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The minimal relationship between simulation fidelity and transfer of learning
Abstract
High-fidelity simulators have enjoyed increasing popularity despite costs that may approach six figures. This is justified on the basis that simulators have been shown to result in large learning gains that may transfer to actual patient care situations. However, most commonly, learning from a simulator is compared with learning in a 'no-intervention' control group. This fails to clarify the relationship between simulator fidelity and learning, and whether comparable gains might be achieved at substantially lower cost.
This analysis was conducted to review studies that compare learning from high-fidelity simulation (HFS) with learning from low-fidelity simulation (LFS) based on measures of clinical performance.
Using a variety of search strategies, a total of 24 studies contrasting HFS and LFS and including some measure of performance were located. These studies referred to learning in three areas: auscultation skills; surgical techniques, and complex management skills such as cardiac resuscitation.
Both HFS and LFS learning resulted in consistent improvements in performance in comparisons with no-intervention control groups. However, nearly all the studies showed no significant advantage of HFS over LFS, with average differences ranging from 1% to 2%.
The factors influencing learning, and the reasons for this surprising finding, are discussed.
... Research indicates that high-fidelity simulations are not necessarily considered to be more stressful (Finan et al. 2012) and may result in overconfidence (Masiello and Mattsson 2017;Massoth et al. 2019). The perception of higher levels of fidelity as being superior to the lower levels is common among both participants and instructors, but there is no clear evidence to support this statement (Fragapane et al. 2018;Kim et al. 2016;Norman et al. 2012). High-fidelity simulations also require extensive resources; for example, finance, time, and personnel (Fragapane et al. 2018;Massoth et al. 2019;Norman et al. 2012). ...
... The perception of higher levels of fidelity as being superior to the lower levels is common among both participants and instructors, but there is no clear evidence to support this statement (Fragapane et al. 2018;Kim et al. 2016;Norman et al. 2012). High-fidelity simulations also require extensive resources; for example, finance, time, and personnel (Fragapane et al. 2018;Massoth et al. 2019;Norman et al. 2012). How well SBT mimics real working conditions is often expressed in terms of simulation fidelity; the degree of realism in the simulated physical, psychological and conceptual environments. ...
... The first question, addressing whether low-fidelity simulation settings differed from high-fidelity settings in experienced workload using NASA-TLX, revealed no significant differences, a noteworthy finding. Participant experience and commitment may explain the non-significance, although the small sample size does not rule out (Fragapane et al. 2018;Massoth et al. 2019;Norman et al. 2012). In other research, the NASA-TLX was proved to be sensitive to experience (Barajas-Bustillos et al 2023) which may have had an influence on the results in this study as well. ...
The study compared two simulation environments for training of Swedish naval Command and Control teams by using indirect measures, including workload, combat readiness, and situation awareness. The literature explains simulation-based training as providing a safe avenue to practice relevant scenarios. Fidelity, the degree of realism in the simulation, and workload, the equilibrium between demands and assigned tasks, are crucial factors examined in this study of low- and high-fidelity naval simulations. This study was conducted to better understand the effects of various training methods. An experimental design with repeated measures was used with three consecutive escalating parts. The subjective, multidimensional assessment tool, NASA-Task Load Index was used to rate perceived workload. Combat readiness of the ship and mental demand yielded significant results. For combat readiness of the ship, there was a difference between the low and the high-fidelity setting, for the initial part of the scenario p = 0.037 and for the second part p = 0.028. Mental demand was experienced as higher in the low-fidelity setting, p = 0.036. Notably, the simulated internal battle training for onboard command teams in a low-fidelity setting was found to induce a level of stress comparable with that experienced in a high-fidelity setting. The results indicate that low-fidelity training results in a workload not distinguishable from high-fidelity training and has practical implications for increased use of low-fidelity training as part of (naval) command team training programmes.
... Unfortunately, HFS is not without downsides, as it can be cost-prohibitive and timeprohibitive to utilize and typically requires a synchronous, in-person methodology (Havighurst et al., 2003;Mills & Winston, 2022;Norman et al., 2012;Reed, 2022). Additionally, while the evidence surrounding HFS is robust, several studies have found conflicting results on HFS's effectiveness. ...
... Another mode of simulation is low-fidelity simulation (LFS), which is described as "Experiences such as case studies, role-playing, using partial task trainers or static mannequins to immerse students or professionals in a clinical situation or practice of a specific skill" (Meakim et al., 2013, p. S7). LFS has some substantial advantages to HFS concerning implementation, including dramatic cost savings for educators and organizations (Havighurst et al., 2003;Mills & Winston, 2022;Norman et al., 2012). Haerling (2018) found that LFS was almost three times more cost-effective per student, as LFS costs $10.89 per student versus $36.55 per student for HFS. ...
... Repeated exposure is particularly valuable for learners early in the skill development phase, during which development is centered around recognitions of patterns (Benner, 2004). This concept is reinforced by the concept of cognitive loading theory, which is why LFS is frequently recommended for novice learners due to the limitations of confounding factors that are likely to overwhelm new learners (Munshi et al., 2015;Norman et al., 2012). ...
... Healthcare practitioners can practice their clinical skills in a controlled yet realistic environment using Harvey, which can simulate a range of heart ailments by adjusting blood pressure, respiration, pulse, normal heart sounds, and murmurs (Norman et al., 2012). ...
... Because some AIs can distinguish between malignancy and benignity in tumours or lesions, these technologies are employed for objective second-opinion diagnoses to support the radiologist's interpretation and diagnosis of medical pictures. Studies have shown how this technology enhances diagnostic imaging by lowering observer variability and is a significant support for clinical decisions like suggestions for biopsies or thoracotomies, among other things (Norman et al., 2012). ...
... Dummy-based simulator for mimicking various heart diseases.(Norman et al., 2012) ...
... Most commonly discussed are physical fidelity (how a simulator looks and feels) and functional fidelity (how a simulator behaves or what it does when interacted with). The notion of higher fidelity simulations being more beneficial for learning has been debunked [16], yet the fidelity of using a live animal is a key aspect of the LTT debate. Simply, critics argue there is lower physical fidelity due to anatomical dissimilarity, but supporters state that higher functional fidelity apparent through the presence of bleeding and a reactive physiology supersedes differences in anatomy. ...
... Simply, critics argue there is lower physical fidelity due to anatomical dissimilarity, but supporters state that higher functional fidelity apparent through the presence of bleeding and a reactive physiology supersedes differences in anatomy. The concept of psychological fidelity, meaning the simulation generates cognitive, behavioural and emotional responses expected in the equivalent real-life situation [9,15] may be more relevant, with some evidence that psychological fidelity may be a more critical determinant of learning [16]. ...
Introduction
Surgical simulation training substituting a live animal for a human patient is a continuing practice. Despite clear ethical controversy, many perceive this type of simulation to be ‘high fidelity’ and therefore valuable. This study employs a sociomaterial perspective to explore how use of a live animal mediates learning activity and behaviour during a trauma surgical simulation course.
Methods
This international, focused ethnography generated data through observation of surgical simulation courses in six different countries. A narrative analysis was conducted using instrument-mediated learning theory as a lens for interpretation.
Results
The key finding is the dual and fluid existence of a live animal as an instrument for learning, variably perceived as a simulator tool for training and as a patient that must be saved. When framed as a tool, surgical knowledge and skills are practiced with learning acquired via epistemic and pragmatic mediation. Performing a thoracotomy denotes a critical moment; procedural unfamiliarity, evident haemorrhage and inherent risk of a deadly outcome contribute to uncertainty and clinical complexity. Learners are hence more likely to frame the animal as a patient. This experience has psychological fidelity, feeling more authentic as actions have consequences. Risk of failure to sustain the life of the animal mediates reflexive learning, teaching the learners about themselves and their abilities.
Conclusion
Live animal simulation training mediates surgical learning differently, dependent on whether the animal is framed as an instrument or as a patient. The animal’s ability to bleed and exsanguinate to death creates risk and uncertainty as learners perform complex skills under pressure of significant consequence. Authenticity could be amplified if the animal is framed as a patient throughout the simulated learning event.
... Table 2 provides a summary of the types of fidelity in EPE. However, high physical fidelity (having literal representation of physical elements involved in a specific emergency response) or environmental fidelity not necessarily a guarantee of high functional fidelity (6)(7)(8), and there is a growing narrative that supports a departure from focusing on replicating physical fidelity in simulation-based training to achieve functional fidelity (5). ...
... This suggests that in some instances casualty actors are unable to adequately portray clinical features for exercise participants to functionally carry out their roles and utilise additional information, like ETS casualty cards/actors, to augment functional fidelity (39,40). This demonstrates that simply attaining high physical fidelity is not adequate to achieve high functional fidelity, in the context of the objectives of these exercises, in line with previous studies (6)(7)(8). Moreover, using casualty actors caused confusion with distinguishing between real casualties and actor-casualties during a LD exercise (21), which could even compromise the safety of real-casualties not involved in the exercise that are attending clinical facilities taking part in the exercise. ...
... Fidelity is a term commonly used when discussing model development, 17,18 and it is often interpreted as how realistic a model looks and feels. 11 Despite the emphasis placed on fidelity and the difference in cost and accessibility between low-and high-fidelity models, 19 research in both veterinary and medical education has reported no or minimal difference in learning outcomes between the two model types. 13,19,20 In-stead, it is more important to consider the alignment between the steps performed on the model and live animal. ...
... 11 Despite the emphasis placed on fidelity and the difference in cost and accessibility between low-and high-fidelity models, 19 research in both veterinary and medical education has reported no or minimal difference in learning outcomes between the two model types. 13,19,20 In-stead, it is more important to consider the alignment between the steps performed on the model and live animal. 11 The use of models allows a step-wise approach that enables alignment with competency-based veterinary education, 21 and it is increasingly recognized as best practice by accrediting bodies. ...
Proficiency with ram breeding soundness examinations requires competency with palpation, a skill that can be difficult to teach and assess. There are limited small ruminant clinical skills models available, despite the advantages they offer in veterinary education. We developed reusable models for teaching ram breeding soundness examinations, focusing on scrotal assessment and palpation. Then we integrated these models into a practical session where multiple clinical aspects were included. We created anatomically normal (“sound”) testes using 3D modeling software before editing these to display common abnormalities (“unsound” testes). Then, we 3D printed two-part molds and cast the silicone testes. Testes were inserted into siliconized, lubricated stockings facilitating free movement during palpation. Scrotal sacs were sewn from polar fleece and suspended to mimic natural orientation in a live, standing ram. As well as for scheduled classes, we used the models as a station in our course's Objective Structured Clinical Examination (OSCE) assessment. Our models offer advantages in the veterinary education context. Their relatively low cost and durability facilitates their classification as “open access” within our skills lab for student deliberate practice outside scheduled classes. They provide a uniform student learning experience that does not rely on live animals or clinical case load and aligns with best-practice recommendations from accrediting bodies. Student engagement and OSCE outcomes were good, but going forward it would be ideal to collaborate with a program that uses live rams for teaching and assessing this skill to directly examine the impact of our models on confidence and competence.
... On the other hand, there are considered to be at least two types of realism, or fidelity, in training scenarios; "engineering fidelity:" the physical resemblance to a real event, and "psychological fidelity:" how closely the behaviors in a simulation resemble those of a real event ( Jorm et al., 2016 ;Lavoie et al., 2020 ;Norman, Dore, & Grierson, 2012 ;Sharma, Boet, Kitto, & Reeves, 2011 ). Of these, psychological fidelity is more critical for effective learning ( Jorm et al., 2016 ;Norman et al., 2012 ;Sharma et al., 2011 ). ...
... On the other hand, there are considered to be at least two types of realism, or fidelity, in training scenarios; "engineering fidelity:" the physical resemblance to a real event, and "psychological fidelity:" how closely the behaviors in a simulation resemble those of a real event ( Jorm et al., 2016 ;Lavoie et al., 2020 ;Norman, Dore, & Grierson, 2012 ;Sharma, Boet, Kitto, & Reeves, 2011 ). Of these, psychological fidelity is more critical for effective learning ( Jorm et al., 2016 ;Norman et al., 2012 ;Sharma et al., 2011 ). Losing physical realism does not mean sacrificing effective learning, so long as psychological realism is maintained. ...
... Research indicates that high-delity simulations are not necessarily considered to be more stressful [20] and may result in overcon dence [21,22]. The perception of higher levels of delity as being superior to the lower levels is common among both participants and instructors, but there is no clear evidence to support this statement [23][24][25]. Highdelity simulations also require extensive resources; for example, nance, time, and personnel [22,23,25]. ...
... The perception of higher levels of delity as being superior to the lower levels is common among both participants and instructors, but there is no clear evidence to support this statement [23][24][25]. Highdelity simulations also require extensive resources; for example, nance, time, and personnel [22,23,25]. ...
