Improving learning of a clinical skill: the first year's experience of teaching endotracheal intubation in a clinical simulation facility

Improving learning of a clinical skill: the first year’s experienceof teaching endotracheal intubation in a clinical simulationfacility

Harry Owen & John L Plummer

Background All medical practitioners should be able to

manage the airway of an unconscious patient. Endo-

tracheal intubation is the most effective method of

securing the airway but is a complex skill requiring

much practice. Traditionally, endotracheal intubation

has been taught on patients, but this is not ideal.

Methods We have developed a short course on endo-

tracheal intubation taught in a clinical simulation unit

(CSU). This unit has a large range of airway trainers

and patient simulators, some of which can be manipu-

lated to make intubation more difficult. Endotracheal

intubation is taught in a series of steps in order to avoid

cognitive overload. Each step is taught on an airway

trainer that has no difficult features. Once this is

mastered, more difficult situations are presented which

require application of new techniques and ⁄or equip-

ment. In this way, students learn useful schemas to

apply clinically.

Results In 1 year, over 100 students and trainees were

taught endotracheal intubation in the CSU. The ideal

group size was found to be two students and one

trainer. It took 75 to 90 minutes for most students to

reach a standard where they could be expected to safely

perform the technique on a patient. All comments on

learning endotracheal intubation in this setting were

positive. Many students felt more comfortable learning

on a model than on a patient.

Conclusion Learning clinical procedures on simulators

is becoming an essential part of medical education.

More than one airway trainer may be needed to give

students the expertise to perform endotracheal intuba-

tion on patients.

Keywords *clinical competence; education, medical,

undergraduate ⁄ *methods; endotracheal intubation ⁄*methods; patient simulation; South Australia; teaching.

Medical Education 2002;36:635–642

Introduction

There is a need for improved teaching of airway

management. The community expects doctors to be

able to apply cardiopulmonary resuscitation techniques

during medical emergencies.1 However, studies have

reported poor airway care, leading to increased mor-

bidity or mortality in the prehospital setting2 and

during interhospital transfer.3 Junior medical staff have

reported their undergraduate training as deficient in

exposure to some practical procedures and have said

they would have liked more experience as undergrad-

uates in resuscitation and endotracheal intubation, an

important element of airway management.4

‘Airway management is the scaffolding upon

which the whole practice of anaesthesia is built’5 and

anaesthetists are undoubtedly the airway experts of the

hospital world. However, the belief that anaesthesia is

a postgraduate subject6 has meant that there is no well

accepted or clearly defined core curriculum for

undergraduate teaching in anaesthesia7 and many

health professionals see anaesthesia wholly in terms

of intraoperative care. Anaesthesia is then often

overlooked as a discipline for inclusion in undergra-

duate education, to the detriment of teaching in airway

management.

The Australian Medical Council (AMC), like most

bodies responsible for accrediting medical schools, does

not specifically recommend teaching of particular

disciplines but it does outline the breadth of training

that medical students should receive.8 Under the

Department of Anaesthesia, Flinders University of South Australia

and Flinders Medical Centre, Bedford Park, South Australia

Correspondence: Harry Owen, Department of Anaesthesia, Flinders

University, Flinders Medical Centre, Bedford Park, South Australia

5042, Tel.: 00 61 8 8204 4265; Fax: 00 61 8 8204 4197; E-mail:

[email protected]

Simulation

� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:635–642 635

heading ‘Objectives Relating to Knowledge and

Understanding’, the AMC states that ’Graduates com-

pleting basic medical education should have developed

the following skills to an appropriate level for their stage

of training: … (ix) The ability to recognize serious

illness and to perform common emergency and life-

saving procedures such as caring for the unconscious

patient and cardiopulmonary resuscitation’.8

The School of Medicine at Flinders University

introduced a 4-year graduate-entry medical course in

1996. A curriculum review resulted in the Department

of Anaesthesia concentrating on peri-operative care and

airway management. All students now receive teaching

on airway management in Years 1, 2 and 3, with the

objective of ensuring that all students can prevent

hypoxaemia in unconscious patients. The whole of the

airway management teaching is too large a topic to cover

in a short paper so what follows is a description of our

approach to teaching endotracheal intubation, as part of

airway management, which we now teach in Year 4.

