Transcript Simulation Pedagogy - AIMST University

Clinical Skills Training &
Simulation Pedagogy
“That which we must learn to do, we learn by doing.”
– Aristotle
Prof K.R. Sethuraman
Dean – Faculty of Medicine &
Deputy VC – Academic/International Affairs
AIMST University
Objectives for this Session - a
• List the competencies for a health professional
• Discuss the taxonomy of skills and appropriate
methods for learning them (using the Dale’s Cone)
• Explain simulation pedagogy relevant to skills
training (using Millers Pyramid of competence)
• Discuss the advantages of using simulation as a
teaching/learning tool.
• Explain why debriefing and guided reflection are
part of Simulation Based Education (SBE)
Objectives for this Session - b
• Provide exemplars for which simulation could be
valuable as a learning tool
• Examine current practices and research
regarding the implementation of simulation
• Is ‘learning by simulation’ just "simulated
learning"?
• Discuss some pitfalls and problems with
simulation based learning.
Spectrum of Clinical Competence
• I. CLINICAL
– History, Physical Exam, Management
• II. TECHNOLOGICAL
– Procedural Skills (Diagnosis & Therapy)
• III. HUMANISTIC
– Professionalism, Ethical behaviour
• IV. SOCIAL & PREVENTIVE
– Team work, Cooperation etc.
• Maheux et al. Acad Med 1990; 65: 41-5
Choice of Learning Activity –
Dale’s Cone of Experience
Professional authenticity
Millers model of competence
Does
Shows how
Knows how
Knows
Miller GE. The assessment of clinical skills/competence/performance.
Academic Medicine (Supplement) 1990; 65: S63-S7.
Performance
or “hands on”
Live Demo;
Multimedia
Read, Listen
Domains & Skills (Bloom)
• Cognitive Skills
– Critical thinking, Problem solving etc.
• Psychomotor & Perceptual Skills
– Physical examination,
– Procedural Skills (Diagnosis & Therapy)
• Skills of Affective Domain
– Communication Skills
– Other “soft skills” (Social – Preventive )
Learning Intellectual Skills
• Learn basic facts,
concepts and principles.
• Solve problems under
verbal guidance
– Instructional format
• Solve problems with the
help of hints.
– Guided practice format
• Solve problems
independently.
Learning Psychomotor Skills
• Listen or Read about the
components of the skill.
• Watch a demonstration of the
skill.
• Practise the skill under
supervision and corrective
feedback.
• Practise the skill independently.
Learning Communication Skills
• Listen to narratives, orations or
inspiring anecdotes.
• Watch role play, skill demo, sociodrama, etc.
• Participate in ‘role play-simulation’
• Practise under supervision and
corrective feedback.
• Independent practice.
Stages in Competence
• Unconscious
Incompetence
Ignorance
• Conscious Incompetence
Skill Acquisition
• Conscious Competence
Skill Competency
• Unconscious
Competence
Skill Mastery
http://www.businessballs.com/consciouscompetencelearningmodel.htm
Skill Acquisition
• Skill acquisition represents the initial phase in
learning a new clinical skill or activity
• One or more practice sessions are needed for
learning how to perform the required steps and the
sequence
• Teacher’s guidance is necessary to achieve
correct performance
Skill Competency
• Skill competency represents an
intermediate phase in learning a new
clinical skill or activity
• The participant can perform the required
steps in the proper sequence (if
necessary) but may not progress from
step to step efficiently
Skill Proficiency
• Skill proficiency
represents the final
phase in learning a
new clinical skill or
activity.
• The participant
efficiently and precisely
performs the steps in
the proper sequence.
Mastery Learning Model
-Bloom 1968
Phased Training for Competence
Easy
Complex
Component of a skill
Integrated skills
Isolated
Combined
Simulated
Real life
II. Simulation for
Skill Learning
What is simulation?
Simulate: Aping =
Imitate uncritically and in every aspect
(simia = Ape)
Fidelity of Simulation
• How closely the appearance & behaviour of
the simulation match those of the simulated
system (reality)
– Physical (Engineering) fidelity refers to the
fidelity to the physical characteristics of the real
task (visual, auditory, haptic etc)
– Functional (Psychological) fidelity refers to
the fidelity to the skills involved in the real task
• (cognitive, perceptual, manipulative or behavioural)
N J Maran & R J Glavin. Low- to high-fidelity simulation – a continuum of
medical education? Medical Education 2003;37(Suppl. 1):22–28
The ‘ADDIE’ framework for Design of
Hi Fi Simulations
• Analyze: Analyze relevant learner
characteristics and tasks to be learned
• Design: Define objectives and outcomes; select
an instructional approach (of Gagne)
• Develop: Create the instructional materials
• Implement: Deliver the instructional materials
• Evaluate: Ensure that the instruction achieved
the desired goals
Simulation Based Education (SBE)
• An educational
simulation is:
– A sequential decisionmaking exercise in
which
– students fulfill assigned
roles to manage
– discipline-specific tasks
– according to guidelines
provided by the
instructor
– in an environment that
models reality
Simulation vs.
Game
• In educational
simulations there
are no elements of
fantasy.
• Simulations are
more fluid and
spontaneous.
Simulations for SBE
• Written simulations
• Three-dimensional or
static models
• Audio based
• Video-based
• Computer-based
clinical simulation
• Animal models
• Human cadavers
• Peer to Peer
• Standardized patients
• Task-specific
simulators –
Designed to teach a
specific skill or task
• Immersive simulation
– Virtual reality (VR)
– High Fidelity (Robotic)
Advantages of SBE
• Risks to patients and
learners are avoided
• Undesirable interference
is reduced
• Scenarios can be
created as per need
• Skills can be practised
repeatedly
• Retention and accuracy
are increased
• Training can be tailored to
individuals/teams
• Chronic diseases can be
simulated in its entirety
• Bridges the “classroom –
bedside” gap
• “Intimate examination”
can be practised and
learnt by every student
(e.g. – Rectal exam)
Key elements in SBE
•
Simulation based Education (SBE) has
four key elements –
1.
