Deliberate practice improves pediatric residents' skills and team behaviors during simulated neonatal resuscitation

Development of pediatric simulation-based education - a systematic review

BACKGROUND

This systematic literature review explored the general characteristics, validation, and reliability of pediatric simulation-based education (P-SBE).

METHODS

A literature search was conducted between May 23 and 28 using the PRISMA guidelines, which covered databases such as MEDLINE, EMBASE, CINAHL, and Cochrane Library. In the third selection process, the original texts of 142 studies were selected, and 98 documents were included in the final content analysis.

RESULTS

A total of 109 papers have been published in the ten years since 2011. Most of the study designs were experimental studies, including RCT with 76 articles. Among the typologies of simulation, advanced patient simulation was the most common (92), and high-fidelity simulation was the second most common (75). There were 29 compatibility levels and professional levels, with 59 scenarios related to emergency interventions and 19 scenarios related to communication feasibility and decision making. Regarding the effect variable, 65 studies confirmed that skills were the most common. However, validity of the scenarios and effect variables was not verified in 56.1% and 67.3% of studies, respectively.

CONCLUSION

Based on these findings, simulation based-education (SBE) is an effective educational method that can improve the proficiency and competence of medical professionals dealing with child. Learning through simulation provides an immersive environment in which learners interact with the presented patient scenario and make decisions, actively learning the attitudes, knowledge, and skills necessary for medical providers. In the future, it is expected that such research on SBE will be actively followed up and verified for its validity and reliability.

Resuscitators' opinions on using a respiratory function monitor during neonatal resuscitation

AIM

The aim of this study was to assess the resuscitators' opinions of the usefulness and clinical value of using a respiratory function monitor (RFM) when resuscitating extremely preterm infants with positive pressure ventilation.

METHODS

The link to an online survey was sent to 106 resuscitators from six countries who were involved in a multicentre trial that compared the percentage of inflations within a predefined target range with and without the RFM. The resuscitators were asked to assess the usefulness and clinical value of the RFM. The survey was online for 4 months after the trial ended in May 2019.

RESULTS

The survey was completed by 74 (70%) resuscitators of which 99% considered the RFM to be helpful during neonatal resuscitation and 92% indicated that it influenced their decision-making. The majority (76%) indicated that using the RFM improved their practice and made resuscitation more effective, even when the RFM was not available. Inadequate training was the key issue that limited the effectiveness of the RFM: 45% felt insufficiently trained, and 78% felt more training in using and interpreting the RFM would have been beneficial.

CONCLUSION

Resuscitators considered the RFM to be helpful to guide neonatal resuscitation, but sufficient training was required to achieve the maximum benefit.

Improving Pediatric/Neonatology Residents' Newborn Resuscitation Skills With a Digital Serious Game: DIANA

BACKGROUND

Serious games, and especially digital game based learning (DGBL) methodologies, have the potential to strengthen classic learning methodology in all medical procedures characterized by a flowchart (e.g., neonatal resuscitation algorithm). However, few studies have compared short- and long-term knowledge retention in DGBL methodologies with a control group undergoing specialist training led by experienced operators. In particular, resident doctors' learning still has limited representation in simulation-based education literature.

OBJECTIVE

A serious computer game DIANA (DIgital Application in Newborn Assessment) was developed, according to newborn resuscitation algorithm, to train pediatric/neonatology residents in neonatal resuscitation algorithm knowledge and implementation (from procedure knowledge to ventilation/chest compressions rate). We analyzed user learning curves after each session and compared knowledge retention against a classic theoretical teaching session.

METHODS

Pediatric/neonatology residents of the Azienda Ospedaliera Universitaria Pisana (AOUP) were invited to take part in the study and were split into a game group or a control group; both groups were homogeneous in terms of previous training and baseline scores. The control group attended a classic 80 min teaching session with a neonatal trainer, while game group participants played four 20 min sessions over four different days. Three written tests (pre/immediately post-training and at 28 days) were used to evaluate and compare the two groups' performances.

RESULTS

Forty-eight pediatric/neonatology residents participated in the study. While classic training by a neonatal trainer demonstrated an excellent effectiveness in short/long-term knowledge retention, DGBL methodology proved to be equivalent or better. Furthermore, after each game session, DGBL score improved for both procedure knowledge and ventilation/chest compressions rate.

CONCLUSIONS

In this study, DGBL was as effective as classic specialist training for neonatal resuscitation in terms of both algorithm memorization and knowledge retention. User appreciation for the methodology and ease of administration, including remotely, support the use of DGBL methodologies for pediatric/neonatology residents education.

Taking the Pulse on Pediatric Simulation: A National Survey of Pediatric Residency Programs' Simulation Practices and Challenges

OBJECTIVES

There is abundant literature on simulation use in individual pediatric residency programs but limited overall data on simulation in US pediatric residency programs. This study sought to determine how US pediatric residency programs use simulation for teaching and assessment and the challenges programs face in their use of simulation.

