Deliberate practice and acquisition of expert performance: a general overview

Evaluating the Instructional Design and Effect on Knowledge, Teamwork, and Skills of Technology-Enhanced Simulation-Based Training in Obstetrics in Uganda: Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Simulation-based training is a common strategy for improving the quality of facility-based maternity services and is often evaluated using Kirkpatrick's theoretical model. The results on the Kirkpatrick levels are closely related to the quality of the instructional design of a training program. The instructional design is generally defined as the "set of prescriptions for teaching methods to improve the quality of instruction with a goal of optimizing learning outcomes."

OBJECTIVE

The aim of this study is to evaluate the instructional design of a technology-enhanced simulation-based training in obstetrics, the reaction of participants, and the effect on knowledge, teamwork, and skills in a low-income country.

METHODS

A stepped-wedge cluster randomized trial was performed in a university hospital in Kampala, Uganda, with an annual delivery volume of over 31,000. In November 2014, a medical simulation center was installed with a full-body birthing simulator (Noelle S550, Gaumard Scientific), an interactive neonate (Simon S102 Newborn CPR Simulator, Gaumard Scientific), and an audio and video recording system. Twelve local obstetricians were trained and certified as medical simulation trainers. From 2014 to 2016, training was provided to 57 residents in groups of 6 to 9 students. Descriptive statistics were calculated for ten instructional design features of the training course measured by the 42-item ID-SIM (Instructional Design of a Simulation Improved by Monitoring). The Wilcoxon signed rank test was conducted to investigate the differences in scores on knowledge, the Clinical Teamwork Scale, and medical technical skills.

RESULTS

The mean scores on the ten instructional design features ranged from 54.9 (95% CI 48.5-61.3) to 84.3 (95% CI 80.9-87.6) out of 100. The highest mean score was given on the feature feedback and the lowest scores on repetitive practice and controlled environment. The overall score for the training day was 92.8 out of 100 (95% CI 89.5-96.1). Knowledge improved significantly, with a test score of 63.4% (95% CI 60.7-66.1) before and 78.9% (95% CI 76.8-81.1) after the training (P<.001). The overall score on the 10-point Clinical Teamwork Scale was 6.0 (95% CI 4.4-7.6) before and 5.9 (95% CI 4.5-7.2) after the training (P=.78). Medical technical skills were scored at 55.5% (95% CI 47.2-63.8) before and 65.6% (95% CI 56.5-74.7) after training (P=.08).

CONCLUSIONS

Most instructional design features of a technology-enhanced simulation-based training in obstetrics in a low-income country were scored high, although intervals were large. The overall score for the training day was high, and knowledge did improve after the training program, but no changes in teamwork and (most) medical technical skills were found. The lowest-scored instructional design features may be improved to achieve further learning aims.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN98617255; http://www.isrctn.com/ISRCTN98617255.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12884-020-03050-3.

Evaluating bowel enterotomy closures in simulated deep body cavities using the reversing half-hitch alternating post and square knots: a randomized controlled trial

Background

Square knots can be difficult to construct in deep body cavities. The reversing half-hitch alternating post (RHAP) surgical knot has noninferior tensile strength and performance characteristics in deep body cavities. We compared the enterotomy repairs of novice learners in simulated deep body cavities using RHAP versus square knots after proficiency-based training.

Methods

Undergraduate students were randomized to RHAP (n = 10) or square knot (n = 10) groups and trained to defined proficiency. They then performed hand-sewn enterotomy repairs of cadaveric porcine small bowels on flat surfaces and in simulated deep body cavities. We recorded time to knot-tying proficiency and to enterotomy repair, and burst pressures for the repair.

Results

Mean time-to-proficiency in knot tying was equivalent between the RHAP and square knot groups (23 [standard deviation (SD) 3] v. 21 [SD 2] min, p = 0.33). Mean time for enterotomy repair in deep cavities was shorter for the RHAP group (16 [SD 2] min v. 21 [SD 1] min, p = 0.02). Mean burst pressures for enterotomy repair were equivalent on flat surfaces (128 [SD 41] v. 101 [SD 36] mm Hg, p = 0.31), and were significantly higher for the RHAP group in simulated deep body cavities (32 [SD 13] v. 105 [SD 37] mm Hg, p = 0.05).

Conclusion

The RHAP knots appear to have superior performance versus square knots when tied in a deep body cavity by novice learners. Future work should focus on demonstrating the clinical relevance and broad utility of the RHAP knot in abdominal surgery. Both knot types should be taught to novice learners.

Rapid Cycle Deliberate Practice to Facilitate "Nano" In Situ Simulation: An Interprofessional Approach to Just-in-Time Training

BACKGROUND

Simulation is increasingly used to identify latent threats to patient safety, such as delays in recognition and management of time-sensitive conditions. The Rapid Cycle Deliberate Practice teaching method may facilitate "nano" (brief) in situ simulation training in a critical care setting to improve multidisciplinary team performance of time-sensitive clinical tasks.

OBJECTIVE

To determine whether nano-in situ simulation training with Rapid Cycle Deliberate Practice can improve pediatric intensive care unit team proficiency in identifying and managing postoperative shock in a pediatric cardiac patient.

METHODS

A quality improvement educational project was conducted involving nano-in situ simulation sessions in a combined pediatric and pediatric cardiac intensive care unit. The Rapid Cycle Deliberate Practice method was used with an expert-driven checklist for 30-minute simulation scenarios.

RESULTS

A total of 23 critical care providers participated. The proportion of time-sensitive tasks completed within 5 minutes increased significantly from before to after training (52% [13 of 25] vs 100% [25 of 25]; P ≤ .001). Using a 5-point Likert scale, with higher scores indicating higher levels, the participants reported high degrees of performance confidence (mean, 4.42; SD, 0.20) and satisfaction with the simulation experience (mean, 4.96; SD, 0.12).

CONCLUSION

The Rapid Cycle Deliberate Practice method was used to facilitate nano-in situ simulation training and identify areas requiring additional education to improve patient safety. In situ simulation can educate providers in a cost-effective and timely manner.

Handheld Ultrasound Device Usage and Image Acquisition Ability Among Internal Medicine Trainees: A Randomized Trial

BACKGROUND

There is insufficient knowledge about how personal access to handheld ultrasound devices (HUDs) improves trainee learning with point-of-care ultrasound (POCUS).

OBJECTIVE

To assess whether HUDs, alongside a yearlong lecture series, improved trainee POCUS usage and ability to acquire images.

METHODS

Internal medicine intern physicians (n = 47) at a single institution from 2017 to 2018 were randomized 1:1 to receive personal HUDs (n = 24) for patient care/self-directed learning vs no-HUDs (n = 23). All interns received a repeated lecture series on cardiac, thoracic, and abdominal POCUS. Main outcome measures included self-reported HUD usage rates and post-intervention assessment scores using the Rapid Assessment of Competency in Echocardiography (RACE) scale between HUD and no-HUD groups.

