High fidelity simulation in medical education Roger Kneebone Department of Biosurgery & Technology Imperial College London

Simulation

Acknowledgements  Dr Debra Nestel  Dr Fernando Bello  Jenna Lau  Prof Sir Ara Darzi  Other colleagues at Imperial College London

M Ed in Surgical Education  Started in 2005  Only one in the UK  2 year part time programme  aldevelopment/surgicaleducation aldevelopment/surgicaleducation

Benefits of simulation  Learning skills in safety  Practise without causing harm  Alternative to learning ‘on patients’  Dwindling exposure to real patients  Framework for learning  Learner centred  Expert tuition and feedback

Surgical skills

What is surgical competence? KNOWLEDGE DECISION MAKING SURGICAL COMPETENCE COMMUNICATION DEXTERITY

Realism, fidelity and context

Educational theory

Theoretical framework 1.Gaining technical proficiency 2.The place of expert assistance 3.Learning within a professional context 4.Affective component of learning

Gaining technical proficiency  Acquisition of expertise (Ericsson)  Sustained deliberate practice over many years  Motivation, retention & overlearning  Fighting automatisation  Massed vs distributed practice

The place of expert assistance  Zone of Proximal Development (Vygotsky)  Scaffolding (Bruner) & contingent instruction (Wood)  Recursiveness (Tharp & Gallimore)  Distributed resources (Guile & Young)  Feedback

Learning within a professional context  Situated learning (Lave & Wenger)  Apprenticeship  Communities of practice and learning  Legitimate peripheral participation  Power structures & teamworking  The social construction of identity (Bleakley)

Affective component of learning  Emotional content of learning (Boud)  Positive and negative effects  Importance often overlooked  Supportive learning environment essential

Learning in simulated environments

Desiderata 1.Repeated practice in a safe environment 2.Expert guidance when needed 3.Relevant to actual clinical practice 4.Learning with others in an authentic context 5.Supportive, learner-centred milieu

The reality  Isolated, one-off training courses  Limited or no provision for sustained practice  Tutor support and feedback variable  Artificial setting, unrelated to clinical practice  Organisational pressures >> learner-centred

Learning clinical procedures What happens now?

Technical skills out of context

Competence and performance  Skills centres  ‘Shows how’  Safe but limited simulated environment  Clinical practice  ‘Does’  Complexities and dangers of real life

Clinical procedures  Performing a procedure on a conscious patient …  while interacting effectively with the patient and members of the healthcare team …  combining technical skill, communication and professionalism …  responding appropriately to different levels of challenge

Procedures on conscious patients  Need  Technical skills  Communication  Professionalism  Must be integrated but are taught separately  Conditions for holistic professional practice

Patient focused simulation

What is Patient Focused Simulation?  Hybrid simulation  Presence of a ‘real’ patient in a scenario  Patient played by professional actor  Linked to inanimate model or VR simulator  Variable levels of challenge  Unpredictability mirrors real life

Suturing

Endoscopy

Carotid endarterectomy  Technically complex procedure  Patient conscious  Crises during simulation  Simulated patient Black, Wetzel, Kneebone, Nestel, Wolfe, Darzi 2005

Patient focused simulation  Real person – different qualitative experience  ‘Realistic unpredictability’  Reflects actual practice  Highlights the patient’s perspective  Assures patient safety

Wide sampling of holistic skills Assessment and feedback

Integrated procedural performance instrument IPPI

Procedures  IV infusion  Blood cultures  IM injection  SC injection – explaining to patient  Suturing a wound  Performing an ECG  Using a nebuliser & measuring peak flow  Urinary catheterisation

IPPI session  Clinical procedures  8 scenarios  Range of challenges  Inanimate model or medical equipment  Simulated patient  Trained actor playing patient role  Compliant, angry, disabled, distressed, confused  Trained to provide feedback

Vaginal examination in context

The teacher’s and the learner’s perspective What changes when we become expert?

Threshold concepts Jan Meyer University of Durham, UK Ray Land University of Strathclyde, UK

Simulation or real life An unhelpful preoccupation with the abnormal?

How should we use simulation?

CLINICAL ENVIRONMENT SIMULATED ENVIRONMENT Patients Clinical supervision Tutor support Simulators Clinical practice Simulator-based practice

CLINICAL ENVIRONMENT SIMULATED ENVIRONMENT Identify learning need Simulator based practice Reapply skill Review Further practice as needed Patients Clinical supervision Tutor support Simulators Continue

Conclusions  Simulation offers a rich environment where many important things can be learned  Beware the hegemony of technology  Parallel universe which mirrors clinical reality  Identify learning needs in the real world  Practise and assess using simulation  Reapply in the real world  Our challenge - to integrate these worlds