Virtual patients who talk, breathe and even vomit, are highly valuable in healthcare education. Associate Professor Michelle Kelly and Dr Zoe Bradfield discuss the role of simulation in educating the next generation of health professionals.
Universities across the country are adopting high-tech simulations to teach the next generation of healthcare professionals.
Faithfully recreated hospital wards, complete with virtual patients that can talk, breathe and even vomit, have become the norm, and it’s no gimmick – research is showing that it can be extremely valuable.
David is joined by Associate Professor Michelle Kelly and Dr Zoe Bradfield from Curtin University’s School of Nursing, Midwifery and Paramedicine to discuss the high-tech and surprisingly low-tech approaches to medical simulation.
Email thefutureof@curtin.edu.au.
Curtin University supports academic freedom of speech. The views expressed in The Future Of podcast may not reflect those of the university.
Music: OKAY by 13ounce Creative Commons — Attribution-ShareAlike 3.0 Unported — CC BY-SA 3.0 Music promoted by Audio Library
You can read the full transcript for the episode here.
Intro (00:00): This is The Future Of, where experts share their vision of the future and how their work is helping shape it for the better.
David (00:10): I'm David Blayney. Universities across the country are adopting high tech simulations to teach the next generation of healthcare professionals. Faithfully recreated hospital wards, complete with virtual patients that can talk, breathe, and even vomit, have become the norm and it's no gimmick. Research is showing it can be extremely valuable. To discuss this topic with us today are Associate Professor Michelle Kelly and Dr Zoe Bradfield from Curtin university's School of Nursing, Midwifery and Paramedicine. Thank you very much for coming in today, Michelle and Zoe. Pleasure. Michelle, what kind of simulation are we talking about and what can Curtin students look forward to?
A/Prof Michelle Kelly (00:52): When you mentioned high tech ... we can actually do just as much with low tech options and I'll explain in other details about mental health simulations - just using MP4 players. But essentially in the health professions we're looking at practising on either mannequins or body bits - what we call 'part task' trainers - and working with simulated participants who are representing patients. So it's rehearsing procedures - whether they be actual doing things to a mannequin or interacting and talking with patients. So potential patients. So working on those communication skills. It's teamwork and it's also increasingly virtual/augmented reality and also artificial intelligence. So within the Faculty of Health Sciences, there are a lot of unique discipline simulation activities, but also interprofessional simulation activities. It can be preparation for practice before field work or be a bit of a hurdle or preparation for assessments. So either summative or formative. But essentially the bottom line is that you can't really practise on patients for a first time. So patient safety and ...
David (02:26): Not exactly ethical.
A/Prof Michelle Kelly (02:29): Not exactly ethical ... and more informed patients who access Internet know what might be expected and know the information that should be forthcoming. And it's really about reducing medical error.
David (02:45): Zoe, a big part of midwifery is dealing with the unpredictable and the confronting. How can we use simulations to prepare students for the unexpected?
Dr Zoe Bradfield (02:56): Mm. Yeah, it is, it is a good point. And confronting often in ways that our students won't expect, you know, so I've seen a 'One born every minute' or they've seen one of the documentaries on television. They might be used to seeing perhaps an obstetric emergency where there may be blood or they may be, you know, a woman in duress who might be calling out or screaming, or partner even, in duress. And so they might be expecting the confrontation that comes from seeing sometimes, you know, blood and that sort of stuff. But the confronting often that our students experience that they're not ready for is the emotional and psychological confronting part. And so, yeah, we use simulation really to move from rote kind of knowledge and learning about the theoretical elements of responding to any particular X emergency. For example, shoulder dystocia is one where a baby might be stuck in the birth canal and we, you know, run through the ways that you would address that particular emergency.
Dr Zoe Bradfield (03:58): But it's also really useful for enhancing and teaching the sophisticated and yet necessary skills that we know impact a patient's safety and outcomes. So not just the physical manoeuvres of how would I get this baby out of the pelvis and out of the mother, but things like communication and teamwork and situational awareness are really important. One is 'speaking truth to power'. So students or those in junior kind of healthcare situations often feel intimidated about perhaps suggesting a different manoeuvre or suggesting a different approach. Even if they can see that the one that's being used isn't working. And the practitioners running the actual emergency can sometimes just get really focused on what they're doing and not having this kind of bird's eye view. And so we are able to simulate scenarios where a junior member of staff is able to challenge a senior member of staff in a respectful way to say, look, this isn't working, perhaps we should try X. Because we know that that significantly contributes to patient safety and to outcomes.
