Deliberate practice and acquisition of expert performance: a general overview

Elucidating cognitive processes in cardiac arrest team leaders: a virtual reality-based cued-recall study of experts and novices

BACKGROUND

Team leadership during medical emergencies like cardiac arrest resuscitation is cognitively demanding, especially for trainees. These cognitive processes remain poorly characterized due to measurement challenges. Using virtual reality simulation, this study aimed to elucidate and compare communication and cognitive processes-such as decision-making, cognitive load, perceived pitfalls, and strategies-between expert and novice code team leaders to inform strategies for accelerating proficiency development.

METHODS

A simulation-based mixed methods approach was utilized within a single large academic medical center, involving twelve standardized virtual reality cardiac arrest simulations. These 10- to 15-minutes simulation sessions were performed by seven experts and five novices. Following the simulations, a cognitive task analysis was conducted using a cued-recall protocol to identify the challenges, decision-making processes, and cognitive load experienced across the seven stages of each simulation.

RESULTS

The analysis revealed 250 unique cognitive processes. In terms of reasoning patterns, experts used inductive reasoning, while novices tended to use deductive reasoning, considering treatments before assessments. Experts also demonstrated earlier consideration of potential reversible causes of cardiac arrest. Regarding team communication, experts reported more critical communications, with no shared subthemes between groups. Experts identified more teamwork pitfalls, and suggested more strategies compared to novices. For cognitive load, experts reported lower median cognitive load (53) compared to novices (80) across all stages, with the exception of the initial presentation phase.

CONCLUSIONS

The identified patterns of expert performance - superior teamwork skills, inductive clinical reasoning, and distributed cognitive strategiesn - can inform training programs aimed at accelerating expertise development.

High-Dose, High-Intensity Stroke Rehabilitation: Why Aren't We Giving It?

Current doses and intensities of post-stroke rehabilitation therapy provided as “usual care” are paltry compared to the magnitudes needed to drive large behaviorally-relevant reductions in neurologic impairments. There is convergent evidence indicating that high dose, high intensity rehabilitation is effective for improving outcomes after stroke with large effect sizes compared to usual care. Here we highlight some of this evidence (focusing on studies of upper extremity motor rehabilitation) and then ask the simple question— why are we not delivering high doses and intensities of rehabilitation in clinical practice? We contend that reasons for lack of implementation of high dose, high intensity rehabilitation have to do with questionable conceptual, ideological, and economic assumptions. In addition, there are practical challenges, which we argue can be overcome with technology. Current practice (we refer primarily to the context of US healthcare) in stroke rehabilitation is itself built on very little evidence, indeed considerably less than the cumulative evidence indicating that high dose, high intensity rehabilitation would be more effective. Our hope is that this Perspective will help persuade multiple stake holders (neurologists, physiatrists, therapists, researchers, patients, policy makers, and insurance companies) to advocate for higher doses and intensities of rehabilitation. There is certainly more research to be done on new ways to deliver high-dose, high-intensity neurorehabilitation, as well as zeroing in on its best timing and dosing, and how to best combine it with drugs and physiological stimulation. In the meantime, our view is that a large body of convergent evidence already justifies seeking to incorporate higher doses and intensities of therapy into current clinical practice as the new standard of care.

MGH Laboratory for Translational Neurorecovery: @LTNeurorecovery (X), @ltneuro (Instagram)

MGH Center for Neurotechnology and Neurorecovery: @MGH_CNTR (X)

Asynchronous Technical Feedback: A Workshop for Training Surgical Instructors

Introduction

Asynchronous learning is an efficient method for surgical trainees to gain technical skills by practicing in low-stakes and convenient settings. Effective asynchronous learning requires feedback. Prior work has highlighted the need to train surgical instructors in providing asynchronous technical feedback, as this involves unique skills related to giving feedback on learners' videos. While many existing curricula focus on optimal feedback practices, there remains a gap with regard to asynchronous technical feedback materials.

Methods

Following Kern's six-step approach to curriculum development, we developed a 60-minute workshop, for participants across multiple contexts, on best practices for effective asynchronous technical feedback. We conducted a pilot workshop and then iteratively adjusted the flow and materials for subsequent workshop sessions. We followed survey design principles to create a postworkshop questionnaire evaluating how well the workshop addressed three of the educational objectives.

Results

Forty-six participants attended four iterations of the workshop across three cities. Seven participants attended the pilot session of the workshop, and 39 participants joined the subsequent workshops. Of these 39 participants, 33 (85%) completed the questionnaire. Twenty-eight (85%) of 33 participants indicated that they could state a barrier to providing technical feedback after the workshop, while 30 (91%) of 33 could provide a situation in which to use asynchronous technical feedback. Twenty-seven (82%) of 33 could state a way in which to improve the quality of asynchronous technical feedback.

Discussion

Educators may use these materials to equip instructors with tools for effectively giving learners the feedback needed for asynchronous technical skill acquisition.

"The Environment Fostered True Growth": Harnessing Coaching on an Innovative Medicine Sub-internship

BACKGROUND

Medicine sub-internships aim to prepare students for residency. However, the traditional sub-internship structure, with multiple learners at varied levels, poses obstacles to providing the clinical exposure, learning environment, and direct observation and feedback necessary to develop essential skills.

AIM

Investigate the educational experience of learners on a coaching-centered sub-internship (CCSI) on a resident uncovered ward service.

SETTING AND PARTICIPANTS

From 2017 to 2022, 73 sub-interns and 39 hospitalists participated in the rotation at a community-based university-affiliated urban hospital.

PROGRAM DESCRIPTION

Sub-interns rotated on a CCSI with teams comprised of one attending, one physician assistant, and one student. Students cared for patients across the continuum of hospitalization with frequent coaching by trained attendings. Students engaged in workshops targeting clinical skills essential for internship.

PROGRAM EVALUATION

Students (n = 67/73, 91.8% response rate) rated the quality of the course significantly higher on the CCSI than the traditional sub-internship rotation (mean [SD]) 4.87/5 [0.49] vs. 4.63/5 [0.61]; p < 0.001. Students and faculty found the CCSI fostered coaching, autonomy, accurate assessments, professional development, growth mindset, and readiness for internship.

DISCUSSION

Our model demonstrates that a CCSI can cultivate the skills and mindset to prepare students for internship. This coaching model can benefit students in other settings.

Glenoid Bone Grafting During Primary Reverse Shoulder Arthroplasty: A Learning-Curve Analysis

Background

Reverse shoulder arthroplasty (RSA) with structural bone grafting of the glenoid utilizing an autograft from the resected humeral head is an effective strategy to address severe glenoid bone loss. Although learning curves have been established for RSA, RSA with bone grafting is more technically challenging, with relatively higher complication rates. The number of cases needed for proficiency and the optimal learning strategies have yet to be defined for RSA with bone grafting.

Methods

All patients who underwent primary, single-stage RSA with bone grafting for severe glenoid bone loss at our institution between November 2018 and February 2022 were identified. Perioperative data, including imaging, operative time, complications, revisions, postoperative functional data, and patient-reported outcomes, were recorded and analyzed. The learning curve for a fellowship-trained shoulder and elbow surgeon was analyzed using linear regression and cumulative sum (CUSUM) analysis. CUSUM analysis objectively evaluated differences in operative time over the course of the surgeon's practice and elucidated the completion of the learning curve.

Results

A total of 32 patients (53% male and 47% female; mean age, 68 years) were included in the analysis. The mean follow-up was 28 months. The mean operative time was 127 minutes, and there was a linear decrease in operative time throughout the study. CUSUM analysis using operative times demonstrated that the surgeon's learning curve was 14 patients. When comparing patients among the first 14 cases and the last 18 cases, there was no difference in shoulder range of motion, American Shoulder and Elbow Surgeons (ASES) scores, and Subjective Shoulder Value (SSV), while visual analog scale (VAS) pain scores at the time of final follow-up were better for patients in the surgeon's proficiency phase compared with the learning phase.

Conclusions

In this study, we found a significant linear decrease in operative time with the number of cases completed, without associated detriment to the postoperative outcome or complication rate. Our findings suggest that at least 14 cases may be required before proficiency is obtained with RSA using humeral head bone graft.

Level of Evidence

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Examining self-efficacy among recent graduates of postgraduate dental education programs

PURPOSE

To examine the perceived self-efficacy of dentists who recently completed Graduate Dental Education (GDE) programs and identify how closely it aligns with their supervisors' assessments of them. Self-efficacy has been associated with academic pursuits, motivation, and engagement, which may affect how dental providers practice, seek continuing education, and pursue future opportunities.  METHODS: Recent graduates of military GDE programs rated their self-efficacy on specific tasks within each of the seven domains of dental competencies. Their supervisors completed a similar survey, rating the graduate's performance in the same tasks. Graduates' mean ratings were calculated for each domain, spearman correlations were calculated for all graduate-supervisor task ratings, and the magnitude of differences between graduate and supervisor domain means were examined.

