 | Sonia Twigg I love sim training. I’m one of those people that laughs loudly and cries at the cinema. I find “suspension of disbelief” easy. Interactions in a sim reveal new aspects of myself. And I find out whether I really know the topic or if I simply thought I did. Our educators have strived to create an environment that can be both safe and challenging. I’ve learnt a lot. So I was keen to be part of making a sim. I didn’t expect it to dampen my enthusiasm. |
For a first time creative team, our sim went well. It turned out to be a cerebral sim with a lot of thinking and not a lot of doing. The consultant participants glowed clinically by being ahead of the game with the diagnosis but were not given so many clues that it was obvious from the start. They worked together fantastically while still finding challenges that could be discussed at the end. The main sim artefact that appeared was that the participants expected the scenario to be much harder than we intended which lead to some hesitation to intubate.
Debrief
I did the debrief. Doing a debrief is tricky. There are a number of different methods advised for giving feedback, especially if any negative feedback has to be given. Famous is the “shit sandwich”; sandwiching a negative comment between 2 positive comments. The problem is that it dilutes both positive and negative comments and makes all of it appear contrived. Many people use the socratic approach - one person asks a question and the rest of us try to guess what answer they want. It is an attempt to see what a participant knows instead of just giving the answer but can easily fail if participants don’t understand where the debriefer is leading them.
I used the “Advocacy – Inquiry Approach”(1), a conversational technique. The idea is to use a “stance of curiosity” to try to discover a trainees “internal frame”. Our internal frames, made up of knowledge, assumptions and feelings drive our actions. By uncovering these frames, learners can reframe their assumptions and feelings. The debriefer makes an objective observation about the participant’s actions, then a subjective judgment, followed by a genuinely curious question that attempts to illuminate the participant’s underlying frames. The debriefer’s frames also become obvious. This approach only works if everyone feels safe. They suggest it helps to start with the assumption that everyone in the room is acting with good will.
With input from the whole group, we also briefly reviewed ethylene glycol poisoning and the differential diagnosis of a high anion gap metabolic acidosis (HAGMA)(2)
Criticisms
| The 3 most common criticisms of sim I have heard in my career are;
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| 1. “Sim is not fair.” Sim is not fair. It’s not fair to stand up in front of your colleagues and reveal some of your weaknesses. Nightshifts are not fair either and give no consideration to how you are feeling when the boss is asleep far away and some disaster hits the floor with you in charge. If we can’t be fair, at least we can be kind. So we did not go for the haemophiliac dwarf giving birth to triplets scenario! But we didn't want to make it too easy. Blindfolding the team leader was an interesting idea but perhaps it was too unfair? We certainly could have prepared the participants better. We hoped it would highlight communication skills and it did but at the cost of crippling the leader. | 2. “We were not prepared.” Pre-reading seems to make people feel more confident and allow them to be better role models for the observers. Real life may not let you prepare. Basic resuscitation is not hard to remember. Air goes in and out. Blood goes round and round. ABCD. | 3. “I can’t see the point.” I wondered what is the benefit gained from putting people through this stressful experience? The medical knowledge could be gleaned from a book or a lecture. The benefit must come from the teamwork, leadership and communication skills practice. Or perhaps, as one participant said to me later – “feeling like idiots together really helps people work better as a team.” |
I’m told that general nursing feedback has been that registrars have improved at teamwork and leadership in resus situations on nightshifts since starting regular sim training.
Surely that is the point.
Surely that is the point.
References
- Rudolph et al, “There’s no such thing as “non-judgemental” debriefing: A theory and method for debriefing with good judgement.” Simulation in Healthcare. 1(1), Spring 2006.
- http://lifeinthefastlane.com/ccc/acid-base-interpretation/
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