Pilot of hybrid train­ing imple­mented as contact and remote simu­la­tions with para­medics and first response unit person­nel in North Karelia

The objec­tive of the Sote Hyte Living Lab – Code­vel­op­ment in North Karelia project (the Living Lab project) is to promote the capac­ity of private and public service providers and compa­nies and organ­i­sa­tions to benefit from the oppor­tu­ni­ties of tech­nol­ogy and digi­tal­i­sa­tion to produce new kinds of solu­tions for social, health and well-being services in North Karelia. One section of the Living Lab project tests and devel­ops train­ing imple­mented in the form of local and remote simu­la­tions in coop­er­a­tion with North Karelia para­medics and first-aiders in the devel­op­ment of compe­tence. The aim of the pilot is to gain expe­ri­ences of hybrid train­ing imple­mented for a large number of person­nel, with simul­ta­ne­ous partic­i­pa­tion by contact partic­i­pants in Karelia UAS’s Simula learn­ing envi­ron­ment and by remote partic­i­pants at rescue stations in differ­ent parts of the region. (Kurki & Leppä­nen 2022)

Emer­gency medical services in the province of North Karelia include first response, basic and advanced emer­gency medical care and emer­gency medical care field command­ing. The Siun Sote joint munic­i­pal author­ity has a physi­cian in charge of emer­gency medical care, and the emer­gency medical response centre in the special area of respon­si­bil­ity organ­ises 24-hour emer­gency medical care (FH 60). (Rescue). In emer­gency medical care, 157 para­medics and 42 rescuers/basic level para­medics work full-time. Some shifts involve 15 rescuers/basic level para­medics.  168 contract rescuers (first response unit person­nel) are included in the first response activ­i­ties. (Törrö­nen 2023a). There are 13 rescue stations in the region, distrib­uted across the entire province of North Karelia, at long distances from each other.

The Health Care Act (1326/2010) provides for the organ­i­sa­tion and content of emer­gency medical services. Accord­ing to it, well­be­ing services coun­ties make service-level deci­sions in their area, spec­i­fy­ing, for example, the train­ing required of those partic­i­pat­ing in emer­gency medical services. Para­medics of North Karelia will take part in three contin­u­ing educa­tion courses during the year in order to main­tain basic and care level licences.

The train­ing days for para­medics in North Karelia have previ­ously been arranged as local imple­men­ta­tions, with the trainer trav­el­ling around to train para­medics at all rescue stations in the region, or para­medics have to come from the regions to the Joensuu rescue station for train­ing. Due to the large number of staff, train­ing has been organ­ised several times, and when the staff travel, working time is spent and addi­tional costs are incurred by the employer.

Testing the simu­la­tion hybrid train­ing method

In spring 2023, the Living Lab project was piloted six emer­gency medical services -1 (EMS1) train­ing days for all para­medics in North Karelia.  Five train­ing evenings were organ­ised for first response unit (FRU) person­nel involved in first response activ­i­ties. The project organ­ised for the use of Karelia UAS’s Simula facil­i­ties for imple­ment­ing these train­ing programmes. In addi­tion to simu­la­tion tech­nol­ogy, Simula also provides the option to partic­i­pate in activ­i­ties taking place in differ­ent Simula facil­i­ties via remote connec­tions and remote tech­nol­ogy and to share the image view and voice produced by the Nordic Simu­la­tors AVS system with remote Teams partic­i­pants (Pantsari 2022).

