Barriers to the implementation and uptake of simulation-based training programs in general surgery: a multinational qualitative study

Survey of Current Simulation Based Training in the US Military Health System

INTRODUCTION

Simulation-based medical training has been shown to be effective and is widely used in civilian hospitals; however, it is unclear how widely and how effectively simulation is utilized in the U.S. Military Health System (MHS). The current operational state of medical simulation in the MHS is unknown, and there remains a need for a system-wide assessment of whether and how the advances in simulation-based medical training are employed to meet the evolving needs of the present-day warfighter. Understanding the types of skills and methods used within simulation programs across the enterprise is important data for leaders as they plan for the future in terms of curriculum development and the investment of resources. The aim of the present study is to survey MHS simulation programs in order to determine the prevalence of skills taught, the types of learners served, and the most common methodologies employed in this worldwide health care system.

MATERIALS AND METHODS

A cross-sectional survey of simulation activities was distributed to the medical directors of all 93 simulation programs in the MHS. The survey was developed by the authors based on lists of critical wartime skills published by the medical departments of the US Army, Navy, and Air Force. Respondents were asked to indicate the types of learners trained at their program, which of the 82 unique skills included in the survey are trained at their site, and for each skill the modalities of simulation used, i.e., mannequin, standardized patients, part task trainers, augmented/virtual reality tools, or cadaver/live tissue.

RESULTS

Complete survey responses were obtained from 75 of the 93 (80%) MHS medical simulation training programs. Across all skills included in the survey, those most commonly taught belonged predominantly to the categories of medic skills and nursing skills. Across all sites, the most common category of learner was the medic/corpsman (95% of sites), followed by nurses (87%), physicians (83%), non-medical combat lifesavers (59%), and others (28%) that included on-base first responders, law enforcement, fire fighters, and civilians. The skills training offered by programs included most commonly the tasks associated with medics/corpsmen (97%) followed by nursing (81%), advanced provider (77%), and General Medical Officer (GMO) skills (47%).

CONCLUSION

The survey demonstrated that the most common skills taught were all related to point of injury combat casualty care and addressed the most common causes of death on the battlefield. The availability of training in medic skills, nursing skills, and advanced provider skills were similar in small, medium, and large programs. However, medium and small programs were less likely to deliver training for advanced providers and GMOs compared to larger programs. Overall, this study found that simulation-based medical training in the MHS is focused on medic and nursing skills, and that large programs are more likely to offer training for advanced providers and GMOs. Potential gaps in the availability of existing training are identified as over 50% of skills included in the nursing, advanced provider, and GMO skill categories are not covered by at least 80% of sites serving those learners.

Teaching With the GlobalSurgBox: Trainer Perceptions of a Portable Surgical Simulator

OBJECTIVES

Evaluate the utility of a low cost, portable surgical simulator (GlobalSurgBox) for surgical teaching and its ability to dismantle barriers faced by trainers when attempting to use surgical simulation.

DESIGN

An anonymous survey was administered to surgical trainers who were involved in leading simulation events using the GlobalSurgBox in the past 2 years. The survey was designed to understand current barriers to using simulation as a trainer, and the utility of the GlobalSurgBox in overcoming these barriers.

SETTING

Academic medical training centers or conferences in the United States, Rwanda and Kenya.

PARTICIPANTS

10 practicing surgeons, 3 practicing physicians, 11 surgical residents, 15 medical students and 1 anesthesia resident.

RESULTS

The top 3 barriers for effective teaching were lack of convenient access to the simulator (50%), lack of trainer time (43%) and cost (28%). After using the GlobalSurgBox, 100% and 98% of respondents felt that it encourages more practice and offers significant advantages over current simulators in their program. About 90%, 88% and 70% of respondents believed that the GlobalSurgBox makes surgical simulation more convenient, affordable, and compatible with trainer time limitations, respectively. 83% of trainers agreed that it is a good replica of the operating room experience, and 85% practicing physicians were more likely to give autonomy to trainees after demonstrating competence on the GlobalSurgBox.

CONCLUSION

The GlobalSurgBox mitigates several barriers surgical educators experience when practicing surgical skills with trainees. The convenience of the GlobalSurgBox can help facilitate the development of foundational surgical skills outside of the operating room.

Simulation-based education in ultrasound - diagnostic and interventional abdominal focus

Simulation-based training (SBT) is increasingly acknowledged worldwide and has become a popular tool for ultrasound education. Ultrasound simulation involves the use of technology and software to create a virtual training setting. Simulation-based training allows healthcare professionals to learn, practice, and improve their ultrasound imaging skills in a safe learning-based environment. SBT can provide a realistic and focused learning experience that creates a deep and immersive understanding of the complexity of ultrasound, including enhancing knowledge and confidence in specific areas of interest. Abdominal ultrasound simulation is a tool to increase patient safety and can be a cost-efficient training method. In this paper, we provide an overview of various types of abdominal ultrasound simulators, and the benefits, and challenges of SBT. We also provide examples of how to develop SBT programs and learning strategies including mastery learning. In conclusion, the growing demand for medical imaging increases the need for healthcare professionals to start using ultrasound simulators in order to keep up with the rising standards.

LapBot-Safe Chole: validation of an artificial intelligence-powered mobile game app to teach safe cholecystectomy

BACKGROUND

Gaming can serve as an educational tool to allow trainees to practice surgical decision-making in a low-stakes environment. LapBot is a novel free interactive mobile game application that uses artificial intelligence (AI) to provide players with feedback on safe dissection during laparoscopic cholecystectomy (LC). This study aims to provide validity evidence for this mobile game.

METHODS

Trainees and surgeons participated by downloading and playing LapBot on their smartphone. Players were presented with intraoperative LC scenes and required to locate their preferred location of dissection of the hepatocystic triangle. They received immediate accuracy scores and personalized feedback using an AI algorithm ("GoNoGoNet") that identifies safe/dangerous zones of dissection. Player scores were assessed globally and across training experience using non-parametric ANOVA. Three-month questionnaires were administered to assess the educational value of LapBot.

