Simulation-based education : Understanding the sociocultural complexity of a surgical training “Boot Camp”

Acknowledgements We acknowledge, with thanks the contributions, of the following people who co-designed Boot Camp: Angus JM Watson (Highland Surgical Research Unit, NHSH & UoS), Morag E Hogg (NHSH Raigmore Hospital) and Ailsa Armstrong (NHSH). We also thank Angus JM Watson and Morag E Hogg for helping with the preparation of the funding application which supported this work. Funding Our thanks to the Clinical Skills Managed Educational Network (CSMEN) of Scotland for funding this research.

The use of trauma interprofessional simulated education (TIPSE) to enhance role awareness in the emergency department setting

Peer reviewed

Convergence and translation: attitudes to inter-professional learning and teaching of creative problem-solving among medical and engineering students and staff

Background: Healthcare worldwide needs translation of basic ideas from engineering into the clinic. Consequently, there is increasing demand for graduates equipped with the knowledge and skills to apply interdisciplinary medicine/engineering approaches to the development of novel solutions for healthcare. The literature provides little guidance regarding barriers to, and facilitators of, effective interdisciplinary learning for engineering and medical students in a team-based project context. Methods: A quantitative survey was distributed to engineering and medical students and staff in two universities, one in Ireland and one in Belgium, to chart knowledge and practice in interdisciplinary learning and teaching, and of the teaching of innovation. Results: We report important differences for staff and students between the disciplines regarding attitudes towards, and perceptions of, the relevance of interdisciplinary learning opportunities, and the role of creativity and innovation. There was agreement across groups concerning preferred learning, instructional styles, and module content. Medical students showed greater resistance to the use of structured creativity tools and interdisciplinary teams. Conclusions: The results of this international survey will help to define the optimal learning conditions under which undergraduate engineering and medicine students can learn to consider the diverse factors which determine the success or failure of a healthcare engineering solution.

Content and discontent: a qualitative exploration of obstacles to elearning engagement in medical students

BACKGROUND: Elearning is ubiquitous in healthcare professions education. Its equivalence to 'traditional' educational delivery methods is well established. There is a research imperative to clarify when and how to use elearning most effectively to mitigate the potential of it becoming merely a 'disruptive technology.' Research has begun to broadly identify challenges encountered by elearning users. In this study, we explore in depth the perceived obstacles to elearning engagement amongst medical students. Sensitising concepts of achievement emotions and the cognitive demands of multi-tasking highlight why students' deeply emotional responses to elearning may be so important in their learning.

METHODS: This study used focus groups as a data collection tool. A purposeful sample of 31 participated. Iterative data gathering and analysis phases employed a constant comparative approach to generate themes firmly grounded in participant experience.

RESULTS: Key themes that emerged from the data included a sense of injustice, passivity and a feeling of being 'lost at sea'. The actual content of the elearning resource provided important context.

CONCLUSIONS: The identified themes have strong emotional foundations. These responses, interpreted through the lens of achievement emotions, have not previously been described. Appreciation of their importance is of benefit to educators involved in curriculum development or delivery.

Evaluating the objective structured long examination record for nurse education

An objective structured long examination record (OSLER) is a modification of the long-case clinical examination and is mainly used in medical education. This study aims to obtain nursing students' views of the OSLER compared with the objective structured clinical examination (OSCE), which is used to assess discrete clinical skills. A sample of third-year undergraduate nursing students (n=21) volunteered to participate from a cohort of 230 students. Participants undertook the OSLER under examination conditions. Pre-and post-test questionnaires gathered the students' views on the assessments and these were analysed from a mainly qualitative perspective. Teachers' and simulated patient views were also used for data triangulation. The findings indicate that the OSLER ensures more holistic assessment of a student's clinical skills and particularly essential skills such as communication, and that the OSLER, together with the OSCE, should be used to supplement the assessment of clinical competence in nursing education.

Does video feedback analysis improve CPR performance in phase 5 medical students?

