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This paper will explore the benefits of learning in simulation and argue that it is no longer acceptable to expose our patients to complete novice practitioners. It will also argue that simulation provides excellent opportunities for meaningful inter-professional learning to help novice professionals understand their role within the healthcare team.

A short discussion of the first steps to take when deciding where to invest in simulation-based training and education.

Background: The simulation centre staff identified in 2006 that there was an issue of handling & transporting heavy simulation equipment across rural SA to conduct simulation education. 

Methods: There was much consultation with university staff and clinicians to determine vehicle type, its layout and versatility. The market was reviewed, including second hand ambulances and all new vans. Costs, comfort, features, safety and driving were all compared. The vehicle needed to meet OHS&W standards. 

Results: A Volkswagen Transporter van was purchased and fitted out by a specialist company to include a stretcher and have the capacity to carry a variety of accessories and equipment necessary to run a high fidelity medical emergency scenario in an off site locations rural or remote. 

Conclusions: After a solid 18 months of use, we can now give some useful retrospective information.

Background: Professional bodies such as the Royal Australian College of Surgeons (RACS), Accreditation Council of Graduate Medical Education (ACGME) in the US, and the Royal College of Physicians and Surgeons of Canada (RCPSC) all have published standard frameworks for what competencies they expect from surgeons. Besides this, there have been several definitions of surgical competence offered in the academic literature. There have also been dozens of articles published in recent years on how surgical competence can be assessed. Many of these articles examine the validity of simulation and virtual reality technologies and to what degree skill on these technologies translates to performance in the operating theatre. However, research on the assessment of competency is not closely related to current definitions of competency, and neither is a commonly accepted definition of competency available to be used in this research. 

Methods: This research was in the format of a systematic review. A literature search was performed to identify publications concerned with surgical competence or proficiency dated until December 2009. All categories of publication were included in the results. Further literature searches were performed to specifically identify research on the evaluation or assessment of surgical or laparoscopic skill. 

Results: The RACS defines surgical competency as consisting of several roles: scholar and teacher, health advocate, manager, collaborator, communicator, medical expert, and technical expert. Similar role-based definitions of competence are used by the RCPSC and ACGME, and academic definitions of competence tend also tend to be multifaceted frameworks encompassing similar skills. However, research on the assessment of surgical proficiency and competence tends to be based on evaluating specifically operative skills based on dexterity and coordination. There is a need for closer relationship between accepted definitions of competency and assessment. 

Conclusions: We present a definition of surgical competence which integrates the multiple roles of modern practice, and is based on the literature. We suggest which assessment methods may be best used in the evaluation of surgical competence.

In NSW the SSSP is trialing the use of a Mobile Simulation Unit that takes training directly to medical staff at their workplace. The MSU is a custom-built training facility consisting of a commercial van fitted-out to contain the same facilities and opportunities as a 'static-site' training room. 

The trial of the Mobile Simulation Unit will see it travel to major hospitals around metropolitan and country NSW until December 2010 after which time an assessment of the efficacy of this approach as a means of training delivery will commence. 

This presentation explores the development of the mobile facility from initial specifications, through construction to the outcome of the final product.

Method: A group of 20 novices trainees with no minimal experience on cadaver temporal bone dissections were recruited for a randomised blinded control trial. All participants were given 2 hours of didactic teaching. They were then randomised into 2 groups to receive an additional 2 hours of training of either traditional teaching methods using videos and lectures or guided teaching using a Melbourne University Temporal bone simulator. The trainees were then asked to perform a canal wall down mastoidectomy on a cadaveric temporal bone. The cadaver dissection was video taped and assessed by 2 otologists blinded to participants’ group. The videos were assessed using a modified version of the Welling’s scale [3]. 

Results: The mean performance scores of participants in the simulator-based teaching group were significantly higher than those of the traditional teaching group (80% versus 56%; p-value <0.001). 

Conclusions: This study indicates trainees’ performance on cadaveric temporal bone dissection may improve after guided training on a virtual reality simulator compared with traditional teaching methods alone.

