Medical student´s motivational changes during the COVID-19 university lockdown: a mixed-method study

BACKGROUND

During the crucial stage of the COVID-19 pandemic, face-to-face undergraduate medical education was disrupted and replaced with online teaching activities. Based on its emphasized impact on several outcomes, a deeper insight into the pandemic related effects on medical students´ motivation is aspirational. Therefore, this study aimed to assess the motivational changes that took place during the pandemic in medical students and explored, how motivation of medical students is influenced.

METHODS

Using a mixed method inter-cohort study design, 4th year medical students´ motivation, assessed pre- and post-pandemic were compared. In subsequent qualitative analyses underlying variables that may have contributed to both- medical students´ motivation and pandemic related changes were identified. These variables were then systematically explored- both individually and in combination. In a final step, the results were embedded within the Self-Determination Theory.

RESULTS

Students who were affected by the university lockdown reported significantly higher levels of less self-determined motivation and amotivation. The qualitative analysis identified determinants that influence medical students´ motivation. The common core of these determinants is lacking social interaction and support, with a great emphasis on the interaction with the lecturer and patients.

CONCLUSION

This study emphasizes the crucial role of medical educators, patient contact, social interactions and personal support on students´ motivation. Students need to be strengthened in their beliefs about their abilities, the value of their task at hand and receive encouragement in their efforts. All this will result in an increased identification with the task and less detrimental outcomes.

Continuous Finger-cuff versus Intermittent Oscillometric Arterial Pressure Monitoring and Hypotension during Induction of Anesthesia and Noncardiac Surgery: The DETECT Randomized Trial

BACKGROUND

Finger-cuff methods allow noninvasive continuous arterial pressure monitoring. This study aimed to determine whether continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery. Specifically, this study tested the hypotheses that continuous finger-cuff-compared to intermittent oscillometric-arterial pressure monitoring helps clinicians reduce the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia and the time-weighted average mean arterial pressure less than 65 mmHg during noncardiac surgery.

METHODS

In this single-center trial, 242 noncardiac surgery patients were randomized to unblinded continuous finger-cuff arterial pressure monitoring or to intermittent oscillometric arterial pressure monitoring (with blinded continuous finger-cuff arterial pressure monitoring). The first of two hierarchical primary endpoints was the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia; the second primary endpoint was the time-weighted average mean arterial pressure less than 65 mmHg during surgery.

RESULTS

Within 15 min after starting induction of anesthesia, the median (interquartile range) area under a mean arterial pressure of 65 mmHg was 7 (0, 24) mmHg × min in 109 patients assigned to continuous finger-cuff monitoring versus 19 (0.3, 60) mmHg × min in 113 patients assigned to intermittent oscillometric monitoring (P = 0.004; estimated location shift: -6 [95% CI: -15 to -0.3] mmHg × min). During surgery, the median (interquartile range) time-weighted average mean arterial pressure less than 65 mmHg was 0.04 (0, 0.27) mmHg in 112 patients assigned to continuous finger-cuff monitoring and 0.40 (0.03, 1.74) mmHg in 115 patients assigned to intermittent oscillometric monitoring (P < 0.001; estimated location shift: -0.17 [95% CI: -0.41 to -0.05] mmHg).

CONCLUSIONS

Continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery compared to intermittent oscillometric arterial pressure monitoring.

EDITOR’S PERSPECTIVE

Pilot study of an interprofessional pediatric mechanical ventilation educational initiative in two intensive care units

INTRODUCTION

Inappropriate ventilator settings, non-adherence to a lung-protective ventilation strategy, and inadequate patient monitoring during mechanical ventilation can potentially expose critically ill children to additional risks. We set out to improve team theoretical knowledge and practical skills regarding pediatric mechanical ventilation and to increase compliance with treatment goals.

