Factors relating to the perceived management of emergency situations: a survey of former Advanced Life Support course participants' clinical experiences

BACKGROUND

This study explored individual, team, and setting factors associated with the quality of management of in-hospital emergency situations experienced by former Advanced Life Support (ALS) course participants.

METHODS

This study was a survey of former ALS course participants' long-term experience of management of in-hospital, emergency situations. The survey was carried out in 2012 in Denmark and Norway.

RESULTS

A questionnaire was send to 526 potential responders and (281/479 × 100) 58.7% responded. The results demonstrated that 75% of the emergency situations were perceived as "managed well". In general, the responders' confidence in being ALS providers was high, mean 4.3 (SD 0.8), scale 1-5. Significant differences between the perceived "well" and "not well" managed situations were found for all questions, p<0.001. The largest differences related to perception of co-workers' ability to apply ALS principles, the team atmosphere and communication. Responders' ratings of quality of management of emergency situations increased with intensity of setting. However, the 'clinical setting' was rated significantly lower as attributor to ability to apply ALS principles compared to 'co-workers familiarity with ALS principles', 'own confidence as ALS-provider' and 'own social/inter-personal skills'.

CONCLUSION

The results of this survey emphasise that ALS providers' perceived ability to apply ALS skills were substantially affected by teamwork skills and co-workers' skills. Team related factors associated with successful outcome were related to clear role distribution, clear inter-personal communication and attentive listening, as well as respectful behaviour and positive team atmosphere. Although intensity of setting was attributed to ability to apply ALS principles, this did not affect management of emergency situations to the same extent as individual and team factors.

Filling the void: defining invasive bedside procedural competency for internal medicine residents

BACKGROUND

Residents perform invasive bedside procedures in most training programs. To date, there is no universal approach for determining competency and ensuring quality and safety of care.

OBJECTIVE

We developed and implemented an assessment of central venous catheter insertion competency for internal medicine and internal medicine-pediatrics residents, using measurements for knowledge, skill, and attitude and linking them to procedural outcomes.

METHODS

We conducted a cohort study of a 4-week, resident-run procedure service from July 2007 through June 2011 at a large academic medical center. Knowledge was assessed by using a written test, technical skill by using a checklist, and attitude by self- and supervisor assessments of residents' confidence and capability. Competence was defined as (1) a minimum written test score (70%); (2) a perfect checklist score; (3) a resident's self-assessed confidence and capability scores of 4 or 5 of 5; and (4) faculty rating of the resident's confidence and capability as 5 of 5. A composite success rate was based on procedural outcomes (eg, completed procedures, less than 3 forward needle passes, and complication rate) and was compared to the checklist scores.

RESULTS

A total of 148 internal medicine and medicine-pediatrics residents inserted 639 catheters, and 53 (36%) achieved competence by the end of 4 weeks. Residents judged to be competent by checklist scores had a higher composite success rate than those deemed not competent.

CONCLUSIONS

Our multi-factorial criteria used to define central venous catheter insertion competency effectively discriminated between residents judged to be competent and those judged not competent, using data from procedural outcomes.

Development and psychometric evaluation of the Resuscitation Self-efficacy Scale for nurses

PURPOSE

The purpose of this study was to develop and evaluate psychometric properties of the instrument, Resuscitation Self-Efficacy Scale for nurses.

METHODS

This was a methodological study for instrument development and psychometric testing. The initial item pool derived from literature review and experts resulted in 30 items linked to resuscitation self-efficacy. A convenience sample of 509 Korean nurses from eleven academic teaching hospitals participated in a survey to examine psychometric properties of the scale. To examine construct validity, exploratory factor analysis and known-group comparison were used. Cronbach's coefficient alpha was used to determine the scale's internal consistency reliability.

RESULTS

The final scale included 17 items with four-component structure termed 'Recognition', 'Debriefing and recording', 'Responding and rescuing', and 'Reporting'. These four factors accounted for 57.5% of the variance. Each subscale and the total scale demonstrated satisfactory internal consistency: .82; .88; .87; .83; and .91 respectively. Experienced nurses reported significantly higher self-efficacy mean scores in both total and subscales compared to new graduate nurses.

CONCLUSION

The Resuscitation Self-Efficacy Scale for nurses yields reliable and valid results in appraising the level of resuscitation self-efficacy for Korean nurses. Further study is needed to test and refine the scale.

Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82

Over the past two decades, there has been an exponential and enthusiastic adoption of simulation in healthcare education internationally. Medicine has learned much from professions that have established programs in simulation for training, such as aviation, the military and space exploration. Increased demands on training hours, limited patient encounters, and a focus on patient safety have led to a new paradigm of education in healthcare that increasingly involves technology and innovative ways to provide a standardized curriculum. A robust body of literature is growing, seeking to answer the question of how best to use simulation in healthcare education. Building on the groundwork of the Best Evidence in Medical Education (BEME) Guide on the features of simulators that lead to effective learning, this current Guide provides practical guidance to aid educators in effectively using simulation for training. It is a selective review to describe best practices and illustrative case studies. This Guide is the second part of a two-part AMEE Guide on simulation in healthcare education. The first Guide focuses on building a simulation program, and discusses more operational topics such as types of simulators, simulation center structure and set-up, fidelity management, and scenario engineering, as well as faculty preparation. This Guide will focus on the educational principles that lead to effective learning, and include topics such as feedback and debriefing, deliberate practice, and curriculum integration - all central to simulation efficacy. The important subjects of mastery learning, range of difficulty, capturing clinical variation, and individualized learning are also examined. Finally, we discuss approaches to team training and suggest future directions. Each section follows a framework of background and definition, its importance to effective use of simulation, practical points with examples, and challenges generally encountered. Simulation-based healthcare education has great potential for use throughout the healthcare education continuum, from undergraduate to continuing education. It can also be used to train a variety of healthcare providers in different disciplines from novices to experts. This Guide aims to equip healthcare educators with the tools to use this learning modality to its full capability.

A survey of nurses' perceived competence and educational needs in performing resuscitation

BACKGROUND

Effective training is needed for high-quality performance of staff nurses, who are often the first responders in initiating resuscitation. There is insufficient evidence to identify specific educational strategies that improve outcomes, including early recognition and rescue of the critical patient. This study was conducted to identify perceived competence and educational needs as well as to examine factors influencing perceived competence in resuscitation among staff nurses to build a resuscitation training curriculum.

METHODS

A convenience sample of 502 staff nurses was recruited from 11 hospitals in a single city. Staff nurses were asked to complete a self-administered questionnaire.

RESULTS

On a five-point scale, chest compression was the lowest-rated technical skill (M = 3.33, SD = 0.80), whereas staying calm and focusing on required tasks was the lowest-rated non-technical skill (M = 3.30, SD = 0.80). Work duration, the usefulness of simulation, recent code experience, and recent simulation-based training were significant factors in perceived competence, F(4, 496) = 45.94, p < .001. Simulation-based resuscitation training was the most preferred training modality, and cardiac arrest was the most preferred training topic.

CONCLUSION

Based on this needs assessment, a simulation-based resuscitation training curriculum with cardiac arrest scenarios is suggested to improve the resuscitation skills of staff nurses.

Translational educational research: a necessity for effective health-care improvement

Medical education research contributes to translational science (TS) when its outcomes not only impact educational settings, but also downstream results, including better patient-care practices and improved patient outcomes. Simulation-based medical education (SBME) has demonstrated its role in achieving such distal results. Effective TS also encompasses implementation science, the science of health-care delivery. Educational, clinical, quality, and safety goals can only be achieved by thematic, sustained, and cumulative research programs, not isolated studies. Components of an SBME TS research program include motivated learners, curriculum grounded in evidence-based learning theory, educational resources, evaluation of downstream results, a productive research team, rigorous research methods, research resources, and health-care system acceptance and implementation. National research priorities are served from translational educational research. National funding priorities should endorse the contribution and value of translational education research.

Divergence in student and educator conceptual structures during auscultation training

CONTEXT

Simulation-based medical education allows trainees to engage in self-regulated learning (SRL), yet research aimed at elucidating the mechanisms of SRL in this context is relatively absent. We compared 'unguided' SRL with 'directed' SRL (DSRL), wherein learners followed an expert-designed booklet.

METHODS

Year 1 medical students (n = 37) were randomly assigned to practise identifying seven cardiac murmurs using a simulator and video only (SRL group) or a simulator and video plus the booklet (DSRL group). All participants completed a 22-item test 3 weeks later. To compare interventions, we analysed students' diagnostic accuracy. As a novel source of evidence, we documented how participants autonomously sequenced the seven murmurs during initial and delayed practice sessions. In addition, we surveyed clinical educators (n = 17) to find out how they would sequence their teaching of these murmurs.