Introduction
: This study compares two simulation environments for training of Swedish naval Command and Control (C²) teams by using indirect measures, including workload, combat readiness, and situation awareness (SA). Simulation-based training (SBT) provides a secure avenue to practise relevant scenarios. Fidelity, denoting the degree of realism in the simulation, and workload, characterized as the equilibrium between demands and assigned tasks, are crucial factors examined in this study of low- and high-fidelity naval simulations.
Materials and methods
An experimental design with repeated measures was used with three consecutive escalating parts. The subjective, multidimensional assessment tool, NASA-TLX, was used to rate perceived workload.
Results
One dependent measure yielded significant results; the main effects on combat readiness of the ship were significant. Variations were noted between the initial and subsequent parts of the scenario, as well as between the two simulation environments. No other significant differences were identified for any of the dependent measures. Part three of the scenario was omitted due to missing data. Notably, the simulated internal battle training for onboard C² teams in a low-fidelity setting was found to induce a level of stress comparable with that experienced in a high-fidelity setting.
Conclusion
Low-fidelity SBT can be used for cost-effective training of Swedish naval C² teams on board. The practical implications arising from this research indicate that the utilization of a low-fidelity simulation setting can effectively support the training of other teams, such as those in medical training.
... They observed that learning outcomes cannot simply be generalized from one discipline to another, and emphasized the diversity and complexity of learning environments and situational contexts. Twenty years later, the construct experienced a revival in the research of simulation training, with the hypothesis that particularly realistic simulations ("high-fidelity") would improve the transfer performance of medical students (e.g., Hariri et al., 2004;Norman et al., 2012;Boet et al., 2014;Grierson, 2014). However, the results are ambiguous. ...
... For example, Hariri et al. (2004) found that students who trained with a surgical simulator were able to transfer their knowledge to recognizing anatomical images. On the contrary, Norman et al. (2012) found no benefit of high-fidelity simulations on students' transfer performances. Similarly, several studies have investigated the transfer of basic science knowledge to clinical problem-solving. ...
All anatomical educators hope that students apply past training to both similar and new tasks. This two‐group longitudinal study investigated the development of such transfer of learning in a histology course. After 0, 10, and 20 sessions of the 10‐week‐long course, medical students completed theoretical tasks, examined histological slides trained in the course (retention task), and unfamiliar histological slides (transfer task). The results showed that students in the histology group gradually outperformed the control group in all tasks, especially in the second half of the course, η² = 0.268 (p < 0.001). The best predictor of final transfer performance was students’ retention performance after 10 sessions, β = 0.32 (p = 0.028), and theoretical knowledge after 20 sessions, β = 0.46 (p = 0.003). Results of eye tracking methodology further revealed that the histology group engaged in greater “visual activity” when solving transfer tasks, as indicated by an increase in the total fixation count, η² = 0.103 (p = 0.014). This longitudinal study provides evidence that medical students can use what they learn in histology courses to solve unfamiliar problems but cautions that positive transfer effects develop relatively late in the course. Thus, course time and the complex relationship between theory, retention, and transfer holds critical implications for anatomical curricula seeking to foster the transfer of learning.
... (16,17) A pesar de los desafíos, el impulso hacia la seguridad del paciente y la expansión de la simulación en la formación médica refuerzan el compromiso ético de priorizar el bienestar del paciente. (18,19) La simulación médica basada en evidencia representa una herramienta vital para fortalecer la formación médica y asegurar la competencia y seguridad de los futuros profesionales de la salud. (12,20) El estudio está motivado para identificar los posibles puntos a mejorar en el aprendizaje de habilidades médicas en la simulación clínica dentro de la UAI, potenciándola a través de la adquisición de una retroalimentación por parte de alumnos formados en la institución. ...
Background: Clinical simulation is a key tool for balancing the development of medical skills and patient safety. Following reports from the institute of medicine highlighting the need to prevent medical errors In the United States, an initiative that extended to global healthcare, simulation was implemented as a tool in medical training to bridge the theory - practice gap. The UAI reaffirmed this commitment to clinical simulation training, despite challenges in its implementation, to strengthen education and ensure the competence of future healthcare professionals. The aim of this study is to obtain feedback from UAI students who have received clinical simulation classes. Material and methods: (Complete here). Results: (Complete here). Conclusion: (Complete here). (Utilizar texto justificado).
... (16,17) Despite the challenges, the drive toward patient safety and the expansion of simulation in medical education reinforces the ethical commitment to prioritizing patient well-being. (18,19) Evidence-based medical simulation is a vital tool for strengthening medical education and ensuring the competence and safety of future health professionals. (12,20) This study aims to identify areas for improvement in learning medical skills in clinical simulation within the UAI, enhancing it through feedback from students trained at the institution. ...
The research addressed the use of clinical simulation as an educational strategy for medical students at the Universidad Abierta Interamericana (UAI), in an Argentine context characterized by structural challenges in health and education. Since the reports of the Institute of Medicine (IOM) in 1999 and 2001, simulation has been promoted as a key tool for reducing medical errors and improving the quality of care. This descriptive cross-sectional study set out to identify areas for improvement in the implementation of clinical simulation, through surveys conducted with final-year students who had completed their rotating internship by March 2024.The results showed an overall positive assessment of clinical simulation, highlighting its effectiveness for skills development and its realism. However, opportunities for improvement were also identified. Fifty-one percent of the students pointed out deficiencies in curricular integration and in the measurement of results. In addition, 61% expressed the need for more time to master competencies, and 47% negatively evaluated team training. Instructor training and the educational context were rated as acceptable but perfectible.It was concluded that, although clinical simulation has been a valued training tool at the UAI, its impact could be optimized through structural adjustments in curriculum design, teacher training and the duration of internships. In the current Argentinean context, where educational inequalities are palpable, simulation is presented as a strategic resource for training competent doctors committed to patient safety.
... In simulated training, the ability of the simulation model to train the skill is more important than the similarity of the model with the actual eye [7]. Norman et al. reported no significant advantage of high-fidelity simulator learning over low-fidelity simulation learning [25]. ...
Several simulation models are available for cataract surgery training, but they have limitations in terms of quality and availability. The Farra Eye Model, a new cataract surgery simulator, was developed using 3D-printing technology to provide residents with more options. This study aims to determine its face and content validity as a surgical simulator for training capsulorhexis, a crucial step in cataract surgery. Ophthalmology residents and consultants at the Faculty of Medicine, Universitas Indonesia, were asked to complete three capsulorhexis tasks in the eye model. Then, subjects were surveyed using a validated questionnaire to assess the face and content validity of the model. Responses were recorded using a 5-point Likert scale ranging from (1) disagree to (5) strongly agree. Twenty-two subjects completed thetasks. The overall face validity score was favourable (3.67 ± 0.67). However, the resident group considered capsule elasticity poor (2.73 ± 1.1), while the consultant group still felt it realistic (3.64 ± 0.9). The content validity had a favourable score in the overall assessment (4.15 ± 0.58) and for each assessment component. Despite the challenge of replicating human lens capsule elasticity, the Farra Eye Model demonstrates initial evidence supporting its use for capsulorhexis training. It can be helpful for training programs with limited access to commercially available simulation models.
... In a classroom setting, for example, games have been frowned upon for their lack of graphical quality (Rice, 2006), confusing or complex user interfaces (Fjaellingsdal and Klöckner, 2017), low production values and insufficient gameplay quality (Illingworth and Wake, 2019). Some educational games are also scrutinized for being unrealistic or failing to depict the full complexity of environmental issues, although past research has shown that players are often capable of discounting the game's lack of realism (Feinstein and Cannon, 2002;Norman et al., 2012) as well as asking critical questions as to why some things work in the game but not in real life (Schell, 2010). This especially appears to be the case for more experienced players who are familiar with realistic breaches in games (Fjaellingsdal and Klöckner, 2019). ...
Despite the now unequivocal notion that climate change is driven by anthropogenic activity, communication between concerned climate scientists and laypeople about the severity of the issue is still muddy. Although creative and more approachable venues of communication to climate change and sustainability issues are being explored more regularly than before, there is still room for improvement and upscaling in the attempts to link scientists and laypeople together in the understanding of these outstanding issues. This also applies to the field of environmental gaming, which has become more popular in the recent decade. Despite this increasing popularity, however, most environmental gaming studies exist as small-scale pilot studies that often result in generating limited, albeit promising results in terms of increasing awareness and knowledge around environmental topics. This article explores the use of games in climate- and sustainability education and provides a set of assisting guidelines to ease the process of using games as communication tools about these pressing issues, as well as providing advice on how to upscale environmental gaming from a set of limited pilot studies.
... This focus reflects the belief that high levels of fidelity are required to provide high-quality education, linking directly with the success of students in meeting the intended learning outcomes (e.g., Liu et al. 2008;Renganayagalu et al. 2019). Given the limited empirical support for establishing a direct connection, the notion of fidelity has faced scrutiny in recent times (Norman et al. 2012). Critique of the fidelity concept has led to occasional efforts to introduce alternative concepts like authenticity (Maran and Glavin 2003), functional resemblance, and functional task alignment (Hamstra et al. 2014). ...
In this study, we explore the current practices of experienced instructors in developing scenarios for maritime simulator training and assessment. Scenario design is fundamental to effective simulator-based training but remains underexplored in extant literature. Through a series of semi-structured interviews (n = 16), we identify the core concerns of instructors designing scenarios; (1) realism, authenticity, and fidelity; (2) designing for students' requirements; (3) the importance of clear learning objectives. Based on the results, we propose that functional congruence is a more fitting term than realism, authenticity, and fidelity in this context, as effective simulator training requires a balance between a simulator realistic enough for immersive learning experiences, and a focus on clear learning objectives. In consideration of the need to train students to function as part of a team of competent experts, moreover, we propose the introduction of an established instructional design model into the scenario design process. The proposed model has proven successful in simulator-based training in the similarly high-risk and safety-critical field of healthcare and has the potential to both complement the current practices of experienced instructors and act as a valuable resource for those newer to the role in designing training transferrable to professional practice.
... (16,17) A pesar de los desafíos, el impulso hacia la seguridad del paciente y la expansión de la simulación en la formación médica refuerzan el compromiso ético de priorizar el bienestar del paciente. (18,19) La simulación médica basada en evidencia representa una herramienta vital para fortalecer la formación médica y asegurar la competencia y seguridad de los futuros profesionales de la salud. (12,20) El estudio está motivado para identificar los posibles puntos a mejorar en el aprendizaje de habilidades médicas en la simulación clínica dentro de la UAI, potenciándola a través de la adquisición de una retroalimentación por parte de alumnos formados en la institución. ...
Introduction: clinical simulation is a key tool for balancing medical skills development and patient safety.Objective: to identify possible points for improvement in the learning of medical skills in clinical simulation within the IAU as judged by students.Methods: a cross-sectional, descriptive study was conducted. UAI students who had taken the rotating internship and received simulation sessions were selected. The study setting will be exclusively university and data will be collected by means of surveys. The surveys were elaborated according to McGaghie's 12 sections.Results: the survey was administered to 57 students, with a gender distribution of 33 % male and 67 % female. 57 % had previous experience in a health center outside the IAU. Seventy-five percent considered the simulation to be effective in acquiring skills, and 79 % thought that the evaluations reflected their competencies. However, 63 % thought that the transfer to clinical practice could be improved, and 47 % saw teamwork as ineffective.Conclusions: although the simulations are valued for their realism and effectiveness, areas for improvement were identified, such as curricular integration, evaluation methods, exposure time, and instructor training. It is also suggested to optimize the transfer of skills to real clinical practice and teamwork training
... Wang et al. suggested that complex tasks might be better learned using higher-fidelity simulations, which offer greater cognitive stimuli [2]. Whether handmade phantoms are more suitable for low-stakes procedures (e.g., thoracocentesis) for novices remains a topic of debate [28]. Our findings suggest that low-fidelity phantoms can provide training outcomes comparable to those of high-fidelity phantoms for thoracocentesis. ...
Introduction
This prospective study aims to evaluate the learning effect of US-guided thoracocentesis and pericardiocentesis in novices through simulation training using handmade phantoms.
Methods
The novices included undergraduate-year (UGY) students and first postgraduate-year (PGY-1) residents. Handmade phantoms were utilized for training and immediate assessment. Novices were re-evaluated using high-fidelity phantoms three months after training, while experienced PGY-3 emergency medicine residents were recruited and evaluated with high-fidelity phantoms simultaneously. Data on their performance, puncture time, and number of attempts were collected.
Results
Thirty-six novices (18 PGY-1 and 18 UGYs) and 12 PGY-3 emergency medicine residents were recruited. Alongside clinical observation, novices demonstrated improved skill retention and performance at the 3-month assessment compared to the immediate assessment [5 (4–5) vs. 3.5 (3–4), p = 0.0005] in thoracocentesis, achieving a comparable level of proficiency with the PGY-3 emergency medicine residents [5 (4–5) vs. 5 (5), p = 0.105]. Without clinical observation, novices exhibited a decline in skill proficiency in pericardiocentesis at the 3-month assessment [3 (3–4) vs. 4 (4–4.5), p = 0.015]. The puncture time was comparable between novices and PGY-3 emergency medicine residents for both thoracocentesis and pericardiocentesis. However, novices required a greater number of puncture attempts for pericardiocentesis.
