RESEARCH

 

Simulation in plastic surgery: Features and uses that lead to effective learning

 

 

C P G Nel^I; G J van Zyl^II; M J Labuschagne^III

^IMB ChB, MHPE, FC Plast Surg (SA), MMed (Plastic Surgery), PhD; Department of Plastic Surgery, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
^IIMB ChB, MFamMed, PhD; Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
^IIIMB ChB, MMed (Ophthalmology), PhD School of Biomedical Sciences, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND. Increased competition for surgical exposure and practice, smaller teaching platforms and shorter training times have an impact on the quality of training and competence of plastic surgery registrars. Demands for accountability and minimising patient risks are the driving forces for incorporating simulation in healthcare education. We addressed the problem of whether the features and uses of simulation would enhance postgraduate plastic surgery education and training and ensure more effective learning.
OBJECTIVE. To identify and describe: (i) how simulation impacts on student learning; therefore, how the effectiveness of learning may be enhanced in postgraduate and/or plastic surgery education and training; and (ii) which features and uses of simulation have the potential to enhance learning in plastic surgery.
METHODS. A descriptive design was used for the study. Data were collected by means of semi-structured interviews with 8 national and international role players in simulation.
RESULTS. The results indicated a positive outcome of simulation, as it provides, e.g. a non-threatening environment for learning and improves clinical competency, ensuring an increase in patient safety. The features and uses of simulation render it an excellent method to enhance learning effectiveness at different cognitive levels and to fulfil a specific role in integrated and holistic training, while providing opportunities to practise specific skills. The lack of clinical opportunities can be addressed, and more clinical exposure and practice will result in fewer medical errors.
CONCLUSION. Simulation-based education in postgraduate plastic surgery education and training proved to be an effective teaching-learning method, which provides solutions to current deficiencies, hindrances and gaps in health professions education. The research question was answered and the use of simulation is recommended to enhance plastic surgery education and training and promote safe patient care.

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Evidence of the role of simulation in medical education has emphasised the use of simulation technology over the past number of decades in an effort to increase learner knowledge, to provide students with controlled and safe practice opportunities, and to shape the acquisition of doctors' clinical skills.^[1-3] Simulation is becoming an integral part of medical education at all levels,^[1-3] as medical education, for various reasons, has fast become subject to radical and innovative changes.

Many major shifts in medical education methods are due to changes in the delivery of healthcare. According to Issenberg et al.,^[3] in the USA, for example, the pressures of managed care shape the form and frequency of hospitalisation, 'resulting in higher percentages of acutely ill patients and shorter in-patient stays'. Medical students, therefore, have fewer opportunities to assess patients with a wide variety of diseases and physical findings, while reductions in physician remuneration due to shrinking financial resources constrain the educational time that doctors in training receive.^'41 Consequently, at all educational levels, doctors find it increasingly difficult to keep abreast of skills and topics they need to practise successfully.^[4]

Issenberg et al.^[3] identify 5 factors that contribute to the increased use of simulations in medical education, i.e. lack of clinical teaching opportunities and therefore less patient material due to changes in healthcare delivery; new technologies for diagnosis and management; assessing professional competence; medical errors, patient safety and team training; and the role of deliberate practice.^[4]

Surgical training in the 21st century is characterised by an increasingly objective, standardised approach using equipment, such as simulators, to optimise patient safety, surgical care and hospital resources, and minimise errors.^[5] The driving forces behind these factors are developments in medical error statistics, evidence-based medicine and fewer attending hours. Through increased accuracy, simulation can improve results and lower risk and procedure costs because of fewer procedures and less operating room time. ^[5] Simulation during training allows students ample opportunity to hone their skills and competencies in safe, no-risk circumstances. Insufficient and inefficient clinical teaching has stressed the need for strategies to improve clinical education, including the use of simulation.^[5] Simulation-based medical education is an educational method that makes use of simulation to bridge the gap between theory and practice.^[6] Regarding medical simulation, the word simulation means 'imitation of the operation of a real-world process or system over time'.^[7]

Over the past 30 years, new technologies in medicine have revolutionised patient diagnosis and care. Examples are the development of flexible sigmoidoscopy and bronchoscopy, and minimally invasive surgery, including laparoscopy, and robotics for orthopaedics, urology and cardiology. The benefits of these innovations include reduced postoperative pain and suffering, shorter hospitalisation and earlier resumption of normal activities, as well as significant cost savings.^[8]

