Simulation

The ‘gut bucket’: a novel

training tool for
standardised patients
Karen Delaney-Laupacis, Kerri Weir and Diana Tabak, Standardized Patient Program,
University of Toronto, Ontario, Canada

SPs may lack SUMMARY
knowledge of Background: Standardised
patients (SPs) are often asked to
basic anatomy
portray complex physical roles in
and physiology which authenticity is paramount;
that can however, SPs come from a variety
hamper their of backgrounds, and may lack
portrayal knowledge of basic anatomy and
physiology that can hamper their
portrayal. This lack of knowledge
can lead to gaps in accuracy and
credibility.
Context: In our efforts to bridge
the gap and create training that
would lead to authentic and
confident portrayals, we devel-
oped the ‘gut bucket’. This three-
dimensional learning tool is
tactile, portable, simple and
affordable.
Innovation: The ‘gut bucket’ has
life-size abdominal organs made
from fabric resting in a standard
plastic washbasin. The organs can
be easily removed and manipu-
lated to simulate different
disease states (for example:
appendicitis, kidney stones or
cholecystitis). The tool is visually
engaging and durable, encourag-
ing SPs to handle the organs and
become familiar with their size
and placement within the basin
and on themselves.
Implications: The SPs in our
programme found that the
‘gut bucket’ provided a deeper
level of knowledge, made them
more confident in their portrayal
and enhanced their experience,
and they generally preferred the
‘gut bucket’ over traditional
methods of training. This was
demonstrated using ‘gut bucket’
training evaluation forms. The
‘gut bucket’ can easily be
incorporated into training
sessions to provide a
kinaesthetic approach as well
as increased engagement for the
SPs. We hope others may
benefit by sharing our
experience with the ‘gut
bucket’.

