Reflective Statements

Professional Values and Behaviors

My adopted professional values as simulation educator are continuously evolving as I get more involved in the simulation community. I was the Co-chair for the SSH Asia Pacific Meeting for Simulation in Healthcare (APMSH 2013) and Co-Chair for the SSH International Meeting for Simulation in Healthcare (IMSH 2016). As I recently assume roles as President of the Pan Asia Simulation Society in Healthcare (PASSH), Vice-President for Society for Simulation in Healthcare Singapore (SSHS) and Co-Director of the SingHealth DukeNUS Institute of Medical Simulation (SIMS).

These leadership and committee roles have given me tremendous opportunities to grow and open my mind, stretch my bandwidth to work as a team with my counterparts regionally and internationally as a simulation contact person. I have became more aware of the need to develop further in order to meet various expectations and be motivated to want to help developing centres to benefit their learners and eventually, patients. I have since, conducted simulation faculty course, TeamSTEPPS Fundamental Course (integrated with simulation) and simulation technician development course in the region - Malaysia, China, Thailand, Brunei, Hong Kong, South Korea, Indonesia and India. As I teach in these different places, I have the privilege to meet people of different cultures and I learned of the local healthcare system and how they would apply the simulation modalities in their context. As I teach, I realized that there is so much that I also learn from my learners.

Currently, back in my current institution, I have a team of 20 simulation faculty whom I have trained to provide clinical specialty workshops that adopts simulation as a teaching tool. The simulation faculty are also engaged to conduct simulation at their workplace (in-Situ). Whenever my schedule allows, I will try to be there as a back up or rather, to provide moral support. I see my role as a faculty mentor for young faculty members. Moving forward, my wish is that they can grow to be faulty-trainers in the simulation faculty course and be the sim champion in their area of work in the near future.

In the course of my career, I have designed, secured funding, built and installed 4 Simulation Centres - Ngee Ann Polytechnic, National University Hospital, Jurong Health Services and Sengkang Health. The budget statements were prepared with projections, facility utilization rate and Staff training projections. These statements were submitted to the Singapore Ministry of Health and various education endowment bodies for funding support. Funding secured for the various projects:

SGD$390,000 for the setting up of National University Hospital, Mrs. Lee Kong Chian Critical Care Nursing Simulation Laboratory (floor space: 10 sqm).
SGD$7.1 million for the setting up of Jurong Health Services simulation facilities which includes a Wet Skills Laboratory (floor space: 750sqm).
SGD$$205,000 from Ministry of Health Singapore, for procurement of SimMan3G x 1 unit and SimMan Essential x 1 unit.
SGD$2,991,836 from Ministry of Health Singapore, for setting up the Clinical Education Hub, Sengkang Health (new campus) by mid 2018.

Scholarship—Spirit of Inquiry

I was involved in the Singapore Ministry of Health Simulation Workgroup from 2010 - 2011. The workgroup reviewed best practices and recommended replacement of 80 clinical hours with structured simulation based activities. This area of work is unfinished but since our group was disbanded, it is difficult to provide evaluation on adoption rate to this recommendation. However, the process of working with a nationally form simulation work team has allowed me to conduct fruitful discussions on matters relating to nursing education and simulation-based education.

I maintain awareness of current innovations through my networking with simulation folks and community. The PASSH journal club have been a regular activity offered to its members. I had the honor of presenting in the first PASSH journal club together with a colleague. I am a contributor to the SSH publication - Defining Excellence in Simulation Programs (2015), Healthcare Simulation Education: Evidence, Theory & Practice (2016) and the SSH Dictionary (2016). The involvement in these publication has allowed me to contribute and play a role in sharing existing and creating new knowledge for the simulation community.

As I take on the role of manuscript reviewer for the Advances in Simulation, an official journal for the Society in Europe for Simulation Applied to Medicine (SESAM), I am also becoming more aware in scholarly work processes, research rigor and the rising trend in simulation based education. I am also a abstract reviewer for APMSH (2013 & 2016) and IMSH (2016). I serve on the NLN TEQ Blog advisory board involving as a blog contributor and reviewer. These various experiences have enabled my growth towards integrating evidence in my work and in acknowledging the importance in continuous improvements.

