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Procedia CIRP 54 (2016) 41 – 46

6th CLF - 6th CIRP Conference on Learning Factories

Application of modern educational methods through implementation of the

ambulance simulator at a clinic laboratory (NTNU Gjøvik)
Jo Stertena*, Olga Ogorodnyka
NTNU Gjøvik, Teknologiveien 22, Gjøvik 2815, Norway

* Jo Sterten. Tel.: +47-928-77-430; fax: +47-611-35-170. E-mail address: [email protected]

Abstract

This paper describes development of a novel ambulance simulator implemented at the Nursing department at NTNU Gjøvik and effects of its use
for educational purposes. Cultural aspects of the simulator implementation are also discussed. The article covers peculiarities of the simulator
development process and also description of relation of modern educational techniques (learning factories) to the application of similar novelties
within the learning process. The construction, purpose and educational effects gained after implementation of simulator are described. The paper
can serve as further research basis on topics of the simulators creation and modern educational techniques use.
© 2016
© 2016The TheAuthors.
Authors. Published
Published by Elsevier
by Elsevier B.V.
B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the scientific committee of the 6th CIRP Conference on Learning Factories.
Peer-review under responsibility of the scientific committee of the 6th CIRP Conference on Learning Factories
Keywords: Ambulance simulator; Engineering; Nursing; Learning/Teaching Factories

1.
Introduction could work on patient replicas. This led to creation of the

simulator that is successfully used for teaching students the
In the Northern countries of Europe there are few people per working process inside the ambulance.
square kilometer and the distances between the hospitals are Before the start of the simulator development, project team
often large. Therefore, the ambulances should be well has discussed what should be the final goal. According to users
equipped, so that the initial treatment after an accident or illness wishes, it should have become a simulation of ‘real’ situations
could be done in the ambulance by nurses and doctors. Thus in the ambulance with communication between ambulance
the ambulances are real work places for the medical staff workers and driver. The driver should be able to gain
meaning a tough area to work in and an environment that is experience of driving the ambulance on different roads, while
constantly moving/shaking when the transportation to a other medical workers learn how it is to be saving patients life
hospital takes place. During the winters the roads are slippery, in an unstable environment that is moving and shaking.
which increases the risk and inconvenience for the medical The following study describes methodology and
staff [1]. development process of the ambulance simulator. It depicts
Such working conditions are impossible to be prepared for cooperation of nurses and engineers during the simulator
without any previous experience, while “nursing education creation, as well as shows how implementation of study
programs are faced with increased pressure to produce simulators influences the learning process and application of
graduates who are capable of providing safe patient care” [2]. modern teaching techniques such as learning factories. The
However, this can be solved with help of simulation paper doesn’t describe the ambulance development process and
application. Simulation was applied for many years in the results of implementation in all details, however, it gives an
industry and since 1960s in medical education. It gives insight of what was done, how it was done and which outcomes
possibility to train the nursing staff efficiently without getting were received.
anyone hurt. In order to make the ambulance staff students
ready for the difficulties of their future profession it was
decided to take a real ambulance car out of use and place it on
a hydraulic regulated table. Inside of the car nurses and doctors

2212-8271 © 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the scientific committee of the 6th CIRP Conference on Learning Factories
doi:10.1016/j.procir.2016.05.065
42 Jo Sterten and Olga Ogorodnyk / Procedia CIRP 54 (2016) 41 – 46

