A survey-based cross-sectional study of doctors' expectations and experiences of non-technical skills for Out of Hours work

Ward-based in situ simulation: lessons learnt from a UK District General Hospital

INTRODUCTION

In situ simulation (ISS) enables multiprofessional healthcare teams to train for real emergencies in their own working environment and identify latent patient safety threats. This study aimed to determine ISS impact on teamwork, technical skill performance, healthcare staff perception and latent error identification during simulated medical emergencies.

MATERIALS AND METHODS

Unannounced ISS sessions (n=14, n=75 staff members) using a high-fidelity mannequin were conducted in medical, paediatric and rehabilitation wards at Stepping Hill Hospital (Stockport National Health Service Foundation Trust, UK). Each session encompassed a 15 min simulation followed by a 15 min faculty-led debrief.

RESULTS

The clinical team score revealed low overall teamwork performances during simulated medical emergencies (mean±SEM: 4.3±0.5). Linear regression analysis revealed that overall communication (r=0.9, p<0.001), decision-making (r=0.77, p<0.001) and overall situational awareness (r=0.73, p=0.003) were the strongest statistically significant predictors of overall teamwork performance. Neither the number of attending healthcare professionals, their professional background, age, gender, degree of clinical experience, level of resuscitation training or previous simulation experience statistically significantly impacted on overall teamwork performance. ISS positively impacted on healthcare staff confidence and clinical training. Identified safety threats included unknown location of intraosseous kits, poor/absent airway management, incomplete A-E assessments, inability to activate the major haemorrhage protocol, unknown location/dose of epinephrine for anaphylaxis management, delayed administration of epinephrine and delayed/absence of attachment of pads to the defibrillator as well as absence of accessing ALS algorithms, poor chest compressions and passive behaviour during simulated cardiac arrests.

CONCLUSION

Poor demonstration of technical/non-technical skills mandate regular ISS interventions for healthcare professionals of all levels. ISS positively impacts on staff confidence and training and drives identification of latent errors enabling improvements in workplace systems and resources.

Twelve tips for using tactical decision games to teach non-technical skills

Tactical decision games (TDGs) have been used in healthcare and other safety-critical industries to develop non-technical skills training (NTS). TDGs have been shown to be a realistic, feasible, and useful way of teaching NTS such as decision making, task prioritisation, situational awareness, and team working. Our 12-tips for using TDG to teach NTS are based on our experience of integrating them into an undergraduate medical and nursing programme. We cover how to design successful TDGs, how to facilitate and debrief them and how to integrate TDGs into curricula. We have found TDGs to be a cost-effective, low fidelity, and useful method of delivering NTS teaching, ideally as an adjunct to immersive simulation. Learners find them a useful way to be introduced to NTS in a safe and relaxed environment, with particular emphasis on critical decision making and prioritisation.

Teaching Undergraduate Medical Students Non-Technical Skills: An Evaluation Study of a Simulated Ward Experience

PURPOSE

Research suggests that medical students in the UK report a need to be better prepared for the non-technical skills required for the role of a junior doctor. A Simulated Ward Experience was developed in an attempt to address this need. The purpose of this study was (1) to evaluate the effectiveness of the Simulated Ward Experiences by examining students' reactions regarding the quality of teaching and (2) to examine the main drivers of learning and the extent to which students felt it helped them prepare for their future training.

METHODS

A mixed method evaluation study was conducted using a questionnaire and focus groups. Final year students who participated in the Simulated Ward Experience were invited to contribute to the evaluation, out of which 25 completed the questionnaire and 13 took part in focus group interviews. Data analysis were conducted by means of descriptive statistics for questionnaire data and thematic analysis of focus group transcripts.

RESULTS

The median Likert scores for quality of teaching Non-Technical Skills were either very good or excellent, demonstrating that students were highly satisfied with the way in which these were taught. Qualitative data provided further insights into the aspects of the intervention that promoted learning, and these were categorised into four themes, including realism of the simulation; relevance for the role and responsibilities of the Foundation Year 1 Doctor (including Non-Technical Skills); learning from and with others; and supportive learning environment.

