Sometimes a Mannequin Just Won't Do

  

Despite our best efforts he's still a plastic man with clothes on

 

When I joined the field of simulation in healthcare it is fair to say I had a very narrow view of what this educational modality was for. Primarily, I thought it should be used purely for recreating acute clinical emergencies. This was possibly because I first met 'Sim Man Classic' as a Clinical Skills Instructor, and immediately saw how we could utilise it to teach a range of technical skills such as, ECG rhythm recognition, ABC assessment, Basic Life Support etc etc.

 

You could say I was looking at it from the wrong stand point. I was starting with the mannequin and what it could do, and designing the teaching around that. Instead I should have been thinking about the learning objectives and then deciding whether the mannequin was appropriate at all.

 

Of course I eventually did make the necessary leap of putting educational goals before the  "what can we get the simulator to do today" style of teaching. Although I have to confess it is only relatively recently that I began to realise that I still hadn't quite got the point.

 

I wasn't thinking of simulation in its broader sense. That is I was thinking of it in terms of technology, and not the more rounded view that Simulation is just the recreation of real life for an educational goal. Where in that definition is there any reference to mannequins and simulators?

 

I began to think about this seriously about 4 or 5 years ago. Our centre began running simulation courses for Primary Care, and in particular community nurses. Working closely with commissioners we began designing scenarios that would take place in the patients home. We went to great lengths to recreate a domestic environment in the sim suite. We stripped out the technical kit, put carpet on the floor and added furniture and a TV. We used sound boards to screen off the rest of the sim suite. A few potted plants and books on shelves, a family photo here and there. It looked very realistic. Then we stuck the simulator (fully clothed) in the chair. Gone was the realism.

 

Suddenly it became about what relevant clinical scenarios could we recreate for community nurses that would get the most out of the mannequin, rather than what do they actually need to learn, and does simulation have a role to play at all?

 

I believe it did, but perhaps we didn't need the mannequin. The nurses would have got far more out of the scenarios if they were communicating with a real actor. Yes there may have been points were the psychological fidelity would have fallen down even with a real person. Try getting an actor to develop a rash on cue, or swell up their tongue for example. They don't like being stabbed with needles either. However, we can get round this with make up and facilitation to a degree. We can utilise hybrid simulation (attaching part task trainers such as cannulation arms to the actor) to create an even greater degree of realism. The actor can pull the arm away or flinch at the point of injection, in a way that the mannequin can't. Again, though I'm obsessing about technical skills.

 

Where actors really come into their own is in the teaching of communication skills, breaking bad news, history taking, patient education and counselling. These are all fertile territory for simulation, if we just abandon the notion of always having to have a mannequin. I am not suggesting a revolution here. Mannequins will always be vital in acute clinical emergency training which mixes technical rehearsal with non technical skills training. Nor am I saying anything ground breaking, many sim centres utilise actors regularly in their training, but I doubt it is as widespread as it could be.

 

As our centre begins to expand its portfolio of courses in response to demand we are finding an ever growing need to explore utilising actors in our scenarios. The Francis report is a significant driver for this. Trusts are beginning to look for innovative ways of training staff in attitudes and behaviours, rather than just mandatory training. Requests have been received to run simulation training around dealing with visitors, and for managers on how to coach and interact with staff. customer care, safety and quality are high on the agenda. Simulation has a lot to offer in this area, though I admit it is not a panacea. In pitching sim training to executives these issues should be born in mind.

 

At our centre we are finding a need to utilise actors in scenarios more often, relegating the simulator to the role of extra. Whether it is us playing the role of team members and deliberately making errors in order to allow the trainees to practice challenging team members, or seniors, or dealing with a colleague who is struggling or performing badly the possibilities are limited only by our imagination.

 

Other areas include pharmacy students who would gain far more from interacting with an actor playing the role of the patient that with a simulator. Then there is organ donation where actors as relatives or careers is essential to palliative care simulation where we have successfully utilised  both actors and mannequins to create realistic end of life scenarios, allowing trainees to rehearse complex decision making, breaking bad news and advanced communication skills in a safe environment.

 

From our standpoint I see a growing need for the use of actors in simulation. This is a potential gap in the market that needs filling. Employing professional actors is costly. Fees are around £30 per hour. This cost needs to be factored into training budgets making it beyond some centres, and certainly unrealistic if we are thinking of making this available to the wider workforce. Perhaps we need to engage with the professional and amateur drama schools to explore partnerships enabling centres to negotiate more cost effective partnerships in return for more regular work for the actors. Utilising internships, and drama students is another path we are exploring, as well as looking at funding an actor in residence as stated in a previous blog.

 

Mannequins will always have a role to play in simulation training in my view, but increasingly they will need to share the stage with actors as Trusts and HEI's begin to see the wider applications of simulation post Francis report.