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Keywords:

  • clinical practice;
  • simulation;
  • surgical education

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. The role of simulators in surgical education
  5. The role of the simulation environment
  6. The role of simulation in surgical education
  7. Conclusion
  8. References

The reduction in time for training at the workplace has created a challenge for the traditional apprenticeship model of training. Simulation offers the opportunity for repeated practice in a safe and controlled environment, focusing on trainees and tailored to their needs. Recent technological advances have led to the development of various simulators, which have already been introduced in surgical training. The complexity and fidelity of the available simulators vary, therefore depending on our recourses we should select the appropriate simulator for the task or skill we want to teach. Educational theory informs us about the importance of context in professional learning. Simulation should therefore recreate the clinical environment and its complexity. Contemporary approaches to simulation have introduced novel ideas for teaching teamwork, communication skills and professionalism. In order for simulation-based training to be successful, simulators have to be validated appropriately and integrated in a training curriculum. Within a surgical curriculum, trainees should have protected time for simulation-based training, under appropriate supervision. Simulation-based surgical education should allow the appropriate practice of technical skills without ignoring the clinical context and must strike an adequate balance between the simulation environment and simulators.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. The role of simulators in surgical education
  5. The role of the simulation environment
  6. The role of simulation in surgical education
  7. Conclusion
  8. References

Surgical training has traditionally been based on long apprenticeships, during which trainees learned in the workplace by practising on patients, supervised by their mentors. Contemporary circumstances, such as the introduction of the European Working Time Directive, shorter training duration and shorter patient admission times, have reduced the time available for apprenticeship training.[1, 2]

According to educational theory, the development of expertise demands sustained deliberate practice.[3] It is no longer ethically acceptable, though, for inexperienced trainees to practise on patients in order to develop their expertise, and clinical safety rules have set significant boundaries for practice on real patients.

Recent technological advancements have revolutionized clinical practice, surgery in particular, introducing novel clinical applications that demand the development of new skills. The introduction of minimally invasive surgery, computer-assisted and image-guided procedures, demands familiarization with technology and development of new skills by trainees and established experts who want to adopt the new technologies in their practice.[4]

Pressures on healthcare education, imposed by these circumstances, have led to the introduction of simulation for the training of novices. Simulation offers the opportunity for repeated practice in a safe and controlled environment, focusing on trainees and tailored to their needs.[5] By withdrawing the potential consequences of practice on patients, trainees have the opportunity to make errors and learn from their mistakes.[6] Already there are many available simulators that allow trainees to practise on a wide range of skills and there is a continuous technological race to improve their fidelity in order to offer an enhanced sense of clinical reality.

Although the potential benefits from the use of simulation in healthcare education are well recognized,[7] there is an ongoing debate on how simulation should be used in surgical education in order to get the maximum benefits and how to successfully integrate it in the training curriculum. Many authors focus on simulators as a useful tool for practising procedural skills, while others argue that simulation should recreate the clinical circumstances and environment without focusing only on the acquisition of technical skills. It is therefore important to distinguish the term simulator, meaning the actual equipment, such as mannequin or computer programme, from simulation, which describes the recreation of a clinical event and may sometimes not include a simulator.[8]

The role of simulators in surgical education

  1. Top of page
  2. Abstract
  3. Introduction
  4. The role of simulators in surgical education
  5. The role of the simulation environment
  6. The role of simulation in surgical education
  7. Conclusion
  8. References

Various types of simulators have been introduced in surgical training, which can be categorized according to the technology being used[9, 10] or according to the varying complexity of the skill being simulated[4] (Fig. 1). Cadavers, because of the correct anatomy, are being used in many courses worldwide and the use of live animals has been adopted by many centres in Europe and the USA, although it is not permitted in the UK.[10] Live rat models have been used for microsurgical skills training for many years (Fig. 2).

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Figure 1. The various simulator categories.

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Figure 2. Microsurgical skills training using live rat model simulation.

