Journal Logo


Selected Abstracts of Free Papers Presented at the SimHealth: Innovation, Education and Research in Healthcare ConferenceSeptember 12–15, 2011 Sydney, Australia

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2012 - Volume 7 - Issue 1 - p 62-71
doi: 10.1097/SIH.0b013e3182498a69
  • Free

SimHealth is the official conference of the Australian Society for Simulation in Healthcare (ASSH). Held over 3 days during the southern hemisphere spring, it brings together international and local experts in simulation education, research and development, human factors and health systems. This year’s keynote speakers were Amitai Ziv (MSR, the Israel Center for Medical Simulation), Carolyn Cason (University of Texas at Arlington), Beth Mancini (The University of Texas at Arlington) and Debra Nestel (Gippsland Medical School (GMS), Monash University, Australia. Details for the SimHealth 2012 program can be viewed on the official conference website


Gary Rogers, Nicole Jones de Rooy, Harry McConnell, Marise Lombard, and The CLEIMS Teaching Team

INTRODUCTION: To report the outcomes of a randomised educational trial of a new methodology for extended immersion in medical simulation for senior medical students. 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, interprofessional 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.

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.


Simon Cooper, Tracey McConnell-Henry, Jo Porter, Karen Missen, Leigh Kinsman, Ruth Endacott, Robert Champion2, Robyn Cant

INTRODUCTION: To examine, in a simulated environment, rural nurses’ ability to assess and manage patient deterioration using measures of knowledge, situation awareness, skill performance and a pre-post intervention patient notes review. 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.

METHODS: 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.

CONCLUSIONS: 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.


1. 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


Stephen McDonald

INTRODUCTION: To assess the feasibility of using a computerized virtual reality mastoid surgery simulator as an objective measure of competence in mastoid surgery.

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).

CONCLUSIONS: 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.


Toni Azzopardi, Amanda Johnson, Kirrilee Phillips, Cathy Dickson, Cecily Hengstberger-Sims, Mary Goldsmith, Trevor Allan

INTRODUCTION: With advances in technology and increasing demands on clinical resources, simulation as an alternative learning strategy is becoming increasingly popular in supporting the educational preparation of tertiary students. In particular, schools of nursing have embraced this approach as a component of their undergraduate curriculum. Simulation activities developed using learning outcomes, guided preparation and reflection enable students to exercise clinical decision making in a supportive and realistic clinical setting, prior to attending clinical placement. This supportive learning technology facilitates both the acquisition of competence and confidence by the student which leads to a more meaningful clinical placement experience. 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.

METHODS: 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.

RESULTS: 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.

CONCLUSIONS: 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.


Pamela Andreatta, Sara Boblick-Smith, Jennifer Frankel, Joseph Perosky, Alexandra Bullough, David Marzano

INTRODUCTION: We hypothesized that simulation-based interdisciplinary training would reveal system-level and specialty-specific procedural and policy conflicts with the potential to adversely impact patient care. 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.


Neil Tuttle

INTRODUCTION: To compare an individual’s ability to discriminate stiffness using a haptic device and using real-world objects when cutaneous cues are either included or excluded. 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’s 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.


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.


Yuzo Takahashi, Tsuyoshi Mizuno

INTRODUCTION: The aim of this pilot study is to define possibility and limitation of a humanoid robot for the usage in medical education. Recent technology allows us to make a humanoid robot that mimics a 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 been 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 a medical interview, following a preprogrammed scenario. Skins made of silicon covered the face and hands. Head was covered with a wig, and the body and hands were covered with clothing. The preprogramming 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 preprogrammed 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 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.


Pamela Andreatta, David Marzano, Diana Curran, Perosky Jospeh, Kevin Reynolds

INTRODUCTION: Low-cost, high-fidelity models for laparoscopic surgery training in gynecological oncology are not currently available. The objective was to design a model for developing associated fine, precise laparoscopic dissection skills with accompanying surgical decision making.

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.

Figure 1
Figure 1:
Minimally Invasive Surgery Physician (L) vs. Family Planning Physician (R)

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.


