Keeping it real! Enhancing realism in standardised patient OSCE stations

Background: Objective structured clinical examinations (OSCEs) are a
commonly used method of assessing clinical competency in healthcare education. They can providean opportunity to observe candidates interacting with patients.
There are many challenges in using real patients in OSCEs, and increasingly standardised patients are being used as a preference. However, by using standardised patients there is a risk of making the encounter arti?cial and removed from actual clinical practice.
Context: Efforts made in terms of cognitive, auditory, visual, tactile, psychological and emotional cues can minimise the differences between a simulated
and real clinical scenario. However, a number of factors, including feasibility, cost and usability, need to be considered if such techniques are to be practicable
within an OSCE framework.
Innovation: This article describes a series of techniques that have been used in our institution to enhance the realism of a standardised patient encounter in an
OSCE. Efforts in preparing standardised patient roles, and how they portray these roles, will be considered. A wide variety of equipment can also be used in
combination with a patient and the surrounding environment, which can further enhance the authenticity of the simulated scenario.
Implications: By enhancing the realism in simulated patient OSCE encounters, there is potential to trigger more authentic conscious responses from candidates and implicit reactions that the candidates themselves may be less
aware of. Furthermore, using such techniques may allow faculty members to select scenarios that were previously not thought possible in an OSCE

Handwritten undergraduate case reports

Background: This article describes a 'back to the future' approach to case 'write-ups', with medical students producing handwritten instead of word-processed case reports during their clinical placements. Word-processed reports had been found to have a number of drawbacks, including the inappropriate use of 'cutting and pasting', undue length and lack of focus. Method: We developed a template to be completed by hand, based on the hospital 'clerking-in process', and matched this to a new assessment proforma. An electronic survey was conducted of both students and assessors after the first year of operation to evaluate impact and utility. Results: The new template was well received by both students and assessors. Most students said they preferred handwriting the case reports (55.6%), although a significant proportion (44.4%) preferred the word processor. Many commented that the template enabled them to effectively learn the structure of a case history and to improve their history-taking skills. Most assessors who had previously marked case reports felt the new system represented an improvement. The average time spent marking each report fell from 23.56 to 16.38minutes using the new proforma. Discussion: Free text comments from the survey have led to the development of a more flexible case report template better suited to certain specialties (e.g. dermatology). This is an evolving process and there will be opportunities for further adaptation as electronic medical records become more common in hospital. © Blackwell Publishing Ltd 2012.

Temporary tattoos:a novel OSCE assessment tool

Background: There are many issues regarding the use of real patients in objective structured clinical examinations (OSCEs). In dermatology OSCE stations, standardised patients (SPs) with clinical photographs are often used. Temporary transfer tattoos can potentially simulate skin lesions when applied to an SP. This study aims to appraise the use of temporary malignant melanoma tattoos within an OSCE framework. Method: Within an 11-station OSCE, a temporary malignant melanoma tattoo was developed and applied to SPs in a 'skin lesion' OSCE station. A questionnaire captured the opinions of the candidate, SP and examiners, and the degree of perceived realism of each station was determined. Standard post hoc OSCE analysis determined the psychometric reliability of the stations. Results: The response rates were 95.9 per cent of candidates and 100 per cent of the examiners and SPs. The 'skin lesion' station achieved the highest realism score compared with other stations: 89.0 per cent of candidates felt that the skin lesion appeared realistic; only 28 per cent of candidates had ever seen a melanoma before in training. The psychometric performance of the melanoma station was comparable with, and in many instances better than, other OSCE stations. Discussion: Transfer tattoo technology facilitates a realistic dermatology OSCE station encounter. Temporary tattoos, alongside trained SPs, provide an authentic, standardised and reliable experience, allowing the assessment of integrated dermatology clinical skills.

Learning fluid prescription skills: why is it so challenging?

