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A CASE STUDY ON SIGNIFICANCE OF MEDICAL SIMULATION FOR SOFT SKILLS

TRAINING IN EMERGENCY MEDICAL CRISIS MANAGEMENT Brahim Boukatta1, Abderrahim El Bouazzaoui1, Soumaya Touzani1, Nawfal Houari1,

Soumaya Benmaamar2, Nabil Kanjaa1 1 Department of Anesthesiology, Critical Care & Emergency. Hassan II Teaching Hospital, Fez / Laboratory

ARMU, Faculty of Medicine & Pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Morocco. 2 Laboratory of Epidemiology, Clinical Research and Community Health, Faculty of Medicine & Pharmacy of

Fez, University Sidi Mohammed Ben Abdellah, Fez, Morocco.

ABSTRACT

Background: The simulation help improve patient safety, individual and team performance, and the quality of

care. We distinguish between technical skills and non-technical skills that include communication proficiency,

decision-making, and teamwork. Methods: The aim of this study was to evaluate and assess the effect of

simulation in improving non-technical skills in emergency medical crisis management of medical students. The

study was conducted at the simulation center of University Hospital Center affiliated with the Faculty of Medicine

and Pharmacy of Fez, Sidi Mohamed Ben Abdellah University. The participants were the medical students of the

fifth, sixth and seventh-year. The simulation session was organized with groups of three participants. Each team

participated in three different scenarios. The debrief was structured into four phases (reactions, facts, analysis and

summary). During the debriefing and in the most relaxed atmosphere possible, the soft skills were assessed by an

instructor using the Team Emergency Assessment Measure (TEAM). Results: Eighteen students participated in

this study. For each item of non- technikal skills in TEAM there was significant improvement in the mean scores

of subjects between their first and second session and their first and third session (p <0.05). Conclusions: Our

study shows that simulation sessions improve non-technical skills in all medical students. Consequently, given

their crucial importance in ensuring better patient care, they must be integrated early in the training curriculum of

medical and nursing students.

Keywords: Crisis management; Medical students; Morocco, Non-technical skills; Simulation.

Corresponding Author:

Boukatta Brahim, MD.

Affiliation: Department of Anesthesiology, Critical Care and Emergency, Hassan IId University Hospital, Fez/

Laboratory ARMU, Faculty of Medicine and Pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Morocco

E-mail: boukatta@yahoo.fr

ORCID ID: https://orcid.org/0000-0001-8551-5799

Copyright © 2012- 2021 B. Boukatta et al. This is an open access article published under Creative Commons

Attribution -Non Commercial- No Derives 4.0 International Public License (CC BY-NC-ND). This license

allows others to download the articles and share them with others as long as they credit you, but they can’t change

them in any way or use them commercially. *****Published in 2021

doi: 10.46327/msrjg.1.000000000000203

doi url: https://doi.org/10.46327/msrjg.1.000000000000203

INTRODUCTION

Simulation is a technique to replace or amplify real-

patient experiences with guided experiences,

artificially contrived, that evokes or replicates

substantial aspects of the real world in a fully

interactive manner [1]. Simulation improves patient

safety and the technical and non-technical skills of

teams (communication proficiency, decision-

making, and teamwork) [2, 3]. The aim of this study

was to evaluate and assess the effect of simulation in

improving non-technical skills of medical students in

emergency medical crisis management.

MATERIAL AND METHODS

The study was conducted at the simulation center of

University Hospital Center affiliated with the

Faculty of Medicine and Pharmacy of Fez, Sidi

Mohamed Ben Abdellah University. The

participants were the medical students of the fifth,

sixth and seventh-year. The scenarios chosen by the

pedagogical team were cardiac arrest in adults,

consciousness disorders, beta-blocker poisoning,

polytrauma, severe traumatic brain injury, agitation

in the intensive care unit, febrile jaundice, breaking

bad news to families of hospitalized patients, acute

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severe asthma, management of decompensated

diabetes, severe acute pancreatitis and

pheochromocytoma. These illnesses are frequent in

real-life. To ensure maximum immersion, we used

the high-fidelity adult manikin and standardized

patient that corresponds to a healthy individual

trained to portray a clinical problem or situation for

the purpose of testing or teaching specific skills in

the field of health care professionals (Figure 1).