METHODS

An educational initiative was conducted from August 2019 to July 2021 in a neonatal and pediatric intensive care unit of the University Children's Hospital, Hamburg-Eppendorf, Germany. We tested baseline theoretical knowledge using a multiple choice theory test (TT) and practical skills using a practical skill test (PST), consisting of four sequential Objective Structured Clinical Examinations of physicians and nurses. We then implemented an educational bundle that included video self-training, checklists, pocket cards, and reevaluated team performance. Ventilators and monitor settings were randomly checked in all ventilated patients. We used a process control chart and a mixed-effects model to analyze the primary outcome.

RESULTS

A total of 47 nurses and 20 physicians underwent assessment both before and after the implementation of the initiative using TT. Additionally, 34 nurses and 20 physicians were evaluated using the PST component of the initiative. The findings revealed a significant improvement in staff performance for both TT and PST (TT: 80% [confidence interval (CI): 77.2-82.9] vs. 86% [CI: 83.1-88.0]; PST: 73% [CI: 69.7-75.5] vs. 95% [CI: 93.8-97.1]). Additionally, there was a notable increase in self-confidence among participants, and compliance with mechanical ventilation treatment goals also saw a substantial rise, increasing from 87.8% to 94.5%.

DISCUSSION

Implementing a pediatric mechanical ventilation education bundle improved theoretical knowledge and practical skills among interprofessional pediatric intensive care staff and increased treatment goal compliance in ventilated children.

National consensus on entrustable professional activities for competency-based training in anaesthesiology

Entrustable Professional Activities (EPA) are specialty specific tasks or responsibilities, combining the clinical workplace and the long-demanded competency-based medical education. The first step to transform time-based into EPA-based training is to reach consensus on core EPAs that describe sufficiently the workplace. We aimed to present a nationally validated EPA-based curriculum for postgraduate training in anaesthesiology. Using a predefined and validated list of EPAs, we applied a Delphi consensus approach, involving all German chair directors of anaesthesiology. We then conducted a subsequent qualitative analysis. Thirty-four chair directors participated in the Delphi survey (77% response) and twenty-five completed all the questions (56% overall response). Reflected by the intra-class-correlation, the consensus on the importance (ICC: 0.781, 95% CI [0.671, 0.868]) and the year of entrustment (ICC: 0.973, 95% CI [0.959, 0.984]) of each EPA reached high levels of agreement among the chair directors. The comparison of data assessed in the preceding validation and present study showed excellent and good levels of agreement (ICC entrustment: 0.955, 95% CI [0.902, 0.978]; ICC importance: 0.671, 95% CI [-0.204, 0.888]). The adaptation process, based on the qualitative analysis, resulted in a final set of 34 EPAs. We present an elaborate, fully described and nationally validated EPA-based curriculum, reflecting a broad consensus among different stakeholders of anaesthesiology. We hereby provide a further step towards competency-based postgraduate anaesthesiology training.

Continuous intra-arterial versus intermittent oscillometric arterial pressure monitoring and hypotension during induction of anaesthesia: the AWAKE randomised trial

BACKGROUND

Hypotension during induction of anaesthesia is associated with organ injury. Continuous arterial pressure monitoring might help reduce hypotension. We tested the hypothesis that continuous intra-arterial compared with intermittent oscillometric arterial pressure monitoring reduces hypotension during induction of anaesthesia in noncardiac surgery patients.

METHODS

In this single-centre randomised trial, 242 noncardiac surgery patients in whom intra-arterial arterial pressure monitoring was planned were randomised to unblinded continuous intra-arterial or to intermittent oscillometric arterial pressure monitoring (with blinded intra-arterial arterial pressure monitoring) during induction of anaesthesia. The primary endpoint was the area under a mean arterial pressure (MAP) of 65 mm Hg within the first 15 min of induction of anaesthesia. Secondary endpoints included areas under MAP values of 60, 50, and 40 mm Hg and durations of MAP values <65, <60, <50, and <40 mm Hg.

