Simulation
The ‘gut bucket’: a novel training tool for standardised patients Karen Delaney-Laupacis, Kerri Weir and Diana Tabak, Standardized Patient Program, University of Toronto, Ontario, Canada
SPs may lack knowledge of basic anatomy and physiology that can hamper their portrayal
SUMMARY Background: Standardised patients (SPs) are often asked to portray complex physical roles in which authenticity is paramount; however, SPs come from a variety of backgrounds, and may lack knowledge of basic anatomy and physiology that can hamper their portrayal. This lack of knowledge can lead to gaps in accuracy and credibility. Context: In our efforts to bridge the gap and create training that would lead to authentic and confident portrayals, we developed the ‘gut bucket’. This threedimensional learning tool is
tactile, portable, simple and affordable. Innovation: The ‘gut bucket’ has life-size abdominal organs made from fabric resting in a standard plastic washbasin. The organs can be easily removed and manipulated to simulate different disease states (for example: appendicitis, kidney stones or cholecystitis). The tool is visually engaging and durable, encouraging SPs to handle the organs and become familiar with their size and placement within the basin and on themselves. Implications: The SPs in our programme found that the
‘gut bucket’ provided a deeper level of knowledge, made them more confident in their portrayal and enhanced their experience, and they generally preferred the ‘gut bucket’ over traditional methods of training. This was demonstrated using ‘gut bucket’ training evaluation forms. The ‘gut bucket’ can easily be incorporated into training sessions to provide a kinaesthetic approach as well as increased engagement for the SPs. We hope others may benefit by sharing our experience with the ‘gut bucket’.
120 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123
tct_12077.indd 120
3/6/2014 2:58:55 PM
INTRODUCTION
METHOD
S
Constructivist socio-cultural learning theories,4,5 such as Lewin and Kolb (cycles of learning) and Knowles (adult learning), tell us that deep learning is meaning based, requires active involvement and is experience centred.6–8
tandardised patients (SPs) may have difficulty portraying complex abdominal roles.1,2 Most often SPs complain of inadequate knowledge and difficulty remembering when or why certain simulations must occur. For example, Murphy’s sign: ‘I couldn’t remember where it was supposed to hurt when they asked me to take a big breath while they pushed on my ribcage.’ Some SPs report feelings of anxiety and confusion when they are playing difficult physical roles (‘I never know when I am supposed to say “ouch” with rebound tenderness.’) In these situations accuracy and credibility may be compromised, potentially jeopardising the learner’s experience. In our programme, SP training traditionally incorporates text, pictures and videos3; however, SP and examiner feedback indicated that when training for difficult physical roles, these resources were not enough (‘Rebound tenderness was not done correctly’). We wanted to better prepare SPs, but were unsure how to do this. Our literature search only provided us with more text and videos. We wanted a different approach, something threedimensional to engage SPs kinaesthetically, but we did not have the resources for the models currently available on the market. We wanted the SPs to be able to feel comfortable taking out various organs and getting a real sense of how big it was, how it fits in their abdomen and, if it was enlarged, how it would impact the other organs. We were able to make our own model inexpensively to amplify existing training resources and accommodate different adult learning styles. The simplicity and nominal cost of the ‘gut bucket’ helps create a non-threatening environment where engagement and learning happens easily.
The ‘gut bucket’ takes learning beyond mere memorisation (surface learning) to a constructivist approach that actively engages SPs by allowing them to manipulate the organs within the basin and place the organs on themselves, as well as understand the anatomical placement of organs within the abdomen. For example, inflating the lungs in the ‘gut bucket’ causes the diaphragm to move down, causing the liver to also move down, and allowing an enlarged gall bladder to be palpated. In other words: Murphy’s sign. After such a demonstration SPs can really see and understand why they must ‘catch’ their breath upon inhalation if the learner is palpating their liver edge. Many SPs found once they were able to experience Murphy’s sign in the ‘gut bucket’ they could better simulate this. The SPs enjoyed seeing, for example, where the kidneys are located on themselves, and how a very small kidney stone can block a ureter, leading to extreme back pain or costovertebral angle pain, ‘I never knew why I had to jump when they tap on my back while playing a kidney stone role.’ This familiarity with the organs helped to develop a stronger connection with their body and increased their confidence in playing abdominal roles.
