Patient simulation

Introduction.

‘ Recently, a new breed of medical simulators has been developed as a bridge between the world of lecture room theory and the everyday world of clinical practice. These unique facilities allow health care professionals to ‘experiment with new drugs and treatment in a realistic and interactive environment without exposing the patient to any risk’ (McIndoe, 1999)

Within health care education there are two types of simulation tool; Computer based simulation tools within which the student will work through a computer programme answering questions and making clinical decisions.

And advanced Human Patient simulators (AHPS) which can be seen as :-‘a human mannequin animated with a variety of electromechanical or pneumatic devices that produce respiratory movement, palpable pulses, heart and lung sounds and realistic airway anatomy’ (Murray, 1997)

It is the later of these two types of simulation that will the subject of this case study.

The AHPS is seen ‘to improve upon desk top simulators by presenting information in a realistic form rather than at a computer screen interface’ (Forrest, 1989).

Simulation is becoming increasingly commonplace in healthcare education and as such requires that the appropriate educational theories are utilised to ensure that optimum learning outcomes are achieved.

The following case study will explore the implementation of varied educational theories into simulation-based education, the study will reflect upon the advancement in simulation scenarios used within the Clinical Skills Laboratory at Arrowe Park Hospital on the Wirral.

The study will then reflect upon my experience as both simulation programmer and session facilitator, and upon the difficulties encountered in providing realistic scenarios that provide maximum educational benefits for all participants.

The Clinical Skills laboratory is a multi-disciplinary educational facility situated within the school of nursing in a large general hospital. The skills lab has a usable floor space of 468sqft, the simulator is situated in a small corner of the room.

I have worked with AHPS for the past 12 months, since Arrowe Park became the first UK based General Hospital to purchase this educational tool for multidisciplinary clinical education.

I am the Clinical Skills Laboratory Co-ordinator at Arrowe Park Hospital and as such oversee all simulation projects, providing both educational and technical assistance to all users. I have a particular interest in this form of clinical education, as it facilitates the consolidation of various educational theories in order that simulation facilitates a realistic training environment. Simulation provides the student with a hand’s on appreciation of the skills needed to solve clinical problems effectively.

The implementation of simulation into the educational curriculum’s of many health care workers 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).

It is therefore imperative that in order to encapsulate the clinical governance framework of continuing professional development, with minimal risk to patient’s, that simulation technologies should be exploited as a way of training staff in new techniques, that otherwise would prove too hazardous and infrequent to provide adequate training in the clinical area.(Murray, 1997).

THE PURPOSE OF SIMULATION

Simulation has been used in every industry from NASA to flight training to automobiles. Human patient simulation has been used since 1969 as a teaching tool. Only recently has it become a widespread teaching method in the medical field.

The purpose of Simulation is in its ultimate form, is to accurately replicate real life scenarios/environments as ‘it is thought that the enThis is not however, as limiting as it may first appear. As the session facilitator I am able to successfully guide the session utilising a problem based learning approach (PBL); for as Cox (2000) states the facvironment shapes our behaviour, and that what we learn is determined by the elements in the environment, and not by the individual learner’ (Watson, 1996)The advent of modern AHPS has greatly improved upon scenario based training as :-‘the use of a simulator provides safe and realistic training environments where advanced training scenarios can develop without risk to patients’ (Fletcher, 1995)

Simulation can be seen to provide interactive learning environments within which the student can explore and develop critical thinking and problem solving, as well as applying practical skills to real world scenarios.

The student experience of simulation is one of exploration and involvement, it is not purely a mechanism for observation but a tool that evokes enthusiasm and direct interaction, thus providing an experiential foundation, which as stated by Kolb (1984) facilitates intellectual comprehension.

The airline industry has utilised simulation for many years in the training of flight crews. ‘crew resource management was developed to teach and test the ability of cockpit crew’s to work together in the management of crisis situations’ (Murray, 1997). It is from the airline industries lead that simulation is now used to both educate and assess multi-disciplinary teams in various simulated clinical settings, including crisis management and team working skills.

Working with simulationTo allow the AHPS to be used constructively, then a scenario must first be programmed into the simulators controlling Laptop computer.

The programme will govern the patient’s vital signs, physical presentation and denote how it will react to the student’s interventions.

In my role as both scenario programmer and session facilitator I am able to provide continuity throughout the simulation experience. This does have its benefits as I am therefore aware of the intricacies of the simulation program and am unlikely to get caught out by unforeseen actions and/or developments beyond my own knowledge base.

And here lies the problem, I have 1 yrs experience as a medical gastroenterology nurse and three yrs experience as an Intensive care nurse, although varied clinical experiences they are not holistic within health care, and therefore I am repeatedly challenged to write realistic scenarios for group’s who’s role I have not experienced.