Bingxiang Yang, Zhijie Zou, Yingzi Zhang, Ailing Wang, Jun Zhang, Dan Luo

INTRODUCTION: With the rapid development of nursing, Chinese nursing students are expected to have not just knowledge, but also abilities of communication, problem solving, critical thinking, etc. Therefore, Chinese nursing educators should think how to innovate curriculum design and teaching strategies. In this research study, the aim was to explore how to integrate simulation into nursing curriculum and evaluate its effectiveness in helping students to familiar with clinical situation and provide safe and high quality care to patients.

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.

CONCLUSIONS: 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.


Robyn Clay-Williams, Michelle Kelly2, Bronwyn Everett2, Lin Perry3, Geoff McDonnell4

INTRODUCTION: 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. Assessment and timely management of a deteriorating patient is a priority area for improvement highlighted by several Government, independent and health agency reports1–4. 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 Tanner5-7 on “how expert nurses think” led to the publication of Tanner’s theoretical model of clinical judgement8 (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.


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.


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.


Gheorghe Gavriloaia, Mariuca-Roxana Gavriloaia2, Catalin Neamtu

INTRODUCTION: This paper presents a new noninvasive method that can be used for early and accurate cancer diagnose, when tumors are very small, having a surface more or less rough, depending on whether they are or not malignant. The amplitude of a reflected signal, as a result of an acoustic wave applied by a given tissue, depends on its frequency, material parameters, shape and object size. In the case of broadband signals, very short duration, the amplitudes of spectral components are strongly correlated with the degree of smoothing or roughness of the investigated object. The distribution evaluation of components spectral allows finding useful information on the size and shape of outer surface. In malignant tumors case, the outer surfaces are rough, and the spectral response will be completely different from benign tumors having smooth surfaces.

METHODS: A partial differential equation of second order is used to simulate the propagation of acoustic wave through a certain object. After applying 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, simulating benign tumors, with maximal diameters of 1, 5, 10 and 20 mm were investigated. New outer surfaces could be obtained by adding a random normal distribution component to radius or axes values used in equations describing very irregular surfaces, simulating malignant tumors. The average values of the smooth objects were maintained and the following different relative standard deviations were added: 3%, 10% and 25%. Acoustic wave pulses with very short duration were applied through these tissues. A total of 16 eigenvalues, resonance frequencies, were calculated for all the 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. If the standard deviation has a large value, then the eigenfrequencies are close to each other. If the roughness is less than 4%, changing its frequency spectrum is less significant. Resonant frequencies concentrations are very evident for standard deviations values of 10% and 25%.

CONCLUSIONS: A new method to assess the type of tumor is presented in the article. The acoustic wave 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. More accurate results can be obtained for tumors with diameters less than 10 mm, situations that can not be solved with any other current medical device because of limitation in spatial resolution.


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.


Franki McMahon, Mehrnaz Shoushtarian1, Malcolm Barnett Eastern Health, Box Hill, Victoria

INTRODUCTION: The purpose of the VicPROMPT pilot project is to address a current gap in evidence-based simulation training available in Victorian maternity units, and to significantly improve the management of maternity emergencies in this state. Implementation of this program in the UK has resulted in significant improvements across a range of outcomes. In order to provide evidence of the effectiveness of the training program, the aim is to replicate and build upon the research carried out in the UK to assess whether training improves outcomes for patients and staff in Victorian hospitals participating in the VicPROMPT program. Key indicators assessing the effects of training include i) clinical outcomes, ii) claims data and iii) organisational aspects such as staff attitudes and morale. 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.


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.


Dylan Campher, Lucas Tomczak, Jodie Litherland, Lisa McCoy, Daniel Host1 Queensland Health Centre for Healthcare Improvement, Clinical Skills

INTRODUCTION: The importance of efficient simulation equipment management on a statewide level is demanding a more structured coordination and support model in Queensland. Industry support is expensive and depends on company representatives, often leaving individual simulation centres unable to pay the ongoing maintenance costs associated with each simulator. In Queensland Health, a statewide simulation equipment management system to support smaller unfunded centres with simulation tools is addressing the local clinicians need.

