Identifying Nontechnical Skill Deficits in Trainees Through Interdisciplinary Trauma Simulation

Improving Pediatric Trauma Education by Teaching Non-technical Skills: A Randomized Controlled Trial

BACKGROUND

Pediatric trauma is a significant cause of child mortality, and the absence of non-technical skills (NTS) among health providers is linked with errors in patients' care. In this study, we evaluate the effectiveness of a structured debriefing protocol in enhancing NTS during pediatric trauma simulation.

METHODS

A total of 45 medical students were successfully recruited from two medical schools, one in Brazil and one in Canada. Medical students were assigned to a control (N = 20) or intervention group (N = 25) in a randomized control trial. Following simulated scenarios, participants in the intervention group underwent NTS debriefing, while the control received standard debriefing based on the Advanced Trauma Life Support (ATLS) protocol. Students' confidence, NTS level, and performance were measured through self-assessment surveys, the Non-Technical Skills for Surgeons (NOTSS) score, and adherence to the trauma protocol, respectively. Baseline characteristics and outcomes were compared using t-tests, Mann-Whitney, Wilcoxon signed-rank Kruskal-Wallis, ANOVA, and a repeated-measures ANCOVA. A significance level was set at p < 0.05.

RESULTS

The workshop increased students' confidence in leading trauma resuscitation regardless of their assignment to condition. While controlling for covariates, students in the intervention group significantly improved their overall NOTSS compared to those in the control and in all categories: situational awareness, decision-making, communication and teamwork, and leadership. The intervention teams also demonstrated a significant increase in completing trauma protocol steps.

CONCLUSION

Implementing structured debriefing focusing on NTS enhanced these skills and improved adherence to protocol among medical students managing pediatric trauma-simulated scenarios. These findings support integrating NTS training in pediatric trauma education.

LEVEL OF EVIDENCE

I.

Technology-enhanced trauma training in low-resource settings: A scoping review and feasibility analysis of educational technologies

BACKGROUND

Lack of training contributes to the burden of trauma-related mortality and morbidity in low- and lower-middle-income countries (LMICs). Educational technologies present a unique opportunity to enhance the quality of trauma training. Therefore, this study reviews current technologies used in trauma courses and evaluates their feasibility for LMICs.

METHODS

We conducted a scoping review evaluating the learning outcomes of technology-enhanced training in general trauma assessment, team skills or any procedures covered in the 2020 Advanced Trauma Life Support® program. Based on the Technology-Enhanced Learning criteria, we created and applied a feasibility analysis tool to evaluate the technologies for use in LMICs.

RESULTS

We screened 6471 articles and included 64. Thirty-four (45%) articles explored training in general trauma assessment, 28 (37%) in team skills, and 24 (32%) in procedures. The most common technologies were high-fidelity mannequins (60%), video-assisted debriefing (19%), and low-fidelity mannequins (13%). Despite their effectiveness, high-fidelity mannequins ranked poorly in production, maintenance, cost, and reusability categories, therefore being poorly suited for LMICs. Virtual simulation and digital courses had the best feasibility scores, but still represented a minority of articles in our review.

CONCLUSION

To our knowledge, this is the first study to perform a feasibility analysis of trauma training technologies in the LMIC context. We identified that the majority of trauma courses in the literature use technologies which are less suitable for LMICs. Given the urgent need for pediatric trauma training, educators must use technologies that optimize learning outcomes and remain feasible for low-resource settings.

LEVEL OF EVIDENCE

IV.

Simulation-Based Education in Trauma Management: A Scoping Review

Trauma injuries are an important healthcare problem and one of the main leading causes of death worldwide. The purpose of this review was to analyze current practices in teaching trauma management using simulations, with the aim of summarizing them, identifying gaps and providing a critical overview on what has already been achieved. A search on the Web of Science website for simulation-based trauma training articles published from 2010 onwards was performed, obtaining 1617 publications. These publications were screened to 35 articles, which were deeply analyzed, gathering the following information: the authors, the publication type, the year of the publication, the total number of citations, the population of the training, the simulation method used, the skills trained, the evaluation type used for the simulation method presented in the paper, if skills improved after the training and the context in which the simulation took place. Of the 35 articles included in this review, only a few of them had students as the target audience. The more used simulation method was a high-fidelity mannequin, in which the participants trained in more technical than non-technical skills. Almost none of the studies introduced an automated evaluation process and most of the evaluation methods consisted of checklists or questionnaires. Finally, trauma training focused more on treating trauma patients in a hospital environment than in a pre-hospital one. Overall, improvements in the evaluation method, as well as in the development of trauma training on undergraduate education, are important areas for further development.

