Promoting Excellence and Reflective Learning in Simulation (PEARLS): Development and Rationale for a Blended Approach to Health Care Simulation Debriefing

Sim for Life: Foundations-A Simulation Educator Training Course to Improve Debriefing Quality in a Low Resource Setting: A Pilot Study

INTRODUCTION

Despite the importance of debriefing, little is known about the effectiveness of training programs designed to teach debriefing skills. In this study, we evaluated the effectiveness of a faculty development program for new simulation educators at Mbarara University of Science and Technology in Uganda, Africa.

METHODS

Healthcare professionals were recruited to attend a 2-day simulation educator faculty development course (Sim for Life: Foundations), covering principles of scenario design, scenario execution, prebriefing, and debriefing. Debriefing strategies were contextualized to local culture and focused on debriefing structure, conversational strategies, and learner centeredness. A debriefing worksheet was used to support debriefing practice. Trained simulation educators taught simulation sessions for 12 months. Debriefings were videotaped before and after initial training and before and after 1-day refresher training at 12 months. The quality of debriefing was measured at each time point using the Objective Structured Assessment of Debriefing (OSAD) tool by trained, calibrated, and blinded raters.

RESULTS

A total of 13 participants were recruited to the study. The mean (95% confidence interval) OSAD scores pretraining, posttraining, and at 12 months before and after refresher were 18.2 (14.3-22.1), 26.7 (22.8-30.6), 25.5 (21.2-29.9), and 27.0 (22.4-31.6), respectively. There was a significant improvement from pretraining to posttraining (P < 0.001), with no significant decay from posttraining to 12 months (P = 0.54). There was no significant difference in OSAD scores pre- versus post-refresher training at 12 months (P = 0.49).

CONCLUSIONS

The Sim for Life Foundations program significantly improves debriefing skills with retention of debriefing skills at 12 months.

Fire in the Operating Room: Use of Mixed Reality Simulation with Nurse Anesthesia Students

Background: The occurrence of a fire when implementing anesthesia is a high-risk, low-frequency event. The operating room is a high-stakes environment that has no room for error. Mixed reality simulation may be a solution to better prepare healthcare professionals. The purpose of this quantitative, descriptive study was to evaluate the technical and non-technical skills of student registered nurse anesthetists (SRNAs) who participated in a mixed reality simulation of an operating room fire. Methods: Magic Leap OneTM augmented reality headsets were used by 32 student registered nurse anesthetists to simulate an emergent fire during a simulated tracheostomy procedure. Both technical and non-technical skills were evaluated by faculty members utilizing a checklist. Results: The SRNAs’ overall mean technical skill performance was 18.16 ± 1.44 out of a maximum score of 20, and the mean non-technical skill performance was 91.25% out of 100%. Conclusions: This study demonstrated the utility and limitations in applying novel technology in simulation. Participants demonstrated a strong performance of technical and non-technical skills in the management of a simulated operating room fire. Recommendations for future applications include the use of multiple sensory inputs into the scenario design and including all core team members in the immersive mixed reality environment.

Recent Advances in Simulation for Pediatric Critical Care Medicine

PURPOSE OF REVIEW

This review highlights the emerging fields of simulation research by tying innovation into principles of learning and process improvement.

RECENT FINDINGS

Advances have been made in both educational simulation and simulation for quality improvement, allowing this versatile modality to be more broadly applied to healthcare and systems.

SUMMARY

Simulation in pediatric critical care medicine continues to evolve. Although the majority of simulation is focused on learner education, emerging research has broadened to focus on patient- and system-centered outcomes, leading to improvement in the quality of care delivered in the ICU.

Rapid cycle system improvement for COVID-19 readiness: integrating deliberate practice, psychological safety and vicarious learning

Introduction

In the face of a rapidly advancing pandemic with uncertain pathophysiology, pop-up healthcare units, ad hoc teams and unpredictable personal protective equipment supply, it is difficult for healthcare institutions and front-line teams to invent and test robust and safe clinical care pathways for patients and clinicians. Conventional simulation-based education was not designed for the time-pressured and emergent needs of readiness in a pandemic. We used ‘rapid cycle system improvement’ to create a psychologically safe learning oasis in the midst of a pandemic. This oasis provided a context to build staff technical and teamwork capacity and improve clinical workflows simultaneously.

Methods

At the Department of Anaesthesia and Intensive Care in Prince of Wales Hospital, a tertiary institution, in situ simulations were carried out in the operating theatres and intensive care unit (ICU). The translational simulation design leveraged principles of psychological safety, rapid cycle deliberate practice, direct and vicarious learning to ready over 200 staff with 51 sessions and achieve iterative system improvement all within 7 days. Staff evaluations and system improvements were documented postsimulation.

Results/Findings

Staff in both operating theatres and ICU were significantly more comfortable and confident in managing patients with COVID-19 postsimulation. Teamwork, communication and collective ability to manage infectious cases were enhanced. Key system issues were also identified and improved.

Discussion

To develop readiness in the rapidly progressing COVID-19 pandemic, we demonstrated that ‘rapid cycle system improvement’ can efficiently help achieve three intertwined goals: (1) ready staff for new clinical processes, (2) build team competence and confidence and (3) improve workflows and procedures.

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada

Healthcare resources have been strained to previously unforeseeable limits as a result of the COVID-19 pandemic of 2020. This has prompted the emergence of critical just-in-time COVID-19 education, including rapid simulation preparedness, evaluation and training across all healthcare sectors. Simulation has been proven to be pivotal for both healthcare provider learning and systems integration in the context of testing and integrating new processes, workflows, and rapid changes to practice (e.g., new cognitive aids, checklists, protocols) and changes to the delivery of clinical care. The individual, team, and systems learnings generated from proactive simulation training is occurring at unprecedented volume and speed in our healthcare system. Establishing a clear process to collect and report simulation outcomes has never been more important for staff and patient safety to reduce preventable harm. Our provincial simulation program in the province of Alberta, Canada (population = 4.37 million; geographic area = 661,848 km2), has rapidly responded to this need by leading the intake, design, development, planning, and co-facilitation of over 400 acute care simulations across our province in both urban and rural Emergency Departments, Intensive Care Units, Operating Rooms, Labor and Delivery Units, Urgent Care Centers, Diagnostic Imaging and In-patient Units over a 5-week period to an estimated 30,000 learners of real frontline team members. Unfortunately, the speed at which the COVID-19 pandemic has emerged in Canada may prevent healthcare sectors in both urban and rural settings to have an opportunity for healthcare teams to participate in just-in-time in situ simulation-based learning prior to a potential surge of COVID-19 patients. Our coordinated approach and infrastructure have enabled organizational learnings and the ability to theme and categorize a mass volume of simulation outcome data, primarily from acute care settings to help all sectors further anticipate and plan. The goal of this paper is to share the unique features and advantages of using a centralized provincial simulation response team, preparedness using learning and systems integration methods, and to share the highest risk and highest frequency outcomes from analyzing a mass volume of COVID-19 simulation data across the largest health authority in Canada.

