Simulation in clinical learning

Abstract

Simulation in clinical learning is becoming increasingly commonplace. The use of simulation spans both the undergraduate and postgraduate domains and has come about as a result of a number of driving forces. Medical education reform has been widespread throughout the world.1,2 These reforms recognise the need to prepare undergraduate learners for their roles in the ever changing world of medical practice. Moreover, widespread adoption of the concept of clinical governance has implications for learning in both undergraduate and postgraduate arenas.3 The purpose of clinical governance is to ensure that the highest quality of care is provided to patients. Areas within the remit of clinical governance upon which simulation may have an impact include risk management, lifelong learning, education, training and continuing personal and professional development, staffing and staff management, continuous quality improvement and the management of poor performance. Technological advances in recent years have seen the development of a variety of models and manikins ranging from simple replications of body parts for task-based learning of some examination skills, to high fidelity patient simulators driven by complex pathophysiological computer models developed to provide a highly valid replication of clinical environments. Anaesthesia has been one speciality where the use of high fidelity simulation has been seen to be of great value in promoting patient safety and in developing competence and on-going training,4 drawing from the world of aviation and its experience in flight crew training and teamwork.5 Simulation has extended into other fields, including emergency medicine,6 and surgical training7 and assessment,8 and has crossed into the undergraduate educational arena. In this latter field, opportunities can be created to practise the management of clinical conditions which would otherwise not be possible, safe in knowledge of them taking place in a protected environment.9 At the same time, there has been criticism of medical education from within the profession of the relative paucity of sound educational research that underpins much of medical education innovation.10 Medical simulation offers tremendous opportunities for the advancement of our understanding of learning because it is consistent with very different ways of conceptualising learning, and because research in very different paradigms11 can be accommodated. A more explicit discussion of theories of learning, and of paradigms of research, might therefore helpfully inform future practice and future research on simulation. We begin here to explore something of what this might mean. Early writing on behaviourism focused on the acquisition, retention and decay of new behaviours, and emphasised the effects of such factors as the role of reward and ‘punishment’, the most effective proportions of each in a learning situation, and the consistency with which rewards and punishments are given after a particular action has been performed. For a summary, see Gross, 199212 (p.166 et seq). More recent work in this area has considered the importance of feedback on how closely the student's response matched the ideal response (feedback known as ‘knowledge of results’), the frequency of such feedback and the way in which learners are encouraged to interact with that feedback (e.g. comparing it with their prior estimate of the error involved in their action).13,14 Since behaviourism ignores the ‘black box’ of the mind, it lends itself to ‘low road’ models15,16 for the transfer of learning (making the behaviour automatic so that it can be widely applied). This can be achieved through such tactics as over-learning (see Magill 1989,17 p.395–6). In this supplement, Glavin & Maran make explicit reference to this area of learning theory.18 Constructivism has its basis in Piaget's notion of learners constructing their understanding of the world through their interactions with it. Learning can occur when new experiences of the world fit into a learner's existing cognitive structures (assimilation), and when new experiences cannot be made to fit, and therefore challenge those existing cognitive structures which then have to be changed (accommodation). This theory of learning has had a longstanding influence on thinking about science education.19 The notion of assimilation suggests that a learner will have a richer understanding of a concept when they have experienced a sufficiently broad range of examples such that they appreciate the full range of application of that concept. The notion of accommodation suggests that learners' conceptual structures will be expanded, modified and made more sophisticated when they encounter unexpected experiences (cognitive conflicts) that reveal the inadequacy of existing structures. These processes of assimilation and accommodation happen in individuals' informal learning through their experiences of the world and can also inform formal processes o