The Anatomy Lesson of Dr Nicolaes Tulp : What can it teach us today?

Background

Seventeenth-century surgeons had to be creative about their teaching materials. In Holland and elsewhere it was common practice to use the body of a recently executed criminal for dissection purposes. It was just such an occasion that Rembrandt captured when, in 1632, he painted a portrait of the Amsterdam city anatomist Dr Tulp examining and dissecting a corpse before a group of student doctors (Figure 1). The practice went on in Britain too, where it lasted into the nineteenth century when Burke and Hare famously provided corpses to the medical school in Edinburgh. The trade was tacitly condoned until the first Anatomy Act was passed in 1832. But what can Dr Tulp teach us today? And are his lessons still valid for those who care for the population of people with intellectual disability?

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Figure 1.

Rembrandt Harmenszoon van Rijn, The Anatomy Lesson of Dr Nicolaes Tulp, 1632. By permission of the Royal Picture Gallery Mauritshuis, The Hague.

In what follows we discuss the situation from the perspective of student nurses on a combined learning disability nursing and social work programme. We also consider the possibility that their client group may present challenges to the effectiveness of such a model and that this challenge may go beyond pedagogy and enter the realm of ideology.

If this is the case then the implications may affect us all. This is because as people with intellectual disability increasingly access primary and secondary care they will be cared for by healthcare professionals who are not necessarily familiar with the challenges that working with this cohort entails. The potential for poor care and its consequences is made apparent in Death by Indifference (Mencap, 2007).

So why use simulation?

The increasing use of technology in healthcare along with heightened public and patient expectations have both encouraged the development and use of new educational methods in healthcare education (Gaba, 2004). The government report High Quality Care for All: NHS Next Stage Review recommended the development of a ‘strategy for the appropriate use of e-learning, simulation, clinical skills facilities and other innovative approaches to healthcare education’ (Department of Health, 2008b: 42). Similarly Lord Darzi's report highlights the impact new technologies have had on the education and training of healthcare workers (2008b: 72). The use of simulation in particular has also been encouraged in a number of key documents worldwide, such as the US Institute of Medicine’s seminal report To Err is Human: Building a Safer Health System (1999).

And as Issenberg et al. (2005) note, problems associated with clinical teaching and learning at the bedside and assessing professional competence and patient safety inevitably mean changes in the organization of healthcare. It follows then that as more patients are being treated in primary care or as outpatients, there is a correspondingly higher proportion of acutely ill patients on the wards. Some of these patients will have the label of intellectual disability. In addition – and this is highly relevant to our own situation – the increased demand for clinical placements and the associated decrease in the availability of clinical learning opportunities have meant that healthcare students’ involvement with direct patient care and the opportunities to undertake learning at the bedside have been significantly reduced over the last few years. In the UK, there has now been recognition that a proportion of practice placement hours could (and indeed should) be replaced by simulation-based education to both enhance the students’ learning experience and alleviate the shortage of supervised clinical placement opportunities (Alinier et al., 2006; NMC, 2007; Lambton, 2008).

There is a growing body of evidence which suggests that the use of human patient simulation in healthcare education may help to improve the preparation of learners prior to clinical experience (Cant and Cooper, 2010). It may also be used to address the mounting ethical issues around ‘practising’ on human patients (Bremner et al., 2006). Simulation may therefore provide a way to increase patient safety, improve clinical judgement and develop successful inter-professional team working (Beamson and Wiker, 2005). Its strength as an educational strategy is that simulation provides the opportunity for student learning that is both immersive and experiential (Issenberg et al., 2005). It has the potential to recreate clinical scenarios that are only rarely experienced in real life, and may be used to test both individual health professionals and teams in challenging or crisis situations, and to help them to replay or examine their actions in a non-threatening and safe environment. It is therefore a powerful learning tool that may be used to help healthcare professionals achieve higher levels of competence and thus provide safer care in future (Henneman and Cunningham, 2005; Kneebone, 2005; Aggarwal et al., 2010).

With this in mind we devised a scenario which we believed would provide opportunities for learning using the patient simulator at our disposal.

Rationale for the scenario

Our purpose in undertaking this particular scenario was threefold:

The student group (N = 17) were in their first year (October 2010 intake) and were soon to go out on placement in nursing care areas for the first time. Their backgrounds varied from having no previous experience of working with people with learning disability to some who had been employed as care assistants. They spent two hours in the clinical learning suite getting acquainted with the patient simulator, receiving instruction and having some discussion on caring for people with epilepsy.