RESULTS

HUD interns reported performing POCUS assessments on patients a mean 6.8 (SD 2.2) times per week vs 6.4 (SD 2.9) times per week in non-HUD arm (P = .66). There was no relationship between the number of self-reported examinations per week and a trainee's post-intervention RACE score (rho = 0.022, P = .95). HUD interns did not have significantly higher post-intervention RACE scores (median HUD score 17.0 vs no-HUD score 17.8; P = .72). Trainee confidence with cardiac POCUS did not correlate with RACE scores.

CONCLUSIONS

Personal HUDs without direct supervision did not increase the amount of POCUS usage or improve interns' acquisition abilities. Interns who reported performing more examinations per week did not have higher RACE scores. Improved HUD access and lectures without additional feedback may not improve POCUS mastery.

Training using a simulation-based workshop reduces inaccuracies in estimations of testicular volume

OBJECTIVES

Measuring testicular volume (TV) by orchidometer is routine in the clinic when staging male puberty. We have developed a simulation model for TV estimation and investigated whether training medical students, using a workshop with simulation models, could improve the accuracy and reliability of TV estimation.

METHODS

All participating medical students watched a video representing standard undergraduate training in male pubertal assessment. Volunteers were then randomised directly to assessment or to attend a workshop consisting of a further video and four stations contextualising and practising the skills required for TV estimation, prior to assessment. Three child mannequins displaying testes of 3 mL, 4 mL (twice), 5, 10 and 20 mL were used for assessment. Participants were asked to return a fortnight later for repeat assessment to assess intra-observer reliability, the effect of repeated examinations on accuracy and time on skill retention.

RESULTS

Ninety students participated (55F), 46 attended the workshop and were considered "trained". There was no difference between the groups in numbers of correct estimations (29% trained, 27% untrained, p=0.593). However, the trained group's estimations were closer to the true volume, with more from the trained group one bead away (p=0.002) and fewer more than three beads away from the true volume (p<0.001), compared to the untrained group. Trained participants were more accurate at the second assessment (n=80) (p<0.001) and had greater intra-observer reliability (p=0.004).

CONCLUSIONS

Overall TV estimation accuracy was poor. Workshop-style training improved accuracy, reliability and retention of skill acquisition and could be considered as a useful learning tool.

You Can Teach Every Patient: A Health Literacy and Clear Communication Curriculum for Pediatric Clerkship Students

INTRODUCTION

Poor health literacy has a negative impact on various health care outcomes. Medical schools are not consistently providing health literacy training; when they do, they overly rely on didactics.

METHODS

Our curriculum for third-year pediatric clerkship students taught principles of health literacy and evidence-supported clear communication strategies. Communication skills were structured on a novel mnemonic: CTEP (clear language, teach-back, effectively encouraging questions, and pictures). The curriculum included a 30-minute didactic, followed 1-2 weeks later by a 90-minute interactive workshop. All 188 clerkship students attended the didactic lecture; approximately half (90) attended the follow-up workshop. All students completed a formative objective structured clinical encounter. Standardized patients then evaluated students' use of the four clear communication skills. Students completed a survey to assess confidence, knowledge, and use of the skills.

RESULTS

Compared to the didactic-only group, students in the didactic + workshop group more frequently used teach-back (53% vs. 27%, p < .01) and pictures (46% vs. 10%, p < .01). In addition, the didactic + workshop group had improved recall, self-reported use, and comfort with the skills. The didactic + workshop group solicited questions from the standardized patient less often, and there was no difference in use of clear language between the two groups.

DISCUSSION

An interactive curriculum in health literacy and clear communication for pediatric clerkship students was superior to a didactic alone. Optimizing instructional methods for health literacy skills can help future physicians properly communicate with their patients to improve health outcomes.

Nursing Skills Video Selfies: An Innovative Teaching and Learning Strategy for Undergraduate Nursing Students to Master Psychomotor Skills

Introduction

The quality of care for patients is linked to the performance and competence of nurses. Nurse educators are challenged to prepare graduates to deliver safe, competent, patient-centered care. Nursing skills video "selfie" is an innovative teaching and learning strategy in which nursing students use technology to create videos of themselves (video selfie) performing psychomotor skills.

Method

The instructional exercise of creating the video selfie was administered to a group of nursing students in a medical-surgical class. The laboratory instructors identified three psychomotor nursing skills. In the skills lab, the instructors showed videos to demonstrate how the skills were performed. The students returned demonstration in the lab and were asked to return to the lab independently to practice the skills and to create a video selfie.

Results

The exercise encouraged students to increase the quality and length of practice and master the skill. Students demonstrated confidence to perform the skills and to accurately list each step required to perform the skills. The video selfie was used as a peer evaluation tool and as a faculty assessment tool to guide individual students' instruction, learning, and remediation.

Conclusion

The exercise had some shortcomings. Future quantitative research using survey instruments to collect data from a larger group of nursing students is needed to validate the utility of this innovative teaching and learning strategy in nursing programs.

International expert perspectives on the principles and components of effective intervention for adults who stutter

BACKGROUND

While evidence-based practice is widely endorsed by researchers, clinicians and professional bodies as a guiding framework for the provision of quality care to clients, the reliance on efficacy evidence may overshadow the benefits of other knowledge forms in supporting intervention design and evaluation. Due consideration needs to be given to varied forms of evidence, including practice and patient evidence. Stuttering intervention for adults is one area in which there is a significant shortage of practice-based research literature.

AIMS

This study aimed to add to practice evidence by exploring the perspectives of international researchers and clinical experts on the components of effective stuttering intervention. This practice-based evidence will be used to inform the multi-stakeholder co-design of an evidence-based stuttering intervention for adults.

METHODS & PROCEDURES

Criteria defining expertise were developed based on a review of the literature. Experts were recruited using purposive sampling and snowballing. Seventeen international experts were approached, of which 10 completed semi-structured interviews. Interview questions were developed and centred on five topics: the nature of stuttering; efficacy evidence base; intervention techniques, principles of effective intervention; and outcome measurement.

OUTCOMES & RESULTS

Inductive thematic analysis identified three overarching themes: 'One size doesn't fit all', 'A really collaborative relationship where we are both bringing our sense of expertise to this' and 'Some of the most frustrating things'.

CONCLUSIONS & IMPLICATIONS

These findings emphasize the complexity of stuttering intervention, the need for individually tailored treatments and the role of multiple factors, beyond therapeutic technique, that influence treatment outcomes. Findings also demonstrate the benefit of collecting practice-based evidence to support clinical decision-making and intervention evaluation. What this paper adds What is already known on the subject Evidence-based practice involves the synthesis of multiple forms of knowledge, including research, practice and patient evidence to support clinical decision-making and intervention evaluation. Research evidence for stuttering intervention effectiveness is the dominant form of knowledge in stuttering literature, while other forms such as practice and patient evidence are less represented. What this paper adds to existing knowledge This study provides valuable practice evidence for effective stuttering intervention components, including individually tailored intervention, person-related factors and therapeutic alliance. It highlights the need to consider multiple forms of knowledge to guide the design and evaluation of intervention. What are the potential or actual clinical implications of this work? Clinicians should adopt a person-centred care approach when designing and evaluating an intervention for adults who stutter. Multiple factors beyond therapeutic technique influence treatment outcomes and should be incorporated into any intervention for adults who stutter.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

PURPOSE

Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient.

SOURCE

Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus.

