Distributed Simulation in surgical training: An off-site feasibility study

Abstract

Background: Simulation offers recognised training benefits, but the cost of high-fidelity contextualised simulation is prohibitive and its accessibility limited to specialised Distributed Simulation centres. Distributed simulation (DS) is an innovative concept of low-cost, portable and high-fidelity contextualised simulation. However, it has previously only been trialled at a central London teaching hospital.

Aims: (1) To explore the off-site feasibility of DS. (2) To determine the response of end-users to DS.

Methods: A DS naive researcher recreated a standardised porcine laparoscopic cholecystectomy scenario at a District General Hospital using DS. A research diary detailed the logistical feasibility of the project, whilst mixed methods were used to determine the response of the 10 surgeons who completed the full-team simulation.

Results: DS is feasible off-site with end-users comparing it favourably to their previous simulation experiences. Surgeons perceived DS as being most useful for building the operative confidence of juniors between learning the basics on a bench top model and before entering the operating theatre.

Conclusions: DS has the potential to provide high-fidelity contextualised simulation as an adjunct to, and not a replacement for, surgical training. Unlike other modalities, it is low cost and portable, thereby addressing concerns over affordability and accessibility.

Introduction

The structure of surgical training in the UK is changing, with anticipated gaps in training resulting from reduced working hours (Cresswell et al. 2009). Methods to augment surgical training may therefore be required to prevent any compromise in the future provision of high-quality patient-centred care. Simulation is one potential solution.

It has been demonstrated that the value of training on a simple bench top simulator is increased when it is placed in the appropriate context (Kassab et al. 2012). High-fidelity contextualised simulation is currently only offered by static facilities (Aggarwal et al. 2004). However, many trainees are unable to benefit due to cost and accessibility issues.

Distributed Simulation (DS) is a validated, low-cost and portable concept, devised to widen access to contextualised simulation. It comprises an inflatable shell containing the minimum necessary cues to provide a sense of realism and in-built recording facilities (Kneebone et al. 2010). Such inflatable simulation facilities have been promoted in educational policy (Temple 2010).

However, validation studies have only been performed at a large central London teaching hospital where there is high acceptability, and regular use, of simulation. There is therefore a need to explore the use of DS in a hospital without a strong simulation culture.

Table

Practice points

DS is a validated, low-cost and portable, contextualised simulation environment. This study provides the first demonstration that DS can successfully be used off-site by naive participants at a DGH. DS compared favourably to participants’ previous simulation experiences. DS may be most appropriate for building operative confidence between learning on bench top models and before entering the operating theatre. DS has the potential to provide high-fidelity contextualised simulation as an adjunct to, though not a replacement for, surgical training.

Aims

1. To explore the off-site feasibility of DS.

2. To determine the response of end-users to DS.

Methods

Study design

A researcher naive to DS (AH) was recruited to lead the off-site project under the supervision of a DS expert (EK). Ethical approval was obtained from the off-site location, a District General Hospital (DGH) serving a population of 500,000 that was selected based upon its transport links and simulation culture.

The study's design followed a full-team porcine laparoscopic cholecystectomy (LC) scenario used in the DS validation study at a teaching hospital (Kassab et al. 2011), but modified to accommodate off-site logistical constraints at the DGH. A research diary was kept by the lead researcher (AH) from the time that the study was first discussed through to its completion. It was used as a journal recording the study's progress and to document any problems that arose for the benefit of the research team.

Participants

Informed consent was obtained from surgeons, anaesthetists and scrub nurses who were recruited locally by convenience sampling. Senior surgeons were defined as having performed >50 LC independently, and junior surgeons as <50.

Five senior surgeons (five consultant surgeons, five male, median age 44 years, median 300 LC as primary surgeon and 200 assisting) and five junior surgeons (five SHOs, four male, median age 29 years, median one LC as primary surgeon and 12 assisting) participated in this study. All surgical participants had some form of prior simulation experience, but only one senior and one junior surgeon had previously participated in a full-team simulation.

Intervention

Participating surgeons completed a LC for a consultant colleague who had been called away. They clipped and cut the cystic (bile) duct before dissecting the gallbladder free from the liver, at which point the scenario was ended.

Each scenario was performed twice: first with the senior surgeon operating and the junior assisting, and then again with the roles reversed. In total, 10 scenarios were performed by five teams. Due to clinical commitments, it was not possible to maintain the same anaesthetic and scrub teams for the duration of the study.

Evaluation

Each surgeon rated the face (10 items) and content (18 items) validity of the DS environment on six-point Likert scales (1 = not very authentic and 6 = very authentic) immediately after completing their scenario as the primary surgeon. A research psychologist then conducted individual, audio recorded, semi-structured interviews with them, lasting <15 min. All participants, including the support staff (anaesthetists and scrub nurses), were asked a core set of questions from a pre-determined topic guide in order to obtain vital information about the environment (visual and auditory) and authenticity of the non-surgeon's experience. This was fed back to the research team for consideration in further work.