Many universities are developing and building simulation skills centres that enable the depiction of ward areas, and the simulators have been developed to look and respond to interventions with increasing realism. Since their inception in the 1980s, simulation manikins have become more and more sophisticated and now enable a wide range of invasive and non-invasive procedures to be performed on them, as well as enabling teamwork training. These higher fidelity models, such as SimMan (Laerdal^©), are able to reproduce different aspects of human physiology in real time, including, for example, the patient’s response to drug administration. The focus on high fidelity simulation and realistic patient scenarios facilitates the inclusion of both clinical and communication skills, and this enables the student to view the patient in a more holistic context.

The scenario

We opted to introduce our students to human patient simulation by programming the manikin to experience an episode of status epilepsy. People with learning disabilities are 20 times more likely than the rest of the population to have epilepsy and the more severe the person’s learning disability the more likely it is that their epilepsy will be difficult to control and that they will experience complications such as status epilepticus (Department of Health, 2008b). Status epilepticus is a medical emergency which requires urgent treatment with rescue medication. It is characterized by lengthy and severe contractions (Lowenstein et al., 1999). Rectal diazepam or buccal midazolam are the medications most often used. For the simulation session we decided that the manikin would require diazepam to be administered rectally.

Although the students were aware of the use of manikins in the department, this was their first ‘hands-on’ experience with the technology. They were also the first learning disability students on our course to have the opportunity to engage with a patient simulator, and this was the prompt to include their reaction to the experience within the module evaluation.

In groups of three or four the students struggled to adjust the manikin’s clothing, to manoeuvre his limbs and to administer the medication. The sheer awkwardness of the scenario impressed on them the difficulties of balancing the need to undertake a clinical procedure quickly and safely against the broader, more conceptual concerns around privacy and dignity.

Feedback and findings

Students are aware that they may be asked to provide feedback on sessions as part of routine module evaluation, and we highlighted to them that on this occasion we wanted written comments on their reactions to the patient simulator. A questionnaire was emailed to the students who were encouraged to respond to it within two weeks while their recollections remained fresh and before placement learning took over their lives. The questionnaire is replicated in the Appendix.

All questionnaires were completed anonymously (questionnaires were numbered LDSW01, 02 etc.). Of the 17 questionnaires sent out we received 14 replies, of which 11 were complete in all sections. It is on these 11 responses that we have based our study.

We had discussed the session in the days prior to its delivery and had settled on five areas that we wanted to explore via the questionnaire. These were summarized under the following headings: keeping it real; disability; the human touch; theory and practice; and your experience. We remained open to the possibility that the students might want to discuss other issues entirely, but in the event the feedback was comprehensive and the topic guide appeared to have been effective in eliciting responses.

We were keen to find out generally about the efficacy of using the manikin as an aid to teaching and learning. In addition we wanted to explore the ethical underpinnings to find out if the obvious gap between a manikin and a human was exaggerated at all when the idea of learning disability was introduced. In considering the responses from our students we were happy to see a close fit between the reported experiences detailed here and those cited by Baillie and Curzio (2009). We report on the responses from students in the sections that follow.

Discussion

The student responses from this small study indicate a strong liking for simulation as a way of learning and this is in line with the majority of the literature (Cant and Cooper, 2010). There were however a number of issues that emerged relating to the fidelity of the manikin and the realism of the scenario. While fidelity to real life has been achieved in many areas of human patient simulation, there are still aspects of patient anatomy and physiology that have yet to be fully realized. Some authors have commented on the lack of realism in some areas, including the feel of the skin, skin colour, and skin temperature (Euliano, 2001; Good, 2003; Haskvitz and Koop, 2004). The lack of realism may not just apply to the simulation device. As Morton (1997) noted, simulation is still constrained by the degree to which it can mimic what constitutes reality.

And as Greenberg et al. (2002) note, despite the obvious technological advances in replicating bio-fidelity, simulators still are not able to adequately convey ‘humanness’ to students. Manikins are cold to the touch and made of rubber and plastic. Their appearance is unnatural, and even with the capability to generate a human voice, there are limits to how real these devices can seem. This may account in some measure for any reluctance to engage in conversation.

