Mr Julian van Dijk - SimHealth 2012 Scientific Convenor
Dr Stuart Marshall - SimHealth 2012 Abstract Chair
Professor Peter Brooks - SimHealth 2012 Convenor
SimHealth is the official conference of the Australian Society for Simulation in Healthcare (ASSH), the health division of Simulation Australia Ltd. 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. Keynote speakers were Tanja Manser, (University of Fribourg, Switzerland), Walter Eppich (Northwestern University Feinberg School of Medicine Chicago USA), Jason Stein (Department of Medicine and Division of Hospital Medicine, Emory University USA) and KT Waxman (University of San Francisco School of Nursing and Health Professions USA). Details for the SimHealth 2013 program can be viewed on the official conference website www.simhealth.com.au
1 Prediction of Aptitude for Colonoscope Tip Control
Dr Hans De Visser, Ms Nancy Yu, Dr Norm Good, Dr Andrew Hill, Associate Professor Marcus Watson
THE AUSTRALIAN E-HEALTH RESEARCH CENTRE, CSIRO, QUEENSLAND HEALTH CLINICAL SKILLS DEVELOPMENT SERVICE, SCHOOL OF PSYCHOLOGY, THE UNIVERSITY OF QUEENSLAND, SCHOOL OF MEDICINE, THE UNIVERSITY OF QUEENSLAND.
INTRODUCTION: This paper aims to determine whether a significant relationship exists between the ability to efficiently steer a virtual endoscope model using a computer keyboard and the ability to efficiently steer the endoscope model using the control knobs on a (modified) real endoscope.
In colonoscopy, the gastroenterologist is required to manoeuvre a flexible endoscope through the highly deformable colon by using the steerable tip of the endoscope. Poor natural motor skills and spatial awareness could inhibit a gastroenterologist from ever becoming as efficient as their peers. Endoscopy training programs could benefit significantly from a cost efficient test to identify early on in the training process those individuals that are highly suitable to become gastroenterologists and those that are not likely to succeed because of poor aptitude.
METHODS: Fifteen volunteers with non-medical backgrounds were asked to perform a number of path-following tasks within the virtual environment of the CSIRO Colonoscopy Simulator. For each task, participants were required to use either a computer keyboard or a modified endoscope to control the movement of a virtual endoscope tip to follow a path on the (virtual) endoscope monitor. The experiments consisted of six sessions that were evenly spread over three weeks. Each session consisted of two sets of tasks, one with each controller type: keyboard or endoscope. Which controller was used first at the first session alternated between participants, and also alternated for each participant between sessions. Each set consisted of the same six tasks randomly ordered. Participants were assessed on the time it took them to finish each task.
RESULTS: Both the keyboard and endoscope have similar learning curves, which usually tend to plateau within six sessions. Multiple linear regression models were fitted to the test results from the first and last sessions with the keyboard (KB1 and KB6 respectively) and with the endoscope (ED1 and ED6 respectively). They indicate that a) KB1 is a strong predictor of ED6 (R2 = 0.615); b) ED1 is an even stronger predictor (R2 = 0.823); c) adding KB1 to ED1 hardly improves that prediction (R2 = 0.828); and d) the inclusion of KB6 does not improve prediction, hence multiple keyboard tests are not required.
CONCLUSIONS: The results suggest that a single set of keyboard tests, requiring just a normal PC, could be used as one of the initial criteria for exclusion of those prospective colonoscopy trainees that are likely to be the weakest performers in the long run. If the remaining applicant cohort requires further culling to meet the training programme’s capacity, a single set of endoscope tests could be used as a criterion. Due to the small sample size, the above conclusions remain to be validated further. A follow-up study with experts is needed to determine the validity of these tests as predictors for actual colonoscopy performance.
2 Whole-Team OR Simulations - What are the Educational Needs?
Dr Matt Gers, Dr David Cumin, Associate Professor Jennifer Weller
CMHSE, UNIVERSITY OF AUCKLAND.
INTRODUCTION: To determine content needs for a teamwork-focused multi-disciplinary operating room (OR) simulation course.
Observational research of Operating Room (OR) teams supports the proposition that failures in teamwork and communication are common and lead directly to compromised patient care and reduced productivity1 . The need for inter-professional collaboration and skills in effective teamwork is widely acknowledged2–9 . Simulation is now a popular choice for training purposes10 . The most successful and valid simulations are those that are based on real cases. We believe that the non-technical challenges in simulations should also be grounded in real teamwork failures, ideally those that are context-specific. However, one issue that has not been explored with respect to whole-team OR simulation training, is which teamwork issues are seen as important and of practical relevance to practicing OR staff. Such views, once known, can guide realistic simulation course development.
