"They did too well"

When observing a new faculty member it is not unusual to see a look of relief on his/her face when the participants in a scenario (finally) make a mistake. The faculty member may believe that if no mistakes are made then the facilitator will have nothing to talk about in the debrief. Below are a few tips on how to deal with the participants who "did too well".

Don't create a special crisis

Some may be tempted to throw a curveball into the scenario. "They're doing great, okay... Your patient has now arrested and he's also aspirated." Try and avoid this. Your scenario should be running to your learning objectives. Creating a special crisis in order to have something to talk about in the debrief, means they're going to be talking about the crisis and not your learning objectives.

It's not you, it's them

The introductory paragraph contains an obvious mistake: "the facilitator will have nothing to talk about in the debrief". The debrief is not an opportunity for the facilitator to talk. The debrief allows the facilitator to facilitate the discussion the group is having. This means that the faculty member should concentrate on how to make sure the learning objectives get discussed, not on whether the participants did or didn't do well.

Good scenarios are not designed to create mistakes

Good scenarios are designed to explore performance based on the learning objectives of your course, some will do well, others less well. All performance can be discussed. The words of Peter Dieckmann and Charlotte Ringsted are worth remembering:

"Learners' errors should not be seen as a personal victory in scenario design and implementation." (p.55 - Essential Simulation in Clinical Education (Forrest, McKimm and Edgar (eds)))

Be enthusiastic and explore

Although "advocacy and inquiry debriefing" may have its faults (see blogpost here), its appeal to the facilitator to display genuine curiosity is a valid point. When the participants "did too well", why did that happen? What was their communication, leadership, teamwork, etc. like? How can we ensure that the next group of participants will do just as well?

Final thoughts

The desire to see participants make mistakes is a phase in the evolution of the facilitator. Most move beyond it, happy in the knowledge that good performance is a fertile ground for discussion as much as poor performance is.

When the equipment fails...

On 18th July 2015 Martin Bromiley tweeted:

The implication is that one should not pretend that something hasn't failed in a sim session. There are a few points for reflection here.

1) There are considerable differences between aviation and healthcare sim

Airline pilots have much more exposure to simulation than the average healthcare worker, this means that equipment failure in aviation sim can be addressed by rescheduling the session. This is not normally the case in healthcare where a given participant may only be able to take part in a sim session every three years.

Aviation sims are much better funded than healthcare sims. In healthcare the use of out-of-date drugs and second-hand equipment is the norm. Equipment failure is therefore more likely in healthcare.

Healthcare sims also tend to involve the use of a plethora of equipment from different manufacturers and "cobbled-together" pieces of kit such as a simulated blood gas machine or a simulated X-ray machine. These are more likely to fail than bespoke flight simulators.

The bottom line? Aviation sims are less likely to fail and when they do, the ability to reschedule a sim session means that equipment failures can be "explored" to see how the participants cope with an unexpected problem.

2) There are different types of equipment failures

One of the most common types of failure in (mannequin-based) simulation is the mannequin itself. Loss of power or communications with the controlling device can mean the mannequin "dies". Other equipment failures may mean that, for example, one cannot feel a pulse on one arm, or that the pupils don't dilate, or that the simulated blood gas machine stops working. The faculty response to each of these equipment failures will be different and this brings us on to point 3.

3) Response to equipment failure depends on the type of failure, faculty experience, the scenario and your learners

If we take sudden mannequin failure as an example, and three different scenarios:

1. Patient in septic shock, hypoxic, hypotensive and moribund
2. Patient with life-threatening asthma, silent chest and tiring
3. Patient about to undergo elective surgery for laparoscopic cholecystectomy, chatting to anaesthetist

In the first two it would seem reasonable to continue the scenario, with a pulseless, lifeless patient while you try to re-establish connection to the mannequin (or plug him back in). In the third scenario, it would be best to interrupt the scenario, acknowledge a technical issue and fix it.

Of course, this still doesn't cover the "pretend it hasn't failed" situation. Imagine a home-made "X-ray machine" which displays an X-ray at the touch of a button. However, when the confederate radiographer goes to display the X-ray nothing happens. One option would be to get the participants to decide what they would do in such a situation in real life, e.g. get another X-ray machine, continue on clinical judgment, auscultate chest, ultrasound, etc.. Another option would be to "pretend it hasn't failed" with the confederate providing them with a hard-copy of the X-ray. This latter option may be particularly apt if the rest of the scenario depends on the ability of the participants to correctly interpret the X-ray.

Final thoughts

This post should not come across as a carte blanche to make up for poor equipment maintenance or scenario planning. The "pretend it hasn't failed" response should be rare and limited to minor failures which will not throw the participants out of the simulated reality you have created for them (e.g. "I wasn't sure when he stopped breathing that he had really stopped or that you wanted us to pretend that he hadn't.") "Pretend it hasn't failed" is not the correct wording even when that is what you want the participants to do; well-trained faculty and confederates will be able to sculpt the scenario so that the equipment failure is quickly forgotten. "Pretend it hasn't failed" is also not the correct response when you are carrying out in situ systems-testing; the participants should deal with this as they would in real life. Lastly, if it's a course and the scenario learning objectives can still be achieved when the equipment has failed then, by all means, the participants should be allowed to develop their own solution to the problem. As faculty experience (and expertise) increases, one will become better at predicting the likely consequences of a failure and the best response.

