I was delighted to speak at the European Society of Emergency Medicine in Vienna this year. One talk is with the Young Emergency Medicine Doctors (YEMD) group on the use of teaching simulation for ‘soft skills’. This blog is linked to that talk to help back up the general principles talked about.
What are soft skills?
This title was chosen for me to be accessible to a multilingual audience, and that’s fine, although I am a little concerned that this might give the impression that this is less important than ‘hard skills’. The talk was essentially about how we use simulation to develop non-technical, elements of human factors, interpersonal behaviours and healthcare culture skills in the emergency department setting. There is no doubt (and a lot of evidence) that healthcare systems work best when teams function well. Confusingly there are almost as many structures and definitions for the factors affecting performance as there are stars in the sky. You will probably have your own; I like the simple categorisation of medical education intending to influence the following domains.
Whilst the the first two are the focus of many of our teaching strategies, delving into relationships and attitudes is harder in the traditional classroom format. However, with simulation we can examine, debrief, reflect and explore relationships and attitudes in ourselves and in our colleagues. Let’s consider how we can enhance simulation training to develop these skills.
In Situ or in the Sim Lab?
Here at St.Emlyn’s we are advocates of in situ simulation1,2. Simulation in the workplace allows teams who work together to train together with obvious benefits when attempting to explore how participants interact with each other. Much of our beheviour in the workplace, and especially under stress, is guided by cultural norms related to any particular healthcare economy, country, hospital, speciality or department3.Observing these in situ has clear advantages as compared to removing participants to a different location such as a simulation centre. Similarly if we are to explore interpersonal reactions we behave differently with strangers as opposed to the familiar work colleagues. If our end goal is to improve performance in the worplace then there is a logical argument that the best place to do this is within the work setting.
A counter argument would be that in situ simulation is often compromised by time and workload pressures which may adversely influence the quality of the debrief. This may of course be true on occasions but despite this we do believe that in situ simulation with a familiar environment and workforce is the best place to observe and influence soft skills.
In Virchester we frequently run our in situ sim sessoins in the emergency department with members of staff who happen to be on duty at that time. This allowa the realistic formation of teams that reflect the experience and skill mix that would really be present. Nobody is required to act out of role and as the scenario takes place within the ED real equipment, real locations and real communication pathways can be tested.
Real patients or mannequins?
You can use either, but if you are interested in exploring characteristics such as patient:clinician communication, empathy, language and listening then it’s better to have a real person as your patient. For more procedural tasks where you want candidates to ‘do’ procedures then in general a mannequin will work best. Real people acting the part of patients is very emotive and thus facilitates exploring interpersonal interactions but can be awkward if the person playing the patient (or relative) is known to the team. For example I love playing the role of a patient or relative when teaching on courses such as APLS4, but it does not work so well in the ED. I’m too well known and there exists a perceived power distance betwen me and the participants. In my experience few people can manage this difficulty (@_nmay seems to manage it).
Simulations in any setting should have a purpose and should ideally link into a curriculum. Thus scenarios should be constructed such that they are likely to produce the opportunity to observe behaviours. This is not usually that difficult as all but the simplest team scenarios will result in numerous interactions and the opportunity to observe, reflect and progress.
A quick run through Medline will reveal many, many, many papers on the subject of debriefs5. Thankfully a recent review suggests6,7 (as we have long argued) that there is more commonality between methods than differences and we should probably just relax about adherence to any particular method so long as they encompass essential assessment (e.g. psychological safety, shared mental models), conversational techniqes/educational strategies (e.g. learning conversations) and debriefing adjuncts (e.g. video). In Virchester we follow a model for debriefing based on learning conversations8. This is a method of debriefing championed by the Advanced Life Support Group and is one that most, if not all, our participants will have experienced in past training. The method you use may be different, but I suspect that if you are using a method it will encompass very similar elements. We don’t routinely use video as this is tricky to deliver in the in situ environment in balance with questions about it’s effectiveness9.
This was a significant move on from the past method of Pendleton’s rules10,11 which have received a poor reputation in recent years, though in truth I think that was because many people had not really followed what Pendleton really wanted.
In terms of the conversation itself we use a range of techniques to explore what happened, but more importantly why they happened and what that means to the team.
The techniques of advocacy with enquiry12–14 in particular underpin the exploration of soft skills, primarilly as it explores the experience from the learners perspective. By observing and exploring interactions during the experience the facilitator can use this technique with different members of the team exploring how the interactions were experienced individually and then collectively. Simple techniques such as asking what happened, then why do participants think something happened, then how did it make them feel and subsequently behave is a useful exploratory tool.
Since the soft skills in medicine frequently relate to interpersonal interactions we believe that debriefing as a team is essential to explore the experiences and beliefs of all team members and not just that of the team leader. In our experience a team debrief that truly values and engages all members works well in gaining insight not just into what happened, but also why it happend and then how that that makes the team feel.
For example when we started our insitu simulations we found that team leaders would automatically allocate the defib duties to a junior doctor. Frequently one who was unfamiliar with that machine, and despite there being trained and competent nurses in the team who could do the job better. Debriefing as a team revealed the skill distribution within the department but also allwed us to explore how members of the team felt about such decisions. Did it put the junior docs under pressure? Did it undermine the nurses? etc. This exploration has led to changes in behaviour and the way that our teams interact in the workplace with real patients. Team debriefing is essential to this sort of progress.
Sharing and disseminating.
Although we advocate simulation as a learning tool there is no doubt that it is labour intensive and for most participants it will be relatively infrequent. At St.Emlyn’s we run 2-3 simulation sessions a week which is a lot. However, we are a large department and so from an individual perspective it is often weeks to months between simulations. Thus the lessons from sim sessions need to be shared through other mechanisms. Standard reporting and links in to clinical governance and other educational activities are important.
We have a system where every member of the simulation team is asked to declare a learning point at the end of each session. We encourage and support the learners in describing all learning outcomes, not just the technical, but the non-technical too. Facilitators also contribute to this list of learning points which is then recorded and thematically analysed for trends. This has allowed us to identify themes around hierachies, use of first names and both positive and negative behaviours in our teams.
Anecdotally this experience in the sim sessions has transferred to our day to day management of patients. We see better interactions and more functional teams in the resus room.
NB. It’s worth thanking our wonderful Sim Fellows of the past few years who have supported and developed the systems in Virchester. Kirsten, Oli and Rebecca: You’re all fabulous.