BackgroundBreaking bad news (BBN) is a critically important skill set for residents. Limited formal supervision and unpredictable timing of bad news delivery serve as barriers to the exchange of meaningful feedback.Purpose of studyThe goal of this educational innovation was to improve internal medicine residents’ communication skills during challenging BBN encounters. A formal BBN training programme and innovative on-demand task force were part of this two-phase project.Study designInternal medicine residents at a large academic medical centre participated in an interactive workshop focused on BBN. Workshop survey results served as a needs assessment for the development of a novel resident-led BBN task force. The task force was created to provide observations at the bedside and feedback after BBN encounters. Training of task force members incorporated video triggers and a feedback checklist. Inter-rater reliability was analysed prior to field testing, which provided data on real-world implementation challenges.Results148 residents were trained during the 2-hour communications skills workshop. Based on survey results, 73% (108 of 148) of the residents indicated enhanced confidence in BBN after participation. Field testing of the task force on a hospital ward revealed potential workflow barriers for residents requesting observations and prompted troubleshooting. Solutions were implemented based on field testing results.ConclusionsA trainee-led BBN task force and communication skills workshop is offered as an innovative model for improving residents’ interpersonal and communication skills in BBN. We believe the model is both sustainable and reproducible. Lessons learnt are offered to aid in implementation in other settings.

IntroductionThree-dimensional (3D) printed multimaterial ascending aortic simulators were created to evaluate the ability of polyjet technology to replicate the distensibility of human aortic tissue when perfused at physiological pressures.MethodsSimulators were developed by computer-aided design and 3D printed with a Connex3 Objet500 printer. Two geometries were compared (straight tube and idealised aortic aneurysm) with two different material variants (TangoPlus pure elastic and TangoPlus with VeroWhite embedded fibres). Under physiological pressure, β Stiffness Index was calculated comparing stiffness between our simulators and human ascending aortas. The simulators’ material properties were verified by tensile testing to measure the stiffness and energy loss of the printed geometries and composition.ResultsThe simulators’ geometry had no effect on measured β Stiffness Index (p>0.05); however, β Stiffness Index increased significantly in both geometries with the addition of embedded fibres (p<0.001). The simulators with rigid embedded fibres were significantly stiffer than average patient values (41.8±17.0, p<0.001); however, exhibited values that overlapped with the top quartile range of human tissue data suggesting embedding fibres can help replicate pathological human aortic tissue. Biaxial tensile testing showed that fiber-embedded models had significantly higher stiffness and energy loss as compared with models with only elastic material for both tubular and aneurysmal geometries (stiffness: p<0.001; energy loss: p<0.001). The geometry of the aortic simulator did not statistically affect the tensile tested stiffness or energy loss (stiffness: p=0.221; energy loss: p=0.713).ConclusionWe developed dynamic ultrasound-compatible aortic simulators capable of reproducing distensibility of real aortas under physiological pressures. Using 3D printed composites, we are able to tune the stiffness of our simulators which allows us to better represent the stiffness variation seen in human tissue. These models are a step towards achieving better simulator fidelity and have the potential to be effective tools for surgical training.

IntroductionSelf-efficacy is defined as people’s internal beliefs about their ability to have an impact on events that affect their lives. As part of the COVID-19 pandemic, we carried out in situ simulation for anaesthesiologists and operating room (OR) nurses. Simulation was focused on the recommendations on the use of specific personal protective equipment (PPE) as well as on airway management and intubation. We hypothesised that in situ procedural simulation should increase their perceived self-efficacy.MethodsBetween 16 March and 20 March 2020, 208 healthcare workers took part in in situ procedural simulation. A questionnaire was sent to participants on 21 April 2020. Six self-efficacy items related to PPE and airway manoeuvres were assessed before and after training on a Numeric Rating Scale from 0 to 10.ResultsSixty-seven participants (32%) replied to the questionnaire. The before–after comparison of the six items revealed an increase in perceived self-efficacy for each of them. A before training difference was observed between nurses, board-certified anaesthetists and trainees in anaesthesia in perceived self-efficacy for putting on (6 (3–8) vs 4.5 (2.25–6) vs 2 (0–6), p=0.007) and remove PPE (8 (5–8) vs 4.5 (3.25–6) vs 4 (1–6), p=0.009). No difference in perceived self-efficacy after training was observed between nurses, board-certified anaesthetists and trainees in anaesthesia.ConclusionsIn situ simulation improves the perceived self-efficacy of OR nurses and anaesthesiologists on specific skills related to the care of patients with COVID-19.