2.
Development of the ambulance simulator Thus, design for usability should be applied from the
beginning until the end of the development process. Therefore,
The two part of this section present theoretical concepts used of great importance for the product developers is to get to
during the process of product development in order to complete ‘know the user’ and the use of the product.
the project, while the third tells about the components, which Before the start, it was planned to bring together nurses,
the product consists of. doctors and engineers to set up project features and
peculiarities for the ambulance simulator before the beginning
2.1.
Product development theory of development process itself. This would lead to increase of
quality and functionality of the final product, as setting up the
When the new product development starts, the reason for project team consisting only of engineers could lead to missing
that can be need of new knowledge creation and/or challenges of certain necessary for the learning process components or
[3] as shown in Figure 1. features. Adding nurses and doctors to the crew would
At the same time, development of the new products can, as significantly increase the practical component of simulator
two extremes, be made according to dynamic theories [4] or created, as they have more experience and understanding of
classical theories – such as the stage-gate method [5]. In case skills required for successful work of the ambulance staff. In
of ambulance simulator, the product development was started other words, such approach allowed having users of the
because of the challenge and, in particular, need to increase the ambulance simulator taking part in the product development,
level of preparation of medical personnel for the ambulance thus increasing its future application.
services. The simulator was created following the dynamic However, having in team people with significantly different
product development procedure. Such “models are designed to backgrounds (medicine and engineering) led to combination of
handle unstable conditions and increasingly complex two communities of practice in one group. Communities of
developments” [3]. practice can be defined as “groups of people who share a
In similar cases the change management concept is also concern or a passion for something they do and learn how to
often involved. “Change management has been defined as ‘the do it better as they interact regularly” [11]. Often these are
process of continually renewing an organization’s (team’s) groups of people with a same set of professional skills and
direction, structure, and capabilities to serve the ever- interests that join in order to increase their knowledge or reach
changing needs of external and internal customers’” [6,7]. In common goals. In [11] examples of activities typical for
case of ambulance simulator, the needs were changing because communities of practice is proposed: problem solving, requests
of peculiarities of the development process, which will be for information, coordination and synergy, mapping
described later in the paper, thus leading to changes in team’s knowledge and identifying gaps, etc. According to [12,13]
task. communities of practice include three important dimensions:
mutual engagement, a joint negotiated enterprise and a shared
repertoire of negotiable resources accumulated over time.
  
  Mutual engagement means regular interaction for people that
 
   

 

work together and thus have the same field of activities or for
 
 


professionals that have similar education and meet each other
  
in smaller or bigger groups to discuss/solve common
   challenges and problems. The joint enterprise, in its turn, refers
   

 to the process and “is not just a stated shared goal, but a
  negotiated enterprise, involving the complex relationships of
mutual accountability that become part of the practice of the
community” [12,13]. Shared repertoire is accumulated over
Fig. 1. Different starting conditions for new product development [4]. time and usually results in specialized terminology and
resources (knowledge, pictures, common gestures, etc.).
Among other methods participatory action research (PAR) Combination of people from different communities of
was also used [8,9]. The main characteristics of PAR are: active practice in one team led to additional challenges during the
participation of researchers and participants in order to create project run. Usually it can be complicated to cooperate in
new knowledge, importance of self- and critical awareness, various engineering disciplines and/or projects, but here a
which leads to the change and building of alliances between the much greater challenge occurred: nurses with care, as the main
participants allowing taking active part in planning, background, simply did not want to participate. An expressed
implementation and dissemination of the research process [10]. reason for the unwillingness to participate was that the nurses
In order to make the product under development even better did not see any role in a technology project. However, luckily
a user centered approach was also applied. It includes users the male head of the clinic laboratory and an emergency nurse,
influencing the development process and continuously testing who had a significant motivation and technical insights from
the development outcome from the start of the development to his experience in the area, expressed interest in the project and
the delivery of a new product [3]. Application of this approach participated until the end. As a result, the project development
has started with broad discussion of requirements to the team mainly consisted of engineers with only two people
simulator from side of medical team members. having the medical background, but having even the minor part
of the crew with the necessary user experience was helpful.
 Jo Sterten and Olga Ogorodnyk / Procedia CIRP 54 (2016) 41 – 46 43

