Comparing self-guided learning and educator-guided learning formats for simulation-based clinical training

Motivation Unraveled: Giving Choice to Football Players to Improve Anterior Cruciate Ligament Injury Prevention

ABSTRACT

Benjaminse, A, Nijmeijer, EM, Gokeler, A, Broekhaar, DC, and Cortes, N. Motivation unraveled: giving choice to football players to improve anterior cruciate ligament injury prevention. J Strength Cond Res XX(X): 000-000, 2024-Providing athletes some control over a training session facilitates motor skill acquisition. This is a promising concept to use in anterior cruciate ligament (ACL) injury prevention, as the key for risk reduction is to improve quality of movement. The goal of this study was to better understand why improved motor learning occurred when football players had the opportunity to choose when to receive feedback when practicing sidestep cutting (SSC) movements. Healthy male recreational football players (n = 22, 22.9 ± 1.7 years, 185.5 ± 7.2 cm, 79.3 ± 9.2 kg) were included and assigned to the self-control (SC) or the yoked (YK) group. The players performed anticipated and unanticipated SSC. They received video instructions and were instructed to "copy the movement of the model to the best of their ability." During the training blocks, the SC group could ask for feedback, whereas the YK group could not. Cutting movement assessment scores (CMAS) were measured to test quality of movement and the Intrinsic Motivation Inventory was administered to measure constructs of motivation. In the anticipated condition, SC group showed better scores in immediate post and the retention test compared with pretest (p < 0.001), whereas the YK group showed worse scores in the retention test compared with immediate posttest (p = 0.001). Perceived competence (p = 0.017) and self-efficacy (p = 0.032) were consistent factors that correlated with improved CMAS in the SC group. This has given us innovative insights into underlying mechanisms optimizing the quality of movement, necessary to improve current ACL injury prevention approaches.

The exploration of remote simulation strategies for the acquisition of psychomotor skills in medicine: a pilot randomized controlled trial

Background

Progress in remote educational strategies was fueled by the advent of the COVID-19 pandemic. This pilot RCT explored the efficacy of a decentralized model of simulation based on principles of observational and peer-to-peer learning for the acquisition of surgical skills.

Methods

Sixty medical students from the University of Montreal learned the running subcuticular suture in four different conditions: (1) Control group (2) Self-learning (3) Peer-learning (4) Peer-learning with expert feedback. The control group learned with error-free videos, while the others, through videos illustrating strategic sub-optimal performances to be identified and discussed by students. Performance on a simulator at the end of the learning period, was assessed by an expert using a global rating scale (GRS) and checklist (CL).

Results

Students engaging in peer-to-peer learning strategies outperformed students who learned alone. The presence of an expert, and passive vs active observational learning strategies did not impact performance.

Conclusion

This study supports the efficacy of a remote learning strategy and demonstrates how collaborative discourse optimizes the students' acquisition of surgical skills. These remote simulation strategies create the potential for implantation in future medical curriculum design.Trial Registration: NCT04425499 2020-05-06.

An evolutionary concept analysis of learner-centered teaching

BACKGROUND

An increasing emphasis on a paradigm shift from the traditional teacher-centered approach has led to the adoption of learner-centered teaching in many nursing education programs. However, the lack of consensus regarding the meaning warranted an analysis of learner-centered teaching.

OBJECTIVE

The objective of this analysis was to clarify the concept of learner-centered teaching for nursing education and research.

DESIGN

An evolutionary framework was used to perform a comprehensive review of both theoretical and empirical literature relevant to learner-centered teaching. An evolutionary concept analysis is a method of inquiry used to analyze the literature, with the purpose of identifying the attributes, antecedents, and consequences of a concept.

SAMPLE AND SETTING

Empirical and theoretical literature selected from the fields of education, nursing, and medicine.

METHODS

A comprehensive review and analysis of theoretical and empirical publications from nursing, medicine and education disciplines provided a rich data source for this concept analysis.

RESULTS

Four defining attributes of learner-centered teaching were identified: autonomy, empowerment, collaboration, and engagement. Four antecedents, three surrogate terms, eight related concepts, and nine primary consequences of learner-centered teaching were also identified. Exemplar cases of learner-centered teaching emerged from personal teaching practice experience and the empirical literature.

CONCLUSIONS

Learner-centered teaching is a complex concept with many aspects conceptualized or operationalized which make it difficult to authoritatively define the concept. However, the features of learner-centered teaching identified in this analysis offered a good basis for the evaluation, application, and further development of the concept in nursing.

A Systematic Review and Meta-analysis on the Impact of Proficiency-based Progression Simulation Training on Performance Outcomes

OBJECTIVE

To analyze all published prospective, randomized, and blinded clinical studies on the proficiency-based progression (PBP) training using objective performance metrics.

BACKGROUND

The benefit of PBP methodology to learning clinical skills in comparison to conventional training is not settled.

