Simulation based training
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《英国医生杂志》
Simulation has been used for many years to train aviation and military personnel for work in hazardous environments. Effective and safe performance in these settings requires both highly skilled individuals and a high degree of team coordination. In addition to individual competence, communication between team members and decision making become particularly important during the management of crisis scenarios. Over the past few years several articles have described the use of simulations, simple and computer based, for the acquisition of technical skills in surgery, endoscopy, and anaesthesia. 1-3 The focus has largely been on the acquisition and assessment of individual technical skills, but now the role of simulations in training teams to work with a greater degree of coordination is being acknowledged.
Simulations are beginning to play an important part in the training of personnel in the operating theatre, emergency department, and the obstetric suite.3 w1 w2 For example, courses in anaesthesia crisis resource management address the technical skills and knowledge required to effectively manage crises, but also place considerable emphasis on judgment, decision making, vigilance, and communication with other team members.3 Our group in Imperial College has extended the use of surgical simulations beyond the acquisition and assessment of solely technical skills, to training teams in the operating theatre.4 Using a simple synthetic model integrated with an anaesthetic mannequin, our group has developed a simulated operating theatre for the training and assessment of surgeons.w3 The simulation has been further modified to develop a crisis scenario (bleeding).w4 Feedback on technical and team skills is provided by a surgeon and a psychologist. Scenarios are now being developed that draw on the skills of all members or the surgical team, with feedback to anaesthetists, nurses, and surgeons.
Considerable debate continues over the use of simulations for the assessment of professional competence. Evidence shows that recently developed methods of assessment, such as video based global rating scales and checklists, can be integrated with simulations to assess technical skills in surgery objectively.5 In addition, virtual reality simulators have been validated for the assessment of technical skills in surgery and endoscopy.6w4 Anaesthetists have assessed time taken to respond to a crisis and have developed scoring systems based on actions performed during simulations.7 However, the focus so far has been on the assessment of psychomotor proficiency. Gaba et al modified a rating scale developed for the assessment of non-technical or team skills in cockpit crews to anaesthesia.8 Fletcher et al have developed and validated a rating scale to assess the non-technical skills of anaesthetists.9 Our group is in the process of developing performance measures for the whole surgical team.w5 At present, such ratings scales are useful for providing structured and clinically relevant feedback.10 However, measures of individual and team performance are not yet sufficiently developed or validated for routine use in summative assessments.
Simulation based training has been evaluated in aviation using questionnaire surveys and observations of cockpit crew, which show an improvement in performance after training in crisis resource management.11 Simulation based training is considered to be a crucial factor in the high degrees of safety achieved in commercial aviation. In medicine, preliminary research already reflects the benefit of simulations on the psychomotor performance of surgical trainees.12 In addition, participants undertaking simulation training believe that it enhances their performance and clinical effectiveness.3
The advantages of simulation based learning are many. The learning is interactive and occurs in realistic environments. Learners can make mistakes and appreciate their consequences without causing harm to patients. The management of crisis events can be practised and rehearsed to enable personnel to be better prepared when such events occur in real life. Most importantly, teams can be trained to work in a coordinated and effective manner.
Looking ahead we see several challenges for simulation. Although numerous simulators are available for training technical skills in surgery and endoscopy, we need to integrate these into the training curriculum in a structured manner. In addition, we need to integrate mannequin based simulations into the nursing and medical curriculums and understand how and when it may make its most effective contribution. By a process of task analysis we need to understand much more about what makes a simulation realistic and effective. Costly and complicated mannequins and simulators may not always be necessary for effective training. We need to develop reliable and valid measures of individual and team performance to underpin both training and evaluation of training. Finally, we need better evidence of the efficacy and cost effectiveness of simulation if it is to advance beyond its current niche to occupy a central place in medical and nursing training.
K Moorthy, research fellow
Clinical Safety Research Unit, Department of Surgical Oncology and Technology, Imperial College, London W2 1NY (k.moorthy@imperial.ac.uk)
C Vincent, professor, A Darzi, Professor
Clinical Safety Research Unit, Department of Surgical Oncology and Technology, Imperial College, London W2 1NY
References w1-w5 are on bmj.com
Competing interests: None declared.
References
Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg 2000;87: 28-37.
Tuggy ML. Virtual reality flexible sigmoidoscopy simulator training: impact on resident performance. J Am Board Fam Pract 1998;11: 426-33.
Holzman RS, Cooper JB, Gaba DM, Philip JH, Small SD, Feinstein D. Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth 1995;7: 675-87.
Moorthy K, Munz Y, Adams S, Pandey Y, Darzi A. A human factors analysis of technical and team skills during procedural simulations. Br J Surg 2004;90(suppl 1): 88-9.
Moorthy K, Munz Y, Sarker S, Darzi A. The objective assessment of technical skills in surgery. BMJ 2003;327: 1032.
Gallagher AG, Satava RM. Virtual reality as a metric for the assessment of laparoscopic psychomotor skills. Learning curves and reliability measures. Surg Endosc 2002;16: 1746-52.
Byrne AJ, Greaves JD. Assessment instruments used during anaesthetic simulation: review of published studies. Br J Anaesth 2001;86: 445-50.
Gaba DM, Howard SK, Flanagan B, Smith BE, Fish KJ, Botney R. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology 1998;89: 8-18.
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.
Moorthy K, Munz Y, Forrest D, Pandey V, Undre S, Darzi A. Face validity and participants perceptions of the value of surgical crisis management (SCM) training. Br J Surg 2004;91(suppl 1): 79.