Dr Zoe Bradfield (05:06): So and as I mentioned before, about being confronted with your own anxiety in those particular situations. So how do I respond when I see a woman in duress? How do I respond when I see a particular emergency situation? Because how I respond is really important and that's what I can control. How I respond. And if there are, you know, our students often come with a bank of life experience into our courses and say, for example, if they themselves have experienced a birth and things haven't gone as planned for them, then they will be confronted with and required to acknowledge where their own story intersects with that which they are trying to learn about. But from the other perspective, from the health professional perspective. And so it provides that really important opportunity for the students to engage and acknowledge where they need to do some work. What about this is my anxiety and how do I need to reframe and perhaps even, you know, talk with someone therapeutically about reframing this as a health professional perspective, rather than reacting like it's my own personal experience. So yeah, we use it in lots of different ways.
David (06:17): Simulations are ... they're human-like, but they're not really human. Is there a ... is there a fear that students might not become accustomed to the real symptoms that humans have - the sweating, the dizziness, the clamminess, and indeed, when you're working with people who were simulating, who are presenting, with particular symptoms but aren't really able to, you know, replicate those as would someone afflicted with an illness ... how does it affect the the quality of teaching?
A/Prof Michelle Kelly (06:51): There are very detailed standards for delivering and developing simulations in healthcare. And if I can also highlight that aviation and the lessons learned. And Zoe mentioned what was really great at assertiveness. In situations where in an operating theatre, the analogy of a surgeon to a pilot in an aircraft not performing as they should. Perhaps there might be lack of sleep or influenced by other factors. Then everyone in that arena really has responsibility for patient safety or the safety of a crew and passengers on an aircraft. So that's also an important part. So we've learned a lot from aviation, but it's distinctly different in healthcare because you're not really flying a plane. But there are a lot of similarities, but also a lot of differences. So there's a group in the United States called the international nursing association for clinical simulation learning (INACSL).
A/Prof Michelle Kelly (08:10): And that group have put out some standards for practice. Equally there's been some good research from Australian nursing academics around quality indicators. So it's very clearly outlined how you should create and deliver and be responsible and look out for the reactions that Sophie referred to, which is people in a situation referring back to their own experience. And you want this to be a positive outcome and you don't want to impact negatively on this person's experience of sim because they've recently experienced same situation themselves. So you've always got to be checking out for that. But the standards - and also the there's a national Australian framework as well, it's called the net sim framework - and that also guides how people should create and deliver and evaluate simulations. Part of that is how to prepare and monitor SP feedback so that's 'simulated participants' and they could either be actors or healthcare clinicians, but if they are giving feedback during a debrief session, which is unpacking what's just happened in a scenario, then you need that to be reproducible and on-point and not go off-point, and again, have any negative consequences to the learning. So that speaks to the quality aspect that you were talking about.
Dr Zoe Bradfield (09:57): Yeah, look, and actually, you know, the mannequins that we use when we're using mannequins, they're quite sophisticated now. So for example, we have one that we use with the midwifery students and she's called Lucina and she has a pedal pulse, which is a pulse on the top of her foot which is an important indicator for peripheral circulation. And so we'll often, just when we're introducing the students to Lucina, we'll get them to touch her and her skin is very lifelike. And invariably a student will touch her foot and then they'll jump and they'll notice that she actually has a pulse on her foot. And because her skin is so lifelike, it's not, we haven't quite yet got it warm like a human, but I don't think we're far off from that from a technological perspective. So there are lots of realisms that you know, technology has allowed us to introduce into the mannequins and with our bank of simulated participants that we have - we have a collection, don't we - that are really well trained, and they receive lots of pre-briefing and debriefing. We take care of them really well, but they are used to meeting what we need basically for our students to learn in the ways that they need to.
David (11:13): And could you, could you tell me more about how, how actors and how role-playing works in a, in a teaching environment?
Dr Zoe Bradfield (11:18): Yeah, I'll let Michelle take that one.
A/Prof Michelle Kelly (11:22): We've been using role play for many, many years and not just in in health professions. But it's a way of rehearsing those conversations that you don't necessarily want to be delivering for the first time in the clinical setting. So a good example there is when parents bring their children in, to the emergency department, and there's an event and the child is being resuscitated and, particularly with paediatrics, they like to, clinicians like to be able to have someone to talk to the parents about what's going on. Variable whether that happens in adults settings as well, but you don't want to be having that first conversation at that point in time. So that's one example of the importance of sim for rehearsing conversations. A couple of other examples are when you're breaking bad news, so it might be a diagnosis of cancer or in some work I've done at another university with the state-based organ and tissue donation service, is rehearsing that conversation where you request organ donation from the relatives at a very tough time where they're trying to process that this person is now braindead, but they're still alive in front of them.
