Reconsidering fidelity in simulation-based training

Effectiveness of a new basic course incorporating medical trainer simulator for HEMS education in Japan: a pre-post intervention study

BACKGROUND

Japan's HEMS (Helicopter Emergency Medical Services) has recently shifted from quantitative expansion to qualitative improvement, highlighting the need for standardizing training and enhancing safety. This study aimed to evaluate a newly developed basic training course that integrates a Medical Trainer (MeTra) simulator, addressing the need for standardized education and improved safety in HEMS operations.

METHODS

In total, 208 HEMS professionals (83 doctors, 49 nurses, and 76 operational staff) participated in the revamped course, which combines e-learning, practical discussions, and MeTra simulation. Self-reported questionnaires assessing non-technical (4 items) and technical skills (6 items) using a 5-point Likert scale were administered pre- and post-course. Wilcoxon signed-rank tests evaluated changes in perceived competence. We also measured the MeTra simulator's fidelity and overall course satisfaction.

RESULTS

All non-technical and technical skills items improved significantly (p < 0.05), with notable gains in patient management during aircraft malfunction (average increase of 1.49 points) and fire extinguisher use (average increase of 1.11 points). Participants rated the MeTra simulator highly, especially for its enclosed environment, with 91% rating it four or higher, and for its communication system fidelity, with 96% rating it four or higher. Overall course satisfaction was high, with 96% rating it four or higher. Nonetheless, in line with Cook's caution on Kirkpatrick Level 2 data, these findings primarily reflect participants' perceptions rather than objective performance, and no control group was included.

CONCLUSIONS

The new basic course incorporating the MeTra simulator may enhance self-reported competencies for diverse HEMS professionals. This standardized education program marks a significant step towards aligning Japan's HEMS training with international standards.

Development of a cost-effective, reusable, resuscitative hysterotomy task trainer for emergency medicine trainees

We designed, developed, and constructed a reusable, durable, low-cost resuscitative hysterotomy (RH) task trainer with functional and structural fidelity for repetitive practice and education for emergency medicine trainees. The availability of commercial caesarean task trainers is limited, and their high cost often poses a barrier to training. Although similar procedures, RH and traditional caesarean section are unique, and to the authors' knowledge there are currently no commercial task trainers specifically designed for RH. Current RH literature recommends completing the procedure within five minutes to improve the survival chances of both the fetus and the mother during active or imminent cardiac arrest. While RH is not a technically complex procedure relative to other procedures, it involves specific technical steps and requires clinicians to act decisively. Our RH task trainer was created using low-cost expired materials sourced from our hospital system and additional items purchased online. The RH task trainer was designed to be easily assembled, have minimal recurring material costs, and with quick set-up and clean-up for repetitive practice. When used within a simulation-based scenario, learners are also challenged with the decision to proceed with an RH; thus, providing experiential development of this decision-making step which is unparalleled in comparison to most traditional training formats. Overall, our RH trainer can be built for approximately 230 US dollars. The ability to create low-cost and easily accessible opportunities for repetitive practice of RH contributes to the limited pool of non-commercial RH task trainers, offering valuable experiential instruction for this unique, high-acuity, low-occurrence procedure. Brief description We developed a reusable, durable, low-cost resuscitative hysterotomy (RH) task trainer with functional and structural fidelity for repetitive practice and education for emergency medicine trainees at a tertiary care training hospital. Further, we aimed to create a task trainer that enhanced the cognitive and procedural skills required for performing RH within a high-stress clinical environment.

Educational outcomes of simulation-based training in regional anaesthesia: a scoping review

BACKGROUND

Structured training in regional anaesthesia includes pretraining on simulation-based educational platforms to establish a safe and controlled learning environment before learners are provided clinical exposure in an apprenticeship model. This scoping review was designed to appraise the educational outcomes of current simulation-based educational modalities in regional anaesthesia.

METHODS

This review conformed to PRISMA-ScR guidelines. Relevant articles were searched in PubMed, Scopus, Google Scholar, Web of Science, and EMBASE with no date restrictions, until November 2023. Studies included randomised controlled trials, pre-post intervention, time series, case control, case series, and longitudinal studies, with no restrictions to settings, language or ethnic groups. The Kirkpatrick framework was applied for extraction of educational outcomes.

RESULTS

We included 28 studies, ranging from 2009 to 2023, of which 46.4% were randomised controlled trials. The majority of the target population was identified as trainees or residents (46.4%). Higher order educational outcomes that appraised translation to real clinical contexts (Kirkpatrick 3 and above) were reported in 12 studies (42.9%). Two studies demonstrated translational patient outcomes (Level 4) with reduced incidence of paraesthesia and clinical complications. The majority of studies appraised Level 3 outcomes of performance improvements in either laboratory simulation contexts (42.9%) or demonstration of clinical performance improvements in regional anaesthesia (39.3%).

CONCLUSIONS

There was significant heterogeneity in the types of simulation modalities used, teaching interventions applied, study methodologies, assessment tools, and outcome measures studied. When improvisations were made to regional anaesthesia simulation platforms (hybrid simulation), there were sustained educational improvements beyond 6 months. Newer technology-enhanced innovations such as virtual, augmented, and mixed reality simulations are evolving, with early reports of educational effectiveness.

Pediatric Endocrinology Education Among Trainees: A Scoping Review

INTRODUCTION

Pediatric endocrinology education is a fundamental part of all pediatric endocrinology training. Hence, understanding the current methods used for training learners on skills required and understanding methods or topics that may be underexplored could help improve the quality of training.

OBJECTIVE

This study aims to explore training and assessment strategies used in pediatric endocrinology training across medical education programs through a scoping review.

METHODS

Search strategy was developed with a librarian, and bibliographic databases (e.g., MEDLINE and EMBASE) were searched from January 2005 to July 2024. Pilot screenings ensured consistent inclusion/exclusion decisions among reviewers. Full-text articles were included if they were related to pediatric endocrinology education and focused on medical learners.

RESULTS

We included 45 of 5814 sources of evidence for data extraction. Majority focused on knowledge of Type 1 and Type 2 diabetes and diabetes ketoacidosis (N = 18), followed by differences in sex development and pubertal assessment (N = 12). The most frequently used training method was through didactics. Additionally, the most frequently used assessment measures included knowledge tests (N = 25). Also, a limited number of studies targeted obesity (N = 2), gender care (N = 3), thyroid (N = 1) and hypoglycaemia (N = 1), and no studies targeted common topics such as bone health and adrenal insufficiency.

CONCLUSION

This review reveals the current emphasis on diabetes-related topics and traditional teaching in pediatric endocrinology education. It suggests a need for more innovative methods, like simulation-based learning and varied assessment techniques, to better equip trainees. Addressing these gaps can improve trainee confidence, patient care, and health outcomes for children with endocrine disorders.

Building Global Partnerships: A Qualitative Exploration of In-Person Training for HealthCare Simulation Educators Working in Low-Resource Settings

INTRODUCTION

Effective educational initiatives can elevate the quality of patient care globally. Simulation-based education is widely used in high-resource settings, but barriers exist to its widespread use in low-resource settings. Vital Anesthesia Simulation Training (VAST) overcomes these barriers by offering immersive, low-cost portable simulation along with simulation facilitator training. During the COVID-19 pandemic, in-person courses were stopped for more than 2 years. Postpandemic, a 3-day VAST SIMposium was hosted in Rwanda to unite 42 VAST facilitators from 12 widespread countries to introduce new and revised course materials and to rejuvenate dormant skills. The purpose of this study was to explore how the VAST SIMposium influenced perceived development of skills, confidence, and engagement in a community of practice for simulation educators working in low-resource settings.

METHODS

This qualitative study involved in-depth interviews with a purposive sample of 16 VAST SIMposium attendees. Transcripts of audio recordings were analyzed using inductive thematic analysis.

RESULTS

Six themes were identified during data analysis: 1) Diversity with shared passion for medical education; 2) Supportive in-person learning environment; 3) Simulation-based education relevant to low-resource settings; 4) Camaraderie; 5) Building knowledge, skills, and confidence; and 6) Being part of a community of practice.

CONCLUSION

The SIMposium rejuvenated passion, knowledge, skills, and, most importantly, strengthened global connections and partnerships. These collaborations will benefit areas that are underrepresented in simulation and will ultimately improve patient outcomes. A SIMposium of this format is an efficient and effective way to foster sustainable global dissemination of simulation-based global health education.

Time Is a Tool: Evaluation of a Prolonged Casualty Care Curriculum With a Focus on Temporal Fidelity

INTRODUCTION

In current and anticipated future conflicts, including large-scale combat operations, medical teams are tasked to provide prolonged casualty care (PCC) or extended patient care that occurs when delays in evacuation exceed the team's capabilities. Although the principles of PCC are often taught to military medical providers using simulation, educators rarely dedicate the time to training required to simulate the prolonged nature of these encounters. Therefore, a lack of knowledge exists regarding which aspects of extended care may be lost in an accelerated training scenario.

