2.6 UTILISATION OF RESOURCES IN SELF-DIRECTED CLINICAL SKILLS
2.6.1 The use of Simulation as a Resource in Clinical Skills Laboratory
Simulation is widely used both within and outside the health profession. Simulation-based training began with life-like mannequins and now encompasses an entire range of
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systems, from synthetic models through to high-fidelity simulation suites. These models can also be used for training in new technologies, for applying existing technologies to new environments and in prototype testing (Aggarwal et al., 2010:34).
According to Bricker and Pardee simulation ‘is a technique to replace or amplify real patient experiences with guided experiences, artificially contrived, that evokes or replicates substantial aspects of the real world in a fully interactive manner’ (Bricker &
Pardee, 2011:34). As an educational strategy, simulation provides the opportunity for learning that is both immersive and experiential (Bricker & Pardee, 2011:34). Thus, to improve education and ultimately enhance patient safety, healthcare professionals are using simulation in many forms including simulated and virtual patients, static and interactive mannequin simulators, task trainers, screen-based (computer) simulations (Wilt & King, 2012:103). Moreover, simulation has the potential to recreate scenarios that are rarely experienced and test professionals in challenging situations and to carefully replay or examine their actions (Cates, 2011:95). It is a powerful learning tool to help the modern healthcare professional achieve higher levels of competence and safer care.
Beyond the impact on individual and team performance, simulation techniques provide an opportunity to improve system performance (Wang, Fitzpatrick & Petrini, 2013:311).
There are three broad domains in which simulation is used by healthcare professionals.
First, they can be used for practice and assessment of technical procedures. This can take a variety of forms ranging from simple bench models to sophisticated virtual reality machines. Second, simulated or standardised patients have long been used to teach clinical skills and are the foundation for performance-based assessment. Third, simulation technologies are used for team training, improving function in tension-filled complex situations (Aggarwal et al., 2010:34).
In Zimbabwe, students found simulation helpful and enjoyable and their confidence increased after teaching. It offers students a broader exposure to psychiatric conditions than they received during clinical attachment to the inpatient wards. The study suggested that involving psychiatry trainees and nursing staff may be a sustainable approach in settings with a small number of consultants and limited funds to pay for professional
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actors (Piette, Muchirahondo, Mangezi, Iversen, Cowan, Dube, Peterkin, Araya & Abas, 2015:23). This is in line with Rauter and colleagues’ assertion that simulators are commonly used to train complex and dangerous tasks, to save costs, and to investigate the effect of different factors on task performance. They argue that, usually, the transfer of simulator training to the real task has not been investigated and that without proof of successful skill transfer, simulators might not help at all or could even be counter- productive learning the real task (Rauter, Sigrist, Koch, Crivelli, Van Raai, Riener & Wolf, 2013:82145). While simulation in healthcare education is common practice and although its teaching strategy increases patient safety, it is not proven to enhance patient-centred care in practice (Rubio-Gurung, Putet, Touzet, Gauthier-Moulinier, Jordan, Beissel, Labaune, Blanc, Amamra, Balandras, Rudigoz, Colin & Picaud, 2014:790). Some studies also argue that simulation is not indispensable and that there should be alternatives to institutions that cannot afford to own one (Ryoo, Ha & Cho, 2013:185; Walshe, O'brien, Murphy & Hartigan, 2013:47).
Simulated patients are used to teach communication skills and to contribute to the authenticity of the simulation. However, establishing how this enhanced authenticity can help to bridge the gap to practice with live patients where patient-centeredness is of crucial importance still needs to be explored. Uys and Treadwell conducted a study to determine whether students who acquired a skill in simulation using a simulated patient displayed more patient-centeredness in practice than students who used a mannequin.
A pre-experimental, post-test-only design with a comparison group was used. The population sample comprised all second-year bachelors' students (N = 36) at a tertiary institution, who were divided into two cohorts. Cohort one was trained to administer an intramuscular injection using a simulated patient with a strap-on injectable device, whilst cohort two used an injection model. Thereafter all participants were assessed on their procedural skills as well as patient-centred care whilst administering an injection to a patient in a hospital. A comparison was made of mean scores for patient-centred care rendered by the two cohorts. The results using Fisher's exact test revealed that the mean score for patient-centeredness of cohort one (88%) was significantly higher (p = 0.001) than that of cohort two (74%). This study concluded that using a simulated patient to teach
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administration of an intramuscular injection enhanced students' patient-centeredness when performing the procedure in practice (Uys & Treadwell, 2014:1).
