Depending on the learning outcomes and what needs to be taught to healthcare students, simulation can be a useful tool for teaching clinical skills and competencies to students. Human patient simulators are computerised simulators mimicking human body functions at a very high level, while simulated patients (SPs) are trained persons who are coached to portray certain conditions. A major advantage of SPs is that they can be used to teach non-technical skills such as communication, professionalism, and empathy to students and they can give feedback to students after the simulation session. 

This is according to Prof Mathys Labuschagne, Head of the Clinical Simulation and Skills Unit in the School of Biomedical Sciences within the Faculty of Health Sciences at the University of the Free State (UFS), during his inaugural lecture on Wednesday 8 March 2023. With the title of his lecture Clinical Simulation: Quo Vadis? Prof Labuschagne gave a glimpse into the future of clinical simulation. 

Prof Labuschagne, who is passionate about health professions education and clinical simulation, said that in the world of work and technology, students should be prepared for the future. “We should move our curricula from a focus on information acquisition to an emphasis on knowledge management and communication.” 

He developed an interest and obtained a PhD in Health Professions Education in June 2012, with the focus on clinical simulation to enhance undergraduate medical education and training at the University of the Free State.

Prof Labuschagne was appointed Head of the Clinical Simulation and Skills Unit at the UFS in 2012. The facility is used for undergraduate and postgraduate clinical simulation training, as well as interprofessional training and research. He has a special interest in simulation as training tool, precision skills training, and mastery of learning and simulation as tool to prepare students for interprofessional education and collaborative practice.

The simulation unit celebrates its 10-year anniversary this year. 

“To understand simulation training, it is important to understand the learning theory behind simulation. When we expose our students to a concrete experience such as a simulation or clinical encounter, they use their previous knowledge to manage the situation. After this experience, students are debriefed. This is where students learn the most – by discovering gaps in their knowledge.  The next step is the abstract conceptualisation, where mental models that guided the behaviour are identified and modified so that this knowledge and information can be put into practice through active experimentation,” said Prof Labuschagne. 

Some of the reasons for using clinical simulation as a training tool are to improve patient safety, address challenges at the clinical training sites and clinical placements, as well as the educational advantages of simulation. 

According to him, it is important to select the best simulation tool for the outcome we want to achieve with our students. Simulated patients are the best for communication skills, professionalism, teamwork, and examination and history-taking skills, because they are real persons, they can speak, they can act like patients, and they can provide feedback to students. It is a wonderful training tool that is being used more and more to train professional and graduate attributes.

“Human-patient simulators are high-fidelity simulators that look like a person, that can breathe, have a heartbeat, and have other bodily functions, such as sweating and crying. These simulators are excellent for teaching students how to manage emergency conditions such as a heart attack or giving the simulator anaesthesia – conditions we cannot allow students to manage on real patients." 

Virtual patients are avatars on a screen with which students can interact to help them develop clinical reasoning and communication skills.

“Fidelity has to do with the level of realism. So how realistic can your simulations be? There are multiple parameters – apart from the manikins, the context, environment, the situation, the team dynamics, the function of time also play a role. The nice thing about simulation is that you can fast forward and slow down a scenario. Instead of having an operation that lasts three hours, we can do it in 15 minutes,” said Prof Labuschagne.

Simulation training can be done with a stepwise approach, where students start with basic skills such as history taking, examination, then they move to procedural training and team training (team dynamics, communication, and interprofessional collaboration). This is preparation for students to move to the clinical platform before they work on real patients.

“When I try to look into the future, the World Economic Forum (WEF) has identified critical characteristics and learning content based on the Fourth Industrial Revolution (4IR) and Education 4.0 for students to survive the Fourth Industrial Revolution. These include technological skills, interpersonal skills, problem-based and collaborative learning, personalised self-paced lifelong learning, global citizenship skills, and innovation and creativity skills.” 

“These are all the skills we can teach our students with simulation, such as specialised training with our specialised simulators. We can teach students, for instance, laparoscopic surgery with a laparoscopic simulator that gives haptic feedback. Apart from what you see on the screen, you can also feel the tissue and external forces such as instruments and fluids reacting with the tissue. We must train our students to also use the specialised equipment in the hospitals, such as ventilators and ultrasound machines. To align with the characteristics identified by the World Economic Forum, our students are not only prepared for the technological challenges, but also to improve interpersonal skills and skills to be a global citizen.” He continued to say that in the end, everything should be focused on patient safety and holistic patient care. 

According to Prof Labuschagne, research in clinical simulation could be divided into four levels – T1 level research where we do research in the simulation laboratory, T2 level research which measures clinical performance outcomes through transference of skills from simulation to clinical practice, T3 level research studies assess patient safety, and T4 value studies that measure the cost-saving benefits of simulation training and return on investment.

“In the past five years, we have published 23 research articles – all simulation related – with three articles that have been accepted but are yet to be published. In the first five years of the simulation unit, we established the unit so that simulation training could be integrated into the curricula, before we could focus on research as well.”

Prof Labuschagne also emphasised the importance of ethics in clinical simulation training. The shared ethical values include the first and most important one – patient safety. Followed by student psychological safety (students work in this environment where they are allowed to make mistakes), simulated patients (real persons in a simulated environment), human-patient simulators and skills-task trainers (we teach students to act professionally towards the simulator, in the same way they would have acted towards a real patient), and last but not least, the educators and facilitators. 

“We often don’t think of simulators as patients or that they should be treated in an ethical way as well.”