Setting a Research Agenda for Simulation-Based Healthcare Education: A Synthesis of the Outcome From an Utstein Style Meeting

Simulation-based education for teaching aggression management skills to healthcare providers in acute healthcare settings: A systematic review

BACKGROUND

Behavioural emergencies involving aggression in acute care hospitals are increasing globally. Acute care staff are often not trained or confident in their prevention or management. Of available training options simulation-based education is superior for clinical medical education and is gaining acceptance for teaching clinical aggression management skills.

OBJECTIVE

The aim of this study was to conduct a systematic review of the effectiveness of simulation-based education for teaching aggression management skills for health professionals working in acute healthcare settings.

METHODS

The study protocol was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement, registered (27/02/2020) and published. We included randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies involving healthcare professionals in acute hospital settings or trainee health professionals who received simulation-based training on managing patient aggression. Comprehensive searches were conducted in PubMed, Ovid MEDLINE, PsycINFO, CINAHL and The Cochrane Library. Two reviewers independently screened all records, extracted data and assessed risk of bias. The primary outcomes included patient outcomes, quality of care, and adverse effects. Secondary outcomes included workplace resource use, healthcare provider related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. A narrative synthesis of included studies was performed because substantial variation of interventions and outcome measures precluded meta-analyses.

RESULTS

Twenty-five studies were included with 2790 participants, 2585 (93 %) acute care hospital staff and 205 (7 %) undergraduate university students. Twenty-two studies combined simulation-based education with at least one other training modality. Three studies were randomised controlled trials, one was a pilot and feasibility cluster randomised controlled trial, one was a three-group post-test design and twenty were pre-/post-test design. Twenty-four studies were deemed to be high/critical or serious risk of bias. Four studies collected primary outcome data, all using different methods and with inconsistent findings. Twenty-one studies assessed performance in the test situation, seven studies provided objective ratings of performance and eighteen provided self-report data. Twenty-three studies reported objective or subjective improvements in secondary outcomes.

CONCLUSIONS

Acute healthcare staff who completed simulation-based education on managing clinical aggression showed statistically significant improvements in knowledge and self-reported confidence. However, there is a lack of evidence about the magnitude of these improvements and impact on patient outcomes.

REGISTRATION

PROSPERO Registration Number CRD42020151002.

TWEETABLE ABSTRACT

Simulation-based education improved acute healthcare clinician knowledge and confidence in managing aggression.

Setting a direction for continuing professional development in anesthesiology: A synthesis of the outcome from an Utstein style meeting

BACKGROUND

An Utstein style meeting of key stakeholders from the existing collaboration surrounding post-graduate training was arranged to set a direction for continuing professional development (CPD) of anesthesiologists in Denmark. A 2-day meeting was planned to guide discussions about competencies in anesthesiology, facilitate the development of a blueprint for a portfolio-based CPD program and provide examples of how a portfolio can be used in practice.

METHODS

The meeting agenda was based on an adaptation of Kern's six-step approach to curriculum development. Twenty-four participants from the university hospitals in Denmark were invited. Prior to the meeting participants were informed of the objectives and the Utstein style process.

RESULTS

Participants acknowledged a need for a more structured approach to CPD, preferably within the current organizational set up at the departmental level, and with a portfolio-based, individualized curriculum. It was recognized that CPD should contain an array of possibilities to accommodate needs and wants of both the individual and the department. It was emphasized that, while anesthesiologists are used to give feedback to trainees, many are less familiar in providing the same to peers, and psychological safety was identified as a prerequisite to support a culture where specialists can reflect openly on each other's performance.

CONCLUSION

The results provide an insight into the attitudes, opportunities, and challenges of anesthesiologists in relation to continuing professional development in Denmark. Generally, participant suggestions are in line with the shift in medical education toward workplace-based learning, feedback and lifelong learning.

Bringing competency-based communication training to scale: A multi-institutional virtual simulation-based mastery learning curriculum for Emergency Medicine residents

PURPOSE

Serious illness communication skills are essential for physicians, yet competency-based training is lacking. We address scalability barriers to competency-based communication skills training by assessing the feasibility of a multi-center, virtual simulation-based mastery learning (vSBML) curriculum on breaking bad news (BBN).

METHODS

First-year emergency medicine residents at three academic medical centers participated in the virtual curriculum. Participants completed a pretest with a standardized patient (SP), a workshop with didactics and small group roleplay with SPs, a posttest with an SP, and additional deliberate practice sessions if needed to achieve the minimum passing standard (MPS). Participants were assessed using a previously published BBN assessment tool that included a checklist and scaled items. Authors compared pre- and posttests to evaluate the impact of the curriculum.

RESULTS

Twenty-eight (90%) of 31 eligible residents completed the curriculum. Eighty-nine percent of participants did not meet the MPS at pretest. Post-intervention, there was a statistically significant improvement in checklist performance (Median= 93% vs. 53%, p < 0.001) and on all scaled items assessing quality of communication. All participants ultimately achieved the MPS.

CONCLUSIONS

A multi-site vSBML curriculum brought all participants to mastery in the core communication skill of BBN and represents a feasible, scalable model to incorporate competency-based communication skills education in a widespread manner.

The Impact of Just-in-Time Simulation Training for Healthcare Professionals on Learning and Performance Outcomes: A Systematic Review

ABSTRACT

Although just-in-time training (JIT) is increasingly used in simulation-based health professions education, its impact on learning, performance, and patient outcomes remains uncertain. The aim of this study was to determine whether JIT simulation training leads to improved learning and performance outcomes. We included randomized or nonrandomized interventional studies assessing the impact of JIT simulation training (training conducted in temporal or spatial proximity to performance) on learning outcomes among health professionals (trainees or practitioners). Of 4077 citations screened, 28 studies were eligible for inclusion. Just-in-time training simulation training has been evaluated for a variety of medical, resuscitation, and surgical procedures. Most JIT simulation training occurred immediately before procedures and lasted between 5 and 30 minutes. Despite the very low certainty of evidence, this systematic review suggests JIT simulation training can improve learning and performance outcomes, in particular time to complete skills. There remains limited data on better patient outcomes and collateral educational effects.

Health Care Simulation in Person and at a Distance: A Systematic Review

ABSTRACT

Distance simulation is a method of health care training in which the learners and facilitators are in different physical locations. Although methods of distance simulation have existed in health care for decades, this approach to education became much more prevalent during the COVID-19 pandemic. This systematic review studies a subset of distance simulation that includes combined in-person and distance simulation elements, identified here as "mixed- distance simulation." A review of the distance simulation literature identified 10,929 articles. Screened by inclusion and exclusion criteria, 34 articles were ultimately included in this review. The findings of this review present positive and negative aspects of mixed-distance simulation formats, a description of the most frequent configurations related to delivery, terminology challenges, as well as future directions including the need for faculty development, methodological rigor, and reporting details.

Integration of simulation-based education in anaesthesiology specialist training: Synthesis of results from an Utstein Meeting

BACKGROUND

Despite its importance in education and patient safety, simulation-based education and training (SBET) is only partially or poorly implemented in many countries, including most European countries. The provision of a roadmap may contribute to the development of SBET for the training of anaesthesiologists.