The development and measurement properties of the trauma NOn-TECHnical skills (T-NOTECHS) scale: A scoping review

PURPOSE

Conduct a scoping review to critically appraise the development and summarize the evidence on the measurement properties of T-NOTECHS including sensibility, reliability, and validity.

METHODS

A literature search was performed using Pubmed and Ovid databases. Studies that described the development process of T-NOTECHS and primary studies that presented evidence of reliability and validity were identified and included. Measurement properties of T-NOTECHS was assessed and summarized under the following: scale development, sensibility, reliability, and validity.

RESULTS

The literature search yielded 245 articles with 24 studies meeting inclusion criteria. The T-NOTECHS was developed with an acceptable robust methodology. It has good sensibility with adequate content, face validity, and feasibility. It is a reliable measure of non-technical skills in the setting of trauma video review, which improves with expert raters or extensive training. The T-NOTECHS is a valid discriminative and evaluative instrument that measures non-technical skills of multidisciplinary trauma teams.

CONCLUSIONS

T-NOTECHS provides reliable and valid measurements of non-technical skills of trauma teams, particularly when assessing trauma video review and non-technical skills training interventions by expert raters.

Debriefing strategies for interprofessional simulation-a qualitative study

Background

Interprofessional education is becoming more common worldwide. Simulation is one format in which this can effectively take place. The debriefing after the simulation is a critical part of the simulation process as it allows reflection and discussion of concepts that arose during the simulation. Debriefing has been noted to be challenging in the literature. Debriefing after interprofessional simulation (IPS) is likely to have even more challenges, many related to the different backgrounds (profession, specialty) of the learners. This study was designed to investigate: ‘How do differing learner professions impact on delivery of post simulation debriefing after team based interprofessional simulation—what are the challenges and what strategies can be used to overcome them?’

Methods

An initial review of the literature was used to identify current understanding and potential themes requiring further exploration. Using the results from the literature as a starting point for topics and questions to be asked, semi-structured interviews were planned, with those who are experienced in debriefing after IPS. The interviews were transcribed then analysed using a framework analysis.

Results

The literature search resulted in twenty relevant papers. Four dimensions were drawn out from these papers that were directly related to debriefing after IPS: ‘the debriefer’, ‘method of debriefing’, ‘the learner’ and ‘psychological safety’. Sixteen interviews occurred between June and August 2020. Ten themes were extracted from the analysis of the transcripts of these interviews: number and specialty of debriefers, credibility, assumptions/preconceptions, nurses vs doctors, method of debriefing, the learner, hierarchy, safe learning environment, inclusion of all learners, and number of debriefers. These themes were fitted in the four dimensions identified in the literature search, and discussed as so.

Conclusion

Several challenges and strategies were identified during this study. ‘It depends’ was a common answer received in the interviews suggesting that there is very little advice that can be given that applies to every situation. The main recommendation from this study is the support for an interprofessional group of debriefers in IPS although this does introduce its own challenges. Further research is suggested around the hierarchy found in IPS debriefing and how this translates to and from clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-022-00214-3.

Transfer of Clinical Decision-Making-Related Learning Outcomes Following Simulation-Based Education in Nursing and Medicine: A Scoping Review

PURPOSE

Simulation is often depicted as an effective tool for clinical decision-making education. Yet, there is a paucity of data regarding transfer of learning related to clinical decision-making following simulation-based education. The authors conducted a scoping review to map the literature regarding transfer of clinical decision-making learning outcomes following simulation-based education in nursing or medicine.

METHOD

Based on the Joanna Briggs Institute methodology, the authors searched 5 databases (CINAHL, ERIC, MEDLINE, PsycINFO, and Web of Science) in May 2020 for quantitative studies in which the clinical decision-making performance of nursing and medical students or professionals was assessed following simulation-based education. Data items were extracted and coded. Codes were organized and hierarchized into patterns to describe conceptualizations and conditions of transfer, as well as learning outcomes related to clinical decision-making and assessment methods.

