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"I'm doing it this way because...": �The science and art of simulation practice

  • November 2017
  • Conference: 8th Annual ASPiH Conference
  • At: Telford, United Kingdom
Authors:
Debra Nestel at Monash University (Australia)
Debra Nestel
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"I'm doing it this way
because...":
The science and art
of simulation practice
Debra Nestel
“Delivering Quality”
8th Annual ASPiH Conference 2017
Disclosures
•Royalties from Springer and Wiley Blackwell
•Research funding from Commonwealth of Australia
•Program funding from Department of Health, Commonwealth of Australia
•NHET-Sim www.nhet-sim.edu.au
•Editor in Chief, Advances in Simulation
•Financial support to attend this meeting from the ASPiH conference organisers
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“Across the day, video-assisted debriefing has been used in
about half the scenarios. What triggers it’s use?”
“It seemed to me that the learners needed more
orientation to the simulators to complete the
task. How do you decide what’s included in their
briefing?”
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“Some faculty offered concurrent feedback while others confined
feedback to trainees only once they’d finished their task. How do
you make that decision?”
Assumptions
•Simulation comes in many forms
•Evidence comes in different forms
•Simulation can be an effective tool to support
learning – seeking Optimization
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“Future research is needed to determine
the role of advanced educational
techniques, including the use of
simulators, in facilitating bronchoscopy
education.”
1902
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“The role of simulation in quality
and safety in healthcare
professional training has had to be
rediscovered.”
(Owen, 2012)
Healthcare simulation research…
•has had exponential growth in the last 20 years
•has had some prominent foci
•crosses many disciplines and professions
•is associated with significant professional community
development
•healthcare simulation peer reviewed journals
•reporting guidelines for research (Extensions to CONSORT and
STROBE statements) See Cheng et al (2016)
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Of course you can read it elsewhere too!
Simulation in Healthcare
•Nestel (2017)
•Analysis of editorials n=38
•April 2006 to April 2017
•27 authors
•Medical doctors (63%)
•Male (67%)
•US-based (86%)
•Inductive thematic analysis
•Deductive analysis
•Community of practice (Wenger)
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Editorial themes
1. Embedding simulation
2. Simulation responding to clinical
practice
3. Educational considerations
4. Research practices
5. Community leadership and
scholarship about the community
Editorial themes
1. Embedding simulation
2. Simulation responding to clinical
practice
3. Educational considerations
4. Research practices
5. Community leadership and
scholarship about the community
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2: Simulation responding to clinical practice
•Decision-making by
individuals and teams
•Exploration of clinical
processes
3: Educational considerations for simulation
•What we use, how and
when…
•Faculty development
•Standards for educators
•Realism, fiction contract,
engagement
•Human dimension
•Ethics
•Debriefing +,-./012345652758 5 9
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•The role of simulation in teaching and learning procedural skills
•Simulation team-based training in healthcare
•Human and systems factors in simulations
•Instructional design and pedagogical science
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Surgical research priorities
Curriculum development
1. How should a simulator curriculum be designed and
evaluated?
2. What are the best methods/metrics to assess technical and
nontechnical performance on simulators and in the OR?
3. What are the performance criteria that surgical trainees need
to achieve to be competent based on their training level (on a
national level)?
4. What is the role of simulation for the certification of
residents and practicing surgeons?
5. How do we train and assess teams effectively using
simulation?
Student &
clinician
learning
•Debriefing
•Performance
assessment
Education
&
workforce
issues
Standards
for
simulators
Modeling
healthcare
systems
Broader
world
Translating
research
Methods Theorizing
Nestel et al, Establishing a national healthcare simulation research agenda
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Theme 1: Using simulation to support student &
clinician learning
1. Under what conditions can simulation
best support learning for safe clinical
practice:
•For individual students?
•For large cohorts?
•For observers?
•For a single episode to a given student?
•For students/clinicians of
different
cultural
backgrounds?
•To shor ten tr aining ti me for spe cif ic skill s
development?
•To fac ili tate tra nsi tio n to cli nic al pra cti ce?
Nestel et al, Establishing a national healthcare simulation research agenda
Theme 2: Debriefing & simulation
14. How do we measure effective
debriefing (from the perspectives of
all participants)?
15. Are there optimal debriefing
techniques?
•How can these be taught?
