Advances in simulation (London, England)最新文献

Many clinicians working in healthcare simulation struggle with competing dual identities of clinician and educator, whilst those who harmonise these identities are observed to be highly effective teachers and clinicians. Professional identity formation (PIF) theories offer a conceptual framework for considering this dilemma. However, many clinician simulation educators lack practical guidance for translating these theories and are unable to develop or align their dual identities.An unusual experience involving the first author's suspension of disbelief as a simulation facilitator sparked a novel reflection on his dual identity as a clinician and as a simulation educator. He re-framed his clinician and simulation 'hats' as cooperative and fluid rather than competing and compartmentalised. He recognised that these dual identities could flow between clinical and simulation environments through leaky 'blended boundaries' rather than being restricted by environmental demarcations.This personal story is shared and reflected upon to offer a practical 'hats and boundaries' model. Experimenting with the model in both clinical and simulation workplaces presents opportunities for PIF and alignment of dual identities. The model may help other clinician simulation educators navigate the complexities of merging their dual identities.

Background: Healthcare workers faced unique challenges during the early months of the COVID-19 pandemic which necessitated rapid adaptation. Clinical event debriefings (CEDs) are one tool that teams can use to reflect after events and identify opportunities for improving their performance and their processes. There are few reports of how teams have used CEDs in the COVID-19 pandemic. Our aim is to explore the issues discussed during COVID-19 CEDs and propose a framework model for qualitatively analyzing CEDs.

Methods: This was a descriptive, qualitative study of a hospital-wide CED program at a quaternary children's hospital between March and July 2020. CEDs were in-person, team-led, voluntary, scripted sessions using the Debriefing in Suspected COVID-19 to Encourage Reflection and Team Learning (DISCOVER-TooL). Debriefing content was qualitatively analyzed using constant comparative coding with an integrated deductive and inductive approach. A novel conceptual framework was proposed for understanding how debriefing content can be employed at various levels in a health system for learning and improvement.

Results: Thirty-one debriefings were performed and analyzed. Debriefings had a median of 7 debriefing participants, lasted a median of 10 min, and were associated with multiple systems-based process improvements. Fourteen themes and 25 subthemes were identified and categorized into a novel Input-Mediator-Output-Input Debriefing (IMOID) model. The most common themes included communication, coordination, situational awareness, team member roles, and clinical standards.

Conclusions: Teams identified diverse issues in their debriefing discussions related to areas of high performance and opportunities for improvement in their care of COVID-19 patients. This model may help healthcare systems to understand how CED tools can be used to accelerate organizational learning to promote safety and improve outcomes in changing clinical environments.

Background: Residents in surgical specialties face a steep hierarchy when managing medical crises. Hierarchy can negatively impact patient safety when team members are reluctant to speak up. Yet, simulation has scarcely been previously utilized to qualitatively explore the way residents in surgical specialities navigate this challenge. The study aimed to explore the experiences of residents in one surgical specialty, obstetrics and gynecology (Ob/Gyn), when challenging hierarchy, with the goal of informing future interventions to optimize resident learning and patient safety.

Methods: Eight 3rd- and 4th-year Ob/Gyn residents participated in a simulation scenario in which their supervising physician made an erroneous medical decision that jeopardized the wellbeing of the labouring mother and her foetus. Residents participated in 30-45 min semi-structured interviews that explored their approach to managing this scenario. Transcribed interviews were analysed using qualitative thematic inquiry by three research team members, finalizing the identified themes once consensus was reached.

Results: Study results show that the simulated scenario did create an experience of hierarchy that challenged residents. In response, residents adopted three distinct communication strategies while confronting hierarchy: (1) messaging - a mere reporting of existing clinical information; (2) interpretive - a deliberate construction of clinical facts aimed at swaying supervising physician's clinical decision; and (3) advocative - a readiness to confront the staff physician's clinical decision. Furthermore, residents utilized coping mechanisms to mitigate challenges related to confronting hierarchy, namely deflecting responsibility, diminishing urgency, and drafting allies. Both these communication strategies and coping mechanisms shaped their practice when challenging hierarchy to preserve patient safety.