FINDINGS AND KEY RECOMMENDATIONS

Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

Disaster Day: A Simulation-Based Disaster Medicine Curriculum for Novice Learners

BACKGROUND

Mass casualty and multi-victim incidents have increased in recent years due to a number of factors including natural disasters and terrorism. The Association of American Medical Colleges (AAMC) recommends that medical students be trained in disaster preparedness and response. However, a majority of United States medical students are not provided such education.

OBJECTIVE

The goal of this study was to evaluate the effectiveness of a 1 day, immersive, simulation-based Disaster Day curriculum.

SETTINGS AND DESIGN

Learners were first and second year medical students from a single institution.

MATERIALS AND METHODS

Our education provided learners with information on disaster management, allowed for application of this knowledge with hands-on skill stations, and culminated in near full-scale simulation where learners could evaluate the knowledge and skills they had acquired.

STATISTICAL ANALYSIS USED

To study the effectiveness of our Disaster Day curriculum, we conducted a single-group pretest-posttest and paired analysis of self-reported confidence data.

RESULTS

A total of 40 first and second year medical students participated in Disaster Day as learners. Learners strongly agreed that this course provided new information or provided clarity on previous training, and they intended to use what they learned, 97.6% and 88.4%, respectively.

CONCLUSIONS

Medical students' self-reported confidence of key disaster management concepts including victim triage, tourniquet application, and incident command improved after a simulation-based disaster curriculum. This Disaster Day curriculum provides students the ability to apply concepts learned in the classroom and better understand the real-life difficulties experienced in a resource limited environment.

Empathy Can Be Taught, and Patients Teach it Best

Empathy toward patients is an essential skill for a physician to deliver the best care for any patient. Empathy also protects the physician from moral injury and decreases the chances for malpractice litigations. The current graduate medical education curriculum allows trainees to graduate without getting focused training to develop empathy as a core competency domain. The tools to measure empathy inherently lack validity. The accurate measure of the provider's empathy comes from the patient's perspectives of their experience and their feedback, which is rarely reaching the trainee. The hidden curriculum in residency programs gives mixed messages to trainees due to inadequate role modeling by attending physicians. This narrative style manuscript portrays a teachable moment at the bedside vividly. The teaching team together reflected upon the lack of empathy, took steps to resolve the issue. The attending demonstrated role modeling as an authentic and impactful technique to teach empathy. The conclusion includes a proposal to include the patient's real-time feedback to trainees as an essential domain under Graduate Medical Education core competencies of professionalism and patient care.

Trainee Experience in Simulation-Based Education of Open Vascular Surgery

BACKGROUND

Simulation continues to be an important adjunct to vascular surgery training, yet the optimal implementation of simulation to complement conventional surgical training continues to evolve. This study aims to find areas for improvement in current simulation-based training of open vascular skills by characterizing the experience of vascular trainees attending a national simulation-based course.

METHOD

This was a survey study conducted at the simulation course of the Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What's New in Vascular and Endovascular Surgery, a national vascular surgery meeting. The survey consisted of 17 questions and was administered on paper or electronically via the Audience Response System, before the start of the course. The survey assessed the participants' experience in formal training, simulation training, and comfort with open surgical procedures.

RESULTS

Between 2013 and 2018, the survey was completed by 150 participants of which 65% were vascular fellows. Only 48% of the participants had formal training in suturing and surgical instruments. Most participants had formal training in basic vascular techniques and advanced vascular operations. In 71%, simulation was incorporated into basic technique training and 60% in open surgical training. Simulation training was most commonly utilized in learning anastomotic techniques and open abdominal aortic aneurysm repair. Simulation skills were deemed translatable to the operating room by 59% of participants. Most participants were comfortable performing open vascular procedures. However, 68% of participants were uncomfortable performing an abdominal aortic aneurysm repair.

CONCLUSIONS

There continues to be a significant portion of trainees who do not undergo a simulation-based education. Current simulation training is being targeted to meet trainee needs in open vascular surgery, specifically open aneurysm repair. Nonetheless, trainees continue to have doubts regarding applicability of simulation-based skills to the operating theater. Further studies investigating access to simulation education as well as its translatability are needed.

Telementoring of Healthcare Teams in the Care of Miners

Background: Given the reemergence of pneumoconiosis in the United States, there is a tremendous need to train rural professionals in its multidisciplinary management. The Miners' Wellness TeleECHO (Telementoring Extension for Community Health Outcomes) Program in New Mexico, United States, provides longitudinal multidisciplinary telementoring to professionals taking care of miners. The impact of this approach has not been previously evaluated.

Objective: To examine the change in self-efficacy of professionals taking care of miners and participating in the TeleECHO Program.

Methods: This is a 12-month longitudinal study involving clinical and nonclinical professionals caring for miners. The study outcome was the change in self-efficacy scores, using a customized instrument of 14 measures grouped into three domains: clinical, medicolegal, and soft skills. The primary outcome used a retrospective pre-post design that collects "pretest" data at the postintervention timeframe.

Results: Participants reported significant improvements in 10 of 14 items (P < 0.05) and a significant decline in 1 of 14 items (with respect to their ability to interpret pulmonary function test results, P < 0.001) since their start dates in the program. Subjects also reported significant improvement with respect to their scores for all three domains and for the 14-item total score (P ⩽ 0.01). Existing participants and clinical professional groups demonstrated greater improvement in selected items than fresh participants and nonclinical professional groups, respectively.

Conclusion: This study is the first in a stepwise approach to determine the benefit of participating in a multidisciplinary telementoring intervention by improving participant self-efficacy in caring for miners with complex mining-related diseases. Our study finding represents a potential solution to a growing access-to-care gap for miners with pneumoconiosis.

Cognitive Interaction Technology in Sport-Improving Performance by Individualized Diagnostics and Error Prediction

The interdisciplinary research area Cognitive Interaction Technology (CIT) aims to understand and support interactions between human users and other elements of socio-technical systems. Important reasons for the new interest in understanding CIT in sport psychology are the impressive development of cognitive robotics and advanced technologies such as virtual or augmented reality systems, cognitive glasses or neurotechnology settings. The present article outlines this area of research, addresses ethical issues, and presents an empirical study in the context of a new measurement and assessment system for training in karate. Recent advances in the field of cognitive assistance systems enabled largely automatized assessments of individual mental representation structures for action sequences, such as choreographed movement patterns in dance or martial arts. Empirical investigations with karate practitioners of different skill levels demonstrate that advanced software-based survey and algorithmic analysis procedures based on cognitive models generate individualized performance predictions for a movement sequence from the Kanku-dai kata (a pre-defined karate movement sequence), which correlated significantly not only with formal expertise (kyu/dan rank) but also with the actual likelihood of mistakes in action execution. This information could prospectively be used to define individual training goals for deliberate practice and incorporated into cognitive interaction technology to provide appropriate feedback. We argue that the development of cognitive interaction systems for sport should explicitly take ethical issues into consideration and present a particular developed engineering approach. The potential benefits of such an assistance system for intermediate and advanced practitioners include more effective and flexible practice, as well as supportive effects, and more flexible training schedules. Furthermore, we argue that researchers from the field of sport psychology can benefit from advances in technological systems that enhance the understanding of mental and motor control in skilled voluntary action.

