Simulation
Simulation training for geriatric medicine Zehra Mehdi, Angela Roots, Thomas Ernst and Jonathan Birns, Department of Ageing & Health, St Thomas’ Hospital, London, UK Alastair Ross, Gabriel Reedy and Peter Jaye, Simulation and Interactive Learning Centre, St Thomas’ Hospital, London, UK SUMMARY Background: Geriatric medicine encompasses a diverse nature of medical, social and ethical challenges, and requires a multidimensional, interdisciplinary approach. Recent reports have highlighted failings in the care of the elderly, and it is therefore vital that specialist trainees in geriatric medicine are afforded opportunities to develop their skills in managing this complex patient population. Simulation has been widely adopted as a teaching tool in medicine; however, its use in geriatric medicine to date has involved primarily role-play or discrete clinical skills training. This article outlines the
development of a bespoke, multimodal, simulation course for specialist trainees in geriatric medicine. Methods: A 1–day multimodal and interprofessional simulation course was created specifically for specialist trainees in geriatric medicine, using six curriculummapped scenarios in which the patient perspective was central to the teaching objectives. Various simulation techniques were used, including high-fidelity human patient manikins, patient actors, with integrated clinical skills using part-task trainers, and role-play exercises. Debriefs by trained faculty members were completed after each scenario.
Results: Twenty-six candidates attended four similar courses in 2012. Quantitative analysis of pre- and post-course questionnaires revealed an improvement of self-reported confidence in managing geriatric scenarios (Z = 4.1; p < 0.001), and thematic analysis of candidate feedback was supportive of simulation as a useful teaching tool, with reported benefits for both technical and non-technical skills. Discussion: Simulation is an exciting and novel method of delivering teaching for specialist trainees in geriatric medicine. This teaching modality could be integrated into the training curriculum for geriatric medicine, to allow a wider application.
This article outlines the development of a bespoke, simulation course for specialist trainees in geriatric medicine
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 387–392 387
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There is evidence that simulation training can improve the quality of care provided for older people
INTRODUCTION
G
eriatric medicine is a challenging specialty concerned with the care of older people, often with multiple co-morbidities, frailty and complex social care needs. In its response to the Francis report, the British Geriatrics Society stated that many of the failings in care affected older patients, who are a potentially vulnerable group with complex needs, in addition to being the main users of the UK National Health Service (NHS).1,2 It is imperative that specialist trainees in geriatric medicine are afforded opportunities during their training to practise skills of adopting a multidisciplinary holistic approach to the care of older patients, and there is evidence that simulation training can improve the quality of care provided for older people.3 Although this teaching method is now widely used in medical education, a dedicated simulation training programme for specialist trainees in geriatric medicine has previously been lacking in the UK. Globally, geriatric simulation programmes are being undertaken, but there is a paucity of published literature describing such courses. The specialist training curriculum in geriatric medicine is diverse, and highlights the importance of trainees developing skills in managing complex medical scenarios involving a variety of medical, social and ethical issues.4 It outlines the need for trainees to develop confidence and competence in providing comprehensive assessments of older people during acute and chronic illness, rehabilitation and at the end of life, and in a range of settings, including accident and emergency, high-dependency units, ward-based and out-patient hospital settings, at home and in intermediate or long-term care. Trainees are also expected to
develop leadership and management skills, working closely with the multidisciplinary team of nurses, therapists, pharmacists, dieticians, and other health and social care professionals. Over the last decade postgraduate medical training has undergone a dramatic change. Traditional training models involved long working hours with experiential learning opportunities, often through ‘practising’ on patients. With the introduction of the European Working Time Directive (EWTD) in 2009, and a greater focus being placed on patient safety, postgraduate medical training has required significant restructuring. The Temple report highlighted that the greatest impact of EWTD is on specialties covering emergency rotas, as higher trainees are often unavailable for more specialist elective training opportunities.5 This is especially true for specialist trainees in geriatric medicine, where trainees are expected to cover the general medical take (intake process including history taking). Simulation is able to deliver medical education in realistic
settings without compromising patient safety. This teaching method has been widely adopted for trainees in a variety of specialties, such as anaesthetics, emergency medicine, and paediatrics.6,7 It enables experiential learning by allowing trainees to become immersed in realistic scenarios, within which the outcome is dependent upon their abilities to manage the clinical problem, as well as display effective non-technical skills. Simulation also allows trainees to practise rare emergency situations, to which they may not otherwise be exposed. The Chief Medical Officer’s report (2008) stipulated that ‘Simulation-based training should be fully integrated and funded within training programmes for physicians at all stages’.8 This article outlines the development of a bespoke simulation course for specialist trainees in geriatric medicine, and assesses the feasibility and benefits of this teaching method in this specialty.