RESULTS

Graduates' perceived self-efficacy ranged from 3.57 to 4.41 out of 5.0. Correlations for each task were universally weak (ρ  =  -0.04-0.27). Correlations for domain means were also weak (ρ  =  0.06-0.14).  Overall, graduates rated themselves lower than their supervisors, with mean differences ranging from -0.17 (p = 0.003, Cohen's d = 0.20) for Professionalism to -0.95 (p < 0.001, Cohen's d = 0.90) for Health Promotion.

CONCLUSIONS

Overall, graduates' perceived self-efficacy was moderate to high for 26 tasks across seven domains. However, in aggregate, graduates underestimated their abilities compared to performance measures from their current supervisors, although effect sizes were small. The accuracy of graduates' self-efficacy varied by program length and the clinical specialty of their supervisors. High-performing graduates always underestimated themselves while low-performing graduates often overestimated themselves.

Implementation of regional anesthesia education for emergency medicine residents and faculty

Background

Using opioids for pain management in emergency departments (ED) poses risks such as respiratory depression and addiction. Ultrasound-guided regional anesthesia (UGRA) offers an alternative to opioids and procedural sedation, yet many emergency medicine (EM) residencies lack formal training for this skill. It is crucial to develop education initiatives aimed at incorporating UGRA techniques into clinical practice for emergency physicians (EPs).

Methods

A regional anesthesia education program for EM residents and faculty was piloted. The intervention comprised a 25-min video on safe UGRA practices followed by a 4-h hands-on course using cadaveric and live models. Participant knowledge was tested before the course and 6 weeks afterward. Test results were analyzed via paired t-test. The electronic health record was reviewed for UGRA blocks performed in the ED 2 months before and after the intervention. Efficacy was evaluated through patient-reported pain improvement and ultrasound image review. Immediate complications are reported.

Results

Twenty-six residents and 11 faculty completed the video review, hands-on course, and the pre/posttests. With a maximum score of 30, median (IQR) pretest scores were 14 (12-17) and increased to 21 (18-23) 6 weeks postcourse, with a median 8 (95% CI 4.1-9.0) points improvement. One-hundred percent of participants found the training helpful. Clinical data were collected from August 26, 2023, to December 25, 2023, and the number of UGRA blocks performed rose from 55 before to 102 after the intervention. Pain improvement was similar before and after the intervention. Review of recorded images indicated proper needle position and anesthetic spread in 91% of blocks precourse and 82% postcourse.

Conclusions

This educational intervention increased UGRA blocks with few complications and a high success rate. Provider knowledge significantly improved, but needle positioning and anesthetic spread were inappropriate in 18% of blocks postcourse, emphasizing the need for ongoing education to enhance UGRA competency among EPs.

Diagnosing diagnostic error of endometriosis: a secondary analysis of patient experiences from a mixed-methods survey

OBJECTIVE

To analyse endometriosis diagnostic errors made by clinicians as reported by patients with endometriosis.

METHODS

This study deductively analysed qualitative data as part of a larger mixed-methods research study examining 'invalidating communication' by clinicians concerning patients' symptoms. Data analysed were responses to an open-ended prompt asking participants to describe an interaction with a clinician prior to their diagnosis in which they felt their symptoms were dismissed. We used three validated taxonomies for diagnosing diagnostic error (Diagnosis Error Evaluation and Research (DEER), Reliable Diagnosis Challenges (RDC) and generic diagnostic pitfalls taxonomies).

RESULTS

A total of 476 relevant interactions with clinicians were identified from 444 patients to the open-ended prompt, which identified 692 codable units using the DEER taxonomy, 286 codable units using the RDC taxonomy and 602 codable diagnostic pitfalls. Most prevalent subcategories among these three taxonomies were inaccurate/misinterpreted/overlooked critical piece of history data (from DEER Taxonomy; n=291), no specific diagnosis was ever made (from diagnostic pitfalls taxonomy; n=271), and unfamiliar with endometriosis (from RDC Taxonomy; n=144).

CONCLUSION

Examining a series of patient-described diagnostic errors reported by patients with surgically confirmed endometriosis using three validated taxonomies demonstrates numerous areas for improvement. These findings can help patients, clinicians and healthcare organisations better anticipate errors in endometriosis diagnosis and design and implement education efforts and safety to prevent or mitigate such errors.

[Assessing therapeutic communication competence of university students in Germany: Lessons learned]

The construct of therapeutic competence should enable measurement of therapist effectiveness, though this poses challenges. This study aimed to investigate the increase in students' competence in clinical communication skills through objective assessment, and to reflect on learning experiences with competence assessment.Communication techniques were taught over three seminar sessions, each using standardized 20-minute role plays. Between the second and third sessions, the participants received structured or unstructured video supervision. Competence was evaluated by two independent rater groups using an adapted Cognitive Therapy Rating Scale (CTRS).The videos of 82 students were analyzed. Interrater reliability was low in the first group of raters (ICC3,1=0.48) and non-existent in the second group (ICC3,1=0.00). A small main effect of assessment time point was observed, indicating a slight, non-significant increase in clinical communication skills from the first to the third session. Neither the effect of supervision nor the interaction effect was significance.Due to the chosen application of the CTRS, a standardized and objective assessment of therapeutic interviewing skills was not feasible, requiring cautious interpretation of the results regarding clinical communication skills. The fit of the measurement instrument, the standardization of the assessed situation and the lack of experience of the raters probably had affected interrater reliability negatively. These aspects can also be a challenge in the newly introduced parcours examination for the licence to practise psychotherapy and must be taken into account when planning and classifying the evaluation.

Deliberate Practice Supervision in Action: The Sentio Supervision Model

Deliberate Practice (DP) is gaining consensus by researchers as a potentially promising method to increase therapist's effectiveness. While many clinicians and trainers now support DP's potential benefits, there is still a lack of guidelines, research, and training on implementing DP in clinical supervision. Recently, Vaz and Rousmaniere have proposed the Sentio Supervision Model as a method to integrate three major supervision-enhancing contributions: the use of routine outcome monitoring, the use of therapy recordings, and the use of DP skills training. We present a case study focusing on one client's treatment progress and their therapist's engagement in weekly supervision following the Sentio Supervision Model. The client had been identified by the outcome measure as being at risk of deterioration, and after DP supervision showed recovery and became on track for a good treatment outcome. Annotated transcripts provide a closer look into the clinical and supervisory process and how the latter influenced the former. We highlight the potential benefits and challenges inherent to this novel Supervision Model.

Physiological stress differentially impacts cognitive performance during-and memory following-simulated police encounters with persons experiencing a mental health crisis

Police officers frequently make decisions under stress and require accurate memories of their perceptions and actions for subsequent investigations. Recognizing that police are frequently called to assist people experiencing a mental health crisis, it is of critical importance to public safety to understand the role of stress on officers' cognition when navigating such encounters. Despite this, how the timing of experiencing stress impacts officer cognition is understudied in applied police contexts and therefore remains unclear. To address this gap in the literature, we analyzed data from a study of 57 police officers who wore heart rate monitors to record physiological arousal before, during, and after two reality-based scenarios (i.e., simulated calls for service) with individuals experiencing mental distress. Scenarios were audio-recorded, transcribed, and coded to measure officers' perceptual memory of important elements in each scene, procedural memory to enact best practices, post-incident memory of their own actions, and higher-level situational understanding. We found a nuanced relationship between the timing of stress and cognitive performance, such that higher heart rate before and during scenarios improved understanding, decision making, and the appropriate choice of use of force option, but at the expense of officers' spatial processing. Increased heart rate during the post-incident debrief was associated with the following: making a lethal force error during the scenario, decreased memory for perceptual aspects of the scenario, and impaired recall of one's own actions. Older and more experienced officers exhibited overall lower physiological arousal, and female officers demonstrated better cognitive performance compared to male officers. These results have practical implications in operational, training, evaluation, and testimonial police contexts and can inform future interventions aimed to improve outcomes when navigating stressful encounters, including crisis intervention.

Deliberate Practice Supervision to Enhance the Effectiveness of Behavioral Activation for Depression: A Case Study

Deliberate Practice (DP) is a model of behavioral skill acquisition structured by several key tasks. The past decade has shown a consistent growth in interest in this form of learning for psychotherapy skills, with promising research suggesting DP training is superior to traditional learning methods of psychotherapy. This paper presents a case study of a single practitioner's experience with Deliberate Practice. It follows a clinician treating a client diagnosed with Major Depressive Disorder (MDD) while learning Behavioral Activation under the guidance of a DP Supervisor. The main components of DP are presented: direct observation of performance, concrete feedback, defining learning goals, performing repeated behavioral rehearsal and the ongoing assessment of performance. Real case vignettes are used to demonstrate these components. The paper concludes with a discussion of challenges that DP supervisors commonly face, and some practical implications for clinicians.