CONCLUSION

This evaluation study provides further evidence of the value of learning in a simulated setting, particularly when it is closely aligned to the real clinical context and creates opportunities to practice skills that are perceived to be relevant by the learner. Study limitations are recognised and suggestions for further studies are provided.

A foundation interim year 1 sequential simulation experience and analysis of preparedness to practice early

This project involved the implementation of a simulation session followed by interviews to assess and improve foundation interim year 1 (FiY1) preparedness. The session focused on the interpretation of investigations, clinical examinations, the implementation of management plans and appropriate escalation. Preparedness was measured quantitatively using Likert-type scales and qualitatively using interviews. Following the simulation, there was a significant increase in median preparedness for giving treatment (3 vs 4; p=0.04), paperwork (2 vs 4; p=0.03) and independent, responsible working (3 vs 4.5; p=0.03), before and after, respectively. Following the FiY1 period, participants demonstrated significant improvement in median preparedness for giving treatment (3 vs 4.5; p=0.01), paperwork (2 vs 5; p=0.01), independent, responsible working (3 vs 4.5; p=0.02), and communication and teamworking (4 vs 5; p=0.01), before and after, respectively. This simulation and the FiY1 period increased preparedness. This study suggests that future medical apprenticeships should provide the same opportunities and responsibilities as the FiY1 programme.

Nontechnical Skills (NTS) in the Undergraduate Surgical and Anesthesiology Curricula: Are We Adequately Preparing Medical Students?

OBJECTIVES

Nontechnical skills (NTS) encompass interpersonal, cognitive, and personal resource skills that can mitigate surgical errors and improve patient outcomes. However, inconsistencies in medical student awareness around NTS suggest limited exposure to these skills. This study aimed to determine the prevalence and content of NTS in medical school surgery and anesthesiology education.

DESIGN AND SETTING

Learning objectives from clerkship core surgery and anesthesiology rotations were collected from Canadian anglophone medical schools. Two raters independently classified each objective under one of the Non-Technical Skills for Surgeons (NOTSS) or Anaesthetists' Non-Technical Skills (ANTS) "Categories" and "Elements" of NTS, or as a non-NTS objective. Rater disagreements were resolved by group consensus. Group discussion was also held to identify examples of objectives that could help develop future curricula. Descriptive statistics were used to determine the number of NTS objectives from each school and within each NOTSS and ANTS Categories and Elements.

RESULTS

Learning objectives were obtained from 12 out of 14 Canadian medical schools. A total of 2116 surgery objectives and 571 anesthesiology objectives were reviewed. Of these, 16 (0.76%) and 26 (4.55%) were identified as NTS objectives in surgery and anesthesiology, respectively. Of the NOTSS and ANTS Categories, "Situation Awareness" and "Decision Making" were represented by only one objective each in both specialties. Approximately half of the NOTSS and ANTS Elements were not represented by a single objective. Group discussion yielded examples of NTS objectives that were excellent, could use improvement, or were too vague to be classified as NTS.

CONCLUSIONS

A paucity of objectives in the clerkship perioperative curricula involve NTS. These findings suggest that NTS are unlikely being adequately introduced as critical skillsets of surgeons and anesthesiologists in undergraduate perioperative education. Future curriculum development should involve greater medical student exposure to NTS as key components of their surgery and anesthesiology education.

Ten tips for organising a Bleep Roulette for final year medical students and new foundation trainees

The initial period adjusting to the roles and responsibilities of a new foundation doctor can be a challenging and anxious time for graduating medical students and new trainees. Over recent years, many educational initiatives such as shadowing placements, assistantships and compulsory induction programmes have been implemented to improve medical student preparedness for clinical practice. Despite this, many graduates still report a lack of confidence and preparedness when starting their clinical placements, specifically within the context of on-call shifts. Bleep Roulette simulation sessions are progressively being used to further bridge the gap from student to trainee and ensure trainees develop prioritisation, organisational and clinical reasoning skills, improving trainee efficiency during an on-call shift. In this article, we provide 10 tips for medical educators, detailing how to design an efficacious Bleep Roulette session for final year medical students and new foundation trainees.

