Faculty Development

The development and adoption of simulation training reflects development in theories of learning from more individually oriented activities to those that view learning as a social and cultural event. Simulations that focus on improving team performance are therefore becoming increasingly commonplace in high risk environments such as anaesthesia, surgery and emergency medicine (Nestel et al, 2008: Ker and Bradley, 2007; Gaba, 2006).

As simulation becomes an accepted part of everyday education and training for health professionals, attention is being paid to how simulation can best be used to develop technical and non-technical skills. Simulation appears to work most effectively when it is designed to meet curricular outcomes, includes realistic and relevant content, interesting and engaging learning methods and prepares learners for working in the clinical context in terms of activities, skills and competencies (Issenberg et al, 2005). Table 2 lists the best practice features of simulation as identified in two systematic literature reviews.

Simulation helps skills acquisition, maintenance and assessment in the move from ‘novice to expert’ (Dreyfus and Dreyfus, 1985). The key element here is building simulation activities into learners’ progression (Figures 1 and 2). For example medical students must practice and master the skills and pass an assessment before embarking on clinical rotations or trainees might have to provide evidence of competence in a simulator before interacting with patients. Learners can therefore have their first encounter with patients at a higher level of technical and clinical proficiency, which protects patients (Ziv et al, 2003).

Figure 2  Simulation Activities integrated into the learning programme
WPBA = workplace-based assessments

Clinicians can use simulated facilities to rehearse both challenging and routine procedures to reduce error (Yule et al, 2006).  The philosophy is based on deliberate practise with appropriate feedback (both during and after the training event).  Because simulation focuses primarily on skills acquisition (technical or non-technical), it is essential that learning activities are planned with clear learning outcomes and that a de-briefing or follow up stage is planned (Cumin et al, 2008).

The absence of learner feedback is the greatest single factor for ineffective simulation training. A lack of feedback may lead to:

1. Learning the wrong learning objective.
2. Not realising what the desired behaviours should be by not focusing on them.
3. Not transferring skills to clinical practice.
4. Spending increasing time on only one aspect of training.

A novel aspect of high fidelity simulation is the ability to play back videos of the scenario that has been played out to an individual or team. Unlike verbal feedback from an observer there is tangible evidence of what the learner did or did not do or say. In addition insight into how they behave under stress (getting angry, withdrawal, making mistakes) is a valuable and powerful learning tool.

Deliberate practice refers to time spent on a specific activity designed to improve performance in a particular aspect of practice. Deliberate practice is a better method to acquire expertise than simple unstructured practice (Ericsson, 2004).  There is a consistent association between the amount and the quality of deliberate practice and performance in domains as varied as chess, music and sport (Ericsson and Charness, 1994). Deliberate practice means that there is effort involved as well as some form of feedback, whether through self assessment, from the simulator or observation by another person.

Short-term training courses are not the same as deliberate practice and do not have the same beneficial effects on long-term performance. Research, with laparoscopic equipment, has shown that structured practice with feedback improves subsequent performance in the same real-life situation (Reznick and MacRae, 2006). Deliberate practice using simulation is particularly useful for new skills, rare events or emergencies.

A lack of opportunity for practice is associated with a poor educational outcome. This is often attributed to insufficient access to the simulator, as training  sessions are usually time dependent, and the simulator is often a hotly-contested resource. In addition, each learner is different, and some learners inevitably need longer or more frequent sessions with the simulator to achieve the same educational results as their co-learners.