METHODS

Search of PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases, from inception to 1st March 2020. Two independent reviewers extracted the data. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess the methodological quality of included studies. Results were pooled using biased corrected standardized mean difference and ratio-of-means. Summary effects were evaluated using a series of fixed and random effects models. The primary outcome was the number of procedural errors performed comparing PBP and non-PBP-based training pathways. Secondary outcomes were the number of procedural steps completed and the time to complete the task/procedure.

RESULTS

From the initial pool of 468 studies, 12 randomized clinical studies with a total of 239 participants were included in the analysis. In comparison to the non-PBP training, ratio-of-means results showed that PBP training reduced the number of performance errors by 60% (P < 0.001) and procedural time by 15% (P = 0.003) and increased the number of steps performed by 47% (P < 0.001).

CONCLUSIONS AND RELEVANCE

Our systematic review and meta-analysis confirms that PBP training in comparison to conventional or quality assured training improved trainees' performances, by decreasing procedural errors and procedural time, while increasing the number of correct steps taken when compared to standard simulation-based training.

Maintaining technical proficiency in senior surgical fellows during the COVID-19 pandemic through virtual teaching

Objectives

The novel coronavirus (COVID-19) pandemic resulted in a severe reduction in operative opportunities for trainees. We hypothesized that augmenting independent practice with a bench model of vascular anastomoses using regular videoconferences and individual feedback would provide meaningful benefit in maintenance of technical skills in senior lung transplant surgical fellows.

Methods

A lung transplantation virtual technical skills course was developed. Surgical fellows were provided with a bench model and surgical instruments. Using a virtual communication platform, teaching sessions were held twice weekly, and fellows performed an anastomosis on camera. Video recordings were reviewed and critiqued by attending staff. At the end of the 3-month course, participants were surveyed about their experience. Warm ischaemic time was compared between fellows' five most recent cases before and after the pandemic.

Results

Seven senior surgical fellows participated and provided feedback. Fellows had graduated medical school an average of 14 years prior to fellowship, and spent an average of 5 hours (range 1.3 - 15 hours) of home practice. Five of seven (71%) participants reported improvement in their technical skills and increased confidence in performing a lung transplant. No significant difference in warm ischaemic time in procedures performed by fellows was identified (70.3 minutes pre-pandemic vs. 68.3 minutes post pandemic, p = 0.68).

Conclusions

A program of virtual technical skills teaching, individual video coaching, and independent practice provided benefit in maintaining technical skills in lung transplant surgical fellows during the COVID-19 pandemic, when equivalent operative experience was unavailable. Lessons learned from this exceptional time can be used to create simulation curricula for senior trainees.

Education in the placement of ultrasound-guided peripheral venous catheters: a systematic review

BACKGROUND

Placing a peripheral vein catheter can be challenging due to several factors, but using ultrasound as guidance increases the success rate. The purpose of this review is to investigate the knowledge already existing within the field of education in ultrasound-guided peripheral vein catheter placement and explore the efficacy and clinical impact of different types of education.

METHODS

In accordance with PRISMA-guidelines, a systematic search was performed using three databases (PubMed, EMBASE, CINAHL). Two reviewers screened titles and abstracts, subsequently full-text of the relevant articles. The risk of bias was assessed using the Cochrane Collaboration risk of bias assessment tool and the New Ottawa scale.

RESULTS

Of 3409 identified publications, 64 were included. The studies were different in target learners, study design, assessment tools, and outcome measures, which made direct comparison difficult. The studies addressed a possible effect of mastery learning and found e-learning and didactic classroom teaching to be equally effective.

CONCLUSION

Current studies suggest a potential benefit of ultrasound guided USG-PVC training on success rate, procedure time, cannulation attempts, and reducing the need for subsequent CVC or PICC in adult patients. An assessment tool with proven validity of evidence to ensure competence exists and education strategies like mastery learning, e-learning, and the usage of color Doppler show promising results, but an evidence-based USG-PVC-placement training program using these strategies combined is still warranted.

The impact of an electronic guide on students' self-directed learning in simulation clinic

INTRODUCTION

Simulation training on high-fidelity simulated models have been used to provide a safe and effective training platform for dental students to develop the skills necessary to treat patients. To surpass challenges of traditional pedagogies in simulation training and reinforce self-directed learning, a bespoke computer application, PerioPal, was designed to complement training of dental students in periodontal instrumentation.

MATERIALS AND METHODS

This study evaluated the impact of PerioPal on a cohort of 92 second-year dental students at an Australian University. During the first semester in 2019, they received traditional simulation periodontal instrumentation training (control semester). In the following semester, PerioPal was implemented as a technological teaching adjunct (intervention semester). Student perceptions of their learning experiences were gathered through a qualitative and quantitative questionnaire. Impact on student performance was evaluated through comparing periodontal instrumental assessment results in control and interventionsemesters.