Reliability of assessment of medical students’ non-technical skills using a behavioural marker system: does clinical experience matter?

Introduction

Non-technical skills are recognised to play an integral part in safe and effective patient care. Medi-StuNTS (Medical Students’ Non-Technical Skills) is a behavioural marker system developed to enable assessment of medical students’ non-technical skills. This study aimed to assess whether newly trained raters with high levels of clinical experience could achieve reliability coefficients of >0.7 and to compare differences in inter-rater reliability of raters with varying clinical experience.

Methods

Forty-four raters attended a workshop on Medi-StuNTS before independently rating three videos of medical students participating in immersive simulation scenarios. Data were grouped by raters’ levels of clinical experience. Inter-rater reliability was assessed by calculating intraclass correlation coefficients (ICC).

Results

Eleven raters with more than 10 years of clinical experience achieved single-measure ICC of 0.37 and average-measures ICC of 0.87. Fourteen raters with more than or equal to 5 years and less than 10 years of clinical experience achieved single-measure ICC of 0.09 and average-measures ICC of 0.59. Nineteen raters with less than 5 years of clinical experience achieved single-measure ICC of 0.09 and average-measures ICC 0.65.

Conclusions

Using 11 newly trained raters with high levels of clinical experience produced highly reliable ratings that surpassed the prespecified inter-rater reliability standard; however, a single rater from this group would not achieve sufficiently reliable ratings. This is consistent with previous studies using other medical behavioural marker systems. This study demonstrated a decrease in inter-rater reliability of raters with lower levels of clinical experience, suggesting caution when using this population as raters for assessment of non-technical skills.

Out of hours, out of sight? Uncovering the education potential of general practice urgent care for UK undergraduates

There is a need to increase undergraduate primary care exposure and subsequently enhance primary care recruitment. This study aimed to establish the current use and education potential of the primary care out of hours (OOH) learning environment. This was a mix methods study. A questionnaire was sent to UK primary care heads of teaching nationally to explore the current use of GP OOHs in the undergraduate curriculum and focus groups evaluated final year medical students' experience of an OOH placement. There was a 100% response rate from primary care heads of teaching. Despite 86% being in favour of integrating OOH placements within the undergraduate curriculum, only 28% of medical schools currently offer primary care OOH placements. 36 out of 240 students volunteered for a clinical OOH session. Focus group data from 6 of these students revealed that the placements provided unique learning opportunities and allowed students to appreciate the organisational structure of the National Health Service (NHS). However, barriers included logistical difficulties with the OOH providers and inadequate supervision. It appears that we are overlooking a unique educational opportunity for medical undergraduates. With increasing demands for GP exposure within the undergraduate curriculum, GP OOH is a useful resource for UK medical schools.

An interview analysis of coordination behaviours in Out-of-Hours secondary care

This paper seeks to elicit and structure the factors that shape the execution and, in particular, the coordination of work in Out of Hours care. Evenings and weekends in UK hospitals are managed by specific Out of Hours (OoH) care arrangements, and associated technology. Managing care within the constraints of staff availability and demands is a key concern for both patient care and staff wellbeing, yet has received little attention from healthcare human factors. A study of sixteen clinical staff used Critical Decision Method to understand how work is coordinated and the constraints and criteria that are applied by the roles managing OoH care. The analysis identified ten types of coordination decision that, in turn, underpinned three types of adaptive behaviour - pre-emption, information augmentation and self-organisation - that were crucial for the effective performance in OoH care. These behaviours explain how OoH staff manage the task demands placed on them, individually and as a team.