RESULTS

A total of 903 participants from 64 countries played LapBot. As game difficulty increased, average scores (p < 0.0001) and confidence levels (p < 0.0001) decreased significantly. Scores were significantly positively correlated with players' case volume (p = 0.0002) and training level (p = 0.0003). Most agreed that LapBot should be incorporated as an adjunct into training programs (64.1%), as it improved their ability to reflect critically on feedback they receive during LC (47.5%) or while watching others perform LC (57.5%).

CONCLUSIONS

Serious games, such as LapBot, can be effective educational tools for deliberate practice and surgical coaching by promoting learner engagement and experiential learning. Our study demonstrates that players' scores were correlated to their level of expertise, and that after playing the game, most players perceived a significant educational value.

Innovating medical education: Development of an affordable, 3-D printed knot-tying simulator

BACKGROUND

Three-dimensional (3-D) printing offers an innovative option to produce clinical simulators because of its low production costs and widespread availability. We aimed to develop a low-cost, 3-D printed knot-tying simulator that overcomes the barriers students face in self-directed skills development.

APPROACH

Medical students completing a procedural residency preparation course (PRPC) completed a pre-survey with Likert scales and multiple choice questions to assess their perceptions of and barriers to self-directed knot-tying practice. Subsequently, a 3-D printed knot-tying simulator, which contains a progression of knot-tying challenges and a designated video curriculum, was designed. After utilising the simulator in a 1-hour, faculty-guided knot-tying session, PRPC students assessed the educational utility and usability of the simulator via a post-survey.

EVALUATION

The primary barriers students faced in engaging in self-directed knot-tying practice included limited accessibility to simulators and insufficient knowledge of knot-tying techniques. Many students (91.3%, n = 21) agreed that practicing with the simulator improved their knot-tying motor skills and was easy to use (100%, n = 23). Twenty-two (95.7%) students agreed that they would continue to use the simulator beyond the knot-tying session and PRPC.

IMPLICATIONS

We demonstrate the educational utility and usability of a novel 3-D printed knot-tying simulator for medical education. Enabling students to engage in self-directed technical skills development is critical in developing surgical skills that can translate to clinical environments. Our simulator highlights the benefits of 3-D printers as an innovative, inexpensive option to improve the availability and accessibility to medical education tools.

Unleashing excellence: using a project management approach to effectively implement a simulation curriculum to improve residents' preparedness

BACKGROUND

Integrating innovative, simulation-based training programs into medical curricula frequently encounters familiar challenges, including scepticism, limited faculty time, and financial constraints. Recognized for its success in business projects, the Harvard Project Management Theory emerges as a promising approach to optimizing the implementation process and achieving sustainable success. This study endeavours to elucidate the application of project management theory in our implementation process and assess its impact on the clinical preparedness of novice residents.

METHODS

The research utilized a structured four-phase implementation strategy-Planning, Build-up, Execution, and Closing-to develop a simulation-based education curriculum. Incorporating project management tools like project charters and risk management tools played a crucial role in facilitating the effective implementation of standardized processes and improved clinical outcomes. Essential components of this innovative management approach encompass stakeholder engagement, milestone definition, and the alignment of institutional policies and processes.

RESULTS

A collective of 395 residents actively engaged in eight monthly simulation-based events, reflecting an average participation rate of 39 residents per lecture (± 19). A noteworthy enhancement was observed in the average rating for knowledge gain, with a significant improvement from 5.9/10 to 8.8/10 (p = 0.0001). Participants highlighted the program's considerable impact on future clinical practice (4.7/5) and teamwork (4.8/5) as particularly valuable aspects. The introduction of a novel organizational structure received favourable feedback from faculty members, with a notable rating of 4.8/5 for predictive time planning. Qualitative insights from the evaluation highlighted the significance of targeted incentive schemes in optimizing the implementation process.

CONCLUSION

This project underscores the constructive influence of project management principles in designing simulation-based curricula, explicitly focusing on stakeholder engagement, faculty motivation, and data utilization. Adopting the Harvard Project Management Approach emerges as a catalyst for heightened success in curriculum design, contributing to enhanced emergency preparedness among novice residents. The positive outcomes observed in this study provide valuable insights for future implementations, offering a foundation for refining and optimizing medical education programs to meet the evolving needs of learners and stakeholders alike.

Nodo-Tie: an innovative, 3-D printed simulator for surgical knot-tying skills development

Introduction

Clinical simulators are an important resource for medical students seeking to improve their fundamental surgical skills. Three-dimensional (3-D) printing offers an innovative method to create simulators due to its low production costs and reliable printing fidelity. We aimed to validate a 3-D printed knot-tying simulator named Nodo-Tie.

Methods

We designed a 3-D printed knot-tying simulator integrated with a series of knot-tying challenges and a designated video curriculum made accessible via a quick-response (QR) code. The Nodo-Tie, which costs less than $1 to print and assemble, was distributed to second-year medical students starting their surgical clerkship. Participants were asked to complete a survey gauging the simulator's usability and educational utility. The time between simulator distribution and survey completion was eight weeks.

Results

Students perceived the Nodo-Tie as easy-to-use (4.6 ± 0.8) and agreed it increased both their motor skills (4.5 ± 0.9) and confidence (4.5 ± 0.8) for tying surgical knots in the clinical setting. Many students agreed the Nodo-Tie provided a stable, durable surface for knot-tying practice (83.7%, n = 41) and that they would continue to use it beyond their participation in the study period (91.7%, n = 44).

Discussion

Medical students found this interactive, 3-D printed knot-tying simulator to be an effective tool to use for self-directed development of their knot-tying skills. Given the Nodo-Tie's low cost, students were able to keep the Nodo-Tie for use beyond the study period. This increases the opportunity for students to engage in the longitudinal practice necessary to master knot-tying as they progress through their medical education.

Key messages

Clinical simulators provide proactive learners with reliable, stress-free environments to engage in self-directed surgical skills development. The Nodo-Tie, a 3-D printed simulator, serves as a cost-effective, interactive tool for medical students to develop their knot-tying abilities beyond the clinical setting.

