There has been rapid growth in the use of clinical skills laboratories in medicine since the 1970s, with their role now well established in undergraduate and postgraduate training. Other names for such a facility include clinical skills center, simulation center, clinical simulation laboratory, and skills lab. Clinical skills laboratories are used to train students in specific practical, clinical, and procedural skills (sometimes referred to as psychomotor skills), using models and simulators with the aims of increasing competence and confidence, improving patient safety, reducing technical errors, and complementing bedside teaching. The facility provides a safe, relatively stress-free environment in which learners can practice repeatedly. Compared to the sometimes variable opportunities in the hospital setting, it provides greater standardization and more structured feedback. There is an increasing body of evidence supporting the effectiveness of models used in clinical skills laboratories and the benefits for trainees’ skill development (Akaike et al., 2012). Ongoing initiatives in simulation-based training (McGaghie et al., 2010) draw from advances in other areas, such as aviation, and increasingly incorporate additional skills such as teamwork, decision-making, leadership, and situational awareness.

Veterinary education is following medicine’s lead and clinical skills laboratories are becoming more commonplace in recognition of the potential benefits in preparing students for the modern workplace (Jaarsma et al., 2008). The acquisition of clinical skills is a key aim of veterinary education in order to achieve the competencies defined by accrediting bodies and required of new graduates. However, there is a risk that some students will complete their studies armed with the prerequisite knowledge, but lacking in some essential practical and clinical skills (Remmen, 1998). The reasons relate to a number of challenges encountered when learning and teaching clinical skills. For instance, the clinical environment (during clinical rotations or extramural studies) can be variable for the student and challenging for the teacher (Remmen et al., 1999). It is important for students to gain experience in real-life situations and have access to clinical cases, but at times the clinician has to prioritize the animal’s safety and the needs of the client. Additionally, when students are learning on a live animal some feel nervous and anxious, especially the first time, and are mindful that mistakes may have serious consequences. Other factors that may limit opportunities for practice include larger cohorts, competing demands on faculty budgets, difficulties sourcing cadavers, and the need to consider the welfare and ethical implications around the use of live animals in education (de Boo and Knight, 2005). Clinical skills laboratories can address many of these challenges and provide training in simple practical skills, more complex clinical and procedural skills, and communication skills, as well as being a suitable venue for assessments such as objective structured clinical examinations (OSCEs). Unlike workplace-based education (e.g., clinical rotations), students can practice without pressure, stress, or anxiety about harming animals, while learning new skills or consolidating and refining existing skills (Langebaek et al., 2012).

Clinical skills laboratories house a variety of models, part-task trainers, and simulators, which promote the development of competencies while supporting the principles of reduction, replacement, and refinement (the 3Rs) of the use of animals in education. Teaching in the clinical skills laboratory provides useful preparation for clinical training, but it is important to note that learning on models is meant to be a supplement, not a complete replacement for animals. However, there seems little doubt that the amount of veterinary training using models in such laboratories will continue to grow, with associated benefits for student learning and animal welfare.

Students have opportunities to learn a range of skills as well as being able to target their practice of specific techniques in a timely manner. Staffing is crucial and should include enough instructors, who may be faculty, practitioners, technicians, and/or students (peer-assisted learning). A manager for the laboratory, and its associated equipment and facilities, will ensure efficient organization and administration and oversight of the budget. Having an academic lead is highly recommended, and they should have responsibility for the design, promotion, and coordination of the clinical skills program and quality assurance of teaching and assessment.

At veterinary colleges with existing laboratories, the clinical skills program is usually closely linked to the curriculum and preferably has specific practical classes embedded in the formal timetable. Teaching and learning of practical and clinical skills should run throughout the period of study (a longitudinal design), with competencies building year on year and with the aim that graduates are able to provide safe and effective entry-level care. Additionally, using the clinical skills laboratory as an assessment center not only extends its utilization, but also provides outcomes assessment data. It is worthwhile considering having an open access policy, with a “drop-in” area where students can repeat skills in their own time and at their individual pace (Dilly et al., 2014). Another benefit of having a clinical skills laboratory and providing as much access as possible is to decrease students’ anxiety prior to their first “hands-on” experience with live animals or before practical assessments and exams.