RESULTS

With introduction of PerioPal, students perceived that the simulation clinic learning environment, better contributed to the speed at which they learnt new instrumentation as well as being able to self-pace their work. They commented that instructional videos and independent learning were most beneficial. Interestingly, students suggested that PerioPal aided their preparation for theoretical assessments more than their practical assessments. After introduction of PerioPal a minor improvement of average practical assessment marks was observed but could not be statistically confirmed as significant.

CONCLUSION

Although the computer-supported learning did not lead to improvement of the students' practical performance a positive effect on the student self-paced learning experience and engagement in simulated environment were observed.

Effects of adaptive and non-adaptive three-week executive control training on interference control: Evidence from the N2, CRN, and ERN

The current pilot study investigated if interference control can be improved by a three-week at-home training comprising a flanker and a n-back task in healthy adults, thus exploring the training's suitability for future clinical application, i.e. as a treatment augmentation for psychological disorders. As training gains are assumed to be modulated by the amount of mismatch between task demands and brain resources, an adaptive and a non-adaptive training were contrasted in separate experiments. In the adaptive training, task difficulty was continuously adapted to participants' performance. In the non-adaptive training procedure, task difficulty remained stable on the lowest difficulty level. As deficits in interference control in psychological disorders often predominantly manifest on the electrophysiological level, the impact of the training procedures on medio-frontal negativities (N2, CRN, ERN) was investigated in addition to behavioral measures. The adaptive training led to significant improvements in interference control, as reflected in reduced response times and error rates in incompatible trials. This was accompanied by specific and complementary changes in medio-frontal negativities: After the adaptive training the N2 in incompatible trials was larger and the CRN in incompatible trials was reduced. The non-adaptive training procedure led to generally faster response times but also an increased error rate, indicating a speed-accuracy trade-off. This was accompanied by global changes to medio-frontal negativities irrespective of compatibility, possibly indicating task disengagement. Taken together, the current studies demonstrate that an adaptive training procedure can improve interference control thereby opening up possible clinical applications.

The Effect of Gradual Self-Control of Task Difficulty and Feedback on Learning Golf Putting

Purpose: This study aimed to examine the effect of gradual self-control of task difficulty and feedback on accuracy and movement pattern of the golf putting sport skill. Method: Sixty students were quasi-randomly assigned to four groups under a varying combination of the two factors of task difficulty control (self-controlled or yoked) and feedback control (self-controlled or yoked). The participants in the two groups (dual-factor gradual self-control and self-controlled task difficulty group) that granted control over task difficulty in the acquisition phase were told they could choose any of the pre-set distances from the target. All groups were given 100% feedback in the first half of the acquisition phase, but the participants in the two groups (dual-factor gradual self-control group and self-controlled feedback) that could control their feedback were told that in the second half of the acquisition phase they would be able to ask for feedback when needed. The practice schedule of each member of the dual-factor gradual self-control group was used as a basis to plan the practice of predetermined distances and feedback presentation to the corresponding participants in the yoked conditions. Results: ANOVA with repeated measures showed that the practice method involving gradual self-control of two factors had a positive impact on accuracy and movement pattern of golf putting in the retention and transfer tests compared to other methods (p_s < .05). Conclusion: The advantages of self-control practice presumably come from better adjustment of challenge points by the learner in the course of the practice.

Nursing Simulation and Transfer of Knowledge in Undergraduate Nursing Programs: A Literature Review

AIM

The purpose of this literature review was to describe what research has been conducted on transfer of knowledge using high-fidelity patient simulation (HFPS) and determine what further research is needed.

BACKGROUND

The use of HFPS has expanded rapidly in recent years. There is research suggesting that HFPS effectively educates nurses for clinical practice.

METHOD

An extensive literature search was conducted and analyzed for themes. Exclusion criteria were studies that focused only on graduate-level nursing education, accelerated programs, medical students, registered nurses, and use of low-fidelity simulation or standardized patients.

RESULTS

Themes that emerged included competence, confidence, safety, timing, method and delivery. Study results varied, with only some showing transfer.

CONCLUSION

More research is needed to determine how HFPS influences knowledge transfer to the clinical setting.

Simulation-based mastery learning in medical students: Skill retention at 1-year follow up

Context: Deficits in basic skill performance and long-term skill retention among medical students and novice doctors are a persistent problem. This controlled study tested whether the addition of a mastery learning component to simulation-based teaching is associated with long-term retention and performance of peripheral venous catheter insertion. Methods: Fourth-year medical students were assigned to receive either the control (simulation without mastery learning, n = 131) or the intervention (simulation + mastery learning, n = 133) instruction in peripheral venous catheter insertion. Performance was assessed at one year post-instruction. Eighty-four students from the control group and 71 from the intervention group participated in the assessment. Results: Students who received the mastery learning instruction achieved higher overall test scores than did controls (median mastery learning score: 20.0, IQR 2.0; median control score 19.0, IQR 3.0; Mann-Whitney U test, p < 0.001, effect size d = 0.82). Pass rates also differed significantly between the groups, with 74.5% (n = 53) of the intervention group passing compared with 33% (n = 28) of the control group (p < 0.001). Conclusions: Mastery learning is an effective means of teaching practical skills to medical students, and is associated with higher scores at a 1-year follow up.

