I am the Clinical Lead for Obstetric Anaesthesia in our trust. My remit, amongst many aspects, includes the investigation of untoward clinical incidents and the dissemination and reinforcement of any lessons learned.
Maternal haemorrhage remains one of the leading direct causes of maternal mortality and morbidity and has continued to feature prominently in national reports (Knight et al., 2018). For the majority of women who died or had severe morbidity, the investigators found that improvements in the management of care would have made a difference to the outcome of the patient. Multidisciplinary team working has been a consistent and special focus of the reports and therefore every effort must be made to ensure that this is optimal.
In our trust, local incident investigations have revealed several areas for improvement in the management of maternal haemorrhage: recognition of haemorrhage, knowledge of the local protocol for alerting the blood bank, obtaining blood products and knowledge of the medical and surgical methods for arresting maternal haemorrhage. Despite sharing the local lessons learnt via email memos and posters, we have found that the above themes unfortunately continue to recur. Additionally, at previous local governance meetings, colleagues across all relevant specialties have requested multidisciplinary simulation training.
The General Medical Council’s (GMC) (2012) guidance for doctors clearly states that the duties of a doctor include teaching and training students and other doctors. Working in collaboration with colleagues is also a recommendation in the GMC’s publication of Good Medical Practice (GMC, 2014). The Code published by the Nursing and Midwifery Council (NMC, 2015) contains published standards that nurses and midwives must uphold: Section 8 details the important components of working co-operatively.
The Royal College of Anaesthetists (RCoA) curricula for both Core (RCoA, 2010a) and Intermediate (RCoA, 2010b) Specialty Trainees also emphasize the competencies required to recognise and manage massive obstetric haemorrhage.
Simulation can provide a replicated clinical setting that, in addition to enabling the learning of technical skills, allows focus on the non-technical skills that are important in crisis management such as obstetric haemorrhage. An added advantage is the opportunity provided for inter-professional education, where participants can learn from and understand the perspective of other healthcare professionals (Robertson & Bandali, 2008).
This session was organised to address these requests and the learning needs analysis took all the above information into account.
Reflecting and reviewing my experiences as a student, teacher and facilitator
During my years at medical school, I was part of the first cohort to be taught using Problem Based Learning (PBL). Having come from an educational system, which promoted didactic teaching and learning by rote, I struggled during the first 2 years. During the pre-clinical years; we were not presented with a real patient but a case vignette that we spent a short time discussing before being required to produce learning objectives. The challenges of PBL have been well described (Boud & Feletti, 1997), and my experience was no exception. I found it very challenging to grasp the basics and to allow myself to branch out from the case that was given to us, and therefore to explore what I really felt I needed to know. It was only during the clinical years, where we were assigned specific patients could I see the pathology in action and the benefits of PBL came to their fore. I have noticed over the years that I tend to draw a lot from the experiences of my own and others’. I find it most natural to learn and teach when the content has a personal slant, a real-life experience that I can easily refer to. It is in these situations that I feel most at ease as a teacher and that the teaching session is more likely to achieve its objectives and receive productive and positive feedback.
The scenario I designed was hence very closely based on a real case I had been involved in; it highlighted all the recurring themes from local and national investigations. Furthermore, after discussion with the simulation team, we agreed that it was reproducible and suitable for our simulation facilities.
My experience as a simulation facilitator over the past ten years has been varied and valuable. I have learnt and been able to critically reflect on candidates’ verbal and written feedback. Equally as important, I have gained valuable lessons from observing my peers and attending workshops and seminars on simulation teaching methodology and debriefing techniques. Most recently I have been focussing on developing my skills on debriefing with good judgement (Rudolph, Simon, Dufresne & Raemer, 2006). The principles described appeal to me and seem to be intuitively applicable to my role as a teacher both in my clinical practice and as a facilitator in the simulation suite. Of the values described by Rudolf et al. (2006), the following hold the most appeal for me:
– Respect for the trainee, who brings their own experience and knowledge to the session
– Being able to practice advocacy and seeking clarity through genuine inquiry and aiming to really understand another’s actions, thereby setting an internal rather than external focus
I have also found it useful to apply the phrases described in the ’Debrief Diamond’ (Jaye, Thomas & Reed, 2015), especially the statements that enable transition from the description to analysis and from the analysis to the application. These statements have brought more structure to my debriefing style and have improved my ability to break behaviours down into specific actions and enable students to reinforce their learning.