16. What debriefing frameworks best
promote
reflection
?
17. How does video-assisted debriefing
support learning?
Nestel et al, Establishing a national healthcare simulation research agenda
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Simulation is not just one thing
Evidence comes in different forms
Heathcare simulation research is flourishing
Responsive to and informs education and
heathcare service
Published research priorities and agendas
Simulation &
procedural (psychomotor) skills
development
Nestel, D., Groom, J., Eikeland-Husebo, S., & O'Donnell J, M. (2011). Simulation for learning and teaching procedural skills: the state of the science.
Simulation in healthcare, 6 Suppl
, S10-13.
Nestel, D., & Kelly, M. ( 2018). Strategies for research in healthcare simulation. In D. Nestel, M. Kelly, B. Jolly, & M. Watson (Eds.),
Healthcare
Simulation Education: Evidence, Theor y and Practice
(pp. 37-44). West Sussex: John Wiley Sons.
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Simulation &
procedural (psychomotor) skills
development
Simple versus complex
Task and part-task trainers
•Opportunity to practice
psychomotor skills of part or a
whole task
•Slow down
•Skip over
•Manageable chunks
•Repetitively practice
•Provide flexible learner ratios
•Offer variable levels of realism
•Out of clinical context
•Spectrum of cost
•Patient safe environment
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1. Hatala, R., Cook, D. A., Zendejas, B., et al. (2014). Feedback for simulation-based procedural
skills training: a meta-analysis and critical narrative synthesis.
Adv Health Sci Educ, 19
(2),
251-272
2. Nicholls, D., Sweet, L., Muller, A., et al. (2016). Teaching psychomotor skills in the twenty-first
century: Revisiting and reviewing instructional approaches through the lens of contemporary
literature.
Med Teach, 38
(10), 1056-1063
3. O'Regan, S., Molloy, E., Watterson, L., et al. (2016). Observer roles that optimise learning in
healthcare simulation education: a systematic review.
Advances in Simulation, 1:4
4. Sawyer, T., White, M., Zaveri, P., et al (2015). Learn, see, practice, prove, do, maintain: an
evidence-based pedagogical framework for procedural skill training in medicine.
Acad Med,
90
(8), 1025-1033
5. Wulf, G., Shea, C., & Lewthwaite, R. (2010). Motor skill learning and performance: a review of
influential factors.
Med Educ, 44
(1), 75-84
1. Hatala, R., Cook, D. A., Zendejas, B., et al. (2014). Feedback for simulation-based procedural
skills training: a meta-analysis and critical narrative synthesis.
Adv Health Sci Educ, 19
(2),
251-272
2. Nicholls, D., Sweet, L., Muller, A., et al. (2016). Teaching psychomotor skills in the twenty-first
century: Revisiting and reviewing instructional approaches through the lens of contemporary
literature.
Med Teach, 38
(10), 1056-1063
3. O'Regan, S., Molloy, E., Watterson, L., et al. (2016). Observer roles that optimise learning in
healthcare simulation education: a systematic review.
Advances in Simulation, 1:4
4. Sawyer, T., White, M., Zaveri, P., et al (2015). Learn, see, practice, prove, do, maintain: an
evidence-based pedagogical framework for procedural skill training in medicine.
Acad Med,
90
(8), 1025-1033
5. Wulf, G., Shea, C., & Lewthwaite, R. (2010). Motor skill learning and performance: a review of
influential factors.
Med Educ, 44
(1), 75-84
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Pedagogical framework for procedural skills training
Maintainpractice prove doseeLearn
Cognitive Psychomotor
Sawyer et al, 2015
So many considerations…
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Learn
•Procedural knowledge
•Cognitive task analysis
•Knowing how v. knowing why
•Instruments
•Multi-sensorial
•anatomy, physiology
•Indications, contraindications, risks, complications
Learn
See
•Demonstrate
•In real clinical practice
•On the simulator
•Partial or whole
procedure
•verbalisation
•by demonstrator and/or
learner
see
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•Spaced, frequency
•Verbalization
•before performing each step
•as performing steps
•Observation of others with physical practice
•Locus of control [learner v teacher]
practice
•Feedback - “moderately
effective”
•Concurrent
•Immediate corrective Feedback
•Non-verbal feedback (hand on
hand)
•Limit verbal input throughout
skill practice
•Terminal
•Benefits for novices
•Motivational impact
•external v. internal focus
•Multiple sources of feedback
•Short-term gains
practice prove
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Mastery learning
Baseline testing
Cognitive task analysis
Deliberate practice
Goal setting
Testing for competence (excellence)
“Defined” skills – procedural orientation
Bill McGaghie, Diane Wayne, Jeffrey Barsuk and their many colleagues
prove
•Under supervision in
clinical practice
•Additional steps
•Communication overlay
•Conscious patient
•Task trainer & simulated
patient
•Patient-focused simulation
do
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Evidence – theory & empirically-based
educational design for psychomotor skills
development
"I'm doing it this way
because...":
The science and art of
simulation practice
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“…the need to re-orient two of the dominant
discourses in health professions’ education
research:
from the imperative of proof to one of
understanding, and
from the imperative of simplicity to one of
representing complexity well.”
