Patient simulation

The facilitation of Interactive Simulation

AIM

The following essay will explore the use of interactive simulation using Advanced Human Patient Simulators as a learning tool within the modern health care setting. It will consider the underpinning educational theories that are used to facilitate this new breed of educational tool, and also reflect upon its potential benefits in preparing health care professionals for clinical practice.

INTRODUCTION

The current trend and development in the use of interactive simulation can be linked to the Department of health’s initiatives to place clinical skills at the forefront of the health service priorities (Lam, 2002:1). Through implementing guidelines on hospital practice, a great emphasis has been placed upon the educational responsibilities of all members of the health care profession from the hospitals Chief executive’s to the individual practitioners themselves.

The General medical council’s 1983 paper Tomorrows doctor placed considerable emphasis on the changing face of medical education and the need to further develop both experiential learning and problem based learning opportunities to ensure that future practitioners are fit to practice .(GMC ,1983).

Nurse education in 2002 has also undergone a transformation due to the recent criticism of pre-registration nurse training which has been seen to provide nurses, who at the end of three years have limited clinical ability, (Jowett, in Buckingham2000:1).

The new nurse curriculum has placed greater emphasis on the acquisition of practical skills and problem based learning and thus simulation is being utilised to form a structured educational environment to facilitate the above training needs.

The use of a simulator allows the facilitation of safe and realistic training environments where advanced training scenarios can develop without risk to patients (Fletcher, 1995, 1998).

Given that educationalists such as Kolb, (1984) have emphasised that, for many professionals, intellectual comprehension requires an experiential foundation, then simulation carries health education into the future without the ethical dilemmas of compromising patient care.

MODERN PATIENT SIMULATOR’S

Interactive patient simulators have until recent years been out of reach of all but a few Hospital based educational facilities due to there high cost. There had been only two simulation centres in the United Kingdom, The Bristol medical centre which was opened in 1997 (Mcindoe,1999:3), and the Stirling centre for simulation in Scotland.

Forest et.al (1998) states that

"High fidelity systems are expensive about $150 000) to buy, they also prove expensive to run in terms of staff and consumables", "Running costs are about £1000 per day".

The modern high fidelity interactive simulator is a whole body mannequin that is controlled by computer software. It can replicate many humanistic functions including those of the cardiovascular and respiratory systems through the utilisation of robotic technology.

The simulators include the ability to act/re-act to external stimuli.

This facilitates the development of new techniques as ‘skills may be defined as actions and reactions which an individual performs in a competent way in order to achieve a goal’.(Ericsson, 1996).

This level of interaction leads to a multi-faceted learning environment where multiple educational theories can be explored in order to form the optimal utilisation of this new breed of technological advancement.

SETTING THE SCENE FOR SIMULATION

The usage of interactive simulation in the form of Advanced human patient simulators (AHPS), poses numerous considerations when developing a suitable learning environment.

From a behaviourists perspective it is integral that the environment reflects reality and thus facilitates as realistic a response as is possible from the student.

John B. Watson (1913) underpinned the importance of the learning environment in his work on the stimulus-response model.

It is thought that the environment shapes our behaviour, and that what we learn is determined by the elements in the environment, and not by the individual learner. (Watson in, Smith, 1996).

In reference to Watsons example it could be argued that a complete replication of each clinical area would be necessary to facilitate an exacting learning environment, one that would completely involve the practitioner.

In reality it is rarely possible to recreate multiple realistic environments and therefore the facilitation of an exacting clinical environment must be interpreted as an ideal and not a necessity.

It is imperative however that the importance of the AHPS surrounding environment is not ignored as the clinical learning environment can influence the development of student attitudes, psychomotor skills ,knowledge and clinical problem solving abilities (Bloom 1964 )

It may not be possible due to financial constraints to provide a fully fitted operating theatre to facilitate the educational needs of trainee Anaesthetists, but it would however be reasonable for the environment to include the familiar tools of the practitioner and ensure that there positioning is both practical and realistic.

It could also be argued that a humanistic perspective such as that made famous by Maslow could explain the importance of a realistic environment in facilitating a quality learning experience.

Tennant ,in Smith (1996) looked at Maslow’s hierarchy of motivation and concluded that in order to achieve level 2/safety then a predictable and orderly world must exist. Maslows thought ‘s can be adapted to explain the paramount need for realism within simulation.

A practitioner that is faced with an unfamiliar environment, must first orientate themselves to their immediate surroundings before any attempt to complete a practical task can be undertaken.

environment that the AHPS surroundings should convey familiarity and place the practitioner at relative ease and thus allow them to direct there attention to the task in hand.

It is essential that distraction be kept to a minimum, as should onlookers and external noise. The use of viewing booths allowing observation through a one-way mirror, helps eliminate the distraction of being watched/judged by peers, and is becoming increasingly commonplace within modern simulation centres.

