Can simulation-based education and precision teaching improve paediatric trainees' behavioural fluency in performing lumbar puncture? A pilot study

The confidence and competence of primary school staff to administer an adrenaline auto-injector

School teachers are often inadequately prepared to use an adrenaline auto-injector (AAI), resulting in potentially dangerous treatment delays. The purpose of this study was to assess the observed competence, and self-reported confidence, of primary school teachers in the Republic of Ireland (RoI) to use an AAI. An evaluation of whether there was a link between confidence and competence was also assessed. Teachers from four primary schools in the RoI completed a questionnaire to assess their prior level of experience, training, and confidence levels with AAI administration. The four steps in administrating trainer AAI to a mannequin simulator were then assessed. A total of 61 teachers participated (out of a population of 80). The mean self-reported confidence was 1.82 out of 5 (SD = 0.96). There was no significant difference in confidence between trained and untrained participants (U = 240.5, NS). Participants who had received AAI administration training performed significantly more of the steps correctly (mean = 3.85, SD = 0.95) as compared to those who had received no training (mean = 2.97, SD = 1.10; U = 180.5, p = 0.008). There was no correlation between confidence in administrating AAI and the percentage of steps in the procedure performed correctly (rho =  -0.17, NS).  Conclusion: Improvements in readiness to administer AAIs can be achieved through the application of more effective approaches to teaching clinical skills, changes to school policies and practices, and consideration of the design of AAIs in order to make their operation safer and simpler. It is important that teachers have the confidence and competence to safely administer an AAI. What is Known: • Poor ability in adrenaline auto-injector use seen across population groups-healthcare professionals, patients, carers, and school staff • Training in the use of adrenaline auto-injectors has positive impact on competency What is New: • Irish school teachers show poor levels of competency in adrenaline auto-injector use • No observed correlation between reported confidence and competency.

Barriers and enablers to achieving clinical procedure competency-based outcomes in a national paediatric training/residency program-a multi-centered qualitative study

BACKGROUND

In 2018, the Royal College of Physicians of Ireland revised its paediatric training program to a competency-based medical education (CBME) training/residency curriculum. This included a requirement to achieve competence in a number of core procedural skills to progress within the program. Internationally, simulation-based medical education (SBME) is gaining interest as an effective teaching pedagogy for training procedural skill competency. The objectives of this study were to (1) identify enablers and barriers for paediatric trainees to achieve their required procedural competencies, (2) gain insight on the feasibility of achieving the required procedural skills, and (3) explore what simulation-based resources are used as well as their role in achieving the required procedural skill competencies.

METHODS

A multi-centered qualitative study using semi-structured interviews was performed. Twenty-four paediatric consultants and trainees were recruited from two academic tertiary hospitals using purposive and snowball sampling. Interviews were conducted between March and September 2021, audio recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Three main themes regarding enablers for achieving procedural competencies were reported and include having protected training time, routine assessments, and a standardized curriculum. Barriers to achieving procedural competencies focused mainly on limited clinical exposure. The use of SBME was recommended by all participants (n = 24, 100%) to assist in achieving procedural competencies and most (n = 15, 62.5%) reported it is feasible to attain the required procedural skills in the paediatric CBME program.

CONCLUSION

It is feasible to achieve the required procedural competencies for most paediatric trainees, but this can be improved with protected training time, routine assessments, and a standardized curriculum. Barriers to achieving these skills mainly center on limited clinical exposure, which can be remedied by SBME. Further research is warranted to determine the costs and types of SBME tools available as well as teaching pedagogies to support paediatric trainees achieve their required procedural competencies.

An assessment of the simulated performance of basic clinical procedures by junior doctors during the first year of clinical practice

BACKGROUND

Upon entering the healthcare system, junior doctors may lack the skills required to care for patients, and feel unprepared for their role, with considerable variation in the level of proficiency in the performance of particular clinical procedures.

OBJECTIVE

To compare the performance and proficiency (self-report and observed) of the performance of nine basic clinical procedures.

METHODS

Seventeen interns were observed performing nine clinical procedures in a simulated setting in June 2021 (Assessment 1) and January 2022 (Assessment 2). The observers identified whether each step in the procedure was performed correctly, and provided an overall assessment of proficiency. The participants also rated their own level proficiency.

RESULTS

At Assessment 1 the number of steps performed correctly ranged from a mean of 41.9-83.5%. At Assessment 2 the number of steps performed correctly ranged from a mean of 41.9-97.8%. The most common median proficiency rating for Assessment 1 was 'close supervision', and was 'indirect supervision' at Assessment 2. There was a significant and large effect size in the improvement in performance from Assessment 1 to Assessment 2. Low correlations were found between observer and self-reported proficiency in performance of the procedures.

CONCLUSIONS

The large improvement in performance across the two assessments is encouraging. However, there is a need to address the variability in performance on graduation from medical school, and to ensure that any assessment of proficiency is not only reliant on self-report.

