USING SIMULATION TO IMPROVE CULTURAL SAFETY AND CLOSE THE GAP BETWEEN PROFESSIONAL SILOS IN MATERNITY CARE
B Bulle,1,4,9 K Freeman,1 K Evans,1,9 S Andy,6 Barbara Gibson-Thorpe,7 K Warde,2 K Johnson,2 J Boyle,4 L Hickey,5 J Whitelaw,5 M Stam,3,8 S Thowtapp,3 T Ginis,10,11 T Farrell1
1MATERNITY SERVICES EDUCATION PROGRAM (MSEP), THE ROYAL WOMEN’S HOSPITAL, MELBOURNE, AUSTRALIA; 2NJERNDA ABORIGINAL CORPORATION, VICTORIA, AUSTRALIA; 3GIPPSLAND AND EAST GIPPSLAND ABORIGINAL COOPERATIVE, VICTORIA, AUSTRALIA (GEGAC); 4MONASH UNIVERSITY, MELBOURNE, AUSTRALIA; 5PAEDIATRIC INFANT PERINATAL EMERGENCY RETRIENAL (PIPER) ROYAL CHILDREN’S HOSPITAL, MELBOURNE, AUSTRALIA; 6VICTORIAN ABORIGINAL COMMUNITY CONTROLLED HEALTH ORGANISATION (VACCHO), MELBOURNE, AUSTRALIA; 7ECHUCA REGIONAL HEALTH (ERH), VICTORIA, AUSTRALIA; 8BAIRNSDALE REGIONAL HEALTH SERVICE, VICTORIA, AUSTRALIA; 9MONASH HEALTH, MELBOURNE, AUSTRALIA; 10AMBULANCE VICTORIA, AUSTRALIA
Abstract: The National Maternity Services Plan (2011)1 supports the need to improve the cultural competence of maternity services. A culturally competent workforce was recognised as a priority reform area in Closing the gap in Indigenous life outcomes (COAG, 2010)2. Clinically focused interdisciplinary education supporting clinicians to provide culturally safe care is limited. This is the first interdisciplinary community led, collaborative initiative to improve care for Aboriginal3 women and their families to include simulation and cultural safety skills training on site in two Victorian maternity services.
Method: Njernda and GEGAC Koori Maternity Services, VACCHO, MSEP, PIPER and Ambulance Victoria have collaborated with Echuca and Bairnsdale Regional Health Services to facilitate two cultural safety workshops to enhance outcomes for Koori mothers and newborns. Participants included GP obstetricians, midwives, Aboriginal health professionals, Aboriginal community elders and paramedics.
Simulated scenarios and hands on work stations allowed participants to practice skills required for stabilisation and transfer during a maternity emergency. Cultural leaders including an Aboriginal simulated patient and her partner provided post scenario feedback and peer review regarding individual, organisational and interorganisational processes to improve cultural safety.
Evaluation: Pre and post surveys detail the usefulness of the workshop in improving cultural safety and clinical knowledge and skills and understanding key aspects of culturally safe maternity care. Qualitative data indicate the successes and challenges of formulating plans to coordinate services between Aboriginal and mainstream providers.
Recommendations: The workshops provided a unique opportunity for collaboration and relationship building across clinician groups to highlight the importance of cultural safety in maternity care. Evaluation results inform further development of a model of cultural safety training specifically developed for rural and regional maternity service providers. Key lessons learnt include;
- ▪ Accurate data to identify Aboriginal mothers and babies is integral to improve health outcomes for Aboriginal families.
- ▪ Involving local Aboriginal community in the design and implementation enables them to share their relative knowledge, historical perspectives and enhances local ownership and collaborative relationships.
- ▪ Including local Aboriginal elders in a peer review panel facilitates an opportunity for mentorship for newer Aboriginal Health Workers.
- ▪ The difference between a welcome to country and acknowledgement to the traditional owners should be included.
- ▪ Provide support and resources for participants to practice an acknowledgment of the local traditional owners.
- ▪ Onsite facilitation supports an efficient approach to service delivery, reduces travel time and improves access to the education.
