Focusing on the professionalism of the future medical worker, it becomes necessary to significantly enhance the practical training of students while maintaining the proper level of theoretical knowledge.
Considering certain problems in the training of nursing staff, in particular, nurses. Among them: the fear of graduates in front of patients, the dissatisfaction of patients with initiation with inexperienced personnel, the restriction of students' access to treatment rooms during internships, and the psychological fear of performing the procedure. It is impossible not to pay attention to the lack of time for practicing each practical skill, which leads to a high risk to the health of the patient.
The way out of this situation is the creation of modern practice rooms with the necessary set of equipment for performing nursing manipulations. It is important to improve pedagogical learning technologies, using such as gaming technology, contextual learning, method of solving situational problems.
Most modern method teaching students practical skills of activity is the use of simulation technologies in the system of training of paramedical personnel.
Translated from the Latin term simulation (simulation- visibility, pretense) - the creation of the appearance of a disease or its individual symptoms by a person who does not suffer from this disease, or an imitation of any physical process using an artificial (for example, mechanical or computer) system. That is, this concept was originally used in medicine. But if there is a patient feigning illness, then there may be a medical professional feigning treatment. Although simulation training began to be actively used in the second half of the last century in those industries where errors in training on real objects could lead to tragic consequences. These are aviation, nuclear energy, railway transport. In medicine, this type of training of specialists actively began to develop in the 70s and today is the generally accepted norm for almost all models of medical education.
The transition from knowledge to skills, and then skills, implies the training of mid-level medical specialists with the introduction of a system of simulation or modeling of certain situations into the learning process.
The use of medical phantoms in practical classes can play an important role in achieving this goal. One of the explanations for the concept phantomO m(French fantome, from Greek phantasma - vision, ghost) gives Big soviet encyclopedia: A life-size model of the human body or part of it that serves as a visual aid.
The main task of medical phantoms is to create clinical situations that are as close as possible to real life situations. In the Moscow Regional Medical College No. 1, in practical classes in professional modules, students, before starting work practice in medical institutions, must master not only patient care skills, but also basic manipulations in accordance with the program of practical classes. Teachers are aware of the urgent need for the correct alignment educational process in college, taking into account the student's full mastery of the theory and testing of manipulations and clinical techniques on mannequins and simulators-phantoms.
Classes in college are built according to a certain algorithm. At the first stage, students receive theoretical knowledge. On the second master practical skills. The third stage is devoted to the development of practical manipulations in conditions close to real ones (real environment, real equipment, a mannequin that independently reacts to student interventions). Students under the guidance of a teacher, through repeated repetition and analysis of mistakes, achieve the perfection of skills in working with equipment and the patient, working in a team, mastering general and professional competencies.
Let us give examples of educational situations set before students and aimed at working out the manipulations used in our college.
Academic discipline:"Fundamentals of resuscitation" (final practical lesson).
Learning situation: Patient A. choked on an olive. A person wheezes, cannot breathe, the skin begins to turn blue.
Task: Provide emergency assistance to the victim.
Manipulation conditions: One student performs the manipulation, the rest observe his action and at the end comment on the mistakes made. This manipulation is performed by each student in turn.
Stage number 1.
To help a person using an appropriate phantom simulator, the student must choose a method for extracting a foreign body, apply this method in practice.
In this situation, students reinforce the Heimlich technique.
A) The procedure for helping a choking person, if he is still on his feet and has not lost consciousness:
1. The student needs to stand behind the victim, wrapping his arms around him.
2. Squeeze one hand into a fist and the side where the thumb is, put it on the victim's stomach at the level between the navel and costal arches (in the epigastric region of the abdomen).
3. Put the palm of the other hand on top of the fist, with a quick push up, press the fist into the stomach.
In this case, the arms must be sharply bent at the elbows, but the chest of the victim should not be squeezed.
4. If necessary, repeat the reception several times until Airways will not be released.
B) The victim is unconscious or cannot be approached from behind:
1. Put the victim on his back.
2. Sit astride the hips of the victim, facing the head.
Put one hand on the other, place the base of the palm of the lower hand between the navel and costal arches (in the epigastric region of the abdomen).
3. Press vigorously on the victim's abdomen in an upward direction towards the diaphragm using your body weight. The victim's head should not be turned to the side.
4. Repeat several times until the airways are clear.
Stage number 2.
In case of failure to extract a foreign body, the victim
cardiac and respiratory arrest occurs. Students (method I - 1 person, method II - 2 people), using the appropriate phantom simulator, must perform cardiopulmonary resuscitation. The phantom simulator of the latest generation shows the correctness of this manipulation with the help of an appropriate indication, which allows the student to correct incorrect actions in a timely manner.
1. The student must check for signs of clinical death in the victim:
Pulse;
Breath;
Pupil reaction to light;
Reaction "cat's eye".
2. Extend the victim's lower jaw.
3. Clean the victim's mouth.
5. Make 2 exhalations into the victim's mouth.
6. Find the correct position for the hands (2 fingers above the xiphoid process, place the base of the palm on the victim's sternum). Make 30 sharp pressure.
7. After 5 cycles: check for a pulse. If there is no pulse, continue to apply pressure.
Stage number 3.
When restoring cardiac activity and respiration of the victim, it is necessary to insert a venous catheter and use it to inject drugs to maintain cardiac activity using an appropriate phantom simulator.
The student independently chooses the necessary equipment (presented on the manipulation table).
1. The student must check the integrity of the packaging and the shelf life of the catheter.
2. Apply a tourniquet to the victim 10-15 cm above the intended catheterization zone.
3. Treat the catheterization site with a skin antiseptic for 30-60 seconds and allow to dry on its own.
4. Fix the vein by pressing it with your finger below the intended insertion site of the catheter.
5. Take the catheter and remove the protective sheath.
6. Insert the catheter on the needle at an angle of 15 degrees to the skin, observing the appearance of blood in the indicator chamber.
7. Reduce the angle of the stylet needle when blood appears in the indicator chamber and insert the needle into the vein by a few millimeters.
8. Fix the stylet needle, and slowly move the cannula from the needle into the vein to the end (do not remove the stylet needle completely from the catheter yet).
9. Remove the tourniquet.
10. Clamp the vein throughout to reduce bleeding and finally remove the needle from the catheter.
11. Remove the plug from the protective sheath and close the catheter.
12. Fix the catheter on the limb.
13. Inject 1 ml of 0.1% epinephrine.
This situation is aimed at consolidating the professional skills of students:
Development of the correct algorithm of actions to assist the victim.
The choice of the necessary manipulation depending on the result of the previous manipulation.
The choice of the necessary medical equipment depending on the manipulation.
Performing manipulations alone or with a partner.
Formation of confidence in their actions when providing assistance to the victim.
Analysis of the actions of other students and mutual assistance.
The complex use of phantom simulators makes it possible to combine theoretical and practical knowledge, disparate manipulations into a single whole of medical interventions, contributes to the development of confidence in one's actions, increasing the interest and motivation of students in the learning process.
List of used literature
1. Muravyov K.A., Khodzhayan A.B., Roy S.V. SIMULATION EDUCATION IN MEDICAL EDUCATION IS A TURNING POINT // Basic Research. – 2015.
2. Journal of Virtual Technologies in Medicine, No. 2, 2015
Used materials and Internet resources
1. http://www.medsim.ru/
2. http://www.ugrasu.ru/
3. http://www.medsim.ru4.
4. http://stand-posters.rf/Fantom.htm
6. Ofordeme K.G., Papa L., Brennan D.F. Botfly myiasis: a case report. CJEM. 2007; 9:380-2.
7. Clyti E., Deligny C., Nacher M., del Giudice P., Sainte-Marie D., Pradinaud R. et al. An urban epidemic of human myiasis caused by Dermatobia hominis in French Guiana. Am. J Trop. Med. Hyg. 2008; 79:797-8.
