Learning Theory Foundations of Simulation-Based Mastery Learning

Evaluation of high-fidelity and virtual reality simulation platforms for assessing fourth-year medical students' encounters with patients in need of urgent or emergent care

BACKGROUND

Medical students in the U.S. must demonstrate urgent and emergent care competence before graduation. Urgent and emergent care competence involves recognizing, evaluating and initiating management of an unstable patient. High-fidelity (HF) simulation can improve urgent and emergent care skills, but because it is resource intense, alternative methods are needed.

STUDY OBJECTIVE

Our primary purpose was to use program evaluations to compare medical student experiences with HF and virtual reality (VR) simulations as assessment platforms for urgent and emergent care skills.

METHODS

During their emergency medicine clerkship, students at The Ohio State University College of Medicine must demonstrate on HF manikins, competence in recognizing and initiating care of a patient requiring urgent or emergent care. Students evaluated these simulations on a five-point quality scale and answered open-ended questions about simulation strengths and weaknesses. Faculty provided feedback on student competence in delivering urgent or emergent care. In 2022, we introduced VR as an alternative assessment platform. We used Wilcoxon Signed Ranks and Boxplots to compare ratings of HF to VR and McNemar Test to compare competence ratings. Comments were analyzed with summative content analysis or thematic coding.

RESULTS

We received at least one evaluation survey from 160 of 216 (74.1%) emergency medicine clerkship students. We were able to match 125 of 216 (57.9%) evaluation surveys for students who completed both. Average ratings of HF simulations were 4.6 of 5, while ratings of VR simulations were slightly lower at 4.4. Comments suggested that feedback from both simulation platforms was valued. Students described VR as novel, immersive, and good preparation for clinical practice. Constructive criticism identified the need for additional practice in the VR environment. Student performance between platforms was significantly different with 91.7% of students achieving competence in HF, but only 65.5% in VR (p≤.001, odds-ratio = 5.75).

CONCLUSION

VR simulation functions similarly to HF for formative assessment of urgent and emergent care competence. However, using VR simulation for summative assessment of urgent and emergent care competence must be considered with caution because students require considerable practice and acclimation to the virtual environment.

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.

Preparing interns for clinical practice through an institution-wide simulation-based mastery learning program for teaching central venous catheter placement

Central venous catheter (CVC) placement is a challenging procedure with known iatrogenic risks. However, there are no residency program requirements to demonstrate baseline CVC procedural competency. Competency-based procedural education has been shown to decrease CVC-associated morbidity, but there has been limited literature about institution-wide efforts to ensure initial trainee competency for CVC placement. This study describes the implementation of a competency-based CVC curriculum for first-year interns across an institution before supervised clinical care. An institution-wide, simulation-based mastery training curriculum was designed to assess initial competency in CVC placement in first-year residents during 2021 and 2022. A checklist was internally developed with a multidisciplinary team. Using the Mastery-Angoff technique, minimum passing standards were derived to define competency levels considered appropriate for intern participation in supervised clinical care. Interns were trained through the competency-based program with faculty assessing intern performance using the CVC checklist to verify procedural competency. Over 2 academic cycles, 229 interns from 20 specialties/subspecialties participated. Overall, 83% of interns met performance standards on their first posttest attempt, 14% on the second attempt, and 3% on the third attempt. Interns from both cycles demonstrated significant improvement from baseline to posttest scores (P < .001). Overall, 10.5% of interns performed dangerous actions during assessment (malpositioning, retained guidewire, or carotid dilation). All interns ultimately achieved the passing standard to demonstrate initial competency in the simulation assessment. All participating interns demonstrated simulation-based competency allowing them to place CVCs under supervised clinical care. Dangerous actions, however, were not uncommon. Simulation-based teaching and learning frameworks were a feasible method to promote patient safety through an institutional-wide verification of preliminary procedural competency.

Impact of Simulation-based Mastery Learning on Management of Massive Hemoptysis

Background

The management of massive hemoptysis is a high-risk, low-volume procedure that is associated with high mortality rates, and pulmonary and critical care medicine (PCCM) fellows often lack training. Simulation-based mastery learning (SBML) is an educational strategy that improves skill but has not been applied to massive hemoptysis management.

Objective

This pilot study aimed to develop a high-fidelity simulator, implement an SBML curriculum, and evaluate the impact on PCCM fellows managing massive hemoptysis.

Methods

We modified a simulator to bleed from segmental airways. Next, we developed an SBML curriculum and a validated 26-item checklist and set a minimum passing standard (MPS) to assess massive hemoptysis management. A cohort of traditionally trained providers was assessed using the checklist. First-year PCCM fellows reviewed a lecture before a pretest on the simulator using the skills checklist and underwent rapid-cycle deliberate practice with feedback. Subsequently, fellows were posttested on the simulator, with additional training as necessary until the MPS was met. We compared pretest and posttest performance and also compared SBML-trained fellows versus traditionally trained providers.

Results

The MPS on the checklist was set at 88%. All first-year PCCM fellows (N = 5) completed SBML training. Mean checklist scores for SBML participants improved from 67.7 ± 8.4% (standard deviation) at pretest to 84.6 ± 6.7% at the initial posttest and 92.3 ± 5.4% at the final (mastery) posttest. Traditionally trained participants had a mean test score of 60.6 ± 13.1%.

Conclusion

The creation and implementation of a massive hemoptysis simulator and SBML curriculum was feasible and may address gaps in massive hemoptysis management training.

Applying simulation learning theory to identify instructional strategies for Generation Z emergency medicine residency education

Introduction

Generation Z learners are entering emergency medicine (EM) residency training, bringing unique learning preferences that influence their engagement with residency education. To optimally teach and motivate this incoming generation of learners, EM educators must understand and adapt to the changing instructional landscape.

Methodology

The Simulation Leaders Advancing the Next Generation in Emergency Medicine (SLANG-EM) Workgroup was created to identify effective educational strategies for Generation Z learners entering EM. Members were faculty in the Society for Academic Emergency Medicine (SAEM) Simulation Academy, well versed in learning theory supporting simulation-based education (SBE) and actively involved in EM residency education.

Unique treatment/analysis

Through primary and secondary literature searches, the SLANG-EM Workgroup identified four distinctive learning preferences of Generation Z learners: (1) individualized and self-paced learning, (2) engaging and visual learning environments, (3) immediate and actionable feedback, and (4) combined personal and academic support. Workgroup members evaluated these learning preferences using a novel conceptual framework informed by the theoretical principles underpinning SBE, recommending instructional strategies for Generation Z EM residency learners across multiple educational environments.

Implications for educators

Instructional strategies were described for the didactic, simulation, and clinical learning environments. In the didactic environment, identified instructional strategies included meaningful asynchronous education, interactive small-group learning, and improved multimedia design. In the simulation environment, educational innovations particularly suitable for Generation Z learners included learner-centered debriefing, rapid-cycle deliberate practice, and virtual simulation. In the clinical environment, described instructional strategies involved setting learner-centered goals and delivering facilitative feedback in the context of an educational alliance. Overall, these instructional strategies were clustered around themes of student-centered education and the educator as facilitator, which align well with Generation Z learning preferences. These findings were synthesized and presented as an advanced workshop, "Delivering Effective Education to the Next Generation," at the 2023 SAEM Annual Meeting.

Twelve tips for developing simulation-based mastery learning clinical skills checklists

Simulation-based mastery learning is a powerful educational paradigm that leads to high levels of performance through a combination of strict standards, deliberate practice, formative feedback, and rigorous assessment. Successful mastery learning curricula often require well-designed checklists that produce reliable data that contribute to valid decisions. The following twelve tips are intended to help educators create defensible and effective clinical skills checklists for use in mastery learning curricula. These tips focus on defining the scope of a checklist using established principles of curriculum development, crafting the checklist based on a literature review and expert input, revising and testing the checklist, and recruiting judges to set a minimum passing standard. While this article has a particular focus on mastery learning, with the exception of the tips related to standard setting, the general principles discussed apply to the development of any clinical skills checklist.