METHODS A dedicated simulation training course for specialist trainees in
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Table 1. Geriatric medicine simulation scenarios, with corresponding simulation techniques and key non-technical skills Curriculum-mapped scenario
Simulation technique
Non-technical skills
Management of the acutely ill elderly patient
High-fidelity life-size manikins
Teamwork Effective communication Leadership Situational awareness Decision making Call for help Set priorities dynamically
Continence care
Patient actors with integrated clinical skills part-task trainers
Effective communication Using available resources Decision making Anticipate and plan
Dementia care
Patient actors
Effective communication Situational awareness Decision making Use all available information
Complex discharge planning
Role-play exercises
Exercise leadership and followership Teamwork Effective communication Decision making Use all available information
Management of delirium resulting from urinary sepsis with renal failure
High-fidelity life-size manikins
Situational awareness Call for help Teamwork/communication Using available resources Decision making
End-of-life care decision making in an acutely ill patient
High-fidelity life-size manikins and relative actor
Decision making Call for help Situational awareness Set priorities dynamically Exercise leadership Effective communication
geriatric medicine was developed by a multidisciplinary working party, comprising health care professionals (from medical and nursing backgrounds) and educationalists to facilitate experiential learning of both technical and non-technical skills. The course was delivered over 1 day at the Simulation and Interactive Learning Centre at St Thomas’ Hospital in London (SaIL), and was available to all specialist trainees in geriatric medicine and nursing staff working in elderly care in the UK. The course included six curriculum-mapped scenarios, employing a variety of simulation techniques and incorporating key non-technical skills (Table 1). Figure 1 exemplifies the resources and staffing
required in delivering one of these scenarios. The course (Figure 2) commenced with an introduction to simulation, a description of the course objectives, and a discussion about human factors, non-technical skills and patient safety. Candidates participated in the scenarios either individually or in small groups, whilst the rest watched live audio-visual transmission remotely. Each scenario was followed by a video-assisted debriefing session using the model of description, analysis and application developed at SaIL, which enables the effective debriefing of a multiprofessional group.3 Candidates completed pre- and post-course
This course in geriatric medicine was developed by a multidisciplinary working party
questionnaires, and were asked to: rate their confidence (on a scale from 0 to 100%) in managing geriatric clinical scenarios and in key non-technical skills (e.g. ‘Take a leadership role in an emergency clinical care situation’); evaluate the educational value of the course (seven items on a fivepoint Likert scale; e.g. ‘How well did the educational programme for the day meet the stated aims?’); and to provide ‘free-text’ feedback with regard to what they learned from the course. Open-ended responses were analysed using thematic techniques9; a selection of verbatim texts in response to each open-ended item was independently cross-coded into thematic
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Simulation was a valuable training modality, addressing areas of the curriculum rarely taught formally
Management of the acutely ill elderly patient
Patients name: Ethel Harrison Patients age/DOB: 75 years Setting: Elderly care ward
Staffing required Control Room: 1 × technician 1 × patient voice 1 × debriefer
Manikin preparation Female patient, IV access Food around mouth and on front of gown Drug chart available with regular meds and oral antibiotics for urinary tract infection
Role players: 1 × FY1 plant
Equipment required High-fidelity life-size manikin, IV fluids, drugs: GTN, Aspirin, Clopidogrel, Clexane, Adrenaline, Amiodarone Resuscitation trolley, ECG, old CXR on admission, admission bloods, medical notes. Case description Ethel presented to A & E with a fall 2 days ago and she is currently on oral antibiotics for a presumed urinary tract infection. She has just been transferred to the elderly care unit for further assessment as her mobilisation on the ward was noted to be poor. The elderly care consultant has not yet seen her. Resuscitation status is undetermined. Ethel suddenly becomes confused and generally unwell whilst eating dinner (6 pm). She is sweaty, short of breath and appears in discomfort. PMHx: Type-II diabetes, angina, HTN, osteoporosis, OA, recurrent UTIs DHx: Metformin, Gliclazide, Ramipril, Alendronic Acid, Adcal D3. Allergies: NKDA SHx: Lives alone, independent ADLs, non-smoker, no alcohol She has developed an acute ST elevation MI. She will remain in a peri-arrest state on the ward. Simulator operation Patient starts off slightly tachycardic and sweaty. As scenario progresses patient becomes hypotensive, increasingly tachycardic and confused. Initial observations: BP 135/80 HR 110 Sats: 96% on air RR 20 GCS 14 (E4 M6 V4), Temp: 37.0
Available tests on request: ECG: Anterolateral ST elevation ABG results Admission blood results Admission CXR
Candidate briefing It is 6 pm on the Elderly Care Unit. Ethel has just been transferred to the ward on treatment for a UTI following a fall at home. She is awaiting assessment for a package of care and has not yet been seen by any of the elderly care team. She is noted to have stopped eating her dinner and appears agitated and confused. The FY1 asks you to review. FY1 plant role It is 6 pm on the Elderly Care Unit, you have been asked by the ward staff to review a patient who has become suddenly increasingly confused over having her dinner. As it is your first week in the job you are very worried and call your registrar immediately. You are able to find anything that is needed and call for help, but you cannot help with the diagnosis or treatment.