A practical guide to virtual debriefings: communities of inquiry perspective

Many simulation programs have recently shifted towards providing remote simulations with virtual debriefings. Virtual debriefings involve educators facilitating conversations through web-based videoconferencing platforms. Facilitating debriefings through a computer interface introduces a unique set of challenges. Educators require practical guidance to support meaningful virtual learning in the transition from in-person to virtual debriefings. The communities of inquiry conceptual framework offer a useful structure to organize practical guidance for conducting virtual debriefings. The communities of inquiry framework describe the three key elements-social presence, teaching presence, and cognitive presence-all of which contribute to the overall learning experience. In this paper, we (1) define the CoI framework and describe its three core elements, (2) highlight how virtual debriefings align with CoI, (3) anticipate barriers to effective virtual debriefings, and (4) share practical strategies to overcome these hurdles.

Corporate leadership training: Value added for your simulation center

Academic leaders in nursing have invested vast resources such as dedicated space, technology, and facilitator education to support their simulation centers. In order to maximize return on investment, one school of nursing and health sciences conducted external leadership training for corporate business mid-level managers utilizing the expertise of their certified simulation educators and their accredited simulation center. The simulation team developed nine scenarios that focused on common corporate workplace challenges. Actors who would normally portray the role of simulated 'patients' were reimagined as standardized 'corporate executives and employees,' and several communication tools from the TeamSTEPPS® curriculum were adapted for use in the corporate setting. These tools were explained in a brief didactic and discussion format prior to use in simulations. Learners participated in simulation scenarios and debriefing exercises using several evidence-based methods. Details related to scenario development, standardized patient training, training experience design, large group simulations, cost development and recommendations for success are provided. Executive evaluations of the experience were so positive that the leadership training has been expanded to other external organizations.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Serotonin Syndrome

Introduction

Serotonin syndrome is caused by an accumulation of serotonin in the body from drug interactions or overdose of serotonergic medications, including commonly used antidepressants. Symptoms can be life-threatening and encompass both neurologic and cardiovascular toxicity, including agitation, seizure, tachycardia, rhabdomyolysis, and hyperthermia.

Methods

This simulation case was developed for pediatric emergency medicine fellows and emergency medicine residents in the pediatric emergency department and can be altered to accommodate other learners. The case involved a 16-year-old male, represented by a low- or high-fidelity manikin, who presented with altered mental status/agitation after an overdose of antidepressant medication. The team of learners was required to perform a primary and a secondary assessment; manage airway, breathing, and circulation; and recognize and initiate treatment for serotonin syndrome. The patient had a seizure resulting in airway compromise requiring advanced airway support, as well as developed rhabdomyolysis requiring aggressive fluid hydration. We created a debriefing guide and a participant evaluation form.

Results

Fifty-seven participants across five institutions completed this simulation, which included residents, fellows, faculty, and students. The scenario was rated by participants using a 5-point Likert scale and was generally well received. Participants rated the simulation case as effective in learning how to both recognize (M = 4.9) and manage (M = 4.8) serotonin syndrome.

Discussion

This pediatric emergency simulation scenario can be tailored for a range of learner backgrounds and simulation environments. We used the participant evaluation form to improve future iterations of the simulation.

Pathophysiology for the Pediatric Critical Care Fellow: Three Representative Simulation Cases

INTRODUCTION

During the course of fellowship training, pediatric critical care fellows are expected to develop a broad and in-depth understanding of the pathophysiology of multiple disease processes. The simulation-based pediatric critical care pathophysiology curriculum we present uses scenarios created by pediatric critical care fellows to teach complex pathophysiology.

METHODS

Each of the three representative cases presented covered a specific pathophysiologic process and required participants to acutely manage (1) an 18-year-old patient with altered mental status in the setting of hepatic encephalopathy; (2) an 8-year-old patient with sepsis, coagulopathy, and acute kidney injury; or (3) a 12-year-old patient with status epilepticus. Each case could be conducted in a simulation suite or an acute care unit bed. We assessed learners' knowledge and attitudes at the end of these simulations with a structured debriefing session and via completion of an evaluation form. The simulations were then followed by a 30-minute interactive didactic session on the topic.

RESULTS

Each scenario had six fellow participants who completed evaluations. After completing each of the three case scenarios presented, the majority of participating pediatric critical care fellows indicated that the content was relevant and sufficiently challenging. They also indicated that these simulation scenarios would improve their clinical practice.

DISCUSSION

This fellow-developed simulation curriculum is novel, highlighting the relevance for critical care fellows' understanding of realistic clinical scenarios while promoting advanced management skills with a pathophysiology focus.

Utilizing Simulation to Identify Latent Safety Threats During Neonatal Magnetic Resonance Imaging Procedure

INTRODUCTION

Transfer of infants for magnetic resonance imaging (MRI) from the neonatal intensive care unit (NICU) requires exposure to unfamiliar environments and involve multiple complex human and system interactions, which can compromise patient safety. In situ simulation (ISS) offers an opportunity to identify latent safety threats (LSTs) that may occur during this high-risk procedure. Our primary aim was to use ISS to identify modifiable LSTs during the MRI procedure: involving neonatal transport to/from NICU to the MRI and the MRI scan. Secondarily, we compared the overall performance and needs of specialized versus nonspecialized transport personnel.

METHODS

In situ simulations of the MRI procedure (transport and scan) were performed for 9 months involving specialized and nonspecialized transport personnel. Two simulation scenarios were used, one involving an intubated infant and one nonintubated infant. After each simulation, participants underwent a standardized debriefing and answered questionnaires on safety threats and team function. The results were then used to identify and implement mitigation strategies.

