Abstracts

Background: In Australia, numbers of health professional students have increased significantly placing pressure on traditional approaches to learning in clinical placements (2). Simulation may provide a solution; as well as enhancing current educational practices.

Methods: The complexity of the project required diverse methodologies: a literature review; in-depth interviews with key informants in each medical school; a survey based on the Australian Curriculum Framework for Junior Doctors (ACFJD) (3); and focus groups. Descriptive statistics and thematic analysis were used to analyse data.

Results: All eighteen Australian medical schools participated in this study. Simulation is widely used with variable quality, quantity and timing, reflecting the diversity of medical school curricula and learning environments. There is at least some use of simulation across all competency, skills and procedure domains in the ACFJD. Most frequent use of simulation was for: emergencies (average 72% of the domain across all medical schools); patient assessment (63%); patient interaction (67%); and skills and procedures (51%). Domains that respondents considered would benefit from increased use of simulation included: emergencies (66%); patient assessment (56%); working in teams (56%); safe patient care (54%); and patient interaction (53%). Six themes emerged from the data: accepting simulation as part of the curriculum; balancing clinical and simulation education; ensuring simulation is fit for purpose; learning first in simulation; integrating simulation into curricula; and using simulation for interprofessional education. Enablers and constraining factors were identified in the following areas: ensuring access, equity and managing logistics; managing simulation centres; capital and recurrent funding; providing physical, human and organisational resources; sustainability of simulation in the curriculum. Generally, access to resources was a significant factor in the provision of simulation education. Specifically, human resources were seen as critical to the development, implementation and evaluation of simulation education.

Conclusions: Simulation, currently being used in all medical school curricula, has potential to address some challenges associated with provision of high quality medical education in contemporary contexts of healthcare service and education.

Acknowledgements: Health Workforce Australia, Brooks P, Watson M, Flanagan B, McMenamin C This abstract has also been submitted to the Asia-Pacific Meeting on Simulation in Healthcare 2011.

References:

1. http://www.hwa.gov.au/grants/rfp
2. Eley DS, Young L, Wilkinson D, Charter A, Baker P: Coping with increasing numbers of medical students in rural clinical schools: options and opportunities. MJA 2008, 188(11):669-671.
3. Graham I, Gleason A, Keogh G, Paltridge D, Rogers I, Walton M, De Paola C, Singh J, McGrath B: Australian curriculum framework for junior doctors. MJA 2007, 186(7):S14-S19.

Aims: To assess whether the introduction of a teaching program that includes the use of simulation for medical students at the beginning of a clinical rotation leads to: – a reduction in time required to display skill competency, as measured by a current standardised exam, the Objective Structured Clinical Examination (OSCE). Additional aims included evaluation of participant's level of engagement, learning strategies and awareness of gaps in their knowledge, skill and attitudes.

Background: “The challenge for all medical schools is to develop a curriculum which, while not neglecting the transmission of factual knowledge and practical skills, also stimulates enquiry, develops analytical ability and encourages the development of desirable professional attitudes in the students” (AMC 2002 assessment and accreditation of medical schools). The CPEP course was designed to use different interactive education modalities, including simulation, to optimize the delivery of two core medical school subjects – cardiovascular and respiratory medicine.

Method: The study was designed as a randomised control trial between two groups of medical students from one clinical school. Both the intervention and control groups attended combined prior teaching on the topics of cardiac and respiratory medicine, conducted by a university as part of their semester eight and nine undergraduate course in 2009-2010. The intervention group participated in CPEP, a four day immersive simulation course, in the first week of their cardiac and respiratory medicine clinical rotations. Two OSCE station were then conducted on an examination day immediately following the CPEP course program. This group then completed the remaining five weeks of the cardiac and respiratory rotation. The control group participants attended the normal program of six week cardiac and respiratory medicine clinical rotations. This group attended an examination day, participating in the same two OSCE stations in the week following their six week rotation. Six CPEP courses were conducted over a two year period. Data collection associated with the project came from two sources: standardised examination (OSCE) and surveys. Standardised examination – objective ratings of examination performance via a global scoring system were provided by examiners experienced in OSCE exams. The marking criterion for the OSCE exam was based on that used by the University.

Surveys – All information was obtained directly from the participants. A commencement of rotation survey was completed by all participants (control and intervention) on day one of their rotations. This collected both demographic data and level of confidence ratings related to their knowledge, skills and attitudes in cardiovascular and respiratory medicine. A post course survey evaluating CPEP course was completed by the intervention group, this re-rated their confidence with cardiovascular and respiratory medicine knowledge, skills and attitudes. A follow up survey of both groups, using the same confidence rating scales, was completed by all participants at week six in their rotation to assess their development in knowledge, skills and attitudes in cardiovascular and respiratory medicine; self rated proficiency in clinical skills.

Results: To be announced at SimHealth 2011 Meeting.

Conclusions: To be announced at SimHealth 2011 Meeting.

Background & Method: A pre-test /post-test design was used to evaluate a series of simulations conducted over a 9 week semester. There were twenty seven scenarios in total, with each individual scenario lasting approximately five to seven minutes and incorporating programmed mannequins, moulage and actors. The scenarios were embedded in a team-based process involving preparation and video-recordings used to debrief. Third year BN Students (n = 219) reported their confidence and competence before and after the simulation series and made comments on their perception of the experience.

Results: Students were primarily female (90%) and from the 19-29 year age bracket (70.3%). Confidence and competence scores improved significantly over time, with an average increase in confidence scores of 1.45 points (effectively 63%) and competence scores of 1.2 points (effectively 48%). Confidence and competence scores were highly correlated both pre-simulation (r = .68, p < .001) and post-simulation (r = .78, p <.001). There was no difference in confidence or competence scores post-simulation according to age, but there were differences by gender so that males reported significantly more confidence and competence than females. Of the students who provided further comments (n = 97, 44%), the majority indicated the most common response was that they enjoyed or appreciated the experience (65%), followed by describing how their experience helped them link theory and practice (24%) or improved their confidence (24%).

Conclusion: A series of medium-fidelity simulations with multiple scenarios is effective in improving BN students' confidence and competence related to critical care practice and is an enjoyable experience for students.

Methods: Research design: This is a quasi-experimental research design. The object of the study is the junior nursing students. Intervention: High-fidelity patient simulators and standard patients were used in the simulation teaching. All of scenarios were stem from real clinic cases and cover common diseases. Students played different roles, such as nurse and observers. Each observer was designated specified task, including performance, communication and cooperation evaluation. Students are encouraged to share their feelings, suggestions and comments freely during debriefing which emphasized respect, non-criticizing and confidentiality. Evaluation method: Interviewing and questionnaire were utilized. The questionnaire of simulation effects which designed by National League for Nursing was adopted, which includes 3 parts: Educational Practices Questionnaire, Student Satisfaction and Self-Confidence in Learning and Simulation Design Scale. 

Results: The feedback from the interviewing showed that students were satisfied with and interested in the simulation teaching. There were also some suggestions: the pre-set scenario could not show the complicated and dynamic clinic situations, objectives could be more specific , Enough information should be provided. Questionnaire Statistics indicated that simulation promoted independent learning, cooperation, provided new ways to learn and improve communication between instructors and students; students prefer to the teaching strategies utilized in simulation; students confirmed that these strategies were effective and benefit; students felt more confident to cope with problems and the ability of critical thinking was improved; students satisfied with aspects of objectives and information, support, problem-solving, Feedback/Guided Reflection and Fidelity (Realism). However, students thought that more learning resources should be provided; compared to other aspects, design of objectives and fidelity should be improved.

Discussion/Conclusion: Integrating simulation into a core nursing course is an innovation in China. Results indicated that simulation bridge the gap between theory and clinic practice as well as improving teaching and learning. However, some limitations also could not be neglected; small-group teaching will limited by personnel resources. More efforts will be dedicated to promote utilization of simulation during teaching of nursing fundamentals, heath assessment and other courses referring to clinic practice.

Paper: Download the paper.

Background: Stiffness discrimination in tasks such as soft tissue palpation is informed by cutaneous receptors as well as kinaesthetic receptors in the muscles, joints and connective tissue. The relative contribution of cutaneous and kinaesthetic components in informing clinical judgements is not known but the ability to simply discriminate stiffness is decreased when either component is removed [1]. Haptic devices are used to train stiffness discrimination [2] and incorporate stiffness discrimination into complex tasks including soft tissue palpation [3-4]. Haptic devices simulate kinaesthetic feedback for procedural tasks, but are generally unable to simulate cutaneous input that occurs during soft tissue palpation. It is not known whether there is a relationship between an individual's kinaesthetic ability to discriminate stiffness with haptic devices and with real-world objects or whether that relationship remains when cutaneous cues are also available in real-world tasks. The usefulness of haptic devices for teaching psychomotor skills may depend on the existence of a relationship between haptic and real-world skills.

Methods: Sixteen penultimate year physiotherapy students (aged 20 to 29 years) participated. Stiffness discrimination in a haptic environment was assessed using the CoreSkills trainer [2], a haptic game-based program for developing generic psychomotor skills. In the ‘firmness game’ the user selects the softest of four virtual surfaces. Points are scored for correct answers and lives lost for errors. Students played the game once until they lost all of their lives. Stiffness discrimination with real-world objects was evaluated by the number of correct answers when ranking the relative stiffness of sets of five silicone discs. With four sets, students palpated the silicone discs directly (allowing both cutaneous and kinaesthetic input) and for the other four cutaneous information was excluded by capping the discs with a rigid plastic cover. Kendal'ss tau_b was calculated to assess the agreement between rankings. Local Ethics Review Committee approval was obtained.

Results: A significant relationship was found between the ability to discriminate stiffness with the haptic device and with the capped silicone discs (kinaesthetic information only) (Kentals tau_b 0.475, p= .016). No relationship was found between the haptic device and the uncovered discs nor was there a relationship for the capped and uncovered discs. There were few errors with the uncovered discs which may have made it difficult to detect relationships between this and other tasks.

Conclusions: Ability to discriminate stiffness using a haptic device seems related to stiffness discrimination in a real-world task; at least when that task only includes kinaesthetic information. It is unclear whether such a relationship also exists when cutaneous information is included. It would seem that a haptic environment can be used to evaluate an individual' s relative kinesthetic ability to discriminate stiffness. Future research is necessary to establish whether improvement by an individual in stiffness discrimination in the real-world can be assessed haptically and whether training in a haptic environment will improve real-world skills in stiffness discrimination.

References:

1. LaMotte, R.H., Softness discrimination with a tool. J Neurophysiol, 2000. 83(4): p. 1777-86.
2. Baillie, S., N. Forrest, and T. Kinnison, The Core Skills Trainer: A set of haptic games for practicing key clinical skills. EuroHaptics, 2010. Part II LNCS: p. 371-376.
3. Baillie, S., et al., Integrating a bovine rectal palpation simulator into an undergraduate veterinary curriculum. J Vet Med Educ, 2005. 32(1): p. 79-85.
4. Bajaj, K., et al., Repeated palpatory training of medical students on the Virtual Haptic Back. Stud Health Technol Inform, 2008. 132: p. 8-13.

Background: Low-cost laparoscopic surgery models that provide objective feedback about performance precision and tissue damage are not currently available.

Methods: Ethics Review Committee approval was secured for this study. We asked novices through expert laparoscopists to complete a series of exercises requiring fine precision and tissue handling in the placement of small foam stickers of varying size and shape (circles, squares, stars, triangles, hearts) on templates of varying density and complexity. The foam pieces were required to align exactly and undamaged within the template, and placed permanently on the template after removing the sticky-backing. All exercises were required to be completed within 20 minutes. Objective measures included the degree of offset for each piece on the template, the amount of damage apparent on each piece, the total time required to complete the exercise, and the total number of accurately placed pieces (at least one part of the piece within the correct template space). Three faculty, blinded to the identity of the subjects, scored all templates.

Results: There were significant performance differences between and across the levels of expertise on all performance parameters (p<0.05). Time:tissue damage:accuracy ratios were the best indicators of skill, however experience performing laparoscopy was not the primary indicator of skill level. The Inter-scorer reliability between the three independent scorers was 0.98 indicating the consistency of the objective measures. Examples of two exercises are included in Table 1.

Conclusions: Low-cost, easily facilitated models using foam stickers for developing laparoscopic surgical precision and tissue handling skills may provide an affordable and portable training option without sacrificing objective performance measures, and may provide more objective evidence for assessment and evaluation than current methods of evaluation. These models also provide an option for laparoscopic skill development in low and limited resource environments globally.

Paper: Download the paper.

Background: Recent technology allows us to make a humanoid robot that mimics human behavior in motion. In far future, the humanoid patient robot is expected to substitute, at least in part, the real patient in medical education. The feasibility of the humanoid patient robot for this purpose is, however, obscure because it has developed just in exceptional cases.

Methods: For body movement, we adapted conventionally available mechanical technology and computer software in Japan. Parts were assembled to form the human-shaped robot sitting on a chair. The motor force was given by electric motors and pneumatical-regulators, so that the head, eyes, jaw, neck, body trunk, upper limbs, fingers were movable just like those of humans. The motion was initiated by voice recognition of the learner's (fake doctor, medical student) questions in medical interview, following a pre-programmed scenario. Skins made of silicon covered the face and hands. Head was covered by a wig, and the body and hands were covered by clothing. The pre-programming for each scenario was performed by installing the motion clip, the voice clip and voice recognition data. As an experimental sample, a myasthenia gravis patient scenario was installed, which involved typical complaints and symptoms in motion.

Results: The robot responds to the learner's questions; complaining that eyelids and arms are heavy, displaying mechanical motions such as typical facial expressions, slowly-relaxing the shoulders, and hunching forward. Although the students just follow the instructions and conduct the diagnostic interview along the pre-programmed scenario, the students can learn how to put useful follow-up questions in response to the patients' answer, and inspect motions typical to the patients with myasthenia gravis. Bipedal locomotion and high fidelity replication of skin were not achieved, which lowered the fidelity.