The virtual reality classroom: a randomized control trial of medical student knowledge of postpartum hemorrhage emergency management

Objective

To investigate the use of a virtual reality learning environment (VRLE) to enhance medical student knowledge of postpartum hemorrhage (PPH) emergency management and insertion of a postpartum balloon.

Methods

A randomized control trial involving medical students from University College Dublin, Ireland. Participants were randomly allocated to the intervention group (VRLE tutorial) or control group (PowerPoint tutorial on the same topic). All participants completed pre-learning experience and post-learning experience surveys. Both groups were timed and assessed on postpartum balloon insertion technique on a model pelvis. The primary outcome was assessment of student knowledge. Secondary outcomes included confidence levels, time taken to complete the task, technique assessment, satisfaction with the learning environment, and side effects of VR.

Results

Both learning experiences significantly (p < 0.001) enhanced student performance on the post-learning experience multiple choice questionnaire, with no difference between the intervention and control groups. In the intervention group, time for task completion was significantly less compared to the control group (1-2 min vs. 2-3 min, p = 0.039). Both learning experiences significantly (p < 0.001) enhanced student confidence, with no significant difference between intervention and control groups. 100% of the students using the VRLE enjoyed the experience, and 82.4% were very likely to recommend use of VRLE in medical education. 94.1% of the students felt the VRLE was beneficial over didactic teaching.

Conclusion

Receiving formal instruction, regardless of format, enhances students' knowledge and confidence of the topic covered. Students who received instruction via the VRLE assembled the postpartum balloon faster than students who received didactic teaching. VR may be beneficial in teaching hands-on procedural skills in obstetrics and gynecology education.

Simulation in the field of transfusion medicine: Scope and utility

Simulation in medical education has made significant inroads in most of the specialties in some form or the other. Transfusion medicine, as a branch, being a new specialty, is imbibing a few things from the world of simulation and provides immense scope for its utilization, given its broad applicability as well as necessity. In the current Indian scenario of transfusion medicine, wherein the transfusion process has undergone significant changes involving critical steps, with fewer but can be serious complications arising due to the transfusion process, it is desirable for students and the staff involved to practice on the simulators to attain the desired level of competency as it allows the practice of hands-on invasive procedures before performing the actual process. The principles, pedagogies, and educational strategies with their modalities used in health care simulation like case-based scenarios, physical models, computer systems, standardized patients, mannequins, virtual reality, and integrated simulators are all being used and the scope for improvisation is always in the fore with technical advancements. The transfusion and related activities include significant risks, so regular training is essential. The costs are also reasonably high, and focusing on being time-efficient is essential as many scenarios need immediate attention and management. Simulation in transfusion medicine has farsighted returns wherein there is the possibility of defining goals and objectives and ensuring that they could be adjusted to the individual learners as per their knowledge and skill level. The simulations can be set up that can train as well as assess cognitive, affective, and psychomotor domains simultaneously in transfusion using multiple modalities.

The PATH to PPE Mastery - Programme for Assessment and Training in HCID (High Consequence Infectious Diseases) PPE (Personal Protective Equipment), Mastery

Background

High Consequence Infectious Diseases (HCIDs), have the potential to cause pandemics and require particular focus for preparedness due to their high mortality rates. The application of Personal Protective Equipment (PPE) for HCIDs is complex and carries significant risk of Health Care Worker (HCW) contamination if done incorrectly. Previous reviews have reported a lack of information on the nature of training provided and the ideal timing of repeat training to best retain skills. Simulation Based Mastery Learning (SBML) is a methodology for skill acquisition which encompasses deliberate practice and repeated assessment until the learner achieves a pre-set Mastery standard. SBML has been demonstrated to improve competence, skill retention and patient outcomes in other clinical procedures. SBML has not been previously studied or utilised in HCID PPE training.

Aim

We aimed to increase the likelihood of safe clinical practice by evidencing that Lothian modified SBML for PPE effectively prepares our priority learners.

Methods

A quasi-experimental within group post-test design was used. Learners undertook a modified SBML programme which included two-hour asynchronous and two-hour synchronous components.

Findings

11 learners (10 infectious diseases registrars and 1 infectious diseases consultant) were enrolled in the programme with 8 completing all stages, all of whom achieved the Mastery passing standard. The resources were highly rated by learners with the exemplar videos of skills highlighted as particularly useful. Self-assessed preparedness for each skill increased following pre-learning and synchronous sessions.

Conclusion

Modified SBML can be used as an effective methodology for the training and assessment of HCWs in the donning and doffing of HCID PPE.

Simulation in a blended learning curriculum for neonatology

Blended learning is a learner-centered educational method that combines online and traditional face-to-face educational strategies. Simulation is a commonly utilized platform for experiential learning and an ideal component of a blended learning curriculum. This section describes blended learning, including its strengths and limitations, educational frameworks, uses within health professions education, best practices, and challenges. Also included is a brief introduction to simulation-based education, along with theoretical and real-world examples of how simulation may be integrated into a blended learning curriculum. Examples of blended learning in Neonatal-Perinatal Medicine, specifically within the Neonatal Resuscitation Program, procedural skills training, and the National Neonatology Curriculum, are reviewed.

Principles of Effective Simulation-Based Teaching Sessions in Medical Education: A Narrative Review

A challenge for medical educators is to provide learning opportunities that allow students to develop technical and non-technical skills as set by the clearly defined learning objectives within their relevant institutions. This is particularly relevant in clinical education, which encompasses a vast majority of medical education. Specifically, clinical education is highly variable, with numerous distractions, interruptions and variability in learning experience and quality of clinical educators which often result in underprepared medical students by the time they transition into clinical practice. Simulation-based teaching (SBT) has been a key pedagogical approach that has been implemented into curriculum design to assist with addressing some of these educational challenges. However, their implementation is highly variable, and research into evidence-based best practice considerations in SBT design and implementation is fundamental to their success in medical student development. A narrative review was performed following a computer-assisted search on electronic databases Medline, Embase and Google Scholar. Relevant papers that explored the role of SBT in medical education were considered for this review. SBT is an important pedagogical approach to support the education of medical students. Their use has the benefit of providing a standardised and safe environment that mimics 'real life' as a means of allowing students to hone key skills with respect to clearly defined learning outcomes. The role of debriefing and feedback is crucial to the development of efficacious SBT programs, and therefore the upskilling and training of educators is a key aspect of evidence-based SBT design. Despite this, medical educators must be cognisant of the limitations of SBT. These include the cost and resources required to develop and implement SBT sessions, the effort and conceptualisation required to standardise and ensure these programs reflect real-life situations as well as the degree of training for facilitators to ensure they can best deliver and achieve learning outcomes and provide effective debriefing and feedback for students. Understanding the educational frameworks and the evidence-based best practice principles for SBT design and implementation is highly necessary for medical educators given the resource demands of SBT programs.

Effect of teaching tools in spatial understanding in health science education: a systematic review

Background

The concept of spatial orientation is integral to health education. Students studying to be healthcare professionals use their visual intelligence to develop 3D mental models from 2D images, like X-rays, MRI, and CT scans, which exerts a heavy cognitive load on them. Innovative teaching tools and technologies are being developed to improve students' learning experiences. However, the impact of these teaching modalities on spatial understanding is not often evaluated. This systematic review aims to investigate current literature to identify which teaching tools and techniques are intended to improve the 3D sense of students and how these tools impact learners' spatial understanding.

Methods

The preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines were followed for the systematic review. Four databases were searched with multiple search terms. The articles were screened based on inclusion and exclusion criteria and assessed for quality.

Results

Nineteen articles were eligible for our systematic review. Teaching tools focused on improving spatial concepts can be grouped into five categories. The review findings reveal that the experimental groups have performed equally well or significantly better in tests and tasks with access to the teaching tool than the control groups.

Conclusion

Our review investigated the current literature to identify and categorize teaching tools shown to improve spatial understanding in healthcare professionals. The teaching tools identified in our review showed improvement in measured, and perceived spatial intelligence. However, a wide variation exists among the teaching tools and assessment techniques. We also identified knowledge gaps and future research opportunities.

Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review

The role of simulation in medical education is crucial to the development of surgeons' skills. Surgical simulation can be used to improve surgical skills in a secure and risk-free environment. Animal models, simulated patients, virtual reality, and mannequins are some types of surgical simulation. As a result, feedback encourages students to reflect on their strengths and weaknesses, enabling them to focus on improvement. Healthcare simulation is a strong educational instrument, and the main goal of this is to give the students an opportunity to do a practical application of what they have learned through theory. Before taking it to the patients, they will already have certain tools they have previously acquired during the practice. This makes it easier for students to identify the knowledge gaps that they must fill to improve patient outcomes. Moreover, simulation brings a wonderful opportunity for students to acquire skills, gain confidence, and experience success before working with real patients, especially when their clinical exposure is limited. The use of simulation to teach technical skills to surgical trainees has become more prevalent. The cost of setting up a simulation lab ranges from $100,000 to $300,000. There are several ways to evaluate the effectiveness of simulation-based surgical training. Repetitive surgical simulation training can improve speed and fluidity in general surgical skills in comparison to conventional training. Few previous studies compared learners who received structured simulation training to a group of trainees who did not receive any simulation training in single-center randomized control research. Significantly faster and less time-consuming skill proficiency was noticeable in simulated trainees. Despite being anxious in the operating room for the first time, simulated trainees completed the surgery on time, demonstrating the effectiveness of surgical simulation training. Traditional surgical training involves senior-surgeon supervision in the operating room. In simulation-based training, the trainees have full control over clinical scenarios and settings; however, guidance and assessment are also crucial. Simulators allow users to practice tasks under conditions resembling real-life scenarios. Simulators can be compared with traditional surgical training methods for different reasons. For example, intraoperative bleeding may occasionally show up not only visibly on the screen but also by shaking the trocars erratically. Without haptics, training on virtual simulators can cause one's pulling and pushing forces, which are frequently greater than what the tissue needs, to be distorted. A good method of simulation training is using virtual reality simulators with haptics and simulated patients. The availability of these facilities is limited, though, and a typical session might include an exercise involving stacking sugar cubes and box trainers. The degree of expertise or competency is one area that needs clarification as medical education transitions to a competency-based paradigm. The article aims to provide an overview of simulation, methods of simulation training, and the key role and importance of surgical simulation in improving skills in surgical residents.

Closing the gender gap in medicine: the impact of a simulation-based confidence and negotiation course for women in graduate medical education

BACKGROUND

Currently, 75-80% of the medical workforce worldwide consists of women. Yet, women comprise 21% of full professors and less than 20% of department chairs and medical school deans. Identified causes of gender disparities are multifactorial including work-life responsibilities, gender discrimination, sexual harassment, bias, lack of confidence, gender differences in negotiation and leadership emergence, and lack of mentorship, networking, and/or sponsorship. A promising intervention for the advancement of women faculty is the implementation of Career Development Programs (CDPs). Women physician CDP participants were shown to be promoted in rank at the same rate as men by year five, and more likely to remain in academics after eight years compared to both men and women counterparts. The objective of this pilot study is to investigate the effectiveness of a novel, simulation-based, single-day CDP curriculum for upper-level women physician trainees to teach communication skills identified as contributing to medicine's gender advancement gap.

METHODS

This was a pilot, pre/post study performed in a simulation center implementing a curriculum developed to educate women physicians on 5 identified communication skills recognized to potentially reduce the gender gap. Pre- and post-intervention assessments included confidence surveys, cognitive questionnaires, and performance action checklists for five workplace scenarios. Assessment data were analyzed using scored medians and descriptive statistics, applying Wilcoxon test estimation to compare pre- versus post-curriculum intervention scores, with p < 0.05 considered statistically significant.

RESULTS

Eleven residents and fellows participated in the curriculum. Confidence, knowledge, and performance improved significantly after completion of the program. Pre-confidence: 28 (19.0-31.0); Post-confidence: 41 (35.0-47.0); p < 0.0001. Pre-knowledge: 9.0 (6.0-11.00); Post knowledge: 13.0 (11.0-15.0); p < 0.0001. Pre-performance: 35.0 (16.0-52.0); Post-performance: 46.0 (37-53.00); p < 0.0001.

CONCLUSION

Overall, this study demonstrated the successful creation of a novel, condensed CDP curriculum based on 5 identified communication skills needed for women physician trainees. The post-curriculum assessment demonstrated improved confidence, knowledge, and performance. Ideally, all women medical trainees would have access to convenient, accessible, and affordable courses teaching these crucial communication skills to prepare them for careers in medicine to strive to reduce the gender gap.

Taking the Pulse of the Current State of Simulation

Simulation in health-care professions has grown in the last few decades. We provide an overview of the history of simulation in other fields, the trajectory of simulation in health professions education, and research in medical education, including the learning theories and tools to assess and evaluate simulation programs. We also propose future directions for simulation and research in health professions education.

Procedural Curriculum to Verify Intern Competence Prior to Patient Care

INTRODUCTION

Emergency medicine (EM) programs train residents to perform clinical procedures with known iatrogenic risks. Currently, there is no established framework for graduating medical students to demonstrate procedural competency prior to matriculating into residency. Mastery-based learning has demonstrated improved patient-safety outcomes. Incorporation of this framework allows learners to demonstrate procedural competency to a predetermined standard in the simulation laboratory prior to performing invasive procedures on patients in the clinical setting. This study describes the creation and implementation of a competency-based procedural curriculum for first-year EM residents using simulation to prepare learners for supervised participation in procedures during patient care.

METHODS

Checklists were developed internally for five high-risk procedures (central venous line placement, endotracheal intubation, lumbar puncture, paracentesis, chest tube placement). Performance standards were developed using Mastery-Angoff methods. Minimum passing scores were determined for each procedure. Over a two-year period, 38 residents underwent baseline assessment, deliberate practice, and post-testing against the passing standard score to demonstrate procedural competency in the simulation laboratory during intern orientation.

RESULTS

We found that 37% of residents required more than one attempt to achieve the minimum passing score on some procedures, however, all residents ultimately met the competency standard on all five high-risk procedures in simulation. One critical incident of central venous catheter guideline retention was identified in the simulation laboratory during the second year of implementation.

CONCLUSION

All incoming first-year EM residents demonstrated procedural competence on five different procedures using a mastery-based educational framework. A competency-based EM curriculum allowed for demonstration of procedural competence prior to resident participation in supervised clinical patient care.

Simulation-based Mastery Learning Improves Emergency Medicine Residents' Ability to Perform Temporary Transvenous Cardiac Pacing

INTRODUCTION

Temporary transvenous cardiac pacing (TVP) is a critical intervention that emergency physicians perform infrequently in clinical practice. Prior simulation studies revealed that emergency medicine (EM) residents and board-certified emergency physicians perform TVP poorly during checklist-based assessments. Our objective in this report was to describe the design and implementation of a simulation-based mastery learning (SBML) curriculum and evaluate its impact on EM residents' ability to perform TVP.

METHODS

An expert panel of emergency physicians and cardiologists set a minimum passing standard (MPS) for a previously developed 30-item TVP checklist using the Mastery Angoff approach. Emergency medicine residents were assessed using this checklist and a high-fidelity TVP task trainer. Residents who did not meet the MPS during baseline testing viewed a procedure video and completed a 30-minute individual deliberate practice session before retesting. Residents who did not meet the MPS during initial post-testing completed additional deliberate practice and assessment until meeting or exceeding the MPS.

RESULTS

The expert panel set an MPS of correctly performing 28 (93.3%) checklist items. Fifty-seven EM residents participated. Mean checklist scores improved from 13.4 (95% CI 11.8-15.0) during baseline testing to 27.5 (95% CI 26.9-28.1) during initial post-testing (P < 0.01). No residents met the MPS at baseline testing. The 21 (36.8%) residents who did not meet the MPS during initial post-testing all met or exceeded the MPS after completing one additional 30-minute deliberate practice session.

CONCLUSION

Emergency medicine residents demonstrated significantly improved TVP performance with reduced variability in checklist scores after completing a simulation-based mastery learning curriculum.

Mastery learning program to teach sleep study scoring

STUDY OBJECTIVES

Scoring a polysomnogram is an essential skill for sleep medicine trainees to meet Accreditation Council for Graduate Medical Education Sleep Medicine Milestones. Appraisal is based on faculty evaluation rather than objective competency assessment. We developed a computer-based polysomnogram scoring curriculum, utilizing the mastery learning method, then compared achievement of competency using the new curriculum against standard institutional training.

