Is Simulation an Effective Educational Tool in Teaching Procedural Skills to Pediatric Residents - Dissertation Example

?Is simulation an effective educational tool in teaching procedural skills to pediatric residents? LITERATURE REVIEW Simulators for medical residentsMedical simulators are computer-based technologies used in the medical profession for practicing skills on. Their purpose is to provide a safe environment in which trainees can learn more efficiently and gain a similar kind of experience as with working on real patients. The practice is similar to using flight simulators for training pilots and war simulators used in the military. The use of simulation technologies for medical training has been studied by the SAEM (Society for Academic Emergency Medicine), the Josiah Macy Jr. Foundation, and the CEMRD (Council of Emergency Medicine Residency Directors) among others. The use of simulators relegates the need for learning through observing and doing. It is considered to be a safer alternative to the traditional methods for providing medical training. Through simulation experience, medical trainees can acquire procedural experience in addition to medical knowledge. There are also other newer methods in use in medical education such as computer or web-based training and using virtual reality systems. The simulation can involve exercises with the full body, provide immersive environments or scenarios, or involve specific tasks or procedures. “High-fidelity simulators are full-body automated mannequins designed to provide realistic tactile, auditory, and visual stimuli” (Vozenilek et al., 2004). Hence, simulations can also involve the use of models such as mannequins or other anatomic structures instead of being entirely computer-based. The quality of the mannequins is improving, as technology develops so as to provide an increasingly realistic experience. In immersive simulation, there is greater provision for developing organization, communication and multitasking abilities alongside. The benefits and long-term effectiveness of simulation training Numerous studies have shown the benefits of simulation training. For example, Rosenthal et al. 2006) showed how scenario-based simulation training (SST) can be effective for medical interns to develop airway management skills. A study by Overly et al. (2007) demonstrated the usefulness of HFS as an assessment tool specifically for developing the ability of pediatric residents to manage acute airways. The study was observational based involving 16 residents and 2 scenarios. The success rate was 56%. Thus, many areas were identified for improving skills but HFS had the potential for assessing ability as well as for teaching the necessary skills for managing acute pediatric airways. According to the Center for Medical Simulation (CMS, 2009), providing simulation practice leads to “improved real-world communication, collaboration, teamwork, and crisis management”. Residents also appreciate the value of simulators but prefer training in the form of small-group sessions (Shanks et al., 2010). The advantages of simulation training prove to be especially beneficial in cases where the required care involves high risk or invasive procedures, when training for difficult environments and preparing for disaster scenarios. For example, Hayden et al. (2002) suggested simulations are ideal “for low frequency but critical procedures”. These procedures would usually be applied in life-threatening situations such as cardiopulmonary arrest for example. Training for rare events tends to be uneven across a large number of medical residents and many residents never get the opportunity to witness or manage such an event, let alone one in which a child is involved (Becker, 2007). Hence, simulation training provides this much need opportunity so that when a real situation is faced, there is better preparation. Instilling confidence in trainees is of particularly importance where the risk to patients is high. In Becker’s (2007) study, assessment was made of how prepared radiology residents were for recognizing and managing children’s severe reactions to iodinated contrast material. It was shown that new methods including simulation training among others could benefit radiology residents for both basic and advanced life support training, hence the case for adopting these methods. However, it has also proven very useful in more routine tasks as well, such as performing accurate blood pressure monitoring (Seybert & Barton, 2007). Simulation has also proven to be very helpful in other branches of medicine such as for training physicians for critical obstetrics (Gherman et al., 2008). Providing high fidelity medical simulation experience to medical trainees has also been shown to be feasible for training for difficult environments such as for an air ambulance helicopter (Wright et al., 2006). Although it is expensive, and some practical problems are encountered, such as speech intelligibility and the hearing of auditory signals, it tends to improve “recognition of the challenges present and provides an important opportunity for training in challenging environments”. It improves the trainees’ self-confidence in a safe environment. The findings of this study can also be applied in other challenging environments such as in a child trauma room. Simulation training could also make trainees deal with ethical dilemmas more effectively and confidently. A study by Gisondi et al. (2004) examined the responses of EMRs to ethical dilemmas during high fidelity patient simulations for assessing resident professionalism. Twenty-seven residents underwent a simulated critical patient