Conclusions: The present pioneer study showed that the humanoid robot available with the conventional technology can mimic patient motion and complaints at least in part. If the scenario is adequately adapted, medical students can practice diagnostic interview and inspection repeatedly, even with rare diseases. This virtual opportunity is expected to sharpen their skill before seeing real patients.

Background: In 2008 Associate Professor Kerry Reid-Searl developed a simulation technique using realistic, human like silicone props to transform herself into another identity. She would emerge as a character with a history relevant to the learning experience. The character would then become the platform for teaching. The technique would involve a three way interplay involving the educator, the character and the learner. Whilst the concept was initially developed for first year undergraduate nursing students, Reid-Searl soon realized that the application and interest was beyond the laboratory context.

In 2010 the concept was refined and named MASK-ED™ (KRS simulation). The teaching process behind, what is a relatively complex technique, was finally articulated in 2010 with resources now being available to enable others to use the technique.

This paper will outline the history, the underlying teaching approach and the current and future applications. The audience will have the opportunity to experience the technique first hand whilst considering the opportunities and application within their own programs. The paper will conclude with the advantages and challenges to this technique.

Background: The trainer that we describe in this study was developed in response to three concerns about existing commercial trainers available for learning the skill of urinary catheterisation. First, the part task trainers commercially available encourage a focus only on the psychomotor components of catheterisation. Their ‘disembodied’ nature leads to neglect of the critical human dimensions of procedure, such as patient consent and human care. Second, students learning on existing commercial trainers complained of their ‘plastic’ nature, which reduced the realism of the experience. Third, existing trainers are very expensive, precluding their use by students unsupervised for self-directed learning practice.

The authors saw an opportunity to address these problems through the development of a new wearable catheterisation trainer. Key factors in this development included collaboration with an Australian company, Technology Concepts, which had developed a novel elastomeric polymer that approximates the characteristics of human skin, and a development grant from the Griffith Enterprise Innovation Fund.

Methods: Year 2 medical students were invited to participate in the evaluation. Participants were randomised by coin-toss to practice with either the prototype new trainer first then an existing commercial part-task trainer or vice versa. They completed questionnaires before and after each practice session.

Results: 105 students participated. Participants rated the new trainer as being much more accurate in simulating performance of the procedure on a real patient (mean score 7.3cm vs 3.3cm on a 10cm visual analogue scale, p<0.0001) and randomisation arm did not impact significantly on participants' ratings. Among 91 participants who offered an opinion on which better simulated the human dimensions of the procedure, 100% nominated the new trainer.

Conclusions: Other data to be presented and participants' direct comments indicate that both better simulation of human tissues and wearability by a simulated patient contributed to participants' preference for the new trainer. The improved simulator offers the potential for students performing the procedure for the first time on hospital patients to be better prepared.

The new trainer offers better simulation of urinary catheterisation in relation to both realism and the human dimensions of the procedure.

Background: Clinical placements are becoming increasingly problematic with multiple education providers reporting difficulties finding sufficient places for students and studies detailing the subsequent compromise in the quality of education experienced during these placements. Research into the theory practice gap of paramedic students at one university found less than 50 per cent of cases experienced during clinical placement lead to skill practice on a real patient. In a separate cross sectional pilot study that focused on paramedic students' experience on clinical placement, 31 per cent of participants were found to be excluded from any form of hands-on patient management.

The goal of any clinical experience, be it in a placement or a simulation, is to provide a context within which clinical concepts can be brought together and practiced. Without genuine student engagement – that is, with the students acting only as observers – clinical placements may offer little more than face validity. This represents a model of competence training that is increasingly being seen as unsustainable.

One alternative, which may offer not only face validity but also content validity is to create a controlled situation that nonetheless offers an immersive experience where participants are able to suspend disbelief leading them to speak and act as if the situation were real. The potential of simulations to enhance learning has been recognised at a Federal level with the increasing pressure on clinical placements and the growing concerns about the work readiness and competence of graduates leading to Health Workforce Australia (HWA) undertaking a $94M Simulated Learning Environments (SLE) program.

While this initiative effectively guarantees an increased reliance on simulation in the training and assessment of paramedic students, the costs and benefits of simulation are difficult to determine, and given the current research in this field is limited in both quantity and quality. This raises the need to closely examine the validity, reliability and effectiveness of simulation as both a teaching and an assessment tool.

Method: A cross-sectional survey of second year paramedic students. This study sought to explore the perceptions and reactions of paramedic students to a Simulated Patients and views the data through a qualitative lens.

Results: Students indicated that the scenarios with Simulated Patients afforded a greater sense of reality the use of peers and the results raise the potential for high fidelity scenarios using SPs to create a controlled, environment that may allow for learning goals previously attributed to clinical placements to be met within the academic curriculum.

Conclusion: The question of whether intended clinical placement learning outcomes can be feasibly met by increasingly the fidelity of simulations using SPs warrants further exploration. Key words: paramedic; simulated patients; scenario; fidelity

References:

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16. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13(suppl 1):i2-i10.
17. Crookes P. Postcards from Sim Centers – what is going on out there?! METI Conference; University of Huddersfield, UK2010.
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Background: Simulation education (now a mainstream educational methodology in healthcare) is developing rapidly; a cornerstone being immersive simulation with realtime interactive debriefing by instructors trained in facilitation and debriefing. Access to this teaching remains challenging for health care workers who are geographically isolated. Remote clinical services (Telemedicine) is recognised, as is the use of videoconferencing for demonstration during teaching. To our knowledge, delivery of a fully immersive teaching course of lectures, interactive sessions, immersive simulation and debriefing using geographically separated facilitators has only been rarely described. We consider this platform novel, and believe it will increase our flexibility in delivering teaching services. 

Methods: The requirements for an ideal system are:

1. Usability: natural real-time interaction of facilitators and participants despite geographic separation
2. Responsiveness: natural control of a manikin from remote sites
3. Directability: direct communication with a Faculty actor at the remote site allows prompting for difficult scenarios
4. Connectivity: traverse disparate corporate networks
5. Flexibility: standardised protocols or freely licensable systems
6. Reliability: ease of use and troubleshooting
7. Feasibility: low cost overheads.

We used an iterative approach to determine the most appropriate system within these requirements. Testing was in three stages: initially delivered via a local area network, then via a hospital network; and across disparate networks.

Results: The system is Internet Protocol (IP) based with the following components:

• An H.323 video conferencing system which allows real-time interaction and communication during interactive sessions and debriefing
• A Remote Desktop Service (RDS) to control the manikin’s software client on a computer at a remote site
• An enslaved audio switching mechanism to allow use of the videoconferencing audio channel for the manikin voice, and natural communication with participants
• Sophisticated IP traversal techniques
• Mobile phone technologies to communicate with a remote Faculty actor.

We employed this system in multiple courses within our Centre using hospital networks and remote sites. Our system enabled natural interaction within scenarios and teaching sessions. Informal one-on-one and group reviews with participants demonstrated an almost universal acceptability of the technique.

Our experiences as facilitators showed subtle changes in teaching methods which are required to improve fidelity of interaction. Facilitators were less able to use body language and to direct conversation by engaging individual participants, thus requiring facilitators to be more direct in their verbal communication. For participants, however, this did not affect acceptability.

Conclusions: Remote simulation is a technology that promises to improve substantially access for remote sites. It enables greater flexibility for facilitators with less travel. It has potential to extend to other contexts such as skills workshops and taping of real-world trauma team resuscitations. It highlights the possibility that strong learning relationships may develop between remote sites and teaching centres as they become part of a regular in-service at remote sites.

References:

1. Mair, F, Whitten, P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000; 320: 1517-20
2. Cooper, JB et al. Video teleconferencing with realistic simulation for medical education. J Clin Anesth. 2000;12:256-61
3. von Lubitz DK et al. Transatlantic medical education: preliminary data on distance-based high-fidelity human patient simulation training. Stud Health Technol Inform. 2003;94:379-85

The aim of this paper is to identify the challenges of implementing a suite of simulation activities into the four day Intensive School of this introductory undergraduate nursing unit of study. In particular, this paper presents the challenges to the development of the intensive school program, the creation and development of specific simulation exercises, plus a description of what worked well, what didn't work and the lessons learned. Evaluation of the success of the simulation experience, utilising student qualitative comments will also be discussed. Suggestions for future recommendations in planning, implementing and engaging undergraduate nursing students in simulation exercises within undergraduate nursing curricula and in particular within an Intensive School model of course delivery will be outlined.

This presentation will outline an overview and evaluation of a pilot Telemedicine project initiated by Loddon Mallee Rural Health Alliance (LMRHA) using broadband networks to augment specialist trauma, critical care and retrieval support from Adult Retrieval Victoria (ARV) and major Melbourne metropolitan hospitals to hospitals in two rural health regions of Victoria. Methods The Virtual Trauma and Critical Care Unit (ViTCCU) was a pilot telemedicine project undertaken by LMRHA between July 2008 to July 2010, connecting four hospitals within the region (Mildura, Swan Hill, Echuca and Bendigo) to four Melbourne Metropolitan hospitals (The Alfred, Austin, Royal Children's and St Vincents). ARV were connected to the system in December 2009. The network allows high definition video conferencing (VC) as well as transmission of radiology and pathology results via a separate data stream. In mid 2010, 15 sites in Grampians Health (GRAHnet) were connected to the system via a ‘bridge’. The ViTCCU project was independently evaluated by KPMG.

Results: The ViTCCU system was used for 100 patients presenting to LHRHA regional hospitals during the pilot project.

Specific outcomes of the project included:

• Significant (10%) reduction in unnecessary transfers from regional to metropolitan hospitals resulting in significant cost savings of $200,000 and decreased social impact on patients and their families
• Regional clinicians feeling better supported in their management of acute trauma and critical care cases
• Improved matching of transferred patients to appropriate metropolitan hospitals
• Reduction in time to organise retrieval and improved matching of retrieval resources to patient need.
• Improvement in the skills and knowledge of regional clinicians as a result of virtual interaction with specialist metropolitan staff³ 

Conclusion: This pilot project has shown that VC technology is a viable modality for remote support of rural clinicians caring for trauma and critical care patients, with short term benefits of improved patient care and reduction in unnecessary ambulance transfers and longer term benefits of improved sustainability of rural health services.

References:

1. National Health and Hospital Reform Commission. Final report. Available at: http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/nhhrc-report. Accesses January 2011.
2. Victorian Government Department of Health. Rural directions – for a stronger healthier victoria: Update of Rural directions for a better state of health. Available at: http://www.health.vic.gov.au/ruralhealth/downloads/
   hs1093_rural_directions_1.pd f. Accessed January 2011
3. LMRHA – ViTCCU Pilot evaluation report – May 2010

AARNet has proposed the establishment of a national health training network aimed ensuring that network links used for health training are characterised by standardised firewall management processes and by bandwidths that are appropriate to purpose.

This presentation describes the proposed network, its initial pilot phase and its associated connections agreement system.

Background: Thermography is a new method that can provide medical information about a tumor issue. A minimum of 0.2°C temperature variation in the region of interest, ROI, could be a sign of malignant thyroid tumors. Thermal signature can be used when the tumor size is even less than 0.5 cm, or in other words, long time before it can be diagnosed using other medical devices. Unfortunately, it is hard many times to obtain sufficient information from the infrared images because their visual quality is usually unsatisfactory due to noise, blurred edges, and lack of textures. The use of partial differential equations, PDE, in image processing has grown significantly over the past years. This paper presents the results of infrared image filtering by using a new model of diffusion tensor for bioheat equation solving with Dirichlet boundary conditions.

Methods: Perona & Malik suggested for the first time using diffusion PDE for image enhancement with Neumann boundary conditions. The diffusion filtering, in its broad meaning, refers to iteratively updating the data. The infrared images show the bioheat radiated by human body. Penne's equation models the bioheat propagating through human body. The new equation from this paper uses the new form of diffusion tensor, different Weickert's form.

Results: The thermal signatures of thyroid were investigated. The data were taken from an infrared camera measuring skin temperature. The image resolution was set as 640 x 480 pixels and 14 bits per pixel, 0.01°C. Thyroid nodules were diagnosed by ultrasound guided fine needle aspiration as well. The ROI was manually selected. It was very difficult to define the contours and centers of the thyroid nodules by using temperature signatures. There was a lot of noise in infrared image and the texture was not homogenously. A nonlinear diffusion filtering was introduced in order to preserve and to enhance edges and local details on denoising. We were focused on the temperature variation inside of image by choosing as Dirichlet conditions in this example: 31.5°C for minimum value, and 31.5°C outside temperature on the exterior rectangle. The new values for diffusion tensor coefficients were evaluated by an original scheme, considering temperature variations between neighboring central pixel. More clearly images were obtained after nonlinear diffusion filtering. This thing could be seen on 2D and 3D representation of ROI. Some rows from image data were plotted before and after filtering process. They show how the nonlinear diffusion filter could achieve the desired performance.

Conclusions: The thermal signature could give information about tumor character, but the temperature variation is low, and special filtering methods are needed. A new filtering method for infrared medical images was presented. The results show that the edges and local details between heterogeneous areas of filtered infrared image were more clearly defined and useful for clinicians.

References:

1. P. Perona and J. Malik, “Scale-space and edge detection using anisotropic diffusion,” IEEE Trans. Pattern Analysis and Machine Intelligence 12(7), pp. 629-639, July 1990.
2. J. Weickert and T. Brox, “Diffusion and regularization of vector- and matrix-valued images,” Inverse Problems, Image Analysis and Medical Imaging, Contemporary Mathematics 313, pp. 251-268, 2002.
3. F. Gibou, “Partial differential equations-based segmentation for radiotherapy treatment planning”, Mathematical Biosciences and Engineering,2(2):209-226, 2005.