Although originally based in pedagogy, John Dewey’s (1938) theories have also tempted me in two important ways. Firstly, I have begun to review my role as a facilitator, looking to be more of an educational guide who needs to identify my learners’ motivation and channel their curiosity, rather than just be a simple conduit for sharing knowledge. Secondly, his emphasis on reflection and evolution of lesson plans based on previous experience has encouraged me to be flexible in my methodology of delivery of learning experiences for my students (Dewey, 1938).
I have taught and facilitated students in a myriad of settings over the past 12 years but this has been the first time I have put so much forethought and time into creating a lesson plan. This dedication to the detail proved invaluable during the running of the session and meant I was rewarded with constructive feedback and detailed reflective notes from the learners at the end of the session. Having pre-briefed the lesson plan with the rest of the faculty also allowed for a better joint understanding of our objectives and improved time management. According to Jensen’s (1980) chapter on “Lesson Plans”, setting aside time at the end of the session specifically for evaluation provides an opportunity for reflection and suggestions for improvement. Previously, I have simply given students a paper feedback from or an online link to complete their feedback at a later date. The simple act of allocating a block of time for feedback and reflection at the end meant that I received comprehensive and contemporaneous notes from the students, and this is a practice I will incorporate into all my future teaching and facilitating endeavours.
The students (anaesthetists of varying experience) had volunteered to attend the simulation session, I thereby utilised Knowles’ theory of adult learning (McGrath, 2009) and incorporated Knowles’ key assumptions for adult learning (Knowles, Holton & Swanson, 1998).
– Self-concept: all the students are in their chosen specialty (anaesthesia) and are responsible for ensuring their work place based assessments are completed and specialty examinations are successfully completed.
– The role of experience: the students all had varying levels of experience. I carefully examined the RCoA’s curricula (RCoA, 2010a, 2010b) to ensure that the scenario design and learning objectives were sensitive to the varying degrees of experience within the group.
– The students’ readiness to learn: As the students had volunteered to attend and based on previous requests, I assumed that the students were willing to engage during the session.
– Orientation for learning: the simulation setting I had chosen leant itself to a problem-centred approach.
– Internal motivation: whilst this is difficult to extrapolate in such a short space of time, I can draw on my own motivators, the most prominent of which have been to improve my performance and provide excellent patient care.
– Finally, I could assume that the students knew the value of learning in this setting
Kolb’s (1984, 2015) experiential learning theory was also applicable to this setting; simulation allows students to have a concrete experience, albeit in a simulated setting. As this case was based on my own experiences, I felt confident in guiding the debriefing session, allowing the students to reflect on their own experiences and facilitating their abstract conceptualisation. Once the group had concluded and learnt from the experience, they would be able to go on and actively experiment in their workplaces. As there was a video link to the debrief room where the non-participating students were able to observe the scenario from start to finish, they were all able to critically examine and scrutinise their colleagues’ experience and fully participate in the various stages of the debrief. This enabled us to explore differences of opinion based on the students’ own experiences and allowed us to form a collaborative approach in finding solutions to the clinical scenario during the debrief.
Kolb and Fry (1975) have also described four styles within their learning style inventory (LSI), each of which is a combination of two stages of the learning cycle. These styles are:
– Divergers: They learn by observing and brainstorming, and need encouragement to look at things from varying perspectives.
– Assimilators: They are able to work on abstract concepts and are able to arrange it in a format that is logical and clear.
– Convergers: They learn best through practical tasks and trialling new ideas
– Accomodators: They prefer to work in teams and overcoming new challenges.
They suggested that by identifying the learning type and tailoring the learning experience, the teacher could play to an individual’s strengths (Kolb & Fry, 1975).
