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Simulation

An innovative model for teaching and learning clinical


procedures

Roger Kneebone, Jane Kidd, Debra Nestel, Suzanne Asvall, Paraskevas Paraskeva & Ara Darzi

Context Performing a clinical procedure requires the Results The scenarios provided a realistic simulation of
integration of technical clinical skills with effective two common clinical situations and proved feasible in
communication skills. However, these skills are often terms of time, facilities and resources within this
taught separately. institution. Students found the opportunity to integrate
Objectives To explore the feasibility and benefits of a communication and technical skills valuable, challen-
new conceptual model for integrated skills teaching. ging and an appropriate learning experience. Immedi-
ate feedback was especially highly valued. Some
Design A qualitative observation and interview-based
students found difficulty integrating technical and
study of undergraduate medical students.
communications skills, but benefited from conducting
Methodology Medical students performed technical and two procedures in the same session.
communication skills in realistic clinical scenarios
Conclusion The integrated model was feasible and was
(urinary catherization and wound closure), using latex
perceived to be valuable. Benefits include the oppor-
models connected to simulated patients (SPs). Proce-
tunity to integrate, within a safe environment, skills
dures were observed, videorecorded and assessed by
which are often taught separately. Promoting reflective
tutors from an adjoining room. Students received
practice may enable the successful transfer of these
immediate feedback from tutors and SPs, before
integrated skills to other procedures.
engaging in a process of individual feedback through
private review of their videotapes. Group interviews Keywords *Clinical competence; *communication;
explored the response of students, SPs and tutors. Data education, medical, undergraduate*methods;
were analysed using standard qualitative techniques. feedback; interpersonal relations; London; teaching.
Subjects Fifty-one undergraduate students were recrui- Medical Education 2002;36:628634
ted from the Faculty of Medicine, Imperial College,
London.

to patient dissatisfaction and reduces adherence to


Introduction
treatment recommendations.35
Having to perform clinical procedures is a source of Performing a clinical procedure involves two sets of
anxiety for students and poses potential risks to skills those related to conducting the procedure itself
patients.1 There is evidence that medical students and those related to communicating with the patient.
approaching qualification perceive their exposure to Although indivisible in practice, these skills are usually
clinical skills to be inadequate, and that many feel ill- taught separately, often by different departments within
equipped to carry out a range of procedures, including an institution. Effective performance requires seamless
urinary catheterization and suturing.2 Moreover, poor integration of the two, and this process needs practice
communication between physicians and patients leads and reflection.
Acquisition of expertise in any domain requires
Departments of Oncology & Surgical Technology (RLK, PP, SA and sustained deliberate practice simple repetition is not
AD) and Cognitive Neuroscience & Behaviour (JK & DN), St Marys enough.6 Moreover, the literature relating to adult
Hospital, Faculty of Medicine, Imperial College of Science,
Technology & Medicine, London, UK
learning and skills acquisition shows the importance of
immediate, focused feedback.7,8
Correspondence: Roger Kneebone, Department of Oncology and
Surgical Technology, 10th Floor, QEQM Wing, St Marys Hospital, Technical skills are widely taught in skills labs, using
Praed Street, London W2 1NY, UK. E-mail: r.kneebone@ic.ac.uk benchtop models made of simulated tissue. Of course

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A model for teaching and learning R Kneebone et al. 629

