Simulation is a technique–not a technology–to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.
David Gaba MD
Absolute golden rule – The scenario is not an entree for a lecture.
This post is pretty simply intended to be a roadmap of my own learning in delivering team-focused scenario based training. There are a number of very smart people I have been privileged to have worked with in the past few years and I thought it may be useful, as much for myself as a collection of thoughts and reflective practice, to put down some structure. I think reflective practice is an important consideration in our education pursuits as much as our clinical roles. I have intentionally steered away from an overly academic approach for this post, as unfortunately I think “simulation” has been somewhat professorialised into a niche industry of it’s own. After all is said and done, simulation is just one teaching technique, there is no great mystery. When it is done well it has the capacity to facilitate learning in a way I have not found through any other teaching technique. When it is done badly, it can damage participants’ self-efficacy and also your credibility as an educator. So feel free to read a bit of a practical overview of what I have learned, much from those with minds greater than my own.
Learning Outcomes – Scenario based simulation is about practise. As such, each scenario should have very focused learning outcomes. Two-to-three would be recommended as an absolute maximum. If you have more, split them into separate stages of scenarios or run a pause and discuss). It is important to note that scenario based simulation is about practise and application of previously learned theory within work-like context. Inputs should be drawn from a range of sources – real adverse clinical events, safety and quality standards, organisational procedures, audit results and consumer feedback. Having robust inputs sets measurable results for evaluation.
Scenario Complexity – Consider the needs of the participants, if they are novice or junior low ‘noise’ and high ‘signal’. Essentially this means consider the core objectives and make them relatively obvious (eg. Prominent diagnostic cues & available resources) and avoid confounding variables such as screaming relatives, aggressive colleagues or the death of a patient (unless these are your core objectives). In more experienced or expert teams higher ‘noise’ and lower ‘signal’ may be appropriate. A useful inclusion is the role of confederate – an informed participant/actor who knows the scenario and endpoints and can steer the scenario from within and increase ‘noise’ if the scenario is too easy or increase ‘signal’ if the case is derailed or the team are in a holding pattern.
Set-up – From a technical perspective, you can’t check a manikin too many times before a scenario. A structured top-to-toe including visualising airway, bagging to assess chest rise and fall, auscultating lung and heart sounds, checking rhythms, defibrillation and pacing to assess response and checking all bolts, screws, attachments and limbs are secure. Also it is very useful to have a list of all peripheral equipment and drugs that are needed.
Pre-brief – Participants hate feeling set-up to fail. The key to participants engaging in a scenario is their ability to buy into the ‘fiction contract’. We are using a manikin, it has limitations. We are often not in the real work environment. Gain consent for the open and challenging conversation. Often, before the scenario, explaining to the participants that, on completion of the scenario, we are going to come back in as a group and have an open and honest conversation about the strengths, weaknesses, opportunities and threats experienced in the scenario and ask the group “Is everyone ok with that?” It is amazing what this does to the group dynamic once permission is granted.
It pays to consider what things may jolt participants out of a scenario and provide a thorough overview of the rules of engagement. Give a top to toe familiarisation with the manikin and it is often good to refer to the manikin by name/character and have it clothed. This assists the ‘buy-in’. Some points to present in the pre-brief include:
- Is it to be an immersive scenario or a pause and discuss?
- Are participants allowed to call for more help and who/how?
- Where are they (setting, time and context)? If in the workplace it is strongly recommended to not say you are somewhere else or at a different time.
- How do the participants get information they can’t get from the manikin?
- How will the instructor respond if participants ask for information that they could obtain through assessing the patient/manikin?
- How will they know when the scenario is finished?
- Are charts, ECGs, blood results available?
- Acknowledge safety considerations, i.e. Live defibrillator, expired drugs, sharps, etc.
- If in the workplace, are participants allowed to open consumables/drugs, etc?
- Do you want participants to actually connect and give fluids, drugs or just simulate/state they have done so?
- In essence consider any variables that may cause the participants to lose focus on the scenario and address these with solutions or rules.
Scenario – In the scenario the end point is crucial. Try not to let participants flounder in holding patterns, it is best to end the scenario and debrief what has happened. If the scenario becomes derailed consider: 1) Is it recoverable? 2) Should I end scenario and start debrief immediately? A strategy for recuing a scenario may be a phone call to the room with very obvious pathology results or medical imaging, sending in a ‘confederate’ as nurse, doctor or family member to steer the scenario back or pause enter as facilitator, conduct a recap and direction and restart.
Debrief – Debriefing is something that improves greatly with experience. From experience and a composite of reading here are a few tips:
- While a structure is good, don’t be a robot.
- Observe others’ debriefing style, but don’t try and replicate exactly, you’ll come off as insincere.
- Remember what the core objectives of the scenario were and consider leading questions that may draw out the learning from the participants.
- The object of scenario based learning is a constructivist approach to knowledge in which the learners engage and build their knowledge through social interaction and arrival at agreed ‘truths’.
- Be flexible. If they didn’t achieve the goal of the scenario, but committed thoroughly and correctly to a course of treatment based on an accidental incorrect cue, debrief the scenario you observed, not the one you intended and try and make links back to the team based learning objectives.
- Play to your strengths and enlist help from the room. (There is often expertise beyond the facilitator in the room. If you get a challenging question throw it back to the group for comment/answer).
Evaluation Tool – Consider the development of the appropriate tool to measure internal validity of the program, i.e. was it well organised, well delivered, areas for improvement and also measure external validity i.e. were learning outcomes achieved at an individual level. Consider what you are planning to do with this data as it may be useful to gain consent at the time for evaluations to be used for quality improvement research as it may assist with ethics waiver or low/negligible risk approval later. Secondary to this is the consideration as to whether a measurable change occurred in relation to the inputs. For example, did training in aseptic non-touch technique correlate to decrease in catheter related bloodstream infections in a particular unit.
Review – Set minor and major review schedules for your scenarios to ensure that the objectives and content still align with best practice and current procedures, supporting documentation is current and compliant with your setting and any latent risks uncovered during the simulation (particularly in situ) are articulated back to the owners of that risk. Remember reflection and self-awareness makes you a much better teacher.
David Gaba (2004), The future vision of simulation in health care.
Barry Issenberg et al (2005), Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review.