Learning objectives

Simulation sessions have two main learning objectives that place equal importance on preventing error and ensuring a safe and effective task performance.

1. To improve the clinical knowledge and understanding necessary to diagnose, manage and treat a neurological emergency. In a sense, this is traditional book learning and factual knowledge.

2. To improve awareness and understanding of human factors or non-technical skills, and how these affect performance. Such factors include the cognitive abilities required for task management and decision-making, as well as social and interpersonal skills, including teamwork, communication and leadership (table 1). This is all about bringing the best out of the team, for example, persuading one person to organise and scan while another phones for a collateral history, while yet another assesses the patient.

Communication within the team is vital; communication failure is a root cause of most adverse events. Clear communication involves stating the obvious and announcing what you are doing, avoiding pronouns (he, she, it, they) and repeating information back to ensure it is correct (e.g. ‘You have just told me to give 1 mg of lorazepam’). It is important to state clearly what you want from someone using ‘closed loop communication’ (e.g. ‘Please phone the patient’s wife and ask the last time she saw him well. Then come back and tell me the answer’). It is vital that all members of the team clearly articulate safety concerns and listen to others. All team members must conceptualise that flat hierarchies improve communication. If one person dominates, others may feel inhibited and not feel confident to say something important; even the most ‘junior’ member must feel empowered to speak up (e.g. ‘The oxygen saturation is dropping on the monitor’). However, a typical group hierarchy is where one person dominates. A flat hierarchy is one where everyone is equal and respected so that everyone can be heard. This also requires assertive communication where appropriate from all team members. Team members must understand the importance of making themselves heard.

The simulation session starts with a brief overview covering human factors, as the learners are often less familiar with these. Once the learners understand the session’s objectives, the faculty can help individuals to identify which learning objectives to focus on in the session. For example, a nurse may be tasked with performing the first set of observations and then providing an SBAR (situation, background, assessment, recommendation) handover to the core trainee. The core trainee would focus on ABCDE assessment and assertive communication to the specialist trainee. The specialist trainee may have a specific clinical objective, for example, managing a seizure while focusing on their own leadership. This particularly helps in a multiprofessional setting with learners of different experience. It is essential to have drawn faculty members from different professions and with different levels of experience to ensure that all learners receive appropriate learning objectives; it is not simply a case of consultant neurologists giving all staff their learning objectives.

Scenario design

Suitable acute neurology clinical scenarios for simulation training include myasthenic crisis, acute basilar artery occlusion, status epilepticus, subarachnoid haemorrhage, acute bacterial meningitis and brain death.3 We have developed a high-fidelity simulation training programme with three acute neurology scenarios: refractory status epilepticus, coma and neuromuscular respiratory failure. Each scenario was carefully created and tailored to the learner group—doctors (core and specialist trainees), nurses and physician associates. We provided information so that each group understood where the scenario started (e.g. you are working in the emergency department and have been asked to see this 75-year-old man). We drew up a full patient synopsis for the faculty, including medication, medical history, social history and allergies. Before running the scenario, we programmed the physiological variables (non-invasive blood pressure, ECG, oxygen saturation and temperature) and set up the equipment in the room. We collated available investigations (laboratory and imaging) that learners could request. We rehearsed scenario progression possibilities (e.g. if the team give glyceryl trinitrate the blood pressure will return to normal, but if they do not treat the blood pressure it will rise and the monitor will show new ischaemic change). Each scenario had specific learning outcomes and debriefing points tailored to the learning groups (e.g. medical or nursing) (table 2) but the faculty could alter scenarios and vary them in real time according to the individual learners’ actions and learning objectives.

Running the session

We run sessions over 4 hours with seven learners from medical and nursing backgrounds and a minimum of three faculty members. The faculty members need to be pluripotent and to reflect the nature of the learners (e.g. consultant, specialist trainee and band 7 practice development nurse).

It is important to start each session with an introduction to the high-fidelity simulation manikin so that learners can become familiar with what the manikin can do and its limitations before experiencing the scenarios. Our manikins can respond physiologically with changes in breathing rate, heart rate, blood pressure and pupils but cannot manifest focal neurology. It is possible to run preprogrammed scenarios that faculty members can vary in real time. The manikin has a voice box so faculty members can speak for the patient, simulating what they might say or trying to mimic dysphasia. As the scenario develops, the participants need to interact with the outside world as they would in real life. They may need to phone the intensive care unit or radiology to request a scan. They may need to ask advice, say, from the cardiology registrar. They may need to request urgent attendance by an anaesthetist. Faculty members, therefore, also take on these other roles (such as switchboard and other medical professionals) and provide collateral history on the phone where necessary. A faculty member may enter the simulation lab as a senior figure to assist, if the scenario has hit a snag or if the participants have requested a particular person (e.g. the respiratory registrar).