Background: Pebblepad e-portfolio is recommended by the Chartered Society of Physiotherapy as a method of storing, completing and evaluating current Continuous Professional Development (CPD) activities. CPD documentation (in either paper or electronic) is mandatory in the United Kingdom and is a pre-requisite for Health Professions Council re-registration, post-graduation. The National Health Service (NHS) Knowledge and Skills Framework (KSF), defines and describes specific knowledge and skills which NHS staff required in their work to deliver quality services. The KSF also provides a comprehensive, mandatory framework for all NHS staff reviews and development (Department of Health, 2004). This project was designed to blend a range of simulation related activities (podcasts, reflective debrief and peer review evidence) to support the CPD of undergraduate physiotherapy students using an e-Portfolio. 

Methods: All 45 undergraduate (MSc pre-registration) Physiotherapy students were invited to participate. The project mapped key simulation activities in years 1 & 2 of 2 as follows: 

• Year 1 - Basic Life Support (low fidelity simulation) and Cardio-respiratory high-fidelity simulation scenarios 
• Year 2 - Cardio-respiratory high-fidelity simulation scenarios Additionally, learning outcomes were mapped alongside the KSF. 

Students were filmed within the Simulation Learning Environment undertaking the simulation activities. The project provided podcasts of these activities for each student, which could be uploaded to their personal Pebblepad accounts. The Pebblepad tagging function enabled simulation podcasts to be saved alongside the related electronic documents (reflective debrief, peer review evidence and /or learning outcomes mapped against the KSF). Outcome Measures: Participants were invited to share their reflective simulation debriefing logs, peer review documentation (cardio-respiratory scenario formative assessment or Basic Life Support summative assessment reports) and complete respective unit evaluations. 

Data Analysis: Analysis included thematic analysis of reflective simulation debriefing logs, peer review documentation and unit evaluations. All data sources are currently being integrated to provide the overall analysis which will be presented at the conference. Results: The Pebblepad e-Portfolio system was used by the undergraduate Physiotherapy students to structure their CPD portfolio alongside core KSF requirements. The presentation shall demonstrate working examples of podcasts and thematic analysis of both reflective debrief activities and unit evaluations from the 2009-2010 Physiotherapy cohorts. Initial findings indicate that students are able to use simulation podcasts to facilitate reflection, peer review and provide detailed evidence of CPD activities. 

Conclusions: This project demonstrates how a range of digital technologies have been carefully selected to enhance the student’s educational experience and facilitate repetitive reflection, post-event within the framework of an e-Portfolio. Participants may chose to use their simulation activities to demonstrate achievement of a range of core dimensions within the NHS KSF. In addition, the e-portfolio featuring simulation may be used as preparation for employment, professional CPD documentation and/or evidence for HPC re-registration. 

Reference: Department of Health (2004) The National Health Service Knowledge and Skills Framework (NHS KSF) and the Development Review Process, London: Department of Health, October 2004.

Background: The maternity care environment is a complex area of professional practice involving many health professionals in dynamic interactions with women and their families over an extended period. In order to maintain the health orientation of well women and to ensure an emotionally positive experience, the educational preparation of midwives requires effective and creative approaches to stimulating knowledge and self-efficacy through the exploration of contemporary issues in maternity care. 

Method: A half-day interactive workshop has been planned to introduce previously produced midwifery practice stimulus video clips and podcasts to a cohort of pre-registration midwifery students. Students will complete a pre and post workshop self-efficacy measure that will assess confidence in talking with women about pain in labour and assisting women to have a normal birth. The use of learning activities such as these provides the opportunity for students to engage in authentic practice situations. In addition to self-efficacy measurements, students will also be asked to rate the usefulness the stimulus clips in relation to their learning on the topics. 

Results: Descriptive statistics from self-efficacy scores will be presented and differences in pre and post workshop measures will be discussed. Effect of the stimulus clips in relation to student learning will also be discussed. Recommendations for continued use and/or expansion of the use of the stimulus videos and podcasts will be made. 

Conclusions: The results of this project will provide valuable information for education providers in the use of simulated learning materials and the impact on student learning.