Endotracheal intubation

Endotracheal intubation is a complex psychomotor

skill. It has been claimed that the literature on the basic

technique is very limited because traditionally the skill

is passed from mentor to student by long apprentice-

ship.9 We developed a short course on endotracheal

intubation using new educational technologies and the

results of recent cognitive science research, with the aim

of improving teaching in this area. The teaching

comprised computer-based teaching materials to pro-

vide students with essential knowledge on endotracheal

intubation and then practice of the clinical skill itself to

acquire proficiency.

In developing the course, a number of options for

training in endotracheal intubation were considered,

including practising on animals, patients or

models ⁄ simulators.

Animals

Ethical issues limit use of animals in practising of

medical procedures. The anatomy of most animal

heads and necks including the larynx is different from

that of humans. Monkeys would be suitable but are

costly, so small mammals such as cats have been used

instead.10 However, the anatomy of the cat airway is

very different to that of humans11 and may give rise to

proactive interference in later learning on humans.

Humans

Cadavers have been used for teaching and practising

endotracheal intubation, but their look and feel is not

’lifelike’10 and their availability limits their usefulness.

Patients in deep comas have also been used12,13 as have

the newly dead ⁄ recently deceased12,13 but ethical issues

now preclude this unless the training cannot be

obtained in any other way14 and specific consent is

obtained from relatives.13–16

Patients being anaesthetized to undergo surgery are

the group most used by students and trainees practis-

ing endotracheal intubation. There is, however, an

appreciable complication rate associated with endotra-

cheal intubation performed by inexperienced person-

nel. Chen17 reported an 18% incidence of oral trauma,

including a 12Æ1% incidence of dental damage, from

endotracheal intubation performed by trainees. The

majority of patients would be upset to discover they

had been the unsuspecting subject of a novice’s first

attempt at a procedure.18 Half the patients in a

teaching hospital did not want medical students

involved with their care but did not feel they could

decline participation.19 In a recent investigation, even

when students knew a patient had specifically reques-

ted that students not be allowed to perform proce-

dures on them, a third of students said they would

intubate that patient if asked to by their supervisor.20

Recent legal decisions indicate that specific consent

should be obtained before a non-expert attempts a

procedure.21

Simulators

Manikin training is one of the best options for

instructing large numbers of students in a variety of

skills.22 It has been reported that paramedics trained in

endotracheal intubation using a systematic manikin-

only teaching programme can attain acceptable indi-

vidual success rates in the field.23 Consequently, we

adopted training on manikins as a core component of

our course.

Key learning points

The limited size of working memory means that a

complex clinical skill may need to be taught as a

number of separate elements.

Students appreciate learning on a simulator before

attempting a procedure on patients.

Practice on multiple simulators is better than

multiple attempts on a single simulator.

Teaching airway skills using simulators • H Owen & J L Plummer636

� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:635–642

Intubation trainers have been used for over

30 years24 but there is little published information on

the relative merits of the available airway and intuba-

tion trainers. A number of different airway trainers with

differing features are now commercially available. In

equipping our facility, we specifically sought out sim-

ulators that looked and performed differently to each

other. The models we use to teach endotracheal

intubation in adults are listed in Table 1.

The teaching environment

The aim of a clinical skills unit is to provide a safe

environment for learners to link theoretical knowledge

and clinical skills.25 We have established a clinical

simulation unit (CSU) in the Department of Anaes-

thesia, which has three teaching laboratories. One

laboratory is permanently set up for teaching airway

skills, including endotracheal intubation. The facility

has 18 airway trainers simulating patients of different

ages, sizes and features and a wide range of equipment

for airway management. In another area there is a

computer-controlled patient simulator (ALS Skillmas-

ter manikin, Laerdal Medical AS, Stavanger, Norway),

which can be modified to make endotracheal intubation

more or less difficult. We also have a full theatre-type

patient simulator (SimMan, Laerdal Medical AS), but

this is not used to teach beginners. The third laboratory

contains several part-task trainers and manikins for

procedures involving needles and other sharps, such as

thoracocentesis, lumbar puncture, peripheral venous

cannulation, central venous cannulation and arterial

blood sampling or arterial cannulation.

