Teaching 12 foundation doctors. I helped organise an

Teaching Simulation to
Foundation Doctors

Introduction:

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Throughout this essay I intend
to describe and reflect upon a teaching session I provided for 12 foundation
doctors. I helped organise an intensive care careers event and taught a
simulation station on the intensive care ward. I aim to reflect on this, and
compare teaching methods and concepts with relevant teaching literature.

 

What
happened?

I helped organise an intensive
care careers event for twelve F1 and F2s. There were two simulation stations
and a lecture on non-invasive ventilation. I taught a simulation station in one
of the ITU bays. The participants had to assess a septic patient, provide
initial management, and escalate to a senior. I wrote a storyboard in advance
which included the scenario, three stages of deterioration and associated
clinical observations, and learning objectives.

When the participants arrived,
we gave them a briefing during which we explained who the patient was, what we wanted
to see the students do, and asked them to nominate a team leader to start the
scenario. During the scenario, my colleague controlled SimMan so I could
provide the voicing and offer advice on how to proceed. The groups performed an
initial assessment and diagnosed the patient with chest sepsis. They commenced
initial treatment, and escalated to an appropriate senior. Following the 20
minute simulation session, we had 10 minutes for debriefing and feedback.

 

Reflection:

It was stressful planning and running
a teaching session during working hours due to time constraints. I wanted to make
the empty bay look like an acute medical bay, get the correct settings ready
for SimMan, and practice the station to ensure it flowed in a logical manner. Unfortunately, I was working and unable
to spend as much time preparing as I’d have liked, meaning I felt more stressed
than normal before teaching. During the event, I was receiving bleeps about
various work-related tasks, which was quite distracting. Eventually, I asked a
colleague to take the bleep from me and hold it for two hours, as I was
interrupted twice in the first session. Another complication which arose from
teaching in the workplace, specific to ITU, was the constant beeping and noise
created by the machines on the ward. I’ve worked on ITU for four months, and
the extra noise is starting to become less intrusive, but I think it bothered
some of the students, particularly those who were less comfortable being in a
strange, new environment. As we progressed, I began to feel more confident and
in control of the sessions, and I began to actively enjoy my role in teaching. I
think the students picked up on my confidence, and seemed to enjoy and participate
more.

Many elements
of 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 have
students practice examining a critically unwell patient on ITU who could not
consent, we aimed to create a realistic environment to allow students to build
their skills. Other feedback said the debrief section was run very well. I’m
pleased the students enjoyed this part of the session, as it can be difficult
to deliver feedback in an enjoyable way. The feedback section involved me
asking the students how they felt about the session, what went well and what
they could improve upon. I asked them how they interpreted the scenario and
their 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 group
the opportunity to ask questions. I think I presented myself in a friendly,
approachable manner which allowed the students to feel comfortable with the
situation. They seemed to feel happy asking questions, and everyone
participated actively.

I enjoy
teaching medical students and junior colleagues, but I felt slightly nervous,
verging on inadequate when teaching seniors or my peers, as though they will
see through the holes in my knowledge and criticise me for this. During this
teaching session, there were a mixture of F1, F2 and clinical fellows present,
including a good friend from Taunton. I found this slightly off-putting during
the first session, and I had to consciously convey that I was the teacher,
leading the session rather than a friend. Other uncertainties lay in
deciding how much freedom to allow the learners; should I allow them to make an
incorrect 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 questions
do not have set answers; I think it can be difficult when teaching those of a
similar experience level to offer them advice and guidance. Therefore, I
allowed the groups a lot of freedom during the first run through of the
scenario, and allowed them to make more mistakes. The scenario over-ran by a
few minutes, which allowed them to escalate to an appropriate senior. As we
moved through the groups I seemed to find my feet a bit more; I engaged with
the groups by asking them to explain their train of thought to me, and offering
advice or suggestions if they were stuck. I think during the second and third
session 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 group
was not clear what the learning objectives were, and they felt the junior
members of the team had the potential to get lost during the scenario. As we
moved through the groups, the later two groups agreed the learning objectives
were “useful” and “relevant”, which implies that they were clearer and
achievable, and that the scenario was “facilitated very well”.

I think providing a ward based
simulation scenario offers a lot of benefit to the learner and teacher. As the
teacher, I was in a familiar situation knowing where the kit is, how to work
the beds, how to use the monitors and observations machines etc, which provides
an element of comfort. I think offering simulation on the ward gives learners a
much more realistic scenario, compared with a clinical skills suite. Offering a
workplace based scenario offers students a sense of realism, simulation tests
their knowledge, improves the non-technical skills, and allows them to gain
knowledge through experience, which I hope will influence their practice.

 

Areas
of Uncertainty:

As mentioned, I found it
difficult teaching my peers, especially when one of them was a good friend. I
think this embodies how we still view medicine as a hierarchal profession, with
our seniors being superior and offering more than the junior team members. I
think to break these barriers, we must teach our peers, teach in
multidisciplinary teams and we must allow and encourage the involvement of
junior team members. Although the junior members of the team may not
necessarily have the same amounts of experience as those more senior, they can
offer different skills to the team. Therefore, I endeavour to teach
post-graduates, such as foundation doctors and core trainees. I have signed up
to teach in series of lectures about medical specialties for F2 doctors, and I
am delivering a presentation to the entire intensive care team which includes
consultants, registrars, core trainees and foundation doctors. I think my fear
of looking unintelligent in front of seniors will be overcome through practice
and preparation.