OBJECTIVE

To develop a global agenda for the integration of simulation into anaesthesiology specialist training; identify the learning domains and objectives that are best achieved through SBET; and to provide examples of simulation modalities and evaluation methods for these learning objectives.

DESIGN

Utstein-style meeting where an expert consensus was reached after a series of short plenary presentations followed by small group workshops, underpinned by Kern's six-step theoretical approach to curriculum development.

SETTING

Utstein-style collaborative meeting.

PARTICIPANTS

Twenty-five participants from 22 countries, including 23 international experts in simulation and two anaesthesia trainees.

RESULTS

We identified the following ten domains of expertise for which SBET should be used to achieve the desired training outcomes: boot camp/initial training, airway management, regional anaesthesia, point of care ultrasound, obstetrics anaesthesia, paediatric anaesthesia, trauma, intensive care, critical events in our specialty, and professionalism and difficult conversations. For each domain, we developed a course template that defines the learning objectives, instructional strategies (including simulation modalities and simulator types), and assessment methods. Aspects related to the practical implementation, barriers and facilitators of this program were also identified and discussed.

CONCLUSIONS

We successfully developed a comprehensive agenda to facilitate the integration of SBET into anaesthesiology specialist training. The combination of the six-step approach with the Utstein-style process proved to be extremely valuable in supporting content validity and representativeness. These results may facilitate the implementation and use of SBET in several countries.

TRIAL REGISTRATION

Not applicable.

The Use of Simulation in Audiology Education: A Systematic Review

PURPOSE

This study aimed to assess the level and quality of evidence supporting the use of simulation in audiology education regarding enhanced knowledge, skills, self-confidence, and satisfaction.

METHOD

A systematic review of qualitative and quantitative peer-reviewed literature published between 2000 and 2023 was conducted. The PICO mnemonic (where P = population, I = intervention, C = comparison, and O = outcomes) was used to frame the clinical question and generate search terms. Search strategies were executed in seven databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to track the peer-reviewed literature identification and selection process. The Joanna Briggs Institute Critical Appraisal Checklists and Levels of Evidence were used to characterize the research studies.

RESULTS

A total of 668 records were identified. Nineteen peer-reviewed publications met the inclusion criteria. Diverse study designs, interventions, assessment techniques, and simulation types were identified. Characteristics of included studies (e.g., author, year, study purpose) were reported by evidence tables. Primary and secondary outcomes were identified and described. Results indicate statistical and/or clinically significant improvements in knowledge, skills, and/or self-confidence following simulation training. Each study was critically appraised, and the level, quality, and strength were assigned.

CONCLUSIONS

The use of simulation as an educational method among audiology students has been shown to dramatically increase knowledge, skills, and self-confidence. However, the use of simulation in audiology education is still behind compared to other health professions. As a result, there are a limited number of simulation-based studies in audiology. Most health academic institutions have well-designed simulation centers; therefore, audiology programs are urged to collaborate with colleagues in other professions and benefit from the services offered by these facilities.

Identifying Royal College-accredited simulation centre research priorities across Canada

To advance the field of health sciences simulation, research must be of high quality and would benefit from multi-institutional collaboration where centres can leverage and share expertise as well as work together to overcome limits to the generalizability of research findings from single-institution studies. A needs assessment in emergency medicine simulation has illustrated the importance of identifying research priorities in Canada. The main purpose of this study was to identify simulation research priority directions for Canadian simulation centres. The current survey study drew on 16 research priorities developed through a two-round internal Delphi study at McGill University that 15 of 17 simulation centre advisory board members participated in. The final 16 research priorities were then rated by a total of 18 of 24 simulation centre directors and/or delegates contacted from 15 of 19 Royal College of Physicians and Surgeons of Canada-accredited simulation centres in Canada. Results revealed nine common research priorities that reached 70% or higher agreement for all respondents. We anticipate that our findings can contribute to building a shared vision of priorities, community, and collaboration to enhance health care simulation research quality amongst Canadian simulation centres.

Comparative Effectiveness of Training with Simulators Versus Traditional Instruction in Veterinary Education: Meta-Analysis and Systematic Review

One of the greatest challenges in veterinary education is adequately preparing students with the clinical skills they need to be successful health care providers. Integration of simulators, devices used to represent real world phenomena under test conditions, into the veterinary curriculum can help address challenges to clinical instruction. The use of simulators in veterinary education is increasing; however, their effectiveness remains unclear. This meta-analysis seeks to synthesize the evidence for simulator training in veterinary education to provide a consensus of effect, guide the integration of simulators into the curriculum, and direct the development of future simulation-based research in veterinary medicine. A systematic search identified 416 potential manuscripts from which 60 articles were included after application of inclusion criteria. Information was extracted from 71 independent experiments. The overall weighted mean effect size for simulator training was g = 0.49 for the random-effects model. The outcome measures of knowledge, time, process, and product all produced statistically significant mean effect sizes favoring simulation (d = 0.41, 0.35, 0.70, 0.53, respectively). A moderator analysis revealed that study characteristics and instructional design features moderated the effectiveness of simulator training. Overall, the results indicate that simulator training in veterinary education can be effective for knowledge and clinical skill outcomes.

Continuous Monitoring of Mental Load During Virtual Simulator Training for Laparoscopic Surgery Reflects Laparoscopic Dexterity: A Comparative Study Using a Novel Wireless Device

Introduction

Cognitive Load Theory (CLT) relates to the efficiency with which individuals manipulate the limited capacity of working memory load. Repeated training generally results in individual performance increase and cognitive load decrease, as measured by both behavioral and neuroimaging methods. One of the known biomarkers for cognitive load is frontal theta band, measured by an EEG. Simulation-based training is an effective tool for acquiring practical skills, specifically to train new surgeons in a controlled and hazard-free environment. Measuring the cognitive load of young surgeons undergoing such training can help to determine whether they are ready to take part in a real surgery. In this study, we measured the performance of medical students and interns in a surgery simulator, while their brain activity was monitored by a single-channel EEG.

Methods

A total of 38 medical students and interns were divided into three groups and underwent three experiments examining their behavioral performances. The participants were performing a task while being monitored by the Simbionix LAP MENTOR™. Their brain activity was simultaneously measured using a single-channel EEG with novel signal processing (Aurora by Neurosteer^®). Each experiment included three trials of a simulator task performed with laparoscopic hands. The time retention between the tasks was different in each experiment, in order to examine changes in performance and cognitive load biomarkers that occurred during the task or as a result of nighttime sleep consolidation.

Results

The participants’ behavioral performance improved with trial repetition in all three experiments. In Experiments 1 and 2, delta band and the novel VC9 biomarker (previously shown to correlate with cognitive load) exhibited a significant decrease in activity with trial repetition. Additionally, delta, VC9, and, to some extent, theta activity decreased with better individual performance.

Discussion

In correspondence with previous research, EEG markers delta, VC9, and theta (partially) decreased with lower cognitive load and higher performance; the novel biomarker, VC9, showed higher sensitivity to lower cognitive load levels. Together, these measurements may be used for the neuroimaging assessment of cognitive load while performing simulator laparoscopic tasks. This can potentially be expanded to evaluate the efficacy of different medical simulations to provide more efficient training to medical staff and measure cognitive and mental loads in real laparoscopic surgeries.