There are recognized challenges in teaching and learning clinical skills. As a result, an increasing number of veterinary colleges are opening clinical skills laboratories and developing clinical skills programs. In the following sections, further points will be discussed relating to developing clinical competencies, designing and equipping the laboratory, and considerations for the teaching, learning, and assessment of clinical skills.

When building a clinical skills laboratory, local physical constraints and financial resources are major factors, but the decisions should still focus on optimizing teaching and learning. The clinical skills laboratory should be designed to support the types of teaching required – that is, hands on, small group – and be easily adaptable for different classes and for use in assessments, such as an OSCE circuit. In addition, the provision of a drop-in area, which may be open access or bookable (sign-in), is beneficial for self-directed learning and provides students with opportunities for repeated practice and to revisit the laboratory when needing to refresh or perfect skills in preparation for a clinical rotation, work placement, or assessment. Suggestions for setting up a clinical skills laboratory are summarized in Box 10.2.

Veterinary clinical skills laboratories have been set up in a variety of ways, sometimes as a bespoke new center or by refurbishing existing buildings, for example an old operating theater, laboratory, or practice, and they may be included within a learning complex, the clinic, or a surgical teaching area. The laboratory may be in one building or more spread out and may or may not be linked to other teaching areas. There are several good reasons for having one center known as the clinical skills laboratory, as it helps signpost the facility to students and faculty, and there are efficiencies in staffing and managing the space. Ideally, when deciding on the location it should be in close proximity to other areas used by students. For example, students on clinical rotations are more likely to drop in and practice if the facility is adjacent to the teaching hospital, although that may not be the best location for students in lower years for learning more basic animal handling skills. In some instances there is more than one facility, with each tailored to the needs of students and staff at different stages in the curriculum and at the most appropriate venues.

The size and number of rooms can range from one single space (preferably large) to a multiroom layout or a complete building complex. The room layout should ideally facilitate multiple training sessions at the same time, and the rooms should be flexible for use in teaching and assessment. One of the benefits of large rooms is being able to run several groups or classes in parallel, or an OSCE circuit when screens can be used to divide the space into multiple smaller areas or OSCE stations. Although the space may appear busy and noisy, students are still able to learn, as the primary focus is on hands-on practice and “doing.” Other rooms may be specific to certain types of teaching, such as consulting and communication skills training. If the facility is based in an existing building, some rooms may already be equipped and are therefore more suitable for specific skills (e.g., surgical preparation, including sinks and flooring with drainage) and often existing equipment can be repurposed. Careful consideration should be given when selecting or purchasing equipment (tables, benches, etc.) to ensure that it will fit within the room(s) and can be moved as required (e.g., to set up an OSCE circuit). Each skill station should have sufficient space for teaching and for students to practice, while there also needs to be enough surfaces for the model(s), equipment, and any supporting learning resources (e.g., instruction sheets).

Ideally, the clinical skills center should include a reception and sign-in area, plenty of storage space (for equipment, spares, and consumables), a prep room (e.g., to prepare for practical classes, to make and repair models), somewhere for students’ belongings, and an office for the laboratory manager and staff. Another important consideration is to provide an area set aside for drop-in and self-directed learning in addition to the formal teaching spaces. The facility should be equipped with technology such as large screens and tablets. Some rooms may be set up for the use of video cameras and links to videos are helpful, for example via QR (quick response) codes. The area will need computer network infrastructure and wi-fi so that e-learning resources, including video recordings, can be used to support student learning, teaching, and assessment. It is worth noting that most technology, as well as other equipment, will require regular updating, ongoing maintenance, and modernization.

As the main focus of a clinical skills laboratory is to provide an environment where students can learn practical and clinical skills in a hands-on way, the most important resources are the models, part-task trainers, simulators, and associated equipment. Some models and part-task trainers from medical education are suitable for use in veterinary clinical skills laboratories, and there are some specific veterinary models available commercially. However, there are significant gaps, and as a result a growing array of home-made models and simulators has been developed by veterinary educators. The veterinary community is proactive in sharing ideas, tips, and “recipe” sheets for home-made simulators via online forums and web pages, for example the Veterinary Clinical Skills & Simulation group on NOVICE (Baillie et al., 2011), and face to face during workshops at conferences (Baillie, Crowther, and Dilly, 2015). When buying commercial models or constructing, adapting, and using home-made ones, it is useful to consider the following aspects:

• Cost (initial, parts, and repair).
  