Supporting self-regulation in simulation-based education: a randomized experiment of practice schedules and goals

Self-regulated learning is optimized when instructional supports are provided. We evaluated three supports for self-regulated simulation-based training: practice schedules, normative comparisons, and learning goals. Participants practiced 5 endoscopy tasks on a physical simulator, then completed 4 repetitions on a virtual reality simulator. Study A compared two practice schedules: sequential (master each task in assigned order) versus unstructured (trainee-defined). Study B compared normative comparisons framed as success (10% of trainees were successful) versus failure (90% of trainees were unsuccessful). Study C compared a time-only goal (go 1 min faster) versus time + quality goal (go 1 min faster with better visualization and scope manipulation). Participants (18 surgery interns, 17 research fellows, 5 medical/college students) were randomly assigned to groups. In Study A, the sequential group had higher task completion (10/19 vs. 1/21; P < .001), longer persistence attempting an ultimately incomplete task (20.0 vs. 15.9 min; P = .03), and higher efficiency (43% vs. 27%; P = .02), but task time was similar between groups (20.0 vs. 22.6 min; P = .23). In Study B, the success orientation group had higher task completion (10/16 vs. 1/24; P < .001) and longer persistence (21.2 vs. 14.6 min; P = .001), but efficiency was similar (33% vs. 35%; P = .84). In Study C, the time-only group had greater efficiency than time + quality (56% vs. 41%; P = .03), but task time did not differ significantly (172 vs. 208 s; P = .07). In this complex motor task, a sequential (vs. unstructured) schedule, success (vs. failure) orientation, and time-only (vs. time + quality) goal improved some (but not all) performance outcomes.

Examining the impact of error estimation on the effects of self-controlled feedback

Two experiments were conducted that examined the motivational and informational perspectives concerning learning advantages from self-controlled practice. Three groups were tasked with learning a novel skill; self-controlled (SC), yoked traditional (YT), and yoked with error estimation required during the acquisition phase (YE). Results from the delayed learning measures showed the YE group performed better than the SC and YT groups, for Expt. 1. A similar pattern emerged for Expt. 2, albeit, this was not significant. While there were no motivation differences across the groups in either experiment, a strong correlation in Expt. 2 was shown between error estimation capabilities, which were best for the YE group, and learning. These combined results suggest that informational processes contribute more to the self-controlled feedback learning advantage, relative to motivational contributions.

Integrating simulation based learning into nursing education programs: Hybrid simulation

BACKGROUND

Hybrid simulation can be developed with mannequins of any fidelity and tabletop simulators with a standardized patient to create a complex, high-level learning activity.

OBJECTIVE

The aim of this study is to analyze the effects of a hybrid simulation technique used with nursing students in a scenario about the emergency setting.

METHODS

This one-group pre-test post-test model quasi-experimental study was carried out with 39 students in Ankara, Turkey, from October 2014 to July 2015.

RESULTS

Nearly all participants reported that the simulation improved their critical thinking, decision-making skills, and self-confidence before the clinical activity and that they felt as though they were real nurses during the activity (94.7%, 97.3%, 84.2%, and 92.1%, respectively).

CONCLUSION

The results of this study support the integration of hybrid simulation experiences throughout the nursing curriculum, as evidenced by positive responses from students through the simulation evaluation questionnaire.

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.

Self-learning basic life support: A randomised controlled trial on learning conditions

AIM OF THE STUDY

To investigate whether pure self-learning without instructor support, resulted in the same BLS-competencies as facilitator-led learning, when using the same commercially available video BLS teaching kit.

METHODS

First-year medical students were randomised to either BLS self-learning without supervision or facilitator-led BLS-teaching. Both groups used the MiniAnne kit (Laerdal Medical, Stavanger, Norway) in the students' local language. Directly after the teaching and three months later, all participants were tested on their BLS-competencies in a simulated scenario, using the Resusci Anne SkillReporter™ (Laerdal Medical, Stavanger, Norway). The primary outcome was percentage of correct cardiac compressions three months after the teaching. Secondary outcomes were all other BLS parameters recorded by the SkillReporter and parameters from a BLS-competence rating form.

RESULTS

240 students were assessed at baseline and 152 students participated in the 3-month follow-up. For our primary outcome, the percentage of correct compressions, we found a median of 48% (interquartile range (IQR) 10-83) for facilitator-led learning vs. 42% (IQR 14-81) for self-learning (p = 0.770) directly after the teaching. In the 3-month follow-up, the rate of correct compressions dropped to 28% (IQR 6-59) for facilitator-led learning (p = 0.043) and did not change significantly in the self-learning group (47% (IQR 12-78), p = 0.729).