Conclusions
Novices showed superior performance in thoracocentesis but experienced skill decay in pericardiocentesis at the 3-month assessment following training with handmade phantoms. This decline may be attributed to the very low frequency of pericardiocentesis cases encountered by novices after training, as well as the higher-stakes nature of the procedure. Further investigation is needed to evaluate the long-term effects of training, skill retention, and transfer of skills to actual patient care. Additionally, research should focus on determining optimal retraining intervals for pericardiocentesis and evaluating the use of standardized pericardiocentesis videos as an alternative to clinical observation.
Trial registration
Registered at ClinicalTrials.gov (NCT04792203) on March 7, 2021.
... Previous research indicates mixed effectiveness between low-and high-fidelity simulations in healthcare education, with high-fidelity enhancing decision-making and skills but not always translating to clinical practice [55][56][57], whereas low-fidelity has been demonstrated as cost-effective for gaining basic skills [55,56]. Both types are valuable, influenced by the learner's stage, with low-fidelity suitable for beginners and highfidelity for more advanced students [58][59][60][61][62]. However, the effectiveness of these simulations relies less on fidelity and more on well-designed clinical scenarios, appropriate debriefing, and effective feedback, which are crucial for enhancing learning outcomes regardless of the simulation's complexity [22,63,64]. ...
Background
In podiatry, there are a variety of clinical tasks that require precision and skill and it is expected that clinicians will obtain these skills during their training. Simulation is a dynamic teaching tool used in healthcare to enhance skill and knowledge acquisition. Currently, the extent and nature of the research on the use of simulation in podiatry teaching and learning are not clear.
Aim
A scoping review was conducted to identify the extent and nature of research activity on the use of simulation in podiatry teaching and learning and identify gaps in the existing literature.
Methods
Any research relating to simulation use in podiatry teaching including various designs and focusing on simulations aimed at improving podiatry teaching or learning were eligible for inclusion. A systematic search was conducted on February 14, 2024 of the following databases: Embase (via Embase.com), MEDLINE (via PubMed), CINAHL, and the Web of Science. Additional papers were identified via bibliographies of included studies. Content analysis of content relating to podiatry teaching and learning was performed and grouped into broad themes, then further narrowing to six themes.
Results
A total of 21 research studies were deemed eligible for inclusion focusing on diverse aspects of podiatry simulation utilized in high‐income countries exclusively. Conducted between 1997 and 2023, these studies were categorized into six key themes: skill improvement, communication and professionalism, clinical competencies and patient safety, educational enhancement, and anatomy and histology education. The simulations, carried out by or assessed for podiatry professionals, staff, or students, ranged from high‐fidelity medical mannequins to low‐fidelity simulations such as a grapefruit model of a diabetes‐related foot ulcer.
Conclusion
Overall, the findings suggest that simulation teaching in podiatry, whether through direct skill enhancement or through educational impact assessments, holds potential in improving competency, confidence, and educational outcomes in podiatry practice. This scoping review identified a small yet diverse evidence base for simulation modalities in podiatry education, demonstrating gaps in long‐term effects and comparative effectiveness studies. It highlights the urgent need for research focused on longitudinal impacts, evaluating various simulation technologies and standardizing best practices to improve podiatry education and align with clinical and patient care needs.
... These situations frequently occur in clinical settings; however, they are difficult to recreate using teaching methods other than simulations. Simulation education helps students identify multiple nursing interventions to improve patient outcomes and manage complex situations [43]. ...
Purpose: Clinical reasoning, which is based on an understanding of the pathophysiological mechanisms of diseases, is a core nursing competency that involves analyzing patient-related data and providing appropriate nursing practices. Simulation-based education is effective in improving clinical reasoning competencies and communication skills. This study evaluated the effectiveness of virtual simulation-based learning in improving the communication skills and clinical reasoning competencies of undergraduate nursing students. Methods: This study used a single-group pretest and posttest quasi-experimental design to evaluate the effectiveness of virtual simulation-based learning. Data were collected from June to September 2020. Thirty-six nursing students in their third and fourth years of study who understood the purpose of this study were selected as participants. The collected data were analyzed using SPSS Statistics 25.0 and Winsteps 3.68.2. Results: The communication skills (t = −12.80, p < .001) and clinical reasoning competency (t = −4.67, p < .001) of the undergraduate nursing students who participated in the virtual simulation-based learning program improved significantly after participation. Additionally, a Rasch model analysis revealed that the overall clinical reasoning competency of undergraduate nursing students improved. Conclusion: Virtual simulation-based learning programs for nursing students should be developed and implemented.
... Although D interactions are considered ideal due to their realism [7], they require more time and cost to develop. S interaction can sometimes be just as effective [44]. D is ideal for precision tasks, like assembling components by touching and aligning with natural behaviors. ...
Enhancing presence in mixed reality (MR) relies on precise measurement and quantification. While presence has traditionally been measured through subjective questionnaires, recent research links presence with objective metrics like reaction time. Past studies examined this correlation with varying technical factors (object realism and behavior) and human conditioning, but the impact of interaction remains unclear. To answer this question, we conducted a within-subjects study (N=50) to explore the correlation between presence and reaction time across two interaction scenarios (direct and symbolic) with two tasks (selection and manipulation). We found that presence scores and reaction times are correlated (correlation coefficient of ), suggesting that the impact of interaction on reaction time correlates with its effect on presence.
... 14,36,39 Prior studies have shown that simulation with repeated practice and feedback improves performance in behavior, skills, and knowledge, and improved performance can be translated to reallife practice. 20,[40][41][42][43][44][45][46][47][48][49][50][51] CED studies have shown that training improves adherence to a specific structure. Our study is the first to measure improvement in observable CED leadership behaviors, and ours is the first with sufficient power to detect improvement in individual elements of behavior. ...
Objectives
Clinical event debriefing (CED) improves healthcare team performance and patient outcomes. Most pediatric emergency medicine (PEM) physicians do not receive formal training in leading CED. Our objectives were to develop a CED curriculum and evaluate its effect on performance, knowledge, comfort, and clinical practice.
Methods
This was a single group pre-post-retention study. We developed a hybrid curriculum with simulation, an interactive module, and individual feedback. We invited faculty and fellows from the PEM division of our hospital to participate. During an in-person training day, participants led standardized clinical simulation scenarios followed by simulated CED with immediate feedback on their leadership performance. They watched an interactive module between scenarios. Participants returned for a retention assessment 2–6 months later with a third simulation and debrief. Participants completed surveys measuring attitudes, experiences, and knowledge. Participants also evaluated the curriculum.
The primary outcome was CED leadership performance using a novel 21-item tool that we developed, the Debrief Leadership Tool for Assessment (DELTA). A blinded, trained rater measured performance with DELTA. Secondary outcomes included changes in knowledge and comfort and changes in clinical practice.
Results
Twenty-seven participants enrolled and completed all parts of the curriculum and assessments. Debrief leadership performance improved by a mean of 3.7 points on DELTA pre-training to post-training (95% confidence interval = 2.7, 4.6, P < 0.01) and by 1.4 points from pre-training to retention (95% confidence interval = 0.1, 2.8, P = 0.03). Knowledge and comfort also significantly improved from pre-training to post-training and were sustained at retention. Most (67%) participants changed their clinical practice of CED after completing the curriculum. All participants would recommend the training to other PEM physicians.
Conclusions
A hybrid simulation-based curriculum in leading CED for PEM physicians was associated with improvement in CED leadership performance, knowledge, and comfort. PEM physicians incorporated training into their clinical practice.
... Two lines of evidence support this contention. First, Norman et al. 59 reviewed studies comparing lowand high-fidelity simulators for three domains-heart sounds, surgical skills, and critical care management and found no difference between high-and low-fidelity simulators. Similar findings have been reported by others in connection with learning contexts not specific to diagnostic skills. ...
Background
Accurate diagnosis in emergency medicine (EM) is high stakes and challenging. Research into physicians’ clinical reasoning has been ongoing since the late 1970s. The dual‐process theory has established itself as a valid model, including in EM. It is based on the distinction between two information‐processing systems. System 1 rapidly generates one or more diagnostic hypotheses almost instantaneously, driven by experiential knowledge, while System 2 proceeds more slowly and analytically, applying formal rules to arrive at a final diagnosis.
Methods
We reviewed the literature on dual‐process theory in the fields of cognitive science, medical education and emergency medicine.
Results and Conclusion
The literature reflects two prominent interpretations regarding the relationship between the fast and slow phases and these interpretations carry very different implications for the training of clinical learners. One interpretation, prominent in the EM community, presents it as a “check‐and‐balance” framework in which most diagnostic error is caused by cognitive biases originating within System 1. As a result, EM residents are frequently advised to deploy analytical (System 2) strategies to correct such biases. However, such teaching approaches are not supported by research into the nature of diagnostic reasoning. An alternative interpretation assumes a harmonious relationship between Systems 1 and 2 in which both fast and slow processes are driven by underlying knowledge that conditions performance and the occurrence of errors. Educational strategies corresponding to this alternative have not been explored in the EM literature. In this paper, we offer proposals for improving the teaching and learning of diagnostic reasoning by EM residents.
... The importance of the 'similarity principle' for transfer of learning has been highlighted by several cognitive psychologists, such as Thorndike [4]. However, the design of activities does not have to be from the real-world and be constructed with features that are similar to real world, such as with the use of low-technology simulation [40]. In addition, learners should be offered the opportunity of repeated practice, otherwise, they will likely forget the content or skill. ...
Transfer of learning occurs when past learning is applied to new situations, and also at a varying time from the initial time of learning. Importantly, research in both academic and clinical areas of health professions education has highlighted that transfer of learning often does not successfully occur. Successful transfer is multi-dimensional and occurs when the learner has the required motivation, mental model, metacognitive processes relevant to the task, and the opportunity to transfer their learning to different situations. An essential aspect of successful transfer is the educator. This Guide provides an overview of an integrated model of transfer that can inform a variety of practical teaching strategies in both academic and clinical areas of health professions education.
... El aprendizaje por simulación de alta fidelidad y el aprendizaje por simulación de baja fidelidad, mejoran el rendimiento cuando se comparan con grupos control que no se someten a ningún entrenamiento 14 . A este respecto, se debe señalar que en la mayoría de los estudios no se observa ninguna ventaja significativa de la simulación con alta fidelidad, sobre la simulación de baja fidelidad con diferencias medias que oscilan entre el 1 y el 2% 14 ; por lo que la propuesta de simulación en modelos biológicos, a pesar de considerarse de baja fidelidad, es una opción viable, siendo reproducible y accesible para la mayoría de las instituciones encargadas de la formación de médicos residentes. ...
Introducción: Los planes de residencia médica quirúrgicos enfrentan el dilema de los métodos de enseñanza tradicionales, que promueven la adquisición de habilidades y competencias por medio de prácticas “in vivo”. Al día de hoy, el proceso de aprendizaje para la práctica quirúrgica de la cirugía cardiaca no ha logrado consolidarse totalmente. El desarrollo de nuevas estrategias de enseñanza es necesario para la evolución de los planes de entrenamiento. Una opción viable es generar programas de simulación en modelos biológicos que se sumen a los planes de enseñanza tradicionales. Objetivo: Evaluar el impacto en el desarrollo de habilidades quirúrgicas de un programa de aprendizaje estructurado de técnicas de cirugía cardiaca en modelos biológicos porcinos en un grupo de residentes de cirugía cardiotorácica. Método: Se implementó un programa de simulación quirúrgica en modelos biológicos porcinos conformado por 20 sesiones teórico-prácticas, simulando la interacción entre cirujano y primer ayudante dentro de quirófano, guiados por un tutor y dos instructores. Se realizó una evaluación y análisis sobre el impacto del programa, en el desarrollo de habilidades y conocimientos adquiridos, al inicio y al término del programa. Resultados: Se realizaron 20 prácticas durante el ciclo académico, con 10 médicos residentes participantes, observándose una evolución favorable en las habilidades motrices de los asistentes evaluados al finalizar el programa, con una media en la calificación inicial de 18.8 (DS ±4.686), que evolucionó a 27.3 (DS ±2.003) de un total de 30 puntos al final del programa. Discusión: Con base en la evaluación del programa, se observó una mejoría en las habilidades quirúrgicas obtenidas por los médicos residentes. Conclusiones: El aprendizaje por simulación implica un proceso de práctica segura para los residentes y pacientes, que tiene un impacto positivo en el desarrollo de habilidades motrices.
... Additionally, students report increased feelings of control and positive mood and attitude after HFS El-hamid et al., 2021;Hansen et al., 2023). Advancements in science and technology for HFS allow mimicry of activities that more accurately resemble real patient situations (Huang et al., 2019;Norman et al., 2012). ...