Figure 1. Example scenario, outlining resources and staffing requirements
REGISTRATION Pre-course questionnaire Learning outcomes and introduction to simulation Familiarisation with Mr/Mrs Simulator Scenario 1 and debrief Scenario 2 and debrief BREAK Scenario 3 and debrief Scenario 4 and debrief LUNCH Scenario 5 and debrief Scenario 6 and debrief Post-course questionnaire Review of the day END
70 per cent to detect an effect of θ = 0.7 (actual effect size 0.78). All candidates gave written informed consent for feedback data to be aggregated for research purposes in accordance with the terms of the Data Protection Act 1998. Ethical approval was given by the Hospital Research Ethics Committee (South London REC 3; approval ref. 09/28), under the terms of the UK NHS Research Ethics Service.
Figure 2. Example of course timetable
RESULTS abstractions, and disagreements were discussed and reconciled. Confidence ratings and ratings of the simulation experience were analysed using spss 19.0 (IBM, New York, USA). We did not assume homogeneity of variance or normality in scale items, and so these were analysed using non-parametric tests. The small study (n = 26) was powered at
Four similar courses were delivered between January and December 2012, with 26 candidates attending in total [21 specialist trainees in geriatric medicine (ST3–ST7) and five band–5 nurses working in elderly care]. The mean self-confidence ratings before and after the course, analysed using a Wilcoxon
signed ranks test for non-parametric data in a paired sample, showed post-course confidence to be significantly higher on all items, with an average improved confidence of around 12 per cent (Table 2). Mean evaluation scores (post-course only) on whether the course was educational, interesting, relevant to practice and useful for reflection were highly correlated (α = 0.901; seven items). The mean evaluation score overall was 4.46 (95% CI 4.28–4.63; where 1 = very poor and 5 = very good). Thematic analysis of ‘free-text’ feedback revealed three broad categories focusing on ‘geriatric medicine’, ‘dealing with acutely unwell patients’ and ‘non-technical skills’ (Box 1). The majority of responses were related to non-technical skills, all of which were judged not to have been taught as effectively by other learning media. Candidates commented that simulation was a valuable training modality, addressing areas of the curriculum rarely taught formally, such as continence assessment, end-of-life decision making and multidisciplinary situations. Candidates also commented that the course could be improved by incorporating longer scenarios and an increased use of video feedback and personal debriefing sessions.
DISCUSSION Specialist trainees in geriatric medicine are required to develop a variety of technical and nontechnical skills to facilitate their management of a complex and challenging patient population. The evolution of medical training in recent years, however, has resulted in a reduction in time available to develop these skills during clinical duties.5 Simulation is a useful method of facilitating experiential learning for specialist trainees in geriatric medicine, and was shown to be feasible. A geriatric-specific
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Table 2. Pre- and post-course confidence ratings for managing geriatric scenarios (n = 26) Mean (SD) pre-course confidence score
Mean (SD) post-course confidence score
Z; p
Entering new clinical situations
72.3 (18.6)
79.8 (14.2)
Z = 3; p < 0.01
Leadership
68.1 (22.3)
80.4 (12.8)
Z = 3.2; p < 0.001
Emergency management
65.2 (20.5)
77.9 (12.7)
Z = 3.5; p < 0.001
Continence management
55.6 (22.3)
74.2 (12.9)
Z = 3.9; p < 0.001
Multidisciplinary meetings
66.0 (19)
78.5 (14.1)
Z = 3.4; p < 0.001
Communication
74.4 (18.2)
81.1 (13.4)
Z = 2.5; p < 0.05
Managing agitated patients
64.6 (20)
78.7 (13)
Z = 3.9; p < 0.001
End-of-life decisions
67.1 (18)
77.7 (13.9)
Z = 3.6; p < 0.001
End-of-life communication
68.3 (19.5)
77.9 (13.9)
Z = 3; p < 0.01
Deploying non-technical skills
64.6 (18.3)
78.7 (12.2)
Z = 3.8; p < 0.001
Total
66.6 (17.5)
78.5 (12.5)
Z = 4.1; p < 0.001
Box 1. Thematic analysis of free-text comments with examples Theme 1: geriatric medicine ‘Keeping an open mind is vital when assessing elderly patients – remembering that elderly patients often have multiple problems/diagnoses‘ (ST3) ‘To give the confused patient space and try to talk to them on a more personal level’ (ST3) ‘Personally found continence scenario very useful’ (Grade not stated) ‘Systematic approach to deal with confused patients’ (Band–5 nurse) Theme 2: dealing with acutely unwell patients ‘Reassessment is vital when assessing/managing acutely unwell patients’ (ST3) ‘Skills to enhance ways to collect and act upon information in complex and high pressured clinical settings’. (ST3) Theme 3: comments relating to non-technical skills Communication – ‘communication is the key’ (Band–5 nurse) Teamwork – ‘Value of teamwork’ (Grade not stated) Taking a step back – ‘Stand back and think about the situation’ (Grade not stated) Delegation – ‘How to use other health professional in clinic areas’ (Band–5 nurse) Sharing ideas – ‘Importance of sharing the mental model’ (ST3) Decision making – ‘Making the decision for end-of-life scenario’ (ST4) Time management – ‘I enjoyed learning new techniques and skills on how to manage my time effectively’ (Band–5 nurse) Leadership – ‘…take leadership role as needed’ (ST7)
