Investigating the Extent Realistic Moulage Impacts on Immersion and Performance Among Undergraduate Paramedicine Students in a Simulation-based Trauma Scenario: A Pilot Study

Understanding The Role of Cognitive Load In Paramedical Contexts: A Systematic Review

Objectives: Cognitive load refers to the working memory resources required during a task. When the load is too high or too low this has implications for an individual's task performance. In the context of paramedicine and emergency medical services (EMS) broadly, high cognitive load could potentially put patient and personnel safety at risk. This systematic review aimed to determine the current understanding of the role of cognitive load in paramedical contexts.Methods: To do this, five databases were searched (Elsevier Embase, ProQuest Psychology, CINAHL, Ovid Medline, and Ovid PsychINFO) using synonyms of cognitive load and paramedical contexts. Included articles were full text, peer reviewed empirical research, with a focus on cognitive load and EMS work. Two reviewers screened titles, abstracts, and full text using a traffic light system against the inclusion and exclusion criteria. The quality of evidence was assessed using the GRADE framework. This study was registered on PROSPERO (CRD42022384246). No funding was received for this research.Results: The searches identified 73 unique articles and after title/abstract and full text screening, 25 articles were included in the final review. Synthesis of the research revealed 10 categories of findings in the area. These are clinical performance, cognitive processes, emotional responses, physical expenditure, physiological responses, equipment and ergonomics, expertise and experience, multiple loads, cognitive load measures, and task complexity.Conclusions: From these findings it was determined that there is agreement in terms of what factors influence cognitive load in paramedical contexts, such as cognitive processes, task complexity, physical expenditure, level of experience, multiple types of loads, and the use of equipment. Cognitive load influences clinical task performance and has a bi-directional relationship with emotion. However, the literature is mixed regarding physiological responses to cognitive load, and how they are best measured. These findings highlight potential intervention points where cognitive load can be managed or reduced to improve working conditions for EMS clinicians and safety for their patients.

Clinical competency development with handmade simulator in highly realistic paediatric dentistry scenarios

INTRODUCTION

The use of simulation is extremely useful in pregraduate students. However, there is a very small number of simulators adapted to paediatric dentistry. A paediatric simulator was created to use in simulated scenarios for paediatric dentistry using an actress in the role of mother. The objectives of the present study were three. First, to analyse the perception of clinical competencies acquired by the students. Second, to examine the realism perceived by the students. Finally, to analyse the influence on the perception of clinical competencies after the integration of a handmade simulator in the Paediatric Dentistry III course.

MATERIALS AND METHODS

Eight clinical scenarios were carried out with a modified Erler Zimmer simulator for children, a professional actress in the role of the mother and two students (in the roles of dentist and assistant) on a paediatric dentistry case of pulpal pathology. The educational intervention was evaluated on 114 students by means of questionnaires with Likert-type answers applied pre- and post-simulation.

RESULTS

The perception of clinical competence in the students increased an average of 0.956 points in relation with the initial clinical evaluation, finding a strong correlation between the perception of subsequent competence and all the perceived realism, with significant statistical differences in all cases. The realism of the simulated participant (professional actress) was the best rated by the students, although not significantly. The realism of the mannequin was positively and strongly correlated with the perceived realism of the cabinet.

CONCLUSION

Simulation using a handmade mannequin with a professional actress in a simulated dental office increased the perception of clinical competence in 4th year dental students and raised the level of overall realism perceived by the student.

Development and evaluation of three-dimensional transfers to depict skin conditions in simulation-based education

Modern medical moulages are becoming increasingly important in simulation-based health professions education. Their lifelikeness is important so that simulation engagement is not disrupted while their standardization is crucial in high-stakes exams. This report describes in detail how three-dimensional transfers are developed and produced so that educators will be able to develop their own. In addition, evaluation findings and lessons learnt from deploying transfers in summative assessments are shared. Step-by-step instructions are given for the creation and application of transfers, including materials and photographic visualizations. We also examined feedback on 10 exam stations (out of a total of 81) with self-developed three-dimensional transfers and complement this with additional lessons learnt. By the time of submission, the authors successfully developed and deployed over 40 different three-dimensional transfers representing different clinical findings in high-stakes exams using the techniques explained in this article or variations thereof. Feedback from students and examiners after completing the OSCE is predominantly positive, with lifelikeness being the quality most often commented upon. Caveats derived from feedback and own experiences are included. The step-by-step approach reported can be adapted and replicated by healthcare educators to build their own three-dimensional transfers. This should widen the scope and the lifelikeness of their simulations. At the same time we propose that this level of lifelikeness should be expected by learners as not to disrupt simulation engagement. Our evaluation of their use in high-stakes assessments suggests they are both useful and accepted.