Simulation in surgical education

Simulation is becoming an important tool in surgical education. Surgical faculty have been forced to modify how they teach technical skills. Instead of a complete reliance on teaching in the operating room, a structured curriculum and dedicated time in the simulation center are being used in many centers. Some of the advantages of this approach include the ability to learn and practice new procedures in a safe and nurturing environment. The disadvantages include the significant cost of virtual reality simulators and the competition, between various training programs, to gain access to simulation.

Assessing Performance in Simulated Cleft Palate Repair Using a Novel Video Recording Setup

OBJECTIVE

To test the feasibility of implementing a high-fidelity cleft palate simulator during a workshop in Santiago, Chile, using a novel video endoscope to assess technical performance.

DESIGN

Sixteen cleft surgeons from South America participated in a 2-day cleft training workshop. All 16 participants performed a simulated repair, and 13 of them performed a second simulated repair. The repairs were recorded using a low-cost video camera and a newly designed camera mouth retractor attachment. Twenty-nine videos were assessed by 3 cleft surgeons using a previously developed cleft palate objective structured assessment of technical skill (CLOSATS with embedded overall score assessment) and global rating scale. The reliability of the ratings and technical performance in relation to minimum acceptable scores and previous experience was assessed.

RESULTS

The video setup provided acceptable recording quality for the purpose of assessment. Average intraclass correlation coefficient for the CLOSATS, global, and overall performance score was 0.69, 0.75, and 0.82, respectively. None of the novice surgeons passed the CLOSATS and global score for both sessions. One participant in the intermediate group, and 2 participants in the advanced group passed the CLOSATS and global score for both sessions. There were highly experienced participants who failed to pass the CLOSATS and global score for both sessions.

CONCLUSIONS

The cleft palate simulator can be practically implemented with video-recording capability to assess performance in cleft palate repair. This technology may be of assistance in assessing surgical competence in cleft palate repair.

Procedural frequency: Results from 18 academic, community and freestanding emergency departments

BACKGROUND

Emergency physicians must maintain procedural skills, but clinical opportunities may be insufficient. We sought to determine how often practicing emergency physicians in academic, community and freestanding emergency departments (EDs) perform 4 procedures: central venous catheterization (CVC), tube thoracostomy, tracheal intubation, and lumbar puncture (LP).

METHODS

This was a retrospective study evaluating emergency physician procedural performance over a 12-month period. We collected data from the electronic records of 18 EDs in one healthcare system. The study EDs included higher and lower volume, academic, community and freestanding, and trauma and non-trauma centers. The main outcome measures were median number of procedures performed. We examined differences in procedural performance by physician years in practice, facility type, and trauma status.

RESULTS

Over 12 months, 182 emergency physicians performed 1582 of 2805 procedures (56%) and supervised (resident, nurse practitioner or physician assistant) an additional 1223 of the procedures they did not perform (43%). Median (interquartile range) physician performance for each procedure was CVC 0 [0, 2], tube thoracostomy 0 [0, 0], tracheal intubation 3 [0.25, 8], and LP 0 [0, 2]. The percentage of emergency physicians who did not perform at least one of each procedure during the 1-year time frame ranged from 25.3% (tracheal intubation) to 76.4% (tube thoracostomy). Physicians who work at high-volume EDs (>50,000 visits per year) performed nearly twice as many tracheal intubations, CVCs, and LPs than those at low-volume EDs or freestanding EDs when normalized per 1000 visits. Years out of training were inversely related to total number of procedures performed. Emergency physicians at trauma centers performed almost 3 times as many tracheal intubations and almost 4 times as many CVCs compared to non-trauma centers.

CONCLUSION

In a large healthcare system, regardless of ED type, emergency physicians infrequently performed the 4 procedures studied. Physicians in high-volume EDs, trauma centers, and recent graduates performed more procedures. Our study adds to a growing body of research that suggests clinical frequency alone may be insufficient for all emergency physicians to maintain competency.

Development and evaluation of a simulation-based transition to clerkship course

BACKGROUND

Transition to clerkship courses bridge the curricular gap between preclinical and clinical medical education. However, despite the use of simulation-based teaching techniques in other aspects of medical training, these techniques have not been adequately described in transition courses. We describe the development, structure and evaluation of a simulation-based transition to clerkship course.

APPROACH

Beginning in 2012, our institution embarked upon an extensive curricular transformation geared toward competency-based education. As part of this effort, a group of 12 educators designed, developed and implemented a simulation-based transition course. The course curriculum involved seven goals, centered around the 13 Association of American Medical Colleges Core Entrustable Professional Activities for entering residency. Instructional techniques included high-fidelity simulation, and small and large group didactics. Student competency was determined through a simulation-based inpatient-outpatient objective structured clinical examination, with real-time feedback and remediation. The effectiveness of the course was assessed through a mixed methods approach involving pre- and post-course surveys and a focus group.

EVALUATION

Of 166 students, 152 (91.6%) completed both pre- and post-course surveys, and nine students participated in the focus group. Students reported significant improvements in 21 out of 22 course objectives. Qualitative analysis revealed three key themes: learning environment, faculty engagement and collegiality. The main challenge to executing the course was procuring adequate faculty, material and facility resources.

REFLECTION

This simulation-based, resource-heavy transition course achieved its educational objectives and provided a safe, supportive learning environment for practicing and refining clinical skills.

Virtual and Augmented Realities in Nursing Education: State of the Science

The use of simulation in nursing education is an integrated part of the curriculum and has demonstrated the benefit for learning in nursing students at all levels. The next stage in simulation-based learning will utilize the wide variety of new technologies that are currently available, including virtual and augmented reality. The use of these new technologies brings with it a need for standard definitions, evaluation of its impact on learning, and new opportunities for research. Efforts are underway to standardized definitions and publish early findings on research using these new technologies. There are many opportunities available for nursing educators to create a new era of simulation-based learning methodologies by incorporating virtual and augmented realities in their curriculum. The state of the science is showing promising outcomes and commercial products are maturing.The utilization of these new technologies should be approached in the same way as other learning methodologies as many new ideas and ways of learning are emerging in this area. It will be critical for nursing educators and faculty to determine the optimal ways to utilize them.

Disaster Ergonomics: Human Factors in COVID-19 Pandemic Emergency Management

OBJECTIVE

We aimed to identify opportunities for application of human factors knowledge base to mitigate disaster management (DM) challenges associated with the unique characteristics of the COVID-19 pandemic.

BACKGROUND

The role of DM is to minimize and prevent further spread of the contagion over an extended period of time. This requires addressing large-scale logistics, coordination, and specialized training needs. However, DM-related challenges during the pandemic response and recovery are significantly different than with other kinds of disasters.

METHOD

An expert review was conducted to document issues relevant to human factors and ergonomics (HFE) in DM.

RESULTS

The response to the COVID-19 crisis has presented complex and unique challenges to DM and public health practitioners. Compared to other disasters and previous pandemics, the COVID-19 outbreak has had an unprecedented scale, magnitude, and propagation rate. The high technical complexity of response and DM coupled with lack of mental model and expertise to respond to such a unique disaster has seriously challenged the response work systems. Recent research has investigated the role of HFE in modeling DM systems' characteristics to improve resilience, accelerating emergency management expertise, developing agile training methods to facilitate dynamically changing response, improving communication and coordination among system elements, mitigating occupational hazards including guidelines for the design of personal protective equipment, and improving procedures to enhance efficiency and effectiveness of response efforts.