RESULTS

From 5,969 unique records, 61 articles were included. Only 7 studies (11%) assessed transfer to clinical practice. In the remaining 54 studies (89%), transfer was exclusively assessed in simulations that often included one or more variations in simulation features (e.g., scenarios, modalities, duration, and learner roles; 50, 82%). Learners' clinical decision-making, including data gathering, cue recognition, diagnoses, and/or management of clinical issues, was assessed using checklists, rubrics, and/or nontechnical skills ratings.

CONCLUSIONS

Research on simulation-based education has focused disproportionately on the transfer of learning from one simulation to another, and little evidence exists regarding transfer to clinical practice. The heterogeneity in conditions of transfer observed represents a substantial challenge in evaluating the effect of simulation-based education. The findings suggest that 3 dimensions of clinical decision-making performance are amenable to assessment-execution, accuracy, and speed-and that simulation-based learning related to clinical decision-making is predominantly understood as a gain in generalizable skills that can be easily applied from one context to another.

A scoping review of nontechnical skill assessment tools to evaluate trauma team performance

BACKGROUND

The objective of this scoping review was to identify assessment tools of trauma team performance (outside of technical skills) and assess the validity and reliability of each tool in assessing trauma team performance.

METHODS

We searched Embase, Cochrane Library, Web of Science, Ovid Medline, and Cumulative Index to Nursing and Allied Health Literature from inception to June 1, 2021. English studies that evaluated trauma team performance using nontechnical skill assessment tools in a simulation or real-world setting were included. Studies were assessed by two independent reviewers for meeting inclusion/exclusion criteria. Data regarding team assessment tools were extracted and synthesized into behavior domains. Each tool was then assessed for validity and reliability.

RESULTS

The literature search returned 4,215 articles with 29 meeting inclusion criteria. Our search identified 12 trauma team performance assessment tools. Most studies were conducted in the United States (n = 20 [69%]). Twenty studies (69%) assessed trauma team performance in a simulation setting; Team Emergency Assessment Measure (TEAM) and Trauma Nontechnical Skills Scale (T-NOTECHS) were the only tools to be applied in a simulation and real-world setting. Most studies assessed trauma team performance using video review technology (n = 17 [59%]). Five overarching themes were designed to encompass behavioral domains captured across the 12 tools: (1) Leadership, (2) Communication, (3) Teamwork, (4) Assessment, and (5) Situation Awareness. The reliability and validity of T-NOTECHS were investigated by the greatest number of studies (n = 13); however, TEAM had the most robust evidence of reliability and validity.

CONCLUSION

We identified 12 trauma team performance tools that assessed nontechnical skills to varying degrees. Trauma Nontechnical Skills Scale and TEAM tools had the most evidence to support their reliability and validity. Considering the limited research in the impact of trauma team performance on patient outcomes, future studies could use video review technology in authentic trauma cases to further study this important relationship.

LEVEL OF EVIDENCE

Systematic reviews and meta-analyses, level IV.

Trauma Bay Virtual Reality - A Game Changer for ATLS Instruction and Assessment

BACKGROUND

Medical educational research highlights the need for high-fidelity, multidisciplinary simulation training to teach complex decision-making skills such as those taught in ATLS. This approach is, however, expensive and time intensive. Virtual reality (VR) education simulation may improve skill acquisition in a cost-effective and time-sensitive manner. We developed a novel trauma VR simulator (TVRSim) for providers to apply ATLS principles. We hypothesized in this pilot study that TVRSim could differentiate practitioner competency with increasing experience and would be well accepted.

METHODS

Providers at a level 1 trauma center (acute care surgeons, novice (MS4 & PGY1), junior (PGY2 & 3), senior (PGY4-6) residents) ran a blunt, polytrauma VR code. Ten critical decision points were assessed: intubation, cricothyroidotomy, chest tube, IV access, FAST, pelvic binder, activation of MTP, administration of hypertonic saline (HTS), hyperventilation and decision to go to the OR. Learner assessment was based upon frequency and time to correct decisions. Participant satisfaction was measured using validated surveys.