METHODS: We conducted focus groups separately with surgeons, anaesthetists, anaesthetic technicians and OR nurses at two metropolitan hospitals. Using a semi-structured question guide based on a leading model of teamwork11 , we enquired about the obstacles to good teamwork in the OR. We took notes and also audio recorded the sessions. After all sessions were conducted we reviewed the audio files to ensure that the notes taken were an accurate and exhaustive summary of the discussions. The notes were then coded using NVivo (QSR, v9) by two researchers specifically looking for educational needs and examples of good and poor teamwork. A second round of coding was performed manually to group the sub-themes into thematic categories. From the responses, the coders also compiled a list of actual situations which could be used in simulations.
RESULTS: We conducted nine focus groups and one interview (n=45). Between 5 and 18 members of each clinical discipline took part. Of the 21 themes initially coded, those concerning ‘communication’ appeared most frequently, followed closely by ‘understanding’. Staff felt teamwork breaks down because of a lack of explicitness, poor briefings, or inadequate explanation by surgeons. A lack of knowledge of team members’ roles and capabilities was also critical in triggering problems. Similarly, strong demarcations and discipline-based information exchange between anaesthetists/anaesthetic technicians and nurses, and also between medical and non-medical staff evidently hamper communications and teamwork.
CONCLUSIONS: Information gained in these sessions demonstrates frequent misunderstandings between disciplines. This lack of understanding includes knowledge of the team. Cross-discipline communication is often inadequate, and there is sometimes poor planning, briefing and explanation of surgical cases. Simulation offers a tool for immersing participants in scenarios that produce teamwork challenges and provide a safe environment to practice solutions. Debriefings and discussions then constitute a powerful learning opportunity. We identified certain kinds of situations in the OR where teamwork often fails, such as low team vigilance at induction, no announcement of massive transfusion, and even frequent cell phone interruption. These situations can be incorporated into simulations and discussed in subsequent debriefs. This provides participants a realistic environment in which to learn much-needed multidisciplinary teamwork skills built on real issues for teamwork.
REFERENCES
1. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Quality and Safety in Health Care 2004;13:330–34.
2. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington DC: National Academy Press, 2000
3. Lin R, Chaboyer W, Wallis M. A literature review of organisational, individual and teamwork factors contributing to the ICU discharge process. Australian Critical Care 2009;22:29–43.
4. Kilner E, Sheppard LA. The role of teamwork and communication in the emergency department - a systematic review. International Emergency Nursing 2010;18:127–37.
5. Hammick M, Freeth D, Koppel I, Reeves S, Barr H. A best evidence systematic review of interprofessional education: BEME Guide no 9. Medical Teacher 2007;29:735–51.
6. Freeth D, Ayida G, Berridge EJ, Mackintosh N, Norris B, Sadler C, et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES) - promoting patient safety in obstetrics with teamwork-focussed interprofessional simulations. Journal of Continuing Education in the Health Professions 2009;29:98–104.
7. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 2009;360:491–99.
8. Leonard M, Graham S, Bonacum D. The human factor - the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13:i85–i90.
9. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century - transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–58.
10. Eppich W, Howard V, Vozenilex j, Curran I. Simulation-based team training in healthcare. Simulation in Healthcare 2011;6:S14–S19.
11. Salas E, Sims DE, Burke CS. Is there a “Big Five” in teamwork? Small Group Research 2005;36:555–99.
3 Space Matters: Creating Effective Learning Spaces
Dr Joanne Gray, Ms Michelle Kelly, Ms Jane Raymond, Ms Rosemarie Hogan
FACULTY OF NURSING, MIDWIFERY AND HEALTH. UNIVERSITY OF TECHNOLOGY, SYDNEY.
INTRODUCTION: The aims of this project were to gain an insight into students’ perception of their preferred simulation laboratory learning environment, and to identify those learning space design concepts that encourage the active engagement of the student.
Evidence suggests that today’s students tend to place great value on connecting with others and want their learning experiences to replicate these values (Van Note Chism, 2006). These students therefore favour active, participatory, experiential learning, much the same learning style they exhibit in their personal lives (Baird & Fisher, 2005). Space can have a significant impact on teaching and learning. The influence of “built pedagogy”, or the ability of space to define how students are taught, is very powerful (Oblinger, 2006). The ways in which a space is designed therefore shapes the learning that happens in that space. Strange and Banning (2002) suggest that although the essential features of the learning environment might theoretically support various possibilities, the layout, location, and arrangement of space and facilities make some behaviours more (or less) likely than others.