CONCLUSIONS

Self-learning is not inferior to facilitator-led learning in the short term. Self-learning resulted in a better retention of BLS-skills three months after training compared to facilitator-led training.

Incorporating simulation into gynecologic surgical training

Today's educational environment has made it more difficult to rely on the Halstedian model of "see one, do one, teach one" in gynecologic surgical training. There is decreased surgical volume, but an increased number of surgical modalities. Fortunately, surgical simulation has evolved to fill the educational void. Whether it is through skill generalization or skill transfer, surgical simulation has shifted learning from the operating room back to the classroom. This article explores the principles of surgical education and ways to introduce simulation as an adjunct to residency training. We review high- and low-fidelity surgical simulators, discuss the progression of surgical skills, and provide options for skills competency assessment. Time and money are major hurdles when designing a simulation curriculum, but low-fidelity models, intradepartmental cost sharing, and utilizing local experts for simulation proctoring can aid in developing a simulation program.

Progressive learning in endoscopy simulation training improves clinical performance: a blinded randomized trial

BACKGROUND AND AIMS

A structured comprehensive curriculum (SCC) that uses simulation-based training (SBT) can improve clinical colonoscopy performance. This curriculum may be enhanced through the application of progressive learning, a training strategy centered on incrementally challenging learners. We aimed to determine whether a progressive learning-based curriculum (PLC) would lead to superior clinical performance compared with an SCC.

METHODS

This was a single-blinded randomized controlled trial conducted at a single academic center. Thirty-seven novice endoscopists were recruited and randomized to either a PLC (n = 18) or to an SCC (n = 19). The PLC comprised 6 hours of SBT, which progressed in complexity and difficulty. The SCC included 6 hours of SBT, with cases of random order of difficulty. Both groups received expert feedback and 4 hours of didactic teaching. Participants were assessed at baseline, immediately after training, and 4 to 6 weeks after training. The primary outcome was participants' performance during their first 2 clinical colonoscopies, as assessed by using the Joint Advisory Group Direct Observation of Procedural Skills assessment tool (JAG DOPS). Secondary outcomes were differences in endoscopic knowledge, technical and communication skills, and global performance in the simulated setting.

RESULTS

The PLC group outperformed the SCC group during first and second clinical colonoscopies, measured by JAG DOPS (P < .001). Additionally, the PLC group had superior technical and communication skills and global performance in the simulated setting (P < .05). There were no differences between groups in endoscopic knowledge (P > .05).

CONCLUSIONS

Our findings demonstrate the superiority of a PLC for endoscopic simulation, compared with an SCC. Challenging trainees progressively is a simple, theory-based approach to simulation whereby the performance of clinical colonoscopies can be improved. (Clinical trial registration number: NCT02000180.).

Defining and comparing learning actions in two simulation modalities: students training on a latex arm and each other's arms

AIMS AND OBJECTIVES

To explore, describe and compare learning actions that nursing students used during peripheral vein cannulation training on a latex arm or each other's arms in a clinical skills centre.

BACKGROUND

Simulation-based training is thought to enhance learning and transfer of learning from simulation to the clinical setting and is commonly recommended in nursing education. What students actually are doing during simulation-based training is, however, less explored. The analysis of learning actions used during simulation-based training could contribute to development and improvement of simulation as a learning strategy in nursing education.

DESIGN

A qualitative explorative and descriptive research design, involving content analysis of video recordings, was used.

METHODS

Video-supported observation of nine nursing students practicing vein cannulation was conducted in a clinical skills centre in late 2012.

RESULTS

The students engaged in various learning actions. Students training on a latex arm used a considerably higher number of learning actions relative to those training on each other's arms. In both groups, students' learning actions consisted mainly of seeking and giving support. The teacher provided students training on each other's arms with detailed feedback regarding insertion of the cannula into the vein, while those training on a latex arm received sparse feedback from the teacher and fellow students.

CONCLUSION

The teacher played an important role in facilitating nursing students' practical skill learning during simulation. The provision of support from both teachers and students should be emphasised to ensure that nursing students' learning needs are met.

RELEVANCE TO CLINICAL PRACTICE

This study suggest that student nurses may be differently and inadequately prepared in peripheral vein cannulation in two simulation modalities used in the academic setting; training on a latex arm and on each other's arms.

Self-regulated learning in simulation-based training: a systematic review and meta-analysis

CONTEXT

Self-regulated learning (SRL) requires an active learner who has developed a set of processes for managing the achievement of learning goals. Simulation-based training is one context in which trainees can safely practise learning how to learn.

