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High fidelity simulation in medical education Roger Kneebone Department of Biosurgery & Technology...
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Transcript of High fidelity simulation in medical education Roger Kneebone Department of Biosurgery & Technology...
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