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Transcript of Simulation paradigms
Simulation has a rich cultural and philosophical history
For Plato: simulation works through affective contagion, by contrast to rational argumentation
For Aristotle: simulation works by presenting a cognitive model.
The model is an abstraction, the validity of which exceeds the reality imitated, because it gives rise to multiple empirical incarnations according to contexts
Some clinical researchers have argued that simulation in clinical practice is rarely theorised (Kneebone), notably in terms of its history as a cultural form (Bleakley and Bligh)
Mapping the field in terms of theoretical paradigms: 4 major traditions distinguished in terms of what a simulation is; what a simulation simulates
Illustrations from an observational study carried out under the auspices of Prof Roger Kneebone's research programme on clinical simulation
Simulation as reproduction
Simulation overcomes the limitations of the real world by:
- immersing learners in an authentic context, not a decontextualised classroom
- supporting active learning, not passivity
- supporting collaborative learning, not authoritative didacticism
Gaba 2004: "Simulation rehearsals are...adjuncts to actual clinical practice, for example where surgeons or an entire operative team can rehearse an unusually complex operation in advance using a simulation of the specific patient"
The work of reproducing reality
Trainee to mannequin: "Can you squeeze my hand?"
Plant to trainee: "He can squeeze your hand"
Satisfying DNAR scenarios
Tutor: You were the son. Very good acting skills, I must say.
As a son
, getting the information from her, how did that make you feel?
I was reassured
, that I was put in a space, that
I wasn’t lied to
, at any point,
I was always given the right information
for that time...because I was clearly anxious,
you didn’t say, we aren’t going to resuscitate your mother. You actually did it in a very skilled way
and so there wasn’t anywhere where I could suddenly, you know, go ballistic,
because this hadn’t been discussed with me, and I thought
that was very well done
The satisfactions of selecting realities
Field notes: Susan says 'In my hospital, there isn't a canula on the whole ward. None of the equipment works. The seniors aren't at all interested in your situation. But I guess there would be no point in simulating this, as
what we want
to learn is the clinical stuff'
Simulation as Simulacrum
Bligh and Bleakley 2006: “there is a fascination with seductive high-fidelity simulation realized through sophisticated technology”
Simulations offer immersive experiences, which learners see/experience as real – falsely. They are
Kneebone 2005: “There seems a danger, indeed, that...simulation may become a self-referential universe, divorced from the wider context of actual clinical practice”.
Simulation as a safe community of practice
Learning from error?
Participating Doctor: She said, do you want me to bring the crash trolley, and I said yes please, and she brought the crash trolley. Then you finished your phone call. Then the cardiology reg called, then...it all seemed to happen very quickly to be honest.
Educator: You had early recognition that things were not quite what you wanted and I think because you had an experienced nurse with you, you worked quite well together, ...which meant that the situation that was unfolding in front of you was being, you know, you were sharing the mental model, although you weren’t quite together, but I thought you showed quite good democratic leadership. You realised who had the skills for what and allocated the tasks.
Simulation re-constitutes the experience of clinical practice
Simulators don’t reproduce the patient’s body or clinical reality – they simulate a way of knowing it, acting on it, participating with it.
Realism is based on intra-action – how clinicians read signals to know about the patient and act on her, i.e. realism is not based on the re-creation of the patient.
E. Johnson: The tutor shows the trainee how to see the simulator as a stand-in for surgery and to see his actions as part of surgery, rather than merely a navigation through a virtual environment. The tutor does a lot of work to reconstitute the medical context – that’s what they are there for.
Learning here has nothing to do with ‘suspension of disbelief’, or learning generic skills, or the realism of the artefacts themselves. Rather a symbolic, cultural context is being reconstituted, with trainees learning to be doctors.
Design and funding implications
Whose practice is reconstituted: the doctor's? the patient's? the nurse's? the anesthetist's?
The problem of interprofessional education
Simulation as forum theatre
Theatre as a space to:
- rehearse reality
- examine how it is constructed
- construct it differently
Forum theatre foregrounds the importance of people being able to adapt simulations rather than run through them.
The 'failure to rescue' course
'Management' versus the nurses
Failure to rescue is due to poor communication skills; or staff shortages in the wake of funding cuts?
What the course simulated: healthcare as a social and economic activity riven by multiple, conflicting priorities
What the scenarios simulated: versions of reality that needed to be changed
What was de-briefed: how such a change could be imagined and put into practice, notably by adapting the division of work
Imagining forum theatre in the hospital:
- a project to develop 'resilience' - which reconceptualises error/failure/risk as a systemic (complex) property emerging from concrete circumstances of work. From Safety 1 to Safety 2
- focusing on how work is done normally, rather than exceptionally; deliberating what is acceptable and what is not
- developing collective/systemic capacities to adapt to unexpected, unrepeatable circumstances
Institute of Education, London
MA Clinical Education
Simulation in Clinical Education module
But what is an 'authentic' situation / reality? What is a real or true error?
Simulation, Education and Clinical Practice: a colloquium to review the current state of play and priorities for the future
Monday 15th December, p.m. IoE
Details on Eventbrite