6 Section I ■ Preparation and Support

the indications and the contraindications for the procedure, and gain a general understanding of what is

involved in the procedure. The learner’s attention is

focused by providing orientation and instructions for

performance and establishing specific goals for “prepractice” activities. Modeling during prepractice, through

demonstration or video, is effective for teaching movement strategies, spatial information, and sequential and

spatial skills for dynamic tasks, including surgical skills.

Development phase: The goal in the development phase is

to achieve mastery of the skill by repeated purposeful practice and feedback. Mastery learning and deliberate practice involves the learner performing the skill until it is performed without error, taking as much time as necessary to

ensure that the skill is performed correctly. The approach

using distributed practice (i.e., several short sessions of

practice rather than one long session) has also been shown

to be effective in procedural skill acquisition and retention.

Automated phase: The automated phase involves perfecting the skill by improving the ability to distinguish essential from nonessential stimuli and continuing to practice

the skill after competency is achieved. This results in a decreasing need for thought processing as the skill develops.

Simulation-Based Training

Simulation-based training is pertinent to and can be incorporated into all aspects of procedural skills training.

The key components of simulation-based training

include:

A. Identifying and Elucidating the

Learning Objectives Specifically

Amenable to Simulation

Clarity of planned learning objectives is integral to planning a useful simulation

B. Prepractice Activities in Preparation

for Simulation

1. Didactic training sessions

2. Prereading material

3. Audiovisual aids such as training videos

C. Choosing the Optimal Simulator

(Tables 1.1–1.4)

1. High-fidelity simulators

2. Low-fidelity simulators

3. Procedural trainers

4. Miscellaneous special training simulators

D. A Defined Simulation Environment

1. At a clinical learning and simulation facility

2. At the hospital or patient care facility

3. Adjacent to site where patient care is to be provided,

and just before performing the procedure on the patient

(“just-in-place and just-in-time training”)

4. Telesimulation using appropriate audiovisual telecommunication equipment for outreach training

E. Prescenario Briefing

1. Ensure confidentiality and respectfulness.

2. Acquaint participants with the capabilities of the simulator.

3. Clarify simulator strengths and weaknesses.

4. Enter into the “fiction contract”: The learner agrees to

suspend judgement of realism for any given simulation,

in exchange for the promise of learning new knowledge

and skills. (This helps to keep the focus on the learning

objectives.)

5. Discuss the root of the scenarios.

F. Running the Appropriately Realistic,

Challenging, and Well-designed Scenario

1. Rehearse in advance

2. Thoughtful use of actor confederates and props to simulate realism

3. Choose the appropriate start, optimal duration, and finish

4. Achieve an optimal alert and activated state in the participants

G. Recording and Identifying the Knowledge

and Performance Gaps of the Participants

During the Scenario

1. Focused observation and recording

2. Use of checklists

3. Use of video

H. Postscenario Debriefing

Postscenario debriefing is the heart of the simulation:

1. Debriefing may focus on actions or both frames (internal images of reality) and actions and help trainees

make sense of, learn from, and apply simulation experience to change frames of thought and resulting

actions. The goal is to provide objective evaluative

feedback.

2. The good judgement approach to debriefing, as advocated by the Institute of Medical Simulation at Harvard,

consists of four phases

a. Preview phase: Helps focus the debriefing content

b. Reactions phase: Clears the air and sets the stage

for discussion of feelings and facts

c. Understanding phase: Promotes understanding

of learner’s performance, and explores the basis for

learner’s actions, using advocacy and enquiry

d. Summary phase: Distills lessons learned for future

use; what worked well, what should be changed

I. Evaluation of the Simulation Session

Acknowledgements to:

Dr. Mhairi Macdonald

Dr. Jenny Rudolph