Theme: 7AA eLearning: Games, resources and platforms
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Exploring the influence of participating in tactical decision games on medical students' recognition and understanding of non-technical skills
Authors: Iain Drummond
Gauhar Sheikh
Trisha Lamb
Janet Skinner
Morwenna Wood
Institutions: University of Edinburgh - Centre for Medical Education - Edinburgh - United Kingdom
NHS Fife - Medical Education - Kirkcaldy
 
Background

Non-technical skills (NTS) can be defined as “the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance” (Flin et al. 2008).  Key NTS required by newly qualified doctors are decision-making, situation awareness, task management and teamwork (Mellanby et al. 2014). Previous research has demonstrated junior doctors and their supervisors perceive that newly qualified doctors have difficulty demonstrating effective NTS behaviour. (Brennan et al. 2010; Tallentire et al. 2011; Tallentire et al. 2012).  There is therefore a need to understand how medical schools can better develop students’ NTS.

Tactical decision games (TDGs) are low-fidelity classroom-based activities designed to increase proficiency in NTS (Flin et al. 2008).  TDGs consist of a developing emergency scenario e.g. a plane crash where participants have a time-limited period to decide on a course of action as an individual and as a group. A facilitator then leads discussion around decisions made by the group, and the rationale underpinning these decisions.  TDGs have been widely used in non-medical domains such as the US marines, military, police and oil and gas industries (Schmitt 1996, Crichton et al. 2000).

We previously found non-medical TDGs to be a feasible and acceptable method of teaching Year 5 medical students about NTS.  We now sought to explore the influence of non-medical TDG participation on students’ recognition and understanding of NTS in an acute care simulation scenario.

Summary of Work

This study was approved by the University of Edinburgh College of Medicine Committee on the use of Student Volunteers.

 A total of 17 students participated in a non-medical TDG session in a total of three groups each containing between four and seven students.  Feedback and discussion followed each of the TDGs, using a validated NTS behavioural marker system.  Sixteen students subsequently participated in an acute care simulation scenario in groups of between two and six students.  The acute care simulation scenarios were designed to cover clinical presentations commonly faced by junior doctors and included acute pulmonary oedema, post-operative sepsis and an acutely confused patient.  All students actively participated in at least one simulation scenario whilst some students also had the opportunity to observe their peers participating in a scenario.  Video-stimulated debrief interviewing (VSDI) was then used to explore students’ real time and early reflective understanding of their NTS behaviours within the scenarios.  A total of eight VSDIs were carried out with four of the eight interviews including observing students who provided a complementary perspective and also contributed to probing the thought processes of the participating students.  The VSDIs were audio-recorded and transcribed data thematically analysed.

Summary of Results

The following themes emerged from analysis of the data:

1.Situation awareness in observation and participation

Students found it easier to maintain situation awareness when observing their peers than when they were actively participating within a scenario:

“Was this when we said it’s good that they’re administering treatment but shouldn’t they phone for help now? “

2. Fixation errors and situation awareness

Students were able to recognise in retrospect situations when they had lost situation awareness due to fixation on particular aspects of a task:

“I think it was quite a good scenario to watch back, and I think it’s good to watch the clip fully as I think it’s the first time – cause they always talk about how you get absorbed in tasks and you think yeah I probably do, but I think actually watching it and realising what you’ve not heard, and I think it’s not until you watch the whole clip back that you realise you just didn’t hear that the first time, or didn’t realise it was said."

3. Self expectation influencing behaviour

Students felt that there was an expectation that certain tasks should be completed before seeking senior help:

“Yeah and so I was worried about her renal function as well, like kidney disease, like before we considered administering a course of antibiotics we wanted to know what her renal function was like.  I felt like before we spoke to someone we want to have at least have achieved that…”

4. Being uncomfortable with uncertainty

Students recognised that they felt uncomfortable in situations when they did not know what was going on and this could have a negative impact on their management of the task:

“And yeah I just felt at this point that okay, the patient is a bit unwell, quite breathless but, I didn’t feel like I could phone anyone as I didn’t know what I was going to pass on about this person, so I felt a bit in limbo – it’s not clear what’s going on, he is sick but I wouldn’t have felt comfortable phoning up a med reg and saying ‘I’ve got a patient who is breathless’.  I think we did later on but I can’t remember what happened in the next 10 minutes.”

5. Managing information and communicating

Students recognised the benefits of establishing and maintaining a shared understanding with their colleagues and their ability to do this improved with experience:

“Well I think what we probably did differently here is we vocalised our thoughts a lot more and we tried to stay on the same page a lot more as well, to make sure that….yeah so I think that worked a lot better this time.”

6. Teamwork dynamics

Students found it easier to work together and get help from their peers than from senior doctors within the scenarios:

“I think like running things past each other a lot was good, and teaming up for things like bloods and examinations and all that kind of stuff, it just makes you feel more confident in what you’d done as well. So yeah, it was a more relaxing environment to work in with everyone knowing and happy with everything.”

 

Conclusion

Students were able to recognise, understand and analyse NTS behaviours in acute care simulation scenarios after participating in a non-medical TDG session. Participating and observing students were able to recognise situations where NTS behaviours could have been improved.  Future TDG and NTS sessions could be adapted to target aspects of NTS that students found challenging in the acute care simulation scenarios.

Take-home Messages

TDGs are a method of developing NTS in final year medical students.

Acknowledgement

The authors wish to thank the students who attended the TDGs and acute care simulation sessions, Dr Catherine Collier for allowing use of the “Decision Making Activity” TDG and June Adamson for assistance in the development and running of the acute care simulation sessions.

We also wish to acknowledge the Clinical Skills Managed Educational Network (CSMEN) and the University of Edinburgh Principal’s Teaching Award Scheme (PTAS) who helped fund this work.

References

Brennan N, Corrigan O, Allard J et al.  2010.  The transition from medical student to junior doctor: today’s experiences of Tomorrow’s Doctors.  Med Educ 44: 449-458.

Crichton M, Flin R, Rattray W.  2000.  Training decision makers – tactical decision games.  J Contingencies Crisis Manage 8: 208-217.

Flin R, Crichton M, Rattray W. 2008.  Safety at the sharp end: a guide to non-technical skills.  Surrey, UK: Ashgate.

Mellanby E, Hume M, Galvin R, Skinner J, Maran N.  2014.  The development of a behavioural marker system for newly qualified doctors in managing acutely unwell patients.  Available from: http://www.csmen.scot.nhs.uk/media/25660/project_report_19.08.14.pdf.

Schmitt J.  1996.  Designing good TDGs.  Mar Corps Gaz 80: 96-98.

Tallentire V, Smith S, Skinner J, Cameron H.  2011.  Understanding the behaviour of newly qualified doctors in acute care contexts.  Med Educ 45: 995-1005.

Tallentire V, Smith S, Skinner J, Cameron H.  2012.  The preparedness of UK graduates in acute care: a systematic literature review.  Postgrad Med J 88: 365-37.

 

 

Background
Summary of Work
Summary of Results
Conclusion
Take-home Messages
Acknowledgement
References
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