RESULTS

Among 10 simulations completed, 7 were by specialized and 3 by nonspecialized teams. In total, 116 LSTs were identified (22 involving medication, 12 equipment, and 82 resources/system issues). Preprocedure deliberation with anticipation/preparedness for patient deterioration, and the need for clinical checklists and protocols were identified as important requirements. After completion of the project, protocols (ie, sedation), checklists (ie, pretransport), and policies (ie, environmental orientation) were adapted to address the gaps.

CONCLUSIONS

In situ simulations were able to identify important safety risks during transport of neonatal patients from the NICU to the MRI suite, informing changes in MRI transport policy.

Prevention of infections associated with peripheral catheters: construction and validation of clinical scenario

OBJECTIVES

to describe the process of construction and content validation of a clinical setting for teaching and learning the recommended practices for preventing bloodstream infection, associated with peripheral venous catheters, for nursing professionals.

METHODS

methodological study of the construction of the scenario based on the National League Nursing Jeffries Simulation Theory, International Nursing Association for Clinical Simulation and Learning, and the Brazilian Health Regulatory Agency. Twelve experts performed content validation. We used to assess the degree of agreement between them, the Content Validity Index, and a descriptive analysis of the suggestions presented.

RESULTS

all the requirements of the simulated clinical scenario reached an agreement between judges of more than 80% in terms of clarity and relevance.

CONCLUSIONS

the steps adopted in the construction and validation of the clinical scenario proved to be adequate and relevant, and the scenario is suitable for training professionals.

A Residency Interview Training Program to Improve Medical Student Confidence in the Residency Interview

INTRODUCTION

The Residency Match is becoming more competitive each year, and more than ever, medical students must prove themselves in the residency interview. Data from the 2018 National Residency Matching Program's Program Director Survey highlight the importance of the interview on Match performance. We developed a residency interview training program with the goal of preparing medical students for residency interviews, and we assessed the impact of the training on medical student confidence.

METHODS

Our residency interview training program includes (1) a short didactic session on the residency interview process, (2) an informational packet with commonly asked questions, (3) two 20-minute practice (mock) interviews, (4) 10 minutes of face-to-face feedback from interviewers, (5) a facilitated group debriefing, and (6) access to a participant's two videotaped interviews and a guided self-assessment. To evaluate the effectiveness of our program, we assessed student confidence with a pre- and postsurvey.

RESULTS

We have been running our residency interview training program since 2014. Over the last 5 years, 73 fourth-year medical students have participated. When polled after completing their first authentic residency interview, students felt they had more knowledge of the interview process, better preparation, and more confidence in their skills to interview successfully; they also believed that the program improved their interview performance.

DISCUSSION

Performance during the residency interview is the most important factor used by residency programs to rank applicants. Using our residency interview training program, medical students can improve their confidence prior to interviews.

Learning Conversations: An Analysis of the Theoretical Roots and Their Manifestations of Feedback and Debriefing in Medical Education

Feedback and debriefing are experience-informed dialogues upon which experiential models of learning often depend. Efforts to understand each have largely been independent of each other, thus splitting them into potentially problematic and less productive factions. Given their shared purpose of improving future performance, the authors asked whether efforts to understand these dialogues are, for theoretical and pragmatic reasons, best advanced by keeping these concepts unique or whether some unifying conceptual framework could better support educational contributions and advancements in medical education.The authors identified seminal works and foundational concepts to formulate a purposeful review and analysis exploring these dialogues' theoretical roots and their manifestations. They considered conceptual and theoretical details within and across feedback and debriefing literatures and traced developmental paths to discover underlying and foundational conceptual approaches and theoretical similarities and differences.Findings suggest that each of these strategies was derived from distinct theoretical roots, leading to variations in how they have been studied, advanced, and enacted; both now draw on multiple (often similar) educational theories, also positioning themselves as ways of operationalizing similar educational frameworks. Considerable commonality now exists; those studying and advancing feedback and debriefing are leveraging similar cognitive and social theories to refine and structure their approaches. As such, there may be room to merge these educational strategies as learning conversations because of their conceptual and theoretical consistency. Future scholarly work should further delineate the theoretical, educational, and practical relevance of integrating feedback and debriefing.

Understanding Debriefing: A Qualitative Study of Event Reconstruction at an Academic Medical Center

PURPOSE

This qualitative study sought to characterize the role of debriefing after real critical events among anesthesia residents at the Hospital of the University of Pennsylvania.

METHOD

From October 2016 to June 2017 and February to April 2018, the authors conducted 25 semistructured interviews with 24 anesthesia residents after they were involved in 25 unique critical events. Interviews focused on the experience of the event and the interactions that occurred thereafter. A codebook was generated through annotation, then used by 3 researchers in an iterative process to code interview transcripts. An explanatory model was developed using an abductive approach.

RESULTS

In the aftermath of events, residents underwent a multistage process by which the nature of critical events and the role of residents in them were continuously reconstructed. Debriefing-if it occurred-was 1 stage in this process, which also included stages of internal dialogue, event documentation, and lessons learned. Negotiated in each stage were residents' culpability, reputation, and the appropriateness of their affective response to events.

CONCLUSIONS

Debriefing is one of several stages of interaction that occur after a critical event; all stages play a role in shaping how the event is interpreted and remembered. Because of its dynamic role in constituting the nature of events and residents' role in them, debriefing can be a high-stakes interaction for residents, which can contribute to their reluctance to engage in it. The function and quality of debriefing can be assessed in more insightful fashion by understanding its relation to the other stages of event reconstruction.

Eye-opening facilitator behaviours: an Interaction Analysis of facilitator behaviours that advance debriefings

INTRODUCTION

Analyses of simulation performance taking place during postsimulation debriefings have been described as iterating through phases of unawareness of problems, identifying problems, explaining the problems and suggesting alternative strategies or solutions to manage the problems. However, little is known about the mechanisms that contribute to shifting from one such phase to the subsequent one. The aim was to study which kinds of facilitator interactions contribute to advancing the participants' analyses during video-assisted postsimulation debriefing.