In the current complex healthcare environment with fewer resources and a reliance on high-level medical equipment, and fewer available clinical settings have led many health educators to using simulation as a method to further augment educational experiences for nursing students (Grant, Dawkins, Molhook, Keltner & Vance, 2014:479). Studies have suggested that complex clinical situations involving simulation using high-fidelity human patient simulators may enhance students’ ability to manage these complex patients in clinical practice (Purling & King, 2012:3451). The benefits of high-fidelity simulations are enormous, and their educational use has the potential to enable knowledge, skills and attitudes to be acquired for all healthcare professionals in a safe, educationally orientated and efficient manner (Aggarwal et al., 2010:34).
Aside from the principal use for simulation in the domain of technical competence, the setting provides learners with an opportunity for self-directed learning. They can make mistakes in a safe environment, learn from their mistakes and achieve proficiency by attaining predefined benchmarks (Wilt & King, 2012:103). Procedures such as insertion of Nasogastric tubes and catheterizations are hitherto procedures that cannot be practised on a patient without assurance of skill proficiency, however with simulation, this can easily be done over and over until proficiency is achieved (Chiang & Chan, 2014:257).
Simulation and the use of simulators to educate healthcare practitioners has been shown to be effective in transferring knowledge to both trainees and practising healthcare professionals. A wide variety of technologies including virtual reality, simulated patients, animal models, and static and interactive mannequins have been shown to be effective teaching tools and several studies have documented the transfer of training to patient care settings (Uys & Treadwell, 2014:1; Aggarwal et al., 2010:36).
The benefits of the broad arrays of existing and developing simulation activities and technologies provide the opportunity for individuals and groups to efficiently and effectively deliver new content or reinforce existing knowledge, as well as practise the application of new knowledge safely until mastery is achieved (Aggarwal et al., 2010:36).
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Simulation training is based on active and adult learning theories with studies having shown that the learning curve of active learning is higher than that of passive learning and that learners can generally remember 90% of what they do by active learning. Bryan et al as cited by Akaike et al (Akaike et al., 2012:28) reported the following five principles in medical education that are relevant and evident in simulation for adults learners: 1) they need to know why they are learning., 2) they are motivated by the need to solve problems., 3) their previous experiences of adult learners must be respected and built upon., 4) the educational approach should match the diversity and background of adult learners., and 5) they need to be involved actively in the process (Akaike et al., 2012:28).
Simulation enables the steps of a procedure or action to be clearly outlined and therefore makes this a preferred method of learning educating nurses.
Similarly, clinical simulation allows both students and professionals to perform their clinical practice in a safe environment, facilitating the standardisation of contents and promoting the integration of theoretical knowledge into the clinical practice (Alconero- Camarero, Gualdron-Romero, Sarabia-Cobo & Martinez-Arce, 2016:128).
It provides students with a real clinical and risk-free experience, it promotes learning and teamwork, and it also helps to make clinical decisions and continually develop a search for knowledge. An essential aspect of the procedure is the debriefing that can take place after the practice, this being defined as the discussion between several people to review a real or simulated case, where participants analyse their actions and reflect on the thinking processes (Alconero-Camarero et al., 2016:128)
Simulation-based education has emerged as key to improving patient safety and numerous healthcare organisations has invested in high-fidelity simulation training centres. However, the high purchasing cost, limited portability, technical expertise and organisational skills required to coordinate these high-fidelity simulation centres are factors that limit their use as a wide-spread teaching and learning methods (Dwyer, Reid Searl, Mcallister, Guerin & Friel, 2015:430). According to Burns and Artman, although simulation provides high-quality care simulated patients or simulators on which learning can happen and its effectiveness evaluated has tremendous proven value. Nonetheless, there are some aspects of high-level clinical judgement and decision-making that might
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be elusive in simulated clinical environments, these having to be mastered during clinical encounters. This probably refers to rare clinical episodes or mass casualty in rudimentary environments, such as war zones (Burns, O'donnell & Artman, 2010). This is an indication that simulation as with any other resource has a limitation in its function.