Practical tips for introducing high-fidelity simulation to undergraduates at a large scale: learning from our experience

Abstract

The letter provides practical tips for developing, implementing and scaling an effective simulation‑based education programme at a large scale for undergraduate medical students. Using time-lapsed scenarios and the pause-discuss method of debrief are some of the useful tips that are discussed further in the letter.

The transition from undergraduate medical student to doctor is challenging. Adapting quickly to a busy working environment, identifying priorities, communicating succinctly and working effectively as part of a multidisciplinary team are recognised difficulties faced by new doctors.¹ Improving this transition forms part of ‘preparation for clinical practice’ (PCP) modules in undergraduate medical programmes. The role of simulation-based education (SBE) in supporting transitions is well recognised, where trainees can practise the complex set of skills required for safe clinical practice in a safe and supportive learning environment.² Traditionally at our institution, a paper-based workbook was used to help prepare final year students for clinical practice. Fictional cases were completed and reviewed by a lecturer. This was a passive learning experience, with no real patient exposure and little scope for meaningful reflection.

In an effort to create a more meaningful, active learning experience, the workbook content was redesigned as a series of high-fidelity simulation scenarios with a view to delivering SBE to 200 final year students at our institution. Existing workbook cases were reviewed by a multidisciplinary team, including a clinical lecturer, professor of simulation and simulation technician. It was determined which cases were suitable to be reworked as simulated scenarios. Simulations were aligned to PCP outcomes. Cases involving acutely unwell patients (eg, chronic obstructive pulmonary disease exacerbation, acute myocardial infarction) were suitable as scenarios as there were clear case progressions and management pathways. Other cases (eg, delirium and polypharmacy) were more nuanced and required careful consideration. An iterative approach was used in scenario development. To facilitate delivery of SBE to a large learner group, six distinct scenarios were developed. Each was divided into two or three parts with a time-lapse. This allowed students to care for a patient at different stages during their hospital attendance. For example, part 1 dealt with the presentation of an acutely unwell patient to the emergency department, part 2 focused on the same patient who deteriorated on the ward and part 3 involved the same stabilised patient who was being discharged. A standard template contained key information and outlined key critical parts and transition points. Accompanying materials were left time-neutral so that they could be used at a later date.

A lack of trained staff is a commonly cited barrier to rolling out SBE.³ A facilitator training day was held for lecturers prior to SBE commencement. Scenarios were discussed, along with the prebrief, stressing the importance of orienting students to a simulated environment and psychological safety of students. Lecturers watched videos of simulations and how to prebrief and debrief. Each scenario was delivered to groups of 36 students, meaning that each case was repeated six times throughout the semester. Selected participants entered the simulator in pairs to reduce feelings of being overwhelmed and to promote teamwork. Others observed via an audiovisual live feed from a nearby room. The number of participants entering a given scenario was predetermined. For each individual scenario part, two students entered initially. Once they had performed a history and clinical examination and ordered investigations, two further students entered to take over. This forced handover to take place. Thus, for a scenario with three parts, 12 students could be actively involved in the case. With six cases in total, each student was given the opportunity to participate in two simulation cases. To engage students who were observing the simulation but were not scenario-participants, a short interactive workbook of the case was created. This prompted the student observers to document differential diagnoses, prescribe medications and complete investigation requests while observing the scenario.

To overcome a lack of supporting staff, clinical lecturers played the role of the nurse (confederate) in the simulator. If students struggled or appeared to dismiss key pieces of information, the ‘nurse’ was able to restore the scenario using a variety of scenario life-saving principles, for example, highlight abnormal vital signs and suggest that senior help is called for.⁴ Medical interns played the role of the senior staff member who was available by telephone when required. To avoid SBE clashing with clinical activities, scenarios were delivered early in the morning, at lunch and in the evenings. Where time was spent, time was also saved: as particular scenarios were covered at SBE, certain topics were removed from didactic teaching.

After each scenario part, the non-conventional stop-and-go/pause-discuss method of debrief was used. As the participants were undergraduates who were new to SBE, it was felt that repetitive shorter debriefings would lead to a better learning experience. Mistaken assumptions and errors could be explored and corrected in a timely manner.⁵ This ensured students had clarity on the case as it progressed and provided an opportunity for facilitators to focus and reorient students before proceeding with the next part of the case. Due to the large numbers of students and repetition, it was felt that participants and facilitators would be better able to recall the specific events immediately afterwards. The limitation of using this model is that it may reduce overall fidelity level and may lead to reduced levels of engagement with the scenario. However, these issues did not arise with our group. The debrief team comprised experienced clinical lecturers and recently graduated interns. This provided both a practical and a real-world perspective to the discussion.

This project was well received by both students and facilitators. Students described improved confidence after completing the sessions, with increased awareness of teamwork and effective communication skills. All clinical lecturers enjoyed the delivery of SBL, interactivity and the ability to observe and provide feedback on skills. This delivery of high-fidelity simulation to a large group of undergraduate students offers a novel approach that is replicable, feasible and scalable (see table 1 outlining some practical tips). Appropriate buy-in is required from all stakeholders. Although time-consuming to prepare, outcomes are valuable. Future directions are the inclusion of nursing students to promote interprofessional learning. With adequate resources, it is also planned to roll out SBE earlier in the undergraduate medical curriculum.

Table 1.

Tips for developing, implementing and scaling an effective SBE programme for undergraduate medical students

Preparatory phase:
1	Recruit a multidisciplinary team when writing the scenarios; all will have unique skills to offer
2	Focus first on predefined learning outcomes and then scenario generation
3	Provide a specific SBE training day for facilitators
Generation of materials
4	Recognise that creating the scenarios will take time: allow sufficient time for generation of supporting materials and review of each case by stakeholders
5	Make all accompanying material time-neutral to allow it to be reused multiple times
6	Divide scenarios into time-lapsed parts to allow for more participants and stages of patient care
7	Consider a short workbook to be completed by the students who do not enter the simulator
Simulation operations
8	Ensure all students are given a prebrief which covers orientation to the environment, format of the sessions, expectations and psychological safety elements
9	Make space in a busy curriculum by using SBE in lieu of other teaching methods
10	Allow students to enter the simulator in pairs and to handover to another set of students to facilitate psychological safety and promote communication
11	Allow facilitators to play the role of different confederates in the scenario
Debrief and feedback
12	Consider using the stop-and-go/pause-discuss method of debrief
13	Develop a tool for structured feedback
14	Develop a slide deck of key points for debriefing each scenario to ensure consistency across multiple learner groups

SBE, simulation-based education.

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