METHODS

The Association of Pediatric Program Director's Healthcare Simulation in Pediatrics Learning Community members developed a 15-multipart question survey on the use of simulation in US pediatric residency programs using best practices in survey design. The survey was distributed electronically to US pediatric residency program directors. Qualitative questions were analyzed by content analysis and quantitative questions using descriptive statistics.

RESULTS

The survey response rate was 21%; respondents were disproportionately from large academic medical centers. Qualitative analysis found that respondents use simulation to teach pediatric residents in the areas of urgent/emergent situations, procedures, and communication, and common challenges to simulation implementation are time, physical resources, expertise, competing priorities, logistics, and buy-in. Quantitative analysis demonstrated that, although respondents are largely confident that their simulation programs improve resident preparedness and competence, few objectively evaluate their simulation programs.

CONCLUSIONS

Pediatric residency programs use simulation for similar purposes and face similar challenges. By collaborating, the resources of the national pediatric simulation community can be leveraged to collect evidence for best practices for simulation use in pediatric residency training.

Video recording in the delivery room: current status, implications and implementation

Many factors determine the performance and success of delivery room management of newborn babies. Improving the quality of care in this challenging surrounding has an important impact on patient safety and on perinatal morbidity and mortality. Video recording (VR) offers the advantage to record and store work as done rather than work as recalled. It provides information about adherence to algorithms and guidelines, and technical, cognitive and behavioural skills. VR is feasible for education and training, improves team performance and results of research led to changes of international guidelines. However, studies thus far have not provided data regarding whether delivery room video recording affects long-term team performance or clinical outcomes. Privacy is a concern because data can be stored and individuals can be identified. We describe the current state of clinical practice in high- and low-resource settings, discuss ethical and medical-legal issues and give recommendations for implementation with the aim of improving the quality of care and outcome of vulnerable babies. IMPACT: VR improves performance by health caregivers providing neonatal resuscitation, teaching and research related to delivery room management, both in high as well low resource settings. VR enables information about adherence to guidelines, technical, behavioural and communication skills within the resuscitation team. VR has ethical and medical-legal implications for healthcare, especially recommendations for implementation of VR in routine clinical care in the delivery room. VR will increase the awareness that short- and long-term outcomes of babies depend on the quality of care in the delivery room.

Evaluation of SIMESON, a training program to improve access to quality health care for pregnant women and newborn in different healthcare facilities of northern Bangladesh

Aim

The study aims to explore the current knowledge and skills of healthcare providers already trained by SIMESON (simulation for essential skills for obstetrical and neonatal care), in reviewing perinatal health situations including current status of healthcare facilities and cost estimation.

Design

It was an observational study.

Methods

Cost estimation following both quantitative and qualitative approaches was also attempted.

Result

Knowledge and skills of 88 healthcare providers about the provision of normal delivery and immediate postpartum care, management of postpartum haemorrhage (PPH), retained placenta and use of bag and mask ventilation to help a baby breathe were found to be considerably strengthened following SIMESON training. During the 6 months after training, there were 477 PPH cases managed successfully with only one death; neonatal deaths observed were 6.6/1,000 live births; twice the number of facility deliveries; and 80% use rate of Ambu bag for helping baby breathe. The estimated cost per trainee was 395.68 USD, and 5.85 USD per beneficiary.

Impact of Task-Oriented Role Assignment on Neonatal Resuscitation Performance: A Simulation-Based Randomized Controlled Trial

OBJECTIVE

Task-oriented role assignment (TORA) is the assignment of a specific role, a list of tasks, and a location to stand to each resuscitation team member. We performed this study to examine the impact of TORA training during a Neonatal Resuscitation Program (NRP) course on neonatal resuscitation team technical performance and behavioral skills.

STUDY DESIGN

Participants were cluster randomized into either a standard NRP course (control) or an NRP course with TORA training. Both technical and behavioral skills were evaluated using standardized simulations. The simulations were video recorded and then scored by two blinded reviewers using previously validated instruments.

RESULTS

A total of 65 participants (62 resident physicians and 3 nurses) participated in 108 simulations (48 controls, 60 TORA). Technical skill scores were similar between the two groups (control = 77.6% [±8.4] vs. TORA = 78.1% [±8.1]; p = 0.74). The TORA group had higher behavior skill scores in 8 of the 10 NRP key behavioral skills and had higher overall behavioral skill scores (control = 30.1 [±7.2] vs. TORA = 34.9 [±4.8]; p < 0.001).

CONCLUSION

In resuscitation teams comprising mostly resident physicians, TORA training resulted in better behavioral skills during simulated neonatal resuscitation. Further study on the impact of TORA training on actual resuscitation performance in interdisciplinary teams is warranted.

Deliberate practice and mastery learning in resuscitation education: A scoping review

STUDY AIM

To summarize the current state of knowledge of deliberate practice and mastery learning (DP and/or ML) as teaching methods for resuscitation education.