Background: When to a particular tissue an acoustic field is applied, the reflected signal amplitude depends on the signal frequency, material parameters, shape and object size. In the case of broadband signals and short duration, the amplitudes of different spectral components are strongly correlated with the degree of smoothing or roughness of the investigated object. Measuring the distribution of components spectral allows getting useful information on the size and shape of outer surface. In malignant tumors case, the outer surface is highly roughly, and the spectral response will be completely different from benign tumors, which would allow a strong distinction between them.

Methods: A partial differential equation of second order is used to simulate the propagation of acoustic field toward a certain object. After imposing of the Dirichlet or Newmann boundary conditions, this equation was solved using the finite element method for two specific patterns, elliptical and spherical, with initially smooth and then rough surfaces. Eigenmodes show the distributions of acoustic pressure inside the objects and eigenvalues specify their bioresonance frequencies.

Results: Spherical and elliptical objects were investigated simulating benign tumors with maximal diameters of 1, 5, 10 and 20 mm. New outer surfaces could be obtained by adding a random normal distribution component to radius or axes values used in equations describing highly irregular surfaces, simulating malignant tumors. The average values of the smooth objects were maintained and the following different relative dispersions were added 3%, 10% and 25%. Acoustic wave pulses with very short duration were applied on these objects. A total of 16 eigenvalues, resonance frequencies, were calculated for all 24 objects. Material parameters were chosen for thyroid tissue. By studying eigenfrequencies corresponding to benign tumors, their values looked to be quite far apart from each other. The first eigenfrequency gives information about the maximum diameter of the tumor. In malignant tumors case, the eigenfrequencies are grouped around certain common values. When dispersion has high value then the eigenfrequencies are closer. If the roughness is less than 4%, changing its frequency spectrum is less significant. Resonant frequencies concentrations are very evident for 10% and 25% values of relative dispersions.

Conclusions: A new method to assess tumor type is presented in the article. The sound is used as non-invasive investigation source. Bioresonance frequencies obtained in this investigation were higher than 1 kHz and smaller than 600 kHz. Eigenvalues corresponding to their acoustic resonance frequencies may allow the separation between the two types of tumors: benign or malignant. Good results can be getting for tumors with diameters less than 10 mm, situations that can not be solved with other medical devices because of spatial resolution limitations.

References:

1. B. Fang, A. G. Kelkar, S. M. Joshi, and H. R. Pota, “Modelling, system identification, and control of acoustic-structure dynamics in 3-D enclosures,” Control Engineering Practice, vol. 12, no. 8, 2004.
2. T. Ran Lin and J. Pan, “Sound radiation characteristics of a box-type structure”, Journal of Sound and Vibration, vol. 325, no. 4-5, pp. 835-851, 2009.
3. M. J. Crocker, Hand Book of Acoustic, Wiley-IEEE, New York, NY, USA, 2008.
4. G. Kokkorakis and J. Roumeliotis “Acoustic eigenfrequencies in a spheroidal cavity with a concentric penetrable sphere” J. Acoust. Soc. Am. 105 (3), (1999)
5. S. Mohamady, K. Ahmad, A. Montazeri, R. Zahari, and N. Abdul Jali, “Modeling and eigenfrequency analysis of sound-structure interaction in a rectangular enclosure with finite element method”, Hindawi Publishing Corporation, Advances in Acoustics and Vibration, Volume 2009, Article ID 371297.

Background: The TR&R™ system uses computer assisted evidence - based algorithms to support clinical decision making in the first 30 minutes of trauma resuscitation, improving algorithm compliance, and reducing error rates via audio visual prompting. Use of the TR&R™ decision support software assisted has been shown to reduced errors in trauma reception and resuscitation by over 20% ¹ In order evaluate software updates and innovations and facilitate reintroduction into the clinical environment without compromising patient care, the package was installed at the Australian Centre for Health Innovation at The Alfred Hospital, Melbourne.

The purpose of this installation was to:

• Trial and validate software upgrades and innovations using computer based simulation
• Train staff in the use of upgraded TR&R™ software
• Trial use of the package in immersive scenarios in a simulated trauma bay
• Facilitate reintroduction of the upgraded software package to the clinical environment using in-situ simulation Other potential opportunities include
• Market and promote the TR&R™ software in a controlled non-clinical environment.
• Evaluate the potential for remote trialling and support of the software package in overseas clinical and simulated environments

Methods: A four phase process of software evaluation and reintroduction to the clinical environment will be described.

• Phase 1 – Evaluation and verification of software upgrade using computer based scenarios and training of staff
• Phase 2 – Evaluation of software and user interface using complex computer based scenarios
• Phase 3 – Real-time evaluation of software using immersive team based scenarios
• Phase 4 – Final insitu-evaluation using immersive scenarios in the Alfred Trauma centre

Conclusion: Computer based and immersive simulation is an effective and safe method to fastrack the evaluation and clinical integration of an upgraded trauma decision support software package

References: 1. Fitzgerald M, et al. Trauma resuscitation errors and Computer-assisted decision support. Arch Surg 2011;146(2):218

Impetus for embracing simulation as a learning strategy has also gathered momentum because of the recent amendments to the Disability Discrimination Act (2009). These amendments require providers of education to take proactive steps to prevent discrimination and to provide reasonable adjustments for students with disability in their course progression while maintaining the academic integrity of the program.

One university's school of nursing and midwifery has responded to this challenge by initiating the Inherent Requirements of Nursing Education (IRONE) project. The purpose of this project was to articulate, develop and embed inherent requirement statements into undergraduate nursing curricula. Part of this process has involved identifying where reasonable adjustments can be made to learning and assessment activities. The use of simulation as an alternative learning strategy became evident as reasonable adjustments could be assessed by using medium and high fidelity simulation tools. This provided the opportunity to evaluate the reasonable adjustments and the student's capacity to function in a simulated learning environment prior to participating in clinical placement. This process would facilitate monitoring of the student's ability to effectively function prior to engaging with the general public.Using simulation in this way supports the learning of students with disability by allowing the academic and disability services to make reasonable adjustments taking into account the student's disability in a fair and equitable manner.

This paper describes the school's leadership in this area and the benefits that simulation offers in supporting the educational preparation of undergraduate nursing students with disabilities. Examples are drawn from the school's experiences which illustrate how medium and high fidelity simulation tools were used. The discussion recommends simulation is used in determining reasonable adjustments for undergraduate nursing students with disabilities as a contemporary curriculum practice. Adoption of simulation in this way will therefore meet two imperatives:

1. Compliance with recent legislative requirements and
2. Embracing advances in learning technologies. It is anticipated that using simulation in this way is more likely to offer students with disabilities an enhanced learning experience.

Aim: The project aims to discover what influences the environment of the pseudo-authentic setting has on the development of the graduate paramedic.

Methods:

• An environmental scan of what is currently being used for simulation in the education of paramedics across Australia
• Semi-structured interview
• Observations
• Questionnaire

Results: This is a work in progress and currently there are a large number of universities across Australia providing education and training for paramedics. Most of these programs are still in their infancy, with only three universities having more the ten years in the sector, and most with less than five years. Currently there is no minimal standard as to what should be included in a pseudo-authentic environment for this cohort of health care professionals. This is practically due to the difficulty in defining what the environment is for a paramedic. Those who have been interviewed have highlighted that the pseudo-authentic setting does not mimic all the aspect of the authentic setting. The pseudo-authentic setting does not replicate fatigue, hunger, weather and noise all of which impact on the performance of those working under these conditions. While there is one facility in Australia that can replicate many of the environmental condition faced by paramedics it is unclear how important this is at this time.

Conclusion: Simulation has become an important part of education for health care professionals around the world. There have been many simulations centres developed for the education of medical practitioners and nurses however, this is not the case for paramedics. While it is recognised the fidelity has been claimed as being important to engage the participants where does this stop, and where does reality become more important? This research should discover what the minimum requirements for an effective simulation environment are for paramedics.

Within the simulation the students are presented with information in a “real time scenario” and from this various decisions have to be made. Depending upon the decisions made the students progress along the various pathways in the scenario to achieve a satisfactory conclusion. Kneebone (2005) suggests that simulation maybe useful as a learning method since it involves four aspects of education in nursing: developing technical aptitude through the practice of psychomotor skills and repetition; assistance of experts adapted to student needs; situated learning within context and integration of the affective (emotional) component of learning.

This presentation will illustrate the use of the simulation in the context of encouraging the students to transfer existing clinical skills to the care of children and in aiding the students to gain an understanding of the major differences in nursing children. Early indications are that this method of skills acquisition, whilst not ideal, does benefit the students and encourages their consideration of the need to adapt to the client group and their families.

Background: Providing end of life care is a challenging and anxiety provoking prospect for many undergraduate nursing students and many nursing students report feelings of lack of preparedness and competence in providing quality end of life care (Leighton & Dubas 2009). It is therefore imperative that undergraduate nursing students are prepared through exposure to simulated clinical end of life care situations that enable the student to effectively communicate and care for dying patients and their families. This preparation is all the more necessary when this care is delivered within rural and remote contexts where students are often isolated or unsupported in the role of providing end of life care to patients (Killam & Carter 2010).

However, challenges in nursing education continue due to limited availability of clinical practical placements for students, where it is widely acknowledged that the most valuable learning experiences are obtained within an experiential learning environment. There is sufficient evidence to suggest that experiential learning methods can positively affect nursing students' attitudes toward death, dying and end of life care (Hurtig & Stewin 1990; Mallory 2003). In response to the limited access to clinical placements nursing faculty are increasingly utilising various methods of simulation in a number of clinical scenarios. Recent advances in simulation techniques enable advanced simulation scenarios such as cessation of life to be conducted within a safe and supportive clinical setting. It has been suggested that patient simulators can ‘provide an effective bridge between the unknown of caring for a dying person and developing the skills necessary to facilitate a meaningful death experience for patients and families’ (Smith-Stoner 2009, p. 115). 

Methods: An Australian rural university team of nursing educators will undertake simulated end of life care training with a large group of third year undergraduate nursing students during an intensive residential school in March 2011. Students will be required to perform end of life care using a high fidelity mannequin and work within a challenging end of life scenario including communicating with the patient and family members.

Results: Feedback will be elicited from students following simulation sessions in the form of formal debriefing and written evaluations. It is expected that these simulated end of life care sessions will provide valuable learning experiences within a safe and non-threatening environment among peers.

Conclusions: The authors are unable to present data on results of the project at the time of abstract submission due to the project being undertaken during intensive residential school during March 2011. It is expected the project and evaluations will be completed and collated in May 2011.

References:

1. Hurtig, W. & Stewin, L. 1990, ‘The effect of death education and experience on nursing students' attitude towards death’, Journal of Advanced Nursing, 15 (1), 29-34.
2. Killam, L. A. & Carter, L. M. 2010, ‘Challenges to the student nurse on clinical placement in the rural setting: a review of the literature’, Rural and Remote Health, Accessed on 3rd February 2011 from http://www.rrh.org.au
3. Leighton, K. & Dubas, J. 2009, ‘Simulated Death: An Innovative Approach to Teaching End of Life Care’, Clinical Simulation in Nursing, 5 (6), e223-e230.
4. Mallory, J. 2003, ‘The impact of a palliative care educational component on attitudes toward care of the dying in undergraduate nursing students’, Journal of Professional Nursing, 19 (5), 305-312.
5. Smith-Stoner, M. 2009, ‘Using High-Fidelity Simulation to Educate Nursing Students About End of Life Care‘, Nursing Education Perspectives, 30 (2), 115-120.

Background: Traditional teaching styles have attracted fluctuating student attendance while failing to capture the ‘hearts and minds’ of students preparing for simulated learning. A pedagogical shift in the philosophy of adult learning from teacher to student centred approaches is essential in order to create learning communities and join students with common interests (Cleary & Sander, 2007). “No generation has experienced so many techno-enhancements and produced so little intellectual progress (Bauerlein, 2008).” Students of the ‘Net Generation’ are inspired by technological innovation as they prepare for careers in the healthcare profession. They have come to expect more than face-to-face lectures delivered in packed theatres devoid of interaction. This generation embraces web-based applications and social networking tools without intimidation, and expects the option of sharp, often mobile, and succinct learning (Snart, 2010). A well-designed simulation incorporates pre-scenario preparation (Horn & Carter, 2007). It is with this in mind that the university decided to become more purposefully innovative by preparing students for simulation using iPod lectures delivered in video format.

With increasing acuity and rapidly evolving health care environments health boards are requiring graduates prepared to a higher level than even 3-5 years ago. Having students ‘fit for purpose’ before simulation experiences can help with knowledge transfer while in the simulation, and in debriefing post-simulation. Responding to this context, the university has instituted mobile technologies to enhance student preparedness while allowing for flexibility in learning. Viewing preparation via iPod (or other mp3 devices) has tapped into the Net Generation's preferred learning pathway allowing for maximum participation and inspired interest. 

Method: It was decided to adopt an online video format to prepare students for the simulation environment. Students were required to watch an online video clip of around 10 minutes followed by an online quiz of 10 questions (all related to content in the video clip). Students were not allowed to participate in the simulation session until they got 8/10 correct in the online quiz. After the simulated session was completed the students proceeded to their first acute clinical placement.

Results: Student interaction with content increased when iPod lectures were used versus a face-to-face format (where less than half actually attended). Interaction with the material was ensured with the use of online quizzes. Additionally, nurses supervising these students in clinical placements had no prior knowledge of this change in preparation from previous years. Feedback from clinical areas around student performance after being prepared in the above manner was that students showed increased confidence, decreased anxiety, improved higher order thinking, and more efficient knowledge transfer after being prepared with online video clips. The online quiz improved student participation and interaction with the material both online and in the simulated setting.