encounter for an Emergency Medicine Resource Management course in which an ethical dilemma was introduced before each encounter. Their responses were then compared with an evaluation checklist for professional performance. It was found that “senior residents (second and third year) performed more checklist items than did first-year residents”. This finding supports the view that residency training does help to instill professional behaviors. Although the sample size is small, the study was significant because it involved discriminating between inexperienced and experienced EMRs in terms of professional competency. Hence, it also establishes that long-term simulation training can be effective for developing professional competency. Providing simulation-based training and obstacles faced During the 2004 AEM Consensus Conference for Informatics and Technology in Emergency Department Health Care, a consensus was reached relating to high fidelity simulation (HFS). It was suggested that EM residency programs “should consider the use of high-fidelity patient simulators to enhance the teaching and evaluation of core competencies among trainees” (Vozenilek et al., 2004). They also made similar positive statements for web-based teaching and VR. The measures suggested for promoting simulation-based training include establishing active partnerships across specialties and collaborative efforts in initiatives for emergency and disaster preparedness. The advantages are believed to be “so significant that, were it not mindful of administrative and cost burdens for individual programs, the consensus panel would have advised that all emergency residency programs obtain access to a simulator” (Vozenilek et al., 2004). Another study that strongly supports the case for including simulation practice in residency training programs was undertaken by Wayne et al. (2006). They assessed 41 postgraduate year 2 residents’ baseline proficiency in advanced cardiac life support (ACLS) scenarios when undergoing a deliberate intervention program focused on developing skills using medical simulation. It was found that simulator training resulted in significant performance improvements and thus the usefulness of the program was rated highly. Furthermore, the residents enjoyed the training, evaluation and feedback while experiencing a simulated clinical environment. At the same time however, it is also necessary to highlight some obstacles to providing simulation-based training. The biggest obstacle has already been mentioned elsewhere and that is cost. Developing laboratories with simulators and providing HFS is cost prohibitive for many medical training establishments. With limited resources, they are simply unable to invest in them. As Wang & Vozenilek (2005) suggested, the ideal solution would therefore be to not rely exclusively on HFS but to use it in combination with other methods. Thus, LFS could be used involving the same SBP issues included in HFS encounters by providing all the opportunities for evaluating skills otherwise unavailable in LFS training models. Simulation-based team training and patient safety Patient safety is a top priority in every healthcare system but human errors are always possible that could lead to a compromise with this safety. In the worst-case scenario, human factors could even have fatal consequences. Simulation training can play an important part in helping to minimize the probability of failing to ensure or provide adequate patient safety. The provision of simulation training is known to be beneficial for improving patient safety in hospitals. This is made possible because simulation training has been shown to help develop self-efficacy and competence using manikins, and to improve operational performance in actual clinical settings (Nishisaki et al., 2007). This was in the context of multidisciplinary team training. Improvements in team operational performance at the bedside and patient outcomes however, are not yet backed by empirical evidence. Nonetheless, medical simulation is considered a very important tool for medical training nowadays. Weaver et al. (2010) mention several further published studies that show how simulation-based team training (SBTT) can be effective for enhancing teamwork skills in the context of emergency medicine (EM). In addition, simulation has the potential to improve patient safety because it can allow those providing care or operating for real for the first time adequate practice in advance. Simulation thus helps to bridge the gap between theoretical learning and the first real experience. Furthermore, simulation is able to capture clinical variation, that is, provide exposure to a wider variety of scenarios for the learner than would otherwise be possible through waiting for real encounters (Laerdal, 2010). It can also be tailored according to individual learner needs and accommodate a range of difficulty levels, which again is not always possible through traditional methods. The feedback process is particularly valuable because it allows for the simulated experience to be uniquely optimized and thereby “slow the decay of acquired skills” (ibid). Furthermore, the exercises can be repeated, especially for replaying rare events. All these advantages help towards improving the chances for eventually improving patient safety in hospitals. That a well-designed curriculum for inculcating team behaviors in turn increases safety-related behaviors has also been shown in studies by the MedTeams project (Morey, 2002). Teamwork is therefore an essential component for providing effective patient care. In this regard, the medical profession can learn how to ensure effective