A Train-the-Trainer Simulation Program Implemented Between Two International Partners

Simulation-based graduate medical education in MR-guided brachytherapy for cervical cancer

Facilitators and Barriers to Implementation of Simulation Based Education in Vascular Surgery in Europe

Recognizing and managing a deteriorating patient, in any setting, can be a challenging and distressing event for health care providers (HCPs). End of life care is a core component of nursing and medical education, yet historically has received minimal focus. Simulation Based Education (SBE) has been shown to be an effective tool for enhancing HCPs competence and confidence when involved with complex clinical scenarios and advocating patient-centred care [1]. The national drive to increase recognition and provision of timely, individualized end of life care is catalysing the need for multidisciplinary team education [2] [3]. To design, deliver and modify SBE programme to enhance quality of patient care as they deteriorate. SBE will be utilized to achieve this by increasing both confidence and competence of a cohesive multidisciplinary team when involved in the care of deteriorating patients. Three SBE study days are held each year which are booked through an online portal. The sessions are facilitated by HCPs from intensive care, palliative medicine, and the practice development team. A handbook outlining SBE scenarios and learning objectives is distributed in advance, this pre-brief allows learners to prepare and understand the format of the day. The teaching day is structured with three clinical scenarios following a patient through different stages of their illness: initially an acute assessment and escalation, leading to consideration of individual treatment escalation plans and ultimately their end-of-life care. Learning through simulation is multifaceted through evidence-based role play, with observers as learners and collective debriefing through facilitated feedback after every scenario. Online feedback provided by all learners has been collated throughout the four-year course development process. Evaluations revealed three main themes; learners valued SBE in terms of replicating practice, de-briefing discussions consolidated learning and enabled learners the opportunity to understand how it will improve their practice and value was placed on multidisciplinary team learning. SBE is an effective method of enhancing the quality of individualized and coordinated care delivered to a deteriorating patient in any setting by HCPs. As an effective tool it also stands aligned with the national drive to improve recognition of patients at the end of their life with proactive advance care planning discussions and holistic care for the dying and their families. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

BackgroundThe use of simulation-based education (SBE) in health professions, such as physical therapy, requires faculty to expand their teaching practice and development. The impact of this teaching on the individual faculty member, and how their teaching process changes or develops, is not fully understood. The purpose of this study was to explore individual physical therapist faculty members’ experience with SBE and how those experiences may have transformed their teaching practice to answer the research questions: How do physical therapist faculty develop through including SBE and are there commonalities among educators?MethodsAn interpretive phenomenological analysis approach was used with a small sample of subjects who participated in three individual semi-structured interviews. Interview questions were created through the lens of transformative learning theory to allow faculty transformations to be uncovered. A two-step thematic coding process was conducted across participants to identify commonalities of faculty experiences with SBE in physical therapist education. Credibility and trustworthiness were achieved through member checking and expert external review. Thematic findings were validated with transcript excerpts and research field notes.ResultsEight physical therapist faculty members (25% male) with a range of 3 to 16 years of incorporating SBE shared their individual experiences. Four common themes related to faculty development were identified across the participants. Themes identified are the following: faculty strengthen their professional identity as physical therapists, faculty are affected by their introduction and training with simulation, faculty develop their interprofessional education through SBE, and faculty experiences with SBE facilitate professional growth.ConclusionPhysical therapist educators had similarities in their experiences with SBE that transformed their teaching practice and professional development. This study provides insight into what physical therapist faculty may experience when adopting SBE.