MATERIALS AND METHODS

To close this knowledge gap within military medical education and training, we modified an existing PCC curriculum at the USU, Operation Gunpowder, to focus on temporal fidelity, extending the length of the simulated encounter to 21 hours. We used a qualitative phenomenological design to explore the students' experiences and perceptions by closely analyzing their assigned reflection papers.

RESULTS

We identified four themes from the students' reflection papers: (1) Recognized effects of fatigue, (2) navigated resource limitations, (3) realized the value of teamwork, and (4) noted the importance of communication and documentation. These themes revealed benefits of incorporating temporal fidelity into PCC training, including self-awareness of personal limits and possible strategies to mitigate fatigue when medical or operational mission requirements dictate sleep deprivation. Future studies are needed to determine other training scenarios that would benefit from adherence to temporal fidelity.

CONCLUSIONS

Wars and disasters require medical providers trained in PCC. Future educational activities aimed at teaching PCC should continue to incorporate temporal fidelity to help teach these valuable lessons.

When is synthetic sufficient? Ethical considerations and alternatives in simulation-based ultrasound education

Simulation-based education (SBE) has become an integral part of training in health professions education, offering a safe environment for learners to acquire and refine clinical skills. As a non-ionising imaging modality, ultrasound is a domain of health professions education that is particularly supported by SBE. Central to many simulation programs is the use of animal models, tissues, or body parts to replicate human anatomy and physiology. However, along with its educational benefits, the use of animals in SBE generates a considerable amount of waste, raising important environmental and ethical concerns. Although research indicates that animal models yield comparable educational outcomes to synthetic models, animal models continue to be preferred in surgical and medical training. In response to these challenges, the principles of Replacement, Reduction, and Refinement (the 3Rs) have emerged as guiding standards to minimise the impact of animal use in research and education. Furthermore, synthetic models align with 3R principles, addressing ethical and environmental issues by reducing animal dependence and waste generation. Synthetic models offer key educational benefits over animal models by closely mimicking human anatomy and pathophysiology, providing consistent and anatomically accurate training. Unlike animal models, they eliminate variability in tissue properties, ensuring standardised and reliable experiences. Moreover, synthetic models can simulate specific pathologies, enabling targeted learning that may be difficult with animal tissue. Resistance related to clinical relevance and preference for animal-based SBE is a persisting challenge that might be overcome through the development of clinically and anatomically relevant tissue-mimicking materials, like those previously developed for other applications such as quality assurance phantoms in diagnostic imaging. The involvement of knowledge or end-user engagement, along with evidence-based design solutions, is crucial to catalyse a paradigm shift in a discipline deeply entrenched in tradition. The combined expertise, skills, and perspectives of medical professionals, educators, academic researchers, and industry specialists could collaboratively develop alternative methods to simulate live animal scenarios, replacing and reducing animal tissue dependence in SBE.

Simulation-Based Education of Health Workers in Low- and Middle-Income Countries: A Systematic Review

INTRODUCTION

Simulation-based education (SBE) is increasingly used to improve clinician competency and patient care and has been identified as a priority by the World Health Organization for low- and middle-income countries (LMICs). The primary aim of this review was to investigate the global distribution and effectiveness of SBE for health workers in LMICs. The secondary aim was to determine the learning focus, simulation modalities, and additional evaluation conducted in included studies.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta Analysis guidelines, searching Ovid (Medline, Embase, and Emcare) and the Cochrane Library from January 1, 2002, to March 14, 2022. Primary research studies reporting evaluation at Level 4 of The Kirkpatrick model were included. Studies on simulation-based assessment and validation were excluded. Quality and risk-of-bias assessments were conducted using appropriate tools. Narrative synthesis and descriptive statistics were used to present the results.

RESULTS

A total of 97 studies were included. Of these, 54 were in sub-Saharan Africa (56%). Forty-seven studies focused on neonatology (48%), 29 on obstetrics (30%), and 16 on acute care (16%). Forty-nine used mannequins (51%), 46 used scenario-based simulation (47%), and 21 used synthetic part-task trainers (22%), with some studies using more than 1 modality. Sixty studies focused on educational programs (62%), while 37 used SBE as an adjunct to broader interventions and quality improvement initiatives (38%). Most studies that assessed for statistical significance demonstrated at least partial improvement in Level 4 outcomes (75%, n=81).

CONCLUSION

SBE has been widely applied to improve outcomes in a variety of contexts across LMICs. Modalities of simulation are typically low-technology versions. However, there is a lack of standardized reporting of educational activities, particularly relating to essential features of SBE. Further research is required to determine which approaches are effective in specific contexts.

Development and Validation of an Equine Castration Model and Rubric

Castration is one of the most common surgeries performed in equine practice. Veterinary students require deliberate practice to reach competence in surgical procedures including equine castration, but availability of patients limits students' practice opportunities. A recumbent equine castration model was created and evaluated using a validation framework consisting of content evidence (expert opinion), internal structure evidence (reliability of scores produced by the accompanying rubric), and evidence of relationship with other variables, specifically the difference in scores between experts and students. A convenience sample of third-year students who had never performed equine castration (n = 24) and veterinarians who had performed equine castration (n = 25) performed surgery on the model while being video recorded. Participants completed a post-operative survey about the model. All veterinarians (100%) agreed or strongly agreed that the model was suitable for teaching students the steps to perform equine castration and for assessing students' skill. The checklist produced scores with good internal consistency (α = 0.805). Veterinarians performed the castration faster than the students (p = .036) and achieved a higher total global rating score (p = .003). There was no significant difference between groups in total checklist score or individual checklist items, except veterinarians were more likely to check both sides for bleeding (p = .038). The equine castration model and rubric validated in this study can be used in a low-stress clinical skills environment to improve students' skills to perform what is otherwise a challenging field procedure. Model use should be followed with live animal practice to complete the learning process.

Estimating Cognitive Workload Using Task-Related Pupillary Responses in Simulated Drilling in Cochlear Implantation

OBJECTIVES

Training of temporal bone drilling requires more than mastering technical skills with the drill. Skills such as visual imagery, bimanual dexterity, and stress management need to be mastered along with precise knowledge of anatomy. In otorhinolaryngology, these psychomotor skills underlie performance in the drilling of the temporal bone for access to the inner ear in cochlear implant surgery. However, little is known about how psychomotor skills and workload management impact the practitioners' continuous and overall performance.

METHODS

To understand how the practitioner's workload and performance unfolds over time, we examine task-evoked pupillary responses (TEPR) of 22 medical students who performed transmastoid-posterior tympanotomy (TMPT) and removal of the bony overhang of the round window niche in a 3D-printed model of the temporal bone. We investigate how students' TEPR metrics (Average Pupil Size [APS], Index of Pupil Activity [IPA], and Low/High Index of Pupillary Activity [LHIPA]) and time spent in drilling phases correspond to the performance in key drilling phases.

RESULTS

All TEPR measures revealed significant differences between key drilling phases that corresponded to the anticipated workload. Enlarging the facial recess lasted significantly longer than other phases. IPA captured significant increase of workload in thinning of the posterior canal wall, while APS revealed increased workload during the drilling of the bony overhang.

CONCLUSION

Our findings contribute to the contemporary competency-based medical residency programs where objective and continuous monitoring of participants' progress allows to track progress in expertise acquisition. Laryngoscope, 134:5087-5095, 2024.

Silicone as a smart solution for simulating soft tissue-an iterative approach to developing a high-fidelity sustainable training model for laparoscopic appendectomy

Background

Laparoscopic appendectomy (LA) is an effective treatment for the surgical care of appendicitis, with this minimally invasive approach allowing patients to typically spend less time in hospital and promptly return to normal life activities. Residents can acquire the competence and confidence needed in a safe learning environment prior to real patient encounters through simulation-based learning of these techniques. We propose a low cost, sustainable, high fidelity simulation-based training model for LA to compliment regular resident practice of these skills.

Methods

A team dedicated to developing this surgical simulation training model was established, equipped with the clinical knowledge and model engineering expertise. We used concepts of design-based research (DBR) to iteratively develop this model at key intervals. Our LA training model underwent four stages of model development prior to unified stakeholder consensus that this model was deemed effective and suitable for integration into formative surgical simulation curricula.

Results

This model simulates most of the key anatomical structures associated with performing an LA. In order to provide high fidelity haptic feedback, attempts were made to mimic the tensile properties of real tissue using different concentrations of silicone. The model can be utilized with laparoscopic box trainers of various sizes due to its scalability. It cost €9.67 to create, and single use appendix components cost €1.22 to build thereafter.

Conclusions

Surgical residents can benefit from the platform that simulation-based education offers to develop the psychomotor skills necessary to perform LA in a safe learning environment. We describe a model for LA, which allows learners to develop their skill proficiency in this area under expert supervision.

Comparison of virtual and in-person simulations for sepsis and trauma resuscitation training in Singapore: a randomized controlled trial

PURPOSE

This study aimed to compare cognitive, non-cognitive, and overall learning outcomes for sepsis and trauma resuscitation skills in novices with virtual patient simulation (VPS) versus in-person simulation (IPS).