Integrating simulation into surgical training: a qualitative case study of a national programme

BACKGROUND

Applying simulation-based education (SBE) into surgical curricula is challenging and exacerbated by the absence of guidance on implementation processes. Empirical studies evaluating implementation of SBE interventions focus primarily on outcomes. However, understanding the processes involved in organising, planning, and delivering SBE adds knowledge on how best to develop, implement, and sustain surgical SBE. This study used a reform of early years surgical training to explore the implementation of a new SBE programme in Scotland. It aimed to understand the processes that are involved in the relative success (or failure) when implementing surgical SBE interventions.

METHODS

This qualitative case study, underpinned by social constructionism, used publicly available documents and the relevant surgical SBE literature to inform the research focus and contextualise data obtained from semi-structured interviews with core surgical trainees (n = 46), consultant surgeons (n = 25), and key leaders with roles in surgical training governance in Scotland (n = 7). Initial data coding and analysis were inductive. Secondary data analysis was then undertaken using Normalisation Process Theory (NPT). NPTs' four constructs (coherence, cognitive participation, collective action, reflexive monitoring) provided an explanatory framework for scrutinising how interventions are implemented, embedded, and integrated into practice, i.e. the "normalisation" process.

RESULTS

Distributed leadership (individual SBE initiatives assigned to faculty but overall programme overseen by a single leader) and the quality improvement practise of iterative refinement were identified as key novel processes promoting successful normalisation of the new SBE programme. Other processes widely described in the literature were also identified: stakeholder collaboration, personal contacts/relational processes, effective communication, faculty development, effective leadership, and tight programme management. The study also identified that learners valued SBE activities in group- or team-based social environments over isolated deliberate practice.

CONCLUSIONS

SBE is most effective when designed as a comprehensive programme aligned to the curriculum. Programmes incorporating both group-based and isolated SBE activities promote deliberate practice. Distributed leadership amongst faculty attracts wide engagement integral to SBE programme implementation, while iterative programme refinement through regular evaluation and action on feedback encourages integration into practice. The knowledge contributed by critically analysing SBE programme implementation processes can support development of much needed guidance in this area.

Hand Sewn Anastomosis Skill Acquisition and In Vivo Transfer Using 3D-Printed Small Bowel Simulator

INTRODUCTION

General surgery residents need to master the hand-sewn bowel anastomosis (HSBA) technique. However, practice opportunities outside of the operating room are rare, and commercial simulators are often costly. The objective of this study is to assess the efficacy of a new, affordable silicone small bowel simulator, made with a three-dimensional (3D) printed mold, as a training tool to learn this technique.

METHODS

This was a single-blinded pilot randomized controlled trial comparing two groups of eight junior surgical residents. All participants completed a pretest using an inexpensive, custom developed 3D-printed simulator. Next, participants randomized to the experimental group practiced the HSBA skill at home (eight sessions), while those randomized to the control group did not receive any hands-on practice opportunities. A posttest was done using the same simulator as for the pretest and practice sessions, and the retention-transfer test was performed on an anesthetized porcine model. Pretests, posttests and retention-transfer tests were filmed and graded by a blinded evaluator using assessments of technical skills, quality of final product, and tests of procedural knowledge.

RESULTS

The experimental group significantly improved after practicing with the model (P = 0.01), while an equivalent improvement was not noted in the control group (P = 0.07). Moreover, the experimental group's performance remained stable between the posttest and the retention-transfer test (P = 0.95).

CONCLUSIONS

Our 3D-printed simulator is an affordable and efficacious tool to teach residents the HSBA technique. It allows development of surgical skills that are transferable to an in vivo model.

Trainee and trainer experiences and recommendations for plastic surgery training: A qualitative pilot study

BACKGROUND

The COVID-19 pandemic has compounded existing training issues for plastic surgeons. The issues that exist result from a complex interplay of system, generational and individual factors, and can be hard to tease out by quantitative means. This pilot study aimed to investigate the perceptions of trainees and trainers of plastic surgical training in the UK.

METHODS

Ten semi-structured interviews were performed using purposive sampling in a central London plastic surgical unit. These were coded into and discussed in four themes: Medical directives and service demands; Sociocultural norms within plastic surgical training; Equity and access; and Plastic surgery training methods.

RESULTS

This study showed that current plastic surgery training is not optimised for learning or well-being, and that inequities are fostered, to the detriment of the specialty. Investment and planning are required to support our trainers and protect the diversity of our trainee group, with efficient and monitored learning essential to maintain our breadth and competence of practice.

CONCLUSION

Expanding this work through a broader study could provide valuable information to contribute to the development of future training schemes and curricula within British plastic surgery.

Percutaneous peritoneal drain placement: A pilot study of pediatric surgery simulation-based training for general surgery residents

INTRODUCTION

General surgery residents often feel unprepared to perform pediatric surgery procedures since case volume and experience may be low. Previously, we successfully implemented a simulation-based training (SBT) module for placement of a silastic silo for gastroschisis. Therefore, we designed a single institution pilot study to assess whether SBT for placement of a percutaneous peritoneal drain for perforated necrotizing enterocolitis (NEC) was feasible and lead to skill acquisition and increased confidence.

METHODS

Our newly created NEC module within our pediatric surgery SBT curriculum for general surgery residents was used. Residents completed two simulation sessions three months apart with confidence testing before and after each session. Skill acquisition and performance were assessed using a standardized case scenario and procedure checklist. Changes in residents' confidence and performance were determined using Wilcoxon Signed-Rank Tests.

RESULTS

Nine post-graduate-year three general surgery residents completed this curriculum. Following completion, residents reported improved confidence completing each step of the procedure initially (p = 0.005) and at 3 months (p = 0.008) with improved technical scores (p = 0.011). The number of residents deemed proficient significantly improved (p = 0.031).

CONCLUSION

Implementation of SBT module for perforated NEC was feasible and improved residents' confidence and proficiency completing the procedure.

