Teaching Simulation toFoundation DoctorsIntroduction:Throughout this essay I intendto describe and reflect upon a teaching session I provided for 12 foundationdoctors. I helped organise an intensive care careers event and taught asimulation station on the intensive care ward. I aim to reflect on this, andcompare teaching methods and concepts with relevant teaching literature. Whathappened?I helped organise an intensivecare careers event for twelve F1 and F2s. There were two simulation stationsand a lecture on non-invasive ventilation.
I taught a simulation station in oneof the ITU bays. The participants had to assess a septic patient, provideinitial management, and escalate to a senior. I wrote a storyboard in advancewhich included the scenario, three stages of deterioration and associatedclinical observations, and learning objectives. When the participants arrived,we gave them a briefing during which we explained who the patient was, what we wantedto see the students do, and asked them to nominate a team leader to start thescenario. During the scenario, my colleague controlled SimMan so I couldprovide the voicing and offer advice on how to proceed. The groups performed aninitial assessment and diagnosed the patient with chest sepsis. They commencedinitial treatment, and escalated to an appropriate senior.
Following the 20minute simulation session, we had 10 minutes for debriefing and feedback. Reflection:It was stressful planning and runninga teaching session during working hours due to time constraints. I wanted to makethe empty bay look like an acute medical bay, get the correct settings readyfor SimMan, and practice the station to ensure it flowed in a logical manner. Unfortunately, I was working and unableto spend as much time preparing as I’d have liked, meaning I felt more stressedthan normal before teaching. During the event, I was receiving bleeps aboutvarious work-related tasks, which was quite distracting. Eventually, I asked acolleague to take the bleep from me and hold it for two hours, as I wasinterrupted twice in the first session.
Another complication which arose fromteaching in the workplace, specific to ITU, was the constant beeping and noisecreated by the machines on the ward. I’ve worked on ITU for four months, andthe extra noise is starting to become less intrusive, but I think it botheredsome of the students, particularly those who were less comfortable being in astrange, new environment. As we progressed, I began to feel more confident andin control of the sessions, and I began to actively enjoy my role in teaching. Ithink the students picked up on my confidence, and seemed to enjoy and participatemore. Many elementsof the simulation station went well; the storyboard I wrote was described as “realistic”and “believable” in the feedback. As it would not be appropriate to havestudents practice examining a critically unwell patient on ITU who could notconsent, we aimed to create a realistic environment to allow students to buildtheir skills.
Other feedback said the debrief section was run very well. I’mpleased the students enjoyed this part of the session, as it can be difficultto deliver feedback in an enjoyable way. The feedback section involved measking the students how they felt about the session, what went well and whatthey could improve upon. I asked them how they interpreted the scenario andtheir actions, and then I explained what they did well, how they could improve,and how I thought their non-technical skills were.
Then, I offered the groupthe opportunity to ask questions. I think I presented myself in a friendly,approachable manner which allowed the students to feel comfortable with thesituation. They seemed to feel happy asking questions, and everyoneparticipated actively.
I enjoyteaching medical students and junior colleagues, but I felt slightly nervous,verging on inadequate when teaching seniors or my peers, as though they willsee through the holes in my knowledge and criticise me for this. During thisteaching session, there were a mixture of F1, F2 and clinical fellows present,including a good friend from Taunton. I found this slightly off-putting duringthe first session, and I had to consciously convey that I was the teacher,leading the session rather than a friend.
Other uncertainties lay indeciding how much freedom to allow the learners; should I allow them to make anincorrect diagnosis? Should I allow them to flounder for a couple of minutes?Should I intervene if the group is not working in a cohesive manner? These questionsdo not have set answers; I think it can be difficult when teaching those of asimilar experience level to offer them advice and guidance. Therefore, Iallowed the groups a lot of freedom during the first run through of thescenario, and allowed them to make more mistakes. The scenario over-ran by afew minutes, which allowed them to escalate to an appropriate senior. As wemoved through the groups I seemed to find my feet a bit more; I engaged withthe groups by asking them to explain their train of thought to me, and offeringadvice or suggestions if they were stuck. I think during the second and thirdsession I took a much more active role in leading and facilitating the group,and this was demonstrated in the feedback forms I received. Initially the groupwas not clear what the learning objectives were, and they felt the juniormembers of the team had the potential to get lost during the scenario.
As wemoved through the groups, the later two groups agreed the learning objectiveswere “useful” and “relevant”, which implies that they were clearer andachievable, and that the scenario was “facilitated very well”.I think providing a ward basedsimulation scenario offers a lot of benefit to the learner and teacher. As theteacher, I was in a familiar situation knowing where the kit is, how to workthe beds, how to use the monitors and observations machines etc, which providesan element of comfort.
I think offering simulation on the ward gives learners amuch more realistic scenario, compared with a clinical skills suite. Offering aworkplace based scenario offers students a sense of realism, simulation teststheir knowledge, improves the non-technical skills, and allows them to gainknowledge through experience, which I hope will influence their practice. Areasof Uncertainty: As mentioned, I found itdifficult teaching my peers, especially when one of them was a good friend. Ithink this embodies how we still view medicine as a hierarchal profession, withour seniors being superior and offering more than the junior team members. Ithink to break these barriers, we must teach our peers, teach inmultidisciplinary teams and we must allow and encourage the involvement ofjunior team members.