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 INTRODUCTION
S
tandardised patients (SPs)
may have difficulty portray-
ing complex abdominal
roles.1,2 Most often SPs complain
of inadequate knowledge and
difficulty remembering when or
why certain simulations must
occur. For example, Murphy’s
sign: ‘I couldn’t remember where
it was supposed to hurt when
they asked me to take a big
breath while they pushed on my
ribcage.’ Some SPs report feelings
of anxiety and confusion when
they are playing difficult physical
roles (‘I never know when I am
supposed to say “ouch” with
rebound tenderness.’) In these
situations accuracy and credibil-
ity may be compromised, poten-
tially jeopardising the learner’s
experience.
In our programme, SP
training traditionally incorpo-
rates text, pictures and videos3;
however, SP and examiner feed-
back indicated that when
training for difficult physical
roles, these resources were not
enough (‘Rebound tenderness
was not done correctly’). We
wanted to better prepare SPs,
but were unsure how to do this.
Our literature search only
provided us with more text and
videos. We wanted a different
approach, something three-
dimensional to engage SPs
kinaesthetically, but we did not
have the resources for the models
currently available on the market.
We wanted the SPs to be able to
feel comfortable taking out
various organs and getting a real
sense of how big it was, how it
fits in their abdomen and, if it
was enlarged, how it would impact
the other organs. We were able
to make our own model inexpen-
sively to amplify existing
training resources and accommo-
date different adult learning
styles. The simplicity and
nominal cost of the ‘gut bucket’
helps create a non-threatening
environment where engagement
and learning happens easily.
tct_12077.indd 121
METHOD
Constructivist socio-cultural
learning theories,4,5 such as Lewin
and Kolb (cycles of learning) and
Knowles (adult learning), tell us
that deep learning is meaning
based, requires active involve-
ment and is experience centred.6–8
The ‘gut bucket’ takes learning
beyond mere memorisation (surface
learning) to a constructivist
approach that actively engages SPs
by allowing them to manipulate
the organs within the basin and
place the organs on themselves, as
well as understand the anatomical
placement of organs within the
abdomen. For example, inflating
the lungs in the ‘gut bucket’ causes
the diaphragm to move down,
causing the liver to also move
down, and allowing an enlarged
gall bladder to be palpated. In
other words: Murphy’s sign. After
such a demonstration SPs can really
see and understand why they must
‘catch’ their breath upon inhalation
if the learner is palpating their
liver edge. Many SPs found once
they were able to experience
Murphy’s sign in the ‘gut bucket’
they could better simulate this.
The SPs enjoyed seeing, for
example, where the kidneys are
located on themselves, and how a
very small kidney stone can block
a ureter, leading to extreme back
pain or costovertebral angle pain,
‘I never knew why I had to jump
when they tap on my back while
playing a kidney stone role.’ This
familiarity with the organs helped
to develop a stronger connection
with their body and increased
their confidence in playing
abdominal roles.
CONSTRUCTION OF THE
MODEL
(Vodcast available www.theclini-
calteacher.com then click ‘read’)
Abdominal cavity
• Use a plastic washbasin
(43 cm × 35 cm) for the cavity.
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 120–123 121
• Tape in place a paper towel ‘I never know
inner tube, cut in half
when I am
lengthwise, to indicate the
spine. supposed to say
“ouch” with
• Cut slits on each side of the
washbasin where the dia-
rebound
tenderness’
phragm will be secured.
• Using the top of a pair of
pantie hose, insert the dia-
phragm through the slits and
tape into place on the outside
of the washbasin (Figure 1).
Lungs
• Cut 29 cm of clear plastic
tubing into three pieces: an
11-cm piece for the trachea
and two 9-cm pieces for the
bronchi.
• Assemble trachea and bronchi
to a copper pipe tee and
attach balloons to the ends of
the bronchi for the lungs.
• Cut a hole in the top of the
washbasin and insert the
trachea (Figure 1).
Heart
• Fill a red balloon with barley
until it is fist sized or weighs
310 g.
• Tape a 6-cm plastic cup into
the basin, just left of the
spine, to elevate the heart.
• Tape the heart to the cup
(Figure 1).
Kidneys
• Construct a kidney pattern
(5.5 cm × 10 cm).
• Pin pattern to fabric and cut,
sew and stuff with fiberfill.
• Pin a 25-cm piece of 3-mm
rubber tubing to each kidney
for the ureters. (Note: left
kidney is higher than the right
because of the liver;
Figure 1.)
Liver and gallbladder
• Construct a liver pattern
(22/26 cm × 14/16 cm).
• Pin pattern to fabric and cut,
sew and stuff with fiberfill.
3/6/2014 2:58:56 PM
 The ‘gut bucket’ Lungs Heart Large and small intestine
takes learning • Make large intestine (1.5 m)
beyond mere by cutting the legs off of a
memorisation pair of pantie hose, and fill
Diaphragm with fiberfill. Attach the two
Kidneys open ends together to make
one long piece.
• To make appendix, knot the tip of
the toe at one end of the pantie
hose (10 cm length × 7 mm
diameter, if normal).
• For the small intestine you will
need 7 m of soft foam tubing.
Figure 1. Plastic washbasin with lungs, heart and kidney in place • Connect large intestine to
small intestine and the small
intestine to the stomach with
twist ties (Figure 3).

Ribs
Stomach • Cut the ribs out of a large piece
Liver of mylar or sculpt them out of
wire and white sports tape.
• Attach a small hinge to the
Pancreas ribs and tape the hinge to the
Gallbladder
basin just above the hole for
the trachea. (The hinge
Figure 2. Liver, gallbladder, pancreas and stomach added to washbasin enables the ribs to be opened
so that the organs can be
better observed; Figure 3).
Ribs
Spleen
• Construct a spleen pattern
(7 cm × 11/12 cm, flat and
squishy).
Small intestines Large intestines • Pin pattern to fabric and cut,
sew and stuff with fiberfill or
cut the spleen out of a thin
kitchen sponge.
• Tuck the spleen underneath the
ninth and 12th left ribs, laterally.
Figure 3. Large and small intestines, and ribs, added to the washbasin