Simu­la­tions have been used in health sector teach­ing for a long time, and as tech­nol­ogy has devel­oped, the utiliza­tion of the simu­la­tions has become more wide­spread. Simu­la­tions can be used to learn many kinds of impor­tant things and skills needed in working life in a safe envi­ron­ment. (Enlund & Huhtiniemi 2021) Simu­la­tions are used to learn oper­at­ing models that empha­sise patient safety, for example. In addi­tion to devel­op­ing indi­vid­ual compe­tence and clin­i­cal skills, simu­la­tions teach both pair and team­work, lead­er­ship, inter­ac­tion, deci­sion-making and situ­a­tional aware­ness, so-called non-tech­ni­cal skills. (Salonen 2013; Univer­sity of Aberdeen 2012)

Simu­la­tion exer­cises have tradi­tion­ally been carried out as local imple­men­ta­tions and in small groups. Adding hybrid teach­ing to simu­la­tion peda­gogy is a new way of imple­ment­ing educa­tion, and more exten­sive consid­er­a­tion should be given to the plan­ning and imple­men­ta­tion of train­ing days. With hybrid teach­ing taking place simul­ta­ne­ously for contact partic­i­pants and remote partic­i­pants, the teacher’s peda­gog­i­cal solu­tions, advance prepa­ra­tions for teach­ing and tech­no­log­i­cal compe­tence are empha­sised. The student’s own prepa­ra­tion and self-direc­tion in learn­ing are also impor­tant. The balance of inter­ac­tion and the expe­ri­ence of commu­nal­ity bring new chal­lenges to be taken into account in hybrid teach­ing. (Ahlgren, Häkki­nen, Kosk­i­nen, Laakso & Selkivuori 2020)

Imple­men­ta­tion of emer­gency medical services -1 train­ing day

Plan­ning of the emer­gency medical services -1 (EMS1) train­ing began in coop­er­a­tion with the two health-sector teach­ers of Karelia UAS partic­i­pat­ing in the Living Lab project and the persons respon­si­ble for emer­gency medical care and first response train­ing at the North Karelia Rescue Depart­ment. The train­ing topics came from busi­ness repre­sen­ta­tives. The respon­si­bil­i­ties were agreed mutu­ally and carried out by both parties. Their tasks included drawing up advance instruc­tions for train­ers and train­ing partic­i­pants, drawing up advance mate­ri­als for self-study, distrib­ut­ing staff equally to differ­ent train­ing days, reserv­ing equip­ment needed for train­ing at rescue stations and Simula, making simu­la­tion scenar­ios and plan­ning a feed­back survey.

The struc­ture and content of the train­ing day were jointly designed to support learn­ing; the train­ing topics included theo­ret­i­cal areas and train­ing in the use of equip­ment before an applied simu­la­tion exer­cise. After the train­ing day, all para­medics will carry out a refresher task in their own online train­ing envi­ron­ment. The eight-hour EMS1 train­ing day included three differ­ent themes with exer­cises. The train­ers are emer­gency service field direc­tors and expert para­medics. A physi­cian in charge of emer­gency medical care also partic­i­pated in the train­ing days. During the train­ing days, the Karelia UAS teach­ers involved in the project took care of Simula’s tech­nol­ogy and remote connec­tion tech­nol­ogy and acted in patient roles in simu­la­tion exercises.

During the train­ing days, train­ers and the required number of para­medics came to Karelia UAS’s Simula facil­ity. At the begin­ning of the train­ing day, remote connec­tions to differ­ent rescue stations were tested and the contents and sched­ule of the train­ing day were explained. It was empha­sised to every­one that the train­ing day is an exer­cise, not a test. Engag­ing theory areas and equip­ment train­ing were imple­mented before the simu­la­tion exer­cise, in which the lessons learned were applied in prac­tice. Contact-partic­i­pat­ing para­medics were actors in simu­la­tion exer­cises. Follow-up tasks were also given to remote partic­i­pants at differ­ent rescue stations, which allowed them to partic­i­pate in the teach­ing discus­sion after the simu­la­tion exer­cise with contact partic­i­pants and train­ers. On the first day of the train­ing, remote tech­nol­ogy prob­lems slightly delayed the smooth progress of the train­ing, but the prob­lems were resolved and no longer occur­ring on the next train­ing days.