RESULTS

There were 224 subjects available for analysis. The median (25th-75th percentile) area under a MAP of 65 mm Hg was 15 (2-36) mm Hg • min in subjects assigned to continuous intra-arterial monitoring and 46 (7-111) mm Hg • min in subjects assigned to intermittent oscillometric monitoring (P<0.001). Subjects assigned to continuous intra-arterial monitoring had smaller areas under MAP values of 60, 50, and 40 mm Hg and shorter durations of MAP values <65, <60, <50, and <40 mm Hg than subjects assigned to intermittent oscillometric monitoring.

CONCLUSION

Continuous intra-arterial arterial pressure monitoring reduces hypotension during induction of anaesthesia compared with intermittent oscillometric arterial pressure monitoring in noncardiac surgery patients. In patients for whom an arterial catheter is planned, clinicians might therefore consider inserting the arterial catheter before rather than after induction of anaesthesia.

CLINICAL TRIALS REGISTRATION

NCT04894019.

Virtual reality as a teaching method for resuscitation training in undergraduate first year medical students during COVID-19 pandemic: a randomised controlled trial

BACKGROUND

Virtual reality (VR) is a computer-generated simulation technique which yields plenty of benefits and its application in medical education is growing. This study explored the effectiveness of a VR Basic Life Support (BLS) training compared to a web-based training during the COVID-19 pandemic, in which face-to-face trainings were disrupted or reduced.

METHODS

This randomised, double-blinded, controlled study, enrolled 1^st year medical students. The control group took part in web-based BLS training, the intervention group received an additional individual VR BLS training. The primary endpoint was the no-flow time-an indicator for the quality of BLS-, assessed during a structural clinical examination, in which also the overall quality of BLS (secondary outcome) was rated. The tertiary outcome was the learning gain of the undergraduates, assessed with a comparative self-assessment (CSA).

RESULTS

Data from 88 undergraduates (n = 46 intervention- and n = 42 control group) were analysed. The intervention group had a significant lower no-flow time (p = .009) with a difference between the two groups of 28% (95%-CI [8%;43%]). The overall BLS performance of the intervention group was also significantly better than the control group with a mean difference of 15.44 points (95%-CI [21.049.83]), p < .001. In the CSA the undergraduates of the intervention group reported a significant higher learning gain.

CONCLUSION

VR proved to be effective in enhancing process quality of BLS, therefore, the integration of VR into resuscitation trainings should be considered. Further research needs to explore which combination of instructional designs leads to deliberate practice and mastery learning of BLS.

The effects of simulation-based education on medical students' motivation

OBJECTIVES

To assess the effects of simulation-based education on medical students' motivation and to compare these effects with the motivational effects of a classical teaching approach (seminar).

METHODS

In this cross-sectional study, motivational qualities of 164 3rd year medical students, who participated in four mandatory simulation-based training and two seminars of the department of anaesthesiology, were assessed. Comparative analysis was made to determine differences and changes of motivation towards participating in each teaching unit and each teaching format, using a one-way analysis of variance and unpaired t-tests.

RESULTS

The different motivational qualities, as well as the computed levels of autonomous and controlled motivation of students towards participating in each of the six teaching units and each teaching format did not differ significantly (F _{(5, 839)} = 0.66, p = 0.657; F _{(5, 839)} = 0.29, p = 0.920; (t ₍₈₄₃₎ = - 0.72, p = 0.471; t ₍₈₄₃₎ = -0.17, p = 0.868). Students` motivation, particularly autonomous motivation, did not enhance after participating in the first SBME, (t ₍₂₆₄₎ = 1.035, p = 0.301), after participating in the second SBME, (t ₍₂₅₄₎ = -0.055, p = 0.956), or after participating in the third training (t ₍₂₅₀₎ = -0.881, p = 0.379).

CONCLUSIONS

Simulation-based medical education provides a valuable teaching approach but, in this study, this teaching approach did not enhance nor stimulate student motivation. Therefore, simulation-based medical education equals classical teaching approaches regarding student motivation. Further investigations are needed to identify how simulation-based medical education could enhance medical students' motivation.

