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Does simulation have a role in palliative medicine specialty training?
  1. Lucy N Walker1 and
  2. Lynne Russon2
  1. 1St Catherine's Hospice, Scarborough, UK
  2. 2Sue Ryder Wheatfields Hospice, Leeds, UK
  1. Correspondence to Dr Lucy N Walker, St Catherine's Hospice, Scarborough, UK; lucynwalker{at}doctors.org.uk

Abstract

Simulation training has been adopted by other industries, particularly aviation, for many years. With patient safety on every agenda, more recently there has been considerable interest and investment in its use for the acute medical specialities. Evidence in palliative medicine, for the use of simulation is mainly limited to advanced communication skills but little is described about its use in developing acute clinical skills. This article describes how in the Yorkshire and Humber Deanery a simulation training day was set up for Palliative Medicine specialty trainees, to assess their knowledge and develop the skills required to deal with acute medical emergencies, as described in the specialty training curriculum for palliative medicine. Scenarios included opioid toxicity, acute left ventricular failure, anaphylaxis, hypoglycaemia and massive haemorrhage. The set up and scenarios are described, along with the mechanisms for delivering feedback. This method of training received positive feedback from trainees and facilitators. The advantages, limitations and potential future role for high-fidelity simulation training for medical trainees and the wider multidisciplinary palliative care team are discussed.

  • Education and training
  • Simulation
  • Specialty Training
  • Palliative Medicine

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Background

Simulation is “the technique of imitating the behaviour of some situation or process (whether economic, military, mechanical, etc) by means of a suitably analogous situation or apparatus, especially for the purpose of study or personnel training.”1

The rise of simulation training

From Madame Du Coudray's fetal model in 17592 to Laerdal's Resusci Annie in 1960,3 simulation in medicine is not a new phenomenon but recent years have seen a boom in both the funding and use of high-fidelity simulation, with some deaneries spending millions on this field.4 ,5

The use of simulation in other industries, particularly aviation, has become increasingly difficult to ignore,6 with Gaba7 suggesting over 20 years ago that “no industry in which human lives depend on the skilled performance of responsible operators has waited for the unequivocal proof of the benefit of simulation before embracing it.”

The publication of ‘To err is Human’8 and ‘An Organisation with a Memory’,9 along with the media response, put patient safety firmly on the government's agenda. Between 2008 and 2009, several high-profile reports were released10–12 highlighting errors due to human factors and technical skills, and the potential role for simulation to help improve outcomes. Most significant was ‘Safer Medical Practice: Machines, Manikins and Polo Mints’13 in which the Chief Medical Officer at the time highlighted simulation as a means to safer patient care and recommended it be fully integrated into the health service.

Simulation has become an important part of training in many acute specialities, including anaesthetics, emergency medicine and core medical training, where emergency scenarios can be re-enacted in a safe environment. In addition, some specialities use simulators for procedural skills such as bronchoscopy or laparoscopic surgery, to improve trainee confidence and familiarity with equipment prior to their use in the real patient setting. Cook et al14 demonstrated technology enhanced simulation is consistently associated with large positive effects on outcomes of knowledge, skills and behaviours in a systematic review. Benefits to patients have also been demonstrated following simulation training for procedural skills.15

Current use of simulation in palliative medicine

Palliative medicine is a specialty that has arguably embraced simulation training when in the form of advanced communication skills courses, but has been slower to see its' value for developing clinical skills. The use of simulated patients for communication skills was first described in 1968,16 and there has been an explosion of literature on simulation in all forms over the intervening years, and most notably since the late 1990s.17 Despite this there are still very few articles describing the use of simulation in palliative medicine and interestingly, few of these objectively test the transferability of skills learnt in a simulated setting to a real life clinical practice.

Most of the evidence of current practice relates to the use of simulation to teach communication skills for issues related to palliative medicine and end of life care. In 1993, Charlton18 described using role play simulation to teach medicine communication skills to undergraduate and postgraduate medical trainees, with both groups describing an improvement in their perceived skills. Findlay et al19 made simulated patients a key component of their communication skills teaching on a diploma in palliative medicine and demonstrated their value in teaching and assessing students but found that patients and examiners produce differing scores of a candidate's ability. Brown et al20 describe using simulated clinical scenarios with standardised parents to teach palliative care to paediatric trainees, and found that those who participated were significantly more comfortable at initiating end of life care discussions when they returned to work.