METHODS

A randomized controlled trial was conducted on junior doctors in 1 emergency department from January to December 2022, comparing 70 minutes of VPS (n=19) versus IPS (n=21) in sepsis and trauma resuscitation. Using the nominal group technique, we created skills assessment checklists and determined Bloom’s taxonomy domains for each checklist item. Two blinded raters observed participants leading 1 sepsis and 1 trauma resuscitation simulation. Satisfaction was measured using the Student Satisfaction with Learning Scale (SSLS). The SSLS and checklist scores were analyzed using the Wilcoxon rank sum test and 2-tailed t-test respectively.

RESULTS

For sepsis, there was no significant difference between VPS and IPS in overall scores (2.0; 95% confidence interval [CI], -1.4 to 5.4; Cohen’s d=0.38), as well as in items that were cognitive (1.1; 95% CI, -1.5 to 3.7) and not only cognitive (0.9; 95% CI, -0.4 to 2.2). Likewise, for trauma, there was no significant difference in overall scores (-0.9; 95% CI, -4.1 to 2.3; Cohen’s d=0.19), as well as in items that were cognitive (-0.3; 95% CI, -2.8 to 2.1) and not only cognitive (-0.6; 95% CI, -2.4 to 1.3). The median SSLS scores were lower with VPS than with IPS (-3.0; 95% CI, -1.0 to -5.0).

CONCLUSION

For novices, there were no major differences in overall and non-cognitive learning outcomes for sepsis and trauma resuscitation between VPS and IPS. Learners were more satisfied with IPS than with VPS (clinicaltrials.gov identifier: NCT05201950).

Simulation-based education in the Pacific Islands: educational experience, access, and perspectives of healthcare workers

BACKGROUND

The World Health Organization (WHO) recommends simulation-based education (SBE) to acquire skills and accelerate learning. Literature focusing on SBE in the Pacific Islands is limited. The aim of this study was to determine Pacific Island healthcare workers' experiences, perspectives, and access to SBE.

METHODS

This was a cross-sectional survey of Pacific Island healthcare workers. We designed an online questionnaire based on existing literature and expert consultation. The questionnaire included Likert scales, multiple-choice, multi-select and open-ended questions. Participants were healthcare workers recruited from professional networks across the region. Descriptive statistics and relative frequencies summarized data, and comparative testing included unpaired t-tests, Mann-Whitney U, Chi-squared and Fisher's exact tests. Free-text responses were presented to illustrate findings.

RESULTS

Responses from 56 clinicians working in 11 Pacific Island countries were included. Fifty were medical doctors (89%), including 31 (55%) surgeons. Participants reported experience with scenario-based simulation (73%), mannequins (71%), and simulated patients (61%). Discrepancies were identified between previous simulation experience and current access for simulated patients (P = 0.002) and animal-based part-task trainers (P = 0.002). SBE was seen as beneficial for procedural skills, communication, decision-making and teamwork. Interest in further SBE was reported by most participants (96%). Barriers included equipment access (59%), clinical workload (45%) and COVID-19 restrictions (45%).

CONCLUSION

Some Pacific Island healthcare workers have experience with SBE, but their ongoing access is predominantly limited to low-technology modalities. Despite challenges, there is interest in SBE initiatives. These findings may inform planning for SBE in the Pacific Islands and may be considered prior to programme implementation.

"I've yet to meet anyone who's not keen for simulation" - a qualitative study of simulation-based education in the Pacific Islands

BACKGROUND

Simulation-based education (SBE) has been increasingly used to train healthcare workers in low-resource settings and has been endorsed by the World Health Organization (WHO). Consideration of the educational and cultural context is important to maximize the effectiveness of SBE. Despite its demonstrable benefits, there have been no studies of the general approach in the Pacific Islands. This study aimed to determine the factors that influence the uptake and success of SBE in the Pacific Islands.

METHODS

In this qualitative study, participants were recruited via professional networks to contribute to focus groups. Questions focused on participants' previous experiences and perspectives on SBE. Data were manually transcribed before thematic analysis. The reporting of the research was guided by the Standards for Reporting Qualitative Research (SRQR). Human Research Ethics Committee approval was obtained.

RESULTS

Two focus groups were conducted with 16 participants from six Pacific Island countries. Six themes and 15 subthemes were conceptualized from the data. Uptake of SBE is challenged by resource availability, clinical workloads and geographic remoteness. However, locally-driven solutions and positive attitudes towards SBE facilitate its success.

CONCLUSION

This study reveals the complexity of factors affecting the uptake and success of SBE in the Pacific Islands. These findings can serve to optimize the impact of existing and future SBE programmes and may be considered by educators prior to programme implementation.

Gamification in the Design of Virtual Patients for Swedish Military Medics to Support Trauma Training: Interaction Analysis and Semistructured Interview Study

BACKGROUND

This study explores gamification in the design of virtual patients (VPs) to enhance the training of Swedish military medics in trauma care. The challenges related to prehospital trauma care faced on the battlefield require tailored educational tools that support military medics' education and training.

OBJECTIVE

The aim of the study is to investigate how to design VPs with game elements for Swedish military medics to support learning in military trauma care. By understanding the reasoning and perceptions of military medics when interacting with VPs, this study aims to provide insights and recommendations for designing VPs with game elements that are specifically tailored to their needs.

METHODS

The study involved 14 Swedish military medics of the Home Guard-National Security Forces participating in a tactical combat care course. Participants interacted with 3 different VP cases designed to simulate military trauma scenarios. Data were collected through think-aloud sessions and semistructured interviews. The data were analyzed using interaction analysis, structured by the unawareness, problem identification, explanation, and alternative strategies or solutions (uPEA) framework, and reflexive thematic analysis to explore participants' reasoning processes and perceptions and identify possible game elements to inform the VP design.

RESULTS

Mapping the military medics' reasoning to the uPEA framework revealed that study participants became more creative after making a mistake followed by feedback and after receiving a prompt to make a new decision. The thematic analysis revealed 6 themes: motivation, "keep on trying"; agency in interaction with VPs; realistic tactical experience; confidence, "I know that the knowledge I have works"; social influence on motivation; and personalized learning. Participants suggested that game elements such as scoring; badges; virtual goods; progress bars; performance tables; content unlocking; hints; challenge; control; imposed choice; narrative; avatars; sensation; randomness; difficulty adapting; competition; leaderboards; social pressure; progression; and renovation can promote engagement, motivation, and support confidence in decision-making.

CONCLUSIONS

Gamification in the design of VPs represents a promising approach to military medical training, offering a platform for medics to practice medical and tactical decision-making in a risk-free environment. The insights gained by the study may encourage designing VPs with game elements, as well as including possibly wrong decisions, their consequences, and relevant feedback, that may support military medics' reflections and decision-making.

Gaming the System? A Qualitative Exploration of Physician Assistant Learner Perceptions of Virtual Patient Education

INTRODUCTION

Virtual patients (VPs) are increasingly used in health professions education. How learners engage with VPs and the relationship between engagement and authenticity is not well understood. We explored learners' perceptions of VP education to gain an understanding of the characteristics promoting meaningful engagement in learning, including perceived authenticity.

METHODS

Using a constructivist grounded theory approach, we conducted interviews and focus groups with 11 students from 2 Canadian Physician Assistant programs, where VP learning was implemented to supplement clinical education during the COVID-19 pandemic. We explored trainee perspectives on the use of VPs as an educational modality. Data were iteratively collected and descriptively analyzed thematically using a constant comparison approach until theoretical sufficiency was reached.

RESULTS

We identified 3 groups of factors influencing these students' VP learning experiences: (1) technical factors related to the VP platform influenced the perceived authenticity of the patient interactions; (2) individual factors of learners' attitudes influenced their engagement and motivation; and (3) contextual factors related to the learning environment influenced the acceptability and perceived value of the learning experience. Overall, the psychological authenticity of the learning platform and students' motivation for self-directed learning were perceived as most important for students' learning experiences.

CONCLUSIONS

Implementing VP learning as a supplement to clinical education should be done with consideration of factors that enhance the psychological authenticity of the learning platform, promote learner engagement and accountability, and encourage acceptability of the learning modality through curricular placement and messaging.

Assessment of a Novel, Adjustable Task Trainer for Cardiac Surgical Skills

INTRODUCTION

A recent needs assessment in Canadian cardiac surgery programs identified the desire for a coronary artery bypass (CABG) and aortic valve replacement (AVR) simulation model for home practice. We aimed to develop and assess a portable, adjustable task trainer for cardiac surgical skills with high functional task alignment.

METHODS

Intraoperative measurements were taken from patients undergoing elective CABG and AVR (N = 30). Measurements were taken in 3 axes and used to create a chest cavity that resembles the mediastinal constraints of a patient undergoing CABG and AVR. The task trainer is adjustable on the following 3 levels: (1) size of the incision, (2) depth of the chest, and (3) relative position of coronary artery or aortic valve model within the chest. Three groups (novices, intermediates, and experts) of cardiac surgery members evaluated the task trainer for functional task alignment and construct validity.