The impact of moulage on learners' experience in simulation-based education and training: systematic review

BACKGROUND

Moulage is a technique used to simulate injury, disease, aging and other physical characteristics specific to a scenario, often used in health and emergency worker training, predominantly for simulation-based learning activities. Its use in allied health fields is unclear. Previous work has explored moulage as an adjunct for authentic simulations, however there is opportunity for broadening its scope.

AIM

To explore the effects of moulage interventions in simulation-based education and training, for learner experience. A secondary aim was to understand which pedagogical frameworks were embedded in moulage interventions.

METHOD

Four electronic databases (PubMed, CINAHL, EmBase, Proquest Central) were systematically searched to December 2022 for studies utilising moulage in simulation-based education experiences. Outcomes were focused on learner satisfaction, confidence, immersion, engagement, performance, or knowledge. Study quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Twenty studies (n = 11,470) were included. Studies were primarily conducted in medicine (n = 9 studies) and nursing (n = 5 studies) and less frequently across other health disciplines. The findings demonstrated greater learner satisfaction, confidence, and immersion when moulage was used against a comparator group. Minimal improvements in knowledge and performance were identified. One study underpinned the intervention with a pedagogical theory.

CONCLUSION

Moulage improves learner experience in simulation-based education or training, but not knowledge or clinical performance. Further research utilising moulage across a broader range of professions is needed. Interventions using moulage should be underpinned by pedagogical theories.

Numerical Assessment Tool to Measure Realism in Clinical Simulation

Realism is indispensable in clinical simulation learning, and the objective of this work is to present to the scientific community the methodology behind a novel numerical and digital tool to objectively measure realism in clinical simulation. Indicators measuring accuracy and naturality constitute ProRealSim v.1.0 (Universidad Europea, Madrid, Spain) which allows the assessing of attained realism for three dimensions: simulated participant, scenography, and simulator. Twelve experts in simulation-based learning (SBL) analyzed the conceptual relevance of 73 initial qualitative indicators that were then reduced to 53 final indicators after a screening study evaluating eight medical clinical simulation scenarios. Inter- and intra-observer concordance, correlation, and internal consistency were calculated, and an exploratory factorial analysis was conducted. Realism units were weighted based on variability and its mathematical contribution to global and dimensional realism. A statistical significance of p < 0.05 was applied and internal consistency was significant in all cases (raw_alpha ≥ 0.9698094). ProRealSim v.1.0 is integrated into a bilingual, free, and open access digital platform, and the intention is to foster a culture of interpretation of realism for its better study and didactic use.

Simulation-Based Education in Trauma Management: A Scoping Review

Trauma injuries are an important healthcare problem and one of the main leading causes of death worldwide. The purpose of this review was to analyze current practices in teaching trauma management using simulations, with the aim of summarizing them, identifying gaps and providing a critical overview on what has already been achieved. A search on the Web of Science website for simulation-based trauma training articles published from 2010 onwards was performed, obtaining 1617 publications. These publications were screened to 35 articles, which were deeply analyzed, gathering the following information: the authors, the publication type, the year of the publication, the total number of citations, the population of the training, the simulation method used, the skills trained, the evaluation type used for the simulation method presented in the paper, if skills improved after the training and the context in which the simulation took place. Of the 35 articles included in this review, only a few of them had students as the target audience. The more used simulation method was a high-fidelity mannequin, in which the participants trained in more technical than non-technical skills. Almost none of the studies introduced an automated evaluation process and most of the evaluation methods consisted of checklists or questionnaires. Finally, trauma training focused more on treating trauma patients in a hospital environment than in a pre-hospital one. Overall, improvements in the evaluation method, as well as in the development of trauma training on undergraduate education, are important areas for further development.

THE USE OF MOULAGE IN CLINICAL SIMULATION: MULTIPLE CASE STUDIES

Objective: identify how and why to use moulage within clinical simulation practices. Method: it is a multiple, inclusive, descriptive and exploratory case study with a qualitative approach. The cases were selected through an intentional sample. After applying the eligibility criteria, four cases of simulated scenarios that used moulage were included and analyzed. Results: all the cases analyzed were developed in extracurricular simulated clinical activities by facilitators with experience in clinical practices, teaching and simulation. The moulages used different techniques, promoting greater interaction with the learner through the use of stimulants of different sense organs, sharpening clinical reasoning, the development of skills, competences, among others. In the four cases, the moulage was performed on a simulated patient, in simulated scenarios and simulated video. The reasons described for moulage were: to provide realism, fidelity, easy application and low cost. Conclusion: it was possible to identify that the moulage is an adequate resource in clinical simulation and that when built with rigor and method, it influences the fidelity and realism of the simulated scenario.