CONCLUSION

This short review highlights the potential for the field's contribution to proactive and resilient DM for the ongoing and future pandemics.

Evaluation of simulated drug dispensing and patient counseling in the course of pharmaceutical improvement: 2009 to 2015

Background

Aiming to facilitate the drug dispensing process and patient counseling, specific professional skills are required. The knowledge, skills and attitudes involved in this process can be improved. From 2012 to 2015, a nationwide course was held, in partnership with the Ministry of Health and the Federal University of Rio Grande do Sul (UFRGS) - Brazil, to train pharmacists working in primary health care through the development of their clinical and communication skills. One of the steps in this process involved the simulation of the drug dispensing process and patient counseling.

Objective

To evaluate the performance of pharmacists in drug dispensing and counseling through patient simulation role-playing held in a face-to-face meeting at the end of a training course.

Methods

A cross-sectional and retrospective study with analysis of patient simulation recordings and data collection using an assessment instrument with scores ranging from 0 to 10 points to assess pharmacist's behavior, skills, and technical knowledge.

Results

Participants presented poor-to-regular performance, with median scores equal to or lower than six. The median time of the drug dispensing simulation was five minutes and the patient counseling was eight minutes. Pharmacists had better scores in the simulation of asthma cases. In drug dispensing, 99.5% of pharmacists had difficulty checking the patient's time availability, 98.5% did not know how to use the devices, and 94.7% did not advise the patient on what to do if they forgot to take a dose. In patient counseling simulation, 1.18% of pharmacists remembered to advise on what do with medication leftovers, and 50.6% asked questions that induced the patient's responses.

Conclusions

The low-to-regular performance showed that pharmacists had difficulties at improving their skills in the performance of complete and effective drug dispensing and patient counseling.

Teaching surgery novices and trainees advanced laparoscopic suturing: a trial and tribulations

INTRODUCTION

The benefits of minimally invasive surgery are numerous; however, considerable variability exists in its application and there is a lack of standardized training for important advanced skills. Our goal was to determine whether participation in an advanced laparoscopic curriculum (ALC) results in improved laparoscopic suturing skills.

METHODS AND PROCEDURES

Study design was a prospective, randomized controlled trial. Surgery novices and trainees underwent baseline FLS training and were pre-tested on bench models. Participants were stratified by pre-test score and randomized to undergo either further FLS training (control group) or ALC training (intervention group). All were post-tested on the same bench model. Tests for differences between post-test scores of cohorts were performed using least squared means. Multivariable regression identified predictors of post-test score, and Wilcoxon rank sum test assessed for differences in confidence improvement in laparoscopic suturing ability between groups.

RESULTS

Between November 2018 and May 2019, 25 participants completed the study (16 females; 9 males). After adjustment for relevant variables, participants randomized to the ALC group had significantly higher post-test scores than those undergoing FLS training alone (mean score 90.50 versus 82.99, p = 0.001). The only demographic or other variables found to predict post-test score include level of training (p = 0.049) and reported years of video gaming (p = 0.034). There was no difference in confidence improvement between groups.

CONCLUSIONS

Training using the ALC as opposed to basic laparoscopic skills training only is associated with superior advanced laparoscopic suturing performance without affecting improvement in reported confidence levels. Performance on advanced laparoscopic suturing tasks may be predicted by lifetime cumulative video gaming history and year of training but does not appear to be associated with other factors previously studied in relation to basic laparoscopic skills, such as surgical career aspiration or musical ability.

A german-language competency-based multisource feedback instrument for residents: development and validity evidence

BACKGROUND

In medical settings, multisource feedback (MSF) is a recognised method of formative assessment. It collects feedback on a doctor's performance from several perspectives in the form of questionnaires. Yet, no validated MSF questionnaire has been publicly available in German. Thus, we aimed to develop a German MSF questionnaire based on the CanMEDS roles and to investigate the evidence of its validity.

METHODS

We developed a competency-based MSF questionnaire in German, informed by the literature and expert input. Four sources of validity evidence were investigated: (i) Content was examined based on MSF literature, blueprints of competency, and expert-team discussions. (ii) The response process was supported by analysis of a think-aloud study, narrative comments, "unable to comment" ratings and evaluation data. (iii) The internal structure was assessed by exploratory factor analysis, and inter-rater reliability by generalisability analysis. Data were collected during two runs of MSF, in which 47 residents were evaluated once (first run) or several times (second and third run) on 81 occasions of MSF. (iv) To investigate consequences, we analysed the residents' learning goals and the progress as reported via MSF.

RESULTS

Our resulting MSF questionnaire (MSF-RG) consists of 15 items and one global rating, which are each rated on a scale and accompanied by a field for narrative comments and cover a construct of a physician's competence. Additionally, there are five open questions for further suggestions. Investigation of validity evidence revealed that: (i) The expert group agreed that the content comprehensively addresses clinical competence; (ii) The response processes indicated that the questions are understood as intended and supported the acceptance and usability; (iii) For the second run, factor analysis showed a one-factor solution, a Cronbach's alpha of 0.951 and an inter-rater reliability of 0.797 with 12 raters; (iv) There are indications that residents benefitted, considering their individual learning goals and based on their ratings reported via MSF itself.

CONCLUSIONS

To support residency training with multisource feedback, we developed a German MSF questionnaire (MSF-RG), which is supported by four sources of validity evidence. This MSF questionnaire may be useful to implement MSF in residency training in German-speaking regions.

How to enhance and assess reflection in specialist training: a mixed method validation study of a new tool for global assessment of reflection ability

BACKGROUND

In Danish GP training we had the ambition to enhance and assess global reflection ability, but since we found no appropriate validated method in the literature, we decided to develop a new assessment tool. This tool is based on individual trainee developed mind maps and structured trainer-trainee discussions related to specific complex competencies. We named the tool Global Assessment of Reflection ability (GAR) and conducted a mixed method validation study. Our goal was to investigate whether it is possible to enhance and assess reflection ability using the tool.

METHODS

In order to investigate acceptability, feasibility, face validity, and construct validity of the tool we conducted a mixed method validation study that combined 1) qualitative data obtained from 750 GP trainers participating in train-the-trainer courses, 2) a questionnaire survey sent to 349 GP trainers and 214 GP trainees and 3) a thorough analysis of eight trainer-trainee discussions.

RESULTS

Our study showed an immediate high acceptance of the GAR tool. Both trainers and trainees found the tool feasible, useful, and relevant with acceptable face validity. Rating of eight audio recordings showed that the tool can demonstrate reflection during assessment of complex competencies.

CONCLUSIONS

We have developed an assessment tool (GAR) to enhance and assess reflection. GAR was found to be acceptable, feasible, relevant and with good face- and construct validity. GAR seems to be able to enhance the trainees' ability to reflect and provide a good basis for assessment in relation to complex competencies.