Effective simulation-based-education (SBE) relies on the use of psychological safety to encourage participants to adopt learning-orientated behaviours [1]. Excessive levels of anxiety or stress can present a challenge for establishing this psychologically safe container [2]. The idea of stress inoculation describes graded exposure to potentially anxiety inducing stimuli with the aim of enhancing performance by encouraging a state of ‘flow’ versus ‘freeze’ [3]. Potentially this could also improve the efficacy of SBE by reducing anxiety and improving psychological safety. We aimed to create a new SBE programme for novice anaesthetists in their first 3 months before starting on-call work. This was designed to create stress inoculation with frequent and regular SBE sessions, and we aimed to assess the impact of this change on pre-session anxiety levels. This new SBE programme was delivered to the 5 novice anaesthetists at our institution over a 12-week period from February to May 2022 and consisted of weekly 30-minute SBE sessions. These were designed to fit with clinical commitments and minimise disruption to training in theatres, whilst following the ASPiH Standards Framework. Alongside weekly post-session evaluation (7-point Likert and free text), learners were asked to retrospectively rate their perceived pre-session anxiety levels from 1–10. Overall feedback from the new programme has been consistently positive, particularly mentioning the benefits of a safe space for discussion, the open and supportive environment, and the benefits of learning from others’ experiences. One learner specifically credited the frequent nature of the sessions with an improvement in their confidence. Self-reported anxiety levels fell across subsequent early sessions (median anxiety score: week 1=4/10, week 3=2/10). Anxiety scores then peaked again at week 8 (median=5/10) before falling again. There was also significant inter-learner variability with one learner recording persistently higher anxiety scores. This new format with regular short sessions appears to be very popular with excellent feedback. There is a reduction in self-reported pre-session anxiety with repeated frequent sessions. However, this is variable between individuals and across the placement, with an increase towards the end potentially reflecting anxiety about starting on the anaesthetic on-call rota. This demonstrates the importance of adapting SBE to both individual learners and the timing of a specific session within a wider SBE programme. Potentially routine evaluation of learner anxiety could allow a more tailored approach and further optimise individual learning. 1. Kolbe M, Eppich W, Rudolph J, Meguerdichian M, Catena H, Cripps A, Grant V, Cheng A. Managing psychological safety in debriefings: a dynamic balancing act. BMJ Simulation & Technology Enhanced Learning. 2020;6(3):164–171 2. Al-Ghareeb A, Cooper S, McKenna L. Anxiety and Clinical Performance in Simulated Setting in Undergraduate Health Professionals Education: An Integrative Review. Clinical Simulation in Nursing. 2017;13(10):478–491 3. LeBlanc, V, Posner, G. Emotions in simulation-based education: friends or foes of learning?. Advances in Simulation. 2022;7(3)

Simulation-based education is a particularly germane strategy for addressing the difficult topic of racism and implicit bias due to its immersive nature and the paradigm of structured debriefing. Researchers have proposed actionable frameworks for implicit bias education, particularly outlining the need to shift from recognition to transformation, with the goal of changing discriminatory behaviors and policies. As simulation educators tasked with training health care professionals, we have an opportunity to meet this need for transformation. Simulation can shift behaviors, but missteps in design and implementation when used to address implicit bias can also lead to negative outcomes. The focus of this article is to provide recommendations to consider when designing simulation-based education to specifically address racism and implicit bias.

To design, implement, and evaluate a simulation-based education (SBE) program for caregivers of children with tracheostomy. Self-reported comfort and confidence in knowledge as well as tracheostomy care skills were assessed before and after a single SBE session for 24 consecutively enrolled caregivers of children with tracheostomies aged <21 years who were hospitalized at an academic medical center from August 2018 to September 2019 by using a survey and checklist, respectively. Mean individual and aggregated scores were compared by using a paired samples t-test, and association between instruments was determined with Spearman correlation. Post-SBE, there was a significant improvement in both self-reported comfort and confidence (P < .001) and checklist assessment of most tracheostomy care skills (P < .001). There were no significant correlations between caregivers' self-reported comfort and confidence and skills pre-SBE (ρ = 0.13) or post-SBE (ρ = 0.14). Cronbach's α coefficients for the survey ranged from 0.93 to 0.95 and for the checklist from 0.58 to 0.67. Seventeen percent of caregivers competently completed the entire checklist post-SBE, with most caregivers missing 1 or 2 critical skills such as obturator removal after tracheostomy insertion. In this pilot study, we demonstrated successful design and implementation of an SBE program for caregivers of children with tracheostomies, revealing improvements in self-reported comfort and confidence as well as in their performance of tracheostomy care skills. Further optimization is needed, and caregivers may benefit from additional SBE sessions to achieve complete skills competency. Future research on the long-term impact of SBE and the peer-to-peer support element of the program is needed.

