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.

High fidelity simulation; challenges encountered in developing and implementing student learning experiences, staff education and researching approaches to learning

High fidelity simulation as a teaching and learning approach is being embraced by many schools of nursing. Our school embarked on integrating high fidelity (HF) simulation into the undergraduate clinical education program in 2011. Low and medium fidelity simulation has been used for many years, but this did not simplify the integration of HF simulation. Alongside considerations of how and where HF simulation would be integrated, issues arose with: student consent and participation for observed activities; data management of video files; staff development, and conceptualising how methods for student learning could be researched. Simulation for undergraduate student nurses commenced as a formative learning activity, undertaken in groups of eight, where four students undertake the ‘doing’ role and four are structured observers, who then take a formal role in the simulation debrief. Challenges for integrating simulation into student learning included conceptualising and developing scenarios to trigger students’ decision making and application of skills, knowledge and attitudes explicit to solving clinical ‘problems’. Developing and planning scenarios for students to ‘try out’ skills and make decisions for problem solving lay beyond choosing pre-existing scenarios inbuilt with the software. The supplied scenarios were not concept based but rather knowledge, skills and technology (of the manikin) focussed. Challenges lay in using the technology for the purpose of building conceptual mastery rather than using technology simply because it was available. As we integrated use of HF simulation into the final year of the program, focus was on building skills, knowledge and attitudes that went beyond technical skill, and provided an opportunity to bridge the gap with theory-based knowledge that students often found difficult to link to clinical reality. We wished to provide opportunities to develop experiential knowledge based on application and clinical reasoning processes in team environments where problems are encountered, and to solve them, the nurse must show leadership and direction. Other challenges included students consenting for simulations to be videotaped and ethical considerations of this. For example if one student in a group of eight did not consent, did this mean they missed the opportunity to undertake simulation, or that others in the group may be disadvantaged by being unable to review their performance. This has implications for freely given consent but also for equity of access to learning opportunities for students who wished to be taped and those who did not. Alongside this issue were the details behind data management, storage and access. Developing staff with varying levels of computer skills to use software and undertake a different approach to being the ‘teacher’ required innovation where we took an experiential approach. Considering explicit learning approaches to be trialled for learning was not a difficult proposition, but considering how to enact this as research with issues of blinding, timetabling of blinded groups, and reducing bias for testing results of different learning approaches along with gaining ethical approval was problematic. This presentation presents examples of these challenges and how we overcame them.

Using ‘think aloud’ as a strategy for learning clinical reasoning in high fidelity case-based simulation for undergraduate nursing students

