Don't Just Sit There: Audience Participation in Simulation

In my last blog I talked a bit about setting the audience up for a simulation. In this blog I wanted to explore this more. Students who volunteer first to simulate are often in the minority but it’s important that the audience don’t feel like it’s an easy ride and just sit there.

The standard lay out when I run a simulation session is like this:

One of the audience members becomes the scribe, recording the clinical history and the story as in unfolds. This provides a point of reference for the students in the simulation as well as helping discussion during debrief. As these example show it also lets students be a bit creative:

View fullsize

View fullsize

View fullsize

View fullsize

View fullsize

We’ve often given students in the audience a checklist and asked them to record proceedings as well as part of student to student feedback.

If you’re giving the students in the simulation information such as an ECG or blood gas, make sure the audience can either see it or get a copy too to involve them. Later on reflect on their conclusions: are they different from those in the simulation?

In the previous blog I mentioned lifelines such as ‘Ask the Audience’. I find reminding the audience that at any moment the students in the simulation might turn round and ask your opinion inspires them to keep paying attention!"

‘Tag Team Simulation’ is something I’ve thought about but not done yet but would be another way to keep the audience engaged - I’d be interested to hear how this works if anyone has done it.

Managing audience members is a key part of the simulation session. If nothing else their engagement is a sign of respect for the students actually doing the simulation and helps create a positive learning atmosphere for everyone.

Thanks for reading

- Jamie

Setting the Stage: The Pre-Brief

Simulation is an indelible part of medical education as well as the training of other healthcare professionals. At DREEAM I’m lucky to be able to work with the great cohort of simulated patients trained by my colleague Ali Whitfield. Working with real human beings rather than mannequins adds another layer of realism and has become a firm fixture in the training we offer at DREEAM.

However, being ‘on stage’ in a simulation remains a very divisive issue for learners. From my experience half of students will feed back how much they love simulation and want more with the other half hating every moment. That’s usually due to previous bad experiences or pre-conceived notions.

As I’ve worked more with simulation as a facilitator I’ve put more emphasis at the beginning; the pre-brief or ‘setting the stage’ partly due to these pre-conceived notions but also as not every student has the same experiences with simulation. Much as an actor wouldn’t expect to just walk onto a stage so a novice student shouldn’t be expected to just perform without some clear guidance.

My pre-briefs usually follow the same pattern:

• Introduce the session and why we are using simulation - it’s not being arbitrarily used to scare but instead with very clear objectives with definite relevance

• The setting (ward, A&E, GP practice whatever) their role (you’re a student/doctor/nurse) and the expectations of the behaviours expected - act as you would as a doctor, treat the simulated patient as a real patient etc. How do referrals work in this scenario? Also, what is expected from the audience? I regularly get one member to act as a scribe on a flip-chart for the learners in the simulation to refer to. Encourage the audience to be active observers

• Orientate the students around the environment and the equipment. Highlight any potential sources of confusion such as differences between the patient’s palpable pulse rate and what is on the monitor. Will there be blood results available? Are we running in real time? This helps keep the scenarios running later on

• Acknowledge simulation can be challenging and where possible allay fears - if you’ve set the scenario up so that any mistakes made will be corrected and death is not an outcome then tell them! In my experience the biggest apprehension toward simulation from students is that we’re trying to catch them out and they’ll kill the patient. If that won’t happen let them know. If it might happen then also let them know and reassure that it’s a safe environment allowing for these mistakes

• Lifelines - the timeout is a common theme in any simulation and it’s important to reassure students about this. I go further and add lifelines similar to ‘Who Wants to be a Millionaire?’ Students can ‘Ask the Audience’ - turn to the learner watching and ask their opinion or ‘Phone a Friend’ - ask the facilitator a closed, focused question; “I think it’s aortic dissection what’s the best imaging for this?” If it’s not going great we can always time-out and take a break; this is fine and should be used if needed

• Is there a specific aspect of simulation they’d like you to look out for? Giving useful feedback can be challenging. Students may have apprehensions about one particular skill or part of simulation such as cannulation or delivering a useful referral based on previous experiences. If they can tell you this beforehand it helps observation and providing feedback the student can use