METHODS

Successful facilitator behaviours were analysed by performing an Interaction-Analytic case study, a method for video analysis with roots in ethnography. Video data were collected from simulation courses involving medical and midwifery students facilitated by highly experienced facilitators (6-18 years, two paediatricians and one midwife) and analysed using the Transana software. A total of 110 successful facilitator interventions were observed in four video-assisted debriefings and 94 of these were included in the analysis. As a starting point, the participants' discussions were first analysed using the phases of a previously described framework, uPEA (unawareness (u), problem identification (P), explanation (E) and alternative strategies/solutions (A)). Facilitator interventions immediately preceding each shift from one phase to the next were thereafter scrutinised in detail.

RESULTS

Fifteen recurring facilitator behaviours preceding successful shifts to higher uPEA levels were identified. While there was some overlap, most of the identified facilitator interventions were observed during specific phases of the debriefings. The most salient facilitator interventions preceding shifts to subsequent uPEA levels were respectively: use of video recordings to draw attention to problems (P), questions about opinions and rationales to encourage explanations (E) and dramatising hypothetical scenarios to encourage alternative strategies (A).

CONCLUSIONS

This study contributes to the understanding of how certain facilitator behaviours can contribute to the participants' analyses of simulation performance during specific phases of video-assisted debriefing.

Stress Testing the Resuscitation Room: Latent Threats to Patient Safety Identified During Interprofessional In Situ Simulation in a Canadian Academic Emergency Department

OBJECTIVES

Emergency department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend on effective interactions between the health care team, the patient, and the environment. Resuscitation teams work in dynamic environments and strive to ensure the timely delivery of necessary treatments, equipment, and skill sets when required. However, systemic failures in this environment cannot always be adequately anticipated, which exposes patients to opportunities for harm.

METHODS

As part of a new interprofessional education and quality improvement initiative, this prospective, observational study sought to characterize latent safety threats (LSTs) identified during the delivery of in situ, simulated resuscitations in our ED. In situ simulation (ISS) sessions were delivered on a monthly basis in the EDs at each campus of a large tertiary care academic hospital system, during which a variety of scenarios were run with teams of ED health care professionals. LSTs were identified by simulation facilitators and participants during the case and debriefing and then grouped thematically for analysis.

RESULTS

During the study period, 22 ISS sessions were delivered, involving 58 cases and reaching 383 ED health care professionals. 196 latent safety threats were identified through these sessions (mean = 3.4 LSTs per case) of which 110 were determined to be "actionable" at a system level. LSTs identified included system/environmental design flaws, equipment problems, failures in department processes, and knowledge/skill gaps. Corrective mechanisms were initiated in 85% of actionable cases.

CONCLUSIONS

Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care. ISS, beyond its role as a training tool for developing intrinsic and crisis resource management skills, can be effectively used to identify system issues in the ED that could expose critically ill patients to harm.

Clinical event debriefing: a review of approaches and objectives

PURPOSE OF REVIEW

This review explores four different approaches and clarifies objectives for debriefing after a clinical event in the emergency department. Psychological debriefing aims to prevent or reduce symptoms of traumatic stress and normalize recovery. Psychological first aid helps team members provide each other with pragmatic social support. Debriefing for simulation-based education promotes learning by team members. Quality improvement approaches and after action reviews focus on systems improvement.

RECENT FINDINGS

Qualitative studies have begun to explore interactions between clinical staff after a significant clinical event. Clearer descriptions and measurements of quality improvements and the effect of clinical event debriefing on patient outcomes are appearing. An increasing number of studies describe melded, scripted approaches to the hot debrief.

SUMMARY

Clinical staff have consistently indicated they value debriefing after a significant clinical event. Differing objectives from different approaches have translated into a wide variety of methods and a lack of clarity about relevant outcomes to measure. Recent descriptions of scripted approaches may clarify these objectives and pave the way for measuring relevant outcomes that demonstrate the effectiveness of and find the place for debriefing in the emergency department.

Aha! Taking on the myth that simulation-derived surprise enhances learning

OBJECTIVES

This paper aims to discuss the recurring education-related issue of the high-fidelity simulation myth. In the current instantiation, educators erroneously believe that trainees benefit from authentic uncertainty and surprise in simulation-based training.

METHODS

We explore the origins of this myth within the experiential learning and social constructivism theories and propose an evidence-based solution of transparent and guided instruction in simulation.

RESULTS

Constructivist theories highlight meaning making as the benefit of inquiry and discovery learning strategies. Inappropriate translation of this epistemology into an element of curriculum design creates unfortunate unintended consequences.

CONCLUSIONS

We propose that the translation of constructivist theories of learning within simulation-based education has resulted in a pervasive myth, which decrees that scenarios must introduce realistic tension or surprises to encourage exploration and insightful problem solving. We argue that this myth is masquerading as experiential learning. In this narrative review, we interpret our experiences and observations of simulation-based education through our expertise in education science and curriculum design. We offer anecdotal evidence along with a review of selected literature to establish the presence of this previously undetected myth.

Telementoring for remote simulation instructor training and faculty development using telesimulation

Introduction

Simulation-based training is essential for high-quality medical care, but it requires access to equipment and expertise. Technology can facilitate connecting educators to training in simulation. We aimed to explore the use of remote simulation faculty development in Latvia using telesimulation and telementoring with an experienced debriefer located in the USA.

Methods

This was a prospective, simulation-based longitudinal study. Over the course of 16 months, a remote simulation instructor (RI) from the USA and a local instructor (LI) in Latvia cofacilitated with teleconferencing. Responsibility gradually transitioned from the RI to the LI. At the end of each session, students completed the Debriefing Assessment for Simulation in Healthcare (DASH) student version form (DASH-SV) and a general feedback form, and the LI completed the instructor version of the DASH form (DASH-IV). Outcome measures were the changes in DASH scores over time.

Results

A total of eight simulation sessions were cofacilitated of 16 months. As the role of the LI increased over time, the debrief quality measured with the DASH-IV did not change significantly (from 89 to 87), although the DASH-SV score decreased from a total median score of 89 (IQR 86–98) to 80 (IQR 78–85) (p=0.005).

Conclusion

In this study, telementoring with telesimulations resulted in high-quality debriefing. The quality—perceived by the students—was higher with the involvement of the remote instructor and declined during the transition to the LI. This concept requires further investigation and could potentially build local simulation expertise promoting sustainability of high-quality simulation.