Background The use of simulation in medical education is increasing, with students taught and assessed using simulated patients and manikins. Medical students at Queen’s University of Belfast are taught advanced life support cardiopulmonary resuscitation as part of the undergraduate curriculum. Teaching and feedback in these skills have been developed in Queen’s University with high-fidelity manikins. This study aimed to evaluate the effectiveness of video compared to verbal feedback in assessment of student cardiopulmonary resuscitation performance Methods Final year students participated in this study using a high-fidelity manikin, in the Clinical Skills Centre, Queen’s University Belfast. Cohort A received verbal feedback only on their performance and cohort B received video feedback only. Video analysis using ‘StudioCode’ software was distributed to students. Each group returned for a second scenario and evaluation 4 weeks later. An assessment tool was created for performance assessment, which included individual skill and global score evaluation. Results One hundred thirty eight final year medical students completed the study. 62 % were female and the mean age was 23.9 years. Students having video feedback had significantly greater improvement in overall scores compared to those receiving verbal feedback (p = 0.006, 95 % CI: 2.8–15.8). Individual skills, including ventilation quality and global score were significantly better with video feedback (p = 0.002 and p < 0.001, respectively) when compared with cohort A. There was a positive change in overall score for cohort B from session one to session two (p < 0.001, 95 % CI: 6.3–15.8) indicating video feedback significantly benefited skill retention. In addition, using video feedback showed a significant improvement in the global score (p < 0.001, 95 % CI: 3.3–7.2) and drug administration timing (p = 0.004, 95 % CI: 0.7–3.8) of cohort B participants, from session one to session two. Conclusions There is increased use of simulation in medicine but a paucity of published data comparing feedback methods in cardiopulmonary resuscitation training. Our study shows the use of video feedback when teaching cardiopulmonary resuscitation is more effective than verbal feedback, and enhances skill retention. This is one of the first studies to demonstrate the benefit of video feedback in cardiopulmonary resuscitation teaching.

Setting the agenda for dental education in Scotland: a priority setting exercise including multiple stakehiolders

Introduction The Scottish Oral Health Research Collaboration identified dental education research (DER) as a key strand of their strategy,(1) leading to the formation of the Dental Education Research Group. The starting point for this group was to understand various stakeholders’ perceptions of research priorities, yet no existing studies were found. The aim of the current study was to identify DER priorities for Scotland in the next 3-5 years. Methods The study utilised a similar methodology to that of Dennis et al,(2) in medical education. Data were collected sequentially using two online questionnaires with multiple dental stakeholders represented at undergraduate and postgraduate levels across urban and rural Scotland. 85 participants completed questionnaire 1 (qualitative) and 649 participants completed questionnaire 2 (quantitative). Qualitative and quantitative data analysis approaches were used. Results Of the 24 priorities identified, the top priorities were: role of assessments in identifying competence; undergraduate curriculum prepares for practice; and promoting teamwork within the dental team. Following factor analysis, the priorities loaded on four factors: teamwork and professionalism, measuring and enhancing performance, personal and professional development challenges, and curriculum integration and innovation. The top barriers were lack of time, funding, staff motivation, valuing of DER, and resources/ infrastructure. Discussion There were many similarities between the identified priorities for dental and medical education research2, but also some notable differences, which will be discussed. Overwhelmingly, the identified priorities in dentistry related to fitness for practice and robust assessment practices. Take home message Priority setting exercises with multiple stakeholders are an important first step in developing a national research strategy. References 1. Bagg J, Macpherson L, Mossey P, Rennie J, Saunders B, Taylor M (2010) Strategy for Oral Health Research in Scotland. Edinburgh: The Scottish Government. 2. Dennis A A, Cleland J A, Johnston P, Ker JS, Lough, M Rees CE (2014) Exploring stakeholders’ views of medical education research priorities: a national study. Medical Education, 48(11): 1078-1091.

Access, attitudes and training in information technologies and evidence-based medicine among medical students at University of Zimbabwe College of Health Sciences.

