Tactical decision games: a novel teaching method for non-technical skills

Tactical decision games (TDGs) are discursive group exercises in which participants describe their response to a scenario. Unlike simulation training, they require few resources. TDGs have not previously been used in postgraduate medicine.

Sixteen doctors took part. In groups, they were presented with a lifelike clinical vignette and asked to describe and justify their actions. Qualitative audio and quantitative written feedback were collected. Thematic analysis was performed. The mean usefulness score given was 9.07/10. Participants found it useful to observe the behaviours and heuristics of their colleagues and liked the short and low-stress sessions focusing on non-technical skills (NTS). However, TDGs were not perceived as being realistic. They may serve as a useful adjunct in the teaching of NTS in postgraduate medical education.

Introduction

A challenge to medical educators is to provide training that can be delivered quickly and cheaply during the working day. The importance of NTS in medical emergencies is well recognised.¹ Simulation training is a valued teaching method² and much of its benefit is the impact on NTS. However, it is resource intensive.

Here we present a novel proof-of-concept of an alternative method of teaching NTS: TDGs. These are discursive group exercises based on a written scenario, which is read out by a facilitator. Participants have a limited time to decide on their actions, which they then describe, justifying their task prioritisation. The facilitator leads a discussion exploring the participants’ rationale. The scenarios are intentionally ambiguous with no ‘correct’ solution.

The use of TDGs was first described within the US military.³ It has since been extended to other high-stakes professions,⁴ all of which have high psychological demands; tasks with multiple objectives; and teams often being assembled at short notice. There are many similar situations in medicine, for example, cardiac arrests.

We wished to ascertain if TDGs improve the NTS of junior doctors and how TDGs were perceived, particularly, compared with simulation training.

Methods

This cohort study took place between August and December 2017 with participants identified by purposeful random sampling. Sixteen junior doctors of different grades (foundation trainees, core trainees and staff grade doctors) in acute medicine, care of the elderly and anaesthesia took part. Group sizes ranged from 3 to 7, and all contained doctors of different grades. Written informed consent was taken. Participants received a lifelike clinical vignette (online supplementary appendix 1) and were asked to prioritise and justify their actions. The vignette was written to be deliberately ambiguous and stressful.

A group discussion, led by a more senior faculty member, exploring the merits of different actions followed. Finally, a semistructured focus group discussion took place. This was audio recorded and transcribed. Free-text written feedback was collected. Thematic analysis was conducted as described previously.⁵

Quantitative data on participants’ self-rated confidence in key NTS domains were collected before and after, as well as perceived usefulness. These were scaled from 0 (not at all confident) to 10 (very confident). The significance of the results was calculated using a Wilcoxon rank-sum test.

Results

Thematic analysis

Thematic analysis of the focus group transcript demonstrated a number of key themes (figure 1).

Figure 1.

Thematic map showing final two main themes. NTS, non-technical skills.

Participants found the peer-to-peer learning valuable, particularly from senior colleagues. The most prominent behaviours people learnt were prioritising, delegating and teamwork. Notably some participants felt better able to delegate upwards to senior colleagues after the session. In contrast, senior trainees tended to underplay the utility of junior team members. However, they would tend to be better at anticipating events and planning beyond immediate resuscitative measures.

Thanks to the way that the focus group was framed, there was an obvious comparison with simulation training, and the format of the TDGs was correspondingly familiar. They also felt that the TDGs were valid and ‘close to real life situations on the ward’. A major criticism was a lack of realism. However, when asked how well the training helped develop NTS, participants tended to say that it was effective in ‘changing people’s mind-set’ and that in simulation training they would not ‘gain much more’.

The TDG was perceived as being less stressful than simulation training. While one participant felt that the stress of simulation training enhanced it, most preferred the lower stress of the TDG.

I think that you absorb more of the learning from it that you can in actual sim, because in actual sim you get this, kind of like, stress.

They also felt that while simulation was good at teaching the management of particular scenarios, TDGs were more useful in the development of NTS. Moreover, their brevity was seen as being positive. Overall, the TDGs were perceived as being very useful.

I think that this sort of session is what we need more of as F1s, as I think that this is what we struggle with: time management and task prioritisation.

Quantitative data

Participants’ confidence in their NTSs overall improved by a mean of 0.83 points. This did not reach statistical significance. The domains studied were task prioritisation, time management, delegating, decision making and information gathering and were all scored from 0 (not at all confident) to 10 (very confident).

The mean score given for usefulness was given as 9.07/10.

Discussion

Here we describe the novel application of a validated teaching method in postgraduate medicine. Our data suggest that participants found it to be useful and that much of the benefit came from observing the behaviours and thought processes of their colleagues. Participants liked that the training sessions were short, discursive and less stressful than simulation training. However, our data imply that TDGs cannot compete with simulation training for realism or the practice of technical skills.

While TDGs will never replace simulation training, they appear to be a useful adjunct in NTS training. We suggest that TDGs could be used routinely as a low-resource method of teaching NTS in postgraduate medical training.