Effect of a Cardiopulmonary Resuscitation Coach on Workload During Pediatric Cardiopulmonary Arrest: A Multicenter, Simulation-Based Study

OBJECTIVES

Optimal cardiopulmonary resuscitation can improve pediatric outcomes but rarely is cardiopulmonary resuscitation performed perfectly despite numerous iterations of Basic and Pediatric Advanced Life Support. Cardiac arrests resuscitation events are complex, often chaotic environments with significant mental and physical workload for team members, especially team leaders. Our primary objective was to determine the impact of a cardiopulmonary resuscitation coach on cardiopulmonary resuscitation provider workload during simulated pediatric cardiac arrest.

DESIGN

Multicenter observational study.

SETTING

Four pediatric simulation centers.

SUBJECTS

Team leaders, cardiopulmonary resuscitation coach, and team members during an 18-minute pediatric resuscitation scenario.

INTERVENTIONS

National Aeronautics and Space Administration-Task Load Index.

MEASUREMENTS AND MAIN RESULTS

Forty-one teams (205 participants) were recruited with one team (five participants) excluded from analysis due to protocol violation. Demographic data revealed no significant differences between the groups in regard to age, experience, distribution of training (nurse, physician, and respiratory therapist). For most workload subscales, there were no significant differences between groups. However, cardiopulmonary resuscitation providers had a higher physical workload (89.3 vs 77.9; mean difference, -11.4; 95% CI, -17.6 to -5.1; p = 0.001) and a lower mental demand (40.6 vs 55.0; mean difference, 14.5; 95% CI, 4.0-24.9; p = 0.007) with a coach (intervention) than without (control). Both the team leader and coach had similarly high mental demand in the intervention group (75.0 vs 73.9; mean difference, 0.10; 95% CI, -0.88 to 1.09; p = 0.827). When comparing the cardiopulmonary resuscitation quality of providers with high workload (average score > 60) and low to medium workload (average score < 60), we found no significant difference between the two groups in percentage of guideline compliant cardiopulmonary resuscitation (42.5% vs 52.7%; mean difference, -10.2; 95% CI, -23.1 to 2.7; p = 0.118).

CONCLUSIONS

The addition of a cardiopulmonary resuscitation coach increases physical workload and decreases mental workload of cardiopulmonary resuscitation providers. There was no change in team leader workload.

[Introduction to debriefing for internists: how to transform real or simulated clinical situations into learning moments]

Debriefing is a phase of synthesis and reflection that immediately follows a real-life or simulated situation. It is an essential educational step that forces the learners to reflect upon the thought processes that underlie their actions. Debriefing encourages a personal and collective reflection in order to remodel erroneous mental schemas and rectify actions done in context. Debriefing cannot be improvised; it requires a sound structure and regular practice in order to be truly effective. The debriefer must be considerate, choose appropriate learning objectives and dedicate ample time to the learners. Debriefing is focused on learning acquired in context-in other words, on the actions that were performed within a real-life or simulated clinical practice situation-and immediately follows the situation. After an initial phase of emotional release, the debriefer will help learners analyse their actions to identify their underlying rationale (contextualization), extract the overarching principles related to the lived situation in order to modify the rationale if needed (decontextualization) and assist the transfer of learning to real life (in the case of simulation) and to similar situations (recontextualization). A final summary of learning achieved during the training session concludes the debriefing. Debriefing is useful in any learning situation, including in internal medicine. Even if simulation is still underused in internal medicine, post-event debriefing can be implanted in our clinical services. Indeed, training our students and shaping them into healthcare professionals rest in no small part on hospital rotations where the intern is confronted with real-patient situations that are suitable to learning. Some in-hospital clinical encounters can be actively transformed into learning opportunities thanks to post-event debriefing, but can also passively morph into bad daily practice if no supporting action is implemented. Debriefing can thus provide an opportunity to develop non-technical skills in critical situations, or doctor-patient communication skills, within a team or between colleagues. These competencies are the hallmark of well-trained interns and are indispensable for the proper functioning of a care team. We will not develop the emotional and psychological management of debriefing in this article. We hope we will helpfully introduce as many of our colleagues as possible to the art of debriefing in most circumstances.

Managing psychological safety in debriefings: a dynamic balancing act

Debriefings should promote reflection and help learners make sense of events. Threats to psychological safety can undermine reflective learning conversations and may inhibit transfer of key lessons from simulated cases to the general patient care context. Therefore, effective debriefings require high degrees of psychological safety-the perception that it is safe to take interpersonal risks and that one will not be embarrassed, rejected or otherwise punished for speaking their mind, not knowing or asking questions. The role of introductions, learning contracts and prebriefing in establishing psychological safety is well described in the literature. How to maintain psychological safety, while also being able to identify and restore psychological safety during debriefings, is less well understood. This review has several aims. First, we provide a detailed definition of psychological safety and justify its importance for debriefings. Second, we recommend specific strategies debriefers can use throughout the debriefing to build and maintain psychological safety. We base these recommendations on a literature review and on our own experiences as simulation educators. Third, we examine how debriefers might actively address perceived breaches to restore psychological safety. Re-establishing psychological safety after temporary threats or breaches can seem particularly daunting. To demystify this process, we invoke the metaphor of a 'safe container' for learning; a space where learners can feel secure enough to work at the edge of expertise without threat of humiliation. We conclude with a discussion of limitations and implications, particularly with respect to faculty development.

Development and evaluation of interprofessional patient simulation activity for physiotherapy and occupational therapy students to assess and manage patients with chronic pain

Background/aims

Opportunities for interprofessional learning are a priority to prepare health professionals for the effective interprofessional assessment and management of patients with chronic pain, yet finding effective and sustainable approaches are a challenge for health professional programmes. The aim of this study was to develop and evaluate an ‘interprofessional management of pain’ learning activity using simulation for physiotherapy and occupational therapy students.

Methods

A total of 40 physiotherapy and 20 occupational therapy students undertook the interprofessional management of pain learning activity. Chronic pain attitudes and beliefs (HC-PAIRS) and perception of interprofessional practice (SPICE-R) were assessed before and following the intervention. A survey relating to content and format of the activity was completed following the intervention.

Results

There was a significant improvement in total HC-PAIRS and SPICE-R scores for both student groups. Both groups demonstrated satisfaction with the activity.

Conclusions

These findings support the use of an interprofessional simulated learning activity with facilitated planning and debriefing to enhance students’ attitudes to chronic pain and interprofessional practice.

