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Scenario training in Advanced Life Support, let’s not forget the basics

I recently completed an Advanced Life Support Course, not one of ours, it was at a tertiary facility and I was a little disturbed to find half the program duration was spent sitting in a circle discussing the communication effectiveness of the Team Leader, how to give a handover using SBAR, and how to implement assertive escalation of communication.  It was a four hour initial Advanced Life Support training course, however we spent almost 2 hours of this time chatting.  While I certainly acknowledge effective communication is a very important aspect of an Emergency Response Team, I was disappointed that vital skills and knowledge in relation to resuscitation were not especially focused on.  Not once was I required to be Team Leader, not once did I have to demonstrate my knowledge of advanced life support practice, nor did I have to know the correct drugs or when to give them.  I was, however, asked about my feelings regarding how well the team communicated. 

It cannot be assumed that just because a learner attends a training session and signs the attendance list that they absorb all the information provided and their knowledge base has been improved. 

For the scenarios that were conducted at the course I attended at the tertiary facility (there were 8 attendees and we completed 4 scenarios) correct treatments were not always instigated and this was not identified or discussed.  Thus, the incorrect treatment that was provided was not addressed, however we did discuss how comfortable we all felt.  Well, if that is my husband or my daughter you are resuscitating, I really do not care if you feel a little uncomfortable, as long as you can efficiently resuscitate and give my loved one the best chance you can of rescue, I would be most grateful.  Have we gone too far with the soft side of training, spending more time on communication and feelings than skills and competence?  Whilst I acknowledge we need effective communication, and this has been lacking in previous years in health care, I fear the pendulum has swung too far.  I believe we need to get the basics right, we need to be sufficiently trained and efficiently prepared to perform our tasks.  Randy Sharp, manager of flight training for California Shock Trauma Air Rescue states, “the goal of training scenarios is to not just check off boxes on a form.  I want to see if they have real life understanding of what they are supposed to do”.1  We need to practice our craft and drill our procedures, or regardless of how well we are able to communicate our feelings, it will not make us ‘feel’ any better if we cannot perform our role.  Our confidence will be suffer, our job satisfaction will deteriorate and our self belief will be crushed.

Effective communication is an essential part of scenario training but it should not be the only focus.  Proficiency in completion of tasks is also vitally important.  Personally, I would not mind if the pilot of a plane communicated our flight dilemmas abruptly, if I was alive or sufficiently able to comment on it.  There is a significant problem however if the pilot effectively communicates to me that we are going to crash as he cannot remember the procedure required to correct the situation, or that he is not sufficiently prepared to complete the required tasks under pressure.  The pilot may compassionately seek my feedback and acknowledge my feelings, but I feel I would not be in a chatty mood!  As Curt Peredina, chief pilot for North Andover Flight Academy, emphasises in relation to successful scenario based training, “placing the student within scenarios is to build their flight skills as well as their judgement and assessment skills”.1   As I travel the countryside delivering advanced life support training courses, I find nurses, doctors and paramedics have developed good communication skills as this was well covered during their years at university.  Semesters of their learning had been spent on effective communication, assertive communication and conflict management.  However, what I have found to be lacking is the proficient execution of skills, and more so the confidence to perform these skills, and not just complex skills, basic skills, such as correctly using a bag-valve-mask device or correctly sizing an oropharyngeal airway.

Scenario training is vital to successfully prepare health care professionals to perform their role, providing skills and confidence within a real-life context.  However, many training organisations seem to have forgotten that scenario training is essentially task-based learning enhanced by the addition of context, relevance, and effective communication with colleagues.  Learning is achieved through doing, actually performing tasks.  The tasks or procedures during the learning should remain the central focus.  Dale Smith confirms in an article on ‘Scenario-based Training: As Real as it Gets’, using scenario based training “is also proving to be extremely helpful in reinforcing even the most basic piloting skills”.1  During the Advanced Life Support Courses we run at HealthCare Training Service, learners are immersed into specific situations that they may encounter in the workplace and provided an opportunity to gain and practice valuable clinical skills.  The learners do make mistakes, however the mistakes are made in a safe environment.  We will learn so much more from our mistakes than the things we do well.  This is the essence of lifelong learning.  We make mistakes and correct, but we have to do the task, not just talk about it.  Afterall that is how we learnt to walk, run, climb and grow.  Someone did not just speak with us about how we might feel about walking or if we felt comfortable trying to walk.  We walked!  We actually stood up, wobbled a bit, and fell down a couple of times, and it felt uncomfortable at times, but we kept going and we learnt.  But we did this in a safe environment with our family or care-givers present to provide guidance and ensure we did not get too harmed.