METHODS

The scoring program consisted of a pretest assessment, sequential acquisition of knowledge utilizing online modules, a posttest, and competency assessment. Fellows needed to demonstrate mastery of each module before moving ahead. Competency was demonstrating ≥ 90% on interscorer reliability assessment on 5 studies (out of up to 10 attempts). Participating fellows were assigned to Mastery Learning Participants (MLP) or Traditional Learning Participants (TLP) groups and completed the program within the first 1-3 months of training.

RESULTS

Of 87 fellows enrolled in the program, 75 participants completed the program (40 MLP and 35 TLP). Among completers, there was no difference in the proportion that achieved competency (MLP 90.0% vs TLP 97.1%; P = .36) or studies needed to achieve competency (MLP 7.25 ± 1.3 vs TLP 7.41 ± 1.3; P = .60). Pretest scores were not significantly different between groups (MLP 61.2% ± 15.9 vs TLP 57.6% ± 16.6; P = .35), but MLP posttest scores were higher than TLP (MLP 80.9% ± 8.8 vs TLP 76.4% ± 9.8; P = .04).

CONCLUSIONS

We demonstrated similar outcomes utilizing a novel, computer-based modular interactive course compared to traditional methods of teaching polysomnogram scoring. We used a mastery learning paradigm and set specific objective competency levels for this skill.

CITATION

Epstein LJ, Plante DT, Rosen IM. Mastery learning program to teach sleep study scoring. J Clin Sleep Med. 2022;18(12):2745-2750.

Frequently Used Conceptual Frameworks and Design Principles for Extended Reality in Health Professions Education

Health professions education (HPE) has witnessed a dramatic increase in the use of extended reality (XR), but there is limited evidence that conceptual frameworks are being effectively employed in the design and implementation of XR. This paper introduces commonly utilized conceptual frameworks that can support the integration of XR into the learning process and design principles that can be helpful for the development and evaluation of XR educational applications. Each framework and design principle is summarized briefly, followed by a description of its applicability to XR for HPE and an example of such application.

Business Simulation Games in Higher Education: A Systematic Review of Empirical Research

Over the last few years, business simulation games (BSGs) in higher education have attracted attention. BSGs tend to actively engage students with course material, promoting higher engagement and motivation and enabling learning outcomes. Increasingly, researchers are trying to explore the full potential of these games with an upsurge of research in the BSG field in recent years. There is a need to understand the current state of research and future research opportunities; however, there is a lack of recent systematic literature reviews in BSG literature. This study addresses this gap by systematically compiling online empirical research from January 2015 to April 2022. We followed PRISMA guidelines to identify fifty-seven (57) papers reporting empirical evidence of the effectiveness of BSGs in teaching and learning. Findings showed that BSGs improve learning outcomes such as knowledge acquisition, cognitive and interactive skills, and behaviour. The review also summarises different issues concerning the integration of BSGs into the curriculum, learning theories used in the selected studies, and assessment methods used to evaluate student achievement in learning outcomes. The findings of this review summarise the current research activities and indicate existing deficiencies and potential research directions that can be used as the basis for future research into the use of BSGs in higher education.

Hands-On Training in a Digital World: A Novel Simulation-Based Virtual Training Program for Placement and Removal of the Subdermal Contraceptive Implant

OBJECTIVE

The COVID-19 pandemic necessitated a shift from traditional in-person instruction for learning new technical skills to virtual delivery of medical education training. The objectives of this study were to develop and evaluate a virtual simulation-based training program for Canadian health care professionals (HCPs) on the insertion, localization, and removal of the etonogestrel subdermal contraceptive implant.

METHODS

A scientific committee of Canadian family planning experts developed a 2-part virtual training program during the COVID-19 pandemic. Core educational content (part 1) was provided in an asynchronous, self-directed, online format. Part 2 consisted of synchronous, simulation-based training using web conferencing. The HCPs were provided with model arms and placebo applicators; the trainers demonstrated implant insertion and removal techniques, and trainees received individual feedback. All trainees were asked to complete an online evaluation upon completion of the program.

RESULTS

Between September 22, 2020, and December 31, 2021, 83 trainers conducted 565 virtual training sessions. A total of 3162 HCPs completed part 1 of the training program, of whom 2740 had completed part 2 by December 31, 2021. Participants reported high levels of satisfaction with virtual simulation-based training; 96.5% of respondents (1570/1627) agreed that the virtual format was effective. Additional training prior to inserting the implant in clinical practice was requested by 4.5% of respondents (75/1671).

CONCLUSION

Virtual simulation-based learning provides effective education and technique training for etonogestrel implant insertion and removal. Online training for implant use can be scaled, as needed, to reach professionals in remote or underserved locations. This virtual training approach may be appropriate for other technical or minor surgical procedures.

Simulation-Based Mastery Learning to Facilitate Transition to Nursing Practice

BACKGROUND

Simulation-based mastery learning (SBML) was developed and implemented to facilitate nursing students' transition to clinical practice.

PURPOSE

To evaluate nursing students' perspectives on the impact of SBML on their transition to clinical practice.

METHOD

A descriptive qualitative study using focus group discussions was conducted with final-year nursing students who had completed their clinical practicum and SBML.

RESULTS

Three themes emerged: authenticity of simulations, whereby students were able to draw some parallels between their simulations and clinical experiences; self-efficacy in clinical practice, which was gained through deliberate practice; and application of cognitive tools, which provided mental frameworks to guide clinical performances.

CONCLUSION

This study highlights the need to ensure the fidelity of the simulations to achieve authentic experiences, provide deliberate practice to develop self-efficacy, and use cognitive tools for mental model formation to create a high-quality SBML program to foster better transfer of simulation learning to real-life setting.

The PIER framework for healthcare simulation integration in undergraduate physiotherapy education

BACKGROUND

The need for healthcare curricula renewal to facilitate a continuum in education from classrooms to diverse healthcare settings is undeniable. Simulation has been recognized as an educational strategy to address healthcare education challenges, with limited reporting on the integration of simulation-based learning experiences in physiotherapy education. The study aimed to describe the finalisation of a framework for integration of healthcare simulation in an undergraduate physiotherapy program.

METHODS

A qualitative descriptive research design was utilized. Five South African experts in the fields of healthcare simulation and/or physiotherapy education contributed to the finalization of the framework during a consensus meeting. Content analysis was employed and credibility was ensured through double coding.

RESULTS

Structural coding yielded five themes- Planning, Implementation, Program Evaluation, Program Revision and Framework. The five themes consisted of fifteen categories, two sub-categories and 44 codes. The planning theme was most robust with seven categories. The Planning, Implementation, Evaluation, Revision (PIER) framework was developed and finalized by expert participants. following the consensus meeting.

CONCLUSION

Needs analyses when planning and incorporating simulation is essential. Collaboration through resource and knowledge sharing is vital in developing a responsive curriculum integrating simulation. Furthermore, facilitator and student preparation are paramount in ensuring active engagement in simulated-based learning experiences. The interconnectedness of all framework elements and integration phases, as well as the implied importance of competent facilitators and prepared students is crucial and highlights careful consideration to be given to these aspects. The PIER framework is generic in nature and represents the continuous process of simulation integration for any healthcare program.

French national survey on simulation-based neonatology education of pediatric residents

The French Society of Neonatology (SFN) conducted a national questionnaire survey on the simulation-based education neonatal curriculum for pediatric residents. The response rate was 93% for the pediatric curriculum coordinators and 97% for the neonatal intensive care unit medical directors and neonatal transport teams. The average hourly volume during the curriculum was 21 ± 17 h. Overall, 89% of regional pediatric curricula offered at least one simulation session. Each simulation program involved newborn resuscitation in the delivery room but often lacked a formalized program. Additionally, half of the neonatology departments provided simulation-based education. Simulation education is now common for training pediatric residents in neonatology in France but it is heterogeneous in the French territory.