RESULTS

The CABG and AVR model had high functional task alignment. There was a high satisfaction for both models and all participants would recommend the AVR and CABG model as an educational tool. Performance time significantly differed between the groups for both models (CABG: P = 0.032 and AVR: P = 0.001), as well as number of errors (CABG: P = 0.04 and AVR: P = 0.043).

CONCLUSIONS

Using real patient data, we were able to develop an adjustable task trainer for training principles of CABG and AVR. Our pilot study provides preliminary sources of evidence for validity and future study will look to assess transferability of skill to the operating room.

Creation of a Novel Ex Vivo 3D Printed Ileal Conduit Task Trainer for Teaching Conduitoscopy Skills

OBJECTIVE

To perform endoscopy in patients with urinary diversions requires specific endoscopic skills, which can currently only be gained in clinical practice. We created a 3D-printed ex vivo ileal conduit model (stoma and conduit with ureters and 2 kidneys) to simulate "conduitoscopy" and evaluated the realism and limitations of the model.

METHODS

Accurate anatomical features were represented using an appropriate reusable design, realistic mechanical qualities with several material types, and 3D-printed components. Different models of bowel and ureters were assessed by the subject-matter experts (SME). The final ileal conduit model (Wallace 1 type anastomosis) was evaluated by 18 SMEs.

RESULTS

Most experts gave their approval to the view of the stoma, as well as the appearance of the bowel, ureteric, and pelvicalyceal systems. A total of 72.1% of SMEs approved the ureteric endoscopic view compared to about 66% who accepted the endoscopic examination of the bowel. The model's overall appearance was good for 61.1% and excellent for 38.8% of experts.

CONCLUSION

Conduitoscopy simulation training can now be facilitated using our novel and unique cutting-edge 3D-printed model. We created a model that is highly anatomically accurate and workable. In our study, anatomical and visual realism was demonstrated. The next step would be increasing the length of the conduit and conduct a validation study.

Developing pre-licensure interprofessional and stroke care competencies through skills-based simulations

Interprofessional collaboration (IPC) in stroke care is accepted as best practice and necessary given the multi-system challenges and array of professionals involved. Our two-part stroke team simulations offer an intentional interprofessional educational experience (IPE) embedded in pre-licensure occupational therapy, physical therapy, pharmacy, medicine, nursing and speech-language pathology curricula. This six-year mixed method program evaluation aimed to determine if simulation delivery differences necessitated by COVID-19 impacted students' IPC perception, ratings, and reported learning. Following both simulations, the Interprofessional Collaborative Competency Assessment Scale (ICCAS) and free-text self-reported learning was voluntarily and anonymously collected. A factorial ANOVA using the ICCAS interprofessional competency factors compared scores across delivery methods. Content and category analysis was done for free-text responses. Overall, delivery formats did not affect positive changes in pre-post ICCAS scores. However, pre and post ICCAS scores were significantly different for interprofessional competencies of roles/responsibilities and collaborative patient/family centered approach. Analysis of over 10,000 written response to four open-ended questions revealed the simulation designs evoked better understanding of others' and own scope of practice, how roles and shared leadership change based on context and client need, and the value of each team member's expertise. Virtual-experience-only students noted preference for an in-person stroke clinic simulation opportunity.

Development and Evaluation of a Surgical Simulator and Assessment Rubric for Standing Castration of the Horse

In veterinary education, simulators are models or devices that can imitate a real patient or scenario and allow students to practice skills without the need for live patients. Castration is a common surgical procedure in all species, and the standing, open technique is frequently performed in horses. Although a simulator has been developed for equine closed castration, a simulator for standing castration in the horse has not yet been described. This two-part study focused on the design, creation, and evaluation of a simulator for teaching standing castration in the horse. A low-technology simulator was created using molded silicone testicles, cohesive bandage, stockings, and socks. A rubric was created for assessing performance using the simulator. Participants were recruited from three groups: university academic staff members (n = 12, majority equine veterinarians), equine veterinarians working in private practice (n = 9), and final-year veterinary students (n = 28). Each group tested the simulator while being graded using the developed rubric, and participants completed an anonymous online feedback questionnaire. Feedback was positive overall, with 98% of respondents (n = 48/49) stating that the model would be a useful addition to the veterinary curriculum. Furthermore, 100% of students reported that using the simulator increased their confidence in performing standing castration in horses. Evaluation of the model included assessment of responses from veterinarians and students regarding realism and usefulness of the simulator, comparison of rubric scores between veterinarians and students, and assessment of the reliability of the rubric. Median student rubric score was significantly lower than qualified veterinarians (p < .001), and Cronbach's alpha demonstrated that there was adequate internal reliability in rubric scoring (α = .85). It was determined that the simulator is effective for teaching the steps of the surgical procedure and for increasing student confidence.

The Use of Smartphone-Based Highly Realistic MCI Training as an Adjunct to Traditional Training Methods

INTRODUCTION

Training for mass casualty incident (MCI) response is critical to ensure that resource allocation and treatment priorities limit preventable mortality. Previous research has investigated the use of immersive virtual environments as an alternative to high fidelity MCI training, which is expensive and logistically challenging to implement. While these have demonstrated positive early results, they still require complex technology deployment, dedicated training facilities, and significant time from instructors and facilitators. This study explores the feasibility of a smartphone-based application for trauma care training and MCI triage to fill the gap between classroom learning and high-fidelity simulation. The goals of this investigation were to evaluate clinician perceptions of a virtual MCI training simulator's usability, acceptability, fidelity, functionality, and pacing.

MATERIALS AND METHODS

This study used a smartphone-based training simulation called Extensible Field and Evacuation Care Training in a Virtual Environment (EFECTIVE), which presents virtual patient scenarios in a gamified, but visually high-fidelity environment. A total of 21 participants were recruited as a convenience sample of medical students, paramedics, nurses, and emergency medicine resident and attending physicians at University of Massachusetts Memorial Medical Center, an urban tertiary care medical center. Participants completed a brief tutorial and then performed a series of virtual patient scenarios and 1 MCI scenario on the simulator, each of which was 5 minutes in duration. Then, each participant completed a survey assessing the perceived usability, acceptability, fidelity, functionality, and pacing of the virtual training simulator. The research protocol was approved by the University of Massachusetts Chan Medical School Institutional Review Board.

RESULTS

48% of participants disagreed that a virtual simulator could completely replace live MCI training, though 71% agreed that app-based simulations could effectively supplement live MCI training and 67% felt that they could be used to learn how to order medical interventions in care under fire scenarios. 80% of participants agreed that the simulation could be used to practice MCI triage and to gain experience with coordinating movement of casualties to casualty collection points. 67% of participants believed that use of virtual simulators would increase their MCI preparedness. 76% agreed that the clinical cases depicted were medically realistic and that the clinical cases presented accurately represented the scenarios described. In addition, despite being presented on a smartphone as opposed to virtual reality, 62% of participants rated the experience immersive.

CONCLUSIONS

This study provides encouraging evidence that easy to deploy smartphone-based simulations may be an effective way to supplement MCI and care under fire training. Although the study is limited by a small sample size, there was strong agreement among participants from a wide variety of emergency medicine roles that such a simulation could train core topics associated with MCI triage. Because app-based simulations are easily deployable and can be executed quickly and frequently, they could be used as a more flexible training model compared to large scale live or virtual reality-based simulations. The results of this investigation also indicate that a sufficient level of medical realism can be achieved without live simulation.

Developing a high fidelity, low cost simulation model for retrosigmoid craniotomy and microvascular decompression of the trigeminal nerve

BACKGROUND

Trigeminal neuralgia is a very painful condition that may require a surgical approach as treatment, which is typically retrosigmoid craniotomy followed by microvascular decompression. Due to the limited margin for error when operating in the small triangular window of the cerebellopontine angle and the infrequency of this condition, the operating room can present a difficult learning environment for surgical trainees. Our aim is to create a synthetic, low-cost, high-fidelity, and largely reusable simulation model that will enable neurosurgical trainees to practice these procedural steps in a safe learning environment.

MATERIALS AND METHODS

Design-based research was employed to develop the model through iterative micro-cycles, with expert evaluation from an educational and clinical team. The model was made from easy to source materials without advanced technology where sustainability, reproduction at scale and cost where significant considerations.

RESULTS

Our model effectively simulates a retrosigmoid craniotomy and microvascular decompression of the trigeminal nerve. The model consists of two distinct parts that are made of synthetic materials. Part A is a single-use, moulded portion of the skull, while part B depicts the cerebellopontine angle and some of its internal anatomical and pathological structures crucial to carrying out all the steps to this procedure. Part A sits ergonomically flush on top of Part B, with both parts subsequently clamped to the table.

CONCLUSIONS

As a proof of concept, we report the development and utilisation of a novel, low-cost, replicable retrosigmoid craniotomy and microvascular decompression of the trigeminal nerve simulation model.