Conclusions: The strategy the school has adopted for 2011 has been to extend this pedagogical approach to other courses with the goal of allowing more flexible approaches to teaching and learning while improving overall student performance in simulation and then in the acute clinical setting. With increasing enrolments, this method has ensured consistent delivery of content in a flexible learning environment with improved participation. The end result has been that students are prepared to a higher level and feel more confident as they proceed to the acute clinical setting.

References:

1. Bauerlein, M. (2008). Turned on, plugged in, online & dumb: Student failure despite the techno revolution. Retrieved from http://www.britannica.com/blogs/?s=turned+on%2C+plugged+in%2C+online+%26+dumb&s earch=Search
2. Cleary, S., & Sander, T. (2007). The Gateway to a learning community within the Bachelor of Nursing – Using Blackboard Course Management System. Studies in Learning, Evaluation and Development, 4(3), 44-35.
3. Horn, M., & Carter, N. (2007). Practical suggestions for implementing simulations. In P. R. Jeffries (Ed.), Simulation in Nursing Education (pp. 59-72). New York: National League for Nursing.
4. Jeffries, P. R., & Rogers, K. J. (2007). Evaluating simulations. In P. Jeffries (Ed.), Simulation in nursing education. New York: National League for Nursing.
5. Snart, J. A. (2010). Hybrid learning: The perils and promise of blending online and face-to-face instruction in higher education. Santa Barbara: Praeger.

Background: More and more simulation training is done in the medical field with many objectives including acquiring knowledge and skills, virtual experiences, brushing up and checking skills, gaining self-confidence, etc. When simulation training is done, evaluation is important to check the effects of learning. Simulation training programs should be elaborated by the results of evaluations. The acquisition of self-confidence can be checked by asking learners for comments, and comparing responses before and after simulation.

Methods: Questionnaires were given twice, before simulation training, and just after training. The two questionnaires use the same questions to evaluate self-confidence, and asked for self-rating on a 7-point Likert scale. (Q1) "Suppose you are going to do the procedure now. Can you do it accurately? " (Q2) "Suppose you are going to do the procedure now. Can you do it calmly?" Questionnaires were used in three different simulation training programs given to nurses, including ICLS (Immediate Cardiac Life Support), Multi-Tasking Exercise training, and blood-draw training. Only the results of nurse training were used in the study to unify the attribution of answers.

Results: In ICLS (N=88) and Blood Draw Training (N=57), the results of the questionnaires before and after differ significantly (P < 0.01). The results of the Multi-Tasking Exercise (N=96) are also significantly different, but the difference is slightly less than that observed in ICLS and Blood Draw Training (P < 0.05). In total (N=241), responses to both Q1 and Q2 are significantly different before and after the training session (P < 0.05). Conclusions: In the three different simulation programs evaluated, nurses significantly gained self-confidence based on the results of the questionnaire used before and after simulation. There are two main reasons why the training of Multi Tasking Exercise may be slightly less effective than the other two. The first is a lack of time for training. The Multi Tasking Exercise is normally done for about 1.5 hours, which may be insufficient for training and discussion. Repeat training after the discussion was done only in a few cases. The Multi Tasking Training sessions are only 1 simulation exercise, so nurses cannot check how their procedures change and whether or not their procedures become improved. The second reason is the specific scenarios used for training. Some scenarios are specific for a particular medical ward, but the others are very basic scenarios for the Multi Tasking Exercise, so nurses can't apply and associate the learning from simulation directly to their daily activities. To enhance effectiveness of the training, we should elaborate training courses and foster facilitators.

References: Technology and Health Care. 2008;16(3):159-69. Nurses' training and confidence on deep venous catheterization. Liachopoulou AP, Synodinou-Kamilou EE, Deligiannidi PG, Giannakopoulou M, Birbas KN.

Methods: At the completion of the learning program a questionnaire was utilised to evaluate the learning experience. The questionnaire was also used to allow students to complete a self assessment on their confidence following the simulated learning activities to perform clinical skills in the clinical setting. The questionnaire was developed using a 10 point likert scale. The evaluation was voluntary and anonymous. The sample size was 630 second year students enrolled in NSG2ACA at both metropolitan and rural campuses.

Results: A total of 468 surveys were returned equalling a 74% return rate. Survey results indicated that students felt more confident in performing technical skills including patient assessment and focused assessments, vital signs, medication administration, intravenous therapy and oxygen therapy following the preclinical simulated learning activities. Overall 62% of the students felt more confident in their skills, knowledge and attitudes following the program. The program also developed the student’s awareness in non technical skills including 61% who felt more confident with time management, 61% more confident with prioritising, and 73% felt more confident working in a team. One of the overwhelming responses identified by students was the impact of simulated learning activities on the communication skills of the students and their awareness of the importance of competent communication on delivering safe and competent care and the patient experience. 80% of the participants of the program felt more confident in their communication skills following the simulated learning experience.

Conclusion: The inclusion of the 10 hour preclinical simulated learning experiences in the 2nd year undergraduate acute care subject highlighted the importance of developing mastery in technical skills and integrating technical and non technical skills into procedural skills prior to clinical placement. The greatest impact was on the students assessment of their communication with the patient and the importance of clear and confident communication skills.

• To assist final year medical students to understand ward round culture and etiquette in the inpatient setting.
• To appreciate the barriers to effective and efficient ward round outcomes
• To develop the team work and communication skills necessary for a ‘good’ ward round

Background: When surveyed, final year students in our Clinical School report the most stressfully anticipated challenges of internship as “prescribing, responding to code blue, communicating in a professionally effective and focussed manner e.g. presentation of cases in ward rounds), and understanding the hierarchical system of inpatient care.” Students reported little appreciation of the difference between “board rounds” (a paper based review of cases to the team), work rounds (where the day to day assessment of patient progress is verified, documented and further evaluated by the intern and perhaps the registrar), hand-over rounds where critical information is prioritised by the home team for action by a covering team, and “show rounds” round, where interns are required to defend their clinical decision making, presenting a distilled assessment and plan of management to the consultant in charge of the patient"s care. Students reported that they felt unequal to the task of responding effectively and efficiently to service ward rounds. To address these issues, a simulated ward round opportunity was crafted as part of a Transition to Practice (Pre-internship) Intensive Program at the Launceston Clinical School. Real patients, with real issues, were interspersed with full immersion technology simulated patients (code blue response). A full and challenging range of system “distractors” were introduced that required the student to respond.

Methods: Students were paired, and introduced to a “simulated ward” of 10 patients. The student pair was responsible for clerking one patient, and reporting to the consultant on the round. A consultant was responsible for 5 patients, and the round incorporated 10 students, much as a teaching round would in an acute care hospital. The Medical consultant was supported by a nursing consultant and an administration resource person who provided results on request from Pathology, Radiology etc. Patients were recruited from a bank of “Patient Partners”, consented teaching partners in an established program, the Patient Partner Program (1), with real health issues but a hospital “admission” crafted appropriately to their illness. Questionnaire feedback was collected from students.

Results: The simulation identified gaps in how medical students are prepared to meaningfully translate their “undergraduate” knowledge and experience into the vocational work place. Qualitative evaluation of the program over three years will be presented. Conclusions Qualitative evaluation of this novel ward round simulation, incorporated into a Transition to Practice program, has demonstrated that it is an effective, sustainable, vocationally based intervention that can assist students in dealing with the stressors of ward work and reinforce patient-centred capabilities.

References:

1. Barr J, Ogden K, Rooney K. Viewpoint: let's teach medical students what patient partnership in clinical practice can be, with the involvement of educationally engaged patients. International Journal of Consumer Studies. 2010;34(5):610-2.

The proposed presentation will outline the VSA model and its implementation with a view to encouraging the establishment of further alliances in other Australian states. Challenges will be highlighted and strategies used in overcoming these will be discussed.

Background: Over the last five years simulation teaching methodologies have been used increasingly within undergraduate nursing education. In addition, the level of technology has increased significantly. As a result many education providers in Victoria have invested substantial funds in specialist teaching facilities. However, simulation in undergraduate nursing education poses some unique challenges with the most pressing issue being the sheer volume of students within programs.

With the support of government funding, the health sector in Victoria has also experienced a rapid increase in the number of skill / simulation centres based within hospitals. Historically, simulation centres in Victoria have operated quite independently of one another resulting in a lack of resource and knowledge sharing and a subsequent duplication of effort. This proliferation in simulation-based learning has put pressure on nursing educators to up-skill and to develop tailored resources to support learning in this environment, e.g: simulation scenarios.

Aim of the innovation: This initiative aims to create a ‘community of practice’ that will bring metropolitan and regional areas together and provide support and development opportunities to nursing educators involved in implementing simulation teaching and learning methodologies.

Model: The VSA has been modelled on the successful Bay Area Simulation Collaborative (BASC), based in San Francisco, and the more recently formed Californian Simulation Alliance. This model provides a platform for: creating a cohesive voice & a common language; facilitating ongoing professional development; information dissemination; best practice identification; scenario development & sharing; fostering collaboration & partnerships; facilitating inter-organisational research; informing standard & policy setting; identifying opportunities & lobbying for funding and forming global links.

Progress to-date: Following an initial scoping visit to California a call was put out across the state for ‘expressions of interest’ in the formation of an alliance in Victoria. This resulted in an enthusiastic response from educators in both regional and metropolitan areas and from across a range of contexts including universities, hospitals and vocational education. A workshop was then held with 52 participants and data collected in relation to the setting of key priority areas.

In late 2010 a Steering Committee was established to review the key priority areas and develop and implement an action plan. Work has also commenced on the development of a website and the identification of training needs across the network.

Plans for early 2011 include the establishment of a Research Committee; Scenario Committee; and a formal link with the Californian Simulation Alliance for the purpose of networking and resource sharing. It is anticipated that the VSA will be well established by September 2011.

One example of this rapidly growing evolution can be readily noted by reviewing the experience of the United States armed forces (namely the Department of Defense {(DOD}). Through the first decade of the 21st century, medical simulation training across DOD was at best, ad hoc and fragmentary. In 2000, for example, the DOD had just one medical simulation center, the National Capital Area Medical Simulation Center.

By 2010, the growth of system wide medical simulation platforms had increased by seven more. Included amongst these are the Army Medical Simulation Training Centers:

• Army Central Simulation Committee
• Air Force Distributed Human Simulation Program
• US Marine Corps Training and Education Command
• Navy Central Simulation Committee
• TriCare Management Activity Patient Safety Office
• Medical Education and Training Campus; and
• National Capital Area Medical Simulation Center.

As established, each of these medical simulation platforms were designed to use curriculum based medical simulation training scenarios designed to target the educational needs of their specific learners This state, however, will change as the newly created Military Medical Training Consortium (MMSTC) comes on line.

The MMSTC, established in late 2010 seeks to enhance medical education and training through knowledge sharing; collaboration on common goals; and joint medical simulation training throughout DOD. Equally important, the consortium will play a key role in over $7.5 million dollars of DOD initiatives in medical simulation that will take place over the next three years.

In the first initiative (Tri Service Medical Simulation Training Initiative (TMSTI}), a $5.5 million project, the consortium will establish a curriculum development methodology and scenario validation process. This will lead to templates that standardize the design, develop, deploy and validate medical simulation across the DOD.

In the second initiative, a $2 million project, the consortium will develop via the TOPS (Tri Service Open Platform for Simulation) project a set of open standards for hardware development so that medical simulation application developers can work toward common platforms that will thus, promote interoperability.

In short, this talk will address the evolution of US military medical simulation through the first decade; and secondarily, it will discuss the inception and purpose of the newly established consortium and its two key initiatives in medical simulation which will continue this evolution of medical simulation grow across DOD through the next decade.

Key indicators assessing the effects of training include:

1. Clinical outcomes
2. Claims data; and
3. Organisational aspects such as staff attitudes and morale.

Background: The PROMPT (Practical Obstetric Multi-Professional Training) program was initially developed in the UK in response to a need for multi-professional obstetric training to reduce adverse neonatal and perinatal outcomes as a result of poor communication and team work. The Vic-PROMPT program provides multi-professional obstetric emergency training within hospital maternity units. This one-day training course is aimed at obstetricians, midwives and anaesthetists and involves lectures and scenario-based drills on the following modules: team-work, maternal collapse including basic life support, maternal cardiac arrest and advanced life support, breech presentation, eclampsia, postpartum haemorrhage and shoulder dystocia. The simulation scenarios are conducted in the delivery suite using real time. The models that are used for the training have been specifically developed for the PROMPT program.

Methods: A number of clinical and organisational measures will be used to assess the impact of training on patients and staff. Clinical data will be obtained from the Victorian Perinatal Data Collection Unit. Cord lactate and decision to delivery data will be obtained from the individual hospital's participating in the project. Unidentified claims data will be used to assess the effects of training. Organisational outcomes will be assessed by the Safety Attitudes Questionnaire which is completed prior to commencement of training and after the training has been completed in 2010 and 2011.

Results: At the time of abstract submission the interim report for the first year of training is being compiled therefore the results are not available. The subjective evaluation responses which have already been collated are overwhelmingly positive and support the implementation of such a program.

Conclusions: Based on evaluation data and subjective anecdotal evidence, at present this method of training is very effective in engaging staff in working with each other but also highlighting aspects of management of obstetric emergencies that need improving within an organisation. It is essential that this type of training has executive support from the outset, as sustaining real time emergency training is difficult due to the logistics and staff costs associated with such a program. This highlights the importance of collaboration in improving patient outcomes and staff morale.