Introduction
Rapid use of technologically driven simulation environment in teaching–learning has caused mixed feelings among students. High-fidelity simulation-based education is superior in cultivating the knowledge, skills, caring, learning interest, and collaboration among nursing students. However, the nursing students’ attitudes and perceptions toward high-fidelity simulation-based education are unexplored.
Objectives
The present study aims to explore the attitude and perception of undergraduate nursing students toward high-fidelity simulation-based education.
Methods
Cross-sectional survey research design was adopted. We used self-administered Education Practices Questionnaire (student version) and Attitude Scale toward Simulation-Based Education to collect the data. A total of 109 nursing students were recruited.
Results
Nursing student's attitude shows (mean = 68.26); perception on educational practices of high-fidelity simulation-based education demonstrates (M = 39.33 ± 7.87) and the importance of high-fidelity simulation-based education shows (M = 37.73 ± 7.45). However, no significant difference observed between the male and female student's attitude (t = −0.286 [0.78]) and perception (t [107] = 0.960 [0.34]). Similarly, no significant difference was observed among the different levels of students p > .005 on perception and attitude toward high-fidelity simulation-based education.
Conclusion
The study proposed to have high-fidelity simulation-based education as an integral part of teaching in clinical training of students at all levels of nursing program.
... For example, high-fidelity tools, although they increase satisfaction and motivation, if they are used disproportionately with the conditions, increase the cognitive load too much and can disrupt learning. 87,88 However, the level of learners is an important factor. 80 Some educators believe low-fidelity modalities (such as static models, lectures, and 2D images) are better for learning basic concepts in novice learners and higher-fidelity modalities are better for learning complex concepts and improving performance and skills in experienced learners. ...
Anatomy is the cornerstone of medical education. Virtual reality (VR) and augmented reality (AR) technologies are becoming increasingly popular in the development of anatomy education. Various studies have evaluated VR and AR in anatomy education. This meta‐analysis aims to evaluate the effectiveness of VR and AR in anatomical education. The protocol was registered in Prospero. Scopus, PubMed, Web of Science, and Cochrane Library databases were searched. From the 4487 articles gathered, 24 randomized controlled trials were finally selected according to inclusion criteria. According to the results of the meta‐analysis, VR had a moderate and significant effect on the improvement of knowledge scores in comparison with other methods (standardized mean difference = 0.58; 95% CI = 0.22, 0.95; p < 0.01). Due to the high degree of heterogeneity (I ² = 87.44%), subgroup analyses and meta‐regression were performed on eight variables. In enhancing the “attitude,” VR was found to be more “useful” than other methods (p = 0.01); however, no significant difference was found for “enjoyable” and “easy to use” statements. Compared with other methods, the effect of AR on knowledge scores was non‐significant (SMD = −0.02; 95% CI = −0.39, 0.34; p = 0.90); also, in subgroup analyses and meta‐regression, the results were non‐significant. The results indicate that, unlike AR, VR could be used as an effective tool for teaching anatomy in medical education. Given the observed heterogeneity across the included studies, further research is warranted to identify those variables that may impact the efficacy of VR and AR in anatomy education.
... In this sense, sport coaches might consider how their activity design might provide affective fidelity (the psycho-emotional similarity to competition), conceptual fidelity (the similarity of perceptual cognitive and problem-solving requirements), action fidelity (the similarity of the skills used in practice and skills used in performance) and physical fidelity (the extent to which training activity represents the physiological demands of competition) [33,[39][40][41] (see Table 1). It has previously been suggested that these 'types' of fidelity can complement or interfere with each other [42]. This framing provides a scaffold for coaches to consider how different types of fidelity might be used to elicit different impacts on athletes. ...
Multiple theoretical perspectives point to the need for sport coaches to be highly intentional in their practice. Semi-structured interviews were conducted with 17 high-level team sport coaches to investigate how they form intentions for impact; how these intentions influence planning for game-form activities; and how coaches judge success against these intentions. Data were subsequently analysed using reflexive thematic analysis, with eight themes being generated. Results suggest that coaches’ intentions could be viewed through the various components of fidelity. In this sense, it appeared that whilst coaches were concerned with notions like action fidelity, affective fidelity and conceptual fidelity, based on the measurement tools available, the predominant intention guiding practice was the physical fidelity of session design. These findings are discussed in relation to the increasing emphasis on the use of tools such as Global Positioning System technology and the apparent absence of markers that may inform other dimensions of activity design both in the short and long term. By considering the types and relative fidelity of practice, we can consider how we are challenging performers and what this might mean for transfer of training to performance. We conclude the paper by suggesting that future research should look to develop practical tools to help the coach consider different types of fidelity experienced by athletes.
... Likewise, early laparoscopic simulators confer high-fidelity simulation of the laparoscopic visual field. However, its fidelity is poor for suturing skills, which rely more on haptic feedback to "feel" the needle against the tissue (9). Understanding the concept of fidelity is fundamental because the concept underpins the design for mastery of learning via simulation. ...
Recently, the authors had a situation in a mobile chat group (WhatsApp) when a medical lecturer was asking what value a human papillomavirus (HPV) test adds to the pap smear for cervical cancer screening. The field experts in the group replied with detailed, erudite explanations. Soon after, another lecturer posted an answer from GPT-3 based chatbot. Despite needing more depth of an expert’s reply, the chatbot gave concise answers, reframing complex medical jargon in plain English without losing crucial medical information, and more. They were easier to understand. All these with the leisure of a human-like engagement. This narration is one of countless news related to ChatGPT, which have been making headlines, academic journals included, to illustrate how the large language model technology may have disrupted conventional educational practice. One discriminatory element distinguishes this technology from all its predecessors; it is not trying to mimic a human response but responding like a human. In this writing, we navigate discussion based on the most fundamental aspect of assessment, its purpose. We revisit the concept of fidelity from the field of simulation to explain how the technology may have rejuvenated the purpose of assessment for learning (formative assessment). Then, we articulate several associated challenges in the conduct of the high-stake assessment of learning (summative assessment). We conclude with an emphasis on the purposes as the guiding principles that remain the same despite the changes in the landscape on the conduct of the assessment.
... From the cognitive perspective, it is also suggested that the cognitive load of high fidelity practice may impede learning (Choi & Wong, 2019;Norman, Dore, & Grierson, 2012). Similarly, the unguided exploration of a complex learning environment may also be detrimental to learning (Paas, Renkl, & Sweller, 2003). ...
... Part-task trainers replicate part of the animal or an individual skill and are typically used for simple psychomotor skills, like knot tying or venipuncture (Maran & Glavin, 2003). It is important to note that in early training, low-fidelity models can be as effective in developing skills as highfidelity models (Norman et al., 2012). Low-fidelity models have the advantage of being cheaper and easier to make or purchase and are feasible in more resource-limited settings. ...
In 2021, the American Association of Veterinary Medical College’s (AAVMC) Board of Directors established a Task Force to develop Guidelines on the Use of Animals in Veterinary Education. The Task Force consisted of representatives from nine AAVMC member schools from four countries across three continents. The Guidelines, published online in October 2022, offered recommendations for schools on how to improve their animal use policies, use of animal alternatives, and transparency.While the Guidelines provided overarching principles and broad recommendations, the next step was to write a handbook to accompany the Guidelines, elaborating on how institutions could implement the Guideline’s recommendations, enabling them to support and promote humane and ethical animal use, guided by the 4 Rs: replacement, reduction, refinement, and respect. The editors worked with internationally recognized co-authors to create the Handbook. The Handbook’s 11 chapters align with the recommendations made in the Guidelines. Authors describe and share best practices for acquisition and use of cadavers; use and management of live animals including small, large, and exotic and zoological species; and highlight where alternatives can be deployed in meeting educational outcomes.The Guidelines and the AAVMC Handbook on the Use of Animals in Veterinary Education allow educators worldwide to review and, where appropriate, adjust their veterinary programs’ approaches and policies. The Guidelines and Handbook should be interpreted as guiding principles and are not meant to be prescriptive. Individual institutions are encouraged to consider their own unique institutional, national and regional circumstances.
... These betweensubjects designs are largely used to prepare students for administering standardized assessments rather than intervention and quantify student success using aggregated measures (e.g., overall confidence, self-efficacy, or percent accuracy) rather than examining individual types of skills (Broadfoot & Estis, 2020;Dudding & Nottingham, 2018;Moineau et al., 2018). Consequently, there is limited information about how students acquire different types of treatment skills and how an individual student can apply the skills learned during an SLE into real clinical practice (Norman et al., 2012;Ward et al., 2014;G. W. Wolford et al., 2021). ...
Purpose
Speech-language pathology programs use simulated learning experiences (SLEs) to teach graduate student clinicians about fidelity to therapeutic interventions, including static skills (clinical actions that are delivered in a prespecified way regardless of the client's behavior) and dynamic skills (contingent responses formulated in response to a client's behavior). The purpose of this study was to explore student learning of static and dynamic skills throughout SLEs and live clinical practice.
Method
Thirty-three speech-language pathology graduate students participated in this study. Students were first trained to deliver an intervention before having their treatment fidelity measured at three time points: an initial SLE, actual clinical practice, and a final SLE. Treatment fidelity was first summarized using an overall accuracy score and then separated by static and dynamic skills. We hypothesized that (a) overall accuracy would increase from the initial simulation to treatment but remain steady from treatment to the final simulation and that (b) students would acquire dynamic skills more slowly than static skills.
Results
In line with our hypotheses, students' overall accuracy improved over time. Although accuracy for static skills was mostly established after the first simulation, dynamic skills remained less accurate, with a slower acquisition timeline.
Conclusions
These results demonstrate that SLEs are efficacious in teaching students the clinical skills needed for actual clinical practice. Furthermore, we show that dynamic skills are more difficult for students to learn and implement than static skills, which suggests the need for greater attention to dynamic skill acquisition during clinical education.
... For example, the lower scores of ICUp in "correct chest compression place" expert scores (OB1) in the ST condition might be associated with their higher motivation to perform well on this task because CPR is a highly important skill in their specialty compared with non-ICUp. Additionally, it is worth considering the salience of collective identity (e.g., physician identity) and measuring and controlling for its influence in fu-healthcare professionals to perform effectively in challenging circumstances (21,22). Integrating these findings into medical curricula and training programs can ultimately contribute to the development of competent and confident healthcare professionals. ...
Objective: Stereotype threat (ST) can lead to decreased performance when individuals face the possibility of confirming negative stereotypes associated with their group. During the Coronavirus disease 2019 (COVID-19) pandemic, non-Intensive Care Unit physicians (non-ICUp) were assigned to work in ICUs. However, social media emphasized the inadequacy of knowledge and skills among these physicians. Given the negative judgments, the study aimed to evaluate the cardiopulmonary resuscitation (CPR) performances of these physicians and investigate the effect of ST. Methods: A total of 63 non-ICUp and 53 Intensive Care Unit physicians (ICUp) physicians working in COVID-19 ICUs were randomly assigned to control and experimental groups. In the experimental group, ST was manipulated by presenting the study’s aim as measuring the difference in CPR performances between ICUp and non-ICUp physicians. The control group received no information. Participants were videotaped while performing a standard CPR scenario and evaluated by independent instructors and mannequin scores. Results: Overall CPR scores were higher among ICUp. Non-ICUp performed better in the ST condition regarding effective chest compression (p=.02) and correct compression rates per minute (p=.02) compared to the control condition. However, ICUp had lower scores for correctly placing chest compressions in the ST condition (p=.03). Conclusion: The higher CPR performance among ICUp was expected. However, the hypothesis suggesting lower performance for non-ICUp under ST conditions was not supported. Inconsistent results regarding the ST effect could be influenced by moderating factors such as task difficulty, knowledge about the existing stereotype, and motivation to perform well. The interaction between the physicians’ specialty and situational factors highlights the importance of creating realistic training environments that simulate high-pressure situations, ultimately contributing to the development of competent and confident healthcare professionals. Future research should further explore the impact of ST-based training on interactions and performance among different healthcare professionals. Keywords: Stereotype threat, intensive care unit, cardiopulmonary resuscitation, CovId-19
... However, high-fidelity models have shown no significant advantage over low-fidelity models when measuring clinical performance. [42] It is more important to distinguish between the functional features, such as sensory and motor information processing, and structural features of simulation training. [43] Research has found that instrument and anatomical similarity, as well as movement patterns, are important factors for skill transfer, corresponding to functional features of the tasks. ...