METHODS: The project had several data collection phases with students participating in a workshop where they viewed trigger photos of a range of different simulation laboratory spaces; working in groups to redesign the simulation laboratory space; using video and photography to capture the design concepts, and then participating in focus group discussions. In addition, a survey of all undergraduate nursing and midwifery students was conducted to gain their views of these learning spaces.
RESULTS: Students provided a range of design concepts that clearly focussed on their preferred style of learning. They identified the need to be actively involved in their learning, to have the space to ‘see and do’ and to learn in realistic settings. The simulation laboratory setting is an ideal environment to enable this type of active, participatory learning to take place, simulating decision-making and problem solving in clinical practice. In addition students identified the aspects of the space that hindered their learning as limited ability to see the teacher demonstrate the skill, limited time to practice, and limited time to engage in further practice after a period of time in the clinical setting. Students articulated the need to learn, practice, undertake the skills learnt in the real clinical setting, and then return again to the practice environment to reinforce their understanding of the skill. This process is congruent with constructivism (Van Note Chism, 2006). Students also voiced their frustration at being surrounded by the simulation equipment, but not being given the time, skills or permission to use this equipment.
CONCLUSIONS: The simulation laboratory setting has the potential to be a powerful and engaging learning environment for students. If however this learning space does not allow the active engagement of all students, key learning opportunities are lost. The results of this research clearly indicate that students are willing to be active participants in their learning and it is imperative to ensure that the learning environment is an engaging space in which students can learn.
REFERENCES
1. Baird, D.E., & Fisher, M. (2005). Social media, gen Y and digital learning styles. Journal of Educational Technology Systems, 34 (1), 205–6
2. Oblinger, D.G. (2006). Space as a change agent. In D.G. Oblinger, (Ed), Learning Spaces. EDUCAUSE (Ebook). Accessed 6.12.2010 http://www.educause.edu/LearningSpaces
3. Strange, C., & Banning J.H. (2002). Educating by Design: Creating Campus Learning Environments That Work. San Francisco: Jossey-Bass
4. Van Note Chism, N. (2006). Challenging traditional assumptions and rethinking learning spaces, In D.G. Oblinger, (Ed), Learning Spaces. EDUCAUSE (Ebook). Accessed 6.12.2010 http://www.educause.edu/LearningSpaces
4 Comprehensive Clinical Care Orientation Using Simulated Patients Informs Quality and Safety Mechanisms Prior to Moving to New Hospital Facilities.
Dr Pamela Andreatta, Dr David Marzano, Dr Roger Smith
UNIVERSITY OF MICHIGAN DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
INTRODUCTION: To qualitatively evaluate system-level challenges associated with new hospital facilities using concurrent, comprehensive simulation-based patient care, and to provide recommendations for averting adverse impact on patient care.
Our institution’s Ob/Gyn Department moved its entire operations from a 25 bed, centrally oriented facility to a tangential location, fourfold increased footprint, 63 patient suites and 4 operating theatres arranged in logistically and physically distinct pods. Concerns over patient safety and quality of care led us to design an immersive orientation in the new facilities using simulated patients, prior to transferring the clinical care of actual patients. We sought to identify and remedy areas of concern about quality and safety.
METHODS: Ob/Gyn clinicians (N=180) participated in simulated patient care necessitating the use of resources required for patient triage, low and high risk antepartum care, normal and urgent intra-partum care, and normal and emergent postpartum care, including surgical interventions. In addition to patient care in the new facilities, participants were paged to consult at each of two institutional emergency departments (ED); pediatric and adult. We asked participants to identify areas of concern, causes for delays, and issues they felt could adversely impact patient care. We analyzed these data using qualitative methods (theme generation, frequency distributions), identified two significant and unanimous care quality challenges, and derived recommendations for systems-level process improvements.
RESULTS: Challenge 1. Communication, coordination, and responses to patient-related concerns within and between team members; (N=180).
Passive communication system adds layers and delays to care.
Inability to prioritize patient events and clinical needs, leading to team inefficiencies.
Increased spatial scale and complexity minimizes direct connection between teams; reduces the knowledge of where personnel and clinical resources are situated or available at any given time.
Increased situational distribution of patients makes locating/tracking them difficult.