These newer techniques, however, demand psychomotor and perceptual skills that differ from traditional approaches, and these innovative methods may be associated with a higher complication rate than traditional practices.^[9] Haluck et al.^[10] maintain that these 'newer technologies have created an obstacle to traditional teaching that included hands-on experience. For example, endoscopy requires guiding one's manoeuvres in a three-dimensional environment by watching a two-dimensional screen, requiring the operator to compensate for the loss of binocular depth cue with other depth cues.' One of the corollaries to these new techniques was the introduction of simulation technology in the training and assessment of students. Research indicates that training programme directors emphasised that virtual reality and computer-based simulations have become indispensable technological tools in clinical education.^[10]

The Accreditation Council for Graduate Medical Education (ACGME) in the USA, in an endeavour to ensure and improve the quality of graduate clinical medical education and to attain a higher level of effectiveness, listed 6 domains of clinical medical competence.^'81 Postgraduate programmes should provide educational experiences, which ensure that graduates demonstrate competence in ACGME project outcomes, i.e. patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism; and system-based practice.^'111 These are the educational experiences that benefit most from simulation in the light of a lack of patients and clinical exposure.

Miller^'121 proposed a framework (Miller's pyramid), which argues that a medical learner's clinical skills should be assessed at four levels: (i) knows (knowledge) - recall of facts, principles and theories; (ii) knows how (competence) - ability to solve problems and describe procedures; (iii) shows how (performance) - demonstration of skills in a controlled setting; and (iv) does (action) - behaviour in real practice.^'41 Simulation technology is increasingly being used in each domain of competence to assess the first three of Miller's levels of learning because of its ability to programme and select learning-specific findings, conditions and scenarios to provide standardised experiences to all examinees and to include outcome measures that yield reliable data.^'131 The research question was whether the features and uses of simulation would enhance plastic surgery education and training and ensure more effective learning.

 

Methods

The research included data collected by means of semi-structured interviews and a Delphi process. This article focuses on outcomes of the interviews. An article dealing with the Delphi part of the study has been published in AJHPE.^[14]

Elements of grounded theory came into play to describe features and uses of simulation, and to relate why simulation lends itself perfectly to be included in educational programmes. Grounded theory (inductive approach) was used to develop recommendations to promote learning in postgraduate plastic surgery education and training, as a grounded theory deals with discovering, developing and verifying by means of systematic data collection and data analysis pertaining to a phenomenon.^[15]

The study focused on the opinions and perspectives of medical and healthcare professionals regarding the features and uses of simulation, and whether and how simulation as an education and training method might influence student learning. The study was aimed at developing recommendations to enhance the effectiveness of learning in postgraduate plastic surgery education and training by employing simulation as one of the methods used.

Semi-structured interviews

Semi-structured individual interviews were used to explore key national and international role players' opinions and perceptions on simulation-based medical education, aimed at investigating and establishing clarification on simulation in postgraduate plastic surgery education and training. The features and uses of simulation that might prove effective in postgraduate plastic surgery were thus determined. The researcher conducted the interviews because he is a skilled interviewer and was familiar with the topic; he knew how to phrase the questions, as he was aware of the frame of reference of the interviewees and the goals of the study. It was also important to concentrate on the responses and monitor the coverage of the topic - which would have been impossible for another interviewer.^[161 An interview guide (Table 1), developed by the author on the basis of a literature review, was used. Occasionally, additional questions arose during the semi-structured interviews; the data thus collected were included in the research. Data on questions 3, 4 and 7 of the interview guide are reported in this article.

 

 

Unit of analysis

National and international role players in simulation and postgraduate education were requested to participate in the semi-structured interviews. Eight participants were invited to participate, all of whom accepted the invitation. Four interviewees were from the USA, Canada and the UK and 4 from South Africa (SA). They were directors of simulation units, clinical heads of clinical medical departments, programme directors of medical and nursing programmes, and education management specialists, researchers and representatives from the simulation industry. Written consent was obtained from all participants.