Dr Zoe Bradfield (12:47): Yeah. And in the maternity setting we use certainly role playing a lot for ... a big part of midwifery is to provide education to the woman without agenda. So to provide woman-centered care, which is the primary brief of midwifery, the role of the midwife is to provide unbiased, evidence-informed information and then to facilitate the woman to make a decision for herself. So empowering women to, you know, facilitate or to actually enact their right to make an informed decision. And so we explore the use of language because our unconscious bias often creeps into the way that we deliver education. And if we're not acknowledging, you know, where perhaps we have bias towards a particular choice - maybe it might be for an induction of labour. And so we would be giving the woman all of the information that she would need in order to make an informed choice, but if we have an agenda, that will eek through into the way that we speak, in the language that we use, perhaps the tone of voice or the posture and ...
David (13:49): Like, "you could either give birth now ... OR ... you could have a caesarian", like, that sort of thing.
Dr Zoe Bradfield (13:53): Yeah, exactly. Exactly. And so our students, you know, they find that really surprising, confronting and valuable, to have that roleplay experience. And because we run it so often and we're very cognizant and aware of it we're, able to highlight that really easily for them and it's incredibly valuable for them. Yeah.
A/Prof Michelle Kelly (14:16): So in addition to the students who might be participating, we have others that are observing. So it's a bit like the game show that you're watching on TV. And if you're the contestant, you're like a deer in the headlights and you might not be able to recall what the appropriate answer is, or what to say. But others who are observing, the pressure's off so, they can actually develop their own learning and then contribute that into a facilitated debrief afterwards.
David (14:48): Is the show you're thinking of Thank God You're Here, out of curiosity?
A/Prof Michelle Kelly (14:52): Yes, or whatever contemporary a TV show.
David (14:56): Can you tell us about how simulation works with respect to mental health?
A/Prof Michelle Kelly (15:01): Well mental health ... I am not a mental health clinician, but I work, have worked with, a lot of mental health academics. And I support them very well because I think it's a critical part of ... not exclusively someone diagnosed with a mental health illness, but mental health really is pretty invisible in some ways. So I think one in five people in the community at any one point in time would suffer from anxiety or depression at one end of the scale, right through to all the other categorical, you know, areas of mental illness. So a couple of the easy, the low tech, but very high emotional fidelity sims we do is 'hearing voices' simulation. Yeah. So this is really just an audio and students can put the earphones in.
A/Prof Michelle Kelly (16:04): It's very carefully prepped and delivered because again - knowing the ratio of potential people in the community who might at one point in time be experiencing mental health or mental illness - they can turn the audio recording on at any time or off at any time. But they're a curated range of voices and noises that have been assembled by people who are voice hearers. So it gives you some idea about what it might be like. So some insights into hearing voices, but you can turn it off at any time. So it certainly helps with engagement of those students when they're on mental health pracs to have some further insight about why people are behaving as they are. And I think this cuts across to police as well, where there might be some responses that aren't in retrospect necessarily the responses that should have been done at the time. Yep. The other really terrific initiative - and this again is at my previous university - is engaging mental health consumers to talk about their recovery. And one of the really telling points and why they want to engage is that one of the mental health consumers remembered - and this turned around her recovery - when one of the nurses said, "I believe you". And that was, at that time in mental health treatments, that was really a positive and a seminal moment for that person's recovery. So they like to give back as well.
Dr Zoe Bradfield (18:00): Yeah they're really powerful. When we got the hearing voices module, I requested to have a go. I've, I do have mental health background when I was nursing - so prior to being a midwife - and so I consider myself compassionate and I've had some experience in working with people with mental illness. But as Michelle alluded to, it's an affliction that is less visible. So it's not like my broken leg with a cast on it. When I'm struggling emotionally, it's difficult for the general public or for others to, to understand or to even have an understanding of what it might be like to be, you know, a consumer with a mental illness. And I was struck. When I first put it on, I was struck by how powerful a teaching tool it was. And I can really see its ability to invoke compassion and empathy like nothing else. You could attend all the lectures in the world, but to actually put that on, as a non-voice hearing person and hear the words and to hear it like a consumer would hear it, nothing else would compare to that. In years of practice.