Challenge 2. Proximal location makes it much more difficult to respond to consultation requests from offsite services; (N=180)
One-way travel times to the adult ED ranged between 10-20 minutes.
Increased patient volume without concomitant increases in staffing makes it difficult to coordinate and provide offsite consultation services (i.e. would leave Ob/Gyn understaffed).
Two emergency rooms (adult/pediatric) now require consultation services, further reducing the ability of Ob/Gyn personnel to respond quickly to requests.
Recommendations: We designed a secure mobile app for iphone/ipad/android platforms that 1) facilitates remote monitoring of patients using two-way streams of multimedia data; 2) supports direct communication between team members (and patients); 3) prioritizes the urgency level of patient alerts; 4) graphically displays the location of personnel, patients, and equipment as well as the availability of rooms; 5) Sends patient information to the entire team with one alert message. Figure 1 shows four example interface screens.
FIGURE 1: Example app screens.
CONCLUSIONS: An immersive simulated patient care orientation in our new hospital revealed two significant areas of concern regarding quality of care. We designed a mobile solution to mitigate the identified challenges. The next steps are to collect evaluation data describing its value to the institution for alleviating the identified challenges.
5 Training in Professional Skills (TIPS): Outcomes of a Non Technical Skills (NTS) Course for Surgical Education and Training (SET) Trainees
Dr Robert O’Brien, Mr Adrian Anthony, Mr David Birks, Mr Phil Moreau, Associate Professor Phil Truskett, Mr Julian van Dijk, Mr John Cartmill
ST VINCENT’S HOSPITAL, ROYAL AUSTRALASIAN COLLEGE OF SURGEONS
INTRODUCTION: Utilise a range of education methods, including simulation, to provide opportunities for SET trainees to increase their understanding of the importance of Non Technical Skills (NTS) in contributing to patient safety and good professional practice.
There has been a changing landscape in patient safety as clinicians and social and organisation scientists have begun to collaborate in systematically analysing the observed behaviours of surgeons in the operating theatre 1. Behavioural failures rather than technical skills are becoming the most common reason for errors in surgery 2,3. Through the recognition of the importance that the role NTS play in improving patient safety and contributing to better outcomes there have been a number of tools developed for teams within the operating theatre to identify the associated NTS behaviours 4,5. Although there are several behaviour marker tools and courses about utilising these tools, programs based around teaching to identify and improve NTS are rare. This course was developed to close the gap in NTS training in line with the competencies outlined by the Royal Australasian College of Surgeons and originally funded through the Department of Health and Aging and ASSH as part of the NTS in Synthetic Learning Environments project in 2008/09.
METHODS: A generic two day course was developed for SET trainees who have undertaken at least two to three years of their training (SET 2 or SET 3) was developed. This course focuses on issues within a clinical setting and challenges the participant’s skills particularly in communication, teamwork, crisis resource management and leadership. A range of interactive lectures, facilitated discussions, small group activities, and simulation scenarios involving simulated patients are used to build on the knowledge and skills throughout the course. Faculty are from a range of backgrounds including consultant surgeons, physicians and medical educators at a ratio of 2:1 participants to instructors. Evaluation data is collected to ascertain how well the objectives have been met and further inform development of the course. TIPS was conducted as a pilot on four occasions before being launched and is currently conducted four times per year with 12 participants per course.
RESULTS: Evaluation data for 6 courses has been collected with an additional two courses to be completed by September 2012 (n=64). The results of the data demonstrate that the use of simulated patients in cases and feedback process to be an important aspect of the program. Strategies for effective communication with patients and colleagues were identified as an area that the trainees found to be valuable. Respondents also found that the program made them more aware of the importance of graded assertiveness and situational awareness within the clinical environment. The opportunity to practically apply knowledge and skills and receive feedback both verbally and via visual recording is an important part of the learning process. This in conjunction with watching peers perform tasks focusing on NTS allowed the participants to gain a greater insight into good professional practice.
CONCLUSIONS: Utilising a range of techniques, including simulation based education methods, to make the connection between theory and practice provides a safe and supportive learning environment for the learning of NTS for SET trainees. Trainees have a greater understanding of the importance and role that NTS play in increasing patient safety and strategies that could be utilised in a range of clinical situations.