I am an enrolled PhD student with the University of Nottingham, UK. The focus of study is the Nurse Facilitator in Interprofessional Education (IPE) in the context of Simulation Based Education. The underpinning theory for the study is Professional Socialisation. The study shall examine the nurse facilitator's role in IPE simulation activity and how the role impact on nursing education within IPE context.

Over the past 4 years, I have been actively presenting plenary speeches, workshops and courses at regional and international simulation conferences. For some courses, I led in teams of 4 or more faculty in course designs and implementation at:

IMSH 2015 - Frameworks for art of speech! Hands-on scenario design for team communication.
IMSH 2016 - Cross Cultural Communication Training through Healthcare Simulation.

Other presentations individual and in collaboration were:

APMSH 2013: Plenary with Suzie Kardong-Edgren: State of Simulation Science in Nursing in Asia and the United States
APMSH 2013: Pre-Conference Workshop for Nursing: Introducing Simulation into Existing Nursing Programs.
APMSH 2013: Workshop - Development of Interdisciplinary Team Training.
APMSH 2013: Workshop - Team Game to Learn Systems Thinking and Organizational Change.
IMSH 2015: Pre-Conference Workshop, 10 Jan 2015: How to design an Integrated Simulation Scenario.
IMSH 2015: Conference Workshop, 12 Jan 2015: Igniting passive learners: Diving into the madding crowds!
IMSH 2016: Conference Workshop, 19 Jan 2015: Engage passive Minds.

More regional presentations are listed on my curriculum vitae.

As I continue presenting, I gather more strategies that helps me "polish" public speaking skills. Also, I am now more able to respond to questions and at times, even difficult questions. I hope to take on more difficult topics for workshops and plenary speeches as I am pushed towards taking responsibility to gather updated information and relevant application of the information. This will enable me to be more self-directed.

Designing & Developing Learning Activities

I have been designing courses and workshop that meets the needs of the Asia region. The needs assessment were conducted through online survey using Google Forms and SurveyMonkey. Here is a sample of the needs assessment report (linked to SurveyMonkey site) that was conducted in the year 2014 for the planning of clinical specialist certificate course for emergency room nurses. Other needs assessments I was involved for:

Conference tracks for APMSH2013 conducted through teleconferencing in 2012.
The need for a regional simulation society conducted in 2013.
All in-house workshops and courses for nursing education and IPE for Sengkang Health since 2014.
A regional conference by the Pan Asia Simulation Society in Healthcare (PASSH) in 2014.

I think I write some good overarching goal statements and objectives statements and this skill may have been developed from frequent practice in writing the statements. I have use the Bloom's taxonomy 6 levels of cognitive domain - generally, use of action-verbs as a guide and it has been working very well for me. In reviewing course curriculum, I like to review the statements every 12 to 18 months. This is to ensure that these objectives are addressing current needs with the latest criteria and conditions (gold standards, evidence-based and rising trends) that are aligned with current trends of strategies in healthcare. In short - they are still valid.

While reviewing the objectives, the course materials, content and implementation are adjusted to ensure meeting learning outcomes.

I have designed numerous courses and workshops that utilized simulation as a teaching tool. Simulation is integrated in these designs to offer a simulated clinical experience to help learners transfer knowledge to practice as soon as possible. The skill sets within the courses are offered through breakout stations; small group learning at breakouts is essential to engage/expose as many learners as possible. My design of clinical courses are presented in the following linked documents:

Tracheostomy Workshop.
Clinical Early Warning and Rescue (with scenario).

In designing courses, I often avoid too much didactic and consider the use simulation and problem-based learning. There are two courses that utilizes the PBL method, when executed, we realized that the learners (our nurses) actually like it a lot as they felt the need to discuss, contribute and present to justify their answers. Somehow, the faculty team dislike it as we felt the sense of losing control over the learners' progress through the course. I suppose it is one of the virtues of PBL that cultivate self-directed learning and we faculty have just to get used to it. Samples of course schedule are presented here:

Assessment and Evaluation of Learners

The course curriculum designs include assessment activities to determine learner's achievements. I use a varieties of assessment tools in the following courses:

Nursing Foundation Course for newly hired nurses - Clinical Core Competency Checklists - high stakes assessment for performance record and institutional accreditation with Ministry of Health and Joint Commission International (JCI)
Life Support Training - Multiple Choice Questions and Skills Checklists - medium-high stakes for identified staff who requires certification to work in a specific department (all staff with patient contact must be Basic Life Support (BLS) certified).
Clinical Specialty Workshops - Skill checklists and pre/post multiple choice test questions to determine prior learning and outcome achievements. 2 workshops utilize the problem-based learning methodology that have questions asked at various stages to cultivate thinking, deriving of patient care solutions and problem solving strategies which the students will derive on their own.
Clinical credentialing and privileging - the certifying of competency shall empower nurses to expand their role to cover advanced practices and skills. Moderate sedation administration, suturing of wound and application of plaster casts are some examples of privileging requiring assessment setup.

The assessment tools are designed to test various level of cognitive domain – recall, comprehension, application, analysis, synthesis and integrative application. With a good mix of questions, the assessment shall help determine if learning outcomes are met. Questions are generally reviewed every year to ensure that these are valid to meet changing trends and guidelines (such as the AHA resuscitation guidelines that is updated once every 5 years). Assessment tools are reviewed by a penal of faculty in order to match clinical authenticity.

The major issue I encounter with assessment is electronically administered tests. The electronic test is administered to current group of nurses working in the hospital for annual competency testing. There are 4 core competencies requires testing, namely administration of blood and blood products, administration of intravenous medication, performing blood glucose monitoring and privileging of laboratory test set ordering. As the group of nurses grow larger, I need to explore strategies to administer online tests effectively to capture realistic scores. The reason being, most nurses are taking the tests in the clinical areas with the help of their peers.

I think we have to consider strategies to allow nurses to be aware and to reflect on their actions towards consequences in providing clinical care. We want nurses to feel that they can do well and be knowledgeable in their work. So that they do not have to resolve to seeking out help during assessment. I am aware that the faculty has very little control over test taking behaviors when assessment is conducted remotely.

Nevertheless, on a more positive note, assessment is also a way to cultivate learning – whether the learner is an actual test candidate or peer assistant during the test. In my opinion, both of them are learning together as the questions are reviewed together.

Implementing & Evaluating Simulation-‐Based Learning Activities

Delivery of educational activity

I have been integrating simulation in many programmes that I have developed/structured. Simulation is a great way to translate learned concepts into actions. Some of our clinical workshops are conducted full day. Apart from didactic (which are now kept to very short bursts of 20 minutes lectures prior to skills application), learners are given breakout hands on sessions which they rotate through skill stations and simulation is the main mode of delivery in these stations. One of the workshops designed to provide multiple simulated experiences is the Tracheostomy workshop.

Out of the 7 breakout sessions, 3 are simulation-based stations that offer scenario based on tracheostomy dislodgement emergency, acute desaturation and humidification & suctioning. The workshop also enhances interprofessional collaboration as we have speech therapist in to teach and demonstrate the use of liquid thickener and speech valve. Nurses learned to mix various liquid consistencies and experienced swallowing the thickened mixtures. The learning experience is translated immediately. These activities replaces didactic lectures as they are more valuable and experiential in nature.

I also have many opportunities in conducting simulation faculty courses both locally and in the Asia region. I have been a strong advocate for simulation as it ha unlimited possibilities in enabling students to learn, think and cultivate habits (good ones, of course). One of the reasons for setting up a local simulation society (Society for Simulation in Healthcare Singapore, SSHS) was to cater a faculty course for our local faculty. Together with 4 other medical colleagues (Prof. Loo Shi, Prof. Agnes Ng, Dr. Dinker Pai & Dr. Elaine Tan), we developed a 3-day Simulation faculty course named - Simulation Essentials for Healthcare Educators (SEHE).

The SEHE course induct novice faculty in adopting simulation as a teaching tool. The course content include adult learning theories, Kern's 6-Step model in developing a curriculum, objectives writing, scenario development, executing simulation, debriefing, low-cost solution in clinical training, use of moulage, use of standardized patients, assessment and team-based simulation. These contents are indispensable in providing an all-rounded simulation faculty course and getting novice faculty ready for their next simulation facilitation.