RESULTS

The DSRL group used 50% more training time than the SRL group (p < 0.001). The groups' diagnostic accuracy, however, did not differ significantly on the post-test, retention test or transfer test items (p > 0.12). Despite practising with the expert-defined 'timing-based' approach to murmur diagnosis (i.e. systolic versus diastolic), 84% of DSRL participants implemented a location-based approach (i.e. practising aortic murmurs separately from mitral murmurs) during a second, unguided practice session. Notably, most SRL participants used that same approach spontaneously. By contrast, clinical educators were split in their use of the timing-based (n = 10) and the location-based (n = 6) approaches. Chi-squared analyses suggested educators' conceptions for organising murmurs differed significantly from students' conceptions.

CONCLUSIONS

Contrary to our predictions, directing students' SRL produced no additional benefit and increased their practice time. Our findings suggest one potential source of these results was a divergence between student and educator conceptions for structuring the practice of cardiac auscultation skills. This phenomenon has not been well articulated in the medical education literature, and may have important implications in many (especially technology-mediated) educational contexts.

International collaborative faculty development program on simulation-based healthcare education: a report on its successes and challenges

PURPOSE

Countries that are less experienced with simulation-based healthcare education (SBHE) often import Western programs to initiate their efforts to deliver effective simulation training. Acknowledging cultural differences, we sought to determine whether faculty development program on SBHE in the United States could be transported successfully to train faculty members in Korea.

METHODS

An international, collaborative, multi-professional program from a pre-existing Western model was adapted. The process focused on prioritization of curricular elements based on local needs, translation of course materials, and delivery of the program in small group facilitation exercises. Three types of evaluation data were collected: participants' simulation experience; participants' ratings of the course; and participant's self-assessment of the impact of the course on their knowledge, skills, and attitudes (KSA) toward simulation teaching.

RESULTS

Thirty faculty teachers participated in the course. Eighty percent of the participants answered that they spent less than 25% of their time as simulation instructors. Time spent on planning, scenario development, delivering training, research, and administrative work ranged from 10% to 30%. Twenty-eight of 30 participants agreed or strongly agreed that the course was excellent and relevant to their needs. The participants' assessment of the impact of the course on their KSA toward simulation teaching improved significantly.

CONCLUSION

Although there were many challenges to overcome, a systematic approach in the adaptation of a Western simulation faculty development course model was successfully implemented in Korea, and the program improves self-confidence and learning in participants.

Ward Nurses’ Resuscitation of Critical Patients

Little is known about the current training and barriers in resuscitation skills among practicing ward nurses. A convenience sample of 459 ward nurses, recruited from 11 academic teaching hospitals in Korea, were surveyed to assess current training and barriers to optimal resuscitation performance on the wards. The Perceived Barriers scale was developed, refined, and its psychometric properties were assessed. Approximately 36% of nurses had received simulation-based resuscitation skills training. Exploratory factor analysis identified four barriers accounting for 58.4% of the variance: insufficient training (37.7%), lack of competence (9.8%), lack of self-confidence (5.9%), and workload and tension (5.1%). Strategic planning and resuscitation skills training should be incorporated into staff development programs to reduce barriers to optimal resuscitation performance and cope with work demands for ward nurses.

Abstract 3468: Correlation of the Miami Emergency Neurologic Deficit (MEND) Exam Performed in the Field by Paramedics with an Abnormal NIHSS and Final Diagnosis of Stroke for Patients Airlifted from the Scene

Introduction Early recognition and rapid transport to a stroke center by prehospital providers is essential in the care of stroke patients. In this study, prehospital providers were trained to perform the Miami Emergency Neurologic Deficit (MEND) exam as part of an 8-hour comprehensive course, Advanced Stroke Life Support (ASLS ® ). The MEND exam was devised to facilitate communication between healthcare providers throughout the continuum of care for stroke patients. It can provide a baseline exam in the prehospital setting, and then be used by nurses for initial evaluation and subsequent exams in the ED, ICU or hospital floor. The MEND exam incorporates all three components of the Cincinnati Prehospital Stroke Scale (CPSS) and six additional components from the NIHSS (level of consciousness, orientation, commands, visual fields, gaze, leg motor, limb ataxia, sensation). The exam takes less than 2 minutes and requires no tools, making it ideal for the Prehospital environment.

