SESAM 2014: The good, the bad… and the missing

Poznan town hall

The 20th Anniversary meeting of the Society in Europe for Simulation Applied to Medicine (SESAM) took place in Poznan, Poland from the 12th-14th June 2014.

The good

Keynotes

The keynote speakers were excellent. Roger Kneebone started us off with a talk about engaging the public, setting up a 2-way conversation between clinicians, scientists and the laypeople. Roger provided lots of food for thought around breaking down the boundaries of the simulation centre, as well as the similarities between experts in other fields (stone masons, lute-makers, tailors) and experts in medicine.

Terry Poulton talked about virtual patients and how they are using the findings from Kahneman's studies to inform the decision-making aspect of the virtual patient programmes. Terry also asked for people who were willing to collaborate with him on a project combining virtual patients and simulation.

Lastly, Walter Eppich discussed feedback and debriefing, how they can be applied to clinical practice and pitfalls to watch out for.

Technology

The SESAM app was great. Simple and easy to use, it allowed you to see the programme including the abstracts of the workshops or lectures. It also allowed you to "favourite" individual sessions, so you could quickly figure out where you needed to go next. Also, if you registered with the app, you could be messaged by other conference attendees, which made meeting up with people very easy. A great addition and "must-have" for future conferences.

The wi-fi was free, fast and easily able to cope with the number of people connected. Unlike some conferences the wi-fi did not drop off intermittently or tell you that the maximum number of people had been connected.

There were charging stations for your iPhone/iPad (other mobile devices are available) which meant you didn't have to go looking in corners of rooms for plug sockets.

Twitter is being used more and more and #sesam2014 allowed you to keep up with developments in other sessions.

Workshops & SimOlympics

SimOlympics (with a scary mannequin)

The workshops were interactive (thank goodness!) and informative. Ross Scalese ran a very good workshop on simulation assessment, covering checklists and rating scales, how to train raters, reliability and validity. The small number of participants (see below "…and the missing") meant that this was almost a one-to-one opportunity to talk about problems and solutions. 

SimOlympics was good fun. Seeing group after group of medical students being put through their paces (with a range of performances) was inspirational.

Range of participants

It was a pleasure to meet people from all over Europe, including Ukraine and Czech Republic, from a range of healthcare backgrounds (paramedics, surgeons, GPs, paediatricians, nurses, etc.) all at different stages of simulation development. The conference was a real melting pot of people which allowed you to learn from some and help others.

The bad

Time-keeping was poor. In particular, the introductions to the keynotes started late and then ran over, which meant that the keynotes themselves were curtailed and/or rushed. Sticking to time is basic "good housekeeping" and, after 20 years, should not still be a problem.

Some sessions were cancelled or the facilitator failed to show up at the last minute. A pre-conference course for simulation technicians was cancelled the week before (although the organisers were happy to refund the money) and a workshop on ROI, to be led by Russell Metcalfe-Smith, resulted in about 20 participants milling around waiting for him, only to be to be told (after about 15 minutes) that the workshop had been cancelled.

…and the missing

There were much fewer participants than at SESAM 2013 in Paris. When you can barely walk around a hospital now without tripping over a mannequin of some sort, the lack of participants was surprising. Explanations include:

• AMEE is in Milan this year. A number of people have said that they can only go to one conference per year and would prefer to go to "beautiful" Milan than Poznan. However, choosing the conference based on the city it is being held in rather than the content seems somewhat strange…
• HPSN Europe is in Istanbul and similar arguments about "beautiful" Istanbul have been aired. In addition, the conference is free. It is unclear whether having a free industry-sponsored conference is of benefit to the advancement of simulation across Europe.
• Budgets in a time of austerity. Having had to make a strong case for attendance at SESAM by SCSC^HF staff it is probable that a "holiday" in Poland would not be supported by many simulation centres. Unfortunately it is a recurring theme that budget holders are happy to pay thousands of pounds/dollars/euros for pieces of equipment but are not willing to pay hundreds of pounds/dollars/euros for staff to be trained or to attend conferences. This short-sightedness needs to be tackled head-on.

