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Clinical Skills Simulation in the Training of Health Care Professionals    * This page contains these sections: Table of contents
This PageThis page was created by Jillean Martyn as part of FET8861 Emerging Environments for Learning in Semester 2 of 2006 This page can be released into the community from 1 December 2006. jillybean21 URinvited2 comment on and/or expand this page .WE ALL ARE, OR WILL BE, CONSUMERS OF HEALTH CARE SERVICES. HOW DO YOU FEEL ABOUT DOCTORS, NURSES, PHYSIOTHERAPISTS, PARAMEDICS ETC LEARNING THEIR CLINICAL SKILLS IN SIMULATION? ISN'T IT BETTER TO PRACTICE ON REAL PATIENTS? IS SIMULATION AS GOOD AS "THE REAL THING"? As a healthcare educator, I want to examine the growing trend for clinical skills training to be done in simulation rather than the traditional "hands-on-the-patient" in the clinical setting. How effective is training in simulation? What is Simulation? Any representation or imitation of reality. An instructional strategy used to teach problem solving, procedures, or operations by immersing learners in situations resembling reality. The learners actions can be analyzed, feedback about specific errors provided, and performance can be scored. They provide safe environments for users to practice real-world skills. They can be especially important in situations where real errors would be too dangerous or too expensive (online glossary). Put more simply....Simulation creates the appearance of being real, giving the experience of a real situation without risks. Why change tradition?The health care system is undergoing massive changes, which is putting pressure on health educators to adapt their programs and teaching methods. Clinical practice placements are limited, and learning organisations are unable to place all students in clinical settings to gain experience and exposure to patients with a variety of conditions. A solution for today’s healthcare environment is a technology-based approach to learning clinical skills.The reality is that undergraduate and post-graduate health professionals will need to learn and practice clinical skills in on-line simulation scenarios and in "virtual" clinical environments. Just as technology is transforming the practice of medicine and the experiences of patients, it is also changing the way tomorrow’s doctors, nurses and other health-care professionals are being trained. In some facilities, practitioners have access to an unprecedented array of sophisticated teaching aids, from human patient simulators that breathe and respond to treatment like real patients to surgical robots that hold instruments and respond to voice commands. Based on flight simulation technology, patient simulation systems create a virtual hospital environment using sophisticated software, video graphics and life-size mannequins that allow students and trained professionals to practice new procedures, respond to real-life patient scenarios, and hone their skills. Patient simulators, programmed to act like nearly any adult or paediatric patient, are enabling student doctors, nurses and allied health professionals to perform procedures and respond to life-threatening emergencies. Simulation is in its infancy in healthcare but has enormous potential as one of many strategies evolving to reduce risk in health care. The two main areas it will affect are research and education/training. Creating and testing research models on simulators prior to exposing patients to a research protocol will reduce some of the risk inherent and necessary in experiments. "Best practices" will follow a path that goes from hypothesis, to research simulation, to clinical research, to evidence based medicine, and on to the final testing ground as practice based evidence. Inrelation to education, medical students and residents will train on simulators to learn and further develop their skills. This will reduce some of the risk that is inherent in medical education. The old saying, "See one, Do one, Teach one", will become, "See one, Sim one, Do one" The goals of simulation are to reduce error, maintain patient safety, encourage innovation and to constantly improve quality and outcomes in our health care system (Loftus, 2006) What sort of clinical skills can be learned using simulation?Most clinical skills required by health care professionals can be learned in simulation. Tools vary from simple manniquins through to fully equipped suites of life-like responsive manniquins, and basic computer-based programs to sophisticated interactive virtual reality programs, to robotics for performing surgical procedures as described above. Here are just some of the actual clinical skills that can be practised in simulation. Cardiac and Respiratory Auscultation (using a stethoscope to listen to heart and lung sounds) Heart and lung auscultation is a valuable and cost-effective tool in the diagnosis of patients with heart or lung disease. However, despite widespread acceptance that proficiency in auscultation is an important component of the physical exam, previous research has shown a deficiency in this bedside skill among medical students and other post-graduate trainees. Ideally, auscultation should be taught at the bedside by experienced clinicians who observe, coach, review and reflect with their students as each (teacher and pupil) examines actual patients with abnormal cardiac or respiratory findings. However, today’s clinical environment creates barriers to this traditional educational approach. Significant erosions in the amount of time available for clinical teachers to fulfill their educational responsibilities, combined with decreasing lengths of stay for sicker, hospitalized patients, have created an educational environment where students and teachers find it difficult to effectively learn, practice and perfect their auscultation skills. Fortunately, the recent growth of technology has created new opportunities to practice these skills. Multimedia-based teaching programs, combining the reproduction of heart and lung sounds and interactive case based teaching, have shown promising results in enhancing learners’ auscultation skills. In particular, several studies of web-based learning materials have reported high levels of student satisfaction, improved learner confidence, and demonstrable gains in knowledge. Other Clinical Skills
Jo Foster Comment: Any clinical skill can be taught via simulation. I think it is critical that this type of learner tools are made part of all health curricula because of the inability to access real patients and all skills during their courses. For safety and positive patient outcomes it is a must. Whether to do the game approach to simulations, PC based simulations or whether to go the full immersive environment is still debateable. There is plenty of research to support all of these and especially from a medical context. The Clinical Skills Laboratory (Dept of Health & UQ) at the Royal Brisbane & Women's Hospital (RBWH) is a full state of the art lab for robotics, virtual reality, videoing and ward setups which cost approx $11-$15 million. It is currently used mostly by emergency and ICU staff for training and for surgery training. The Lab charges for all developments and use of their faciites which is sad as it stops many health educators from using the facilites. Yasmin Childs Comment: The Clinical Skills Laboratory is very impressive. There are also emergency room simulations and the ability to do real medical procedures and have feedback provided. I especially liked the robot patients that can be controlled from a back room to have a range of body responses and reactions to treatment. I concur with Jo about accessing these facilities - too many students and not ever enought resources! Simulation certainly had provided an effective platform for practice without actually putting patience in way of danger. I certainly agree with Jo Foster above that essentially all tasks can be replaced by simulation. There are I believe 2 important factors to consider when discussing simulation and these are:
Simulation in Health Care The Mannequin is no Dummy!Manniquins such as "Resusci Anne" have been used for many years by students (and the general public) learning CPR. The cold plastic torso yielded no feedback on performance. However, the new generation of manniquins can no longer be called "dummies". They provide real-time responses to treatment during various medical scenarios. They can be programmed to breathe, speak, cry, they have bowel and heart sounds, body temperature changes, blood presure changes, eye movement and change in pupil size, and physiological response to medications. Simulators are so realistic that they respond to medications the same way a human body would. A barcode reader near the simulated patient’s intravenous line computes the volume and type of “medicine” — water actually — that the patient received and then triggers the appropriate biochemical response, such as increased heart rate or constricted blood vessels.Are there other industries where on-line or other simulation models are used to augment or replace on-the-job skills acquisition / training?URinvited2 list and describe the type of skills training that you know are used in non healthcare industries. For example, do school teachers have "virtual classrooms" in which to practice managing a face-to-face class?
