The place for simulation

The Department of Health has supported the increase in adoption and use of simulation as a learning technology, but stresses that it should not and cannot entirely replace other forms of learning in healthcare education(54). This is partly a function of the cost and logistical challenges of simulation; compared to other modes of teaching, it is expensive and time consuming for both learners and educators. For this reason, the use of simulation to deliver education for any group or topic should be justified. One of the aims of this work is to establish the current place and potential future directions for SBME in postgraduate medical training in the UK, and this will be discussed later.

1.9.1 Disadvantages of using simulation

Simulation, by definition, attempts to recreate real situations, scenarios and procedures without the presence of a patient. Inevitably, therefore, there will be an element of unreality. Procedural skills are often broken down into component parts, and unless using a hybrid approach, a procedure simulator will offer no human interaction. In addition, any equipment malfunction during the simulation can break the immersion, and disrupt any learning that has occurred. Equipment purchase can be costly, and with rapid improvements in either medical practice or simulation technology can quickly become outdated. Software updates and additional scenarios are often available, but frequently at extra cost. One example of this is seen with the Simbionix Angiomentor™ system in use locally, which was purchased at considerable cost but allows practice of procedures only by the femoral route, whereas there has been a move in recent years to radial arterial access. Updating the simulators for the Yorkshire and Humber region alone would entail a cost of several hundred thousand pounds. The risk of broken immersion here is probably the most serious, if the learner perceives that what is happening is an artificial feature of the simulation, their responses will be different to those in clinical practice, potentially breaking the opportunity for transfer of training. Ingraining of poor practice may occur in the absence of adequate supervision where simulator design is poor, and this will not necessarily be reflected in the output metrics from the simulator such as total procedure time, radiation time or contrast volume. Unlearning these undesirable behaviours can be difficult. Additionally, skills learned on a single occasion will decay if regular practice is not maintained.

There is a substantial learning curve for both learners and facilitators. The technology itself and acquisition of debriefing skill can be daunting to educators, and if not used frequently, these skills themselves may decay. Increased use of pre-prepared learning packages and simulation scenarios may remove some freedom from the teachers and learners to tailor their own learning. Mentorship and peer tutoring programmes may help with this somewhat, and the use of virtual reality

simulation can allow asynchronous learning to occur. The logistics of arranging staff time to train, especially if entire team training is desired, can be challenging in acute care areas where there is little ‘downtime’. There needs to be high level management support to enable such activities and ensure success.

1.9.2 Adoption of simulation

The Association for Simulated Practice in Healthcare (ASPiH) has conducted a large-scale scoping exercise to determine the current status of SBME in the United Kingdom in 2014. A total of 87 simulation centres were identified in the UK. Approximately 80% of these centres are using

simulated patients and advanced manikin simulators, and between 25-30% are using virtual reality trainers. The virtual reality trainers are the least used resources, and interprofessional learning is infrequently seen. The key barriers identified to further expansion of the use of simulation were time related; both the time for educators to teach and develop scenarios, and learner release from job plans, possibly as a consequence of poor management ‘buy-in’(127).

Locally, in the Yorkshire and Humber region, there has been considerable financial investment at both undergraduate and postgraduate level into the provision of buildings and equipment to deliver SBME. Health Education Yorkshire and Humber (HEYH) has invested around £20 million in the creation of new simulation centres and equipping them. This investment has been supported by an extensive leadership fellowship programme to drive forward adoption and research in simulation through the development and running of new programmes and the advertising of their availability.

Professional and governing bodies now recognise simulation as a valid component in the training and maintenance of skills. The Nursing and Midwifery Council (NMC) accept the use of simulation training for up to 300 of the required 2300 practice hours for preregistration nursing students (128). The General Medical Council (GMC) has recognised simulation as a potentially advantageous

System Activity (May 2014) have stopped short of mandating the inclusion of simulation in training curricula as a result of concerns regarding equity of access to simulation facilities and obtaining trainer time to support this(129). The Royal College of Physicians routinely incorporates simulated patients into the summative assessment process to gain membership of the college.