Tell me your date of birth, and I will tell you how good you are in orienteering

Orienteering is a sport where participants must choose the best route between control points marked on the map, combining it with their displacement capacity. It combines endurance running with mental capacity. As in other sports, age can be a determinant in defining differences among youth runners. In this research, the hypothesis is that older orienteers will show better performance than younger orienteers within the same competitive group, for both girls and boys. Overall, official results of the FEDO (Spanish Federation of Orienteering) in long and middle-distance events, from 2005 to 2023, have been analyzed (sprint format events were excluded). Different categories from ten to twenty years of age for both sexes were included, and each category was divided into two years (1Y, 2Y) and two semesters (1S, 2S) within each year, creating four independent variables from the combination of year and semester (1Y1S, 1Y2S, 2Y1S, and 2Y2S). A total of 7,731 entries were examined, 4,318 were boys and 3,109 were girls. Descriptive statistics were analyzed for each variable, showing the mean and standard deviation. Normal distribution was confirmed for all variables (p > 0.05). Results showed a significant performance difference in favor of older orienteers in the youngest categories (U-10, M/F-12, M/F-14, and M-16), with these differences disappearing as age and performance increased (M/F-18 and M/F-20). These findings support the research hypothesis and align with other studies where age-related differences have also been found in other sports.

Interprofessional Discussion for Knowledge Transfer in a Digital "Community of Practice" for Managing Pneumoconiosis: Mixed Methods Study

Background

Pneumoconiosis prevalence is increasing in the United States, especially among coal miners. Contemporaneously with an increased need for specialized multidisciplinary care for miners, there is a shortage of experts to fulfill this need. Miners' Wellness ECHO (Extension for Community Health Outcomes) is a digital community of practice based on interprofessional discussion for knowledge transfer. The program has been demonstrated to increase participants' self-efficacy for clinical, medicolegal, and "soft" skills related to miners' health.

Objective

We aimed to examine characteristics associated with interprofessional discussions and suggest ways to strengthen knowledge transfer.

Methods

This mixed methods study used an exploratory sequential design. We video-recorded and transcribed ECHO sessions over 14 months from July 2018 to September 2019 and analyzed content to examine participant discussions. We focused on participants' statements of expertise followed by other participants' acceptance or eschewal of these statements (utterances). We conducted quantitative analyses to examine the associations of active participation in discussion (primary outcome variable, defined as any utterance). We analyzed the association of the outcome on the following predictors: (1) participant group status, (2) study time frame, (3) participant ECHO experience status, (4) concordance of participant group identity between presenter and participant, (5) video usage, and (6) attendance frequency. We used the generalized estimating equations approach for longitudinal data, logit link function for binary outcomes, and LSMEANS to examine least squares means of fixed effects.

Results

We studied 23 sessions with 158 unique participants and 539 total participants, averaging 23.4 (SD 5.6) participants per session. Clinical providers, the largest participant group, constituting 36.7% (n=58) of unique participants, were the most vocal group (mean 21.74, SD 2.11 average utterances per person-session). Benefits counselors were the least vocal group, with an average utterance rate of 0.57 (SD 0.29) per person-session and constituting 8.2% (n=13) of unique participants. Thus, various participant groups exhibited different utterance rates across sessions (P=.003). Experienced participants may have dominated active participation in discussion compared to those with less or intermediate experience, but this difference was not statistically significant (P=.11). When the didactic presenter and participant were from the same participant group, active participation by the silent group participants was greater than when both were from different groups. This association was not seen in vocal group participants (interaction P=.003). Compared to those participating by audio, those participating on video tended to have higher rates of active participation, but this difference was not statistically significant (P=.11).

Conclusions

Our findings provide insight into the mechanics of interprofessional discussion in a digital community of practice managing pneumoconiosis. Our results underscore the capacity of the novel ECHO model to leverage technology and workforce diversity to facilitate interprofessional discussions on the multidisciplinary care of miners. Future research will evaluate whether this translates into improved patient outcomes.

A mixed reality for midwifery students: a qualitative study of the technology's perceived appropriateness in the classroom

BACKGROUND

Virtual reality and mixed reality have shown great promise in training and education across a range of professional and pedagogical domains. The perception of such technologies by midwifery students remains an underexplored area of study.

METHODS

Thirty-three MSc midwifery students received a demonstration of a proof-of-concept mixed reality lesson about the foetal descent during labour. Twelve students were subsequently interviewed about their experiences, and thematic analysis was used to analyse the qualitative dataset produced by the interview transcripts.

RESULTS

Analysis found [1] that mixed reality was viewed by the students as a valuable novelty which facilitates new insights while scaffolding prior learnings [2], that mixed reality was postulated to gel well with other learning methods and modalities such as simulation-based training, and [3] that while mixed reality was intuitive or easy to use, adaptable or customisable content should be a key consideration in immersive lesson design.

CONCLUSIONS

The study concludes that mixed reality can be a valuable supplement to existing teaching methods and tools. Students expressed optimism about mixed reality's potential to enhance educational outcomes. While it cannot replace dialogue with a qualified instructor, mixed reality may be well suited to facilitating peer-to-peer learning.

CLINICAL TRIAL NUMBER

Not applicable.

Hearing Loss Health Literacy in Speech-Language Pathologists: Impact of Academic Training and On-the-Job Experience

PURPOSE

The purpose of this study was to explore if academic training and/or on-the-job experience predicts general health literacy, hearing loss health literacy, and self confidence levels of speech-language pathologists (SLPs).

METHOD

Participants included 423 SLPs with differing levels of academic training and on-the-job experience working with children who are deaf or hard of hearing (DHH). General health literacy, hearing loss health literacy, and confidence levels treating children who are DHH were assessed. Data were analyzed using SPSS, with descriptive statistics, Pearson's r correlations, and multiple linear regression models.

RESULTS

SLPs had high levels of general health literacy but marginal to low levels of hearing loss health literacy. Neither academic training nor on-the-job experience predicted general health literacy, but they were predictive of hearing loss terminology knowledge. Only on-the-job experience predicted in-depth hearing loss content knowledge. There was an interaction of training and experience for confidence of SLPs in treating children who are DHH. SLPs with greater years of experience exhibited lower confidence with an increasing amount of coursework, whereas SLPs with fewer years of experience displayed higher confidence with an increasing amount of coursework.

CONCLUSIONS

Results indicated that the driving factor for development of in-depth hearing loss health literacy in SLPs is on-the-job experience. Methods of integrating experiential learning into academic training should be evaluated.

A Novel Pediatric Clinical Skills Curriculum to Prepare Medical Students for Pediatrics Clerkship

Introduction

Medical students feel poorly prepared to examine pediatric patients during clerkship. Our institution's introduction to clinical skills course lacked practice with pediatrics physical examination skills. We developed a novel clinical skills curriculum to increase students' confidence in examining pediatric patients.

Methods

Ericsson's deliberate practice conceptual framework guided curriculum design. We utilized a flipped-classroom model to teach the newborn examination. Students watched a video, then practiced with manikins and patients. For the child examination, students attended a lecture and practiced with hospitalized children and facilitators. Students then participated in a Home, Education, Eating/Exercise, Activities/Employment, Drugs, Suicidality, Sexuality, Safety (HEEADSSS) didactic and role play activity. Before and after participation, students completed REDCap surveys ranking confidence in performing pediatric examinations and identifying normal examination findings on a Likert scale (1 = "Not at all confident," 4 = "Extremely confident"). We analyzed data using Wilcoxon rank sum tests.

Results

A total of 97 students participated in the curriculum. Respectively, 56 (58%) and 32 (30%) students completed pre- and post-participation surveys. Post-participation, students reported increased confidence in identifying normal infant (median [interquartile range]; (2 [2,2] vs 4 [3,4]; p < 0.001) and child (2 [2,2] vs 3 [3,4]; p < 0.001) examination findings as well as HEEADSSS assessment components (2 [1.5,2] vs 4 [3,4]; p < 0.001), and had significantly higher scores on confidence performing infant (2 [2,2.5] vs 4 [3,4]; p < 0.001), child (2 [2,2] vs 3 [3,4]; p < 0.001), and HEEADSSS assessment (2 [2,3] vs 4 [3,4]; p < 0.001).

Discussion

This multi-modal curriculum emphasizing pediatric examination skills improved students' confidence in pediatric-specific knowledge and skills prior to clerkship.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02191-w.