Based on the LSI, Honey (2006) developed the Learning Styles Questionnaire, a diagnostic tool that identifies an individual’s preferred learning style based on how an individual takes in information and how they internalise it. These four learning styles are:
More work has been done on learning styles; for example, Fleming and Baume (2006) describe the VARK model (Visual, Auditory, Reading and Kinaesthetic) but argue that over-reliance on one style may hinder learning. Instead, they suggest that if a learner understands their own tendencies, this can open up a discussion about how best to achieve one’s learning outcomes.
Whilst I am aware of the multitude of learning styles that have been described in the literature, I have been unable to locate any evidence that confirms a link to improved learning outcomes. A study of 13 learning styles (Coffield, Moseley, Hall & Ecclestone, 2004) found that some of the most commonly used instruments in pedagogical practice have limitations such as low reliability and poor validity.
I did not attempt to formally establish the students’ individual preferences as I felt there was insufficient time to do so, and that it would not have altered my lesson plan or my debriefing style. However, I have found that my appreciation that students have learning preferences that are different to mine or each other’s, has made it much easier to practice advocacy with inquiry (Rudolph et al., 2006) rather than immediately jumping to conclusions that may be inaccurate.
Whilst arranging this lesson, I considered Maslow’s hierarchy of needs; the lower order needs of physiological comfort and safety (both physical and psychological), and the higher-order needs of belonging, esteem and self-actualisation (Maslow, 1987).
– Our hospital layout consists of a cluster of poorly arranged buildings and it is easy to get lost. The Simulation Suite is in the Medical Education centre which is directly opposite the main hospital building and very easy to find (Physiological comfort).
– The debrief room is large enough to hold up to 12 people very comfortably seated around the main table. It is also well lit and warm (Physiological comfort).
– The pre-scenario debrief was kept informal and my main focus was to ensure that the learners knew that the session had been arranged based on their requests and was designed for their benefit. The participants were assured that the faculty were there to guide and advise them during the debrief and not there to judge or assess their performance. I also guaranteed them complete confidentiality (Psychological safety).
– The audio-visual set up functions well and allows the learners who are not directly involved in the scenario to observe the simulation in real time on a large screen in the debrief room. This would encourage them to participate in the debrief and enhance their interaction and sense of belonging and acceptance (Belonging and esteem).
– I had ensured that the timetable had sufficient time for the debrief so that it would be unhurried and allowed for questions to be answered and insecurities to be addressed. I also wished to give them enough time to collate and reinforce the lessons learnt, and to allow them to form a plan for future learning and changes in their clinical practice (Psychological safety, esteem and self-actualisation).
Benjamin Bloom’s (1956) work on taxonomies of learning in cognitive, affective and psychomotor domains provides a useful method of forming lesson plans and creating learning objectives. The cognitive domain was most helpful to me whilst creating the lesson plan, and I was careful to describe the learning objectives using carefully selected and measurable verbs (McKimm & Swanwick, 2009). I carefully considered the six levels as below:
– Knowledge: I examined the RCoA’s curricula (RCoA, 2010a, 2010b) and ensured that my programme would cover the required knowledge base.
– Comprehension and application: during the conduct of the scenario, I ensured that the participating faculty members guided the students towards the completion of stated tasks, rather than simply expressing their ideas.
– Analysis and synthesis: during debrief, I was mindful in allowing the learners sufficient time to discuss how the scenario affected them and to plan changes in their future clinical practice.
– Evaluation: immediate evaluation would be in the form of feedback and reflection.
The affective taxonomy (Bloom, 1956) relates to matters that are important in teamwork, and relate to attitudes and emotions. Personally, this is the most challenging of the taxonomies for me to fully incorporate into my lessons, especially in larger groups. Nevertheless, when appropriate, I do attempt to get individual learners to reflect on their own beliefs and assist them in resolving inner conflicts. The psychomotor domain (Bloom, 1956) relates to the way in which practical skills are acquired; though they have not formally been applied to the field of medicine, I believe they are extremely relevant in our understanding of how clinical skills can be honed.
On a personal note, the most appealing qualities of Bloom’s (1956) work are its holistic and inclusive aspects. When reading his work, one gets the sense that with time, understanding and the thoughtful application of his theory, every student can be enabled to maximise their potential.
Motivation is a challenging issue to begin to understand and deal with. Poor motivation may cause disruption and a lack of engagement from the learner/ learners.