While the scenario is in progress, other learners observe through a one-way mirror with audio connection and can simultaneously view physiological monitoring and investigation results (figure 2). We provide an observer sheet to prompt their observations, to permit them to make clear annotations and also to highlight the non-technical skills that they might exhibit (table 2). Because the non-technical skills (communication, situation awareness, decision-making and leadership) are often a new concept to the learner, we provide simple observational checklists to allow them to provide feedback to their peers.

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Figure 2

Running the scenario. Learner in the simulation suite (A) while faculty monitor and interact in the control room (B) and other learners observe (C). All learners and faculty come together after each scenario for reflection and debriefing (D).

Debriefing

Debriefing is a guided reflection that must occur after a learning event (scenario) (figure 3) and is part of the learning cycle. A structured debrief is essential to facilitate the individual learning objectives. We use the diamond debriefing method developed by the Simulation and Interactive Learning Centre at Guys and St Thomas’ Hospitals, London, UK. The diamond method provides a structured visual reminder of the debrief process (figure 4).6 We find this is simple and effective for facilitators with varying levels of experience. The diamond debrief is specifically designed to explore the non-technical aspects of a simulated scenario with three phases: description, analysis and application.6

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Figure 3

Experiential learning cycle in simulation training.

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Figure 4

The diamond debrief.

1. Description: This starts with a factual description of what happened in the scenario focusing on the timeline of facts, for example, ‘Then at 10.45 the registrar came in and was given a handover of the clinical situation by X. He then gave drug Y.’ It is important to establish the facts in a non-judgemental way and to resist the temptation to discuss emotions at this stage. The facilitators then clarify any outstanding clinical questions, for example, ‘This scenario was designed to show the management of status epilepticus, the recommended management of which is…’ and then we would provide references and further reading. This reinforces appropriate clinical knowledge without focusing on the individual participants. This allows a transition to the analysis.

2. Analysis: Most of the time is spent in analysis where the participants are asked how they perceived a given aspect of the scenario; the discussion then focuses in detail around one human factor (see table 3 for examples). This phase can often be very illuminating, for example, where one participant may have noted communicated information but did not acknowledge it, while the other may have felt ignored and less inclined to speak later in the scenario. Both sides would have a point and the group can benefit by understanding the ebb and flow of communication.

3. Application: During this phase, participants are encouraged to consider how they may apply the knowledge in their own clinical environment.

Feedback

Between 2015 and 2018, we ran six separate multiprofessional acute neurology sessions each lasting 4 hours and containing three scenarios. A total of 60 staff (13 nursing; 9 physician associates; 38 medical) attended, of whom 44.4% had previously experienced simulation training. On a 7-point Likert scale, they rated enjoyment of the course 5.78 (SD±1.09) and relevance to clinical practice 6.29 (SD±0.88). Analysing precourse and postcourse questionnaires showed there was a significant improvement in their confidence in managing neurology emergency situations but not in non-technical skills (table 4). Free text completion of written feedback of the question, ‘What is the one thing you take away from the course?’ yielded 50 responses that were placed in themes. Most (78%) were regarding human factors and these divided into categories of communication and teamwork (26), situation awareness (7) and leadership (6) (see table 5 for examples). This suggested that they were more aware of the need for effective communication and teamwork and the importance of human factors but did not yet feel confident in their ability. If expressed in terms of the learning cycle (figure 3), the concrete experience of the scenario challenged the participants and motivated team members to think critically, reflect and learn. The facilitated debriefing empowered learners to challenge their own beliefs and habits in a safe environment. To some extent they saw themselves as others see them and also they could see themselves actually in action. To complete the cycle would require the learners then to perform a second scenario to consolidate knowledge and understanding of human factors. Participants commonly fed back that they would like to participate in more scenarios. It may be more beneficial to give each learner the opportunity to participate in a scenario twice in each session. We plan to hold a future simulation on the ward using shorter sessions to allow repeated simulation training for individual learners.