O USO DA MOULAGE NA SIMULAÇÃO CLÍNICA: ESTUDO DE CASOS MÚLTIPLOS

Objetivo:identificar como e porque utilizar a moulage dentro das práticas de simulação clínica. Método: trata-se de estudo de casos múltiplos, inclusivo, de caráter descritivo e exploratório com abordagem qualitativa. Os casos foram selecionados por meio de uma amostra intencional. Após aplicação dos critérios de elegibilidade, foram incluídos e analisados quatro casos de cenários simulados que utilizaram moulage. Resultados: todos os casos analisados foram desenvolvidos em atividades clínicas simuladas extracurriculares por facilitadores com experiência em práticas clínicas, na docência e na área de simulação. As moulages utilizaram técnicas diferentes, promovendo maior interação com o aprendiz pelo uso de estimulantes de diferentes órgãos do sentido, aguçando o raciocínio clínico, o desenvolvimento de habilidades, competências, entre outros. Nos quatro casos, a moulage foi realizada em paciente simulado, em cenários simulados e vídeo simulado. Os motivos descritos para moulage foram: prover realismo, fidelidade, fácil aplicação e baixo custo. Conclusão: foi possível identificar que a moulage é um recurso adequando em simulação clínica e que quando construída com rigor e método, influencia na fidelidade e no realismo do cenário simulado.

So Much Moulage, So Little Time: A Guide to Performing Moulage for Mass Casualty Scenarios

Simulation has become a central component of healthcare education. Allowing learners to experience low-frequency high-risk situations, such as a mass casualty event, in a safe learning environment is a basic tenet of simulation-based education in healthcare. Creating realistic simulations often involves advanced moulage to accurately represent illness and injury. However, providing advanced moulage for mass casualty exercises can be time-consuming, resource-intensive, and costly. Here we discuss a novel means to execute moulage for multiple victims while maintaining a high level of realism. We executed two simultaneous mass casualty exercises as part of medical student education and employed our novel 3-step moulage process. Step 1-Preparation included case development, generation of a victim list, and victim designation into “zones” within the simulation. Step 2-Creation entailed making wounds, in-house 3D printing materials, and assembling each victim’s moulage bag. Step 3-Application was an assembly line method of executing all victims’ moulage on the day of the simulation. This method of moulage supported the highly realistic simulation activity that learners have come to expect while decreasing time, resources, and cost.

Simulating a self-inflicted facial gunshot wound with moulage to improve perceived realism, immersion, and learning in simulation-based airway management training

Moulage is used to create mock wounds and injuries for clinical education and training. We developed a moulage technique to simulate a facial gunshot wound for use in simulation-based training. We removed sections of a manikin’s face and used moulage materials to mock various aspects of the wound. The manikin was used in a simulated scenario that teaches clinicians how to manage a complicated airway. The moulage was evaluated with a self-report questionnaire that assessed participants’ perceptions of the realism of the wound, the degree to which the wound contributed to their scenario immersion, and the degree to which the wound enhanced their learning experience on a 5-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. Participants’ average response to each item was significantly higher than the neutral midpoint, and the median response was ‘strongly agree’. Our work suggests that the simulated facial gunshot wound contributed to perceived scenario immersion and enhancement of the learning experience, supporting existing literature that suggests moulage is a valuable tool in healthcare simulation. Future work could investigate the effect of moulage using objective measures and explore the potential to use extended reality technology in conjunction with moulage to improve immersion even further.

How does moulage contribute to medical students' perceived engagement in simulation? A mixed-methods pilot study

Introduction

Moulage is used frequently in simulation, with emerging evidence for its use in fields such as paramedicine, radiography and dermatology. It is argued that moulage adds to realism in simulation, although recent work highlighted the ambiguity of moulage practice in simulation. In the absence of knowledge, this study sought to explore the impact of highly authentic moulage on engagement in simulation.

Methods

We conducted a randomised mixed-methods study exploring undergraduate medical students' perception of engagement in relation to the authenticity moulage. Participants were randomised to one of three groups: control (no moulage, narrative only), low authenticity (LowAuth) or high authenticity (HighAuth). Measures included self-report of engagement, the Immersion Scale Reporting Instrument (ISRI), omission of treatment actions, time-to-treat and self-report of authenticity. In combination with these objective measures, we utilised the Stimulated Recall (SR) technique to conduct interviews immediately following the simulation.