Figure 1: The high-fidelity adult manikin

The simulation session was organized in four parts

with groups of 3 participants. Group 1 corresponds

to novice participants and group 6 to the most

experienced participants. Each team participated in

three different scenarios (Table I). The average

session duration, from the briefing to the debriefing

was 50 minutes. The session began with a briefing,

during which the medical teachers exposed the

material, the environment, the clinical context with a

presentation of the clinical case. The scenario lasts

15 minutes. The debriefing, at the end of each

session, was structured into four phases (reactions,

facts, analysis and summary). During the debriefing,

and in the most relaxed atmosphere possible, we

assessed the overall feeling of participants, analyzed

the technical skills (method of interrogation,

diagnostic process and treatment) and controlled the

respect of hygiene rules and soft skills.

(Communication, teamwork…)

Table I: distribution of participants by scenarios

Team Scenario 1 Scenario 2 Scenario 3

N°1 Cardiac arrest in adults Consciousness disorders Severe traumatic brain injury

N°2 Polytrauma Agitation in the intensive care unit Febrile jaundice

N°3 Acute severe asthma Decompensated diabetes Cardiac arrest in adults

N°4 Severe acute pancreatitis Breaking bad news Cardiac arrest in adults

N°5 Cardiac arrest in adults Breaking bad news Consciousness disorders

N°6 Pheochromocytoma Breaking bad news Beta-blocker poisoning

The soft skills were assessed by an instructor using

the Team Emergency Assessment Measure. To

achieve this objective, we have chosen the

Teamwork Emergency Assessment Measure

(TEAM), an observational scale designed for

measuring team processes and performance, which

has been developed and validated in accordance with

the psychometric theory [4-7]. It comprises eleven

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items rated on a four-point Likert response scale and

covering three dimensions namely leadership,

teamwork, and task management–and one overall

team performance rating item (TEAM) (Figure 2)

[8].

Figure 2: Team Emergency Assessment Measure (TEAM)

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RESULTS:

Eighteen students participated in this study. The results from the first sessions reflect the real level of the

participants’ skills and are the most representative of pre- intervention control scores (pre-existing skill levels of

medical students before assessing additional training). The scores from the second session correspond to the

additional skills acquired from the previous session’s training. The scores from the third session should correspond

to the additional skills obtained from the second session’s training (Table II).

Table II: Scores for groups

Group Scenario 1 (Score/ 56) Scenario 2 (Score/ 56) Scenario 3 (Score/ 56)

Group 1 7 16 25

Group 2 12 23 24

Group 3 15 29 34

Group 4 14 26 32

Group 5 15 28 41

Group 6 33 36 38

Before the simulation training, the participants often didn’t appoint a leader, and when the leader identifies himself,

he was unable to work and organize the team, distribute tasks, give clear and precise orders and redistribute the

roles. About the teamwork, there is a poor communication, lack of feedback and of coordination and the

participants were unable to work as a team. After simulation and debriefing, all of these failures improved over

the course sessions. So, for each item of non- technical skills in TEAM, there was a significant improvement in

the mean scores of subjects between their first and second session and their first and third session. Statistical

analysis (Test t) showed a significant difference between the mean scores of the different groups when comparing

the different scenarios (p<0.05) (Table III).

Table III: statistical comparison of the means of the results during the different scenarios

Scenarios Mean (standard deviation) p

Scenario 1 16 (8,85) 0,001

Scenario 2 26,33 (6,65)

Scenario 2 26,33 (6,65) 0,02

Scenario 3 32,33 (6,83)

Scenario 1 16 (8,85) 0,002

Scenario 3 32,33 (6,83)

These results represent the effect of the intervention of a simulation session with debriefing. Three very strong

points emerge from this analysis. The first point is that there is a significant difference in non-technical

performance between the novice groups who have never benefited from this training (First to fifth group) and the

6th group who have already benefited from this training (Figure 3).

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Figure 3: Comparison between group 1 and group 6

The second point, we recorded an improvement in these skills during the sessions, with a clear difference between

the first and the third session (Figure 4). The third point is that the performances were maintained for the sixth

group over time.