METHODS

A scoping review of PubMed, Scopus, and Embase was conducted through March 1, 2021. Studies examining the effect of the incorporation of either deliberate practice and/or mastery learning during resuscitation education were eligible for inclusion. Included studies were dichotomized into studies comparing deliberate practice and/or mastery learning to other training methods (randomized controlled trials) and studies examining before and after impact of deliberate practice and/or mastery learning alone (observational studies). Studies and findings were tabulated and summarized using the scoping review methodology published by Arksey and O'Malley.

RESULTS

63 published studies were screened; sixteen studies met all inclusion criteria (4 randomized controlled trials and 12 observational studies). One randomized controlled trial and eleven observational studies demonstrated improvement in skill and/or knowledge following educational interventions using deliberate practice and/or mastery learning. Significant variability between studies with regard to research designs, learner groups, comparators, and outcomes of interest made quantitative summarization of findings difficult.

CONCLUSIONS

The incorporation of deliberate practice and/or mastery learning in resuscitation education may be associated with improved educational outcomes and less skill decay than other educational methods. Current literature on DP and ML suffers from a lack of consistency in research methodology, subjects, and outcomes. Future research should employ uniform definitions for deliberate practice and mastery learning, follow research design that isolates its effect, and examine generalizable and translatable outcomes.

Evaluation of audio-voice guided application for neonatal resuscitation: a prospective, randomized, pilot study

OBJECTIVES

To examine whether audio-voice guidance application improves adherence to resuscitation sequence and recommended time frames during neonatal resuscitation.

METHODS

A prospective, randomized, pilot study examining the use of an audio-voice application for guiding resuscitation on newborn mannequins, based on the Neonatal Resuscitation Program (NRP) algorithm. Two different scenarios, with and without voice guidance, were presented to 20 medical personnel (2 midwives, 8 nurses, and 10 physicians) in random order, and their performance videotaped.

RESULTS

Audio-voice guided resuscitation compared with non-guided resuscitation, resulted in significantly better compliance with NRP order sequence (p<0.01), correct use of oxygen supplementation (p<0.01) and performance of MR SOPA (Mask, reposition, suction, open mouth, pressure, airway) (p<0.01), and shortened the time to "positive pressure ventilation" (p<0.01).

CONCLUSIONS

In this pilot study, audio-voice guidance application for newborn resuscitation simulation on mannequins, based on the NRP algorithm, improved adherence and performance of NRP guidelines.

Simulation-Based Neonatal Resuscitation Team Training: A Systematic Review

CONTEXT

Several neonatal simulation-training programs have been deployed during the last decade, and in a growing number of studies, researchers have investigated the effects of simulation-based team training. This body of evidence remains to be compiled.

OBJECTIVE

We performed a systematic review of the effects of simulation-based team training on clinical performance and patient outcome.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library.

STUDY SELECTION

Two authors included studies of team training in critical neonatal situations with reported outcomes on clinical performance and patient outcome.

DATA EXTRACTION

Two authors extracted data using a predefined template and assessed risk of bias using the Cochrane risk-of-bias tool 2.0 and the Newcastle-Ottawa quality assessment scale.

RESULTS

We screened 1434 titles and abstracts, evaluated 173 full texts for eligibility, and included 24 studies. We identified only 2 studies with neonatal mortality outcomes, and no conclusion could be reached regarding the effects of simulation training in developed countries. Considering clinical performance, randomized studies revealed improved team performance in simulated re-evaluations 3 to 6 months after the intervention.

LIMITATIONS

Meta-analysis was impossible because of heterogenous interventions and outcomes. Kirkpatrick's model for evaluating training programs provided the framework for a narrative synthesis. Most included studies had significant methodologic limitations.

CONCLUSIONS

Simulation-based team training in neonatal resuscitation improves team performance and technical performance in simulation-based evaluations 3 to 6 months later. The current evidence was insufficient to conclude on neonatal mortality after simulation-based team training because no studies were available from developed countries. In future work, researchers should include patient outcomes or clinical proxies of treatment quality whenever possible.

Neonatal Resuscitation: A Blended Learning Curriculum for Medical and Physician Assistant Students

INTRODUCTION

Demonstration of competence in neonatal resuscitation is critical for health care providers who provide newborn care because each year, approximately 400,000 (10%) newborns require resuscitation in delivery rooms across the United States. Therefore, neonatal resuscitation skills certification is provided to graduates entering specific specialties at the beginning of residency and renewed biennially through the American Academy of Pediatrics and the American Heart Association. However, there is no formal curriculum to prepare medical (MD) and physician assistant (PA) students prior to graduation.