Development and Integration of Models for Teaching Ram Breeding Soundness Examinations in Veterinary Education

Proficiency with ram breeding soundness examinations requires competency with palpation, a skill that can be difficult to teach and assess. There are limited small ruminant clinical skills models available, despite the advantages they offer in veterinary education. We developed reusable models for teaching ram breeding soundness examinations, focusing on scrotal assessment and palpation. Then we integrated these models into a practical session where multiple clinical aspects were included. We created anatomically normal ("sound") testes using 3D modeling software before editing these to display common abnormalities ("unsound" testes). Then, we 3D printed two-part molds and cast the silicone testes. Testes were inserted into siliconized, lubricated stockings facilitating free movement during palpation. Scrotal sacs were sewn from polar fleece and suspended to mimic natural orientation in a live, standing ram. As well as for scheduled classes, we used the models as a station in our course's Objective Structured Clinical Examination (OSCE) assessment. Our models offer advantages in the veterinary education context. Their relatively low cost and durability facilitates their classification as "open access" within our skills lab for student deliberate practice outside scheduled classes. They provide a uniform student learning experience that does not rely on live animals or clinical case load and aligns with best-practice recommendations from accrediting bodies. Student engagement and OSCE outcomes were good, but going forward it would be ideal to collaborate with a program that uses live rams for teaching and assessing this skill to directly examine the impact of our models on confidence and competence.

Improving quality through simulation; developing guidance to design simulation interventions following key events in healthcare

Simulation educators are often requested to provide multidisciplinary and/or interprofessional simulation training in response to critical incidents. Current perspectives on patient safety focus on learning from failure, success and everyday variation. An international collaboration has led to the development of an accessible and practical framework to guide the implementation of appropriate simulation-based responses to clinical events, integrating quality improvement, simulation and patient safety methodologies to design appropriate and impactful responses. In this article, we describe a novel five-step approach to planning simulation-based interventions after any events that might prompt simulation-based learning in healthcare environments. This approach guides teams to identify pertinent events in healthcare, involve relevant stakeholders, agree on appropriate change interventions, elicit how simulation can contribute to them and share the learning without aggravating the second victim phenomenon. The framework is underpinned by Deming's System of Profound Knowledge, the Model for Improvement and translational simulation. It aligns with contemporary socio-technical models in healthcare, by emphasising the role of clinical teams in designing adaptation and change for improvement, as well as encouraging collaborations to enhance patient safety in healthcare. For teams to achieve this adaptive capacity that realises organisational goals of continuous learning and improvement requires the breaking down of historical silos through the creation of an infrastructure that formalises relationships between service delivery, safety management, quality improvement and education. This creates opportunities to learn by design, rather than chance, whilst striving to close gaps between work as imagined and work as done.

Contextual determinants impacting final year nursing students' emergency team communication during deteriorating patient simulations: A grounded theory study

BACKGROUND

Ability to focus on development of students' team communication and non-technical skills may be reduced in content saturated nursing curricula. Even when communication and simulation-based education is provided, students' utilisation of non-technical skills remains challenging. Although simulation is a recognised means to learn communication skills, little is known about nursing students' team communication in simulated settings.

OBJECTIVE

To understand the process by which final year undergraduate nursing students communicate in simulated team emergencies.

DESIGN

Using constructivist grounded theory, data was collected using semi-structured interviews and student observations and analysed using constant comparative analysis.

SETTING

Simulation laboratories in one university nursing school in Australia.

PARTICIPANTS

21 final year nursing students in seven teams.

METHODS

Data were gathered from interviews and video observations of final year nursing students during simulated team emergencies.

RESULTS

Interview data and observations of video-recordings revealed contextual determinants that influence communication within teams: the simulation context, the student context and the team context. Team member characteristics, such as cultural and linguistic background, life experiences, gender and age, the ability to shift from leadership to followership as well as environmental factors such as mask wearing and simulation fidelity, contributed to uncertainty in communicating that nursing team effectiveness.

CONCLUSIONS

Improvement of contextual conditions necessitates implementation of supportive strategies. These include development of educational initiatives, and further research in experiential learning as a modality for learners to experience team communication. Further, simulation context, student context and team context are important considerations. Meeting clinical communication learning needs of students allows better preparation to care for deteriorating patients as graduates.

Collating evidence to support the validation of a simulated laparotomy incision and closure-training model

BACKGROUND

It is essential to evaluate the functionality of surgical simulation models, in order to determine whether they perform as intended. In this study, we assessed the use of a simulated laparotomy incision and closure-training model by collating validity evidence to determine its utility as well as pre and post-test interval data.

METHOD

This was a quantitative study design, informed by Messick's unified validity framework. In total, 93 participants (surgical trainees ​= ​80, experts ​= ​13) participated in this study. Evaluation of content validity and the models' relationships with other variables was conducted, along with a pre and post-test confidence assessment.

RESULTS

The model was deemed realistic and useful as a teaching tool, providing strong content validity evidence. In assessment of relationships with other variables, the expert group out-performed the novice group conclusively. Pre and post-test evaluation reported a statistically significant increase in confidence levels.

CONCLUSION

We present strong validity evidence of a novel laparotomy incision and closure simulation-training model.

Developing a clamshell thoracotomy training model to support hybrid teaching in simulation-based education

OBJECTIVE

Thoracotomy is an acute, time-sensitive procedure. Simulation-based education provides a safe-learning platform to learn these techniques under close supervision.

METHODS

We used the spiral model and concepts of functional fidelity to guide the evolutionary design and fabrication of a hybrid thoracotomy simulator.

RESULTS

This model simulates a clamshell thoracotomy that physically integrates with bespoke manikins and adds a high-fidelity technical skills element to immersive team-based simulation training.

CONCLUSIONS

We describe the creation of a thoracotomy simulation model that allows trainees to practice these techniques in a safe-learning environment.

The MIDAS touch: Frameworks for procedural model innovation and validation

Background

Simulation-based procedural practice is crucial to emergency medicine skills training and maintenance. However, many commercial procedural models are either nonexistent or lacking in key elements. Simulationists often create their own novel models with minimal framework for designing, building, and validation. We propose two interlinked frameworks with the goal to systematically build and validate models for the desired educational outcomes.

Methods

Simulation Academy Research Committee and members with novel model development expertise assembled as the MIDAS (Model Innovation, Development and Assessment for Simulation) working group. This working group focused on improving novel model creation and validation beginning with a preconference workshop at 2023 Society for Academic Emergency Medicine Annual Meeting. The MIDAS group sought to (1) assess the current state of novel model validation and (2) develop frameworks for the broader simulation community to create, improve, and validate procedural models.

Findings

Workshop participants completed 17 surveys for a response rate of 100%. Many simulationists have created models but few have validated them. The most common barriers to validation were lack of standardized guidelines and familiarity with the validation process.We have combined principles from education and engineering fields into two interlinked frameworks. The first is centered on steps involved with model creation and refinement. The second is a framework for novel model validation processes.

Implications

These frameworks emphasize development of models through a deliberate, form-follows-function methodology, aimed at ensuring training quality through novel models. Following a blueprint of how to create, test, and improve models can save innovators time and energy, which in turn can yield greater and more plentiful innovation at lower time and financial cost. This guideline allows for more standardized approaches to model creation, thus improving future scholarship on novel models.

Stress responses in surgical trainees during simulation-based training courses in laparoscopy

BACKGROUND

Simulation-based training courses in laparoscopy have become a fundamental part of surgical training programs. Surgical skills in laparoscopy are challenging to master, and training in these skills induces stress responses in trainees. There is limited data on trainees' stress levels, the stress responses related to training on different laparoscopic simulators, and how previous experiences influence trainees' stress response during a course. This study investigates physiologic, endocrine and self-reported stress responses during simulation-based surgical skills training in a course setting.

METHODS

We conducted a prospective observational study of trainees attending basic laparoscopic skills training courses at a national training centre. During the three-day course, participants trained on different laparoscopic simulators: Two box-trainers (the D-box and P.O.P. trainer) and a virtual reality simulator (LAPMentor™). Participants' stress responses were examined through heart rate variability (HRV), saliva cortisol, and the State Trait Anxiety Inventory-6 (STAI-6). The correlation between previous laparoscopic experiences and stress response measurements was explored.

RESULTS

Twenty-four surgical trainees were included in the study. Compared to resting conditions, stress measures were significantly higher during simulation-training activity (the D-box (SDNN = 58.5 ± 23.4; LF/HF-ratio = 4.58 ± 2.71; STAI-6 = 12.3 ± 3.9, P < 0.05), the P.O.P trainer (SDNN = 55.7 ± 7.4; RMSSD = 32.4 ± 17.1; STAI-6 = 12.1 ± 3.9, P < 0.05), and the LAPMentor™ (SDNN = 59.1 ± 18.5; RMSSD = 34.3 ± 19.7; LF/HF-ratio = 4.71 ± 2.64; STAI-6 = 9.9 ± 3.0, P < 0.05)). A significant difference in endocrine stress response was seen for the simulation-training activity on the D-box (saliva cortisol: 3.48 ± 1.92, P < 0.05), however, no significant differences were observed between the three simulators. A moderate correlation between surgical experience, and physiologic and endocrine stress response was observed (RMSSD: r=-0.31; SDNN: r=-0.42; SD2/SD1 ratio: r = 0.29; Saliva cortisol: r = 0.46; P < 0.05), and a negative moderate correlation to self-reported stress (r=-0.42, P < 0.05).