Surgical training using the apprenticeship model of “see one, do one, teach one” originated with Halsted in the 19 th century and has continued forward. However, it may not be the most optimal and effective way to train clinicians. Simulation-based training emerged in recent decades and follows a stepwise approach starting with basic skills training, moving on to procedural training culminating in team training in an authentic environment. Simulation is used for specific and specialized skills training, deliberate practice, mastery of learning, and rapid knowledge acquisition, creating a structured teaching and learning framework. Simulation-based education programs must be embedded into a curriculum and should not be an optional add-on. Several curriculum design models exist. In this review, the five-phase ADDIE approach was used to inform a prototype curriculum. ADDIE is the acronym for analyze, design, develop, implement, and evaluate. It is used for systematic instructional design where knowledge and performance gaps have been identified and where every step in the design is dictated by the learning outcomes. The ADDIE model is an iterative instructional design where the results of the formative evaluation of each phase may lead to any of the previous phases. The process validates the procedures and products related to the development of learner-centered learning encounters and adds credibility by analyzing and evaluating procedures and interrelatedness. Sufficient evidence that simulation training improves individual and team performance is available. It has a positive effect on self-confidence, knowledge, and operational performance. Further evidence proves that deliberate practice, procedural simulation, and debriefing can be transferred to operational performance in clinical settings and could result in safer and more efficient care for patients, health-care providers, and health systems.
Background
Simulation‐based training has significantly improved healthcare professionals' skills and patient outcomes. Immersive virtual reality is gaining attention in this field and offers potential educational benefits. However, little is known about how key stakeholders in simulation‐based training and debriefing receive a complex intervention like immersive virtual reality. This study explores the enablers, barriers and applied debriefing strategies involved in using immersive virtual reality in simulation‐based training.
Methods
We purposefully sampled simulation centre directors, course leaders and researchers within debriefing, simulation‐based emergency training and immersive virtual reality. First, they observed and debriefed an online immersive virtual reality‐based emergency training. Then, they participated in an individual semi‐structured interview that was audio recorded and transcribed. We coded and analysed the data based on a reflexive thematic analysis method with a constructionist framing, guided by normalisation process theory as a theoretical lens. All co‐authors informed and validated the identified themes.
Results
We conducted 10 individual semi‐structured interviews and generated five main themes on factors that supported or impeded the normalisation of immersive virtual reality for simulation‐based training: understanding, engagement, strategies in action, appraisal and psychological safety.
Discussion
Immersive virtual reality contains unique challenges and potential for simulation‐based training. Its strengths and limitations should be carefully considered in relation to learning goals, the target group and context. This study explored the advantages and disadvantages of various immersive virtual reality features in relation to different learning objectives and proposed practical strategies for enhancing learning in immersive virtual reality simulation‐based training.
Background
Benign anorectal diseases such as haemorrhoids, perianal abscesses and fistulas are prevalent and disabling conditions that can be difficult to diagnose and treat.
This review aims to evaluate current education for training doctors around these diseases to inform the revision and development of surgical curricula.
Materials and methods
A literature search was conducted in MEDLINE, Embase and Google Scholar and data from included articles were charted in a semi-structured table. Quantitative outcomes were presented using simple descriptive statistics. Qualitative data were analysed using a reflexive thematic analysis framework.
Results
Ten studies were included. Most education was centred around haemorrhoids and delivered in the format of lectures and simulations. Harnessing the benefits of both on-demand and in-person content was key to optimising education delivery. In simulation studies, low-fidelity models were generally sufficient to meet educational objectives. There was universal agreement that the purpose of education was to supplement or prepare for clinical exposure, rather than to replace or ‘bridge gaps’ in experience. Education was found to be most useful and relevant when delivered to junior surgical or non-surgical cohorts.
Conclusions
This review elucidates gaps in current literature on benign anorectal disease education and provides recommendations for the development and implementation of future education for surgical trainees. There is a need for education that addresses a broader range of anorectal conditions and has a greater focus on the retention and clinical translation of acquired knowledge and skills. Interventions should be designed to enhance clinical exposure and maintain relevance throughout training progression.
Objectives
This pilot study assessed the feasibility of a virtual patient‐based learning (VPBL) platform as an educational tool to address insufficient clinical exposure to temporomandibular disorder (TMD) cases in predoctoral dental education.
Methods
The VPBL platform, developed with Articulate Storyline, featured 15 virtual patients (VPs) based on Diagnostic Criteria for TMD. In a two‐step study, 40 third‐ and fourth‐year dental students rated the platform's feasibility, acceptability, appropriateness, burden, and usability using standardized Likert‐based scales. In Cohort 1, 20 students (65.0% females; 26.9 ± 3.3 years old) evaluated the 15 VPs and provided feedback. Cohort 2‐study consisted of adjusting the VPs based on feedback from Cohort 1 and re‐piloting the cases on 20 randomly selected 4th‐year students (68.4% females; 26.8 ± 1.9 years old). Scores from Cohort 1 and Cohort 2 were compared using independent t‐tests; qualitative exit interviews were conducted on all participants.
Results
The Cohort 1 study revealed high ratings in acceptability (4.4 ± 0.5, range 1–5), appropriateness (4.4 ± 0.6, range 1–5), feasibility (4.2 ± 0.5, range 1–5), and usability (73.8 ± 15.2, range 0–100), with a minimal burden (the greatest being the difficulty of use, 1.9 ± 0.6, range 0–4). In the Cohort 2 study, the VPBL was adjusted according to feedback, and five additional VPs were created. Compared to the Cohort 1‐study, the modified‐VPBL obtained significantly higher scores in acceptability (4.8 ± 0.3, p = 0.015), appropriateness (4.7 ± 0.4, p = 0.035), feasibility (4.7 ± 0.4, p = 0.004), usability (83.6 ± 12.9, p = 0.034), and lower scores in difficulty of use (1.5 ± 0.3, p = 0.022).
Conclusions
The VPBL platform demonstrated feasibility as an educational tool for integration into the TMD curriculum for third‐ and fourth‐year dental students. These Phase I data provide scientific validation for more rigorous testing on a broader scale.
Introduction
Training for mass casualty incident (MCI) response is critical to ensure that resource allocation and treatment priorities limit preventable mortality. Previous research has investigated the use of immersive virtual environments as an alternative to high fidelity MCI training, which is expensive and logistically challenging to implement. While these have demonstrated positive early results, they still require complex technology deployment, dedicated training facilities, and significant time from instructors and facilitators. This study explores the feasibility of a smartphone-based application for trauma care training and MCI triage to fill the gap between classroom learning and high-fidelity simulation. The goals of this investigation were to evaluate clinician perceptions of a virtual MCI training simulator’s usability, acceptability, fidelity, functionality, and pacing.
Materials and Methods
This study used a smartphone-based training simulation called Extensible Field and Evacuation Care Training in a Virtual Environment (EFECTIVE), which presents virtual patient scenarios in a gamified, but visually high-fidelity environment. A total of 21 participants were recruited as a convenience sample of medical students, paramedics, nurses, and emergency medicine resident and attending physicians at University of Massachusetts Memorial Medical Center, an urban tertiary care medical center. Participants completed a brief tutorial and then performed a series of virtual patient scenarios and 1 MCI scenario on the simulator, each of which was 5 minutes in duration. Then, each participant completed a survey assessing the perceived usability, acceptability, fidelity, functionality, and pacing of the virtual training simulator. The research protocol was approved by the University of Massachusetts Chan Medical School Institutional Review Board.
Results
48% of participants disagreed that a virtual simulator could completely replace live MCI training, though 71% agreed that app-based simulations could effectively supplement live MCI training and 67% felt that they could be used to learn how to order medical interventions in care under fire scenarios. 80% of participants agreed that the simulation could be used to practice MCI triage and to gain experience with coordinating movement of casualties to casualty collection points. 67% of participants believed that use of virtual simulators would increase their MCI preparedness. 76% agreed that the clinical cases depicted were medically realistic and that the clinical cases presented accurately represented the scenarios described. In addition, despite being presented on a smartphone as opposed to virtual reality, 62% of participants rated the experience immersive.
Conclusions
This study provides encouraging evidence that easy to deploy smartphone–based simulations may be an effective way to supplement MCI and care under fire training. Although the study is limited by a small sample size, there was strong agreement among participants from a wide variety of emergency medicine roles that such a simulation could train core topics associated with MCI triage. Because app-based simulations are easily deployable and can be executed quickly and frequently, they could be used as a more flexible training model compared to large scale live or virtual reality–based simulations. The results of this investigation also indicate that a sufficient level of medical realism can be achieved without live simulation.
Introduction
Simulation is an effective teaching method with increasing growth and recognition and refers to the artificial representation of a real-life scenario. The aim of this study was to compare simulation with and without the use of a simulated observations monitor and to investigate differences in students’ impression of realism, engagement, learning, and enjoyment.
Methods
Simulation sessions were delivered to second and third-year Swansea University Medical Students, and a total of 15 students were included. Students carried out 2–3 scenarios each with and without the use of a simulated observations monitor. Data collection was conducted via student surveys and a joint interview.
Results
All students had an increased sense of realism with the use of the simulated observations monitor, feeling a closer resemblance to what would be experienced in clinical practice. They felt this improved their learning, making them more prepared for the real-life scenario. The monitor was more dynamic, responding to their interventions, helping them maintain focus and engagement throughout. A key theme was the reduction of interruptions or deviations from the scenario to communicate with the examiner or ask for observations. The visual and audible affects provided additional stimuli, adding to the realistic nature of the simulation.
Discussion
Simulation has been shown to be a useful education tool, but there is less evidence to support the use of higher fidelity over lower fidelity simulation. The terms are often used inconsistently, and many factors affect the students’ perceived sense of realism. This study shows that the addition of a simple device such as the simulated observations monitor can produce a higher level of fidelity, particularly in terms of the stimuli provided and student perceptions of realism, which may be effective in improving engagement with the simulation, learning, and aid recall when presented with similar scenarios in a real-life situation.
Objective
We evaluated the effectiveness of a consistent and structured self-practice coronary anastomosis program using a homemade low-fidelity beating-heart simulator.
Methods
An intermediary trainee was subjected to an 8-week structured self-practice program. The program was divided into 2 parts of nonbeating and beating practices with a minimum number of timed anastomoses. Each part was followed by an assessment using an objective skills assessment tool score. The beating-heart simulator was built using motorized toy blocks connected wirelessly to a smartphone application. This was coded to enable rate selection. A junior consultant was compared to the subject at the end of the program. Both were tasked to perform 1 coronary anastomosis for both off-pump coronary artery bypass (OPCAB) and minimally invasive CAB (MICS) setup. The primary outcomes were anastomotic time and score compared with the junior consultant. Secondary outcomes were progression of anastomotic time and score throughout the program.
Results
Overall performance of the studied subject approached the performance of the junior consultant in terms of time (OPCAB, 489 vs 605 s; MICS, 712 vs 652 s) and scores (OPCAB, 21 vs 20.7; MICS, 19 vs 20.6). There were inverse correlations between anastomosis time and number of practices for both nonbeating and beating anastomoses. Overall improvement was observed in terms of assessment scoring by 26.6%.
Conclusions
A structured self-practice program using an affordable and accessible simulator was able to help trainees overcome the MICS anastomosis learning curve quicker when introduced earlier. This may encourage earlier adoption of MICS among surgeons.
The education literature has explored various educational methods to combat didactic stagnation, as lecture styles from the last century are not as effective with contemporary learners. Medical education must adapt to continue engaging learners from the Millennial generation and Generation Z. While the thoughtful use of PowerPoint or other slide software continues to have a place in medical education, additional educational modalities exist with growing evidence supporting them. Low-stakes quizzing through gamification, flipped classroom approaches, and simulations are all useful educational methods to augment an emergency medicine curriculum for medical students and resident physicians. With a modest time investment on behalf of the educator and occasionally the learner, all these approaches can be implemented fairly easily in a current curriculum to refresh and enhance educational goals with very little monetary investment required.
Fetal blood scalp sampling (FBS) is a critical obstetrical procedure used to assess intrapartum fetal well-being. Unfortunately, standardized task trainers for training Obstetrics and Gynecology (OB-GYN) residents in this technique are currently lacking. In response to this gap, we present a cost-effective task trainer designed to assist trainees in mastering the art of performing FBS.
We provide a step-by-step guideline for the development of a cost-effective task trainer tailored for simulating FBS. Six OB-GYN residents underwent a structured theoretical session followed by practical training with the task trainer. Pre- and post-training questionnaires were administered to evaluate the simulator’s efficacy as an educational tool.
All participants acknowledged the task trainer’s efficacy in enhancing their understanding of the procedure, resulting in elevated knowledge and confidence across all assessed aspects. Furthermore, every participant endorsed the training for fellow trainees and “agreed or strongly agreed” that the simulator faithfully replicated the procedural experience.
This low-cost simulation model for FBS is a valuable training tool with high acceptance and satisfaction rates among participants. Its use has the potential to improve patient safety and increases participants confidence in performing the procedure.