Methodology
Key learning points
The setting
Procedural and communication skills must be
performed together but are often taught separately. At the St Marys Hospital campus of the Imperial
College Faculty of Medicine the undergraduate clinical
Realistic clinical scenarios can be created by
skills facility includes 4 teaching suites, each with an
linking benchtop models with simulated patients.
interview room (which can be equipped to resemble a
Students can perform procedures in a safe ward or emergency room) and an adjoining observation
environment which recreates many contextual room. Events in the interview room can be watched in
cues of clinical practice. real time and simultaneously recorded, using a remote-
controlled ceiling-mounted video camera.
Immediate structured feedback from tutors and
simulated patients has high perceived value.
Scenario preparation
Students perceive scenario-based practical
procedures to be a powerful learning experience. Two commonly encountered clinical scenarios were
created. Each was chosen to reflect a clinical task which
clinical medical students were likely to encounter in the
not all technical skills are taught in this way, but by course of their training, and each was designed to
allowing repeated practice to take place in a controlled mimic real life as closely as possible. Each scenario took
environment, simulation has become a keystone of place in a room resembling a ward or treatment room,
training.9 Although simulation is effective in teaching with handwashing facilities and a range of procedure
the rudiments of technique, there is a danger that packs, gloves and other equipment.
learning will take place in isolation from its clinical
context.10 While laboratory-based teaching may pro- Scenario 1 urinary catheterization
vide a satisfactory basis for surgical procedures carried After arranging a standard catheterization model on an
out under general anaesthetic, it can ignore the inter- examination couch, the SP was positioned at an angle to it,
personal skills which are an essential component of supported by a wall (Fig. 1). An illusion of seamlessness
carrying out a clinical procedure on a conscious patient. was created by covering up the join with bedclothes and
Communication skills teaching is now well estab- placing the legs of a mannequin appropriately (Fig. 2).
lished in UK medical schools.11,12 The value of This allowed the student to carry out the steps of the
working with simulated patients (SPs) is widely recog- procedure on the model while interacting with the patient.
nized.13 Such patients can create realistic scenarios
and are trained to step out of role afterwards to give Scenario 2 wound closure
constructive feedback. Videorecording allows the lear- A simulated tissue skin pad (with a previously inflicted
ner to replay and reflect upon their performance. Using wound) was strapped to the SPs upper limb (Fig. 3).
SPs in combination with feedback and video replay is a The skin pad was mounted on a firm perspex backing,
highly effective teaching tool, offering potential to to prevent inadvertent needlestick injury during injec-
develop insight. These skills can be taught and retained tion of local anaesthetic. The arm was covered with a
over several years.14 fenestrated drape (Fig. 4) and the patient reclined upon
Communication skills training, however, has not been a couch (Fig. 5).
specifically applied to clinical procedures. This paper
presents a new approach to skills training and describes a
Participants
learning model in which students practise technical and
communication skills in realistic clinical scenarios, using Students
simulated tissue connected to SPs to create a safe zone. Second and third year undergraduate medical students
This pilot study was designed to address the follow- undertaking surgical attachments were recruited to the
ing research questions: study. All had received instruction in catheterization
1. To what extent is it feasible to simulate a clinical and wound closure during their six week attachment,
procedure by linking models made of artificial tissue using benchtop models in the Skills Laboratory. In
with simulated patients? addition, all participating students had received com-
2. What benefits of this approach are perceived by munication skills teaching prior to entering the study,
students and their tutors? as part of our institutions syllabus. Sampling strategy

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630 A model for teaching and learning R Kneebone et al.

included explanation of the clinical background to the


case and the technical procedure to be carried out,
briefing on possible issues which might arise and
instruction on how to present feedback at the end of
each scenario.

Process of the sessions

Running the sessions


A 3-stage conceptual model was used for the process
(see Fig. 6).
Before starting the session, each student was given an
instruction sheet, outlining the patients clinical prob-
lem and defining the task. Ten minutes were allotted for
each procedure and a warning signal provided at 8 min.
Each procedure was observed in real time (using closed
circuit television) by a technical and a communication
Figure 1 Setting up the urinary catheterisation scenario: Stage 1. skills tutor, and all procedures were assessed using a
combination of checklist and global rating scales.15,16

Providing feedback
Immediately after the procedure finished, student and
SP wrote down their impressions on a simple structured
form. The tutors then facilitated a 5-minute feedback
session, starting with the students perception of what
went well and what could be improved. The SP
commented from the patients perspective, then the
tutors gave specific, focused feedback on technical and
communication skills. The procedure and feedback
session were recorded on videotape.

Reflection
Immediately after receiving the feedback, each student
reviewed their videotape and the recorded feedback.
Each student conducted this review process alone and
Figure 2 Setting up the urinary catheterisation scenario: Stage 2. in another room. Students were asked to mark their
recorded performance, using identical rating scales and
was based on availability of students, and all study checklists to those used by the tutors. An exploration of
participants were volunteers. students responses to this reflective process took place
in the evaluative group interviews.
Tutors
Five tutors took part in the study. Three (RLK, SA and
Evaluation of the process
PP) were drawn from the Department of Surgery and 2
(DN and JK) from the Department of Cognitive When all students had completed both procedures a
Neuroscience & Behaviour. One tutor from each group interview was carried out, which included all the
discipline (surgery and communication skills) was students, the SPs and the tutors. These interviews took
present during each scenario. place at the end of the respective session, when all
participants had had an opportunity to experience all
Simulated patients aspects of the intervention. All group interviews were
Experienced SPs were recruited from the bank of semi-structured and were conducted using a topic guide.
actors used for the communication skills training One researcher acted as moderator. All interviews were
programme. Each received a 20 minute induction recorded using video andor audiotape, and detailed
session with the tutors before the scenarios began. This contemporaneous written notes were kept of each session.

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A model for teaching and learning R Kneebone et al. 631

Figure 3 Wound closure scenario: attaching a skin pad to the SP. Figure 4 Wound closure scenario: covering the skin pad with a
fenestrated drape.

Figure 5 Wound closure scenario in


action.

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632 A model for teaching and learning R Kneebone et al.