'Waiting in the wings'; Lived experience at the threshold of clinical practice

CONTEXT

The transition to clinical practice is challenging. Lack of preparedness and issues with support, responsibility and complex workplace interactions contribute to the difficulties encountered. The first year of clinical practice is associated with negative consequences for new doctors' health and well-being. The contemporaneous lived experience of new graduates on the threshold of clinical practice has not been described. Deeper understanding of this phase may inform interventions to ease the transition from student to doctor.

METHODS

We used interpretative phenomenological analysis (IPA) to explore the individual experience of making the transition from medical student to doctor, focusing on the period prior to commencing clinical practice. Fourteen recent graduates were purposively recruited, and semi-structured interviews were conducted with each, with respect to how they anticipated the transition.

RESULTS

We draw on the metaphor of the actor 'waiting in the wings' to describe participants' lived experience on the threshold of practice. The experience of the actor, about to step into the spotlight, was mirrored in participants' perceptions of an abrupt transformation to come, mixed feelings about what lay ahead, and the various strategies that they had planned to help them to perform their new role convincingly.

DISCUSSION

Participants in this study braced themselves for a trial by ordeal as they contemplated commencing clinical practice. The hidden curriculum shaped their understanding of what was expected of them as new doctors, and inspired dysfunctional strategies to meet expectations. Solutions to make the experience a more positive one lie in the approximation of the roles of senior medical student and newly qualified doctor, in explicitly addressing the hidden curriculum and generating cultural change. An emphasis on experience-based learning through contribution to patient care, guided reflection on the hidden curriculum and shifting cultural expectations through faculty development and strong local leadership can contribute to these objectives.

Implementation of a 2-Day Simulation-Based Course to Prepare Medical Graduates on Their First Year of Residency

OBJECTIVES

Residents beginning their specialization in pediatrics and emergency medicine (EM) are rapidly involved in oncall duties. Early acquisition of crisis resource management by novice residents is essential for patient safety, but traditional training may be insufficient. Our aim was to investigate the impact of a 2-day simulation-based course on residents to manage pediatric and neonatal patients.

METHODS

First year residents participated in the course. They completed two questionnaires concerning perceived stress and self-efficacy in technical skills (TSs) and non-TSs (NTSs) at 3 times: before (T0), after (T1), and 6 weeks after the course (T2).

RESULTS

Eleven pediatric and 5 EM residents participated. At T0, stress about "communicating with parents" (P = 0.022) and "coordinating the team" (P = .037) was significantly higher among pediatric compared with EM residents; self-efficacy was not different between the specialities. After training, perceived stress about "managing a critical ill child" and perceived stress total significantly decreased among EM residents, whereas it remained the same among pediatricians (respectively, P = 0.001 and P = 0.016). Regarding self-efficacy, it had significantly increased in both groups (P < 0.001). Specifically, the increase in TSs self-efficacy was significant after the training (p = .008) and after 6 weeks (p < .001), and the increase in NTs self-efficacy was only significant after 6 weeks (P = 0.014).

CONCLUSIONS

Our course improved perceived stress, TSs, and NTSs self-efficacy of residents. This encourages us to formalize this as a prerequisite for admission to the pediatric and EM residency.

Factors affecting -individual task prioritisation in a workplace setting

Task prioritisation (TP), the ability to arrange assigned responsibilities in order of importance, has been identified by doctors as the most important non-technical skill when working out of hours. This review aimed to identify the factors influencing task prioritisation in a workplace setting. The following databases were searched for relevant studies: BNI, CINAHL, EMBASE, MEDLINE and PsycINFO as well as the reference lists of relevant articles, review papers and Google Scholar. Data were extracted from the studies using a standard proforma. Twenty relevant papers were identified from management, aviation and healthcare fields. Task prioritisation ability differed across individuals and was associated with personality and experience. Tasks were prioritised based on length, urgency, importance and reward. With practice people become more efficient at task prioritisation. Practical applications include education, personalised task management software and intrusive notifications. Additional research is needed to assess the effects of such interventions in a healthcare setting.

