Book of the Month: Using Simulations for Education, Training and Research (Dieckmann (ed))

About the editor

Peter Dieckmann is a work and organisational psychologist and head of research at the Danish Institute for Medical Simulation (DIMS). Dieckmann is a former Vice-President and President of the Society in Europe for Simulation Applied to Medicine (SESAM), as well as the former Chair of the Society for Simulation in Healthcare (SSH) Research Committee. His publication history is extensive and he is rightly considered an expert in the field of medical simulation.

About the contributors

While June's book of the month (Stress and Human performance) was US-dominated, this book is Europe-centric. The contributors are based in Belgium (2), Denmark (1), Germany (2), Norway (1), Sweden (1), Switzerland (2) and The Netherlands (1). The contributors are psychologists (Sven De Weerdt, Art Dewulf, Johan Hovelynck, Tanja Manser, Klaus Mehl, Theo Wehner), a social scientist (Ericka Johnson), a medical doctor (Marcus Rall) and a physicist/clinical engineer (Arne Rettedal).

Who should read this book?

Simulation-based educators should read this book, particularly those who are involved in designing programmes of training or who are responsible for designing the simulator environment and purchasing equipment. 

In summary

This book is part of a publication series entitled "Work Research Multidisciplinary" by Pabst Science Publishers, edited by Theo Wehner and Tanja Manser. The aim of the series is to show that complex research questions require a multidisciplinary approach and "help to show different perspectives of different disciplines on a specific topic."

The book is divided into 3 parts:

• Part I: This consists of two sections which provide a context for the study detailed in Part II.

• The use of simulations from different perspectives: a preface (Dieckmann)
• On the ecological validity of simulation settings for training and research in the medical domain (Dieckmann, Manser, Rall & Wehner)
• Part II: This, the core of the book, consists of a condensed version of Dieckmann's PhD dissertation, translated from German: "Simulation settings for learning in acute medical care"
• Part III: This part is meant to broaden the perspective detailed in Part II and presents aspects of simulation settings that the contributors believe to be important.
• A closer look at learning in and around simulations: a perspective of experiential learning (De Weerdt, Hovelynck, Dewulf)
• Simulation as a tool for training and analysis (Mehl)
• Extending the simulator: Good practice for instructors using medical simulators (Johnson)
• Illusion and technology in medical simulation: If you cannot build it make them believe (Rettedal)

I haven't got time to read 214 pages!

Read pages 13-16 to get an overview of the book and help you decide what to focus on. p.93-104 are worth looking at, as they are a distillation of the views of simulation educators as to the goals, success factors and barriers of various stages of a simulation course. Unfortunately much of the remainder of the book's best arguments and ideas are, like panning for gold, only revealed after much hard work (see "What's bad about this book?" below)

What's good about this book?

The book has a number of thought-provoking sections.

Part I:

Dieckmann tells us we must move beyond the "scenario/debrief" model and view the simulation as a social setting, in which participants are trying to avoid some things, hoping to achieve others and how can we best achieve a realistic environment. In addition, we must not become obsessed with "making it real" but instead concentrate on the elements that make it sufficiently realistic for the participants to achieve their goals.

The contributors also caution about using an improvement in scores within the same session to show a real improvement, as this may merely reflect familiarisation with the simulator.

Part II:

Dieckmann talks about the "irony of safety" where healthcare workers are rarely exposed to events which require their best performance. He also provides us with a model for the components of a simulation course:

1. Setting introduction
2. Simulator briefing (Mannequin familiarisation)
3. Theory input (Micro teaching, Algorithms…)
4. Scenario briefing
5. Simulation scenario
6. Debriefing
7. Ending

In this section, Dieckmann explains some of the ways that a simulator/simulation can be used. For example, we can use some of the "unrealistic" aspects of the simulator to emphasise characteristics more clearly than we can in clinical practice. We can for example remove all the "noise" that a patient presents with in terms of social history, co-morbidities etc. and focus on the "signal" of the salient pathology. The simulator can also be used to try out things in a safe environment, e.g. "Do everything you can to NOT work well as a team" and use them as a springboard for discussion. Dieckmann also suggests that we can use the simulator to train people in "control actions", these are generic actions which people can use in complex situations in order to help establish control, e.g. consciously stepping back and scanning the environment.

