Thursday, 16 August 2012

Simulation, orthodoxy and doctrine...

Over the past year or so, I have been involved in a range of faculty development activity for medical and healthcare educators using simulation in Higher Education and NHS contexts. The emphasis of my work has been on enhancing the educational value of simulation, shifting the gaze from technical and clinical aspects. In doing this, I have found myself grappling with what I can only call simulation ‘orthodoxy’… my observations on the 'simulation doctrine' follow.

Simulation improves patient safety.

It seems to me that many of the claims about simulation are based on assumptions of transfer, from one context to another. For example, we note that simulation has improved safety in the aviation industry and assume it will do the same in medicine. We see that performance is enhanced in simulation and assume that this enhanced performance will readily transfer to the workplace. Yet we know that transfer is a problematic concept in education generally, and medical education specifically. Studies of transition to greater levels of medical responsibility, for example, show dips in performance in new jobs, because transfer from one context, setting or team to another is not a straightforward process.  How sure are we really that simulation achieves all that is claimed in its name?

Fidelity matters.

Beware the seductive appeal of new does not appear to be a significant determiner of the learning experienced. Can I suggest we start a dialogue about authenticity, which I suspect is more important? By authenticity, I mean the extent to which participants are able to engage in a simulation experience that feels meaningful, congruent and close to their lived experiences of working in clinical teams, in clinical contexts. Which brings me on to the next point…

Role-play is accepted as a proxy for actual performance

Too often in simulation we bring together a group of learners, all at the same stage in training, typically all within the same professional grouping, and give them parts to play. We ask a group of FY1s to ‘play’ the registrar, the nurse, the consultant and so on. In so doing, we ask them to play out their understandings of ways of being, thinking and acting…fine, if the goal is to work with their stereotypes! If simulation is to be meaningful, I think we need to stop thinking about role play, and move into role-rehearsal. We need to give opportunities to rehearse the types of work activity that are at the level of expectation (or just beyond) the learners point in development. We need to construct scenarios that seek authenticity in terms of roles, responsibilities and contexts. 

We are missing a real opportunity to bring ‘real’ teams into the simulated space, to run through scenarios they have already experienced, to consider different ways of being and acting in order to improve practice. Simulation is used in ways that are anticipatory of future action, why not use them to re-think the past? Which leads us to consider the types of learning experience we offer in simulation.

All simulated scenarios involve ‘surprises’ and ‘challenges’

From observation and discussion, it appears to me that the typical simulated scenario involves a moment (or several) of surprise, placing the learner in a position of uncertainty and challenge. Typically I witness a short briefing, a scenario that plays out to the agreed conclusion, with faculty observing and intervening only to lead the debrief. This is, of course, a perfectly legitimate use of simulation, if the intended learning outcome is to develop approaches to dealing with uncertainty /acute clinical situations. I fear this downplays much of the learning value of simulation.

  • How would it be if we used simulation to explore a range of responses to more typical situations? 
  • How would it be if we involved learners in choosing or shaping the scenario, so they could rehearse situations they are daunted by? 
  • How would it be if in the briefing, we gave an account of what was going to be encountered, and talk through possible ways of responding before the scenario? 
  • How would it be if faculty came alongside the learner, with an option on both sides to ‘freeze’ the scenario, to discuss possible options for action before moving on? 

Such variations would allow us to maximize the learning value of simulation.

Debrief and feedback are inter-changeable

In the past 6 months I have asked faculty to provide me with a simple definition of each of these terms and an account of the pedagogic strategies they use for each. The answers suggest that distinctions are unclear and that strategies merge into each other. The simulation literatures aren’t that helpful in this regards either! I do think they serve different purposes and require different actions as result. My working distinctions are as follows…

Feedback, is for me at least, a developmental conversation. This conversation (dialogue, not monologue) builds upon what is known (or shared) about performance, as a basis for moving forward. Whilst group feedback is possible (if the performance of the whole group is the focus), feedback is typically about the development of an individual. So, after a simulation session, this would mean finding time to talk to the individual about their performance and what they might do to develop their practice in light of that. With their consent, this might be ‘in the round’, so that peers might offer suggestions and benefit from listening in to tutor guidance. It is not ‘a given’ that an individual’s performance in the simulated scenario is open for discussion in the group (no more than it would be on a ward round, for example).

The term debrief has military origins – according to one on-line dictionary, to debrief means to question someone (typically a soldier or spy) about a completed mission or undertaking. The soldier provides a vivid account of what s/he has experienced (sight, sound, smell, sense). The purpose of the debrief, in this case, is for the unit to gain inside information, and, together, to consider next steps for action. 

Translating this into medical simulation, the debrief is a pedagogic strategy where  the lived experience of one team member is offered up to the whole group as a shared resources for learning. By inviting the learner to provide a narrative account, which includes affective responses to their experience of simulation, they are offering a gift to the group. Together they analyse ways of responding. Together they seek to make connections between the simulated experience and those experienced in vivo. Together they identify the learning arising from the scenario that they each can benefit from. This kind of debrief would be particularly powerful when bringing teams in to analyse existing practices and try out new ways of working to enhance patient care.

Simulation has the potential to be a powerful educational tool, if seen as that, a tool that supports learning of individuals (hence feedback) and development of teams and practice (hence debrief). It is time to take a critical stance to simulation and consider how it might make a meaningful, authentic contribution to developing patient care.


  1. I almost missed this post what with holidays and everything!

    This made me think about the way that we use actors/simulated patients in teaching communication skills. As we meet the various scenarios I spend quite a lot of time preparing the students for the situation they will be 'rehearsing'. I want students to feel prepared for what they will do. And sometimes we call time out and rethink strategies in the middle of the roleplay.
    Oh, I've just remembered that I have written a blog post about this in the past!

    Thanks as always!

  2. You are allowed a blog -break for holidays and everything! Welcome back and thanks for these comments - loved your blog posting too - seems we have been thinking about, and grappling with similar issues. What I loved about your post is the authenticity (of the blog, but also the interactions you describe with your learners). In briefing, 'holding' and 'debriefing' it seems to me at least, that you are making those vital connections between the 'proxy' clinic (in simulation) and the lived experiences of patients, students, clinicians and so forth. More dialogue before, during and after simulation sessions makes such a learning difference. :)

    1. Well, thank you! I love the 'learning difference' phrase and might have to start using it!

  3. I find it a meaningful and authentic contribution. Thank you! Hope that you will keep up the excellent work on your fur=ture publishing! Best regards, essay editing service free -!