Effective management of the learning environment and educational activity

Currently, most of the clinical programs that I facilitate are conducted in-situ. The use of an actual clinical environment is a huge advantage for us as nurses are familiar with their surroundings, there is no need for lengthy pre-simulation orientation. And we gain very good insights to clinical infrastructure capability as we discover learner's ability to perform clinically given the effects of motion-space-time resources that they work in day-to-day. And how they can effectively to overcome constraints even with one side of the domain (of motion-space-time).

The clinical environment is very well exposed to people traffic - such as doctors, nurses, patients and family members of our patients. In order to protect our learner from distractions and also the fear of spoken words being heard, I will seek help from the ward clinical instructor to identify a more remote room or cubicle of the ward for the simulation activity. Announcements are made to all personnel to avoid approaching the training room unnecessary.

There were a few occasions that I am given a cubicle with 5 other patients. What was done for the interest of the learners were introduction of the program and faculty to the patients. Consent were sought from the 5 patients as they may feel invasion of privacy and deprived of resting time. The use of bedside curtain screens helps very much in providing a safe space for our staff learners. However, I was really lucky as all our patients (those who encountered our introductions for simulation in-situ) understand that we are a teaching hospital and we have the duty to educate. They didn't mind the activity occurring next to their beds. And a few of them even participated in call for help, move their seats to create more space and also participate in communication with the nurses. As faculty, I feel very empowered to have our patients partner us in educating our nurses.

I don't utilize much video recording for debriefing purpose, hence, for in-situ simulation, there is no recording as well. The SimMan software has a debriefer viewer which I review the logged activities and marked events and use it as my debriefing points.

Feedback and debriefing techniques

We are a multi-cultural country. Our learners are from the Asian countries - Singapore, Malaysia,

Philippines, China, Myanmar and India. With different background in training and attitudes towards

learning, I am aware of the need to identify strategies that will allow my learners to feel at ease so that

they can "open up" to speak during debriefing. I used to following the cardinal rules on providing an opening to debrief session by saying "what is shared here, remains here". Somehow, after a few conversations with my staff learners, I learned that they don't really "buy" the idea. So I've changed my strategy to open my debriefing session by stating my intention. And this to them, makes more sense and project us as faculty to be more genuine to want to help them learn. So, my intention statements are:

I can see what you were doing, but I cannot see what you were thinking (borrowed from Dr. Dan Raemer). So, we will spend the next 10 - 20 minutes to talk about why you do things the way you did. And hopefully, this will help you gather some ideas on what needs to be changed or improved.
This is a teaching scenario. I want us to spend the next few minutes to talk about what happened in the scenario. Please help me understand your actions and your thought process when you were managing the case.
I know that the manikin is fake, but your actions are/were real. So, I would like us to explore the reasons or purposes of your decision making behind those actions. All of us should contribute to the discussion.

For the debriefing structure, I use the GAS model - Gather-Analyze-Summarize. I am very comfortable in using this model as it provides a structure to start off the debriefing. I have also attended the Comprehensive Instructor Workshop offered by the Center for Medical Simulation, Boston. I have learned to debrief using the Advocacy / Inquiry (AI) method. I like to use the AI when I am curious about certain learner action.

I am also submitting a media on my debriefing style. Please refer to the Media Submission page.

Performance improvement

I have gather evaluation of simulation training from all leaners. The evaluation is collated and shared with the department in order to revise teaching content, program delivery and faculty effectiveness. This is part of our education quality improvements process. I use the standardized form in my organization for evaluation. There are 2 domains: Likert scales questions and free text section for other possible comments that is not captured using the Likert scale. I have also include a self-rated question on how learners perceive their skills before and after the program.

So far, our evaluations have been very positive. The learners enjoyed the courses and simulation in-situ. They requested for more sessions and suggested having these simulation sessions run once every 3 months. I am very motivated with learners' responses.

Some recent evaluation received for Simulation faculty Courses led by me:

Sengkang Health Internal Simulation Faculty Courses - 10 & 11 May 2016 , 22 & 23 August 2016 and 18 & 19 October 2016.

Evaluation received from external courses:

1. Simulation Faculty Induction Course for Thailand Delegates - 4 & 5 February 2016

2. Xiangya Second Hospital, Changsha, China

- TeamSTEPPSs Fundamentals (23 October 2016 & 25 October 2016)

- Simulation Faculty Course (24 October 2016)