Final thoughts

The SESAM2014 conference was extremely worthwhile attending. If you were unable to attend because of monetary constraints you need to make a stronger case. If you feel that you aren't part of a network or are unsure how to integrate simulation into your curriculum or need advice about inter-professional education then SESAM is the forum for you. If you want to get the chance to listen to and speak to some of the trailblazers in simulation (Kneebone, Eppich, Scalese, Dieckmann and more) then SESAM is where you need to be. SESAM2015 is in Belfast, Northern Ireland, June 24th-27th. Hope to see you there...

Book of the Month: Stress and Human Performance (Driskell & Salas (eds))

About the editors

Eduardo Salas is currently Professor of Psychology and Program Director for the Human Systems Integration Research Department at the Institute for Simulation & Training at the University of Central Florida. When this book was published in 1996, Salas was a senior research psychologist and Head of the Training Systems Division at the Naval Air Warfare Center, Orlando, Florida.

James E. Driskell is President and Senior Scientist, Florida Maxima Corporation and Adjunct Professor, Rollins College, Winter Park, Florida. The Florida Maxima Corporation is, according to its website "a small business that conducts basic and applied research in the social and behavioral sciences in government, academia, and industry."

Salas and Driskell continue to collaborate on topics such as deception, team performance and stress.

About the contributors

There are 17 contributors to this book, including the 2 editors. The foreword states: "this book brings together a set of authors who are not only prominent researchers within this field, but are also actively involved in the application of this research to real-world settings." Unfortunately only 2 of the authors are not from the US and 8 of them work in Florida. It is possible that the rest of the world had nothing to add to this book but more likely that the strong tendency to collaborate with people you know meant that this book is rather US-focused.

Who should read this book?

This book was written for:

"...researchers in applied psychology, human factors, training and industrial/organizational psychology. (As well as) practitioners in industry, the military, aviation, medicine, law enforcement, and other areas in which effective performance under stress is required"(p. viii)

The editors are clear that this book deals with acute stress, and not with chronic stressors, stress-related disorders or "coping". By acute stress the editors mean "emergency conditions" where the stress is novel, intense and time-limited.

Parts of the book are relevant to the simulation-based medical educator (see below).

In summary

The book is split into 3 main sections:

1. Introduction. A chapter looking at definitions of stress and its effect on performance.
2. Stress Effects. 4 chapters which look at how stress affects performance.
1. The effect of acute stressors on decision making
• Looks at decision-making strategies (non-analytical and analytical; similar to Kahneman's System 1 and 2; recognition-primed, naturalistic etc.)
2. Stress and military performance
• Looks at stressors of military personnel and methods for improving performance under stress (including CRM). Importance of team training.
3. Stress and aircrew performance: A team-level perspective
• Importance of teamworking and teamwork training, for dividing up tasks, for monitoring one another's behaviour and for providing support
4. Moderating the performance effects of stressors
3. Interventions. 3 chapters which look at how to minimise the effects of stress.
1. Selection of personnel for hazardous performance
2. Training for stress exposure
• Fidelity requirements; sequencing and training content
3. Training effective performance under stress: queries, dilemmas, and possible solutions

I haven't got time to read 295 pages!

Read the following bits (depending on your area of interest):

Chapter 1 for a good introduction and overview of stress and its impact on performance. 

Chapter 2 p.69-83 for a very good description of USS Vincennes shooting-down of the Iranian airliner.
Chapter 3 p.105-116 to understand why team training is important (not just because it looks good).

Chapter 4 p.143-149 for an overview of how an organisation can help or hinder team performance

Chapter 6 p.203-206 and 213-217 for an overview of personality types and stress

Chapter 7 p.247-253 for Stress exposure training (SET) guidelines

Chapter 8 p.272 for concluding remarks on training effective performance

Chapter 9 if you're interested in human-system interface issues

What's good about this book?