The application of simulation-based medical education in low- and middle-income countries; the Myanmar experience

Simulation-based medical education (SBME) has become a routine part of practice in many disciplines including paediatric surgery. There is an evolving evidence base of its benefits both for surgical education, training and also patient education in high-income countries (HICs) but not in the low- and middle-income country (LMIC) setting. The advantages are hypothesised to be the same in both of these settings, although our experience is that they may be increased. In this article we describe the various modalities of SBME that maybe utilised in a LMIC in South East Asia. The various tips for the establishment of a successful simulation-based paediatric surgical programme and the potential pitfall that should be avoided are discussed.

DebriefLive: A Pilot Study of a Virtual Faculty Development Tool for Debriefing

INTRODUCTION

The quality of healthcare simulation learning relies heavily on effective debriefers. Traditional methods of faculty development in debriefing lack a structured approach to achieve expertise via graduated and reflective practice.

METHODS

The Simulation Learning, Education and Research Network (SimLEARN) developed DebriefLive, a virtual teaching environment, bringing together faculty and participant debriefers from across the Veterans Health Administration. Recorded simulation sessions were viewed followed by the opportunity for participant debriefers to debrief virtual learners. Participant debriefers were then provided structured and objective debriefings of the debriefings with the added opportunity for immediate practice. Program evaluation data for the pilot sessions were collected via electronic survey including a mix of Likert scale questions as well as short answer responses.

RESULTS

On a 7-point Likert scale, participant debriefers (n = 15) rated the content as effective (mean = 6.67, SD = 0.47) and appropriate to their level (mean = 6.47, SD = 0.47). The technology of video-based scenarios (mean = 6.6, SD = 0.61), followed by avatar-based debriefing sessions (mean = 6.6, SD = 0.8), was felt to be accurate and appropriate. All participants would agree or strongly agree with recommending this training program to colleagues.

CONCLUSIONS

Simulation instructors and fellows across the spectrum of the Veterans Health Administration found the innovative computer-based faculty development program DebriefLive acceptable as well as effective in increasing self-efficacy in debriefing. DebriefLive is an innovative and potentially disruptive tool, combining best practices in simulation theory and virtual technologies, for the training and assessment of debriefers.

Simulation as a Nursing Education Disrupter

Simulation as an evidence-based pedagogy began emerging at a time when many constraints were being imposed on clinical experiences for nursing students. As research illuminated the advantages of simulation and standards were developed, educators began to recognize the limitations of the clinical setting, such as the inability to provide experiences in teamwork and delegation, and a focus on tasks. Simulations are crafted to provide an experience that matches content that is being taught in class, and debriefing techniques guide learners in a reflective process that promotes the development of clinical reasoning and judgment. The National Council of State Boards of Nursing study concluded that simulation could be substituted for 50% of clinical hours. Simulation-exposed gaps in the curriculum and its pedagogical principles are now extending to adaptations of its use in the classroom and in clinical postconferences. They are also shaping teacher-student conversations in the office and the hallways. Use of simulation for assessment is beginning to evolve. In a little more than 10 years, it has started a revolution that will continue to have a major impact on all aspects of nursing education in the future.

An Evaluation of a New Debriefing Framework: REFLECT

BACKGROUND

Postresuscitation debriefing (PRD) is recommended by the American Heart Association guidelines but is infrequently performed. Prior studies have identified barriers for pediatric emergency medicine (PEM) fellows including lack of a standardized curriculum.

OBJECTIVE

Our objective was to create and assess the feasibility of a time-limited, structured PRD framework entitled REFLECT: Review the event, Encourage team participation, Focused feedback, Listen to each other, Emphasize key points, Communicate clearly, and Transform the future.

METHODS

Each PEM fellow (n = 9) at a single center was a team leader of a pre-intervention and post-intervention videotaped, simulated resuscitation followed by a facilitated team PRD. Our intervention was a 2-hour interactive, educational workshop on debriefing and the use of the REFLECT debriefing aid. Videos of the pre-intervention and post-intervention debriefings were blindly analyzed by video reviewers to assess for the presence of debriefing characteristics contained in the REFLECT debriefing aid. PEM fellow and team member assessments of the debriefings were completed after each pre-intervention and post-intervention simulation, and written evaluations by PEM fellows and team members were analyzed.

RESULTS

All 9 PEM fellows completed the study. There was an improvement in the pre-intervention and post-intervention assessment of the REFLECT debriefing characteristics as determined by fellow perception (63% to 83%, P < 0.01) and team member perception (63% to 82%, P < 0.001). All debriefings lasted less than 5 minutes. There was no statistical difference between pre-intervention and post-intervention debriefing time (P = 1.00).

CONCLUSIONS

REFLECT is a feasible debriefing aid designed to incorporate evidence-based characteristics into a PRD.

Finding common ground: meta-synthesis of communication frameworks found in patient communication, supervision and simulation literature

BACKGROUND

Effective communication between patients-clinicians, supervisors-learners and facilitators-participants within a simulation is a key priority in health profession education. There is a plethora of frameworks and recommendations to guide communication in each of these contexts, and they represent separate discourses with separate communities of practice and literature. Finding common ground within these frameworks has the potential to minimise cognitive load and maximise efficiency, which presents an opportunity to consolidate messages, strategies and skills throughout a communication curriculum and the possibility of expanding the research agenda regarding communication, feedback and debriefing in productive ways.

METHODS

A meta-synthesis of the feedback, debriefing and clinical communication literature was conducted to achieve these objectives.

RESULTS

Our analysis revealed that the concepts underlying the framework can be usefully categorised as stages, goals, strategies, micro-skills and meta-skills. Guidelines for conversations typically shared a common structure, and strategies aligned with a stage. Core transferrable communication skills (i.e., micro-skills) were identified across various types of conversation, and the major differences between frameworks were related to the way that power was distributed in the conversation and the evolution of conversations along the along the path of redistributing power. As part of the synthesis, an overarching framework "prepare-EMPOWER enact" was developed to capture these shared principles across discourses.

CONCLUSIONS

Adopting frameworks for work-based communication that promote dialogue and empower individuals to contribute may represent an important step towards learner-centred education and person-centred care for patients.

Simulation-Based Event Analysis Improves Error Discovery and Generates Improved Strategies for Error Prevention

INTRODUCTION

An adverse event (AE) is a negative consequence of health care that results in unintended injury or illness. The study investigates whether simulation-based event analysis is different from traditional event analysis in uncovering root causes and generating recommendations when analyzing AEs in hospitalized children.