'A roller coaster of emotions': a phenomenological study on medical students lived experiences of emotions in complex simulation

BACKGROUND

Simulation-based education can induce intense learner emotions. The interplay between emotions and learning is less well understood. Gaining greater insights into learner emotions has potential to guide how best we manage emotions and optimise learning. This study aimed to understand learners' lived emotional experiences in complex simulation and the perceived impact on learning.

METHODS

Eight final-year medical students participated in the study. Wearing video-glasses, participants took part in a ward-based simulation. Video-footage was used to elicitate exploratory interviews and analysed using Template Analysis reflexively.

RESULTS

Analysis yielded four main themes: 'nervous anticipation': encapsulating the fear, anxiety and uncertainty experienced by learners prior to simulation; 'shock and awe': feelings of anxiousness and being overwhelmed at the start of a simulation; 'in the moment: flowing or buffeting with the emotions': experiencing fear of being judged as incompetent, but also experiencing positive emotions such as satisfaction; 'safe-landing?': whilst debriefing aimed to encourage more positive emotions, negative emotions about the simulation could persist even with debriefing.

CONCLUSIONS

Complex simulation can evoke intense emotions in students. If students experienced a positive progression, they reported positive emotions and felt competent which was perceived to have a positive impact on learning. If students experienced failure, they reported strong negative emotions which made them question about their future performance and was perceived as negative for learning. Bringing to the surface these complex emotional dynamics, could permit educators to be aware of and adapt the emotional climate within simulation in order to optimise learning.

Evaluating a Multimodal Clinical Anesthesia Course Integrated Into an Existing Veterinary Curriculum

INTRODUCTION

This study evaluated a multimodal, simulation-based course in veterinary anesthesia integrated into an existing veterinary curriculum.

METHODS

A simulation-based, multimodal training course in clinical anesthesia was evaluated using outcomes from multiple levels of the Kirkpatrick Model of Training Evaluation. Cognitive and affective outcomes were evaluated before and after instruction. Head-mounted cameras were used to record clinical performance during students' first live patient anesthesia experience in the curriculum.

RESULTS

Pretest-posttest analysis of cognitive and affective outcomes for course participants revealed significant increases in knowledge and self-efficacy. Course participants received higher ratings on clinical task performance and professional skills (ie, communication and collaboration) compared with a matched control group when evaluated by blinded, external raters using a standardized rubric.

CONCLUSIONS

These findings indicate that implementing a multimodal anesthesia simulation-based course directly into the curriculum can enhance cognitive and affective outcomes and prepare students for subsequent anesthesia-related patient care experiences.

Utstein Style for emergency care - the first 30 years

BACKGROUND

Utstein Abbey near Stavanger in Norway, hosted a meeting in 1990 on guidelines for the uniform reporting of data from out-of-hospital cardiac arrest. In this paper we describe the last 30 years of the Utstein style.

METHODS

A systematic literature search identified publications from Utstein-style meetings or groups using the Utstein format.

RESULTS

30 outputs were found, describing primarily resuscitation structure, process and outcome measures. They originated from all over the world and from multiple medical disciplines. Some were co-published in multiple journals.

CONCLUSIONS

The meeting at Utstein Abbey in 1990 has had a sustained and far-reaching impact, particularly in resuscitation science, implementation and outcomes. The Utstein format will continue to evolve following the key principles from the original meeting and with the ultimate aim of improving patient care and outcomes.

School-based research agenda on healthcare simulation for nursing education in Hong Kong

Background

Healthcare simulation has been used as a pedagogical strategy in nursing education. Evidence has shown one of the positive impacts that simulations replace clinical placement. These wide-ranging initiatives are essential, and they can guide a nursing school’s simulation training. However, researching each innovation in the nursing field is beyond the scope.

Methods

To focus our research and develop the capacity and capability to incorporate healthcare simulation in nursing education, we used a consensus building process to establish a school’s research agenda. A modified Delphi process was adopted to reach a consensus among 10 nursing faculty members in one university with a visiting professor’s support.

Results

The three themes were identified as (1) embedding simulation into the baccalaureate in nursing curriculum, (2) designing effective simulation-based education and (3) simulating education in the broader world (adolescents). These themes were further categorised into two areas that used simulation in the educational and community settings. Sixty per cent of the faculty members agreed that the question, ‘How can simulation be incorporated into clinical placements to enhance students’ learning?' should be the highest research priority.

Conclusion

This study adds understanding to incorporate simulation-based education in the nursing curriculum and community provides insights into future research.

Clinical Competence Assessed Using Simulation: Development of a Standardized Tool to Assess Nutrition-Focused Physical Exam Skill Competence for Registered Dietitian Nutritionists

OBJECTIVE

This study details development and testing of a tool designed to evaluate clinical competence by registered dietitian nutritionists (RDNs) on the nutrition-focused physical exam (NFPE). The process demonstrated in this study can be adapted for assessment of other clinical skills in competency-based education programs, such as Accreditation Council on Education in Nutrition and Dietetics' Future Model of Dietetics Education.

DESIGN AND SETTING

The tool was tested for content validity, then used to assess the videotaped performance of the NFPE with standardized patients in a simulated clinical environment.

PARTICIPANTS

Seven expert raters assessed the relevance of the tool's items for content validity. For other tests, the tool was used by 3 dietetics faculty to score a group of 18 RDNs.

VARIABLES AND ANALYSIS

Content validity was tested using the item-level Content Validity Index. Interrater reliability and internal consistency of the tool were calculated and assessed.

RESULTS

The interrater reliability results indicated excellent agreement between raters, both overall (kappa statistic = 0.86; 95% confidence interval, 0.86-0.87; P < 0.001) and on individual items. Cronbach α statistic was calculated at α = .91, indicating excellent internal consistency.

CONCLUSIONS

The tool represents an instrument that can assess competence in the NFPE among RDNs and may be used as a template for development of other competency-based education assessment tools.

Simulation of operating room crisis management - hypotension training for pre-clinical students

BACKGROUND

Simulation training is an essential criterion for medical staff. The majority of residents are trained in operating room crisis management (ORCM), but only a few pre-clinical anesthesia undergraduate students are trained. Anesthesia methodology and technology were studied by the anesthesia undergraduate students in theory, but they were not able to practically resolve all clinical problems scientifically and reasonably. Consequently, there is a need to apply their competencies and bring together their technology knowledge practically. The crisis management of operating room emergencies was a method of choice applied and used over time. Here, we designed the scenarios for comprehensive crisis management to train anesthesia undergraduate students. We tried to establish or identify the problems which occurred during attempts to implement these scenarios.

METHODS

Anesthesia undergraduate students initially examined the basic theory, fundamental practice techniques, and case studies before the simulation training program. Subsequently, they participated in comprehensive ORCM training. Training outcomes were evaluated through different viewpoints: understanding the subject, crisis management, nontechnical skills, and a user experience evaluation.

RESULTS

Anesthesia undergraduate students performed significantly better with completion of ORCM, indicated by higher scores in all four tests (P < 0.001), as well as clinical crisis management (P = 0.0016) and nontechnical skills (P = 0.0002). Following the simulation, the students described the experience as helpful in "combining theoretical knowledge with clinical practice", helpful with memorization, and in "promoting understanding of the subject," while "learning clinical logic authentically" and "inspiring learning interests."

