|SYMPOSIUM: SIMULATION IN MEDICAL EDUCATION
|Year : 2017 | Volume
| Issue : 1 | Page : 72-77
Scenario development strategies and process for simulation-based education in anesthesiology
Sujatha P Bhandary1, Jonathan A Lipps1, Mohamed Ehab Ramadan1, Kimberly D Jenkins2, Jason M Stroud2, Thomas J Papadimos2
1 Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
2 Department of Anesthesiology, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
|Date of Web Publication||7-Jul-2017|
Sujatha P Bhandary
Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesiology, The Ohio State University Wexner Medical Center, Doan Hall N.411, 410 W 10th. Avenue, Columbus, OH 43210
Source of Support: None, Conflict of Interest: None
Scenario creation is fundamental to simulation. An effective design is necessary to optimize training. This paper describes the process of creating and applying mannequin-based high-fidelity simulation case scenarios for a graduate program in anesthesiology. The objective of scenario building is to provide an opportunity for trainees to learn the management of both common and rare case scenarios to better prepare them for the written and applied board examinations and real-life situations. Scenario development for high-fidelity simulation requires assembling all the elements to recreate a realistic environment while considering the trainees' different learning styles. The goal is to create scenarios that help the learner build knowledge, skills, and confidence.
The following core competencies area addressed in this article: Patient care, Interpersonal and communication skills, Systems-based practice.
Keywords: Design principles, education, scenario, simulation
|How to cite this article:|
Bhandary SP, Lipps JA, Ramadan ME, Jenkins KD, Stroud JM, Papadimos TJ. Scenario development strategies and process for simulation-based education in anesthesiology. Int J Acad Med 2017;3:72-7
|How to cite this URL:|
Bhandary SP, Lipps JA, Ramadan ME, Jenkins KD, Stroud JM, Papadimos TJ. Scenario development strategies and process for simulation-based education in anesthesiology. Int J Acad Med [serial online] 2017 [cited 2019 Oct 22];3:72-7. Available from: http://www.ijam-web.org/text.asp?2017/3/1/72/209845
| Introduction|| |
Simulation can be defined as a person, device, or set of conditions made to resemble or amplify a real-life situation. The effectiveness and educational potential of a simulator in training anesthesiology residents have been recognized, tested, and well documented dating back to the late 1960s. Unlike more traditional learning methods, simulation enables learners to demonstrate their knowledge by applying it in a realistic, yet safe, controlled environment. The benefits of simulation as an educational modality have been described extensively. As a result, simulation-based education (SBE) has become an essential component of graduate anesthesiology education programs where it is a requirement that every resident complete at least one simulated experience per year. Furthermore, with the implementation of the objective structured clinical examination as a component of the applied examination for the American Board of Anesthesiology Certification in 2018, SBE has moved beyond a means to provide a formative learning experience and into the realm of high-stakes summative assessment. Therefore, careful design of case scenarios is fundamental to successful SBE. Designing scenarios can be a daunting task without a scenario development process and a team in place to implement it. Effective scenario design is essential to meet the specific learning objectives and provide a meaningful learning experience. The trigger for the scenario creation is variable; it can be for the purpose of curriculum development, to identify and bridge a gap in knowledge or procedural skills, or to practice rare scenarios. The eventual goal of SBE is to improve performance in real life. Herein, we will discuss the strategies and processes for scenario development.