8. Goksu T., Lonsdorf A., Jappe U., Junghanss T. Furunculoid skin lesions after travel to the tropics. Internist (Berl.). 2007; 48:311-3.
9. Hu J.M., Wang C.C., Chao L.L., Lee C.S., Shin C.M., Telford S.R. First report of furuncular myiasis caused by the larva of botfly, Dermatobia hominis, in a Taiwanese traveler. Asian Pac. J Trop. Biomed. 2013; 3:229-31.
10. Sidelnikov Yu.H., RudikA.A. Dermatobiasis in Khabarovsk. Far East J of Infectious Pathology. 2008; 13:169-72. (in English)
11. Clyti E., Pages F., PradinaudR. Update on Dermatobia hominis: South American furuncular myiasis. Med. Trop. (Mars.). 2008; 68:7-10.
12. M.R.L., Barreto N.A., Varella R.Q., Rodrigues G.H.S., Lewis D.A. et al. Penile myiasis: a case report. sex. Transm. Infect. 2004; 80:183-4.
13. Boruk M., Rosenfeld R.M., Alexis R. Human botfly infestation presenting as peri-auricular mass. Int. J. Pediatr. Otorhinolaryngol. 2006; 70:335-8.
14. Denion E., Dalens P.H., CouppieP., Aznar C., Sainte-MarieD., Carme B. et al. External ophthalmomyiasis caused by Dermato-bia hominis. A retrospective study of nine cases and a review of the literature. Acta Ophthalmol. Scand. 2004; 82:576-84.
15. Rossi M.A., Zucoloto S. Fatal cerebral myiasis caused by the
tropical warble fly, Dermatobia hominis. Am. J Trop. Med. Hyg. 1973; 22:267-9.
16. Vijay K., Kalapos P., Makkar A., Engbrecht B., Agarwal A. Human botfly (Dermatobia hominis) larva in a child's scalp mimicking osteomyelitis. Emerg. Radiol. 2013; 20: 81-3.
17. Clyti E., Nacher M., Merrien L., El Guedj M., Roussel M., Sainte-Marie D., Couppie P. Myiasis owing to Dermatobia hominis in a HIV-infected subject: Treatment by topical ivermectin. Int. J. Dermatol. 2007; 46:52-4.
TEACHING ISSUES
I heard and forgot, I saw and remembered, I did and understood Confucius
I.I. Kosagovskaya, E.V. Volchkova, S.G. Pack
MODERN PROBLEMS OF SIMULATION EDUCATION IN MEDICINE
1GBOU VPO First Moscow State Medical University. THEM. Sechenov of the Ministry of Health of Russia, 119991, Moscow, st. Trubetskaya, 8
Before applying them to real patients, students must acquire practical skills in clinical work in special centers equipped with high-tech simulators and computerized mannequins that allow simulating clinical situations. One of the important prerequisites for the implementation of this principle is the creation of modern simulation centers. The article discusses the problems that need to be solved for the successful and effective implementation of simulation training in medical education. Keywords: simulation training in medicine; simulation technologies; simulation center; simulation training; simulation methods; formation of practical competencies.
I.1. Kosagovskaya1, E. V. Volchkova1, S. G. Pak1
CURRENT PROBLEMS OF THE SIMULATION-BASED EDUCATION IN MEDICINE
II.M. Sechenov First Moscow State Medical University, 8-2, Trubetskaya street, Moscow, Russian Federation, 119991
Practical skills of clinical work before applying them to real patients, students should acquire in special centers, equipped with high-tech simulators and computerized mannequins, permitting to simulate the clinical situations. One of the important prerequisites to the implementation of this principle is the creation of modern simulation centers. In the article there are discussed the problems which must be sold for the successful and effective implementation of a simulation training in the medical education.
Key words: simulation training in medicine; simulation technologies; simulation center; simulation training; simulation techniques; development of practical competencies.
The rapid development of high-tech medicine in the modern world places increased demands on the quality of medical services. The quality of medical care and the quality of life of patients should underlie the evaluation of both professional activity individual specialists and institutions, and the level of healthcare in general. In the US, 98,000 deaths a year are due to medical errors. There are no such official statistics in the Russian Federation, but the problem of forming the practical competencies of a doctor is also quite acute. Thus, according to a survey of medical school graduates in 2012, only 12% of them rate their knowledge of practical skills as good. in addition, an insufficient level of development of non-technical skills (including teamwork, leadership, effective communication, the level of knowledge and the ability to make the right decisions) are common causes of medical errors.
Obviously, modern medical education must also correspond to the ongoing technological revolution and changes in the surrounding information environment. High modern requirements for the development of practical skills by medical students, for updating educational material and the approach of the educational environment to the new environment of practical healthcare make virtual technologies in medical education a key direction in the development of higher medical school.
Relevance of the problem
The classical system of clinical medical education is not able to fully solve the problem of high-quality practical training of a doctor. The main obstacles to this are the lack of continuous feedback between the student and the teacher, the impossibility of practical illustration of the whole variety of clinical situations, as well as moral, ethical and legislative restrictions in the communication of students with the patient. Therefore, the key task of modern secondary, higher and postgraduate medical education is to create conditions for the development of a wide range of competencies and well-established practical skills among students without the risk of harming the patient. This includes the development of the ability to make quick decisions and perform flawlessly a number of manipulations or interventions, especially in emergencies.
it is obvious that the training of specialists responsible for the life and health of people in the modern world simply cannot be built without the most important simulation component. A lot of experience has already been accumulated, proving the effectiveness of simulation training.
Numerous evidences have been obtained that testify to the successful transfer of the skills acquired by the doctor to the treatment of the patient, which could not but lead to the extensive development of a network of simulation centers. Thus, for 5 years from 2003 to 2008 in the United States, the number of residencies has sharply increased, where simulation training of doctors is used,
For correspondence: Kosagovskaya Irina Igorevna, Ph.D. honey. Sciences, Associate Professor public health and preventive medicine of the First MPMU them. THEM. Sechenov, e-mail: [email protected]
Correct Correct
interpretation choice of treatment
ECP,% niya,%
Specialized and medical 17.4 21.2
ambulance brigades
ambulance teams 18.7 19.2
specializing in emergency medicine. Thus, in 2003, simulation training existed in 33 (29%) residencies out of 134 respondents, and in 2008 - in 114 (85%) .
The global trend towards an increase in the number of simulation centers has not left Russia aside either. A circle of specialists in this field is being formed, international experience is being adapted to the peculiarities of domestic education. Several Russian specialized routs with mixed participation have already taken place, where, in addition to solving the promotional tasks of the conference organizers, there was an interested discussion of really important applied aspects of simulation training. Simulation techniques have firmly entered the system of medical education and have become an integral part of training in health care. In most educational institutions, new structural subdivisions have appeared - simulation and certification centers. Due to decentralized development, all of them have acquired a different organizational structure, specialization, equipment options, and work according to different methods and standards.
At the beginning of 2012, the Russian Society for Simulation Education in Medicine (ROSOMED) was created, which brought together enthusiasts and like-minded professionals in the field of training medical personnel without risk for the patient and the doctor, using simulation technologies. During this short period of time, the ROSOMED society became a co-organizer of two large all-Russian conferences with international participation, the society's experts spoke at European and world congresses, joint developments of simulation equipment with leading world and domestic manufacturers were launched and successfully implemented, a team of authors wrote the first domestic manual "Simulation medical education". In the spring of 2013 under the Ministry of Health Russian Federation The Committee for Continuing Medical Education was established. The first steps have been taken to develop domestic standards for simulation training, new classifications of equipment and simulation and certification centers have been proposed.
Studies have been conducted proving the need to improve the effectiveness of training medical personnel (see table), which can be achieved through the active introduction of continuous vocational education simulation trainings.
About terminology
Currently, there are various definitions of the concept of "simulation learning". If to speak
about this approach regardless of professional activity, then most often simulation training is considered as a mandatory component in professional training, using a model of professional activity in order to provide each student with the opportunity to perform professional activity or its individual elements in accordance with professional standards and / or procedures (rules) .