CONCLUSIONS

This research indicates that ORCM could be implemented as a useful learning tool for pre-clinical anesthesia undergraduate students. The ORCM could be an excellent training method to help improve students' professional competence in crisis management and nontechnical skills, integrating the knowledge and technology of the field of anesthesiology.

Increased competency of registered dietitian nutritionists in physical examination skills after simulation-based education in the United States

PURPOSE

This study aimed to translate simulation-based dietitian nutritionist education to clinical competency attainment in a group of practicing registered dietitian nutritionists (RDNs). Using a standardized instrument to measure performance on a newly-required clinical skill, the nutrition-focused physical exam (NFPE), competence was measured both before and after a simulation-based education (SBE) session.

METHODS

Eighteen practicing RDNs were recruited by their employer, Spectrum Health. Following a pre-briefing session, participants completed an initial 10-minute encounter, performing NFPE on a standardized patient (SP). Next, participants completed a 90-minute SBE training session on skills within the NFPE, including hands-on practice and role play, followed by a post-training SP encounter. Video recordings of the SP encounters were scored to assess competence in 7 skill areas within the NFPE. Scores were analyzed for participants’ initial competence and change in competence.

RESULTS

The proportions of participants with initial competence ranged from 0% to 44% across the 7 skill areas assessed. The only competency where participants initially scored in the “meets expectations” range was “approach to the patient.” When raw competence scores were assessed for changes from pre- to post-SBE training, the paired t-test indicated significant increases in all 7 competency areas following the simulation-based training (P<0.001).

CONCLUSION

This study showed the effectiveness of a SBE training program for increasing competence scores of practicing RDNs on a defined clinical skill.

How do we teach simulation-based dental education? Time for an evidence-based, best-practice framework

Historically, simulation-based dental education was taught using practical skills and the action of doing. An increased awareness of the importance of patient safety in healthcare education and delivery has seen considerable advances in the application of simulation-based education across several healthcare disciplines including medicine, nursing and anaesthetics. Dental simulation-based education requires improved standards of best-practice, and evidence-based, curriculum design that is based on theoretical frameworks, conceptual frameworks and educational theories. In this commentary, we explore the educational theory and the development of healthcare simulation, including internationally recognised standards of best practice and the simulation-based activity cycle. Given simulation-based education should be fit-for purpose, the components of these standards are examined within the specific context of dental education. We propose an evidence-based, best-practice framework that can be applied in the design and delivery of contemporary simulation-based dental curriculum.

Validity evidence of a task trainer for normal and difficult lumbar puncture: A cross-sectional study

Validation of the anatomically complex configurations of the Lumbar Puncture Simulator II (KYOTO KAGAKU CO., LTD., 15 Kitanekoya-cho Fushimi-ku Kyoto, Japan 612-8388) have not been reported. Previous validation of the normal anatomic configuration has been reported. This study aims to evaluate evidence for construct and content validity of 4 interchangeable lumbar puncture (LP) complex anatomic configurations of this simulator.We performed a cross-sectional study between April 2018 and May 2019. Novice volunteer medical students and expert physicians who had performed over 30 LP procedures performed sequential LP procedures on each of 4 simulated interchangeable anatomic LP puncture blocks (normal, obesity, geriatric, combined geriatric/obesity). Primary outcome measures compared between groups for each LP procedure were return of cerebrospinal fluid within 5 minutes and a calculated performance score. Subjective face validity and content validity 5-point Likert questionnaires were completed by participants.35 novice (n = 19) and expert (n = 16) subjects completed 140 procedures. Significant differences were found between novice and expert groups for both cerebrospinal fluid success rates and performance scores for normal (P = .001/P = .001) geriatric (P = .005/P = .002) and obesity (P = .003/P = < .001) configurations. There were no differences for the geriatric/obesity configuration. Expert median score of simulator realism (face validity) was 4 (range 3-4); median score of utility as a training tool (content validity) was 4 (range 4-5).We provide evidence for construct validity for each of the complex LP configurations, except combined geriatric/obesity. Expert physicians found the simulator sufficiently realistic to effectively teach LP skills.

Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process

OBJECTIVES

There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore initiated to define priorities in health care simulation that contribute the most to improve patient safety.

METHODS

An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies for these problems.

RESULTS

The expert group agreed on the following topics: technical skills, nontechnical skills, system probing, assessment, and effectiveness. For each topic, 5 patient safety problems were suggested that each topic might contribute to solve. Solutions to these problems and implementation strategies for these solutions were identified for technical skills, nontechnical skills, and system probing. In the case of assessment and effectiveness, the expert group found it difficult to suggest solutions and implementation strategies mainly because of lacking consensus on metrics and methodology.

CONCLUSIONS

The expert group recommends that the 5 topics identified in this consensus process should be the main focus when health care simulation is implemented in patient safety curricula.

Improving the Use of Simulation in Nursing Education: Protocol for a Realist Review

BACKGROUND

Nursing education has evolved in line with societal needs, and simulation-based learning (SBL) is increasingly being used to bridge the gap between practice and education. Previous literature reviews have demonstrated the effectiveness of using SBL in nursing education. However, there is a need to explore how and why it works to expand the theoretical foundation of SBL. Realist reviews are a theory-based approach to synthesizing existing evidence on how complex programs work in particular contexts or settings.

OBJECTIVE

This review aims to understand how, why, and in what circumstances the use of simulation affects learning as part of the bachelor's program in nursing.

METHODS

A realist review will be conducted in accordance with the realist template for a systematic review. In particular, we will identify and explore the underlying assumption of how SBL is supposed to work, that is, identify and explore program theories of SBL. The review will be carried out as an iterative process of searching, appraising, and synthesizing the evidence to uncover theoretical concepts that explain the causal effects of SBL. In the final section of the review, we will involve stakeholders in the Norwegian community in a web-based Delphi survey to ensure that the emerging theoretical framework derived from the published literature aligns with stakeholders' experience in practice.

RESULTS

The Norwegian Centre for Research Data (project number 60415) has approved the study. We have performed an initial literature search, whereas quality appraisal and data extraction are ongoing processes.

CONCLUSIONS

The final outcome of the review is anticipated to extend the theoretical foundation for using simulation as an integrated component of the bachelor's program in nursing. Furthermore, the findings will be used to produce a briefing document containing guidance for national stakeholders in the community of simulation-based nursing education. Finally, the review findings will be disseminated in a peer-reviewed journal as well as national and international conferences.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16363.

Simulation-based mastery learning compared to standard education for discussing diagnostic uncertainty with patients in the emergency department: a randomized controlled trial

BACKGROUND

Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications.

METHODS

The trial is a multicenter, two-arm randomized controlled trial designed to teach communication skills using simulation-based mastery learning (SBML). Resident emergency physicians from two training programs will be randomly assigned to immediate or delayed receipt of the two-part UCEM intervention after completing a baseline standardized patient encounter. The two UCEM components are: 1) a web-based interactive module, and 2) a smart-phone-based game. Both formats teach and reinforce communication skills for patient cases involving diagnostic uncertainty. Following baseline testing, participants in the immediate intervention arm will complete a remote deliberate practice session via a video platform and subsequently return for a second study visit to assess if they have achieved mastery. Participants in the delayed intervention arm will receive access to UCEM and remote deliberate practice after the second study visit. The primary outcome of interest is the proportion of residents in the immediate intervention arm who achieve mastery at the second study visit.