Innovative Technology to Improve Simulation Access for Rural Clinicians

Rural pediatric clinicians face barriers to accessing health care simulation, an educational standard to prepare for high-acuity, low-occurrence (HALO) events. Simulation is typically accessible in urban academic medical centers, as it is resource-intensive owing to the necessary equipment and expertise needed to implement training. Rural hospitals face geographic and financial barriers to providing simulation training. Paradoxically, rural clinicians may benefit from additional training owing to infrequent clinical HALO events in rural centers. Emerging simulation modalities, including mobile simulation, telesimulation, and extended reality, offer more accessible simulation alternatives for rural clinicians, addressing geographic and financial gaps in access.

Simulation-Based Echocardiography Training Enhanced Competence and Self-Confidence in Neonatal Residents

AIM

Mastering echocardiography scans is essential in neonatology, but bedside training can be difficult due to the instability of neonatal patients. The aim of this study was to demonstrate the benefits of simulation-based training for residents learning echocardiography.

METHODS

This multicentre randomised controlled trial involved residents from three French neonatology departments. The authors compared a control group with theoretical and bedside training and a simulation group with additional simulation-based training. Evaluations were conducted three and 6 months after training using two scoring methods: a reference score for the quality of the echocardiographic sections and a custom-made score for recognising anatomical structures.

RESULTS

We randomised 52 residents from 1 May 2021 to 31 May 2023. After 3 months, the residents in the simulation group achieved a higher mean score than the residents in the control group for both the reference score (11.5 ± 2.3 points vs. 7.4 ± 3.4 points, p < 0.001) and the custom-made score (25.8 ± 5.3 points vs. 16.9 ± 7.8 points, p < 0.001). The difference remained significant at 6 months and the custom-made score showed good agreement with the reference score.

CONCLUSION

Simulation-based training was a valuable approach for training neonatal residents to perform echocardiography and more extensive training courses should be developed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT06442683.

Improved Casualty Depiction System for Simulated Mass Casualty Exercises

INTRODUCTION

Assessing military medical teams' ability to respond to large-scale mass casualty (MASCAL) events has become a priority in preparing for future conflicts. MASCAL exercises rely on large numbers of simulated patients with limited medical training. Role-players must be appropriately prepared to ensure that medical exercises adequately assess the expected capabilities of military medical units. The Uniformed Services University of the Health Sciences (USUHS) has evaluated future military providers for decades using a large-scale, multiday, immersive simulation called Bushmaster. Despite a robust casualty training system, the fidelity of the portrayals remained limited.

MATERIALS AND METHODS

Through collaboration with national military medical experts, a comprehensive casualty depiction system was developed. This system relied on structured casualty cards linked to time-based illness scripts. Structured casualty cards included an appropriate balance of disease non-battle injuries and trauma, included multipatient presentations based on shared events (i.e., multiple injured personnel due to an aircraft crash), normal and pathologic combat stress, population/unit considerations, requirements for different roles within the medical unit, and expected clinical outcomes. Illness scripts, supplemented by video guides, included time-based courses of illness/injury and prescribed responses to different typical treatments. This system was piloted during an annual MASCAL exercise (Operation Bushmaster) at USUHS. Clinical faculty were queried on the fidelity of this new system while role-players were evaluated on feasibility.

RESULTS

Three hundred casualty cards linked to 49 illness scripts were created, peer-reviewed, and piloted at Bushmaster. A total of 170 military members with limited medical training portrayed simulated patients utilizing the new casualty depiction system. Clinical faculty members strongly agreed that the improved casualty depiction system improved the realism of individual patient presentations (96%). Eighty-three percent of role-players strongly agreed that the casualty depiction system was easy to understand.

CONCLUSIONS

This improved casualty depiction system was a feasible approach to enhance the fidelity of a MASCAL exercise. It has since been shared with military medical units around the globe to assist with their MASCAL exercises, making future multisite evaluations of this casualty depiction system possible.

How breakthroughs happen: Unearthing the boundary conditions of eco-friendly deliberate practice and eco-innovation performance

Surprisingly innovation process based on deliberate practice has rarely been unearthed that might explore the boundary conditions of the eco-friendly deliberate practice and eco-innovation performance relationship. Anchored on the organizational support theory and the social cognitive, the current study seeks to investigate the impacts of perceived organizational support (POS) and developmental leadership (DL) on eco-innovation performance (EP) through the mediating role of eco-friendly deliberate practice (EDP). In addition, the study explores the boundary effects of employee resilience (ER) on the relationship between EDP and EP. The study collects time-lagged (i.e., "three-wave") and multisource (i.e., "self-rated and supervisor-rated") data from 383 respondents working in the service sector organizations in Pakistan. The authors processed data in SmartPLS (v 4.0) to assess the measurement model and the structural model. The study finds that POS and DL have significant positive relationships with EDP. Further, EDP partially mediates the links between POS, DL, and EP. Moreover, ER intervenes the association between EDP and EP such that at high levels of ER, the relationship is stronger and vice versa. Despite growing interest in deliberate practice, the boundary conditions of EDP in the work context are rarely investigated. This is the first study that explores the contextual and individual factors that can underpin the influence of EDP on EP.

Improving medical students' responses to emergencies with a simulated cross-cover paging curriculum

New residents are often unprepared to respond to medical emergencies. To address this gap, we implemented a simulated cross-cover paging curriculum. All senior medical students enrolled in a required specialty-specific (internal medicine, procedures, emergency medicine [EM], obstetrics and gynecology [OBGYN], family medicine and pediatrics) residency preparation course (RPC) in 2020-2021 participated. Students received 3-6 specialty-specific pages that represented an urgent change in clinical status about a simulated patient. For each page, students first called a standardized registered nurse (SRN) to ask additional questions, then recommended next steps in evaluation and management. The SRNs delivered immediate verbal feedback, delayed written feedback, and graded clinical performance using a weighted rubric. Some items were categorized as 'must do,' which represented the most clinically important actions. Trends in clinical performance over time were analyzed using the Jonckheere-Terpstra test. Of the 315 eligible students, 265 (84.1%) consented for their data to be included in the analysis. Clinical performance improved from a median (interquartile range) of 59.4% (46.9%, 75.0%) on case 1 to 80.0% (68.0%, 86.7%) on case 6 (p < .001). The percentage of 'must do' items improved significantly, from 69.2% (53.8, 81.8%) to 80.0% (66.7%, 88,9%) (p < .001). Scores improved over time for all specialty courses except for EM and OB/GYN. Surveyed students largely found this to be a valuable addition to the RPC curriculum with a 4.4 overall rating (1 = poor to 5 = excellent). This novel curriculum fills important gaps in the educational transition between medical school and residency. The simulated paging platform is adaptable and generalizable to learners entering different residency specialties.

From Virtual Reality to Reality: Fine-Tuning the Taxonomy for Extended Reality Simulation in Dental Education

INTRODUCTION

Digital simulation in dental education has substantially evolved, addressing several educational challenges in dentistry. Following global lockdowns and sustainability concerns, dental educators are increasingly adopting digital simulation to enhance or replace traditional training methods. This review aimed to contribute to a uniform taxonomy for extended reality (XR) simulation within dental education.

METHODS

This scoping review followed the PRISMA and PRISMA-ScR guidelines. PubMed/MEDLINE, EMBASE, Web of Science and Google Scholar were searched. Eligible studies included English-written publications in indexed journals related to digital simulation in dental/maxillofacial education, providing theoretical descriptions of extended reality (XR) and/or immersive training tools (ITT). The outcomes of the scoping review were used as building blocks for a uniform of XR-simulation taxonomy.

RESULTS

A total of 141 articles from 2004 to 2024 were selected and categorised into Virtual Reality (VR), Mixed Reality (MR), Augmented Reality (AR), Augmented Virtuality (AV) and Computer Simulation (CS). Stereoscopic vision, immersion, interaction, modification and haptic feedback were identified as recurring features across XR-simulation in dentistry. These features formed the basis for a general XR-simulation taxonomy.

DISCUSSION

While XR-simulation features were consistent in the literature, the variety of definitions and classifications complicated the development of a taxonomy framework. VR was frequently used as an umbrella term. To address this, operational definitions were proposed for each category within the virtuality continuum, clarifying distinctions and commonalities.

CONCLUSION

This scoping review highlights the need for a uniform taxonomy in XR simulation within dental education. Establishing a consensus on XR-related terminology and definitions facilitates future research, allowing clear evidence reporting and analysis. The proposed taxonomy may also be of use for medical education, promoting alignment and the creation of a comprehensive body of evidence in XR technologies.