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Simulation, as an ‘act of assuming the outward qualities or appearances of a given object or process’,[11] can have various levels of fidelity, a term that describes the extent to which the appearance and behaviour of the simulator/simulation match the appearance and behaviour of the simulated system.[12] Maran and Glavin[12] describe two types of simulator fidelity: physical or engineering fidelity, which describes the replication of the physical characteristics of the real task, and psychological fidelity, which describes the reality of representation of the real task skills by the simulation. Continuous research and technological developments attempt to improve the levels of fidelity by improving the visual and haptic representations of the simulated task.[2] Any increase in engineering fidelity leads to an increase in computational power demands and cost, creating a challenge for developers to create simulators that have the appropriate physical fidelity with the least computational power and cost, so that the simulator can be made widely available. According to Maran and Glavin,[12] psychological fidelity, which is of greater significance than physical fidelity, can be achieved even with simple simulators, although caution should be paid not to oversimplify the representation of complex skills to avoid negative transfer of skills to the real clinical task. Another aspect of psychological fidelity might be the recreation by the simulator/simulation of the actual clinical environment, during which the cues provided by the simulation contribute to the illusion of actually being in clinical practice. The importance of this aspect of simulation will be discussed later.

Any discussion about the fidelity or appropriateness of a simulator is better to be done in relation to the task or skill that we want the simulator to recreate. For example, to teach novices suturing skills a simple foam suturing pad might be appropriate, but if we want the novice to learn correct tissue handling a simulator that closely represents the properties of human tissue, such as cadaveric or animal tissue, will be more appropriate. Similarly with laparoscopic skills, if we simply want the novice to learn about depth perception and simple laparoscopic manipulative skills a closed box laparoscopic trainer will be adequate, but if we want to give to the trainee a realistic representation of how to perform a cholecystectomy, a more sophisticated recreation of the real haptic and visual cues, such as with the LAP Mentor (Simbionix, Cleveland, OH, USA), for example (Fig. 3), would be more appropriate in order to achieve transfer of skills.

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Figure 3. The LAP Mentor simulator.

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The role of the simulation environment

  1. Top of page
  2. Abstract
  3. Introduction
  4. The role of simulators in surgical education
  5. The role of the simulation environment
  6. The role of simulation in surgical education
  7. Conclusion
  8. References

Contemporary educational theory has recognized the importance of context in learning. Lave and Wenger,[13] in their theory of situated learning, describe how trainees develop their expertise and build their professional identities through active participation in a community of practice and interaction with the other members of the community. Kneebone et al.,[14] recognizing the importance of context in surgical education, argue that simulation, instead of offering decontextualized practice of isolated practical skills, should be contextualized in the clinical environment. They call for a closer alignment between simulation and clinical practice and describe a process of assessment and rehearsal of clinical learning needs in the simulated environment before applying them in real clinical practice.[5]

Various ways to achieve contextualization have been described. By delivering simulation at the actual clinical environment, what Paige et al.[15] define as point-of-care simulation, we have the chance to practise real scenarios in the environment that will actually happen in clinical practice, such as the operating room in this instance. Other authors have described on-site simulation projects in other areas of clinical practice, such as anaesthesia[16] and emergency care.[17] The practice of scenarios with real teams in a familiar environment, according to Paige et al.,[15] can explore and uncover team operational problems in a safe environment without the possible consequences on patients, giving the opportunity for application of the explored solutions to these problems in clinical practice. Some authors argue, though, that the provision of simulation at the actual point of care has the limitations of cost and wide availability of high-fidelity simulation and the challenge of being able to fit simulation in the current limited capacities of health systems.[8, 18] Another issue might be that providing simulated training in the actual workplace might interfere with the actual clinical processes running at the same setting.[19] Kneebone et al.[8] suggest a possible solution to these issues by developing the concept of distributed simulation. In an attempt to address the issues of access and cost in high-fidelity contextualized simulation, they describe a process of ‘selective abstraction’, during which the key elements of clinical practice are identified and recreated in the simulated environment. With this approach, the author argues that instead of trying to replicate clinical practice, we recreate a ‘good enough’ environment that creates an appropriate level of fidelity while maintaining the properties of low cost and portability, making it more accessible. Portable simulation, though, can present potential problems as well, such as unexpected mechanical and computational mobile equipment problems or damage to the equipment during the frequent transport.[19]