DISCUSSION

Patients' understanding of the care they received has implications for care quality, safety, and patient satisfaction, especially when they are discharged without a definitive diagnosis. Developing a patient-centered diagnostic uncertainty communication strategy will improve safety of acute care discharges. Although use of SBML is a resource intensive educational approach, this trial has been deliberately designed to have a low-resource, scalable intervention that would allow for widespread dissemination and uptake.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov (NCT04021771). Registration date: July 16, 2019.

How to include medical students in your healthcare simulation centre workforce

Running simulation centre activities requires a substantial amount of human resources. Here we present ideas on how medical students can be integrated into the simulation centre workforce to support the goal of delivering simulation-based education. The ideas are centred around the many different roles the students can fulfil and how this can be applied in other centres interested in integrating medical students into the workforce. The ideas are based on the experience from a regional Danish simulation centre, the Copenhagen Academy for Medical Education and Simulation (CAMES), where the work of medical students appears to be beneficial for both students, teaching and research faculty, and the growth of the simulation centre.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does simulation-based training in medical education need additional stressors? An experimental study

The increased curricular integration of simulation-based training (SBT) in medical education is accompanied by researchers' calls to examine the effectiveness of SBT. We address conflicting results regarding effects of an added stressor on learning outcomes. In an experimental setting, one group of medical students (N = 20) performed cardiopulmonary resuscitation on a patient simulator. For a second group (N = 21) the scenario differed in that they encountered a defect defibrillator. We found participants of both groups to show increased biological stress-levels, independent of group allocation. Paradoxically, participants who encountered the equipment failure subjectively reported less stress. We discuss the implications of the comparable high stress levels in both groups with regards to future studies. We further discuss the result regarding subjective stress levels within the framework of attribution theory. Practitioner summary: The results of our experimental study underline the need for evidence-based choices of additional stressors for the design of simulation scenarios. We describe the choice of stimuli and setting in detail to maximise practical value for the construction of simulation-based medical trainings.

Why health professions education needs functional linguistics: the power of 'stealth words'

CONTEXT

Language is one of the primary modalities for teaching and learning in the health professions in contexts ranging from the more formal teaching relationships of medical school to the guided practice of trainees through continuing education and the deliberate practice of lifelong learning. Yet linguistic analysis, with the possible exception of discourse analysis, has not become a core methodological tool in the field of health professions education (HPE). The purpose of this paper is to argue for the more widespread adoption of one particular approach to linguistics, one that examines less of what learners and instructors say and looks more at how they say it: functional linguistics.

FUNCTIONAL LINGUISTICS

THE POWER OF 'STEALTH WORDS': This approach theorises and structures the functions of language, regularly focusing attention on 'stealth words' such as I, but and was. Drawing on a rich body of literature in linguistics, psychology, the learning sciences and some early work in HPE, we demonstrate how functional linguistic tools can be applied to better understand learners' and instructors' beliefs, reasoning processes, values and emotions.

FUNCTIONAL LINGUISTICS AND REFLECTION

AN APPLICATION OF STEALTH WORDS: A brief qualitative analysis of one tool - analysis of the generic use of 'you' to mean 'one' or 'anyone' - demonstrates how functional linguistics can offer insight into physicians' bids for credibility and alignment as they think aloud about their clinical reasoning.

FUNCTIONAL LINGUISTICS AND HPE

FUTURE DIRECTIONS: Finally, we offer suggestions for how functional linguistic tools might address questions and gaps in four active research areas in HPE: reflection; emotion and reasoning; learning in simulated contexts, and self-regulated learning.

CONCLUSIONS

We argue that the words used by learners, instructors and practitioners in the health professions as they move through undergraduate and graduate training into practice can offer clues that will help researchers, instructors and colleagues to better support them.

Audiology and Speech-Language Pathology Simulation Training on the 1-3-6 Early Hearing Detection and Intervention Timeline

Purpose This study aimed to find out more about the effect of the use of the 1-3-6 early hearing detection and intervention (EHDI) timeline and interprofessional simulation training on audiology and speech-language pathology graduate students' confidence level of knowledge and skills. Method A 1-group pretest-posttest quasi-experimental study design was used to assess self-ratings of confidence in knowledge and skills. The mean age for 50 graduate students participating in this study was 25.32 years ( SD = ±3.77, range: 22-37 years). Participants completed a pre- and postevent questionnaire in which they rated their level of confidence for specific knowledge and skills. Three case scenarios represented by standardized parents were developed, and 8 students volunteered to participate in implementing the 1-3-6 EHDI timeline, whereas others participated as observers. All participants participated in the briefing and debriefing sessions immediately before and after each scenario. Participants were asked to rate their readiness for interprofessional education/practice and their satisfaction of the educational experience after the last case scenario. Results Overall, the pre- and postsimulation event questionnaire revealed a significant improvement in the participants' self-rated confidence levels in knowledge and skills. The mean difference between pre- and postevent scores was 0.78 ( p < .01). The mean interprofessional learning was 2.13 (range: 1.16-2.57, SD = ±0.24) based on a Likert scale, where 1 = strongly agree and 5 = strongly disagree. The mean satisfaction level was 4.37 (range: 3.94-4.72, SD = ±0.24) based on a Likert scale, where 1 = not satisfied and 5 = very satisfied. Conclusions The results demonstrated the value of using interprofessional simulation training among audiology and speech-language pathology students to improve their confidence in knowledge and skills. The curriculum developed in this study for the 1-3-6 EHDI timeline provides resources for educators in both professions and other related professions.

A conceptual framework for simulation in healthcare education - The need

This study used a social constructivist approach to explore the literature in relation to the acknowledgment and application of models and frameworks in simulation based learning and teaching activities in health care education. This paper addresses the data collection phases in the research design in developing a Conceptual Framework for Simulation in Healthcare Education.

BACKGROUND

Two literature review activities occurred in the study. The first literature review explored the challenges in the literature for further research in relation to the educational factors that have an impact upon simulation as a learning and teaching modality. This part of the research process was to identify the publications that address simulation as a learning and teaching modality and uncover evidence to justify the study. The literature revealed that there were limited publications in relation to simulation as a learning and teaching modality that was underpinned by a conceptual framework.

DESIGN

The study research design employed Evaluation Research to conduct a further intensive review of the literature as part of phase one of data collection. The second part of phase one of data collection was the surveying of randomly selected simulation education centres around the world to ascertain their employment of a conceptual framework in the application of simulation as a learning and teaching modality. Phase two was the genesis of the conceptual framework and Phase three was the evaluation of the draft framework using a modified Delphi Technique by randomly selected simulation experts.

RESULTS

The intensive literature review highlighted that authors acknowledged education-based theories but this did not extend to the application of a conceptual framework to simulation as a learning and teaching modality. The survey provided the evidence to support the development of a Conceptual Framework for Simulation in Healthcare Education for the conceptualisation, design, development and delivery of simulation teaching and learning activities in health care education. The simulation experts provided valuable data and commentary in the final formation of the conceptual framework.