So while the replacement of ‘blood and guts with bits and bytes’ (Gorman et al., 2000: 353) does to some extent sanitize the learning process, there are other areas that technology finds it more difficult to reach. It is along these psycho-social axes where physical and clinical conditions collide with value judgements that the limits of simulation as a technique are reached.

Administering rectal diazepam is an undignified process. It is an invasive procedure which brings the practitioner into intimate contact with their patient. The manikin, however, has no dignity and this lack of human emotion was remarked on in some feedback (see below). Using the manikin has also confronted us with a philosophical problem that cannot be reasoned away. For no matter to what degree a patient simulator replicates the physical signs and symptoms of a condition or a clinical episode, the manikin remains of a different kind. In making the conceptual leap between caring for a piece of equipment and caring for a human being, students are challenged by the obvious artificiality. This gap between the scenario and the reality it attempts to mimic is exaggerated when students are asked to believe that their ‘patient’ has a variety of global impairments.

And when we consider the responses in the feedback, it was clear that while the absence of anything that could be taken as a manifestation of ‘intellectual disability’ was noted, this did not of itself influence the care the students tried to provide. This, however, should not be taken as an indicator that the same thinking would necessarily apply if a different cohort of professionals were introduce to the same scenario. In the UK the early years of the twenty-first century have revealed several examples of poor care standards in settings where people with intellectual disability receive care. The names Orchard Hill and Winterbourne View may be familiar to some readers. It is also apparent from the content of recent reports (Mencap, 2007; Department of Health, 2008a; Parliamentary and Health Services Ombudsman, 2009) that non-disability specialist cohorts of professionals such as adult nurses have also neglected and misinterpreted the needs of individuals with intellectual disability with sometimes fatal consequences. A closer reading of the content of the Six Lives report indicates that discrimination on the basis of disability is at the core of such ‘significant and distressing failures in service’ (Parliamentary and Health Services Ombudsman, 2009: 15). It is just possible that a high-fidelity manikin with no facility for speech and pre-programmed to be unresponsive to standard communication methods might turn out to be just the right teaching and learning aid to function as a life-saver for others in future. This idea will remain speculative until we are in a position to conduct more extensive evaluation of our programmes. Meantime we will continue to use the manikins for demonstrating the application of clinical skills in scenarios. They are well received by the students and provide valuable opportunities for learning.

The responses indicate a strong liking for the scenario as a way of learning. And despite concerns for the artificiality of the setting, the students seem to have found little trouble in believing in the scenario. But although the manikin remains a highly faithful simulator – displaying the outward signs and symptoms of someone experiencing chest pains, for example – ultimately it remains a piece of kit. The fidelity of the scenario relies on the learner being able to engage in a ‘willing suspension of disbelief’ (Coleridge, 1975/1817). In adopting this position the learner must see beyond the readings on monitors and interpret these as evidence of some clinical emergency which threatens their patient and demands action on their part to avoid further deterioration in the condition.

Conclusions

The principal lesson that we learn from Dr Tulp is that in the case of people living with profound and multiple intellectual disability there is only so much we can learn from a patient simulator. However, there is a clear advantage to using a manikin for practising certain clinical skills and students report confidence in the process.

Simulation-based education and training in healthcare provide students with the ability to experience caring for a patient with a condition that they have not been exposed to in the clinical setting, or to care for a patient in a potentially life-threatening situation (Abrahamson et al., 2006; Henrichs et al., 2002; Lasater, 2007). It is argued that participating in simulation will help to prevent students making errors in the future, and practice in a safe, supportive environment where it is permissible to make mistakes will help to improve clinical outcomes in the long term.

Although both the research literature and anecdotal experience agree that simulation helps to prepare students to perform in real clinical settings and that the experiences in the simulation environment do transfer to clinical practice, it is clear that research still needs to be carried out to determine how best to implement and facilitate simulation training, particularly in areas such as learning disability nursing. From the students’ perspective, if simulation is to work it must be believable. However, in spite of the apparent move towards simulation, there still remain a number of clear caveats for educationalists. As Aggarwal et al. (2010) note, the major challenge to the use of simulation in the future is the difficulty in demonstrating that it makes a difference to patient care outcomes. Our next move is to replicate this session with student cohorts from beyond the learning disability nursing intakes. This will go some way towards meeting the requirements outlined in the Health Care for All.