Figure 6 A model for teaching and learning.

faculty resources within our institution. However, a


Data analysis
half-day session (maximum of 8 students, each per-
Each interview tape was first reviewed repeatedly and forming 2 scenarios) was labour-intensive, requiring
coded for emergent themes by RLK, using a graphical four tutors and two SPs.
software package (Mind Manager) supported by verbatim The students felt that the scenarios provided a
transcription. Another member of the research team realistic simulation of common clinical situations.
examined the procedure videotapes independently in order
I actually felt really stupid when I did the catheter,
to cross-check the evaluation process. A written summary
because when I pulled back the cloth Id actually
was produced after each session and reviewed by all
forgotten that it was going to be plastic, it was that
members of the research group. Further discussion led to
realistic! [group interview 4]
exploration of ideas for modifications to the next session.
The SPs experienced no difficulty in applying their
existing acting and feedback-giving skills within these
Results
scenarios.
Seven scenario sessions took place during a 10-month
period. Fifty-one students conducted both procedures,
Perceived benefits
providing a total of 102 performances. The following
findings are based on observation and group interview Students
analysis. All students thought that the opportunity to integrate
communication and technical skills on an SP was a
valuable and challenging learning experience.
Feasibility

The tutors observations showed that setting up realistic


scenarios is feasible in terms of time, facilities and

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A model for teaching and learning R Kneebone et al. 633

Its different with a living, breathing, talking patient. about the students previous experience in carrying out
[Its] hard to talk to the patient and concentrate on the procedure, appropriate use of silence, obtaining
what youre doing. [group interview 1] consent and empowering patients to ask questions.
Students appeared to benefit from conducting two
At first youre in shock, when youre doing it the first
scenarios in the same session. For the majority of
time. Before, when we were practising on the models, I
participants, the communication skills demonstrated in
thought Yeah, yeah, I know how to do it, but doing it
the second scenario seemed to be more effective. It
on the actors it was a real shock. No matter how much
seemed that providing two scenarios, where the second
youve practised beforehand, just doing it on a patient
was performed after the student had had opportunity to
with a real person there, it really helped. [group
receive and reflect upon feedback from the first,
interview 2]
resulted in a gain in performance. Most students were
They thought this challenge was appropriate. unable to complete the task within the allotted time and
so had little opportunity to practise their skills in closing
We dont want to be doctors who just get on with the
the interview.
procedure and ignore the patient. This is what gets you
to practise. [group interview 1]
Simulated patients
Some students indicated the scenarios gave them The SPs identified with the students experience.
insight into their feelings.
Its a bit like an actor learning to handle his props
For the first time it exposes you to your own feelings. while delivering his lines takes great skill, I can tell
When I was trying to catheterize, the patient was you. [group interview 3]
going Ow, Ow, and I was thinking Why cant you
All were favourably impressed by the students
just shut up, itll be done in a minute, let me get on
professionalism and sensitivity.
with it. [group interview 1]
It was very sensitive. Everybody, varying degrees, but
Feedback was highly valued. In particular, receiving
everybody without any exception at all, I thought
immediate, focused and personalized feedback from
treated the patient extremely well. [group interview 6]
experts in 3 fields dramatically increased the perceived
usefulness of reviewing the videotapes.
Negative responses
That was very helpful. It was like, the mistakes that
youd made, or the good things that youd done, on Negative as well as positive responses were actively
your sheet, but it was someone telling you that stuck sought from all groups. Negative comments were few,
in your head. [group interview 6] and most related to details of the scenarios (e.g. the
provision of a range of glove sizes). One group of students
Many students expressed their discomfort at being
objected to the amount of time they spent waiting for
faced with unexpected decisions (e.g. which sutures to
their colleagues to finish watching their videotapes.
choose), but acknowledged that this reflected the reality
of clinical experience and was useful for their learning.
Discussion
Tutors
This study explored the potential of a new teaching
Tutors found that observing the scenarios provided
method. We created a safe zone in which students could
valuable insights into the learning process. In general,
integrate their clinical and communication skills within a
students were able either to carry out a technical
supportive learning environment that would encourage
procedure or interact with the SP, but showed difficulty
reflective practice. We have developed a conceptual
in integrating the two. Any unexpected elements, such
model for the process, which specifies the roles played by
as having to choose between several types of suture,
participants in each 30 minute iteration (Fig. 6).
interfered seriously with the students ability to perform.
Our results show that it is feasible to integrate SPs
Students were able to reproduce procedures they had
with plastic models and that students, SPs and tutors all
been specifically taught, but demonstrated difficulty in
perceive benefits to working in this way. Key points
transferring skills (such as aseptic technique) learned in
were the realism of the scenarios, the difficulties the
one scenario to another.
students encountered in integrating skills from different
There was a wide range of communication abilities.
domains, and the perceived value of immediate feed-
Skills requiring further development include making
back in both technical and communication skills. The
empathic statements, responding to patients questions

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634 A model for teaching and learning R Kneebone et al.

students in our study seemed on the border between


Funding
conscious incompetence and conscious competence,
appearing both responsive to feedback and motivated to We acknowledge the support of the Imperial College
act upon it. Centre for Educational Development who funded this
Our foci in this study were the feasibility of the research via a Teaching Research Grant.
conceptual model and our participants subjective
response to its potential for teaching and learning.
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Contributors
Received 13 September 2001; editorial comments to authors 23
All authors contributed to the production of the November 2001; accepted for publication 13 December 2001
manuscript and to the work it describes.

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