Factors Affecting Implementation of Simulation-Based Education After Faculty Training in a Low-Resource Setting

INTRODUCTION

Simulation instructor training is a recognized key component of health care simulation implementation, including in low-resource settings. PediSTARS India (Pediatric Simulation Training and Research Society) has developed and delivered several instructor training courses and more recently a 3-level faculty development program. However, there is variability in adoption of simulation at workplaces. The goal of this study was to identify factors that influence translation of instructor training into workplace simulation.

METHODS

At the conclusion of their faculty development program, participants of the 2018 PediSTARS simulation instructor workshop were invited to participate in a qualitative study with an online questionnaire followed by a semistructured interview. The 3 key questions explored the "enablers," "barriers," and "changes needed" at workplaces for simulation-based training. The responses were analyzed and classified into broad themes.

RESULTS

Of the 76 participants of the workshop, 11 were interviewed. The enablers were classified under 3 themes; "management support," "trained team" and "smart sourcing." Barriers were "lack of infrastructure," "lack of time," and "lack of simulation culture." The proposed changes were to "raise awareness," "strengthen systems," and "curricular integration."

CONCLUSIONS

This study demonstrates the importance of institutional leadership support for simulation-based training and also that new instructors should focus on training teams in the workplace and mapping simulation activities to existing curricula. These results have wide applicability to a variety of health care settings and instructor training programs. Collaboration between organizations for further research about the impact of simulation-based training on patient safety and outcomes is also required.

Faculty support bundle for simulation education

BACKGROUND

Postgraduate training programmes rely on faculty to meet core educational needs, including simulation. Time is arguably the most valuable resource for academic physicians, which presents a challenge for recruiting faculty to provide extra-clinical teaching. To increase faculty engagement in simulation-based education (SBE), we first identified barriers to participation. Next, we sought to overcome barriers using a self-determination theory (SDT) framework to increase motivation using strategies that addressed faculty autonomy, competence and relatedness.

METHODS

Faculty from a single department of emergency medicine were surveyed about factors influencing participation in SBE. Responses were grouped into themes and used to develop the intervention-a faculty support bundle-to overcome common barriers and promote participation. Supports focused on course materials, organisational consistency and peer recognition. Faculty participation in SBE pre- and post-implementation of the support bundle was analysed via chi-squared analysis. Faculty who delivered SBE were resurveyed after the implementation phase to explore how the support bundle affected their experience.

RESULTS

Initial survey response was 41%. Reported barriers to participation in SBE included scheduling issues, preparation time, competing responsibilities, lack of confidence with simulation and lack of interest. Twenty-four faculty participated in SBE during the pre-implementation phase, compared to 39 post implementation (p = 0.03).

DISCUSSION

The faculty support bundle increases faculty participation in SBE. Strategies focused on internal motivators identified using an SDT framework. In contrast to traditional external motivators, these were no cost interventions. Those seeking to increase faculty participation in SBE should consider implementing similar strategies.

Training to proficiency in surgery using simulation: is there a moral obligation?

A deontological approach to surgical ethics advocates that patients have the right to receive the best care that can be provided. The 'learning curve' in surgical skill is an observable and measurable phenomenon. Surgical training may therefore carry risk to patients. This can occur directly, through inadvertent harm, or indirectly through theatre inefficiency and associated costs. Trainee surgeon operating, however, is necessary from a utilitarian perspective, with potential risk balanced by the greater societal need to train future independent surgeons.New technology means that the surgical learning curve could take place, at least in part, outside of the operating theatre. Simulation-based deliberate practice could be used to obtain a predetermined level of proficiency in a safe environment, followed by simulation-based assessment of operative competence. Such an approach would require an overhaul of the current training paradigm and significant investment in simulator technology. This may increasingly be viewed as necessary in light of well-discussed pressures on surgical trainees and trainers.This article discusses the obligations to trainees, trainers and training bodies raised by simulation technology, and outlines the current arguments both against and in favour of a simulation-based training-to-proficiency model in surgery. The significant changes to the current training paradigm that would be required to implement such a model are also discussed.

Developing a simulation-based training curriculum in transesophageal ultrasound with the use of the endobronchial ultrasound-endoscope

There is an increasing need to focus on how best to train respiratory physicians to perform EUS with bronchoscope-guided fine-needle aspiration biopsy (EUS-B-FNA). At current, training is mostly performed in the clinical environment under expert supervision; however, the advent of simulation-based education now provides a low-risk setting for novice trainees to learn and practice basic endosonography skills from identifying and understanding normal anatomy as well as pathology, maneuvering of endoscope, interpretation of images, and mastering of sampling techniques. In this descriptive educational paper, we used a six-step approach as a framework to describe the development of a structured training program combining EUS-B-FNA with the already well-established certification training program in endobronchial ultrasound transbronchial needle aspiration. This comprehensive training curriculum includes a theoretical course to achieve foundational knowledge, followed by simulation-based training until mastery standards are met, and supervised clinical apprenticeship. All steps should end with an objective assessment to achieve certification. This systematic development will hopefully encourage endosonography leaders and educators to collaborate and implement an evidence-based comprehensive endosonography curriculum that aims to provide the trainee with the essential EUS-B competencies to ensure that lung cancer patients are diagnosed and staged correctly.

Development and Learner-Based Assessment of a Novel, Customized, 3D Printed Small Bowel Simulator for Hand-Sewn Anastomosis Training

Hand-sewn bowel anastomosis (HSBA) is an essential skill for surgical residents to learn, as it is used in numerous surgical procedures. However, the opportunities to practice this skill before attempting it on patients are limited. Practice on simulators can help improve this technique, but there is a paucity of realistic, cost-efficient simulators for the acquisition of HSBA skills.

This technical report describes the development of our simulator that consists of a small bowel manufactured from silicone and a 3D-printed clamp system to hold the bowel in place. Our simulator was co-designed by a clinical team of surgeons and then assessed for perceived acceptability and effectiveness by 16 junior residents in various surgical specialties at our faculty. A majority of the learners rated our simulator to be a good or very good learning tool for HSBA, although they suggested some minor improvements.