Partic­i­pants’ feed­back on the emer­gency medical services -1 (EMS1) train­ing day

At the end of the train­ing days, the contact and remote partic­i­pants were asked to provide feed­back on the train­ing day. The feed­back survey and a summary of the results of the feed­back received were produced by Karelia’s master’s degree students as part of their future thesis. In their thesis, they analysed the expe­ri­ences of older para­medics (over 45 years) in the train­ing organ­ised as contact and remote participation.

Feed­back was collected through a Webropol survey, and 110 responses were received from partic­i­pants in the EMS1 train­ing (N=214). 55% of the respon­dents felt that partic­i­pa­tion in the hybrid train­ing method was a better way to partic­i­pate than train­ing imple­mented as contact teaching:

 “The option to partic­i­pate remotely and develop effec­tive educa­tion in all aspects is sensible.”

“It was possi­ble to focus on the simu­la­tion exer­cises and observe things better when the event was organ­ised remotely.”

During the hybrid train­ing days, one quarter of the partic­i­pants were in Simula and the rest partic­i­pated remotely. During two train­ing sessions, the partic­i­pants were only in Simula due to the smaller total number of participants.

The results showed that most para­medics had partic­i­pated in simu­la­tion train­ing earlier. Only 10 % of the respon­dents had no previ­ous expe­ri­ence of simu­la­tions. Based on previ­ous simu­la­tion expe­ri­ence, the simu­la­tion was perceived as an effec­tive learn­ing method in open feed­back, even though the simu­la­tion expe­ri­ences varied by individual:

“Simu­la­tion learn­ing is still a good way to learn.”

“I can’t think of anything good to say about simu­la­tion-type train­ing, it just doesn’t suit for everyone.”

“More simu­la­tions and more equip­ment should be discussed. Every­one should be able to join the simu­la­tions.” 

A lot of advance mate­r­ial had been made for the EMS1 train­ing days, and most respon­dents felt that they supported the achieve­ment of the train­ing day’s objec­tives if only they had had the time to read them before the training:

 “The advance study mate­r­ial was compre­hen­sive and I am sure it prop­erly prepared those who read it for the train­ing.” 

Most respon­dents felt that the content of the train­ing day was suit­able and that the objec­tives were achieved, although oppos­ing opin­ions were also voiced:

“Things that were new to me were brought to the train­ing day and they were inter­est­ing, and I will certainly need them at work.”

“The topics were way too demand­ing for the EMS1 day. After all, every­one partic­i­pates in the train­ing, fire chiefs/rescuers and para­medics (basic and advanced level)!”

 The struc­ture of the train­ing day was consid­ered good:

 “The teach­ing lectures before simu­la­tions were good”.

The train­ers received very good feed­back on their activities:

 “The train­ers were clear and the contents of the topics were brought up very well. They knew how to present and teach them clearly and high­light the most impor­tant issues.”

 “didn’t have a test feeling”

 “The train­ing day had a relaxed atmos­phere and there was no need to be afraid of making mistakes.”

Consid­er­a­tion of remote partic­i­pants during hybrid train­ing was found to have been well realised:

“Big kudos for the train­ers! Ener­getic activ­i­ties and taking all partic­i­pants into account as well as showing inter­est in what they brought up.”

Improve­ment of tech­nol­ogy was high­lighted in the devel­op­ment proposals

There was also room for improve­ment in the imple­men­ta­tion of the train­ing day. Based on the feed­back, the image conveyed from the debrief­ing space to remote partic­i­pants was not always clear. During device train­ing, trans­mit­ting the image to remote partic­i­pants was changed to a portable camera connec­tion, and keeping the image stable was chal­leng­ing until the choice of camera with its support legs was correct. Hearing the voice was also a chal­lenge for remote partic­i­pants, espe­cially when the partic­i­pants in the simu­la­tions spoke at the same time, the speech was not clear – this was also a problem for contact participants:

 “In many cases, it was not possi­ble to under­stand the speech in simu­la­tions remotely, and rela­tively small screens made it diffi­cult to follow events, so situ­a­tional aware­ness was rather vague from time to time.”