RESULTS

All 31 providers intubated and obtained IV access. Novices and juniors frequently failed at HTS and hyperventilation decisions. Juniors often failed at cricothyroidotomy (60%), and OR (100%) decisions. Mean time to all decisions except going to the OR was longer for all groups compared to ACS surgeons. Mean number of decisions/min was significantly higher for surgeons and seniors compared to juniors and novices. Mortality was 92.3% for novices, 80% for juniors, 25% for seniors and 0% for the attendings. Participants found TVRSim comfortable, easy to use/interact with/performance enhancing, and helped develop skills and learning.

CONCLUSIONS

In this pilot study using a sample of convenience, TVRSim was able to discern decision-making abilities among trainees with increasing experience. All trainees felt the platform enhanced their performance and facilitated skill acquisition and learning. TVRSim could be a useful adjunct to teach and assess ATLS skills.

LEVEL OF EVIDENCE

III, diagnostic test/education.

Examining non-technical skills for ad hoc resuscitation teams: a scoping review and taxonomy of team-related concepts

BACKGROUND

Non-technical skills (NTS) concepts from high-risk industries such as aviation have been enthusiastically applied to medical teams for decades. Yet it remains unclear whether-and how-these concepts impact resuscitation team performance. In the context of ad hoc teams in prehospital, emergency department, and trauma domains, even less is known about their relevance and impact.

METHODS

This scoping review, guided by PRISMA-ScR and Arksey & O'Malley's framework, included a systematic search across five databases, followed by article selection and extracting and synthesizing data. Articles were eligible for inclusion if they pertained to NTS for resuscitation teams performing in prehospital, emergency department, or trauma settings. Articles were subjected to descriptive analysis, coherence analysis, and citation network analysis.

RESULTS

Sixty-one articles were included. Descriptive analysis identified fourteen unique non-technical skills. Coherence analysis revealed inconsistencies in both definition and measurement of various NTS constructs, while citation network analysis suggests parallel, disconnected scholarly conversations that foster discordance in their operationalization across domains. To reconcile these inconsistencies, we offer a taxonomy of non-technical skills for ad hoc resuscitation teams.

CONCLUSION

This scoping review presents a vigorous investigation into the literature pertaining to how NTS influence optimal resuscitation performance for ad hoc prehospital, emergency department, and trauma teams. Our proposed taxonomy offers a coherent foundation and shared vocabulary for future research and education efforts. Finally, we identify important limitations regarding the traditional measurement of NTS, which constrain our understanding of how and why these concepts support optimal performance in team resuscitation.

Costs of hospital trauma team simulation training: a prospective cohort study

OBJECTIVES

This study investigated the costs of 2-hour multiprofessional in situ hospital trauma team simulation training and its effects on teams' non-technical skills using the T-NOTECHS instrument.

BACKGROUND

Simulation is a feasible and effective teaching and learning method. Calculating the costs of simulated trauma team training in medical emergency situations can yield valuable information for improving its overall cost-effectiveness.

DESIGN

A prospective cohort study.

SETTING

Trauma resuscitation room in Central Finland Hospital, Finland.

PARTICIPANTS

475 medical professionals in 81 consecutive, simulated trauma teams.

PRIMARY AND SECONDARY OUTCOME MEASURES

Team simulation training costs in 2017 and 2018 were analysed in the following two phases: (1) start-up costs and (2) costs of education. Primary outcome measures were training costs per participant and training costs per team. Secondary outcome measures were non-technical skills, which were measured on a 5-25-point scale using the T-NOTECHS instrument.

RESULTS

The annual mean total costs of trauma team simulation training were €58 000 for 40 training sessions and 238 professionals. Mean cost per participant was €203. Mean cost per team was €1220. The annual costs of simulation training markedly decreased when at least 70-80 teams participated in the training. Mean change in T-NOTECHS score after simulation training was +2.86 points (95% CI 1.97 to 3.75;+14.5%).

CONCLUSIONS

The greater the number of teams trained per year, the lower the costs per trauma team. In this study, we developed an activity-based costing method to calculate the costs of trauma team simulation training to help stakeholders make decisions about whether to initiate or increase existing trauma team simulation training or to obtain these services elsewhere.

