreation of performance gaps found in these reviews resultantly provide the infrastructure for the “data set of real events.” These chart audits can provide realistic detail that can be presented to crewmembers with learning opportunities and provide a link to the overall quality improvement process; they also create an evidencebased approach to the delivery of educational content.
Now that the direction has been suggested for the overall construct of the simulation-based learning event from Hamman, let’s discuss just how the learning takes place. Kayes et al3 cite the following 3 principles deduced from a review of research on experiential learning in teams in general:
1. “To learn from their experiences, teams must create aconversational space where members can reflect on and
September-October 2015 261
Figure 1. Kolb’s Learning Cycle
talk about their experiences together.” The team must be flying under “visual flight rules” in that they must be able to see what they are doing by active reflection.
2. “As a team develops from a group of individuals into aneffective learning system, members share the functional tasks necessary for team effectiveness.” The team cannot rely on 1 dominant person to lead the event, but rather a shared and equal assumption of responsibility must occur.
3. “Teams develop by following the experiential learningcycle.” This is the cycle developed by Kurt Lewin and discussed by Kolb of concrete experience, reflective observation, abstract conceptualization, and active experimentation.
Kolb’s model closely follows the tenets of simulation by recommending that 1) knowledge, skills, and attitudes are assessed by presenting them in the context of a real-world environment; 2) there is a built-in time frame for debriefing (an open dialogue of the positive and negative aspects of the event); and 3) through this active reflection on the event, learning and improvement occurs. As noted in the Kolb model (Fig. 1), this reflects an evolving and continual process of examining ideas through practice.
Furthermore, it would be ideal to create a realistic scenario, emphasizing a team-based application with an evidence-based data set of real events using chart audits and peer review. These processes are typically already in place. Understand that although we preach CRM daily and how everything is a teambased success or failure, frequently our education constructs do not support this thought. Team-based, multidisciplinary educational events are an integral part of the design and delivery of air medical education. Evidence-based education assists us in costeffectiveness by replacing the concept of “throwing darts.” Teambased delivery addresses the concept of how we live and operate in this high-stakes environment—create a realistic environment; initiate a team-based application of psychomotor, cognitive, and affective skill sets presented in the context of real life events; identify and measure outcomes based on objectives for the event; and provide the actual learning stage through a debriefing in which students can actively reflect in open dialogue. As was coined in the movie White Squall,7 “Where we go one, we go all.” The air medical industry is a team-based unit, and education should be designed, delivered, and evaluated as such.
1. Hackman RJ. Teams, leaders, and organizations: new directions for crew-oriented flight training. In: Wiener E, Kanki B, Helmreich R, eds. Cockpit Resource Management. San Diego, CA: Academic Press; 1993:47-70.
2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press; 2000.
3. Kayes AB, Kayes DC, Kolb DA. Experiential learning in teams. Simul Gaming. 2005;36:330-354.
4. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall; 1984.
5. Henriksen K, Moss F. From the runway to the airway and beyond. Qual Saf Health Care. 2004;13(suppl 1):i1.
6. Hamman WR. The complexity of team training: What we have learned from aviation and its applications to medicine. Qual Saf Health Care. 2004;13(suppl 1):i72-i79.
7. Scott R. White Squall [Film]. Los Angeles, CA: Hollywood Pictures; 1996.
David Matics, MS, is a Certified Flight Paramedic and Simulation Education Integration Specialist at Healthnet Aeromedical Services in Charleston, WV.
Copyright 2015 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2015.04.006
262 Air Medical Journal 34:5