METHODS

We developed a neonatal resuscitation curriculum for MD and PA students using a blended learning approach. The curriculum included web-based interactive teaching modules, a demonstration video of a mock neonatal resuscitation, and a neonatal resuscitation simulation. Final-year MD and PA students were evaluated using pre-/posttest, a neonatal resuscitation checklist, and an optional survey on interprofessional communication skills, roles, and responsibility.

RESULTS

Eighteen health professions learners completed the neonatal resuscitation curriculum. A paired-samples t test was conducted to compare pretest and posttest scores. There was a significant difference in pretest (M = 61.4, SD = 15.3) and posttest (M = 78.6, SD = 8.0) scores, t(17) = -4.7, p < .001. The mean score on the checklist was 79%. Learners strongly agreed/agreed that the simulation improved skills performance (100%), communication skills (92%), and understanding of roles and responsibilities (83%) during a neonatal resuscitation.

DISCUSSION

There were improvements in knowledge, procedural, and interprofessional skills in learners who received the neonatal resuscitation curriculum.

Simulation in Neonatal Resuscitation

Approximately 1 in 10 newborns will require basic resuscitation interventions at birth. Some infants progress to require more advanced measures including the provision of positive pressure ventilation, chest compressions, intubation and administration of volume/cardiac medications. Although advanced resuscitation is infrequent, it is crucial that personnel adequately trained in these techniques are available to provide such resuscitative measures. In 2000, Louis Halmalek et al. called for a "New Paradigm in Pediatric Medical Education: Teaching Neonatal Resuscitation in a Simulated Delivery Room Environment." This was one of the first articles to highlight simulation as a method of teaching newborn resuscitation. The last decades have seen an exponential growth in the area of simulation in newborn care, in particular in newborn resuscitation and stabilization. Simulation is best defined as an instructional strategy "used to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner." Simulation training has now become an important point of how we structure training and deliver improved healthcare to patients. Some of the key aspects of simulation training include feedback, deliberate practice, outcome measurement, retention of skills and curriculum integration. The term "Train to win" is often used in sporting parlance to define how great teams succeed. The major difference between sports teams is that generally their game day comes once a week, whereas in newborn resuscitation every day is potentially "game day." In this review we aim to summarize the current evidence on the use of simulation based education and training in neonatal resuscitation, with particular emphasis on the evidence supporting its effectiveness. We will also highlight recent advances in the development of simulation based medical education in the context of newborn resuscitation to ensure we "train to win."

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Benefits of recording and reviewing neonatal resuscitation: the providers' perspective

OBJECTIVE

To assess benefits of recording and reviewing neonatal resuscitation as experienced by neonatal care providers.

DESIGN

A qualitative study using semistructured interviews questioning neonatal care providers about their experiences with recording and reviewing neonatal resuscitation. Data were analysed using the qualitative data analysis software Atlas.ti V.7.0.

SETTING

Neonatal care providers working at neonatal intensive care units (NICUs) of the Leiden University Medical Center, the Netherlands, and the University of Pennsylvania School of Medicine, USA, participated in this study.

RESULTS

In total, 48 NICU staff members were interviewed. Reported experiences and attitudes are broadly similar for both NICUs. All interviewed providers reported positive experiences and benefits, with special emphasis on educational benefits. Recording and reviewing neonatal resuscitation is used for various learning activities, such as plenary review meetings and as tool for objective feedback. Providers reported to learn from reviewing their own performance during resuscitation, as well as from reviewing performances of others. Improved time perception, reflection on guideline compliance and acting less invasively during resuscitations were often mentioned as learning outcomes. All providers would recommend other NICUs to implement recording and reviewing neonatal resuscitation, as it is a powerful tool for learning and improving. However, they emphasised preconditions for successful implementation, such as providing information, not being punitive and focusing on the benefits for learning and improving.

CONCLUSION

Recording and reviewing neonatal resuscitation is considered highly beneficial for learning and improving resuscitation skills and is recommended by providers participating in it.

Retention of Basic Neonatal Resuscitation Skills and Bag-Mask Ventilation in Pediatric Residents Using Just-in-Place Simulation of Varying Frequency and Intensity: A Pilot Randomized Controlled Study

OBJECTIVES

Pediatric residents quickly lose neonatal resuscitation (NR) skills after initial training. Helping Babies Breathe is a skills-based curriculum emphasizing basic NR skills needed within the "Golden Minute" after birth. With this pilot study, we evaluated the feasibility of implementing a Golden Minute review and the impact on overall performance and bag-mask ventilation (BMV) skills in pediatric interns during and/or after their NICU rotation, with varying frequency and/or intensity of "just-in-place" simulation.

METHODS

During their NICU rotation, interns at 1 delivery hospital received the Golden Minute module and hands-on simulation practice. All enrolled interns were randomly assigned to weekly retraining or no retraining for their NICU month and every 1- or 3-month retraining post-NICU for the remainder of their intern year, based on a factorial design. The primary measure was the score on a 21-item evaluation tool administered at the end of intern year, which was compared to the scores received by interns at another hospital (controls).