Successful advanced life support training utilises structured scenarios facilitated by highly experienced trainers who provide relevant stories to set up the scenarios which relate to real-life situations making the learning memorable.  In our advanced life support scenarios the learner is required to gain information, critically evaluate, make decisions, coordinate resources (human and material), and communicate to colleagues and family.  The open-ended debrief at the conclusion of each scenario is vital to integrate the learning undertaken and ensure the learner has a positive learning experience.  Scenario based training needs to be comprehensive in its approach.  This is affirmed by Claude Lauzon, vice president of Civil Aviation Services, “if you don’t see a scenario through to the end, you can actually have some negative training for that situation.  You will not have rehearsed a complete story”.1  Most adults do not learn by watching colourful graphics, cartoons, a mass of powerpoint slides or chatting endlessly.  The learners may enjoy the cartoon and become mesmerised by the graphics, however to remember what is being taught, adult learners have to do.  Adult learners have to be engaged, performing tasks and procedures over and over, connecting the learning to past experience and being able to reflect on the information being presented and the learning experience. 

Providing health care in the real world is complex and challenging, hence the advanced life support scenarios need to be equally complex and challenging if we are to prepare our colleagues to face the task at hand in real life and successfully manage the situation.  The aviation industry and defence force utilise drills to improve success rates for completing tasks, and enhance efficient decision making, in situations that are stressful and there is a lot of information to process in a timely manner.  There is no straight, smooth, direct path to instruct every health care professional on how to manage every resuscitation event that may occur.  Patients, and the resuscitation of our patients, are complex.  By completing advanced life support training and experiencing an array different scenarios the learner is able to build patterns of care in their mind which builds confidence to manage a resuscitation even if it should occur in an unexpected environment with additional complexities.  The clinicians develop an enhanced ability to clinically assess, critically evaluate, anticipate problems, anticipate treatments and overall become more effective care providers.  In our advanced life support courses, learning is enhanced by using quizzes which ask “What is the next step you should do?”.  Such questioning invests the learner and aids the transfer of information into the long term memory. 

Performing tasks during scenario training that are relevant to the learner’s work environment makes the training relevant and learners become more motivated and inspired to learn.  The scenario based learning utilised in our Advanced Life Support courses create strong connections in the learner’s brain, as it utilises past experience, relevance and emotion to grab the learner’s attention.  These connections enable the learning to pass from the short term memory to the long term memory.  It is also important that the training is sufficiently challenging and real-life to engage the learner, so even in the mock situation the learner is invested in the outcome. 

Our advanced life support courses utilise scenario training which incorporates the gathering of information, performing clinical assessment, completion of a number of tasks and procedures, coordinating resources and effective communication.  All these factors are important in scenario based training to assist learners to be ready to perform their role in the real-world.  The scenarios are challenging, relatable, motivational and of equal importance inspiring.  Scenario training improves execution of skills, develops critical thinking and enhances decision-making; all are essential elements for providing effective care to our patients.  Through effective scenario based training learners not only gain vital knowledge and skills but also have enhanced confidence to respond, which is our main goal.  To view some of the advanced life support scenarios that we run at HealthCare Training Service, subscribe to our elearning site and you will be able to see the advanced life support scenarios being played out.  Go to www.hcts.com.au and click on the elearning tab.  Let’s get the balance right.

Reference:

Smith, D. (2010) Scenario-based Training: As Real as it Gets.  Retrieved from http://www.aviationtoday.com/regions/usa/Scenario-based-Training-As-Real-as-it-Gets_68235.html

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