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

http://www3.imperial.ac.uk/edudev/professionaldevelopment/surgicaleducation

Surgical skills

What is surgical competence?

KNOWLEDGE

DECISION MAKING

SURGICAL COMPETENC

E

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

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

Simulatorbasedpractice

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

r.kneebone@imperial.ac.uk