The facilitator ‘is not there to be used as a resource, even if they are a " topic expert".’The role of Problem based learning within simulation is as stated by Littlejohn (1998) a ‘strategy for encouraging critical thinking and problem solving skills along with content knowledge through the use of real world situational problems’.

The utilisation of real world situations facilitates a realistic learning environment that as stated by Bloom (1964) :-‘Can influence the development of student attitudes, psychomotor skills, knowledge and clinical problem solving abilities’

Both its size and its architecture limit the simulators immediate environment.

The implementation of environment specific scenarios such as Operating theatres and maternity suites prove impossible to replicate, as not only financial restrictions are manifested but also the impracticalities of physically modifying the skills Labs immediate surroundings.

It is therefore a necessity that the equipment to hand is both operational and familiar, as the need for the student to feel safe within the training environment is essential,

Maslow (1968) concluded that a predictable and orderly world must exist in order for student to feel safe, and that safety is essential to ensuring the students remain motivated.

Within simulation realism is paramount when attempting to elicit suitable responses from the users.

The students ability to act/re-act within a simulation can be directly related to their depth of involvement within that given scenario, and therefore the more realistic the environment, the more evident the students involvement within the educational tool..Educational strategies within simulation For the scenario programmer the process of writing an educationally sound, clinically credible scenario is a notable challenge. The utilisation of any single educational theory, would serve only to partly facilitate an educational tool as complex as AHPS.

It is for this reason that multiple educational theories must be utilised in an attempt to present the student with an involving simulation experience.

Problem based learning can be seen as ‘learning and teaching stemming from, and coming after, exposure to a scenario (the ‘problem’) which maybe written, videotaped or a patient (Aspergren, Blomqvist and Borgstrom, 1998).

The scenario commences with a problem, and this will usually manifest itself in the form of an adverse patient condition or illness.

This can range from a patient with a respiratory disorder, which the student then examines in order to establish a diagnosis, through to the extremes of major trauma and disaster.

The obvious injuries associated with major traumas can easily be utilised as diversions to the real problems, in an attempt to concentrate the students attention on needs assessment skills, and critical thinking.

There is no greater motivator for PBL students than a physical problem that they must actively interact with in order for them to solve.

It is imperative that ‘the students feel comfortable within there given role and that the scenario is within there expected capabilities. Clear student learning objectives are required at all stages, but excessive demands and expectations are often counter productive’. (Feather & Fry 1999).

Therefore both the programming and facilitating roles' must be individually tailored to each level of student depending upon experience and ability.

It is appropriate that the educational theories of experiential learning are also utilised when providing a session utilising simulation.

Experiential learning can be traced back as far back as far as around 450 BC when Confucius stated:-"Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand."

The idea of direct involvement as providing optimal educational impact has been embraced by theorists such as Carl Rogers and David Kolb, both of whom wrote extensively upon the benefits of learning through doing.

Kolb (1984) went on to devise a learning cycle within which it is believed that the process of experiential learning takes place.(See Appendix 1 Kolb’s Learning Cycle).

The utilisation of AHPS, directly involves the student within the scenario and thus facilitates the learning experience.

It is from experience that humanists such as Rogers (1969) believe that behaviour is modified and thus new skills are learned.

The simulation programme must be written as to involve each member of the multidisciplinary team, and therefore a scenario that presented only one problem such as urinary catheterisation would be educationally unsound.

A catheter insertion scenario would only serve to facilitate the learning objectives of the student performing the catheterisation procedure and not the entire multidisciplinary team.

It is therefore necessary to maximise physical interaction for all team members by ensuring that the AHPS is treated a whole patient and not just an individual body part or problem.

The treating of individual body parts has been a notable problem within medical education, as previously only single limb models where readily available, thus forcing the student to treat the body part and not the patient as a whole.

The advent of the whole body simulator has allowed student’s to take a more holistic approach to clinical education and improve upon communication skills at the same time as gaining the acquisition of practical skills.

My own beliefs are that a well-written scenario that prompts immediate response/involvement from the student can to a great degree make up for the lack of realism within the immediate surroundings. It is not an ideal and I must state that I have not had the luxury of a dedicated simulation room that can be modified to replicate a realistic setting for the scenario.

I have however facilitated complex and specialist scenarios that have elicited appropriate responses from the students and that have by the participant’s admission proved realistic and hugely beneficial educational experiences.

Simulation facilitation

My role as the session facilitator is one of great adaptability, during some sessions I will stand silently at the computer, controlling the simulators actions. In other scenarios I will take on the role of a team member and act out this role while discretely operating the simulator from its two remote control handsets.

The sessions in which I act out the role of a team member are notably more productive, for as stated by Fry,et.al (1999) the facilitator should encourage the involvement of all students, and it is far more realistic when another team member prompts actions from the team, than when the simulation operator is stood at a computer station shouting instructions.