Overall, our silicone small bowel model appears to be an effective and inexpensive way to acquire this surgical skill.

Designing a synthetic simulator to teach open surgical skills for limb exploration in trauma: a qualitative study exploring the experiences and perspectives of educators and surgical trainees

Background

Simulation is an important adjunct to aid in the acquisition of surgical skills of surgical trainees. The simulators used to adequately enable trainees to learn, practice and be assessed in surgical skills need to be of the highest standards. This study investigates the perceived requirements of simulation and simulators used to acquire skills in limb exploratory procedures in trauma.

Methods

Semi-structured interviews were conducted with an international group of 11 surgical educators and 11 surgical trainees who had experience with surgical simulation. The interviews focused on the perceptions of simulation, the integration of simulators within a curriculum and the features of a simulator itself. Interviews were recorded, transcribed and underwent thematic analysis.

Results

Analysis of the perspectives of surgical educators and surgical trainees on simulated training in limb trauma surgery yielded three main themes: (1) Attitudes to simulation. (2) Implementing simulation. (3) Features of an open skills simulator. The majority felt simulation was relevant, intuitive and a good way for procedure warmup and the supplementation of surgical logbooks. They felt simulation could be improved with increased accessibility and variety of simulator options tailored to the learner. Suggested simulator features included greater fidelity, haptic feedback and more complex inbuilt scenarios. On a practical level, there was a desire for cost effectiveness, easy set up and storage. The responses of the educators and the trainees were similar and reflected similar concerns and suggestions for improvement.

Conclusion

There is a clear positive appetite for the incorporation of simulation into limb trauma training. The findings of this will inform the optimal requirements for high quality implementation of simulation into a surgical trauma curriculum and a reference to optimal features desired in simulator or task trainer design.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01417-7.

Challenges to the implementation of in situ simulation at HEMS bases: a qualitative study of facilitators' expectations and strategies

INTRODUCTION

Facilitators play an essential role in simulation-based training on helicopter emergency medical services (HEMS) bases. There is scant literature about the barriers to the implementation of simulation training in HEMS. The purpose of this explorative interview study was to identify factors that the local facilitators anticipated would challenge the smooth implementation of the program, and their strategies to overcome these before the national implementation of in situ simulation-based training locally, and subsequently, one year after the programme was initiated, to identify the actual challenges they had indeed experienced, and their solutions to overcome these.

METHODS

A qualitative study with semi-structured group interviews of facilitators was undertaken before and after one year of simulation-based training on all HEMS bases and one Search and Rescue base. Systematic text condensation was used to extract facilitators' expectations and experiences.

RESULTS

Facilitators identified 17 themes in the pre-study-year interviews. Pedagogical, motivational and logistical issues were amongst the dominant themes. Other key themes included management support, dedicated time for the facilitators and ongoing development of the facilitator. In the post-study-year interviews, the same themes were identified. Despite anxiety about the perceptions of, and enthusiasm for, simulation training amongst the HEMS crews, our facilitators describe increasing levels of motivation over the study period.

CONCLUSION

Facilitators prognosticated the anticipated challenges to the successful implementation of simulation-based training on HEMS bases and suggested solutions for overcoming these challenges. After one year of simulation-based training, the facilitators reflected on the key factors for successful implementation.

[Use of surgical simulators in further education-A nationwide analysis in Germany]

BACKGROUND

In addition to learning theoretical knowledge, the medical specialist training in surgery necessitates the acquisition of practical surgical competences. Simulation-based teaching concepts represent an alternative to education and advanced training on patients. The aim of this study was to analyze the distribution and implementation of surgical simulators in German hospitals.

METHODS

The data analysis was carried out based on an individual on-line questionnaire with a total of 19 standardized questions. This was sent to the senior surgeons in hospitals and clinics via the email distributors of specialist societies for surgery in Germany.

RESULTS

A total of 267 complete datasets were analyzed (response rate 12%). Of the participants 84% reported that they were active in a teaching hospital. At the time of the investigation 143 surgical simulators were in use at 35% of the hospitals and clinics included in the evaluation. There were clear regional differences between the individual federal states. Of the participants, 21.1% did not have a simulator at the hospital but the acquisition of one was planned. Simulation training was most frequently used by students (41.1%) and physicians during further education (32.5%). Simulators were not integrated into advanced surgical training in 81.8%. Of the participating hospitals, 94% showed an interest in integration into surgical specialist training in the future.

CONCLUSION

The results of this survey confirmed the special importance of simulation-based training for surgical education in German hospitals; however, at the same time there were clear deficits in information concerning user behavior and a deficiency in the perceived integration of simulation training in advanced training for surgery.

Experiences and Perceptions of Ophthalmic Simulation-Based Surgical Education in Sub-Saharan Africa

BACKGROUND

Simulation-based surgical education (SBSE) can positively impact trainee surgical competence. However, a detailed qualitative study of the role of simulation in ophthalmic surgical education has not previously been conducted.

OBJECTIVE

To explore the experiences of trainee ophthalmologists and ophthalmic surgeon educators' use of simulation, and the perceived challenges in surgical training.

METHODS

A multi-center, multi-country qualitative study was conducted between October 2017 and August 2020. Trainee ophthalmologists from six training centers in sub-Saharan Africa (SSA) (in Kenya, Uganda, Tanzania, Zimbabwe and South Africa) participated in semi-structured interviews, before and after an intense simulation training course in intraocular surgery. Semi-structured interviews were also conducted with experienced ophthalmic surgeon educators. Interviews were anonymized, recorded, transcribed and coded. An inductive, bottom-up, constant comparative method was used for thematic analysis.

RESULTS

Twenty-seven trainee ophthalmologists and 12 ophthalmic surgeon educators were included in the study and interviewed. The benefits and challenges of conventional surgical teaching, attributes of surgical educators, value of simulation in training and barriers to implementing ophthalmic surgical simulation were identified as major themes. Almost all trainees and trainers reported patient safety, a calm environment, the possibility of repetitive practice, and facilitation of reflective learning as beneficial aspects of ophthalmic SBSE. Perceived barriers in surgical training included a lack of surgical cases, poor supervision and limited simulation facilities.