This systematic review, following PRISMA standards, aimed to assess the effectiveness of higher versus lower fidelity simulation on health care providers engaged in team training. A comprehensive search from January 1, 2011 to January 24, 2023 identified 1390 studies of which 14 randomized (n = 1530) and 5 case controlled (n = 257) studies met the inclusion criteria. The certainty of evidence was very low due to a high risk of bias and inconsistency. Heterogeneity prevented any metaanalysis. Limited evidence showed benefit for confidence, technical skills, and nontechnical skills. No significant difference was found in knowledge outcomes and teamwork abilities between lower and higher fidelity simulation. Participants reported higher satisfaction but also higher stress with higher fidelity materials. Both higher and lower fidelity simulation can be beneficial for team training, with higher fidelity simulation preferred by participants if resources allow. Standardizing definitions and outcomes, as well as conducting robust cost-comparative analyses, are important for future research.
In recent years, simulators have emerged as powerful knowledge transfer tools in medicine, aviation, engineering, and many other industries. Simulators provide an immersive and interactive learning environment, and it allows users to gain practical experience and gain critical skills without requiring real-world resources or exposure to potential risk The use of simulators as digital proxies provide new learning opportunities characterized by applications, benefits, limitations and challenges which are discussed. On these bases, the future potential of simulators in transforming educational and training approaches is also considered.
Although technology-enhanced simulation has widespread appeal, its effectiveness remains uncertain. A comprehensive synthesis of evidence may inform the use of simulation in health professions education.
To summarize the outcomes of technology-enhanced simulation training for health professions learners in comparison with no intervention.
Systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011.
Original research in any language evaluating simulation compared with no intervention for training practicing and student physicians, nurses, dentists, and other health care professionals.
Reviewers working in duplicate evaluated quality and abstracted information on learners, instructional design (curricular integration, distributing training over multiple days, feedback, mastery learning, and repetitive practice), and outcomes. We coded skills (performance in a test setting) separately for time, process, and product measures, and similarly classified patient care behaviors.
From a pool of 10,903 articles, we identified 609 eligible studies enrolling 35,226 trainees. Of these, 137 were randomized studies, 67 were nonrandomized studies with 2 or more groups, and 405 used a single-group pretest-posttest design. We pooled effect sizes using random effects. Heterogeneity was large (I(2)>50%) in all main analyses. In comparison with no intervention, pooled effect sizes were 1.20 (95% CI, 1.04-1.35) for knowledge outcomes (n = 118 studies), 1.14 (95% CI, 1.03-1.25) for time skills (n = 210), 1.09 (95% CI, 1.03-1.16) for process skills (n = 426), 1.18 (95% CI, 0.98-1.37) for product skills (n = 54), 0.79 (95% CI, 0.47-1.10) for time behaviors (n = 20), 0.81 (95% CI, 0.66-0.96) for other behaviors (n = 50), and 0.50 (95% CI, 0.34-0.66) for direct effects on patients (n = 32). Subgroup analyses revealed no consistent statistically significant interactions between simulation training and instructional design features or study quality.
In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.
Many models of professional self-regulation call upon individual practitioners to take responsibility both for identifying the limits of their own skills and for redressing their identified limits through continuing professional development activities. Despite these expectations, a considerable literature in the domain of self-assessment has questioned the ability of the self-regulating professional to enact this process effectively. In response, authors have recently suggested that the construction of self-assessment as represented in the self-regulation literature is, itself, problematic. In this paper we report a pair of studies that examine the relationship between self-assessment (a global judgment of one's ability in a particular domain) and self-monitoring (a moment-by-moment awareness of the likelihood that one maintains the skill/knowledge to act in a particular situation). These studies reveal that, despite poor correlations between performance and self-assessments (consistent with what is typically seen in the self-assessment literature), participant performance was strongly related to several measures of self-monitoring including: the decision to answer or defer responding to a question, the amount of time required to make that decision to answer or defer, and the confidence expressed in an answer when provided. This apparent divergence between poor overall self-assessment and effective self-monitoring is considered in terms of how the findings might inform our understanding of the cognitive mechanisms yielding both self-monitoring judgments and self-assessments and how that understanding might be used to better direct education and learning efforts.
Cardiac auscultation is a core clinical skill. However, prior studies show that trainee skills are often deficient and that clinical experience is not a proxy for competence.
To describe a mastery model of cardiac auscultation education and evaluate its effectiveness in improving bedside cardiac auscultation skills.
Untreated control group design with pretest and posttest.
Third-year students who received a cardiac auscultation curriculum and fourth year students who did not.
A cardiac auscultation curriculum consisting of a computer tutorial and a cardiac patient simulator. All third-year students were required to meet or exceed a minimum passing score (MPS) set by an expert panel at posttest.
Diagnostic accuracy with simulated heart sounds and actual patients.
Trained third-year students (n = 77) demonstrated significantly higher cardiac auscultation accuracy compared to untrained fourth year students (n = 31) in assessment of simulated heart sounds (93.8% vs. 73.9%, p < 0.001) and with real patients (81.8% vs. 75.1%, p = 0.003). USMLE scores correlated modestly with a computer-based multiple choice assessment using simulated heart sounds but not with bedside skills on real patients.
A cardiac auscultation curriculum consisting of deliberate practice with a computer-based tutorial and a cardiac patient simulator resulted in improved assessment of simulated heart sounds and more accurate examination of actual patients.
Simulation-based education improves procedural competence in central venous catheter (CVC) insertion. The effect of simulation-based education in CVC insertion on the incidence of catheter-related bloodstream infection (CRBSI) is unknown. The aim of this study was to determine if simulation-based training in CVC insertion reduces CRBSI.
This was an observational education cohort study set in an adult intensive care unit (ICU) in an urban teaching hospital. Ninety-two internal medicine and emergency medicine residents completed a simulation-based mastery learning program in CVC insertion skills. Rates of CRBSI from CVCs inserted by residents in the ICU before and after the simulation-based educational intervention were compared over a 32-month period.
There were fewer CRBSIs after the simulator-trained residents entered the intervention ICU (0.50 infections per 1000 catheter-days) compared with both the same unit prior to the intervention (3.20 per 1000 catheter-days) (P = .001) and with another ICU in the same hospital throughout the study period (5.03 per 1000 catheter-days) (P = .001).
An educational intervention in CVC insertion significantly improved patient outcomes. Simulation-based education is a valuable adjunct in residency education.
Recognition memory for words was tested in same or different contexts using the remember/know response procedure. Context was manipulated by presenting words in different screen colors and locations and by presenting words against real-world photographs. Overall hit and false-alarm rates were higher for tests presented in an old context compared to a new context. This concordant effect was seen in both remember responses and estimates of familiarity. Similar results were found for rearranged pairings of old study contexts and targets, for study contexts that were unique or were repeated with different words, and for new picture contexts that were physically similar to old contexts. Similar results were also found when subjects focused attention on the study words, but a different pattern of results was obtained when subjects explicitly associated the study words with their picture context. The results show that subjective feelings of recollection play a role in the effects of environmental context but are likely based more on a sense of familiarity that is evoked by the context than on explicit associations between targets and their study context.
This study examines whether technical skills learned on a bench model are transferable to the human cadaver model.
Twenty-three first-year residents were randomly assigned to three groups receiving teaching on six procedures. For each procedure, one group received training on a cadaver model, one received training on a bench model, and one learned independently from a prepared text. Following training, all residents were assessed on their ability to perform the six procedures.
Repeated measures analysis of variance revealed a significant effect of training modality for both checklist scores (F(2,44) = 3.49, P <0.05) and global scores (F(2,44) = 7.48, P <0.01). Post-hoc tests indicated that both bench and cadaver training were superior to text learning and that bench and cadaver training were equivalent.
Training on a bench model transfers well to the human model, suggesting strong potential for transfer to the operating room.
Changes in medical practice that limit instruction time and patient availability, the expanding options for diagnosis and management, and advances in technology are contributing to greater use of simulation technology in medical education. Four areas of high-technology simulations currently being used are laparoscopic techniques, which provide surgeons with an opportunity to enhance their motor skills without risk to patients; a cardiovascular disease simulator, which can be used to simulate cardiac conditions; multimedia computer systems, which includes patient-centered, case-based programs that constitute a generalist curriculum in cardiology; and anesthesia simulators, which have controlled responses that vary according to numerous possible scenarios. Some benefits of simulation technology include improvements in certain surgical technical skills, in cardiovascular examination skills, and in acquisition and retention of knowledge compared with traditional lectures. These systems help to address the problem of poor skills training and proficiency and may provide a method for physicians to become self-directed lifelong learners.
Complex skills, such as ureteroscopy and stone extraction, are increasingly taught to novice urology trainees using bench models in surgical skills laboratories. We determined whether hands-on training improved the performance of novices more than those taught only by a didactic session and whether there was a difference in the performance of subjects taught on a low versus a high fidelity model.
We randomized 40 final year medical students to a didactic session or 1 of 2 hands-on training groups involving low or high fidelity bench model practice. Training sessions were supervised by experienced endourologists. Testing involved removal of a mid ureteral stone using a semirigid ureteroscope and a basket. Blinded examiners tested subjects before and after training. Performance was measured by a global rating scale, checklist, pass rating and time needed to complete the task.
There was a significant effect of hands-on training on endourological performance (p <0.01). With respect to bench model fidelity the low fidelity group did significantly better than the didactic group (p <0.05). However, no significant difference was found between the high and low fidelity groups (p >0.05). The low fidelity model cost Canadian 3,700 to purchase.
Hands-on training using bench models can be successful for teaching novices complex endourological skills. A low fidelity bench model is a more cost-effective means of teaching ureteroscopic skills to novices than a high fidelity model.
To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment.
The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study.
Sixteen surgical residents (PGY 1-4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80).
No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P <.007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P <.04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case; P <.008, Mann-Whitney test).
The use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.
1969 to 2003, 34 years.
Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus.
Review and synthesize existing evidence in educational science that addresses the question, 'What are the features and uses of high-fidelity medical simulations that lead to most effective learning?'.
The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the 'grey literature' were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality.
Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention.
Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol.
Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. HEADLINE RESULTS: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following: providing feedback--51 (47%) journal articles reported that educational feedback is the most important feature of simulation-based medical education; repetitive practice--43 (39%) journal articles identified repetitive practice as a key feature involving the use of high-fidelity simulations in medical education; curriculum integration--27 (25%) journal articles cited integration of simulation-based exercises into the standard medical school or postgraduate educational curriculum as an essential feature of their effective use; range of difficulty level--15 (14%) journal articles address the importance of the range of task difficulty level as an important variable in simulation-based medical education; multiple learning strategies--11 (10%) journal articles identified the adaptability of high-fidelity simulations to multiple learning strategies as an important factor in their educational effectiveness; capture clinical variation--11 (10%) journal articles cited simulators that capture a wide variety of clinical conditions as more useful than those with a narrow range; controlled environment--10 (9%) journal articles emphasized the importance of using high-fidelity simulations in a controlled environment where learners can make, detect and correct errors without adverse consequences; individualized learning--10 (9%) journal articles highlighted the importance of having reproducible, standardized educational experiences where learners are active participants, not passive bystanders; defined outcomes--seven (6%) journal articles cited the importance of having clearly stated goals with tangible outcome measures that will more likely lead to learners mastering skills; simulator validity--four (3%) journal articles provided evidence for the direct correlation of simulation validity with effective learning.
While research in this field needs improvement in terms of rigor and quality, high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings.
Simulation technology is widely used in medical education. Linking educational outcomes achieved in a controlled environment to patient care improvement is a constant challenge.
This was a retrospective case-control study of cardiac arrest team responses from January to June 2004 at a university-affiliated internal medicine residency program. Medical records of advanced cardiac life support (ACLS) events were reviewed to assess adherence to ACLS response quality indicators based on American Heart Association (AHA) guidelines. All residents received traditional ACLS education. Second-year residents (simulator-trained group) also attended an educational program featuring the deliberate practice of ACLS scenarios using a human patient simulator. Third-year residents (traditionally trained group) were not trained on the simulator. During the study period, both simulator-trained and traditionally trained residents responded to ACLS events. We evaluated the effects of simulation training on the quality of the ACLS care provided.
Simulator-trained residents showed significantly higher adherence to AHA standards (mean correct responses, 68%; SD, 20%) vs traditionally trained residents (mean correct responses, 44%; SD, 20%; p = 0.001). The odds ratio for an adherent ACLS response was 7.1 (95% confidence interval, 1.8 to 28.6) for simulator-trained residents compared to traditionally trained residents after controlling for patient age, ventilator, and telemetry status.
A simulation-based educational program significantly improved the quality of care provided by residents during actual ACLS events. There is a growing body of evidence indicating that simulation can be a useful adjunct to traditional methods of procedural training.
In this study, we compared two different training simulators (the computer screen-based simulator versus the full-scale simulator) with respect to training effectiveness in anesthesia residents. Participants were evaluated in the management of a simulated preprogrammed scenario of anaphylactic shock using two variables: treatment score and diagnosis time. Our results showed that simulators can contribute significantly to the improvement of performance but that learning in treating simulated crisis situations such as anaphylactic shock did not significantly vary between full-scale and computer screen-based simulators. Consequently, the initial decision on whether to use a full-scale or computer screen-based training simulator should be made on the basis of cost and learning objectives rather than on the basis of technical or fidelity criteria. Our results support the contention that screen-based simulators are good devices to acquire technical skills of crisis management. Mannequin-based simulators would probably provide better training for behavioral aspects of crisis management, such as communication, leadership, and interpersonal conflicts, but this was not tested in the current study.