Conclusions: Understanding the complex processes in which residents engage when confronting hierarchy can serve to inform the development and study of curricular innovations. Informed by these processes, we must move beyond solely teaching residents to speak up and consider a broader curriculum that targets not only residents but also faculty physicians and the learning environment within the organization.

Introduction: Stress can affect the ability to acquire technical skills. Simulation-based training (SBT) courses allow surgical trainees to train their technical skills away from stressful clinical environments. Trainees' subjective experiences of stress during SBT courses on laparoscopic surgery remains understudied. Here, we explored the subjective stress experiences of surgical trainees during mandatory laparoscopic SBT courses. We aimed to obtain a broader understanding of which factors of the simulation training the trainees perceived as eliciting stress.

Methods: A qualitative study with semistructured individual interviews was undertaken to explore trainees' subjective experiences of stress. Twenty surgical trainees participated while attending courses at a national training center for advanced laparoscopic surgery. Questions explored trainees' stress experiences during the SBT courses with a focus on perceived stressors related to laparoscopic simulation training on two box-trainers and one virtual reality simulator. Interview data were analyzed using inductive, qualitative content analysis methods to identify codes, categories, and themes.

Results: Findings indicated that trainees have a variety of stress experiences during laparoscopic SBT. Three main themes were identified to be related to stress experiences: simulation task requirements, psychomotor skill levels and internal pressures, with subcategories such as task difficulty and time requirements, unrealistic haptic feedback and realism of graphics, inconsistent and poor technical performance, and self-imposed pressures and socio-evaluative threats.

Conclusions: Insights into surgical trainees' experience of stress during laparoscopic SBT courses showed that some stress experiences were directly related to simulation training, while others were of psychological nature. The technical and efficiency requirements of simulation tasks elicited stress experiences among trainees with less laparoscopic experience and lower levels of psychomotor skills. Self-imposed pressures played an integral part in how trainees mobilized and performed during the courses, suggesting that levels of stress might enhance laparoscopic simulation performance. For course facilitators aiming at optimizing future laparoscopic SBT courses, attending to the realism, providing clarity about learning objectives, and having awareness of individual differences among trainees' technical level when designing the simulation tasks, would be beneficial. Equally important to the laparoscopic SBT is to create a psychological safe learning space in order to reduce the internal pressures of trainees.

Background: Physicians' communication skills are important for patient-centered care. Although working with simulated patients (SPs) in case simulations is common for training communication skills, studies seldom include a wide range of challenging behaviors or explore students' own experiences of learning communication skills with SPs. Therefore, this study was aimed at investigating how medical students perceive communication training involving challenging consultations with SPs and the impact on their learning experiences.

Methods: Twenty-three medical students from the same class were interviewed in focus groups about their experiences of simulation training with actors as SPs. In the simulation training, the students were instructed to deliver bad news, manage negative patient reactions, and encourage behavioral changes in reluctant patients. This was followed by feedback and a debriefing exercise. The interviews were analyzed with content analysis.

Results: Students reported that actors as SPs made the simulations more realistic and enabled them to practice various communication skills for challenging consultations in a safe way and manage their own feelings, thereby promoting new learning experiences. Elements such as actors' flexibility in changing behaviors during role-play and exposure to different challenging behaviors, like negative emotions, were regarded as valuable. The importance of an accepting and permissive climate for the debriefing exercise was highlighted, though without taking too much time from the simulation training. Feedback directly from the SP was appreciated.

Conclusions: Actors as SPs were perceived as a valuable part of challenging communication training and added elements to the learning process. Future studies should include a wider range of challenging behaviors in training with SPs and evaluate the effects of such training on students' use of communication skills.