CONSTRUCTION OF THE MODEL (Vodcast available www.theclinicalteacher.com then click ‘read’)
• Tape in place a paper towel inner tube, cut in half lengthwise, to indicate the spine. • Cut slits on each side of the washbasin where the diaphragm will be secured.
‘I never know when I am supposed to say “ouch” with rebound tenderness’
• Using the top of a pair of pantie hose, insert the diaphragm through the slits and tape into place on the outside of the washbasin (Figure 1). Lungs • Cut 29 cm of clear plastic tubing into three pieces: an 11-cm piece for the trachea and two 9-cm pieces for the bronchi. • Assemble trachea and bronchi to a copper pipe tee and attach balloons to the ends of the bronchi for the lungs. • Cut a hole in the top of the washbasin and insert the trachea (Figure 1). Heart • Fill a red balloon with barley until it is fist sized or weighs 310 g. • Tape a 6-cm plastic cup into the basin, just left of the spine, to elevate the heart. • Tape the heart to the cup (Figure 1). Kidneys • Construct a kidney pattern (5.5 cm × 10 cm). • Pin pattern to fabric and cut, sew and stuff with fiberfill. • Pin a 25-cm piece of 3-mm rubber tubing to each kidney for the ureters. (Note: left kidney is higher than the right because of the liver; Figure 1.) Liver and gallbladder
Abdominal cavity
• Construct a liver pattern (22/26 cm × 14/16 cm).
• Use a plastic washbasin (43 cm × 35 cm) for the cavity.
• Pin pattern to fabric and cut, sew and stuff with fiberfill.
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123 121
tct_12077.indd 121
3/6/2014 2:58:56 PM
The ‘gut bucket’ takes learning beyond mere memorisation
Heart
Lungs
Diaphragm Kidneys
Large and small intestine • Make large intestine (1.5 m) by cutting the legs off of a pair of pantie hose, and fill with fiberfill. Attach the two open ends together to make one long piece. • To make appendix, knot the tip of the toe at one end of the pantie hose (10 cm length × 7 mm diameter, if normal). • For the small intestine you will need 7 m of soft foam tubing.
Figure 1. Plastic washbasin with lungs, heart and kidney in place
• Connect large intestine to small intestine and the small intestine to the stomach with twist ties (Figure 3). Ribs Stomach
Liver
Pancreas
Gallbladder Figure 2. Liver, gallbladder, pancreas and stomach added to washbasin
• Cut the ribs out of a large piece of mylar or sculpt them out of wire and white sports tape. • Attach a small hinge to the ribs and tape the hinge to the basin just above the hole for the trachea. (The hinge enables the ribs to be opened so that the organs can be better observed; Figure 3).
Ribs
Spleen • Construct a spleen pattern (7 cm × 11/12 cm, flat and squishy). Small intestines
Large intestines
• Pin pattern to fabric and cut, sew and stuff with fiberfill or cut the spleen out of a thin kitchen sponge. • Tuck the spleen underneath the ninth and 12th left ribs, laterally.
Figure 3. Large and small intestines, and ribs, added to the washbasin
• Construct gallbladder by using a funnel to fill a green balloon with barley until about 8 cm long and 4 cm wide, if fully distended, and can hold 50 ml.
• Pin pattern to fabric and cut, sew and stuff with fiberfill (Figure 2).
• Pin the gallbladder into place on the backside of the liver (Figure 2).
• Construct a stomach pattern (about fist sized).
Pancreas • Construct a pancreas pattern (12/16 cm and carrot shaped).
Stomach
• Pin pattern to fabric and cut, sew and stuff with fiberfill. • Cut a hole in the diaphragm to insert the upper end of the stomach (Figure 2).