teamwork from simulation-based training programs devised for aviation and military use. Communication for example, is an important and integral part of ensuring effective teamwork. In order to be effective for specifically improving patient care however, a number of other factors also need to be taken into consideration in arranging simulation-based training. These include design factors, delivery evaluation and transfer into practice. Based on these aforementioned factors, Salas et al. (2008) devised 10 principles and practical tips for health care organizations to implement simulation training effectively for enhancing patient safety. However, Shapiro et al. (2008) mentions fewer, four, but most critical principles for developing and evaluating an approach for designing teamwork based SBT. These principles are as follows: 1. Principle 1: Establish the team-based competencies to be assessed and trained – the learning outcomes. 2. Principle 2: Provide opportunities for guided teamwork practice – carefully craft scenarios. 3. Principle 3: Measure team performance – diagnose teamwork strengths and weaknesses. 4. Principle 4: Develop robust debriefing protocols – link feedback to learning outcomes. Another advantage of a team formation is that individuals within the team can specialize in specific skills. Regardless, all trainees must be taught the necessary cognitive and procedural skills for the same ultimate purpose of ensuring patient safety. Simulation-based training for developing procedural skills Following established medical procedures is an important part of medical practice and learning these procedures requires practical skills to be developed. These skills complement the cognitive skills acquired from gaining medical knowledge. That is, it is not normally sufficient to read and memorize a procedure; rather, it requires practice and perfection. As procedural skills are very important in the medical profession, training for them is an also an important inclusion in a residents’ training program. This allows the necessary skills to be acquired without compromising patient safety (Langhan et al., 2009). Procedural skills are required to be taught in a number of medical education programs. For example, the ACGME has requirements for fellows “to acquire the necessary procedural skills and develop an understanding of their indications, risks, and limitations” as part of section IV.A.2.a).(3) for its program in pediatric transplant hepatology regarding patient care (ACGME, 2008). In its program for otolaryngology, residents’ knowledge of anatomy is required to be demonstrated through procedural skills in cadaver dissection, temporal bone lab, and/or surgical simulator labs (ACGME, 2011). Procedural skills are thus an essential component of medical training courses for residents. Such RRC requirements for the training of EM residents are usually decided by consensus panels, and the specific topics are usually defined from patient complaints and diagnostic codes (Druck et al., 2009). Simulation technology can play a useful role in providing this practice until perfection is achieved in a safe and controlled environment. By the time the medical procedures are carried out on real patients, it is expected that the possibility of any errors due to carrying out a wrong procedure would be minimized. Depending on the nature of the treatment or operation, the risks of mistakes in procedures could be great. It is therefore paramount for medical trainees to be not only thoroughly familiar but also proficient in performing standard procedures, and sufficiently competent to handle a situation in case the procedure needs to be adjusted under special circumstances. Langhan et al. (2009) demonstrated these benefits in a study designed to assess the impact of a simulation-based procedural skills training course on residents’ competence in performing critical resuscitation procedures. The study involved 28 resident participants that underwent 8 hours of intensive simulation-based training. Self-assessment questionnaires were administered both prior to and after the program, and again after 3 months. Statistically significant improvements were found in the knowledge and clinical skills ratings made by the participants. The training positively influenced both areas. Junior level residents did not show any further increase beyond the training program but senior level residents did. The researchers thus concluded that resident participation in a simulation based course for resuscitation training does help to significantly improve both theoretical knowledge and competence in procedural skills. Improving training for procedural skills On the contrary, another study also designed to train pediatric residents in resuscitation procedures, found that although confidence had developed, there were significant deficits in various critical resuscitation skills (Nadel et al., 2000). In fact, no resident was able to perform all the four skills tested successfully. It is pertinent to point out that firstly, this study was carried out a decade ago, and secondly the residents were not provided any simulation experience during the workshop. The purpose of mentioning this study is to highlight the importance of procedural training for medical residents, including for important life-saving skills such as resuscitation. In practice, as far as the current state of procedural training is concerned, it is often unsystematic and unstructured, and educational tools despite being evaluated are underutilized (Aggarwal et al., 2007). In addition, certain issues can arise in the provision of training for procedural skills that must be taken