Endovascular aortic repair (EVAR) is being used increasingly for the treatment of infrarenal abdominal aortic aneurysms. Improvement in educational strategies is required to teach future vascular surgeons EVAR skills, but a comprehensive, pre-defined e-learning and simulation curriculum remains to be developed and tested. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE), an assessment tool for simulation based education (SBE) in EVAR, has previously been designed to assess EVAR skills, and a pass limit defining mastery level has been set. However, EVARATE was developed for anonymous video ratings in a research setting, and its feasibility for real time ratings in a standardised SBE programme in EVAR is unproven. This study aimed to test the effect of a newly developed simulation based modular course in EVAR. In addition, the applicability of EVARATE for real time performance assessments was investigated. The European Society of Vascular Surgery (ESVS) and Copenhagen Certification Programme in EVAR (ENHANCE-EVAR) was tested in a prospective cohort study. ENHANCE-EVAR is a modular SBE programme in EVAR consisting of e-learning and hands-on SBE. Participants were rated with the EVARATE tool by experienced EVAR surgeons. Twenty-four physicians completed the study. The mean improvement in EVARATE score during the course was+11.8 (95% confidence interval 9.8 - 13.7) points (p < .001). Twenty-two participants (92%) passed with a mean number of 2.8 ± 0.7 test attempts to reach the pass limit. Cronbach's alpha coefficient was 0.91, corresponding to excellent reliability of the EVARATE scale. Differences between instructors' EVARATE ratings were insignificant (p= .16), with a maximum variation between instructors of ± 1.3 points. ENHANCE-EVAR, a comprehensive certifying EVAR course, was proven to be effective. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE) is a trustworthy tool for assessing performance within an authentic educational setting, enabling real time feedback.

As Accessible as a Book on a Library Shelf: The Imperative of Routine Simulation in Modern Health Care

The Royal College of Anaesthetists recommends use of simulation-based-education (SBE) during the initial 12-week novice placement for new anaesthetic trainees [1]. For many UK anaesthetic departments, the complexity and cost of patient simulators [2] may reduce opportunities for SBE during novice training. However, avoiding the physical fidelity trap [3] and utilising both conceptual and psychological fidelity to good effect might mitigate this issue. As novice trainees are already familiar with the theatre environment from day-to-day clinical practice, the learning outcomes from SBE generally cover rarer emergencies which can still be covered during SBE outside of the theatre environment. We aimed to assess the feasibility of running weekly low physical fidelity SBE across the entire 12-week novice period instead of the smaller number of ad-hoc sessions delivered previously. Our new SBE programme consisted of 30-minute sessions held in the anaesthetic department conference room to minimise impact on stretched theatre capacity and educator availability. To further maximise efficiency, we created a portable simulation set-up using a basic resuscitation manikin on a patient trolley, a disused anaesthetic machine, and a tablet device with a simulated monitor application. This could all be set-up and stored away in under 5 minutes. Our focus on conceptual and psychological fidelity led to the creation of a new scenario bank which identified common issues encountered by new anaesthetic trainees, rather than emergencies rarely encountered by even an experienced anaesthetist. Scenarios needed to be highly plausible and solvable by the novice trainee. Learners were then asked to complete a feedback survey after each session. Feedback from this new simulation programme was very positive and comparable to previous feedback. Across all sessions (n=12) and trainees (n=5), the median Likert scores for perceived relevance, realism, and appropriate challenge were 6/7, 5/7, and 6/7 respectively. All trainees across all sessions indicated they found it useful, enjoyable, and would attend again. In particular, free text responses praised the ability to focus on a single simulated issue without the cognitive overload of the wider theatre environment experienced by new trainees, and the psychological safety benefits of simulation and debriefing in a more relaxed non-theatre setting. This appears to be a feasible and well accepted alternative to our traditional approach, with additional benefits for trainees and reduced impact on service delivery. We now intend to explore use of this approach to deliver increased SBE to the wider anaesthetic and multidisciplinary team. 1. Royal College of Anaesthetists. Simulation Strategy 2018–2023. London: RCoA 2018 2. Fletcher J, Wind A. Cost Considerations in Using Simulations for Medical Training. Military Medicine. 2013;178(10S):37–46. 3. Helyer R, Dickens P. Progress in the utilization of high-fidelity simulation in basic science education. Advances in Physiology Education. 2016;40(2):143–144.

The study explored factors influencing implementation of simulation-based education (SBE) in nursing and midwifery education in Malawi. This study aimed to identify factors influencing nursing and midwifery educators in selected training institutions and clinical sites. The study covered one district and four central hospitals, five professional training institutions, Ministry of Health and Nurses and Midwives Council of Malawi officials. Using mixed-methods approach, quantitative data were gathered from 293 participants, including 149 final-year nursing and midwifery students, and 144 clinical instructors. Qualitative data were obtained from 24 faculty members, 11 clinical instructors and two key informants. Researchers conducted 37 in-depth interviews, 10 focus group discussions and eight desk reviews. Descriptive statistics were used to analyse the quantitative data, while content analysis was used for qualitative findings. Five themes emerged from qualitative data: absence of simulation in regulatory body syllabi, insufficient formal training, demand for knowledgeable clinical instructors, inadequate human and material resources, and resistance to change. Survey results indicated that 83% of the participants had theoretical SBE knowledge but lacked practical skills, with only 13% considering SBE as a current teaching method. Educators emphasised lack of infrastructure, skills laboratories, teaching hospitals, equipment, and a deficit in formal training as critical barriers to SBE implementation. The study concluded that skilled educators, appropriate infrastructure and resources could facilitate SBE implementation in Malawi. Recommendations included regulatory body support, formal training for educators, utilisation of low-fidelity simulators, and establishment of SBE centres and corners in health facilities.

