Incorporating Simulation-Based Education Into Stroke Training
Simulation-based education (SBE) has become a mainstay in medical education. It is a versatile educational technique that can be applied not only to refine psychomotor skills, but also to develop the care pathways, interprofessional behavior, and clinical decision-making needed for practice as a stroke clinician.
The majority of stroke training internationally continues to follow an apprenticeship model, where trainees learn through clinical exposure while delivering patient care. Although this approach contextualizes learning to the clinical environment, it frequently involves tension between the patient-centeredness of clinical care and learner-centeredness of training needs. Consequently, it may not be possible for a single learning environment to be both patient- and learner-centered.1 A potential solution to overcome this friction is the use of simulation training; a learner-centered approach that remains patient-focused.
Advances in simulation technology and techniques have proven complementary to trends in medical education, allowing realistic learning environments for training in stroke medicine. Consequently, neurovascular SBE is becoming widespread. However, delivering SBE needs careful design and individuals who have an understanding of its underlying principles, recognizing that clinical experience alone is not a proxy for simulation instructor effectiveness.2
Here, we will consider not only the principles and practicalities for delivering effective SBE, but also how the versatility of SBE may benefit training across the range of knowledge, skills, and attitudes needed for practice as a stroke clinician.
Principles of Simulation in Stroke Training
SBE involves an array of simulation techniques: role-play, simulated patient actors, high-fidelity mannequins and clinical environments, procedural simulators, virtual reality, or the combination of techniques (Figure). This enables simulations to be tailored to develop specific skillsets.
Stroke is an exemplar of how SBE may benefit training along an entire clinical pathway (hyper-acute, clinic, or rehabilitation settings). Virtual reality simulation has been used successfully in training for mechanical thrombectomy,3 and scenario-based simulation with simulated patients improves hyper-acute pathway performance and outcomes.4 Affective and behavioral aspects of inter-disciplinary care relevant to stroke can be improved through the use of simulated patient consultations or multidisciplinary activities.5
Underpinning these approaches is a common set of educational principles.2 In this section, we will review 3 main considerations—fidelity, feedback, and transfer to clinical practice—for developing a SBE program.
Fidelity
Arguably the key tenet of SBE is fidelity; the extent to which the simulation replicates reality. Fidelity is multifaceted, comprising engineering fidelity (simulations appearing realistic) and psychological fidelity (simulations eliciting behaviors required for successful completion of the task).6
Although basic procedural skills may be taught using SBE with high engineering fidelity but low psychological fidelity, learning more complex skills often demands more complex simulations incorporating high levels of both. Advances in stroke simulation technology have increased both engineering and psychological fidelity, such as actual thrombectomy devices with haptic (tactile) feedback and computer-generated vessel geometry to replicate performing the procedure under a variety of conditions.3
Although such high-fidelity simulators are likely to remain expensive and limited in availability, not all effective SBE needs to be complex or expensive. Affective and behavioral aspects of stroke inter-disciplinary care can be developed through simulated patients with high fidelity but low cost. For example, skills in complex discharge planning or end-of-life care can be improved through the use of simulated patient consultations or multidisciplinary activities.5 Furthermore, simulated patient consultations may be used to develop diagnostic skills and clinical decision-making in specific clinical settings, such as neurovascular clinics.
Feedback
If fidelity is critical to creating authentic learning experiences, feedback is key to consolidating these experiences to improve learning. Feedback should not be an afterthought following the simulation, but rather considered at every stage of the scenario. Reflecting this, effective feedback in SBE may follow the 3 Ps of feedback:
1.
Planning how to incorporate feedback effectively into scenario design.
2.
Prebriefing participants to establish learner-generated objectives and learning needs.
3.
Providing feedback responses during the scenario (simulated responses to learners’ actions) and after scenario completion.7
Commonly it is this final stage that receives most attention, typically involving a formalized debrief; a postevent process that prompts deeper learning by promoting reflection to formulate future strategies for overcoming difficulties or consolidating positives. Alternatively, reflection may be prompted during the scenario by pausing the simulation after a critical event. Alternative approaches may then be trialed and evaluated immediately by replaying the scenario either in whole or in part.
Giving feedback is an art, with multiple approaches proposed. In the authors’ experience, a feedback method well-suited for simulation is ALOBA (Agenda-Led Outcome-Based Analysis), where the learner’s agenda/needs and ways to achieve it are discussed with the facilitator and wider group before the activity, with feedback at the debrief focusing on whether/how the outcome was achieved.8 This model empowers learners to direct their own learning while fostering a collaborative approach among the group to achieve it.
Transfer to Practice
Ultimately, the key for SBE is that learning is transferred to clinical practice, rather than being simply an enjoyable experience or limited to knowledge transfer only. Evaluation must reflect this: although course completion questionnaires may gauge learner satisfaction and initial learning response, it is important that longer-term benefit to performance, and the efficacy of the simulation program itself, is evaluated.