Flipped learning enhances non-technical skill performance in simulation-based education: a randomised controlled trial

BACKGROUND

Many efforts of the past years aimed to build a safer health care system and hereby, non-technical skills (NTS) have been recognised to be responsible for over 70 % of preventable medical mishaps. In order to counteract those mishaps, several simulation-based trainings have been implemented in health care education to convey NTS. Still, the best and effective way to foster NTS in simulation-based training is not known. Due to the importance of NTS, this gap in knowledge needs to be filled. A possible approach to convey NTS effectively during simulation-based medical education (SBME), might be the use of the flipped learning approach. The benefits of flipped learning regarding the improvement of human factors (NTS), have not been investigated yet. Therefore, the authors introduced flipped learning as an experimental intervention into their SBME emergency trainings and aimed to analyse, whether flipped learning improved students´ NTS performance compared to lecture-based learning (LBL).

METHODS

In a randomized controlled trial, 3rd year medical students participated in a SBME training and then received either a further SBME training with integrated flipped learning on NTS (intervention), or a further SBME training and an accompanying lecture on NTS (control). NTS performance was assessed on three skill dimensions with a validated behavioural marker system.

RESULTS

The authors analysed NTS performance of 102 students, prior and after their allocation to each teaching method. The baseline NTS performance of both groups did not differ, whereas the intervention group enhanced significantly on all three skill dimensions (t (44) = 5.63, p < .001; t (44) = 4.47, p < .001; t (44) = 4.94, p < .001).

CONCLUSION

The integration of flipped learning into SBME yields a significant improvement of NTS performance and therefore medical educators should consider the application of flipped learning to convey complex human factors and skills.

Understanding how the motivational dimension of learning is influenced by clinical teaching in medical education: A prospective cohort study

Introduction

Many changes of medical curricula have been conducted in the past years. Based on learning psychology, three dimensions of learning have to be covered, in order to create the best possible curricula: Cognitive, metacognitive and motivational. The metacognitive and cognitive dimension (what/how to teach) have always been considered and the motivational dimension has been neglected, although the importance and benefits of motivation in learning have been emphasized repeatedly. One way to influence motivation in medical curricula are the teaching formats, as it has been shown that the construction of a curriculum can influence students' motivation. So far, evidence about the motivational effects of teaching formats are scarce.

Methods

In a prospective interventional cohort study, 145 3rd year medical students were sampled. The effects of a 3-day bedside teaching in the operating theatre and two simulation-based trainings on students' motivation (outcome measure) were analysed. It was hypothesized, that the simulation training and the bedside teaching enhance autonomous motivation and decrease controlled motivation.

Results

The bedside-teaching decreased external (controlled) motivation (-0.14, p = .013, 95% CI [-0.24, -0.03]), alongside with identified (autonomous) motivation (-0.22, p < .001, 95% CI [-0.34, -0.10]). The simulation-based trainings did not change students' motivation.

Conclusion

To prevent the unintended decrease of identified (autonomous) motivation, undergraduates should be supervised and introduced carefully, when attending bedside teaching in unknown medical fields. Simulation-based medical education certainly has plenty of benefits in medical education but its effects on the motivational dimension of learning needs further investigations.

Understanding Why All Types of Motivation Are Necessary in Advanced Anaesthesiology Training Levels and How They Influence Job Satisfaction: Translation of the Self-Determination Theory to Healthcare