- ▪ Face to face delivery supports enhanced collaboration and understanding of the role of the Aboriginal Hospital Liaison Officer and Aboriginal Health Worker.
- ▪ Using an Aboriginal simulated patient wearing a life like birth suit enhances fidelity.
- ▪ Simulated maternity emergency education has a strong synergy with cultural safety training.
- ▪ Structured reflection and debriefing allows facilitators to reinforce safe clinical practice while cultural leaders reinforce key aspects of cultural safety.
- ▪ To sustain the learning beyond the initial program, participants should reflect a broad scope and skill set available within the maternity service.
- ▪ Learning resources to support the program should be presented in various formats.
- ▪ Facilitating the workshop over one and a half days enhances networking opportunities and improves collaboration between service providers.
- AHMAC. (2011b). National Maternity Services Plan. Canberra: Australian Health Ministers’ Advisory Council, Commonwealth of Australia.
- COAG. (2010). Closing the gap in Indigenous life outcomes in early childhood- Attachment A. Canberra: Council of Australian Governments.
- Throughout this document, the term Aboriginal is used to refer to both Aboriginal and Torres Strait Islander people.
TERMINOLOGY & CONCEPTS: A COMMON LANGUAGE FOR HEALTHCARE SIMULATION
Mr Andrew Spain,1 Mr Joe Lopreiato2
1SOCIETY FOR HEALTHCARE IN SIMULATION; 2UNIFORMED SERVICES UNIVERSITY
Abstract: Healthcare Simulation has developed at an extraordinary pace. One of the downsides to this is that the use of terms and phrases has often been blended, mixed, created, or misused. This has created confusion and misunderstanding, especially when different terms are used to mean the same thing, or when common terms in other domains have been misapplied.
Methods: A collaborative task force was convened in January 2013 to address this problem and begin the work to improve communication and commonality. This multi-disciplinary group, with representation from many healthcare simulation societies, has been using lexicographic principles and processes to review the language used, compile terms that are commonly used, and move towards creating a shared language with a shared understanding.
Analysis: The work done so far has underscored the need for this work. Agreement may not be possible on many terms due to nuances in different types of healthcare simulation for example, but it is definitely felt that the work has value, is meaningful, and will improve healthcare simulation.
Results: Thus far, a first round collection of terms was requested from the simulation societies represented in the group, and from a search of the internet and other resources. This created a list of over 600 items of commonly used terms and their meanings. While this did not have input for all societies, it was felt to be a very good start. With input from lexicographic experts, this list has been refined into a shorter list of items that has been viewed as more healthcare simulation specific. A style guide has been created for common format for definitions that meets lexicographic standards. The task force has been working to compile these definitions; the work to date is being shared here. Further, continued work is underway to evaluate the literature in healthcare simulation to identify key terms that need to be addressed. This is primarily through corpus software that is specifically designed to support lexicographic work.
Questions for the audience
- Describe the value of having a shared language in healthcare simulation (that differentiates it from the larger modelling & simulation and other communities).
- Describe the challenges you have had in understanding terminology used.
- How will this work, in your view, support healthcare simulation?
- List some terms or concepts in language that you believe need to be addressed in healthcare simulation?
EVALUATION OF A NEW CRISIS MANAGEMENT COURSE FOR JUNIOR ANAESTHETIC DOCTORS
Dr Caroline Zhou,1 Dr Alexander Garden,2 Mr Peter Watt3
1DEPARTMENT OF ANAESTHESIA AND PAIN MANAGEMENT, TAURANGA HOSPITAL, NEW ZEALAND; 2DEPARTMENT OF ANAESTHESIA, WELLINGTON REGIONAL HOSPITAL, NEW ZEALAND; 3WELLINGTON REGIONAL CENTRE FOR SIMULATION & SKILLS EDUCATION, WELLINGTON, NEW ZEALAND
Abstract: Junior anaesthetic doctors often work with off-site supervision once initial competencies have been achieved, which takes at least 6 months of full time anaesthesia experience. They can face life-threatening crises at any time. The current ANZCA-mandated Effective Management of Anaesthetic Crises course (EMAC)1 can be difficult to access and junior anaesthetic trainees are unlikely to have attended EMAC before working with off-site supervision. In addition there is great variation in the amount of crises management training between training institutions2, and the authors perceive this as a risk for junior anaesthetic trainees.