RESULTS

Twenty-eight interns were enrolled in the intervention. For the primary outcome, at the end of intern year, the 1- and 3-month groups had higher scores (18.8 vs 18.6 vs 14.4; P < .01) and shorter time to effective BMV (10.6 vs 20.4 vs 52.8 seconds; P < .05 for both comparisons) than those of controls. However, the 1- and 3-month groups had no difference in score or time to BMV.

CONCLUSIONS

This pilot study revealed improvement in simulated performance of basic NR skills in interns receiving increased practice intensity and/or frequency than those who received the current standard of NR training.

Stress response in the daily lives of simulation repeaters. A randomized controlled trial assessing stress evolution over one year of repetitive immersive simulations

BACKGROUND

Simulations in healthcare reproduce clinical situations in stressful conditions. Repeated stress exposure might influence the learning process in simulation as well as real-life.

OBJECTIVES

1) To record heart rate and heart rate variability evolution during one-day simulation over one year; 2) To analyze the effect of repetitive high-fidelity simulations on the risk of post-traumatic stress disorder.

STUDY DESIGN

Single-center, investigator-initiated RCT. 48 participants were randomized in 12 multidisciplinary teams of French Emergency Medical Services to manage infant shock in high-fidelity simulations. In the experimental group, 6 multidisciplinary teams were exposed to 9 different simulation sessions over 1 year. In the control group, 6 multidisciplinary teams participated in only 3 simulation sessions, in common with those of the experimental group (initial, intermediate after 6 months, and finally after 1 year). Heart rate (HR) and heart rate variability (HRV) were analyzed on a 24-hour Holter from the day prior to simulation until the end of simulation. Questionnaires of Impact of Event Scale-Revised at 7 days and Post-traumatic Check-List Scale at 1 month were used to detect possible post-traumatic stress disorder in participants. p<0.05 was considered significant.

RESULTS

Stress increased during each simulation in the two groups. After analysis on the 24-hour period, there was no significant difference between the two groups during the initial simulation session in terms of heart rate and heart rate variability. In the 24-hour period of the intermediate and final simulation sessions, the level of stress was higher in the control group during the diurnal (p = 0.04) and nocturnal periods (p = 0.01). No participant developed post-traumatic stress disorder after the 72 simulation sessions.

CONCLUSIONS

Despite the stress generated by simulation, the more the sessions were repeated, the less were their repercussions on the daily lives of participants, reflected by a lower sympathetic activity. Moreover, repetition of simulations did not lead to post-traumatic stress disorder.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02424890.

Neonatal resuscitation experience curves: simulation based mastery learning booster sessions and skill decay patterns among pediatric residents

Background Following neonatal resuscitation program (NRP) training, decay in clinical skills can occur. Simulation-based deliberate practice (SBDP) has been shown to maintain NRP skills to a variable extent. Our study objectives were (a) to determine whether a single 30 min simulation-based intervention that incorporates SBDP and mastery learning (ML) can effectively restore skills and prevent skill decay and (b) to compare different timing options. Methods Following NRP certification, pediatric residents were randomly assigned to receive a video-recorded baseline assessment plus SBDP-ML refresher education at between 6 and 9 months (early) or between 9 and 12 months (late). One year following initial certification, participants had repeat skill retention videotaped evaluations. Participants were scored by blinded NRP instructors using validated criteria scoring tools and assigned a global performance rating score (GRS). Results Twenty-seven participants were included. Residents in both early and late groups showed significant skill decay 7 and 10 months after initial NRP. SBDP-ML booster sessions significantly improved participants' immediate NRP performance scores (p<0.001), which persisted for 2 months, but were again lower 4 months later. Conclusions NRP skills may be boosted to mastery levels after a short SBDP-ML intervention and do not appear to significantly decline after 2 months. Brief booster training could potentially serve as a useful supplement to traditional NRP training for pediatric residents.

Optimizing Mastery Learning Environments: A New Approach to Deliberate Practice for Simulation-based Learning

BACKGROUND

Deliberate practice (DP) is a method of mastery learning widely used in healthcare education. Investigations into improved mastery learning environments are important as we move to competency-based educational models. The objective of this pilot project is to create and test the feasibility of a simulation-based learning methodology based on close adherence to the tenants of DP for the acquisition of mastery knowledge.

METHODS

We created a new methodology for simulation-based mastery learning modules after review of the tenants of DP. A module was constructed to highlight important aspects of supraventricular tachycardia (SVT) management in accordance with current American Heart Association practice guidelines and underwent expert review. Ten emergency medicine interns completed the module as part of the pilot. The number of case attempts, critical actions completed, and time to cardioversion of unstable patients were recorded. Resident confidence was reported before and several months after the module via survey instrument.

