UNIT 2 – Procedural training and task trainers
As educators, the first aim of our job is to improve the competence of our students [1].
That is, to improve their skills, their ability to perform well as healthcare professionals.
When talking about skills we know that these are broadly divisible in two categories [2]: technical skills and non technical skills. Technical and procedural skills refer to the ability to perform specific tasks or procedures, such as inserting a catheter or administering medication, or to operate equipment or technology, such as a ventilator or an ultrasound machine. Non-technical skills (NTS), can be defined as a constellation of cognitive and social skills, exhibited by individuals and teams, needed to reduce error and improve human performance in complex systems. NTS have been described as generic ‘life-skills’ that can be applied across all technical domains and are deemed to be ‘non-technical’, in that they have traditionally resided outside most formal technical education curricula [3].
To train a proficient healthcare professional it is necessary to train both the technical and the non-technical skills [4,5,6]
Procedural training and task trainers are used to train specifically the former: the technical skills. To train NTS other types of simulation are used, that will be explained in other sections.
According to the framework proposed by Chiniara et al [7], procedural simulation is one of the modalities of simulation, and focuses on acquiring and improving procedures and technical skills. Its main characteristic is that it allows the learner to replicate specific behaviors and movements inherent in the real-life counterpart. It also allows the learner to train in the specific sequence of actions – procedures – that are required to appropriately perform a specific technical skill.
In procedural training the learning objective is to train or retrain the learner on a single, specific task, allowing the training of specific psychomotor skills and their associated procedures.
This requires the use of a trainer (called task trainer or skill trainer) that is a synthetic or wet training device specifically designed for this purpose.
These type of trainers usually reproduce a part of the human body (hence they are also called part task trainer, or PTT), provide a “good enough” realism (e.g. they reproduce the landmarks needed in the procedure), are not very complex technical wise and therefore they are also usually cheap if compared to whole-body manikins used in other type of simulations.
Low-fidelity mannequins and task are ideal for teaching basic skills such as airway management, CPR, injections, blood draws, bladder catheter in male and female, gynecologic procedures and lumbar punctures, procedural trainers and imaging equipment for ultrasound-guided procedures such as renal biopsy and thoracentesis.
There are many different types of task trainers, possibly one for each of the most common procedures, with more vendors offering similar products.
Without the aim to be complete, we can list, as an example:
- trainers for venous and arterial access, central and peripheral
- trainers for semeiotic (auscultation, palpation)
- trainers for ultrasound training (these are also called phantoms)
- wearable trainers (e.g. for breast examination) to be used on manikins or persons
- trainers for catheterization
- trainers for intubation, ventilation, cricothyrotomy
- trainers for surgical procedures, suture
To design and implement a good procedural training simulation, we need to take these steps:
- decide the training goal, that is, which procedure we want our learners to train on
- choose the appropriate skill trainer to use
- learn how the skill trainer works, and how to perform that procedure in that skill trainer and in the reality, to infuse specific knowledge and tricks to learner
- list and prepare all the other materials that are used during the procedure
- decide how to evaluate and / or give feedback to learners.
Of course the trainers need to be proficient in performing the procedure as well as in operating the task trainer and knowing its limitations.
Advantages and disadvantages
Compared to other types of trainers, especially whole body manikins, procedural trainers are usually cheaper, more robust and durable, built to withstand multiple training sessions, more compact, not very complex and thus less prone to breaking. Since task trainers are built specifically to simulate one or just a few procedures, they sport a good-enough to good realism and mostly they perform well what they have been built for.
Task trainers allow to replicate multiple time the same procedure with no variation, thus allowing the students to go through the same exercise more than once, refining their skill.
Due to the repeatability of the exercise, task trainers are also a tool to assess and evaluate the proficiency of a student in a particular skill and give an objective feedback.
Assessment through procedural training can be done for example using an observatory grid, checklists and rating scales.
One of the main disadvantages of procedural training is quite resource intensive, requiring a time to perform the simulation higher than in other types of training.
This is due to the fact that each learner has to physically try the procedure that is the object of the training, often requiring to be closely supervised by the teacher.
Hence procedural training requires a high teacher to student ratio, usually 1:1 at least during the performing of the exercise, and group exercises, that are used in other types of training to reduce this ratio, here can not be used.
To speed up things it is possible to have many students training at the same time, but this requires the purchase of more skill trainers and an increased number of staff attending the students training.
Another disadvantage of skill trainers is that since each task trainer is built to allow training of one or just a few procedures, it is required to purchase many different trainers to cover all the possible procedures that we aim to train our students on.