References:

1. Draycott, T., et al., Does training in obstetric emergencies improve neonatal outcome? General Obstetrics, 2006.
2. Draycott, T.J., et al., Improving neonatal outcome through practical shoulder dystocia training. Obstetrics and Gynecology, 2008. 112(1): p. 14-20.
3. Crofts, J.F., et al., Documentation of simulated shoulder dystocia: accurate and complete? BJOG 2008. 115(10): p. 1303.
4. Davey, M.A., et al., Births in Victoria 2005 and 2006, Victorian Perinatal Data Collection Unit and D.o.H.S. Statewide Quality Branch, Editors. 2008: Melbourne.
5. CCOPMM, Annual Report for the Year 2007 Incorporating the 46th Survey of Perinatal Deaths in Victoria (The Consultative Council on Obstetric and Paediatric Mortality and Morbidity), H.H.S.P. Division and V.G.D.o. Health, Editors. 2010: Melbourne.
6. Haynes, K., C. Stone, and J. King, Major morbidities associated with childbirth in Victoria: Obstetric haemorrhage and associated hysterectomy., D.o.H.S. Public Health Group, Editor. 2004: Melbourne.
7. Veitch, V., M.-A. Davey, and J. King, Victorian Maternity Services Performance Indicators, V.G.D.o.H. services, Editor. 2007: Melbourne.
8. Standards, A.C.o.H., Australasian Clinical Indicator Report: 2001-2008. Determining the Potential to Improve Quality of Care: 10th Edition. 2008.
9. Nordstrom, L. and S. Arulkumaran, Intrapartum fetal hypoxia and biochemical markers: a review. Obstetrical & Gynecological Survey, 1998. 53(10): p. 645-57.
10. Siassakos, D., et al., Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG, 2009. 116(8): p. 1089-1096.
11. Sexton, J.B., et al., The Safety Attitudes Questionnaire: Psychometric Properties, Benchmarking Data, and Emerging Research. BMC Health Services Research, 2006. 6: p. 44.

1. the target participants who vary from novices to experts;
2. their emphasis of simulation educational methods including E learning, practical workshops, simple scenarios, intensive full scale immersive scenarios and debriefing;
3. their use of modalities including task trainers, simple manikins, sophisticated robotic manikins and actors;
4. the content which spans didactic clinical topics to highly experiential learning about non-technical skills; and
5. the scale of the programs which range from small bespoke courses to those intended for state-wide deployment.

With considerable choice available to us how do we decide what's best for any group in respect to educational methods and modalities?

Aim: This presentation provides appraises a suite of validated paediatric training programs deployed over the last decade by a community of instructors associated with a large simulation training centre with the aim of informing educators on instructional design for paediatric simulation.

Methods: The presentation will be presented as a journey describing the development of six paediatric simulations programs: 

1. Paediatric Emergency Trauma and Life Support (PETALS)
2. Paediatric Team Training (PTT)
3. Paediatric Trauma Team Training (PTTT)
4. Paediatric Emergency Medicine Crisis Management (PEMCM)
5. Paediatric In-situ Program, and
6. Resus4Kids™

These locally developed courses range from networked programs deployed to large numbers of staff to small bespoke programs designed to meet the particular target groups. An appraisal of the strengths and weaknesses of these will be provided drawing on personal reflection, educational theory and published literature, the latter including BEME guidelines for effective simulation training .

Results: Evaluation data will be provided including quantitative and qualitative methods. Several themes emerge including the experience of participants and instructors and the importance of mobility and in-situ deployment. A dominant theme is the ingoing tension between the aims of achieving high levels of realism and uniformity. Respectively, these are achieved with sophisticated scripts, intensive involvement from faculty and tolerance of improvisation during scenarios versus tight control of conditions and scenario scripts. The tensions between achieving realism and uniformity mirror those observed by researchers measuring validity and reliability as metrics of validity in educational assessment.

Conclusions: One of the strengths of simulation-based educational methods is its ability to be easily adapted to respond to specific training needs of learners. In the future the sustainability of these programs will in part be influenced by their ability to be deployed to large numbers of entry level health professionals, favouring simple, scalable programs achieving high reliability in respect to delivery of content. However, small groups of health professionals will continue to have needs for highly specialised training, requiring more focussed content and sophisticated simulation modalities. Ideally, a range of simulation programs should be available representing both ends of the spectrum of scenario-based simulation.

References:

1. Paediatric Emergency Trauma and Life Support (PETALS) developed for staff working within Northern Sydney Local Health Network
2. Paediatric Team Training (PTT) developed by the SCSSC and affiliates on behalf of the Greater Eastern and Southern Child Health Network (GESCHN)
3. Paediatric Trauma Team Training (PTTT) developed by the SCSSC and affiliates on behalf of GESCHN and the NSW Institute for Trauma and Injury Management (ITIM)
4. Paediatric Emergency Medicine Crisis Management (PEMCM) developed as a collaboration between Children'&#s Hospital Westmead, the SCSSC and ITIM.
5. Paediatric In-situ Program developed by the SCSSC and affiliates on behalf of GESCHN and the NSW Institute for Trauma and Injury Management (ITIM)
6. Resus4Kids developed by Western Sydney Child Health Network (WESCHN)
7. Issenberg SB, McGaghie WC, Petrusa ER. BEME Guide 4: Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. http://www2.warwick.ac.uk/fac/med/beme/reviews/published/issenberg/ [Accessed February 14 2011]

The objective of this paper is to examine IMG performance after an educational intervention to introduce a communication protocol. This paper compares the IMGs' performance to the performance of local students who received the same training

Methods: The study context was patient safety training in a simulation setting at one Australian hospital. One group of participants were final year medical students and the other group were IMGs involved in a placement programme who had not previously worked as doctors in Australia. Both groups received a 40-minute education session about the communication tool (ISBAR). Telephone referrals made during the practice scenarios were recorded and analysed using conversation analysis techniques. Overall structural organisation of the data was also examined with reference to the stages of the communication protocol taught and call duration was measured.

Findings: Preliminary results show that although all were experienced medical practitioners, the IMGs required more time to make the referrals and were less effective at presenting clinical information than the medical students. The reason-for-call sequence seems to be particularly difficult for IMGs to negotiate. Implications for clinical practice: The findings highlight the need to tailor training programmes to the specific learning needs of IMGs and will inform a restructure of our educational practices for IMGs.

Aims: The purpose of this pilot project was to develop and investigate the usefulness and relevancy of an interdisciplinary and collaborative learning experience for third year nursing and paramedic students. The simulation was set in a rehabilitation centre with transfer of the simulated patient to an emergency department.

Results indicate extremely positive nursing and paramedic students' perceptions of all elements of the interdisciplinary simulation interaction and debriefing process. Students enthusiastically embraced the opportunity to engage in inter-professional communication and decision making. An analysis of student interactions with one another throughout the interaction and in the debriefing revealed the presence of role confusion, changing leadership and unstructured communication of patient information. Results demonstrated a need for both nurses and paramedics students to develop more a more systematic and shared approach to patient handover and knowledge of the role of nurses, paramedics and medical staff if interdisciplinary communication and decision making is to improve.

Recommendations: The evaluations by both students and academics highlighted a need for ongoing development of interdisciplinary learning with the inclusion of high fidelity simulation. In addition, the project demonstrated the need for health professionals to further examine and collaboratively develop guidelines for interdisciplinary handover.

Background: Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting [1]. Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. For students learning to manage complex clinical situations, teaching approaches are required that make these instinctive cognitive processes explicit and clear [2-5]. In line with professional expectations, nursing students in third year at Queensland University of Technology (QUT) are expected to display clinical reasoning skills in practice. This can be a complex proposition for students in practice situations, particularly as the degree of uncertainty or decision complexity increases [6-7]. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students [4, 8]. This project aims to use the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students are assisted to uncover cognitive approaches that best assist them to make effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection on their practice.

Methods: In semester 1 2011 at QUT, third year nursing students will undertake high fidelity simulation for the first time. There will be two cohorts for strategy implementation (group 1= use think aloud as a strategy within the simulation, group 2= not given a specific strategy outside of nursing assessment frameworks) in relation to problem solving patient needs. Students will be briefed about the scenario, given a nursing handover, placed into a simulation group and an observer group, and the facilitator/teacher will run the simulation from a control room, and not have contact (as a ‘teacher’) with students during the simulation. Then debriefing will occur as a whole group outside of the simulation room where the session can be reviewed on screen. The think aloud strategy will be described to students in their pre-simulation briefing and allow for clarification of this strategy at this time. All other aspects of the simulations remain the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials).

Results: Results of a qualitative analysis of student and facilitator report on student ability to meet the learning objectives of solving patient problems using clinical reasoning and experience with the ‘think aloud’ method will be presented. A comparison of clinical reasoning learning outcomes between the two groups will determine the effect on clinical reasoning for students responding to patient problems.

Conclusions: In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs.

References:

1. Lasater, K., High-fidelity simulation and the development of clinical judgement: students' experiences. Journal of Nursing Education, 2007. 46(6): p. 269-276.
2. Lapkin, S., et al., Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: a systematic review. Clinical Simulation in Nursing, 2010. 6(6): p. e207-22.
3. Kaddoura, M.P.C.M.S.N.R.N., New Graduate Nurses' Perceptions of the Effects of Clinical Simulation on Their Critical Thinking, Learning, and Confidence. The Journal of Continuing Education in Nursing, 2010. 41(11): p. 506.
4. Banning, M., The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. Nurse Education Today, 2008. 28: p. 8-14.
5. Porter-O'Grady, T., Profound change:21st century nursing. Nursing Outlook, 2001. 49(4): p. 182-186.
6. Andersson, A.K., M. Omberg, and M. Svedlund, Triage in the emergency department-a qualitative study of the factors which nurses consider when making decisions. Nursing in Critical Care, 2006. 11(3): p. 136-145.
7. O'Neill, E.S., N.M. Dluhy, and C. Chin, Modelling novice clinical reasoning for a computerized decision support system. Journal of Advanced Nursing, 2005. 49(1): p. 68-77.
8. Lee, J.E. and N. Ryan-Wenger, The "Think Aloud" seminar for teaching clinical reasoning: a case study of a child with pharyngitis. J Pediatr Health Care, 1997. 11(3): p. 101-10.

Aim: The aim of the project was to develop a multimedia resource that employed ‘real’ patient stories in simulation to enhance user engagement in an online environment. This presentation will focus on the use of ‘real’ patient stories in simulation and outcomes on user engagement.

Background: The transfer of information from one health care professional to another is a fundamental part of patient care and is undertaken in the context of a multitude of complex environments. Failure to provide effective transfer of communication has been linked to adverse patient events. Effective inter-professional communication is therefore integral to the provision of safety and quality in patient care.1 A curriculum review undertaken at the participating university indicated a lack of formal or set teaching resources in the Bachelor of Nursing that focused on the skill acquisition of handover. A funded project was therefore implemented to promote student engagement, professional communication and disciplinary knowledge by producing an interactive learning resource to facilitate skill acquisition in the area of clinical handover.

Methods: The project was undertaken across four interrelated stages including:

• Development of the resource content
• Constructing the resource
• Resource available for use
• Evaluation and dissemination

Stage 1: This stage consisted of establishing a collaborative partnership with a South Australian metropolitan hospital and university, attainment of ethics approval from both the University and Hospital Ethics Committees (HREC), the development of consent forms and information sheets for participant recruitment and establishing project insurance. In order to enhance the authentic feel of this resource, it was required to use clinical examples based on real clinical notes and associated clinical charts. All materials and resources were de-identified as per HREC requirements.

Stage 2: This stage involved working closely with the multimedia developer to commence work on the editing of resources and integration of materials into the software platform.

Stage 3: This stage tested the practical application of the tool. The test link was sent to all academic staff within the School of Nursing & Midwifery asking staff to pilot the tool and provide evaluative feedback (survey) in terms of the tool's functionality, capability, degree of flexibility, ease of integration into course curriculum, usability/sustainability and pedagogical value. Results Stage 4 The evaluation process has been undertaken across all stages of the project involving design and development staff, teaching staff, user's and project consultants. Methods implemented for formal evaluation of the tool include electronic survey and user focus group discussions. Data analysis is currently underway and will be presented at the conference.

Conclusion /Discussion: Where to from here? An important outcome of this project is a hospital-wide execution of a new clinical handover policy at St Andrew's Hospital instigating the catalyst for change in practice to ensure patient safety and quality in healthcare. This will include nurse education conducted at all levels, incorporating the tool. A demonstration of the interdisciplinary clinical communication module will be provided to conference delegates

References:

1. Australian Commission on Safety and Quality in Health Care (2010). The OSSIE Guide to Clinical Handover Improvement. Sydney, ACSQHC.

This presentation will explore the nature and purpose of inter-professional learning (IPL) and examine what the learning objectives of IPL are and whether these objectives can be achieved effectively in a simulated learning environment. With a background in IPL and health workforce research, the presenter will consider existing inter-professional simulated learning initiatives and the scope for future innovations in this area. The presentation will cover inter-professional simulated learning initiatives in medicine, nursing and allied health and will consider the suitability of the different types of simulation from high fidelity technological solutions for clinical simulation, to non-technical role play and the use of actors. A range of clinical and non-clinical training scenarios based on real life health care contexts will be presented and the benefits and risks involved in using simulation in these contexts will be examined.

The aims of the study were to develop, trial and evaluate an inter-professional learning (IPL) approach. This was then compared to standard educational approaches used for medical and nursing students provided uniprofessionally (UPL). Students' performance in an authentic simulated scenario was evaluated. Pre and post testing instruments included a Delirium Knowledge Test and the Readiness for Inter-professional Learning Scale. Video recording and observation of the simulation measured the team work and communication skills of IPL and UPL groups. Follow up surveys determined the perceptions of the students during this experience and individual interviews provided an opportunity for further exploration of perceptions of the students during this experience.

Results indicate positive feedback about the overall experience from students and tutors. IPL students rated the experience higher than UPL students in terms of increased confidence in the collaborative management of a patient with delirium. All students, but particularly IPL nursing students, rated the experience as an important driver to influence effective inter-professional clinical practice. Differences were noted between groups (UPL and IPL & Medicine and Nursing) about different activities of the learning experience. This study revealed that a complex inter-professional learning intervention is logistically possible and highly valued by students.