An environment that allows realistic simulation to take place must ensure a climate of trust. Carl Rogers (1969) stated that ‘the facilitation of significant learning rests upon the certain attitudinal qualities that exist in the personal relationship between facilitator and learner’.

Fear is a prominent factor in the facilitation of interactive simulation; the student may be affected not only by the fear of failure, but also the fear of judgement as to their ability to perform/cope in a real life situation. Rogers emphasised that an environment that ensures that the threat to the self of the learner is reduced to a minimum will most effectively promote significant learning.(Rogers, 1969).

It must therefore be reinforced prior to attempting any scenario that it is not a test, and will in no way form a judgement as to the practitioner’s capabilities to perform in a real life situation.

LEARNING THROUGH SIMULATION

Theories of experiential learning are fundamental in the modern health care education system.

It is seen as ‘the process where by knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience’. (Kolb, 1984:41).

The realisation of an effective simulation is the quality of the experiential outcome and therefore the student’s ability to relate and reinforce the learned outcomes into their real life practice.

‘Experiential learning is based on the notion that ideas are not fixed or unchangeable elements of thought but are formed and re-formed through experience’ (Fry, Ketteridge and Marshall, 1999)

Kolb developed a model of experiential learning to assist in the

Facilitation of learning. (Kolb, 1984).

Kolb felt that experiential learning consisted of a cycle of four elements.

1. Concrete evidence

2. Reflective observation

3. Abstract conceptualisation

4. Active experimentation

These four elements are present in almost all experiential learning situations. They need not be seen to take any particular order of priority within the cycle nor is one not possible without the other.

In partaking in simulation, many factors from Kolb’s cycle are represented.

1. The student is presented with a AHPS which will simulate certain clinical features to allow an accurate representation of a recognised medical condition.(Concrete evidence)

2. The practitioner will then Clinically examine the AHPS and form opinions as to the patient’s current condition

(Reflective Observation)

3. The practitioner will then utilise both the observed facts and their prior gained knowledge base to assimilate a course of action to resolve the simulated problem.

(Abstract conceptualisation)

4. The Practitioner must now treat the AHPS in order to identify the accuracy of their judgements and in order to attain the eventual goal, of task completion.

(Active experimentation)

kolbs experiential learning cycle does allow the facilitation of the immediate problem but as stated by Boud et al (1983) it plays insufficient attention to the process of reflection (Smith, 1996)

Within the facilitation of interactive simulation it is imperative that significant time for reflection takes place.

The discussion of a simulator scenario with all participants directly after the session, with the aim to enhance self reflection, is called ‘debriefing’ . (Rall, Manser, Howrad, 2000)

‘Debriefing after a simulator session is seen as a key element of simulator training’ (Rall, 2000).

Within the spectrum of debriefing the student is taken through a real time representation of their interaction within the scenario.

The simulation software provides a record of activity that allows the recording of each intervention, and decision’s as it takes place in real time.

This allows ‘instantaneous play back of the events to the actual participants so that informed debriefing sessions may be conducted that capitalise on learning opportunities that would otherwise have been missed’. (McIndoe, 1999)

The informed debriefing sessions are used constructively to build upon the students existing knowledge.

Maslows theories on motivation can be seen to provide insight into the usefulness of constructive feed back.

‘Learning can, thus be seen as a form of self-actualisation, it contributes to psychological health’ (Sahakian, in Smith, 1996).

Through the use of feed back the learners self esteem needs are met and confidence is gained in areas of competence.

Debriefing also allows for self-actualisation in relation to realising one’s capacities and potentialities.

Simulation encourages the exploration of the theories surrounding problem-based learning (PBL).

PBL provides a strategy for encouraging critical thinking and problem solving skills through the use of real world simulation. (Littlejohn, 1989).

The value of a PBL approach to the facilitation of simulation is highlighted by (McIndoe, 1999) who states that ‘ Simulation based education can deliver the environment to initiate pure problem based learning’

PBL has become commonplace within the curriculums of the health care professions and has found much esteem in preparing the practitioners of the future.

PBL can ‘demonstrate that theory and practice should not be seen as separate activities which need to be joined but as arising from a single source, each complementing and informing the other’. (Townsend, 1990:61).

The use of PBL in simulation has proved successful as it provides all of the fundamental problem solving elements, as do experiential theories, but unlike the theories of kolb etc, PBL

‘has been identified as one way to facilitate the development of reflection and critical reflection’. (Williams, 2001).

Within PBL the Simulation acts as an initial problem from which the students must explore the problem in structured manner sharing knowledge and understanding (Fry, Ketteridge, Marshall, 1999).
The students themselves then make decisions on what they need to learn in relation to the given scenario.

The facilitator within a PBL approach remains non-didactic and ‘is not there to be used as a resource, even if they are a "topic expert".’ (Cox, 2000).