McPaghy (1999) describes a simulation as "a person, device, or set of conditions that authentically recreates the actual problem. The student or trainee must respond to the situation in the way that he would do in real life" .
David Paba of Stanford University has proposed a more detailed definition of this term, according to which a simulation is "a technique (not a technology) that allows you to replace or enrich the practical experience of the trainee with an artificially created situation that reflects and reproduces the problems that occur in the real world. , in a fully interactive manner." Paba also proved the need for planning in the organization of the educational process; he emphasized that simulation is primarily about learning, and not about the technology that underlies the simulation.
Nicolas Maran and Ronnie Plavin of the Scottish Clinical Simulation Center described simulation as "an educational technique that involves an interactive, 'immersive' activity by recreating a real clinical picture in whole or in part, without any associated risk to the patient."
Thus, simulation is an imitation, modeling, realistic reproduction of the process. And simulation in medical education is a modern technology for teaching and evaluating practical skills, abilities and knowledge, based on realistic modeling, simulating a clinical situation or a single physiological system, for which biological, mechanical, electronic and virtual (computer) models can be used.
Simulation training should be carried out by specially trained full-time instructors (teacher-trainers, training masters), who, together with practicing specialists (experts), will create and accumulate the baggage of various scenarios, conduct methodological work, and, together with technical workers (technicians and engineers), develop and maintain training facilities (software, computers, simulators, simulators, phantoms, models and professional equipment) in working and safe condition based on the system of engineering and maintenance and supply of consumables.
One of the important stages of simulation training is debriefing.
Debriefing (from the English. debriefing - discussion after completing the task) - following the execution of the simulation exercise, its analysis, analysis of the "pluses" and "minuses" of the actions of the trainees and discussion of the experience they have gained. This type of activity activates reflective thinking in trainees and provides feedback for evaluation.
ki the quality of the simulation task and the consolidation of the acquired skills and knowledge. Studies show that trainees have a limited understanding of what happens to them when they are involved in a simulation experience. Being at the center of the action, they only see what can be seen from the perspective of an active participant. Therefore, it is thanks to debriefing that the simulation experience turns into a conscious practice, which will ultimately help the trainee prepare both emotionally and physically for future professional activities.
According to S. Salvoldelli et al. conducting a debriefing significantly increases the effectiveness of a simulation session on crisis situations in anesthesiology. In another study, it was found that the inclusion of debriefing in the simulation training of anesthesiologists increased the effectiveness of training, as well as the duration of retention of acquired knowledge and skills by cadets.
Forms and methods of medical simulation training
The history of the use of medical simulation in the education of doctors dates back many millennia and is inextricably linked with the development of medical knowledge and the progress of scientific and technological progress. Thus, the success of the chemical industry led to the emergence of plastic dummies, the progress of computer technology predetermined the creation of virtual simulators and patient simulators.
In the domestic healthcare system, among other things, various phantoms, models, dummies, simulators, virtual simulators and others have appeared and are being widely implemented. technical means training, allowing to model processes, situations and other aspects of the professional activity of medical workers with varying degrees of reliability. At the same time, if individual phantoms for practicing the simplest practical skills have been used in some educational institutions for a long time, then the introduction of complex virtual simulators and management systems for their use in education appeared only in the last decade. To date, sufficient experience has been accumulated in the application of simulation methods in education, including medical education.
Doctors who begin their practical work need a fairly long period to master the practical skills of performing various medical interventions. Thus, according to different authors, doctors specializing in endovideosurgery need to perform from 10 to 200 laparoscopic cholecystectomy, 20-60 fundoplications, etc.
The traditional forms of teaching the practical skills of a doctor include the following options: on animals, on cadavers, with the participation of patients (assistance during curation and operations). All these training options have significant drawbacks - when training on animals, it is necessary to maintain and maintain a vivarium, pay for the work of its employees, and purchase animals; at the same time, the number and time of manipulations is limited, constant individual monitoring of the teacher with a subjective assessment of the work of the student is necessary, there are organizational problems in the use of drugs, it is necessary to take into account the protests of animal rights activists, ethical problems
etc. It is just as difficult and inconvenient to train on corpses, which requires the organization of a special service, while the work is unrealistic.
To achieve the proper level of practical skills, it is necessary to perform 100-200 procedures under the supervision of a teacher. These training options require expensive equipment, tool kits, and consumables. And finally, due to the risk of harm to the patient, the risk of developing iatrogenic complications, the acquisition of initial, basic practical skills with the participation of patients should be considered unacceptable.
The only effective and safe way to develop practical skills is currently provided by virtual technologies. The situations simulated on the computer actively react to the actions of the cadets and completely imitate the physiological response of the patient to the actions of the doctor or reproduce the adequate response of the tissues to the manipulations of the surgeon. Doctors who have mastered practical skills with the help of virtual simulators move on to real interventions much faster and more confidently, their further real results become more professional. Besides, computer modelling, based on the objective data of a real patient (MRI, CT, ultrasound, etc.) allows you to predict in advance and even work out the upcoming examination or operation, which reduces the potential risk and improves the quality of medical care.
Training on robots - patient simulators allows you to assess the initial level of teamwork and significantly improve it in the learning process. In a study conducted on simulators in the simulation of traumatic shock, a significant increase in team skills during the training process was proved. At the same time, it is worth considering the data of the study, which proved that the assimilation of SIMR skills is higher on simulator robots than on simulators.
Currently, dozens of companies around the world produce virtual simulators for many medical specialties. Dozens are dedicated to them. annual conferences, hundreds of articles are published . Virtual simulators have a number of undeniable advantages over the training options discussed above - there are no current financial costs, the duration and mode of training are not limited in time, any number of repetitions of the exercise is possible with automatic, instant and impartial qualitative and quantitative assessment until its full proven mastery is achieved and consolidation, the constant presence of a teacher is not required, methodological recommendations are carried out automatically, the program itself indicates the mistakes made, and objective certification is performed. Already the first completed studies by N. Seymour, T. Grantcharov show the advantages of virtual simulators. According to the authors, the use of a virtual simulator in the educational process significantly, by 2.5 times, reduces the number of mistakes that novice surgeons make when performing their first laparoscopic operations. The results of the research confirm the validity of the continued introduction of simulation virtual technologies in medical education and training programs.
Realism of the simulation equipment (fi-
delity) used to educate health workers is divided into seven levels . When developing simulators, each subsequent level is more difficult to implement. In accordance with these levels of realism, all simulators can be classified:
1. Visual, when traditional teaching technologies are used - diagrams, printed posters, models of the human anatomical structure. It can also be the simplest e-books and computer programs. The basis of any practical skill is visual simulation training, during which correct sequence actions during medical procedures. The disadvantage is the lack of practical training of the trainee.
2. Tactile, when the passive reaction of the phantom is reproduced. In this case, manual skills, coordinated movements and their sequence are practiced. Thanks to realistic phantoms, it is possible to bring certain manipulations to automatism, to acquire technical skills in their implementation.
3. Reactive, when the simplest active reactions of the phantom to the student's actions are reproduced. Assessment of the accuracy of the actions of a trained person is carried out only at a basic level. Such dummies and simulators are made of plastic, supplemented by electronic controllers.
4. Automated - these are the reactions of the mannequin to external influences. Such simulators use computer technology based on scripts, when certain actions are given a specific response by a phantom. Cognitive skills and sensory motor skills are being developed.
5. Hardware - the situation of the medical office, operating room. Thanks to such training systems, a confident ability to act in a similar reality is achieved.
6. Interactive - a complex interaction of a simulator mannequin with medical equipment and a cadet. Automatic change in the physiological state of an artificial patient, an adequate response to the introduction of drugs, to incorrect actions. At this level, the trainee's qualifications can be directly assessed.
