Appearance
Interaction with the learner
Educational context
Part-task trainer
Realistic, but of a single body part
Feels realistic, but limited or no response
Repetitive practice of isolated skill
Fully body simulator
Realistic body, often with associated physiological modelling
Allows examination (e.g. pulses) and realistic interactions
Realistic practice of whole scenarios
Screen simulator
2D image of patient, equipment, or staff
Realistic response to input via keyboard or mouse
Cognitive exploration of a variety of situations
Virtual reality
3D image of a patient, equipment, or staff
Realistic response to input via a variety of methods
Realistic practice, often of a defined task
Real people as simulators
Real people
Verbal and non-verbal communication
Practice of a variety of clinical skills
Hybrid simulation
Any combination of the above
Verbal and non-verbal communication and interaction
Realistic practice
Simulated environments
An entire clinical environment
Full interaction with patient and team
Realistic practice and team training
1.4.1 Part-Task Training
Part-task simulation training is the breaking down of a large, multicomponent task into simpler individualised elements. This type of training focuses on the specific fundamentals of a task and the development of ‘automated skills’, which would otherwise be challenging to achieve in the context of a complex task. They are specifically designed to replicate only part of an actual clinical scenario [4]. Some simple examples include venupuncture, cannulation and suture pads. This type of training is now familiar to most healthcare professionals.
More complex part-task trainers are now commonplace in surgical training. There is substantial evidence available on how to incorporate these trainers into a wider training programme [5]. In particular, it is important that trainees experience part-task training at an appropriate point in their learning curve. Once a trainee has mastered the technical skill required, the part-task can be incorporated into a wider clinical scenario where other non-technical skills will be needed (Fig. 1.1).
Fig. 1.1
Part-task trainer for chest drain insertion
There are now realistic part-task trainers for almost every practical procedure that occurs in Intensive Care. Realistic, airway and tracheostomy trainers are widely available [6]. The use of chest drain and central venous access trainers is now well established. The developing trend is to incorporate these trainers into specific learning modules that form part of a wider curriculum [7].
A typical modular approach to teaching chest drain insertion would begin with some screen-based material, outlining the anatomical, technical and equipment issues. The students would then progress to working through the procedure on a part-task trainer facilitated by an experienced practitioner. Once the students have reached an acceptable level, the part-task trainer can be inserted into a more complex simulated scenario. The students are then required to carry out the same technical task, but under time pressure and a certain level of stress. This stepwise fashion allows the skills learned to be gradually reinforced. At each stage, a formal feedback session is essential.
The uniformity of part-task trainers to some degree allows a level of comparative assessment. This may be useful in monitoring the students’ progress and detecting problems at an early stage.
1.4.2 High-Fidelity Simulation Training
High-fidelity or ‘immersion’ simulation incorporates knowledge, technical and procedural skills alongside non-technical skills such as communication and teamwork within realistic scenarios. The high-fidelity manikins give immediate, real-time feedback on the patients’ condition and response to interventions. This dynamic component encourages the participants to become immersed in the scenario; so, their responses and behaviours become closely related to a ‘real’ situation. This dynamic component of high-fidelity simulation training has been shown to lead to increased confidence and decreased anxiety amongst the trainees. However, the key element is the debriefing session where participants partake in a detailed discussion of their experiences as a part of an experiential learning process. This process is most effective if carried out as a team exercise, with all those involved taking part. The validity of high-fidelity simulation training lies in careful planning, authenticity, close clinical resemblance and high clinical relevance (Fig. 1.2).
Fig. 1.2
High-fidelity simulation team training
An example of high-fidelity simulation training in the Intensive Care Unit (ICU) setting was conducted in the University of Toronto where a new protocol for cardiac arrest in patients with severe acute respiratory syndrome (SARS) was evaluated. The simulation training raised issues that had previously not been considered, in particular the time taken to don the personal protection system (PPS) in an acute situation, techniques of defibrillation, and ergonomic factors such as minimising stethoscope use to avoid dislodging the PPS helmet. Effective changes were then made to improve the protocol [7]. High-fidelity simulation has been used effectively to familiarise ICU staff with new complex treatments, such as extracorporeal membrane oxygenation [8].
All ICUs will have critical incidents. High-fidelity simulation is an effective way of examining these incidents in a safe and positive environment leading to improvements in patient outcomes.
1.4.2.1 Non-technical Skills and Human Factors Training Using High-Fidelity Simulation
It is increasingly recognised that part-task training alone, whilst useful, cannot fully prepare a learner for working in a high-pressure environment. Working successfully in a busy, multidisciplinary clinical area such as the Intensive Care Unit requires a variety of ‘non-technical skills’, such as situational awareness, team working and communication. Within the aviation industry, focused training on these skills is routine and often referred to as ‘Crew Resource Management’; within medicine, the terms ‘Crisis Resource Management’ (CRM) or ‘Human Factors training’ are more common [8].
Whilst it is relatively straightforward to design protocols to teach a practical skill, such as central line insertion, or a sequence of tasks such as an Advanced Life Support algorithm, an approach to teaching these ‘soft skills’ may be less readily apparent. High-fidelity simulation training is well placed to meet this need. In a high-fidelity situation, learners are exposed to a simulated clinical environment that has been designed to be as realistic as possible. Manikins have evolved in complexity over the years to allow an increasing number of clinical scenarios to be played out, and it is now possible to simulate high-fidelity medical, surgical, anaesthetic, paediatric and obstetric cases. This requires dynamic interactions with a simulated whole patient, other members of a clinical team, a ward environment, medical equipment, and additional demands such as prioritisation and external communications.