Fabro et al21 describe using high-fidelity simulation to teach end of life care to nursing students. The students described an increase in confidence at caring for patients at the end of life and the scenario was felt to offer adequate learning experiences for a scenario which students may struggle to get exposure to during their on the ward training. Gilliland et al22 describe using high-fidelity simulation to teach end of life care to pharmacy students, and found it helped to challenge attitudes and improve knowledge acquisition around end of life care. Attempts have also been described to use simulation to teach interprofessional groups to plan for the care of a new palliative care patient, addressing spiritual and cultural aspects in particular with medical, nursing, chaplaincy and social work students.23 A similar multidisciplinary course focusing on care in the last days of life was found to reduce perceived helplessness when caring for dying patients, in particular confidence with in communication with families and the provision of spiritual care rose.24

Perhaps the most accurate reflection of current simulation practice in palliative medicine is to be found in the numerous conference abstracts published. These reflect a trend towards using high-fidelity simulation to teach generalist nurses how to manage patients at the end of life including symptoms and communication, showing this can improve confidence and knowledge25 ,26 and the value of a facilitated debriefing to allow reflection and peer teaching.27 ,28 Similar models have been used to teach end of life care to first year nursing students, and found that compared to traditional teaching, high-fidelity simulation meant students were better prepared emotionally and in terms of ‘hands on’ skills for their first placement.29

Other abstracts describe using simulation to teach end of life communication tasks to Core Medical trainees, resulting in improved confidence and knowledge30 and using actors to deliver Advance Care Planning discussion training to generalists.31 Some centres have used simulation for interprofessional learning to teach communication skills to multidisciplinary groups, focusing on discussions with families of intubated patients about switching to palliative care32 and setting goals in a simulated family meeting.33

The only reported use of simulation for palliative medicine specialists among these abstracts, was in paediatric palliative medicine. One group described placing doctors and nurses working in this field, in high-fidelity simulation scenarios of difficult situations they encounter in hospices, demonstrating a significant improvement in confidence and knowledge at the end of the study day.34

The specialty training curriculum for palliative medicine states that trainees need “to have the knowledge, understanding and skills to manage emergencies in palliative medicine” and lists 26 specific scenarios.35 Many of these scenarios lend themselves well to a simulation setting.

Setting up a simulation day

Session development

The Yorkshire and Humber Deanery have made a significant investment in simulation technology and all specialties to develop a strategy to make use of these. We designed a 1 day simulation training programme for palliative medicine specialty Trainees in the West/ East Yorkshire region using the simulation suite at Pinderfields hospital to particularly develop acute medical and emergency skills.

The suite includes a simulation room with a manikin and unobtrusive cameras and microphones which record the scenario as it unfolds. A separate control room is used to alter cameras views, control the SimMan and give feedback to actors in the scenario who wear an earpiece. Additionally, trainees watch the scenarios in real time in a viewing room before offering feedback to the trainee who was in the scenario, led by a consultant facilitator.

‘SimMan 3G’, is a high fidelity manikin, with changeable heart and lung sounds, pulses and pupil sizes and the ability to talk and interact with its surroundings. The deanery funded several simulation fellow posts across the region, and this was particularly valuable for assistance with using the technology and providing guidance on how to increase trainee participation. They recommended hiring an actor to play a relative in some of the scenarios to increase the sense of reality and suggested offering trainees a workplace-based assessment for the day.

Session structure and content

The session ran for a full day. Trainees were divided into two groups, with one working through simulated medical emergency scenarios and the other group doing paracentesis on a model with the opportunity for a direct observation of procedural skills assessment. The groups swapped over after lunch. Ideally, each trainee attending should have the opportunity to undertake a scenario and receive feedback. The session was facilitated by five consultants, who observed the scenarios from a control room and then took turns to lead the trainee debriefing after each. The consultants acting as faculty received a briefing at the start of the day with advice on providing effective feedback and how the simulation equipment operates. Trainees and consultants collected a certificate of attendance for their portfolios.

Scenarios

We developed five scenarios for trainees to undertake (see table 1) based on the emergencies listed in the specialty training curriculum and appropriate learning objectives were developed. For each scenario a script and backstory was written for the patient and for the relative, so they could answer any questions the trainee might ask. An algorithm of the SimMan's initial settings (eg, observations, examination signs) was created and how these should alter depending on the treatment administered. A guidance sheet was produced for the consultant and supplied prior to the course, detailing what would happen in the scenario, instructions on how to brief the trainee at the start, a checklist for what was expected of the trainee, and a copy of any relevant guidelines for management. An example simulation scenario pack is available in the online supplementary appendices for this article.