Regehr (2010)
Thank-you
debra.nestel@monash.edu
dnestel@unimelb.edu.au
Twi tt er @DebraNestel
ResearchGate https://www.researchgate.net/profile/Debra_Nestel
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Additional references
•Cheng, A., Kessler, D., Mackinnon, R., et al. (2016). Reporting Guidelines for Health Care Simulation
Research: Extensions to the CONSORT and STROBE Statements.
Advances in Simulation
(1)
•Nestel, D., Groom, J., Eikeland-Husebo, S., et al. (2011). Simulation for learning and teaching procedural
skills: the state of the science.
Simulation in Healthcare, 6 Suppl
, S10-13
•Regehr, G. (2010). It’s NOT rocket science: rethinking our metaphors for research in health professions
education.
Medical Education, 44
, 31-39
•McGaghie, W. C. (2015). When I say ... mastery learning.
Med Educ, 49
(6), 558-559
•Barsuk, J. H., Cohen, E. R., Williams, et al (2017). Simulation-Based Mastery Learning for Thoracentesis
Skills Improves Patient Outcomes: A Randomized Trial.
Acad Med
.
•Abbott, E. F., Thompson, W., Pandian, T. K., Zendejas, B., Farley, D. R., & Cook, D. A. (2017). Personalized
Video Feedback and Repeated Task Practice Improve Laparoscopic Knot-Tying Skills: Two Controlled Trials.
Acad Med, 92
(11S Association of American Medical Colleges Learn Ser ve Lead: Proceedings of the 56th
Annual Research in Medical Education Sessions), S26-S32
•Owen, H. (2016).
Simulation in Healthcare Education: An Extensive History
. Switzerland: Springer
ResearchGate has not been able to resolve any citations for this publication.
Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial
Article
Purpose: Physicians-in-training often perform bedside thoracenteses in academic medical centers, and complications are more common among less experienced clinicians. Simulation-based mastery learning (SBML) is one potential solution to this problem. This study evaluated the effects of a randomized trial of thoracentesis SBML on patient complications: iatrogenic pneumothorax (IP), hemothorax, and reexpansion pulmonary edema (REPE). Method: The authors randomized internal medicine residents to undergo thoracentesis SBML at a tertiary care academic center from December 2012 to May 2016. They subsequently compared thoracentesis complications from procedures performed by SBML-trained residents, traditionally trained residents (no simulation training), and those referred to pulmonary medicine or interventional radiology (IR). Results: During the study period, 917 thoracenteses were performed on 709 patients. IP occurred in 60 (6.5%) procedures, of which 7 (11.6%) were clinically meaningful. SBML-trained residents performed procedures with a trend toward lower combined clinically meaningful complications (IP, hemothorax, REPE) compared with traditionally trained residents (7.9% vs. 0%; P = .06). SBML-trained residents caused fewer clinically meaningful IPs compared with traditionally trained residents, pulmonary, and IR referrals (P = .02). Hemothorax occurred after 4 (0.4%) thoracenteses, and SBML-trained residents had a trend toward lower hemothorax (0) compared with other groups (P = .07). REPE occurred after 3 (0.3%) procedures, with no differences between groups. SBML-trained residents performed procedures with lower combined clinically meaningful complications compared with other groups (P = .008). Conclusions: Residents randomized to an SBML intervention performed thoracenteses with low rates of clinically meaningful complications. Rigorous education represents a successful quality improvement strategy.