Specialists' learning from facilitating group peer telementoring: a qualitative study

BACKGROUND

Group peer telementoring supports interprofessional learning through multi-directional and synchronous engagement where experienced and knowledgeable individuals exchange guidance and support with differently experienced and knowledgeable individuals. A leading example of group peer telementoring among medical specialists and medical generalists is Project Extension for Community Healthcare Outcomes (Project ECHO), a rapidly spreading program with demonstrated learning outcomes among community-based medical generalists. Yet the multi-directional exchanges that characterize group peer telementoring interactions suggest that specialists facilitating sessions may also learn from the group experiences. We explored what medical specialists learn from community-based medical generalists and from other specialists as a result of facilitating and participating in group peer telementoring.

METHODS

Pairs of ECHO administrative staff and researchers interviewed medical specialists who facilitated Project ECHO work. Using interview transcripts, we identified 129 learning episodes in which 53 specialists discussed what they learned from their Project ECHO experiences. An inductive multi-phase thematic analysis was used to identify what medical specialists were learning and from whom.

RESULTS

Three primary themes emerged from the data. Specialists learned about community-based health care, including learning about unique and novel community-based treatments and patient needs. Specialists broadened and deepened their knowledge of patient care, including taking an interprofessional view and learning more about their own specialty area. Specialists also learned about learning, including revelations about power hierarchies, the importance of opening space for learning, and practicing humility.

CONCLUSIONS

Project ECHO's emphasis on group peer telementoring brought the realities of community-centric care to the attention of medical specialists, deepening their knowledge about patient care and about learning. Specialists learned from community-based medical generalists, other medical specialists within their discipline, and from medical specialists with other expertise. The "all teach, all learn" space that medical specialists endeavored to create in Project ECHO for community-based medical generalists created a safe space for specialists to admit what they did not know. Continued facilitation and participation in group peer telementoring may provide medical specialists with feedback about diagnoses, treatments, and community-based resources for low-income rural and inner-city patients that contributes to their continued development and medical education.

Unravelling the art of developing skilled communication: a longitudinal qualitative research study in general practice training

Doctor-patient communication is a core competency in medical education, which requires learners to adapt their communication flexibly to each clinical encounter. Although conceptual learning models exist, information about how skilled communication develops over time is scant. This study aims to unpack this process of communication learning and to identify its facilitators. We conducted a longitudinal qualitative study employing a constructivist grounded theory approach in a General Practice training setting. Over a 6-month period, we closely monitored 8 first-year and 5 third-year trainees (n = 13) by means of clinical observations, stimulated recall interviews and audio diaries. In an iterative process of data collection and analysis, we triangulated these sources across trainees (horizontal analysis) and over time (vertical analysis) to identify how themes evolved. This analysis led us to the construction of a six-stage cyclic conceptual model during which trainees: (1) have an impactful experience; (2) become aware of own communication; (3) look for alternative communication behaviours; (4) experiment with new behaviours; (5) evaluate the effectiveness; and (6) internalise the new communication behaviours. Additionally, conditions were found to support learning and reflection. Becoming a skilled communicator seems to require a continuous approach, with repeated practice and reflection to adapt and internalise communication in the clinical encounter. Consequently, we recommend that trainees be supported with tailored feedback to strengthen their communication repertoire. Ideally, they should be guided by supervisors who serve as coaches in a safe learning environment with regular, planned learning activities.

Using Politeness Theory to Deconstruct How Preregistrant Pharmacists Approach Disagreement in the Workplace

OBJECTIVE

Using politeness theory, this study investigates how preregistrant pharmacists engage in workplace disputes.

METHODS

Overall, 56 students participated in 2 mock job judgment scenarios. In scenario A (n = 25), the conflict was with a colleague of lower hierarchical status, while in scenario B (n = 32), the conflict was with a colleague of equal hierarchical status. Using politeness theory, responses were coded into 3 tiers: (1) engagement in the face-threatening act (FTA); (2) use of on/off-record approaches; and (3) communicative strategies. For tier 1, reasons for engaging in the FTA were also coded.

RESULTS

89% of the participants indicated they would unequivocally engage in the FTA. For scenario A, the pharmacist's roles and responsibilities (40%) and for scenario B, situational urgency/safety (65%) were the key drivers. Scenario A participants were more likely to use an on-record approach (80%) than those in scenario B (68%). Empathetic approaches (56%) were more common in scenario A, while explanatory approaches (64%) were more frequent in scenario B.

CONCLUSION

This study shows that preregistrant pharmacists are aware of the principles of face-work. While the study only reflects what participants believe they would do, not their actual ability in professional disputes, it supports current research that students need simulated low-stakes opportunities to practice communication skills before entering the workplace, especially where situational urgency is present. Integration of politeness theory in workshop and feedback design could help students to link awareness to actual interaction, although the theory should be expanded to integrate urgency as a factor impacting all levels of interactional decision-making.

Simulation-Based Training Program for Peripherally Inserted Central Catheter Placement: Randomized Comparative Study of in-Person Training With Synchronous Feedback Versus Distance Training With Asynchronous Feedback

INTRODUCTION

Simulation training that includes deliberate practice is effective for procedural skill training. Delivering feedback remotely and asynchronously has been examined for more cost-efficient training. This prospective randomized study aimed to compare 2 feedback techniques for simulation training: synchronous direct feedback versus asynchronous distance feedback (ASYNC).

METHODS

Forty anesthesia and internal medicine residents were recruited after study approval by the institutional ethics committee. Residents reviewed instructional material on an online platform and performed a pretraining assessment (PRE) for peripherally inserted central catheter (PICC) placement. Each resident was then randomly assigned to 1 of 2 training types, practice with synchronous direct feedback (SYNC) or practice with ASYNC. Training consisted of four, 1-hour practice sessions; each was conducted once per week. Both groups underwent posttraining evaluation (POST). The PRE and POST assessments were videotaped and evaluated by 2 independent, blinded reviewers using a global rating scale.

RESULTS

Thirty-five residents completed the training program and both evaluations. Both groups had significantly improved global rating scale scores after 4 sessions. The SYNC group improved from 28 to 45 points ( P < 0.01); the ASYNC group improved from 26.5 to 46 points ( P < 0.01). We found no significant between-group differences for the PRE ( P = 0.42) or POST assessments ( P = 0.13).

CONCLUSION

This simulation-based training program significantly improved residents' peripherally inserted central venous catheter placement skills using either modality. With these results, we are unable to demonstrate the superiority of synchronous feedback over ASYNC. Asynchronous feedback training modality represents a new, innovative approach for health care procedural skills training.

Toward Improving Human Training by Combining Wearable Full-Body IoT Sensors and Machine Learning

This paper proposes DigitalUpSkilling, a novel IoT- and AI-based framework for improving and personalising the training of workers who are involved in physical-labour-intensive jobs. DigitalUpSkilling uses wearable IoT sensors to observe how individuals perform work activities. Such sensor observations are continuously processed to synthesise an avatar-like kinematic model for each worker who is being trained, referred to as the worker's digital twins. The framework incorporates novel work activity recognition using generative adversarial network (GAN) and machine learning (ML) models for recognising the types and sequences of work activities by analysing an individual's kinematic model. Finally, the development of skill proficiency ML is proposed to evaluate each trainee's proficiency in work activities and the overall task. To illustrate DigitalUpSkilling from wearable IoT-sensor-driven kinematic models to GAN-ML models for work activity recognition and skill proficiency assessment, the paper presents a comprehensive study on how specific meat processing activities in a real-world work environment can be recognised and assessed. In the study, DigitalUpSkilling achieved 99% accuracy in recognising specific work activities performed by meat workers. The study also presents an evaluation of the proficiency of workers by comparing kinematic data from trainees performing work activities. The proposed DigitalUpSkilling framework lays the foundation for next-generation digital personalised training.

Perceptions of supervision and feedback in PaedCompenda, the competency-based, post-graduate curriculum in pediatrics (www.paedcompenda.de)

Aim

Both teachers and learners had clear reservations in the beginning about the usefulness and benefits of supervision and feedback, which were to be implemented as a teaching method in the competency-based, post-graduate curriculum in general ambulatory pediatrics, known as PaedCompenda (www.paedcompenda.de). This paper investigates the different perceptions of the physicians undergoing specialist training (Ärzte in Weiterbildung) and elucidates these differences.

Method

The following data were collected as part of the research on the three-year-long implementation (2019-2023):1) Four focus group discussions (N=28) with physician trainees who had no experience in primary care pediatrics or with the post-graduate curriculum;2) Problem-oriented interviews, one at the beginning and again at the end, with physician trainees (N=28) undergoing specialist training at 19 participating medical practices belonging to two post-graduate education networks;3) Videos of patient consultations with the physician trainees (N=23);4) Videos of feedback conferences regarding the videotaped patient consultations (N=7).This data was evaluated using reconstructive grounded theory.