Simulation education internationally has traditionally been individual small scale centres, delivering excellent education to a local group. There are few large scale models for standardised delivery of training. For simulation training to have a beneficial effect, evidence shows that saturation is required, that is all staff should undertake training regularly. For Queensland, this means a rapid increase in the volume of training delivered were required for best effect on Queensland Health staff and therefore patient care.

METHODS: The Clinical Skills Development Service has developed a sustainable process, model and system to manage simulation equipment assets across the state. The team has demonstrated this service provision by use of an integrated database to manage and coordinate simulation equipment distribution, usage, maintenance and repair, freighting, loan library, evaluation, procurement, training and establishment. A costing model to forecast associated costs have been developed in conjunction with usage data to predict maintenance cost.

RESULTS: Tracking of over 1400 simulation tools throughout Queensland is managed via a database and process to ensure adequate resource deployment and access for clinician education throughout the state of Queensland. A cost effective maintenance model addressing equipment usage hours have ensured repair costs of simulators are minimised, saving over $1.1 million per year and reducing the loss of training opportunities.

CONCLUSIONS: A systems approach to coordinate simulation equipment on a large scale results in greater efficiency gains of equipment management. Economies of scale produces cost saving in the areas of maintenance and repair and ensure that simulation education is more accessible to the everyday clinician.


Bronwyn Avard, Kerry O’Neill, Jonathon Van Diemen1 ICU, The Canberra Hospital, ACT

INTRODUCTION: As part of the multidisciplinary redevelopment of the education program in our Intensive Care Unit (ICU), we wished to introduce a high-fidelity simulation based teaching program. All applications for additional funding were unsuccessful, necessitating the creative utilisation of existing resources to create realistic simulated learning environments. A strategic planning day was conducted in November 2009 to which all members of the multidisciplinary education team in the ICU were invited. This day reinforced our desire to focus our teaching efforts on interprofessional activities, and to introduce an in-situ simulation program. Those faculty with an interest in learning how to teach in the simulated learning environment undertook workshops in crisis resource management and debriefing. Subsequent to this, scenarios were developed based on a needs analysis of crisis events to which the ICU team respond. Despite notification that associated funding applications had been unsuccessful, the team elected to commence the simulation-based curriculum.

METHODS: Existing resources included an advanced life support (ALS) mannequin with electronically generated breath sounds and limited vocalisation, palpable pulses at its wrist and neck, and remotely controllable ALS rhythms. Scenarios were conducted in any unoccupied bed-space in the ICU. A lap-top computer, web-cam and associated microphone were used to ensure facilitator and observers could remain out of view of the participants behind bedside curtains or in the adjacent ante-room to single rooms.

High fidelity was achieved via a number of methods. For ward-based deteriorating patient scenarios, props were utilised extensively to simulate the environment. For ICU-based scenarios, simulating vital sign derangements were the most challenging. Invasive blood pressure was simulated by providing an appropriate pulse pressure to the arterial line transducer via a high pressure bag being manually compressed on the other side of the patient curtain. Oxygen saturation was often surreptitiously measured from a confederate nurse or family member, or via the facilitator from behind a curtain. Invasive catheters were plumbed into drainage bags concealed via bandages and clothing. Electrocardiography was measured directly from the electronic mannequin.

Scenarios were conducted almost fortnightly throughout the year, depending on facilitator availability. In total 176 staff participated in the program, with undergraduate nurses and doctors also involved during their clinical placements in the unit.

RESULTS: Despite our initial fears that high fidelity may not have been achievable with our limited resources, we were pleasantly surprised at what we were able to create. Participants provided overwhelmingly positive feedback, with >95% responding that they strongly agreed with the statements that they learnt more about crisis resource management and would recommend the program to their colleagues. Repeat participants in the program were common and frequently demonstrated skills they had learnt and retained from previous sessions.

CONCLUSIONS: A number of participants reported changes to their clinical team-work after participating in the program.


Pamela Andreatta, David Marzano, Joseph Perosky, Kevin Reynolds, Diana Curran1 University of Michigan Medical School

INTRODUCTION: The objective was to design a model for developing precise and respectful laparoscopic tissue handling skills with accompanying objective assessment measures. 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.

Figure 1
Figure 1:
Examples of two exercises

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.