Data collection and analysis

The author conducted individual interviews with 8 participants, based on an interview guide. The interviews were audio-recorded, transcribed and checked by an independent person who was not part of the study. Field notes taken during the interviews contributed to the data. The data were analysed using the grounded theory approach, which requires continuous comparison of data, following the data analysis steps of coding, categorisation and theory generation.^[17] Theory building occurred by finding patterns in the data, which continued until saturation of data was reached.^[18] As more data were collected and re-reviewed, codes were grouped into concepts, and then into categories. These categories formed the basis for new theory, and were compared with data collected during the literature study. Data saturation was reached when no more ideas came to the fore.

Reliability and trustworthiness

Reliability was ensured by making use of an explorative study (with 2 individuals who were involved, had a sound knowledge of simulation and complied with the selection criteria), determining strict criteria for sampling, using the carefully constructed interview guide, as well as an interview process that was audio-taped and carefully described.^[19] Trustworthiness of the interviewing process was ensured by involving voluntary interviewees with a clear understanding of what the interviewer expected from them, and using open-ended questions, as well as the transcription and verification of data. Scientific record keeping ensured dependability.^[19]

Ethical approval

Ethical approval to conduct the research was obtained from the Ethics Committee of the Faculty of Health Sciences, University of the Free State, Bloemfontein, SA (ref. no. ECUFS 122/2015).

 

Results

Data collected by means of questions 3, 4 and 7 of the semi-structured interviews are reported in this article. Data were analysed, findings were summarised and qualitative perspectives are shared on the influence of simulation on student learning (Table 2) and how the effectiveness of learning can be enhanced (Table 3). The features and uses of simulation that may enhance learning in postgraduate education and training served as basis for a number of recommendations to enhance the effectiveness of learning in postgraduate plastic surgery education and training (Table 4). Quotes from interviewees' responses are indicated in inverted commas, followed by a code number assigned to each of the participants.

 

 

Simulation influences student learning (Table 2), as it substitutes other learning strategies; it supports adult learning principles, as it requires students to prepare, placing a responsibility on them as adult learners; it provides self-confidence and skills, motivating students to confront life-threating situations, making a difference to a patient's life; it provides the opportunity to learn by repetition, to work individually or in groups; it fosters communication; and it ensures that the student attains and sustains a specific level of competency.

Interviewees' opinions on how simulation can enhance the effectiveness of learning are indicated in Table 3 and emphasise the role of simulation as a non-threatening learning method that enhances the effectiveness of learning. Students can practise with less stress in a completely safe environment before working with real patients; this highlights the advantages of training using simulation. Simulation also enhances the effectiveness of learning by fostering interpersonal, interprofessional patient communication, communication regarding health and reasoning skills. Through deliberate, as well as repetitive practice, learning is enhanced (Table 3). The debriefing aspect offers another way of learning and allows students to decide on self-improvement. Authentic scenarios help students to learn more effectively than when using paper cases. The assessment opportunities of simulation improve student learning.

Recommendations to enhance the effectiveness of learning in postgraduate plastic surgery education and training are offered in Table 4. To apply the unique features and uses of simulation in a correct manner influences the effectiveness of learning in a positive way.

 

Discussion

The third and fourth semi-structured interview questions addressed the effect of simulation on student learning and how learning may be enhanced by simulation as a learning method in postgraduate and/or plastic surgery education and training. The opinion was that simulation does enhance the effectiveness of learning as far as the mastery of knowledge, skills, clinical competence and professional conduct is concerned.

The findings of data gathered during the semi-structured interviews were compared with perspectives gained from the literature review. Key outcomes of this research were the identification of the features and uses of simulation, and how simulation might be applied to enhance the effectiveness of learning in plastic surgery. As specific features and uses of simulation influence learning positively, these should be maximised in plastic surgery education. The results of the study provided ample evidence that simulation improves teaching and learning in medical (surgical) postgraduate education, as is evident from the following research.

According to Issenberg et al.,^[4] 'traditional medical training has focused on individual learning to care for individual patients. Medical education has neglected the importance of teamwork and the need to develop safe systems. The knowledge, skills and attitudes needed for safe practice are not normally acquired, nor are they required, as part of medical education.' Simulation is an appropriate method for team training - a prerequisite for interprofessional healthcare required of modern medical education.

Simulation offers the possibility of a cyclic learning dimension structure, i.e. a safe, purposefully planned learning environment, including variations of learning strategies/methods and the opportunity to select material offering different applicable learning opportunities, and ensuring a unique learning experience where the learning can be evaluated by the registrar or feedback/debriefing can be done by a consultant to achieve competence, or to re-plan and/or deliberately practise specific, identified learning units.