• Give them appropriate information beforehand. Most of the simulations I do with students are based in the Emergency Department. One is with a patient presenting with chest pain who turns out to have a pulmonary embolus. In real life there would be an ECG. I provide this ECG and give them a moment to read it. I ask what the students are thinking and why. They usually say Acute Coronary Syndrome. At the end after diagnosing PE during the feedback I then ask them to take us through the process of how they ended up changing their mind from ACS to PE (usually because the patient complains of calf pain). I reinforce how important it is to always consider ACS but also what aspects should make us think PE (yes calf pain is important but the patient had oxygen saturations of 90% with no lung history, a clear chest and her ECG shows AF.) - this shows the nature of a true ‘working diagnosis’ as well as helping us understanding each others thought processes

Ultimately the pre-brief is about you and your learners finding out about each other. Standardise as much as you can. Students who go first may resent being ‘the example’ so think about making a video to show everyone what is expected at the beginning. This is then easier for you later on. I think pre-brief is an investment in your simulation sessions. The more and better you do at the beginning the bigger and more rewarding your session will be.

Thanks for reading

Jamie

Medical Education - There's An App For That

Third year medical students at the University of Nottingham on clinical attachment at the Queens Medical Centre spend one week with us in DREEAM and the Emergency Department. Emergency Medicine can be daunting for experienced students let alone those right at the beginning of the clinical phase of the course. Also, as students arrive in the spring their week is often shortened due to Bank Holidays and other commitments such as core teaching. I wanted to find a way to give the students as much information as possible about the working of the department and its protocols as well as a way of increasing contact time to make the most of their attachment. A smartphone application seemed a practical solution.

IT’S EASY

The thought of creating an application might bring to mind Matrix-style screens of numbers and formulas indecipherable to anyone except hackers and programmers. The truth is it has never been easier to create your own application thanks to a number of websites which require no coding experience. A simple Google search reveals just what a crowded market the app building industry has become so I recommend a bit of research to find the platform that works best for you. Most of them work along the lines of choosing a template and then picking functionality such as social media links to add literally in a ‘drag and drop’ style. I chose AppMakr due to its ease of use and because the app also works as a website allowing students to access it on their computers and laptops as well.

The whole process is based on simply picking what functionality you want (say a calendar) and dragging it across. Each function is based on an RSS feed so you link your calendar to a Google calendar or your podcast icon to a SoundCloud feed. In order for the app to have our department’s Initial Assessment Tools (IATs) I created a Google Drive folder containing the guidelines as PDF files and used the shareable link. This meant clicking on the IATs button opened the IATs up for the students to use.

Backgrounds can be played around with. I tried importing pictures but found the resolution and sizes difficult; I think this had more to do with the images I was trying to bring in rather than the website itself.

You can pay to create your app and submit it to iTunes for consideration (it will need to be very good to get approved) or AppMakr will create a mobile website for free. The mobile website for this application can be found here. All students need to do is set the website to the home screen of their mobile or tablet and there, instant application. It was that simple.

Simply pressing on the green cross brings up the list of functions. The green cross acts as a kind of home button.

Using Google Drive links the presentation buttons bring up the slides for each session. The IATs function works the same. The calendar links to a Google Calendar account created especially for this application.

External resources were linked to the application as well. Certain Free Open Access Medical Education (FOAM) resources were linked as well as dedicated Social Media, Podcast and YouTube resources to help the students during the attachment. Unlike other apps this worked without internet connection which helps in the concrete basement of our Emergency Department!

Finally, a forum was created into which students and educators could log in and communicate. This helped share resources and further discussions. This brings me on to my next point:

FLIPS THE CLASSROOM AND BLENDS YOUR CURRICULUM

The flipped classroom describes students being given learning resources before a teaching session. The teaching session is then used to explore the material in greater detail (Heacademy.ac.uk, 2018). The role of the teacher in the flipped classroom has been described as a facilitator and coach or ‘guide on the side’ (Baker 2000). This notion resonates within suggested theories in medical education regarding the exponential growth as well as the shortening half life of knowledge such as connectivism (Siemens 2005) or navigationism (Brown 2006). The growth of Web 2.0 resources such as blogs and podcasts further facilitates this.

Using the application it was possible via the forum and word of mouth to point the students to a particular resource (say a podcast on Abdominal Pain) and advise them to listen to it before their session on Abdominal Pain. By flipping the classroom we can establish a set level of prior knowledge the traditional session can then build on. This maximises the time together. There’s a number of resources aimed at helping educators set up a flipped classroom programme such as this one from the Flipped Learning Network.