Objective: To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. Summary Background Data: The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. Methods: Sixteen surgical residents (PGY 1–4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80). Results: No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P < .007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P < .04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case;P < .008, Mann-Whitney test). Conclusions: The use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.
This study examined and compared the effectiveness of videotape training versus hands-on instruction in preparing senior nursing students to respond to emergency clinical situations. Fourth year nursing students (n=27) were randomly assigned to one of three groups; one group received videotaped instruction, one group engaged in a hands-on experience, and one group, a control, received no instruction. Students were evaluated using a three-station objective structured clinical examination that involved high-fidelity simulations. Differences between the control and the two instructional groups were significant (p = .007); however, there was no significant difference between the two types of instruction. It was concluded that instruction on crisis management with a high-fidelity simulator, using either video or hands-on instruction, can result in a significant improvement in performance.
In a free recall experiment, divers learnt lists of words in two natural environments: on dry land and underwater, and recalled the words in either the environment of original learning, or in the alternative environment. Lists learnt underwater were best recalled underwater, and vice versa. A subsequent experiment shows that the disruption of moving from one environment to the other was unlikely to be responsible for context-dependent memory.
Despite limited data on patient outcomes, simulation training has already been adopted and embraced by a large number of medical schools. Yet widespread acceptance of simulation should not relieve us of the duty to demonstrate if, and under which circumstances, training learners on simulation benefits real patients. Here we review the data on performance of healthcare providers or trainees following simulation training, and discuss ways of enhancing transfer of learning from simulated to real patients. While there is tremendous potential for simulation in medical education and healthcare, further studies are needed to identify if and when simulation training improves the quality of care delivered to patients, and to compare the cost-effectiveness of simulated learning experiences to lower fidelity and less expensive interventions.
To evaluate the effectiveness of a novel, simulation-based educational model rooted in scaffolding theory that capitalizes on a systematic progressive sequence of simulators that increase in realism (i.e., fidelity) and information content.
Forty-five medical students were randomly assigned to practice intravenous catheterization using high-fidelity training, low-fidelity training, or progressive training from low to mid to high fidelity. One week later, participants completed a transfer test on a standardized patient simulation. Blinded expert raters assessed participants' global clinical performance, communication, procedure documentation, and technical skills on the transfer test. Participants' management of the resources available during practice was also recorded. Data were analyzed using multivariate analysis of variance. The study was conducted in fall 2008 at the University of Toronto.
The high-fidelity group scored higher (P < .05) than the low-fidelity group on all measures except procedure documentation. The progressive group scored higher (P < .05) than other groups for documentation and global clinical performance and was equivalent to the high-fidelity group for communication and technical skills. Total practice time was greatest for the progressive group; however, this group required little practice time on the resource-intensive high-fidelity simulator.
Allowing students to progress in their practice on simulators of increasing fidelity led to superior transfer of a broad range of clinical skills. Further, this progressive group was resource-efficient, as participants concentrated on lower fidelity and lower resource-intensive simulators. It is suggested that clinical training curricula incorporate exposure to multiple simulators to maximize educational benefit and potentially save educator time.
Simulation-based training is useful in improving physicians' skills. However, no randomized controlled trials have been able to demonstrate the effects of simulation teaching in real-life patient care. This study aimed to determine whether simulation-based training or an interactive seminar resulted in better patient care during weaning from cardiopulmonary bypass (CPB)-a high stakes clinical setting.
This study was conducted as a prospective, single-blinded, randomized controlled trial. After institutional research board approval, 20 anesthesiology trainees, postgraduate year 4 or higher, inexperienced in CPB weaning, and 60 patients scheduled for elective coronary artery bypass grafting were recruited. Each trainee received a teaching syllabus for CPB weaning 1 week before attempting to wean a patient from CPB (pretest). One week later, each trainee received a 2-h training session with either high-fidelity simulation-based training or a 2-h interactive seminar. Each trainee then weaned patients from CPB within 2 weeks (posttest) and 5 weeks (retention test) from the intervention. Clinical performance was measured using the validated Anesthesiologists' Nontechnical Skills Global Rating Scale and a checklist of expected clinical actions.
Pretest Global Rating Scale and checklist performances were similar. The simulation group scored significantly higher than the seminar group at both posttest (Global Rating Scale [mean +/- standard error]: 14.3 +/- 0.41 vs. 11.8 +/- 0.41, P < 0.001; checklist: 89.9 +/- 3.0% vs. 75.4 +/- 3.0%, P = 0.003) and retention test (Global Rating Scale: 14.1 +/- 0.41 vs. 11.7 +/- 0.41, P < 0.001; checklist: 93.2 +/- 2.4% vs. 77.0 +/- 2.4%, P < 0.001).
Skills required to wean a patient from CPB can be acquired through simulation-based training. Compared with traditional interactive seminars, simulation-based training leads to improved performance in patient care by senior trainees in anesthesiology.
Cognitive load theory aims to develop instructional design guidelines based on a model of human cognitive architecture. The architecture assumes a limited working memory and an unlimited long-term memory holding cognitive schemas; expertise exclusively comes from knowledge stored as schemas in long-term memory. Learning is described as the construction and automation of such schemas. Three types of cognitive load are distinguished: intrinsic load is a direct function of the complexity of the performed task and the expertise of the learner; extraneous load is a result of superfluous processes that do not directly contribute to learning, and germane load is caused by learning processes that deal with intrinsic cognitive load.
This paper discusses design guidelines that will decrease extraneous load, manage intrinsic load and optimise germane load.
Fifteen design guidelines are discussed. Extraneous load can be reduced by the use of goal-free tasks, worked examples and completion tasks, by integrating different sources of information, using multiple modalities, and by reducing redundancy. Intrinsic load can be managed by simple-to-complex ordering of learning tasks and working from low- to high-fidelity environments. Germane load can be optimised by increasing variability over tasks, applying contextual interference, and evoking self-explanation. The guidelines are also related to the expertise reversal effect, indicating that design guidelines for novice learners are different from guidelines for more experienced learners. Thus, well-designed instruction for novice learners is different from instruction for more experienced learners. Applications in health professional education and current research lines are discussed.
This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.
This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969-2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003-2009.
The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.
Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.
Prior research has demonstrated that residents have poor clinical skills in cardiology and respirology. It is not clear how these skills can be improved because the number of patients with suitable clinical findings whose cooperation might help residents to better develop these clinical skills is limited. Objectives Our objective was to evaluate the effect of training on a cardiorespiratory simulator (CRS) on skills acquisition, retention and transfer.
We randomly allocated 146 students to CRS training in either chest pain or dyspnoea and compared each student's performance on the clinical presentation in which he or she had received CRS training with performance on the control presentation.
Immediately after training, students were more accurate in identifying abnormal clinical findings on the CRS (70.0% versus 52.2%; d = 7.6, P < 0.0001) and showed improved diagnostic performance (72.1% versus 55.6%; d = 4.3, P = 0.0007) on the training clinical presentation. At the end of the course they were still better at identifying abnormal findings (57.1% versus 51.7%; d = 2.5, P = 0.004) and diagnosing correctly (50.0% versus 38.1%; d = 3.0, P = 0.002) on problems included in the training clinical presentation. However, they showed no difference between training and control presentations in diagnostic performance when required to transfer their skills between problems (45.9% versus 43.8%; P = 0.5) or in performance on multiple-choice questions (64.1% versus 63.6%; P = 0.8).
Students can acquire and retain clinical skills with CRS training, but demonstrate limited ability to transfer these to other problems. Further studies are needed to explore ways of improving learning and transfer with CRS training.
Context:
Although there are increasing numbers of studies of outcomes of high-fidelity patient simulators, few contrast their instruction with that provided by equivalent low-fidelity, inexpensive simulators. Further, examination of decays in learning and application (transfer) to real patient problems is rare. In this study, we compared the effects of training using a high-fidelity heart sound simulator (Harvey) and a low-fidelity simulator (a CD) on recognition of both simulated heart sounds and those in actual patients.
Methods:
A pilot study with 10 students was conducted to show the feasibility of the methods and some evidence of modality-specific learning (the Harvey-trained group scored 72% correct on Harvey and 36% correct on CD test examples; the CD-trained group scored 60% correct on both CD and Harvey test examples). A main study was then initiated involving 37 Year 3 medical students from the University of Leeds. They received 1 hour of common instruction, after which one group received 3 hours of specific instruction on Harvey. The second group received 3 hours of instruction using a CD. Six weeks later, both groups were tested blind with real patients with stable heart sounds. Stations were observed by an examiner who scored communication skills and examination skills using 5-point scales.
Results:
The Harvey-trained group was slightly but not significantly better than the CD-trained group at identifying heart sounds (3.11 versus 2.47, respectively; P = 0.06). However, there was no difference between the Harvey and CD-trained groups in diagnosis (2.94 versus 2.84, respectively), communication skills (18.9 versus 19.6, respectively) or examination skills (17.4 versus 17.5, respectively).
Conclusions:
The study found little evidence that students trained with a high-fidelity simulator were more able to transfer skills to real patients than a control group. Although there was some suggestion that the Harvey-trained group was better at recognising heart sounds, there was no difference between groups in diagnostic accuracy or clinical skills.
Previous studies have indicated that fiberoptic orotracheal intubation (FOI) skills can be learned outside the operating room. The purpose of this study was to determine which of two educational interventions allows learners to gain greater capacity for performing the procedure.
Respiratory therapists were randomly assigned to a low-fidelity or high-fidelity training model group. The low-fidelity group was guided by experts, on a nonanatomic model designed to refine fiberoptic manipulation skills. The high-fidelity group practiced their skills on a computerized virtual reality bronchoscopy simulator. After training, subjects performed two consecutive FOIs on healthy, anesthetized patients with predicted "easy" intubations. Each subject's FOI was evaluated by blinded examiners, using a validated global rating scale and checklist. Success and time were also measured.
Data were analyzed using a two-way mixed design analysis of variance. There was no significant difference between the low-fidelity (n = 14) and high-fidelity (n = 14) model groups when compared with the global rating scale, checklist, time, and success at achieving tracheal intubation (all P = not significant). Second attempts in both groups were significantly better than first attempts (P < 0.001), and there was no interaction between "fidelity of training model" and "first versus second attempt" scores.
There was no added benefit from training on a costly virtual reality model with respect to transfer of FOI skills to intraoperative patient care. Second attempts in both groups were significantly better than first attempts. Low-fidelity models for FOI training outside the operating room are an alternative for programs with budgetary constraints.
A total of 208 fourth-year students at five medical schools participated in an evaluation of a cardiology patient simulator (CPS). One group (116 students) used the CPS during a fourth-year cardiology elective, while another group (92 students) completed a cardiology elective that did not include use of the CPS. There were no differences between the two groups on a multiple-choice test on cardiology and a skills test on the CPS at the beginning of the clerkship. After the clerkship, the students in the CPS group achieved significantly higher scores on a multiple-choice test, a skills test on the CPS, and a skills test on cardiology patients. Both the students and faculty members expressed very favorable attitudes toward the CPS, but the patients perceived no differences between the two student groups. These data demonstrate that the CPS enhances learning both the knowledge and the skills necessary to perform a bedside cardiovascular evaluation and that the skills obtained from use of the simulator are transferable to use with patients.
No abstract available. (C) 1999 Association of American Medical Colleges
One of the most remarkable changes in aviation training over the past few decades is the use of simulation. The capabilities now offered by simulation have created unlimited opportunities for aviation training. In fact, aviation training is now more realistic, safe, cost-effective, and flexible than ever before. However, we believe that a number of misconceptions--or invalid assumptions--exist in the simulation community that prevent us from fully exploiting and utilizing recent scientific advances in a number of related fields in order to further enhance aviation training. These assumptions relate to the overreliance on high-fidelity simulation and to the misuse of simulation to enhance learning of complex skills. The purpose of this article is to discuss these assumptions in the hope of initiating a dialogue between behavioral scientists and engineers.
The availability of simulator technology at the University of Toronto (Toronto, Ontario, Canada) provided the opportunity to compare the efficacy of video-assisted and simulator-assisted learning.
After ethics approval from the University of Toronto, all final-year medical students were invited to participate in the current randomized trial comparing video-based to simulator-based education using three scenarios. After an introduction to the simulator environment, a 5-min performance-based pretest was administered in the simulator operating room requiring management of a critical event. A posttest was administered after students had participated in either a faculty-facilitated video or simulator teaching session. Standardized 12-point checklist performance protocols were used for assessment purposes. As well, students answered focused questions related to the educational sessions on a final examination. Student opinions regarding the value of the teaching sessions were obtained.