I am also able to control the direction of the learning environment by ensuring that students do not stray too far from the learning objectives.

Modifying the simulator behaviour from the handsets can control the pace and direction of learning. By increasing the urgency of treatment,

the student is forced to take immediate action in order to resolve the problem, and improve the patient outcome.

The session facilitator must also ensure that the environment remains one of open and effective communication.

A vital consideration for the session facilitator is that of providing a tool for reflection.

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 appreciations’.

The utilisations of experiential learning theories such as Kolb’s learning cycles, are suitable for the facilitation of the physical simulation, but as stated by Boud (1983) ‘Pay insufficient attention to the process of reflection’.

Problem based learning is a proven tool for the facilitation of reflection and as stated by Williams (2001) ‘has been identified as one way to facilitate the development of reflection and critical reflection’.

Within the skills laboratory the simulation sessions are recorded using digital video technology and then played back to the participants as a method of facilitating reflection.

The playback of the simulation ‘allows instantaneous playback 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 reflection of individuals performance within the scenario can provide important information as to the individuals human interaction skills both stressed and unstressed (Forrest, 1998).

The process of watching yourself interacting with other team members can provide a harsh reality check for team members whose behaviour is in need of modification, in order to improve overall team working objectives.

The value of reflection after the simulation should not be underestimated, as McIndoe (1999) has stated ‘an appraisal of the situation with the benefit of previous experience and input from other sources cements the learning experience’.

Developing Simulation as an Educational tool

Advanced simulation can overcome the limitations of the traditional training methods—such as classroom instruction and observation—used in medicine. It allows learning by means of trial and error, in a risk-free manner.’

The complexity of providing realistic, educationally beneficial simulation scenarios is at its very least a multifaceted task.

Simulation requires such in-depth preparation and consideration that to label any individual educational theory as suited to this task would be a naïve statement indeed.

I must concede that I am convinced that almost all-educational theories could be utilised in the facilitation of interactive simulation, and that if I had not been restricted by word count, that I would have been able to explore there suitability.

The simulations learning objectives will largely denote which theory will be best suited to developing the simulation, in order to achieving the learning outcomes.

Both the theories of PBL and experiential learning carry great relevance in their ability to construct educationally beneficial simulations.

Kolbs (1984) experiential learning cycle can be extensively utilised within simulation. Stopping the simulation at relevant points thus providing concrete experience then by facilitating reflection, and then conceptualisation followed by re-applying the scenario to allow active experimentation to take place.

Problem based learning theories allow the students to work as a team breaking down the scenario into individual problems within which each team member takes responsibility for their element of the problem in an effort to solve the problem as a whole.

Wiklund (1999)Conclusion

It must be noted that as stated by Murray, (1997) ‘all levels of cognitive learning are not equally appropriate for full environment simulation. Lower levels of learning such as knowledge acquisition and comprehension may be better taught in classrooms’.

Murray also stated that ‘Clinical training involves higher-level application of the facts and principles learned primarily in libraries and lecture halls. Higher levels of cognition, including synthesis and analysis, are even more appropriately taught and tested in a simulation environment’.The thoughts of Murray, Forrest, McIndoe and many other specialists in the field of simulation, are all based upon the same fundamental principles.

The utilisation of AHPS within clinical education is not appropriate for the teaching of the basics of clinical skills such as it’s theoretical elements.

Simulation is a complex tool that can provide as realistic a response as is possible from the student, in an attempt to modify the student’s behaviour, Rogers (1969).

Simulation provides the opportunity to consolidate theory and practical application of single body part simulators, and facilitates a holistic approach to patient care.

As an educational tool, I truly believe that interactive simulation is the future

Of health care education. The motivational benefits of an AHPS are quite incredible to experience.

The realism of a AHPS is relatively poor at first glance, yet when involved within a scenario, even the most experienced of Consultant Doctors have become drawn into its perceived reality, and have been subject to the realistic pressure it provides in replicating real life emergency care.

In order to gain maximum educational benefit from simulation then multiple theoretical principles must be developed.

Simulation is as complex an educational tool as is available to the clinical educator, and therefore it requires the uppermost care when both programming and facilitating simulation strategies.

The immediate surroundings should convey clinical reality, and as stated by Maslow (1968) should place the student within a safe familiar environment in order to facilitate safety and maximise motivation.

The student should be immediately able to identify learning outcomes, in the form of problems, and through critical thinking and direct interaction is able to work within the simulation and gain maximum educational benefit.

As simulation becomes more affordable and the National Health Service continues to place emphasis on the acquisition of clinical skills, AHPS will be continually developed into more realistic educational tools that will provide our hospitals with highly skilled practitioners able to deal with rare and dangerous emergencies and improve overall patient care.

This Article may not be reproduced in any form without the express permission of the author ©Patientsimulation.2002

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