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Vicki LeBlanc PhD (University of Toronto) introduces us to her data on feedback and enhanced hybrid simulation learning on communication skills. Her expertise is in Human Factors and Decision-making particularly in stressed and non-ideal situations.
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Does It Work?..and Why?Research into the effectiveness of
simulation as a teaching tool
Vicki R LeBlanc, PhDWilson Centre; University of Toronto
SIMULATION
The representation or reproduction of something real by imitation
Physical objects (task trainers)
Process or skill (suturing)
People (standardized patients, confederates)
Environments (virtual worlds, immersive simulation)
SIMULATION
• Struggle - resources, access, time, funding, etc…
• Position papers & advocacy (Ziv, Gaba, Reznick, etc..)
• Climate of scepticism
1980S-MID 2000S
• National/International Societies
• Simulation Conferences & Courses
• Accreditation Standards
2011: CLIMATE OF LEGITIMACY
….Important role in acceptance
RESEARCH
• Robust acceptance by trainees • Enhanced learning • Transfer to clinical setting
RESEARCH EVIDENCE
Educators and students exposed to mannequin-based simulation85% of students & 85% of educators rated session as excellent
> 80% sim-based training should be required for all medical students
Gordon et al., Acad Med 2001
ROBUST ACCEPTANCE
• Robust acceptance by trainees • Enhanced learning • Transfer to clinical setting
RESEARCH EVIDENCE
D Tabak, CA Moulton, A Birze, H MacRae, D Nestel, R Kneebone, V LeBlanc
ENHANCED LEARNING USING HYBRID SIMULATIONS
Specific Research Aims
To determine the effectiveness of
the hybrid simulation in teaching
communication and interpersonal
skills to medical students and
surgical residents
Study Design
4th Year Medical Students
N = 16
PGY1Surgery
ResidentsN = 16
Wound Closure Drunk and Angry
Urinary Catheterization Uncomfortable
Patient Feedback
Volar Cast Irritated
Skin Lesion Blind and Afraid
Pre-Test Post -Test
No Feedback
Outcome Measures
Validated communication scale (2 blinded raters)
EmpathyResponse to patient’s feelings and needs
CoherencePlan and organization of the interview
Verbal ExpressionCommand of language
Non Verbal ExpressionEngagement with non verbal expression
Hodges B. Med Teach 2003; 25:250-254
Validated technical scales
0
10
20
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50
60
70
80
90
100
overall emphathy cohesion verbal non-verbal
Communication Scores: Pre Intervention
No Feedback
Feedback
%
No main effect of feedback p=.752
0
10
20
30
40
50
60
70
80
90
100
overall empathy cohesion verbal non-verbal
* *
Significant effect of feedback p<0.05
Communication Scores: Post Intervention
* * *No Feedback
Feedback
%
Technical Scores: GRS
No Feedback
Feedback
%
Pre Post
0
10
20
30
40
50
60
70
80
90
100
catheter-pre wound-pre skin exc-post cast-post
0
10
20
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100
Cath Wound Skin Cast
No Feedback
Feedback
Technical Scores: Checklist
%
Pre Post
IPPI can be used to deliver effective formative feedback
Feedback > Exposure
Improvements not at cost of non-intervention skill
Conclusions
The advantages of simulation-based education lead to enhanced performance and clinical care
TRANSFER TO CLINICAL SETTING
ENHANCED LEARNING
20 anesthesiology residents; 2-h training session: - High-fidelity simulation-based training - Interactive seminar
Each trainee then weaned patients from CPB - within 2 weeks (posttest) - within 5 weeks (retention test)
Bruppacher et al., Anesthesiology; 2010
Post Test Retention
Non technical
skills
Clinical checklist
Non technical
skills
Clinical checklist
Seminar11.8 75.4 11.7 77.0
Simulation 14.3 89.9 14.1 93.2
TRANSFER TO CLINICAL SETTING
Simulation-based learning of central line insertions
- Greater success
- Reduced complications
- Reduced infection rates
Barsuk et al; Arch Intern Med; 2009
BUT…..Some evidence of lack of improvements:
Olympio (2003): no improvement in management of intubation
Borges (2010): no changes in management of “cannot intubate,
cannot ventilate” scenarios
Wenk (2009): simulation not better than PBL for intubation
Not possible to state that simulation, itself, IS or IS NOT effective for learning
Important to understand what elements of simulation facilitate learning
It’s no longer a question of
IF
But a question of
HOW
FEEDBACKIMPORTANT CHARACTERISTICS
Key element to learning and skill acquisition without debriefing, students fail to learn
Issenberg et al. (2005) Medical Teacher; Stefanidis et a.l (2007) Surgery Xeroulis et al. (2007) Surgery; Walsh et al. (2009) Academic Medicine
FEEDBACK
Medical students learning suturing and knot tying skill
Control group: practice with no feedback
Concurrent: feedback as student performs the task
Summary: feedback after completion of the task
SUMMARY VS CONCURRENT FEEDBACK
Xeroulis et al., 2006; Surgery
Immediate post-test:
• Control < Concurrent = Summative
1-month retention test:
• Control = Concurrent < Summative
RESULTS
Continuous, intensive feedback inhibits learning:
• Over-guidance: learners overly depend on feedback and perform poorly in it’s absence
• Inhibits intrinsic learning strategies and problem solving activities necessary to master skills
NOT JUST ANY FEEDBACK
PRACTICEIMPORTANT CHARACTERISTICS
Podcast Study- In Progress
How to optimize podcasts in health professions education
• Mental practice:
-cognitive rehearsal of the steps in a tasks without overt physical movement
• Modeling:
-Viewing of a demonstration of what needs to be learned
Fahad Alam, Sylvain Boet, Vicki LeBlanc
Pre-Test (Multiple Choice)
Randomization
PodcastNo Mental Practice No Modeling
(n=15)
Podcast With Mental Practice No Modeling
(n=15)
Podcast No Mental Practice With Modeling
(n=15)
Podcast With Mental Practice With Modeling
(n=15)
Post-Test (Multiple Choice)
Basic Airway Management Simulation Scenario
Preliminary results
Data collection: mid-point, with 7-8 per group
MCQ improvements:
Control < Mental Practice = Modeling < MP and Modeling
Summary
Significant scholarship in simulation over 20 years
- Learner reactions
- Can lead to improved performance
- Learning transfers to clinical setting
Important focus of current research…
…understanding how to optimize simulation-based learning
“The field of patient simulation has gotten to where it is now because it
makes sense, but we need more science behind it to guide its use.”
Jim Gordon