Two is a crowd

A team may, very loosely, be defined as two or more people working towards a common goal. The benefits of working in a team are manifold: shared physical and mental workload, balancing of strengths and weaknesses, error trapping, etc. More accurately, the preceding sentence should be modified to say "The benefits of working in a good team are manifold." We have all had experience of dysfunctional teams which were much less than the sum of their parts, and would probably have functioned better if the individuals had worked independently. As Reason and Hobbs state: "Team management errors are one of the most serious threats to safety... problems include":

• team leaders being over-preoccupied with minor technical problems
• failure to delegate tasks and responsibilities
• failure to set priorities
• inadequate monitoring and supervision
• failures in communication
• failure to detect and/or challenge non-compliance with SOPs
• excessively authoritarian leadership styles
• junior members of the crew or team being unwilling to correct the errors of their seniors

Although much depends on effective team members, the above list suggests that good leadership is paramount. Ironically, the education system from primary school on to postgraduate education praises and rewards individual excellence. This means that the A+ students who have become excellent personal achievers are then expected to work in, and lead, teams with very little prior preparation for this role. Although courses, such as Advanced Life Support (ALS), expect candidates to show leadership skills, the team members are often faculty members and have to be spoon-fed instructions. Ostensibly this allows candidates to be assessed on their skills, without variable support from the team, but it creates unrealistic scenarios.

It is perhaps not surprising for the director of a simulation centre to suggest that simulation is part of the solution to team training. However, this is one of the greatest benefits of inter-professional simulation, whether in situ or in the simulation centre. Repeated practice with a focused debrief allows, some might say forces, teams to become more effective. There is still too much expectation within healthcare that competent individuals, when placed in the same room, will work well together. Unfortunately this is not the case. And practicing on an ad hoc basis with real patients is not only unethical but also ineffective; the lack of time for a debrief and the lack of uninvolved observers makes learning from real patients difficult. So, could your team could be practicing working together in a simulation centre (or in situ)? And if your team isn't doing this then how do you justify poor performance in real cases?

Book of the month: Essential Simulation in Clinical Education (Forrest, McKimm and Edgar (eds))

Disclaimer: The reviewer (M Moneypenny) co-authored a small section of a chapter in this book. He is also a friend of a number of the contributors (but has tried to write an objective piece!)

About the editors
Kirsty Forrest is Professor and Director of Medical Education at the Australian School of Advanced Medicine, Macquarie University, Sydney, Australia. Judy McKimm is Professor of Medical Education and Director of Strategic Educational Development at Swansea University, Swansea, UK. Simon Edgar is Director of Medical Education, NHS Lothian, Edinburgh, UK and Education Coordinator, SCSCHF, Larbert, UK. The three editors combine a significant amount of expertise in medical education, simulation  and clinical practice.

About the contributors

There are 32 contributors (not including the editors), one from Ireland, one from New Zealand, 2 from Canada, 3 from the USA, 4 from Denmark and 21 from the UK. Although perhaps "UK-centric", the geographical spread results in a more diverse authorship than, for example, "Practical Health Care Simulations". 

Who should read this book?

The back cover states: "A superb companion for those involved in multi-disciplinary healthcare teaching, or interested in health care education practices…" In reality the book should probably be on the reading list for anyone who is starting out in simulation-based (medical) education. More experienced educators may find specific chapters, aligned with their own interests, of relevance.

In summary

The book is divided into 14 chapters:

1. Essential simulation in clinical education
2. Medical simulation: the journey so far
3. The evidence: what works, why and how?
4. Pedagogy in simulation-based training healthcare
5. Assessment
6. The roles of faculty and simulated patients in simulation
7. Surgical technical skills
8. The non-technical skills
9. Teamwork
10. Designing effective simulation activities
11. Distributed simulation
12. Providing effective simulation activities
13. Simulation in practice
14. The future for simulation

What's good about this book?

Every chapter starts with an overview and concludes with a short summary and an even shorter "key points" which is useful both as a reminder and as a reference for the reader in order to decide if the entire chapter is worth reading.

The editors make it clear in Chapter 1 that simulation is not a panacea. This view has been echoed elsewhere by Andrew Buttery (@andibuttri) on Twitter and by Trisha Greenhalgh (@trishgreenhalgh) in the British Journal of General Practice. Simulation is not magic and not all simulation is "good" simulation. "High fidelity" is also placed into context by Tom Gale and Martin Roberts who state: "…the blind use of the highest fidelity available is a principle which should be avoided" (p.63).

Chapter 3 "The evidence: what works, why and how?" by Doris Østergaard and Jacob Rosenberg is essential reading for all who are involved in designing simulation-based interventions and those undertaking research. They consider the features which make simulation effective, including feedback, deliberate practice and curriculum integration and they also look at some of the challenges faced by researchers in simulation.

What's bad about this book?

The order of the chapters could be reconsidered. The chapters on designing and providing effective simulation activities would logically appear nearer the beginning of the book, and the chapter on assessment nearer the end. In addition, there is a chapter on "Teamwork" but not one on "Leadership" (although one might argue that good leadership is part of good teamwork). Lastly, an entire chapter on distributed simulation (DS), although interesting, is probably not required in a book covering "essential" simulation. A section on DS could have been included in the "Simulation in practice" chapter.

Although overall a very good chapter, Chapter 5 "Assessment" by Thomas Gale and Martin Roberts refers to "assessment tools with appropriate reliability/validity…" (p.61). However the tools themselves are not inherently reliable or valid, the scores produced by the use of the tools may be, and then initially only within the context in which the tool was created.

Final thoughts

This book covers the important topic areas well, including assessment, the roles of faculty and how to create effective simulations. This book therefore deserves a space on every simulation centre's bookshelf, as it provides a good overview of practical simulation in a digestible format.