Human interaction and communication with patients is at the heart of clinical practice. Most procedures performed by novices in real clinical practice demand, aside from the appropriate skills to perform the actual procedure, communication with the patient. Sometimes the communication skills required in order to perform the task are more important than the practical skills competency required to perform the actual task, such as when dealing with an uncooperative or angry patient. An interesting approach that integrates patient's communication skills and professionalism in simulation is being explored by Imperial College London. Patient-focused simulation[20] combines an inanimate simulator with a simulated patient, usually an actor. Examples of this approach include the practice of venepuncture on a simulated arm attached to a patient or a combination of a virtual reality simulator, such as an endoscopy simulator, attached to a patient.

Activity theory, as described by Engestrom and Middleton,[21] argues that identities are not stable in a community of practice and change as a result of conflict between the individual members of the community. Within the healthcare communities of practice, although the members have a common goal, which is patient care, sometimes their individual tasks and goals clash, leading to conflict. Simulation, by recreating the circumstances and the environment of clinical practice, offers the opportunity to explore the dynamics of these communities of practice and find solutions to improve communication and cooperation between healthcare professionals. There are several examples of successful projects in the literature that used simulated scenarios at the actual clinical setting or in a simulated clinical environment to explore the functionality of multidisciplinary teams[15, 22] or to teach communication and teamwork skills to healthcare professionals.[23]

The role of simulation in surgical education

  1. Top of page
  2. Abstract
  3. Introduction
  4. The role of simulators in surgical education
  5. The role of the simulation environment
  6. The role of simulation in surgical education
  7. Conclusion
  8. References

Simulation has many potential benefits for healthcare education, therefore the challenge is how to utilize simulation to achieve the best possible results. Issenberg et al.,[7] in a systematic review of literature on simulation, have identified the features and aspects of simulators that contribute to effective learning. These features, listed in a descending frequency of reference in the literature, were: the provision of feedback, repetitive practice, integration with the curriculum, varying level of difficulty, multiple learning strategies, ability to capture clinical variation, provision of a controlled environment, individualized learning, defined outcomes and simulator validity.

Many authors mention that in order for simulation to be effective as an educational process, it has to be integrated into the educational curriculum.[4, 5, 24] In order to successfully integrate simulation into the curriculum, a didactic instruction that includes the indications of the skills and possible complications of the procedure should precede the practice of skills.[4] Although educational theory informs us that sustained deliberate practice is important for the development of expertise,[3] because of the individual variability between learners, it is difficult to quantify the amount of practice on simulators required for the development of a certain skill. Validated methods of assessment of transferable skill should be therefore established for simulator training in order to be able to follow a competency-based approach, similar to the contemporary approaches to healthcare education in general, which takes into account individual variability. Also, as part of an educational curriculum, instead of an episodic and opportunistic approach to simulated training, there should be dedicated protected time for simulation training.[25] Kneebone et al.[14] describe a dynamic to-and-fro process of identification of personal learning needs, master of the skill on simulator-based training, and then application of the skill in clinical context. This process can be very beneficial to learning if integrated in a structured way in the curriculum.

