By Victoria Brazil (@SocraticEM)
There is ample evidence that simulation-based training is effective for healthcare professionals seeking to learn or improve procedural skills. We know what optimal simulation-based training looks like: realistic mannikins or part task trainers, careful educational design, and opportunities for practice and feedback. Researchers have explored the learning curves for various procedures, and how closely they correlate with learning on patients.
Less well explored is how much training we need to maintain these skills. What ‘dose’ (volume, frequency) do we need? This draws attention away from our learning curves to our forgetting curves! Mapping these curves is challenging. Factors such as the inherent task complexity, baseline skill level and frequency of skill performance in real world practice are all relevant. But the issue is important. Skills decay, with implications for patient care. Accrediting bodies largely make informed guesses about their annual requirements for practitioners to demonstrate their maintenance of competence.
Haynes and colleagues explore this issue in their study of simulation-based training for neonatal resuscitation, and the specific procedure of face mask ventilation (1). They trained practitioners from six different health professions in neonatal resuscitation, using a relatively simple mannikin and a carefully designed educational program. This approach worked. Practitioners achieved high scores on their skills assessment after the training. But then the authors turned their attention to skills maintenance. Practitioners were asked to do self-directed training over the next 9 months, using a ‘low dose, high frequency’ approach. The project team made it easy for them. A training station was set up in the workplace, and HCPs could do a 5 to 10-minute training scenario on demand. After nine months they reviewed how much training had been done and how it correlated with skill level.
In its simplest interpretation, the authors found that 5 episodes of training correlated with maintenance of skills for global performance of face mask ventilation i.e. 0.6 training episodes per month. Beyond this simple outcome, the granular detail was also interesting. For example, the pediatricians maintained their skills without simulation training because they were doing frequent neonatal resuscitation in the real world. Not all elements of the skill were maintained equally (e.g. maintaining a mask seal versus generating the right pressure with the bag). Some required more practice. But the authors show us how we might establish some metrics for skills maintenance in an otherwise evidence free zone. And they performed this investigation with a pragmatic approach, i.e. seeing how much training is really done when you ask busy healthcare practitioners to maintain their skills with self-directed practice. Similar work has been done for basic life support and resuscitation.
The research team had some advantages: a mannikin with high levels of tactile fidelity for mask ventilation, a task that lend itself to quantitative metrics (e.g. measured pressures/volume) and equipment that was able to measure these variables with a high degree of accuracy. And they worked hard, undertaking a large-scale project with intensive statistical support. Can we realistically spend this much time to find similar metrics for all our procedural skills?
I hope that, at the very least, we codify a process for exploring forgetting curves and recommending the ‘dose’ of simulation or other training required to mitigate them. I think that mental practice is one way this might be feasible and is surprisingly under- examined for this purpose.
Many thanks to Dr Haynes and her team for providing such an exemplar for this work.
Victoria
References
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