CONCLUSIONS

Simulation is perceived as an important and valuable model for education amongst trainees and ophthalmic surgeon educators in SSA. Advocating for the expansion and integration of educationally robust simulation surgical skills centers may improve the delivery of ophthalmic surgical education throughout SSA.

Low-tech intraocular ophthalmic microsurgery simulation: A low-cost model for home use

In order to maintain manual dexterity and surgical skills, trainees are encouraged to partake in regular simulation. Current options for intraocular surgical simulation require specialist microscopic equipment which is expensive and requires access to simulation facilities. A set of core simulation exercises and basic surgical skills of performing the corneal incisions, capsulorhexis, improving the manual dexterity, and suturing were identified, discussed, and agreed among authors before designing this simulation exercise. In this paper, we propose a smartphone-based, low-cost, low-tech model with corresponding exercises for intraocular simulation that can be used at home for the above-mentioned surgical skill set. This model provides an easy, portable, and reproducible method of simulation and can serve as an adjunct to patient-facing surgical training, especially in the current pandemic, where the excess to the simulation facilities or setup of these facilities may be difficult.

Cost-effective and adaptable cataract surgery simulation with basic technology

Purpose

To assess the subjective validity of a cost-effective and adaptable cataract surgery simulation technique using basic technology.

Methods

We devised and filmed a range of simulation techniques that mimic steps of phacoemulsification cataract surgery using various “everyday” basic materials. This video was combined in a “parallel” fashion with live cataract surgery so that all steps of surgery were simulated. Subsequently, we distributed an online subjective validation questionnaire on Google Forms with the embedded simulation video in a generic invitation that was forwarded via email and/or text messages/WhatsApp messenger amongst Ophthalmologists of all grades within our regions (Kent, Surrey and Sussex, London and Wales Postgraduate Deaneries).

Results

Face validity: 66 (99%) participants agreed that the explanations in the video were clear and 53 (79%) concurred with the realistic feel of simulated technique. Instrumentation and adaptations demonstrated were deemed user friendly and conducive to replicate by 99% participants. Content validity: 60 (90%) of participants agreed the techniques described in the video reflected the technical skills required to train cataract surgeons. Forty-nine (74%) agreed that the simulation techniques were relevant for acquiring other generic and transferable microsurgical and manual dexterity skills.

Conclusions

We demonstrated subjective validity of our cost-effective cataract simulation technique. Our model can be used as an adjunct to intraocular and virtual reality training for cataract surgery by removing the barrier of cost and improved exposure to real instruments used in cataract surgery.

An analysis of the cost of postgraduate training in surgery in Ireland compared to other specialties

Introduction

Postgraduate specialty training in Ireland is associated with considerable cost. Some of these are mandatory costs such as medical council fees, while others are necessary to ensure career progression, such as attendance at courses and conferences. In particular, surgical specialities are believed to be associated with high training costs. It is unknown how these costs compare to those borne by counterparts in other specialities.

Aims

The aims of this study were to

Quantify the amount that trainees in Ireland spend on postgraduate training

Determine whether a difference exists between surgery and other non-skill-based specialties in terms of expenditure on training

Methods

A standardised non-mandatory questionnaire was circulated to trainees across two training centres in Ireland. Trainees at all levels were invited to participate.

Results

Sixty responses were obtained. Fifty-seven questionnaires were fully completed and included for analysis. The median expenditure on training was higher for surgical than non-surgical specialities. Subgroup analysis revealed surgical training was associated with higher expenditure on higher degrees and courses compared to medical training (p = 0.035). > 95% of trainees surveyed felt that greater financial support should be available for trainees during the course of their training.

Conclusions

This study demonstrated that a career in surgery is associated with higher ongoing costs for higher degrees and courses than counterparts in non-surgical training. All surgical trainees surveyed felt that better financial support should be available. Increasing financial support for may be a tangible way to mitigate against attrition during training.

National Implementation of In Situ Simulation-Based Training in Helicopter Emergency Medical Services: A Multicenter Study

OBJECTIVE

Medical simulation is used in helicopter emergency services as a tool for training the crew. Using in situ simulation, we aimed to evaluate the degree of implementation, the barriers to completing simulation training, and the crew's attitude toward this form of training.

METHODS

This was a 1-year prospective study on simulation at all 14 Norwegian helicopter emergency services bases and 1 search and rescue base. Local facilitators were educated and conducted simulations at their discretion.

RESULTS

All bases agreed to participate initially, but 1 opted out because of technical difficulties. The number of simulations attempted at each base ranged from 1 to 46 (median = 17). Regardless of the base and the number of attempted simulations, participating crews scored self-evaluated satisfaction with this form of training highly. Having 2 local facilitators increased the number of attempted simulations, whereas facilitators' travel distance to work seemed to make no difference on the number of attempted simulations.

CONCLUSION

Our study reveals considerable differences in the number of attempted simulations between bases despite being given the same prerequisites. The busiest bases completed fewer simulations than the rest of the bases. Our findings suggest that conditions related to the local facilitator are important for the successful implementation of simulation-based training in helicopter emergency services.

Utilizing In-Hospital Fabrication to Decrease Simulation Costs

BACKGROUND

Two restrictive factors for surgical training through simulation, are the cost of and accessibility to materials and consoles for simulation models. Commercial surgical simulation models continue to maintain high prices with a wide range of fidelity levels. We believe that by utilizing in-house fabrication, these barriers can be decreased while maintaining and even improving the functionality of surgical simulation models as well as increase their individualization and customization.

METHODS

By using a combination of digital and manual fabrication techniques such as 3D printing and basic mold making methods, we were able to create models equivalent to current commercial products by utilizing the first of its kind MakerHEALTH space and collaborating with our surgical simulation staff. We then compared our research and development, start-up, materials, operational, and labor costs to buying comparable commercial models with the simulation usage rates of our institution.