The requirements of a geriatricsspecific course affords the educational opportunity to use a full range of simulation modalities
simulation course allows trainees to reflect on technical and nontechnical skills, thus improving their confidence in working as part of a multidisciplinary team. This form of teaching is becoming more prevalent in all medical specialties, and is strongly supported by the Chief Medical Officer’s report (2008).8 Whereas simulation courses are typically reliant on high- or low-fidelity techniques, the requirements of a geriatrics-specific course affords the educational opportunity to use a full range of simulation modalities: high-fidelity, low-fidelity, part-task trainers, patient actors and role-play exercises. The results of these pilot courses are promising, with a reported improvement in trainees’ confidence in technical and non-technical skills. Overall, trainee opinion was supportive of simulation as a training tool in geriatric medicine; however, the benefits are limited by selfreporting, small sample size, a lack of formal feedback from patient actors and assessment of the candidates to demonstrate an
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Simulation training ... complements rather than replaces real-life experience
improvement in skills. In view of this, the findings are hard to generalise. In addition, although the course was offered to doctors and nurses, only one or two nurses attended each course (five in total), and all were of the same grade. For a fully interprofessional course we would have liked equal numbers of candidates as well as faculty members. It is important to note that although simulation training affords situational learning without compromising patient safety, it complements rather than replaces real-life experience.7 Further studies are required to assess the retention of the skills gained from the course, the efficacy of simulation compared with more traditional teaching modalities and the effects on patient outcomes. Additionally, the effects of repeated simulation experiences on longer-term learning outcomes require further exploration. Finally, although this course was designed for specialist trainees and nursing staff in geriatric medicine, it would be feasible to offer such a course to all other health professionals as an educational tool for improving competencies in managing elderly patients.
CONCLUSIONS Given the recent reports highlighting failings in the care of elderly patients,1,10 it is crucial that trainees in geriatric medicine are given opportunities to practise the skills stipulated in the specialist training curriculum.4 Simulation is a useful teaching tool that may be used to improve these skills, and we would support its incorporation into specialist training schemes in geriatric medicine. REFERENCES 1. Mid Staffordshire NHS Foundation Trust 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry – Executive Summary. London: Crown Copyright. 2. British Geriatrics Society. BGS responds to the Francis Report. 6 February 2013. Available at http://www.bgs.org.uk/index.php/ press/2410-bgs-francis-report. Accessed on 24 September 2013. 3. Ross AJ, Anderson JE, Kodate N, Thomas L, Thompson K, Thomas B, Key S, Jensen H, Schiff R, Jaye P. Simulation training for improving the quality of care for older people: an independent evaluation of an innovative programme for inter-professional education. BMJ Qual Saf 2013;22:495–505. 4. Joint Royal Colleges of Physicians Training Board. Specialty training
curriculum for geriatric medicine curriculum. London: Joint Royal Colleges of Physicians Training Board; 2010. 5. Professor Sir John Temple. Time for Training. A Review of the impact of the European Working Time Directive on the quality of training. May 2010. Available at http:// www.mee.nhs.uk/PDF/14274%20 Bookmark%20Web%20Version.pdf. Accessed on 24 September 2013. 6. Chakravarthy B, Haar ET, Bhat SS, McCoy CE, Denmark TK, Lotfipour S. Simulation in Medical School Education: Review for Emergency Medicine. West J Emerg Med 2011;12:461–466. 7. Gaba D, Howard S, Fish K, Smith B, Sowb Y. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience. Simulat Gaming 2001;32:175–193. 8. Sir Liam Donaldson. Safer Medical Practice in Chief Medical Officer’s Annual Report 2008. Available at http://www.avon.nhs.uk/kris/_ Docs/CMO%20report.pdf. Accessed on 24 September 2013. 9. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77–101. 10. National Confidential Enquiry into Patient Outcome and Death. Elective & Emergency Surgery in the Elderly: An Age Old Problem 2010. Available at http://www.ncepod. org.uk/2010report3/downloads/ EESE_fullReport.pdf. Accessed on 24 September 2013.