Using Precision Teaching to Improve Typically Developing Student's Mathematical Skills Via Teleconferencing

This study evaluated the effects of Precision Teaching in improving typically developing students' mathematical skills when delivered via teleconferencing in India. Four students received Precision Teaching, while nine acted as control participants. Precision teaching involved instruction in three mathematical skills; two prerequisite skills and the primary skill of mixed addition and subtraction facts. Instruction included untimed practice, timed practice, goal-setting, graphing, and a token economy. Participants who received Precision Teaching received ten practice sessions for the prerequisite skills and 55 sessions for the primary skill. The results demonstrated improvements in the prerequisite skills of varied magnitude and considerable improvements in the primary skill, which were maintained above baseline performance levels. In addition, those who received Precision Teaching were below the 15th percentile rank at the initial assessment and above the 65th percentile at the post-intervention assessment in the math fluency subtest of the Kaufman Test of Educational Achievement-Third Edition. Control participants did not demonstrate similar improvements. Results suggest that Precision Teaching could produce accelerated outcomes even when delivered via teleconferencing. Therefore, it could be a valuable system for helping students ameliorate potential learning losses resulting from the COVID-19 pandemic.

Lumbar puncture training with healthcare simulation improves self-confidence and practical skills of French medical residents in geriatrics

PURPOSE

To assess the skill level and self-confidence of medical residents in geriatrics with regard to conducting the lumbar puncture (LP) procedure and to study the potential benefits of training with simulation and virtual reality.

METHODS

First, a questionnaire survey was conducted among all French residents in geriatrics in the Paris area to assess their knowledge and self-confidence regarding the practice of LP in older adults. Second, we set up a simulation LP training session combined with virtual reality (3D video) training for selected respondents of the first survey. Third, we performed post-simulation survey for the attendees of the simulation training. Finally, a follow-up survey was conducted to examine the change in self-confidence and the success rate in clinical practice.

RESULTS

Fifty-five residents responded to the survey (response rate = 36.4%). The importance of mastering LP was fully recognized by the residents in geriatrics (95.3%), so most of them (94.5%) advocated for the need for additional practical training. Fourteen residents took part in the training (average rating = 4.7 on a 5-point scale). Simulation was regarded by 83% of the respondents as the most useful tool for their practice. We observed a significant pre/post-training mean improvement in self-estimated success of 20.6% (Wilcoxon matched-pairs signed-rank W = - 36, p = 0.008). The post-training success rate of the residents in real-life clinical practice was good (85.8%).

CONCLUSION

Residents were aware of the importance of mastering LP and requested additional training. Simulation may represent a major driver to improve their self-confidence and practical skills.

Qualitative Methodology for Planning and Executing In-Person and Virtual Neurosurgery Educational Opportunities for Medical Students: Lessons Learned from Five Years of Medical Student Neurosurgery Training Center Initiatives

INTRODUCTION

There is a growing need for collaborative and broad-scale medical student neurosurgery educational initiatives. Here, we propose a comprehensive methodology and structure for hosting both in-person and virtual learning opportunities for early trainees interested in clinical neurosciences.

METHODS

We conducted an internal review of educational courses hosted by Medical Student Neurosurgery Training Center from 2017 to 2022. Inspired by the lessons learned from these activities, we examine the elements vital to the planning, production, funding, and execution of future programs.

RESULTS

Six domains were deemed important for carrying out medical student neurosurgery educational opportunities: directorship, curriculum, logistics, faculty and instructor outreach, funding, and marketing. Each of these elements is discussed in detail for both in-person and web-based programs, as well as an examination of the advantages and disadvantages of various implementation strategies.

CONCLUSIONS

Based on the Medical Student Neurosurgery Training Center experience, successful production and hosting of both in-person and virtual educational endeavors seems to be contingent on a collaborative effort by medical students, resident physicians, and neurosurgery faculty. Including medical students throughout the planning phase adds to the overall educational value of each experience and promotes program longevity and consumer engagement. Curricula should be guided by clear learning objectives and a variety of teaching modalities available to the organization. Finally, methods for assessing course outcomes are important, including institutional review board-approved data curation and analysis. Further investigation of neurosurgical learning outcome measurement is needed and has the potential to shape the future of medical student education and neurosurgery career preparation.

Using virtual reality in lumbar puncture training improves students learning experience

BACKGROUND

Lumbar puncture (LP) is a commonly performed medical procedure in a wide range of indications. Virtual reality (VR) provides a stimulating, safe and efficient learning environment. We report the design and the evaluation of a three dimensions (3D) video for LP training.

METHODS

We recorded a stereoscopic 180-degrees 3D video from two LPs performed in clinical settings in Fernand Widal Lariboisière University Hospital, Paris, France. The video was administered to third-year medical students as well as to a residents and attendings group during LP simulation-based training sessions.

RESULTS

On 168 participants (108 novice third-year medical students, and 60 residents and attendings with prior LP experience), satisfaction after video exposure was high (rated 4.7 ± 0.6 on a 5-point scale). No significant discomfort was reported (comfort score graded 4.5 ± 0.8 on 5). LP-naive students displayed higher satisfaction and perceived benefit than users with prior LP experience (overall, P < 0.05). Trainees evaluated favorably the 3D feature and supported the development of similar tutorials for other medical procedures (respectively, 3.9 ± 1.1 and 4.4 ± 0.9 on 5).