In Situ Simulation for Ventilator Management in Emergency Medicine

BACKGROUND

Emergency physicians have a residency graduation milestone to effectively manage the airway and initiate mechanical ventilation. However, many emergency medicine (EM) residents report rarely or never feeling comfortable managing mechanically ventilated patients. Our goal was to determine the effectiveness of an in situ simulation program for EM residents to successfully manage a ventilator on a high-fidelity patient simulator.

METHODS

This was a prospective observational educational study of EM residents executed in four steps. Baseline performance was assessed by observed standard clinical examination (OSCE) in a checklist manner after our routine classroom-based annual ventilator teaching. The in situ simulation was executed in a small-group format located in the trauma bay of the ED using only equipment available in the clinical setting. Performance at 1 week and 8 months after the educational intervention was assessed by repeat OSCE. The results were assessed using paired Student's t-tests.

RESULTS

There was a statistically significant improvement in all checklist markers of successful ventilator management on repeat OSCE after the in situ simulation intervention. A final unannounced retention OSCE was administered 8 months after the intervention with no additional interval training. The improved performance persisted 8 months later.

CONCLUSIONS

This in situ simulation study demonstrated improved checklist scoring on ventilator management in simulated critically ill patients by EM residents. This improvement persisted 8 months after the educational intervention.

All-Time Best Norwegian Track and Field Athletes: to What Extent Did They Achieve Outstanding Results at the Ages of 15 and 18 Years?

The aim of the study was to determine how many Norwegian athletes who, during all the times they had achieved the European Athletics Championship 2020—Entry Standards (EAC20ES), were also ranked among the 20 all-time-best athletes at the ages of 15 and 18 years. The number of athletes who achieved the EAC20ES during their career, and the percentage of those who were among top 20 in the age groups 15 and 18 years, were determined from the Norwegian all-time-best results lists. A total of 202 athletes achieved the EAC20ES in the studied time period. Of these, 14.4% and 42.1% were ranked among the top 20 all-time best in one or more events at the ages of 15 and 18 years, respectively. However, among those who had won an international gold medal, these percentages were much higher. Eight out of 12 champions (66.7%) were ranked among the top 20 all-time best in one or more event at 15 years of age, and 11 of 12 champions (91.6%) were ranked among the top 20 all-time best at 18 years of age. Athletes that went on to win international championships typically performed better as adolescents compared to other athletes who also reach an international level as seniors. However, due to the low number of international champions, the date should be interpreted with caution.

Coronary Anastomosis Simulation: Directed Interventions to Optimize Success

BACKGROUND

The role of simulation-based training in coronary artery bypass grafting remains undefined. Barriers to simulator use include clinical and personal obligations, insufficient materials, and lack of mentorship. The purpose of this study was to implement a longitudinal, residency-wide coronary anastomosis simulation curriculum.

METHODS

A prospective observational study was conducted from 2018 to 2019 at a single academic center. All residents of the Thoracic Surgery training program participated. Each participant was provided a low-fidelity coronary anastomosis simulator, high-quality instruments, and faculty mentor. Formal assessments were held quarterly, and residents were encouraged to practice alone and with their mentor. Baseline and follow-up metrics were compared with simple descriptive statistics.

RESULTS

Seventeen residents and 12 faculty participated in the study. Residents demonstrated increased use of the simulator, with 21% participating in independent practice at baseline and 82% in the fourth quarter (P = .02). The median score on the Thoracic Surgery Directors Association Vessel Anastomosis Assessment improved from 42 out of 65 at baseline to 54 out of 65 in the fourth quarter (P = .04), and mean anastomosis time was reduced by 5 minutes 6 seconds (P = .02). Over 12 months, junior residents demonstrated a mean reduction in anastomosis time of 6 minutes 36 seconds, and senior residents decreased anastomosis time by 3 minutes 6 seconds (P = .02).

CONCLUSIONS

Providing residents with a low-fidelity coronary anastomosis trainer with high-quality instruments and a faculty mentor improved rates of independent practice, Thoracic Surgery Directors Association assessment scores, and anastomosis time. Our next step is validating the coronary simulator curriculum by measuring improvement of resident performance in the operating room.

Identifying optimal program structure, motivations for and barriers to peer coaching participation for surgeons in practice: a qualitative synthesis

BACKGROUND

Continuous advancement of surgical skills is of utmost importance to surgeons in practice, but traditional learning activities without personalized feedback often do not translate into practice changes in the operating room. Peer coaching has been shown to lead to very high rates of practice changes and utilization of new skills. The purpose of this study was to explore the opinions of practicing surgeons regarding the characteristics of peer coaching programs, in order to better inform future peer coaching program design.

METHODS

Using a convenience sample, practicing general surgeons were invited to participate in focus group interviews. Allocation into groups was according to years in practice. The interviews were conducted using open-ended questions by trained facilitators. Audio recordings were transcribed and coded into themes by two independent reviewers using a grounded theory approach.

RESULTS

Of 52 invitations, 27 surgeons participated: 74% male; years in practice: < 5 years: 33%; 5-15 years: 26%; > 15 years: 41%. Three main themes emerged during coding: ideal program structure, motivations for participation, and barriers to implementation. For the ideal structure of a peer coaching program all groups agreed coaching programs should be voluntary, involve bidirectional learning, and provide CME credits. Live, in situ coaching was preferred. Motivations for coaching participation included: desire to learn new techniques (48%), remaining up to date with the evolution of surgical practice (30%) and improvement of patient outcomes (18%). Barriers to program implementation were categorized as: surgical culture (42%), perceived lack of need (26%), logistical constraints (23%) and issues of coach-coachee dynamics (9%).

CONCLUSION

Peer coaching to refine or acquire new skills addresses many shortcomings of traditional, didactic learning modalities. This study revealed key aspects of optimal program structure, motivations and barriers to coaching which can be used to inform the design of successful peer coaching programs in the future.

The use of a stronger instructional design by implementing repetitive practice in simulation-based obstetric team training: trainees' satisfaction

Objective

This study compares satisfaction levels from multiprofessional obstetric care teams about simulation-based obstetric team training courses with and without the instructional design feature repetitive practice.

Methods

The present study is part of a multicentre cluster-randomised controlled trial (TOSTI trial) that investigated the effectiveness of a 1 day, multiprofessional, simulation-based obstetric team training. The initial training group received a training which was designed based on best practice. After 1 year, the control group received a training course in which the instructional design was changed by providing repetitive practice. All participants were asked to fill in a 29-item evaluation form with seven questions about baseline characteristics and 22 questions about training features. The questions about training features could be rated on a scale of 1 to 5. Finally, all participants were asked to rate the total training day on a scale of 1-10.

Results

The best practice group consisted of 471 trainees and the repetitive practice group of 549, including gynaecologists, residents, midwives and nurses. The best practice group rated the total training day significantly higher than the repetitive practice group (mean 8.8, SD 0.6 and mean 8.7, SD 0.6; p<0.003, Cohen's d=0.19). Several training features were also scored higher in the best practice group.

Conclusion

This study showed that obstetric healthcare professionals rated a simulation-based obstetric team training course, with and without repetition of scenarios, both high. The training without the repetitive elements gained higher scores for the total training dayand several, and several training features were scored higher. The difference between the mean scores and the effect sizes for the training features were small. This implies that repetitive practice can be integrated in simulation-based team training to optimise learning effects, with small effects on trainees satisfaction.