7. Integrated - the interaction of simulators and medical devices. During the operation, virtual simulators demonstrate all the necessary indicators. psychomotor skills, sensorimotor skills of technical and non-technical skills are being worked out. The transition to the next level of realism will increase the cost of simulation equipment by a factor of three (the “triple rule”).
Separately, I would like to dwell on such a form of simulation training as a "standardized patient". A standardized patient is a person (usually an actor) who has been trained to simulate a disease or condition with a high degree of realism such that even an experienced clinician cannot recognize the simulation. work with a "standardized patient" allows assessing the skills of taking an anamnesis, adherence to deontological principles and assessing the clinical thinking of a doctor.
The use of actors instead of patients during practical training was first tested in 1963 by teachers at the University of Southern California while teaching medical students as part of a three-year neurology training program. The role of patients was played by
teres trained to portray pathological conditions. A description of this experiment was published in 1964, but then, half a century ago, the method was considered expensive and unscientific. Then in 1968 the practice of using assistants to demonstrate a gynecological examination was introduced. A more broadly similar covert integration of patient actors into the work of clinics occurred in the 1970s, during which there was a change in the name of "instructor patients" to "standardized patients".
In 1993, the Medical Council of Canada first included the assessment of the skills of medical students using standardized patients in the licensing program, and the following year this method of assessing knowledge and skills was officially adopted by the educational commission for foreign medical graduates. Scientific studies have proven the obvious effectiveness of simulation training compared to traditional (Fig. 1) .
The validity, reliability and practicality of the "practical clinical examination" has been confirmed and described in many studies, the data became the basis for the official approval of the National Board of Medical Examiners (NBME) for the practice of using standardized patients in IV-VII courses of study. The first mandatory testing for US medical students (Clinical Skills - Phase II) was completed in 2004 as part of the state licensing program. The practice of using a “standardized patient” also exists in the system of Russian medical education, however, due to the high cost and difficulty of organization, it has not received wide distribution.
Speaking about modern simulation educational technologies, one should, apparently, separate the concept of technology for teaching practical skills and algorithms using specialized simulators and mannequins and the concept of simulation - clinical simulation of critical situations using a specialized training system, the main component of which is a multifunctional computerized mannequin - an imitator of a real patient.
The first involves teaching a certain practical skill or even a group of skills, a technique or algorithm using simulators or dummies of varying degrees of complexity. The main goal of such training is to teach a specialist to work with his hands, giving him the opportunity to perform specific practical manipulations, such as intubation, providing vascular access, defibrillation, and many others. This concept can also include the practical development of individual methods and algorithms, which becomes possible in the course of practical work on dummies and allows the doctor to present in detail, streamline and remember the necessary procedure in a critical situation. This is an individual training of a specialist without being tied to his work in a team, which does not require recreating the realism of the patient, the place of emergency care or anesthesia care, and the entire situation with the patient as a whole.
The second concept - simulation in emergency medicine - implies a wider context. The main objectives of simulation training are teaching how to work with a patient in a critical situation in conditions as close as possible to those in which
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Rice. 1. Results of a randomized anonymous clinical trial on the effectiveness of simulation training in the operating room.
specialist works. These conditions recreate the appearance of a real patient and his vital functions (starting with the ability to talk, breathe, reproduce pulsations on peripheral vessels, sounds, tones, heart, lung, gastrointestinal tract noises to fixing indicators on monitors of real medical equipment). computer program allows you to change the parameters of the patient and create scenarios - clinically recreate various critical conditions that the trained specialist will learn to cope with using their knowledge, analytical abilities, clinical experience, practical skills, necessary medical equipment and personal characteristics. The main point of simulation training is the maximum imitation of all components that can be involved in real life. life situation associated with the treatment of a patient in a critical situation. The maximum reproduction of the place where the events unfold should be ensured (this can be an operating room equipped with everything necessary, an intensive care unit with real beds and neighbors on the right and left, an ambulance equipped according to approved standards, etc.). It is possible, if appropriate, to recreate the psychological moments of ongoing events, which are achieved by attracting "actors" - medical students, employees medical institution or just volunteers.
And, of course, to conduct simulation training, a team should be formed, in which the doctor will provide the necessary assistance. It must be remembered that one of the main tasks of simulation training is learning to work in a team with your colleagues. This allows you to learn how to quickly distribute roles and responsibilities, make your own decisions or unquestioningly obey the senior in the team, and, ultimately, to an effective and professional solution to the patient's problem.
Methodological approaches to simulation training
For the effective use of simulation training, it is necessary to comply with the basic methodological and organizational principles:
1. Integration of simulation training into the current system of vocational education at all levels.
2. The presence of a legislative framework that contains a rule on admission to work (training) with patients, as well as a list of mandatory competencies in specialties that require the priority organization of simulation training. As a result, it should become the norm to prevent (remove) from training (work) with patients persons who have not passed certification using simulation methods in accordance with the list of competencies in their specialty (level of education). The legislative framework should be flexible and improved as this direction develops.
3. Intensive organization of the educational process, modular construction of the simulation training program and opportunities for simultaneous training of different categories of medical personnel (by type and specialty).
4. Objectivity of certification based on approved standards (rules), for compliance with the criteria and with the documentation and video recording of the process and results of pedagogical control, during which the impact of the examiner's personality should tend to zero.
5. The presence of independent experts and observers during the state certification procedures is mandatory from among employers (professional societies), as well as two members of societies associated with the protection of patients' rights (each time changing).
6. A unified system for evaluating the results of simulation training (for all organizers using these simulation methods).
7. Availability of a system of state accounting for the results of passing the relevant modules of simulation training by specialists (registry of specialists).
8. Availability of a personnel training system (teachers, instructors) providing simulation training.
The pedagogical approach to creating a simulator has also become fundamentally new. The goal of simulation training is not only the acquisition of manual technical skills. The trainee must be aware of his presence in the medical environment, his inextricable connection with the operated patient, with his pathological condition. To do this, treatment cases are implemented in the form of tasks. The trainee is invited not only to perform technical actions, but also to assess the clinical situation, to make the right tactical decision. The actions of the simulator operator do not just change the virtual tissues, it worsens the condition of the virtual patient, provokes the development of complications in him, which will then have to be dealt with. This undoubtedly increases the realism of the simulation and the significance of such training in general.
There is a visual tool (Miller's pyramid, Fig. 2) for assessing the progress of a student (resident) - from a beginner to an expert. Actually lowest level, the student has mastered knowledge that he can use to solve tests and in written or oral examinations. In the “know how” stage, they can use their knowledge in more complex exams that require the application of knowledge. In the "show how" stage, they can demonstrate their skills in simulated conditions or in certification exams. But only in the "does" stage do they use their skills in real practice.
This simple grading model for clinical
competence indicates that the analysis of clinical competence using simulation technologies is carried out at the stage of "shows how (demonstrates)", "does" and at the same time the performance or Active participation in the implementation of a particular skill.
The introduction of control over the level of preparedness through a system of simulation training, a mandatory stage of certification in the conditions of simulation training of professional activities for each student and trainee could help solve the problem of personnel certification. However, it is generally recognized that the process of such control should not be punitive, and the main efforts should be directed to promoting professional development, identifying limitations and reducing the risk that a poorly trained doctor or nurse may bear.
Standard training module or standard simulation module (SIM) - a unit of the educational process of simulation training, equal to three hours of working time of the training center, allotted for direct interaction of students with learning tools (practical training), accompanied by pedagogical control. Each such unit has a formulated final result of preparation and a certain cost. The presence of such a unit of the educational process will make it possible to calculate the need for training specialists. SIM is necessary for organizing the educational process, and each of them includes a list of practical skills that will be formed (controlled) by students during this time.
The list of skills in the SIM should be combined according to the thematic principle, according to the equipment used for this and the achievability of training goals in 3 hours. In addition to clinical SIMs, it is necessary to develop SIMs for training new employees of simulation training centers and experts involved for this. SIMs can be implemented as standalone trainings and/or as part of a larger simulation training program.