Problem Statement: Root cause analysis of sentinel events often cite miscommunication as a factor in outcomes. National organizations are promoting improved interdisciplinary communication and collaboration as important steps toward enhanced patient safety. There is evidence that using crisis resource management to promote teamwork improves collaboration and communication in occupations where lives are dependent on successful team dynamics in emergency situations.

Among the study hospital's Rapid Response Team members there are concerns regarding interpersonal communication, professional collaboration and decision-making. This Rapid Response Team has been in place since 2006, and the recent addition the Hospitalist physician has shifted team dynamics. The nature of the team make the stakes high in promoting its success, so the professional development educators have been charged with developing education to facilitate a team training initiative. Rapid response teams are in place to promote patient safety, therefore promoting effective interdisciplinary teamwork, communication, and collaboration will benefit all stakeholders. Past educational programs have faced challenges with participation, lack of participant engagement, and dissatisfaction with course design and timing. Satisfaction is important to facilitate learning and must be addressed to make any program successful.

Research Design: This research will use action research to assess learning needs and allow stakeholders input in course design. Focus groups with purposeful samples of rapid response team stakeholders will be held to determine their perceptions of team strengths and areas for potential improvement, as well as how best to design trainings to meet these needs. From the initial stakeholder focus group data, a Delphi survey will be created to further determine the template for the team training program. Principles of andragogy will be used to promote engagement. A Team Climate Inventory tool will be used pre and post the assessment phases of the action research to monitor for changes.

Relevance: Rapid response teams have been successful internationally in improving patient safety by bringing a team of experts to the bedside to assist with a patient in distress or someone whom staff nurses are concerned about. Improving team dynamics, communication, and collaboration, especially in an “ad hoc” interdisciplinary team such as this rapid response team, should further improve patient safety. Participation by stakeholders in planning the training should increase the sense of ownership and relevance and ultimately participant satisfaction, providing a design model for future educational initiatives.

The focus of the program was on delirium and its collaborative management. It was developed following the successful outcomes of a large-scale comparative investigation conducted in 2008. In 2010, students participated in a three-hour program, which included a DVD of an inter-professional conversation about delirium between a senior nurse and doctor; an interprofessional paper-based case study and an immersive simulation scenario using a trained actor. This was followed by a nurse and doctor led debrief.

Key factors to the successful implementation included appointing a dedicated person to manage the program and its logistics, ensuring engagement and training of medical and nursing tutors, and organisational leadership. The evaluation consisted of a post experience questionnaire including the Readiness for Inter-professional Learning Scale and open-ended questions to explore student's perceptions of the program.

Results are currently being analyzed and will be presented at the conference but initial findings indicate that students highly valued the immediate opportunity to put theory into practice and they viewed inter-professional learning as a driver to influence effective inter-professional clinical practices. The program has been so successful this year that it will be delivered to over 800 students in 2011.

A dynamic model of reasoning, based on a research model of nurses' thinking and decision-making[5] in relation to the deteriorating patient was presented elsewhere at this meeting. In this roundtable, we are seeking input from clinicians and academics regarding how the model can be used in healthcare educational and clinical environments. Potential uses for the model include support of undergraduate education or professional development in clinical reasoning training within the context of patient case studies, playing out and debriefing simulation scenarios, planning and evaluating the impact of eHealth interventions such as a nurse decision support strategy or initiative, data collection framework for patient safety and systems improvement, and analysis of critical incidents. We would further like to explore how the model can be translated into the workplace to narrow the theory/practice gap.

Format of the Session: The session will consist of two components. Firstly, the dynamic model of reasoning will be demonstrated via a computer simulation. The simulation will be followed by a roundtable, guided discussion on potential uses of the model in the healthcare environment. This presentation is allocated 40 minutes.

Outline of Intended Activities:

Demonstration by the roundtable facilitators of the computer simulation model.

Facilitated discussion with participants of potential clinical and educational uses and contexts of the clinical reasoning model. 

Aims and Learning Objectives: The aim of the roundtable is to explore practical uses of the model, and to establish priorities for future development and investigation. By the end of this session participants would:

• have been introduced to the potential benefits of system modelling for improved healthcare processes via the clinical reasoning model as a case study
• appreciate how systems modelling can contribute to health care clinical practice
• have provided feedback and advice on the practical applications of the clinical reasoning computer model for continued development and utility

Methods: In developing a rating scale, it was necessary to take into account the health care user, the clinical task, and the environmental context. Required outcomes include the need to interpret findings in terms of safety, in addition to usability. The scale also must be able to be used by clinicians who are not trained in usability engineering evaluation techniques. The Clinical Usability Rating of Equipment (CURE) Scale was developed from the Cooper Harper Rating Scale⁵, the scale used by test pilots to rate aircraft handling qualities over the last 40 years. It will be validated via a series of equipment assessments in the patient simulation environment.

Results: The CURE Scale is presented in the form of a decision tree. The user designs a series of test scenarios or tasks for the equipment or system under test, to be performed either in the workplace or in the patient simulation environment. Task outcomes are nominated at two levels – desired and (min) acceptable. The tasks are then performed by the user(s) and outcomes recorded. The decision tree guides the user to a rating that incorporates a description of the outcome in terms of task performance and safety, and provides advice regarding a suitable rectification process for any identified deficiencies.

Conclusions: After validation, the scale will be available for use in testing and evaluating clinical equipment and systems in health care.

References:

1. Carayon P. Handbook of human factors and ergonomics in health care and patient safety. Mahwah, N.J.: L. Erlbaum, 2007.
2. Dieckmann P, Rall M, Østergaard D. The role of patient simulation and incident reporting in the development and evaluation of medical devices and the training of their users. Work: A Journal of Prevention, Assessment and Rehabilitation 2009;33(2):135-43.
3. Kushniruk AW, Patel VL. Cognitive and usability engineering methods for the evaluation of clinical information systems. Journal of Biomedical Informatics 2004;37(1):56-76.
4. Daniels J, Fels S, Kushniruk A, Lim J, Ansermino JM. A framework for evaluating usability of clinical monitoring technology. Journal of Clinical Monitoring & Computing 2007;21(5):323-30.
5. Cooper GE, Harper RP, Aeronautics USN, Administration S. The use of pilot rating in the evaluation of aircraft handling qualities: National Aeronautics and Space Administration, 1969.

Background: Medical simulation has gained widespread acceptance within the military medical community. In particular, computer-based trainers for dexterous skills learning is an important focus. Much of the development effort is spearheaded by commercial interests. While this has resulted in significant accomplishments, new entrants in the field are discouraged by high startup costs and the lack of clear standards.

The military medical community has banded to form a collaborative partnership. Known as the Military Medical Simulation and Training Consortium, the MMSTC aims to identify and work on common goals within its member institutions. As part of its technology initiative, the MMSTC will standardize on a core computing platform for all of its computer-based dexterous skills training. TOPS will satisfy this requirement.

Methods: TOPS is a 3-year initiative between the MMSTC, academia and industry. Its primary deliverable is an open (published) standard describing the hardware and interface requirements of the core computing platform. This standard will be licensed royalty-free to any hardware vendor or software developer working on medical simulation applications.

The TOPS standard will be mandated as a requirement for all computer-based medical simulators deployed within the MMSTC. The TOPS standard will be developed iteratively. It will begin with a requirements analysis of the MMSTC training curriculum. A series of workshops with stakeholders, academia and industry will develop the first draft standard. Testing with the MMSTC community will ensure.

Results derived from this effort will be used to shape and refine the standard. This process will end with a consensus document that meets the training requirements of the MMSTC, and is achievable by industry. As part of the development process, we seek input from the international community beneficial to this initiative.

Results: Developing a documented standardized computer-based medical simulation platform is the ultimate goal of this initiative.

Conclusions: A standards-based computing platform for MedSim benefits both the US Department of Defense (DoD) and commercial interests. Once implemented, industry can be assured of a large, deployed base of simulators for which future applications can find a market. New entrants into the field benefit from a reduced start-up cost: they can focus on software development for a known hardware configuration. The DoD benefits from competition driving down procurement cost, and boosting innovation. Maintenance and logistics efficiencies are also improved.

Background: Queensland Health Clinical Skills Development Service operates in a “hub and spoke” model of a central coordination centre, affiliated centres and pocket simulation centres. Clinical leaders within hospital departments express increasing interest in establishing education within their local environments.

Data/Methods: The logistics surrounding organisational requirements and limited resource distribution to support the need for readily available education is mapped to explore and coordinate the process. Selection of equipment distribution is dependent on several factors influencing the decision; the most important is the motivated local clinical leader. Utilising a clearly defined system allows for structured teams to coordinated, manage and establish effective and innovative pocket simulation centres. Critical has been the training simulations coordinators from the local facilities to support the delivery of training at the pocket sites.

Results: Current coordinated simulation precincts across Queensland Health: Clinical Skills Development Centre Hub – 1 Pocket Simulation Centres Established at February 2011= 20 (expected 80 by 2014). A structured approach is being utilised, outlining a clearly mapped process of the teams and individual roles involved to establish these sites. Simulation equipment usage has increased and with it training opportunities, due to the availability of the right simulation equipment delivered by trained simulation coordinators. The use of a central hub supporting Pocket Simulation Centres has significantly reduced both capital development requirements and equipment maintenance costs. Applying ‘parenting’ rules, such as consistency in faculty and simulation coordinator education has improved the coordination of a state wide approach to setting up simulation sites.

Conclusions: Developing a process to establish pocket simulation centres has been a valuable tool in standardising the approach to individual sites and utilising resources effectively to distribute this model throughout Queensland Health. Not only is access to quality simulation training improving through this distributed model but the overall cost of delivery and ongoing support is significantly reduced.

Background: Clinical Learning through Extended Immersion in Medical Simulation (CLEIMS) is a new methodology for medical student learning. It involves senior students working in teams of 4-5 through the clinical progress of one or more patients over a week, utilising a range of simulation methodologies (simulated patient assessment, simulated significant other briefing, virtual story continuations, pig-trotter wound repair, online simulated on-call modules, inter-professional simulated ward rounds and high fidelity mannequin-based emergency simulations), to enhance learning in associated workshops and seminars. A randomised educational trial comparing the methodology to seminars and workshops alone began in 2010 and interim results were reported at last year's conference. Updated results are presented here and final primary endpoint outcomes will be available by the time of the conference.

Methods: 80 medical students volunteered to participate, of whom 44 were randomised to the intervention arm and 36 to the control arm. Participants undertook one week of the program in Year 3 in 2010 and will undertake a second week, focusing on the care of an Indigenous family, in Year 4 in 2011. They completed study-specific assessment at the end of each rotation as well as summative assessment at the end of each year.

Results: No significant difference was seen between the study arms in multiple choice and script concordance questions on workshop content but intervention arm participants scored better in a prescribing exercise (mean score 67.9 vs 63.1, P= 0.02) and a resuscitation practical test (mean time-to-defibrillation 87 seconds vs 130 seconds, P=0.007) at the end of the first CLEIMS week. There were no significant between-arm differences in summative assessment marks at the end of the first year, which avoided the stopping rule allowing the trial to continue into the second year.

Discussion: Significant between-arm differences were seen in some primary endpoints but no significant differences in summative marks have been seen so far. Final primary endpoint outcomes will be presented at the conference.

Conclusions: The CLEIMS methodology appears to enhance some aspects of student learning.

Background: Health educators have been challenged to review teaching methods and improve the preparation of graduates. Incorporating clinical simulation into undergraduate curricula is one strategy which provides opportunities to address this and assist learners prepare for the complexities of practice (Jefferies, 2007). While simulation provides excellent opportunity for students to ‘try out’ their skills and apply theory in practice, it is resource intensive. Educators are often challenged to find creative ways of managing large numbers of students and at the same time provide individuals with experiences that will enhance practice development.

Methods: This presentation reports an innovative approach used by the School of Nursing Midwifery and Indigenous Health at the University of Wollongong to enhance the facilitation of teaching and learning in simulation laboratories and provide all students with the opportunity to actively be involved in simulation. The design incorporates lectures, tutorials and workshops in an inter-connected learning pathway where by student learning and simulation practice are integrated. The presentation will briefly outline the curriculum design underpinning this approach and detail structure of simulation activities. An example of how this strategy has been used with senior students challenged with developing and demonstrating more advanced professional practice skills associated with time management, team nursing and total patient care will be included.

Results: This approach has been successful in providing opportunities for up to 24 students to have hands on experience in simulation at one time. Replicating this approach has allowed 300 nursing students from across three campuses to have the experience of immersive simulation teaching and learning experience.

Conclusions: While this initiative was designed to enhance the delivery of nursing curricula, the framework has the potential to be replicated in other qualifications. This presentation will be of interest to people managing the challenge of running simulation with limited resources and catering for large numbers of students.

References: Jeffries, P. (Ed.). (2007 ). Simulation in Nursing Education: From Conceptualization to Evaluation. New York: National League for Nursing.

Background: Nurses ability to manage deterioration and ‘failure to rescue’ are of significant concern with questions over knowledge and clinical skills. Simulated emergencies may help to identify and develop core skills and enhance patient safety. Design: A mixed methods triangulation design (convergent model) incorporating quantitative ratings of performance, patient notes review and qualitative data from video based reflective review (photo-elicitation).

Methods: Thirty five nurses from a single ward completed a knowledge questionnaire and two video recorded simulated scenarios in a rural hospital setting. Patient actors simulated deteriorating patients with an AMI and COPD. Situation awareness was measured at the end of each scenario using the Situation Awareness Global Assessment Technique. All patient notes from the ward were reviewed for the 10 weeks before and after the intervention aiming to identify vital sign recordings and help seeking behaviour.