Results

A distinctly more positive perception of the benefits of supervision and feedback as a teaching and learning method was seen in the physicians who received specialist training at the practices following the PaedCompenda curriculum. In regard to method, it is crucial that the educational setting can be experienced as a learning opportunity. Playing a central role in this is constructive and conducive feedback (a. dysfunctional routines, b. underlying lack of confidence, and c. overlooked problems).

Conclusions

This paper shows the opportunities of an institutionalized form of supervision and feedback as part of a competency-based, post-graduate curriculum while also making it clear that implementation is challenging. Furthermore, the medical specialists who serve as trainers need to be specifically trained to know which approaches promote learning effectively.

Nurses' models of spiritual care: Predictors of spiritual care competence

OBJECTIVES

Previous studies have shown that nurses' spiritual care competence is related to characteristics of personal spirituality, training adequacy, and comfort, confidence, and frequency of provision of spiritual care. However, these studies assumed that all participants understood spiritual care in the same way, and used self-ratings of spiritual care competence, which are problematic. Our previous study found that spiritual care was understood in 4 qualitatively different ways that can be arranged in order of competence. This study aimed to re-examine the relationships between nurse characteristics and spiritual care competence, using spiritual care understanding as a proxy for competence.

METHODS

Data was collected from a convenience sample of nurses who completed an anonymous, online survey. The survey provided qualitative data about what spiritual care means for them. The survey also provided quantitative data regarding nurse characteristics. This study created sub-groups of nurses based on their understanding of spiritual care, and used the quantitative data to construct a profile of nurse characteristics for each sub-group. Kruskal-Wallis statistical tests determined whether nurse characteristics differed across the 4 sub-groups.

RESULTS

Spiritual care competence was not related to confidence or comfort in providing spiritual care. Relationships with spirituality, training adequacy, and frequency of provision of spiritual care were not linear; i.e., higher competence did not always correspond with higher scores of these characteristics.

SIGNIFICANCE OF RESULTS

The results raise concerns about the construct validity of using comfort and confidence as estimates of spiritual care competence. That the relationships between competence and spirituality, training adequacy, and frequency of spiritual care provision was not as linear as portrayed in extant literature, suggests that outcomes of training may depend on the type of spiritual care understanding subscribed to by training participants. The findings offer insights about how nurses could achieve high levels of spiritual care performance.

Manual Uterine Aspiration Simulation for Emergency Medicine Learners

Introduction

Manual uterine aspiration is a potentially lifesaving procedure for treating patients with hemorrhagic complications of early pregnancy loss. While early pregnancy loss is a common diagnosis seen in the emergency department, manual uterine aspiration education is lacking for emergency medicine physicians.

Methods

We designed a 90-minute procedural skills training session for 30 emergency medicine learners. The session included a brief lecture and video demonstration, followed by two micro-skills stations before finally completing the simulated procedure in its entirety. At each station, learners were asked to verbalize the steps and landmarks for the procedure before performing them on models. Participants completed a combined pre-post survey evaluating their perceived knowledge of the procedure and self-efficacy in performing the procedure.

Results

Thirty learners who participated in the workshop were surveyed, with a 100% response rate. All participants reported increased comfort with the procedure and knowledge about the procedure. All participants completed a successful simulated procedure. Participants also indicated increased interest in learning more about manual uterine aspiration and its potential application within the emergency medicine physician's scope of practice.

Discussion

We developed a workshop to train emergency medicine learners in manual uterine aspiration to stop life-threatening hemorrhage in the setting of early pregnancy loss. The workshop was well received by learners and increased their self-efficacy and desire for additional training with this procedure. Similar curricula should be tried at other institutions.

Integrating Intra- and Interindividual Phenomena in Psychological Theories

Psychological science is divided into two distinct methodological traditions. One tradition seeks to understand how people function at the individual level, while the other seeks to understand how people differ from each other. Methodologies that have grown out of these traditions typically rely on different sources of data. While both use statistical models to understand the structure of the data, and these models are often similar, Molenaar (2004) showed that results from one type of analysis rarely transfer to the other, unless unrealistic assumptions hold. This raises the question how we may integrate these approaches. In this paper, we argue that formalized theories can be used to connect intra- and interindividual levels of analysis. This connection is indirect, in the sense that the relationship between theory and data is best understood through the intermediate level of phenomena: robust statistical patterns in empirical data. To illustrate this, we introduce a distinction between intra- and interindividual phenomena, and argue that many psychological theories will have implications for both types of phenomena. Formalization provides us with a methodological tool for investigating what kinds of intra- and interindividual phenomena we should expect to find if the theory under consideration were true.

From Two Dimensions to Multidimensions: A Mechanistic Model to Support Deliberate CPD Development, Coordination, and Evaluation

INTRODUCTION

The effectiveness of continuing professional development as an intervention to improve health professional behavior and patient health is variable and contentious. To clarify the causal relationships underlying program outcomes and facilitate a necessary shift from outcomes-only-based approaches to outcome-based and theory-based approaches in program development and evaluation, we developed a model of mechanisms mapped to relevant outcomes.

METHODS

Mechanisms identified in a prior realist synthesis of opioid agonist therapy continuing professional development programs were iteratively tested and refined using purposive and opportunistic sampling and realist approaches against two systematic reviews of programs in analgesic prescribing and palliative care. Further testing involved practical application within programs in sustainable health care and pain management.

RESULTS

Ninety reports on 75 programs and practical application to multiple additional programs informed the final model consisting of five distinct mechanisms: motivation transformation, expert influence, confidence development, self-efficacy facilitation, and community of practice expansion. The mechanisms and related analysis emphasize that continuing professional development is heterogeneous, complex, and context dependent.

DISCUSSION

Shifting toward outcome-based and theory-based approaches facilitates further conceptual shifts at intraprogram and interprogram and interintervention levels toward more deliberate program development and evaluation, increased program complementarity and subsequent collaboration. It clarifies opportunities for intercalation of continuing professional development with other intervention sciences. The model presents a resource for practitioners, researchers, and policymakers to advance continuing professional development planning, coordination, and evaluation.

Theoretical, Conceptual, and Operational Aspects in Simulation Training With Rapid Cycle Deliberate Practice: An Integrative Review

SUMMARY STATEMENT

An integrative review following Whittemore and Knafl's 5-stage approach (problem identification, literature search, data evaluation, data analysis, and presentation) was conducted to synthesize the evidence on the theoretical, conceptual, and operational aspects of simulation training with rapid cycle deliberate practice (RCDP). After the literature search, 2 reviewers independently read and critically evaluated primary studies using the eligibility criteria. A third more experienced reviewer solved disagreements between the reviewers.This review included 31 articles. Eight themes were identified and grouped into 2 pre-established categories: theoretical/conceptual and operational aspects. The first category had the following 3 themes: definition of RCDP, concepts related to the principles of RCDP, and theories underpinning RCDP. The second category had the following 5 themes: total training time, number of participants in the training, training system, first scenario without intervention, and progressive difficulty. This review showed that knowledge about RCDP is still under construction. As a new simulation strategy, there are some theoretical, conceptual, and operational differences in the studies applying RCDP interventions as simulation training.

Comparative analysis of motor skill acquisition in a novel bimanual task: the role of mental representation and sensorimotor feedback

Introduction

This study investigates the multifaceted nature of motor learning in a complex bimanual task by examining the interplay between mental representation structures, biomechanics, tactile pressure, and performance. We developed a novel maze game requiring participants to maneuver a rolling sphere through a maze, exemplifying complex sequential coordination of vision and haptic control using both hands. A key component of this study is the introduction of cognitive primitives, fundamental units of cognitive and motor actions that represent specific movement patterns and strategies.

Methods

Participants were divided into two groups based on initial performance: poor performers (PPG) and good performers (GPG). The experimental setup employed motion capture and innovative tactile sensors to capture a detailed multimodal picture of the interaction process. Our primary aims were to (1) assess the effects of daily practice on task performance, biomechanics, and tactile pressure, (2) examine the relationship between changes in mental representation structures and skill performance, and (3) explore the interplay between biomechanics, tactile pressure, and cognitive representation in motor learning.

Results

Performance analysis showed that motor skills improved with practice, with the GPG outperforming the PPG in maze navigation efficiency. Biomechanical analysis revealed that the GPG demonstrated superior movement strategies, as indicated by higher peak velocities and fewer velocity peaks during task execution. Tactile feedback analysis showed that GPG participants applied more precise and focused pressure with their right-hand thumb, suggesting enhanced motor control. Cognitively, both groups refined their mental representation structures over time, but the GPG exhibited a more structured and sophisticated cognitive mapping of the task post-practice.