Victor Vroom (Vroom, 1994) reasoned that behaviour is based on a person’s expectation, valence and instrumentality. I will explain how I applied this theory when considering my audience:
– Expectation: a subjective measure of the belief and confidence the learner has in their own capabilities. I strengthened this association by reassuring them during the briefing session, thanking them for their involvement and respecting their contribution.
– Valence: a measure of the value the learner assigns to any reward they may get, for example a qualification (extrinsic) or increased confidence (intrinsic). This link was simple to reinforce, as I had been specifically asked to organise this session and the learners were very keen to participate and learn about the management of obstetric haemorrhage. It was also an “easy win on” their part to gain part of their expected training portfolio and yearly requirements to attend a simulation session.
– Instrumentality: measures the belief the learner has in the teacher in delivering the expected learning outcomes. I ensured that the learning objectives were delivered and the students’ feedback reflected their overall satisfaction with the simulation session.
The learner’s perspective
In addition to considering their motivation, I took into account the following aspects:
– Previous experience in Obstetric anaesthesia: Two of the students were novices with no experience, one had three months’ experience and the most senior anaesthetist student had over ten years’ experience. Conversely, those with the least clinical experience had spent the most time learning in a simulated environment. I therefore decided to pair a novice with our most experienced anaesthetist for the simulation scenario.
– Personal issues: One of our students has been identified as a trainee in difficulty by the College Tutor, and I am aware of their situation as I am one of their clinical supervisors. However, for the purpose of this session I did not find it necessary to make any alterations for their sake (and this was agreed upon with their educational supervisor)
– Timing of the session: Our clinical day always begins at 08:00, so the start time of 08:30 was realistic and achievable.
– Language/ cultural: One of the students has English as their second language. I have worked with this individual and am aware that the language barrier and cultural differences have led to misrepresentation in the past, and was therefore poised to be more vigilant and protective of this individual.
Developing lesson outcomes:
I based my lesson outcomes on the SMART acronym (Doran, 1981). Five elements form the basis of this tool, and below is my application of it to this teaching exercise:
– Specific: the lesson objectives were all related to the multidisciplinary management of massive obstetric haemorrhage and have been outlined in the lesson plan
– Measurable: I used specific verbs (McKimm & Swanwick, 2009) that would enable a useful evaluation, and I have also outlined my methods for assessing learning in my lesson plan
– Acceptable: Having reviewed local incident investigations, national reports (Knight et al., 2018) and the national curriculum for anaesthetic training (RCoA, 2010a, 2010b), I believe my learning outcomes were entirely suitable.
– Realistic: I had set aside the entire morning for this exercise and the achievement of the learning objectives will be evident when the learner feedback and evaluation is transcribed later in my essay.
– Time-bound: The timescale for the simulation and debrief was also contemplated carefully and has been detailed in the lesson plan.
Scenario design and conduct of scenario
As I have stated previously, this scenario was based very closely on a case I was personally involved with. The setting and initial patient parameters were clearly stated and I worked very closely with the simulation technician during the scenario to determine the clinical parameters based on the students’ actions. The details of this can be found in the lesson plan.
My invitations to faculty members had been accepted and I was expecting to have a Consultant Obstetrician, an Operating Department Practitioner (ODP), a Consultant Anaesthetist and a Midwife. Unfortunately, due to a clinical emergency, the Obstetrician and ODP were unable to attend at the last minute. We were able to find alternative faculty members who had the relevant insight and experience: our Clinical Skills Facilitator (a GP trainee who has completed 6 months in Obstetrics) and the Simulation Centre manager (who was an ODP for 17 years). Our faculty midwife is also a practice development educator and her interest in the welfare of our students was apparent during the debrief; she was sensitive yet able to provide an honest opinion when asked for it. However, the absence of an experienced Obstetrician did leave an impression and this was reflected in the feedback.