Background: The Medical Education Partnership Initiative, has helped to mitigate the digital divide in Africa. The aim of the study was to assess the level of access, attitude, and training concerning meaningful use of electronic resources and EBM among medical students at an African medical school. Methods: The study involved medical students at the University of Zimbabwe College of Health Sciences, Harare. The needs assessment tool consisted of a 21-question, paper-based, voluntary and anonymous survey. Results: A total of 61/67 (91%), responded to the survey. 60% of the medical students were ‘third-year medical students’. Among medical students, 85% of responders had access to digital medical resources, but 54% still preferred printed medical textbooks. Although 25% of responders had received training in EBM, but only 7% found it adequate. 98% of the participants did not receive formal training in journal club presentation or analytical reading of medical literature, but 77 % of them showed interest in learning these skills. Conclusion: Lack of training in EBM, journal club presentation and analytical reading skills have limited the impact of upgraded technology in enhancing the level of knowledge. This impact can be boosted by developing a curriculum with skills necessary in using EBM.

Systems 1 and 2 thinking processes and cognitive reflection testing in medical students

Background: Diagnostic decision-making is made through a combination of Systems 1 (intuition or pattern-recognition) and Systems 2 (analytic) thinking. The purpose of this study was to use the Cognitive Reflection Test (CRT) to evaluate and compare the level of Systems 1 and 2 thinking among medical students in pre-clinical and clinical programs. Methods: The CRT is a three-question test designed to measure the ability of respondents to activate metacognitive processes and switch to System 2 (analytic) thinking where System 1 (intuitive) thinking would lead them astray. Each CRT question has a correct analytical (System 2) answer and an incorrect intuitive (System 1) answer. A group of medical students in Years 2 & 3 (pre-clinical) and Years 4 (in clinical practice) of a 5-year medical degree were studied. Results: Ten percent (13/128) of students had the intuitive answers to the three questions (suggesting they generally relied on System 1 thinking) while almost half (44%) answered all three correctly (indicating full analytical, System 2 thinking). Only 3-13% had incorrect answers (i.e. that were neither the analytical nor the intuitive responses). Non-native English speaking students (n = 11) had a lower mean number of correct answers compared to native English speakers (n = 117: 1.0 s 2.12 respectfully: p < 0.01). As students progressed through questions 1 to 3, the percentage of correct System 2 answers increased and the percentage of intuitive answers decreased in both the pre-clinical and clinical students. Conclusions: Up to half of the medical students demonstrated full or partial reliance on System 1 (intuitive) thinking in response to these analytical questions. While their CRT performance has no claims to make as to their future expertise as clinicians, the test may be used in helping students to understand the importance of awareness and regulation of their thinking processes in clinical practice.

The S.T.A.B. Trial - Standardised Testing of Artificial Blood. A comparative study of various products that may be used as artificial blood for high fidelity simulation training in the critical care setting

Aim: In the current climate of medical education, there is an ever-increasing demand for and emphasis on simulation as both a teaching and training tool. The objective of our study was to compare the realism and practicality of a number of artificial blood products that could be used for high-fidelity simulation. Method: A literature and internet search was performed and 15 artificial blood products were identified from a variety of sources. One product was excluded due to its potential toxicity risks. Five observers, blinded to the products, performed two assessments on each product using an evaluation tool with 14 predefined criteria including color, consistency, clotting, and staining potential to manikin skin and clothing. Each criterion was rated using a five-point Likert scale. The products were left for 24 hours, both refrigerated and at room temperature, and then reassessed. Statistical analysis was performed to identify the most suitable products, and both inter- and intra-rater variability were examined. Results: Three products scored consistently well with all five assessors, with one product in particular scoring well in almost every criterion. This highest-rated product had a mean rating of 3.6 of 5.0 (95% posterior Interval 3.4-3.7). Inter-rater variability was minor with average ratings varying from 3.0 to 3.4 between the highest and lowest scorer. Intrarater variability was negligible with good agreement between first and second rating as per weighted kappa scores (K = 0.67). Conclusion: The most realistic and practical form of artificial blood identified was a commercial product called KD151 Flowing Blood Syrup. It was found to be not only realistic in appearance but practical in terms of storage and stain removal.

