Introducing simulation-based education to healthcare professionals: exploring the challenge of integrating theory into educational practice

Abstract

Background

Introducing simulation-based education to the curricular programme of healthcare professionals can be challenging. This study explored the early experiences of healthcare professionals in the use of simulation. This was in the context of the Kuwait–Scotland transformational health innovation network programme.

Methods

Two cohorts of healthcare professionals undertook a simulation module as part of faculty development programme in Kuwait. Participants’ initial perceptions of simulators were gathered using a structured questionnaire in the clinical skills centre. Their subsequent ability to demonstrate the application of simulation was evaluated through analyses of the video-recordings of teaching sessions they undertook and written reflections of their experiences of using simulation.

Results

In theory, participants were able to identify simulators’ classification and fidelity. They also recognised some of the challenges of using simulators. In their teaching sessions, most participants focused on using part-task trainers to teach procedural skills. In their written reflections, they did not articulate a justification for their choice of simulator or its limitations.

Conclusion

Keywords

Simulation-based education deliberate practice mentorship

Introduction

Simulation is an instructional technique that aims to substitute for, or elaborate on real clinical experiences using guided educational experiences to evoke or replicate essential elements of the real world in an interactive way.¹ It can be used to recreate patient care scenarios in a realistic clinical setting for the purpose of learning, feedback and assessment.² A wide variety of simulation equipment and techniques are now available for learners at different levels of competency, including part-task trainers, computer-based systems, model-driven or instructor-driven integrated simulators, advanced complex skills trainers and simulated patients.^3,4 However, the successful implementation of simulation in medical education can be challenging. The need for faculty development ^3,5 coupled with establishing specialised simulation facilities with appropriate resources⁵ are required to ensure success.

Simulation-based education (SBE) has been increasingly used for the acquisition, refinement and maintenance of clinical skills across the spectrum of medical specialties.^4,6–10 It can provide opportunities for training healthcare professionals at varying levels of competency, ranging from novices to experts.¹¹ There has been a worldwide exponential rise in the use of simulation to teach healthcare professionals a wide range of clinical skills essential for safe clinical practice^12,13 and in interprofessional education.^14–16 A number of studies show that SBE improves the clinical skills and practices of healthcare professionals which often translate into improved patient care.^17–19 Therefore, healthcare educators need to learn and master new instructional skills to implement simulation effectively in clinical teaching.⁵

Despite the worldwide increase in both the evidence and use of simulation, most evidence about SBE comes from western education systems. There are few, if any, studies describing the use of simulation in healthcare professionals’ education in the Middle East, and whether the challenges facing healthcare professionals introducing SBE would be the same. This study investigated the early perceptions of the use of simulators by multidisciplinary healthcare educators and the challenges of transforming the theoretical knowledge gained about simulation into their educational practice.

Methods

Context

Kuwait is a Middle Eastern state bordering the Arab Gulf. The pool of healthcare professionals working in Kuwait provides care mainly through the governmental healthcare sector at primary, secondary and tertiary levels. These healthcare professionals have diverse educational backgrounds, with experience as clinicians and educators from Kuwait, other Middle East countries and from the United States, United Kingdom and India. The wide variation in their training backgrounds and experiences of different educational systems presents a particular challenge in introducing the use of simulation to their educational practice.

A national clinical skills and simulation facility was established in Kuwait at the Dasman Diabetes Institute (DDI) in 2011. This multipurpose facility was developed in partnership with the University of Dundee as part of the Kuwait–Scotland Health Innovation Network (KeSHIN).²⁰ A transformational healthcare system development has been established through this network with its first priority to improve diabetes care. Faculty development has been one of the major building blocks of the KeSHIN. Central to the faculty development is a postgraduate (Master's Level) programme incorporating training in educational techniques, organisational development and clinical standards. Healthcare professionals including physicians, pharmacists, nurses and dieticians with a special interest in diabetes enrol in the program and participate in an interprofessional learning experience.

One of the 12 week educational modules of the postgraduate programme is the Clinical Skills and Simulation for Education and Practice Module, which aims to promote the use of simulation to enhance safe clinical practice. Healthcare professionals who are novice educators in terms of simulation are introduced to the use of simulation to enhance their educational practices. The interactive module introduces the use of simulation to participants based on educational theories. The analysis, classification and use of simulators are integral to the theoretical learning process. The educational underpinning of the module is based on experiential learning theory, learning through experience with subsequent reflection to deepen understanding, exploration of the broader context of experience and integration of the new learning into practice.²¹ The learning and teaching activities of the module are delivered using the adult learning principles of self-directed learning.²²

In the first week of the module, participants are assigned reading materials and online exercises to provide them with basic understanding of simulation. They attend face-to-face teaching sessions for four days in the following week at the Clinical Skills Centre, DDI. During these sessions, participants learn about simulation through demonstrations, interactive lectures and small group discussions. Following the face-to-face teaching week, they continue with self-directed learning for the remainder of the module timeframe.