CONCLUSION

Based on the outcomes of the literature review, questionnaire and modified Delphi Technique the need for the development, and subsequent structure and utility of the Conceptual Framework for Simulation in Healthcare Education was verified.

Concepts for the Simulation Community: Development of the International Simulation Data Registry

STATEMENT

The past several decades have seen tremendous growth in our understanding of best practices in simulation-based healthcare education. At present, however, there is limited infrastructure available to assist programs in translation of these best practices into more standardized educational approaches, higher quality of care, and ultimately improved outcomes. In 2014, the International Simulation Data Registry (ISDR) was launched to address this important issue. The existence of such a registry has important implications not just for educational practice but also for research. The ISDR currently archives data related to pulseless arrest, malignant hyperthermia, and difficult airway simulations. Case metrics are designed to mirror the American Heart Association's Get With the Guidelines Registry, allowing for direct comparisons with clinical scenarios. This article describes the rationale for the ISDR, and outlines its development. Current data are presented to highlight the educational and research value of this approach. Projected future developments are also discussed.

Simulation-based training of junior doctors in handling critically ill patients facilitates the transition to clinical practice: an interview study

BACKGROUND

Junior doctors lack confidence and competence in handling the critically ill patient including diagnostic skills, decision-making and team working with other health care professionals. Simulation-based training on managing emergency situations can have substantial effects on satisfaction and learning. However, there are indications of problems when applying learned skills to practice. Our aim was to identify first-year doctors' perceptions, reflections and experiences on transfer of skills to a clinical setting after simulation-based training in handling critically ill patients.

METHODS

We used a qualitative approach and conducted semi-structured telephone interviews with a sample of twenty first-year doctors six months after a 4-day simulation-based training course in handling critically ill patients. Interviews were transcribed verbatim. A content-analysis approach was used to analyse the data.

RESULTS

The following main themes were identified from the interviews: preparedness for clinical practice, organisational readiness, use of algorithms, communication, teamwork, situational awareness and decision making. The doctors gave several examples of simulation-based training increasing their preparedness for clinical practice and handling the critically ill patient. The usefulness of algorithms and the appreciation of non-technical skills were highlighted and found to be helpful in managing clinical difficulties. Concern was expressed related to staff willingness and preparedness in using these tools.

CONCLUSIONS

Overall, the simulation-based training seemed to facilitate the transition from being a medical student to become a junior doctor. The doctors experienced an ability to transfer the use of algorithms and non-technical skills trained in the simulated environment to the clinical environment. However, the application of these skills was more difficult if these skills were unfamiliar to the surrounding clinical staff.

TRIAL REGISTRATION

Not applicable.

Problem-based learning for anesthesia resident operating room crisis management training

BACKGROUND

Senior anesthesia residents must acquire competency in crisis management for operating room (OR) emergencies. We conducted problem based learning (PBL) OR emergency scenarios for anesthesia residents, focused on emergencies in 'Airway', 'Circulation', 'Central venous catheter', and 'Pain management complications'. Non-technical skills are an integral component of team-based OR emergency management.

METHODS

Prior to integrated OR emergency clinical and non-technical skills PBL training, participating 35 anesthesia residents completed two 5-point scale surveys regarding frequency of emergency experiences in the operating room, and self-confidence for anesthesia-related crisis management. Repeat administration of the self-confidence survey was completed immediately following PBL training.

RESULTS

Post-PBL resident clinical management self- confidence improved (P<0.05) in all scenarios on Circulation, Central venous catheter, and Pain treatment related complication topics. Impossible intubation, impossible oxygenation, and awake intubation did not show significant difference following PBL.

CONCLUSION

Our findings suggest that PBL for OR emergency management can improve resident self- confidence in anesthesia residents.

Pretest Scores Uniquely Predict 1-Year-Delayed Performance in a Simulation-Based Mastery Course for Central Line Insertion

INTRODUCTION

Within simulation-based mastery learning (SBML) courses, there is inconsistent inclusion of learner pretesting, which requires considerable resources and is contrary to popular instructional frameworks. However, it may have several benefits, including its direct benefit as a form of deliberate practice and its facilitation of more learner-specific subsequent deliberate practice. We consider an unexplored potential benefit of pretesting: its ability to predict variable long-term learner performance.

METHODS

Twenty-seven residents completed an SBML course in central line insertion. Residents were tested on simulated central line insertion precourse, immediately postcourse, and after between 64 and 82 weeks. We analyzed pretest scores' prediction of delayed test scores, above and beyond prediction by program year, line insertion experiences in the interim, and immediate posttest scores.

RESULTS

Pretest scores related strongly to delayed test scores (r = 0.59, P = 0.01; disattenuated ρ = 0.75). The number of independent central lines inserted also related to year-delayed test scores (r = 0.44, P = 0.02); other predictors did not discernibly relate. In a regression model jointly predicting delayed test scores, pretest was a significant predictor (β = 0.487, P = 0.011); number of independent insertions was not (β = 0.234, P = 0.198).

CONCLUSIONS

This study suggests that pretests can play a major role in predicting learner variance in learning gains from SBML courses, thus facilitating more targeted refresher training. It also exposes a risk in SBML courses that learners who meet immediate mastery standards may be incorrectly assumed to have equal long-term learning gains.

Building a Community of Practice for Researchers: The International Network for Simulation-Based Pediatric Innovation, Research and Education

STATEMENT

The scope and breadth of simulation-based research is growing rapidly; however, few mechanisms exist for conducting multicenter, collaborative research. Failure to foster collaborative research efforts is a critical gap that lies in the path of advancing healthcare simulation. The 2017 Research Summit hosted by the Society for Simulation in Healthcare highlighted how simulation-based research networks can produce studies that positively impact the delivery of healthcare. In 2011, the International Network for Simulation-based Pediatric Innovation, Research and Education (INSPIRE) was formed to facilitate multicenter, collaborative simulation-based research with the aim of developing a community of practice for simulation researchers. Since its formation, the network has successfully completed and published numerous collaborative research projects. In this article, we describe INSPIRE's history, structure, and internal processes with the goal of highlighting the community of practice model for other groups seeking to form a simulation-based research network.

Simulation-based education to improve communication skills: a systematic review and identification of current best practice

Background

Good communication in healthcare between professionals and between professionals and patients is important in delivering high-quality care. Evidence of translation of technical skills taught through simulation into the clinical environment has been demonstrated, but the evidence for the impact of communication skills is less well known.

Objectives

To identify and critically appraise the evidence for the impact of communication taught through simulation-based education (SBE) and use this evidence to suggest a model for future SBE interventions for communication skills.

Study selection

MEDLINE, CINAHL, EMBASE and PsycINFO were searched for articles pertaining to communication skills taught through simulation. A content expert was consulted to suggest additional studies. 1754 studies were initially screened for eligibility, with 274 abstracts screened further. 147 full-text articles were further assessed for eligibility, with 79 of these excluded. The remaining 68 studies were reviewed and 18 studies were included in the qualitative synthesis as studies designed to show benefits beyond the simulation centre.