OBJECTIVES

The purpose of the present study was to evaluate, in the simulation-based training context, the effectiveness of interventions designed to support trainees in SRL activities. We used the social-cognitive model of SRL to guide a systematic review and meta-analysis exploring the links between instructor supervision, supports or scaffolds for SRL, and educational outcomes.

METHODS

We searched databases including MEDLINE and Scopus, and previous reviews, for material published until December 2011. Studies comparing simulation-based SRL interventions with another intervention for teaching health professionals were included. Reviewers worked independently and in duplicate to extract information on learners, study quality and educational outcomes. We used random-effects meta-analysis to compare the effects of supervision (instructor present or absent) and SRL educational supports (e.g. goal-setting study guides present or absent).

RESULTS

From 11,064 articles, we included 32 studies enrolling 2482 trainees. Only eight of the 32 studies included educational supports for SRL. Compared with instructor-supervised interventions, unsupervised interventions were associated with poorer immediate post-test outcomes (pooled effect size: -0.34, p = 0.09; n = 19 studies) and negligible effects on delayed (i.e. > 1 week) retention tests (pooled effect size: 0.11, p = 0.63; n = 8 studies). Interventions including SRL supports were associated with small benefits compared with interventions without supports on both immediate post-tests (pooled effect size: 0.23, p = 0.22; n = 5 studies) and delayed retention tests (pooled effect size: 0.44, p = 0.067; n = 3 studies).

CONCLUSIONS

Few studies in the simulation literature have designed SRL training to explicitly support trainees' capacity to self-regulate their learning. We recommend that educators and researchers shift from thinking about SRL as learning alone to thinking of SRL as comprising a shared responsibility between the trainee and the instructional designer (i.e. learning using designed supports that help prepare individuals for future learning).

Verification of accurate technical insight: a prerequisite for self-directed surgical training

Simulation-based surgical skills training during preclinical education is a persistent challenge due to time constraints of trainees and instructors alike. Self-directed practice is resource-efficient and flexible; however, insight into technical proficiency among trainees is often lacking. The purpose of this study is to prospectively assess the accuracy of self-assessments among medical students learning basic surgical suturing. Over seven weekly practice sessions, preclinical medical students performed serial repetitions of a simulation-based suturing task under one-on-one observation by one of four trainers. Following each task repetition, self- and trainer-assessments (SA-TA) were performed using a 36-point weighted checklist of technical standards developed a priori by expert consensus. Upon study completion, agreement between SA and TA was measured using weighted Cohen's kappa coefficients. Twenty-nine medical students each performed a median of 25 suture task repetitions (IQR 21.5-28). Self-assessments tended to overestimate proficiency during the first tertile of practice attempts. Agreement between SA and TA improved with experience, such that the weighted kappa statistics for the two-handed and instrument ties were >0.81 after 18-21 task attempts. Inexperienced trainees frequently overestimate technical proficiency through self-assessments. However, this bias diminishes with repetitive practice. Only after trainees have attained the capacity to accurately self-assess can effective self-directed learning take place.

Effects of self-control and instructor-control feedback on motor learning in individuals with cerebral palsy

In this study we investigated the effects of "self-control and instructor-control feedback" on motor learning in individuals with cerebral palsy (CP). For this reason 22 boy students with CP type I (12.26±3.11 years of age) were chosen. They were put into self-control feedback, instructor-control feedback and control groups. All participants practiced dart throwing skill for 5 sessions (4 blocks of 5 trails each session). The self-control group received knowledge of results (KR) feedback for half of their trials whenever they wanted. The instructor-control group received KR feedback after half of both their good and bad trails. The control group received no feedback for any trails. The acquisition test was run immediately at the end of each practice session (the last block) and the retention and transfer tests were run 24h following the acquisition phase. Analyses of variance with repeated measures and Post hoc tests were used to analyze the data. According to the results of this study, individuals with CP have the ability of acquiring and retaining a new motor skill. Also, it was found that self-control feedback is effective than instructor-control feedback on learning of a motor task in individuals with CP as in the average population. These findings show that rules regarding feedback also apply to people afflicted with CP.

Preparedness of urban, general emergency department staff for neonatal resuscitation in a Canadian setting

OBJECTIVES

The level of expertise and degree of training in neonatal resuscitation (NNR) of emergency physicians is not standardized and has not been measured. We sought to determine the self-reported comfort with, knowledge of, and experience with NNR of emergency department (ED) staff in a general ED prior to the opening of a new neonatal intensive care unit (NICU) and to explore factors associated with NNR comfort.

METHODS

Using Dillman methodology, we electronically surveyed full-time emergency physicians and nurses. Participants rated knowledge, comfort, and experience on 5-point Likert scales. We used logistic regression to explore factors associated with NNR comfort.

