The Practice Learning Ladder Ron Bowles, PhD (ABD) INTRODUCTION/BACKGROUND DIFFERENT WAYS OF KNOWING: BLENDS OF FIDELITY: 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. The findings in this study suggest that existing paramedic simulations and the practicum represent radically different learning environments, each with its own sets of roles, expectations, patterns of practice, and methods of evaluation that call on different epistemological and ontological conceptions of what constitutes competent practice, what knowledge matters most, and how learning occurs. The varied learning activities in this study fostered different ways of knowing as learners moved from the consistency of context-independent skill performance to the socially-constructed adaptation of procedures and protocols in dynamic simulations, and, finally, to the sociallynegotiated understandings arising from co-emergent activity in a field setting. Effective simulations require situational blends of fidelity to create environments realistic enough to meet their pedagogic goals. Simulations intended to foster clinical competence and clinical judgment must provide occasions for discernment; they must create a milieu involving complex interpersonal interactions and genuine opportunities for clinical decision-making. Thus, paramedic simulations must be as concerned with role, environmental, interpersonal, and social/cultural fidelity as with physiological and procedural fidelity. In this sense, populating HFS more richly with actors and authentic interdisciplinary responders may often be as important as the use of HF mannequins and standardized patients. I gathered data from 75 simulations from two sets of scheduled classroom simulations in the Primary Care Paramedic program and a new high fidelity simulation module created for this study. I collected data that explored how participants acted and interacted, what sources of authority they called upon. Blends of fidelity associated with types of activities in the Practice Learning Ladder H L N High fidelity Low fidelity Neutral or medium fidelity Role Case Richness/ Information Context of Practice Community of Practice Diversity Cultural Setting Practicum Clinical Immersive Simulation Experience Proficiency Exposure, Practice Problem-solving Procedural Differential Diagnosis, Simulation Decision-making Drills/OSCE Skill Station Procedures Skill performance Instructional role Nature of Assessment Individual coaching and mentoring Post-call/ Post- shift critique Better answers within Social constructivist, experiential framework community of set in overall discussion of practice best practice Reflection, feedback Reflection Recognition, Application Assessment, feedback Collaborative feedback Individual coaching “Right” answers within contextual framework Adaptation Collaborative discussion & acceptable performance based on best practice Collaborative discussion Reflection Peer-based practice with post-exercise critique Better answers based on best practice Analysis Synthesis? “Acceptable / Unacceptable” based on procedural criteria and mastery checklists Structured feedback Criteria-based checklists Peer-based practice with coaching Post-call critique “Right” answers within contextual framework, concrete rules with contextual interpretation Sequencing “Acceptable / Unacceptable” against mastery checklists Structured feedback Criteria-based checklists Guided practice coaching Mastery “Acceptable / Unacceptable” Performance against mastery checklists Mastery level checklists Integration I gratefully acknowledge the Social Sciences and Humanities Research Council and the Justice Institute of British Columbia for support of this research Underlying Learning Theory Guided Practice “Right” answers, context dependent “Right” answers, context independent Mastery / Situated Learning Situated Learning Culture of Practice Participant Practice Activity Primary Learning Method Professional Environmental Evaluation Curricular Interpersonal Learning Goal Context/ Scenario Practicum Clinical Immersive Simulation H H N H H N H H H H L H H L H H L H N/A N/A N H H N H L H H L H H N/A H H L H Procedural Simulation H H N N L N H N N N L L Drills/OSCE Skill Station L L H H L L L L L L L L H H L L N L N L L L L L Practice Learning Ladder Analysis Focus Patient Procedural Blends of Fidelity: Physiological 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 mixedmethod 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. Learning Activity Cognitivism Cognitivism Mastery Mastery JUSTICE INSTITUTE OF BRITISH COLUMBIA