Patterns of Skills Acquisition in Anesthesiologists During Simulated Interscalene Block Training on a Soft Embalmed Thiel Cadaver: Cohort Study

BACKGROUND

The demand for regional anesthesia for major surgery has increased considerably, but only a small number of anesthesiologists can provide such care. Simulations may improve clinical performance. However, opportunities to rehearse procedures are limited, and the clinical educational outcomes prescribed by the Royal College of Anesthesiologists training curriculum 2021 are difficult to attain. Educational paradigms, such as mastery learning and dedicated practice, are increasingly being used to teach technical skills to enhance skills acquisition. Moreover, high-fidelity, resilient cadaver simulators are now available: the soft embalmed Thiel cadaver shows physical characteristics and functional alignment similar to those of patients. Tissue elasticity allows tissues to expand and relax, fluid to drain away, and hundreds of repeated injections to be tolerated without causing damage. Learning curves and their intra- and interindividual dynamics have not hitherto been measured on the Thiel cadaver simulator using the mastery learning and dedicated practice educational paradigm coupled with validated, quantitative metrics, such as checklists, eye tracking metrics, and self-rating scores.

OBJECTIVE

Our primary objective was to measure the learning slopes of the scanning and needling phases of an interscalene block conducted repeatedly on a soft embalmed Thiel cadaver over a 3-hour period of training.

METHODS

A total of 30 anesthesiologists, with a wide range of experience, conducted up to 60 ultrasound-guided interscalene blocks over 3 hours on the left side of 2 soft embalmed Thiel cadavers. The duration of the scanning and needling phases was defined as the time taken to perform all the steps correctly. The primary outcome was the best-fit linear slope of the log-log transformed time to complete each phase. Our secondary objectives were to measure preprocedural psychometrics, describe deviations from the learning slope, correlate scanning and needling phase data, characterize skills according to clinical grade, measure learning curves using objective eye gaze tracking and subjective self-rating measures, and use cluster analysis to categorize performance irrespective of grade.

RESULTS

The median (IQR; range) log-log learning slopes were -0.47 (-0.62 to -0.32; -0.96 to 0.30) and -0.23 (-0.34 to -0.19; -0.71 to 0.27) during the scanning and needling phases, respectively. Locally Weighted Scatterplot Smoother curves showed wide variability in within-participant performance. The learning slopes of the scanning and needling phases correlated: ρ=0.55 (0.23-0.76), P<.001, and ρ=-0.72 (-0.46 to -0.87), P<.001, respectively. Eye gaze fixation count and glance count during the scanning and needling phases best reflected block duration. Using clustering techniques, fixation count and glance were used to identify 4 distinct patterns of learning behavior.

CONCLUSIONS

We quantified learning slopes by log-log transformation of the time taken to complete the scanning and needling phases of interscalene blocks and identified intraindividual and interindividual patterns of variability.

How to plan for simulation integration into undergraduate physiotherapy training

Background. The benefits of simulation in healthcare education are undeniable, and in the current healthcare climate, a drastic change in delivering healthcare training is critical. Therefore, integration of simulation is essential, and necessitates detailed planning and well-trained educators. Objectives. To develop a conceptual framework for the integration of simulation in South African (SA) undergraduate physiotherapy programmes. Methods. A non-experimental descriptive research design using a modified Delphi survey was conducted. Results from a systematic review identifying simulation integration framework elements informed the Delphi survey. A purposive sample of 15 healthcare educationalists from SA and abroad were approached to participate. Data were analysed as percentages, and feedback was provided to panel members following each round. Results. A response rate of 73.3% (n=11) was achieved. Planning was explored as one of the themes. Both institutional- and discipline-specific needs analyses were identified as essential (93%), and societal needs were useful to consider (64%). Resource identification and sharing (84%) were regarded as vital, and expert collaboration in curriculum development (79%) with scaffolded skills integration (75%) was advised. The necessity for trained facilitators (93%) and educator role identification (71%) was evident. Statements related to mastery learning/deliberate practice and the use of simulation for assessment purposes yielded the least consensus. Conclusion. A constructively aligned curriculum based on both student and institutional needs and resource availability in guiding simulation integration was regarded as essential. Educator competency in both the development and delivery of the programme, especially debriefing methods, is vital for optimising student learning.

Does your team know how to respond safely to an operating room fire? Outcomes of a virtual reality, AI-enhanced simulation training

BACKGROUND

Operating room (OR) fires are rare but devastating events requiring immediate and effective response. Virtual Reality (VR) simulation training can provide a safe environment for practice of skills in such highly stressful situation. This study assessed interprofessional participants' ability to respond to VR-simulated OR fire scenarios, attitudes, numbers of attempt of the VR simulation do participants need to successfully respond to OR fires and does prior experience, confidence level, or professional role predict the number of attempts needed to demonstrate safety and pass the simulation.

METHODS

180 surgical team members volunteered to participate in this study at Beth Israel Deaconess Medical Center, Boston, MA. Each participant completed five VR OR simulation trials; the final two trials incorporated AI assistance. Primary outcomes were performance scores, number of attempts needed to pass, and pre- and post-survey results describing participant confidence and experiences. Differences across professional or training role were assessed using chi-square tests and analyses of variance. Differences in pass rates over time were assessed using repeated measures logistic regression.

RESULTS

One hundred eighty participants completed simulation testing; 170 (94.4%) completed surveys. Participants included surgeons (17.2%), anesthesiologists (10.0%), allied health professionals (41.7%), and medical trainees (31.1%). Prior to training, 45.4% of participants reported feeling moderately or very confident in their ability to respond to an OR fire. Eight participants (4.4%) responded safely on the first simulation attempt. Forty-three participants (23.9%) passed by the third attempt (VR only); an additional 97 participants (53.9%) passed within the 4-5th attempt (VR with AI assistance).

CONCLUSIONS

Providers are unprepared to respond to OR fires. VR-based simulation training provides a practical platform for individuals to improve their knowledge and performance in the management of OR fires with a 79% pass rate in our study. A VR AI approach to teaching this essential skill is innovative, feasible, and effective.

The Use of Patient Simulations to Teach and Assess Clinical Competencies in Colleges of Podiatric Medicine: A Survey of US Podiatric Medical Schools

Human and mechanical simulations are used to teach and assess clinical competencies in medical education. In 2014, the National Board of Podiatric Medical Examiners implemented the Clinical Skills Patient Encounter, an examination using standardized patients. Similar clinical skills examinations already existed as part of medical and osteopathic licensure examinations. The purpose of this study was to assess the use of simulation-based education in the nine colleges of podiatric medicine in the United States to inform podiatric clinical faculty and other stakeholders about current trends within the podiatric education system. In 2019, the Clinical Skills Patient Encounter committee of the National Board of Podiatric Medical Examiners developed a survey and contacted each podiatric school to voluntarily participate. The mailed survey instrument gathered information on patient simulation modalities, years used, clinical content application, simulation program administration, facilities and equipment available, and the role of simulation educators. All nine schools participated anonymously. The survey showed that simulation modalities were used in all of the schools during the first 3 years, although there was considerable variance in their use.

SPECTRa: An Online Tool for Simulating Prehospital Patient Care

OBJECTIVES

To (1) develop a simulation software environment to conduct prehospital research during the COVID-19 pandemic on paramedics' teamwork and use of mobile computing devices, and (2) establish its feasibility for use as a research and training tool.

BACKGROUND

Simulation-based research and training for prehospital environments has typically used live simulation, with highly realistic equipment and technology-enhanced manikins. However, such simulations are expensive, difficult to replicate, and require facilitators and participants to be at the same location. Although virtual simulation tools exist for prehospital care, it is unclear how best to use them for research and training.

METHODS

We present SPECTRa-Simulated Prehospital Emergency Care for Team Research-an online simulated prehospital environment that lets participants care concurrently for single or multiple patients remotely. Patient scenarios are designed using Laerdal's SimDesigner. SPECTRa records data about scenario states and participants' virtual interaction with the simulated patients. SPECTRa's supporting environment records participants' verbal communication and their visual and physical interactions with their interface and devices using Zoom conferencing and audiovisual recording. We discuss a pilot research implementation to assess SPECTRa's feasibility.