This can be heavy on the budget, thus reducing the ability to purchase multiple copies of the same trainers that would allow to speed up the training of many students at once, requires the faculty to be trained in the operation of many different task trainers, and finally can bog down the storage room of even the bigger of the centers.
Future directions and emerging trends
The miniaturization of electronics and lower prices for technology will not play a big role in the future development of procedural training, as most of the skill trainers are not based on high technology but are rather static (e.g. a venipuncture trainer) and will mostly benefit from an improvement on the material used in their build (e.g. more skin like silicons).
Newer technologies however play a role in a novel trend regarding procedural training, that is the hybridization of the skill trainer with mixed reality (MR). Recently some vendors started to market hybrid solutions in which the trainee interacting with the skill trainer wears a virtual reality (VR) or augmented reality (AR) headset. Thanks to the headset, the trainee can visually interact with a virtual environment and at the same time, thanks to the skill trainer, has a physical, real, feedback.
For instance, thanks to MR, an abdominal examination trainer that represents the torso of a patient, is augmented so that the trainees can see the whole virtual patient and interact with it [8].
Thanks to the spreading of MR technologies, in the near future we will see an increase in the number of hybrid products of this kind, that conjugate MR and task trainers.
The fact that task trainers are designed to train for a single specific task and hence they are usually not very complicated from a technology point of view, make them the ideal candidate to be made “in house”.
Due to their low complexity, in fact, it is possible to create some skill trainers by yourself, by using some ingenuity and simple do-it-yourself (DIY) techniques [9].
Reports of the use of these low cost solutions and their effectiveness can be found in literature [10,11], and online it is possible to find an increasing number of guides, instructions and reference materials [12,13] to make your own task trainers.
To produce DIY skill trainers requires some extra equipment, some skilled operators, some extra time, patience and care and surely is less easy than buying a product commercially available; nevertheless, it is an option that could allow simulation centers with tight budget to implement their simulation equipments at a small price and could foster interdisciplinary cooperation (e.g. between medical and technical staff).
References
1. McClelland, D. C. (1973). Testing for competence rather than for “intelligence.” American Psychologist, 28(1), 1–14. https://doi.org/10.1037/h0034092
2. Nasir ANB, Ali DF, et al. Technical skills and non-technical skills: predefinition concept. Presentation at the IETEC’11 Conference, Kuala Lumpur, Malaysia. 2011.
3. Prineas, S., Mosier, K., Mirko, C., Guicciardi, S. (2021). Non-technical Skills in Healthcare. In: Donaldson, L., Ricciardi, W., Sheridan, S., Tartaglia, R. (eds) Textbook of Patient Safety and Clinical Risk Management . Springer, Cham. https://doi.org/10.1007/978-3-030-59403-9_30
4. Engel N, Patey R E, Ross S, Wisely L. Non-technical skills BMJ 2008; 337 :0812454 doi:10.1136/sbmj.0812454
5. Helyar V. Flight school:learning lessons from aviation BMJ 2006; 332 :0606252 doi:10.1136/sbmj.0606252
6. Rosendal AA, Sloth SB, Rölfing JD, Bie M, Jensen RD. Technical, Non-Technical, or Both? A Scoping Review of Skills in Simulation-Based Surgical Training. J Surg Educ. 2023 May;80(5):731-749. doi: 10.1016/j.jsurg.2023.02.011. Epub 2023 Mar 9. PMID: 36906398.
7. Gilles Chiniara, Gary Cole, Ken Brisbin, Dan Huffman, Betty Cragg, Mike Lamacchia, Dianne Norman & Canadian Network For Simulation In Healthcare, Guidelines Working Group (2013) Simulation in healthcare: A taxonomy and a conceptual framework for instructional design and media selection, Medical Teacher, 35:8, e1380-e1395, DOI: 10.3109/0142159X.2012.733451
8. https://bemedskilled.com/gp
9. Ellinas H, Denson K, Simpson D. Low-Cost Simulation: How-To Guide. J Grad Med Educ. 2015 Jun;7(2):257-8. doi: 10.4300/JGME-D-15-00082.1. PMID: 26221446; PMCID: PMC4512801
10. May BJ, Khoury JK, Winokur RS. Tools for Simulation; Low Budget and No Budget. Tech Vasc Interv Radiol. 2019 Mar;22(1):3-6. doi: 10.1053/j.tvir.2018.10.002. Epub 2018 Nov 2. PMID: 30765073.
11. Nachshon A, Mitchell JD, Mueller A, Banner-Goodspeed VM, McSparron JI. Expert Evaluation of a Chicken Tissue-based Model for Teaching Ultrasound-guided Central Venous Catheter Insertion. J Educ Perioper Med. 2017 Jul 1;19(1):E503. PMID: 28377943; PMCID: PMC5327868
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