RESULTS

We were able to decrease the costs of a 6 model simulation sample set (appendectomy, cholecystectomy, common bile duct exploration, ventral hernia, chest tube insertion, and suture pads) at our institution from $99,646.60 to $13,817.21 for a medical student laborer, $14,500.56 for a surgical resident laborer, $15,321.08 for a simulation staff laborer, and $18,984.48 for an attending physician laborer.

CONCLUSION

We describe successful approaches for the creation of cost-effective and modular simulation models with the aim of decreasing the barriers to entry and improving surgical training and skills. These techniques make it financially feasible for learners to train during larger faculty-led workshops and on an individual basis, allowing for access to simulation at any time or place.

Role of Digital Resources in Minimally Invasive Colorectal Surgery Training

Laparoscopic techniques have become the standard for many benign and malignant colorectal pathologies. Recently, the application of robotic-assisted technologies has been, and continues to be, explored. These new technologies require different skill sets and bring novel training challenges, and today's trainees must demonstrate competence in more techniques than ever. Compounding this is the reducing time spent operating in current training programs due to caps on working hours and service pressures. The need for adjunctive training strategies outside the operating room has prompted development of multimedia and digital resources to build the cognitive skills crucial in both nontechnical and technical aspects of surgery. Many are based on principles of cognitive task analysis, breaking down operations, and key decisions into nodal points to be mentally rehearsed. Resources built on this technique have shown improvements in both operative and nonoperative skills, suggesting these resources can advance trainees along the learning curve in minimally invasive surgical techniques. More work to fully elucidate the clinical benefits of such resources is required before their role as a substitute for lost operative training hours can be established. Despite this, alongside other developing technologies such as simulation, they are a promising addition to the armamentarium of the modern-day colorectal trainee.

Implementing, embedding and sustaining simulation-based education: What helps, what hinders

OBJECTIVES

Although there is much evidence to support the use of simulation-based education (SBE) in undergraduate education of health care professionals, less attention has been paid to how SBE, viewed as a complex intervention, is implemented and becomes embedded and sustained. This paper aims to explore factors that inhibited or promoted SBE becoming normal practice in undergraduate health care professional programmes.

METHODS

Participants involved in the organisation, design and delivery of SBE in the north of England were recruited purposefully from higher education institutions (HEI) and National Health Service (NHS) Trusts through local networks for qualitative telephone interviews. Transcripts were analysed inductively using a hybrid approach involving simultaneous inductive open coding and deductive coding using normalisation process theory (NPT) as a theoretical lens.

FINDINGS

A total of 12 NHS staff from 11 trusts and seven individuals from four HEIs were interviewed. There was considerable variation in the approach taken to implementation across organisations, which resulted in varying degrees of embeddedness. Implementation was challenged or enabled by organisational leadership, professional buy-in and the development and maturity of the strategic approach. Variation in understanding of the scope and pedagogical aims of SBE led to inequity between professions and organisations in investment and participation, as well as design and delivery of SBE.

CONCLUSIONS

Given the complexity of SBE, best practice in implementation should be considered fundamental to the successful delivery of SBE. The findings provide an explanation of how contextual factors can support or hinder implementation to maximise potential benefits and learning outcomes; this understanding can be used to better inform development of SBE strategies and highlight potential factors needed to navigate contextual barriers so that learning outcomes can be maximised.

Development of a Low-cost, High-fidelity Skin Model for Suturing

BACKGROUND

In a survey of students at our institution, suturing was the most desired workshop for simulation; however, cost, quality, and availability of skin pads is often prohibitive for suturing workshops. In-hospital fabrication may be utilized to manufacture noncommercial, high-fidelity, and low-cost simulation models. We describe the production, value, and face validation of our simulated skin model.

MATERIALS AND METHODS

Using an in-hospital fabrication laboratory, we have developed a model for skin and subcutaneous tissue. Our model uses a variety of commercially available materials to simulate the epidermis, dermis, subcutaneous fat, fascia, and muscle. A cost analysis was performed by comparing it with other commonly used commercial skin models. Expert surgeons assessed the material characteristics, durability, and overall quality of our model in comparison with other commercial models.

RESULTS

The materials cost of our novel skin pad model was 30.9% of the mean cost of five different commonly used foam and silicone-based commercial skin models. This low-cost model is more durable than the commercial models, does not require skin pad holders, and is of higher fidelity than the commercial products. In addition to skin closure, our model may be used to simulate fascial closure or fasciotomy.

CONCLUSIONS

Model creation using in-hospital workspaces is an effective strategy to decrease cost while improving quality of surgical simulation. Our methods for creation of an inexpensive and high-fidelity skin pad may be purposed for several soft tissue models.

Simulation capacity building in rural Indian hospitals: a 1-year follow-up qualitative analysis

Introduction

The benefits of simulation-based medical training are well described. The most effective way to plant and scale simulation training in rural locations remains undescribed. We sought to plant simulation training programmes for anaesthesia emergencies in two rural Indian hospitals.

Methods

Two Indian consultant anaesthetists without experience in medical simulation underwent a 3-day course at the Boston Children’s Hospital’s (BCH) Simulator Program. They returned to their institutions and launched simulation programmes with an airway manikin and mock patient monitor. The 1-year experience was evaluated using individual, in-depth interviews of simulation facilitators. Three staff members (responsible for facilitating medical simulations over the prior year) at two rural hospitals in India were interviewed. None attended the BCH training; instead, they received on-the-job training from the BCH-trained, consultant anaesthetist colleagues.

Results

Successes included organisational adoption of simulation training with exercises 1 year after the initial BCH-training, increased interdisciplinary teamwork and improved clinical competency in managing emergencies. Barriers to effective, local implementation of simulation programmes fell into three categories: time required to run simulations, fixed and rigid roles, and variable resources. Thematic improvement requests were for standardised resources to help train simulation facilitators and demonstrate to participants a well-run simulation, in addition to context-sensitive scenarios.