SIM involves only practical exercises. To conduct training on one topic, several SIMs can be implemented in a row. Each SIM, carried out in the form of training, must necessarily have the following four parts:
1. Input control of the level of preparedness, briefing, setting goals and objectives of the training (up to 20% of the time);
2. Direct implementation of the educational task;
3. Debriefing, discussion of implementation;
4. Final completion (up to 10% of the time).
At least 70% of the time should be devoted to the second and third parts, while, depending on the type of competencies, the distribution between them can be correlated from 60:10 for individual skills to 30:40 for professional activities in general. In the annotation for each SIM, in addition to the list of competencies, the maximum number of trainees in the group should be indicated.
Currently, the obligatory nature of simulation training and / or control is defined:
For students, in the order of the Ministry of Health and Social Development of Russia dated January 15, 2007 No. 30 "On approval of the procedure for admitting students of higher and secondary medical educational institutions participation in the provision of medical care to citizens", which mentions
Clinical outcomes (individual) and outcomes (general population)
Action in real practice
Demonstration of preparedness (simulation, exam)
Interpretation, applied approach (description of action plan)
Theoretical knowledge (written exam)
Rice. 2. Miller's pyramid.
dummies (phantoms), but the volumes and rules for their use are not regulated in any way;
For interns and residents in the orders of the Ministry of Health and Social Development of Russia dated December 5, 2011 No. 1475n and No. 1476n "On approval of federal state requirements to the structure of the main professional educational program postgraduate professional education (residency, internship)" states that the training simulation course should be 108 academic hours (3 credits) for residents and 72 academic hours (2 credits) for interns;
Letter No. 16-2/10/2-3902 of April 18, 2012 from the Ministry of Health and Social Development of the Russian Federation specifies that internship and residency training under the programs of postgraduate professional education in accordance with the above orders has been carried out since 2012/13, there may be persons who have successfully mastered the disciplines of the educational program and completed the training simulation course are admitted.
Thus, it is legally approved that the use of simulation training is mandatory for programs of secondary, higher and postgraduate continuing medical education and should precede practice. Nevertheless, it is necessary to determine how this direction should function in order to properly use all its advantages.
Typology and organization of simulation centers
The work of the simulation center depends on many factors. This is the presence of specialized premises designed to accommodate the existing set of equipment and future students, the organization of the learning and management process.
Some of these factors are funded and set by default. But many issues can be determined by the faculty, such as curricula and teaching structure. Here, a lot depends on the personal attitude of teachers to simulation medicine. At the moment, the issue of creating an innovative structural unit in the education system is being considered - a full-fledged simulation clinic. It can be assumed that this is the missing
Beginning
a link providing educational continuity between the preclinical and clinical stages of education. In effect, the rough transition that existed between teaching in the classroom and teaching in the clinic is being smoothed out. This will undoubtedly reduce the stress that a novice doctor experiences when performing a particular technique at the patient's bedside, and will favorably affect the quality of treatment.
Simulation techniques have firmly entered the system of medical education and have become an integral part of training in health care. In most educational institutions, new structural subdivisions have appeared - simulation and certification centers. Due to decentralized development, all of them have acquired a different organizational structure, specialization, equipment options, and work according to different methods and standards.
To bring the whole variety of currently existing structures of simulation training, they can be systematized according to a number of features:
1. Dimensions: from several rooms to multi-storey detached educational buildings.
2. Geography: "metropolitan" simulation centers; federal, regional, district centers; small towns.
3. By medical specialties:
Specialized
training is conducted in one or more related disciplines, for example, in the specialty "anesthesiology, resuscitation, emergency care".
Multidisciplinary
Training is conducted in various medical specialties.
Virtual clinic
the organizational structure of the training center is similar to a multidisciplinary hospital, due to which it is possible to train medical teams, heterogeneous in specialties, conduct team trainings, and develop non-technical skills.
4. Level of mastered skills: basic; clinical skills, manipulations, operations; high-tech interventions.
5. The contingent of trainees: students of a medical college or university; residents; doctors; drivers; employees of power structures and the Ministry of Emergency Situations.
6. number of students: thousands of students - university, college; hundreds of cadets and residents - university, FUV, PDO, NMO; dozens of doctors - specialization in VMP.
7. Duration of study: years - university, residency; months - specialization; weeks and days - refresher courses, short-term trainings.
8. Connection with practice:
Has a medical base in the clinic;
It has an experimental operating room for conducting educational and research operations on biological models - a vivarium;
Has training classes on the basis of the Bureau of Forensic Medical Examination, the hospital morgue, the Department of Pathological Anatomy;
Does not have a clinical/experimental unit.
9. Location:
Educational institution (university, university department, medical faculty of a classical university or medical college) - centers of practical skills and abilities at medical educational institutions.
Medical organization. Training centers of hospitals for quality management of medical care, ensuring the high professionalism of doctors and paramedical personnel, improving and retraining healthcare facility staff
Manufacturer. Corporate training centers of the manufacturing company - for training employees and clients to work on the equipment / tools / with pharmaceutical preparations of the company.
Industry. Mastering medical practical skills for applied industry purposes, for example, for training sailors, oil workers, collectors, employees of the Ministry of Emergency Situations, the Ministry of Internal Affairs, security companies, etc.
Mobile training centers are mounted on the base Vehicle or using portable stand-alone simulation devices. Mobility allows you to bring simulation training closer to the user, to conduct training at the workplace (in situ) - in the operating room, resuscitation, at the scene of a traffic accident, etc.
10. Staff composition: differences between training centers by availability degrees teaching staff, qualifications of teachers in the field of simulation training, trainings they have completed in their specialty.
11. Form of ownership:
State. The purpose of creating state simulation centers is to increase the level of practical skills of students and doctors in the interests of the whole society.
Commercial training centers. The goal is to make a profit by selling simulation training services. Short-term, intensive, but most often expensive training courses. They can be organized on the basis of state university or hospital training centers on a lease basis or on partnership terms.
Corporate training centers are a kind of private ones, so their goal is similar - making a profit. It is achieved indirectly by increasing the demand for the company's products from trained consumers. Due to the high cost, courses are subsidized by the manufacturer or provided to customers free of charge.
Public-private partnership. The combination of founders leads to a confusion of goals, but in the short term they coincide - the training of doctors. In the end, both parties win: the state improves the qualifications of healthcare workers, and the company receives qualified consumers of their products.
Thus, dozens of various simulation centers are currently operating in Russia, which differ significantly from each other in a dozen characteristics. At the same time, there is no single classification - simple, understandable, but, at the same time, structured, corresponding to the practical tasks of medical education. It should provide starting points for making decisions about the need to open a center, the choice of type, specialization, equipment and staffing of the center, accurate
setting goals and drawing up curricula, approving methods and empowering.
It is proposed to divide the simulation and certification centers into three levels:
I level - basic, regional significance;
II level - leading, district value;
III level - the highest, federal value.
When dividing the centers into levels, some of the above criteria are considered basic, or primary, and the rest are secondary, logically arising from the first.
The main criteria are:
The quality of the educational process, which is indirectly characterized by the qualifications of teachers, the equipment of the center, the innovativeness and effectiveness of the methods used.
Own methodological developments
Conducting research, testing of medical equipment and other scientific work by the staff of the center.
The number of publications on methodological and scientific developments in domestic and foreign literature and their citation.
The active participation of the center's employees in the work of specialized conferences.
Professionalism of the personnel of the center - work experience, previous trainings and current activity to improve the skills of employees, available certificates and accreditation of the center and its individual employees.
The remaining criteria are important in the complex, but, in fact, each of them individually is not decisive. Even a large metropolitan center, generously equipped with the latest equipment, with weak management and low-skilled staff, can have a low workload and a deservedly low reputation. the features of the centers of each of the three levels are described in more detail below.
