High fidelity simulation in medical education

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High fidelity simulation in medical education

• Roger Kneebone
• Department of Biosurgery Technology
• Imperial College London

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Simulation
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Acknowledgements

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

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M Ed in Surgical Education

• Started in 2005
• Only one in the UK
• 2 year part time programme
• http//www3.imperial.ac.uk/edudev/professionaldeve
  lopment/surgicaleducation

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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

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Surgical skills
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What is surgical competence?
KNOWLEDGE
DECISION MAKING
SURGICAL COMPETENCE
DEXTERITY
COMMUNICATION
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Realism, fidelity and context
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Educational theory
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Theoretical framework

• Gaining technical proficiency
• The place of expert assistance
• Learning within a professional context
• Affective component of learning

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Gaining technical proficiency

• Acquisition of expertise (Ericsson)
• Sustained deliberate practice over many years
• Motivation, retention overlearning
• Fighting automatisation
• Massed vs distributed practice

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The place of expert assistance

• Zone of Proximal Development (Vygotsky)
• Scaffolding (Bruner) contingent instruction
  (Wood)
• Recursiveness (Tharp Gallimore)
• Distributed resources (Guile Young)
• Feedback

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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)

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Affective component of learning

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

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Learning in simulated environments
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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

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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 gtgt learner-centred

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Learning clinical procedures

• What happens now?

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Technical skills out of context
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Competence and performance

• Skills centres
• Shows how
• Safe but limited simulated environment
• Clinical practice
• Does
• Complexities and dangers of real life

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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

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Procedures on conscious patients

• Need
• Technical skills
• Communication
• Professionalism
• Must be integrated but are taught separately
• Conditions for holistic professional practice

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Patient focused simulation
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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

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Suturing
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Endoscopy
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Carotid endarterectomy

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

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Patient focused simulation

• Real person different qualitative experience
• Realistic unpredictability
• Reflects actual practice
• Highlights the patients perspective
• Assures patient safety

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Wide sampling of holistic skills

• Assessment and feedback

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Integrated procedural performance instrument

• IPPI

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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

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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

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Vaginal examination in context
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The teachers and the learners perspective

• What changes when we become expert?

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Threshold concepts

• Jan Meyer
• University of Durham, UK
• Ray Land
• University of Strathclyde, UK

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Simulation or real life

• An unhelpful preoccupation with the abnormal?

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How should we use simulation?
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CLINICAL ENVIRONMENT
Patients
Clinical practice
Clinical supervision
Tutor support
Simulator-based practice
Simulators
SIMULATED ENVIRONMENT
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CLINICAL ENVIRONMENT
Patients
Identify learning need
Reapply skill
Review
Continue
Clinical supervision
Tutor support
Simulatorbasedpractice
Further practice as needed
Simulators
SIMULATED ENVIRONMENT
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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

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r.kneebone_at_imperial.ac.uk