Results: From the patient notes review there was a 50% reduction in episodes of clinical mismanagement including improvements in vital signs recording and help seeking actions in relation to patient deterioration. Knowledge of deterioration management varied considerable (range 27%-91%) with a mean score of 66%. This score is notably lower than a cohort of third year student nurses who scored an average of 74% on the same test1. Average skill scores across the two scenarios (AMI and COPD) were low (50%) with many important observations and actions missed, including failures to call for assistance. As each ‘patient’ declined staff performance also declined with a reduction in all observational records and actions, reaching statistical significance in many areas. Measures of situation awareness were also low with an average score of 50%. Performance decrements appeared, in many cases, to be related to high anxiety levels. In this study participants tended to focus on single signs and symptoms and failed to use systematic approaches to patient assessment. However, all identified that patients were deteriorating and observations were initiated early.

Conclusion: Knowledge levels and skills were generally low in this rural hospital sample however data from the patient notes review suggested that the intervention (high fidelity simulation and feedback) enhanced vital sign recording and help seeking behaviour.

References: Cooper S. Kinsman L. Buykx P. McConnell-Henry T. Endacott R. Scholes J. (2010) Managing the Deteriorating Patient in a Simulated Environment: Nursing Students' Knowledge, Skill, And Situation Awareness. Journal of Clinical Nursing. Vol 19, Issue 15, 2309-2318

Background: The aim of simulation-based training is to analyze performance during enactments of actual patient scenarios, detect areas of deficiency or excess, and initiate performance improvements that will transfer to applied clinical practice. The relative rarity and unpredictability of Obstetric emergencies makes it difficult to assess whether or not simulation acquired competencies transfer to applied clinical performance.

Methods: Ethics Review Committee approval was secured for this study. We conducted 2-hour, weekly training sessions over a 6-month period focusing on interdisciplinary team management of emergency events where the patient is pregnant. All scenarios required participation from Obstetrics/Gynecology, Anesthesiology, Neonatology, and Emergency Medicine residents, nurses, faculty and ancillary staff. We assessed the program's effect on applied clinical behavior by tracking clinical data (case logs) associated with Obstetric emergencies that presented at our institution during the year of the training program, including the details of the case, the clinical team, and the program-related training status of the clinical team members.

Case Results: A 25 year-old pregnant patient at 23+5 weeks gestation diagnosed with Acute Inflammatory Demyelinating Polyneuropathy (AIDP/Guillain–Barré) was admitted to a general care unit. During her inpatient rehabilitation, she acutely aspirated, and proceeded to full cardiopulmonary arrest. A code team was called to the unit, but failed in their attempts at resuscitation. A second-year (PGY2) Obstetric resident who had completed the simulation program correctly paged the Obstetric and Neonatal emergency team, explicitly stating to bring surgical and neonatal resuscitation supplies with them. Within 6 minutes, the Chief Obstetric resident and Neonatal staff arrived and the PGY2 performed an emergency Caesarean section in the patient's room. The patient was adequately resuscitated, and both mother and baby were subsequently discharged to home in good condition.

Conclusion: This AIDP/Guillain–Barré case recounts the results of a rare Obstetric incident where the transfer of competencies gained from simulation-based training led to successful interdisciplinary management of an actual clinical emergency. The Obstetric residents and Neonatology teams both credited their routine simulation training as significant contributors to their knowledge, skills and confidence in being able to maintain their poise to provide evidence-based care in this emergency situation. This case demonstrates transfer of simulation-based abilities to applied clinical care that directly, and favourably, impacted two patients.

Aims: This study aims to construct a model for learning reasoning in the workplace, using computer based system dynamic processes, to support clinical decision-making in relation to detection and management of the deteriorating patient.

Background: Assessment and timely management of a deteriorating patient is a priority area for improvement highlighted by several Government, independent and health agency reports[1-4]. Computer modelling of judgement processes can identify areas of difficulty in decision-making and assist nurses and other health care professionals to recognise and seek timely assistance for patients who deteriorate. Seminal work by Benner and Tanner[5-7] on “how expert nurses think” led to the publication of Tanner's theoretical model of clinical judgement[8] (Figure 1). This model maps the primary processes involved in clinical reasoning, and forms the basis of curricula in nursing courses internationally and within Australia. By explicitly modelling the time nurses take to progress through the processes of decision-making when planning and providing patient care, we can identify points where potential error and harm could occur, and thereby potentially improve patient outcomes. Figure 1 

Methods: A concept map, based on Tanner's Clinical Judgement Model, was developed and converted to a computational system dynamics model, using the approach described by Rudolph et. al. The model was refined via input from experienced nursing academics and practitioners. To obtain data to populate the model, nurses' performance will be observed in three training encounters: an undergraduate critical care nursing elective trauma patient simulation; a postgraduate critical care nursing oral viva challenge and a postgraduate acute care nursing simulation. Videotapes of simulation exercises will be analysed to allow concurrent tracking of nurses' verbal statements and actions. This also allows the time taken by nurses to interpret cues, and to initiate action, to be calculated. Post hoc video reviews will be conducted with nurse participants to facilitate exploration and interpretation of ambiguous cues, and to examine cognitive processes underpinning decisions. Opinions from experienced viva examiners will provide additional data on clinical decision-making processes.

Results: The study produced a dynamic model of reasoning, showing how nurses of varying experience make decisions about care requirements for deteriorating patients. Importantly, the model is potentially able to identify nurses’ patterns of problem-solving behaviour, and pinpoint where delays in clinical decision-making processes are most likely to occur. ‘What if’ scenarios can be run on the model to explore the impact of factors affecting decision-making on the timely identification and management of the deteriorating patient. This is expected to have significant clinical benefits by providing an opportunity for educators to develop targeted training programs that help staff recognize and appropriately manage patients who are clinically deteriorating.

Conclusions: The dynamic model of reasoning will be available to be used for clinical practice review, training development and assessment activities. The model could be used to support professional development in clinical reasoning training using case studies, playing out and debriefing simulation scenarios, planning and evaluating the impact of eHealth interventions such as nurse decision support, data collection framework for patient safety and systems improvement, and analysis of critical incidents.

References:

1. Australian Institute of Health and Welfare and Commission for Safety and Quality in Health Care. Sentinel events in Australian public hospitals 2004-05, 2007.
2. Institute of Medicine. To err is human: building a safer health system, 1999.
3. NSW Health. Patient safety and clinical quality program: third report on incident management in the NSW health public system 2005-2006, 2006.
4. Garling P. Final Report of the Special Commission of Inquiry Acute Care Services in NSW Public Hospitals: State of NSW, 2008.
5. Benner P, Tanner CA, Chesla CA. Expertise in nursing practice: caring, clinical judgment and ethics. 2nd ed. New York: Springer, 2009.
6. Benner P. Using the Dreyfus Model of Skill Acquisition to Describe and Interpret Skill Acquisition and Clinical Judgment in Nursing Practice and Education. Bulletin of Science Technology Society 2004;24(3):188-99.
7. Benner PE. From novice to expert: excellence and power in clinical nursing practice Menlo Park, California: Addison-Wesley Pub, 1984. Rudolph, Jenny, Morrison, J. Bradley, and Carroll, John. The Dynamics of Action-Oriented Problem Solving: Linking Interpretation and Choice Academy of Management Review 34. 4 (2009): 733-758
8. Tanner C. Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education 2006;45(6):204.

Background: The aim of simulation-based team training is to analyze teamwork during enactments of real-life patient scenarios, detect areas of deficiency or excess, and through debriefing initiate performance improvements that will transfer to applied patient care. Simulation-based training can benefit patient safety initiatives by providing the opportunity to develop clinical competencies in the context of interdisciplinary practice around rare or infrequent clinical events where both individual and team performances are critical for preventing patient morbidity or mortality.

Methods: Ethics Review Committee approval was secured for this study. We designed an Obstetric emergency management program as an intervention targeting interdisciplinary teams of physicians, nurses and ancillary health professionals tasked with managing Obstetric emergencies. Clinical professionals (N=79) participated in the program, with equivalent representation from all targeted groups during each session. Teams met weekly for 2-hours over six months. Training included aspects of team-based reasoning, decision-making, communication, management, and follow-up in the provision of clinical care for a pregnant patient and her fetus during an emergency event. In addition to the simulation-based sessions, we provided a web-based portal including links to institutional and departmental policies and procedures, state and federal regulations, and professional practice guidelines for each specialty involved in the program. We designed presenting cases to include unusual and challenging attributes to explore system-based practices that are seldom evaluated in day-to-day patient care. All scenarios were built around Obstetric emergencies presenting to the Emergency Department and were designed to require consultation from the participating departments, as well as ancillary specialty services such as respiratory therapy, social work, and SANE (Sexual Assault Nurse Examiner).

Results: Transcripts from the debriefing sessions identified five main types of system-level and specialty-specific practices, policies and procedures that could potentially cause conflict within the clinical team or adversely impact patient care, each of which was in evidence during every training session and often at multiple occurrences within the session. We named these categories and illustrate each type with an example:

1. Policies Certatim,
2. Policies Impossibilia,
3. Policies Casualis,
4. Policies Oblivio, and
5. Policies Absens.

Policies Certatim includes policies that either compete or conflict with each other; Policies Impossibilia includes ineffective policies that are practically unfeasible to adhere to; Policies Casualis includes informal policies within each of the clinical departments – typically verbal protocols were virtually indecipherable by team members from other specialties. Policies Oblivio includes unfamiliar policies that were not considered when providing patient care. Policies Absens includes policies that were either vague or non-existent, but were strongly advised.

Conclusions: The results of this study demonstrate that simulation-based interdisciplinary team training can serve to identify systems-based policy discrepancies that remain undiscovered due to the relative infrequency with which they are required. In addition to providing a channel for the acquisition and maintenance of clinical skills, interdisciplinary team training can serve to identify system-level needs that might otherwise remain obscured.

Aims: This study compared individual anaesthetists' teamwork behaviours in clinical settings with their behaviours in routine and crisis simulations. Our hypothesis was that anaesthetists will demonstrate similar behaviours across these situations. 

Background: To safely provide patient care in today's healthcare system, a team-based approach is required (1). Communication, shared situational awareness and decision-making, and workload management are key components, and simulation-based training has been embraced as an appropriate method to develop these teamwork skills(2). There is considerable evidence to support the validity of surgical simulators for training and assessment (3) and some support for the ecological validity of anaesthesia simulations based on activity patterns (4). However, there is insufficient evidence to show that anaesthetists' teamwork behaviours in the simulator are a reflection of their behaviour in the workplace, or that good teamwork behaviours under routine conditions predict teamwork behaviours in a crisis.

Method: Based on published instruments, we developed and validated a coding framework for interactions between anaesthetists and the OR team. We videotaped anaesthetists and anaesthetic assistants in three settings: 1) an operating room (OR); 2) a routine simulation modelled on typical cases and events in that OR; and 3) a simulated case with an intraoperative crisis. Anaesthetists and their assistants completed a questionnaire after each simulation, rating the realism of the different components of teamwork and if these behaviours occurred more or less frequently in the simulator than in the OR. For each anaesthetist in each of the 3 settings, two pre-defined segments of video were selected for analysis. These were entered into Observer XT video-analysis software for analysis by two trained non-medical coders using the coding framework.

Results: Seventeen anaesthetists were videoed in all three settings. Three additional anaesthetists were videoed in the two simulations only, generating 114 video segments, each of approximately 20 minutes duration. Participants rated the different behavioural components of their performance as realistic or very realistic and scored individual teamwork behaviours as occurring at a similar frequency in the simulations and the OR. There were some differences in perceptions between anaesthetists and their assistants. The crisis simulation was perceived to be slightly more like real life than the routine simulation. Preliminary analysis of the coding suggests consistent patterns of team interactions for anaesthetists across the three settings. Areas of consistency and differences will be presented. Conclusion We have developed and validated a tool for coding team interactions in the OR. This tool can be used by non-experts and applied to different team members. Our results provide initial evidence supporting the ecological validity of simulation for training and research in healthcare team interactions.

References:

1. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiology Scandinavica. 2009;53:143-51.

2. Salas E, DiazGranados D, Weaver S, King H. Does team training work? Principles for health care. Academic Emergency Medicine. 2008;11:1002-9.

3. Cannon-Bowers JA, Bowers C, Procci K. Optimizing Learning in Surgical Simulations: Guidelines from the Science of Learning and Human Performance. Surgical Clinics of North America. 2010;90(3):583-603.

4. Manser T, Dieckmann P, Wehner T, Rallf M. Comparison of anaesthetists' activity patterns in the operating room and during simulation. Ergonomics. 2007;50(2):246-60.

Introduction: Simulation has become an important part of the education of health care professional today. The role of simulation is to support clinical practicums and assist in the development a well rounded healthcare profession. In the case of continuing education it's a means of developing the required skills, knowledge and attitudes for new or updated clinical practice. However, there are limitation placed on the power of simulation by the language used and the espoused views, verses the theories in action(1). These attitudes can change a simulation from a simple behavioural session into a powerful experiential learning process where the participants can make “judgments-in-context” as defined by Beckett(2). Also the language currently in use focuses on the participants and the educators on the technical aspects. Simulation is more than technical skills training. Simulation can develop a capable person technically and cognitively, and the language needs to reflect this. The language should be more holistic and move beyond competency to capabilities.

Methods: This research involved eighteen educator and eighteen students to assess the ability of simulation to provided facilitated experience that can develop or assist in the development of clinical judgment in the participants. The data was gathered through semi-structured interviews and participant observations. All data was manually analysed with key points being placed on an open grid for analysis looking for key themes and ideas.