Some improve­ment was accom­plished through instruc­tions and taking turns at speak­ing. A micro­phone was commis­sioned for the instruc­tions sent from the control room, and the speech was commu­ni­cated better through it to remote partic­i­pants. On the first day of the train­ing, there were tech­ni­cal issues with Simula and no tech­ni­cal special­ist service was avail­able, so a little more time was spent solving the problem. On other train­ing days, there were no prob­lems with remote-connec­tion technology.

Rescue stations have joined the Secu­rity Network (TUVE) as part of the public administration’s secu­rity network activ­i­ties.  The oper­a­tion of the TUVE network must not be compro­mised, for example by using a Teams connec­tion in this network (Ministry of Finance). For this reason, the remotely partic­i­pat­ing rescue stations had their own chal­lenges in seeing the image and hearing the sound when differ­ent devices and network connec­tions were used for the Teams connection:

“If certain loca­tions have diffi­culty with audio or video, would it be appro­pri­ate to revise at the network connec­tions and speeds of the stations as well as audio and video devices to meet current video play­back requirements?”

Overall, people were satis­fied with the train­ing days:

 “Impor­tant topics, support field work well. Karelia’s simu­la­tion facil­i­ties as part of the train­ing are really good.”

Based on the feed­back, devel­op­ment measures were already carried out after the first train­ing day. In the future, camera views based on differ­ent train­ing needs should be taken even more into account in advance. Teach­ing videos on device train­ing could be made for advance self-study, and they would support the instruc­tion of devices in use during the train­ing day, as the neces­sary number of devices and equip­ment would be avail­able. The amount of self-study mate­r­ial should be taken into account, and suffi­cient time should be ensured for every­one to go through it. Solu­tions should be found for better hearing of sound by those on a remote connec­tion; one option could be to try reduc­ing the number of micro­phones during the simu­la­tion exer­cise, so that the most impor­tant voices in terms of teach­ing would be heard better.

In addi­tion, more even distri­b­u­tion of remote partic­i­pants to differ­ent train­ing days should be consid­ered, so that the number of remote partic­i­pants would not be too large for some train­ing days. A “support person” should be ensured at remote stations to ensure tech­ni­cal connec­tiv­ity and general arrange­ments during the train­ing day. This was imple­mented as planned at some rescue stations. In simu­la­tion facil­i­ties, it should be noted that a tech­ni­cal special­ist would be avail­able to support the activ­i­ties and solve tech­ni­cal prob­lems if necessary.

Imple­men­ta­tion of first response train­ing evenings and feedback

The plan­ning of the First Response Unit (FRU) person­nel train­ing began in coop­er­a­tion with the two health-sector teach­ers of Karelia UAS partic­i­pat­ing in the Living Lab project and the persons in charge of the first response train­ing (emer­gency field direc­tors and expert para­medics). The plan­ning and imple­men­ta­tion of the emer­gency medical services -1 (EMS1) train­ing were used in the plan­ning of first response unit person­nel train­ing evenings. Five FRU train­ing evenings were organ­ised, three hours at a time.

The struc­ture of the train­ing was designed in accor­dance with the DrcABCDE proto­col, and occu­pa­tional safety was a cross-cutting theme in all simu­la­tion exer­cises. Partic­i­pants in the FRU train­ing evenings were mainly First Response Unit person­nel (contract rescuers) involved in first response activ­i­ties, but in addi­tion to them, train­ing partic­i­pants also included on-shift para­medics at rescue stations, to the extent of their own inter­est. In addi­tion to the train­ers, Karelia’s Simula had four to six contract rescuers per train­ing evening, and on average, 30 to 60 partic­i­pants per train­ing evening from differ­ent rescue stations in the region were involved in remote connections.

