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Research into Simulation

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Vicki LeBlanc PhD (University of Toronto) introduces us to her data on feedback and enhanced hybrid simulation learning on communication skills. Her expertise is in Human Factors and Decision-making particularly in stressed and non-ideal situations.

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Research into Simulation

  1. 1. Does It Work?..and Why? Research into the effectiveness of simulation as a teaching tool Vicki R LeBlanc, PhD Wilson Centre; University of Toronto
  2. 2. SIMULATION The representation or reproduction of something real by imitation
  3. 3.  Physical objects (task trainers)  Process or skill (suturing)  People (standardized patients, confederates)  Environments (virtual worlds, immersive simulation) SIMULATION
  4. 4. • Struggle - resources, access, time, funding, etc… • Position papers & advocacy (Ziv, Gaba, Reznick, etc..) • Climate of scepticism 1980S-MID 2000S
  5. 5. • National/International Societies • Simulation Conferences & Courses • Accreditation Standards 2011: CLIMATE OF LEGITIMACY
  6. 6. ….Important role in acceptance RESEARCH
  7. 7. • Robust acceptance by trainees • Enhanced learning • Transfer to clinical setting RESEARCH EVIDENCE
  8. 8. Educators and students exposed to mannequin-based simulation 85% of students & 85% of educators rated session as excellent > 80% sim-based training should be required for all medical students Gordon et al., Acad Med 2001 ROBUST ACCEPTANCE
  9. 9. • Robust acceptance by trainees • Enhanced learning • Transfer to clinical setting RESEARCH EVIDENCE
  10. 10. D Tabak, CA Moulton, A Birze, H MacRae, D Nestel, R Kneebone, V LeBlanc ENHANCED LEARNING USING HYBRID SIMULATIONS
  11. 11. Specific Research Aims To determine the effectiveness of the hybrid simulation in teaching communication and interpersonal skills to medical students and surgical residents
  12. 12. Study Design 4th Year Medical Students N = 16 PGY1 Surgery Residents N = 16 Wound Closure Drunk and Angry Urinary Catheterization Uncomfortable Patient Feedback Volar Cast Irritated Skin Lesion Blind and Afraid Pre-Test Post -Test No Feedback
  13. 13. Outcome Measures Validated communication scale (2 blinded raters) Empathy Response to patient’s feelings and needs Coherence Plan and organization of the interview Verbal Expression Command of language Non Verbal Expression Engagement with non verbal expression Hodges B. Med Teach 2003; 25:250-254 Validated technical scales
  14. 14. 0 10 20 30 40 50 60 70 80 90 100 overall emphathy cohesion verbal non-verbal Communication Scores: Pre Intervention No Feedback Feedback % No main effect of feedback p=.752
  15. 15. 0 10 20 30 40 50 60 70 80 90 100 overall empathy cohesion verbal non-verbal * * Significant effect of feedback p<0.05 Communication Scores: Post Intervention * * * No Feedback Feedback %
  16. 16. Technical Scores: GRS No Feedback Feedback % Pre Post 0 10 20 30 40 50 60 70 80 90 100 catheter-pre wound-pre skin exc-post cast-post
  17. 17. 0 10 20 30 40 50 60 70 80 90 100 Cath Wound Skin Cast No Feedback Feedback Technical Scores: Checklist % Pre Post
  18. 18. IPPI can be used to deliver effective formative feedback Feedback > Exposure Improvements not at cost of non-intervention skill Conclusions
  19. 19. The advantages of simulation-based education lead to enhanced performance and clinical care TRANSFER TO CLINICAL SETTING
  20. 20. ENHANCED LEARNING 20 anesthesiology residents; 2-h training session: - High-fidelity simulation-based training - Interactive seminar Each trainee then weaned patients from CPB - within 2 weeks (posttest) - within 5 weeks (retention test) Bruppacher et al., Anesthesiology; 2010
  21. 21. Post Test Retention Non technical skills Clinical checklist Non technical skills Clinical checklist Seminar 11.8 75.4 11.7 77.0 Simulation 14.3 89.9 14.1 93.2
  22. 22. TRANSFER TO CLINICAL SETTING Simulation-based learning of central line insertions - Greater success - Reduced complications - Reduced infection rates Barsuk et al; Arch Intern Med; 2009
  23. 23.  BUT…..Some evidence of lack of improvements:  Olympio (2003):  no improvement in management of intubation  Borges (2010):  no changes in management of “cannot intubate, cannot ventilate” scenarios  Wenk (2009):  simulation not better than PBL for intubation
  24. 24. Not possible to state that simulation, itself, IS or IS NOT effective for learning Important to understand what elements of simulation facilitate learning
  25. 25. It’s no longer a question of IF
  26. 26. But a question of HOW
  27. 27. FEEDBACK IMPORTANT CHARACTERISTICS
  28. 28. Key element to learning and skill acquisition  without debriefing, students fail to learn Issenberg et al. (2005) Medical Teacher; Stefanidis et a.l (2007) Surgery Xeroulis et al. (2007) Surgery; Walsh et al. (2009) Academic Medicine FEEDBACK
  29. 29. Medical students learning suturing and knot tying skill Control group: practice with no feedback Concurrent: feedback as student performs the task Summary: feedback after completion of the task SUMMARY VS CONCURRENT FEEDBACK Xeroulis et al., 2006; Surgery
  30. 30. Immediate post-test: • Control < Concurrent = Summative 1-month retention test: • Control = Concurrent < Summative RESULTS
  31. 31. Continuous, intensive feedback inhibits learning: • Over-guidance: learners overly depend on feedback and perform poorly in it’s absence • Inhibits intrinsic learning strategies and problem solving activities necessary to master skills NOT JUST ANY FEEDBACK
  32. 32. PRACTICE IMPORTANT CHARACTERISTICS
  33. 33. Podcast Study- In Progress  How to optimize podcasts in health professions education • Mental practice: -cognitive rehearsal of the steps in a tasks without overt physical movement • Modeling: -Viewing of a demonstration of what needs to be learned Fahad Alam, Sylvain Boet, Vicki LeBlanc
  34. 34. Pre-Test (Multiple Choice) Randomization Podcast No Mental Practice No Modeling (n=15) Podcast With Mental Practice No Modeling (n=15) Podcast No Mental Practice With Modeling (n=15) Podcast With Mental Practice With Modeling (n=15) Post-Test (Multiple Choice) Basic Airway Management Simulation Scenario
  35. 35. Preliminary results  Data collection: mid-point, with 7-8 per group  MCQ improvements: Control < Mental Practice = Modeling < MP and Modeling
  36. 36. Summary Significant scholarship in simulation over 20 years  - Learner reactions  - Can lead to improved performance  - Learning transfers to clinical setting Important focus of current research… …understanding how to optimize simulation-based learning
  37. 37. “The field of patient simulation has gotten to where it is now because it makes sense, but we need more science behind it to guide its use.” Jim Gordon

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