Table 1

Outline of simulation scenarios

In addition, a set of patient notes was produced to accompany each scenario which could give trainees useful information to determine the aetiology of the patient's deterioration and to guide appropriate management such as discussions about patient wishes and resuscitation status. An example of this supporting documentation is also available in the online supplementary appendices. A British National Formulary and Palliative Care Formulary were also provided. A telephone was available in the room so the trainee could contact the consultant for advice if required.

Supplementary supporting documentation

Where an actor was involved, they were sent their background a few days in advance, with further briefing on the day about what would happen in the scenario and how they should react. A hospice nurse attended the day and participated in each scenario; they were given a handover about the ‘patient’ but limited information about how scenario that would develop to ensure they reacted naturally like the trainee. They wore an earpiece so the consultant facilitating could provide guidance if needed.

A technical support worker altered the SimMan settings from a control room as the scenario evolved based on the algorithm designed, but could make additional changes at the observing facilitators request if the scenario difficulty needed amending for a trainee. In addition, he provided his voice for the SimMan and would answer any questions from the trainee, nurse or relative.

Each scenario ran for ∼15 min, with a further 30 min debrief where the trainee joined the other learners in the viewing room to discuss their scenario and watch back any relevant clips with a consultant facilitator. A video of one of the scenarios is available in the online supplementary appendices for this article. Each trainee was offered a mini-clinical evaluation exercise assessment on their performance in the scenario.

Evaluation

Trainee feedback

Trainees gave written feedback on the day. All trainees felt the course was enjoyable and of relevance to their practice.‘Really found this valuable. Very realistic scenarios & very useful to be able to practice this/medical protocols for emergencies. Thank you’ Trainee One‘Very relevant scenarios. Well supported and safe environment.’ Trainee Two

While trainees had dealt with many of the medical emergencies before in an acute medical setting, they appreciated the opportunity to update their skills in a palliative care context.‘Refreshed the medical emergencies—assessment and management in palliative medicine and helps in practice’ Trainee Four‘Refreshing of acute guidelines (will impact on clinical practice)’ Trainee Three

Trainees valued the opportunities to gain a workplace-based assessment as evidence of their skills. They found the cases relevant and appreciated the use of actors. Facilitators provided useful debriefings.‘Excellent relevant case. Good facilitators/actors’ Trainee Five

While trainees had been most enthusiastic for the opportunity to perform a simulated paracentesis prior to the course, the feedback revealed that the medical emergency scenarios were the most valuable learning experiences on the day. Despite trainees initial apprehension about entering a simulated scenario, they felt that these should be the focus of future events.‘Would like to run more ‘emergency’ situations. Really good experience of uncommon but important scenarios.’ Trainee Six‘More of them (scenarios)!’ Trainee Seven

Consultant feedback

Five palliative medicine consultants attended to act as teaching faculty and all reported they had enjoyed the day. They found it offered a good introduction to simulation as a teaching tool and in particular the high-fidelity manikins. They reported finding it very valuable to see trainees dealing with emergencies, as they often occur out of hours when unsupervised and competency is just assumed rather than objectively assessed. It also provided the supervising consultants an opportunity to refresh their acute medical management knowledge.

In addition, it was very useful to have an acute medicine simulation fellow present for the day, who taught on similar courses for general internal medicine (GIM) registrars and highlighted the risk that palliative medicine trainees became too focused on communication with patients and families, at times at the expense of stabilising the patient who still required urgent active treatment, whereas the latter was often the case on GIM training days.

Discussion

Over the last decade the hospice in-patient population has become increasingly complex, with many patients with cancer having admissions much earlier in their disease course while also receiving concurrent active oncological treatments. In addition, the rising patient cohort with chronic non-malignant disease, where prognostication is often tricky and many want ongoing active treatment for acute deteriorations, brings its own set of challenges. Many patients who would historically have been managed in a hospital are now being treated in hospices, reflecting patient choice and a wider agenda of avoiding hospital admissions.