The next subsection gives an overview of simulators use in patient inside of the ambulance, which would need to be saved
the medical education. while driving the car.
As a result, the simulator was created consisting of
2.2.
Simulators use in the medical education construction, which includes a real ambulance from Gjøvik
County Hospital, a hydraulic regulated system imitating the
Even though there is a huge need of practical knowledge movement of the ambulance on different roads and all
within medical field of education, such types of simulators are electronics necessary to show the ‘road’ on the wall in front of
in a rather nascent stage [14]. According to [14] simulator can the windscreen. In the ambulance car a robot-patient with
be defined as “a physical object or representation of the full or human features is also placed. All technical components added
part task to be replicated”, while simulation is “applications together are imitating an injury situation that is to be managed
of simulators for education or training”. Both of these terms during the training.
fit perfectly to description of ambulance simulator developed Figures 2 and 3 show the ambulance on the shaking table
and applied at NTNU in Gjøvik, as it is imitating a process of and how it is equipped.
work of the ambulance crew both in the aspect of driving the
car and saving the patient, also, it is used for nursing students
training.
The history of simulators used for medical education starts
in early 1960s with creation of mannequin for training in mouth
to mouth ventilation by a Norwegian manufacturer of plastic
toys – Asmund Laerdal [14]. Later in the mid-1960s at the
University of Southern California an era of computer
controlled simulators began with appearance of a mannequin
that was simulating a whole patient. It was controlled by both
hybrid digital and analogue computers. Unfortunately, the cost
of such simulator construction was too expensive and there was
only one of this type that was constructed. Fig. 2. The ambulance placed on the shaking table.
In 1968 a full sized mannequin called “Harvey” able to
imitate 27 cardiac conditions was created. This simulator went
through huge amount of tests in educational efficacy. “Pilot
studies documenting Harvey’s effectiveness in teaching
bedside cardiological examination skills were first reported in
1980” [14,15].
In 1988 in [16] a computer simulator possible to be used in
order to teach students basic endoscopic retrograde
cholangiopancreatography (ERCP) techniques was described.
Later on, use of simulators started to become something more
usual, however, still complicated to achieve because of
difference in needs and possibilities in means of technology
and cost. In 1988 and 1989 the first conferences for simulators
Fig. 3. The interior of the ambulance.
developers were held. In the following years number of similar
activities was growing, including organizations of
symposiums, conferences and meetings. Figure 4, on the other hand, shows an example of the virtual
Nowadays amount of simulators used for medical education road the driver had to maneuver the ambulance on.
is much bigger, however, still not as big as it should be. There
are dozens of simulators used for training different aspects of
medical personnel work, such as Human Patient,
Bronchoscopy, Anesthesiology and many others [17].
The following subsection describes the ambulance
simulator construction.

2.3.
The ambulance simulator construction

After creation of working team, the final aim of the project

was set up, as mentioned in the introduction section. The goal
was defined as development of a simulator for training in ‘real’ Fig. 4. Example of a virtual road the ambulance driver had to drive on.
situations happening inside the ambulance car with
communication between the medical staff and a driver. The The project was completed as a part of NTNU Gjøvik
ambulance simulator was supposed to contain of the ambulance strategy (Gjøvik University College previously), where both
car that is shaking due to imitation of driving, screen that would interdisciplinary work and welfare technologies are highlighted
be showing the road in front of the car and, of course, the as key priorities. Therefore, the Dean of the Nursing
44 Jo Sterten and Olga Ogorodnyk / Procedia CIRP 54 (2016) 41 – 46