Although the junior members of the team may notnecessarily have the same amounts of experience as those more senior, they canoffer different skills to the team. Therefore, I endeavour to teachpost-graduates, such as foundation doctors and core trainees. I have signed upto teach in series of lectures about medical specialties for F2 doctors, and Iam delivering a presentation to the entire intensive care team which includesconsultants, registrars, core trainees and foundation doctors. I think my fearof looking unintelligent in front of seniors will be overcome through practiceand preparation. Reviewingthe Literature:I decided toreview some background theories before reviewing literature regarding workplacebased education. I used Google Scholar and PubMed for my searches, where Ientered terms such as “medical education workplace”.
Adult learning,also known as andragogy, has been described by Malcolm Knowles (Knowles, 1980) as:· Self- directedand motivated,· Drawing onprevious experiences, · Work relevant tolearner needs, · Based onproblem solving. Learning is autonomous,with the student directing their own experiential learning. There is anassumption adult learners are motivated to self-directed learning, however thismay simplify certain complex topics(Knowles, 1980,Yardley et al.
, 2012). Andragogic learning is applicable to teaching medicinein the workplace, as without a strict curriculum, there is often impetus forstudents to direct their own learning. This is a very learner centred theory, movingthe process of learning from the teacher to the student. Constructivism theorisesthat learning is a “process whereby knowledge is created through the transformationof experience” (Kolb, 1984, Yardleyet al., 2012). It’s a learning process where previous knowledge is built upon; connectionsbetween old memories, and new experiences come together to form new knowledgethrough reflection (Kolb, 1984, Yardleyet al.
, 2012, Torre et al., 2006). Teaching in the workplace offers students the ability to build onprevious knowledge they have attained in theoretical terms, and apply this toreal life situations and build their knowledge in a way which motivates andsuits them(Torre et al., 2006). Biggs and Tang suggest that constructivealignment is provides greater emphasis on the teacher to provide facilitatedlearning within the learning experience(Biggs and Tang,2011). It allows for students to learn via experience but puts impetus on thefacilitators to provide and guide their learning; they align the situation toprovide learning, which allows for the educator to have more control over thestudents’ learning experiences(Biggs and Tang,2011). This theory resonates with me, as it provides context for the student’slearning, and the interactions with seniors have greater meaning, rather thantransitory interactions. I think this theory is applicable to ward-based simulationscenarios, as it allows students to build on background knowledge with afacilitator guiding them through a scenario depending on their degree ofcompetency.
It allows for a structured feedback model, such as the one minutepreceptor model, which allows the teacher to review informally, yeteffectively, the learning experience with the student(Sajjad and Mahboob,2015). Teachers should make use of the students’ entry level knowledge(Singh, 2009) and this is especially pertinent when running asimulation scenario. For example, we expected students to be capable toexamining a patient, and initiating treatment. My goals for the session were tobuild upon this pre-existing knowledge base, and develop inter-personal skills,and recognise the sick patient.
Through building on pre-existing knowledge, weaim to guide and influence how the students practice in medicine, allowing forhigher level learning in terms of Bloom’s taxonomy(Bloom and Krathwohl,1956).During my simulation session, I tried to recreate awork environment, to allow students to assess a critically ill patient in asafe environment. Flexnor highlights that learning in a working environment,particularly caring for patients, provides powerful stimulus for learning andthis can be achieved by the supervision of novices by experienced teaching physicians(Cooke et al.
, 2006). Billet reviewed learning in the workplace, andhighlighted many positive aspects of using the workplace as a teachingenvironment. He highlights that the workplaces provides specific opportunitiesfor learners to engage and participate in relevant ways that benefit theirlearning- for example practicing clinical skills(Billet, 2004). This suggests specific learning opportunitiesoffer students new perspectives, and methods of learning through direct actionand participation. Billet and Boud suggest workplace experiencesinfluence learners indirectly also; students learn indirectly by observing moreknowledgeable colleagues; observing their behaviours and language(Billet and Boud,2001).
Billet also addresses criticisms made of theworkplace as a learning environment. It’s suggest that learning in the workplace is adhoc; it is informal and unstructured(Billet,2004). These negative connotations suggestthe learning which occurs in the workplace is sub-optimal when compared withformal learning based within educational facilities, however I argue thatlearning within the workplace provides students with insights and educationinto the hidden curriculum, especially within a career such as medicine.
Thehidden curriculum highlights small, but important areas of learning, such asusing hospital IT systems, how to communicate within the hospital hierarchy,and ways to develop inter-personal communication skills. During the simulationscenario, we tried to create these learning opportunities for the students, byasking them to simulate initiating patient management, including ordering testsand referring to senior doctors etc. Billet also comments upon theabsence of qualified teachers(Billet,2004), however this is disputable given thelarge numbers of post-graduate level teaching courses available and the numberof doctors embarking upon these.
Billet’s paper is linguistically challenging;I found the language florid and difficult to interpret. He also discusses theworkplace as a learning environment without any specificity to medicine,therefore all the interpretations are available to other vocational careers. Anotherdifficulty with teaching in the workplace stems from the strain put on thoseteaching, the healthcare professionals who are required to build learningexperiences within their day-to-day jobs(Sajjadand Mahboob, 2015), as reflected upon earlier by myself. Summary: I found this an enjoyableteaching session which made use of my current workplace in ITU, and allowedparticipants to experience critically unwell patients in a safe environment. Feedbackwas good with an average score of 8.45/10.
I have reflected on my strengths andweaknesses, and addressed how I will improve my teaching practice. Finally, Ihave briefly reviewed the literature surrounding work based education and adultlearning theories.