One of the innovative designs of this blended learning programme is that the participants’ assessment is carried out through experiential assignments. This includes a project in which participants implement simulation in the design, delivery and evaluation of a teaching session which is conducted at the Clinical Skills Centre and is video-recorded. Each participant decides the topic of the teaching session, defines the intended learning outcomes and then, video-records the session. Participants also have to submit an academic report describing the project with a critical analysis of their teaching sessions and a reflective account on their learning.

Participants

Multidisciplinary healthcare professionals including physicians, dentists, pharmacists, nurses and other healthcare professionals participated in this study. They included two cohorts of healthcare professionals who undertook the simulation module offered in 2012 and 2013. All participants were novice educators in terms of the use of simulation as an educational technique.

Study design

This pilot study was designed to explore the theory–practice gap in the early application of simulation by a cohort of healthcare professional educators. The initial perceptions of the use of simulators by the healthcare professional educators early in the clinical skills and simulation module were explored using a structured questionnaire. Participants’ subsequent ability to demonstrate the application of simulation in their practice as educators was assessed independently by two experts in SBE by analysing the videoed teaching sessions which the participants undertook in weeks 6–8 of the module. The participants’ written reflections of their experience of using simulation in their educational practice in weeks 10–12 were also evaluated. The participants were assured of their confidentially and anonymity. Ethical approval for the study was obtained from the Ethical Review Committee, DDI (Reference number: RA/028/2013).

Structured questionnaire

The structured questionnaire was completed during the face-to-face teaching sessions conducted in the second week of the module at the Clinical Skills Centre, DDI. Participants were asked to rotate through five clinical skills stations each demonstrating the use of different simulators (Box 1). At each station, participants completed a questionnaire that contained a series of open-ended questions (Box 2).

Box 1.

The five stations demonstrating the use of the different simulators.

Station 1 SimMan/Simbaby

Station 2 Resusci-Anne/Little Anne with resuscitation kit AED/airway management kit

Station 3 Part-task trainers, including naso-gastric tube, catheterisation models, venepuncture arm, ophthalmoscopes and heads

Station 4 Harvey

Station 5 Simulated patient with script

Box 2.

The structured questionnaire completed by the participants.

Please describe the simulator

How would you classify the simulator?

How would you describe the fidelity of the simulator?

What clinical features can the simulator reproduce?

When could you use this simulator in your teaching?

What would be the challenges in using this simulator?

Data analysis

Qualitative data obtained from participants’ responses to the structured questionnaire were analysed using framework analysis.²³ The stages of framework analysis include familiarisation with the data, identification of a thematic framework, indexing the data and charting the codes under the appropriate themes.²³ This analysis aimed to identify key themes within participants’ responses which were analysed independently by two of the authors to enhance the reliability of qualitative data analysis.^24,25 The emerging themes were discussed between the two raters to agree on the final presentation of data.

Review of videoed teaching sessions and written critiques

The participants’ use of simulators in their educational practice was recorded on video as part of their assessment for the module together with critical analysis of their teaching sessions and a reflective account on their learning. The analysis of these experiential assignments was carried out in two parts:

Firstly, participants’ videoed sessions as educators using simulation in practice were reviewed and analysed to:

Identify what simulator was used in their educational practice.

Determine the appropriateness of the choice of the simulator for the clinical skill being taught based on the learning outcomes identified and the BEME review of effective use of simulators.²⁶

Secondly, the written reflections by participants of their experience of using simulation in their educational practice were analysed to:

Identify the evidence for justification for use of the chosen simulator.

Identify the challenges they had faced in its usage for the teaching session.

Results

Participants

The participants included all the healthcare professionals who undertook the clinical skills and simulation module in 2012 and 2013 (n = 37). Both cohorts included 23 medical, 6 pharmacists and 8 other healthcare professionals. They were 20 females and 17 males.

Results from questionnaire analysis

Table 1 shows a summary of the participants’ responses to the questionnaires. All participants were able to determine the simulator classification, fidelity and possible applications. They also recognised some of the potential challenges for using these simulators in their practice as educators including: the limited availability of equipment, lack of realism, requirement for technical support for the high-fidelity simulators and need for specialist training for simulated patients.