A Bayesian Account of Generalist and Specialist Formation Under the Active Inference Framework

This paper offers a formal account of policy learning, or habitual behavioral optimization, under the framework of Active Inference. In this setting, habit formation becomes an autodidactic, experience-dependent process, based upon what the agent sees itself doing. We focus on the effect of environmental volatility on habit formation by simulating artificial agents operating in a partially observable Markov decision process. Specifically, we used a "two-step" maze paradigm, in which the agent has to decide whether to go left or right to secure a reward. We observe that in volatile environments with numerous reward locations, the agents learn to adopt a generalist strategy, never forming a strong habitual behavior for any preferred maze direction. Conversely, in conservative or static environments, agents adopt a specialist strategy; forming strong preferences for policies that result in approach to a small number of previously-observed reward locations. The pros and cons of the two strategies are tested and discussed. In general, specialization offers greater benefits, but only when contingencies are conserved over time. We consider the implications of this formal (Active Inference) account of policy learning for understanding the relationship between specialization and habit formation.

Courage, Fortitude, and Effective Leadership of Surgical Teams During COVID-19

The world as we once knew it has been drastically altered secondary to coronavirus disease 2019 (COVID-19). The impact of these changes, particularly for those practicing in the medical profession, extends beyond the physical to the psychological, emotional, and spiritual. We discuss the factors that contribute to these stresses, way to manage them, and how we as leaders of our teams can inspire resilience and help our colleagues endure these most difficult times.

Is There Variability in Scoring of Student Surgical OSCE Performance Based on Examiner Experience and Expertise?

OBJECTIVE

To investigate the influence of clinical experience and content expertise on global assessment scores in a Surgical Objective Structured Clinical Exam (OSCE) for senior medical undergraduate students.

DESIGN

Scripted videos of simulated student performance in an OSCE at two standards (clear pass and borderline) were awarded a global score on each of two rating scales by a range of clinical assessors. Results were analysed by examiner experience and content expertise.

SETTING

The study was designed in a large Medical School in Ireland. Examiners were consultant and training grade doctors from three university teaching hospitals.

PARTICIPANTS

147 assessors participated. Of these, 75 (51%) were surgeons and 25 (17%) had sub-speciality surgical expertise directly relevant to the OSCE station. 41 were consultants.

RESULTS

Responsible academic scoring set the benchmark. By multivariable linear regression analysis, neither clinical experience (consultant status) nor relevant content expertise in surgery was independently predictive of assessor grading for either clear pass or borderline student performance. No educational factor (previous examining experience/training, self-rated confidence in assessment or frame of reference) was significant. Assessor gender (male) was associated with award of a fail grade for borderline performance. Trainees were reliable graders of borderline performance but more lenient than the gold standard for clear pass. We report greater agreement with the gold standard score using the global descriptive scale, with strong agreement for all assessors in the borderline case.

CONCLUSIONS

Neither assessor clinical experience nor content expertise is independently predictive of grade awarded in an OSCE. Where non-experts or trainees assess, we find evidence for use of a descriptive global score to maximise agreement with expert gold standard, particularly for borderline performance. These results inform the fair and reliable participation of a range of examiners across subspecialty stations in the surgical OSCE format.

On Becoming a Master Surgeon: Role Models, Mentorship, Coaching, and Apprenticeship

Cardiothoracic surgery is a high risk, high reward specialty demanding exceptional performance for desired outcomes. Whereas the demand for technical excellence, critical thinking skills, judgment, and overall experience is clear, the pathway to optimize performance improvement after training is completed is less clear. "Role modeling," "mentorship," "coaching," and "apprenticeship" are all buzz words that have flooded the proverbial air of our specialty in recent years. The goal of this article is to describe strategies, including career development relationships, continuing medical education, and professional societal involvement, that are key to continuing to improve one's craft and identify career phases when such elements are most applicable.

Recent Advances in Simulation for Pediatric Critical Care Medicine

PURPOSE OF REVIEW

This review highlights the emerging fields of simulation research by tying innovation into principles of learning and process improvement.

RECENT FINDINGS

Advances have been made in both educational simulation and simulation for quality improvement, allowing this versatile modality to be more broadly applied to healthcare and systems.

SUMMARY

Simulation in pediatric critical care medicine continues to evolve. Although the majority of simulation is focused on learner education, emerging research has broadened to focus on patient- and system-centered outcomes, leading to improvement in the quality of care delivered in the ICU.

Rapid cycle system improvement for COVID-19 readiness: integrating deliberate practice, psychological safety and vicarious learning

Introduction

In the face of a rapidly advancing pandemic with uncertain pathophysiology, pop-up healthcare units, ad hoc teams and unpredictable personal protective equipment supply, it is difficult for healthcare institutions and front-line teams to invent and test robust and safe clinical care pathways for patients and clinicians. Conventional simulation-based education was not designed for the time-pressured and emergent needs of readiness in a pandemic. We used ‘rapid cycle system improvement’ to create a psychologically safe learning oasis in the midst of a pandemic. This oasis provided a context to build staff technical and teamwork capacity and improve clinical workflows simultaneously.

Methods

At the Department of Anaesthesia and Intensive Care in Prince of Wales Hospital, a tertiary institution, in situ simulations were carried out in the operating theatres and intensive care unit (ICU). The translational simulation design leveraged principles of psychological safety, rapid cycle deliberate practice, direct and vicarious learning to ready over 200 staff with 51 sessions and achieve iterative system improvement all within 7 days. Staff evaluations and system improvements were documented postsimulation.

Results/Findings

Staff in both operating theatres and ICU were significantly more comfortable and confident in managing patients with COVID-19 postsimulation. Teamwork, communication and collective ability to manage infectious cases were enhanced. Key system issues were also identified and improved.

Discussion

To develop readiness in the rapidly progressing COVID-19 pandemic, we demonstrated that ‘rapid cycle system improvement’ can efficiently help achieve three intertwined goals: (1) ready staff for new clinical processes, (2) build team competence and confidence and (3) improve workflows and procedures.

Sustainable Sport Development: The Influence of Competitive-Grouping and Relative Age on the Performance of Young Triathletes

Competitive-grouping by chronological age is a common organizational strategy in competition which may unintentionally promote relative age effects, for the benefit of older individuals within the same competitive-group, especially in young athletes. This work presents the aim of analyzing differences in young triathletes on their performance within each competitive group. A total of 1243 entries of both sexes, both children—13–14 years old—and cadets—15–17 years old—participated. Firstly, we identified the year in the competitive group and relative-age semester for all the triathletes who competed in a total of six seasons from 2013 to 2018. Secondly, the performance indicator was calculated in all the segments in a triathlon competition for all triathletes. The Kruskal-Wallis Test and U Mann Whitney Test was applied. It was observed that all cadet triathletes born in the first semester of the year (S1, born in January–June) were faster; for both boys and girls. Likewise, it was observed that older triathletes who competed within the same category were faster, but only in males and for both competitive groups: children (p < 0.0083), and cadet (p < 0.0033). In conclusion, families, coaches and sports political agencies need a greater knowledge and understanding of the effects of relative age and competitive grouping to understand the important role of age in the development of sports talent demonstrated in this study.