RESULTS

Six cases of patients presenting with SVT were created and critical actions were defined. Cases were ordered in increasing difficulty to form a module in which learners were placed immediately into more complex contexts to practice the skill of SVT management with feedback provided between each case attempt. Residents averaged 2.5 attempts to complete case one. All completed case six on first attempt. All residents completed the six cases within the 2-hour module. Time to cardioversion decreased significantly on repetitive practice. Increased resident confidence in several areas of SVT management was maintained several months postintervention.

CONCLUSION

The best methods for the use of DP to encourage mastery learning have not been well defined. Participation in our pilot case increased novice trainee performance and confidence in the management of SVT. Several challenges inherent in testing mastery knowledge acquisition were encountered and will inform future study of this new educational strategy.

Simulation for Milestone Assessment: Use of a Longitudinal Curriculum for Pediatric Residents

INTRODUCTION

Determining clinical competency on the milestones requires direct observation of residents, which is difficult for faculty members who are also providing patient care. Simulation can potentially represent an effective standardized tool for high-stakes assessment. Using a longitudinal simulation curriculum with formative and summative components, we conducted a pilot investigation to examine whether (1) performance on the formative cases predicted performance on the summative cases and (2) performance on the summative cases correlated with the clinical competency committee's (CCC) milestone placement.

METHODS

We developed 6 formative and 6 matched summative cases for pediatric interns that covered core pediatric topics. The interns progressed through the formative cases in pairs during the course of the academic year and then through the summative cases back to back individually at the end of the year. The interns were evaluated using a competency-based simulation evaluation. We determined the relationship between the formative and summative scores and between the summative scores and those from the CCC.

RESULTS

The relationship between formative and summative scores was not statistically significant. There was a statistically significant relationship between summative and CCC scores.

CONCLUSIONS

Significant methodological limitations preclude definite conclusions about the predictive power of simulation cases for Pediatric Milestones-based assessment. However, our work is an example of how simulation is a potentially useful tool for assessing residents' skill development on the Pediatric Milestones. More rigorous research is needed to determine the extent to which simulation can be used for high-stakes, milestones-based assessment.

Video recording of neonatal resuscitation: A feasibility study to inform widespread adoption

AIM

To determine the feasibility of introducing video recording (VR) of neonatal resuscitation (NR) in a perinatal centre.

METHODS

This was a prospective cohort quality improvement study on preterm infants and their caregivers. Based on evidence and experience of other centers using VR intervention, a contextually relevant implementation and evaluation strategy was designed in the planning phase. The components of intervention were pre-resuscitation team huddle, VR of NR and video debriefing (VD), all occurring on the same day. Various domains of feasibility and sustainability as well as feasibility criteria were predefined. Data for analysis was collected using quantitative and qualitative methods.

RESULTS

Seventy-one caregivers participated in VD of 14 NRs facilitated by six trained instructors. Ninety-one percent of caregivers perceived enhanced learning and patient safety and, 48 issues were identified related to policy, caregiver roles, and latent safety threats. Ninety percent of caregivers expressed their willingness to participate in VD activity and supported the idea of integrating it into a resuscitation team routine. Eighty-three percent and 50% of instructors expressed satisfaction with video review software and quality of audio VR. No issues about maintenance of infant or caregivers’ confidentiality and erasure of videos were reported. Criteria for feasibility were met (refusal rate of < 10%, VR performed on > 50% of occasions, and < 20% caregivers’ perceiving a negative impact on team performance). Necessary adaptations to enhance sustainability were identified.

CONCLUSION

VR of NR as a standard of care quality assurance activity to enhance caregivers’ learning and create opportunities that improve patient safety is feasible. Despite its complexity with inherent challenges in implementation, the intervention was acceptable, implementable, and potentially sustainable with adaptations.

Twelve tips for applying the science of learning to health professions education

Findings from the science of learning have clear implications for those responsible for teaching and curricular design. However, this data has been historically siloed from educators in practice, including those in health professions education. In this article, we aim to bring practical tips from the science of learning to health professions educators. We have chosen to organize the tips into six themes, highlighting strategies for 1) improving the processing of information, 2) promoting effortful learning for greater retention of knowledge over time, 3) applying learned information to new and varied contexts, 4) promoting the development of expertise, 5) harnessing the power of emotion for learning, and 6) teaching and learning in social contexts. We conclude with the importance of attending to metacognition in our learners and ourselves. Health professions education can be strengthened by incorporating these evidence-based techniques.

Deliberate Practice as a Theoretical Framework for Interprofessional Experiential Education

OBJECTIVE

The theory of deliberate practice has been applied to many skill-based performance activities. The primary aim of this project was to integrate synergistic principles from deliberate practice and consensus-derived competencies for interprofessional education into a framework upon which educational models to advance interprofessional experiential education (IEE) might be built.