CONCLUSION

Trainees have a significant higher stress response during simulation-training compared to resting conditions, with no difference in stress response between the simulators. Significantly higher cortisol levels were observed on the D-box, indicating that simulation tasks with time pressure stress participants the most. Trainees with more surgical experience are associated with higher physiologic stress measures, but lower self-reported stress scores, demonstrating that surgical experience influences trainees' stress response during simulation-based skills training courses.

Psychometric evaluation of the Decision Support System (DSS) for municipal nurses encountering health deterioration among older adults

BACKGROUND

A valid and reliable tool is crucial for municipal registered nurses (RNs) to make quick decisions in older adults who show rapid signs of health deterioration. The aim of this study was to investigate the psychometric properties of the Decision Support System (DSS) among older adults in the municipal healthcare system.

METHODS

Firstly, we utilized the Rasch dichotomous model to analyze the DSS assessments (n=281) that were collected from municipal RNs working with older adults in the municipal healthcare system. We examined the properties of the DSS in terms of its unidimensionality, item fit, and separation indices. Secondly, to investigate inter-rater agreement in using the DSS, four experienced municipal RNs used the DSS to assess 60 health deterioration scenarios presented by one human patient simulators. The 60 DSS assessments were then analyzed using the ICC (2,1), percentage agreement, and Cohen κ statistics.

RESULTS

The sample of older adults had a mean age of 82.8 (SD 11.7). The DSS met the criteria for unidimensionality, although two items did not meet the item fit statistics when all the DSS items were analyzed together. The person separation index was 0.47, indicating a limited level of separation among the sample. The item separation index was 11.43, suggesting that the DSS has good ability to discriminate between and separate the items. At the overall DSS level, inter-rater agreements were good according to the ICC. At the individual DSS item level, the percentage agreements were 75% or above, while the Cohen κ statistics ranged from 0.46 to 1.00.

CONCLUSIONS

The Rasch analysis revealed that the psychometric properties of the instrument were acceptable, although further research with a larger sample size and more items is needed. The DSS has the potential to assist municipal RNs in making clinical decisions regarding health deterioration in older adults, thereby avoiding unnecessary emergency admistion and helping.

Bringing damage control surgery simulation to life: developing a novel surgical anatomy model within immersive military trauma surgery simulation

Haemorrhage from junctional injuries remains the most common cause of battlefield death. Changes to surgical training have meant acquiring and maintaining trauma surgical skills is becoming more difficult for military surgeons. The multidisciplinary Military Operational Specialist Team Training (MOSTT) course is designed to bridge the gap between civilian practice and the deployed environment, as part of predeployment trauma training. It involves immersive team simulation and uses cadaveric dissection for surgical skills practice.A novel surgical anatomy model, featuring junctional haemorrhage surgical task trainers of the groin and shoulder, was designed using reconstructed CT and MRI images obtained from a human volunteer. The model is designed to look and feel as realistic as possible, with the added dimension of pulsatile 'blood' flow from a simulation gunshot injury.This surgical anatomy model has been trialled, as part of the MOSTT course, by 90 surgeons and perioperative practitioners, with feedback analysis used for iterative model development. Feedback demonstrated that, alongside more traditional cadaveric dissection, this surgical anatomy model adds value to current predeployment training delivered within the immersive simulation of the MOSTT course. Research by the authors about the effects of this model on surgical ability and performance is ongoing. However, there is clear potential for this model to be used in other environments, including on exercises and as part of consolidation training while deployed.

Design and utilisation of a novel, high-fidelity, low-cost, hybrid-tissue simulation model to facilitate training in robot-assisted partial nephrectomy

Robot-assisted partial nephrectomy (RAPN) has rapidly evolved as the standard of care for appropriately selected renal tumours, offering key patient benefits over radical nephrectomy or open surgical approaches. Accordingly, RAPN is a key competency that urology trainees wishing to treat kidney cancer must master. Training in robotic surgery is subject to numerous challenges, and simulation has been established as valuable step in the robotic learning curve. However, simulation models are often both expensive and suboptimal in fidelity. This means that the number of practice repetitions for a trainee may limited by cost restraints, and that trainees may struggle to reconcile the skills obtained in the simulation laboratory with real-world practice in the operating room. We have developed a high-fidelity, low-cost, customizable model for RAPN simulation based on porcine tissue. The model has been utilised in teaching courses at our institution, confirming both feasibility of use and high user acceptability. We share the design of our model in this proof-of-concept report.

Creation and Validation of a Massive Hemoptysis Simulator

BACKGROUND

Simulation for the management of massive hemoptysis is limited by the absence of a commercially available simulator to practice procedural skills necessary for management.

RESEARCH QUESTION

Is it feasible to create and validate a hemoptysis simulator with high functional task alignment?

STUDY DESIGN AND METHODS

Pulmonary and critical care medicine (PCCM) attending physicians from four academic institutions in the Denver, Colorado, area and internal medicine residents from the University of Colorado participated in this mixed-methods study. A hemoptysis simulator was constructed by connecting a 3-D-printed airway model to a manikin that may be intubated. Attending PCCM physicians evaluated the simulator through surveys and qualitative interviews. Attendings were surveyed to determine simulation content and appropriate assessment criteria for a hemoptysis simulation. Based on these criteria, expert and novice performance on the simulator was assessed.

RESULTS

The manikin-based hemoptysis simulator demonstrated adequate physical resemblance, high functional alignment, and strong affective fidelity. It was universally preferred over a virtual reality simulator by 10 PCCM attendings. Twenty-seven attendings provided input on assessment criteria and established that assessing management priorities (eg, airway protection) was preferred to a skills checklist for hemoptysis management. Three experts outperformed six novices in hemoptysis management on the manikin-based simulator in all management categories assessed, supporting construct validity of the simulation.

INTERPRETATION

Creation of a hemoptysis simulator with appropriate content, high functional task alignment, and strong affective fidelity was successful using 3-D-printed airway models and existing manikins. This approach can overcome barriers of cost and availability for simulation of high-acuity, low-occurrence procedures.

Education Research: Epilepsy Monitoring Unit Staff Education Using a High-Fidelity Manikin: A Pre-Post Intervention Study

Background and Objectives

Given the inherent risks of seizure provocation in the epilepsy monitoring unit (EMU), both miscommunication and incomplete training about the importance of when and why certain measures are taken can cause critical gaps in care for patients in an especially vulnerable state. To provide a framework that would help minimize these potential pitfalls, our objectives were 2-fold: (1) identify deficits in EMU safety and assessment using a checklist of predetermined items, including key measures essential to the care of EMU patients and (2) develop a simulation training program to address these deficits with education for staff on optimal practices.

Methods

After creation of an EMU safety checklist, authors retrospectively reviewed video from 12 consecutive patients (time zero; T0) admitted to the Baylor St. Luke's EMU to assess checklist compliance and seizure response times (both electrographic and clinical). EMU staff were then trained in small teams with the help of a simulation program developed using a high-fidelity manikin. After training was complete, EMU practices and response times were reassessed in short-term (T1) and long-term (T2) follow-up intervals.

Results

When all 3 groups were compared, significant behavioral improvements (Kirkpatrick level 3) were seen in several critical evaluation and safety measures. Statistically significant improvements from T0 to T1 (p < 0.05) were seen in orientation assessment, speech assessment, motor assessment, oxygen administration, and vital sign collection. Score improvement persisted at T2 but showed a relative decline over time in 11 of 14 measures.

Discussion

Education of staff in the EMU is paramount to ensure appropriate assessment of the seizure semiology and patient safety measures. Implementation of a novel simulation-based education platform demonstrated wide-ranging improvements in staff performance of safety and testing measures. Stratification between short-term and long-term assessment periods shows that while many categories showed overall improvement, regular training may be needed to sustain improvements in assessment and patient safety. Multicenter longitudinal studies assessing the efficacy of this or similar interventions should be performed to identify best patient practices.

Simulating mitral repair: lessons learned

PURPOSE OF REVIEW

With the growing complexity of cardiac surgical cases, increased focus on patient safety, and minimally invasive techniques, simulation-based training has experienced a renaissance. This review highlights important elements of simulation-based training, focusing specifically on available simulators for mitral valve repair and the uses for simulation.

RECENT FINDINGS

Referring to simulators as being high or low fidelity is oversimplified. Fidelity is a multifactorial concept, and for surgical task trainers, structural and functional fidelity should be discussed. For mitral valve repair, there are a spectrum of simulators, including tissue-based models, bench-top models, and hybrid models. All these simulator modalities serve a role in training if they align with predetermined objectives. There have been advancements in mitral valve repair simulation, notably patient-specific 3D printed silicone replicas of disease.

SUMMARY

There is evidence to support that simulation improves performance in the simulated environment, but future investigation should look to determine whether simulation improves performance in the clinical setting and ultimately patient outcomes.