RESULTS The SPs were asked to complete evaluations of the ‘gut bucket’ anonymously after being trained on various abdominal roles. The evaluations contained five questions as well as a recommendation for the tool and written feedback (Table 1). SPs were asked to score the questions using a five-point Likert scale (5, ‘strongly agree’; 1, ‘strongly disagree’), and 10 evaluations were returned and tabulated.
122 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123
tct_12077.indd 122
3/6/2014 2:58:56 PM
Table 1. ‘Gut bucket’ training evaluation form Questions
1 2 Strongly disagree
3
4
The gut bucket is a useful training tool
5 Strongly agree 10
I prefer the gut bucket as a training tool to diagrams and videos
1
2
7
Training with the gut bucket deepened my knowledge of the relevant abdominal anatomy
10
Interactivity with the gut bucket enhanced my overall experience
10
I feel more confident in my portrayal as a result of training with the gut bucket
10
All of the SPs strongly agreed that the ‘gut bucket’ is helpful. All of the SPs said they would recommend the ‘gut bucket’ to other learners. Positive feedback comments included: ‘…much better experience than a drawing or discussion’, ‘very helpful’, ‘experiential is very important’, ‘relevant’ and ‘creative and engaging’. Limitations The model is a very basic representation of the human abdominal organs, and was designed specifically for the training needs of the SPs in our programme. The ‘gut bucket’ was not intended to be a completely accurate representation of the human abdomen, but rather a tool to facilitate the simulation of physical roles. The evaluations were very encouraging; however, the sample size was small.
DISCUSSION Building the ‘gut bucket’ was a powerful learning experience for us as SP trainers. During the assembly we were struck by the possibilities for this tool. Suddenly, training rebound tenderness became easy, the simulation of appendicitis
became simple and other complex portrayals no longer required long searches for the perfect video or picture. This simple tool added a new level of enthusiasm and engagement to our training sessions. We have presented a novel, experiential, inexpensive and practical training tool for training abdominal physical roles. The SPs reported that training with this tool improved their knowledge and confidence in accurately portraying abdominal roles, and preferred this method over the traditional approach with text and pictures. We recognise that a larger sample size is needed; however, the low cost and practicality of the ‘gut bucket’ make this a very accessible tool. The ‘gut bucket’ has generated interest from other SP programmes as well as health care teaching programmes with limited resources. We are currently working on adding a genito-urinary component to the ‘gut bucket’. Please contact the authors for a complete step-by-step instruction manual, with patterns and pictures.
Low cost and practicality of the ‘gut bucket’ make this a very accessible tool
REFERENCES 1.
Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. Acad Med 1993;68:443–451.
2.
Nestel D, Layat Burn C, Pritchard S, Glastonbury R, Tabak D. Viewpoint: The use of simulated patients in medical education. AMEE Guide 42; 2011.
3.
Standardized Patient Program. Available at http://www.spp.utoronto.ca. Accessed on 1 September 2012.
4.
Jarvis P, Holford J, Griffin C, eds. The Theory and Practice of Learning. London: RoutledgeFalmer; 2005; pp. 32–75.
5.
Lieb S. Principles of adult learning. Vision 1991; Fall. Available at http://honolulu. hawaii.edu/intranet/committe/ FacDevCom/guidebk/teachtip/ adults-2.htm. Accessed on 10 February 2013.
6.
Knowles M. The Adult Learner: A Neglected Species. 4th ed. Houston: Gulf Publishing; 1990.
7.
Kolb DA. Experiential learning as the science of learning and development. Englewood Cliffs (NJ): Prentice Hall; 1984.
8.
Bruner JS. Toward a Theory of Instruction. Cambridge (Mass): Harvard University Press; 1967.
