Working without worry: transition to foundation year 1 simulation training

Concept

As final year medical students prepare for their initial Foundation Year 1 (FY1) rotations, there remains a stressful period ahead; a time during which newly qualified doctors must rapidly learn to apply knowledge they have spent many years acquiring. The foundation programme is 2 years of professional development after graduation from medical school to prepare medical students for their chosen specialty training. FY1 doctors are expected to manage patients with acute and chronic conditions, recognise, initiate management and escalate care of deteriorating patients, integrate within a multidisciplinary team, and take appropriate responsibility while working within the limitations of their competence.¹

Our goal was to develop a simulation-based training programme to bridge the gap between the self-directed knowledge acquisition and personal time management of medical school, and the multidisciplinary hospital environment, where working as a team towards shared goals under time pressure and high cognitive load requires efficient assessment, communication and teamworking. With this in mind we have developed a programme tailored to the specific needs of final year medical students in this transition period prior to starting Foundation Year training.

The simulation content was developed in response to feedback from current final year students and FY1 doctors at our institution, and the national student survey and foundation trainee feedback. A high proportion of final year medical students feel underprepared for the transition to FY1 doctors,² and feedback explored concerns and challenges like time management, teamworking, communication, handover, resilience and stress management.

The simulation scenarios introduced exposure to situations perceived as stressful for newly qualified doctors in a safe environment to allow application of technical and knowledge-based skills. Debrief provided a supportive platform to explore student concerns and discuss ways to minimise stress and optimise outcomes. Participating students had prior exposure to simulation-based training in years 3 and 5 and using the theory of spiral learning we built upon this previous experience in both simulation complexity and debrief.³

Development and delivery

Current FY1 doctors were asked for examples of stressful situations for which they felt poorly prepared, and current final year medical students (target participant audience) were asked what their principle concerns of commencing FY1 were. Local feedback focused on specific situations of dealing with deteriorating patients while the national survey reflected more generic human factors and ergonomics including time management, teamworking, communication, handover, resilience and stress management.

Based on recurrent concerns raised we developed four simulation scenarios designed to mimic stressful situations encountered as a junior doctor which reflected both national and local survey results. These included postoperative ST elevation myocardial infarction deteriorating into ventricular fibrillation (VF) arrest, acute confusional state due to septic shock, acute pulmonary oedema on background of pneumonia and life-threatening asthma.

Twenty-six candidates took part in the Working Without Worry (WWoW) simulation programme. Each session started with introductions, the concept and intended outcomes of WWoW, and a chance to ‘meet the mannekin’. A maximum of six candidates per session were divided into pairs to attempt one of the four scenarios, with the remaining candidates watching from an observation room. Minimum faculty ensured a dedicated sim mannekin technician, able to manipulate parameters dependant on actions taken, a sim voice able to respond to the candidates and provide cues such as agitation of reducing level of consciousness, an observer to oversee each scenario and prepare for leading the debrief, and a plant to assist candidates with bedside requests including intravenous fluids, oxygen and basic monitoring equipment. Faculty consisted of two consultant anaesthetists, a simulation fellow and senior trainees from a range of specialties including emergency medicine and anaesthetics. Each simulation lasted approximately 15 min, with a further 30 min dedicated to debrief and discussion with the group.

Discussion

The experiential learning theory⁴ suggests that effective learning happens when an adult has a concrete experience followed by reflection on that experience leading to analysis and conclusions which are then used in future situations. Good simulation-based education provides concrete experience in the form of a scenario, followed by a debrief tailored towards reflection and conclusions which may help in clinical practice. By using scenarios fed back to us as stressful or difficult we provided the concrete experience, and debriefing allowed us to guide reflection on the assessment and basic management of the critically unwell, the importance of good communication and finally avenues of help available and appropriate escalation. By summarising the learning points at the end of each scenario trainees generated their own conclusions to translate in their own clinical practice.

Our aim was to help newly qualified FY1 doctors feel better equipped to manage stressful situations when starting their first rotations, by developing strategies to assess, manage and escalate the unwell patient. With this in mind, a number of recurrent learning themes emerged (box 1). Newly qualified doctors are equipped with a broad medical knowledge, however, they may be unfamiliar with using this knowledge and translating it into real life practice under stressful conditions. We focused on applying knowledge such as repeated ABCDE assessments of a deteriorating patient, an SBAR (Situation, Background, Assessment, Recommendation) handover, when to call for help and who is available for advice and support. These themes reflect the difficulty of putting theory into practice, and more focused experience in exploring them through simulation-based practice before starting work as FY1 trainees may help.⁵

Box 1. Recurrent learning themes.

• Translating theory of SBAR (Situation, Background, Assessment, Recommendation) into concise handover in stressful situations.

• Options for escalation and support.

• Reluctance to call consultants.

• Avoiding fixation on minor points and losing the ‘bigger picture’.

• ABCDE strategy to assess and reassess as the clinical picture evolves.

• Regular summarising to improve team situational awareness.

• Appropriate delegation and role of closed-loop communication.

25 of 26 trainees rated WWoW as very good or excellent. Examples of written feedback included ‘useful tips about how best to handover patients to seniors’, ‘It is important to highlight the headlines of the patient and be clear about what I expect from my colleagues’, ‘very useful to take part in simulation to apply clinical knowledge to ’real life' scenarios’ and ‘people act very differently under stress even though they have the knowledge. Keep to a structure. Don’t be afraid to ask for help’

With further feedback on board we are developing scenarios to emphasise the recurrent learning points we observed during Working Without Worry training. By building resilience we hope to minimise stress and burn out and maximise enjoyment of this busy period of intense learning and development.