Although, as demonstrated by Issenberg et al.,[7] validation is the least considered in the literature factor for effective learning, it is necessary to evaluate simulators before integration into an educational curriculum. Validation describes the process of assessment of a simulator's appropriateness for the intended purpose, evaluating if the simulator leads to learning that is transferable to clinical practice and maintained over time. Gould[2] argues that during the evaluation of a simulator, three criteria have to be assessed: content, face and construct validity. Content validity is present when the content, including steps and behaviour, is appropriate for the desired training objective; face validity is present when the simulator is sufficiently realistic to convey a sense of ‘presence’ to the operator; and construct validity exists when the assessments using the simulator allow us to make correct judgements about the operator's performance. A major concern is that because simulation is changing rapidly, evaluation is difficult to keep up to the development of simulators, leading to the adoption of sometimes poorly evaluated simulators.[5] Without the assessment of face validity, content validity and fidelity, which according to Gould[2] are the key factors determining the transfer of skill, the skills learned on the simulator cannot be successfully applied in clinical practice and can potentially harm patients if they contribute to a false sense of confidence.

Kneebone[26] argues that during practice of procedural skills by novices using simulation, the simulated environment should recreate the actual circumstances of performance in real practice, taking into account the aspects of stress and anxiety. Kneebone and Baillie[27] also mention that simply becoming an expert on a technical skill by isolated practice on a simulator might lead to misleading confidence, because it does not prepare trainees for the unpredictability of real clinical practice. Kassab et al.[18] have demonstrated a deterioration in novice's performance in technical skills during contextualized simulation, when compared with the isolated practice of skills on simulators, attributing this to the extra cognitive load of context. Although it is important for novices to experience the performance of technical skills in simulated clinical practice circumstances, if they have not achieved a minimum level of practical skills competence they will not be able to perform in the complex contextualized simulation environment, losing in that way the opportunity to improve their practical skills. Therefore, it will be more beneficial if trainees develop a certain level of competence through practice on simulators and then experience practising these skills in a contextualized simulation environment.

As mentioned above, there is an ongoing argument in the literature regarding the direction that simulation should take in the training of healthcare professionals. Simulation should not take a direction towards a focus on isolated acquisition of technical skills disregarding the clinical context, neither should focus only on the recreation of the clinical environment and its dynamics disregarding technical skills. Advanced high-fidelity simulators can play an important role in contextualized simulations, helping in the attempt for a realistic recreation of the clinical environment and allowing for the practice of technical skills in an authentic environment. An example of such approach is the use of sophisticated human tissue simulators attached to human actors in patient-focused simulation, which allows the appropriate practice of the technical skills of suturing without ignoring the factor of human interaction, which will be necessary when performing the task in a real-life situation. Another example is the use of a high-fidelity virtual reality simulator, such as LAP Mentor (Simbionix), in a real or simulated theatre environment, such as with distributed simulation for example,[18] where the trainee will be practising on performing a procedure while interacting with other members of the theatre team. Effort should therefore be made for the combined improvement of simulators for effective practice on technical skills and of simulations for the successful recreation of the actual real-world clinical circumstances and environment.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. The role of simulators in surgical education
  5. The role of the simulation environment
  6. The role of simulation in surgical education
  7. Conclusion
  8. References

Continuous research and technological advancements offer today a large number of available simulators and types of simulation. Every type of simulation has to be validated appropriately before it is used for the purposes of training, and the appropriate type must be chosen depending on our educational goals and considering the background knowledge and competency level of trainees. In order for simulation training to be effective, it has to be successfully integrated in a surgical curriculum and aligned with clinical practice.

Technical skills are very important in clinical practice, especially in a field such as surgery, and expertise demands sustained deliberate practice. In a contemporary healthcare education environment that offers a decreasing amount of opportunities for practice at the workplace, simulation offers an attractive solution for the practice of practical skills. The complex and unpredictable clinical environment, though, demands more than technical skills and a simulator, a machine, cannot teach a novice communication skills, professionalism and teamwork, therefore simulation must mirror the clinical environment and recreate the circumstances of real clinical practice. In order to be successful, simulation-based surgical education must strike an adequate balance between the simulation environment and simulators.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. The role of simulators in surgical education
  5. The role of the simulation environment
  6. The role of simulation in surgical education
  7. Conclusion
  8. References