Discussion

The findings highlight the intertwined nature of biomechanical control, tactile feedback, and cognitive processing in motor skill acquisition. The results support established theories, such as the cognitive action architecture approach, emphasizing the role of mental representation in planning and executing motor actions. The integration of cognitive primitives in our analysis provides a theoretical framework that connects observable behaviors to underlying cognitive strategies, enhancing the understanding of motor learning across various contexts. Our study underscores the necessity of a holistic approach to motor learning research, recognizing the complex interaction between cognitive and motor processes in skill acquisition.

The International Performance, Resilience and Efficiency Program Protocol for the Application of HRV Biofeedback in Applied Law Enforcement Settings

Law enforcement officers are routinely exposed to high-threat encounters that elicit physiological stress responses that impact health, performance, and safety. Therefore, self-regulation using evidence-based approaches is a priority in police research and practice. This paper describes a five-module heart rate variability biofeedback (HRVB) protocol that is part of a larger resilience program (the International Performance Resilience and Efficiency Program - iPREP) established in 2014. Supported by 10 years of user-informed research and development, our methods are tailored to address occupational stressors and the practical realities of training and resource availability in operational settings. Building on existing clinical methods that comprise five to six weekly sessions and up to 40-min of daily practice, our iPREP HRVB protocol is typically delivered in a condensed format across 2-3 days and is seamlessly integrated with reality-based training scenarios commonly employed in policing. By combining best practices in clinical HRVB with police-specific pedagogical frameworks, officers receive accelerated and job-relevant training to adaptively modulate autonomic responses to acute and chronic stress. Efficacy of the iPREP HRVB protocol is supported by several research studies of various methodological designs (i.e., randomized control trial, longitudinal cohort) that demonstrate immediate and sustained improvements in police performance and physiological health outcomes. We conclude with a critical appraisal of the available empirical evidence contrasting common and emerging breathing techniques proposed for use in operational policing contexts. The critical appraisal guide is intended to serve as a resource for law enforcement agencies, governing bodies, and operators when choosing appropriate and effective self-regulation training approaches.

Internal and external factors affecting the performance score of surgical trainees doing laparoscopic appendectomy: a prospective, observational cohort study in a structured training programme

BACKGROUND

Laparoscopic appendectomy is a common procedure and introduced early in general surgical training. How internal (i.e. surgeon's experience) or external (i.e. disease severity) may affect procedure performance is not well-studied. The aim of this study was to evaluate factors that may have an influence on the performance scores for surgical trainees.

METHODS

A prospective, observational cohort study of laparoscopic appendectomies performed by surgical trainees (experience < 4 years) operating under supervision. Trainers evaluated trainees' overall performance on a 6-point scale for proficiency. Perioperative data were recorded, including appendicitis severity, operating time and the overall difficulty of the procedure as assessed by the trainer. A "Challenging" procedure was defined as a combination of either/or "perforation" and "difficult". Trainees who had performed > 30 appendectomies were defined as "experienced". The trainees were asked if they had used simulation or web-based tools the week prior to surgery.

RESULTS

142 procedure evaluation forms were included of which 19 (13%) were "perforated", 14 (10%) "difficult" and 24 (17%) "Challenging". Perforated appendicitis was strongly associated with procedure difficulty (OR 21.2, 95% CI 6.0-75.6). Experienced trainees performed "proficient" more often than non-experienced (OR 34.5, 95% CI 6.8-176.5). "Difficult" procedures were inversely associated with proficiency (OR 0.1, 95% CI 0.0-0.9). In "Challenging" procedures, identifying the appendix had lowest proficiency (OR 0.4, 95% CI 0.1-0.9). The procedures assessed as "difficult" had significantly longer operating time with a median (IQR) of 90 (75-100) min compared to 59 (25-120) min for the non-difficult (p < 0.001).

CONCLUSION

Both internal and external factors contribute to the performance score. Perforated appendicitis, technical difficult procedures and trainee experience all play a role, but a "difficult" procedure had most overall impact on proficiency evaluation.

LapBot-Safe Chole: validation of an artificial intelligence-powered mobile game app to teach safe cholecystectomy

BACKGROUND

Gaming can serve as an educational tool to allow trainees to practice surgical decision-making in a low-stakes environment. LapBot is a novel free interactive mobile game application that uses artificial intelligence (AI) to provide players with feedback on safe dissection during laparoscopic cholecystectomy (LC). This study aims to provide validity evidence for this mobile game.

METHODS

Trainees and surgeons participated by downloading and playing LapBot on their smartphone. Players were presented with intraoperative LC scenes and required to locate their preferred location of dissection of the hepatocystic triangle. They received immediate accuracy scores and personalized feedback using an AI algorithm ("GoNoGoNet") that identifies safe/dangerous zones of dissection. Player scores were assessed globally and across training experience using non-parametric ANOVA. Three-month questionnaires were administered to assess the educational value of LapBot.

RESULTS

A total of 903 participants from 64 countries played LapBot. As game difficulty increased, average scores (p < 0.0001) and confidence levels (p < 0.0001) decreased significantly. Scores were significantly positively correlated with players' case volume (p = 0.0002) and training level (p = 0.0003). Most agreed that LapBot should be incorporated as an adjunct into training programs (64.1%), as it improved their ability to reflect critically on feedback they receive during LC (47.5%) or while watching others perform LC (57.5%).

CONCLUSIONS

Serious games, such as LapBot, can be effective educational tools for deliberate practice and surgical coaching by promoting learner engagement and experiential learning. Our study demonstrates that players' scores were correlated to their level of expertise, and that after playing the game, most players perceived a significant educational value.

Improving pediatric procedural skills and EPA assessments through an acute care procedural skills curriculum

INTRODUCTION

Acute procedural skill competence is expected by the end of pediatric residency training; however, the extent to which residents are actually competent is not clear. Therefore, a cross-sectional observational study was performed to examine the competency of pediatric residents in acute care procedures in emergency medicine.

MATERIALS AND METHODS

Pediatric residents underwent didactic/hands-on "Acute Procedure Day" where they performed procedures with direct supervision and received entrustable professional activity (EPA) assessments (scores from 1-5) for each attempt. Procedures included: bag-valve mask (BVM) ventilation, intubation, intraosseous (IO) line insertion, chest tube insertion, and cardiopulmonary resuscitation (CPR) with defibrillation. Demographic information, perceived comfort level, and EPA data were collected. Descriptive statistics and Pearson correlation for postgraduate year (PGY) versus EPA scores were performed.

RESULTS

Thirty-six residents participated (24 PGY 1-2, and 12 PGY 3-4). Self-reported prior clinical exposure was lowest for chest tube placement (n = 3, 8.3%), followed by IOs (n = 19, 52.8%). During the sessions, residents showed the highest levels of first attempt proficiency with IO placement (EPA 4-5 in 28 residents/33 who participated) and BVM (EPA 4-5 in 27/33), and the lowest for chest tube placement (EPA 4-5 in 0/35), defibrillation (EPA 4-5 in 5/31 residents) and intubation (EPA 4-5 in 17/31). There was a strong correlation between PGY level and EPA score for intubation, but not for other skills.

DISCUSSION

Entrustability in acute care skills is not achieved with current pediatrics training. Research is needed to explore learning curves for skill acquisition and their relative importance.

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.

Point-of-Care Ultrasound Psychomotor Learning Curves: A Systematic Review of the Literature

OBJECTIVES

Use of point-of-care ultrasound (POCUS) in clinical medicine and inclusion in medical training is increasing. Some professional societies recommend that 25-50 POCUS examinations be completed for each application learned; however, the amount of practice required is not well studied. As such, a better understanding of the learning curves of POCUS psychomotor skills is needed. This systematic review characterizes the learning curves for POCUS psychomotor skill acquisition.

METHODS

With the assistance of a research librarian, the available literature through August 28, 2023, was identified. The titles and abstracts, and then the full text were reviewed by two reviewers to screen for inclusion. All studies included after full-text review then underwent data extraction and analysis.

RESULTS

The search identified 893 unique studies. Forty-five studies underwent full-text review, with 17 meeting full inclusion criteria. Substantial heterogeneity was noted in study design, duration of education, number and type of learners, and methods for statistical analysis. Clear and validated definitions for learning endpoints, such as plateau points or competency, are lacking. Learning curves and endpoints differ for different applications of POCUS.

CONCLUSION

The results are overall supportive of the recommendations to complete 25-50 examinations per application of POCUS learned. However, specific applications require more practice than others. Certain applications, such as cardiac and the Focused Assessment with Sonography in Trauma (FAST) exams, are closer to 50; while others, such as soft tissue, airway, and eye require no more than 25.