RESULTS

SPECTRa allows researchers to systematically test small-team interaction in single- or multipatient care scenarios and assess the impact of mobile devices on participants' assessment and care of patients. SPECTRa also supports pedagogical features that could allow prehospital educators to provide individual trainees or teams with online simulation training and evaluation.

CONCLUSIONS

SPECTRa, an online tool for simulating prehospital patient care, shows potential for remote healthcare research and training.

Healthcare Simulation: A Key to the Future of Medical Education - A Review

Aim

Simulation originates from its application in the military and aviation. It is implemented at various levels of healthcare education and certification today. However, its use remains unevenly distributed across the globe due to misconception regarding its cost and complexity and to lack of evidence for its consistency and validity. Implementation may also be hindered by an array of factors unique to the locale and its norms. Resource-poor settings may benefit from diverting external funds for short-term simulation projects towards collaboration with local experts and local material sourcing to reduce the overall cost and achieve long-term benefits. The recent shift of focus towards patient safety and calls for reduction in training duration have burdened educators with providing adequate quantity and quality of clinical exposure to students and residents in a short time. Furthermore, the COVID-19 pandemic has severely hindered clinical education to curb the spread of illness. Simulation may be beneficial in these circumstances and improve learner confidence. We undertook a literature search on MEDLINE using MeSH terms to obtain relevant information on simulation-based medical education and how to best apply it. Integration of simulation into curricula is an essential step of its implementation. With allocations for deliberate practice and mastery learning under supervision of qualified facilitators, this technology is becoming essential in medical education.

Purpose

To review the adaptation, spectrum of use, importance, and resource challenges of simulation in medical education and how best to implement it according to learning theories and best practice guides.

Conclusion

Simulation offers students and residents with adequate opportunities to practice their clinical skills in a risk-free environment. Unprecedented global catastrophes provide opportunities to explore simulation as a viable training tool. Future research should focus on sustainability of simulation-based medical education in LMICs.

Increasing Student Confidence With Medically Complex Infants Through Simulation: A Mixed Methods Investigation

PURPOSE

The purpose of this study was to compare student knowledge and confidence, related to the assessment and management of oral feeding readiness in medically complex infants, following a written case study versus a high-fidelity human patient simulation (HPS).

METHOD

A sequential, two-phase, embedded mixed methods design was conducted. Participants were two sequential cohorts of second-year speech-language pathology graduate students enrolled in a didactic Pediatric Dysphagia course. At the end of the course, students completed the same case scenario presented as a written case study (control group; N = 28) or as an HPS (experimental group; N = 24). Pre- and post-knowledge assessment results and self-assessments of confidence conducted at three time points were compared.

RESULTS

All students made gains in knowledge, regardless of intervention (written case study or HPS). Despite different baselines, the percent change in knowledge was significant with the control group improving 33% and the experimental group improving 76% from baseline. Students in the experimental group demonstrated significantly greater gains in confidence with skills enhanced by the hands-on, immersive experience of HPS. Qualitative analysis further identified factors contributing to increased confidence with all students reporting that experience significantly contributes to their confidence in their ability to treat patients.

CONCLUSIONS

While knowledge outcomes were similar between the groups, the confidence that the experimental group gained through the hands-on experiences of HPS fosters student development as confident professionals in assessing feeding readiness and managing medically complex infants. Results support integration of simulation into the graduate curriculum to support student learning.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19233504.

Perception Precedes Reality: A Simulation and Procedural Bootcamp Improves Residents’ Comfort With Transitioning to Clinical Anesthesiology Training

Background

The transition from internship to clinical anesthesiology (CA) training is often difficult given the differences in workflow, procedures, environment, and clinical situations. The primary aims of this study were to determine if a standardized introductory bootcamp could improve clinical knowledge and self-perceived comfort level of new anesthesiology residents in performing common operating room procedures and management of common intraoperative problems. The secondary aim of the study was to see if a standardized bootcamp could be replicated at other programs.

Methods

The introduction to anesthesiology resident bootcamp was developed at one institution in 2015 then expanded to a second program in 2019. The bootcamp was a one-day experience consisting of simulation and task trainers that all rising first-year CA residents (CA-1) participated in during their first month of anesthesiology training. All participating residents were given a survey immediately before and after the bootcamp. The average ratings of the questions were calculated and used as the primary measure. The Anesthesia Knowledge Test (AKT) was used as a surrogate measure of participant knowledge.

Results

From 2015 to 2020, a total of 105 residents completed the pre-survey and 109 completed the post-survey across the two sites. The improvement in average rating was significant (Pre: 2.04±0.46 versus Post: 3.09±0.52 p<0.0001). Individual item analysis also showed significant improvement on all of the eight items (p<0.0001). Analyses by site revealed the same results at both average score and item level. There was no significant cohort difference in either AKT-0 (Control: 57.84±26.86 versus Intervention 50.13±25.14, p=0.14) or AKT-1 (Control: 41.06±26.42 versus Intervention 41.70±26.60, p=0.90) percentile scores.

Conclusions

Incorporation of an introduction to anesthesia bootcamp for new residents significantly improves participant comfort level and is reproducible across institutions. However, it does not improve resident performance on standardized tests.

Achieving physical examination competence through optimizing hands-on practice cycles: a prospective cohort comparative study of medical students

Background

Deliberate practice (DP) was proposed for effective clinical skill training, which highlights focused, repetitive practice and feedback as the key points for practice. Although previous studies have investigated the effect of feedback in DP, little is known about the proper repetitive cycles of clinical skills training especially in physical examination (PE) training.

Methods

We drew learning curves and designed a comparative study to find out the optimal number of hands-on practice cycles, an important aspect of DP, in abdominal PE training for medical students. A comparative study was conducted to validate the optimal number of hands-on practice by dividing students into two cohorts including Cohort A (high-frequency hand-on training) and B (low-frequency hand-on training).

Results

The learning curve study of 16 students exhibited a threshold of four repetitive practices when 81.25% students reached the competence score. A total of 74 students’ final exam scores were collected for analysis. Students in Cohort A (4–5 PEs) scored significantly higher than those in Cohort B (≤3 PEs) (84.41 ± 11.78 vs 76.83 ± 17.51] in the final exam (P = 0.030)).

Conclusion

High-frequency practice can improve students’ competence of abdominal PE skill. We recommend four cycles of hands-on practice for each student in a training course like PE training.

The utilization of simulated patients for teaching and learning in the pharmacy curriculum: exploring pharmacy students' and recent alumni's perceptions using mixed-methods approach

BACKGROUND

The use of simulated patients (SPs) is considered a significant resource for teaching and assessing clinical and communication skills in health professional education. We conducted this study to explore pharmacy students' perspective towards the utilization of SPs in Qatar and to identify areas that require improvement.

METHODS

An explanatory sequential mixed-methods design was used among students and recent graduates of the College of Pharmacy at Qatar University (QU-CPH). First, their perspectives toward the current utilization of SPs at QU-CPH was explored using a quantitative cross-sectional study design. Following this, we conducted six focus group discussions based on the analysis of the questionnaire results. The findings of the two phases were interpreted through integration of the quantitative and qualitative phases.

RESULTS

The majority of the participants (> 90%) reported that interactions with SPs are important in building good communication and counseling skills during professional skills course activities. Similarly, most of the respondents (80%) indicated that interactions with SPs prepared them to apply the clinical skills gained during professional skills and patient assessment sessions in real-life. In addition, they reported that interactions with SPs during competency-based assessments were good experiences. The participants disagreed with the notion that interaction with SPs of opposite gender was uncomfortable for them. Themes identified from the focus groups include: interactions with trained SPs compared to faculty SPs, standardization and consistency of SPs' roles, communication and language barriers, simulations of real-life case scenarios, SPs' competence and preparedness, psychological impact associated with interaction with SPs, proposed strategies for improving the SP program. Identified areas for improvement include the need for strengthening the SP training and orientation program as well as the SP selection criteria.

CONCLUSION

This study showed a positive impact of the utilization of SPs in this pharmacy curriculum as perceived by students and alumni. However, the SP program needs to be optimized in terms of the training and orientation of SPs.