Palliative care in undergraduate curricula : Results of a national scoping study

Background: We wished to explore the ways in which palliative care is included in undergraduate health services curricula in Australia and the barriers to, and opportunities for, such inclusion. Methods: A scoping study of current Australian undergraduate health care curricula, using an email survey of deans (or equivalent) of health faculties was designed utilising all Australian undergraduate courses that prepare medicine, nursing and allied health professionals for entry to practice. Participants were deans or faculty heads from health and related faculties which offered courses relevant to the project, identified from the Australian Government Department of Education, Science and Training website. Sixty-two deans (or equivalent) from 41 Australian universities were surveyed. A total of 42 completed surveys were returned (68% of deans). Main outcome measures were total hours, content, teaching and learning strategies and resources for palliative care education in undergraduate curricula; perceived gaps, barriers, and opportunities to support the inclusion of palliative care education in undergraduate curricula. Results: Forty-five percent of respondents reported the content of current curricula reflected the palliative approach to a large degree. More than half of the respondents reported that their course had palliative care components integrated to a minor degree and a further third to a moderate degree. The number of hours dedicated to palliative care and teaching and learning strategies varied across all respondents, although there was a high degree of commonality in content areas taught. Conclusion: Current Australian undergraduate courses vary widely in the nature and extent to which they provide education in palliative care.

An Assessment of Undergraduate Paramedic Students’ Empathy Levels

Abstract: Objectives Evidence suggests that improved empathy behaviours among healthcare professionals directly impacts on healthcare outcomes. However, the ‘nebulous’ properties of empathic behaviour often means that healthcare profession educators fail to incorporate the explicit teaching and assessment of empathy within the curriculum. The objective of this study was to assess the extent of empathy in paramedic students across seven Australian universities. Methods A cross-sectional study using a paper-based questionnaire employing a convenience sample of first, second, and third year undergraduate paramedic students. Student empathy levels were measured using the Medical Condition Regard Scale (MCRS). Results A total of 783 students participated in the study of which 57% were females. The medical conditions: intellectual disability, attempted suicide, and acute mental illness all produced mean scores above 50 suggesting good empathetic regard, while patients presenting with substance abuse produced the lowest mean score M= 41.57 (SD=12.29). There was a statistically significant difference between males (M= 49.79) and females (M=51.61) p=0.006, for patients with intellectual disability. Conclusions The findings from this study found that student reported poor empathetic regard for patients with substance abuse, while female students report higher levels of empathy than their male colleagues across each medical condition. The overall findings provide a framework for educators to begin constructing guidelines focusing on the need to incorporate, promote and instil empathy into paramedic students in order to better prepare them for future out-of-hospital healthcare practice.

Intern underperformance is detected more frequently in emergency medicine rotations

Objective: To determine the frequency and nature of intern underperformance as documented on in-training assessment forms. Methods: A retrospective review of intern assessment forms from a 2 year period (2009–2010) was conducted at a tertiary referral hospital in Brisbane, Queensland. The frequency of interns assessed as ‘requiring substantial assistance’ and/or ‘requires further development’ on mid- or end-of-term assessment forms was determined. Forms were analysed by the clinical rotation, time of year and domain(s) of clinical practice in which underperformance was documented. Results: During 2009 and 2010 the overall documented incidence of intern underperformance was 2.4% (95% CI 1.5–3.9%). Clinical rotation in emergency medicine detected significantly more underperformance compared with other rotations (P < 0.01). Interns predominantly had difficulty with ‘clinical judgment and decision-making skills’, ‘time management skills’ and ‘teamwork and colleagues’ (62.5%, 55% and 32.5% of underperforming assessments, respectively). Time of the year did not affect frequency of underperformance. A proportion of 13.4% (95% CI 9.2–19.0%) of interns working at the institution over the study period received at least one assessment in which underperformance was documented. Seventy-six per cent of those interns who had underperformance identified by mid-term assessment successfully completed the term following remediation. Conclusion: The prevalence of underperformance among interns is low, although higher than previously suggested. Emergency medicine detects relatively more interns in difficulty than other rotations.