Comparing Peer and Faculty Feedback for Asynchronous Laparoscopic Skill Acquisition

OBJECTIVE

Traditionally, expert surgeons have provided surgical trainees with feedback about their simulation performance, including for asynchronous practice. Unfortunately, innumerable time demands may limit experts' ability to provide feedback. It is unknown whether and how peer feedback is an effective mechanism to help residents acquire laparoscopic skill in an asynchronous setting. As such, we aimed to assess the effect of peer feedback on laparoscopic performance and determine how residents perceive giving and receiving peer feedback.

DESIGN

We conducted a convergent mixed methods study. In the quantitative component, we randomized residents to receive feedback on home laparoscopic tasks from peers or faculty. We then held an end-of-curriculum, in-person laparoscopic assessment with members from both groups and compared performance on the in-person assessment between the groups. In the qualitative component, we conducted interviews with resident participants to explore experiences with feedback and performance. Three authors coded and rigorously reviewed interview data using a directed content analysis.

SETTING

We performed this study at a single tertiary academic institution: the University of California, San Francisco.

PARTICIPANTS

We invited 47 junior residents in general surgery, obstetrics-gynecology, and urology to participate, of whom 37 (79%) participated in the home curriculum and 25 (53%) participated in the end-of-curriculum assessment.

RESULTS

Residents in the peer feedback group scored similarly on the final assessment (mean 70.7%; SD 16.1%) as residents in the faculty feedback group (mean 71.8%; SD 11.9%) (p = 0.86). Through qualitative analysis of interviews with 13 residents, we identified key reasons for peer feedback's efficacy: shared mental models, the ability to brainstorm and appreciate new approaches, and a low-stakes learning environment.

CONCLUSIONS

We found that peer and faculty feedback led to similar performance in basic laparoscopy and that residents engaged positively with peer feedback, suggesting that peer feedback can be used when residents learn basic laparoscopy.

Assessing between-officer variability in responses to a live-acted deadly force encounter as a window to the effectiveness of training and experience

We aimed to infer the effectiveness of officers' training and experience by assessing consistency of behavioural responses between them. If officers facing the same scenario respond in similar ways, this implies their use of shared cognition, through acquired in-common tactical knowledge. Officers (n = 42) responded to a live-acted scenario in which an assailant ultimately discharged his weapon. Triangulated camera positions assessed their movement patterns, final positions, and weapon responses relative to when the assailant fired his weapon. We also assessed the officers' visual search and gathered information regarding their experience and rest. Our second aim was to examine sources of variability in the officers' responses. We found extensive variability in all aspects of the response. Experience did not impact spatial or temporal behavioural responses. However, longer hours awake and lower reported rest negatively impacted officers' responses. We conclude that officers had insufficient training and experience to demonstrate in-common knowledge.Practitioner summary: Police officers showed high spatial and temporal variability in response to the same scenario. This implies inadequate tactical training, and is supported by our finding that training and experience did not impact performance. Instead, the officers' variability was constrained by their visual search, and the hours awake before being tested.

What can be done about workplace wellbeing in emergency departments? 'There's no petrol for this Ferrari'

Workplace wellbeing encompasses all aspects of working life. Peak health organisations recognise that poor workplace wellbeing is costly, both to individuals and to the organisation, and the value in promoting healthy workplaces. Workplace wellbeing improves when its barriers are acknowledged and addressed, and protective factors are promoted. The Emergency Department (ED) is a place of intense and challenging activity, exacerbated by high workloads and overcrowding. This impacts negatively on patient care, staff safety and wellbeing. We held focus groups across four EDs to discuss barriers and enablers to wellbeing and found four core themes: Workplace Satisfaction; Barriers to Wellbeing; Organisational Culture that Prioritises Staff Wellbeing; Self-care and Self Compassion. From this, and existing literature, we collaboratively developed a contextualised staff wellbeing framework titled: 'Staff Wellbeing Good Practice Framework: From Surviving to Thriving, How to Protect your Wellbeing in the Emergency Department' that emphasises their values of Competence, Connection and Control.

Fun with electricity: A novel ballistics gelatin model with LED tracking for ultrasound needle guidance

Background

Use of ultrasound (US) for procedural needle guidance can improve success rates, safety, and accuracy. Often, training is performed on task trainers, which can be prohibitively expensive. Determining undesired needle placement is difficult when the needle is poorly visualized with US. Currently available simulation phantoms cannot provide real-time feedback on the location of needle placement.

Objectives

The primary objective was to develop and determine feasibility of a low-cost simulation phantom with an internal circuit and LED light system to determine when a needle contacts internal structures. We also aimed to determine whether its use was associated with increased comfort level.

Methods

Emergency medicine (EM) residents (PGY-1 to PGY-3) performed in-plane and out-of-plane US needle guidance using homemade phantoms. Comfort levels were assessed by pre- and post intervention survey. Outcomes were measured on Likert scale (minimum = 1, maximum = 5). The primary outcome was change in confidence markers before and after the simulation task. Secondary outcomes were survey results of comparisons of these models to prior training experiences on simulators and humans.

Results

All EM residents (30) in our program were invited to participate. Twenty participants enrolled and completed the study. In the primary outcome, median comfort with out-of-plane and in-plane guidance increased after using the model but was more pronounced for out-of-plane guidance. On a posttest survey, residents rated the models overall very similar to prior experience on simulators (median 5/5 [IQR 4.0-5.0]) and moderately similar to humans (median 3/5 [IQR 3.0-4.0]).

Conclusions

We created a low-cost ballistic gelatin phantom with an internal electric needle guidance system. Use of the phantom for training was associated with increased learner comfort with the procedure. Learners rated the characteristics of the phantom as similar to higher-cost commercial equipment and humans.

Impact of the quality and diversity of reference products on creative activities in online communities

In creativity research, an important unresolved issue relates to identifying the kind of information an individual should be exposed to in order to be highly creative. We aimed to gain insights into this issue; we collected and statistically analyzed three datasets related to three large online communities (namely Cities: Skylines, SCP-wiki, and Archive of Our Own) engaged in mod development and novel writing to examine whether the quality and diversity of other people's products referred to have a positive effect on product generation. Our analysis revealed the following three findings: (1) the quality diversity of reference products generated by others has the most positive impact on the quality of generated products when it is neither high nor low, (2) the content diversity of reference products generated by others has a negative impact on the quality of generated products, and (3) the quality of reference products generated by others has a negative impact on the quality of generated products when it is extremely high. We conclude by discussing the implications of the findings for creativity research.

Can Music Enhance Working Memory and Speech in Noise Perception in Cochlear Implant Users? Design Protocol for a Randomized Controlled Behavioral and Electrophysiological Study

BACKGROUND

A cochlear implant (CI) enables deaf people to understand speech but due to technical restrictions, users face great limitations in noisy conditions. Music training has been shown to augment shared auditory and cognitive neural networks for processing speech and music and to improve auditory-motor coupling, which benefits speech perception in noisy listening conditions. These are promising prerequisites for studying multi-modal neurologic music training (NMT) for speech-in-noise (SIN) perception in adult cochlear implant (CI) users. Furthermore, a better understanding of the neurophysiological correlates when performing working memory (WM) and SIN tasks after multi-modal music training with CI users may provide clinicians with a better understanding of optimal rehabilitation.

METHODS

Within 3 months, 81 post-lingual deafened adult CI recipients will undergo electrophysiological recordings and a four-week neurologic music therapy multi-modal training randomly assigned to one of three training focusses (pitch, rhythm, and timbre). Pre- and post-tests will analyze behavioral outcomes and apply a novel electrophysiological measurement approach that includes neural tracking to speech and alpha oscillation modulations to the sentence-final-word-identification-and-recall test (SWIR-EEG). Expected outcome: Short-term multi-modal music training will enhance WM and SIN performance in post-lingual deafened adult CI recipients and will be reflected in greater neural tracking and alpha oscillation modulations in prefrontal areas. Prospectively, outcomes could contribute to understanding the relationship between cognitive functioning and SIN besides the technical deficits of the CI. Targeted clinical application of music training for post-lingual deafened adult CI carriers to significantly improve SIN and positively impact the quality of life can be realized.

Visual inspection problem-solving strategies at different experience levels

Airport security screening is a visual inspection task comprising search and decision. Problem solving is used to support decision making. However, it is not well understood. This study investigated how airport security screeners employ problem solving during x-ray screening, and how strategies change with experience. Thirty-nine professional security screeners were observed performing x-ray screening in the field at an Australian International Airport. Video and eye-tracking data were collected and analysed to explore activity phases and problem-solving strategies. Less-experienced screeners performed more problem solving and preferred problem-solving strategies that rely on visual examination without decision support or that defer decision making, compared to more-experienced screeners, who performed efficient and independent strategies. Findings also show that screeners need more time to develop problem-solving skills than visual scanning skills. Screeners would benefit from problem-solving support tools and intensified training and mentorship within the first six months of experience to advance problem-solving competencies.