METHODS

CINAHL, ERIC, and MEDLINE databases were searched using the keywords "deliberate practice" and "interprofessional education," both individually and in combination. Relevant articles were selected from the catalog based on support for the premise of the project. Defining characteristics of deliberate practice were distilled with particular emphasis on their application to the Interprofessional Education Collaborative's (IPEC) core competencies. Recommendations for IEE development were identified through the synthesis of deliberate practice principles and IPEC competencies.

RESULTS

There is a high degree of synergy between deliberate practice principles and IPEC competencies. Our synthesis of the literature yielded a cyclical four-step process to advance IEE: (1) implement an IEE plan guided by the student's strengths/weaknesses and in consideration of the collaborative practice skills they wish to develop, (2) engage in IPE experiences that will challenge targeted skills according to the IEE plan, (3) embed frequent opportunities for student reflection and preceptor/team feedback within IEE plan, and (4) revise the IEE plan and the IPE experience based on insights gained during step 3.

CONCLUSION

The cyclical four-step process synthesized through this literature review may be used to guide the development of new IEE models. The purposeful development of IEE models grounded in a theory that has already been operationalized in other skill-based performance areas is an important step to address expanding accreditation standards throughout the health professions mandating interprofessional education for pre-licensure health professional students.

Pediatric Resuscitation Education in Low-Middle-Income Countries: Effective Strategies for Successful Program Development

Despite established international guidelines, there is considerable variability in the quality of resuscitative care received by critically ill children in low-middle-income countries. While this problem is certainly multifactorial, education of health care workers is an important determinant of care quality. This article will discuss approaches to health care worker education in pediatric resuscitation in low-middle-income countries, with emphasis on aspects of educational programs that may contribute to positive educational and clinical outcomes.

Post-event debriefings during neonatal care: why are we not doing them, and how can we start?

Post-event debriefings are a foundational behavior of high performing teams. Despite the inherent value of post-event debriefings, the frequency with which they are used in neonatal care is extremely low. If post-event debriefings are so beneficial, why aren't they conducted more frequently? The reasons are many, but solutions are available. In this report, we provide practical advice on conducting post-event debriefing in neonatal care. In addition, we examine the perceived barriers to conducting post-event debriefings, and offer strategies to overcome them. Finally, we consider opportunities to foster a culture change within neonatal care which integrates debriefing as standard daily work. By establishing a safety culture in neonatal care that encourages and facilitates effective post-event debriefings, patient safety can be enhanced and clinical outcomes can be improved.

Randomized controlled trial of multidisciplinary team stress and performance in immersive simulation for management of infant in shock: study protocol

BACKGROUND

Human error and system failures continue to play a substantial role in adverse outcomes in healthcare. Simulation improves management of patients in critical condition, especially if it is undertaken by a multidisciplinary team. It covers technical skills (technical and therapeutic procedures) and non-technical skills, known as Crisis Resource Management. The relationship between stress and performance is theoretically described by the Yerkes-Dodson law as an inverted U-shaped curve. Performance is very low for a low level of stress and increases with an increased level of stress, up to a point, after which performance decreases and becomes severely impaired. The objectives of this randomized trial are to study the effect of stress on performance and the effect of repeated simulation sessions on performance and stress.

METHODS

This study is a single-center, investigator-initiated randomized controlled trial including 48 participants distributed in 12 multidisciplinary teams. Each team is made up of 4 persons: an emergency physician, a resident, a nurse, and an ambulance driver who usually constitute a French Emergency Medical Service team. Six multidisciplinary teams are planning to undergo 9 simulation sessions over 1 year (experimental group), and 6 multidisciplinary teams are planning to undergo 3 simulation sessions over 1 year (control group). Evidence of the existence of stress will be assessed according to 3 criteria: biological, electrophysiological, and psychological stress. The impact of stress on overall team performance, technical procedure and teamwork will be evaluated. Participant self-assessment of the perceived impact of simulations on clinical practice will be collected. Detection of post-traumatic stress disorder will be performed by self-assessment questionnaire on the 7(th) day and after 1 month.

DISCUSSION

We will concomitantly evaluate technical and non-technical performance, and the impact of stress on both. This is the first randomized trial studying repetition of simulation sessions and its impact on both clinical performance and stress, which is explored by objective and subjective assessments. We expect that stress decreases team performance and that repeated simulation will increase it. We expect no variation of stress parameters regardless of the level of performance.

TRIAL REGISTRATION

ClinicalTrials.gov registration number NCT02424890.

Impact of a low-technology simulation-based obstetric and newborn care training scheme on non-emergency delivery practices in Guatemala

Objective

To assess the effect of a low-technology simulation-based training scheme for obstetric and perinatal emergency management (PRONTO; Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) on non-emergency delivery practices at primary level clinics in Guatemala.

Methods

A paired cross-sectional birth observation study was conducted with a convenience sample of 18 clinics (nine pairs of intervention and control clinics) from June 28 to August 7, 2013. Outcomes included implementation of practices known to decrease maternal and/or neonatal mortality and improve patient care.