| Rationale|| |
At The Ohio State University Wexner Medical Center and at The University of Toledo College of Medicine and Life Sciences, the rationale for scenario creation has been primarily for the purpose of curriculum development to help bridge the gap in knowledge and procedural skills and to enhance effective communication in the operative room setting. Although scenarios can be developed for either formative educational experiences or as a part of a high-stakes summative assessment, at the two institutions, the former predominates. In order for learners to achieve core competencies in anesthesiology, scenarios have been developed to draw on the fundamentals of anesthesiology as outlined by the Accreditation Council for Graduate Medical Education and the American Board of Anesthesiology in the Anesthesiology Milestone Project. Specific objectives include management of the difficult airway, navigation through intraoperative crises such as airway fire and local anesthetic systemic toxicity, placement of invasive lines, and effective cardiopulmonary resuscitation. Topics that are historically deemed challenging to teach and practice (i.e., weaning from cardiopulmonary bypass) have also been created. While the scenarios are scripted to progress along a set of states as with real life, the trainees' actions can be unpredictable and thus flexibility is allowed. Further, the complexity of the case can be changed based on possibility of prior information being passed on from senior to junior class. Appropriate distractions and interprofessional communications by embedded persons in the scenario (i.e., surgeon, nurse, and surgical scrub technologist) are also incorporated to make the scenario more real to life. [Table 1] summarizes an approach that the authors find effective.
| Target Audience|| |
Case scenarios have been developed with the learner level in mind (i.e., Clinical Anesthesiology Year 1, 2, and 3). Whereas beginning level scenarios may focus on more common intraoperative occurrences (bronchospasm, hypotension, and difficult intubation), as the residents progress through the curriculum, they will encounter subspecialty case scenarios (obstetric, pediatric, neuro, cardiothoracic, and vascular). Faculty members that are well versed in both SBE and that particular subspecialty help in the creation, implementation, practice, and execution of the scenarios. Scenarios for senior level residents also may focus more on nontechnical skills such as interpersonal communication, professionalism, supervision, and management of resources. Regardless of the learner level, all scenarios draw on the basic principles of crisis resource management.
It is worth noting that while multidisciplinary and interprofessional simulation may provide additional benefit to the learner with respect to interpersonal communication, this can be logistically very difficult. Aside from occasional safety drills, we do not currently include such scenarios in the anesthesiology resident curriculum. Depending on the goals and objectives for that particular scenario, embedded participants (EPs) may be an equally effective alternative. Likewise, creation of simulation scenarios for the purpose of research and maintenance of certification are also beyond the scope of this paper.
| The Creative Process|| |
Before the creation of the scenarios, members of the SBE committee should meet to determine gaps in knowledge that can be addressed through simulation. Once the gaps are identified and the learning objectives specified, the team can begin the process of creating a scenario that meets those objectives. Before going headlong into scenario writing, it can be helpful to meet with the simulation center personnel (if applicable) to determine the feasibility of the proposed scenario from an engineering and cost-effectiveness standpoint. We use a standardized scenario development worksheet that includes a synopsis of the case, learner prerequisites, didactic needs, learning method, debriefing method, and although rarely utilized in our curriculum, an evaluation method. Each simulation center may have their own institutional scenario development form that fits the needs of that particular center. Regardless of the form, it is important to have uniformity so that all members of the simulation team – the faculty instructor, the simulation technologist, and EPs are familiar with the process.
| Description of Case|| |
Each case stem includes a brief description of the patient, which will be provided to the learner before beginning the scenario. This description includes age, gender, medical and surgical history, home medications, allergies, laboratory test results and imaging, current ongoing procedure or surgery, and patient location (i.e., preoperative area, operating room, and postanesthesia care unit). Before initiation of the case scenario, the learner is given ample time to review this information and ask relevant questions pertaining to this existing case, stage/phase of surgery, or procedure under way. If at the beginning of the scenario, the patient is awake, the learner can direct questions to the mannequin. The learner is also made aware of the availability of additional staff or resources.
| Learning Objectives|| |
The goals of the scenario are clearly defined to the learner before the beginning of each case. For example, he or she may be told to perform a preoperative evaluation, come up with an anesthetic plan, and induce the patient. The learner is instructed to respond to situations as they would in a natural working environment. It is essential that the participant be previously oriented to the simulation laboratory environment and its limitations so that suspension of disbelief can be achieved and unnecessary time and attention not be spent during the scenario on technical issues. Since many of the scenarios will focus on management of an intraoperative crisis (i.e., hemorrhage, malignant hyperthermia, etc.,), the objectives of the scenario must necessarily be hidden from the learner to maintain an element of surprise.
