From Diagnosis to Discernment:
F t i Clinical
Fostering
Cli i l J
Judgment
d
t iin High
Hi h Fidelity
Fid lit Si
Simulations
l ti
Ron Bowles, PhD (c)

Introduction

Discussion

Every time the students move from one performance domain to
another, whether it’s from independent study to the classroom or from
simulations to on car, it’s like they step off a cliff and fall into an abyss.
Some students just need a couple of calls and off they go again.
Others flounder and take longer to find their feet. And some never do
make the transition.

Comparison of immersion in CS 220, CC 253, and HF simulations

Simulation and fidelity are often used as unitary concepts in the literature.
Yet, the simulations in this study represent several distinct types of learning
environments, each calling for differing blends of fidelity to effectively
support their particular learning goals.

Paramedic instructor describing the movement
of recruit students from the simulation setting
to the field practicum placement
My research explores a “gap” separating traditional simulation learning
from field practice – a chasm between the comfort of technical competence
and the complexity of clinical practice. This study explores the gap through
the lens of developing clinical judgment in the context of high fidelity
simulations involving recruit paramedics in a Canadian setting.

One of the key findings of this study focuses on the need to foster
discernment as a missing, critical ability in recruits to enter a dynamic
environment, attend to and obtain data from multiple and sometimes
conflicting and competing sources, and recognize the salient features of
the particular case at hand – to see what is different in each case, not to
focus on what is similar to previous episodes.

M th d
Methods
The questions in this study explore the relationships and interactions of
participants and selected elements or agents in the simulation
environment. I set my research as a mixed-method multiple-case study
examining individual simulations as primary objects of study that are
embedded in, and in which are embedded, multiple other possible objects
of study.

Intuitively, this “gap” seems a simple pause as students move from one
learning domain to another.
another Yet there is more here
here. Traditional paramedic
programs are based on a conception of learning as progression from
acquiring knowledge in the classroom and developing skills in simulation to
their integration and application in the field practicum. In this view, the
practicum is an extension of the simulation lab, or, perhaps, simulations are
a subset of field practice. The findings in this study, however, suggest that
traditional simulations and the field practicum represent radically different
learning environments – nested and overlapping environments sharing
significant common elements, but distinct – each with its own sets of roles
and expectations, patterns of practice, and methods of assessment and
evaluation that call on different epistemological and ontological conceptions
of what constitutes competent practice, what knowledge matters most, and
how learning occurs. I argue that the gap represents the tension of
experiencing technical competence and clinical competence as different
ways of knowing.

Traditional curriculum structures rest on assumptions that learning is
essentiallyy progressive
p g
building
g of skills, knowledge,
g and jjudgment.
g
This
study suggests that learning is less linear, less stable – and yet – more
comprehensive than the program’s underlying curriculum framework
assumes.

I gathered data from Core Skills and Classic Case classroom simulations in
the Primary Care Paramedic program and a new high fidelity simulation
module created for this study. I used observation and video recordings of
75 simulations within the “natural” setting of the curriculum as well as focus
group interviews to collect data that explored how the various agents and
participants in the simulations acted and interacted, what sources of
authority they called upon, what forms and substance their reports and
discussions took, and what artifacts they created. I developed descriptive
statistics from questionnaires and quantitative examination of specific
activities and functions observed in the video recordings and interviews.

Instructors
st ucto s a
and
dp
preceptors
ecepto s “know”
o
in d
different
e e t ways.
ays Instructors
s uc o s see
seek
and enforce the consistency of technical competence based on
predetermined “right” and “wrong” answers. Preceptors function in a more
dynamic, unpredictable, and unknown environment in which they must
construct their own understanding of the situation before developing a
relevant and clinically competent response.
The current paramedic curriculum structure sees the practicum and field
environments as extensions of the classroom, and high fidelity simulation
as a potential
t ti l b
bridge
id b
between
t
th
these environments.
i
t Y
Yet,
t th
there are
fundamental differences in the way that practitioners in these two
overlapping but distinct communities of practice conceive of learning and
determine what constitutes acceptable practice. The difference is more
than mere semantics – it is an ontological divide between two
fundamentally different world views, each with distinct ways of defining
knowledge, acknowledging truth, and assessing performance.

Key References
Davis, B. & Sumara, D. (2006). Complexity and education: Inquiries into learning, teaching, and
research. Mahwah, NJ: Lawrence Erlbaum Associates.
Dreyfus, H. L. & Dreyfus, S. E. (1986). Mind over machine: The power of human intuition and
expertise in the era of the computer. New York: Free Press.
Fenwick, T. J. (2003). Learning through experience: Troubling orthodoxies and intersecting
questions. Malabar, FL: Krieger.
Kincheloe, J. L. & Berry, K. S. (2004). Rigour and complexity in educational research:
Conceptualizing the bricolage. Berkshire, Eng: Open University Press.
Riessman, C. K. (1993). Narrative analysis. Newbury Park, CA: Sage.
Schön, D. A. (1987). Educating the reflective practitioner. San Francisco: Jossey Bass.
Zsambok, C. E. & Klein, G. (1997). Naturalistic Decision Making. Mahwah, NJ: Lawrence Erlbaum
Associates.

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