Simulation developing a pit crew approach (parallel rather than sequential assignments) to hyper-acute stroke responses reduces door-to-needle time and poor (modified Rankin Scale score, 5–6) outcomes at 90 days.4 This transfer to real-world clinical pathways illustrates how SBE may improve individual and team performance, particularly where multiple professionals must operate effectively in a time-critical and high-stakes environment. Errors attributable to human factors (eg, lack of shared goals, impaired situational awareness, miscommunication) may be detected and reduced through systematic cross-checks using crew-resource management SBE, an approach focusing on nontechnical skills involved in team-working (eg, environment familiarization, clear communication, effective leadership, team organization strategies). Such approaches may improve performance in stroke care by developing standardized team-based algorithms reinforced by regular training across a range of common and uncommon events and complications.9
Practicalities of Establishing Stroke SBE
Establishing a SBE program requires consideration of how these principles can be applied with the resources available, particularly trainer availability given increasing clinical service pressures. At our centers, dedicated fellowships in SBE have provided clinicians with protected time to develop skills in SBE facilitation. Such institutional investment has promoted innovative SBE and availability of highly trained SBE educators.
Learner engagement is essential. A lack of fidelity to trainees’ real-world clinical experiences or failure to match learning outcomes against trainees’ learning needs will reduce engagement and the benefit of SBE. Close collaboration between SBE providers, program directors, and trainee representatives ensures SBE meets training needs.
Deciding whether SBE occurs in skills labs or clinical environments involves compromise between greater control over scenarios in the former against the increased fidelity and transfer to clinical practice afforded by the latter. Such decisions may be influenced by the stage of the learner: for junior trainees, new psychomotor processes, or communication approaches may be best developed in the controlled and safe environment of the skills lab, while transfer to clinical practice for more senior trainees may be best refined through SBE in clinical environments. Session frequency, and timing of the transition in environment, should be tailored to the progress and learning needs of the individual trainee.
The Future of Simulation
Recently, there has been a move to an outcome-based approach to training; so-called mastery learning. In contrast to solely process-driven approaches, where numbers of procedures performed or time spent in training are surrogates for a trainee’s competency, mastery learning entails outcome-based metrics to evaluate learner performance and determine training progression.
Outcome-based postgraduate training necessitates changes in curriculum design, in particular the need for robust methods to measure performance standards. As well as its role in formative learning, SBE may also enhance summative assessment by providing quantifiable measurements on different aspects of performance across a spectrum of difficulty and clinical variation to produce a comprehensive evaluation of competency. In mechanical thrombectomy, such metric-based assessment of proficiency enhances and standardizes performance.3
It is arguably an artificial distinction to consider learning, assessment, and curricula in isolation. Moving to outcome-based curricula necessitates outcome-based performance assessments, and such assessments will, in turn, drive learning. In this regard, SBE may facilitate deliberate practice, a learning theory that proposes that mastery learning is achieved and performance enhanced through repetition of a cognitive or psychomotor action with incremental refinement based upon expert feedback. Importantly, the facilitator does not require superior technical skill to facilitate this, but rather must be keenly observant and skilled at providing feedback.7 Frequent SBE and regular simulator-facilitated revalidation is one way to encourage deliberate practice, which is a more powerful predictor of superior expert performance than experience or academic aptitude.7,10
Hence, for SBE to be truly effective it must be integrated throughout curricula, rather than being seen as a desirable adjunct to training. As well as frequent planned simulator sessions targeting the key competencies in the curriculum, there should also be opportunities and inbuilt flexibility for trainees to replay scenarios that they have found difficult during clinical work. Such integrated SBE affords the trainee a safe environment in which to trial alternative approaches and promote deeper learning after critical events or during remediation training.
Conclusions
Stroke medicine requires a mastery of cognitive, psychomotor, and affective skills. Effective SBE can be an invaluable tool for developing and maintaining these skills along the entire stroke pathway; driving up standards while protecting patient safety and supporting trainees. Rather than simply a desirable adjunct to fellows’ training, we advocate for simulation being an integrated and essential component of stroke medicine curricula.
Acknowledgments
Drs Evans, Minhas, and Mehdi are Take Up Stroke Fellows at the British Association of Stroke Physicians.
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- Mechanical Thrombectomy Workshops Improve Procedural Knowledge and Skills Among Neurointerventional Teams in Low- to Middle-Income Countries, Stroke, 55, 7, (1886-1894), (2024)./doi/10.1161/STROKEAHA.124.046516
- Development and Videographic Evaluation of a Vascular Access Simulation-Based Curriculum for Surgical and Medical Trainees, Annals of Surgery Open, 5, 3, (e464), (2024).https://doi.org/10.1097/AS9.0000000000000464
- Comprehensive portrait of stroke fellowship training in Brazil: A national survey study, Journal of Stroke and Cerebrovascular Diseases, 33, 6, (107697), (2024).https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.107697
- The integration of simulation into a post registration neurological course: a phenomenological research study, British Journal of Neuroscience Nursing, 19, 1, (6-13), (2023).https://doi.org/10.12968/bjnn.2023.19.1.6
- Hospital size, remoteness and stroke outcome, QJM: An International Journal of Medicine, 116, 4, (288-291), (2022).https://doi.org/10.1093/qjmed/hcac276
- In situ high fidelity simulation of the pre procedure start timeframe in cerebral thrombectomy, Acta Neurologica Belgica, 123, 2, (623-624), (2022).https://doi.org/10.1007/s13760-022-01903-6
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