into consideration when devising appropriate training programs. For example, their relevance as identified by the pediatric Residency Review Committee (RRC) and residents’ perceptions of them could differ from the actual practice patterns of general pediatricians or the actual skills determined by faculty. Druck et al. (2009) compared trainees’ preparation to the practical importance of EM procedural skills in order to examine their relevance. They undertook a longitudinal study spanning 10 years and involving a 46-item web-based survey administered to graduates of one particular residency program in Denver. Several areas were included in the survey such as number of years of experience, additional procedural training beyond residency, confidence, preparation, and the importance in practice for 12 specific procedures. These procedures were selected in consultation with a panel of experts. The latter two were measured on four-point Likert scales. Significant discrepancies were found between preparation during residency and the importance in practice in respect of 8 of the 12 procedural skills. Over-preparation was to a significant degree in the case of extensor tendon repair, arterial line placement, diagnostic peritoneal lavage and ultrasonography whereas under-preparation was evident in the case of transvenous pacing, CT scan interpretation, slit lamp examinations and procedural sedation. On the other hand, confidence was strongly positively correlated with preparation suggesting good internal consistency of the research instrument. The four processes in which no significant differences were found were lumbar puncture, applanation tonometry, anoscopy and compartment pressure measurement. The discrepancies shown by the above study highlight the need for identifying possible areas in which under or over-preparation could occur during residency training. Moreover, the positive correlation between confidence and preparation highlights the importance of residency training as “the primary locus of instruction for clinical procedures” (Druck et al., 2009). A worrying implication of these conclusions is that patient safety may not be adequately ensured, as some of the training falls short of being relevant. It is therefore recommended that needs assessments be made periodically so that there is a better match between what is taught during training and what is likely to be required in actual practice. Moreover, the required identification can best be made by practicing emergency physicians (EPs) themselves who have recently emerged from residency training. This is because they are in a unique position to compare the training they have recently undertaken with the demands or real world clinical practice (Kern et al., 1985). Simulation-based training in the medical practice curriculum The ACGME (Accreditation Council for Graduate Medical Education) defines six core competencies in respect of assessing and accrediting residency educational outcomes so that the level of competency of residents in terms of knowledge, skills and attitudes reaches that of new practitioners. These competencies are (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement (PBLI), (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice (Mery et al., 2008). The 2007 Model of the Clinical Practice of Emergency Medicine usually serves as the model for the curriculum for EM residents. It was designed based on expert recommendations and incorporates both empirical data and expert reviews. The results of national surveys are also sometimes used in designing residency-training programs. As far as SBP (systems-based practice) is concerned, in the context of EM, high fidelity patient simulation has the potential to supplement case-based learning, as shown by Wang & Vozenilek (2005). Based on their research, they devised a simulation-based curriculum specifically for developing core competency for EM systems-based practice. The ACGME (2006) describes SBP as requiring the residents to “demonstrate an awareness of and responsiveness to the larger context and system of health care …”. This involves working effectively, proper coordination, the incorporation of risk and cost considerations, etc. Its key components are twofold: The need to develop knowledge and awareness of the larger context and health care system The need to be able to make efficient use of resources for providing excellent patient care Training for EM can benefit immensely from SBP given that EM involves the daily assessment and treatment of all patients and all the key hospital services. Expertise in EM is also necessary for management tasks, consultation, team working, multitasking, handling legal issues, out-of-hospital care, when modifying treatment, etc. It is reasonable therefore, for the ACGME to recommend simulation experience for training medical residents for developing some of the core competencies. In particular, HFS avoids the unpredictability associated with presenting patients, and repeated experiences can help to easily document the development of a resident’s clinical ability (Wang & Vozenilek, 2005). Moreover, in distinction to the traditional case-based learning approach, simulation practice allows SBP issues to be handled in real time and its complexity to be better understood. The challenge of integrating simulation into a curriculum “requires informed implementation in ways that take advantage of simulation’s unique ability to facilitate guided application of new knowledge” (Takayesu et al., 2010). Thus, providing simulation practice has the potential to benefit trainees but only if it is integrated into the curriculum effectively. What this