Evidence supports the substitution of both clinical placement time and traditional educational activities with simulation-based education (SBE). However, lack of resources can be a barrier to SBE implementation. Peer simulation provides an alternative to simulated patient (SP)-based SBE by educating students to portray patient roles. This diversifies learning experiences for students using SBE and may decrease costs. This study aimed to determine the impact of students portraying the roles of patients in a simulation-based learning environment (peer simulation) on learning outcomes in entry-level health care professional students. Seven databases were searched (from inception to 8 May 2019) using terms including 'peer simulation,' 'role-play' and 'simulated/standardised patient.' The studies included described a health care professional student SBE interaction involving peer simulation. Data were extracted by two independent investigators. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI) and Critical Appraisal Skills Programme (CASP). A descriptive analysis was completed and meta-analysis conducted in instances in which outcomes could be pooled. A total of 12 studies met the inclusion criteria. Constructs measured by the studies included communication, empathy, self-efficacy and confidence. Five randomised controlled trials compared peer simulation with the use of SPs and demonstrated greater or equivalent patient empathy gains in peer simulation. Meta-analysis determined no difference in communication capabilities between the two groups. Students perceived peer simulation as comparably valuable and frequently superior to other forms of learning. This review was unable to determine effective design features of peer simulation initiatives. Students were positive about peer simulation, but there has been limited evaluation of learning outcome attainment. Significant heterogeneity was observed; studies were diverse in design, outcome measures and the training provided for peer patients. Peer simulation positively influences student communication and development of patient empathy and offers an alternative to learning with SPs. Further rigorous research is required to understand the impact of peer simulation for a broader range of learning outcomes and to confirm the impact of this developing educational approach.

ObjectiveThis study aimed to explore patients' experiences of their involvement in the design and delivery of interprofessional education interventions focussing on mental ill‐health for students studying in undergraduate healthcare and healthcare‐related programmes.DesignA qualitative methodology using a Grounded Theory approach was used to undertake an iterative series of focus groups with members of a university's Patient, Carer and Public Involvement (PCPI) Group who have a history of mental ill‐health and were involved in the development and delivery of educational interventions for students on undergraduate healthcare and healthcare‐related programmes. Their experiences of being involved in teaching and learning activities, collaboration with academic staff and integration into the academic faculty were explored. Constant comparative analysis facilitated the identification and prioritisation of salient themes.ResultsFive salient inter‐related themes emerged from the data: (1) reduced stigma and normalisation of experience of illness; (2) enhanced self‐worth; (3) improved well‐being; (4) community and connection; and (5) enduring benefits.ConclusionsA supportive university community and a designated academic PCPI co‐ordinator facilitate a supportive environment for patients and carers to develop as educators, contribute to the training of future healthcare professionals and improve their own personal well‐being. Appropriately resourced and well‐supported initiatives to integrate patients, carers and the public into the functions of an academic faculty can result in tangible benefits to individuals and facilitate meaningful and enduring connections between the university and the wider community within which it is situated.Patient and Public InvolvementPatients have been involved in the design of the teaching and learning initiatives that this study was primarily focused on. Patients were given autonomy in determining how their experiences should be incorporated into teaching and learning experiences.

There is a growing trend in medical education toward globalization, and simulation-based education (SBE) is at the forefront of this trend. There are important considerations when establishing simulation programs in limited resource settings (LRS) internationally, including integration of cultural and linguistic factors, scalability, and sustainability and partnership with local in-country stakeholders. This chapter highlights several SBE programs that have been widely disseminated in LRS and which have demonstrated efficacy in those environments. It will only be through continued curriculum development, rigorous program evaluation, and outcomes-based research that SBE has the potential to improve the health of children worldwide and to enhance the feasibility to achieve progress on the healthcare-related United Nations Millennium Development Goals on a global scale.

Continuing Professional Development in Pharmacy