At the begin­ning of the train­ing evening, remote connec­tions to differ­ent rescue stations were tested and the contents and sched­ule of the train­ing evening were explained. It was empha­sised to every­one that the train­ing day is an exer­cise, not a test. On the first train­ing evening, every­one was told how to act in simu­la­tion exer­cises, as the contract fire­fight­ers had no prior expe­ri­ence of partic­i­pat­ing in simu­la­tion exercises.

At the begin­ning of the train­ing evening, the train­ers lectured on the theory related to the theme, followed by an applied simu­la­tion exer­cise. The three-hour FRU train­ing included two themes with exer­cises. Contact partic­i­pants were actors in the simu­la­tion exer­cises, and those who partic­i­pated remotely received moni­tor­ing tasks during the simu­la­tion exer­cises and partic­i­pated in teach­ing discus­sions after the simu­la­tion exer­cises, together with the contact partic­i­pants and train­ers. At the end of the train­ing evenings, the contact and remote partic­i­pants were asked to provide feed­back on the train­ing and its imple­men­ta­tion. Two health-sector teach­ers in the Living Lab project produced a feed­back survey and a summary of the results of the feed­back received. 

A total of 60 partic­i­pants gave feed­back on FRU train­ing evenings (N=201). The number of partic­i­pants in each train­ing evening varied; some partic­i­pated in each train­ing evening, some in one or more. The expe­ri­ence of partic­i­pat­ing in first response activ­i­ties varied greatly. Some had only just started with their first response activ­i­ties, and some had more than five years of oper­at­ing expe­ri­ence. Only a few partic­i­pants had a degree in health care, and they could include even paramedics.

The feed­back was analysed after each train­ing evening, and the neces­sary devel­op­ment measures were carried out imme­di­ately. For example, the teach­ing discus­sions held after the simu­la­tion exer­cises were sched­uled as more concise enti­ties. Voice audi­bil­ity was a chal­lenge, as was the case with the EMS1 train­ing days. A micro­phone was added for the instruc­tions given from the control room to improve the audi­bil­ity of voice to remote partic­i­pants. A tech­ni­cal problem occurred on one train­ing evening, but it was resolved quickly. There were no tech­ni­cal prob­lems on other train­ing evenings.

Based on the feed­back received, contract rescuers consid­ered the FRU train­ing evenings imple­mented as a hybrid form to be a func­tional imple­men­ta­tion method with a suit­able level of require­ments, includ­ing simu­la­tion exer­cises. The objec­tives of the train­ing were achieved, the things to be taught were learned and everyone’s partic­i­pa­tion was success­ful during the train­ing. Enthu­si­asm for partic­i­pat­ing in simu­la­tion exer­cises increased as a result of the train­ing evenings and the expe­ri­ence gained from them. Partic­i­pa­tion in simu­la­tion exer­cises was consid­ered posi­tive, and the partic­i­pants were given feed­back through posi­tive devel­op­ment in a good spirit:

“Increas­ing the number of contact days and creat­ing an estab­lished oper­at­ing method! Enabling FRU simu­la­tions in the future!!”

Hybrid simu­la­tion train­ing will expand in the autumn

The EMS1 and FRU train­ings piloted through the Living Lab project as contact and remote partic­i­pa­tion were success­ful. The struc­ture of the train­ing days was well planned for learn­ing; the theory and equip­ment exer­cises supported an applied simu­la­tion exer­cise. Almost all para­medics had expe­ri­ence of partic­i­pat­ing in simu­la­tion exer­cises earlier. However, taking part in a simu­la­tion exer­cise as a profes­sional seemed to be a more excit­ing expe­ri­ence based on the feed­back, as remote partic­i­pants were also involved. In addi­tion, para­medics partic­i­pat­ing remotely brought up the pres­surised situ­a­tion of their para­medic colleagues partic­i­pat­ing in the simu­la­tion exer­cise. This phenom­e­non iden­ti­fied in the expe­ri­ences of profes­sion­als is inter­est­ing, as, for example, based on feed­back given as a student, partic­i­pa­tion in simu­la­tions has not gener­ally been consid­ered so pressured.