Purpose Determine the correlation of the MEND exam completed by a prehospital provider on scene to the initial NIHSS performed by the neurologist at the receiving facility, and the final diagnosis.

Methods All prehospital providers from three Fire Rescue agencies participated in the training (96 EMT-P, 68 EMT, 5 RN). The Prehospital providers conducted the CPSS, and if abnormal, placed the helicopter team on standby. They then completed the MEND exam and communicated their findings to a receiving hospital stroke neurologist. We retrospectively reviewed the MEND exam performed by the prehospital providers to determine the correlation with the same components of the initial NIHSS at the hospital. While the NIHSS assigned a numerical value to those specific components, the MEND exam did not. Additionally, we examined the final discharge diagnosis to determine how many patients had a stroke or transient ischemic attack (TIA).

Results From Sept. 2008 to June 2011, 51 patients met the criteria of having both a MEND exam and NIHSS completed. There were 32 males (63%) and 19 females (37%) with a median age of 67 years (44-98 years). The average NIHSS score was 9 (range 0-30). 90.2% (46 of 51) of patients had an NIHSS that correlated to the findings on the MEND (95% C.I. 90.1-90.3). Of the 5 remaining patients, 1 completely recovered on the flight (diagnosed with a TIA), and 3 had a NIHSS score of 0 and were diagnosed with other conditions. Stroke or TIA was diagnosed in 40 patients (78.4%). Of 37 strokes, 32 were ischemic (86.5%) and 5 hemorrhagic (13.5%). The 11 patients not diagnosed with a stroke had several other pathologies (e.g. seizure, hypertensive crisis, viral encephalitis, complex migraine).

Conclusion The MEND exam completed in the Prehospital setting correlated well with the initial NIHSS performed at the receiving facility. The MEND exam is a valuable tool when assessing stroke patients and determining need for air transport.

Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence

PURPOSE

This article presents a comparison of the effectiveness of traditional clinical education toward skill acquisition goals versus simulation-based medical education (SBME) with deliberate practice (DP).

METHOD

This is a quantitative meta-analysis that spans 20 years, 1990 to 2010. A search strategy involving three literature databases, 12 search terms, and four inclusion criteria was used. Four authors independently retrieved and reviewed articles. Main outcome measures were extracted to calculate effect sizes.

RESULTS

Of 3,742 articles identified, 14 met inclusion criteria. The overall effect size for the 14 studies evaluating the comparative effectiveness of SBME compared with traditional clinical medical education was 0.71 (95% confidence interval, 0.65-0.76; P < .001).

CONCLUSIONS

Although the number of reports analyzed in this meta-analysis is small, these results show that SBME with DP is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals. SBME is a complex educational intervention that should be introduced thoughtfully and evaluated rigorously at training sites. Further research on incorporating SBME with DP into medical education is needed to amplify its power, utility, and cost-effectiveness.

A blended approach to invasive bedside procedural instruction

OBJECTIVE

This study assessed the impact of a blended, standardized curriculum for invasive bedside procedural training on medical knowledge and technical skills for Internal Medicine residents.

METHODS

The investigators developed a curriculum in procedural instruction and performance for Internal Medicine house staff, and implemented the program at a tertiary care academic medical center with a primary affiliation with a US medical school. The investigators chose procedures recommended for technical competence by the American Board of Internal Medicine: lumbar puncture, thoracentesis, paracentesis, central venous catheter insertion, and knee arthrocentesis. The program included: (1) assessment of baseline medical knowledge and technical proficiency on mannequins, (2) video instruction of procedure, (3) faculty-led discussion of critical concepts, (4) faculty demonstration of the procedure on mannequin, (5) individual practice on simulators, (6) post-intervention knowledge evaluation, and (7) post-intervention skills evaluation. The performance achieved during the initial skills evaluation on a mannequin was compared to the performance achieved on the first patient subsequent to the instructional portion.

RESULTS

All participants with complete data demonstrated a statistically significant pre-intervention to post-intervention improvement (p < 0.05) in comprehensive medical knowledge and procedural skills.

CONCLUSION

A blended, standardized curriculum in invasive bedside procedural instruction can significantly improve performance in participants' medical knowledge and technical skills.