IntroductionThe transition from medical student to doctor has long been a source of concern, with widespread reporting of new graduates’ lack of preparedness for medical practice. Simulation has been suggested as a way to improve preparedness, particularly due to the difficulties in allowing full autonomy for patient care for undergraduate medical students. Few studies look at simulation alone for this purpose, and no studies have compared different simulation formats to assess their impact on preparedness.MethodsThis mixed-method study looked at two different simulation courses in two UK universities. Data were collected in two phases: immediately after the simulation and 3–4 months into the same students’ postgraduate training. Questionnaires provided quantitative data measuring preparedness and interviews provided a more in-depth analysis of experiential learning across final year and how this contributed to preparedness.ResultsThere were no significant differences between the two courses for overall preparedness, stress or views on simulation, and no significant differences in opinions longitudinally. Although the study initially set out to look at simulation alone, emergent qualitative findings emphasised experiential learning as key in both clinical and simulated settings. This inter-relationship between simulation and the student assistantship prepared students for practice. Longitudinally, the emphasis on experiential learning in simulation was maintained and participants demonstrated using skills they had practised in simulation in their daily practice as doctors. Nevertheless, there was evidence that although students felt prepared, they were still scared about facing certain scenarios as foundation doctors.DiscussionThe results of this study suggest that simulation may positively affect students’ preparedness for practice as doctors. Simulation will never be a replacement for real clinical experience. However, when used prior to and alongside clinical experience, it may have positive effects on new doctors’ confidence and competence, and, therefore, positively impact patient care.

Simulation in medical education teaches students to recognise patterns that can be life-saving. As an emergency medicine (EM) resident (LSS) and a medical educator (RF), we witness the ways in which patterns in the medical curriculum shape our future medical providers. The recognition of a dangerous pattern has brought us together to call for increased gender diversity in one of the most fundamental skills medical learners must master: cardiac life support training. As an EM resident, I (LSS) am the clay being shaped by the medical system. In the emergency department (ED), where I hope to spend my career, chest discomfort, nausea and diaphoresis set a series of actions into motion. I am taught to fear missing a classic presentation of myocardial infarction (MI) and to keep high suspicion for life-threatening conditions. MI in women often presents with symptoms other than chest pain, which the American Heart Association (AHA) details on a page separate from general MI symptoms.1 The page emphasises that symptoms in women can be subtle and are often overlooked as acid reflux or the influenza, making recognition of MI in women especially difficult. In the ED, over two-thirds of physicians are men.2 “I am a woman in medicine” is an inescapable part of my daily inner monologue. I feel a solidarity with my female patients. I pay attention to how I approach their pain and I look for the ways in which women downplay their symptoms. It was initially easy for me to rationalise the 2018 study findings that women treated by male …

ObjectiveTo investigate the effectiveness of a virtual reality (VR), three-dimensional (3D) clinically orientated temporal bone anatomy module, including an assessment of different display technologies.MethodsA clinically orientated, procedural and interactive anatomy module was generated from a micro-CT of a cadaveric temporal bone. The module was given in three different display technologies; 2D, 3D with monoscopic vision, and 3D with stereoscopic vision. A randomised control trial assessed the knowledge acquisition and attitudes of 47 medical students though a pretutorial and post-tutorial questionnaire. The questionnaire included questions identifying anatomic structures as well as understanding structural relations and clinical relevance. Furthermore, a five-point Likert scale assessed the students’ attitudes to the module and alternative learning outcomes, such as interest in otology and preparedness for clinical rotations.ResultsAs a whole cohort, the total test score improved significantly, with a large effect size (p≤0.005, Cohen’s d=1.41). The 23 students who returned the retention questionnaire had a significant improvement in total test score compared with their pretutorial score, with a large effect size (p≤0.005, Cohen’s d=0.83). Display technology did not influence the majority of learning outcomes, with the exception of 3D technologies, showing a significantly improvement in understanding of clinical relevance and structural relations (p=0.034). Students preferred 3D technologies for ease of use, perceived effectiveness and willingness to use again.ConclusionsThe developed VR temporal bone anatomy tutor was an effective self-directed education tool. 3D technology remains valuable in facilitating spatial learning and superior user satisfaction.