One hundred forty-four medical students participated in the study (scenario 1, n = 43; scenario 2, n = 48; scenario 3, n = 53). There was a significant improvement in posttest scores over pretest scores in all scenarios. There was no statistically significant difference in scores between simulator or video teaching methods. There were no differences in final examination marks when the two educational methods were compared. Student opinions indicated that the experiential simulator sessions were more enjoyable and valuable than the video teaching sessions.
Both simulator and video types of faculty-facilitated education offer a valuable learning experience. Future work is needed that addresses the long-term effects of experiential learning in the retention of knowledge and acquired skills.
Unlabelled:
In this study, we compared two different training simulators (the computer screen-based simulator versus the full-scale simulator) with respect to training effectiveness in anesthesia residents. Participants were evaluated in the management of a simulated preprogrammed scenario of anaphylactic shock using two variables: treatment score and diagnosis time. Our results showed that simulators can contribute significantly to the improvement of performance but that learning in treating simulated crisis situations such as anaphylactic shock did not significantly vary between full-scale and computer screen-based simulators. Consequently, the initial decision on whether to use a full-scale or computer screen-based training simulator should be made on the basis of cost and learning objectives rather than on the basis of technical or fidelity criteria. Our results support the contention that screen-based simulators are good devices to acquire technical skills of crisis management. Mannequin-based simulators would probably provide better training for behavioral aspects of crisis management, such as communication, leadership, and interpersonal conflicts, but this was not tested in the current study.
Implications:
We compared two different training simulators (computer screen-based versus full-scale) for training anesthesia residents to better document the effectiveness of such devices as training tools. This is an important issue, given the extensive use and the high cost of mannequin-based simulators in anesthesiology.
To examine the effect of instructional format on medical students' learning of ECG diagnosis.
Two experiments employed different learning and practice methods. In the first, students were randomly allocated to one of two instructional approaches, one organized around features (e.g., QRS voltage) and the other around diagnostic categories (e.g., bundle branch blocks), followed by a practice phase. In the second experiment, the instruction was standardized, and students were randomly allocated to one of two practice phases, either "contrastive" where examples from various categories are mixed together, or "non-contrastive" where all the examples in a single category are practiced in a single block.
In the first experiment, there was no significant differences in students' diagnostic accuracy on novel ECG examples. In the second experiment, students exposed to the contrastive approach in the practice phase had superior diagnostic accuracy (46%) compared to 30% accuracy for the non-contrastive session, p < 0.05).
These experiments highlight two important features in the design of instructional materials. First, learning around the features of the problem (analogous to problem-based learning) may have no advantages over learning the category. Second, the design and organization of deliberate practice can result in significant learning gain.
Simulation-based testing methods have been developed to meet the need for assessment procedures that are both authentic and well-structured. It is widely acknowledged that, although the authenticity of a procedure may be a contributing factor to its validity, authenticity alone never is a sufficient factor.
In this paper we describe the mainstream development of various simulation-based approaches, with their strengths and weaknesses. The purpose is not to provide a review based on an extensive meta-analysis but to present crucial factors in the development of these methods and their implications for current and future developments.
The description of these simulation-based instruments uses a subdivision according to the layers of Miller's pyramid. Written and computer-based simulations are aimed at measuring the 'knows how' layer, observation-based techniques such as standardised patient-based examinations and objective structured clinical examinations target the 'shows how' layer and performance practice measures assess performance at the 'does' layer.
In all simulations, case specificity was found to pose the most prominent threat to reliability, while too much structure threatened to trivialise the assessment. The conclusion is that authentic and reliable assessment is predicated on a wise balance between efficiency and adequate content sampling.
Context:
Changes in medical training and culture have reduced the acceptability of the traditional apprenticeship style training in medicine and influenced the growth of clinical skills training. Simulation is an educational technique that allows interactive, and at times immersive, activity by recreating all or part of a clinical experience without exposing patients to the associated risks. The number and range of commercially available technologies used in simulation for education of health care professionals is growing exponentially. These range from simple part-task training models to highly sophisticated computer driven models.
Aim:
This paper will review the range of currently available simulators and the educational processes that underpin simulation training. The use of different levels of simulation in a continuum of training will be discussed. Although simulation is relatively new to medicine, simulators have been used extensively for training and assessment in many other domains, most notably the aviation industry. Some parallels and differences will be highlighted.
Virtual reality (VR) simulators now have the potential to replace traditional methods of laparoscopic training. The aim of this study was to compare the VR simulator with the classical box trainer and determine whether one has advantages over the other.
Twenty four novices were tested to determine their baseline laparoscopic skills and then randomized into the following three group: LapSim, box trainer, and no training (control). After 3 weekly training sessions lasting 30-min each, all subjects were reassessed. Assessment included motion analysis and error scores. Nonparametric tests were applied, and p < 0.05 was deemed significant.
Both trained groups made significant improvements in all parameters measured ( p < 0.05). Compared to the controls, the box trainer group performed significantly better on most of the parameters, whereas the LapSim group performed significantly better on some parameters. There were no significant differences between the LapSim and box trainer groups.
LapSim is effective in teaching skills that are transferable to a real laparoscopic task. However, there appear to be no substantial advantages of one system over the other.
To evaluate the impact of bench model fidelity on the acquisition of technical skill using clinically relevant outcome measures.
Fifty junior surgery residents participated in a 1-day microsurgical training course. Participants were randomized to 1 of 3 groups: 1) high-fidelity model training (live rat vas deferens; n = 21); 2) low-fidelity model training (silicone tubing; n = 19); or 3) didactic training alone (n = 10). Following training, all participants were assessed on the high- and low-fidelity bench models. Immediate outcome measures included procedure times, blinded, expert assessment of videotaped performance using checklists and global rating scales, anastomotic patency, suture placement precision, and final product ratings. Delayed outcome measures (obtained from the live rat vas deferens 30 days following training) included anastomotic patency, presence of a sperm granuloma, and the presence of sperm on microscopy.
Following training, checklist (P < 0.001) and global rating scores (P < 0.001) on the bench model simulators were higher among subjects who received hands-on training, irrespective of model fidelity. Immediate anastomotic patency rates of the rat vas deferens were higher with increasing model fidelity training (P = 0.048). Delayed anastomotic patency rates were higher among subjects who received bench model training, irrespective of model fidelity (P = 0.02). Rates of sperm presence on microscopy were higher among subjects who received high-fidelity model training compared with subjects who received didactic training (P = 0.039) but did not differ among subjects in the high- and low-fidelity groups.
Surgical skills training on low-fidelity bench models appears to be as effective as high-fidelity model training for the acquisition of technical skill among novice surgeons.
The ability to perform clinical procedures safely is a key skill for health care professionals. Performing such procedures on conscious patients is challenging and requires a combination of technical and communication skills. We have developed quasi-clinical scenarios, where inanimate models attached to simulated patients provide a convincing learning environment. Procedures are rated by expert observers and by the 'patient' and recorded for subsequent review. This study explores the potential of locating such scenarios within a real clinical setting, allowing participants to experience the challenges of the workplace while ensuring patient safety. An innovative portable digital recording device (the 'Virtual Chaperone') is evaluated for use in clinical settings.
A qualitative design (observation and interview studies) investigated volunteer medical students undertaking 2 procedure scenarios (insertion of urinary catheter and wound closure with sutures) within the accident unit of a large London hospital. All procedures were observed in real time and recorded digitally (using the Virtual Chaperone). A protocol was used for structured feedback. Observational and interview data was analysed using standard qualitative techniques.
Seven sessions with 22 undergraduate medical students took place over 9 months within 1 centre. Data confirmed the feasibility of using a moveable, self-contained training scenario within an authentic clinical setting. Overall, the response from participants was positive.
Scenario-based teaching within an authentic clinical environment is feasible and perceived by participants to be educationally useful. This approach blurs traditional boundaries between skills laboratory teaching and clinical practice and may offer considerable advantages in training for clinical procedures.
This study assessed the effects of learning laparoscopic knot-tying through a series of progressively more difficult steps versus learning the skill in full complexity.
Junior residents (N = 24) practiced either (1) suturing in full complexity under 2-dimensional conditions or (2) simple cone transfer drills under 3-dimensional and then 2-dimensional conditions, followed by suturing under 3-dimensional and then 2-dimensional conditions. Pre-, post-, and delayed (1 week) laparoscopic suturing performances were assessed by using objective motion efficiency variables and final product analyses.
Both groups showed similar improvements on all measures, which were well retained over the 1-week period (P < .01).
Despite spending less time practicing actual suturing, the group of residents who progressed through the sequence of steps performed as well as those who practiced the entire task in its full complexity, a finding that has implications for minimizing teaching resources and training costs.
Although there is growing evidence that practice on bench model simulators can improve the acquisition of technical skill in surgery, the degree to which these models have to approximate real-world conditions (model fidelity) to optimize learning is unclear. Previous research suggests that low-fidelity models may be adequate for novice learners. The purpose of this study was to assess the effect of model fidelity and surgical expertise on the acquisition of vascular anastomosis skill.
Twenty-seven surgical residents participated in this institutional review board-approved study. Junior residents (postgraduate year 1 and 2) and senior residents (postgraduate year 4 or higher) were randomized into two groups: low-fidelity (n = 13) and high-fidelity (n = 14) model training. Both groups were given a 3-hour hands-on training session: the low-fidelity group used plastic models, and the high-fidelity group used human cadaver arms (brachial arteries) to practice graft-to-arterial anastomosis. One week later, all subjects participated in an animal laboratory in which they performed a single vascular anastomosis on a live, anesthetized pig (femoral artery). A blinded vascular surgeon scored candidate performance in the animal laboratory by using previously validated end points, including a checklist and final product analysis score.
Acquisition of skill was significantly affected by model fidelity and level of training as measured by both the checklist (P = .03) and final product analysis (P = .01; Kruskal-Wallis). Specifically, junior residents practicing on high-fidelity models scored better on the checklist (P = .05) and final product analysis (P = .04). Senior residents practicing on high-fidelity models scored better on final product analysis (P < .05).
Training in the laboratory does improve skill when assessed in a realistic setting. Both expertise groups showed better skill transfer from the bench model to live animals when practicing on high-fidelity models. For vascular anastomosis, it is important to provide appropriate model fidelity for trainees of different abilities to optimize the effectiveness of bench model training.
Simulation-based teaching (SBT) is increasingly used in medical education. As an alternative to other teaching methods there is a lack of evidence concerning its efficacy. The aim of this study was to evaluate the potency of SBT in anesthesia in comparison to problem-based discussion (PBD) with students in a randomized controlled setting. Thirty-three fourth-year medical students attending a curricular anesthesiology course were randomly allocated to either a session of SBT or a session of PBD on an emergency induction method. Ten days later all students underwent examination in a simulator. The performance of each student was evaluated by weighted tasks, established according to a modified Delphi process. Confidence and a multiple-choice questionnaire were additionally performed pre- and post-intervention. A total of 32 students completed the study. Participants in the SBT group presented with significantly higher self-assessment scores after the intervention than students in the PBD group. However, students in the SBT group achieved only slightly and statistically insignificantly higher scores in the theoretical and simulator examination (p > 0.05) with only a moderate effect size of d = 0.52. The current study demonstrates that both PBD and SBT lead to comparable short-term outcomes in theoretical knowledge and clinical skills. However, undesirably, SBT students overrated their anticipated clinical abilities and knowledge improvement.
High-stakes assessments of doctors' physical examination skills often employ standardised patients (SPs) who lack physical abnormalities. Simulation technology provides additional opportunities to assess these skills by mimicking physical abnormalities. The current study examined the relationship between internists' cardiac physical examination competence as assessed with simulation technology compared with that assessed with real patients (RPs).
The cardiac physical examination skills and bedside diagnostic accuracy of 28 internists were assessed during an objective structured clinical examination (OSCE). The OSCE included 3 modalities of cardiac patients: RPs with cardiac abnormalities; SPs combined with computer-based, audio-video simulations of auscultatory abnormalities, and a cardiac patient simulator (CPS) manikin. Four cardiac diagnoses and their associated cardiac findings were matched across modalities. At each station, 2 examiners independently rated a participant's physical examination technique and global clinical competence. Two investigators separately scored diagnostic accuracy.
Inter-rater reliability between examiners for global ratings (GRs) ranged from 0.75-0.78 for the different modalities. Although there was no significant difference between participants' mean GRs for each modality, the correlations between participants' performances on each modality were low to modest: RP versus SP, r = 0.19; RP versus CPS, r = 0.22; SP versus CPS, r = 0.57 (P < 0.01).
Methodological limitations included variability between modalities in the components contributing to examiners' GRs, a paucity of objective outcome measures and restricted case sampling. No modality provided a clear 'gold standard' for the assessment of cardiac physical examination competence. These limitations need to be addressed before determining the optimal patient modality for high-stakes assessment purposes.
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