Results from the video recordings and written critiques

The analysis of the video recordings revealed that participants focussed largely on teaching procedural skills, mostly using part-task trainers, for implementing their teaching sessions. They used what they perceived to be accessible and least operator-dependant options available to them. For example, the use of a Resusci-Anne for teaching manual blood pressure recording or using SimMan for diabetic foot examination as opposed to a simulated patient or part-task anatomical model. In the critique of their teaching sessions, few participants justified the rationale for their choice of simulator or the specific clinical skill chosen as a topic for the session. Little reference was made to the simulator’s classification, fidelity or the challenges of using that simulator in their educational practice.

Discussion

This study highlighted the challenge of introducing SBE to the educational practice of healthcare professionals who are novices in the use of simulation. This was manifested in the difficulty the educators faced in transferring the learning gained from the simulation module to the realities of their educational practice.

The questionnaire responses by the novice educators demonstrated a theoretical understanding of the type and fidelity of the simulators to which they were exposed. The participants initially identified the possible applications of the simulators and they anticipated the potential challenges to their use. Many of the novice educators’ perceived challenges of the use of simulators concur with the challenges which are frequently reported in the literature. For example, some simulation equipment such as manikin-based integrated simulators are very costly, both in terms of purchase and running costs, which limit their availability to specialist centres.³ On the other hand, part-task trainers are relatively inexpensive but they lack realism.³ As anticipated by participants, the main challenges in using simulated patients are the expense^27,28 and the time and effort required for their training.²⁹ This would suggest that the assigned self-reading materials and the face-to-face teaching sessions of the module were sufficient to provide participants with theoretical understanding about simulators types, fidelity and possible applications, as well as recognition of the potential challenges to simulators use in clinical skills teaching.

However, in the observations of their subsequent practice in using the simulators in their videoed teaching sessions, the majority of participants used part-task trainers and focused on the narrow spectrum of procedural skills development. The participants’ choices could probably be attributed to their lack of expertise on the use of simulators. In addition, the simulator used by the participants was not always appropriate for the purpose of the session. There was an obvious mismatch between the simulator chosen for the teaching session and the selection of a simulator which could actually recreate the reality required. In their written critique of their teaching sessions, the novice educators failed to share the justification for their choice of simulators, or to reflect on the challenges they had faced in their use.

According to Bloom's taxonomy,³⁰ participants in this study were able to show evidence of knowledge retention. This was evident by their ability to recall or recognise specific facts about simulators that could serve in the development of their skills. However, they were not able to adequately apply their learning from the clinical skills environment into their educational practice. Thus, learning from the module only achieved the lowest domain of learning (knowledge) and did not permit learners to achieve the higher domains, such as the application of knowledge into practice.

We consider that for novice educators to master the use of simulation, they are required to be engaged in deliberate practice of the newly acquired educational skill. Deliberate practice is an educational approach, which involves intense repetitive performance of a cognitive or psychomotor skill, combined with rigorous skills assessment, along with the provision of specific and informative feedback that gradually results in better skills performance in a controlled setting.^11,31,32 It is one of the main educational principles underpinning learning clinical skills using SBE.³³ A review of the available evidence suggests that SBE with deliberate practice are superior to traditional clinical medical education in achieving specific clinical skill acquisition goals.³⁴ Deliberate sustained practice of a skill with a determination to improve is required to gain and retain expertise in any domain.³⁵ Therefore, perhaps the need for deliberate practice also applies to achieving a mastery level in the use of simulation in the educational practice of healthcare professionals, as well as for the prevention of skills decay. Another important element to master the newly acquired educational skill could be the need for workplace mentorship. The vast majority of participants’ learning in the simulation module was achieved through self-directed learning. Aside from the face-to-face teaching days, mentoring was provided to participants through an online learning tool or via email. Mentorship in the practice area has been found instrumental to embed the newly acquired clinical skills from SBE.¹² Extended periods of workplace mentorship could have been needed to allow these novice educators develop their skills of using simulation in their educational practice.

The short timeframe of the module was not sufficient to provide participants with sufficient repetitive practice on the use of simulators for clinical skills education, nor was it adequate to offer them direct sustained mentorship. However, the findings of this study clarify the need to support novice educators in the introduction of new instructional techniques in their educational practice to enhance the standards of clinical skills competence. Further developments are required to assist these novice educators to sustain the newly acquired educational skill, to enable them transfer what they learnt into their educational practice and to prevent their skills decay.

Conclusion

This study demonstrated a theory-to-practice gap in the early use of simulation by healthcare educators. The findings highlight the need for deliberate practice and adequate mentorship for educators to develop confidence and competence in the use of simulation as part of their educational practice. However, the simulation module provided an interprofessional learning opportunity for healthcare professionals in Kuwait to learn about the role and application of different simulators. Over time, this would enhance the standards of safe clinical skills practice in Kuwait.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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