IntroductionLearner workload during simulated team-based resuscitations is not well understood. In this descriptive study, we measured the workload of learners in different team roles during simulated paediatric cardiopulmonary resuscitation.MethodsPaediatric emergency nurses and paediatric and emergency medicine residents formed teams of four to eight and randomised into roles to participate in simulation-based, paediatric resuscitation. Participant workload was measured using the NASA Task Load Index, which provides an average workload score (from 0 to 100) across six subscores: mental demand, physical demand, temporal demand, performance, frustration and mental effort. Workload is considered low if less than 40, moderate if between 40 and 60 and high if greater than 60.ResultsThere were 210 participants representing 40 simulation teams. 138 residents (66%) and 72 nurses (34%) participated. Team lead reported the highest workload at 65.2±10.0 (p=0.001), while the airway reported the lowest at 53.9±10.8 (p=0.001); team lead had higher scores for all subscores except physical demand. Team lead reported the highest mental demand (p<0.001), while airway reported the lowest. Cardiopulmonary resuscitation coach and first responder reported the highest physical demands (p<0.001), while team lead and nurse recorder reported the lowest (p<0.001).ConclusionsWorkload for learners in paediatric simulated resuscitation teams was moderate to high and varied significantly based on team role. Composition of workload varied significantly by team role. Measuring learner workload during simulated resuscitations allows improved processes and choreography to optimise workload distribution.

IntroductionCOVID19 has significantly impacted undergraduate medical education. At Hull York Medical School, the elective period for fifth-year students was cancelled and a seven-week online distance learning course was developed and initiated, focusing on key learning outcomes. Our aim was to incorporate live simulation to add an interactive element to online fifth-year teaching.MethodsWe wrote and recorded immersive 360-degree scenarios tailored to learning outcomes for the week. These focused on the assessment, investigation, and management of an unwell patient. The scenarios were delivered as small group teaching sessions through online meeting software weekly for seven weeks. Clinical teaching fellows guided sessions, encouraging participation, the application of knowledge and progression of clinical reasoning. Quantitative and qualitative feedback was collected after every session and pre/post course evaluation was conducted. A Likert scale from 1 to 5 was used to subjectively assess student’s confidence in the assessment and management of acutely unwell patients.ResultsThe number of students participating in the online simulation course ranged from 127 to 149; 84 to 136 completed the surveys each week. 95.8% of students reported virtual simulation as a beneficial form of learning. Of those, 60.4% stated virtual simulations complemented other forms of teaching and 39.6% felt that simulations were more beneficial. Mean confidence rating improved from 3.52 to 4.12 for assessment and 2.89 to 3.68 for management of acutely unwell patients (p-value<0.001). Themes that emerged qualitatively were: 1) Interactive and dynamic nature of the sessions allowed students to feel involved in ward based work, 2) Near-peer teaching made the learning experience more relevant to their future jobs as junior doctors, 3) Students reported that given the current circumstances, the virtual simulations allowed them to put their knowledge into clinical practice.Discussion and ConclusionOnline simulation was a valuable learning resource to final year medical students at the Hull York Medical School during their distance learning block. It improved the student’s confidence in the assessment and management of acutely unwell patients and provided an interactive educational experience that helped prepare them for hospital placements. Delivering simulation in small groups online is a novel teaching method that can be used in line with social distancing measures and can be developed further for both undergraduate and postgraduate education.