A Systematic Review of Trauma Crew Resource Management Training: What Can the United States and the United Kingdom Learn From Each Other?

OBJECTIVE

Crew Resource Management (CRM) training incorporates methods such as simulation, debrief, and teamwork training to emphasize human factors skills. This systematic review aimed to assess differences in CRM between UK and USA trauma personnel.

DESIGN

A structured search of the databases MEDLINE and Embase in addition to unstructured reference review and Google Scholar search was undertaken without time restraint to identify articles describing CRM training courses of trauma personnel. Predetermined criteria for inclusion included comprehensive reports of CRM training in trauma personnel with participant assessment. Articles were analyzed for course details and descriptions, Kirkpatrick domains and levels utilized, and measure items and outcomes.

RESULTS

Twenty-nine full-text articles (24 USA, 5 UK) met predetermined criteria. UK-based CRM had a heavy emphasis on doctors while USA-based CRM reached a range of multidisciplinary civilian and military professionals. UK-based CRM focused on skills outcomes using pre- and post-training questionnaires, whereas USA-based training focused on behavior and nontechnical skills utilizing validated standardized measures. CRM-based training, and particularly courses incorporating simulation and multidisciplinary methods, resulted in significantly improved preparedness for trauma, emergency skills, and clinical behavioral change.

CONCLUSIONS

CRM training has the potential to give significant benefits to participant learning, teamwork behaviors, and clinical care outcomes. The USA appears to utilize a focused multidisciplinary and human factors approach to trauma training, which could be adopted by UK institutions to improve cohesive team performance and patient care.

Multi-Disciplinary Trauma Evaluation and Management Simulation (MD-TEAMS) training for emergency medicine and general surgery residents

BACKGROUND

Successful trauma resuscitation relies on multi-disciplinary collaboration. In most academic programs, general surgery (GS) and emergency medicine (EM) residents rarely train together before functioning as a team.

METHODS

In our Multi-Disciplinary Trauma Evaluation and Management Simulation (MD-TEAMS), EM and GS residents completed manikin-based trauma scenarios and were evaluated on resuscitation and communication skills. Residents were surveyed on confidence surrounding training objectives.

RESULTS

Residents showed improved confidence running trauma scenarios in multi-disciplinary teams. Residents received lower communication scores from same-discipline vs cross-discipline faculty. EM residents scored higher in evaluation and planning domains; GS residents scored higher in action processes; groups scored equally in team management. Strong correlation existed between team leader communication and resuscitative skill completion.

CONCLUSION

MD-TEAMS demonstrated correlation between communication and resuscitation checklist item completion and communication differences by resident specialty. In the future, we plan to evaluate training-related resident behavior changes and specialty-specific communication differences by residents.

Educational Interventions to Enhance Situation Awareness: A Systematic Review and Meta-Analysis

STATEMENT

We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes.

Experience of emergency healthcare professionals in cardiopulmonary resuscitation and its relationship with self-efficacy: A qualitative approach

AIM

To gain a deeper knowledge of the phenomenon of cardiopulmonary resuscitation by capturing the meanings that professionals attach to the behaviour of reanimation and its relationship with Social Cognitive Theory.

METHOD

Qualitative research from a phenomenological approach focussing on field work with a focus group of professionals from Madrid (doctors, nurses and technicians), as well as a previous study. After the transcription of the data, it was coded, categories were formed and it was grouped into dimensions, interpreting the data according to the Social Cognitive Theory. Data was collected from other sources, experience of professionals and family members who had witnessed a cardiopulmonary resuscitation, until the saturation of the data.

RESULTS

The phenomena that affect the people involved in a cardiopulmonary resuscitation were explored holistically. The relevant aspects to feel able to perform cardiopulmonary resuscitation, as well as those that may hinder the behaviour were identified. Two dimensions were found, personal and situational factors, as well as several categories in each dimension related to Bandura's theory of self-efficacy.

CONCLUSIONS

Professionals' self-efficacy in a cardiopulmonary resuscitation does not always depend on the technical skills acquired. Personal and situational factors influence the professional being able to vary their behaviour cognitively and emotionally. This knowledge enables cardiopulmonary resuscitation competencies in a clinical situation to be improved and individualized training programmes to be designed in teaching practice.