Corresponding author’s contact details: Dr Zehra Mehdi, Department of Ageing & Health, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, UK. E-mail: [email protected]
Funding: None. Conflict of interest None. Ethical approval: Candidates gave written, informed consent for feedback data to be aggregated for research purposes, in accordance with the terms of the Data Protection Act 1998. Ethical approval was given by the Hospital Research Ethics Committee (South London REC3; approval ref. 09/28), under the terms of the UK NHS Research Ethics Service. doi: 10.1111/tct.12156
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Simulation training for geriatric medicine Zehra Mehdi, Angela Roots, Thomas Ernst and Jonathan Birns, Department of Ageing & Health, St Thomas’ Hospital, London, UK Alastair Ross, Gabriel Reedy and Peter Jaye, Simulation and Interactive Learning Centre, St Thomas’ Hospital, London, UK SUMMARY Background: Geriatric medicine encompasses a diverse nature of medical, social and ethical challenges, and requires a multidimensional, interdisciplinary approach. Recent reports have highlighted failings in the care of the elderly, and it is therefore vital that specialist trainees in geriatric medicine are afforded opportunities to develop their skills in managing this complex patient population. Simulation has been widely adopted as a teaching tool in medicine; however, its use in geriatric medicine to date has involved primarily role-play or discrete clinical skills training. This article outlines the
development of a bespoke, multimodal, simulation course for specialist trainees in geriatric medicine. Methods: A 1–day multimodal and interprofessional simulation course was created specifically for specialist trainees in geriatric medicine, using six curriculummapped scenarios in which the patient perspective was central to the teaching objectives. Various simulation techniques were used, including high-fidelity human patient manikins, patient actors, with integrated clinical skills using part-task trainers, and role-play exercises. Debriefs by trained faculty members were completed after each scenario.
Results: Twenty-six candidates attended four similar courses in 2012. Quantitative analysis of pre- and post-course questionnaires revealed an improvement of self-reported confidence in managing geriatric scenarios (Z = 4.1; p < 0.001), and thematic analysis of candidate feedback was supportive of simulation as a useful teaching tool, with reported benefits for both technical and non-technical skills. Discussion: Simulation is an exciting and novel method of delivering teaching for specialist trainees in geriatric medicine. This teaching modality could be integrated into the training curriculum for geriatric medicine, to allow a wider application.
This article outlines the development of a bespoke, simulation course for specialist trainees in geriatric medicine
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 387–392 387
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7/7/2014 8:19:34 PM
There is evidence that simulation training can improve the quality of care provided for older people
INTRODUCTION
G
eriatric medicine is a challenging specialty concerned with the care of older people, often with multiple co-morbidities, frailty and complex social care needs. In its response to the Francis report, the British Geriatrics Society stated that many of the failings in care affected older patients, who are a potentially vulnerable group with complex needs, in addition to being the main users of the UK National Health Service (NHS).1,2 It is imperative that specialist trainees in geriatric medicine are afforded opportunities during their training to practise skills of adopting a multidisciplinary holistic approach to the care of older patients, and there is evidence that simulation training can improve the quality of care provided for older people.3 Although this teaching method is now widely used in medical education, a dedicated simulation training programme for specialist trainees in geriatric medicine has previously been lacking in the UK. Globally, geriatric simulation programmes are being undertaken, but there is a paucity of published literature describing such courses. The specialist training curriculum in geriatric medicine is diverse, and highlights the importance of trainees developing skills in managing complex medical scenarios involving a variety of medical, social and ethical issues.4 It outlines the need for trainees to develop confidence and competence in providing comprehensive assessments of older people during acute and chronic illness, rehabilitation and at the end of life, and in a range of settings, including accident and emergency, high-dependency units, ward-based and out-patient hospital settings, at home and in intermediate or long-term care. Trainees are also expected to
develop leadership and management skills, working closely with the multidisciplinary team of nurses, therapists, pharmacists, dieticians, and other health and social care professionals. Over the last decade postgraduate medical training has undergone a dramatic change. Traditional training models involved long working hours with experiential learning opportunities, often through ‘practising’ on patients. With the introduction of the European Working Time Directive (EWTD) in 2009, and a greater focus being placed on patient safety, postgraduate medical training has required significant restructuring. The Temple report highlighted that the greatest impact of EWTD is on specialties covering emergency rotas, as higher trainees are often unavailable for more specialist elective training opportunities.5 This is especially true for specialist trainees in geriatric medicine, where trainees are expected to cover the general medical take (intake process including history taking). Simulation is able to deliver medical education in realistic
settings without compromising patient safety. This teaching method has been widely adopted for trainees in a variety of specialties, such as anaesthetics, emergency medicine, and paediatrics.6,7 It enables experiential learning by allowing trainees to become immersed in realistic scenarios, within which the outcome is dependent upon their abilities to manage the clinical problem, as well as display effective non-technical skills. Simulation also allows trainees to practise rare emergency situations, to which they may not otherwise be exposed. The Chief Medical Officer’s report (2008) stipulated that ‘Simulation-based training should be fully integrated and funded within training programmes for physicians at all stages’.8 This article outlines the development of a bespoke simulation course for specialist trainees in geriatric medicine, and assesses the feasibility and benefits of this teaching method in this specialty.