CONCLUSION

We report our experience with a 3D video for LP training. VR support could increase knowledge retention and skill acquisition in association to LP simulation training.

Positive effects of lumbar puncture simulation training for medical students in clinical practice

BACKGROUND

Lumbar puncture (LP) is an invasive medical procedure that can be done by any doctor. Several simulation-based trainings have been built however the evaluations of the theoretical knowledge and the impact of the simulation-based training have never been performed in real life. The objective was to evaluate the impact of a LP training on the theoretical knowledge improvement and the performance of a LP in clinical practice.

METHODS

Before and after medical students' training, theoretical knowledge and confidence level were assessed. Over a 6 months period, the impact of simulation training was evaluated by the success rate of students' first LP carried out in hospitalized patients and compared to the results of a no-training control.

RESULTS

Students' theoretical knowledge and confidence level showed significant improvement after simulation training on 115 students (p < 0.0001). The evaluation in real life based on 41 students showed that the success rate of the first LP in patients was higher in the LP simulation group compared to the control group (67% vs 14%, p = 0.0025). The technical assistance was also less frequently needed in the LP simulation group (19% vs 57%, respectively, p = 0.017). The rate of students who participated in this educational study was low.

DISCUSSION

Simulation-based teaching was an effective way to improve students' theoretical and practical knowledge. Whether this approach translates to other procedural skills in real clinical settings merits further study. The low participation rate in the study is due to the fact that students are not used to be included in educational studies and to the complexity of evaluation in routine clinical practice.

Human reliability analysis of bronchoscope-assisted percutaneous dilatational tracheostomy: implications for simulation-based education

BACKGROUND

Teaching and assessing clinical procedures requires a clear delineation of the individual steps required to successfully complete the procedure. For decades, human reliability analysis (HRA) has been used to identify the steps required to complete technical procedures in higher risk industries. However, the use of HRA is uncommon in healthcare. HRA has great potential supporting simulation-based education (SBE) in two ways: (1) to support training through the identification of the steps required to complete a clinical procedure; and (2) to support assessment by providing a framework for evaluating performance of a clinical procedure. The goal of this study was to use HRA to identify the steps (and the risk associated with each of these steps) required to complete a bronchoscope-assisted percutaneous dilatational tracheostomy (BPDT). BPDT is a potentially high-risk minimally invasive procedure used to facilitate tracheostomy placement at the bedside or in the operating theatre.

METHODS

The subgoals, or steps, required to complete the BPDT procedure were identified using hierarchical task analysis. The Systematic Human Error Reduction and Prediction Approach (SHERPA) was then used to identify potential human errors at each subgoal, the level of risk and how these potential errors could be prevented.

RESULTS

The BPDT procedure was broken down into 395 subgoals, of which 18% were determined to be of high-risk. The most commonly identified remediation strategies for reducing the risk of the procedure included: checklist implementation and audit, statutory and mandatory training modules, simulation training, consultant involvement in all procedures, and fostering a safety-focused hospital culture.

CONCLUSION

This study provides an approach for how to systematically identify the steps required to complete a clinical procedure for both training and assessment. An understanding of these steps is the foundation of SBE. HRA can identify 'a correct way' for teaching learners how to complete a technical procedure, and support teachers to give systematic and structured feedback on performance.

Using simulation to explore the impact of device design on the learning and performance of peripheral intravenous cannulation

BACKGROUND

The design of medical devices impacts upon the performance of healthcare professionals and patient safety. However, multiple devices serving the same function are often available. The purpose of this study was to use simulation as a means of examining the impact of differences in device design on (1) learning of, or attainment of behavioral fluency in, peripheral intravenous cannulation (PIVC); and (2) the generalization, or transfer, of learning on one device to performance of PIVC using an untrained device.

METHODS

A total of 25 final cycle medical students participated in this study which used a randomized two-group design. Participants were randomly assigned to learn PIVC using either a closed PIVC device (a single device which consists of an intravenous cannula with a pre-attached extension tube; n = 14) or an open PIVC device (a two-piece device made up of an intravenous cannula and a separate extension tube which is attached following insertion of the cannula; n = 11). Task analyses were developed for the performance of PIVC using each device. Subsequently, simulation-based fluency training was delivered to both groups using their assigned PIVC device, and continued for each participant until the fluency criterion was achieved. Following achievement of fluency, participants were asked to perform PIVC using the untrained device (i.e., the PIVC device that they had not been trained on).

RESULTS

All participants in both groups met the fluency criterion, and no significant differences were observed in the number of trials or total training required by groups to achieve fluency. Participants in both groups improved significantly from baseline (M = 11.69) to final training trial (M = 100). However, a significant decrement in performance (M = 81.5) was observed when participants were required to perform PIVC using the untrained device.

CONCLUSIONS

Participants achieved fluency in PIVC regardless of the device used. However, significant decrements in performance were observed when participants were required to perform PIVC using a novel device. This finding supports the need for careful consideration of devices purchased and supplied in the clinical setting, and the need for training prior to the introduction of novel devices or for new staff members.