Dylan Campher1, Marcus Watson1, Lucas Tomczak1 Queensland Health Centre for Healthcare Improvement, Clinical Skills Development Service

INTRODUCTION: An increased awareness in expectation and demand from the community, colleges and employers has driven the need for more innovative educational delivery methods such as simulation education. Over the past five years, a coordinated approach to establishing healthcare simulation precincts has seen a network of collaboration developed across the state of Queensland. Establishing innovative, in hospital pocket simulation centres allow for readily available education. 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.

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.


Elizabeth Pryor, Stuart Marshall, Robyn Woodward-Kron2, Timothy McNamara21Southern Health Simulation and Skills Centre, 2Melbourne University, Victoria

INTRODUCTION: Most studies of the communication skills of International Medical Graduates (IMGs) focus on doctor-patient interactions; few have examined intra-professional discourse. Having been “socialised into different communities of practice”, IMGs can find this aspect of healthcare communication challenging. 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.

RESULTS: 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.

CONCLUSIONS: 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.


Seumas Hsylop, Christopher Carpenter, Leonie Watterson Sydney Clinical Skills and Simulation Centre, Sydney, NSW

INTRODUCTION: To describe and evaluate a technological platform which enables realtime interactive simulation training for geographically separated instructors and participants. 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,i as is the use of videoconferencing for demonstration during teaching.iiTo 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.iii We consider this platform novel, and believe it will increase our flexibility in delivering teaching services.


The requirements for an ideal system are:

  1. Usability: natural realtime 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 realtime 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 inservice at remote sites.


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. Trarnsatlantic medical education: preliminary data on distance-based high-fidelity human patient simulation training. Stud Health Technol Inform. 2003;94:379–85


Louise Alexander, Amy Dearsley Holmesglen, Victoria

INTRODUCTION: The aims of this study were to explore the impact of an integrated simulation approach on the level of clinical preparedness in mental health nursing for 2nd year undergraduate nursing students. In particular to examine the connection between simulation with standardised patients prior to placement and an increase in student-reported clinical preparedness.

Pre and post clinical placement questionnaires were analysed and interpreted from to determine the effectiveness of human patient simulation in mental health nursing. Particularly in relation to reducing pre-placement anxiety and preparedness for placement, in an era where meaningful learning opportunities can often be hindered for a variety of reasons.

METHOD: A qualitative pilot study was conducted for this research. Students completed a questionnaire pre and post clinical placement to determine whether the simulation’s improved their confidence about communication and assessment skill development. A number of questions were asked to identify what they felt helped their preparedness for placement, what enhanced their confidence and how the simulation experience impacted their placement.

RESULTS: Results noted that students found the experience of immersive simulation in a mental health scenario a positive undertaking. Respondents noted that they felt more prepared for mental health clinical placement after participating in the simulation, and that this in turn, had positive effects in reducing their anxiety levels.

Students overwhelmingly cited ‘simulation’ and ‘simulated patients’ as the most effective modality for preparing them for placement and noted that this experience increased their confidence, encouraged professionalism, enhanced their understanding of mental illness presentations and was realistic.

CONCLUSIONS: Simulation is now widely accepted as a contemporary and fundamental aspect of healthcare whereby the provision of safe and immersive learning opportunities result in improved outcomes for students, educators, and more importantly, clients alike. While simulation has cemented itself as a viable and effective tool in general medical fields, there is yet to be significant research on the positive impact simulation in mental health nursing can yield. The potential outcomes are vast. This study demonstrates the impact that realistic simulation has on confidence levels, thus potentially enhancing therapeutic relationship-engaging with mental health clients, not to mention the potential enhancement in recruitment.

The benefits of using simulation to address mental health placement short falls, means that all students can be guaranteed a controlled and safe interaction with a mental health ‘client’, thus addressing placement shortfalls, and third-party hindrance.

Simulation should not be seen as the ‘poor cousin’ to hospital-based clinical placement; rather it provides a comprehensive opportunity to engage in an immersive, secure and innovative learning environment where the promotion of safe clinical decision making opportunities are abundant.

© 2012 Society for Simulation in Healthcare