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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.
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High fidelity simulation in medical education Roger Kneebone Department of Biosurgery & Technology Imperial College London
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
What is surgical competence? KNOWLEDGE DECISIONMAKING SURGICAL COMPETENCE DEXTERITY COMMUNICATION
Theoretical framework • Gaining technical proficiency • The place of expert assistance • Learning within a professional context • 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 • Repeated practice in a safe environment • Expert guidance when needed • Relevant to actual clinical practice • Learning with others in an authentic context • 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?
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
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
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
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 Procedures
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
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?
CLINICAL ENVIRONMENT Patients Clinical practice Clinicalsupervision Tutor support Simulator-based practice Simulators SIMULATED ENVIRONMENT
CLINICAL ENVIRONMENT Patients Identify learning need Reapply skill Review Continue Clinicalsupervision Tutor support Simulatorbasedpractice Further practice as needed Simulators SIMULATED ENVIRONMENT
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