A/Prof Michelle Kelly (19:22): And in some of the training - again that I did at another university - there's a physical reaction as well. And someone had to actually leave the room because of her physical response to these voices and noises.
Dr Zoe Bradfield (19:38): I became quite emotional and, and so then my thought was, this is literally 30 seconds of the track that I've listened to. And yet these other people that we're working with it's day in, day out, for days and days on end.
David (19:51): And it's not something you can turn off.
Dr Zoe Bradfield (19:53): It's not something you can turn off and there's very little control over it. And so, yeah, a profound, again, recognition of the empathy and compassion that must be shown to these people that must be shown.
A/Prof Michelle Kelly (20:07): And part of the delivery is also walking around the campus with these with the MP4 audio playing. And they have to go and have a conversation, order a coffee, talk to someone on the phone. So it's trying to reproduce what it might be like. So pretty powerful, but low tech.
David (20:30): And one final question. Where do you see things trending in terms of, of using simulation and using technology to teach people in in, in health care? Do you see know virtual reality or any other ... you mentioned augmented reality before. Do you see any advancements on the horizon?
A/Prof Michelle Kelly (20:52): Absolutely. And look, mannequins and body bits, part task trainers, certainly have a place, because you need to be rehearsing, doing things like advanced life support, trauma scenarios, putting tubes and intravenous cannula in. But I'm increasingly seeing a move, particularly within nursing, towards working with SPs or simulator participants because it's those nuanced facial expressions that you can't, at the moment, reproduce with a mannequin. However, robotics are really pushing forward in this space. And if you ever been to Disneyland and see the early animatronics that they did, they were way ahead of the game there. But that would take a lot of input and dollars and research to get it quite right with the sweatiness, the color change in the skin, the temperature change in the skin. They're all things that, at the moment, are not quite there. But I'm not quite sure about a Star Wars type future, but you never know because things are moving at a really rapid pace.
Dr Zoe Bradfield (22:13): Yeah, I get quite excited as a midwifery educator. There's a couple of really nuanced midwifery skills that we try and teach, or we must teach, our students. One of those is abdominal palpation and the next one is vaginal examination. And both of those are really key, critical clinical skills for midwives to have, that involve basically palpating or feeling, and making a clinical judgment based on what you're feeling. Now, there is a little bit of external vision or visual sort of inspection involved in the assessment as well. But the most part of it you're feeling and trying to make an assessment. And for many women, particularly in labour but also in, you know, in pregnancy, the trajectory of their clinical care is based on the accuracy of our assessments and the way that we teach them to students, and we use simulation and that sort of stuff. And students have to perform abdominal palpations on, on real women. It's an important skill for thim to have. But the VR space and the augmented reality space, I'm really excited about potentially getting access to that tech, because if we could give the students - I'm imagining in my mind the VR goggles - and we could be feeling, but then you could be seeing inside what's actually happening. You know, you could feel the parts, you could see the parts of the features that you're feeling. And so there would be both that visual and that palpation feedback, which would really just enhance the way that students could learn that skill, which is already pretty tricky. And yeah, same for vaginal examination, really important clinical skills that are effectively blind, and we have to do the best that we can to teach them under those circumstances. So yeah, bring it on.
A/Prof Michelle Kelly (23:54): I know. The eye tracking for me is a really interesting part of giving an objective visual back to students about where a novice looks and for how long. So if we are looking at patient notes, if we're looking at the monitor, you can get a visual output of big circles where novices are looking for a long time at something and they're trying to understand what it is and what it means. When you compare that to an expert, they are looking at far fewer points for a shorter period of time. So rather than a scattergun approach as a novice, they get an idea of what it might take to actually get to an expert assessment of the material information in front of them. Yeah, it's really exciting. If we only had the time and money Zoe!
David (24:48): It does, well, the high tech future sounds quite exciting, but also it's nice to hear that the, that the low tech solutions are still working as well. The lowest tech of all being just a, just a person with a clipboard being told to do something. I think we'll leave it there. Thank you very much Zoe and Michelle for coming in and for sharing your knowledge on this topic.
A/Prof Michelle Kelly (25:07): Our pleasure. It's exciting.
David (25:08): You've been listening to The Future Of - a podcast powered by Curtin University. If you have any questions about any of the topics we've raised today, please feel free to get in touch by following the links in the show notes.