Studies applying the self-determination theory have shown that intrinsic motivation and autonomous regulation lead to job satisfaction and to better job performance. What has not been worked out clearly yet are the effects of extrinsic motivation and controlled regulation on affect, job performance and job satisfaction. However, it has been described that controlled regulation is often necessary for mundane tasks. In anaesthesiology, routine daily tasks can be perceived as mundane by those who have achieved a certain level of training (e.g., consultants). Therefore, it was hypothesised that consultants have high expressions of all motivational qualities. Furthermore, it was hypothesised that job satisfaction of anaesthesiologists is correlated with autonomous motivation. The hypotheses were tested in a cross-sectional study design within a group of anaesthesiologists. The study participants reported the same pattern throughout the motivational continuum. Consultants reported the highest levels of all motivational qualities, including controlled regulation, as well as the highest levels of job satisfaction. Junior residents reported high levels of amotivation and extrinsic regulation. The lowest levels of identified regulation and job satisfaction were reported by the group of attendings. Job satisfaction was positively correlated with intrinsic motivation and negatively correlated with amotivation. Therefore, our findings from the field of anaesthesiology show that the expressions of high levels of controlled regulation might be necessary for specialists to engage in mundane daily tasks. Intrinsic motivation and autonomous regulation are necessary for job satisfaction and the presence of controlled regulation and extrinsic behavioural regulation have no declining effects. Furthermore, the decrease of amotivation will lead to enhanced job satisfaction and the resulting consequences will be extensive. Junior residents need to be supported with the aim to enhance their feeling of autonomy and competence in order to decrease amotivation and to foster autonomous regulation and hence to increase job satisfaction and well-being. Further special focus should be on attendings to counteract their lacking identification with the job. Hereby, the provision of feedback and professional perspectives might foster the process of re-identification.

Correlation of medical students' situational motivation and performance of non-technical skills during simulation-based emergency training

BACKGROUND

Non-technical skills (NTS) are an indispensable element of emergency care and need to be prevalent alongside with good technical skills. Though, questions of how to teach (instructional design) and improve NTS effectively remain unresolved. One adjustment screw to enhance performance of NTS, which is detached from instructional designs and learning efforts might be motivation. Theoretical models and observational studies suggest that high levels of intrinsic (situational) motivation result in better performance and better learning. Therefore, this study analyzed the influence of motivation on performance of NTS, by exploring if high levels of intrinsic motivation lead to better performance of NTS in medical students.

METHODS

In this prospective cross-sectional cohort study, the authors assessed the correlation of situational motivation and performance of NTS within a cohort of 449 undergraduates in their 1st to 4th year of medical studies, in a total of 101 emergency simulation trainings. Situational motivation was measured with the validated Situational Motivation Scale (SIMS), which was completed by every undergraduate directly before each simulation training. The NTS were evaluated with the Anesthesiology Students´ Non-Technical skills (AS-NTS) rating tool, a validated taxonomy, especially developed to rate NTS of undergraduates.

RESULTS

Student situational motivation was weakly correlated with their performance of NTS in simulation-based emergency trainings.

CONCLUSION

Although motivation has been emphasized as a determining factor, enhancing performance in different fields and in medicine in particular, in our study, student situational motivation was independent from their performance of NTS in simulation-based emergency trainings (SBET).

Development and validation of a postgraduate anaesthesiology core curriculum based on Entrustable Professional Activities: a Delphi study

Background: Postgraduate training curricula should not be based on time-spans or predefined numbers of performed procedures. One approach to link competencies to clinical tasks is the concept of Entrustable Professional Activities (EPA). The goal of this study was the definition, ranking and validation of EPAs for anaesthesiology postgraduate training and the creation of an anaesthesiologic core curriculum. Methods: Anaesthesiologists of different levels of training participated in the study (single-center, cross-sectional) . First, an expert group defined a preliminary list of EPAs. Then a first Delphi round (n= 47 participants) was applied to identify daily anaesthesiology tasks with the goal to define EPAs. From the first Delphi round a new set of EPAs was defined, using the template and mapping method. Through an alignment process, conducted by the expert group, the preliminary EPAs and the new set of EPAs from the first Delphi round were summarised into a new list of EPAs. This list was presented to the study participants in a second Delphi round (n=80 participants), with the goal to validate and rank each EPA and to define the year of entrustment. For this purpose, participants were asked in the second Delphi round if each EPA should be included into an anaesthesiology core curriculum and in which year of training entrustment should take place. Furthermore, they were asked to rank each EPA on a numeric scale, defining its importance. From this numeric scale, the content validity index (CVI) for each EPA was calculated. Consensus of the results from the second Delphi round was calculated, using the one-way random effects model to calculate Intra-Class-Correlations (ICC). Percentages of agreement among the whole set of EPAs of this study and a previously published set of EPAs were computed. Results: A core-curriculum comprising of 39 EPAs was developed. The EPAs were subdivided into superior/high and inferior/low scoring EPAs, reflecting their importance and were mapped to the year of entrustment. The results reached high consensus among the different participating anaesthesiologist groups (overall agreement was 0.96 for the CVI of each EPA and 0.83 for the year in which the EPAs should be entrusted). Agreement with the previously defined set of EPAs was 73.3%. Conclusion: This study provides a further step in transforming postgraduate anaesthesiology training into a more contemporary approach. Other studies are necessary to complete and amend the presented core curriculum of EPA based postgraduate anaesthesiology training.