Department allocated money and time resources for employees to, firstly, become more independent while studying, thus
to be motivated and actively take part in the development developing the habit of creative thinking and, secondly, gaining
project. practical skills that will be useful in their future profession. The
During development process, some technical problems developed ambulance simulator can be called an attempt of
occurred causing the nurses to be skeptical towards it. First of brining the real world into the classroom and making it a part
all, the engineers working on development of the simulator’s of the real hospital to some extent (learning hospital/factory).
construction didn’t know which car are they going to receive.
This has increased the time of the project execution, since 4.
Reflections
planning and work couldn’t start because of this simple issue.
Secondly, after discovery of which car would be received, it Application of ambulance simulator has affected not only
was possible only to get the measurements and sizes of it, but the learning process, but also brought interesting findings
not the ambulance car itself. It was still used at the hospital and related to so-called cultural crash between nurses and
would be finally delivered for application in the simulator only engineer’s cooperation during the product development.
after the end of all the preparation processes and development Unfortunately, communication conditions between
of hydraulic and electronic systems. Thirdly, the team wasn’t representatives of different spheres didn’t function as good as
receiving all the necessary equipment for the beginning of work it was supposed to leading to problems and misunderstanding.
on time and thus had to wait again. After the car was finally Such situation was result of combination of two absolutely
received, it was discovered that the ‘driving bridge’ constructed different communities of practice that were hardly speaking to
for the simulator was not strong enough to hold the car on the each other because of lack of common mutual engagement,
hydraulic system and had to be changed and replaced. There joint enterprise and a shared repertoire.
were also minor problems related to absence of people related Engineers and nurses were easy agreeing on user
to the project at their work places occurring. After finally requirements and specifications of the product, while the
putting together all the parts of the simulator, electronic system specifications of design targets and details showed to be
didn’t function exactly as it was supposed to, creating need to difficult to decide. When the engineers already developed
make necessary changes and improvements. These are ones of certain part of the product, the nurses reacted negatively and
the main reasons for use of dynamic project development as were critical about the solutions causing re-engineering. Here
well as change management within the project. However, in the the change management was used in order to try to optimize
end, all the issues were successfully resolved and the interest the development process.
to the ambulance simulator has risen significantly making However, such behavior resulted in development process
skeptical opinions to disappear. Today the simulator is used for being non-linear and consisting of several loops, thus
training of students that are going to work as ambulance staff increasing the cost of the overall product. The reasons for
in future. clashes appearing the most often were core values and
difference of professional language. Both core values and
3.
Modern learning techniques professional language are part of the shared repertoire that
wasn’t shared at all.
As it was mentioned before, the ambulance simulator is used
in the training of physicians, emergency nurses and 4.1
Core Values
paramedics. After actual implementation of the simulator the
learning techniques used started to change more towards It is hard to say that nurses and engineers have similar
practical orientation being adapted to the “learning by doing” professions in any aspect; so, the difference in views on the
concept. It is easy to observe that “learning by doing develops most important values in professional sub culture was huge.
deeper and more profound knowledge and greater commitment Engineers were worried about development and design of smart
than learning by reading, listening, planning or thinking” [18]. products that make life better and easier for older people,
However, for some of the students and teachers use of modern avoiding waste and efficient operation.
technologies during the educational process was challenging At the same time, nurses were taking care of: delivering care
even though it proved being more beneficial both for the to the patient by the use of their skills in a good way and by
knowledge level and educational degree. This is result of being having action competence.
used to the old system of education and educational techniques, Both views are important, however, combining them within
which are mostly theoretically based. the product development process may lead to a costly and
Thus it is important to implement certain features of the inefficient work.
learning/teaching process leading to slight adaptation of
students and teaching staff to more practically orientated 4.2
Professional language
education.
This can be done through turning the ordinary classrooms However, core values are not the only reasons to cause
into the learning/teaching factories. “Learning Factories misunderstanding. Often usual words are perceived as negative
pursue an action-oriented approach with participants ones leading to unwilling to cooperate.
acquiring competencies through structured self-learning For an engineer such words as: production, customer,
processes in a production-technological learning efficiency, robot, technology, lean, waste, resource scarcity and
environment” [19]. This means that students have opportunity procedure are commonly accepted and easy to understand. At
 Jo Sterten and Olga Ogorodnyk / Procedia CIRP 54 (2016) 41 – 46 45

the same time, nurses often prefer quite different words as: Gjøvik. It provides description of the product development
supporting equipment for human care instead of robot method, which was chosen to be participatory action research
technology, patient/user instead of customer and good working following the principles of dynamic product development and
routine instead of lean/production. design for usability with engagement of specialists from both
In this case, it is possible to divide such key words into three engineering and medical spheres (communities of practice). As
groups: blockers, yellow words and green words. the engineers and the nurses working together on the simulator
Those words that are perceived as critical, in other word development had different backgrounds and previously
blockers, can destroy cooperation as they can be perceived as followed different trainings the development process turned out
attacks on subculture/community of practice. to be rather inefficient, because of combination of people from
Yellow category word can also be perceived as negative different communities of practice in one group.
association for some and lead to willing to stop the cooperation Specifics of the project made it impossible to do it following
process, however, unlike blockers, they are not perceived as the traffic light method, thus leading to use of dynamic
attack. development with non-linear processes and loops. Presentation
Green category words are those accepted in both camps and of development of use of simulators for medical education is
are not associated with negative. The next subsection will also provided.
propose ways to solve the above mentioned problems and Despite the cooperation and communication problem, an
suggestions of further improvement of the simulator. innovation from the public sector arouse based on a unique
welfare technological product. The goal set up by the project
4.3.
Solution of problems and suggestions of improvement team was reached brining the ambulance simulator for the
training and licensing of ambulance staff. Now students
In order to make teams combining different communities of received possibility to be trained both as ambulance drivers and
practice more efficient it is possible to use the following as ambulance personnel, as it was requested.
advices: Implementation of the ambulance simulator made
-
Increase quality of team management; application of “learning by doing” and learning factories
-
Combine in team those people that have background techniques possible to be integrated into the classroom leading
from different communities of practice; to increase of practical knowledge of the future ambulance
-
For the long term projects hold trainings for participants staff. The paper can serve as further research basis on topics of
with explanation of peculiarities of different fields; the simulators development and modern educational
-
Use terms that are understandable for each community techniques use. Suggestions of further simulator improvement
of practice involved. are also provided.
These are only some of ways of avoiding the cultural
clashes, however, their use should be enough to increase References
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