IIt is well recognised that medical students and junior doctors find fluid prescription a challenging topic. This study was designed to gain a greater understanding of the experiences that medical students face related to learning about fluid prescribing. Methods: A qualitative approach, using focus groups, was employed in this research. Final-year medical students in academic year 2011-12 at Queen's University Belfast were invited to participate during their 'Assistantship' placement in March 2012. Discussions in focus groups, consisting of between six and eight students, were recorded and transcribed verbatim. The research team, consisting of three separate investigators, conducted thematic analysis independently. A final consensus regarding emerging themes was reached by discussion within the whole research team. Medical students and junior doctors find fluid prescription a challenging topic Results: Five prominent themes emerged: 'Teaching experience: a disruptive variation'; 'Curricular disconnections'; 'The driving test: Theory-practice transformation'; 'Role modelling: which standard to aspire to?'; and finally 'Reconciling the perceived risk'. Discussion: This re search provided insights into medical students' opinions of the teaching practices and learning experiences related to fluid prescribing. The learning of prescribing skills is complex andcontextual. In the development of such skills, medical students are often exposed to conflicting educational experiences that challenge the novicelearner in making judgements on best prescribing practice. This study adds to the body of evidence that fluid prescription is a difficult topic, and has generated a number of multifaceted and strategic recommendations to potentially improve fluid prescription teaching.

Integrating elements of undergraduate curriculum learning

Integrating elements of undergraduate curriculum learning Rapidly advancing practice and recognition of nursing, midwifery and medicine as a vital interrelated workforce, implies a need for a variety of curricula opportunities. This project addresses the challenge for healthcare educators to widen student engagement and participation through inter-professional education by creating learning environments whereby student interactions foster the desire to develop situational awareness, independent learning and contribution to patient advocacy. Overall aim of this ‘Feeding and Nutrition in Infants and Children’ project is to provide opportunities for integrated learning to enable students to advance their knowledge and understanding of current best practice. This Inter-professional (IPE) student-lead workshop was initially implemented in 2006-07 in collaboration with the Centre for Excellence in IPE, within the curricula of medical and nursing programmes¹. Supported by the development of a student resource pack, this project is now being offered to Learning Disability nursing and Midwifery students since September 2014. Methods: Fourth year medical students, undertaking a ‘Child Healthcare module’, alongside nursing and /or midwifery students are divided into groups with three or four students from each profession. Each group focuses on a specific feeding problem that is scenario-based on a common real-life issue prior to the workshop and then present their findings / possible solutions to feeding problem. They are observed by both facilitators and peers, who provide constructive feedback on aspects of performance including patient safety, cultural awareness, communication, decision making skills, teamwork and an appreciation of the role of various professionals in managing feeding problems in infants and children. Results: Participants complete a Likert-scale questionnaire to ascertain their reactions to this integrated learning experience. Ongoing findings suggest that students evaluate this learning activity very positively and have stated that they value the opportunity to exercise their clinical judgement and decision making skills. Most recent comments: ‘appreciate working alongside other student’s / multidisciplinary team approach’ As a group students engage in this team problem-solving exercise, drawing upon their strengths and abilities to learn from each other. This project provides a crucial opportunity for learning and knowledge exchange for all those medical, midwifery and nursing students involved. Reference: 1. Purdy, J. & Stewart, M (2009) ‘Feeding and Nutrition in Infants and Children: An Interprofessional Approach’. The Clinical Teacher, vol 6, no.3. Authors: Dr. Angela Bell, Centre for Medical Education, Queen’s University Belfast. Doris Corkin, Senior Lecturer (education), Children’s Nursing, School of Nursing & Midwifery, Queen’s University Belfast. Carolyn Moorhead, Midwifery Lecturer, School of Nursing & Midwifery, Queen’s University Belfast. Ann Devlin, Lecturer (education), Learning Disability Nursing, School of Nursing & Midwifery, Queen’s University Belfast.

Reaching out: medical students leading in local communities

Background: Queen's University Red Cross is a medical student-led volunteer group with a key aim of promoting social change within local communities and empowering young people to aspire to higher education. We describe ‘The Personal Development Certificate’, a 12–week community development programme devised by third-year medical students at Queen's University Belfast to target young people who are lacking educational motivation, are disengaged at home or are marginalised through social circumstances.