REFERENCES
1. Flin R, Mitchell L, (Eds): Safer Surgery. Analysing Behaviour in the Operating Theatre, Aldershot: Ashgate, 2009
2. Bogner M. (ed) Human error in Medicine. LEA: Hillsdale, NJ, 1994
3. Bogner M. (ed) Misadventures in Health Care. LEA: Mahwah, NJ, 2004
4. Yule S, Flin R. Maran N, Rowley D, Youngson G, Paterson-Brown S. Surgeon’s Non-technical Skills in the Operating Room: Reliability Testing of the NOTSS Behaviour Rating System, World Journal of Surgery (2008) 32: 548 –556
5. Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Quality and Safety in Healthcare (2009): 18: 104–108.
6 Development of a Novel, Low-Cost, Laparoscopic Simulator for the Performance of Pelvic Lymphadenectomy in Cancer Surgery
Dr R Kevin Reynolds, Dr Pamela Andreatta
UNIVERSITY OF MICHIGAN
INTRODUCTION: Learning advanced laparoscopy for surgical treatment of cancer requires the novice surgeon to develop several key skills including recognition of surgical planes, awareness of anatomic structures including potentially dangerous or fragile areas, and mastery of dissection by applying appropriate force to tissues without causing injury. An instructor must allow the learner to carry out the steps of a lymphadenectomy when the skills of the learner are subjectively deemed to be adequate to the task without placing the patient at undue risk. The premise of surgical simulation is that practice of related skills on a simulator will improve surgical skill necessary to safely carry out pelvic lymph node resection prior to operating on human subjects. The primary aim of this project was to develop a novel, low-cost laparoscopic simulator capable of replicating tissues for which coordinated surgical skills must be utilized in the performance of lymph node resection.
BACKGROUND: Laparoscopic lymph node resection is both prognostic and therapeutic for treating a number of cancers including endometrial cancer. The pelvic nodes are attached to critical vascular and neural structures that are easily damaged. Boundaries of the pelvic node dissection include the bifurcation of the common ileac artery superiorly, the psoas muscle laterally, the inguinal ligament inferiorly, the anterior division of the hypogastric artery medially, and the obturator nerve posteriorly. The nodes are soft, easily fractured, and bleed easily. There is no simulator that currently replicates the anatomy and the technique of lymph node dissection for cancer treatment surgery.
METHODS: A pelvic sidewall model was created with clay upon which various materials were tested to replicate the appearance, integrity and fragility of normal arteries, veins, nerves, and lymph nodes. A die was produced for the arterial and venous systems with which vessels were cast using several polymer combinations in addition to silicone rubber. Nerves were constructed using rubber bands, and nodes were replicated with soft materials including foam rubber, clay, Silly Putty™, polystyrene foam; and Floam™, a soft, moldable child’s toy. Adhesives including silicone adhesive, Super Glue™, and rubber cement were tested for attachment of nodes to vessels with realistic adhesion to replicate the surgical procedure.
RESULTS: The first models were not realistic because vessels were too stiff or too fragile and nodes were too hard or too adherent to the vessels. The final model utilized silicone rubber vessels that were pliable but not impervious to damage thereby replicating the properties of real vessels. Nodes were replicated realistically using Floam™ attached to vessels with rubber cement. Trial dissections using a laparoscopic box trainer and video capture demonstrated a realistic look and feel of the node dissection.
CONCLUSIONS: Until now, there has been no realistic model to allow a novice surgeon to practice improvement of skills needed for the complex and delicate pelvic lymphadenectomy procedure. This project was successful in the development of a realistic lymphadenectomy model with low-cost materials. The model will be tested for validity and training utility in the near future.
7 Establishing a Clinical Simulation Support Unit (CSSU) in Western Australia: How we Achieved it and Why it Promotes Successful Outcomes
Dr Claire Langdon, Mr Richard Clark
INTRODUCTION: This paper will discuss how the Clinical Simulation Support Unit has brought a strategic and cohesive approach to the delivery of Simulation Training in Western Australia. We will discuss how it was achieved, and lessons learned from our experience. WA Health historically:
Provided approximately 1,250 simulation training courses annually. Eighty percent of these were medium to low fidelity courses focusing on life support and emergency medical treatment. These courses accounted for approximately 60% of training expenditure, and were mostly half- or one-day courses.
Had insufficient dedicated staffing to provide or support simulation training without enough staff to make full use of available equipment.
Had no formal communication networks in place for simulation training, with no statewide coordination of simulation training for the various health professions.
Had a central budget as well as Area Health Service (AHS) monies. This resulted in independent development of simulation training at various sites and increased the likelihood of
○ duplicating effort unnecessarily,
○ failing to detect gaps in functionality,
○ uncoordinated maintenance, and
○ delivering less than adequate staff and course development.