• Construct gallbladder by using • Pin pattern to fabric and cut,

a funnel to fill a green balloon
with barley until about 8 cm
long and 4 cm wide, if fully
distended, and can hold 50 ml.
• Pin the gallbladder into place
on the backside of the liver
(Figure 2).
Pancreas
• Construct a pancreas pattern
(12/16 cm and carrot shaped).
sew and stuff with fiberfill
(Figure 2).
Stomach
• Construct a stomach pattern
(about fist sized).
• Pin pattern to fabric and cut,
sew and stuff with fiberfill.
• Cut a hole in the diaphragm to
insert the upper end of the
stomach (Figure 2).
RESULTS
The SPs were asked to complete
evaluations of the ‘gut bucket’
anonymously after being trained
on various abdominal roles. The
evaluations contained five ques-
tions as well as a recommendation
for the tool and written feedback
(Table 1). SPs were asked to score
the questions using a five-point
Likert scale (5, ‘strongly agree’; 1,
‘strongly disagree’), and 10 evalua-
tions were returned and tabulated.

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 Table 1. ‘Gut bucket’ training evaluation form Low cost and
practicality of
Questions 1 2 3 4 5
Strongly Strongly the ‘gut bucket’
disagree agree make this a
very accessible
The gut bucket is a useful training tool 10
tool
I prefer the gut bucket as a training tool to diagrams and 1 2 7
videos
Training with the gut bucket deepened my knowledge of the 10
relevant abdominal anatomy
Interactivity with the gut bucket enhanced my overall 10
experience
I feel more confident in my portrayal as a result of training 10
with the gut bucket

All of the SPs strongly agreed
that the ‘gut bucket’ is helpful. All
of the SPs said they would
recommend the ‘gut bucket’ to
other learners. Positive feedback
comments included: ‘…much better
experience than a drawing or
discussion’, ‘very helpful’, ‘experi-
ential is very important’, ‘relevant’
and ‘creative and engaging’.
Limitations
The model is a very basic represen-
tation of the human abdominal or-
gans, and was designed specifically
for the training needs of the SPs
in our programme. The ‘gut bucket’
was not intended to be a com-
pletely accurate representation of
the human abdomen, but rather
a tool to facilitate the simulation
of physical roles. The evaluations
were very encouraging; however,
the sample size was small.
DISCUSSION
Building the ‘gut bucket’ was a
powerful learning experience for us
as SP trainers. During the assembly
we were struck by the possibilities
for this tool. Suddenly, training
rebound tenderness became easy,
the simulation of appendicitis
became simple and other complex
portrayals no longer required long
searches for the perfect video or
picture. This simple tool added a
new level of enthusiasm and en-
gagement to our training sessions.
We have presented a novel,
experiential, inexpensive and
practical training tool for training
abdominal physical roles. The SPs
reported that training with this
tool improved their knowledge and
confidence in accurately portraying
abdominal roles, and preferred this
method over the traditional
approach with text and pictures.
We recognise that a larger sample
size is needed; however, the low
cost and practicality of the
‘gut bucket’ make this a very
accessible tool.
The ‘gut bucket’ has generated
interest from other SP programmes
as well as health care teaching
programmes with limited resourc-
es. We are currently working on
adding a genito-urinary compo-
nent to the ‘gut bucket’.
Please contact the authors for a
complete step-by-step instruction
manual, with patterns and pictures.
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4. Jarvis P, Holford J, Griffin C, eds.
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Corresponding author’s contact details: Karen Delaney-Laupacis, Standardized Patient Program, University of Toronto, 88 College St, Toronto,
M4G 1H1, Ontario, Canada. E-mail: dylandmeg@sympatico.ca

Funding: None.

Conflict of interest: None.

Ethical approval: Not required.

doi: 10.1111/tct.12077

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