Methods: The Philips IntelliVue MPxx series of patient monitors support the uplinking of monitoring data and equipment settings from third-party medical equipment, such as ventilators and gas analyzers, through the use of VueLink modules [3]. We installed two VueLink Open Interface modules with RS232 adapter cables on an IntelliVue MP50 monitor, and connected both modules to a Macintosh laptop via USB-to-serial adapters. We developed custom software for the laptop that (1) interfaced with the METI ECS software to retrieve vital signs numerics and waveforms from the simulated patient in real-time, and (2) transformed the data into the format required by the VueLink Open Interface protocol. 

Results: We were able to successfully display the METI ECS’ vital signs on the Philips patient monitor, including waveforms (ECG, pleth, ABP, CVP, etc), numerics (HR, SpO2, ABP, CVP, NBP, Temp, etc), equipment settings, and alarm messages. Each VueLink module was able to display two waveforms and six numeric values simultaneously on the patient monitor, with a maximum of two modules per monitor. The connections occasionally dropped out because of delays in responding to data requests from the monitor (lack of hard real-time capabilities on the laptop), but were automatically re-established after 15-30 seconds. 

Discussion: We were able to extend one of the key benefits of high-end simulators (integration with clinical monitors) to low-cost, portable models. With our solution, in-situ simulations can be performed with portable mannequins and existing monitoring equipment, or the output of screen-based simulators such as Body can be presented on clinical monitors for teaching purposes [4]. In future work, we plan on improving the connection stability, interfacing other simulators to IntelliVue monitors, and providing monitoring capabilities not currently available on the ECS such as capnography [5]. 

References: 

1. Cumin D, Merry AF. Simulators for use in anesthesia. Anaesthesia 2007;62:151-62. 
2. Van Meurs WL, Good ML, Lampotang S. Functional anatomy of full-scale patient simulators. J Clin Monit 1997;13:317-24. 
3. Philips Medical Systems. Philips M1032A VueLink Module Data Sheet. The Netherlands: Koninklijke Philips Electronics; 2005. 
4. Lighthall GK, Harrison TK. A controllable patient monitor for classroom video projectors. Sim Healthcare 2010;5:58-60. 
5. Liu D, Jenkins S. Simulating capnography in software on the METI Emergency Care Simulator. Sim Healthcare 2009;4:223-7.

Methods: We identified size, shape and body scan data that can be applied to making patient simulators. We used this data to investigate how current manikins would need to be modified to reflect the predominant shape of patients. 

Results: A National Size and Shape Survey from 1250 adult Australian women was undertaken in 2002. The Civilian American and European Surface Anthropometry Resource Project (CAESAR®) incorporates 1D and 3D data from 4000 whole body scans. We compared manikins with real world patient (see figure).

Conclusions: Instruction strategies that meet learning needs of students has been identified as an important future challenge in improving breast cancer education. (2) Breast examination simulators that do not model the shape of patients encountered impacts adversely on confidence and competence. Also, realism of feel will require anatomically correct, multi-layer construction of a breast. 

References: 

1. Saslow D, et al. (2004) CA Cancer J Clin
2. Fiche J, et al. (2010) J Canc Educ

Background: Force feedback in virtual reality surgical simulators is typically developed through repeated cycles of expert feedback. This approach is subjective and time-consuming. Some researchers have begun to calibrate and validate simulators using measures of real forces. Agus et al [1,2] applied this approach to temporal bone surgery simulation and the Beihang University group [3,4,5,6] applied it to dental drilling simulation. Research in this area to date has been largely limited to drilling a single material, often using simplified drilling tasks. No investigations have been carried out using expert and novice surgeons to facilitate a comparison of the forces applied by individuals of different skill levels. This study addresses some of these issues, while also providing data on the forces applied during alveolar drilling which is currently absent from the literature. 