Context: Community-based education is of increasing importance within undergraduate and postgraduate medical education in the UK, and further afield. We evaluated the perceived improvements in key skills such as teamwork, leadership, communication, and problem solving in students following participation in this programme, and the extent to which their attitude and appreciation of community-based medicine changed.

Innovation: Following facilitation of this community-based initiative, all students reported a perceived improvement in the acquired skill sets. Students made strong links from this programme to previous clinical experiences and appreciated the opportunity to translate a series of classroom-learned skills to real-life environments and interactions. The students’ appreciation and understanding of community-based medicine was the single most improved area of our evaluation.

Implications: We have demonstrated that medical students possess the skills to develop and facilitate their own educational projects. Non-clinical, student-led community projects have the potential to be reproduced using recognised frameworks and guidelines to complement the current undergraduate medical curriculum

Neurology assessment by objective structured video examination (OSVE)

Summary
Background
The ability to carry out a neurological examination and make an appropriate differential diagnosis is one of the mainstays of our final Bachelor of Medicine (MB) exam; however, with the introduction of objective structured clinical examinations (OSCEs) it has become impossible to arrange for adequate numbers of suitable real patients to participate in the exam.

Context
It is vital that newly qualified doctors can perform a basic neurological examination, interpret the physical signs and formulate a differential diagnosis.

It is vital that newly qualified doctors can perform a basic neurological examination

Innovation
Since 2010 we have introduced an objective structured video examination (OSVE) of a neurological examination of a real patient as part of our final MB OSCE exam. The students view clips of parts of the examination process. They answer questions on the signs that are demonstrated and formulate a differential diagnosis.

Implications
This type of station is logistically a lot easier to organise than a large number of real patients at different examination sites. The featured patients have clearly demonstrated signs and, as every student sees the same patient, are perfectly standardised. It is highly acceptable to examiners and performed well as an assessment tool. There are, however, certain drawbacks in that we are not examining the student's examination technique or their interaction with the patient. Also, certain signs, in particular the assessment of muscle tone and power, are more difficult for a student to estimate in this situation

Undergraduate interprofessional education using high-fidelity paediatric simulation

BACKGROUND: High-fidelity simulation is becoming increasingly important in the delivery of teaching and learning to health care professionals within a safe environment. Its use in an interprofessional context and at undergraduate level has the potential to facilitate the learning of good communication and teamworking, in addition to clinical knowledge and skills.

METHODS: Interprofessional teaching and learning workshops using high-fidelity paediatric simulation were developed and delivered to undergraduate medical and nursing students at Queen's University Belfast. Learning outcomes common to both professions, and essential in the clinical management of sick children, included basic competencies, communication and teamworking skills. Quantitative and qualitative evaluation was undertaken using published questionnaires.

RESULTS: Quantitative results - the 32-item questionnaire was analysed for reliability using spss. Responses were positive for both groups of students across four domains - acquisition of knowledge and skills, communication and teamworking, professional identity and role awareness, and attitudes to shared learning. Qualitative results - thematic content analysis was used to analyse open-ended responses. Students from both groups commented that an interprofessional education (IPE) approach to paediatric simulation improved clinical and practice-based skills, and provided a safe learning environment. Students commented that there should be more interprofessional and simulation learning opportunities.

DISCUSSION: High-fidelity paediatric simulation, used in an interprofessional context, has the potential to meet the requirements of undergraduate medical and nursing curricula. Further research is needed into the long-term benefits for patient care, and its generalisability to other areas within health care teaching and learning.