| Fidelity and Equipment|| |
When developing a scenario, it is important to choose a level of fidelity that is necessary to achieve the chosen learning objectives. Having a state of the art facilities is helpful [Figure 1]. However, for example, partial task trainers may be all that is required to teach line placement, neuraxial anesthesia, and fiber-optic intubation. For procedural tasks, high-fidelity mannequin-based simulation may be unnecessary and low-fidelity modalities may be equally as effective. For other learning objectives, more traditional didactic techniques may be equally useful and cost effective. However, in case of rare, critical scenarios, it may be necessary to use high-fidelity mannequin  When this is the case, the learning environment is created to resemble a real-life operating room to enhance environmental and psychological fidelity. Likewise, other fully functioning standard operating room equipment is available for use by the learner. This includes but is not limited to patient monitors, defibrillator, anesthesia machine, infusion pumps, and airway equipment. For subspecialty cases, we use props (external pacemaker, cardiopulmonary bypass machine, and surgical instruments) to help set the stage. Computer-based charting, if standard at that institution, may also be introduced. While residents are encouraged to draw up and push medications (all comprised saline-filled vials and syringes), administration of fake blood products can be demonstrated by merely “hanging” the bag. While this may slightly compromise the fidelity, it also allows the simulation team to reuse the equipment for future learners. While we believe that increased fidelity is important to allow for realism, excessively complex scenarios may be unnecessarily time consuming to set up and expose the scenarios to flaws in execution. Finding a balance requires experience, but simple scenarios may be just as effective in demonstrating teaching points.
| Script|| |
The script is the written plan for the scenario and includes a set of states with prescribed vital signs. The script should include the time course over which the changes occur in response to a specific trigger event. For example, the patient's heart rate should increase by 30 over 10 s during laryngoscopy. The script should include all of the major vital signs (blood pressures, heart rate, oxygen saturation, end-tidal CO2, and temperature) as well as more invasive measurements (central venous pressure, pulmonary artery pressure, cardiac output, and intracranial pressure) depending on the scenario. The script should also include electrocardiogram (ECG) appearance as the scenario may involve ST-segment changes in specific distributions and patient appearance. The latter may simply be “intubated, sedated under general anesthesia” but may also be more detailed in the event of focal physical examination findings (i.e., dilated, nonreactive pupil, pneumothorax, etc.). In addition, the script should be written such that each state contains specific operator details to make the scenario run more smoothly. At times, a scenario may be written such that the patient or an EP verbally responds to a learner's action. In this case, scripted responses and facilitator details should be written to allow for consistency in achieving the desired learning objectives for the case. While the states are scripted to occur over a specified period, time may be sped or slowed down to in the simulation laboratory to allow the learner to achieve specific objectives. For example, while a real patient might rapidly deoxygenate in the absence of secure airway, this process may be slowed to allow the learner to accomplish the task. This may be altered depending on the trainee's. Likewise, we may also include a “death state” whereby improper management leads the patient down the pathway to pulseless electrical activity. Death of the simulator should not be taken lightly as it may have psychological ramifications on the learner and be antithetical to the learning objectives. This is a controversial topic that has been extensively written about and discussed. Suffice it to say that while a script may contain this state, we use it with caution and often reserve it for more senior level learners.
Finally, each state should include a set of specific goals and objectives. The facilitator may find it helpful to reiterate the scenario information during the exercise in order to help guide the students. Visually reference the information on the monitor or on the mannequin during the scenario to help guide it smoothly. He or she may also make notes on the participant's performance with respect to the objectives and then use that later either for assessment or to assist with the debriefing.
| Moulage|| |
Moulage is defined as the application of makeup, molds, or props to the mannequin's body to enhance the level of realism [Figure 2]. Moulage should match the description of the case and/or the region of interest (i.e., chest, abdomen, and extremity). In addition to adding an element of realism, it may help the learner focus and solve the problem at hand. Any of the preexisting lines (intravenous line, arterial line, urinary catheter, etc.) that are relevant to the scenario should also be considered. Any moulage should be specified on the scenario development form that is provided to the simulation technologist. At our institution, the moulage is mapped onto a representation of the mannequin's body.