Figure 4: The evolution of group performance after training sessions

DISCUSSION:

Medical teaching has placed significant emphasis on

knowledge acquisition and the mastering of

technical skills [9]. However, critical incident

reporting and observational studies, both in the

clinical setting and on patient simulators, have

identified nontechnical skills to be major

determinants of successful crisis management [10,

11]. The term non-technical skills (NTS) or soft

skills was derived primarily from the aircraft

industry, such skills include leadership, teamwork,

decision making and situation awareness [12]. The

Leadership is the ability of an individual or a group

0

5

10

15

20

25

30

35

40

Scenario 1

Scenario 2

Scenario 3

Group 1 Group 6

0

5

10

15

20

25

30

35

40

45

Group 1 Group 2 Group 3 Group 4 Group 5 Group 6

Scenario 1

Scenario 2

Scenario 3

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of individuals to influence and guide followers or

other members of an organization [13]. The

teamwork include clarity of goals, effective and

efficient communication, defined roles and

horizontal leadership [14]. Situation awareness is

described as the perception of the elements in the

environment within a volume of space and time, the

comprehension of their meaning and the projection

of their status in the near future [15]. Unfortunately,

these skills are not necessarily acquired by medical

students through routine clinical experience and may

need to be specifically taught. These skills are all the

more necessary in the management of crisis

situations, whether in anesthesia or in emergency

medicine. In this stressful context, where the medical

staff (doctors, nurses) must be vigilant, fast and

extremely precise, the concept of crew resource

management (CRM), which is a tool that was

initially developed by the aviation industry and

which has largely contributed to reducing the

incidence of aircraft accidents over the past 4

decades is perfectly suited [16]. CRM training has

been shown to improve team performance and

decrease error during medical and surgical crises in

the operating room [17, 18]. The CRM were adapted

for anaesthesia by Gaba and colleagues (anesthesia

crisis resource management) [10]. they comprise

fifteen points in anesthesia crisis resource

management (ACRM) : Know the environment,

anticipate and plan, call for help early, exercise

leadership and followership, distribute the workload,

mobilize all available resources, communicate

effectively, use all available information, prevent

and manage fixation errors, cross (double) check,

use cognitive aids, re-evaluate repeatedly, use good

teamwork, allocate attention wisely and set priorities

dynamically. Most of the studies in the area of crisis

resource management training for emergency

medicine focused on emergency medicine residents

or interdisciplinary trauma teams. The aim of this

study is to evaluate and assess the effect of

simulation in improving non-technical skills in

emergency medical crisis management of medical

student. Cooper Simon in a literature review showed

that various non-technical measures of skills are

available; only a few have been used in emergency

care and there is a need to increase the targeted

assessment of teamwork skills for a better

understanding of team performance to improve

patient safety in emergency medical care [19].

Teodora shows that even one day training on CRM

principles using a combination of didactic and

simulation sessions may significantly improve

nontechnical skills in all the categories involved in

an inter- professional emergency team [20]. Vera

Hagemann shows that the effectiveness of a single

brief seminar on non-technical skills to improve

student’s non-technical skills [20]. Our study shows

that CRM teaching with simulation sessions

improves non-technical skills in all medical students

learning curve. Consequently, given their crucial

importance to ensuring better patient care, they must

be integrated early in the training curriculum of

medical and nursing students.

CONCLUSION

Clinical medicine is becoming focused more on

patient safety and quality. Our study shows that the

medical simulation is a good technique of teaching

the technical and soft skills for graduate medical

education, undergraduate medical education, and

continuing medical education, so it must be

integrated into the educational curriculum even

before the start of clinical placements.

ACKNOWLEDGMENTS

The authors appreciate all the medical students who

helped in conducting this research, the simulation

center of the department of anesthesiology, critical

care and emergency of Hassan IId Teaching Hospital,

Fez and the ARMU laboratory, Faculty of Medicine

and Pharmacy of Fez, Sidi Mohamed Ben Abdellah

University, Morocco.

CONFLICT OF INTEREST

The authors did not declare any conflict of interest.

FUNDING

No funding to declare.

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