Level I simulation centers:
Simulation centers of I, regional (basic) level have the following characteristics:
Placed at large hospitals, in many universities and medical colleges.
They provide simulation training and certification to students of the university (college), residents or doctors of the region in which the center is located.
Trainings can be conducted both in different specialties and in one narrow specialty. The training program is mainly focused on mastering basic skills.
The centers are relatively small, occupying several rooms with a total area of up to 300 m2.
They have a variety of simulation equipment of I-VI levels (phantoms, simulators, individual virtual simulators).
The budget for equipping with simulation equipment does not exceed 30 million rubles.
There are up to 5 units in the staff list of the centers: director, secretary-administrator, instructors, engineer. Training sessions can be conducted with the involvement of teachers of departments or leading specialists of health care facilities
The staff of the centers can develop new methods of simulation training, but do not have the authority to test or approve them.
Level II simulation centers:
Simulation centers II, district level are characterized by the following:
Students of the university, interns and doctors from the entire federal district in which the center is located pass the development of practical skills and their certification, the users of new medical equipment are being mastered.
The Centers conduct trainings both in different specialties and one by one. It can also be a highly specialized center that provides educational services in one type of high-tech medical care (for example, transplantology, minimally invasive cardiac surgery and angiography, etc.).
They are located on the basis of leading universities and research institutes, have premises with a total area of 500 to 2000 m2.
The centers have a variety of simulation equipment of 1-UP levels of realism (phantoms, simulators, virtual simulators, up to complex virtual training systems).
Centers may have their own experimental operating room (vivarium).
The total cost of equipping with simulation equipment reaches 150 million rubles, but cannot be less than 25 million rubles.
In the schedule of the centers from 3 to 10 staff positions: the head of the center, secretary-administrator, instructors, IT-specialist, service engineer.
Many lectures and practical training sessions are conducted with the involvement of faculty members or medical specialists, including those from other cities and countries.
Employees of the centers are required to improve their skills by participating in conferences, trainings and master classes.
Employees of the centers not only develop new methods of simulation training, but also have the right to test third-party methods.
Methodological and scientific developments should be cited in specialized literature.
Level III Simulation Centers:
Simulation centers III, federal level have the highest status and can be characterized by the following:
In addition to students and residents, a significant part of the educational process is aimed at improving the qualifications of doctors and their attestation, as well as training teachers of simulation centers of levels I and II (TTT programs - Tram-^e-Tgater). The geography of trainees is the whole Russian Federation, as well as cadets from near and far abroad.
New medical equipment is being tested using simulation technologies - on virtual simulators or robots, and users are being trained in the principles of operating new equipment.
In the centers of the highest level, scientific research is carried out on simulation technologies.
Most of the specialties, including narrow specialties, are represented in the centers; training is provided in high-tech types of medical care.
The centers are located on the basis of the head, leading universities and clinical research institutions, they are large educational structures, occupy separate floors or buildings with a total area of 1000 m2.
Equipped with simulation equipment of all levels VII, including complex virtual training systems.
The Center incorporates a "Virtual Clinic", which allows you to work out the processes of interaction between doctors
whose various specialties and departments at all stages of the patient's treatment - from admission to the emergency room, diagnosis and surgery to transfer from intensive care to the general ward and final discharge.
In our own experimental operating room (vivarium), the skills of interventions obtained on simulators are consolidated and scientific and practical experiments are carried out.
The total cost of equipping the center with simulation equipment exceeds 150 million rubles and can reach up to 500 million rubles.
The staff list of the Federal Centers includes at least 5 employees and their number can reach 20: the head of the center, his deputy, secretary-administrator, instructors, IT specialists, service engineers.
In addition, teachers of specialized departments, domestic and foreign lecturers are involved.
The employees of the center should, according to principles similar to NMOs, improve their skills on an ongoing basis, annually participating in the work of specialized conferences, seminars, trainings and master classes.
At the level III center, new methods of simulation training are being developed, which should be cited in domestic and, preferably, foreign literature.
The Center not only conducts approbation of third-party methods, but is also authorized to approve them.
Thus, only centers of the III, highest, level, according to the totality of the main criteria, should receive the right not only to develop new methods, but also to test and approve third-party developments; not only engage in the educational process, but actively lead scientific work and testing of medical equipment; not only to train cadets, but also to train teachers of simulation centers of I and II levels (TTT programs). And, on the other hand, a large center, with a large staff, equipped according to the highest class, but at the same time not leading an active educational and scientific and methodological activity, cannot, in the author's opinion, claim the status of a "federal" center of III level.
Problems of practical implementation of simulation training
The accumulated experience of simulation training in the Russian Federation allows, first of all, to be convinced of the indisputable advantages of simulation training:
Clinical experience in a virtual environment without risk to the patient;
Objective assessment of the achieved level of skill;
Unlimited number of repetitions of skill development;
Training in convenient time, regardless of the work of the clinic;
Practicing actions for rare and life-threatening pathologies;
Transfer of part of the functions of the teacher to the virtual simulator;
Improving the efficiency of training medical specialists in new high-tech methods, as well as new procedures within the framework of already practiced methods;
Reducing stress during the first independent manipulations.
Thus, the virtual simulator, of course, does not replace traditional forms learning - lek-
training, a seminar, watching videos and multimedia materials, curating patients, etc., however, before allowing a doctor to see a patient, it is necessary to work out practical skills on the simulator and certify the acquired skills. The above is confirmed by the studies of foreign colleagues, which show that specialists highly appreciate the opportunity to participate in simulation training. Despite feeling tense and sometimes real stress when working with such a "difficult patient", they prefer to see the immediate results of the treatment, and not just read about them in textbooks or listen to lectures. Most of all, the survey shows, professionals value the opportunity to make mistakes and learn from them in a safe environment. educational environment.
In teaching the discipline "Infectious Diseases", the use of simulation technologies has its own characteristics, associated both with the specifics of the clinical course of infectious diseases, and with the knowledge and skills of senior students in basic theoretical and clinical training modules. The choice of simulation training forms should be aimed at developing a high level of clinical competence in the field of diagnosis and treatment of infectious diseases, which should be integrated with communication and teamwork skills. This will allow you to effectively apply the acquired clinical competence in the specific practice of a doctor.
Before using them in working with real patients, students must acquire clinical skills in special centers equipped with high-tech simulators and computerized mannequins that allow modeling certain clinical situations, including those for infectious diseases. In the conditions of training centers, the content of training is aimed not only at mastering individual skills, but also at interdisciplinary training in teamwork, the development of safe forms of professional behavior and communication skills with the patient. But this requires the creation of such modern simulation centers, possibly within the framework of a clinical and educational cluster.
Another form of simulation training in the field of teaching infectious diseases, which is no less difficult to implement in practice, can be “standardized patients”, which are the best alternative to real patients. they can normally play the role of the patient, including psychological and physiological aspects. Volunteers, laboratory staff, teachers themselves, interns and others can be trained as standardized patients. Analysis of a conditional clinical case also provides for teamwork, which allows students to jointly plan work, distribute responsibilities, help each other, cooperate, interact in a group, discuss, understand and accept each other's point of view or defend their own at each stage - interpretation of the analysis, diagnosis, treatment.
There is already an understanding of the need for simulation medicine, equipment is being purchased, simulation centers are being opened, but so far there is no main thing - simulation training standards. Now everyone
the simulation center operates according to its program. Programs have been written for clinical residency, resuscitation and non-resuscitation specialists, paramedics. In universities, there is a variation in approaches to learning, methods, structure of classes, methods of assessment. This is connected both with the possibilities and with the traditions of a particular department. It seems relevant to standardize teaching programs for simulation medicine. Given the importance of the problem, it is necessary to take into account the vast experience of foreign clinics and professional organizations in the development of Russian standards. The creation of expert groups in specialties will make it possible to systematize the writing of recommendations.