Anaesthesiology students' Non-Technical skills: development and evaluation of a behavioural marker system for students (AS-NTS)

BACKGROUND

Non-Technical Skills (NTS) are becoming more important in medical education. A lack of NTS was identified as a major reason for unsafe patient care, favouring adverse events and team breakdown. Therefore, the training of NTS should already be implemented in undergraduate teaching. The goal of our study was to develop and validate the Anaesthesiology Students' Non-Technical Skills (AS-NTS) as a feasible rating tool to assess students' NTS in emergency and anaesthesiology education.

METHODS

The development of AS-NTS was empirically grounded in expert- and focus groups, field observations and data from NTS in medical fields. Validation, reliability and usability testing was conducted in 98 simulation scenarios, during emergency and anaesthesiology training sessions.

RESULTS

AS-NTS showed an excellent interrater reliability (mean 0.89), achieved excellent content validity indexes (at least 0.8) and was rated as feasible and applicable by educators. Additionally, we could rule out the influence of the raters' anaesthesiology and emergency training and experience in education on the application of the rating tool.

CONCLUSIONS

AS-NTS provides a structured approach to the assessment of NTS in undergraduates, providing accurate feedback. The findings of usability, validity and reliability indicate that AS-NTS can be used by anaesthesiologists in different year of postgraduate training, even with little experience in medical education.

Analysis of potential biomarkers and modifier genes affecting the clinical course of CLN3 disease

Mutations in the CLN3 gene lead to juvenile neuronal ceroid lipofuscinosis, a pediatric neurodegenerative disorder characterized by visual loss, epilepsy and psychomotor deterioration. Although most CLN3 patients carry the same 1-kb deletion in the CLN3 gene, their disease phenotype can be variable. The aims of this study were to (i) study the clinical phenotype in CLN3 patients with identical genotype, (ii) identify genes that are dysregulated in CLN3 disease regardless of the clinical course that could be useful as biomarkers, and (iii) find modifier genes that affect the progression rate of the disease. A total of 25 CLN3 patients homozygous for the 1-kb deletion were classified into groups with rapid, average or slow disease progression using an established clinical scoring system. Genome-wide expression profiling was performed in eight CLN3 patients with different disease progression and matched controls. The study showed high phenotype variability in CLN3 patients. Five genes were dysregulated in all CLN3 patients and present candidate biomarkers of the disease. Of those, dual specificity phosphatase 2 (DUSP2) was also validated in acutely CLN3-depleted cell models and in CbCln3(Δex7/8) cerebellar precursor cells. A total of 13 genes were upregulated in patients with rapid disease progression and downregulated in patients with slow disease progression; one gene showed dysregulation in the opposite way. Among these potential modifier genes, guanine nucleotide exchange factor 1 for small GTPases of the Ras family (RAPGEF1) and transcription factor Spi-B (SPIB) were validated in an acutely CLN3-depleted cell model. These findings indicate that differential perturbations of distinct signaling pathways might alter disease progression and provide insight into the molecular alterations underlying neuronal dysfunction in CLN3 disease and neurodegeneration in general.