AIMS This paper reports on the implementation of a research project that trials an educational strategy implemented over six months of an undergraduate third year nursing curriculum. This project aims to explore the effectiveness of ‘think aloud’ as a strategy for learning clinical reasoning for students in simulated clinical settings. BACKGROUND Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting [1]. Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. For students learning to manage complex clinical situations, teaching approaches are required that make these instinctive cognitive processes explicit and clear [2-5]. In line with professional expectations, nursing students in third year at Queensland University of Technology (QUT) are expected to display clinical reasoning skills in practice. This can be a complex proposition for students in practice situations, particularly as the degree of uncertainty or decision complexity increases [6-7]. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students [4, 8]. This project aims to use the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students are assisted to uncover cognitive approaches that best assist them to make effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection on their practice. MEHODS In semester 2 2011 at QUT, third year nursing students will undertake high fidelity simulation, some for the first time commencing in September of 2011. There will be two cohorts for strategy implementation (group 1= use think aloud as a strategy within the simulation, group 2= not given a specific strategy outside of nursing assessment frameworks) in relation to problem solving patient needs. Students will be briefed about the scenario, given a nursing handover, placed into a simulation group and an observer group, and the facilitator/teacher will run the simulation from a control room, and not have contact (as a ‘teacher’) with students during the simulation. Then debriefing will occur as a whole group outside of the simulation room where the session can be reviewed on screen. The think aloud strategy will be described to students in their pre-simulation briefing and allow for clarification of this strategy at this time. All other aspects of the simulations remain the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). RESULTS Methodology of the project and the challenges of implementation will be the focus of this presentation. This will include ethical considerations in designing the project, recruitment of students and implementation of a voluntary research project within a busy educational curriculum which in third year targets 669 students over two campuses. CONCLUSIONS In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs. References 1. Lasater, K., High-fidelity simulation and the development of clinical judgement: students' experiences. Journal of Nursing Education, 2007. 46(6): p. 269-276. 2. Lapkin, S., et al., Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: a systematic review. Clinical Simulation in Nursing, 2010. 6(6): p. e207-22. 3. Kaddoura, M.P.C.M.S.N.R.N., New Graduate Nurses' Perceptions of the Effects of Clinical Simulation on Their Critical Thinking, Learning, and Confidence. The Journal of Continuing Education in Nursing, 2010. 41(11): p. 506. 4. Banning, M., The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. Nurse Education Today, 2008. 28: p. 8-14. 5. Porter-O'Grady, T., Profound change:21st century nursing. Nursing Outlook, 2001. 49(4): p. 182-186. 6. Andersson, A.K., M. Omberg, and M. Svedlund, Triage in the emergency department-a qualitative study of the factors which nurses consider when making decisions. Nursing in Critical Care, 2006. 11(3): p. 136-145. 7. O'Neill, E.S., N.M. Dluhy, and C. Chin, Modelling novice clinical reasoning for a computerized decision support system. Journal of Advanced Nursing, 2005. 49(1): p. 68-77. 8. Lee, J.E. and N. Ryan-Wenger, The "Think Aloud" seminar for teaching clinical reasoning: a case study of a child with pharyngitis. J Pediatr Health Care, 1997. 11(3): p. 101-10.

Using ‘think aloud’ as a strategy for improving clinical reasoning in high fidelity case-based simulation for undergraduate nursing students.

Theme Paper for Curriculum innovation and enhancement theme AIM: This paper reports on a research project that trialled an educational strategy implemented in an undergraduate nursing curriculum. The project aimed to explore the effectiveness of ‘think aloud’ as a strategy for improving clinical reasoning for students in simulated clinical settings. BACKGROUND: Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting (Lasater, 2007). Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students (Banning, 2008, Lee and Ryan-Wenger, 1997). This project used the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students were assisted to uncover cognitive approaches to assist in making effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection about their practice. MEHODS: In semester 2 2011 at QUT, third year nursing students undertook high fidelity simulation (some for the first time), commencing in September of 2011. There were two cohorts for strategy implementation (group 1= used think aloud as a strategy within the simulation, group 2= no specific strategy outside of nursing assessment frameworks used by all students) in relation to problem solving patient needs. The think aloud strategy was described to students in their pre-simulation briefing and allowed time for clarification of this strategy. All other aspects of the simulations remained the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). Ethics approval has been obtained for this project. RESULTS: Results of a qualitative analysis (in progress- will be completed by March 2012) of student and facilitator reports on students’ ability to meet the learning objectives of solving patient problems using clinical reasoning and experience with the ‘think aloud’ method will be presented. A comparison of clinical reasoning learning outcomes between the two groups will determine the effect on clinical reasoning for students responding to patient problems. CONCLUSIONS: In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs.

Development of a switch mode assisted linear amplifier for use as a high fidelity voltage source

Frequency Domain Spectroscopy (FDS) is one of the major techniques used for determining the condition of the cellulose based paper and pressboard components in large oil/paper insulated power transformers. This technique typically makes use of a sinusoidal voltage source swept from 0.1 mHz to 1 kHz. The excitation test voltage source used must meet certain characteristics, such as high output voltage, high fidelity, low noise and low harmonic content. The amplifier used; in the test voltage source; must be able to drive highly capacitive loads. This paper proposes that a switch-mode assisted linear amplifier (SMALA) can be used in the test voltage source to meet these criteria. A three level SMALA prototype amplifier was built to experimentally demonstrate the effectiveness of this proposal. The developed SMALA prototype shows no discernable harmonic distortion in the output voltage waveform, or the need for output filters, and is therefore seen as a preferable option to pulse width modulated digital amplifiers. The lack of harmonic distortion and high frequency switching noise in the output voltage of this SMALA prototype demonstrates its feasibility for applications in FDS, particularly on highly capacitive test objects such as transformer insulation systems.