Medical students' learning processes the first time they role-play in psychiatry: A grounded theory study

BACKGROUND

Recent changes in psychiatric care and teaching that limit patient contact for medical students can be overcome in part by simulation-based education. Understanding the learning processes of medical students involved in psychiatric simulation-based programmes could usefully inform efforts to improve this teaching. This study explored the learning processes of medical students the first time they role-play in psychiatry.

METHODS

We used constructivist grounded theory to analyse semi-structured interviews of 13 purposively sampled medical students and the six psychiatrists who trained them. To improve the triangulation process, the results of this analysis were compared with those of the analyses of the role-play video and the debriefing audio-tapes.

RESULTS

Five organising themes emerged: improving the students' immediate perception of patients with mental disorders; cultivating clinical reasoning; managing affect; enhancing skills and attitudes and fostering involvement in learning psychiatry.

CONCLUSION

Results suggest that psychiatric role-playing can improve students' progressive understanding of psychiatry through the development of intuition and by allaying affects. Emotional elaboration and student involvement appear to be key features.

Just-in-time clinical video review improves successful placement of Sengstaken-Blakemore tube by emergency medicine resident physicians: A randomized control simulation-based study

OBJECTIVE

Successful completion of life-saving procedures may benefit from a concise just-in-time (JIT) intervention. Video is an optimal medium for JIT training, but currently available video-based references are not optimized for a JIT format, especially in time-pressured situations prior to high-risk clinical contexts. We aimed to create and evaluate the efficacy of a brief video review of emergent Sengstaken-Blakemore tube (SBT) insertion for acutely decompensating variceal hemorrhage when used just prior to clinical performance in a simulated setting.

METHODS

We created a less than 3-minute audio-optional JIT training video on SBT insertion. We recruited emergency medicine resident physicians to participate in a simulation scenario in which they had to quickly place an SBT. Participants were randomized to either a 3-minute procedure review by any media they chose (control) or review of the JIT video (intervention). Performance on a checklist created by a multidisciplinary group of SBT experts (passing score > 18 and maximum = 28) served as the primary outcome. We analyzed performance in checklist scores controlling level of training through a one-way analysis of covariance (ANCOVA). We analyzed rates of passing scores via a chi-square analysis.

RESULTS

We randomized 32 participants to media review (control) or JIT video (intervention). The intervention group had an overall mean (±SD) performance of 19.8 (±9.0) and the control group had a mean (±SD) score of 6.6 (±7.4). After adjusting for postgraduate year, we found a significant difference in final checklist scores between the two groups (mean difference = 12.8, 95% confidence interval [CI] = 7.6 to 18.0). Percentages of participants reaching a minimum passing score were two of 16 (12.5%) in the control group and 10 of 16 (62.5%) in the intervention group (odds ratio = 11.7, 95% CI = 9.9 to 13.5). Cohen's kappa indicated substantial agreement (κ = 0.714) between reviewer scores.

CONCLUSIONS

A readily available, focused, audio-optional JIT video increased performance for SBT insertion in a simulated setting. Future work may include testing of this format for more commonly performed emergency procedures and determination of effect on bedside performance in the clinical setting.

Design and evaluation of a simulated wound management course for postgraduate year one surgery residents

Background

It is vital to cover wound management knowledge and operations in the early stages of resident training. With this in mind, a simulated wound management course for postgraduate year one surgery residents (PGY1s) was designed and its effectiveness was evaluated.

Methods

A retrospective quasi-experimental method was used. PGY1s in 2014 constituted the control group, and PGY1s in 2015 and 2016 constituted the intervention group. The course given to the control group comprised didactic teaching followed by deliberate practice plus immediate personalized feedback. The newly designed course given to the intervention group was reconstructed and disassembled into four components according to the simulation-based mastery learning model, which were baseline test, interactive learning, basic skills practice, and reflective learning. The same performance assessments were used in the control and intervention group, including process measurement and outcome measurement.

Results

The process measurement showed that the intervention group’s scores were significantly higher in the “dissociation of subcutaneous tissue” and “quality of suturing and knots”. The outcome measurement showed that the accuracy of debridement was greatly improved and both key and total suture numbers were significantly higher in the intervention group.

Conclusions

Simulation-based mastery learning was incorporated into our proposed course framework, promoting the learning outcome of PGY1s. It has the potential to be adapted for other surgical training sites for residents in China.

Automatic and Objective Assessment of Motor Skills Performance in Flexible Bronchoscopy

BACKGROUND

Motor skills have been identified as a useful measure to evaluate competency in bronchoscopy. However, no automatic assessment system of motor skills with a clear pass/fail criterion in flexible bronchoscopy exists.

OBJECTIVES

The objective of the study was to develop an objective and automatic measure of motor skills in bronchoscopy and set a pass/fail criterion.

METHODS

Participants conducted 3 bronchoscopies each in a simulated setting. They were equipped with a Myo Armband that measured lower arm movements through an inertial measurement unit, and hand and finger motions through electromyography sensors. These measures were composed into an objective and automatic composite score of motor skills, the motor bronchoscopy skills score (MoBSS).

RESULTS

Twelve novices, eleven intermediates, and ten expert bronchoscopy operators participated, resulting in 99 procedures available for assessment. MoBSS was correlated with a higher diagnostic completeness (Pearson's correlation, r = 0.43, p < 0.001) and a lower procedure time (Pearson's correlation, r = -0.90, p < 0.001). MoBSS was able to differentiate operator performance based on the experience level (one-way ANOVA, p < 0.001). Using the contrasting groups' method, a passing score of -0.08 MoBSS was defined that failed 30/36 (83%) novice, 5/33 (15%) intermediate, and 1/30 (3%) expert procedures.

CONCLUSIONS

MoBSS can be used as an automatic and unbiased assessment tool for motor skills performance in flexible bronchoscopy. MoBSS has the potential to generate automatic feedback to help guide trainees toward expert performance.

Resident competencies before and after short intensive care unit rotations: a multicentre pilot observational study

PURPOSE

Residency programs need to understand the competencies developed by residents during an intensive care unit (ICU) rotation, so that curricula and assessments maximize residents' learning. The primary study objective was to evaluate the feasibility for training programs and acceptability by residents of conducting a multi-competency assessment during a four-week ICU rotation.

METHODS

We conducted a prospective, multicentre observational pilot study in three ICUs. During weeks 1 and 4 of an ICU rotation, we conducted repeated standardized assessments of non-critical care specialty residents' competencies in cognitive reasoning (script concordance test [SCT]), procedural skills (objective structured assessment of technical skills [OSATS]-global rating scale], and communication skills through a written test, two procedural simulations, and a simulated encounter with a "family member". The feasibility outcomes included program costs, the proportion of enrolled residents able to complete at least one three-station assessment during their four-week ICU rotation, and acceptability of the assessment for the trainees.

RESULTS

We enrolled 63 (69%) of 91 eligible residents, with 58 (92%) completing at least one assessment. The total cost to conduct 90 assessments was CAD 33,800. The majority of participants agreed that the assessment was fair and that it measured important clinical abilities. For the 32 residents who completed two assessments, the mean (standard deviation) cognitive reasoning and procedural skill scores increased between weeks 1 and 4 [SCT difference, 3.1 (6.5), P = 0.01; OSATS difference for bag-mask ventilation and central line insertion, 0.4 (0.5) and 0.6 (0.8), respectively; both P ≤ 0.001]. Nevertheless, the communication scores did not change significantly.

CONCLUSIONS

A monthly multi-competency assessment for specialty residents rotating in the ICU is likely feasible for most programs with appropriate resources, and generally acceptable for residents. Specialty residents' cognitive reasoning and procedural skills may improve during a four-week ICU rotation, whereas communication skills may not.

Simulation-based mastery improves nursing skills in BSc nursing students: a quasi-experimental study

BACKGROUND

Clinical education is an essential part of nursing education. Selected clinical teaching methods influence the quality of education. Simulation-based mastery learning has been used to improve clinical skills among nursing students and may provide a novel way to enhance nursing skills. This study aimed to assess the effect of simulation-based mastery learning on the clinical skills of undergraduate nursing students from 2017 to 2019.