METHODS A dedicated simulation training course for specialist trainees in
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Table 1. Geriatric medicine simulation scenarios, with corresponding simulation techniques and key non-technical skills Curriculum-mapped scenario
Simulation technique
Non-technical skills
Management of the acutely ill elderly patient
High-fidelity life-size manikins
Teamwork Effective communication Leadership Situational awareness Decision making Call for help Set priorities dynamically
Continence care
Patient actors with integrated clinical skills part-task trainers
Effective communication Using available resources Decision making Anticipate and plan
Dementia care
Patient actors
Effective communication Situational awareness Decision making Use all available information
Complex discharge planning
Role-play exercises
Exercise leadership and followership Teamwork Effective communication Decision making Use all available information
Management of delirium resulting from urinary sepsis with renal failure
High-fidelity life-size manikins
Situational awareness Call for help Teamwork/communication Using available resources Decision making
End-of-life care decision making in an acutely ill patient
High-fidelity life-size manikins and relative actor
Decision making Call for help Situational awareness Set priorities dynamically Exercise leadership Effective communication
geriatric medicine was developed by a multidisciplinary working party, comprising health care professionals (from medical and nursing backgrounds) and educationalists to facilitate experiential learning of both technical and non-technical skills. The course was delivered over 1 day at the Simulation and Interactive Learning Centre at St Thomas’ Hospital in London (SaIL), and was available to all specialist trainees in geriatric medicine and nursing staff working in elderly care in the UK. The course included six curriculum-mapped scenarios, employing a variety of simulation techniques and incorporating key non-technical skills (Table 1). Figure 1 exemplifies the resources and staffing
required in delivering one of these scenarios. The course (Figure 2) commenced with an introduction to simulation, a description of the course objectives, and a discussion about human factors, non-technical skills and patient safety. Candidates participated in the scenarios either individually or in small groups, whilst the rest watched live audio-visual transmission remotely. Each scenario was followed by a video-assisted debriefing session using the model of description, analysis and application developed at SaIL, which enables the effective debriefing of a multiprofessional group.3 Candidates completed pre- and post-course
This course in geriatric medicine was developed by a multidisciplinary working party
questionnaires, and were asked to: rate their confidence (on a scale from 0 to 100%) in managing geriatric clinical scenarios and in key non-technical skills (e.g. ‘Take a leadership role in an emergency clinical care situation’); evaluate the educational value of the course (seven items on a fivepoint Likert scale; e.g. ‘How well did the educational programme for the day meet the stated aims?’); and to provide ‘free-text’ feedback with regard to what they learned from the course. Open-ended responses were analysed using thematic techniques9; a selection of verbatim texts in response to each open-ended item was independently cross-coded into thematic
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 387–392 389
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Simulation was a valuable training modality, addressing areas of the curriculum rarely taught formally
Management of the acutely ill elderly patient
Patients name: Ethel Harrison Patients age/DOB: 75 years Setting: Elderly care ward
Staffing required Control Room: 1 × technician 1 × patient voice 1 × debriefer
Manikin preparation Female patient, IV access Food around mouth and on front of gown Drug chart available with regular meds and oral antibiotics for urinary tract infection
Role players: 1 × FY1 plant
Equipment required High-fidelity life-size manikin, IV fluids, drugs: GTN, Aspirin, Clopidogrel, Clexane, Adrenaline, Amiodarone Resuscitation trolley, ECG, old CXR on admission, admission bloods, medical notes. Case description Ethel presented to A & E with a fall 2 days ago and she is currently on oral antibiotics for a presumed urinary tract infection. She has just been transferred to the elderly care unit for further assessment as her mobilisation on the ward was noted to be poor. The elderly care consultant has not yet seen her. Resuscitation status is undetermined. Ethel suddenly becomes confused and generally unwell whilst eating dinner (6 pm). She is sweaty, short of breath and appears in discomfort. PMHx: Type-II diabetes, angina, HTN, osteoporosis, OA, recurrent UTIs DHx: Metformin, Gliclazide, Ramipril, Alendronic Acid, Adcal D3. Allergies: NKDA SHx: Lives alone, independent ADLs, non-smoker, no alcohol She has developed an acute ST elevation MI. She will remain in a peri-arrest state on the ward. Simulator operation Patient starts off slightly tachycardic and sweaty. As scenario progresses patient becomes hypotensive, increasingly tachycardic and confused. Initial observations: BP 135/80 HR 110 Sats: 96% on air RR 20 GCS 14 (E4 M6 V4), Temp: 37.0
Available tests on request: ECG: Anterolateral ST elevation ABG results Admission blood results Admission CXR
Candidate briefing It is 6 pm on the Elderly Care Unit. Ethel has just been transferred to the ward on treatment for a UTI following a fall at home. She is awaiting assessment for a package of care and has not yet been seen by any of the elderly care team. She is noted to have stopped eating her dinner and appears agitated and confused. The FY1 asks you to review. FY1 plant role It is 6 pm on the Elderly Care Unit, you have been asked by the ward staff to review a patient who has become suddenly increasingly confused over having her dinner. As it is your first week in the job you are very worried and call your registrar immediately. You are able to find anything that is needed and call for help, but you cannot help with the diagnosis or treatment.