At the same time, the problems that need to be solved for the successful and effective implementation of simulation training in medical education are identified:
Creation of the concept of simulation training in the system of medical education in the Russian Federation;
Creation of a regulatory and regulatory framework for simulation training;
Development and implementation of educational-methodical and software-instrumental support of the simulation educational process;
Training of teaching staff for simulation training;
Financial support of the simulation training system;
Conducting research projects to study the effectiveness of simulation training.
In connection with the attraction a large number university specialists for the implementation of simulation training increases the overall level of readiness of employees for the introduction of virtual technologies in pedagogical process, thinking in general is being modernized, the pedagogical approaches of teachers are being improved and enriched.
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Volchkova Elena Vasilievna, Dr. sciences, prof., head. cafe infectious diseases of the First Moscow State Medical University. THEM. Sechenov; Pak Sergey Grigorievich, Dr. med. Sciences, prof., corresponding member. RAMS, honorary head. cafe infectious diseases of the First Moscow State Medical University. THEM. Sechenov.
1The analysis of the problem of simulation training in medical education at the present stage is carried out. The scheme of integration of the simulation training system into the educational process for students of I-VI courses in the specialties "General Medicine" and "Pediatrics" is presented, which is used in the Center for Practical Skills of the StSMA. The necessity of creating large multidisciplinary educational and methodological units in the format of training and simulation centers for clinical training of students and young professionals in medical universities is substantiated, with the implementation of well-defined clusters of practical training in the educational process at all stages of education, including pre-university. The importance of using simulation technologies in teaching large contingents of students is especially emphasized.
simulation training
practical skills center
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Implementation of priority national projects in the healthcare sector, the processes of reform and modernization of the industry have revealed with particular acuteness the problem vocational training medical workers.
There is an acute shortage of highly qualified specialists everywhere in the industry. Therefore, it is natural that one of the main directions in the field of higher medical education is the need to significantly strengthen the practical aspect of training future doctors while maintaining the proper level of theoretical knowledge.
It is the state of the student's clinical training that is characterized, in our opinion, as a very complex and "sore" issue in the work of any university, regardless of its status and size. On the one hand, the growing requirements of new state educational standards for the professional competencies of graduates, and on the other hand, the unresolved problems of clinical departments that experience well-known difficulties in their work, make it difficult to train specialists already at the initial stages of clinical education.
When passing clinical disciplines, a full analysis of each of the supervised patients is not always carried out, and even more so the teacher's control over the quality of each student's performance of an objective examination of the patient. In a real clinic, this situation is aggravated by the lack of individual provision of students with thematic patients and forced work in a group. In recent years, the situation has been aggravated by the widespread introduction of market relations in clinics and changes in the legislative framework.
In this regard, the emergence of opportunities in the organization of phantom and simulation training of students is seen by us as a reasonable and necessary direction in the educational process. We want to emphasize this specifically for students, starting from the first year, and not only for individual groups of medical residents and interns.
Currently, simulators are used to train and objectively evaluate students in many areas of human activity that involve high risks.
Simulation training methods in medicine have been known for a long time, in particular, dummies have been used in anesthesiology since the 80s of the XX century. The use of simulators, dummies, phantoms allows you to repeatedly work out certain exercises and actions while providing timely, detailed professional instructions in the course of work.
It is simulators that can repeatedly and accurately recreate important clinical scenarios and the ability to adapt the learning situation for each student.
However, in the literature available to us, we found little conclusive data on the use of simulators in linear student learning programs. The new state educational standards, “by-laws” do not at all determine the role and place of simulation training in the educational process, the methodology and didactics of training are not defined.
Each university moving in this direction at its own "fear and risk" now solves the issues of recruiting and organizing the work of simulation training, often experiencing resistance even in its own teams - the evidence base for the effectiveness of the use of simulators is still insufficiently developed, their cost is high, time costs and resistance are significant changes, but the process of creating centers of simulation training is carried out, including in medical universities.
The first modest steps in the work of the Center for Practical Skills of the Stavropol State Medical Academy showed the feasibility of investing material resources in the implementation of the idea of creating a center and received a positive response from many representatives of the teaching staff of our Academy.
Now it is clear that the role of the center will not be reduced to a room equipped with special phantoms. The Center is an educational and methodological unit where not only individual practical skills and manipulations will be developed, but also educational and methodological work, scientific research, experimentation in teaching technologies with access to clinical bases and paraclinical departments will be carried out. Thus, ideally, this is the way to create a single training and simulation center for clinical training of students and young professionals, where well-defined clusters of practical training will be implemented at all stages of education, including pre-university.
We see these main clusters as follows: "emergency medicine", "patient care", "pediatrics - emergency care, child care", "anesthesiology and resuscitation", "surgery and laparoscopy", "obstetrics and gynecology". At present, the center has begun full-fledged work with a new school year according to the established regulations.
The first stage that students will go through in the training center is theoretical training - this is a specially designed special course in one of the sections of medicine. For example, these are recommendations for basic or advanced resuscitation - Guidelines ERC or AHA 2005.
After that, students go to the training halls to master practical skills, where simulators are assembled by topic for practicing certain medical procedures: vascular access, restoration of patency of the upper respiratory tract, cardiopulmonary resuscitation, pneumothorax puncture, immobilization and transportation, bladder catheterization, gastric lavage, care for stomas and catheters, auscultation, gynecological and obstetric manipulations.
Then follows the stage of computer simulation, when in the classroom the student must go through certain modules of the interactive curriculum (cardiac arrest, respiratory disorders, arrhythmias, poisoning and overdose, metabolic disorders and thermoregulation).
And then, having theoretical training (the first stage), having practical skills (the second stage) and having worked out a virtual algorithm for the treatment of emergency conditions, the student enters the simulation part of the center (imitation of the ward), where, in conditions close to real ones (real environment, real equipment , a dummy that independently reacts to his interventions), he, through repeated repetition and analysis of mistakes, achieves the perfection of his psychomotor skills, skills in working with equipment and the patient, and teamwork skills.
Undergraduate students who are preparing for nursing practice, before working in a hospital, must master not only the skills of caring for a patient, but also the basic resuscitation complex and the basics of emergency care in major critical conditions (suffocation, hypertensive crisis, fainting, etc.). ) This is necessary in order for the student to feel more confident when working with patients, i.e. the educational process at the center will be structured so that by the time of transfer to the clinical departments, the student has fully mastered in theory and worked out on mannequins and simulators manipulations and clinical techniques in accordance with the requirements of state educational standards in the specialties "General Medicine" and "Pediatrics". For example: at present, the teaching of the discipline "Resuscitation and Intensive Care" at the pediatric faculty is carried out at the 3rd year (2 hours - CPR training), at the 5th course in the 10th semester (pre-hospital stage of emergency care for the most frequent pathology in the volume 24 hours) and the 6th course in 11-12 semesters (hospital stage of emergency care in the amount of 36 hours). There is also a lecture course. According to the decision of the Academic Council of the Stavropol State Medical Academy, in order to improve the mastery of practical skills at the bedside, the practice of first aid and emergency care was approved for students of the 6th year of the pediatric faculty (one night duty).
According to the requirements of GEF3 for the training of pediatricians, even more attention should be paid to the mastery of practical skills by students.
Also, according to the training program, pediatricians should be taught in the discipline "Anesthesiology and Resuscitation" in the 11-12th semester of study in the amount of 2 credits + 1 unit for independent work.
Given the complexity of the discipline being studied, it is not possible to fit two large sections of teaching into the indicated amount of hourly workload while maintaining the quality of teaching practical skills.
In addition, it is the 5th year students of the Faculty of Pediatrics who pass the exam in the section of resuscitation and intensive care during the comprehensive exam in pediatric surgery in the 10th semester, that is, before passing the course of practical classes according to the new educational standard.