Method: A new course, New Anaesthetic Registrars Crisis Management (NARCM), was designed specifically for these junior doctors to improve their crises management skills, both in crew management principles and medical/technical expertise. The course has been held every six months since December 2012, to coincide with the start dates for new registrars. NARCM runs over 2 days, utilising hands-on skill training, role-play simulation, immersive simulation, and problem-based discussions. It aims to address a range of both clinical and non-clinical skills, such as communication strategies, airway management, special patient populations and peri-operative emergencies.
Participants on the December 2012 and June 2013 course were asked to voluntarily and anonymously participate in the follow-up study to evaluate the effectiveness of NARCM. Informed consents were obtained. No ethical approval is required for anonymous and voluntary observational studies of this sort. The study subjects were asked to answer questionnaires that explored perceptions of their abilities to manage anaesthetic crises before the course started and immediately after the course finished. They were sent email invitations to complete internet-based questionnaires at 3-month and 1-year post-course. Their anonymity was protected at all stages. The use of self-rating of confidence rather than changes in competence is supported by literature3,4,5.
Evaluation: All participants had at least 6-months of anaesthesia experience at the time of the course, and 3-5 years of post-graduate medical experience. 17/21 participants agreed to participate. At 3-months, 15/17 responded (88.2 %), and 1 year after the 2012 course, 4/10 participants responded. The 1-year follow-up for the June 2013 course is pending.
The respondents were asked about how confident they feel about various aspects of crisis management, the results of which were shown in table 1 (1= not at all confident, and 5= very confident). There appear to be an increase in confidence levels in all areas, which persisted to 1 year. They were also asked to report if they had used knowledge or strategies learned on the course, whether they had been in situations similar to those simulated on the course, and whether NARCM had changed their practice. All respondents had used skills learned on the course both at 3 months and 1 year. 9/15 (60%) respondents at 3 months and 3/4 (75%) at 1 year reported that they had been in similar situations as those simulated on the course, all of whom found the simulation useful in dealing with the real life situations. At 3 months, 11/15 (73%) respondents stated that they had changed practice as a result of the course. However, at 1-year, only 1 out of 4 respondents reported a change in practice at this point. Free text comments regarding usefulness of scenarios and how they changed their practice reflected the course learning objectives.
Recommendations: From this small sample, there appears to be a need for crisis training for junior anaesthetic doctors. NARCM appears to improve the confidence of junior anaesthetic doctors during crisis management, with benefit at 1 year. The scenarios used during the course replicate common emergencies they were likely to face, and this was perceived as helpful in the management of real life situations. However more emphasis on the management of obstetric emergencies may be needed.
- Weller, J., Morris, R., Watterson, L., Garden, A., Flanagan, B., Robinson, B., et al. (2006). Effective management of anaesthetic crises: development and evaluation of a college-accredited simulation-based course for anaesthesia education in Australia and New Zealand. Simulation in Healthcare: The Journal of The Society for Medical Simulation, 1(4), 209-14.
- Education subcommittee, ANZCA. (2013). proceeding of national meeting Dec 2013. Wellington.
- Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence. The Journal of the American Medical Association, 296(9), 1094-1102.
- Stewart, J., O’Halloran, C., Barton, J. R., Singleton, S. J., Harrigan, P., & Spencer, J. (2000, November). Clarifying the concepts of confidence and competence to produce appropriate self-evaluation measurement scales. Medical Education, 34(11), 903-909.
- Tiwari, A., Lam, D., Yuen, K. H., Chan, R., Fung, T., & Chan, S. (2005, May). Student learning in clinical nursing education: perceptions of the relationship between assessment and learning. Nurse Education Today, 25(4), 299-308.