Background: Simulation research that seeks to solve the problem of silence among interprofessional teams has focused almost exclusively on training subordinate team members to be more courageous and to speak up to team leaders using direct challenge scripts despite the great interpersonal cost. Consequently, the existing literature overemphasizes the responsibility of subordinate team members for speaking up and fails to consider the role and responsibilities of team leaders in sustaining silence. The purpose of this study is to identify and describe the subtle behaviors and actions of team leaders that both promote and discourage speaking up.

Methods: This study used a simulation-primed qualitative inquiry approach. Obstetricians (OB) at one academic center participated in an interprofessional simulation as an embedded participant. Five challenge moments (CM) were scripted for the OB involving deliberate clinical judgment errors or professionalism infractions. Other participants were unaware of the OB embedded participant role. Thirteen iterations were completed with 39 participants. Twelve faculty members completed a subsequent semi-structured interview. Scenarios were videotaped; debriefs and interviews were audio-recorded and transcribed verbatim. Data were analyzed using an inductive thematic approach.

Results: After participating in an interprofessional simulation, faculty participants reflected that being an approachable team leader requires more than simply avoiding disruptive behaviors. We found that approachability necessitates that team leaders actively create the conditions in which team members perceive that speaking up is welcomed, rather than an act of bravery. In practice, this conceptualization of approachability involves the tangible actions of signaling availability through presence, uncertainty through thinking aloud, and vulnerability through debriefing.

Conclusions: By using faculty as embedded participants with scripted errors, our simulation design provided an ideal learning opportunity to prompt discussion of the subtle behaviors and actions of team leaders that both promote and discourage speaking up. Faculty participants gained a new appreciation that their actions create the conditions for speaking up to occur before critical incidents through their verbal and non-verbal communication.

Background: Systematic reviews on simulation training effectiveness have pointed to the need to adhere to evidence-based instructional design (ID) guidelines. ID guidelines derive from sound cognitive theories and aim to optimize complex learning (integration of knowledge, skills, and attitudes) and learning transfer (application of acquired knowledge and skills in the workplace). The purpose of this study was to explore adherence to ID guidelines in simulation training programs for dealing with postpartum hemorrhage (PPH), a high-risk situation and the leading cause of maternal mortality worldwide.

Methods: A total of 40 raters analyzed simulation training programs as described in 32 articles. The articles were divided into four subsets of seven articles and one subset of four articles. Each subset was judged by seven to ten raters on adherence to ID guidelines. The 5-point Likert score rating scale was based on Merrill's First Principles of Instruction and included items relating to key ID features categorized into five subscales: authenticity, activation of prior knowledge, demonstration, application, and integration/transfer. The authors searched for articles published in English between January 2007 and March 2017 in PubMed, Eric, and Google Scholar and calculated the mean Likert-scale score, per subscale, and interrater reliability (IRR).

Results: The mean Likert-scale scores calculated for all subscales were < 3.00. For the number of raters used to judge the papers in this study (varying between 7 and 10), the IRR was found to be excellent for the authenticity and integration/transfer subscales, good-to-excellent for the activation of prior knowledge and application subscales, and fair-to-good for the demonstration subscale.

Conclusion: The results demonstrate a paucity of the description of adherence to evidence-based ID guidelines in current simulation trainings for a high-risk situation such as PPH.

Background: Early recognition and call for help, fast initiation of chest compressions, and early defibrillation are key elements to improve survival after cardiac arrest but are often not achieved. We aimed to investigate what occurs during the initial treatment of unannounced in situ simulated inhospital cardiac arrests and reasons for successful or inadequate initial resuscitation efforts.

Methods: We conducted unannounced full-scale in situ simulated inhospital cardiac arrest followed by a debriefing. Simulations and debriefings were video recorded for subsequent analysis. We analyzed quantitative data on actions performed and time measurements to key actions from simulations and qualitative data from transcribed debriefings.