The book is generally well-written and, on the whole, the arguments made are easy to follow. We are told how stress may be defined by orientation to the environment (i.e. the environment is a stressful one), by orientation to the individual or by orientation to the relationship between the environment and the individual. The editors prefer the latter and provide a nice working definition of stress (quoting Lazarus and Folkman (1984)):

"Psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being" (p.6)

The editors therefore distinguish between a threat, where the capacity to respond is exceeded, and a challenge, where the person has sufficient capacity to respond and the expected gain exceeds potential harm. By the same token, "stress" is in the eye of the beholder and what is stressful to one person will be a minor challenge to someone else.

There is a good explanation of two different theories of task load. The first is the bucket (or capacity) theory, where a limited pool of attentional resources is available and when the bucket is "full" there is a reduction in performance. The second is the structural theory which envisages a parallel processing system which must go through an attentional serial bottleneck and it is this bottleneck which slows down performance.

There is a good discussion of the impact of the organisation on the team, including how the organisation forms teams, how it supports them and how it helps teams to interface with one another. The recommendations in terms of support include:

1. A reward system that provides positive reinforcement for excellent team work
2. An education system that provides the relevant training and resources required by team members
3. An information system that provides (in a timely fashion) the data and resources necessary to assess, evaluate and formulate effective crew coordination strategies

What's bad about this book? 

The book specifically does not look at chronic stressors, such as life stress, fatigue or sleep loss. Nor does it examine the effects of boredom on performance. Unfortunately we don't live or work in that utopian world where those influences are irrelevant. It may in fact be the case that the chronic stressors play a significant, even pivotal, part in turning a challenge into a threat, overwhelming our coping mechanisms. A book which refers to both chronic and acute stressors and their (synergistic?) role in failures would be very welcome.

Klein's chapter (Chapter 2: The Effect of Acute Stressors on Decision Making) is a confusing addition. In a book on stress and performance, Klein states:

"(Stressors) can degrade the quality of judgments, prevent the use of rational decision strategies, and severely compromise performance; at least that is a popular appraisal of stressors. The thesis of this chapter is that each of these assertions is either incorrect or misleading"(p.49)

Klein does try and mitigate this statement by then arguing that time stress, for example, leads to poor performance not because of the increase in stress but the decrease in time. He also argues that naturalistic decision-making is not "rational" anyway, is resistant to stress and that stress can improve performance. By p. 55 he is back-tracking slightly: "At the beginning of this chapter we claimed that stressors do not necessarily degrade decision making. (my italics)" The chapter reads poorly and Klein constructs straw men using semantic arguments about what "stress" really means.

In addition, although the book is presented as starting off with a section on stress and its effects followed by a section on dealing with stress, some of the earlier chapters (e.g. chapter 3) have "dealing with stress" sub-sections within them.

Final thoughts

There are repeated instances where, although simulation is not referred to, the benefits of using simulation to deal with or train for stress are made evident. For example, on page 12 "The development of positive performance expectations is a crucial factor in preparing personnel to operate under high-demand conditions."On page 15 "…performers were less distracted (by noise) when the task was well-practiced". On page 83 "To help decision makers avoid potential disruptions due to stressors, it may be useful to train them to better manage time pressure, distracting levels of noise, and high workload."

This book also provides the SBMEducator with some ammunition for courses with advanced-level participants. Stress can be induced using noise, group pressure, task load, threat or time pressure. In addition, stress can be induced by task similarity, so if you want to distract the participant use a visual distraction for when they need to focus on a visual task and auditory distractions when the task relies on auditory cues.

This book has emphasised the need to look at how we, as simulation providers, can both ensure that the environment is stressful enough (to ensure learning) but not so stressful that the participants are overwhelmed. In addition, we could do more to help participants recognise their stress reactions for what they are and explore with them how they can continue to perform optimally under stressful conditions. Lastly, SBME can increase the skills and skill levels of participants and, at the same time, make participants more aware of where their personal capabilities lie.

Rent this book out and read the sections which are relevant to your work, it will increase your understanding of stress, its effects and preventive/mitigating actions.