Is the Deliberate Practice View Defensible? A Review of Evidence and Discussion of Issues

The question of what explains individual differences in expertise within complex domains such as music, games, sports, science, and medicine is currently a major topic of interest in a diverse range of fields, including psychology, education, and sports science, to name just a few. Ericsson and colleagues' deliberate practice view is a highly influential perspective in the literature on expertise and expert performance-but is it viable as a testable scientific theory? Here, reviewing more than 25 years of Ericsson and colleagues' writings, we document critical inconsistencies in the definition of deliberate practice, along with apparent shifts in the standard for evidence concerning deliberate practice. We also consider the impact of these issues on progress in the field of expertise, focusing on the empirical testability and falsifiability of the deliberate practice view. We then discuss a multifactorial perspective on expertise, and how open science practices can accelerate progress in research guided by this perspective.

Practicing Connections: A Framework to Guide Instructional Design for Developing Understanding in Complex Domains

Research suggests that expert understanding is characterized by coherent mental representations featuring a high level of connectedness. This paper advances the idea that educators can facilitate this level of understanding in students through the practicing connections framework: a practical framework to guide instructional design for developing deep understanding and transferable knowledge in complex academic domains. We start by reviewing what we know from learning sciences about the nature and development of transferable knowledge, arguing that connectedness is key to the coherent mental schemas that underlie deep understanding and transferable skills. We then propose features of instruction that might uniquely facilitate deep understanding and suggest that the connections between a domain’s core concepts, key representations, and contexts and practices of the world must be made explicit and practiced, over time, in order for students to develop coherent understanding. We illustrate the practicing connections approach to instructional design in the context of a new online interactive introductory statistics textbook developed by the authors.

Modern Aspects of Cyber-Security Training and Continuous Adaptation of Programmes to Trainees

Nowadays, more-and-more cyber-security training is emerging as an essential process for the lifelong personnel education in organizations, especially for those which operate critical infrastructures. This is due to security breaches on popular services that become publicly known and raise people’s security awareness. Except from large organizations, small-to-medium enterprises and individuals need to keep their knowledge on the related topics up-to-date as a means to protect their business operation or to obtain professional skills. Therefore, the potential target-group may range from simple users, who require basic knowledge on the current threat landscape and how to operate the related defense mechanisms, to security experts, who require hands-on experience in responding to security incidents. This high diversity makes training and certification quite a challenging task. This study combines pedagogical practices and cyber-security modelling in an attempt to support dynamically adaptive training procedures. The training programme is initially tailored to the trainee’s needs, promoting the continuous adaptation to his/her performance afterwards. As the trainee accomplishes the basic evaluation tasks, the assessment starts involving more advanced features that demand a higher level of understanding. The overall method is integrated in a modern cyber-ranges platform, and a pilot training programme for smart shipping employees is presented.

Determining competence in performing obstetric combined spinal-epidural procedures in junior anesthesiology residents: results from a cumulative sum analysis

BACKGROUND

The epidural anesthesia technique is a challenging skill to master. The Accreditation Council for Graduate Medical Education (ACGME) stipulates that anesthesiology residents must complete 40 epidural procedures by the end of junior residency. The rationale is unknown. The aim of this prospective study was to determine the minimum case experience required to demonstrate competence in performing obstetric combined spinal-epidural procedures among junior residents, using an objective statistical tool, the cumulative sum (CUSUM) analysis.

METHODS

Twenty-four residents, with no prior experience performing epidurals, sequentially recorded all obstetric combined spinal-epidural procedures as a 'success' or 'failure', based on study criteria. Individual CUSUM graphs were plotted, with acceptable and unacceptable failure rates set at 20% and 35%, respectively. The number of procedural attempts necessary to demonstrate competence was determined.

RESULTS

Twenty-four residents (mean (SD) age 29 (2) years) participated in the study. Median (IQR) number of procedures was 78 (66-85), with a median (IQR) success rate of 86% (82-89%). Nineteen of 24 residents required a median (IQR) of 40 (33-50) attempts to demonstrate competence. Five did not achieve procedural competence in the training period. The CUSUM graphs highlighted performance trends that required intervention.

CONCLUSION

Competence was achieved by 19/24 residents after the ACGME-required case experience of 40 combined spinal-epidural procedures, based on a predefined acceptable failure rate of 20%. In our experience, CUSUM analysis is useful in monitoring technical performance over time and should be included as an adjunct assessment method for determining procedural competence.

Online patient simulation training to improve clinical reasoning: a feasibility randomised controlled trial

BACKGROUND

Online patient simulations (OPS) are a novel method for teaching clinical reasoning skills to students and could contribute to reducing diagnostic errors. However, little is known about how best to implement and evaluate OPS in medical curricula. The aim of this study was to assess the feasibility, acceptability and potential effects of eCREST - the electronic Clinical Reasoning Educational Simulation Tool.

METHODS

A feasibility randomised controlled trial was conducted with final year undergraduate students from three UK medical schools in academic year 2016/2017 (cohort one) and 2017/2018 (cohort two). Student volunteers were recruited in cohort one via email and on teaching days, and in cohort two eCREST was also integrated into a relevant module in the curriculum. The intervention group received three patient cases and the control group received teaching as usual; allocation ratio was 1:1. Researchers were blind to allocation. Clinical reasoning skills were measured using a survey after 1 week and a patient case after 1 month.

RESULTS

Across schools, 264 students participated (18.2% of all eligible). Cohort two had greater uptake (183/833, 22%) than cohort one (81/621, 13%). After 1 week, 99/137 (72%) of the intervention and 86/127 (68%) of the control group remained in the study. eCREST improved students' ability to gather essential information from patients over controls (OR = 1.4; 95% CI 1.1-1.7, n = 148). Of the intervention group, most (80/98, 82%) agreed eCREST helped them to learn clinical reasoning skills.

CONCLUSIONS

eCREST was highly acceptable and improved data gathering skills that could reduce diagnostic errors. Uptake was low but improved when integrated into course delivery. A summative trial is needed to estimate effectiveness.

A Process Evaluation of a Performance Psychology Intervention for Transitioning Elite and Elite Musicians

The present study presents a process evaluation of a performance psychology intervention for transitioning elite and elite musicians. The goal of the intervention was to provide participants with an amalgamation of evidence-informed principles, aimed to improve their quality of practice and performance preparation. The intervention consisted of an educational session followed by four workshops. In total, eight transitioning elite and seven elite musicians participated. Process measures included quantitative and qualitative workshop evaluations, monitoring logs, and semi-structured interviews. Overall, the intervention was evaluated positively by the participants. However, differences were present between the groups, with the elite musicians typically evaluating the intervention more favorably compared to the transitioning elites. Specific positive outcomes included an increased awareness and re-examining of current practice strategies, more structured and goal-directed practice, increased practice efficiency and focus, a more proactive approach to performances, and increased attention for the physical aspects of playing. Moreover, a number of contextual considerations and implementation challenges became evident. Important implications for performance psychology interventions and practitioners in music are discussed.