The modern palliative medicine consultant needs to be confident at managing medical emergencies in addition to symptom management and end of life care. Recognising acute deterioration, responding with appropriate initial management and establishing the best setting for ongoing treatment forms a crucial area of the curriculum for specialty trainees. While the majority of trainees now come through Core Medical Training,36 and those who do not will have undergone a requisite period of exposure to acute hospital medical specialties,37 by the time that trainees are approaching their certificate of completion of training it is often a number of years since they had daily exposure to medical emergencies. It is recognised that competence is only maintained through regular practise and simulation training can provide additional exposure to acute medical scenarios to ensure that palliative medicine trainees maintain these infrequently used and rarely supervised skills.

Trainees may not encounter all of the emergencies on the curriculum during their training, particularly anaphylaxis and therefore having the chance to demonstrate competence in a simulated environment is invaluable. There is rarely time in an emergency situation to ask a supervisor to come and observe a trainee's performance, so the immediate consultant feedback through debriefing, provides a powerful opportunity to highlight areas of strength and also those where further learning is needed and potentially specific personal development plan additions. Offering a workplace-based assessment for the trainee who leads the scenario can provide evidence of their leadership and situational awareness skills.

The debrief is argued to be the most important component of simulation training, as this is where the learner makes sense of what happened during the scenario.38 While the trainee who led the scenario gains the most from this, those observing will give constructive feedback and will also learn from the discussion surrounding appropriate management options and relevant guidelines. It may also make them reflect on how their own knowledge would have fared in the same situation. The opportunity to discuss similar cases from ‘real life’ practice helps to increase the relevance to the learners. Cheng et al39 suggest terminal debriefing with time for reflective discussion may be most useful in complex team scenarios. The day also benefited significantly from the presence of an acute medicine trainee in the debriefs who could provide updates on changes in practice, and highlight the balance of communicating with the patient and their relatives, while not losing sight of the need to stabilise the patient as a priority.

Trainees questioned the value of simulation training in palliative medicine prior to the day, equating their previous experiences with environments where intensive monitoring and equipment is available. By specifically adapting the simulation suite to reflect a hospice, where cardiac monitoring and sometimes an incomplete range of emergency drugs would available, the relevance was increased. In some scenarios, the nurse was instructed that only certain strengths or forms of a treatment were available, so that trainees requesting something different, had to adapt their management plan, much like they would in a hospice environment. By using a hospice nurse and a professional actor, who interacted with the SimMan exactly like they would a real patient, trainees quickly forgot they were working with a manikin and the sense of an artificial scenario that simulation can often create was lost. It also allows the opportunity to assess communication skills and how trainees manage the human factors that play a role in emergencies.

By providing an earpiece to the nurse in the scenario, there is a scope for the person overseeing the scenario to provide advice to get a struggling trainee back on track or additionally the voice function of a SimMan can be exploited to allow the patient to give extra hints. By writing some flexibility into the scenarios, the trainee who performs very well can be challenged further by unexpected deteriorations in the patient that makes them think a little deeper about the clinical situation; this has been shown to be an effective design feature of simulation training.40

While one might argue that competence in a simulated environment is not analogous to clinical competence, much like with resuscitation training, the opportunity to practice infrequently encountered scenarios can still be valuable. Many hospitals now have simulation suites with ever more sophisticated SimMen, so the potential for palliative medicine trainees and hospices in general to access this valuable educational tool is increasing. The disadvantages of using simulation in training are the significant preparation time required and sourcing expensive and maintained equipment, however, we would encourage educators to consider how they might use simulation when designing future training opportunities. Box 1 offers useful tips for setting up a simulation day. Our future plans include developing a bank of clinical cases, sharing with other local units and assessing self-efficacy before and after the learning event.

Box 1

Useful tips when setting up a simulation day

  • Don't underestimate the preparation time needed to develop the scenarios and start this early.

  • Try to involve a colleague from acute medicine on the day, as they can give valuable teaching on the latest guidelines.

  • Remember to leave sufficient time for debriefing after each scenario- ideally this should be the longest section.

  • Include other members of the palliative care team in the scenarios to simulate the normal working environment and allow learning for the whole team

Build up a bank of cases to use for future events.

Conclusions

High-fidelity simulation can offer a valuable and enjoyable way to ensure that palliative medicine specialty trainees maintain their skills at dealing with medical emergencies, and can offer supervised exposure to those clinical scenarios on the curriculum that are infrequently encountered.

References

View Abstract

Footnotes

  • Contributors Simulation training is a rapidly expanding area in Medical Education but there is relatively little published on high fidelity simulation in the field of palliative medicine. This article summarises the current published literature and is the first article to our knowledge to describe the potential role for simulation in UK Palliative Medicine specialty training.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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