The teaching

A task analysis was undertaken to determine the most

appropriate instructional design. Procedural analysis

was used initially because the task sequence involved

overt actions. A learning heirarchies analysis was also

used to determine the prerequisites for performing

elements of the procedure (subtasks). This combina-

tion analysis led to the instructional sequence.

Deconstructing the technique also identified the dis-

crete elements of the procedure (chunks) that could be

taught separately. This ‘chunking’ was important to

avoid cognitive overload26 but the ‘chunks’ needed to

be large enough to retain their context and be

meaningful to students. The elements were taught in

an order chosen to give a sense of logical progress

towards mastery of the task (Fig. 1). The teaching

first involved watching a video we had made,

which demonstrated the technique using both an

Figure 1 Flowchart of steps in teaching and learning endotra-

cheal intubation.

Table 1 Adult airway models used in teaching endotracheal

intubation

Ambu adult airway trainer

CLA airway trainer

Gaumard adult airway trainer (Simon)

Laerdal adult airway trainer*

Laerdal ALS skillmaster manikin*

Laerdal difficult airway trainer

Lifeform ‘Airway Larry’*

Lifeform ‘CPArlene

Medical Plastics Limited – Airway trainer*

Medical Plastics Limited – Trauma Head*

Simulaids adult airway trainer

Simulaids trauma airway trainer

VBM ‘Bill’ airway trainer

* Used in teaching endotracheal intubation to novices.

Teaching airway skills using simulators • H Owen & J L Plummer 637


anatomically correct model and a dissected model that

allowed otherwise hidden aspects of the technique to

be displayed. Use of video images from the perspective

of the operator has recently been reported to improve

success rates.27 The video was then replayed with the

students holding the equipment (laryngoscope and

endotracheal tube) and modelling the required move-

ments (simulated rehearsal). The Macintosh blade was

used because that is the blade pattern most likely to be

encountered by students and because some students

find newer, ‘improved’ blade designs more difficult to

use even through they may allow for a better view of

the glottis.28 It was stressed to the students that if the

glottis (vocal cords) could not be seen, the intubation

attempt should be aborted and the lungs artificially

ventilated with bag and mask. We wanted to avoid the

high failure rate described by others and the attendant

risk of hypoxia.29

In the next step, the instructor demonstrated the

technique of endotracheal intubation on an airway

trainer, emphasizing the steps necessary for successfully

passing the endotracheal tube through the vocal cords.

This was the only goal of this element, and issues such as

which size of endotracheal tube to use, how far beyond

the vocal cords the tube should be advanced, etc., were

deliberately not detailed at this time in order to manage

cognitive load. Then the instructor observed the stu-

dents’ first attempts and gave immediate and specific

feedback on one or two good and ⁄or bad aspects of the

students’ performances. The need to avoid using the top

teeth as a fulcrum for the laryngoscope blade was

emphasized. This is one of the most commonly made

mistakes30 and it actually makes intubation more

difficult.31 The simulator used for these first attempts

was one without any features that would make endo-

tracheal intubation particularly difficult (i.e. with a good

mouth opening, without a big tongue, without a small

lower jaw, without prominent upper teeth, etc.), such as

the Medical Plastics Ltd airway trainer, Medical Plastics

Laboratory, Gatesville, TX, USA.

When the students had mastered this part of the

procedure, the consequences of some common mis-

takes were demonstrated. These errors included lever-

ing on the upper teeth with the laryngoscope and

getting too close and advancing the endotracheal tube

too far. Advancing the tube too far gives rise to one lung

ventilation, which was graphically displayed using the

Laerdal airway management trainer, an airway trainer

with exposed lungs.