Current use of simulation for EPA assessment in emergency medicine

OBJECTIVE

Approximately five years ago, the Royal College emergency medicine programs in Canada implemented a competency-based paradigm and introduced the use of Entrustable Professional Activities (EPAs) for assessment of units of professional activity to assess trainees. Many competency-based medical education (CBME) based curricula, involve assessing for entrustment through observations of EPAs. While EPAs are frequently assessed in clinical settings, simulation is also used. This study aimed to characterize the use of simulation for EPA assessment.

METHODS

A study interview guide was jointly developed by all study authors and followed best practices for survey development. A national interview was conducted with program directors or assistant program directors across all the Royal College emergency medicine programs across Canada. Interviews were conducted over Microsoft Teams, interviews were recorded and transcribed, using Microsoft Teams transcribing service. Sample transcripts were analyzed for theme development. Themes were then reviewed by co-authors to ensure they were representative of the participants' views.

RESULTS

A 64.7% response rate was achieved. Simulation has been widely adopted by EM training programs. All interviewees demonstrated support for the use of simulation for EPA assessment for many reasons, however, PDs acknowledged limitations and thematic analysis revealed certain themes and tensions for using simulation for EPA assessment. Thematic analysis revealed six major themes: widespread support for the use of simulation for EPA assessment, concerns regarding the potential for EPA assessment to become a "tick- box" exercise, logistical barriers limiting the use of simulation for EPA assessment, varied perceptions about the authenticity of using simulation for EPA assessment, the potential for simulation for EPA assessment to compromise learner psychological safety, and suggestions for the optimization of use of simulation for EPA assessment.

CONCLUSIONS

Our findings offer insight for other programs and specialties on how simulation for EPA assessment can best be utilized. Programs should use these findings when considering using simulation for EPA assessment.

Developing a phantom for simulating robotic-assisted complete mesocolic excision using 3D printing and medical imaging

BACKGROUND

Robotic-assisted complete mesocolic excision is an advanced procedure mainly because of the great variability in anatomy. Phantoms can be used for simulation-based training and assessment of competency when learning new surgical procedures. However, no phantoms for robotic complete mesocolic excision have previously been described. This study aimed to develop an anatomically true-to-life phantom, which can be used for training with a robotic system situated in the clinical setting and can be used for the assessment of surgical competency.

METHODS

Established pathology and surgical assessment tools for complete mesocolic excision and specimens were used for the phantom development. Each assessment item was translated into an engineering development task and evaluated for relevance. Anatomical realism was obtained by extracting relevant organs from preoperative patient scans and 3D printing casting moulds for each organ. Each element of the phantom was evaluated by two experienced complete mesocolic excision surgeons without influencing each other's answers and their feedback was used in an iterative process of prototype development and testing.

RESULTS

It was possible to integrate 35 out of 48 procedure-specific items from the surgical assessment tool and all elements from the pathological evaluation tool. By adding fluorophores to the mesocolic tissue, we developed an easy way to assess the integrity of the mesocolon using ultraviolet light. The phantom was built using silicone, is easy to store, and can be used in robotic systems designated for patient procedures as it does not contain animal-derived parts.

CONCLUSIONS

The newly developed phantom could be used for training and competency assessment for robotic-assisted complete mesocolic excision surgery in a simulated setting.

Trauma surgical simulation: discussing the replacement of live animals used as human patient simulators

BACKGROUND

Despite advances in simulator technology, live anaesthetised animals continue to be used as human patient simulators for medical professionals to practice techniques in the management of surgical trauma. This article describes the process of convening a working group of individuals with a professional interest in simulation to discuss the use of live animals and consider if and how they can be replaced in the future.

MAIN BODY

A working group was formed of voluntary attendees to a workshop held at the SESAM 2023 conference. Iterative discussions reflecting on the topic were used to produce statements summarising the working group's opinions. The working group determined that live animals are used as human patient simulators due to the presence of accurate and responsive physiology in the presence of bleeding, realistic tissue tactility and an emotional response experienced by the learner due to interaction with the animal. They were unable to reach a consensus on replacement, determining that there is currently no single model which is able to provide all the learning aspects which a live animal model can provide. Several suggestions were made regarding development of technologies and pedagogical change.

CONCLUSION

Replacement of live animals in surgical simulation is not straightforward but should be an aspiration, if possible. For the ongoing development of trauma surgical simulation models, it is important to combine the knowledge, skills and perspectives of medical stakeholders and educators, academic researchers and industry experts in producing alternative options to the use of live animal simulators.

The impact of moulage on learners' experience in simulation-based education and training: systematic review

BACKGROUND

Moulage is a technique used to simulate injury, disease, aging and other physical characteristics specific to a scenario, often used in health and emergency worker training, predominantly for simulation-based learning activities. Its use in allied health fields is unclear. Previous work has explored moulage as an adjunct for authentic simulations, however there is opportunity for broadening its scope.

AIM

To explore the effects of moulage interventions in simulation-based education and training, for learner experience. A secondary aim was to understand which pedagogical frameworks were embedded in moulage interventions.

METHOD

Four electronic databases (PubMed, CINAHL, EmBase, Proquest Central) were systematically searched to December 2022 for studies utilising moulage in simulation-based education experiences. Outcomes were focused on learner satisfaction, confidence, immersion, engagement, performance, or knowledge. Study quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Twenty studies (n = 11,470) were included. Studies were primarily conducted in medicine (n = 9 studies) and nursing (n = 5 studies) and less frequently across other health disciplines. The findings demonstrated greater learner satisfaction, confidence, and immersion when moulage was used against a comparator group. Minimal improvements in knowledge and performance were identified. One study underpinned the intervention with a pedagogical theory.

CONCLUSION

Moulage improves learner experience in simulation-based education or training, but not knowledge or clinical performance. Further research utilising moulage across a broader range of professions is needed. Interventions using moulage should be underpinned by pedagogical theories.

Development and Usability of an Inexpensive and Reusable Phantom for Ultrasound-Guided Needle Cannulation

Introduction Ultrasound-guided peripheral venous catheter placement (UG-PVCP) is a key skill for establishing intravenous access, especially in patients with anatomical challenges. Ultrasound is highly operator-dependent, and it is essential to ensure a sufficient level of competence when educating healthcare professionals. Competence can be acquired through simulation-based training (SBT) using phantoms or simulators. We developed a phantom for SBT, and in this study, we explore the phantom's usability and technical fidelity. Methods Novices with no experience in UG-PVCP and experts who routinely performed the procedure were asked to perform three ultrasound-guided catheter placement attempts on the phantom. Afterward, they were asked to complete a usability questionnaire consisting of 14 questions exploring the usability and fidelity of the phantom. Results Fifty-seven participants were included in the study: 29 novices and 28 experts. When assessing positive questions about the frequency of use, ease of use, integration of functionality, quickness to learn, and confidence level, the study showed a median score of 4 to 5 out of 5 in the two groups. The median was 1 to 2 out of 5 for negative questions assessing cumbersomeness, unnecessary complexity, and model inconsistency. In an additional comment textbox, one participant mentioned that the cannulation did not feel realistic but that it was good for cannulation practice. Conclusions We believe the phantom is suitable for an educational curriculum since it shows a high level of usability, scoring high on positive questions while scoring low on negative questions, and having high functional fidelity.

Approaches to Laparoscopic Training in Veterinary Medicine: A Review of Personalized Simulators

Veterinary minimally invasive surgery (MIS) has experienced notable growth in recent years, yet the availability of specialized training tools remains limited and not readily accessible to practitioners worldwide. While borrowing simulators from human medicine practices suffices for acquiring fundamental laparoscopic skills, it proves inadequate when addressing procedure-specific nuances. Veterinary professionals are now taking steps to create simulators tailored to their patients, although the validation process can be time-consuming. Consequently, the availability of advanced laparoscopic simulators for veterinary training remains scarce. The present study aims to highlight custom-made simulators. A comprehensive search across five databases was conducted to uncover the simulators documented from 2010 to 2022. A total of five simulators emerged from this search, with four grounded in a canine model and only one in an equine model. These models underwent validation and were found to be effective in training surgeons for their designated tasks. The findings underscore a limited array of simulators, predominantly catering to two species (horses and dogs). Considering these findings, it is evident that further research is imperative to create laparoscopic simulators capable of facilitating advanced veterinary training. This would enable the continued evolution of surgical techniques across diverse species, including ruminants, small mammals, and non-mammalian animals.

Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study

BACKGROUND

A multidisciplinary group of stakeholders were used to identify: (1) the core competencies of a training program required to perform in-hospital ECPR initiation (2) additional competencies required to perform pre-hospital ECPR initiation and; (3) the optimal training method and maintenance protocol for delivering an ECPR program.

METHODS

A modified Delphi process was undertaken utilising two web based survey rounds and one virtual meeting. Experts rated the importance of different aspects of ECPR training, competency and governance on a 9-point Likert scale. A diverse, representative group was targeted. Consensus was achieved when greater than 70% respondents rated a domain as critical (> or = 7 on the 9 point Likert scale).