Figure 1. Example scenario, outlining resources and staffing requirements
REGISTRATION Pre-course questionnaire Learning outcomes and introduction to simulation Familiarisation with Mr/Mrs Simulator Scenario 1 and debrief Scenario 2 and debrief BREAK Scenario 3 and debrief Scenario 4 and debrief LUNCH Scenario 5 and debrief Scenario 6 and debrief Post-course questionnaire Review of the day END
70 per cent to detect an effect of θ = 0.7 (actual effect size 0.78). All candidates gave written informed consent for feedback data to be aggregated for research purposes in accordance with the terms of the Data Protection Act 1998. Ethical approval was given by the Hospital Research Ethics Committee (South London REC 3; approval ref. 09/28), under the terms of the UK NHS Research Ethics Service.
Figure 2. Example of course timetable
RESULTS abstractions, and disagreements were discussed and reconciled. Confidence ratings and ratings of the simulation experience were analysed using spss 19.0 (IBM, New York, USA). We did not assume homogeneity of variance or normality in scale items, and so these were analysed using non-parametric tests. The small study (n = 26) was powered at
Four similar courses were delivered between January and December 2012, with 26 candidates attending in total [21 specialist trainees in geriatric medicine (ST3–ST7) and five band–5 nurses working in elderly care]. The mean self-confidence ratings before and after the course, analysed using a Wilcoxon
signed ranks test for non-parametric data in a paired sample, showed post-course confidence to be significantly higher on all items, with an average improved confidence of around 12 per cent (Table 2). Mean evaluation scores (post-course only) on whether the course was educational, interesting, relevant to practice and useful for reflection were highly correlated (α = 0.901; seven items). The mean evaluation score overall was 4.46 (95% CI 4.28–4.63; where 1 = very poor and 5 = very good). Thematic analysis of ‘free-text’ feedback revealed three broad categories focusing on ‘geriatric medicine’, ‘dealing with acutely unwell patients’ and ‘non-technical skills’ (Box 1). The majority of responses were related to non-technical skills, all of which were judged not to have been taught as effectively by other learning media. Candidates commented that simulation was a valuable training modality, addressing areas of the curriculum rarely taught formally, such as continence assessment, end-of-life decision making and multidisciplinary situations. Candidates also commented that the course could be improved by incorporating longer scenarios and an increased use of video feedback and personal debriefing sessions.
DISCUSSION Specialist trainees in geriatric medicine are required to develop a variety of technical and nontechnical skills to facilitate their management of a complex and challenging patient population. The evolution of medical training in recent years, however, has resulted in a reduction in time available to develop these skills during clinical duties.5 Simulation is a useful method of facilitating experiential learning for specialist trainees in geriatric medicine, and was shown to be feasible. A geriatric-specific
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Table 2. Pre- and post-course confidence ratings for managing geriatric scenarios (n = 26) Mean (SD) pre-course confidence score
Mean (SD) post-course confidence score
Z; p
Entering new clinical situations
72.3 (18.6)
79.8 (14.2)
Z = 3; p < 0.01
Leadership
68.1 (22.3)
80.4 (12.8)
Z = 3.2; p < 0.001
Emergency management
65.2 (20.5)
77.9 (12.7)
Z = 3.5; p < 0.001
Continence management
55.6 (22.3)
74.2 (12.9)
Z = 3.9; p < 0.001
Multidisciplinary meetings
66.0 (19)
78.5 (14.1)
Z = 3.4; p < 0.001
Communication
74.4 (18.2)
81.1 (13.4)
Z = 2.5; p < 0.05
Managing agitated patients
64.6 (20)
78.7 (13)
Z = 3.9; p < 0.001
End-of-life decisions
67.1 (18)
77.7 (13.9)
Z = 3.6; p < 0.001
End-of-life communication
68.3 (19.5)
77.9 (13.9)
Z = 3; p < 0.01
Deploying non-technical skills
64.6 (18.3)
78.7 (12.2)
Z = 3.8; p < 0.001
Total
66.6 (17.5)
78.5 (12.5)
Z = 4.1; p < 0.001
Box 1. Thematic analysis of free-text comments with examples Theme 1: geriatric medicine ‘Keeping an open mind is vital when assessing elderly patients – remembering that elderly patients often have multiple problems/diagnoses‘ (ST3) ‘To give the confused patient space and try to talk to them on a more personal level’ (ST3) ‘Personally found continence scenario very useful’ (Grade not stated) ‘Systematic approach to deal with confused patients’ (Band–5 nurse) Theme 2: dealing with acutely unwell patients ‘Reassessment is vital when assessing/managing acutely unwell patients’ (ST3) ‘Skills to enhance ways to collect and act upon information in complex and high pressured clinical settings’. (ST3) Theme 3: comments relating to non-technical skills Communication – ‘communication is the key’ (Band–5 nurse) Teamwork – ‘Value of teamwork’ (Grade not stated) Taking a step back – ‘Stand back and think about the situation’ (Grade not stated) Delegation – ‘How to use other health professional in clinic areas’ (Band–5 nurse) Sharing ideas – ‘Importance of sharing the mental model’ (ST3) Decision making – ‘Making the decision for end-of-life scenario’ (ST4) Time management – ‘I enjoyed learning new techniques and skills on how to manage my time effectively’ (Band–5 nurse) Leadership – ‘…take leadership role as needed’ (ST7)