Corresponding author’s contact details: Karen Delaney-Laupacis, Standardized Patient Program, University of Toronto, 88 College St, Toronto, M4G 1H1, Ontario, Canada. E-mail: [email protected]
Funding: None. Conflict of interest: None. Ethical approval: Not required. doi: 10.1111/tct.12077
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123 123
tct_12077.indd 123
3/6/2014 2:58:59 PM
The ‘gut bucket’: a novel training tool for standardised patients Karen Delaney-Laupacis, Kerri Weir and Diana Tabak, Standardized Patient Program, University of Toronto, Ontario, Canada
SPs may lack knowledge of basic anatomy and physiology that can hamper their portrayal
SUMMARY Background: Standardised patients (SPs) are often asked to portray complex physical roles in which authenticity is paramount; however, SPs come from a variety of backgrounds, and may lack knowledge of basic anatomy and physiology that can hamper their portrayal. This lack of knowledge can lead to gaps in accuracy and credibility. Context: In our efforts to bridge the gap and create training that would lead to authentic and confident portrayals, we developed the ‘gut bucket’. This threedimensional learning tool is
tactile, portable, simple and affordable. Innovation: The ‘gut bucket’ has life-size abdominal organs made from fabric resting in a standard plastic washbasin. The organs can be easily removed and manipulated to simulate different disease states (for example: appendicitis, kidney stones or cholecystitis). The tool is visually engaging and durable, encouraging SPs to handle the organs and become familiar with their size and placement within the basin and on themselves. Implications: The SPs in our programme found that the
‘gut bucket’ provided a deeper level of knowledge, made them more confident in their portrayal and enhanced their experience, and they generally preferred the ‘gut bucket’ over traditional methods of training. This was demonstrated using ‘gut bucket’ training evaluation forms. The ‘gut bucket’ can easily be incorporated into training sessions to provide a kinaesthetic approach as well as increased engagement for the SPs. We hope others may benefit by sharing our experience with the ‘gut bucket’.
120 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123
tct_12077.indd 120
3/6/2014 2:58:55 PM
INTRODUCTION
METHOD
S
Constructivist socio-cultural learning theories,4,5 such as Lewin and Kolb (cycles of learning) and Knowles (adult learning), tell us that deep learning is meaning based, requires active involvement and is experience centred.6–8
tandardised patients (SPs) may have difficulty portraying complex abdominal roles.1,2 Most often SPs complain of inadequate knowledge and difficulty remembering when or why certain simulations must occur. For example, Murphy’s sign: ‘I couldn’t remember where it was supposed to hurt when they asked me to take a big breath while they pushed on my ribcage.’ Some SPs report feelings of anxiety and confusion when they are playing difficult physical roles (‘I never know when I am supposed to say “ouch” with rebound tenderness.’) In these situations accuracy and credibility may be compromised, potentially jeopardising the learner’s experience. In our programme, SP training traditionally incorporates text, pictures and videos3; however, SP and examiner feedback indicated that when training for difficult physical roles, these resources were not enough (‘Rebound tenderness was not done correctly’). We wanted to better prepare SPs, but were unsure how to do this. Our literature search only provided us with more text and videos. We wanted a different approach, something threedimensional to engage SPs kinaesthetically, but we did not have the resources for the models currently available on the market. We wanted the SPs to be able to feel comfortable taking out various organs and getting a real sense of how big it was, how it fits in their abdomen and, if it was enlarged, how it would impact the other organs. We were able to make our own model inexpensively to amplify existing training resources and accommodate different adult learning styles. The simplicity and nominal cost of the ‘gut bucket’ helps create a non-threatening environment where engagement and learning happens easily.
The ‘gut bucket’ takes learning beyond mere memorisation (surface learning) to a constructivist approach that actively engages SPs by allowing them to manipulate the organs within the basin and place the organs on themselves, as well as understand the anatomical placement of organs within the abdomen. For example, inflating the lungs in the ‘gut bucket’ causes the diaphragm to move down, causing the liver to also move down, and allowing an enlarged gall bladder to be palpated. In other words: Murphy’s sign. After such a demonstration SPs can really see and understand why they must ‘catch’ their breath upon inhalation if the learner is palpating their liver edge. Many SPs found once they were able to experience Murphy’s sign in the ‘gut bucket’ they could better simulate this. The SPs enjoyed seeing, for example, where the kidneys are located on themselves, and how a very small kidney stone can block a ureter, leading to extreme back pain or costovertebral angle pain, ‘I never knew why I had to jump when they tap on my back while playing a kidney stone role.’ This familiarity with the organs helped to develop a stronger connection with their body and increased their confidence in playing abdominal roles.