RESULTS

35 international ECPR experts from 9 countries formed the expert panel, with a median number of 14 years of ECMO practice (interquartile range 11-38). Participant response rates were 97% (survey round one), 63% (virtual meeting) and 100% (survey round two). After the second round of the survey, 47 consensus statements were formed outlining a core set of competencies required for ECPR provision. We identified key elements required to safely train and perform ECPR including skill pre-requisites, surrogate skill identification, the importance of competency-based assessment over volume of practice and competency requirements for successful ECPR practice and skill maintenance.

CONCLUSIONS

We present a series of core competencies, training requirements and ongoing governance protocols to guide safe ECPR implementation. These findings can be used to develop training syllabus and guide minimum standards for competency as the growth of ECPR practitioners continues.

A Novel Simulation Model Significantly Improves Confidence in Canthotomy and Cantholysis Among Ophthalmology and Emergency Medicine Trainees

BACKGROUND

Orbital compartment syndrome is a potentially blinding eye condition. Timely diagnosis and treatment are paramount to optimize visual outcomes. Lateral canthotomy and cantholysis is the definitive management and a required competency for emergency physicians and ophthalmologists. Lack of confidence in the procedure can result in delayed treatment and poor outcomes.

OBJECTIVES

Our aim was to create a low-cost, realistic, simulation model to ensure trainees were confident in performing lateral canthotomy and cantholysis.

METHODS

A model was created using equipment found in the emergency department. This model's efficacy was assessed using pre- and post-teaching questionnaires measuring learner's self-perceived confidence.

RESULTS

Forty-seven emergency medicine and 18 ophthalmology registrars rated their confidence in the procedure using a 5-point Likert scale (1 = not very confident, 5 = extremely confident); 42% (n = 27) of participants felt 'quite confident' (4 on Likert scale) in carrying out the procedure unsupervised out of hours after the teaching session, compared with 9.23% (n = 6) before (p < 0.01). Our model resulted in significant increases in all three measures of confidence (diagnosing orbital compartment syndrome, locating the necessary equipment and performing canthotomy and cantholysis) and was rated as 4.35 (1 = not at all helpful, 5 = extremely helpful) in understanding the anatomy of the region. Sixty-six percent (n = 43) of participants stated they would like further simulation teaching.

CONCLUSIONS

Our model is low cost, easy to assemble, and anatomically correct. The user can 'strum' the inferior canthal tendon without cutting the lower lid, appreciating the difference between canthotomy and cantholysis. Use of this model significantly increased the number of learners who felt "quite confident" with performing the procedure. Use of this model should be considered for trainees in ophthalmology and emergency medicine.

Simulation-Based Breast Biopsy Training Using a Low-Cost Gelatin-Based Breast Model in Rwanda

BACKGROUND

An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy and assessed first-time user experience.

METHODS

An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy for approximately $4.40 USD. Components include medical-grade gelatin, Jell-O™, water, olives, and surgical gloves. The model was used to train two cohorts comprising 30 students total during their junior surgical clerkship. The learners' experience and perceptions on the first Kirkpatrick level were evaluated using pre- and post-training surveys.

RESULTS

Response rate was 93.3% (n = 28). Only three students had previously completed an ultrasound-guided breast biopsy, and none had prior exposure to simulation-based breast biopsy training. Learners that were confident in performing biopsies under minimal supervision rose from 4 to 75% following the session. All students indicated the session increased their knowledge, and 71% agreed that the model was an anatomically accurate and appropriate substitute to a real human breast.

CONCLUSIONS

The use of a low-cost gelatin-based breast model was able to increase student confidence and knowledge in performing ultrasound-guided breast biopsies. This innovative simulation model provides a cost-effective and more accessible means of simulation-based training especially for low- and middle-income settings.

Evaluating user experience with immersive technology in simulation-based education: A modified Delphi study with qualitative analysis

BACKGROUND

Immersive technology is becoming more widespread in simulation-based medical education with applications that both supplement and replace traditional teaching methods. There is a lack of validated measures that capture user experience to inform of the technology utility. We aimed to establish a consensus of items and domains that different simulation experts would include in a measure for immersive technology use.

METHODS

A 3-stage modified Delphi using online software was conducted to support the conceptual framework for the proposed measure. The first round was informed by prior work on immersive technology in simulation. In the first round, participants were asked to describe what we could measure in simulation-based education and technology. Thematic analysis generated key themes that were presented to the participants in the second round. Ranking of importance in round 2 was determined by mean rank scores. The final round was an online meeting for final consensus discussion and most important domains by experts were considered.

RESULTS

A total of 16 simulation experts participated in the study. A consensus was reached on the ideal measure in immersive technology simulation that would be a user questionnaire and domains of interest would be: what was learnt, the degree of immersion experienced, fidelity provided, debrief, psychological safety and patient safety. No consensus was reached with the barriers that this technology introduces in education.

CONCLUSIONS

There is varied opinion on what we should prioritise in measuring the experience in simulation practice. Importantly, this study identified key areas that aids our understanding on how we can measure new technology in educational settings. Synthesising these results in to a multidomain instrument requires a systematic approach to testing in future research.

Artificial Intelligence Versus Human-Controlled Doctor in Virtual Reality Simulation for Sepsis Team Training: Randomized Controlled Study

BACKGROUND

Interprofessional communication is needed to enhance the early recognition and management of patients with sepsis. Preparing medical and nursing students using virtual reality simulation has been shown to be an effective learning approach for sepsis team training. However, its scalability is constrained by unequal cohort sizes between medical and nursing students. An artificial intelligence (AI) medical team member can be implemented in a virtual reality simulation to engage nursing students in sepsis team training.

OBJECTIVE

This study aimed to evaluate the effectiveness of an AI-powered doctor versus a human-controlled doctor in training nursing students for sepsis care and interprofessional communication.

METHODS

A randomized controlled trial study was conducted with 64 nursing students who were randomly assigned to undertake sepsis team training with an AI-powered doctor (AI-powered group) or with medical students using virtual reality simulation (human-controlled group). Participants from both groups were tested on their sepsis and communication performance through simulation-based assessments (posttest). Participants' sepsis knowledge and self-efficacy in interprofessional communication were also evaluated before and after the study interventions.

RESULTS

A total of 32 nursing students from each group completed the simulation-based assessment, sepsis and communication knowledge test, and self-efficacy questionnaire. Compared with the baseline scores, both the AI-powered and human-controlled groups demonstrated significant improvements in communication knowledge (P=.001) and self-efficacy in interprofessional communication (P<.001) in posttest scores. For sepsis care knowledge, a significant improvement in sepsis care knowledge from the baseline was observed in the AI-powered group (P<.001) but not in the human-controlled group (P=.16). Although no significant differences were found in sepsis care performance between the groups (AI-powered group: mean 13.63, SD 4.23, vs human-controlled group: mean 12.75, SD 3.85, P=.39), the AI-powered group (mean 9.06, SD 1.78) had statistically significantly higher sepsis posttest knowledge scores (P=.009) than the human-controlled group (mean 7.75, SD 2.08). No significant differences were found in interprofessional communication performance between the 2 groups (AI-powered group: mean 29.34, SD 8.37, vs human-controlled group: mean 27.06, SD 5.69, P=.21). However, the human-controlled group (mean 69.6, SD 14.4) reported a significantly higher level of self-efficacy in interprofessional communication (P=.008) than the AI-powered group (mean 60.1, SD 13.3).

CONCLUSIONS

Our study suggested that AI-powered doctors are not inferior to human-controlled virtual reality simulations with respect to sepsis care and interprofessional communication performance, which supports the viability of implementing AI-powered doctors to achieve scalability in sepsis team training. Our findings also suggested that future innovations should focus on the sociability of AI-powered doctors to enhance users' interprofessional communication training. Perhaps in the nearer term, future studies should examine how to best blend AI-powered training with human-controlled virtual reality simulation to optimize clinical performance in sepsis care and interprofessional communication.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05953441; https://clinicaltrials.gov/study/NCT05953441.

Handoffs and the challenges to implementing teamwork training in the perioperative environment

Perioperative handoffs are high-risk events for miscommunications and poor care coordination, which cause patient harm. Extensive research and several interventions have sought to overcome the challenges to perioperative handoff quality and safety, but few efforts have focused on teamwork training. Evidence shows that team training decreases surgical morbidity and mortality, and there remains a significant opportunity to implement teamwork training in the perioperative environment. Current perioperative handoff interventions face significant difficulty with adherence which raises concerns about the sustainability of their impact. In this perspective article, we explain why teamwork is critical to safe and reliable perioperative handoffs and discuss implementation challenges to the five core components of teamwork training programs in the perioperative environment. We outline evidence-based best practices imperative for training success and acknowledge the obstacles to implementing those best practices. Explicitly identifying and discussing these obstacles is critical to designing and implementing teamwork training programs fit for the perioperative environment. Teamwork training will equip providers with the foundational teamwork competencies needed to effectively participate in handoffs and utilize handoff interventions. This will improve team effectiveness, adherence to current perioperative handoff interventions, and ultimately, patient safety.