Given the above, since September 2011 a decision was made to allocate 1.5 credits for teaching practical skills to 5th year students of the Pediatric Faculty on the basis of the Center for Practical Skills in the section "Anesthesiology". At the 6th year of the pediatric faculty, the issues of resuscitation and emergency care at the hospital and pre-hospital stages are already resolved at the patient's bedside at the training bases of the course. The teaching of skills is carried out by the course teachers due to their extensive practical work experience.
We offer a scheme of work and a list of practical skills studied at the Center.
3 course of all faculties - the volume of classes is 2 hours
Carrying out primary cardiopulmonary resuscitation on dummies at the prehospital stage with mandatory quality control of mastering the skill;
Passing the test before passing nursing practice in order to be admitted to its passage.
5th year of the Faculty of Pediatrics - the volume of classes is 24 hours per group (one week of classes in the 10th semester)
Defibrillator rules. Preparation of the defibrillator for work, calculation of the required dose of the defibrillation discharge;
Analysis of cardiac arrhythmias according to ECG monitoring or ECG recording (work on a manikin simulating cardiac arrhythmias);
Carrying out the initial stage of intensive therapy for cardiac arrhythmias;
Evaluation of indicators of CO 2 monitoring in exhaled air. Making a tactical decision based on the results of the received data;
Rules for communicating with parents of a child in critical condition. Ways and means of eliminating conflict situations.
Thus, we propose to consider simulation technologies in teaching ordinary students not only as constituent part clinical training, and moreover, as one of the mechanisms that trigger and shape clinical thinking at a high and motivated level. Consequently, these forms of education need deterministic methodological support and control from the leading educational and methodological associations, scientific evaluation and further research and improvement.
Reviewers:
Aidemirov A.N., Doctor of Medical Sciences, Professor, Head. Department of Thoracic Surgery, Stavropol Regional Clinical Center for Specialized Medical Assistance, Chief Thoracic Surgeon of the Stavropol Territory, Stavropol;
Karakov K.G., Doctor of Medical Sciences, Professor, Head. Department of Therapeutic Dentistry, Head of the Center for Practical Skills of the Faculty of Dentistry, Stavropol State Medical Academy of the Ministry of Health and Social Development of the Russian Federation, Stavropol
The work was received by the editors on September 23, 2011.
Bibliographic link
Muravyov K.A., Khodzhayan A.B., Roy S.V. SIMULATION EDUCATION IN MEDICAL EDUCATION IS A TURNING POINT // Fundamental Research. - 2011. - No. 10-3. – P. 534-537;URL: http://fundamental-research.ru/ru/article/view?id=28909 (date of access: 02/01/2020). We bring to your attention the journals published by the publishing house "Academy of Natural History"
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Experience in creating a training simulation center at the Chelyabinsk State Medical Academy
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Improving the efficiency of mastering manual and medical-tactical skills by introducing high-tech robotic dummies and modern resuscitation equipment into the educational process in order to improve the quality of obstetrics and perinatal care
The amount of information that a civilization has is completely updated every five years. The development of this volume by an individual is possible only in the process of regular continuous education. Many technologies have appeared in the modern educational space, one of them is simulation training, which is a product of scientific and industrial technologies transformed into an innovative educational space. For the first time simulation technologies began to be used in aviation. Gradually, the use of simulators spread to various industries, including medicine. In a modern clinic, primary training in practical skills has some limitations: lack of communication skills among students and young doctors in dealing with patients and their dissatisfaction, lack of time to practice each skill, psychological fear of performing a procedure, high risk to the patient's health. At the same time, obtaining theoretical knowledge is not very difficult - students, interns, residents and trainees of advanced training programs have books, articles, lectures, video materials, Internet resources at their disposal [Lebedinsky et al., 2007; Svistunov et al., 2014; Perepelitsa, 2015]. The use of simulation technologies is designed to increase the efficiency of the educational process, the level of professional skills and practical skills of medical workers, providing them with the most effective and safe transition to medical activities in real conditions. This ensures continuous professional education medical personnel in accordance with modern algorithms. During the training, not only clinical skills are developed, but also the ability to communicate with colleagues and patients. For this, special simulators and simulators have been created and game teaching methods are being developed that allow simulating various clinical situations, including rare ones. The work of the simulation center depends on many factors: the availability of specialized premises designed to accommodate the existing equipment and students, the organization of the learning and management process. Some of these factors are determined by funding. Curricula and the structure of education can be determined by the teaching staff. Here, much depends on the personal attitude of teachers to simulation medicine. At the moment, we are approaching the creation of an innovative structural unit in the education system - a full-fledged simulation clinic - the missing link that provides educational continuity between the preclinical and clinical stages of physician education [Pasechnik et al., 2013; Svistunov et al., 2014]. The emergence of simulation centers smooths out the difficult transition that existed between teaching at a desk and teaching in a clinic. Training in a simulation clinic will reduce the anxiety that a student experiences when performing a certain technique at the bedside of the patient, and will favorably affect the quality of treatment. During the training, certain manipulation skills are practiced on phantoms and mannequins of various levels of realism from simple to complex. The initial levels of realism allow you to master certain manual skills on the mannequin. After mastering some manual skills, you can move on to the next level of realism, i.e. use a more complex mannequin that allows simulating, for example, various situations in anesthesiology and resuscitation. The tasks of the assistance provided are constantly expanding: diagnostics are required, for example, the type of cardiac arrest, defibrillation, and the administration of drugs. Learning at the next level of realism involves simulating a real environment. For students, the whole situation is a surprise: the number of victims, their position in the hall, the availability of equipment. In addition, the psycho-emotional state of students is additionally affected by specific external factors that can be reproduced in the conditions of the simulation center: the howl of a siren, a smoke screen, subdued lighting. On the highest stage realism, remote-controlled simulation robots are used. At this stage, not only manual skills are fully developed, but also clinical thinking. In a simulation clinic, it is possible to create scenarios for various clinical situations, including rare ones [Murin et al., 2010; Pasechnik et al., 2013; Perepelitsa et al., 2015]. Application information technologies in the educational process implies the presence of qualified teachers capable of working in a new information and educational environment [Tipikin, 2009; Methodical recommendations.., 2011; Svistunov et al., 2014]. The creation of simulation centers in medical universities is a necessary step in acquiring and improving the professional skills of students and doctors of various specialties. It should be expected that the introduction of simulation training will improve the quality of professional training of medical personnel, and hence the quality of care they provide. The Ministry of Health and Social Development of the Russian Federation has prepared a number of documents regulating the creation and use of simulation methods in teaching: assistance to citizens"; order of the Ministry of Health and Social Development of the Russian Federation of December 5, 2011 No. 1475 “On approval of federal state requirements for the structure of the main professional educational program of postgraduate professional education”, which approves the training simulation course: for residents it is 108 academic hours (3 credits), for interns - 72 academic hours (2 credits); letter of the Ministry of Health and Social Development of the Russian Federation dated April 18, 2012 No. 16-2 / 10 / 2-3902 “On the procedure for organizing and conducting practical training in the main educational programs of secondary, higher and postgraduate medical or pharmaceutical education and additional professional educational programs moms”, which clarifies that training in postgraduate professional education programs in internship and residency in accordance with the above orders has been carried out since 2012/13 and persons who have successfully mastered the disciplines of the educational program and completed training simulation course. Thus, the introduction of simulation teaching methods into the system of training graduates of medical schools, young professionals and into the system of continuous professional development is currently a vital necessity, approved by law and should precede clinical practice. 9 For effective simulation training, the following principles must be observed: 1) development and implementation of simulation training in the Federal State Educational Standard; 2) a list of necessary competencies in specialties that require development in the simulation process; 3) modular construction of the training program in the simulation center; 4) creation of conditions for simultaneous training of specialists of various medical specialties in order to identify leadership qualities in students, to form teamwork skills; 5) development of objective criteria for assessing simulation training; 6) creation of a register of specialists who have undergone simulation training; 7) creation of a system for training teachers, instructors who provide the process of simulation training.