Had an ongoing need to develop strategies to manage efficient, cost-effective and safe training for undergraduate students from all health disciplines.
In 2012 the Clinical Simulation Support Unit was established as part of the Health Simulation Training Strategy for Western Australia. This paper will discuss how the CSSU has successfully brought together stakeholders from Public, Private, NGO and Education to plan and deliver cohesive simulation training in WA.
METHODS: The Immersive and Simulation Based Learning (ISL) Committee was formed in 2008 and brought together stakeholders from different jurisdictions to work collaboratively in planning how delivery of simulation training in WA could be achieved. Responding to a need for increased capacity for simulation training, Health Workforce Australia made funding available for distribution for capital works and programs. The CSSU has followed the blueprint developed by the Committee to successfully deliver the most cohesive and cross-sectoral program of capital and recurrent projects.
RESULTS: Development of a successful working relationship among members of the ISL Committee has led to programs of simulation training being rolled out throughout WA that thoughtfully balances the needs of educational institutes and those of health services to produce our service: One that “Prioritises strategies that address gaps in simulation training within WA Health, provides strong clinical leadership for future planning, provides a nucleus of expertise and coordinate state-wide simulation training resources across professions and disciplines in order to improve patient safety and outcomes.”
CONCLUSIONS: Lessons learned and strategies that promoted cohesiveness in the establishment of the ISL committee and the CSSU will be discussed in detail.
REFERENCES
WA Health Simulation Training Strategy (HSTS) Medical Workforce Branch, Department of Health Western Australia 2010
8 Promoting Team Health – an Exploration of the Value of a Simulated Interprofessional Learning Program for Rural Health Students
Associate Professor Penny Paliadelis, Professor Ieva Stupans, Ms Anthea Fagan, Ms Jackie Lea, Associate Professor Linda Turner, Dr Maree Puxty
SCHOOL OF HEALTH, UNIVERSITY OF NEW ENGLAND, SCHOOL OF SCIENCE & TECHNOLOGY, UNIVERSITY OF NEW ENGLAND, SCHOOL OF HEALTH, UNIVERSITY OF NEW ENGLAND, SCHOOL OF HEALTH, UNIVERSITY OF NEW ENGLAND, SCHOOL OF RURAL MEDICINE, UNIVERSITY OF NEW ENGLAND.
INTRODUCTION: This paper reports on the innovative design and outcomes of a short learning program undertaken by a range of rurally based undergraduate health students. The medical, nursing, pharmacy and social work students worked through two case scenarios via high and low fidelity simulations, using actors, and supported by an online learning site. The program was designed to enhance effective interprofessional teamwork and communication skills prior to graduation. The attitudes and experiences of students who completed the program were explored via pre and post program questionnaires, audience response software and qualitative feedback.
The international literature clearly identifies the needs for greater integration of interprofessional education into the curricula of entry-level health professions to enhance mutual respect, effective team-work and patient-centred care across all practice settings. This paper will report on the design and outcomes of an interprofessional learning program that involved undergraduate students of medicine, nursing, pharmacy and social work learning together via a range of simulations and panel sessions to enhance their teamwork and communication skills.
METHODS: The learning program was developed by a team of academic and clinical health professionals around the care of two clients with chronic conditions and a range of social problems, within a rural health context. An evaluation methodology was chosen to explore the students’ attitudes and experiences of participating in this program. Data consisting of pre and post program surveys, audience response data and qualitative comments, which was analysed to determine the effectiveness of the program in using simulations to promote interprofessional learning.
RESULTS: A majority of participating students had some pre-conceived ideas about the value of interprofessional learning via simulations to their professional practice; however following participation in the program they were overwhelmingly positive about the value of this type of learning to their future practice. They felt that the simulated activities gave them a greater appreciation of their role within the interprofessional team and they commented about the valuable insights they gained into the expertise and scope of practice of their clinical colleagues.
CONCLUSIONS: The student participants found this learning activity extremely valuable, stimulating and challenging, with most indicating that they would welcome more opportunities to learn within interprofessional groups. The outcomes may be useful for academic and clinical educators and will inform the expansion of interprofessional learning activities at a rural university in New South Wales, Australia.
9 Team Stress Profiles During Obstetric Emergencies
Dr Pamela Andreatta, Dr David Marzano
UNIVERSITY OF MICHIGAN DEPARTMENT OF OBSTETRICS AND GYNECOLOGY.