Students were then introduced to a series of models

with different features that required either a change in

technique, such as external laryngeal manipulation to

improve glottic visualization32 and ⁄or use of intubation

aids for success. Generally, students were not specific-

ally told how to be successful in these cases. Instead,

they were first allowed to flounder and then assisted to

develop an approach based on applying principles

learnt earlier that would result in successful intubation

(guided discovery). This is analogous to learning to fly

in a flight simulator, where, having mastered level flight

in still air, the student is then presented with the task of

flying in crosswinds, etc. Our students were allowed

enough trials to master the new situation before they

were moved on to another challenge. This was to make

sure that the information in ‘working memory’ was

encoded into long-term memory.33 Typically, there was

a decrement in performance when students were

presented with a new airway model, but, over several

trials, the manoeuvres necessary to achieve satisfactory

performance were learnt. After a number of variations

had been experienced, students were encouraged to

reflect on their performance so that they might develop

schemas or templates of behaviours that they could

apply when presented with a new situation in order to

improve the likelihood of success.

In training, less is generally more; tutors should

teach what students need to know and not what is nice

to know.34 Therefore, during the early stages of

mastering endotracheal intubation, non-essential tasks

were omitted. For example, in order to reduce

cognitive load, students were initially given the appro-

priate equipment and it was set up correctly for them.

Later, students were expected to choose their equip-

ment (albeit from a reduced range) and prepare it

themselves. Sometimes, students would ask a question

about an element that would be taught in the future.

This was good; it meant the student had recognized

the need for that information and was ready to receive

it. The question was answered by delivering that

element and the remaining elements to be taught were

then re-sequenced accordingly. At first the students

were allowed as much time as they needed to perform

the technique, but later, as they became more expert,

the element of time pressure was introduced. Timed

intubation has previously been described as a measure

of competence.35

The students

In the first year, 115 health professionals learnt endo-

tracheal intubation in our CSU. Most were medical

students (n ¼ 95) who wanted to acquire the skill, but

student throughput also included some trainees in

critical care medicine and paramedics who needed to be

able to undertake endotracheal intubation as part of

their work.



We tried teaching group sizes of between one and five

students and found two to be most effective. Endotra-

cheal intubation is almost effortless to the expert but

the novice uses a large amount of effort and the left arm

muscles quickly become fatigued due to inefficient

technique, limiting the practice rate. When two stu-

dents are being taught, there is usually enough time

between each student’s attempt at intubation for

recovery. However, with three or more students, the

time between feedback on an attempt and then prac-

tising the technique again was so long we lost the

attention of some students.

Sessions longer than 90 minutes seemed to be too

fatiguing for many trainees. We now believe sessions of

75–90 minutes to be optimal. This allows trainees to

have around 12–14 attempts at endotracheal intuba-

tion. Beyond this number of attempts, the learning

curve flattens and benefits diminish (Fig. 2). However,

comparison of trainee paramedics and medical stu-

dents suggests different rates of skill acquisition

(Fig. 2). The majority of medical students (90%)

had little prior experience of patient care. The trainee

paramedics had extensive skills in airway management

as ambulance officers and we believe these skills

helped with learning endotracheal intubation.

We generally started the students on the less difficult

models because we hypothesized that they would learn

more effectively by coming to know what led to success

rather than by coming to know what led to failure. Our

analysis, using Bush & Mosteller’s36 learning model,

suggests that students do indeed learn far more from

successful endotracheal intubation than from failure.37

Trainees typically used between three and five different

models in a session.

Plummer & Owen37 reported that there is significant

variation in difficulty of intubation of different airway

trainers. Table 2 shows success rates of students with

various trainers on their ninth attempt. By this time, the

students had attempted endotracheal intubation on a

number of models and understood the principles of the

technique. The different success rates are predomin-

antly due to differences in difficulty between the

models.

The students were provided with a form for collec-

tion of demographic data and self-evaluation. At the

end of this form was a space requesting additional

comments. Of the first 100 students, 93 provided

feedback, with 61 describing it as ‘great’, ‘excellent’,

‘valuable’, ‘invaluable’, etc. Five thought the timing

Figure 2 Estimated learning curves for two groups of trainees.