The final part of this section includes Dieckmann's recommendations for simulation practice, which include:

• Consider the simulation setting as a whole with different parts
• Distinguish verification from validation and check both
• Distinguish teaching processes from learning outcomes
• Keep it simple
• Make it a co-operation, not a fight
• Go beyond the clinical reality by using the full potential of the simulation reality

Part III:

In this part, we are introduced to the idea of simulation as a grown-up game, where participants can play and learn through playing. In his chapter, Mehl shows us how poor simulations can be in terms of showing participants their level of performance, the progress they have made and the errors they need to avoid. Running a simulation without an effective debrief can leave participants none the wiser as to where they are doing well and where they need to improve. Johnson underlines the importance of making the mannequin human by, for example, having a conversation with the mannequin during the familiarisation stage.  

What's bad about this book?

The main problem with this book is the language and vocabulary. Although Dieckmann may be forgiven for using scientific language for the condensed version of his dissertation, the other contributors have no such excuse. It may be that  English is not the first language of many of the contributors but at times the book becomes almost unreadable:

"A better understanding of potential alterations of experience and behaviour in simulation settings will allow for critically reflecting these effects in the interpretation of results from simulation-based studies."

 "However, the materialisation of these elements of medicine is only one half of the process of reifying medical practice."

"We propose that simulations represent a meeting point between blueprint and experiential approaches, expert and participative stances, and positivist and constructionist epistemologies."

Einstein said: "If you can't explain it simply, you don't understand it well enough." Although the contributors may understand the concepts very well, they have some way to go to help the rest of us.

Final thoughts

One of the main take home messages from this book was the unfortunate obsession of some educators in the simulation setting with the physical. "Simulators must be made to look more real", they cry, "and then the simulation will be perfect." These materialists ignore the social, inter-personal aspects of simulation: the scene-setting of the brief at the start of the day, the importance of the confederate in performing the magic act of turning the mannequin into a person, the subtle cues provided by the participants in the debrief. Materialists think that if you buy the right bit of kit, preferably costing a lot of money, then the rest is just fluff. Instead it is the other way around, the "fluff" makes the kit work.

Unfortunately, and somewhat ironically, because of the dryness of the language and the obtuse vocabulary this book falls into a similar trap. Although it rewards the determined reader, the book is not an easy read, its readership will be small and those who do read it are most likely experienced educators who already practice the magic. A more digestible book carrying the same messages would be welcome.

The ice bucket challenge and other buckets

Bill Gates has a fancy ice bucket

This time next year no one will remember what the ice bucket challenge was about, so a brief description is called for:

In the summer of 2014 people in the United States started pouring ice water over their heads in support of the Amyotrophic Lateral Sclerosis (ALS) Association. Spread via social media the challenge was adopted by the Motor Neurone Disease Association in the UK and then Macmillan Cancer Support. Various versions exist, one of the more popular is to have to donate a small amount of money if accepting the challenge and a larger amount if not willing to be drenched in ice-cold water. (Billionaires tend to accept the challenge).

The tenuous link to simulation and human factors is that buckets are also found in our areas of interest…

The s**t buckets (James Reason's three bucket model)

James Reason asks us to consider three buckets, each bucket has things that will fill it up:

1. Self
1. Knowledge
2. Skill
3. Expertise
4. Current capacity (stressed, tired, ill…)
2. Context
1. Equipment and devices (poorly maintained, broken, poorly designed…)
2. Physical environment (too hot, noisy, unlit…)
3. Workspace (novel, poorly laid out, interruptions…)
4. Team and support (unfamiliar, poorly led, unclear roles…)
5. Organisation and management (poor safety culture, steep authority gradient…)
3. Task
1. Errors (omission, commission, fixation…)
2. Complexity
3. Novelty
4. Process (overlaps, multi-tasking…)

The more full the buckets are, the greater the risk of poor performance/error. Reason suggests that the more full the buckets are the more attention we need to focus on the task and, at a certain fill level, not start the task.

The mental workload bucket

This bucket was referred to in a previous blogpost. The workload bucket fills up as the number of tasks increase. The capacity and volume that a given task occupies are also affected by stress and expertise. When the workload bucket is full, it overflows and "something" has to make way for the new task.

The IV fluids bucket

The last bucket is for the simtechs. The IV fluids bucket sits under the bed/trolley/gurney and collects the fluids and drugs that participants on a sim course give the mannequin. This means that instead of pretending to give 6 litres of 0.9% NaCl, the participants can really give it and watch for hyperchloraemic acidosis...

Further reading

Reason J (2004) Beyond the organisational accident: the need for ‘error wisdom’ on the frontline. Quality and Safety in Health Care. 13, (Suppl 2), ii28–ii33.