METHODS

Two simulation scenarios were created based on real-life AEs identified through the hospital's Safety Reporting System. Scenario A involved an error of commission (inpatient drug error) and scenario B involved detecting an error that already occurred (drug infusion error). Each scenario was repeated 5 times with different, voluntary clinicians. Content analysis, using deductive and inductive approaches to coding, was used to analyze debriefing data. Causes and recommendations were compiled and compared with the traditional event analysis.

RESULTS

Errors were reproduced in 60% (3/5) of scenario A. In scenario B, participants identified the error in 100% (5/5) of simulations (average time to error detection = 15 minutes). Debriefings identified reasons for errors including product labeling, memory aid interpretation, and lack of standard work for patient handover. To prevent error, participants suggested improved drug labeling, specialized drug kits, alert signs, and handoff checklists. Compared with traditional event analysis, simulation-based event analysis revealed unique causes for error and new recommendations.

CONCLUSIONS

Using simulation to analyze AEs increased unique error discovery and generated new recommendations. This method is different from traditional event analysis because of the immediate clinician debriefings in the clinical environment. Hospitals should consider simulation-based event analysis as an important addition to the traditional process.

Development, Implementation, and Evaluation of a Faculty Development Workshop to Enhance Debriefing Skills Among Novice Facilitators

Introduction Effective debriefing during simulation-based training (SBT) is critical to promote learning outcomes. Despite debriefing's central role in learning and various published debriefing methods and techniques, little is known about faculty development structure for debriefing training among novice facilitators. Continuing medical education courses often use simulation-based methods but provide minimal training in debriefing techniques to novice facilitators. We describe the development, implementation, and evaluation of a structured debriefing training workshop for novice facilitators. Methods Designed and conducted by simulation debriefing experts, a debriefing workshop was provided to novice facilitators serving as faculty during the simulation-based Sedation Provider Course (PC) at the 2018 Society of Pediatric Sedation conference. Emphasizing evidence-based key elements of effective debriefing, the workshop was divided into three components: 1) an introductory 30 minute didactic, 2) 75 minutes role modeling of simulated effective and ineffective debriefing 3) 120 minutes repetitive deliberate practice sessions with summative and formative feedback. Effective transfer of learned debriefing skills was assessed during facilitators' PC debriefing using the Objective Structured Assessment of Debriefing (OSAD) tool, facilitators' self-efficacy, and PC student learners' evaluation of facilitator debriefings during the PC. Results Sixteen facilitators participated in the 4-h workshop and the next day served as PC faculty. The median OSAD score was 31 (13-40) for all facilitators. OSAD components with lowest and highest performance were "Establishing Learning Environment" with a median score of 1 (1-5) and "Engagement of Learners," with a median score of 4.75 (2.5-5). Facilitators' self- assessment in debriefing significantly improved on the 5-point Likert scale pre- and post-workshop, respectively. PC student learners' evaluations revealed high degrees of satisfaction with debriefing quality. Conclusions A proposed model integrating full-length debriefing and repetitive practice paired with summative and formative feedback provides a feasible and effective approach for debriefing training of novice facilitators for simulation-based educational courses.

Development of an instructor guide tool: 'Three Stages of Holistic Debriefing'

Objective:

to describe the development of an English and Brazilian Portuguese Holistic Debriefing Tool focused on nursing educator to promote a reflective learning.

Method:

a methodology study, with three phases: integrative literature review; tool development and review of a panel of nursing experts. The literature review tracked a systematic process. For the tool development were used literature review results, Lederman’s Debriefing Process and Zabala’s learning framework as theoretical referential to promote a reflective learning in High-Fidelity Simulation. The panel of nursing experts analysed the quality of the tool.

Results:

literature review evidenced gaps about educator pedagogical preparation and indicated no holistic debriefing tool exists which captures formative and summative aspects of debriefing guidance to assist the educator to debrief. Debriefing tool was purposed with two pages: first page were recommended how conduct debriefing and second page is a questions guidance. The tool evaluation was undertaken for a total of three modifications for congruence and concept reader clarity.

Conclusion:

it was proposed a holistic debriefing tool focused on nursing educator. This study provides an overall picture of the process to promote a reflexive learning in High-Fidelity Simulation and to contribute to formal nursing educator training to apply best pedagogical practice.

Simulation in Neurocritical Care: Past, Present, and Future

Simulation-based medical education is a technique that leverages adult learning theory to train healthcare professionals by recreating real-world scenarios in an interactive way. It allows learners to emotionally engage in the assessment and management of critically ill patients without putting patients at risk. Learners are encouraged to work at the edge of their expertise to promote growth and are provided with feedback to nurture development. Thus, the training is targeted to the learner, not the patient. Despite its origins as a teaching tool for neurological diseases, simulation-based medical education has been historically abandoned by neurocritical care educators. In contrast, other critical care educators have embraced the technique and built an impressive foundation of literature supporting its use. Slowly, neurocritical care educators have started experimenting with simulation-based medical education and sharing their results. In this review, we will investigate the historical origins of simulation in the neurosciences, the conceptual framework supporting the technique, current applications, and future directions.

Does team reflexivity impact teamwork and communication in interprofessional hospital-based healthcare teams? A systematic review and narrative synthesis

Background

Teamwork and communication are recognised as key contributors to safe and high-quality patient care. Interventions targeting process and relational aspects of care may therefore provide patient safety solutions that reflect the complex nature of healthcare. Team reflexivity is one such approach with the potential to support improvements in communication and teamwork, where reflexivity is defined as the ability to pay critical attention to individual and team practices with reference to social and contextual information.

Objective

To systematically review articles that describe the use of team reflexivity in interprofessional hospital-based healthcare teams.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six electronic databases were searched to identify literature investigating the use of team reflexivity in interprofessional hospital-based healthcare teams.

The review includes articles investigating the use of team reflexivity to improve teamwork and communication in any naturally occurring hospital-based healthcare teams. Articles’ eligibility was validated by two second reviewers (5%).

Results

Fifteen empirical articles were included in the review. Simulation training and video-reflexive ethnography (VRE) were the most commonly used forms of team reflexivity. Included articles focused on the use of reflexive interventions to improve teamwork and communication within interprofessional healthcare teams. Communication during interprofessional teamworking was the most prominent focus of improvement methods. The nature of this review only allows assessment of team reflexivity as an activity embedded within specific methods. Poorly defined methodological information relating to reflexivity in the reviewed studies made it difficult to draw conclusive evidence about the impact of reflexivity alone.