In our hospital, there is a dedicated anaesthetist for the labour ward who is supported by the Senior resident anaesthetist and the Theatre anaesthetist. Our trainees only proceed to the Obstetric Unit after 12 months and therefore have no direct experience in this area. I therefore decided to allocate the most experienced anaesthetists as the first responder and one of the least experienced as second responder in this scenario. Vygotsky’s (1978) emphasis on the Zone of Proximal Development and learning from our Most Knowledgeable Others is applicable in this setting; the less experienced learners (who had no experience in Obstetric Anaesthesia) would benefit from watching and engaging in debrief with their more experienced counterparts. Vygotsky also developed the model of scaffolding, which described the teacher’s role as keeping the group focussed whilst allowing them to take risks in a safe environment and reaching higher levels of understanding; this is the very essence of simulation training.
The scenario progressed over approximately 15 minutes, after which we invited the faculty and students to the debrief room.
The origins of debriefing lie in the military, where it is used initially to defuse the situation and allow the individual to process the event. This is followed by analysis and strategy formation for future endeavours.
A systematic review by Issenberg, McGaghie, Petrusa, Gordon and Scalese (2005), identified feedback (including debriefing) as the most important feature of simulation. Debrief has been described as the “heart and soul” of the simulation experience (Rall, Manser & Howard, 2000) and as such must be delivered by an appropriately trained faculty and have sufficient time allowed to it.
During the pre-simulation brief, I had already set a safe and confidential scene. It is vitally important to create a climate where learners feel safe, respected and valued (Gibb, 1961) so that they are able to focus on learning. A survey of perceived barriers to the use of simulation based education identified that in addition to time and cost, the factors that prevented use of simulation were: stress, the intimidating environment and fear of the educator or their peers’ judgement (Savoldelli, Naik, Hamstra & Morgan, 2005).
My structure for facilitating the debrief consisted of an initial phase of description allowing participants to react and defuse. This was followed by a phase of in-depth discussion and analysis, during which I referred to the objectives on my learning plan to ensure that the discussion covered these points, allowing for some divergence but guaranteeing the planned focus. The final analysis phase was more reflective, where we collectively examined the lessons learned and made a plan for incorporating these into daily clinical practice. The learners were highly engaged in the process and were able to generate some unprompted discussion amongst themselves, but owing to the group’s overall lack of experience in Obstetric Anaesthesia, did need an increased level of involvement from me to discuss and analyse the experience.
The main challenge for me was to find a balance between allowing the participants to defuse and directing the discussion towards the learning objectives without minimising the learners’ feelings and affecting their self-esteem. To this end, I found it most helpful to employ some of the phrases suggested in the “Debrief Diamond” (Jaye et al., 2015), which allowed me to guide the learners in a way that felt direct yet non-confrontational.
We spent just over forty-five minutes in the debrief room, and were able to achieve the learning objectives as outlined in the feedback and reflection below.
Student/participant feedback and reflection
All four students were anaesthetists of varying experience, and their feedback is detailed below. Please note that all comments have been transcribed exactly as found in the feedback forms, complete with erroneous spelling and nonstandard grammar.
1. Did you find the scenario applicable to your practice? 1= not applicable and 5= very applicable.
Average score: 4.75
2. Was the scenario realistic? 1= not realistic, 5= realistic.
Average score: 4.75
3. Do you feel more confident in your ability to manage a similar patient? 1= not confident, 5= confident.
Average score: 4.25
4. Was the learning during debriefing helpful for your development? 1= not helpful, 5= helpful.
Average score: 4.75
5. Was the scenario useful in allowing you to practice communication with obstetric/ midwifery colleagues? 1= not useful, 5= useful.
Average score: 4.7
6. Do you feel the scenario was pitched at the right level for you? Students were asked to choose from ‘too difficult’, ‘about right’ and ‘too easy’. 3 candidates chose “about right” and the fourth did not answer the question.
7. Is there anything you would suggest to improve your learning experience?
“Due to the nature of the obstetric environment, maybe there is a need to be more strict?”
Please describe your overall impression of this scenario (what happened and how did it make you feel?)
– Good scenario- haemorrhage is a scenario that can present in many forms
– Great scenario
– Achieved what simulation is supposed to achieve: identified gaps in knowledge, built on team-working skills, built on communication skills
– I think strongly that the participation in simulation on a regular basis must be improving the performance in a real scenario as it is widely accepted that thinking under stress may not be reflecting the reality, ability and knowledge of every individual colleague. This particular scenario was very well set/ organised and I believe every single part of it has contributed to my practice in the future. Also- it has unveiled steps which due to the nature of the obstetric environment must be taken in details i.e. communication with seniors, drug availability
Please outline your key learning point(s) from this scenario.