The confidence of speech-language pathology students regarding communicating with people with aphasia

Background Aphasia is an acquired language disorder that can present a significant barrier to patient involvement in healthcare decisions. Speech-language pathologists (SLPs) are viewed as experts in the field of communication. However, many SLP students do not receive practical training in techniques to communicate with people with aphasia (PWA) until they encounter PWA during clinical education placements. Methods This study investigated the confidence and knowledge of SLP students in communicating with PWA prior to clinical placements using a customised questionnaire. Confidence in communicating with people with aphasia was assessed using a 100-point visual analogue scale. Linear, and logistic, regressions were used to examine the association between confidence and age, as well as confidence and course type (graduate-entry masters or undergraduate), respectively. Knowledge of strategies to assist communication with PWA was examined by asking respondents to list specific strategies that could assist communication with PWA. Results SLP students were not confident with the prospect of communicating with PWA; reporting a median 29-points (inter-quartile range 17–47) on the visual analogue confidence scale. Only, four (8.2%) of respondents rated their confidence greater than 55 (out of 100). Regression analyses indicated no relationship existed between confidence and students‘ age (p = 0.31, r-squared = 0.02), or confidence and course type (p = 0.22, pseudo r-squared = 0.03). Students displayed limited knowledge about communication strategies. Thematic analysis of strategies revealed four overarching themes; Physical, Verbal Communication, Visual Information and Environmental Changes. While most students identified potential use of resources (such as images and written information), fewer students identified strategies to alter their verbal communication (such as reduced speech rate). Conclusions SLP students who had received aphasia related theoretical coursework, but not commenced clinical placements with PWA, were not confident in their ability to communicate with PWA. Students may benefit from an educational intervention or curriculum modification to incorporate practical training in effective strategies to communicate with PWA, before they encounter PWA in clinical settings. Ensuring students have confidence and knowledge of potential communication strategies to assist communication with PWA may allow them to focus their learning experiences in more specific clinical domains, such as clinical reasoning, rather than building foundation interpersonal communication skills.

Enhancing paramedics procedural skills using a cadaveric model

Background Paramedic education has evolved in recent times from vocational post-employment to tertiary pre-employment supplemented by clinical placement. Simulation is advocated as a means of transferring learned skills to clinical practice. Sole reliance of simulation learning using mannequin-based models may not be sufficient to prepare students for variance in human anatomy. In 2012, we trialled the use of fresh frozen human cadavers to supplement undergraduate paramedic procedural skill training. The purpose of this study is to evaluate whether cadaveric training is an effective adjunct to mannequin simulation and clinical placement. Methods A multi-method approach was adopted. The first step involved a Delphi methodology to formulate and validate the evaluation instrument. The instrument comprised of knowledge-based MCQs, Likert for self-evaluation of procedural skills and behaviours, and open answer. The second step involved a pre-post evaluation of the 2013 cadaveric training. Results One hundred and fourteen students attended the workshop and 96 evaluations were included in the analysis, representing a return rate of 84%. There was statistically significant improved anatomical knowledge after the workshop. Students' self-rated confidence in performing procedural skills on real patients improved significantly after the workshop: inserting laryngeal mask (MD 0.667), oropharyngeal (MD 0.198) and nasopharyngeal (MD 0.600) airways, performing Bag-Valve-Mask (MD 0.379), double (MD 0.344) and triple (MD 0.326,) airway manoeuvre, doing 12-lead electrocardiography (MD 0.729), using McGrath(R) laryngoscope (MD 0.726), using McGrath(R) forceps to remove foreign body (MD 0.632), attempting thoracocentesis (MD 1.240), and putting on a traction splint (MD 0.865). The students commented that the workshop provided context to their theoretical knowledge and that they gained an appreciation of the differences in normal tissue variation. Following engagement in/ completion of the workshop, students were more aware of their own clinical and non-clinical competencies. Conclusions The paramedic profession has evolved beyond patient transport with minimal intervention to providing comprehensive both emergency and non-emergency medical care. With limited availability of clinical placements for undergraduate paramedic training, there is an increasing demand on universities to provide suitable alternatives. Our findings suggested that cadaveric training using fresh frozen cadavers provides an effective adjunct to simulated learning and clinical placements.