RESULTS

The response rate was 67.3% (n  =  107). Only 4.2% of staff reported ever participating in a NNR, and only 38.7% reported any previous NNR training. Between 75 and 85% of participants rated their comfort level in caring for neonates, sense of preparedness, and knowledge of managing a sick neonate as poor or very poor. A recent neonatal clinical encounter was the strongest predictor of perceived comfort in NNR (OR  =  22.2, 95% CI 5.0-98.7), as was completion of the Neonatal Resuscitation Provider (NRP) course (OR  =  3.1, 95% CI 1.4-7.0).

CONCLUSIONS

Perceived comfort with, knowledge of, and preparedness for NNR were poor in an urban, general ED prior to the opening of an NICU. Recent neonatal clinical encounter and participation in the NRP course were the strongest predictors of improved NNR comfort. In future work, we intend to assess the impact of simulation-based training on comfort with NNR among ED staff who primarily treat adults.

Mastery learning for health professionals using technology-enhanced simulation: a systematic review and meta-analysis

PURPOSE

Competency-based education requires individualization of instruction. Mastery learning, an instructional approach requiring learners to achieve a defined proficiency before proceeding to the next instructional objective, offers one approach to individualization. The authors sought to summarize the quantitative outcomes of mastery learning simulation-based medical education (SBME) in comparison with no intervention and nonmastery instruction, and to determine what features of mastery SBME make it effective.

METHOD

The authors searched MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, Scopus, key journals, and previous review bibliographies through May 2011. They included original research in any language evaluating mastery SBME, in comparison with any intervention or no intervention, for practicing and student physicians, nurses, and other health professionals. Working in duplicate, they abstracted information on trainees, instructional design (interactivity, feedback, repetitions, and learning time), study design, and outcomes.

RESULTS

They identified 82 studies evaluating mastery SBME. In comparison with no intervention, mastery SBME was associated with large effects on skills (41 studies; effect size [ES] 1.29 [95% confidence interval, 1.08-1.50]) and moderate effects on patient outcomes (11 studies; ES 0.73 [95% CI, 0.36-1.10]). In comparison with nonmastery SBME instruction, mastery learning was associated with large benefit in skills (3 studies; effect size 1.17 [95% CI, 0.29-2.05]) but required more time. Pretraining and additional practice improved outcomes but, again, took longer. Studies exploring enhanced feedback and self-regulated learning in the mastery model showed mixed results.

CONCLUSIONS

Limited evidence suggests that mastery learning SBME is superior to nonmastery instruction but takes more time.

Divergence in student and educator conceptual structures during auscultation training

CONTEXT

Simulation-based medical education allows trainees to engage in self-regulated learning (SRL), yet research aimed at elucidating the mechanisms of SRL in this context is relatively absent. We compared 'unguided' SRL with 'directed' SRL (DSRL), wherein learners followed an expert-designed booklet.

METHODS

Year 1 medical students (n = 37) were randomly assigned to practise identifying seven cardiac murmurs using a simulator and video only (SRL group) or a simulator and video plus the booklet (DSRL group). All participants completed a 22-item test 3 weeks later. To compare interventions, we analysed students' diagnostic accuracy. As a novel source of evidence, we documented how participants autonomously sequenced the seven murmurs during initial and delayed practice sessions. In addition, we surveyed clinical educators (n = 17) to find out how they would sequence their teaching of these murmurs.

RESULTS

The DSRL group used 50% more training time than the SRL group (p < 0.001). The groups' diagnostic accuracy, however, did not differ significantly on the post-test, retention test or transfer test items (p > 0.12). Despite practising with the expert-defined 'timing-based' approach to murmur diagnosis (i.e. systolic versus diastolic), 84% of DSRL participants implemented a location-based approach (i.e. practising aortic murmurs separately from mitral murmurs) during a second, unguided practice session. Notably, most SRL participants used that same approach spontaneously. By contrast, clinical educators were split in their use of the timing-based (n = 10) and the location-based (n = 6) approaches. Chi-squared analyses suggested educators' conceptions for organising murmurs differed significantly from students' conceptions.

CONCLUSIONS

Contrary to our predictions, directing students' SRL produced no additional benefit and increased their practice time. Our findings suggest one potential source of these results was a divergence between student and educator conceptions for structuring the practice of cardiac auscultation skills. This phenomenon has not been well articulated in the medical education literature, and may have important implications in many (especially technology-mediated) educational contexts.

Understanding Self-Controlled Motor Learning Protocols through the Self-Determination Theory

The purpose of the present review was to provide a theoretical understanding of the learning advantages underlying a self-controlled practice context through the tenets of the self-determination theory (SDT). Three micro-theories within the macro-theory of SDT (Basic psychological needs theory, Cognitive Evaluation Theory, and Organismic Integration Theory) are used as a framework for examining the current self-controlled motor learning literature. A review of 26 peer-reviewed, empirical studies from the motor learning and medical training literature revealed an important limitation of the self-controlled research in motor learning: that the effects of motivation have been assumed rather than quantified. The SDT offers a basis from which to include measurements of motivation into explanations of changes in behavior. This review suggests that a self-controlled practice context can facilitate such factors as feelings of autonomy and competence of the learner, thereby supporting the psychological needs of the learner, leading to long term changes to behavior. Possible tools for the measurement of motivation and regulation in future studies are discussed. The SDT not only allows for a theoretical reinterpretation of the extant motor learning research supporting self-control as a learning variable, but also can help to better understand and measure the changes occurring between the practice environment and the observed behavioral outcomes.