L’identification et la remédiation des difficultés de raisonnement clinique en médecine (État des pratiques, recherche d’outils et processus pour soutenir les cliniciens enseignants)

INTRODUCTION : Le raisonnement clinique est au coeur de l’exercice professionnel. Cependant, nous manquons d'instruments pour identifier et objectiver les difficultés de raisonnement clinique, et il existe relativement peu de descriptions de méthodes de remédiation définies. Un important travail reste donc à faire, pour mieux comprendre comment les difficultés se manifestent dans le raisonnement clinique des étudiants en formation, mais également pour rendre ces concepts plus accessibles aux enseignants; ceci permettra alors d’améliorer la qualité de la démarche d’identification des difficultés, et d’envisager des remédiations ciblées et efficaces. OBJECTIFS : Cette recherche s’articule d’une part, autour de l’objectivation et la compréhension des pratiques actuelles des cliniciens enseignants en médecine, d’autre part, autour de la construction et l’implantation d’outils et de processus susceptibles de faciliter la démarche de diagnostic et de remédiation des difficultés de raisonnement clinique. MÉTHODOLOGIE : Une recherche de type qualitative, utilisant les méthodes de la recherche action participative s’est révélée pertinente pour atteindre nos objectifs. La recherche est composée de quatre étapes : 1. Une étude exploratoire. 2. La construction et de l’implantation d’un premier outil dans trois milieux cliniques en médecine familiale. 3. L’élaboration d’une taxonomie des difficultés de raisonnement clinique ainsi que la construction d’un nouvel outil. 4. Le développement d’une approche globale pour soutenir et former les cliniciens enseignants. RÉSULTATS : Les enseignants ont une perception rapide, mais qui demeure globale et intuitive, des potentielles difficultés de raisonnement clinique des résidents. Cette perception ne se traduit pas forcément en termes pédagogiques. Nous avons pu observer l’absence de processus pédagogiques organisés et structurés pour la gestion de ces difficultés. Ceci semble projeter les cliniciens enseignants dans une zone d’inconfort, en les confrontant à un manque de maîtrise et à l’incertitude au sujet de leurs actions pédagogiques. La catégorisation des difficultés de raisonnement clinique que nous avons construite permet d’identifier les difficultés telles qu’elles se manifestent dans le quotidien des supervisions cliniques. Cet outil a cependant besoin d’être intégré dans un processus plus global. CONCLUSION : Une approche globale qui comprenne le développement de processus implantés par le Département, l’implantation d’outils, la vulgarisation de la théorie, et la formation des enseignants est déterminante.

Percepción de residentes de medicina de urgencias en Colombia del ambiente educativo en los servicios de urgencias

Introducción: La atención de calidad en urgencias sólo es posible si los médicos han recibido una enseñanza de alta calidad. La escala PHEEM (Postgraduate Hospital Educational Environment Measure) es un instrumento válido y fiable, utilizado internacionalmente para medir el entorno educativo, en la formación médica de posgrado. Materiales y métodos: Estudio de corte trasversal que utilizó la escala PHEEM versión en español para conocer el entorno educativo de los programas de urgencias. El coeficiente alfa de Cronbach se calculó para determinar la consistencia interna. Se aplicó estadística descriptiva a nivel global, por categorías e ítems de la escala PHEEM y se compararon resultados por sexo, año de residencia y programa. Resultados: 94 (94%) residentes llenaron el cuestionario. La puntuación media de la escala PHEEM fue 93,91 ± 23,71 (58,1% de la puntuación máxima) que se considera un ambiente educativo más positivo que negativo, pero con margen de mejora. Hubo una diferencia estadísticamente significativa en la percepción del ambiente educativo entre los programas de residencia (p =0,01). El instrumento es altamente confiable (alfa de Cronbach = 0,952). La barrera más frecuente en la enseñanza fue el hacinamiento y la evaluación fue percibida con el propósito de cumplir normas. Discusión: Los resultados de este estudio aportaron evidencia sobre la validez interna de la escala PHEEM en el contexto colombiano. Este estudio demostró cómo la medición del ambiente educativo en una especialidad médico-quirúrgica, con el uso de una herramienta cuantitativa, puede proporcionar información en relación a las fortalezas y debilidades de los programas.