requires, are clear objectives mapped to appropriate methods, appropriate integration in the learning environment, a suitable didactic schedule, active participation, and provision for structured feedback. It also requires greater time commitment to allow for sufficient practice, and therefore careful planning in order “to facilitate [the] flow of learners through a series of simulations in ways that maximize learning” (Takayesu et al., 2010). Once the simulation part of the training is appropriately integrated into the curriculum however, there are possibilities for the enhancement of learning and boosting of morale. The several advantages have already been discussed earlier. At the same time, it also facilitates introducing new technologies and procedures due to becoming accustomed to computer-based technologies. Moreover, there is a need for greater standardization and validation of curricula that effectively utilize proven technology for teaching competence, minimizing wasted time and focusing on the various skills required for specific practices (Grantcharov & Reznick, 2008). Evidence based evaluation tools currently utilized in medical education Walczak et al. (2010) conducted a large-scale systematic review; of how evidence-based medicine (EBM) courses are evaluated. Several online databases were scoured from which 1230 studies were identified, and of these, only five were selected based on meeting the selection criteria. However, no assessment tools for evaluating the effectiveness of courses were found. This shows that there could be a lack of sufficiently developed assessment tools and thus the need to develop such tools. However, scope for evaluation does exist in many residency-training programs involving practice with computer-based simulation. These are usually incorporated into the software. At the Baystate Medical Center for example, a simulation center is an important part of the residency program “to augment training of surgical knowledge and manual skills” (Earle, 2006). Its integration is considered critical for teaching general competencies related to medical knowledge, patient care, practice-based learning, communication skills, systems-based practice, etc. It also has the additional advantage of allowing the curriculum to be adjusted in line with individual needs. As far as evaluation is concerned, the program provides nonjudgmental feedback using a computer-based feedback form. The purpose of the feedback is to “increase the rate at which meaningful information can be given and received without the fear that a personal judgment has been made”. The system includes performance tracking and scope to adjust the training as required. The data collected includes preparation, technical performance, percentage participation, overall rating, comments, etc. The feedback on operative performance is in the form of a rating besides comments from attending surgeons. The rating is based on a four-point global rating scale. This tool evaluates six technical parameters, which are “tissue handling, instrument dexterity, knot-tying ability, operative efficiency, independent progress, and equipment troubleshooting ability”. The tool has been found to be a valid instrument for detecting the progress of residents. Over time, case times tend to decrease, participation in the programs increases, and the tool has the potential to indicate the effectiveness of the learning process. ABBREVIATIONS ACGME Accreditation Council for Graduate Medical Education ACLS Advanced Cardiac Life Support CEMRD Council of Emergency Medicine Residency Directors CMS The Center for Medical Simulation EBM Evidence Based Medicine EM Emergency Medicine EP Emergency Physician EMR Emergency Medicine Residents HFS High-Fidelity Simulation LFS Low-Fidelity Simulation PBLI Practice-Based Learning and Improvement RRC Residency Review Committee SAEM Society for Academic Emergency Medicine SBP Systems-Based Practice SBTT Simulation-based team training SST Scenario-based simulation training VR Virtual Reality References ACGME. (2006). Systems based practice. Accreditation Council for Graduate Medical Education. Retrieved 16 Fmebruary 2011 from http://www.acgme.org/outcome/e-learn/introduction/SBP.html. ACGME. (2008). ACGME program requirements for graduate medical education in pediatric transplant hepatology. 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Wang, Ernest E. & Vozenilek, John A. (2005). Addressing the systems-based practice core competency: a simulation-based curriculum. Academic Emergency Medicine, Vol. 12, No. 12, pp. 1191-1194. Wayne, Diane; Butter, John; Siddall, Viva et al. (2006). Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. Journal of General Internal Medicine, Vol. 21, Issue 3, pp. 251-256. Walczak, Jacek; Kaleta, Anna; Gabrys, Elzbieta et al. (2010). How are ‘teaching the teachers’ courses in evidence based medicine evaluated? A systematic review. BMC Medical Education, Vol. 10, No. 64. Weaver, Ballie; Salas, Eduardo; Lyons, Rebecca et al. (2010). Simulation-based team training at the sharp end: a qualitative study of simulation-based team training design, implementation, and evaluation in healthcare. Journal of Emergencies, Trauma, and Shock, Vol. 3, Issue 4, pp. 369-377. Wright, Stewart W.; Lindsell, Christopher J.; Hinckley, William R. et al. (2006). High fidelity medical simulation in the difficult environment of a helicopter: feasibility, self-efficacy and cost. BMC Medical Education, Vol. 6, No. 49. Doi: 10.1186/1472-6920-6-49. Additional bibliography Fleisher, Gary R. & Ludwig, Stephen. (2010). Textbook of pediatric emergency medicine. 6th edition. Lippincott Williams & Wilkins. Read More