THE SATISFACTION WITH SIMULATION EXPERIENCE SCALE (SSES): A CROSS-CULTURAL PSYCHOMETRIC APPRAISAL
Assoc Prof Brett Williams,1 Prof Tracy Levett-Jones,2 Mr Ehab Khasawneh3
1MONASH UNIVERSITY; 2UNIVERSITY OF NEWCASTLE; 3JORDAN UNIVERSITY OF SCIENCE & TECHNOLOGY
Abstract: The aim of this study was to undertake a psychometric comparative appraisal of the SSES using paramedic students from Australia and Jordan.
Background: Simulated learning environments are a vital component in paramedic education; to allow students to practise in a safe learning environment during their undergraduate degree, develop technical and ‘non-technical’ skills and also to reinforce competencies not exposed to during clinical placements. Therefore having instruments such as the SSES with strong measurement properties to provide valid and reliable results is important. While two studies [1,2] have reported on the psychometric properties of the SSES, none have examined the validity or reliability of the SSES comparing cross-cultural groups.
Methods: A cross-sectional study using a paper-based English version of the SSES was administered to students (all year levels) from the Bachelor of Emergency Health at Monash University and Bachelor of Paramedic and Emergency Care at Jordan University of Science & Technology during semester 2, 2013. The SSES is a 3-factor 18-item scale that measures students’ satisfaction with simulation . Participants rate their level of agreement with each item on a 5-point Likert scale (1=strongly disagree – 5=strongly agree). Data from the SSES were analysed with Principal Components Analysis (PCA) with Varimax rotation.
Result: A total of (n=511) paramedic students participated in the study; 60% (n=306) from Australia, and 40% (n=205) from Jordan. The majority of the participants were female 61% (n=313), aged < 26 years of age 82% (n=420), and had been actively involved in a mannequin-based simulation during their degree more than 20 times 37% (n=187).
Statistically significant differences were noted on the three original factors between Australian and Jordanian students: Debrief and Feedback (mean=38.66 vs. mean=34.15; p<0.0001), Clinical Reasoning (mean=21.31 vs. 18.28; p<0.0001), and Clinical Learning (mean=17.59 vs. 15.46; p<0.0001). These results suggest Jordanian students were less satisfied with simulation compared with their Australian counterparts.
While the total scale produced an overall Cronbach alpha (α) coefficient >.90, significant differences were noted between both cohorts in the Clinical Learning factor: Australia .86 versus Jordan .22 suggesting serious internal consistency issues with this factor.
Examination of the dimensionality of the SSES also revealed a number of differences compared with the original factor structure. Principal Components Analysis of the 18 items initially revealed 3 factors with eigenvalues above 1, accounting for 55.5% (Australia) and 90% (Jordan) of the total variance. However when item loadings were examined three items were below the .40 cut-off and three items crossed loaded <.30. With these six items deleted further PCA revealed a one factor solution (α=.92) for the Australian cohort and two-factors (α=.94; and α=.94) for the Jordanian students suggesting a better model fit for both cohorts. Structural differences between both cohorts exist, suggesting that the SSES is not adaptable between different cultural groups (see table 1).
Conclusions: This study has shown that the SSES in these cohorts is psychometrically different to the original SSES; results also suggest that SSES items are interpreted differently by diverse cultures. These results provide important data for paramedic educators involved in simulation education and training in Australia and Jordan. Having psychometrically robust measurement tools such as the SSES is vital for the simulation community; this study provides further validity and reliability outcomes for others to replicate.
- Levett-Jones T, McCoy M, Lapkin S, Noble D, Hoffman K, Dempsey J, et al. The development and psychometric testing of the Satisfaction with Simulation Experience Scale. Nurse Education Today. 2011;31(7):705-10.
- Williams, B. Dousek, S. The Satisfaction with Simulation Experience Scale SSES: A Validation Study. Journal of Nursing Education and Practice. 2012;2(3).
