Medical students as simulation educators: students’ experience of a 7-week simulation-based education rotation

Abstract

Medical students will have future roles as clinician educators, and need to develop knowledge and skills for that role. Specific skills in simulation-based education (SBE) may be valuable in many educational settings. We aimed to understand the impact of a 7-week placement in SBE on the development of medical students’ knowledge, skills and perspectives as educators. We reviewed the experience of three graduated students (also coauthors of this article) who participated in the rotation in 2018. This case study includes analysis of the students’ electronic portfolios, rotation reports and subsequent reflections of the student coauthors. Five themes were identified:—‘Development as a professional’, ‘Active participation in an educator team’, ‘Diverse experience in simulation skills and techniques’, ‘Role models and mentoring’ and ‘Rethinking feedback’. Students describe the development of practical knowledge and skills, and more fundamental reflections on the nature of learning, feedback and their personal professional development. We suggest that integration of a simulation education elective within a medical school curriculum helps build capacity for effective SBE delivery, and has positive impacts on students for their future roles as doctors, educators and lifelong learners.

Introduction

The development of medical students as educators is important. Medical students will have future teaching roles as doctors, their communication skills may improve and hence improve physician–patient interaction, and ‘medical students with better understanding of teaching and learning principles may become better learners.’¹ There are many reported examples of formal programmes to train students as teachers,^2–5 with significant heterogeneity in learning objectives, formats and outcomes. There are fewer programmes offering combined didactic principles of teaching in concert with practical application, and ‘little is known about the effect of more substantial teaching programmes, such as a month-long block or a longitudinal programme over several months’.³

The development of specific skills in simulation-based education (SBE) is a relatively rare opportunity for medical students. SBE is suited to learning a broad range of clinical skills and healthcare teamwork, but requires skilled faculty to be effective. Most current simulation faculties have learnt through immersive, ‘apprenticeship’ style experience, often complemented by formal learning, including courses, workshops, certificate programmes, university degrees and fellowship programmes.^{6 7} The content and scope of formal programmes range across technical, educational and administrative skills, reflecting the diversity of expertise required for effective SBE.

Many courses are offered on an ‘ad hoc’ basis and Nestel et al call for faculty development that is ‘coordinated and facilitated through development of communities of practice (CoP).’⁸ Lave and Wenger define ‘CoP’ as groups of people who share an interest and profession that provide a social context for participatory learning.⁹ Learning in a CoP is a collaborative and social process,¹⁰ offering opportunities to acquire tacit knowledge, values and beliefs important to the SBE community.

We aimed to understand the impact of a 7-week placement in SBE on the development of medical students’ knowledge, skills and perspectives as simulation educators. We were especially interested in the contributions of formal learning and immersive experience within a simulation educator CoP to those impacts.

Methods

Context

Since 2017, Bond University medical programme offers a 7-week student elective in SBE (subsequently referred to as the ‘SBE rotation’). Students are selected based on an expression of interest in the rotation—from a range or research and professional project options on offer for final year students. Selection is not based on any expressed interest in specific specialities or teaching career interests.

During this immersion, students participate as part of the simulation team at Gold Coast Health Service and Bond University (figure 1). The team includes clinician educator trainees in simulation and health professional education across the continuum of medical training, as well as specialised simulation educators. Through a combination of structured learning and working with experienced simulation clinical educators, students learn skills in scenario design, practical delivery and simulation debriefing (online supplementary file 1). Students maintain a logbook during their rotation—a chronological list of learning activities undertaken, together with key learning points and any next steps (eg, reading or further experience) identified as a result of the activity. They also write weekly reflections—an unstructured, short (paragraph or two) piece focused on whatever students felt was most appropriate.

Figure 1.

SBE rotation Community of Practice

Students’ attainment of the learning objectives is assessed using weekly review of student portfolios by supervisors, and via a final written rotation report. This report is structured using a proforma required by the medical programme.

Study design

We reviewed the experience of three graduated students (also coauthors of this article) who participated in the rotation in 2018. These were the only student who participated in the rotation in 2018, and they each completed the rotation at different times of the year.

We analysed the students’ electronic portfolios, rotation reports and their subsequent reflections approximately 12 months after the SBE rotations.

Student coauthors were invited by email to participate in the study after their successful graduation from the medical programme.

Data collection

Data included for analysis was from four sources—weekly reflections and logbook recorded by the students at the time of their SBE rotation, a detailed rotation report completed at the end of the rotation, and an individual written reflection undertaken 12 months after the rotation (and after graduation from medical school).

The reflection was structured by responses to four questions, designed by the first author (online supplementary file 2)

Data analysis

Using an inductive approach, authors NA and VB independently reviewed student portfolios, weekly reflections and 12-month written reflections. Using the six-step process described by Braun and Clarke,¹¹ material was independently coded, and draft subthemes and subthemes proposed.

Student authors (GP, MC and LM) independently reviewed the 12-month written reflections of each student, and identified examples that either reflected or were in contrast to their own experience. All authors then met to compare findings and create agreement on relevant themes and subthemes. Representative quotes were selected from the data sources by consensus.

Research team

VB and NA are emergency physicians and clinician educators who supervise the SBE rotation, among a variety of other education and simulation responsibilities across the learning continuum. VB is the supervisor for other members of the SBE CoP illustrate in figure 1. GP, MC and LM are currently medical interns at different hospitals in Australia, who undertook the SBE rotation in 2018. None had prior formal educational experience or training prior to undertaking the SBE rotation.