Results

Overall, 25 and 17 births occurred in intervention and control clinics, respectively. Active management of the third stage of labor was appropriately performed by 20 (83%) of 24 intervention teams versus 7 (50%) of 14 control teams (P = 0.015). Intervention teams implemented more practices to decrease neonatal mortality than did control teams (P < 0.001). Intervention teams ensured patient privacy in 23 (92%) of 25 births versus 11 (65%) of 17 births for control teams (P = 0.014). All 15 applicable intervention teams kept patients informed versus 6 (55%) of 11 control teams (P = 0.001). Differences were also noted in teamwork; in particular, skill-based tools were used more often at intervention sites than control sites (P = 0.012).

Conclusion

Use of PRONTO enhanced non-emergency delivery care by increasing evidence-based practice, patient-centered care, and teamwork.

Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches

IMPORTANCE

Optimal approaches to teaching bedside procedures are unknown.

OBJECTIVE

To identify effective instructional approaches in procedural training.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014.

STUDY SELECTION

We included research articles that addressed procedural training among physicians or physician trainees for 12 bedside procedures. Two independent reviewers screened 9312 citations and identified 344 articles for full-text review.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data from full-text articles.

MAIN OUTCOMES AND MEASURES

We included measurements as classified by translational science outcomes T1 (testing settings), T2 (patient care practices) and T3 (patient/public health outcomes). Due to incomplete reporting, we post hoc classified study outcomes as 'negative' or 'positive' based on statistical significance. We performed meta-analyses of outcomes on the subset of studies sharing similar outcomes.

RESULTS

We found 161 eligible studies (44 randomised controlled trials (RCTs), 34 non-RCTs and 83 uncontrolled trials). Simulation was the most frequently published educational mode (78%). Our post hoc classification showed that studies involving simulation, competency-based approaches and RCTs had higher frequencies of T2/T3 outcomes. Meta-analyses showed that simulation (risk ratio (RR) 1.54 vs 0.55 for studies with vs without simulation, p=0.013) and competency-based approaches (RR 3.17 vs 0.89, p<0.001) were effective forms of training.

CONCLUSIONS AND RELEVANCE

This systematic review of bedside procedural skills demonstrates that the current literature is heterogeneous and of varying quality and rigour. Evidence is strongest for the use of simulation and competency-based paradigms in teaching procedures, and these approaches should be the mainstay of programmes that train physicians to perform procedures. Further research should clarify differences among instructional methods (eg, forms of hands-on training) rather than among educational modes (eg, lecture vs simulation).

Correlations between technical skills and behavioral skills in simulated neonatal resuscitations

OBJECTIVE

Neonatal resuscitation requires both technical and behavioral skills. Key behavioral skills in neonatal resuscitation have been identified by the Neonatal Resuscitation Program. Correlations and interactions between technical skills and behavioral skills in neonatal resuscitation were investigated.

STUDY DESIGN

Behavioral skills were evaluated via blinded video review of 45 simulated neonatal resuscitations using a validated assessment tool. These were statistically correlated with previously obtained technical skill performance data.

RESULT

Technical skills and behavioral skills were strongly correlated (ρ=0.48; P=0.001). The strongest correlations were seen in distribution of workload (ρ=0.60; P=0.01), utilization of information (ρ=0.55; P=0.03) and utilization of resources (ρ=0.61; P=0.01). Teams with superior behavioral skills also demonstrated superior technical skills, and vice versa.

CONCLUSION

Technical and behavioral skills were highly correlated during simulated neonatal resuscitations. Individual behavioral skill correlations are likely dependent on both intrinsic and extrinsic factors.

Applying adult learning practices in medical education

The application of the best practices of teaching adults to the education of adults in medical education settings is important in the process of transforming learners to become and remain effective physicians. Medical education at all levels should be designed to equip physicians with the knowledge, clinical skills, and professionalism that are required to deliver quality patient care. The ultimate outcome is the health of the patient and the health status of the society. In the translational science of medical education, improved patient outcomes linked directly to educational events are the ultimate goal and are best defined by rigorous medical education research efforts. To best develop faculty, the same principles of adult education and teaching adults apply. In a systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education, the use of experiential learning, feedback, effective relationships with peers, and diverse educational methods were found to be most important in the success of these programs. In this article, we present 5 examples of applying the best practices in teaching adults and utilizing the emerging understanding of the neurobiology of learning in teaching students, trainees, and practitioners. These include (1) use of standardized patients to develop communication skills, (2) use of online quizzes to assess knowledge and aid self-directed learning, (3) use of practice sessions and video clips to enhance significant learning of teaching skills, (4) use of case-based discussions to develop professionalism concepts and skills, and (5) use of the American Academy of Pediatrics PediaLink as a model for individualized learner-directed online learning. These examples highlight how experiential leaning, providing valuable feedback, opportunities for practice, and stimulation of self-directed learning can be utilized as medical education continues its dynamic transformation in the years ahead.