• Reusability (single or multiple use: how many times a model or component can be used before needing replacement).
  
• Alignment with (usefulness in relation to) the aims of the clinical skills program.
  
• Appropriateness for the stage and needs of the learner.
  
• Limitations compared to performing the task on the real animal.
  
• Transferability of skills to the real task.
  
• Storage requirements.

Even though the focus of most clinical skills laboratories is on teaching with models, there are times when the use of live animals and cadavers is appropriate. However, sourcing of cadavers and policies around the use of live animals in teaching will be dependent on the regulations and ethical guidelines of each country and university. The clinical skills laboratory will also need to include the appropriate biosecurity measures. In order to promote animal welfare and the principles of humane veterinary education, the following questions should be considered:

• Which skills can be taught or assessed with simulators and models or using nonharmful teaching methods?
  
• What types of models and simulators are available to train and prepare students for their practical handling and clinical experiences?
  
• What types of supporting learning resources (e.g., videos) are accessible and available to demonstrate a specific skill and/or complex procedure (e.g., spaying or neutering)?
  
• Is there a need to use cadavers (if yes, are these cadavers ethically sourced)?
  
• What type of noninvasive self-examination could be undertaken (e.g., ultrasound)?
  
• What is the maximum acceptable use of a live animal for teaching purpose (e.g., number of students, time period)?

Simulation aims to complement teaching and learning by replacing live animals with reasonably realistic but nonetheless artificial substitutes. There is a wide range of models and types of simulator, which are broadly classified as follows:

• Low fidelity: simple, usually cheap models and part-task trainers designed for a specific skill, task, or part of a procedure (Scalese and Issenberg, 2005). Examples include suture pads, toy dogs for bandaging, home-made venipuncture models, and a range of injection models (different species and sites).
  
• Intermediate fidelity: typically simulating several skills or steps of a technique, incorporating more aspects of the real task. Examples include a home-made heart sounds simulator, canine intubation (home-made or commercial; Aulmann et al., 2015), and an ophthalmology model.
  
• High fidelity: often simulating complete procedures or techniques, closer to representing the real task or animal, and usually more expensive than simpler models. Examples include physical or virtual-reality simulators for rectal palpation of the cow and the horse, and surgical models, such as a bitch spay.
  
• Simulated clients (SCs): if communication skills training is run in the clinical skills laboratory, then SCs are usually recruited and are individuals (actors or role players) trained to portray a client in a scripted and standardized encounter (Adams and Kurtz, 2006) during teaching and OSCE-type assessments.
  
• Contextualized simulation: a hybrid form of simulation that supports training combining technical with other skills, including communication, application of knowledge, and decision-making (Kneebone and Baillie, 2008; Baillie, Pierce, and May, 2010).

The clinical skills laboratory provides an active learning environment and supports teaching of psychomotor skills in ways that lectures do not. There is an increasing body of evidence that learning on models and simulators positively influences the learning experience and skill acquisition; and evidence-based protocols have emerged that provide guidance for effective simulation-based training (Akaike et al., 2012; McGaghie et al., 2010). As well as practicing skills on the models, students will be able to receive feedback on performance from teachers and peers and, in some cases, the simulator. Videotaping can also be used to review performance and as part of a debriefing exercise.

When considering how to support the learner, a distinction should be made between two types of delivery: participating in taught practical classes and self-directed learning. Whatever the approach, the skill station must be well designed, with clear, step-by-step instructions provided. This is particularly important for an open-access or drop-in area, for when students return after the formal teaching to revise, improve, and further develop their skills. Without clear instructions there is a risk that students will be reluctant to return and practice on their own, or that they may develop inappropriate skills or approaches. The supporting learning resources can be provided in various formats, such as instruction booklets (see Box 10.3) or sheets (the text illustrated with good-quality photographs and diagrams), videos, posters, information cards, and slide shows. The resources should be easily accessible to students, not just in the clinical skills laboratory but at other times and places – that is, for private study and when undertaking extramural rotations and off-site work placements.