Ambulance paramedic trainees, who generally had considerable

prior experience in clinical procedures, were successful in

approximately 30% of initial endotracheal intubation attempts

and improved rapidly, approaching 100% success rates after

around six attempts. Medical students, who had more limited

prior experience, began with a lower success rate and learned

more slowly. Based on data from Plummer & Owen.37

Table 2 Percentage of successful intubations by medical stu-

dents, on ninth attempt

Model

Number

of students

Percentage

successful

MPL Intubation Head 13 77

Lifeform Airway Larry 22 73

MPL Trauma Intubation Head 11 73

Laerdal Airway Management

Trainer

10 60

Laerdal Adult Intubation Model 9 44

Table 3 Advantages of using an airway training facility to teach

endotracheal intubation

No risk to patient whilst teaching basics

Students can practise as often as required

Many attempts can be made in quick succession

Practice can be scheduled to suit timetable of student and

supervisor

Errors can be allowed (to demonstrate consequences) without any

risk to patient safety

Procedure can be undertaken slowly or stopped for teaching and

restarted

Different situations (including uncommon but life-threatening

conditions) can be created

Different techniques and equipment can be tried in the same

situation

Difficulty can be increased incrementally as expertise is acquired

Environment can be controlled to limit cognitive load and

distractions

Students appreciate being able to become skilled in a technique

before attempting it on a patient



was good ⁄perfect, five wanted more time and eight

wanted to come back for more practice. Nine partic-

ipants commented that the instruction ⁄ feedback was

good and four commented specifically that the one

instructor:two students ratio was good, although there

were many more general comments on the value of

small group size.

Many students commented positively on being pre-

sented with progressively more challenging situations.

Thirteen students thought it was reassuring to have had

the session and ⁄or it had increased their confidence.

The only negative comments were a wish for more time

to practise. As noted above, we believe that sessions of

75–90 minutes are optimal and additional practice

should take the form of multiple sessions rather than

longer sessions. However, after a single session, most

(93%) trainees reached the required standard to

attempt intubation on a patient. This standard was

defined as ’had the attempt been made on a live patient,

the desired outcome would have been achieved without

significant risk of adverse events’.

Discussion

We have found our structured approach to teaching

endotracheal intubation in the CSU to be both effective

and attractive to students (Table 3). Many adult

teaching methods and recent research were used with

the aim of increasing the efficiency of training and

improving performance. Showing a video from the

perspective of someone performing an intubation has

been reported to increase initial intubation success

rates.27 However, we deliberately kept our video very

short (less than 2 minutes) and showed only what was

needed to visualize the glottis and pass an endotracheal

tube between the vocal cords. In the video, we

emphasized two mistakes that make endotracheal

intubation more difficult than it needs to be, namely,

poor head and neck positioning38 and levering the

blade of the laryngoscope on the upper teeth.30,31

Learning must include acquisition, retention and

retrieval, and in clinical practice, knowledge retrieval

must be accompanied by the ability to apply it

appropriately in different and novel situations. Learn-

ing must therefore also include an aspect of novelty,

such as provided by different models, varying levels of

pressure to perform and unexpected difficulties.

Endotracheal intubation is a sophisticated psycho-

motor skill that, in clinical practice, requires knowledge

retrieval under time pressure in situations with limited

time for problem solving. In this situation, the best

approach is to provide a suite of action sequences or

subroutines that can be evoked when the need is

recognized. This use of schemas is how experts avoid

the working memory ‘bottleneck’ that paralyses novic-

es.26 Unfortunately, these associations cannot be taught

readily. Everybody has different schemas – even experts

differ in their approach to the same problem. However,

by structuring the exposure to learning situations, the

trainee can be encouraged to develop personal schemas

that can be used in particular circumstances with a high

probability of success. This is how a ‘novice’ becomes an

‘expert’.39

Acquisition and retention of knowledge and skill

require information to be moved from working mem-

ory (with limited capacity) to long-term memory. This

transfer requires rehearsal within a short time. When

endotracheal intubation is taught in the operating

theatre, the time between endotracheal intubation

attempts is frequently measured in hours. This is

hardly conducive to effective learning and may be a

factor in the slow rate that trainees learn endotracheal

intubation. In contrast, in the CSU the student can

receive feedback after each attempt and then apply

and rehearse using the new information. The student

also has the opportunity to try several different

techniques in the same situation and to recognize

and learn why particular manoeuvres are better in

certain situations.