Results

A total of 33 medical students participated in the study. There was no statistically significant difference between groups on the overall ISRI score. There were statistically significant results between groups on the self-reported engagement measure, and on the treatment actions, time-to-treat measures and the rating of authenticity. Four primary themes ((1) the rules of simulation, (2) believability, (3) consistency of presentation, (4) personal knowledge ) were extracted from the interview analysis, with a further 9 subthemes identified ((1) awareness of simulating, (2) making sense of the context (3) hidden agendas, (4) between two places, (5) dismissing, (6) person centredness, (7) missing information (8) level of training (9) previous experiences).

Conclusions

Students rate moulage authenticity highly in simulations. The use of high-authenticity moulage impacts on their prioritisation and task completion. Although the slower performance in the HighAuth group did not have impact on simulated treatment outcomes, highly authentic moulage may be a stronger predictor of performance. Highly authentic moulage is preferable on the basis of optimising learning conditions.

Rapid Application Temporary Tattoos for Medical Moulage: From Development to Testing and Commercialization

Military medical education and training often utilize theatrical makeup, or moulage, to simulate injuries or pathologies. Traditional methods of moulage application are incredibly realistic when expertly applied. However, moulage can be expensive in terms of supplies, manpower, and time. We proposed that by creating a library of illustrations for use with temporary tattoos, the overall cost of moulage could decrease with little to no impact on training goals and objectives. The development, detailed testing and plans for commercialization are outlined herein.

Virtual Reality Triage Training Can Provide Comparable Simulation Efficacy for Paramedicine Students Compared to Live Simulation-Based Scenarios

Background: Mass-casualty incidents (MCIs) are catastrophic. Whether they arise from natural or man-made disasters, the nature of such incidents and the multiple casualties involved can rapidly overwhelm response personnel. Mass-casualty triage training is traditionally taught via either didactic lectures or table top exercises. This training fails to provide an opportunity for practical application or experiential learning in immersive conditions. Further, large-scale simulations are heavily resource-intensive, logistically challenging, require the coordination and time of multiple personnel, and are costly to replicate. This study compared the simulation efficacy of a bespoke virtual-reality (VR) MCI simulation with an equivalent live simulation scenario designed for undergraduate paramedicine students. Methods: Both simulations involved ten injured patients resulting from a police car chase and shooting. Twenty-nine second-year paramedicine students completed the live and VR simulation in a random order. The training efficacy of the VR and live simulation was evaluated with respect to student immersion and task-difficulty, clinical decision-making (i.e. triage card allocation accuracy and timeliness), learning satisfaction, and cost of delivery. Results: While perceived physical demand was higher in the live simulation compared to VR (p < 0.001), no differences were observed across mental demand, temporal demand, performance, effort or frustration domains. No differences were found for participant satisfaction across the two platforms. No differences were observed in the number of triage cards correctly allocated to patients in each platform. However, participants were able to allocate cards far quicker in VR (p < .001). Cost of running the VR came to AUD $712.04 (staff time), compared to the live simulations which came to AUD $9,413.71 (staff time, moulage, actors, director, prop vehicle), approximately 13 times more expensive. Conclusion: The VR simulation provided near identical simulation efficacy for paramedicine students compared to the live simulation. VR MCI training resources represent an exciting new direction for authentic and cost-effective education and training for medical professionals.

Expert opinions on the authenticity of moulage in simulation: a Delphi study

BACKGROUND

Moulage is a technique in which special effects makeup is used to create wounds and other effects in simulation to add context and create realism in an otherwise fabricated environment. The degree to which moulage is used in the simulated environment is varied; that is, there is no guide for how authentic it is required to be. To objectively assess whether a higher level of authenticity in moulage influences engagement and better outcomes, a common model to assess authenticity is required. The aim of this study was to explore expert opinions on moulage in simulation and develop an instrument for the classification of moulage in simulation.

METHODS

The instrument was developed in 3 phases: expert panellist recruitment, domain identification, and consensus rounds. A Delphi technique was used to explore themes of authenticity using Dieckmann's Theory of Realism as a frame of reference. An initial list of elements was raised by a panel of international experts. The experts participated in a further four rounds of questioning, identifying and then ranking and/or rating elements of authenticity in moulage. A priori consensus threshold was set at 80%.

RESULTS

In round 1, 18 of 31 invited panellists participated, and a total of 10 completed round 5 (attrition 44%). As a result of the Delphi, the Moulage Authenticity Rating Scale was developed. Under the three domains of realism, 60 elements were identified by experts. A total of 13 elements reached the consensus threshold, whilst tensions regarding the necessity for authentic moulage were identified throughout the rounds.

CONCLUSION

This study demonstrates the complexity of moulage in simulation, with particular challenges surrounding the experts' views on authenticity. A prototype instrument for measuring moulage authenticity is presented in the form of the Moulage Authenticity Rating Scale (MARS) to further aid progress in understanding the role of authentic moulage in simulation.