The PBL facilitator :-

· establishes or reiterates group ground rules when taking a new group;

· assists in creating a learning environment in which students can admit they do not know something;

· makes sure that students fee able to question and query each other , using an appropriate manner;

· encourages the involvement of all students;

· asks students periodically to summarize a case or aspects of it ;

· at the end of each problem asks students to summarize their findings, evaluate how they tackled the problem and suggest how the process could have been more effective;

· gives feedback to students about there performance in a specific, constructive manner(generally within the group setting).

(Fry, Ketteridge, Marshal, 1999).

The facilitator lead’s the debriefing session/evaluation ‘both informally at the end of each group discussion and formally at the end of each scenario’. (Cox, 2000).

The PBL approach allows the simulation to be undertaken using a systematic approach to allow all participants the opportunity to provide input and opinion as to a solution.

The students are also provided with a structured system for ensuring that reflection takes place.

The Debriefing provides food for thought as the group assess their objectives against their outcomes using the computers event log.

Boud et al. (1985), identifies reflection as ‘ a generic term for those intellectual and affective activities in which individuals engage to explore new experiences in order to lead to new understandings and appreciation’s’.

The use of simulation and PBL maintains that through the use of reflection that changes in practice can be made, as can the assimilation of new understanding and therefore the self-actualisation of the practitioner themselves.

The use of reflection to create a new set of Objectives and facilitate a constructive methodology while re-attempting previous scenarios, can be seen as a form of operant conditioning.

The debriefing allows attained goal’s to be actualised and unsuccessful elements to be re-assessed.

This is seen by Wiliams (2001) as allowing the practitioner to

’ grapple with the complexities of the situations, search for connections across disciplines, and use existing and newly acquired knowledge to generate outcomes’.

The flexibility of the simulators computer controlled software allows for any number of variables to take place within any given scenario. The interactive properties of the simulator allow the PBL experience to evolve, at a pace that reflects the student’s capabilities.

The scenario may also be designed in a way to elicit certain responses from the learner and therefore reinforce best practice.

Throughout the planning stage of the scenario it is imperative that the learning outcomes are adhered to and that both the time scale and the interventions are both achievable and realistic.

The Future of Simulation.

Throughout this essay the apparent benefits of the utilisation of simulation within health care education have been explored.

The theoretical methodology and the practical considerations that must be respected have also been related to, but does simulation training improve practice competencies?

Exploring an increase in patient safety as a marker, then it must be considered that ‘no other high risk industry using simulator training for improving safety of operations (including flight simulators) has ever been able to show an increase in safety ‘(Rall, 2000).

When exploring the perceived increase in both confidence and competence by the practitioner’s themselves then there is supporting evidence to substantiate the effectiveness of simulation.

Dr Stephen Tomlinson, the executive secretary of the council of heads of Medical schools has stated that :" I believe that models can provide the student with more confidence , and a more practised student is less likely to infringe on the space, liberty and dignity of the patient". (Tomlinson, in Svoboda,1998).

Research Produced by McIndoe (1999) based at the Bristol Simulation centre has shown that 98% of trainees preferred problem based simulation to teaching methods such as ward rounds and lectures.

The same research also stated that 100% of nurses that had attended the Bristol simulation centre felt that it improved there practical skills although only 64% of nurses felt that simulation had improved there confidence with patients.

These statistics do show the perceived benefits of simulation as an educational tool but is there a negative aspect to simulation?

Not only is simulation financialy demanding but it is also time intensive when writing scenarios.

It is therefore imperative that when considering a scenarios outcomes that the learning outcomes of the student are considered.

Forcing a junior practitioner to act as would be expected of a senior will prove only to detract from the learning potential of the student and cause a breach of trust. It may also cast aspersions as to the facilitator’s intentions and to the credibility of their learning objectives.

It is also imperative that the debrief allows the student reflective time to voice any fears or concerns that may have arisen from a well-facilitated simulation.

‘Serious harm to trainees may result from poorly debriefed sessions’ (Rall, 2000).

The ultimate end product of a mismanaged simulation is the death of the AHPS, the debrief must therefore contain a supportive structure as the realism of the scenario may cause detrimental psychological effects, and that could impede upon an effective learning outcome.

Educationally simulation is invaluable in recreating situations that would prove reckless to endanger patient safety in real life, a situation such as an upper airway inflammation due to anaphylaxis that required a needle Cricothyroidotomy would be impossible to recreate safely without the use of an AHPS.

With the considerations of a realistic environment and an achievable scenario AHPS can look forward to continued development within the health care setting and an increased utilisation by multidisciplinary teams.

And anyway ‘who would like to fly with a pilot not being simulator-trained in emergency flight procedures?’(Rall, 2000).

Neal Jones 2002 ©Patientsimulation

This article may not be reproduced in any form without the authors express permission.