Comparison of action density patterns between simulator and clinical settings

Abstract

SANTANDER-02-11 The question of whether simulator settings represent the salient characteristics of real work situations remains unanswered. This study aims to assess the ecological validity of simulator settings on an empirical basis by analysing action sequences across various settings. In our research on action sequences in clinical practice we focus on the ways in which complexity and unexpected events (i.e. disturbances, interruptions etc.) are handled by the anaesthetists [1]. Methods: After obtaining informed consent, 6 anaesthetists (3 first year and 3 third year residents) took part in the study. All participants were observed during 2 cases with patients and 3 simulator cases involving laparoscopic surgery. In the simulator setting the participants were exposed to 1 routine case (control scenario) followed by 1 case with acute haemorrhage and 1 with anaphylactic shock. A trained observer familiar with the operating theatre and the procedures recorded the anaesthetist's interventions (i.e. elements of actions) throughout the entire case applying a new observation method, sensitive to overlapping operations in action sequences. In a previous study the methodological problem of recording and interpreting overlapping operations [2] could be overcome by applying a new computer-based observation method [3]. In order to describe action sequences, we generated quantitative measures of action density that serve as an indicator of the relative amount of overlapping operations. These measures help to analyse the extent to which total activity and particular operations fluctuate during a specific anaesthesia case. Results: The results of our process-oriented case analysis show that action density exhibits a characteristic and distinct distribution during the conduction of anaesthesia. For example, periods characterized by increased action density are the induction of and the emergence from anaesthesia. These variations in action density during the course of anaesthesia can be observed in clinical as well as in simulator cases. Moreover, in all simulator cases involving unexpected events an increase in action density can be observed during this event. Discussion: As described in literature on the organization of multiple actions on an individual or group level, concurrent actions may occur due to increased task complexity. By drawing an analogy overlapping operations in action sequences may be interpreted as an indicator for coping with complexity varying during different phases of an anaesthesia case. The comparison of clinical and simulator cases empirically supports the assumption that there are similar action sequences on this level of analysis. Moreover, overlapping operations seem to have a central position when dealing with the various requirements related to the occurrence of unexpected events in a simulator scenario. Conclusions: The results of this study can be interpreted as an indication of the huge potential of simulators as research instruments when striving for an improved understanding of the anaesthetists' practice in the management of unexpected events. A research strategy integrating clinical and simulator settings has the potential to contribute to the evaluation of simulator settings (e.g. its ecological validity) and thereby lead to improvements in the design of settings for research and training. This will be crucial to assure the quality of education and medical practice in an increasingly complex healthcare system.