– Good debrief on clinical points
– Good structure and organisation of entire programme
– Reviewing major haemorrhage protocol
– Learning about causes of obstetric haemorrhage
– Going over uterotonics and other methods of optimising a patient who is bleeding
– Knowledge of guidelines- particularly in this trust, are difficult to access and there is poor understanding of which guidelines exist and where to find them amongst trainees. Simulation helps to familiarise juniors with these guidelines
– Basic management of massive obstetric haemorrhage; initial management, escalation priorities, drugs
– New updated massive haemorrhage guidelines
– New phone number
– Be more loud in ordering bloods/ examination/ contacting people
In addition to myself, our faculty consisted of a Practice Development Midwife, a Clinical Skills facilitator, the simulation manager and the simulation technician. Their feedback is detailed below. Please note that all comments have been transcribed exactly as found in the feedback forms, complete with erroneous spelling and nonstandard grammar.
1. Did you find the scenario easy to follow and implement? 1= very difficult, 5= very easy.
Average score: 4.75
2. Was the scenario realistic? 1= not realistic, 5= realistic.
Average score: 4.25
3. Were the guidelines for debriefing topics helpful? 1= not helpful, 5= helpful
Average score: 4.5
4. Was the scenario useful in simulating communication with obstetric / midwifery colleagues in a similar situation? 1= not useful, 5= useful
Average score: 4.5
5. Is there anything that you would suggest to improve this scenario?
– Perhaps senior anaesthetist can come in later, allowing the junior to formulate their own ideas about the scenario
– Very clear brief for me to follow
– Having a ‘real’ obs+gyn reg would be useful. I appreciate one was supposed to attend.
– I would expect an obstetrician before the anaesthetist in a PPH
As outlined in my lesson plan, I sent an email survey two weeks after the session. None of the students had responded within a week of the email, so I tried to meet with them personally. I managed to do so with two of the students and made a note of their comments:
– “It was so useful to learn about uterotonics”
– “I now know exactly how to activate the major haemorrhage protocol and how to request blood products”
– “I didn’t realise that obstetric haemorrhage isn’t always obvious, that was one of the main take-home messages for me”
My reflection and conclusion
Adults learn best when they are actively engaged in the learning, are able to participate in the learning experience and then able to make sense of the experience and relate it to their own practice (Fanning & Gaba, 2007). Simulation and debrief allow this process to occur in a controlled fashion and together form an experiential learning process which may lead to long-lasting learning, and this was my rationale behind selecting simulation as my method of delivering teaching.
The absence of our faculty Obstetrician and ODP was not entirely unpredictable. Although I found replacement faculty members, I believe the quality of debrief would have been significantly enhanced with their input. In the current NHS climate of budgetary restraints and staff shortages, I have found it increasingly challenging to organise multidisciplinary training. A possible solution would be to establish a programme of in situ simulation, and this is a subject area that I will be researching next.
My commitment to reflective practice has been unwavering and allowed me to really focus on the quality of the teaching I deliver. In addition to considering the feedback from learners and faculty, I often relate my teaching to my previous experiences as a learner. Brookfield’s (1995) ideas are probably most in accord with my feelings about reflective practice as a teacher. He describes reflection through four critical lenses:
– Autobiographical: relating learning experiences to one’s teaching
– Learner’s lens: Feedback and comments from learners
– Colleague’s lens: Feedback and comments from faculty
Theoretical literature lens: I think this perfectly describes the process I have gone through for the duration of this and during the research and writing of this essay.
It is clear from my experience that multidisciplinary training for Obstetric emergencies such as haemorrhage is not only recommended but desirable. This was the first of such sessions conducted in our simulation centre and, although it required a significant amount of resources, was very well received and achieved the desired learning outcome. The future direction for our unit would be to achieve a similar quality of learning for a much wider audience and one of the approaches may be to collaborate with the simulation centre team and embark upon in situ simulation in the Obstetric unit; this is a project that I am currently discussing with our Trust’s Lead for Simulation.
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