Directed self-regulated learning versus instructor-regulated learning in simulation training

OBJECTIVES

Simulation training offers opportunities for unsupervised, self-regulated learning, yet little evidence is available to indicate the efficacy of this approach in the learning of procedural skills. We evaluated the effectiveness of directed self-regulated learning (DSRL) and instructor-regulated learning (IRL), respectively, for teaching lumbar puncture (LP) using simulation.

METHODS

We randomly assigned internal medicine residents in postgraduate year 1 to either DSRL ('directed' to progress from easy to difficult LP simulators during self-regulated learning) or IRL (in groups of four led by an instructor). All participants practised for up to 50 minutes and completed a pre-test, post-test and delayed (by 3 months) retention test on the simulator. Pairs of blinded trained experts independently rated all videotaped performances using a validated global rating scale and a modified version of a validated checklist. Participants provided measures of LP experience and self-reported confidence. We analysed the pre-post (n = 42) and pre-post-retention performance scores (n = 23) using two separate repeated-measures analyses of variance (anovas) and computed Pearson correlation coefficients between participants' confidence and performance scores.

RESULTS

Inter-rater agreement was strong for both performance measures (intra-class correlation coefficient > 0.81). The groups achieved similar pre-test and post-test scores (p > 0.05) and scores in both groups improved significantly from the pre- to the post-test (p < 0.05). On retention, a significant interaction (F(2,42) = 3.92, p = 0.03) suggests the DSRL group maintained its post-test performance, whereas that in the IRL group dropped significantly (p < 0.05). Correlations between self-reported confidence and post-test performance were positive and significant for the DSRL group, and negative and non-significant for the IRL group.

CONCLUSIONS

Both IRL and DSRL led to improved LP performance immediately after practice. Whereas the IRL group's skills declined after 3 months, the DSRL group's performance was maintained, suggesting a potential long-term benefit of this training. Participants in the DSRL group also developed a more accurate relationship between confidence and competence following practice. Further research is needed to clarify the mechanisms of self-regulated learning and its role in simulation contexts.

Trainees' perceptions of practitioner competence during patient transfer

BACKGROUND

Technical and communicative skills are both important features for one's perception of practitioner competence.

PURPOSE

This research examines how trainees' perceptions of practitioner competence change as they view health care practitioners who vary in their technical and communicative skill proficiencies.

METHODS

Occupational therapy students watched standardized encounters of a practitioner performing a patient transfer in combinations of low and high technical and communicative proficiency and then reported their perceptions of practitioner competence.

RESULTS

The reports indicate that technical and communicative skills have independently identifiable impacts on the perceptions of practitioner competency, but technical proficiency has a special impact on the students' perceptions of practitioner communicative competence.

CONCLUSIONS

The results are discussed with respect to the way in which students may evaluate their own competence on the basis of either technical or communicative skill. The issue of how this may lead trainees to dedicate their independent learning efforts to an incomplete set of features needed for the development of practitioner competency is raised.

Theory and practice in the design and conduct of graduate medical education

Medical education practice is more often the result of tradition, ritual, culture, and history than of any easily expressed theoretical or conceptual framework. The authors explain the importance and nature of the role of theory in the design and conduct of graduate medical education. They outline three groups of theories relevant to graduate medical education: bioscience theories, learning theories, and sociocultural theories. Bioscience theories are familiar to many medical educators but are often misperceived as truths rather than theories. Theories from such disciplines as neuroscience, kinesiology, and cognitive psychology offer insights into areas such as memory formation, motor skills acquisition, diagnostic decision making, and instructional design. Learning theories, primarily emerging from psychology and education, are also popular within medical education. Although widely employed, not all learning theories have robust evidence bases. Nonetheless, many important notions within medical education are derived from learning theories, including self-monitoring, legitimate peripheral participation, and simulation design enabling sustained deliberate practice. Sociocultural theories, which are common in the wider education literature but have been largely overlooked within medical education, are inherently concerned with contexts and systems and provide lenses that selectively highlight different aspects of medical education. They challenge educators to reconceptualize the goals of medical education, to illuminate maladaptive processes, and to untangle problems such as career choice, interprofessional communication, and the hidden curriculum.Theories make visible existing problems and enable educators to ask new and important questions. The authors encourage medical educators to gain greater understanding of theories that guide their educational practices.