Findings

The 18 identified studies with an impact at a Kirkpatrick level of ≥3, are analysed; 4 looking specifically at communication between healthcare professionals and 14 looking at communication between health professionals and patients or relatives.

Conclusions

There is some evidence that the improvements in communication taught through simulation can be translated into benefits measurable beyond the simulation centre, but this evidence is limited due to the way that most of the studies are designed. We suggest a model for SBE aimed at teaching communication skills that is informed by the current evidence and takes into account the need to collect higher-level outcome data.

An overview of realist evaluation for simulation-based education

This article describes the key features of realist (realistic) evaluation and illustrates their application using, as an example, a simulation-based course for final year medical students. The use of simulation-based education (SBE) is increasing and so too is the evidence supporting its value as a powerful technique which can lead to substantial educational benefits. Accompanying these changes is a call for research into its use to be more theory-driven and to investigate both 'Did it work?' and as importantly 'Why did it work (or not)?' An evaluation methodology that is capable of answering both questions is realist evaluation. Realist evaluation is an emerging methodology that is suited to evaluating complex interventions such as SBE. The realist philosophy positions itself between positivist and constructivist paradigms and seeks to answer the question 'What works for whom, in what circumstances and why?' In seeking to answer this question, realist evaluation sets out to identify three fundamental components of an intervention, namely context, mechanism and outcome. Educational programmes work (successful outcomes) when theory-driven interventions (mechanisms) are applied to groups under appropriate conditions (context). Realist research uses a mixed methods (qualitative and quantitative) approach to gathering data in order to test the proposed context-mechanism-outcome (CMO) configurations of the intervention under investigation. Realist evaluation offers a valuable methodology for researchers investigating interventions utilising simulation-based education. By investigating and understanding the context, mechanisms and outcomes of SBE interventions, realist evaluation can provide the deeper level of understanding being called for.

Using the METRICS model for defining routes to scholarship in healthcare simulation

INTRODUCTION

In this paper, we explored the utility and value of the METRICS model for modeling scholarship in healthcare simulation by: (1) describing the distribution of articles in four healthcare simulation journals across the seven areas of METRICS scholarship; and (2) appraising patterns of scholarship expressed in three programs of simulation scholarship and reflecting on how these patterns potentially influence the pursuit of future scholarly activities.

METHODS

Two raters reviewed abstracts of papers published between January 2015 and August 2017 in four healthcare simulation journals and coded them using METRICS. Descriptive statistics were calculated for scholarship type and distribution across journals. Twenty-eight articles from three scholars were reviewed, with patterns of scholarship within articles mapped to METRICS. Descriptive synthesis was constructed through discussion between two reviewers.

RESULTS

A total of 432 articles from four journals were reviewed. The three most commonly published areas of scholarship were: 32.2% (139/432) evaluation, 18.8% (81/432) innovation, and 15.3% (66/432) conceptual. The METRICS model was able to represent different kinds of scholarship expressed in all of the papers reviewed and across programs of research. Reflecting on patterns of scholarship within their scholarly programs was helpful for research in planning future directions.

CONCLUSIONS

The METRICS model for scholarship can describe a wide range of patterns of simulation scholarship within individual articles, programs of research, or across journals.

The value proposition of simulation-based education

Simulation has become an integral part of physician education, and abundant evidence confirms that simulation-based education improves learners' skills and behaviors and is associated with improved patient outcomes. The resources required to implement simulation-based education, however, have led some stakeholders to question the overall value proposition of simulation-based education. This paper summarizes the information from a special panel on this topic and defines research priorities for the field. Future work should focus on both outcomes and costs, with robust measurement of resource investments, provider performance (in both simulation and real settings), patient outcomes, and impact on the health care organization. Increased attention to training practicing clinicians and health care teams is also essential. Clarifying the value proposition of simulation-based education will require a major national effort with funding from multiple sponsors and active engagement of a variety of stakeholders.

Translational simulation: not 'where?' but 'why?' A functional view of in situ simulation

Healthcare simulation has been widely adopted for health professional education at all stages of training and practice and across cognitive, procedural, communication and teamwork domains. Recent enthusiasm for in situ simulation-delivered in the real clinical environment-cites improved transfer of knowledge and skills into real-world practice, as well as opportunities to identify latent safety threats and other workplace-specific issues. However, describing simulation type according to place may not be helpful. Instead, I propose the term translational simulation as a functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions, independent of the location of the simulation activity.

Classifying simulation-based studies using the description, justification and clarification framework: a review of simulation conference abstracts

Introduction

Simulation-based medical education (SBME) is an accepted learning methodology with an ever-expanding evidence base. Concerns have been expressed that research output in SBME lacks explicit links to educational theory. Using the 'Description, Justification and Clarification' framework we have investigated the extent to which SBME conference abstracts declare the educational theory underpinning their studies.

Methods

Abstracts from four major international SBME conferences (for 2014 and 2015) were reviewed. Abstracts were classified using the framework offered by Cook et al who classified studies published in major educational journals. Clarification studies are those which specifically declare and test their underpinning educational approach.

Results

We reviewed 1398 conference abstracts which we classified as Description 54.4%, Justification 36.3% and Clarification 9.3%. The two most frequently declared educational theories were Cognitive Theories and Experiential Learning.

Conclusion

The low proportion of Clarification studies found in the SBME conference abstracts reflects previous findings highlighting the lack of medical education studies that establish how and why SBME works. Researchers should be encouraged to declare their underpinning educational theories when presenting their work. Conference organisers play an important role in facilitating this through allowing sufficient word count in their submission criteria.

Preparation With Web-Based Observational Practice Improves Efficiency of Simulation-Based Mastery Learning

INTRODUCTION

Our current understanding of what results in effective simulation-based training is restricted to the physical practice and debriefing stages, with little attention paid to the earliest stage: how learners are prepared for these experiences. This study explored the utility of Web-based observational practice (OP) -featuring combinations of reading materials (RMs), OP, and collaboration- to prepare novice medical students for a simulation-based mastery learning (SBML) workshop in central venous catheterization.

METHODS

Thirty medical students were randomized into the following 3 groups differing in their preparatory materials for a SBML workshop in central venous catheterization: a control group with RMs only, a group with Web-based groups including individual OP, and collaborative OP (COP) groups in addition to RM. Preparation occurred 1 week before the SBML workshop, followed by a retention test 1-week afterward. The impact on the learning efficiency was measured by time to completion (TTC) of the SBML workshop. Web site preparation behavior data were also collected.

RESULTS

Web-based groups demonstrated significantly lower TTC when compared with the RM group, (P = 0.038, d = 0.74). Although no differences were found between any group performances at retention, the COP group spent significantly more time and produced more elaborate answers, than the OP group on an OP activity during preparation.

DISCUSSION

When preparing for SBML, Web-based OP is superior to reading materials alone; however, COP may be an important motivational factor to increase learner engagement with instructional materials. Taken together, Web-based preparation and, specifically, OP may be an important consideration in optimizing simulation instructional design.