METHODS

This quasi-experimental study was conducted with two groups (the control and intervention). A hundred and five students were selected by random convenience sampling, and written consent was obtained. The intervention group participated in a simulation-based mastery learning intervention, and the control group received no intervention except for traditional training. The students of both groups completed the demographic information questionnaire and the checklist before and after the intervention. The results were analyzed by SPSS version 21 and descriptive and inferential statistics.

RESULTS

The results showed no significant differences between the two groups before the intervention (p> 0.05). In addition, students' performance in the intervention and control groups improved significantly at the post-test compared with the baseline (p< 0.05). Furthermore, the Cohen test implied that the simulation-based mastery model used by the intervention group was significantly more effective than the traditional training used by the control.

CONCLUSION

These findings showed that mastery learning was more effective in improving clinical skills in undergraduate nursing students. The results suggest that other nursing and health programs can be developed by implementing a mastery-based learning model.

Changing the view: impact of simulation-based mastery learning in pediatric tracheal intubation with videolaryngoscopy

OBJECTIVE

To determine the effect of a training program using simulation-based mastery learning on the performance of residents in pediatric intubations with videolaryngoscopy.

METHOD

Retrospective cohort study carried out in a tertiary pediatric hospital between July 2016 and June 2018 evaluating a database that included the performance of residents before and after training, as well as the outcome of tracheal intubations. A total of 59 pediatric residents were evaluated in the pre-training with a skills' checklist in the scenario with an intubation simulator; subsequently, they were trained individually using a simulator and deliberate practice in the department itself. After training, the residents were expected to have a minimum passing grade (90/100) in a simulated scenario. The success of the first attempted intubation, use of videolaryngoscopy, and complications in patients older than 1year of age during the study period were also recorded in clinical practice.

RESULTS

Before training, the mean grade was 77.5/100 (SD 15.2), with only 23.7% (14/59) of residents reaching the minimum passing grade of 90/100. After training, 100% of the residents reached the grade, with an average of 94.9/100 (SD 3.2), p<0.01, with only 5.1% (3/59) needing more practice time than that initially allocated. The success rate in the first attempt at intubation in the emergency department with videolaryngoscopy was 77.8% (21/27). The rate of adverse events associated with intubations was 26% (7/27), representing a serious event.

CONCLUSIONS

Simulation-based mastery learning increased residents' skills related to intubation and allowed safe tracheal intubations with video laryngoscopy.

Experiential Learning in Project-Based Quality Improvement Education: Questioning Assumptions and Identifying Future Directions

PURPOSE

Project-based experiential learning is a defining element of quality improvement (QI) education despite ongoing challenges and uncertainties. The authors examined stakeholders' perceptions and experiences of QI project-based learning to increase understanding of factors that influence learning and project experiences.

METHOD

The authors used a case study approach to examine QI project-based learning in 3 advanced longitudinal QI programs, 2 at the University of Toronto and 1 at an academic tertiary-care hospital. From March 2016 to June 2017, they undertook 135 hours of education program observation and 58 interviews with learners, program directors, project coaches, and institutional leaders and reviewed relevant documents. They analyzed data using a conventional and directed data analysis approach.

RESULTS

The findings provide insight into 5 key factors that influenced participants' project-based learning experiences and outcomes: (1) variable emphasis on learning versus project objectives and resulting benefits, tensions, and consequences; (2) challenges integrating the QI project into the curriculum timeline; (3) project coaching factors (e.g., ability, capacity, role clarity); (4) participants' differing access to resources and ability to direct a QI project given their professional roles; and (5) workplace environment influence on project success.

CONCLUSIONS

The findings contribute to an empirical basis toward more effective experiential learning in QI by identifying factors to target and optimize. Expanding conceptualizations of project-based learning for QI education beyond learner-initiated, time-bound projects, which are at the core of many QI educational initiatives, may be necessary to improve learning and project outcomes.

Clinical simulation strategies for knowledge integration relating to initial critical recognition and management of COVID-19 for use within continuing education and health-related academia in Brazil: a descriptive study

BACKGROUND

The COVID-19 pandemic has led to an immense need to develop training on case recognition and management, with a focus on patients' and health professionals' safety at several levels of healthcare settings in Brazil. Different simulation strategies can be included in the diverse clinical care phases for these patients.

OBJECTIVE

To suggest a complete simulation-based training program for Brazilian hospitals and/or academic institutions at this moment of the pandemic.

DESIGN AND SETTING

Descriptive analysis on possible simulated clinical cases using different methodologies, thereby supporting suspected or confirmed COVID-19 patients.

METHODS

This was a reflective theoretical descriptive study on an educational program based on clinical simulation, with four practical phases at different performance and complexity levels. Wearing, handling and adequately disposing of personal protective equipment, along with specific respiratory procedures in different healthcare settings up to intensive care for seriously infected patients were addressed.

RESULTS

This program was designed for application at different Brazilian healthcare levels through different clinical simulation strategies. Summaries of expected performance were suggested in order to standardize technical capacity within these simulation settings, so as to serve these levels.

CONCLUSIONS

Developing training programs for situations such as the current COVID-19 pandemic promotes safety not only for patients but also for healthcare workers. In the present context, clear definition of which patients need hospital outpatient or inpatient care will avoid collapse of the Brazilian healthcare system. Institutions that do not have simulated environments can, through the examples described, adopt procedures to promote didactic information in order to help healthcare professionals during this time.

High consequence infectious diseases training using interprofessional simulation and TeamSTEPPS

BACKGROUND

The comfort level of health care workers to respond to an infectious disease outbreak or epidemic is likely directly related to the amount of education, training, and experience they have in responding to these events.

METHODS

A quasi-experimental study evaluated health care workers' state anxiety, self-efficacy, and interprofessional teamwork when working with patients simulated to have a potentially high consequence infectious disease.

RESULTS

Pretest-posttest 1 scores revealed a significant decrease in state anxiety (P < .0001) and an increase in self-efficacy (P < .0001). Overall state anxiety preintervention (pretest) to postintervention (posttest 3) significantly decreased (P = .0265). Overall TeamSTEPPS knowledge significantly increased (P < .0001) from baseline.

CONCLUSIONS

Simulation exercises are an effective strategy to increase self-efficacy and decrease state anxiety for health care workers. Positive teamwork scores indicate that the subjects value interprofessional teamwork.

Cadaveric Simulation Training in Cardiothoracic Surgery: A Systematic Review

Simulation training has become increasingly relevant in the educational curriculum of surgical trainees. The types of simulation models used, goals of simulation training, and an objective assessment of its utility and effectiveness are highly variable. The role and effectiveness of cadaveric simulation in cardiothoracic surgical training has not been well established. The objective of this study was to evaluate the current medical literature available on the utility and the effectiveness of cadaveric simulation in cardiothoracic surgical residency training. A literature search was performed using PubMed, Cochrane Library, Embase, Scopus, and CINAHL from inception to February 2019. Of the 362 citations obtained, 23 articles were identified and retrieved for full review, yielding ten eligible articles that were included for analysis. One additional study was identified and included in the analysis. Extraction of data from the selected articles was performed using predetermined data fields, including study design, study participants, simulation task, performance metrics, and costs. Most of these studies were only descriptive of a cadaveric or perfused cadaveric simulation model that could be used to augment clinical operative training in cardiothoracic surgery. There is a paucity of evidence in the literature that specifically evaluates the utility and the efficacy of cadavers in cardiothoracic surgery training. Of the few studies that have been published in the literature, cadaveric simulation does seem to have a role in cardiothoracic surgery training beyond simply learning basic skills. Additional research in this area is needed.

Simulation and Modeling Applications in Global Health Security

Global health security (GHS) is dependent upon having an adequate and prepared health security workforce. There are currently numerous challenges in establishing and maintaining a health security workforce. The frequency and magnitude of disasters have increased significantly over the past 30 years. Current and future GHS threats, both manmade and natural, require a prepared and flexible healthcare provider workforce ready to respond to current or emerging GHS threats. Developing and maintaining GHS -specific skills in the healthcare workforce is a tremendous logistical challenge. Innovative education technologies, including simulation and digital learning, can be leveraged to achieve preparedness for GHS threats.

This chapter focuses on the application of modeling and simulation to support Global Health Security planning, preparedness and operations.