The requirements of a geriatricsspecific course affords the educational opportunity to use a full range of simulation modalities
simulation course allows trainees to reflect on technical and nontechnical skills, thus improving their confidence in working as part of a multidisciplinary team. This form of teaching is becoming more prevalent in all medical specialties, and is strongly supported by the Chief Medical Officer’s report (2008).8 Whereas simulation courses are typically reliant on high- or low-fidelity techniques, the requirements of a geriatrics-specific course affords the educational opportunity to use a full range of simulation modalities: high-fidelity, low-fidelity, part-task trainers, patient actors and role-play exercises. The results of these pilot courses are promising, with a reported improvement in trainees’ confidence in technical and non-technical skills. Overall, trainee opinion was supportive of simulation as a training tool in geriatric medicine; however, the benefits are limited by selfreporting, small sample size, a lack of formal feedback from patient actors and assessment of the candidates to demonstrate an
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Simulation training ... complements rather than replaces real-life experience
improvement in skills. In view of this, the findings are hard to generalise. In addition, although the course was offered to doctors and nurses, only one or two nurses attended each course (five in total), and all were of the same grade. For a fully interprofessional course we would have liked equal numbers of candidates as well as faculty members. It is important to note that although simulation training affords situational learning without compromising patient safety, it complements rather than replaces real-life experience.7 Further studies are required to assess the retention of the skills gained from the course, the efficacy of simulation compared with more traditional teaching modalities and the effects on patient outcomes. Additionally, the effects of repeated simulation experiences on longer-term learning outcomes require further exploration. Finally, although this course was designed for specialist trainees and nursing staff in geriatric medicine, it would be feasible to offer such a course to all other health professionals as an educational tool for improving competencies in managing elderly patients.
CONCLUSIONS Given the recent reports highlighting failings in the care of elderly patients,1,10 it is crucial that trainees in geriatric medicine are given opportunities to practise the skills stipulated in the specialist training curriculum.4 Simulation is a useful teaching tool that may be used to improve these skills, and we would support its incorporation into specialist training schemes in geriatric medicine. REFERENCES 1. Mid Staffordshire NHS Foundation Trust 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry – Executive Summary. London: Crown Copyright. 2. British Geriatrics Society. BGS responds to the Francis Report. 6 February 2013. Available at http://www.bgs.org.uk/index.php/ press/2410-bgs-francis-report. Accessed on 24 September 2013. 3. Ross AJ, Anderson JE, Kodate N, Thomas L, Thompson K, Thomas B, Key S, Jensen H, Schiff R, Jaye P. Simulation training for improving the quality of care for older people: an independent evaluation of an innovative programme for inter-professional education. BMJ Qual Saf 2013;22:495–505. 4. Joint Royal Colleges of Physicians Training Board. Specialty training
curriculum for geriatric medicine curriculum. London: Joint Royal Colleges of Physicians Training Board; 2010. 5. Professor Sir John Temple. Time for Training. A Review of the impact of the European Working Time Directive on the quality of training. May 2010. Available at http:// www.mee.nhs.uk/PDF/14274%20 Bookmark%20Web%20Version.pdf. Accessed on 24 September 2013. 6. Chakravarthy B, Haar ET, Bhat SS, McCoy CE, Denmark TK, Lotfipour S. Simulation in Medical School Education: Review for Emergency Medicine. West J Emerg Med 2011;12:461–466. 7. Gaba D, Howard S, Fish K, Smith B, Sowb Y. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience. Simulat Gaming 2001;32:175–193. 8. Sir Liam Donaldson. Safer Medical Practice in Chief Medical Officer’s Annual Report 2008. Available at http://www.avon.nhs.uk/kris/_ Docs/CMO%20report.pdf. Accessed on 24 September 2013. 9. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77–101. 10. National Confidential Enquiry into Patient Outcome and Death. Elective & Emergency Surgery in the Elderly: An Age Old Problem 2010. Available at http://www.ncepod. org.uk/2010report3/downloads/ EESE_fullReport.pdf. Accessed on 24 September 2013.
Corresponding author’s contact details: Dr Zehra Mehdi, Department of Ageing & Health, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, UK. E-mail: [email protected]
Funding: None. Conflict of interest None. Ethical approval: Candidates gave written, informed consent for feedback data to be aggregated for research purposes, in accordance with the terms of the Data Protection Act 1998. Ethical approval was given by the Hospital Research Ethics Committee (South London REC3; approval ref. 09/28), under the terms of the UK NHS Research Ethics Service. doi: 10.1111/tct.12156
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