Results: Competencies encompass more than just the skill. To be competent at something, the participants need to be able to demonstrate the knowledge and understanding through ‘wise action’ in the application of their skills and knowledge. This is moving beyond simple knowledge recall, to the application of that knowledge and skills through appropriate decision-making in a variety of settings. If the language used does not reflect this broader context of competency, then simulation could be locked into that of simple technical skills development and not provide for the broader learning.

Conclusion: Simulation across the participants in this research used the same language to describe the activities within simulation. This language did not vary from educational sector type. The language used was competency-based and behavioural. This language needs to be carefully monitored and modified as it could limit the power of simulation, and reduce it to a technical skills training system, instead of a holistic educational pedagogy. The term ‘skill’ could be replaced in some instances with ‘capabilities’, as this is a more inclusive term. The term ‘skill’, has become associated with the process of doing, i.e., driving a nail, performing CPR. A broader use of the language should allow for greater flexibility in defining what is competent, and take into consideration judgment, and other higher order thinking that is required to be a capable health care professional.

References:

1. Argyris C, Schön D. Theory in practice: Increasing professional effectiveness,. San Francisco: Jossey-Bass; 1974
2. Beckett D. Holistic Competence: Putting Judgements First. Asia Pacific Education Review. 2008; 9(1):21-30.

To develop a program with MCTAs recruited from the lay community, we sought to describe and evaluate strategies to facilitate their training and retention.

After selection of a suitable cohort, a training schedule was devised, informed by standard pedagogical principles and experience from the existing female CTA program. Strategies to promote learning and retention were developed using a semi-consultative iterative approach. Evaluation used quantitative and qualitative methods.

Eighteen men completed 18 hours' training over 6 weeks. Based on observations and evaluations, several strategies were identified that enhanced compliance and enthusiasm with the training program, including: depersonalization through role-play, medicalization of the encounter, normalization of anatomical variation, graded progression of performing and experiencing the intimate examination process, and liberal use of humour.

Assuming initial motivation, enabling strategies for retention during pre-accreditation training are based on various means of desensitization. These can be delivered unselfconsciously. Details to assist implementation of various strategies will be provided.

Recruiting members of the lay community as MCTAs has benefits for both medical education and raising overall awareness of men's health. Desensitization strategies should be an integral part of the training process.

• To establish a simulated teaching program addressing the area of breast examination
• To evaluate the success of a program combining a clinical teaching associate session, simulation using a rubber breast model and a communications exercise with breast cancer consumer advocates
• To evaluate competency by reviewing results of a formal OSCE 18 months after participation in the program.

Background: In Victoria, Australia breast cancer is the leading cause of female cancers and is the second highest cause of deaths. (1) Breast cancer has a well established screening program but it is still vital that medical practitioners are skilled in the area of communication and physical examination of the breast region. Given the increasing difficulties of finding appropriate patients for clinical teaching (2), The University of Melbourne has established a simulated teaching program in the area of breast exam.

Methods: The program was established with three teaching components:

1. Clinical Teaching Associate component. Training was undertaken to instruct teaching associates of the evidence-based technique for breast exam and also formal feedback to students
2. Simulation using rubber models with supervision under trained medical academics
3. Recruitment of breast cancer consumer advocates to simulate scenarios to which student may face and to illustrate the patient experience

The program was created as a half-day session. For the purpose of this study a whole year cohort was surveyed with subsequent follow up of results from a formal OSCE exam 18 months later.

Results: There were 262 participants. Over 97% had not had previous exposure to the breast examination as a teaching encounter with 78% indicating neutral or no confidence in undertaking the communication and examination components of the breast examination. After the completion of the program 94% of students indicated that their learning needs had been met and that over 87% indicated increased confidence in undertaking the examination (p=0.001). Students reported favourably on the following:

• The Clinical Teaching Associate (CTA) was able to give constructive feedback on physical examination technique (97%) and communication skills (87%)
• The Consumer Advocate increased my understanding of cancer care issues (90%)
• In ranking the program, the CTA ranked highest in usefulness followed by the Consumer Advocate and then breast model simulation (97%, 92% and 80% respectively)

On formal examination of the same group of students 18 months letter, the OSCE median score for the breast examination was 78/100. The exam tested for both communication and breast examination technique.

Conclusion: The simulated program has been assessed as being useful and appropriate for teaching of the breast examination. The components developed work synergistically together to maximise the learning experience in a time of increased student numbers. The OSCE assessment undertaken,18 months later reflect retention of skills.

References:

1. Olson LG, Hill SR, Newby DA. Barriers to student access to patients in a group of teaching hospitals. Med J Aust. 2005 Nov 7;183(9):461-3.
2. Victoria Cancer Statistics – website http://www.cancervic.org.au/ – hyperlink – Cancer Statistics 2010

Aims: To increase medical students' confidence and competence in men's health examinations using simulation and individual tuition.

Background: Diseases of men's reproductive organs cause considerable morbidity and mortality. Prostatic hypertrophy is very common and results in diminished quality of life. Prostate cancer is the second most common cause of death from cancer in men of all ages(1). Testicular cancer, which affects mainly young men, is curable if caught early. Surveys have shown that when men attend medical practitioners they want them to be, among other things, both competent and confident.(2,3) Yet, while there is little information about genital examinations, there is evidence that our students graduate with little experience of rectal examination. Even those that have had experience have low levels of confidence in their findings.(4,5) If we are to achieve long term improvement in men's health this deficiency needs to be addressed.

Method: We have recruited volunteers from the community (urological teaching associates, UTAs). These men were taught the technique of hernia, genital and rectal examination as well as communication and feedback skills. They then teach the students whilst being examined themselves. Each tutorial involves 2 students and 2 UTAs. It starts with an introduction and then the examination is demonstrated by the UTAs. This is followed by a role play in which each student examines a UTA and is given individual feedback on their performance.

Results: The students evaluate their confidence in performing these examinations on a 5 point Likert scale at the start of the tutorial and this is repeated at the end of the tutorial along with their assessment of their learning in various areas for example technical skills and communication skills. So far, 130 students have taken part in the tutorial. There are dramatic shifts in the students’ confidence in their ability to perform these examinations - from almost all being not confident in the beginning, to all having a degree of confidence afterwards.

Conclusion: These results need to be confirmed by larger numbers but they mirror the results of our similar women's health program which has been running for 8 years.(6) This is an amazing change for a 2 hour intervention. It is another example of strength of simulation in education. This innovative program could revolutionise the teaching of the examinations in the men’s health area and help to overcome the barriers that exist at present.

References:

1. M5 project – men's preventive health – a collaborative project between RACGP, Australian government and departments and not-for-profit agencies
2. Metz ME, Seifert MH Jr. Men's expectations of physicians in sexual health concerns J Sex Marital Ther. 1990 Summer;16(2):79-88
3. Smith JA, Bollen C. A focus on health promotion and prevention through the development of the national men's health policy. Health promotion J Austr. 2009 Aug:20(2):98-101
4. Lawrentschuk N, Botlon D. Experience and attitudes of final year medical students to digital examination. MJA 2004; 181(6):323-5
5. Fitzgerald D, Connolly SS, Kerin MJ. Digital rectal examination: a national survey of undergraduate medical training in Ireland. Postgrad med J 2007 Sep:83(983):599-601
6. Fairbank C. Effective teaching of pelvic examination. The Clinical Teacher 2009: 1-4

Background: The VoxelMan TempoSurg virtual reality temporal bone simulator could potentially be used as an assessment tool for ENT trainees. A key requirement for this is evidence of reliability in scores given by multiple raters. Previous work has shown good reliability when assessing video clips (unpublished). This study investigates whether assessment of still images by multiple raters is reliable.

Methods: Twelve trainees of varying levels of ENT experience were given 10 minutes to perform a standardised task on the VoxelMan TempoSurg simulator. Four still images were taken at intervals throughout this period to document the progress made by each trainee. Subsequently these images were presented to 12 other ENT surgeons with different levels of experience. These surgeons were asked to judge the experience of the simulator users based on the still images, and score each set of 4 images using a 6 point scale.

Results: Concordance of scores given by the 12 raters to the 12 sets of images was investigated using Kendall's W Coefficient of Concordance. Using this statistic a high level of concordance was seen across the raters (W=0.721, p=0.0000). When the raters were stratified into 2 subgroups based on level of ENT experience, there was no significant change in the level of concordance (W=0.758, p=0.000 for raters with <5 years experience (n=7), and W=0.739, p=0.000 for those with >5 years ENT experience).

Conclusions: Assessment of still images is reliable across multiple raters, and compares favourably with assessment of video clips (unpublished data).

Methods: 20 ENT registrars of varying seniority were recruited to the study. First, all completed a questionnaire detailing previous mastoid surgery experience and a self-evaluation of skill level. Next they were given 15 minutes to practice drilling a virgin temporal bone on the simulator. Ten minutes were then given to select an appropriately sized burr and continue a partially completed cortical mastoidectomy. It was explained that credit would be given for a smooth and steady drilling action, avoidance of damage to important structures, and progress made in the task. A film of the drilling was recorded on the computer, which was later blindly and independently assessed by 2 consultants. Each assessment involved giving an overall impression score to each participant. In addition, a score for a number of domains (eg flow of operation, respect for tissues) was given in an attempt to introduce greater objectivity, as previously validated in surgical skills research. The domain scores were summed, and the total used as an alternative to the overall impression score.

Results: The relationship between the scores given by the 2 consultant observers was investigated using Spearman rank-order correlation coefficient (rho). There was a strong positive correlation between the consultants’ scores for both the overall impression score (rho=0.724, n=20, p<0.0005) and the domain total score (rho= 0.659, n=20, p=0.002). Spearman correlation coefficients also suggested a strong positive correlation between the overall impression scores and the domain total scores (rho=0.863, p<0.0005) There were also strong positive correlations when Spearman rank-order correlation coefficients was used to investigate the relationships between the consultants’ scores and both the year of study and the self-rating of registrars (in all cases rho>0.5, and p<0.05).

Conclusion: The virtual reality mastoid surgery simulator appears to be a valid and reliable tool for the assessment of competence and experience in mastoid surgery. It may therefore have a role in the summative assessment of trainees.

Aims: Laparoscopy requires an instructor to convey instructions to a trainee using verbal cues for guidance of camera and instrument movement. The hypothesis tested in this project is that verbal cues can be refined to convey instructions efficiently to trainees at various levels of experience. The primary aim was to validate a novel laparoscopic navigation simulator as a useful tool for development of surgical skills of surgeons-in-training by linking verbal cues with coordinated hand-eye movement in a quantifiable environment using video capture. The secondary aim was to develop tools to assess communication using verbal instructions formatted differently in order to optimize operating room communication between the instructor and the trainee.

Background: Laparoscopic surgery requires the instructor to direct a trainee using verbal cues rather than pointing or directly assisting hand movement of the trainee. The instructor typically has his/her hands on two laparoscopic instruments, and this precludes pointing or directing as an educational method. The instructor must therefore convey complex three-dimensional instructions to the trainee using only verbal cues. Trainees often struggle to navigate the laparoscopic camera and instruments to the correct target in live surgical procedures. A number of different styles of verbal cues may be adopted by the instructor such as directional instructions for the trainee's hands versus instructions that guide to an anatomic end-point without giving specific directional instruction. This simulator was built to allow trainees at various levels to master complex movements of laparoscopic cameras using only verbal cues for instruction and to validate a platform for testing differing formats of verbal cues.

Methods: Eight training boxes with internal, numbered navigational mazes were constructed for use in low fidelity laparoscopic surgery box trainers. Verbal cues using only directional commands such as anterior, posterior, right left, in and out were recorded onto an MP3 player. Participants navigated the mazes with only verbal cues. Progress was recorded using a multi-channel video recorder that monitored internal camera motion and external hand motion. Twenty trainees at various levels from first year of training in obstetrics and gynecology through residency and post-doctoral fellowships, to senior faculty participated in the exercise. Video was graded in a blinded fashion using time, gross, and fine motion scoring.

Results: This simulation demonstrated a significant difference of motion errors and camera wobble between beginner and expert level surgeons, as expected. Significant variance was noted in scores based on assessment of motion error, gross and fine motion analyses. Time was a more predictable end point, but did not accurately score quality of movements or number of movement errors.

Conclusion: Improvement of operating room laparoscopy skills by trainee surgeons will likely benefit by further development of novel simulators to allow practice of complex, three-dimensional movement and by testing of different verbal formats to convey directions. This project was successful in validating the novel simulator models and the testing of verbal cues. Further testing will be conducted using different verbal formatting to optimize communication.

Methods: Ethics Review Committee approval was secured for this study. We asked residents/fellows to remove the peel of a Clementine in as few pieces as possible, separate and remove all pith from and between all fruit segments, and return the Clementine to as close to its natural state as possible with completely closed skin (sutured). Clinical decision-making included deciding when to complete the procedure "open" or when unacceptable segment damage would result by removing difficult to extract pith. The analogy corresponds to deciding when to leave cancerous lesions or metastases in place to be treated through other methods (radiation, chemo, etc.), rather than risking damage to the vital organs or other healthy tissues. Faculty, blinded to the training status of the subjects, assessed their video-recorded performance using a rating scale, in addition to noted objective performance measures.

Results: Faculty ratings indicated significant differences between the performance of junior/senior residents and fellows (p<0.05) on operative planning/plan use, gross/fine dissection skills, instrument selection/control, tissue handling/damage, operative reasoning, clinical Judgment, and overall performance. Subjects reported specific advantages for using the exercise to develop surgical skills, reasoning and decision making. Examples of two subjects of varying skill are included in Figure 1 (see paper).

Conclusions: A low-cost, easily facilitated simulation-based model for developing advanced laparoscopic surgical skills may advance the preparation of residents and fellows for gynecological oncology practice, providing a platform for development/maintenance of skills, critical thinking and clinical judgment. This model could also provide an option for laparoscopic skill development in low and limited resource environments globally.

Paper: Download the paper.