Roger Kneebone

Simulation in surgical training: educational issues and practical implications.

Background Surgical skills are required by a wide range of health care professionals. Tasks range from simple wound closure to highly complex diagnostic and therapeutic procedures. Technical expertise, although essential, is only one component of a complex picture. By emphasising the importance of knowledge and attitudes, this article aims to locate the acquisition of surgical skills within a wider educational framework.

Simulation and clinical practice: strengthening the relationship.

Introduction  This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life.

Evaluating clinical simulations for learning procedural skills: a theory-based approach.

Simulation-based learning is becoming widely established within medical education. It offers obvious benefits to novices learning invasive procedural skills, especially in a climate of decreasing clinical exposure. However, simulations are often accepted uncritically, with undue emphasis being placed on technological sophistication at the expense of theory-based design. The author proposes four key areas that underpin simulation-based learning, and summarizes the theoretical grounding for each. These are (1) gaining technical proficiency (psychomotor skills and learning theory, the importance of repeated practice and regular reinforcement), (2) the place of expert assistance (a Vygotskian interpretation of tutor support, where assistance is tailored to each learners needs), (3) learning within a professional context (situated learning and contemporary apprenticeship theory), and (4) the affective component of learning (the effect of emotion on learning). The author then offers four criteria for critically evaluating new or existing simulations, based on the theoretical framework outlined above. These are: (1) Simulations should allow for sustained, deliberate practice within a safe environment, ensuring that recently-acquired skills are consolidated within a defined curriculum which assures regular reinforcement; (2) simulations should provide access to expert tutors when appropriate, ensuring that such support fades when no longer needed; (3) simulations should map onto real-life clinical experience, ensuring that learning supports the experience gained within communities of actual practice; and (4) simulation-based learning environments should provide a supportive, motivational, and learner-centered milieu which is conducive to learning.

An innovative model for teaching and learning clinical procedures

Context  Performing a clinical procedure requires the integration of technical clinical skills with effective communication skills. However, these skills are often taught separately.

Observational Teamwork Assessment for Surgery: Content Validation and Tool Refinement

BACKGROUND Effective teamwork is crucial for safe surgery. Failures in nontechnical and teamwork skills are frequently implicated in adverse events. The Observational Teamwork Assessment for Surgery (OTAS) tool assesses teamwork of the entire team in the operating room. Empirical testing of OTAS has yet to explore the content validity of the tool. STUDY DESIGN This was a cross-sectional observational study. Data were collected in 30 procedures by 2 trained researchers. Five teamwork behaviors were scored (ie, communication, leadership, cooperation, coordination, and monitoring) and behavior exemplar completion was recorded (phase 1). Expert operating room personnel (5 surgeons, 5 anesthesiologists, and 5 scrub nurses) assessed the content validity of the OTAS exemplar behaviors. Finally, a panel of operating room patient-safety experts refined the exemplars (phase 2). RESULTS In total, the observability (presence/absence) of 130 exemplars was assessed by 2 blinded observers in 30 general surgical cases. Observer agreement was high (Cohens κ ≥ 0.41) for 83.85% (109 of 130) of exemplar behaviors; 60.77% (79 of 130) of exemplar behaviors were observed frequently with high observer agreement. The majority of the exemplars were rated by expert operating room practitioners and an expert panel as substantial contributors to teamwork and patient safety. Based on expert consensus, 21 behavior exemplars were removed from OTAS and an additional 23 were modified. CONCLUSIONS The exemplars of OTAS demonstrated very good content validity. Taken together with recent evidence on the construct validity of the tool, these findings demonstrate that OTAS is psychometrically robust for capturing teamwork in the operating room.

Complexity, risk and simulation in learning procedural skills

Background  A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learners evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualise a dynamic awareness of prevailing risk and the implications of moving between zones.

Assessing procedural skills in context: exploring the feasibility of an Integrated Procedural Performance Instrument (IPPI)

Background  The assessment of clinical procedural skills has traditionally focused on technical elements alone. However, in real practice, clinicians are expected to be able to integrate technical with communication and other professional skills. We describe an integrated procedural performance instrument (IPPI), where clinicians are assessed on 12 clinical procedures in a simulated clinical setting which combines simulated patients (SPs) with inanimate models or items of medical equipment. Candidates are observed remotely by assessors whose data are fed back to the clinician within 24 hours of the assessment. This paper describes the feasibility of IPPI.

Distributed simulation--accessible immersive training.

Distributed simulation (DS) is the concept of high-fidelity immersive simulation on-demand, made widely available wherever and whenever it is required. DS provides an easily transportable, self-contained ‘set’ for creating simulated environments within an inflatable enclosure, at a small fraction of the cost of dedicated, static simulation facilities. High-fidelity simulation is currently confined to a relatively small number of specialised centres. This is largely because full-immersion simulation is perceived to require static, dedicated and sophisticated equipment, supported by expert faculty. Alternatives are needed for healthcare professionals who cannot access such centres. We propose that elements of immersive simulations can be provided within a lightweight, low-cost and self-contained setting which is portable and can therefore be accessed by a wide range of clinicians. We will argue that mobile simulated environments can be taken to where they are needed, making simulation more widely available. We develop the notion that a simulation environment need not be a fixed, static resource, but rather a ‘container’ for a range of activities and performances, designed around the needs of individual users. We critically examine the potential of DS to widen access to an otherwise limited resource, putting flexible, ‘just in time’ training within reach of all clinicians. Finally, we frame DS as a ‘disruptive innovation’ with potential to radically alter the landscape of simulation-based training.

Blurring the boundaries: scenario-based simulation in a clinical setting

Context  The ability to perform clinical procedures safely is a key skill for health care professionals. Performing such procedures on conscious patients is challenging and requires a combination of technical and communication skills. We have developed quasi‐clinical scenarios, where inanimate models attached to simulated patients provide a convincing learning environment. Procedures are rated by expert observers and by the ‘patient’ and recorded for subsequent review. This study explores the potential of locating such scenarios within a real clinical setting, allowing participants to experience the challenges of the workplace while ensuring patient safety. An innovative portable digital recording device (the ‘Virtual Chaperone’) is evaluated for use in clinical settings.

Learning the skills of flexible sigmoidoscopy – the wider perspective

Background  Nurse‐led gastrointestinal endoscopy is a priority clinical area in the UK. Endoscopic procedures are challenging to learn, requiring a combination of technical competence (manipulating a flexible endoscope and interpreting the findings) and interpersonal skills (engaging effectively with a conscious patient who is frequently apprehensive).