Conclusion

An in-person training of simulation facilitators to promote medical simulation programmes in rural hospitals produced ongoing simulation programmes 1 year later. In order to make these programmes sustainable, however, increased investment in developing simulation facilitators is required. In particular, simulation facilitators must be prepared to formally train other simulation facilitators, too.

Medical simulation utilization among pediatric anesthesiology fellowship programs

BACKGROUND

Simulation-based education is a mainstay in education of pediatric anesthesiology trainees. Despite the known benefits, there is variability in its use and availability among various pediatric anesthesiology fellowship programs.

AIM

The primary aim was to understand the current state of simulation-based education among pediatric anesthesiology fellowship programs and define barriers that impede the development of an effective simulation program.

METHODS

This survey-based, observational study of simulation activities within United States-based pediatric anesthesiology fellowship programs was approved by the Institutional Review Boards (IRB) of the authors' institutions. A 35-question survey was developed in an iterative manner by simulation educators (AA, WW, DY) and a statistician familiar with survey-based research (AN) using research electronic data capture (REDCap) for tool development and data collation. Descriptive and thematic analyses were performed on the quantitative and qualitative responses in the survey, respectively, and were stratified with small, medium, and large fellowship programs.

RESULTS

Forty-five of 60 (75%) fellowship programs responded to the survey. The presence of a dedicated simulation program director and number of simulation instructors was positively associated with the size of program and years in operation. Dedicated simulation support was variable across programs and was usually present within the larger programs. A positive association also existed for educational activities among all programs mostly based on size of program and years in operation. Protected time was the most commonly cited barrier to having a comprehensive and sustainable simulation program. There was general agreement for establishing a standardized and shared curriculum among fellowship programs. Approximately 70% of simulation programs had no formal simulation instructor training requirement.

CONCLUSIONS

Simulation-based curricula are broadly offered by many fellowship programs. Improved collaboration locally, regionally, and nationally may improve educational opportunities for fellowship programs, particularly the small ones. These efforts may begin with the development of a standardized curriculum and formal instructor training programs.

Simulation-based surgical education in cardiothoracic training

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part-task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three-dimensional printing and computer-based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.

Simulation-based medical training for paediatric residents in Italy: a nationwide survey

BACKGROUND

A prompt start to an appropriate neonatal and paediatric resuscitation is critical to reduce mortality and morbidity. However, residents are rarely exposed to real emergency situations. Simulation-based medical training (SBMT) offers the opportunity to improve medical and non-technical skills in a controlled setting. This survey describes the availability and current use of SBMT by paediatric residents in Italy with the purpose of understanding residents' expectations regarding neonatal and paediatric emergency training, and identifying gaps and potential areas for future implementation.

METHODS

A survey was developed and distributed to Italian residents. SBMT was defined as any kind of training with a mannequin in a contextualised clinically realistic scenario.

RESULTS

The response rate was 14.4%, covering the 71% of Italian paediatric residency programmes. Among them, 88% stated that Out of the 274 residents, 88% stated that they received less than 5 h of SBMT during the past training year, with 66% not participating in any kind of simulation activity. In 62% of the programmes no simulation training facility was available to residents. Among those who received SBMT, 46% used it for procedures and skills, 30% for clinical scenarios, but only 24% of them reported a regular use for debriefing. Of the overall respondents, 93% were interested in receiving SBMT to improve decision-making abilities in complex medical situations, to improve technical/procedural skills, and to improve overall competency in neonatal and paediatric emergencies, including non-technical skills. The main barriers to the implementation of SBMT programmes in Italian paediatric residencies were: the lack of experts (57%), the lack of support from the school director (56%), the lack of organisation in planning simulation centre courses (42%) and the lack of teaching materials (42%).

CONCLUSIONS

This survey shows the scarce use of SBMT during paediatric training programmes in Italy and points out the main limitations to its diffusion. This is a call to action to develop organised SBMT during paediatric residency programs, to train qualified personnel, and to improve the quality of education and care in this field.

A Randomized Controlled Trial of Skills Transfer: From Touch Surgery to Laparoscopic Cholecystectomy

BACKGROUND

Surgical training has traditionally involved teaching trainees in the operating room. However, intraoperative training is time-intensive and exposes patients to greater risks. Touch Surgery (TS) is an application that uses animation to provide simulation training via cognitive task analysis as an adjunct to intraoperative training.

METHODS

Forty students were recruited and randomly allocated to either a control or intervention group. Each group received the same preparation before intervention, including a 10-min introduction to laparoscopic equipment and a 15-min educational tutorial on laparoscopic cholecystectomies. The participants then received training via either TS (intervention) or written information (control). Their performance was compared using a validated scoring tool on a porcine laparoscopic cholecystectomy model. Significance was defined as P < 0.050.

RESULTS

In total, n = 22 and n = 18 participants were randomly assigned to intervention and control groups, respectively. There was no significant difference between age (P = 0.320), year of medical school (P = 0.322), handedness (P = 1.000), or gender (P = 0.360) of the groups. The overall mean performance score was higher for intervention (mean ± SD = 41.9 ± 22.5) than control (mean ± SD = 24.7 ± 19.6; P = 0.016). There was no significant difference between scores for each intraoperative segment between the intervention and control group (P > 0.050).

CONCLUSIONS

This study demonstrates that TS is effective for providing cognitive training in laparoscopic cholecystectomies to medical students. It is likely that this effect will be seen across modules and other platforms that use cognitive task analysis alongside high-fidelity animation. Further work is necessary to extend this to other surgical procedures for evaluating its longitudinal effectiveness.

Education and the pediatric surgeon

There have been many changes in the domain of clinical surgery over the last 2 decades, but probably none more so than in education. The British Association of Pediatric Surgeons recognizes the importance of this topic and has commissioned a special session on this subject jointly with the International Pediatric Endosurgery Group. Free papers presented on a number of educational subjects and specific topics of recruitment and simulation were covered in invited lectures. The session was completed with a keynote lecture from the renowned educationalist Professor Roger Kneebone.

LEVEL OF EVIDENCE

5 (Expert Opinion).