CONSTRUCTION OF THE MODEL (Vodcast available www.theclinicalteacher.com then click ‘read’)
• Tape in place a paper towel inner tube, cut in half lengthwise, to indicate the spine. • Cut slits on each side of the washbasin where the diaphragm will be secured.
‘I never know when I am supposed to say “ouch” with rebound tenderness’
• Using the top of a pair of pantie hose, insert the diaphragm through the slits and tape into place on the outside of the washbasin (Figure 1). Lungs • Cut 29 cm of clear plastic tubing into three pieces: an 11-cm piece for the trachea and two 9-cm pieces for the bronchi. • Assemble trachea and bronchi to a copper pipe tee and attach balloons to the ends of the bronchi for the lungs. • Cut a hole in the top of the washbasin and insert the trachea (Figure 1). Heart • Fill a red balloon with barley until it is fist sized or weighs 310 g. • Tape a 6-cm plastic cup into the basin, just left of the spine, to elevate the heart. • Tape the heart to the cup (Figure 1). Kidneys • Construct a kidney pattern (5.5 cm × 10 cm). • Pin pattern to fabric and cut, sew and stuff with fiberfill. • Pin a 25-cm piece of 3-mm rubber tubing to each kidney for the ureters. (Note: left kidney is higher than the right because of the liver; Figure 1.) Liver and gallbladder
Abdominal cavity
• Construct a liver pattern (22/26 cm × 14/16 cm).
• Use a plastic washbasin (43 cm × 35 cm) for the cavity.
• Pin pattern to fabric and cut, sew and stuff with fiberfill.
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123 121
tct_12077.indd 121
3/6/2014 2:58:56 PM
The ‘gut bucket’ takes learning beyond mere memorisation
Heart
Lungs
Diaphragm Kidneys
Large and small intestine • Make large intestine (1.5 m) by cutting the legs off of a pair of pantie hose, and fill with fiberfill. Attach the two open ends together to make one long piece. • To make appendix, knot the tip of the toe at one end of the pantie hose (10 cm length × 7 mm diameter, if normal). • For the small intestine you will need 7 m of soft foam tubing.
Figure 1. Plastic washbasin with lungs, heart and kidney in place
• Connect large intestine to small intestine and the small intestine to the stomach with twist ties (Figure 3). Ribs Stomach
Liver
Pancreas
Gallbladder Figure 2. Liver, gallbladder, pancreas and stomach added to washbasin
• Cut the ribs out of a large piece of mylar or sculpt them out of wire and white sports tape. • Attach a small hinge to the ribs and tape the hinge to the basin just above the hole for the trachea. (The hinge enables the ribs to be opened so that the organs can be better observed; Figure 3).
Ribs
Spleen • Construct a spleen pattern (7 cm × 11/12 cm, flat and squishy). Small intestines
Large intestines
• Pin pattern to fabric and cut, sew and stuff with fiberfill or cut the spleen out of a thin kitchen sponge. • Tuck the spleen underneath the ninth and 12th left ribs, laterally.
Figure 3. Large and small intestines, and ribs, added to the washbasin
• Construct gallbladder by using a funnel to fill a green balloon with barley until about 8 cm long and 4 cm wide, if fully distended, and can hold 50 ml.
• Pin pattern to fabric and cut, sew and stuff with fiberfill (Figure 2).
• Pin the gallbladder into place on the backside of the liver (Figure 2).
• Construct a stomach pattern (about fist sized).
Pancreas • Construct a pancreas pattern (12/16 cm and carrot shaped).
Stomach
• Pin pattern to fabric and cut, sew and stuff with fiberfill. • Cut a hole in the diaphragm to insert the upper end of the stomach (Figure 2).