High fidelity probe and mitigation of mirror thermal fluctuations

Thermal noise arising from mechanical loss in high reflective dielectric coatings is a significant source of noise in precision optical measurements. In particular, Advanced LIGO, a large scale interferometer aiming to observed gravitational wave, is expected to be limited by coating thermal noise in the most sensitive region around 30–300 Hz. Various theoretical calculations for predicting coating Brownian noise have been proposed. However, due to the relatively limited knowledge of the coating material properties, an accurate approximation of the noise cannot be achieved. A testbed that can directly observed coating thermal noise close to Advanced LIGO band will serve as an indispensable tool to verify the calculations, study material properties of the coating, and estimate the detector’s performance.

This dissertation reports a setup that has sensitivity to observe wide band (10Hz to 1kHz) thermal noise from fused silica/tantala coating at room temperature from fixed-spacer Fabry–Perot cavities. Important fundamental noises and technical noises associated with the setup are discussed. The coating loss obtained from the measurement agrees with results reported in the literature. The setup serves as a testbed to study thermal noise in high reflective mirrors from different materials. One example is a heterostructure of Al_xGa_1−xAs (AlGaAs). An optimized design to minimize thermo–optic noise in the coating is proposed and discussed in this work.

High-fidelity replication of Dammann gratings using soft lithography

We report the experimental results of using the soft lithography method for replication of Dammann gratings. By using an elastomeric stamp, uniform grating structures were transferred to the LTV-curable polymer. To evaluate the quality of the replication, diffraction images and light intensity were measured. Compared with the master devices, the replicas of Dammann gratings show a slight deviation in both surface relief profile and optical performance. Experimental results demonstrated that high-fidelity replication of Dammann gratings is realized by using soft lithography with low cost and high throughput. (C) 2008 Optical Society of America.

High-fidelity, broadband stimulated-Brillouin-scattering-based slow light using fast noise modulation.

We demonstrate a 5-GHz-broadband tunable slow-light device based on stimulated Brillouin scattering in a standard highly-nonlinear optical fiber pumped by a noise-current-modulated laser beam. The noisemodulation waveform uses an optimized pseudo-random distribution of the laser drive voltage to obtain an optimal flat-topped gain profile, which minimizes the pulse distortion and maximizes pulse delay for a given pump power. In comparison with a previous slow-modulation method, eye-diagram and signal-to-noise ratio (SNR) analysis show that this broadband slow-light technique significantly increases the fidelity of a delayed data sequence, while maintaining the delay performance. A fractional delay of 0.81 with a SNR of 5.2 is achieved at the pump power of 350 mW using a 2-km-long highly nonlinear fiber with the fast noise-modulation method, demonstrating a 50% increase in eye-opening and a 36% increase in SNR in the comparison.

Simple trapped-ion architecture for high-fidelity Toffoli gates

We discuss a simple architecture for a quantum TOFFOLI gate implemented using three trapped ions. The gate, which, in principle, can be implemented with a single laser-induced operation, is effective under rather general conditions and is strikingly robust (within any experimentally realistic range of values) against dephasing, heating, and random fluctuations of the Hamiltonian parameters. We provide a full characterization of the unitary and noise-affected gate using three-qubit quantum process tomography.

HIGH-FIDELITY MUSIC CODING AT 4 BITS.

A very high-quality sub-band ADPCM music coding scheme which compresses high-fidelity music signals, bandlimited to 15kHz, to an equivalent PCM representation of only 4 bits per sample, is described. By processing music sampled at 32 kHz, this coder exhibits a total bit rate of only 128kbit/s and is consequently applicable to the ISDN. Subjective tests conducted with this coder have shown that music recovered from the compression scheme is essentially indistinguishable from the original material. The results obtained are of major importance, not only for ISDN and broadcasting, but also for other digital audio technology such as compact disc (CD) and digital audio tape.