Results: We conducted 36 simulations. Time to diagnosis of cardiac arrest was 37 (27; 55) s. Time to first chest compression from diagnosis of cardiac arrest was 37 (18; 74) s, time to calling the cardiac arrest team was 144 (71; 180) s, and time to first shock was 221 (181; 301) s. We observed participants perform several actions after diagnosing the cardiac arrest and before initiating chest compressions. Domains emerging from the debriefings were teaming and resources. Teaming included the themes communication, role allocation, leadership, and shared knowledge, which all included facilitators and barriers. Resources included the themes knowledge, technical issues, and organizational resources, of which all included barriers, and knowledge also included facilitators.

Conclusion: Using unannounced in situ simulated cardiac arrests, we found that key elements such as chest compressions, calling the cardiac arrest team, and defibrillation were delayed. Perceived barriers to resuscitation performance were leadership and teaming, whereas experience, clear leadership, and recent training were perceived as important facilitators for treatment progress.

Background: Debriefing is effective and inexpensive to increase learning benefits of participants in simulation-based medical education. However, suitable communication patterns during debriefings remain to be defined. This study aimed to explore interaction patterns during debriefings and to link these to participants' satisfaction, perceived usefulness, and self-reported learning outcomes.

Methods: We assessed interaction patterns during debriefings of simulation sessions for residents, specialists, and nurses from the local anaesthesia department at the Bern University Hospital, Bern, Switzerland. Network analysis was applied to establish distinctive interaction pattern categories based on recorded interaction links. We used multilevel modelling to assess relationships between interaction patterns and self-reported learning outcomes.

Results: Out of 57 debriefings that involved 111 participants, discriminatory analyses revealed three distinctive interaction patterns: 'fan', 'triangle', and 'net'. Participants reported significantly higher self-reported learning effects in debriefings with a net pattern, compared to debriefings with a fan pattern. No effects were observed for participant satisfaction, learning effects after 1 month, and perceived usefulness of simulation sessions.

Conclusions: A learner-centred interaction pattern (i.e. net) was significantly associated with improved short-term self-reported individual learning and team learning. This supports good-practice debriefing guidelines, which stated that participants should have a high activity in debriefings, guided by debriefers, who facilitate discussions to maximize the development for the learners.

Background: Within the last decades, robotic surgery has gained popularity. Most robotic surgeons have changed their main surgical activity from open or laparoscopic without prior formal robotic training. With the current practice, it is of great interest to know whether there is a transfer of surgical skills. In visualization, motion scaling, and freedom of motion, robotic surgery resembles open surgery far more than laparoscopic surgery. Therefore, our hypothesis is that open-trained surgeons have more transfer of surgical skills to robotic surgery, compared to surgeons trained in laparoscopy.

Methods: Thirty-six surgically inexperienced medical students were randomized into three groups for intensive simulation training in an assigned modality: open surgery, laparoscopy, or robot-assisted laparoscopy. The training period was, for all study subjects, followed by performing a robot-assisted bowel anastomosis in a pig model. As surrogate markers of surgical quality, the anastomoses were tested for resistance to pressure, and video recordings of the procedure were evaluated by two blinded expert robotic surgeons, using a global rating scale of robotic operative performance (Global Evaluative Assessment of Robotic Skills (GEARS)).

Results: The mean leak pressure of bowel anastomosis was 36.25 (7.62-64.89) mmHg in the laparoscopic training group and 69.01 (28.02-109.99) mmHg in the open surgery group, and the mean leak pressure for the robotic training group was 108.45 (74.96-141.94) mmHg. The same pattern was found with GEARS as surrogate markers of surgical quality. GEARS score was 15.71 (12.37-19.04) in the laparoscopic training group, 18.14 (14.70-21.58) in the open surgery group, and 22.04 (19.29-24.79) in the robotic training group. In comparison with the laparoscopic training group, the robotic training group had a statistically higher leak pressure (p = 0.0015) and GEARS score (p = 0.0023). No significant difference, for neither leak pressure nor GEARS, between the open and the robotic training group.

Conclusion: In our study, training in open surgery was superior to training in laparoscopy when transitioning to robotic surgery in a simulation setting performed by surgically naive study subjects.