Analysis

Surgeon demographics and Likert scale ratings were analysed using descriptive statistics (SPSS version 19). Mean overall scores were calculated for items comprising face and content validity, and independent samples t-tests performed between surgeon groups (senior versus junior). Mann–Whitney U-tests were performed, between the same groups, for single-item scores treated as ordinal data (e.g. DS compared with other forms of simulation). Participant interviews were analysed by two researchers (EK and AH) using thematic analysis. No feedback on technical or non-technical performance was provided to the participants by the research team, as this was beyond the scope of this study.

Results

Research diary – Feasibility

It was possible for a DS naive researcher to perform the off-site feasibility study with minimal assistance. The DS equipment was comfortably transported in the boot of a small car (capacity ˜360 L), and the necessary equipment was easily sourced locally or from industry. The logistical difficulties were either specific to the chosen scenario, e.g. sourcing equipment that was suitable for use with porcine material, or general to simulation, e.g. recruiting clinical staff who were free of clinical commitments for a full session. This made it impossible to replicate the method used in the original DS validation study.

Quantitative data

The mean score for DS face validity was 4.62 (SD 0.45) for senior surgeons and 5.02 (SD 0.51) for junior surgeons. An independent samples t-test demonstrated no significant difference between the two groups (t = −1.31, p = 0.23). The mean score for DS content validity was 4.57 (SD 0.35) for senior surgeons and 5.04 (SD 0.40) for junior surgeons (t = −2.03, p = 0.08).

Both groups’ ratings compared DS favourably to previous simulation experiences (senior surgeons median = 5, range 4–6 and junior surgeons median = 6, range 5–6). A Mann–Whitney U-test demonstrated no significant difference between groups (U = 9.00, z = −0.81, p = 0.42). Each group also supported the use of DS in the training and assessment of both technical (median = 5 range 4–6 and median = 6 range 4–6 for senior and junior surgeons, respectively, U = 6.00, z = −1.47, p = 0.14) and non-technical skills (median = 5, range 4–6 and median = 6, range 4–6, U = 10.5, z = −0.45, p = 0.65).

Qualitative data

Interviews with senior surgeons demonstrated a consensus opinion that the operating theatre should remain the gold standard for acquiring surgical skills, with specific concerns about simulation relating to organisational, logistical and faculty issues (Table 1).

Table 1.  Qualitative data

	Participant role	Participant code	Quote^a
Positive themes
Desire for further access to DS	Senior surgeon	S02	I want one of these in the skills lab
Realism of the DS environment	Scrub nurse	SN4	The background sounds really helped
Realism of the operative procedure	Junior surgeon	S01	As real life as you can get
Comparison with other simulations	Junior surgeon	S07	The best that I have used
Applications	Anaesthetist	A1	More complex trauma scenarios
Relevance	Scrub nurse	SN1	This is a much safer way to learn
Negative themes
Operating theatre gold standard	Senior surgeon	S06	Sometimes you just have to operate
User dependence	Medical student	MS1	Some people stay in role better
Set up and maintenance	Senior surgeon	S08	This would be too much work
Access issues	Scrub nurse	SN4	Time could be a problem
Faculty issues	Anaesthetist	A1	Needs clinical staff to run it
Environment	Anaesthetist	A5	It was slightly constrained for space

Note: ^aOne quote selected per theme identified.

Junior surgeons agreed that the operating theatre is the ideal environment to acquire surgical skills but all wanted further access to high-fidelity contextualised simulation as part of their training. Benefits included being the primary surgeon, individual consultant supervision, no responsibility or ethics of operating on a real patient, nor the time constraints of a theatre list. However, juniors did not want time spent in simulation to be included as part of their contracted working hours (restricted to 48 h by the European Working Time Directive). Instead, they suggested that simulation training should occur during their own, personal, time.

Anaesthetists and scrub nurses were impressed by the DS environment and realism of the operating team dynamic. Both groups were keen for further involvement in more complex procedures, e.g. trauma.

Discussion

DS is feasible as a portable method of contextualised surgical simulation training and is intuitive enough for a DS naive researcher to use. All participants highlighted the realism of the operating environment, demonstrating how a portable, inflatable, low-cost simulation can recreate just enough of the intended environment to be deemed authentic.

Feasibility issues related to setting up the off-site simulation in general, e.g. sourcing equipment, or the chosen scenario, e.g. sourcing, storing, handling and disposing of porcine tissue. Many of these issues are not specific to off-site simulation, and must be considered and accounted for in the organisational phase of any study.

Off-site face and content validity were assessed, with positive ratings from both senior and junior surgeon groups. DS also compared favourably to participants’ previous experiences of simulation on bench top models, box trainers, virtual reality and in full-team scenarios. However, interviews highlighted a cultural difference in attitude towards simulation between senior surgeons at a DGH and their peers at a teaching hospital. DGH consultants were far more sceptical of the benefits of simulation in general, perhaps due to a lack of familiarity with it.

DS was perceived as being most useful for building the operative confidence of juniors between learning the basics on a bench top model and before entering the operating theatre.

Conclusion

This feasibility study is the first demonstration that a DS naive researcher can successfully use DS off-site with minimal support. Target end-users were keen for further access to DS facilities but suggested that such simulation should act as an adjunct to, and not a replacement for, surgical training.

Acknowledgements

The authors thank STeLI for funding this study, the Oxford deanery for approving this study, as well as Covidien, Ethicon, Olympus, Storz and Stryker, for loaning the necessary equipment.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.