Tell me what you want, what you really, really want: Emergency Medicine trainees survey (by Laura McGregor, Ed Co for EM)

One of our aims at SCSC^HF is to maximise the utilisation and effectiveness of simulation for learning amongst frontline healthcare staff.  In keeping with this, one of the first things I wanted to do when I started my role as Educational Coordinator for Emergency Medicine (EM) at SCSC^HF was to determine the true training needs of EM trainees across Scotland.  Using this information I hoped we would be able to start adapting  and further developing  existing simulation courses as well as design new courses to meet the current educational needs of today’s EM trainees in Scotland.  The survey responses were presented at the Scottish ASPiH conference in April of this year….. for those who missed it, here is some of the detail.

Through an online survey we collected responses from 68 trainees (62% response rate).  There were responses from each of the four deaneries and across the breadth of training grades from CT1 to ST6, as well as out of programme trainees and those undertaking Paeds EM.  Of the total, 68% had previously been on a simulation based course – leaving 32% who had never had any such teaching, this didn’t truly surprise me, but I was a little saddened to think of a third of our EM trainees never having had such important educational opportunities.

Previous experiences of simulation-based medical education (SBME)

Trainees gave feedback about the positive and negative aspects of their previous experiences of SBME:

What would EM trainees like to learn through SBME?

Further to this we collected data regarding both the technical and nontechnical skills that they felt they could – and would like to – learn through SBME.   These responses in particular will aid us in shaping the development of new courses and linking them to the College of Emergency Medicine Curriculum.
The 3 highest priority technical skills were:

1. Emergency airway skills
2. Major trauma
3. Paediatric emergencies

The 3 highest priority non-technical skills were:

1. Teamwork and coordination
2. Authority and assertiveness
3. Leadership

What stops EM trainees from attending SBME courses?

We also asked about the factors that inhibit trainees being able attend courses  - 93% cited limited study leave as the main factor, and 64% also felt cost was another important factor. 

General views of EM trainees regarding SBME 

We asked questions specific to the trainees' general views of the importance of SBME in EM in Scotland.

• 95% felt that there was a need for more SBME 
• 93% felt that SBME should be formalised as part of their local training programme
• 88% felt that they would like to become a member of simulation faculty in the future and teach on simulation courses themselves
• 88% felt that improving SBME for EM in Scotland would be helpful to trainees given the current EM crisis in recruitment and retention of doctors

I was particularly encouraged by the fact that trainees are not only enthusiastic about being taught through SBME but are also keen to teach others – I am hoping that given the opportunity many might complete the faculty development course that is already available at SCSC^HF. 

So what now?

In terms of course development  - we have recently run a pilot course for ACCS level trainees that was a great success and will return in the autumn.  Later this month we are also running a further pilot course specifically for advanced Paediatric EM skills.  The PEM course has been developed by an excellent faculty - Dr Roger Alcock (Consultant in EM and PEM at Forth Valley), Dr Marie Speirs (Consultant in PEM at Yorkhill RHSC), Dr David Rowney (Consultant Anaesthesia, Intensive Care and Retrieval at Edinburgh RHSC) and me.  This pilot course is already overbooked and I am sure is going to be a great success and prove to be popular.  Each of these courses are also aimed at developing the nontechnical skills that have been highlighted as important learning needs – particularly teamwork and team coordination.

Further to this we are currently examining the possibility of developing a Major Trauma Course (potentially led by SCSC^HF faculty as in situ training within individual Emergency Departments) as well as a course designed specifically for EM trainees in Obstetric and Gynaecological Emergencies.  Although the target audience for these courses will initially be the EM trainees themselves, it is intended and anticipated that nursing staff and paramedic staff will be involved in time as observer candidates.  

So to conclude…. the trainees have told us what they really, really want…. And we will continue to try to fulfil these specific trainees needs at SCSC^HF.

For more info:

Have a look at our EM page on the website:
http://scschf.org/courses/emergency-medicine/

Contact Laura:
Laura.McGregor@lanarkshire.scot.nhs.uk