Results

Results of the analyses are presented in table 1. Five themes were identified.

Table 1.

Themes - SBE student elective

Theme	Examples Drawn from project reports, weekly reflections and student coauthor responses to questions
Development as a professional	Strengthened my appreciation for ‘life-long’ learning by exposing me to the diverse aspects in knowledge development from case-based simulations…relevance of this project to one’s professional development is endless. This project has given me the chance to improve as an individual, identifying strengths and weakness but also enhance my understanding of the dedication and time it requires to facilitate ‘life-long’ learning. believe this project has provided me with the essential skills and knowledge to successfully design, organise and run simulations.
Active participation as an educator	Feeling part of the team, I participated in many development sessions to build on technical upskilling as well as mastering the skill of debriefing Observation and participation in numerous styles of simulation. Creating cases Actively participating in conducting simulations and eventually leading my own debriefing sessions were the most useful in developing my skills as a sim educator My highlight was the point at which I felt comfortable and confident in leading an effective debriefing session with medical students after a simulation scenario that I was actively running.
Diverse experience in simulation skills and techniques	I had the opportunity to participate in a large variety of simulations ranging in complexity from multidisciplinary team ‘red blanke’t’ simulations to more simple simulations for junior medical students. The mentoring, modelling of debriefing frameworks and opportunity to participant in the many diverse roles of SBE over the seven weeks assisted me in achieving the project outcomes. Ensuring simulation cases are realistic and that correct modalities are chosen to ensure that participants have the best learning opportunity. By clarifying expectations of participants and orientating participants to the scenario, the pre-brief can aid in reducing evaluation apprehension and preventing over-stimulation, thus affecting performance and learning.
Learning from role models	Set my expectations for clinical educator incredibly high. Watching the facilitators adapt by having prolonged pauses in order for students to response, re-phrasing questions and applying double-looped learning to understand ‘why’ a student proposed that management compared to an alternative was eye-opening to say the least.
Rethinking feedback	Be able to provide constructive feedback, which is important during debrief and aids participants in completing Kolb’s learning cycle. Exploring the scenario and participant’s experience, drawing out important lessons and gaps in knowledge leading to one or more greater outcomes in improving or changing our medical practices. I made an important self-recognition that previously in tutoring sessions, I had fallen into the trap of giving feedback on observed behaviours only. As I became more aware of the language and style of feedback and questioning of the students, I became more confident and adaptable in my teaching style.

SBE, simulation-based education.

Development as a professional

Students suggest that the ‘deep dive’ into thinking about educational process and considering the impact on their learners prompted powerful reflection on their own learning, including fundamental concepts like ‘lifelong learning’. The experience is perceived to build confidence, skills and motivation to undertake educational roles in the future.

Active participation in an educator team

Being given responsibility and opportunity is perceived by students to accelerate their knowledge and skills, to a level that surprises them.

Diverse experience in simulation skills and techniques

Students describe being exposed to a wide range of skills and educational practice in SBE, including technical, education and logistic knowledge.

Role models and mentoring

The elective is heavily apprenticeship based, and students identify the power of observing role models in action, including the diverse range of skills within the group of simulation faculty at the institution.

Rethinking feedback

Simulation debriefing appears to have a particularly significant impact on students’ perspectives, including reflection on fundamental concepts about the nature of feedback and its impact on learning. Portfolios include many examples of students reflecting on their own and their supervisors’ efforts to lead small group learning conversations.

Discussion

Our experience with a 7-week elective in SBE offers insights into the development of junior clinician educators, within the specific context of SBE. Students report the development of practical knowledge and skills, but also some fundamental reflections on the nature of learning, feedback and their personal professional development.

Congruent with reported experience in clinical learning,¹² mentored responsibility and autonomy appear to be accelerants of learning for junior simulation educators, who can rapidly achieve a surprising level of skill. The ‘legitimate peripheral participation’⁹ as part of the team was reported as challenging but confidence building, and support our design of complementing formal learning with practical application in an integrated rotation, within a local CoP.

There were no reported negative perceptions of the experience, although we accept our study design with student and supervisor coauthors is biased towards positive outcomes.

This is a single-case study report, and its generalisability may be limited. The team in which these students are embedded is a skilled and diverse group of educators, which may not be available in all programmes or institutions.

We continue to offer this programme to final year medical students at Bond University, with the same core elements. Based on the themes identified in this study, and our own subsequent experience, we make the ‘CoP’ opportunities and impacts more explicit to students. The SBE elective continues to grow in popularity with nine students undertaking the elective in 2019.

We offer suggestions for a medical student simulation elective based on this study and our informal experience with the programme over 3 years at our institution (box 1).

Box 1. Recommendations for a medical student simulation-based education elective.

• Ensure adequate orientation—to understand student goals, clarify breadth of expectations and introduce to the team.

• Balance autonomy with mentored experience, and review frequently.

• Encourage reflection on busy, diverse, practical experience through a structured lens of clear learning objectives.

• Make explicit the reflection on teaching to students’ own role as a learner, including receiving feedback.

• Encourage reflection on the value to learning within a community of practice and the underpinning values and perspectives uniquely gleaned through a ‘community of practice’.

Conclusion

This programme enhances student skills and perspectives as a simulation educator. A secondary outcome is personal development through feedback and role modelling from mentors. We suggest that integration of a simulation education elective within a medical school curriculum helps build capacity for effective SBE delivery, and has positive impacts on students for their future roles as doctors, educators and lifelong learners.