Exploring the experiences and opinions of hospital pharmacists working 24/7 shifts

Objectives

The expansion of out-of-hours pharmacy services results from a drive to improve patient care and promote integration into the wider healthcare team. However, there has been little attempt to explore these intended outcomes as well as the potential problems arising from working out of hours. The aim of this study was to explore the experiences and views of pharmacists who work shifts as part of a 24/7 pharmacy service.

Methods

Semistructured interviews with shift-working pharmacists were conducted. Data were analysed using a framework approach.

Results

Pharmacists described the positive impact they had on patient safety by ensuring the prompt supply of time-critical medicines and their proactive role in preventing adverse drug events. Pharmacists' on-site presence and attendance at handover promoted integration into the wider team and facilitated unplanned interventions. However, requests for non-urgent supplies were a source of frustration. Disparity of pharmacists' perceptions of senior support demonstrated a need to explore communication further and the importance of non-technical skills, such as communication in service provision. Shift work appeared to be a double-edged sword for work-life balance, preventing participation in regular hobbies, but providing flexibility. Service improvements could include technician support, greater feedback provision and improved ordering processes.

Conclusions

Overall, pharmacists believed the shift service exhibited numerous advantages over a traditional remote on-call service, particularly in improving aspects of patient safety and integration into the wider healthcare team. Clarity of the service scope and development of non-technical skills are areas for improvement and development.

Early acquisition of non-technical skills using a blended approach to simulation-based medical education

Background

Non-technical skills are emerging as an important component of postgraduate medical education. Between 2013 and 2016, a new blended training program incorporating non-technical skills was introduced at an Australian university affiliated hospital. Program participants were medical officers in years 1 and 2 of postgraduate training.

Methods

An interdisciplinary faculty trained in simulation-based education led the program. The blended approach combined open access online resources with multiple opportunities to participate in simulation-based learning. The aim of the study was to examine the value of the program to the participants and the effects on the wider hospital system. The mixed methods evaluation included data from simulation centre records, hospital quality improvement data, and a post-hoc reflective survey of the enrolled participants (n = 68).

Results

Over 30 months, 283 junior doctors were invited to participate in the program. Enrolment in a designated simulation-based course was completed by 169 doctors (59.7%). Supplementary revision sessions were made available to the cohort with a median weekly attendance of five participants. 56/68 (82.4%) of survey respondents reported increased confidence in managing deteriorating patients. During the period of implementation, the overall rate of hospital cardiac arrests declined by 42.3%. Future objectives requested by participants included training in graded assertiveness and neurological emergencies.

Conclusions

Implementation of a non-technical skills program was achieved with limited simulation resources and was associated with observable improvements in clinical performance. The participants surveyed reported increased confidence in managing deteriorating patients, and the program introduction coincided with a significant reduction in the rate of in-hospital cardiac arrests.

NightShift simulation to train newly qualified doctors in non-technical skills: a feasibility study

There is growing evidence of greater rates of morbidity and mortality in hospitals during out-of-hours shifts, which appears to be exacerbated during the period in which newly qualified doctors commence work. In order to combat this issue, an online simulation of a night shift was developed and trialled in order to improve the non-technical skills of newly qualified doctors and, ultimately, improve clinical outcomes. A randomised feasibility trial of the electronic training simulation was performed with medical students (n=30) at the end of their training and in the initial weeks of working at a large teaching hospital. The study showed that participants in the intervention group completed their non-urgent tasks more rapidly than the control group: mean (SD) time to complete a non-urgent task of 85.1 (50.1) versus 157.6 (90.4) minutes, p=0.027. This difference persisted using linear regression analysis, which was undertaken using rota and task volume as independent cofactors (p=0.028). This study shows the potential for simulation technologies to improve non-technical skills.