2.
3.
4.
Create motivation a priori (briefing)
Active learner, not passive recipient of info
Individualized and paced for each learner
Prompt feedback on success and error
(debriefing)
Rationale for Teacher in SBE –
Objectivism vs. Constructivism
Objectivist view
– the real world can be
described and
structured in terms of
objects
– a well-structured
experience will result
all the learners
acquiring an identical
perspective on
knowledge
• Constructivist view
– each learner projects
his or her own reality
onto the world.
– the world does not
exist independently
as a consistently
objective component
– identical perspective
on knowledge is a
naïve notion
Role of the Teacher in SBE
• Not all experiences
are equally educative
(Dewey)
• A teacher has to
assist the learner in
understanding the
simulated process &
• guide the student
through critical
thinking processes to-
• help the students
– differentiate between
reliable and
unreliable facts
– to look for patterns
within these bits of
information
– to construct new
knowledge from the
experience.
Debrief Consolidates Learning
• Often the real learning takes place in the
debrief session
• Debrief goals are:
– What did the students experience?
– What did they learn?
– How can they apply that learning to future
experiences and learning?
Debrief – Things to avoid
– Don’t Lecture
– Don’t provide your analysis before
listening to the team
– Don’t create the sense of an
interrogation
– Avoid a rigid agenda; let them
construct the learning outcomes
– Don’t interrupt team discussion
unless needed
Three C’s of education
Constructive
Contextual
Collaborative
These apply well to the debrief sessions
III. Skill Learning through
Simulation
 Problem Solving Skill
 Communication skill
 Physical Examination Skills
 Integrated Complex Skills
Problem Solving Skill
Simulated Patient Management
Problem (S-PMP)
Demo …
Communication skill
TALKING WITH PATIENTS
Talking with Patients – Value of
History
In primary care,
about 86% of the
Diagnostic value is
from historical data
[ Ref - Hampton JR et al.
BMJ 1975;2: 486-9]
Exam
Lab
Learning to Elicit
History
• Role play simulation!
• Let them play DoctorPatient roles and learn
“There is no cement like interest;
no stimulus like the hint of practical
consideration." [A Flexner-1910]
Role Play Simulation –
The Method
• Triad of “Doctor” “Patient” & “Observer”
• Assigned a problem, e.g. headache to elicit history
• Each "patient" is individually coached on an entity e.g., migraine, tension headache, etc - totally 4 or 5
• Next day, every “Patient” is assigned to a "Doc" and
an observer – 4 or 5 groups
• They interact for about 30 minutes in any mutually
acceptable language
Role Play Simulation –
The Method – contd..
• Observer (3rd in the triad) monitors for
– Realism in interview, and
– Any use of medical jargon in lieu of lay-words
• In the plenary session, systematic
debriefing is done on
– History & Analysis of the history
– Lay medical words if unknown or unclear
Role Play Simulation –
FEEDBACK
• Students were mostly appreciative:
– "Felt like Sherlock Holmes"
– "Fun way to learn ‘boring’ history"
– "Never knew so many conditions exist in which
patients are physically normal"
– "Since student-patient gap is bypassed, I could
realise the value of eliciting history"
Simulation for Physical
Examination Skills
Peer Physical Examination (PPE)
• Students act as models for each other to learn the skills.
• PPE has high acceptability, but poses some challenges.
• PPE may be less acceptable among culturally and linguistically
diverse students.
Suzanne Outram and Balakrishnan R Nair. Peer physical examination:
time to revisit? MJA 2008; 189 (5): 274-276
Detecting Errors in Physical
Exam for Effective Debriefing
Physical Exam Skills
MISSION
• Every student must perform the core
'must do' skills
• Observe each one perform & give
corrective feedback
• Try and eliminate all learning errors
Types of Learning Errors
Type A
Omission or poor technique
of performing a step
Type B
Failure to perceive or to
correctly interpret a clinical
sign
Procedural
Steps &
Interpretation
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Perception &
Interpretation
Student
Score
Gr.
Candidate ID number
1
2
3
4
5
6
7
8
9
x
tot
al
9
8
3
10
5
9
10
Procedural
Steps &
Interpretation
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Perception &
Interpretation
Student
Score
Gr.
total
Candidate ID number
1
2
3
4
5
6
7
8
9
x
9
8
9
10
8
9
4
Corrective Strategies
• Type A Error =
inadequate
understanding or
inadequate practice
of the procedural
steps
• Can be corrected by
effective demo
during feedback
• Type B Error = poor
perceptual concepts
and inability to
discriminate between
normal Vs abnormal
• Corrective Learning
by ‘Concept
Attainment Model’
Immersive Simulation for
Critical Care Skills
Stress of Realistic Simulation
without harming patients
Barriers to the Widespread Use of
SBE for Skill Learning
• The cost of equipment, personnel, maintenance
and training.
– the initial cost of a simulation center approximates
RM 0.5 to 1 million.
• The lack of valid and reliable assessment tools
for simulation learning (esp. predictive validity).
• The lack of academic recognition for the time
spent in developing simulation scenarios
(compared with publishing scholarly work)
Barriers - “Why Change?” Resistance
• We have always done it this way…
• We, the products of traditional method are OK…
• Why should we change?
To Sum Up:
Education –Teaching – Learning
Education is about learning
&
Teaching is NOT = Learning
Education is to achieve learning outcomes
So, Education should be adapted to skill learning
An Enlightened Teacher is -
!
Terima Kasih !