Preprogramming versus “Running on the fly:” To allow for a logical, predictable sequence of events in a given scenario, it may be helpful to preprogram hemodynamic changes in advance. These states will have already been delineated in the script. Some commercially available high-fidelity mannequins allow for the programming of states such that changes in all of the mannequin's dynamic organ systems (i.e., heart, lungs, eyes, and airway) occur simultaneously over a prescribed setup time in response to a trigger event. Preprogramming also allows the instructor and simulation technologist to focus on the progression of the scenario. If more than one pathway is expected, the facilitator might be having two or more branching states depending on the learner's actions. However, it is unreasonable to anticipate every possible action by the learner, and especially with novices, management can be especially unpredictable. Based on the learner's actions, the facilitator or simulation technologist may need to manually input hemodynamic changes in real time also known as “running on the fly.” While this is more difficult and requires greater experience with the software, it also allows for enhanced realism. For example, a novice learner might administer a beta-blocker to treat tachycardia occurring as a result of massive blood loss. The instructor may not have expected this action in their script and subsequent preprogramming and therefore must improvise to allow for the realistic consequence of bradycardia and worsening hypotension in response to this action. Allowing for realistic outcomes in this instance would be essential to the learning objectives of the scenario. To accomplish these sessions, we have found it necessary to have two facilitators and one simulation technologist to coordinate and respond to dynamic events. This allows for the maximum flexibility of case scenario. In certain cases, despite appropriate course of action, patients may not respond to medications or have an adverse outcome just as in real life.
| Adjuncts Such as Video Clips and Additional Laboratory Test Results|| |
To engage learners in a scenario, it may be necessary to provide supplemental material such as imaging and laboratory values. These may be available at the outset of the case (i.e., ECG, blood chemistry) or requested during the scenario. In the case of cardiothoracic subspecialty scenarios, we have provided video clips of transesophageal echocardiography projected onto a screen in the simulation bay upon request. Additional clips are queued up in response to clinical management (i.e., administration of fluid bolus and inotropes). Likewise, the learner may request laboratory values such as arterial blood gasses which should change based on the state of the patient. The instructor should anticipate this when creating the scenario and has laboratory values already available for specific states. Just as in real life, the results should not be immediately available so that interim management can take place.
| Distractions|| |
It may be useful to add an element of distraction to increase the complexity of the case. Examples include an anxious patient in the setting of a difficult airway, a missing piece of equipment during a critical event, a surgeon vehemently opposing the participant's course of action, an over-enthusiastic intern asking unrelated questions, or a distressed family member in the recovery area. Distractors add to the cognitive load of the learner and may limit his or her ability to effectively handle the scenario. Such events are meant to replicate real life and may be useful if the focus of the scenario is performance under pressure. However, just as these added elements can distract the learner, they can also distract from the learning objectives if used inappropriately or excessively. We exercise caution and limit use of distraction to more advanced learner.
| Etiquette and Nontechnical Skills|| |
Regardless of whether it is in real life or in a simulated learning environment, proper etiquette is required to manage situations. In the health-care profession anger, rudeness, frustration, and sadness are all encountered on a routine basis. These emotions may be expressed by colleagues, patients, and patients' family members from unanticipated events, high-stress medical conditions, and chronic fatigue. This puts immense burden on health-care professionals, and learning to cope with these conditions is an important nontechnical skill for anesthesiologist. With this in mind, facilitators may design a scenario to elicit specific emotions on the part of the learner. The demonstration of proper etiquette and professionalism in the face of a challenging emotional milieu may be the learning objective for the scenario. The scenario authors should incorporate proper etiquette as a part of professional expectation and address this during debriefing. Beyond etiquette, nontechnical skills such as task management, teamwork, situational awareness, and decision-making are all domains that that can be adversely affected by environmental factors. These nontechnical skills, while essential to the anesthesiologist, are not reliably addressed by traditional educational modalities. Simulation provides the medium to create situations which reliably challenge residents' nontechnical skills. Facilitators might also consider using the anesthetist' nontechnical skills scale to more objectively measure learner behavior during the simulation.