A NEW LOCALLY DEVELOPED VIRTUAL REALITY COLONOSCOPY SIMULATOR
Dr Hans de Visser, Mr David Conlan, Mr Josh Passenger, Dr Cedric Dumas, Dr Olivier Salvado
THE AUSTRALIAN E-HEALTH RESEARCH CENTRE, CSIRO
Abstract: Colorectal cancer is the third most common form of cancer and the second leading cause of cancer-related death in the Western world. Current rates indicate that one in 12 Australians will develop colorectal cancer by the age of 85, one of the highest rates in the world [1, 2]. The survival rate for colorectal cancer depends on the stage in which it is detected , hence the Australian government introduced the National Bowel Cancer Screening Program, aiming to improve early detection rates. When the program was introduced in 2006, it was anticipated to cause a further increase in the already steadily rising number of colonoscopies. Hence, an increased capacity for colonoscopy training was needed. Colonoscopy training simulators available at the time were evaluated by independent studies as being too easy “to learn to play the game”, lacking in visual realism, which reduces the immersion into the virtual environment and consequently, only useful for novice training [4, 5]. The CSIRO set out to develop a new simulator to overcome these shortcomings, in order to provide training beyond the novice level and reduce the amount of costly  and risky on-patient training.
Method: Our simulator (Figure 1a) was developed in collaboration with experts from the Royal Brisbane and Women’s Hospital (RBWH), The University of Queensland (UQ) and the Queensland Health Clinical Skills Development Service (QH-CSDS). It addresses the known issues of the existing simulators by combining very realistic visualisation (Figure 1c) with physics-based models and unique 2 Degrees-of-Freedom haptic feedback. Current simulators only provide insertion force feedback, whereas our simulator also provides torque feedback. Noticing and controlling torque is crucial in detecting and resolving loops during colonoscopy, which is one of the most challenging aspects of the procedure.
Evaluation: Our simulator has been rated by simulator experts as incomparably better than what is currently available, with a unique parametric approach that allows for virtually unlimited variations in the generation of realistic looking colon geometry (Figure 1b). This evaluation was part of a qualification done by our UQ collaborators and commercial partner. The simulator has played an integral part in the development of the Colonoscopy Curriculum by UQ and QH-CSDS and is currently being commercialised by a leading simulation company, Surgical Science, with an expected full introduction to the market later in 2014. Our prototype has been used in the inaugural nurses in colonoscopy training held in Brisbane in December 2012. It was also used in the WGO colonoscopy training for the Pacific region in Fiji in July 2013, providing this developing region for the first time with access to state-of-the-art simulation equipment.
Recommendations: It takes much more than a physician and an IT expert to develop a computer based medical simulator. The team at CSIRO possesses expertise in programming, computer visualisation, biomechanical modelling and human-computer interaction, and they collaborate extensively with education and training experts at UQ and QH-CSDS and with gastroenterology experts from the RBWH and many other hospitals and organisations. Finally, many trainers will not use all features of a simulator; instead they will combine the best aspects of different simulators into a complete training suite. Any simulator should be flexible enough for a trainer to be able to adapt it to their curriculum, rather than to have to adapt their curriculum to the simulator.
- Australian Institute of Health and Welfare & Australasian Association of Cancer Registries 2010. Cancer in Australia: an overview, 2010. Cancer series.
- Australian Institute of Health and Welfare 2012. Cancer incidence projections: Australia, 2011 to 2020. Cancer Series no. 66. Cat. No. CAN 62. Canberra: AIHW.
- O’Connell JB, Maggard MA, Ko CY. Colon Cancer Survival Rates with the New American Joint Committee on Cancer Sixth Edition Staging. JNCI J Natl Cancer Inst (2004) 96 (19): 1420-1425. doi: 10.1093/jnci/djh275
- Dunkin B, Adrales G, Apelgren K, Mellinger J. Surgical simulation: a current review. Surg Endoscopy 2007;21:357-66.
- Gerson LB. Evidence-Based Assessment of Endoscopic Simulators for Training. Gastrointest Endoscopy Clin N Am 2006;16:489-509.
- Bridges M, Diamond DL. The financial impact of teaching surgical residents in the operating room. Am J Surg 1999;177:28-32.
- de Visser H, Passenger J, Conlan D, Russ C, Hellier D, Cheng M, Acosta O, Ourselin S, Salvado O. Developing a Next Generation Colonoscopy Simulator. Int J Image Graphics, 10(2):203-17, 2010.