Endotracheal intubation teaching also includes what

to do when endotracheal intubation cannot be com-

pleted within a very short time. We only need to eat

occasionally but we must breathe 10–16 times per

minute because we carry very little oxygen reserve.

Endotracheal intubation must be successfully comple-

ted quickly or alternative (although less secure) meth-

ods of lung ventilation must be commenced. In the

clinical setting, the trainer will often take over the

procedure if allowing the student to fail could threaten

patient safety. However, in clinical simulation the

‘flounder factor’ can be used deliberately to enhance

learning. The student has the explicit ‘right to make

mistakes’ during learning as this widens their experi-

ence and should reduce problems in the future.40

According to the Yerkers-Dobson Law, some anxi-

ety is good for learning, but a high level of anxiety is

debilitating.41 Many students find learning procedures

on patients very stressful42 and this may both inhibit

them from undertaking the task and reduce the

educational value of the episode. In the operating

theatre, students are very aware that endotracheal

intubation must be completed within a very short

time (ideally less than a minute) as delay can lead to

severe adverse patient outcome. There is also ’pro-

duction pressure’ on the trainer. This environment is

not at all conducive to learning! Several students



commented in the feedback that they felt ’comfort-

able’ learning in the CSU. Positive views of learning

new clinical skills in a training laboratory before using

such skills on patients has been reported previously.43

We did not, however, allow students to feel too

comfortable and continually raised performance

requirements and increased the difficulty of the task

to maintain the challenge.

We are currently studying the transfer of the skill of

endotracheal intubation learnt on medical models to

patients. Initial observations have been very encour-

aging and feedback from students has been very

positive. Indeed, word of mouth has resulted in an

increasing number of requests from health professional

trainees to receive endotracheal intubation skills train-

ing in the clinical simulation laboratory. This training

has become a popular elective topic for medical

students in Years 3 and 4.

At the end of the teaching session on endotracheal

intubation, an assessment of proficiency was made.

Students attaining the required skill level were given

permission to attempt the technique, under close

supervision, on patients. Students not attaining the

required standard were encouraged to participate in

further training sessions. It is likely that in the future

it will be less acceptable for students without prior

experience to attempt procedures on patients.20

Patients should be given specific information when

consent is obtained, which should include informa-

tion on the skill level of the student and trainer.21

Patients may be more willing to give consent when

the student has developed proficiency in performing

the skill on a simulator. Clearly, anaesthesia depart-

ments should have policies that protect the rights of

patients.

Clinical simulation does more than protect the

patient from the total novice. By allowing the student

or trainee to develop proficiency in complex tasks, it

reduces delays caused by teaching. There will be a

reduced complication rate and reduced costs for the

organization. Disposable items are often expensive but

they can be reused many times on a manikin whilst a

trainee gains proficiency in their use. An editorial

suggested that all anaesthesia departments should

establish a teaching area specifically for airway man-

agement training.5 However, creating a teaching unit

with only one or two models for practice is unlikely to

be as effective as one with several.

Conclusion

We have developed a structured teaching programme to

introduce medical students and trainees from other

health professions to endotracheal intubation. This has

been much appreciated by students. We are currently

investigating to what extent it provides them with skills

essential to undertake endotracheal intubation on

patients. This was a pilot programme that is now being

extended to study skill transfer and, ultimately, skill

retention. Clinical simulation will become an essential

component of medical education.

Contributors

Scientific Education Supplies, Mansfield, Queensland,

helped source several of the airway trainers. The

authors undertook the planning, data collection,

analysis and preparation of this paper.

Acknowledgements

Scientific Education Supplies, Mansfield, Queensland,

Australia (http://www.ses.com.au) helped source sever-

al of the airway trainers. Ms Val Follows RN, the

clinical simulation coordinator, helped prepare the area

and equipment for the teaching.

Funding

Grants from Laerdal Foundation for Acute Medicine

(2000) and the Australian and New Zealand College of

Anaesthetists (2001) assisted with this project.

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Received 9 July 2001; editorial comments to authors 23 August 2001;

accepted for publication 16 January 2002



Documents

Improving learning of a clinical skill: the first year's experience of teaching endotracheal intubation in a clinical simulation facility