Deliberate practice, not just time and experience in clinical settings, is key to the development of medical clinical competence.^[4] Deliberate practice involves '(a) repetitive performance of intended cognitive and psychomotor skills in a focused domain, coupled with (b) rigorous skills assessment that provides learners with (c) specific, informative feedback, that results in increasingly (d) better skills performance in a controlled setting'.^[4] Simulation is the ideal way to ensure deliberate practice, regardless of whether patient material is available or not. Research emphasises the importance of repetition for clinical skills acquisition and maintenance,^[20] and research evidence clearly shows that high-fidelity medical simulations facilitate learning.^[4]

Simulation-based education allows students to practise and acquire patient care skills in a controlled and safe learning environment. Feedback to students, the opportunity for deliberate and repetitive practice, multiple learning strategies, individualised learning within a controlled environment, and the opportunity for hands-on experience foster students' self-confidence and play a cardinal role in mastering educational outcomes.^[8]

To revolutionise medical education, an increased efficiency of education by standardising the curriculum, an individualisation of education and a shift from time-based training to competency-based training are essential.^[21] Residents (registrars/specialists in training) may receive little guidance in terms of the knowledge, competencies, skills and attitudes that they are expected to acquire during residency. Surgical training in the 21st century is characterised by an increasingly objective, standardised approach using equipment such as simulators to optimise patient safety, surgical care and hospital resources, and to minimise errors.^[5] The driving forces behind this are developments in medical error statistics, evidence-based medicine and fewer attending hours. Through increased accuracy, simulation can improve results and also lower risk and procedure cost because of fewer procedures and less operating room time.^[5]

Simulation can play an important role in postgraduate education; however, it cannot totally substitute education involving real patients in genuine settings.

 

Conclusion

From the findings of this research, it is clear that simulation can be introduced as a teaching method and a learning opportunity for residents to improve plastic surgery education and training. To ensure success, however, clear recommendations on how simulation can enhance effective learning, and a description of the role and value of simulation based on scientific research, should be available. This requires the development of guidelines for teaching through simulation as part of training programmes for evidence-based plastic surgery education/practice.

Research is required to enhance the role of simulation in plastic surgery training,^[22,23] and this study made a contribution in that regard by identifying why and how simulation can improve the effectiveness of postgraduate and/ or plastic surgery teaching and learning. 'Simulation has the potential to play an integral role in developing better and safer health care services for patients worldwide, avoiding risk and providing real-life opportunity for students to hone their skills.'^[22,23] The features and uses of simulation discussed here will contribute to and lay the foundation for more effective learning in plastic surgery education and training in the future. The novel contribution made by this study entails the compilation of the advantages simulation holds for medical education, with special reference to postgraduate plastic surgery education, and the detail in which this teaching-learning method is expounded.

Declaration. The research for this study was done in partial fulfilment of the requirements for CPGN's PhD degree at the University of the Free State.

Acknowledgements. The authors gratefully acknowledge the assistance received from the participants in the overall PhD study, who were willing to take part in the pilot testing and quality control of the Delphi questionnaires. We also acknowledge the role players who participated in the explorative study that conducted the interviews, and specifically the interviewees involved in the research reported in this article, for their valuable contributions and their time in participating in individual semi-structured interviews. We thank Prof. G Joubert, Head: Department of Biostatistics, Faculty of Health Sciences, University of the Free State, for her advice during the early stages of the research, and for the protocol development and quality assurance of the study; and Dr M J Bezuidenhout, University of the Free State, for support with regard to the scientific formulation and language editing of the publication, as well as editing of the references.

Author contributions. CPGN designed the study, wrote the protocol, collected data and performed the analysis, interpreted data and wrote the manuscript. GJvZ and MJL were supervisors of the study, reviewed the protocol and manuscript and contributed substantially to the conceptualisation, design, analysis and interpretation of data and scientific content. All authors approved the final version of the manuscript.

Funding. This research was partially funded by a grant from the Health and Welfare Sector Education Training Authority (HWSETA).

Conflicts of interests. None.

 

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Correspondence:
C P G Nel
drcnel@gmail.com

Accepted 16 January 2020