| Embedded Participants|| |
EPs, also known as confederates, may be introduced into a scenario for a variety of reasons. They may be used to elicit communication skills on the part of the learner (i.e., delivering bad news to a family member after a bad outcome) or to provide useful information or assistance during a scenario (i.e., chest compressions during a code). When the scenario takes place in the operating room environment common, EPs include the surgeon, a circulating nurse, and a surgical technologist. Having appropriate EP roles lends greater fidelity to the case. The downside of having more EPs, however, is the added resources required to have a successful session. In our experience, we have found it sufficient to have just one or two EPs in most scenarios. These may be played by actors or by simulation faculty. The latter is required when the role is of a health-care professional. On occasion, another learner may be used in the role of an EP after some coaching. While EPs actions should be scripted in advance, it may be helpful to have some means of communicating with the facilitator (i.e., Bluetooth headset) in real time during the scenario in the event of any unexpected change.
| Practicing the Scenario|| |
It is important to practice the scenario in advance of the actual session to ensure that the transitions in states occur smoothly, the equipment is functional, and the imaging/laboratory test results are available. During the practice run, elements that were not considered during scenario design but necessary for execution may become apparent. Coordination between the facilitators and simulation technologist is essential to having a successful simulation that meets the educational objectives for the learner.
| Conclusion|| |
Training and education in anesthesiology is changing and evolving as time, pressure, and legislative demands mount on physicians. SBE, when properly executed, is an effective training tool to teach and evaluate the next generation of anesthesiologists. A comprehensive, systematic approach to scenario design that keeps in mind the demands of the learners and their educational goals is essential. In addition, cooperation between facilitators, simulation technologists, and EPs from the outset is essential to carrying out the plan as written. Although the creation of high-fidelity mannequin-based scenarios is resource intensive and challenging, it also provides a unique opportunity for trainees to rehearse both their technical and nontechnical skills in a safe, controlled environment without exposing patients to harm. The eventual goal of SBE is to improve time, precision, accuracy, and error reductions in high-stakes scenarios and ultimately create better patient outcomes.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Gaba DM. The future vision of simulation in health care. Qual Saf Health Care 2004;13 Suppl 1:i2-10.
Abrahamson S, Denson JS, Wolf RM. Effectiveness of a simulator in training anesthesiology residents. J Med Educ 1969;44:515-9.
Green M, Tariq R, Green P. Improving patient safety through simulation training in anesthesiology: Where are we? Anesthesiol Res Pract 2016;2016:4237523. doi: 10.1155/2016/4237523. [Epub ahead of print].
Steadman RH, Huang YM. Simulation for quality assurance in training, credentialing and maintenance of certification. Best Pract Res Clin Anaesthesiol 2012;26:3-15.
The anesthesiology milestone project. J Grad Med Educ 2014;6 1 Suppl 1:15-28.
Friedman Z, Siddiqui N, Katznelson R, Devito I, Bould MD, Naik V. Clinical impact of epidural anesthesia simulation on short-and long-term learning curve: High- versus low-fidelity model training. Reg Anesth Pain Med 2009;34:229-32.
Gaba DM, Howard SK, Fish KJ, Smith E, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simul Gaming 2001;32:175-93.
Corvetto MA, Taekman JM. To die or not to die? A review of simulated death. Simul Healthc 2013;8:8-12.
Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists' non-technical skills (ANTS): Evaluation of a behavioural marker system. Br J Anaesth 2003;90:580-8.
[Figure 1], [Figure 2]