Sjuksköterskestudenters skattade upplevelser av lärandemiljön före och efter inrättandet av Kompetenscentrum

Bakgrund: Under senare år har allt fler kliniska träningscentra för färdighetsträning etablerats för att möjliggöra en trygg och säker lärandemiljö med simuleringsmöjligheter för studerande och personal. Klinisk färdighetsträning är en viktig del i sjuksköterskeutbildningen vid Högskolan Dalarna (HDa) där lärandemiljön på Kompetenscentrum (KC) kan bidra till en förbättring av lärandemiljön i den kliniska färdighetsutbildningen. Syfte: Syftet med denna studie var att undersöka sjuksköterskestudenters upplevelser via skattning av lärandemiljön för klinisk färdighetsutbildning före och efter inrättandet av Kompetenscentrum. Metod: Studien genomfördes som en enkätundersökning med kvasiexperimentell design. Enkätens baserades på Saarikoski och Leino-Kilpis mätinstrument CLES där frågeställningar om lärandemiljön modifierades med hjälp av Delphimetoden utifrån de tre olika dimensionerna: utbildningsmiljö, relation och lärarens roll. Mätningen före inrättandet genomfördes under hösten 2010 och mätningen efter inrättandet genomfördes hösten 2011. Totalt ingick 266 sjuksköterskestudenter i studien varav 198 (74 %) besvarade enkäten. Resultat: Sjuksköterskestudenter skattade upplevelsen av lärandemiljön mer positiv efter inrättandet av Kompetenscentrum där resultatet visar en signifikant högre skattning i 8 de av de 16 frågorna. Sjuksköterskestudenterna skattade att de upplever att utbildningsmiljön är mer verklighetstrogen, de är mer nöjda med färdighetsträningen samt att den inspirerar dem till att arbeta som sjuksköterska. Att relationen mellan dem och läraren bygger på respekt och att det är en mer positiv atmosfären under färdighetsträningen. Däremot påvisades ingen signifikant skillnad i studenternas upplevelse av den kliniska lärarens roll. Slutsats: Det är uppenbart att lärandemiljö har betydelse för sjuksköterskestudentens integration av såväl teoretiska som praktiska kunskaper vilket medför att färdigheterna förbättras och ger en bra grund för arbetet som sjuksköterska. Strategier bör vidtas för att vidmakthålla och utveckla lärandemiljön på KC samt fokusera ytterligare på integrering av teori och praktik.

Spirituality: Do teachers and students hold the same opinion?

Background:  Few studies have investigated potential differences between the opinions of educators and undergraduates regarding spirituality in patient care. Understanding these differences, could lead to better strategies for educational proposes. Purpose:  To compare the opinions of medical teachers (MTs) and medical students (MSs) regarding spirituality training in a Brazilian medical school. Methods:  A cross-sectional study was conducted. MTs and MSs filled out a questionnaire containing the Duke Religion Index, and questions regarding spirituality in clinical practice and at medical school. A comparison between early-curriculum MSs, late curriculum MSs and MTs was carried out. Chi-square (categorical) and Mann-Whitney (continuous/ordinal) tests were used. Results:  A total of 475 MSs and 44 MTs were evaluated. Results showed that MSs did not address spirituality as frequently as MTs (p<0.001), and that most participants did not feel prepared to address this issue, and believe that Brazilian medical schools are not giving all the required information in this field. Nevertheless, they believe MSs should be prepared to discuss these issues. Late-curriculum MSs believed that spirituality plays a more positive role in patient health (p=0.027), and were more prone to address this issue than early-curriculum MSs (p=0.023). Conclusion:  These findings revealed some of the challenges faced by spirituality medical training in Brazil, and differences between MTs and MSs regarding this issue. Further studies are needed to replicate these findings in other countries. © Blackwell Publishing Ltd 2013.

Benefits of communication skills training after real patient exposure

The established communication skills training (CST) curriculum consists of continuous education, frequent practice with real patients, supervision and feedback from medical teachers. The limitation of this curriculum is that students have to directly apply the theoretical basis they are provided with to real patients. To improve the existing CST curriculum a CST module involving simulated patients was introduced in order to develop more complex communication skills.