Simulation is resource heavy in terms of time, space, equipment, and faculty, with limitations on the number of people you can deliver each session to. During the COVID-19 pandemic, social distancing makes face to face simulation more challenging.After working with a local healthcare VR team through a return to training project,1 we explored benefits and acceptability of remotely debriefing 360° videos of simulated paediatric emergencies. Remote debrief has been used successfully in the past to train teams2 and faculty.3However, it’s use in the context of 360 content is still novel. The theory being that because the participant is an ‘active observer’ this would bring a more immersive experience.Summary of Educational ProjectUsing 360° content filmed at RD&E hospitals, we ran remote virtual simulation sessions over MS Teams video conferencing platform in local and regional paediatric teaching sessions. We asked the learners to watch a scenario (eg; https://youtu.be/KpQl0VUfERI), from which we guided them to interact with the video, directing their view in the 360° media to whatever interested them. This was followed with a debrief following a standard structure.We then collected feedback on its acceptability & similarity to face to face simulation.Summary of ResultsApril 2020 – July 2020. 6 Sessions at least 66 learners, 38 gave feedback. 4 different 360 scenarios used. Used for local, regional (South-West) and international (Wales) teaching. Levels ranged from medical students to Paediatric consultants. Most Common device used: computers or smartphone. Location accessed: Work and Home.Feedback was globally positive 100% ‘would use it again’, average rating of 8.3/10 (10= Loved it, 1=Hated).Feedback was rich and promising:‘more life-like than expected’‘safer than real sim as I didn’t feel judged’‘360 element meant you had a different perspective’.N.B We had more senior grade learners than our usual simulation sessions – this directed debriefs towards the non-technical learning which was discussed more than the medical learning.Additional positives include;- easy accessibility for anyone to view 360 video (no need beyond normal consumer technology)- no need for additional faculty- relatively quick and engaging to run remotely.The experiences have established ‘best practises’ for this modality.ConclusionWe recommend remote 360 sim with debrief as a fantastic adjunct to standard simulation. The modality is well received and a safe method of providing people with an experience of emergency scenarios which is improved though debrief.ReferencesMason T G627(P) Is virtual resus training the future? Can 360 degree ‘immersive video’ engage paediatric trainees safely in life support training? – A project as part of the south west return to paediatric training course (SWRPT). Archives of Disease in Childhood 2019;104:A254.Meaklim A. Remote debriefing - A new paradigm for low resource and rural hospitals?. 2016;31:59–62.Gross IT, Whitfill T, Auzina L, et al. Telementoring for remote simulation instructor training and faculty development using telesimulation BMJ Simulation and Technology Enhanced LearningPublished Online First: 18 May 2020. doi: 10.1136/bmjstel-2019-000512

IntroductionSimulation is a powerful tool used in healthcare to improve clinical practice and in-situ simulation, in particular, can be used to identify latent errors within a particular department.1 Although anaesthetists recognise its importance, simulations often involve anaesthetists only and take place within dedicated high fidelity simulation suites. We initiated a program of multi-disciplinary in-situ simulations in the theatre department of a London hospital over six months for theatre, recovery and anaesthetic staff.MethodsAt Homerton Hospital, theatres are run in two distinct areas – six main operating theatres in one building and three day-surgery theatres in another. We ran bi-monthly simulations alternating between main theatres and the day stay unit at times convenient to the lead nurse and the anaesthetic college tutor. We used feedback sheets mapped to the RCOA curriculum to identify learning gaps for staff. We used a mannequin or an actor as the patient, and iSIM technology to mimic and change bedside observations depending on the actions of the participant. If we had permission, we would use any additional equipment found in their normal working environment. The simulation for the participants including debrief lasted an hour in total, although the whole process took longer to set up and replace all equipment. We ran nine simulations before terminating due to the COVID-19 pandemic.ResultsWe identified several safety threats during the process including deficiencies in clinical knowledge and lack of availability of emergency drugs or equipment. We have been able to implement improvements based on our findings and this has led to the purchase of a fridge for the storage of emergency medications, and the implementation of a new fire protocol for theatres. Overall feedback from participants and from clinical leads was very good, and we used the RCOA curriculum and feedback forms to guide us in creating relevant simulation scenarios. More extensive results can be presented at the conference.DiscussionIn-situ simulation allows clinicians to rehearse in their normal working environment and supports MDT learning alongside familiar colleagues. This has the advantage of highlighting latent errors in systems performance that would not have occurred in a dedicated simulation suite, and reveals potential errors before patient safety is compromised. Although the programme was terminated earlier than anticipated due to the ongoing pandemic, we are hopeful that it will resume soon under the leadership of the next simulation fellow.ReferenceLamberta M, Aghera A. Latent Safety Threat Identification via Medical Simulation. [Updated 2019 Nov 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549909/