Personal experience of using simulation in skills training in any industry.Did it make you "work-ready"? Was it a useful learning environment?
ConclusionThe apprentice model, which has been used to educate doctors and other health care professionals since the era of Hippocrates, has survived the test of time and become established as an effective methodology. Simulation-based training represents an evolution of this teaching paradigm in which the needs of adult learners are met more effectively. This type of training holds the potential to increase competency as well as promote and, more importantly, improve patient safety. Simulation involves immersion of the trainee in a realistic situation (the scenario) and the creation of a physical space designed to replicate real life (the simulator) that is sufficiently realistic to achieve suspension of disbelief on the part of the trainee. The compelling effectiveness of simulation lies in the application of educational theory. According to educational research, the most significant learning experiences occur in authentic activity, during immersion in realistic settings, via hands-on training (Anderson,2006; Dongilli et al, 1998).Training of factual knowledge alone is valuable but not sufficient in professional fields, especially in medicine and nursing where complex problems which often involve uncertainty, ambiguity, and possible rapid change are not uncommon. Learning from books and lectures is useful but should be amplified by direct experience. However, developing experience only by treating and caring for actual patients can be risky. Errors made in a simulated setting provide excellent learning opportunities to identify limitations and participate in training. Such methods do not injure the patient. Most of all, healthcare personnel not only learn "what" to do but, with simulation based training, they also improve their thought and action processes—that is, they learn to deal more effectively with dynamic task settings. A well developed simulation can focus on a number of independent (but potentially interactive) competencies and can identify specific decision making problems of a care provider, allowing focused training that is cost and time effective (Satish and Streufert, 2002) Related pages in this knowledgeGarden communityVisions of the Future Yasmin Childs Games and Education Jo Foster Augmented Reality Jean Clayton Second Life Andrew Weppner Another Second Life Alan Jones e-Simulations Paul Penfold Related web sitesClinical Simulation in Nursing Education: The Official Journal of the International Association of Clinical and Simulated Learning http://www.INACSL.org  High-fidelity nursing education using simulation. The experience of nursing students. http://www.whsc.emory.edu/_pubs/en/2005fall/high_fidelity.html Outcomes measurement initiative for upskilling of doctors in simulated learning environments. http://www.vhahf.org/vhahf/summaries/2005464_OhioHealth_Foundation.asp Pharmacy student simulated learning centre http://www.pharmacy.buffalo.edu/school_res_fac_pclc.shtml The Virtual Emergency Room http://www.siaa.asn.au/get/2410917155.pdf Virtual Care: UC Davis health System, California http://www.ucdmc.ucdavis.edu/cvc/ Virtual Hospital - http://www.vh.org/ - this ceased opertion in Jan 2006 because of lack of funding but much of the content is still available.Virtual Naval Hospital - http://www.vnh.org/ ReferencesAnderson, JoDee M (2006) Introduction to Simulation-based Training, Neoreviews, No.6: 411-413.Dongilli T, DeVita M, Schaefer J J, Grbach W, Fiedor M L, Grenvik A, Lutz J W (1998) The Use of Simulation Training in a Large Multi-Hospital Health System to Increase Patient Safety. Anesthesia and Analgesia 98(Supplemental)A51 - s22 Glossary: www.neiu.edu/~dbehrlic/hrd408/glossary.htm (accessed 18 August 2006)Klein, Tamara (nd) Medical Students and Virtual Patients http://update.estrategy.ubc.ca/2005/07/19/medical-students-and-virtual-patients-its-all-in-the-game (accessed 21 August 2006)Loftus, Terry (2006) http://transformingcrisis.blogspot.com/2006_04_01_transformingcrisis_archive.html (accessed 11 October 2006)Satish,U and Streufert,S (2002) Value of a cognitive simulation in medicine: towards optimizing decision making performance of healthcare personnel. Available online: http://qhc.bmjjournals.com/cgi/content/full/11/2/163 (Accessed 17 October 2006)Torre D, Pfeifer K J, Lamb G C, Walters M P, Sebastian J L, Simpson D E (2004) An assessment of the impact of multimedia technology-based learning tools on the cardiac auscultation skills of third-year medical students. Med Educ Online 2004;9:22. Available http://www.med-ed-online.org. (accessed 20 August 2006)
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