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Some ideas about scenario development…
The idea of high-fidelity simulation training is to present the participants with realistic problems and provide them with a means to examine the processes by which the problem may be solved. This means that the exercise must be a combination of ‘realistic fiction’ (the problem together with the social and physical environment) and a manipulation of time (an ability to freeze, reverse, accelerate and repeat action). The basis of learning is reflection on performance and, in most cases, conversations amongst participants about practice.
In medical simulation it is almost always imperative that the realistic fiction includes as many as possible of the members of the real teams involved in the delivery of care. Ironically, the least realistic aspect of high-fidelity simulation in medicine is the reproduction of patient and environmental reality. The latter may be improved to some extent but technical limitations constrain improvements in the latter. This needs to be considered when designing educational events involving simulation.
This concept developed by educational theorist, John Biggs and involves ‘aligning’ learning activities with the teaching method and assessment. Biggs’ model involves the ‘three Ps’:
Presage. (Students existing knowledge, interest, experience, ethos, etc)
Process. (Teaching and learning activities)
Product. (Learning outcomes)
The unconventional aspect of this theory in the context of simulation is its emphasis on assessment as the ‘driver’ of learning because there is a common view that ‘debriefing’ after performance must not be too judgemental or undermining. However, assessing learning outcomes is necessary if teachers and learners want to have an understanding of the efficacy of the process. This does not necessarily mean that there needs to be an examination or some such thing. In the context of simulation assessment may be part of feedback sessions and may use self-assessment tools, check-lists, facilitator-led discussion and so on. It does mean that we need to define clearly our proposed learning outcomes and how we are going to determine they have been achieved before we design the process taking ‘presage’ factors into account. The difficulty for inter-professional team-based learning is that the presage factors (as well as, perhaps, learning outcomes) will vary considerably amongst learners.
The development process
From a practical point of view (and in order to anchor simulated cases in reality) it is easier to base cases for scenarios on real patients. Helpfully, the Joint Faculty of the Royal Colleges of Physicians have listed the most common acute presentations based on predominant symptom. Not all can be considered to be suitable for simulation but about 15 could be used. The presentations are listed with learning objectives which may be useful but for the new FERRETS programme learning outcomes should be mapped as much as possible to the Foundation Programme curriculum. In addition, an appropriate nursing equivalent will need to identified and used.
The following procedure could be used:
- A real clinical case is identified as being potentially suitable for use.
- A brief summary of the patient and their illness is made using the pro forma.
- The case is considered against the inclusion criteria
- An anonymised copy of the notes (or part of the notes) is made.
- A copy (or reference to) radiology, chem path, haematology, blood gases and other investigations is made and made accessible electronically.
- A list of learning outcomes is made.
- A constructive alignment table is drawn up for each group of participants using the template (there should be considerable overlap amongst groups).
- Each column of the table is expanded:
- presage for each group is described
- a summary of the whole learning process (including pre-course learning, scenario, feedback strategy, assessment and post-course activities) are briefly described.
- the set up and clinical events during the scenario are described in terms of how these will be used to deliver learning outcomes.
- learning outcomes are listed with assessment methods against them.
- Case is programmed into simulator.
- Environment check list is developed.
- Briefing materials are developed.
- Observation check lists are developed (based on learning outcomes).
- Facilitator guidance developed.
- Scenario run through and revisions.
Case inclusion criteria
- The case is emblematic of one of the selected top clinical presentations.
- The case has adequate complexity (in terms of co-morbidity, differential diagnosis, potential controversy in management)
- The case fits in with overall learning agenda
- There are adequate existing diagnostic materials
- The case is feasible to simulate.