Conducting multicenter research in healthcare simulation: Lessons learned from the INSPIRE network

Simulation-based research has grown substantially over the past two decades; however, relatively few published simulation studies are multicenter in nature. Multicenter research confers many distinct advantages over single-center studies, including larger sample sizes for more generalizable findings, sharing resources amongst collaborative sites, and promoting networking. Well-executed multicenter studies are more likely to improve provider performance and/or have a positive impact on patient outcomes. In this manuscript, we offer a step-by-step guide to conducting multicenter, simulation-based research based upon our collective experience with the International Network for Simulation-based Pediatric Innovation, Research and Education (INSPIRE). Like multicenter clinical research, simulation-based multicenter research can be divided into four distinct phases. Each phase has specific differences when applied to simulation research: (1) Planning phase, to define the research question, systematically review the literature, identify outcome measures, and conduct pilot studies to ensure feasibility and estimate power; (2) Project Development phase, when the primary investigator identifies collaborators, develops the protocol and research operations manual, prepares grant applications, obtains ethical approval and executes subsite contracts, registers the study in a clinical trial registry, forms a manuscript oversight committee, and conducts feasibility testing and data validation at each site; (3) Study Execution phase, involving recruitment and enrollment of subjects, clear communication and decision-making, quality assurance measures and data abstraction, validation, and analysis; and (4) Dissemination phase, where the research team shares results via conference presentations, publications, traditional media, social media, and implements strategies for translating results to practice. With this manuscript, we provide a guide to conducting quantitative multicenter research with a focus on simulation-specific issues.

The simulated clinical environment: Cognitive and emotional impact among undergraduates

CONTEXT

Simulated clinical immersion (SCI) is used in undergraduate healthcare programs to expose the learner to real-life situations in authentic simulated clinical environments. For novices, the environment in which the simulation occurs can be distracting and stressful, hence potentially compromising learning.

OBJECTIVES

This study aims to determine whether SCI (with environment) imposes greater extraneous cognitive load and stress on undergraduate pharmacy students than simulated patients (SP) (without environment). It also aims to explore how features of the simulated environment influence students' perception of learning.

METHODS

In this mixed-methods study, 143 undergraduate pharmacy students experienced both SCI and SP in a crossover design. After the simulations, participants rated their cognitive load and emotions. Thirty-five students met in focus groups to explore their perception of learning in simulation.

RESULTS

Intrinsic and extraneous cognitive load and stress scores in SCI were significantly but modestly higher compared to SP. Qualitative findings reveal that the physical environment in SCI generated more stress and affected students? focus. In SP, students concentrated on clinical reasoning. SCI stimulated a focus on data collection but impeded in-depth problem solving processes.

CONCLUSION

The physical environment in simulation influences what and how students learn. SCI was reported as more cognitively demanding than SP. Our findings emphasize the need for the development of adapted instructional design guidelines in simulation for novices.

A Big Data and Learning Analytics Approach to Process-Level Feedback in Cognitive Simulations

Collecting and analyzing large amounts of process data for the purposes of education can be considered a big data/learning analytics (BD/LA) approach to improving learning. However, in the education of health care professionals, the application of BD/LA is limited to date. The authors discuss the potential advantages of the BD/LA approach for the process of learning via cognitive simulations. Using the lens of a cognitive model of radiograph interpretation with four phases (orientation, searching/scanning, feature detection, and decision making), they reanalyzed process data from a cognitive simulation of pediatric ankle radiography where 46 practitioners from three expertise levels classified 234 cases online. To illustrate the big data component, they highlight the data available in a digital environment (time-stamped, click-level process data). Learning analytics were illustrated using algorithmic computer-enabled approaches to process-level feedback.For each phase, the authors were able to identify examples of potentially useful BD/LA measures. For orientation, the trackable behavior of re-reviewing the clinical history was associated with increased diagnostic accuracy. For searching/scanning, evidence of skipping views was associated with an increased false-negative rate. For feature detection, heat maps overlaid on the radiograph can provide a metacognitive visualization of common novice errors. For decision making, the measured influence of sequence effects can reflect susceptibility to bias, whereas computer-generated path maps can provide insights into learners' diagnostic strategies.In conclusion, the augmented collection and dynamic analysis of learning process data within a cognitive simulation can improve feedback and prompt more precise reflection on a novice clinician's skill development.

Radiation therapy students' perceptions of their learning from participation in communication skills training: An innovative approach

Introduction

Communication skills training has been progressively integrated into the Bachelor of Radiation Therapy programme in New Zealand throughout the last 3 years. This innovative study aimed to explore students’ perceptions of their learning from participation in communication skills workshops. The purpose was to expose students to a variety of common clinical situations that they could encounter as a student radiation therapist.

Methods

Common scenarios from the radiation therapy setting were developed, using trained actors as a standardised patient, staff member or member of the public. Students were briefed on their scenario and then required to manage their interactions appropriate to its context. A staff member and peers observed each student's interaction via a digital screen and assessed the student's performance in six key skills. Each student was video recorded so that they could review their own interaction. Verbal and written feedback was given to each student. Students evaluated their experience using a 5‐point Likert scale.

Results

Quantitative and qualitative data were collected from 116 of 150 students who consented to participate. Three main themes emerged from the data: the value of learning from peers; preparation for the clinical environment; and the ability to self‐reflect. The quantitative data indicated that students’ perceptions of the tool are positive and an effective learning experience.

Conclusions

Students’ perceptions of participation in the communication skills workshops, with the integration of trained actors, are positive and students perceive the scenarios to be helpful for their learning. Opportunities are indicated to further develop of students’ ability to self‐reflect.

Simulation With PARTS (Phase-Augmented Research and Training Scenarios): A Structure Facilitating Research and Assessment in Simulation

INTRODUCTION

Assessment in simulation is gaining importance, as are scenario design methods increasing opportunity for assessment. We present our approach to improving measurement in complex scenarios using PARTS [Phase-Augmented Research and Training Scenarios], essentially separating cases into clearly delineated phases.

METHODS

We created 7 PARTS with real-time rating instruments and tested these in 63 cases during 4 weeks of simulation. Reliability was tested by comparing real-time rating with postsimulation video-based rating using the same instrument. Validity was tested by comparing preintervention and postintervention total results, by examining the difference in improvement when focusing on the phase-specific results addressed by the intervention, and further explored by trying to demonstrate the discrete improvement expected from proficiency in the rare occurrence of leader inclusive behavior.

RESULTS

Intraclass correlations [3,1] between real-time and postsimulation ratings were 0.951 (95% confidence interval [CI], 0.794-0.990), 1.00 (95% CI, --to--), 0.948 (95% CI, 0.783-0.989), and 0.995 (95% CI, 0.977-0.999) for 3 phase-specific scores and total scenario score, respectively. Paired t tests of prelecture-postlecture performance showed an improvement of 14.26% (bias-corrected and accelerated bootstrap [BCa] 95% CI, 4.71-23.82; P = 0.009) for total performance but of 28.57% (BCa 95% CI, 13.84-43.30; P = 0.002) for performance in the respective phase. The correlation of total scenario performance with leader inclusiveness was not significant (rs = 0.228; BCa 95% CI. -0.082 to 0.520; P = 0.119) but significant for specific phase performance (rs = 0.392; BCa 95% CI, 0.118-0.632; P = 0.006).

CONCLUSIONS

The PARTS allowed for improved reliability and validity of measurements in complex scenarios.