The forum allowed further discussions around cases (anonymised) or other subjects that couldn’t be covered in the timetabled sessions. These discussions were held between 1700-1900 in the evening and all students were encouraged to participate. This use of online resources alongside traditional sessions is called blended learning (Heacademy.ac.uk, 2018). The point was that the sessions would lead onto online discussion which would then be referred back to in the next face-to-face session which takes some time to get used to but is rewarding. The Higher Education Academy has a great page on blended learning here.

REAL LIFE PRACTICE IN SIMULATION

In all 18 students ‘downloaded’ the application. There was an orientation session at the beginning as well as clear guidance on professional online behaviour; so called ‘netiquette’ (Webroot.com, 2018).

All sessions were designed to integrate the application either through guideline reference in simulation or signposted online resources during seminar sessions. All students used the application in at least one session with 11 students (61%) using the application in every session.

The forum transcription was analysed for any emergent themes. As I already discussed the forum was a key part of the ‘flipped classroom’ and improving communication before educators and students. This resulted in logistical messages communicating session changes or short term information such as interesting patients:

There was signposting to resources to consolidate sessions or for prior learning before teaching:

There were also online discussions instigated around investigations or clinical questions:

The reason(s) for students using the application during simulation was assessed. By far and away the most common reason was to look up departmental guidelines (13) followed by looking up national guidelines (4), looking up free open access resources (2) and to look back on a presentation (1).

Students were asked to rate the application on a Likert scale. All students rated the application positively (4 or 5) with 14 (78%) rating the application 5/5.

Finally, students were given a free text box for further feedback. As the diagram below shows this feedback focused on themes of reference and reflecting real life practice:

This suggests that medical students appreciate the role of guidelines and technology in clinical practice. The importance of digital literacy and navigating resources for expedient care is well documented with the Royal College of Nursing and Health Education England launching programmes to improve and formalise skills in this area (The Royal College of Nursing, 2018 and Health Education England, 2018). Studies have looked at promoting digital literacy amongst medical students (Mesko, Győrffy and Kollár, 2015). Perhaps with the rise of connectivism and/or navigationism as a learning paradigm we will see even more work into this area with digital literacy becoming a key skill alongside clinical acumen. Anecdotally speaking to the students the biggest barrier to using the application was familiarity. Once this was overcome they felt comfortable using it and contributing on the forum.

Students value innovation from educators but this requires careful design of the curriculum and resources to ensure feasibility and compatibility.  The project suggests that application design is feasible for educators with limited coding experience and the results indicate that students engage well with a blended curriculum.  Engagement with the application was related to student confidence and perceived relevance.  Mobile learning tailored with simulation offers students a realistic experience.  Resource design may become a crucial part of educator development.  Students require guidance with new resources when presented to them.

Reference

Baker, J. W. (2000) The “Classroom Flip”: Using Web Course Management Tools to Become the Guide on the Side. In: the 11th International Conference on College Teaching and Learning: Jacksonville, Florida.

Brown, T. (2006) "Beyond constructivism: navigationism in the knowledge era", On the Horizon, Vol. 14 Issue: 3, pp.108-120, https://doi.org/10.1108/10748120610690681

Flipped Learning Network (FLN). (2014) The Four Pillars of F-L-I-P™

Heacademy.ac.uk. (2018). Blended learning | Higher Education Academy. [online] Available at: https://www.heacademy.ac.uk/knowledge-hub/blended-learning-0 [Accessed 19 Oct. 2018].

Heacademy.ac.uk. (2018). Flipped learning | Higher Education Academy. [online] Available at: https://www.heacademy.ac.uk/knowledge-hub/flipped-learning-0 [Accessed 19 Oct. 2018].

Health Education England. (2018). Digital literacy. [online] Available at: https://www.hee.nhs.uk/our-work/digital-literacy [Accessed 29 Oct. 2018].

Mesko, B., Győrffy, Z. and Kollár, J. (2015). Digital Literacy in the Medical Curriculum: A Course With Social Media Tools and Gamification. JMIR Medical Education, 1(2), p.e6.

Siemens, G. (2005). Connectivism: A learning theory for the digital age.International Journal of Instructional Technology and Distance Learning, 2(1), 3-10.

The Royal College of Nursing. (2018). Improving Digital Literacy | Royal College of Nursing. [online] Available at: https://www.rcn.org.uk/professional-development/publications/pub-006129 [Accessed 29 Oct. 2018].

Webroot.com. (2018). What is Netiquette? A Guide to Online. [online] Available at: https://www.webroot.com/hk/en/resources/tips-articles/netiquette-and-online-ethics-what-are-they [Accessed 29 Oct. 2018].