Conclusion

The reviewed literature suggests that VRE is well placed to provide more locally appropriate solutions to contributory patient safety factors, ranging from individual and social learning to improvements in practices and systems.

Trial registration number

CRD42017055602.

Using Mirror Patients to Enhance Patient Safety

STATEMENT

Unannounced, in situ simulations offer opportunities for interprofessional teams to train for pediatric emergencies and uncover latent safety threats (LST). Simulation fidelity is an important component of in situ simulations. Threats to fidelity include creating a fictional patient vignette, which limits realism and the opportunity for patient handoffs. The "mirror patient" model may enhance in situ simulation fidelity by using actual patient profiles, thereby removing vignettes and allowing for handoffs. This model may also aid in discovering LSTs. The mirror patient was positively received by participants, who reported realistic and useful simulation experience that provided a safe and supportive learning environment. Uncovering, recording, and reviewing LSTs into an institutional safety event reporting system allowed for tracking and accountability, including process improvement, equipment changes, and provider training without risk to any real patient. This model may further improve means to enhance hospital patient safety.

Balancing Deliberate Practice and Reflection: A Randomized Comparison Trial of Instructional Designs for Simulation-Based Training in Cardiopulmonary Resuscitation Skills

INTRODUCTION

A key question in simulation-based education is how to maximize learning within time and resource limits, including how best to balance hands-on practice versus reflective debriefing. Several instructional design frameworks suggest setting the balance according to the type of learning objective(s); however, broad professional activities such as team-based cardiopulmonary resuscitation include several interrelated component skills. This study experimentally manipulated hands-on practice versus reflective debriefing for cardiopulmonary resuscitation skills, hypothesizing that the former best supports learning taskwork (eg, compression quality), whereas the latter best supports learning teamwork.

METHODS

The study was a randomized comparison trial with a pretest and posttest. Twenty-six teams of 5 to 6 first-year residents underwent either "drill" practice of key resuscitation phases, designed to maximize deliberate practice opportunities for individual and team skills, or "scrimmage" practice, designed to maximize full-scenario rehearsals and reflective debriefs. Key taskwork and teamwork behaviors were coded, and compression quality was collected and analyzed from an accelerometer.

RESULTS

Most performance parameters improved considerably from a pretest to posttest for both taskwork (eg, percent correct compression depth 62%-81%, P = 0.01) and teamwork (eg, role leadership, 47%-70%, P = 0.00). Only 2 parameters improved differently by condition, favoring "drill" training: checking "Do Not Actively Resuscitate" wristband (odds ratio = 14.75, P = 0.03) and use of compression adjuncts (estimated marginal means = 75% versus 67%, P = 0.03).

CONCLUSIONS

Consistent with the notion that component skills in resuscitation do not clearly and exclusively constitute "taskwork" versus "teamwork," both instructional designs led to similar improvements despite differences in the balance between hands-on practice versus reflection.

A Randomized Trial of Multiple-Patient Simulation Preparation to Improve Novice Nurses' Competence and Self-Efficacy

AIM

The purpose of the study was to determine best practices for multiple-patient simulation (MPS) preparation and frequency to improve behavioral performance in nursing students.

BACKGROUND

MPS provides a safe environment for novice nurses to practice priority setting, delegation, and multitasking, but evidence for best practices is needed.

METHOD

A multisite, blinded, randomized trial was conducted to evaluate the effect of three simulation preparation methods (expert modeling, voice-over PowerPoint, and reading assignments) on students' competence and self-efficacy for providing care to multiple patients in the simulation lab. Participants (n = 73) were enrolled in capstone clinical courses at two schools of nursing.

RESULTS

Though there was no difference in raw change in competence score among the study groups, there was a statistically significant difference in pretest and posttest scores. The change in self-efficacy did not correlate with the change in competence.

CONCLUSION

These findings will help educators understand how novice nurses benefit from repeated MPS activities.

Supplementing Clinical Practice in Nursing Homes With Simulation Training: A Qualitative Study of Nursing Students' Experiences

INTRODUCTION

Limited access to nurse supervisors, insufficient learning support and staff with high workloads are well documented in the research literature as barriers to nursing students´ learning in clinical practice in nursing homes. Due to these barriers nursing students may benefit from additional learning support from nurse educators during their clinical practice period.

OBJECTIVE

The study aimed to explore nursing students' experiences of supplementary simulation training as a tool to support learning during clinical practice in nursing homes.

METHODS

A descriptive qualitative design was used. Twenty-seven first-year nursing students from a university college in Norway were interviewed after attending a seven-week practice period in nursing homes with supplementary simulation training. Three semi-structured focus group interviews were audio recorded, transcribed, and analysed using systematic text condensation.

FINDINGS

Three categories of student experiences were identified: enhancing the reasoning behind care, transferring knowledge and experiences between the learning environments and enhancing the sense of mastery.

CONCLUSION

The supplementary simulation training seemed to complement clinical practice by consolidating the students' learning during the clinical practice period, enhance the students' motivation and sense of mastery, and consequently their efforts to seek out new challenges, explore and learn both in the clinical and the simulated environment.

Challenging feedback myths: Values, learner involvement and promoting effects beyond the immediate task

CONTEXT

Research suggests that feedback in the health professions is less useful than we would like. In this paper, we argue that feedback has become reliant on myths that perpetuate unproductive rituals. Feedback often resembles a discrete episode of an educator "telling," rather than an active and iterative involvement of the learner in a future-facing process. With this orientation towards past events, it is not surprising that learners become defensive or disengaged when they are reminded of their deficits.

METHODS

We tackle three myths of feedback: (a) feedback needs praise-criticism balancing rules; (b) feedback is a skill residing within the teacher; and (c) feedback is an input only. For each myth we provide a reframing with supporting examples from the literature.

CONCLUSIONS

Equipping learners to engage in feedback processes may reduce the emotional burden on both parties, rendering techniques such as the feedback sandwich redundant. We also highlight the benefits for learners and teachers of conceptualising feedback as a relational activity, and of tracing the effects of information exchanges. These effects may be immediate or latent, and may manifest in different forms such as changes in learner evaluative judgement or professional identity.