Simulation and Debriefing in Neonatal-Perinatal Medicine

Introduction

Whereas teaching is something that is (passively) done to trainees, learning is something that trainees must (actively) do themselves. Because not everything that is taught is necessarily learned , programs that best facilitate skill acquisition in trainees are those that focus on learning rather than on teaching. Traditional didactic programs are passive by nature, and the settings in which they are held are typically isolated from realistic cues, distractors, and time pressure; thus, such programs are unable to prepare learners adequately for all of the challenges inherent when working in the real environment. Learning is best facilitated when the learning opportunities are tailored to meet the needs of the learners. Training models that offer the same content in the same fashion to all learners (thus implying that competency can be attained and maintained simply by spending a particular, often arbitrary, amount of time at a task) fail to recognize that adults have different strengths, weaknesses, and life experiences and acquire and maintain different skills at different rates. Some characteristics of effective adult learning strategies include the following:

• Focus on active rather than passive learning activities.

• Integration of skill sets while performing under realistic conditions.

• Emphasis on competency/proficiency (the ability to perform successfully) rather than compliance (adherence to rules, such as participation in an activity for a predetermined period of time).

Although learning in a real environment may appear ideal at first glance, a deeper analysis reveals otherwise. The most obvious problem with using the real environment as the primary source of skill acquisition and maintenance is that any mistake could negatively affect (even prove lethal) to the human beings in that environment. The pace of actual work in the real environment is often too fast to allow trainees to take full advantage of the learning opportunities therein. Moreover, typically there is no way to ensure that all important learning opportunities will present themselves in the real environment during the time that the trainee is present. Finally the real environment is also typically a very expensive environment and is populated with a number of professionals whose job description may not include providing learning opportunities for trainees.

Simulation may be defined broadly as any exercise that allows an individual to experience a situation that, although not real, nevertheless generates authentic responses on his or her part. The best simulations realistically recreate the key visual, auditory, and tactile cues of actual situations to provide experiences that closely mimic the conditions encountered when working in the real environment. Provision of these key cues creates a high level of fidelity to the real environment. As a result of this degree of realism, those participating in the simulation respond as they would to a real-life situation; thus, their performance during a simulated situation can be hypothesized to resemble what it would be in the real world. In general, the term simulation is typically reserved to describe more comprehensive learning, assessment, and research activities that occur in realistic physical and virtual environments; activities conducted in less comprehensive environments (case studies, role-playing, and practice of one particular skill in isolation from other elements associated with that skill) may be better labeled as task training. By suspending their knowledge that they are working in a contrived situation, participants display knowledge, skills, and behaviors similar or identical to those manifest when working in the real environment. The closer a participant in a simulation mimics real-life performance, the more likely he or she will be able to identify and address any weaknesses that become apparent. Identification and remediation of weaknesses is the raison d'être of simulation.

What are the features of the best simulation-based learning programs that make them effective in facilitating the acquisition and maintenance of cognitive, technical, and behavioral skills? Each element of a successful program, including the scenarios, is built around specific learning objectives that are tailored to meet the needs of the participants. Every effort is made to ensure that the scenarios to which they are exposed are realistic in detail, challenging in scope, and relevant to their daily work. Finally, expert feedback and facilitated debriefings assist the participants in their critical self-reflection on performance. Effective simulation is not dependent on the purchase and use of highly complex and expensive technology; more important are carefully designed scenarios that align with the needs of the participants, provision of important (not necessarily all ) cues, and conduct of skillfully led debriefings.

Simulation-Based Training in High-Risk Industries

Simulation-based learning opportunities are the standard for skill acquisition in industries such as commercial aviation, aerospace, nuclear power, and the military, in which the risk of death or severe injury to human beings is very real. The use of simulation in these domains is characterized by an emphasis on probing human beings and the systems they design (both technological and social) for weaknesses and then designing and testing solutions to address those weaknesses. This type of learning is the result of a culture that not only fosters but also demands a willingness to learn from mistakes made during simulated events, thus decreasing the chances of repeating such mistakes when working in the real environment.

The National Aeronautics and Space Administration (NASA) was established in 1958 to conduct aeronautical research and administer the human and robotic exploration of space. Space travel is an inherently risky business; how else can one describe a process that places human beings in a rocket filled with tons of liquid fuel and then ignites that fuel in the hope that it will propel those humans into the vacuum of space? The value of simulation was made clear during the Apollo 13 mission, launched on April 11, 1970, as the third mission to land humans on the moon. To prepare for this mission, the three members of the prime crew, Jim Lovell (captain), Tom Mattingly (command module pilot), and Fred Haise (lunar module pilot) trained in NASA's flight simulators for months. One week before launch, Mattingly was exposed to the measles; because he was not immune to the disease, his backup, Jack Swigert, was given simulator time with Lovell and Haise in the week preceding launch to “ensure that Lovell, Swigert, and Haise could function with unquestioned teamwork through even the most arduous and time-critical simulated emergency conditions.” A decision by the flight surgeon only one day before launch scrubbed Mattingly from the prime crew and placed Swigert in the left-hand seat as command module pilot for the mission. Fifty-six hours into the flight, as Apollo 13 was approximately 200,000 miles away from the earth en route to the moon, an explosion in the service module's cryogenic oxygen system resulted in the uncontrolled venting of oxygen into space, creating a situation that threatened not only the success of the mission, but also the lives of the crew (oxygen was the source of the crew's breathing air and substrate for the fuel cells that generate electrical power). As has been thoroughly documented, the crew did return safely to earth. What is less well known is that, years before Apollo 13 launched, the procedures that allowed the crew to survive and recover from this devastating event were devised by engineers charged with envisioning every possible failure and then designing procedures to address these failures. These procedures were tested under current mission parameters in the flight simulators almost continuously during the crisis and when deemed reliable were relayed to the crew. In the formal post-mission debriefing, the crew referred to their experiences in flight simulation in excess of 40 times. The successful track record of simulation, established over decades in other domains, serves as a model for its use in health care.

Simulation-Based Training in Health Care

Any discussion of training in health care must start with what it is that can be learned. There are three sets of skills that may be acquired and refined by health care professionals:

• What we know in our brains (cognitive skills—content knowledge and decision making)

• What we do with our hands (technical skills)

• How we employ the first two skill sets while caring for patients and working under realistic time pressure with our colleagues (behavioral skills)

Content knowledge is the skill set most familiar to trainees and is typically the major (or only) skill set that is formally evaluated, usually through written or online tests. Decision making may also be evaluated in this manner through the use of clinical vignettes followed by questions as to appropriate next steps to be taken. Technical skills such as intubation are critical to many aspects of health care delivery. Despite their importance, such skills are most commonly practiced at skills stations using models that poorly represent human anatomy and physiology; in addition, they are typically evaluated by subjective rather than objective criteria. Behavioral skills (including but not limited to leadership, teamwork, and effective communication) are also important to successful patient outcomes ( Box 6.1 ). Unfortunately, these skills are rarely, if ever, specifically addressed in learning programs directed at health care professionals. Many patient care tasks actually incorporate elements of all three of these skill sets. Intubation is one such example. Far from being simply a technical skill, effective and safe intubation requires coordination and integration of multiple cognitive skills (knowing the indications for intubation and the signs of successful and unsuccessful intubations), sequential discrete technical skills (assembling, testing, and inserting the laryngoscope), and a number of behavioral skills (effectively communicating observations and needs, evenly distributing the workload, and delegating responsibilities), all of which must also be accomplished in a time-efficient manner ( Box 6.2 ).