Creating an e-learning module from learning objects using a commentary or 'personal learning assistant'

The use of learning objects (LOs), small chunks of learning stored digitally and reused or referenced to support learning, was described as a promising approach to the creation of e-learning modules or programmes. In practice, however, the early enthusiasm has waned and the approach has not been widely adopted. It is argued that this was due, at least in part, to a neglect of the pedagogy and an emphasis on the technical aspects of interoperability and reusability. This article describes a practical approach to constructing a learning module using LOs where a commentary links LOs selected for inclusion in the programme. The commentary tells the story of the e-learning module and provides the learner with a context for an LO. It can be viewed as a 'personal learning assistant' that advises students about the management of their learning and relates the e-learning module to the overall learning outcomes for the curriculum. The commentary also allows the lecturer to comment on LOs selected for inclusion in the programme which otherwise might have to be adapted or excluded when the programme was constructed. The use of a commentary to link and introduce LOs has been successfully adopted in the development of e-learning programmes. Teachers are encouraged to consider the approach and to look again at the use of LOs to create e-learning resources.

A fourth-year medical school clerkship that addressed negative attitudes toward geriatric medicine

Despite extensive educational efforts, many medical students still have negative attitudes toward the field of geriatric medicine and the care of older adult patients. This article describes a fourth-year geriatric clerkship that addressed this issue by providing opportunities for students to actively discuss many of the negative stereotypes that exist regarding geriatric medicine. Emphasis was also placed on personalizing the course content to show the relevance of geriatric medicine to all medical students. During the 2008/09 academic year, 150 students completed the rotation. Although no students expressed an interest in pursuing a career as a geriatrician, they expressed a highly favorable evaluation of this personalized geriatric clerkship and voted this clerkship "the most outstanding clinical course" at the medical school.

A critical review of simulation-based medical education research: 2003-2009

OBJECTIVES

This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.

METHODS

This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969-2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003-2009.

RESULTS

The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.

CONCLUSIONS

Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.

Assessing cardiac physical examination skills using simulation technology and real patients: a comparison study

OBJECTIVE

High-stakes assessments of doctors' physical examination skills often employ standardised patients (SPs) who lack physical abnormalities. Simulation technology provides additional opportunities to assess these skills by mimicking physical abnormalities. The current study examined the relationship between internists' cardiac physical examination competence as assessed with simulation technology compared with that assessed with real patients (RPs).

METHODS

The cardiac physical examination skills and bedside diagnostic accuracy of 28 internists were assessed during an objective structured clinical examination (OSCE). The OSCE included 3 modalities of cardiac patients: RPs with cardiac abnormalities; SPs combined with computer-based, audio-video simulations of auscultatory abnormalities, and a cardiac patient simulator (CPS) manikin. Four cardiac diagnoses and their associated cardiac findings were matched across modalities. At each station, 2 examiners independently rated a participant's physical examination technique and global clinical competence. Two investigators separately scored diagnostic accuracy.

RESULTS

Inter-rater reliability between examiners for global ratings (GRs) ranged from 0.75-0.78 for the different modalities. Although there was no significant difference between participants' mean GRs for each modality, the correlations between participants' performances on each modality were low to modest: RP versus SP, r = 0.19; RP versus CPS, r = 0.22; SP versus CPS, r = 0.57 (P < 0.01).

CONCLUSIONS

Methodological limitations included variability between modalities in the components contributing to examiners' GRs, a paucity of objective outcome measures and restricted case sampling. No modality provided a clear 'gold standard' for the assessment of cardiac physical examination competence. These limitations need to be addressed before determining the optimal patient modality for high-stakes assessment purposes.

Simulation technology for skills training and competency assessment in medical education

Medical education during the past decade has witnessed a significant increase in the use of simulation technology for teaching and assessment. Contributing factors include: changes in health care delivery and academic environments that limit patient availability as educational opportunities; worldwide attention focused on the problem of medical errors and the need to improve patient safety; and the paradigm shift to outcomes-based education with its requirements for assessment and demonstration of competence. The use of simulators addresses many of these issues: they can be readily available at any time and can reproduce a wide variety of clinical conditions on demand. In lieu of the customary (and arguably unethical) system, whereby novices carry out the practice required to master various techniques--including invasive procedures--on real patients, simulation-based education allows trainees to hone their skills in a risk-free environment. Evaluators can also use simulators for reliable assessments of competence in multiple domains. For those readers less familiar with medical simulators, this article aims to provide a brief overview of these educational innovations and their uses; for decision makers in medical education, we hope to broaden awareness of the significant potential of these new technologies for improving physician training and assessment, with a resultant positive impact on patient safety and health care outcomes.