Helmreich RL, Foushee HC. Why cockpit resource management? Empirical and theoretical bases of human factors in training and aviation. In: Wiener E, Kanki BG, Helmreich RL, editors. Cockpit resource management. San Diego, CA: Academic Press, 1993: 3-45.
Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004;91: 146-50.
Simulations are beginning to play an important part in the training of personnel in the operating theatre, emergency department, and the obstetric suite.3 w1 w2 For example, courses in anaesthesia crisis resource management address the technical skills and knowledge required to effectively manage crises, but also place considerable emphasis on judgment, decision making, vigilance, and communication with other team members.3 Our group in Imperial College has extended the use of surgical simulations beyond the acquisition and assessment of solely technical skills, to training teams in the operating theatre.4 Using a simple synthetic model integrated with an anaesthetic mannequin, our group has developed a simulated operating theatre for the training and assessment of surgeons.w3 The simulation has been further modified to develop a crisis scenario (bleeding).w4 Feedback on technical and team skills is provided by a surgeon and a psychologist. Scenarios are now being developed that draw on the skills of all members or the surgical team, with feedback to anaesthetists, nurses, and surgeons.
Considerable debate continues over the use of simulations for the assessment of professional competence. Evidence shows that recently developed methods of assessment, such as video based global rating scales and checklists, can be integrated with simulations to assess technical skills in surgery objectively.5 In addition, virtual reality simulators have been validated for the assessment of technical skills in surgery and endoscopy.6w4 Anaesthetists have assessed time taken to respond to a crisis and have developed scoring systems based on actions performed during simulations.7 However, the focus so far has been on the assessment of psychomotor proficiency. Gaba et al modified a rating scale developed for the assessment of non-technical or team skills in cockpit crews to anaesthesia.8 Fletcher et al have developed and validated a rating scale to assess the non-technical skills of anaesthetists.9 Our group is in the process of developing performance measures for the whole surgical team.w5 At present, such ratings scales are useful for providing structured and clinically relevant feedback.10 However, measures of individual and team performance are not yet sufficiently developed or validated for routine use in summative assessments.
Simulation based training has been evaluated in aviation using questionnaire surveys and observations of cockpit crew, which show an improvement in performance after training in crisis resource management.11 Simulation based training is considered to be a crucial factor in the high degrees of safety achieved in commercial aviation. In medicine, preliminary research already reflects the benefit of simulations on the psychomotor performance of surgical trainees.12 In addition, participants undertaking simulation training believe that it enhances their performance and clinical effectiveness.3
The advantages of simulation based learning are many. The learning is interactive and occurs in realistic environments. Learners can make mistakes and appreciate their consequences without causing harm to patients. The management of crisis events can be practised and rehearsed to enable personnel to be better prepared when such events occur in real life. Most importantly, teams can be trained to work in a coordinated and effective manner.
Looking ahead we see several challenges for simulation. Although numerous simulators are available for training technical skills in surgery and endoscopy, we need to integrate these into the training curriculum in a structured manner. In addition, we need to integrate mannequin based simulations into the nursing and medical curriculums and understand how and when it may make its most effective contribution. By a process of task analysis we need to understand much more about what makes a simulation realistic and effective. Costly and complicated mannequins and simulators may not always be necessary for effective training. We need to develop reliable and valid measures of individual and team performance to underpin both training and evaluation of training. Finally, we need better evidence of the efficacy and cost effectiveness of simulation if it is to advance beyond its current niche to occupy a central place in medical and nursing training.
K Moorthy, research fellow
Clinical Safety Research Unit, Department of Surgical Oncology and Technology, Imperial College, London W2 1NY (k.moorthy@imperial.ac.uk)
C Vincent, professor, A Darzi, Professor
Clinical Safety Research Unit, Department of Surgical Oncology and Technology, Imperial College, London W2 1NY
References w1-w5 are on bmj.com
Competing interests: None declared.
References
Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg 2000;87: 28-37.
Tuggy ML. Virtual reality flexible sigmoidoscopy simulator training: impact on resident performance. J Am Board Fam Pract 1998;11: 426-33.
Holzman RS, Cooper JB, Gaba DM, Philip JH, Small SD, Feinstein D. Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth 1995;7: 675-87.
Moorthy K, Munz Y, Adams S, Pandey Y, Darzi A. A human factors analysis of technical and team skills during procedural simulations. Br J Surg 2004;90(suppl 1): 88-9.
Moorthy K, Munz Y, Sarker S, Darzi A. The objective assessment of technical skills in surgery. BMJ 2003;327: 1032.
Gallagher AG, Satava RM. Virtual reality as a metric for the assessment of laparoscopic psychomotor skills. Learning curves and reliability measures. Surg Endosc 2002;16: 1746-52.
Byrne AJ, Greaves JD. Assessment instruments used during anaesthetic simulation: review of published studies. Br J Anaesth 2001;86: 445-50.
Gaba DM, Howard SK, Flanagan B, Smith BE, Fish KJ, Botney R. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology 1998;89: 8-18.
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.
Moorthy K, Munz Y, Forrest D, Pandey V, Undre S, Darzi A. Face validity and participants perceptions of the value of surgical crisis management (SCM) training. Br J Surg 2004;91(suppl 1): 79.
Helmreich RL, Foushee HC. Why cockpit resource management? Empirical and theoretical bases of human factors in training and aviation. In: Wiener E, Kanki BG, Helmreich RL, editors. Cockpit resource management. San Diego, CA: Academic Press, 1993: 3-45.
Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004;91: 146-50.