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Simulation in Healthcare Education
Book
  • Mar 2016
Simulation in healthcare education has a long history, yet in many ways, we have been reinventing the wheel during the last 25 years. Historically, simulators have been much more than simple models, and we can still learn from aspects of simulation used hundreds of years ago. This book gives a narrative history of the development of simulators from the early 1700s to the middle of the 20th century when simulation in healthcare appeared to all but die out. It is organized around the development of simulation in different countries and includes at the end a guide to simulators in museums and private collections throughout the world. The aim is to increase understanding of simulation in the professional education of healthcare providers by exploring the historical context of simulators that were developed in the past, what they looked like, how they were used, and examples of simulator use that led to significant harm and an erosion of standards. The book is addressed to the healthcare simulation community and historians of medicine. The latter in particular will appreciate the identification and use of historic sources written in Latin, German, Italian, French, Polish and Spanish as well as English. © Springer International Publishing Switzerland 2016. All rights reserved.
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Simulation for Learning and Teaching Procedural Skills The State of the Science
Article
  • Aug 2011
Simulation is increasingly used to support learning of procedural skills. Our panel was tasked with summarizing the "best evidence." We addressed the following question: To what extent does simulation support learning and teaching in procedural skills? We conducted a literature search from 2000 to 2010 using Medline, CINAHL, ERIC, and PSYCHINFO databases. Inclusion criteria were established and then data extracted from abstracts according to several categories. Although secondary sources of literature were sourced from key informants and participants at the "Research Consensus Summit: State of the Science," they were not included in the data extraction process but were used to inform discussion. Eighty-one of 1,575 abstracts met inclusion criteria. The uses of simulation for learning and teaching procedural skills were diverse. The most commonly reported simulator type was manikins (n = 17), followed by simulated patients (n = 14), anatomic simulators (eg, part-task) (n = 12), and others. For research design, most abstracts (n = 52) were at Level IV of the National Health and Medical Research Council classification (ie, case series, posttest, or pretest/posttest, with no control group, narrative reviews, and editorials). The most frequent Best Evidence Medical Education ranking was for conclusions probable (n = 37). Using the modified Kirkpatrick scale for impact of educational intervention, the most frequent classification was for modification of knowledge and/or skills (Level 2b) (n = 52). Abstracts assessed skills (n = 47), knowledge (n = 32), and attitude (n = 15) with the majority demonstrating improvements after simulation-based interventions. Studies focused on immediate gains and skills assessments were usually conducted in simulation. The current state of the science finds that simulation usually leads to improved knowledge and skills. Learners and instructors express high levels of satisfaction with the method. While most studies focus on short-term gains attained in the simulation setting, a small number support the transfer of simulation learning to clinical practice. Further study is needed to optimize the alignment of learner, instructor, simulator, setting, and simulation for learning and teaching procedural skills. Instructional design and educational theory, contextualization, transferability, accessibility, and scalability must all be considered in simulation-based education programs. More consistently, robust research designs are required to strengthen the evidence.
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It's NOT rocket science: Rethinking our metaphors for research in health professions education
Article
The health professional education community is struggling with a number of issues regarding the place and value of research in the field, including: the role of theory-building versus applied research; the relative value of generalisable versus contextually rich, localised solutions, and the relative value of local versus multi-institutional research. In part, these debates are limited by the fact that the health professional education community has become deeply entrenched in the notion of the physical sciences as presenting a model for 'ideal' research. The resulting emphasis on an 'imperative of proof' in our dominant research approaches has translated poorly to the domain of education, with a resulting denigration of the domain as 'soft' and 'unscientific' and a devaluing of knowledge acquired to date. Similarly, our adoption of the physical sciences''imperative of generalisable simplicity' has created difficulties for our ability to represent well the complexity of the social interactions that shape education and learning at a local level. Using references to the scientific paradigms associated with the physical sciences, this paper will reconsider the place of our current goals for education research in the production and evolution of knowledge within our community, and will explore the implications for enhancing the value of research in health professional education. Reorienting education research from its alignment with the imperative of proof to one with an imperative of understanding, and from the imperative of simplicity to an imperative of representing complexity well may enable a shift in research focus away from a problematic search for proofs of simple generalisable solutions to our collective problems, towards the generation of rich understandings of the complex environments in which our collective problems are uniquely embedded.
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