 

Reviewing
the Literature:

I decided to
review some background theories before reviewing literature regarding workplace
based education. I used Google Scholar and PubMed for my searches, where I
entered terms such as “medical education workplace”.

Adult learning,
also known as andragogy, has been described by Malcolm Knowles (Knowles, 1980) as:

·        
Self- directed
and motivated,

·        
Drawing on
previous experiences,

·        
Work relevant to
learner needs,

·        
Based on
problem solving.

Learning is autonomous,
with the student directing their own experiential learning. There is an
assumption adult learners are motivated to self-directed learning, however this
may simplify certain complex topics(Knowles, 1980,
Yardley et al., 2012). Andragogic learning is applicable to teaching medicine
in the workplace, as without a strict curriculum, there is often impetus for
students to direct their own learning. This is a very learner centred theory, moving
the process of learning from the teacher to the student.

Constructivism theorises
that learning is a “process whereby knowledge is created through the transformation
of experience” (Kolb, 1984, Yardley
et al., 2012). It’s a learning process where previous knowledge is built upon; connections
between old memories, and new experiences come together to form new knowledge
through reflection (Kolb, 1984, Yardley
et al., 2012, Torre et al., 2006). Teaching in the workplace offers students the ability to build on
previous knowledge they have attained in theoretical terms, and apply this to
real life situations and build their knowledge in a way which motivates and
suits them(Torre et al., 2006). Biggs and Tang suggest that constructive
alignment is provides greater emphasis on the teacher to provide facilitated
learning within the learning experience(Biggs and Tang,
2011). It allows for students to learn via experience but puts impetus on the
facilitators to provide and guide their learning; they align the situation to
provide learning, which allows for the educator to have more control over the
students’ learning experiences(Biggs and Tang,
2011). This theory resonates with me, as it provides context for the student’s
learning, and the interactions with seniors have greater meaning, rather than
transitory interactions. I think this theory is applicable to ward-based simulation
scenarios, as it allows students to build on background knowledge with a
facilitator guiding them through a scenario depending on their degree of
competency. It allows for a structured feedback model, such as the one minute
preceptor model, which allows the teacher to review informally, yet
effectively, 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 a
simulation scenario. For example, we expected students to be capable to
examining a patient, and initiating treatment. My goals for the session were to
build upon this pre-existing knowledge base, and develop inter-personal skills,
and recognise the sick patient. Through building on pre-existing knowledge, we
aim to guide and influence how the students practice in medicine, allowing for
higher level learning in terms of Bloom’s taxonomy(Bloom and Krathwohl,
1956).

During my simulation session, I tried to recreate a
work environment, to allow students to assess a critically ill patient in a
safe environment. Flexnor highlights that learning in a working environment,
particularly caring for patients, provides powerful stimulus for learning and
this can be achieved by the supervision of novices by experienced teaching physicians(Cooke et al., 2006). Billet reviewed learning in the workplace, and
highlighted many positive aspects of using the workplace as a teaching
environment. He highlights that the workplaces provides specific opportunities
for learners to engage and participate in relevant ways that benefit their
learning- for example practicing clinical skills(Billet, 2004). This suggests specific learning opportunities
offer students new perspectives, and methods of learning through direct action
and participation. Billet and Boud suggest workplace experiences
influence learners indirectly also; students learn indirectly by observing more
knowledgeable colleagues; observing their behaviours and language(Billet and Boud,
2001).

Billet also addresses criticisms made of the
workplace as a learning environment. It’s  suggest that learning in the workplace is ad
hoc; it is informal and unstructured(Billet,
2004). These negative connotations suggest
the learning which occurs in the workplace is sub-optimal when compared with
formal learning based within educational facilities, however I argue that
learning within the workplace provides students with insights and education
into the hidden curriculum, especially within a career such as medicine. The
hidden curriculum highlights small, but important areas of learning, such as
using hospital IT systems, how to communicate within the hospital hierarchy,
and ways to develop inter-personal communication skills. During the simulation
scenario, we tried to create these learning opportunities for the students, by
asking them to simulate initiating patient management, including ordering tests
and referring to senior doctors etc. Billet also comments upon the
absence of qualified teachers(Billet,
2004), however this is disputable given the
large numbers of post-graduate level teaching courses available and the number
of doctors embarking upon these. Billet’s paper is linguistically challenging;
I found the language florid and difficult to interpret. He also discusses the
workplace as a learning environment without any specificity to medicine,
therefore all the interpretations are available to other vocational careers. Another
difficulty with teaching in the workplace stems from the strain put on those
teaching, the healthcare professionals who are required to build learning
experiences within their day-to-day jobs(Sajjad
and Mahboob, 2015), as reflected upon earlier by myself.

 

Summary:

I found this an enjoyable
teaching session which made use of my current workplace in ITU, and allowed
participants to experience critically unwell patients in a safe environment. Feedback
was good with an average score of 8.45/10. I have reflected on my strengths and
weaknesses, and addressed how I will improve my teaching practice. Finally, I
have briefly reviewed the literature surrounding work based education and adult
learning theories.