Quality Education for a Healthier Scotland CLINICAL SKILLS Managed Educational Network Excellent skills for excellent care Exploring the role of Tactical Decision Games (TDGs) as a novel method of teaching Non-Technical Skills (NTS) Iain Drummond University of Edinburgh/NHS Fife

Quality Education for a Healthier Scotland Background - 1 GMC Tomorrow’s Doctors (2009) key outcomes include: 1) “The ability to provide immediate care in medical emergencies.” 2) “…to make clinical judgements and decisions based on the available evidence, in conjunction with colleagues and as appropriate for the graduate’s level of training and experience. This may include situations of uncertainty.”

Quality Education for a Healthier Scotland Background - 2 Challenging transition between Year 5 MBChB and FY1 Acute care is a particularly challenging area: WHO Definition (2013): “….promotive, preventive, curative, rehabilitative or palliative actions, whether oriented towards individuals or populations, whose primary purpose is to improve health and whose effectiveness largely depends on time-sensitive and, frequently, rapid intervention.”

Quality Education for a Healthier Scotland Background - 3 To provide optimal acute care doctors must demonstrate effective Non- Technical Skills (NTS) behaviours: NTS: “the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance”.

Quality Education for a Healthier Scotland Acute Care Non- technical skills (NTS) CategoriesElements 1) Situational AwarenessInformation gathering Recognising and understanding Projection to future states 2) TeamworkSpeaking up Establishing a shared understanding Establishing a team 3) Decision MakingGenerating options Balancing options Reviewing of decisions 4) Task managementPrioritising tasks Maintaining accepted standards Being prepared Identifying and utilising resources

Quality Education for a Healthier Scotland Tactical Decision Games (TDGs) Low-fidelity classroom-based activities designed to increase proficiency in NTS Developing emergency scenario with time limited period to decide on a course of action Group come to decision regarding course of action and feed decisions back to facilitator and other groups Facilitator-led discussion around decisions made and rationale underpinning decisions

Quality Education for a Healthier Scotland Features of TDGs Time-limited/pressured Conditions may change within scenario Intentionally ambiguous/no “right or wrong” answers Participants may “follow-through” decisions made Participants make difficult high-stakes decisions in a team in a safe environment

Quality Education for a Healthier Scotland TDGs use in safety-critical industries Originally developed in a decision skills training programme for US Marine Corps squad leaders Subsequently used in oil and gas drilling industry, Scottish Prison Service, nuclear power industry, military (and others) Medicine – limited to unpublished work only

Quality Education for a Healthier Scotland TDGs – participant experience from other industries  Helpful in making difficult decisions under time pressure and uncertainty  Improved team performance  Improved confidence  Less reliance on SOPs  More willing to take risks  Learning from experience of others  Gaining insight into role of others  Useful feedback on performance

Quality Education for a Healthier Scotland Aim of Research Project To explore the role of Tactical Decision Games (TDGs) as a novel method of teaching Non-Technical Skills (NTS) to final year medical students

Quality Education for a Healthier Scotland Phase 1 Objectives 1) To explore the feasibility of using TDGs as a novel teaching method with final year medical students. 2) To explore how to use TDGs most effectively to teach NTS to final year medical students

Quality Education for a Healthier Scotland Provisional Phase 2 Objectives 2A) To investigate whether participating in TDGs subsequently influences NTS behaviour (in an acute care setting) (If it does) to explore in what ways participating in TDGs influences NTS behaviour 2B) To develop medical TDGs

Quality Education for a Healthier Scotland Phase 1 Methodology Action research study; students as co-creators Informed by pragmatic and constructivist epistemology 2 generic TDGs, acute care simulation and focus group Short presentation and discussion around NTS between TDGs TDGs/simulations video recorded and focus groups audio recorded and transcribed Iterative process as findings of 1 cycle inform development of the next

Quality Education for a Healthier Scotland Phase 1 Data Analysis Thematic analysis of focus group data and participant observation in TDG sessions Generic/medical/mixed games Length/format of sessions/size of groups Pre-assigning roles Active and passive participation Feedback Ambiguity and uncertainty Consequences

Quality Education for a Healthier Scotland Phase 2 Methodology Will be informed by results of Phase 1 Potential use of Behavioural Marker System (BMS) to evaluate NTS performance following TDG participation Potential development of medical games in an iterative process

Quality Education for a Healthier Scotland Summary NTS account for 70-80% of errors in safety critical industries High-fidelity simulation is one means of developing NTS but is expensive and faculty intensive TDGs represent a potential low-fidelity, affordable and sustainable alternative method of teaching NTS