INTRODUCTION: Stress affects human performance and decision-making, and the degree of stress experienced by physicians and nurses during emergency situations has the potential to limit their effectiveness as both clinicians and team leaders.[1–10]
The purpose of this study was to assess the stress levels of clinical team members (leaders and non-leaders) during the management of simulated Obstetric Emergencies.
METHODS: A sample of 68 physicians, residents and nurses from Obstetrics, Emergency Medicine, Anesthesia and Neonatology participated in simulation-based drills to manage Obstetric Emergency cases as interdisciplinary teams. A total of 58 cases were included in the drills, each with low, moderate or high difficulty ratings depending on the clinical and psychosocial factors associated with the case. Cases were randomly selected and team members participated in up to four cases each, with no more than two cases per drill. Baseline, peak and mean heart rates were captured during the cases for each team member using wrist-worn non-invasive heart rate monitors. Individual stress levels were calculated using baseline-peak heart rate differentials to characterize peak stress, and baseline-mean heart rate differentials for sustained stress during each case. Case difficulty and team-leader status were considered in the analysis of variance. Direct measurement of clinical performance related to stress level was not measured for this study because we could not predict when stress responses would be in effect due to the dynamic nature of each team’s case management.
RESULTS: There were significantly higher heart rates indicating peak-stress levels (t (58) = −21.071, p =.000) and sustained stress-levels (t (58) = −18.842, p =.000) for all participants across all cases. Case complexity affected team stress such that more difficult cases corresponded to increased peak-stress and sustained-stress for all team members. Mean heart rate differentials indicated significant increased peak-stress levels (F (2, 56) = 3.824, p =.028) and sustained stress-levels (F (2, 56) = 6.746, p =.002) for all participants across all cases. Team leaders experienced significantly higher peak-stress levels (F (1, 57) = 11.326, p =.001) and sustained stress-levels (F (1, 57) = 13.556, p =.001) than non-leader clinical providers. Interaction effects between case difficulty and team leader status were significant for peak-stress (F (3,55) = 13.412, p =.000) and sustained-stress (F (3,55) = 8.305, p =.000). Case difficulty did not contribute to peak-stress levels for non-leader clinical providers, but more challenging cases did increased their sustained-stress (F (2, 42) = 5.882, p =.006). For team leaders, increased case difficulty further increased peak-stress (F (2, 14) = 6.464, p =.012) and sustained-stress (F (2, 14) = 6.198, p =.014).
CONCLUSIONS: The results of this study demonstrated that it is possible to measure stress experienced by clinicians during simulation drills, and that although stress is experienced by all team members, team leaders have both significantly greater stress and sustained stress during the team management of Obstetric emergencies. It also confirms that stress reactions are in effect during simulated drills. These findings suggest the value of simulation-based training for developing stress inoculation behaviors to gain optimal performance for all team members, but especially for team leaders during crises.[11–16] Future studies will address direct measurement of clinical performance with increased stress levels.
REFERENCES
1. Easterbrook JA. The effect of emotion on cue utilization and the organization of behavior. Psychol Rev . May 1959;66 (3): 183–201.
2. Humara M. The relationship between anxiety and performance: a cognitive behavioral perspective. Athletic Insight . 1999;1(2):1–14.
3. Mandler G. Thought processes, consciousness, and stress In: Human Stress and Cognition: An information Processing Approach . New York: John Wiley & Sons; 1979
4. Van Gemmert AW, Van Galen GP. Stress, neuromotor noise, and human performance: a theoretical perspective. J Exp Psychol Hum Percept Perform . Oct 1997;23(5): 1299–1313.
5. Rutledge T, Stucky E, Dollarhide A, et al. A real-time assessment of work stress in physicians and nurses. Health Psychol . Mar 2009;28 (2): 194–200.
6. Hunt EA, Shilkofski NA, Stavroudis TA, Nelson KL. Simulation: translation to improved team performance. Anesthesiol Clin . Jun 2007;25 (2): 301–319.
7. Andreatta PB, Bullough AS, Marzano D. Simulation and team training. Clin Obstet Gynecol . 2010 Sep;53(3):532–44. PMID: 20661038
8. Müller MP HM, Fichtner A, Hardt F, Weber S, Kirschbaum C, Rüder S, Walcher f, Koch T, Eich C. Excellence in performance and stress reduction during two different full scale simulator training courses: A pilot study. Resuscitation . 2009;80:919–924.
9. Stucky ER, Dresselhaus TR, Dollarhide A, et al. Intern to attending: assessing stress among physicians. Acad Med . Feb 2009;84 (2): 251–257.