RESULTS The SPs were asked to complete evaluations of the ‘gut bucket’ anonymously after being trained on various abdominal roles. The evaluations contained five questions as well as a recommendation for the tool and written feedback (Table 1). SPs were asked to score the questions using a five-point Likert scale (5, ‘strongly agree’; 1, ‘strongly disagree’), and 10 evaluations were returned and tabulated.
122 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123
tct_12077.indd 122
3/6/2014 2:58:56 PM
Table 1. ‘Gut bucket’ training evaluation form Questions
1 2 Strongly disagree
3
4
The gut bucket is a useful training tool
5 Strongly agree 10
I prefer the gut bucket as a training tool to diagrams and videos
1
2
7
Training with the gut bucket deepened my knowledge of the relevant abdominal anatomy
10
Interactivity with the gut bucket enhanced my overall experience
10
I feel more confident in my portrayal as a result of training with the gut bucket
10
All of the SPs strongly agreed that the ‘gut bucket’ is helpful. All of the SPs said they would recommend the ‘gut bucket’ to other learners. Positive feedback comments included: ‘…much better experience than a drawing or discussion’, ‘very helpful’, ‘experiential is very important’, ‘relevant’ and ‘creative and engaging’. Limitations The model is a very basic representation of the human abdominal organs, and was designed specifically for the training needs of the SPs in our programme. The ‘gut bucket’ was not intended to be a completely accurate representation of the human abdomen, but rather a tool to facilitate the simulation of physical roles. The evaluations were very encouraging; however, the sample size was small.
DISCUSSION Building the ‘gut bucket’ was a powerful learning experience for us as SP trainers. During the assembly we were struck by the possibilities for this tool. Suddenly, training rebound tenderness became easy, the simulation of appendicitis
became simple and other complex portrayals no longer required long searches for the perfect video or picture. This simple tool added a new level of enthusiasm and engagement to our training sessions. We have presented a novel, experiential, inexpensive and practical training tool for training abdominal physical roles. The SPs reported that training with this tool improved their knowledge and confidence in accurately portraying abdominal roles, and preferred this method over the traditional approach with text and pictures. We recognise that a larger sample size is needed; however, the low cost and practicality of the ‘gut bucket’ make this a very accessible tool. The ‘gut bucket’ has generated interest from other SP programmes as well as health care teaching programmes with limited resources. We are currently working on adding a genito-urinary component to the ‘gut bucket’. Please contact the authors for a complete step-by-step instruction manual, with patterns and pictures.
Low cost and practicality of the ‘gut bucket’ make this a very accessible tool
REFERENCES 1.
Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. Acad Med 1993;68:443–451.
2.
Nestel D, Layat Burn C, Pritchard S, Glastonbury R, Tabak D. Viewpoint: The use of simulated patients in medical education. AMEE Guide 42; 2011.
3.
Standardized Patient Program. Available at http://www.spp.utoronto.ca. Accessed on 1 September 2012.
4.
Jarvis P, Holford J, Griffin C, eds. The Theory and Practice of Learning. London: RoutledgeFalmer; 2005; pp. 32–75.
5.
Lieb S. Principles of adult learning. Vision 1991; Fall. Available at http://honolulu. hawaii.edu/intranet/committe/ FacDevCom/guidebk/teachtip/ adults-2.htm. Accessed on 10 February 2013.
6.
Knowles M. The Adult Learner: A Neglected Species. 4th ed. Houston: Gulf Publishing; 1990.
7.
Kolb DA. Experiential learning as the science of learning and development. Englewood Cliffs (NJ): Prentice Hall; 1984.
8.
Bruner JS. Toward a Theory of Instruction. Cambridge (Mass): Harvard University Press; 1967.
Corresponding author’s contact details: Karen Delaney-Laupacis, Standardized Patient Program, University of Toronto, 88 College St, Toronto, M4G 1H1, Ontario, Canada. E-mail: [email protected]
Funding: None. Conflict of interest: None. Ethical approval: Not required. doi: 10.1111/tct.12077
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123 123
tct_12077.indd 123
3/6/2014 2:58:59 PM