Karelia UAS has imple­mented simu­la­tion exer­cises for nursing students as hybrid teach­ing in supple­men­tary studies in acute nursing. Some of the students have partic­i­pated in simu­la­tion exer­cises remotely, and some have come to the school for contact imple­men­ta­tion and partic­i­pated in simu­la­tion exer­cises as actors. The feed­back given by nursing students on the imple­men­ta­tion of the simu­la­tion hybrid train­ing in spring 2023 was posi­tive, regard­less of whether the partic­i­pant was on-site or remote (Hirvo­nen 2023). The involve­ment of remote partic­i­pants was not perceived as a pres­sure factor during the simu­la­tion exer­cises, even though the studies included unfa­mil­iar students from differ­ent groups. Based on the feed­back, para­medics taking part in the EMS1 train­ing who had no previ­ous expe­ri­ence in simu­la­tions liked the hybrid train­ing method imple­mented as contact and distance partic­i­pa­tion better than para­medics with previ­ous expe­ri­ence in simu­la­tions. Contract rescuers who partic­i­pated in the first response unit (FRU) person­nel train­ing did not have previ­ous expe­ri­ence in simu­la­tions, and they were really enthu­si­as­tic about simu­la­tion exer­cises and hybrid training.

What factors can affect this perceived pres­sure phenom­e­non? Have any nega­tive expe­ri­ences been gained during previ­ous simu­la­tion exer­cises, and do they affect the origin of the phenom­e­non? Or is the mindset that a profes­sional should not fail during a simu­la­tion exer­cise – espe­cially with colleagues watch­ing? Perhaps the partic­i­pants only have expe­ri­ence of simu­la­tions imple­mented as contact partic­i­pa­tion, and it is perceived as a less pres­surised exer­cise situ­a­tion than one where colleagues partic­i­pate in a joint exer­cise remotely?

If hybrid remote and contact simu­la­tion train­ing is to be used in differ­ent fields and in a country of long distances, all simu­la­tion instruc­tors and partic­i­pants should contribute to obtain­ing better expe­ri­ences from simu­la­tion exer­cises. Prac­ti­cal train­ing should be empha­sised instead of tests. Even profes­sion­als are also learn­ing new things together and sharing compe­tence. Feed­back should always be given posi­tively. Possi­ble errors can also be handled without blame, and follow-up talk about simu­la­tion exer­cises should be omitted. We can all influ­ence these matters. When an atmos­phere is created where one genuinely dares to learn together in a safe, simu­lated exer­cise envi­ron­ment, more gains than losses will be achieved – be it a small number of partic­i­pants in a contact imple­men­ta­tion or a larger number of remote partic­i­pants simultaneously.

In autumn 2023, the coop­er­a­tion with North Karelia’s emer­gency medical care will continue and expand. The Emer­gency medical services -2 train­ing days (EMS2) will be attended by 157 para­medics (advanced level) and around 70 nurses and doctors from the joint emer­gency care, emer­gency ward and emer­gency assis­tance coun­selling and guid­ance services from Siun Sote. (Törrö­nen 2023b) The plan­ning of the train­ing days has already begun.

Of these train­ing processes, the Living Lab project will produce a service struc­ture model that can be used in coop­er­a­tion with busi­nesses in the educa­tional service needs of differ­ent organ­i­sa­tions and compa­nies, espe­cially in areas of long distances, both nation­ally and internationally.

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Author:

Jaana Pantsari, lecturer, nurse train­ing, Karelia Univer­sity of Applied Sciences

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Sources:

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Salonen, H. 2013. Mitä simu­laa­ti­olla tulisi ensi­hoidon koulu­tuk­sissa opettaa – ryhmähaas­tat­telu ensi­hoidon simu­laa­tio-opetuk­sen asiantun­ti­joille. Master’s thesis. Depart­ment of Nursing Science. Univer­sity of Eastern Finland. https://core.ac.uk/download/pdf/15170406.pdf 16 May 2023

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