10. Abell N. The index of clinical stress: A brief measure of subjective stress for practice and research. Social Work Research and Abstracts . 1991;27:12–15.
11. Lepnurm R, Lockhart WS, Keegan D. A measure of daily distress in practising medicine. Can J Psychiatry . Mar 2009;54(3):170–180.
12. Inzana CM, Driskell JE, Salas E, Johnston JH. Effects of preparatory information on enhancing performance under stress. J Appl Psychol . Aug 1996;81(4):429–435.
13. Smith R, Nye S. Comparison of induced affect and covert rehearsal in the acquisition of stress management coping skills. Journal of Counseling Psychology . 1989;36(1):17–23.
14. Robbins I. The psychological impact of working in emergencies and the role of debriefing. J Clin Nurs . May 1999;8(3): 263–268.
15. Saunders T, Driskell JE, Johnston JH, Salas E. The effect of stress inoculation training on anxiety and performance. J Occup Health Psychol . Apr 1996;1(2):170–186.
16. McCue JD, Sachs CL. A stress management workshop improves residents’ coping skills. Arch Intern Med . Nov 1991;151 (11): 2273–2277.
10 Using Low Cost Devices to Provide Metrics for Motor Skills Training:
Dr Timothy Coles, Dr Cedric Dumas, Dr David Fielding, Dr Andrew Hill, Dr Marcus Watson
THE AUSTRALIAN E-HEALTH RESEARCH CENTRE, CSIRO ICT CENTRE, DEPARTMENT OF THORACIC MEDICINE, ROYAL BRISBANE AND WOMEN’S HOSPITAL, QUEENSLAND HEALTH CLINICAL SKILLS DEVELOPMENT SERVICE, UQ SCHOOL OF PSYCHOLOGY, UQ SCHOOL OF MEDICINE
INTRODUCTION: This abstract aims to report on the development of a new part task simulation platform for study and assessment of the medical motor skills of both trainees and experts. A case study for bronchoscope manipulation is proposed.
Flexible bronchoscopy is a diagnostic intervention involving the insertion of a light and camera into the bronchial tree to perform visual inspection for suspicious lesions and to perform biopsies for analysis.
Bronchoscope navigation is typically learnt in vivo through the apprentice model, where a trainee observes a procedure, practises it under supervision and, when proficient, becomes a mentor themselves. It is a challenging intervention to master in part due to the anatomical variability of the tree structures, where competency requires training in a set of complex theoretical and practical skills. Although alternatives such as mannequin and virtual reality based procedural training exist, fine manipulation control and navigation is only learnt through experience, as a lack of posture knowledge limits the ability to train in these areas. The difficulty to verbalise and/or to assess posture, haptics and fine motor control compounds this training problem because accurate information is difficult to concisely describe.
METHODS: To capture additional information during observations of real and simulated bronchoscopies within the Royal Brisbane and Women’s Hospital’s thoracic medicine department, a platform for capturing body posture and bronchoscope manipulation during simulated procedures is proposed. The platform is based on low cost devices that can be easily replicated and deployed. Figure 1 depicts the proposed setup.
FIGURE 1: A demonstration of the proposed low cost capture environment. A bronchoscopist, whose motion is tracked, performs a capture task using a low cost Wii interface.
RESULTS: To become competent a trainee Bronchoscopist should aim to achieve unconscious competency in manipulation and navigation. A basic skill necessary to achieve this, but usually learnt slowly over time through the mentoring of an experience Bronchoscopist, is the adoption of an efficient body and endoscope posture during a procedure. Although it is thought that this simplifies the complexities of navigation and reduces physical fatigue, practitioner posture has not been studied in depth due to the difficulty of capturing such information. The proposed body and hand posture capture platform provides a method of formalising this information relative to a simulated patient. The system features:
- A body posture tracking system, based on a Microsoft Kinect© and the OpenNI API for real-time posture tracking.
- A hand movement tracking system, based on a Wii Remote Plus© controller with a custom infrared positioning bar and the WiiYourself API, to compare the absolute and relative positions between the bronchoscopist’s hands and a simulated patient’s head.
CONCLUSIONS: Identifying specific key posture traits of experts can be useful to better train novices to perform successful bronchoscopies, in turn improving patient safety. A full study using this proposed system is to follow. The system is intended to be modular and flexible so it can be adapted to different types of endoscope based procedures (colonoscopy, gastroscopy, bronchoscopy) and eventually to other medical training situations.