Methods: The studied drilling task was that of removing jaw bone to expose the root of a tooth without damaging the tooth itself, or surrounding teeth. Fourth year dentistry students (N=6), practicing dentists with less than 10 years of experience (N=5), and expert dentists (N=4) performed this task using a Surgairtome II drill with fissure bur on ovine jaws attached to a custom-built tri-axial force sensor. In addition to three dimensional force measurements, audio-visual records of each session were kept. Controlled recordings of tooth drilling forces were also carried out in order to examine the resulting forces when tooth is unintentionally damaged by participants. 

Results: Statistical analyses were effective in establishing the force ranges and average forces involved in drilling tooth and bone, as well as providing an understanding of the force characteristics of each participant group. Experts were found to apply the largest forces during the drilling task (mean=0.6N, average maximum=1.9N), followed by current dentistry students (mean=0.5N, average maximum=1.2N). A comparison of forces over time showed that forces applied by students and recent dentistry graduates varied rapidly over time compared to experts, who had the smoothest force curves. Cross-referencing with video data showed that students and recent graduates used rapid jabbing strokes while experts used long sweeping strokes. The average stroke duration for students was 0.4 seconds, 0.5 seconds for recent graduates, and 1.0 second for experts. These results were found to be statistically significant within our sample. 

Conclusions: Teaching trainees to recognise the tooth-bone boundary during dentoalveolar procedures critically depends on a realistic simulated representation of this boundary. This study has developed a method of measuring the forces exerted while drilling at the interface of tooth and bone. The resulting data have been used to show how differences in forces applied by participants can be used to determine their skill levels. The data are now being used to calibrate the haptic feedback of a dentoalveolar surgical training simulator, and to provide automated force-based feedback to trainees as they use the simulator.

References:

1. Agus M., Giachetti A., Gobbetti E., Zanetti G., Zorcolo A. A haptic model of a bone-cutting burr. Stud. Health Technol. Inform., 94:4-10, 2003. 
2. Agus M., Brelstaff G.J., Giachetti A., Gobbetti E., Zanetti G., Zorcolo A. Physics-based burr haptic simulation: tuning and evaluation. In Proceedings of the 12th International Symposium on Haptic Interfaces for Virtual Environments and Teleoperator Systems (HAPTICS 2004), 2004. 
3. Liu G., Zhang Y., Wang D., Hao J., Lu P., Wang Y. Cutting force model of dental training system. In Proceedings of the IEEE/RSJ International Conference on Intelligent Robots and Systems (IROS 2005), 925-929, August 2005. 
4. Liu G., Zhang Y., Wang D., Townsend W.T. Stable haptic interaction using a damping model to implement a realistic tooth-cutting simulation for dental training. Virtual Reality, 12(2):99-106, 2008.
5. Wang D., Zhang Y, Wang Y., Lee Y.-S., Lu P., Wang Y. Cutting on triangle mesh: local model- based haptic display for dental preparation surgery simulation. IEEE Transactions on Visualization and Computer Graphics, 11(6):671-683, 2005. 
6. Wu J., Yu G., Wang D., Zhang Y., Wang C.C.L. Voxel-based interactive haptic simulation of dental drilling. In Proceedings of the ASME 2009 International Design Engineering Technical Conference & Computers and Information in Engineering Conference (IDETC/CIE 2009), 2009.

• Develop a taxonomy of behavioural markers that characterise high performing ward-based multidisciplinary healthcare teams
• Develop and validate a behavioural marker tool (Team Function Assessment Tool - TFAT) to evaluate the non-technical skills of ward-based teams
• Identify critical variables that promote ‘psychological safety’, thereby enhancing team effectiveness
• Examine how members in healthcare teams engage in the effective exchange and coordination of expertise through the development of a transactive memory system. 

Background: Diverse multidisciplinary teams develop as a response to an increasingly complex environment and are thought to promote high levels of innovation and strategic thinking[1]. In addition to the knowledge component, effective teams need to have competencies in skills, and attitudes regarding their work in a team environment [2], [3]. Healthcare teams providing acute services within Australia, generally operate within a traditional hierarchical organisational structure rather than one that is team based. In order to improve the effectiveness of healthcare teams, we need to be able to reliably measure team effectiveness against a clear set of “gold standard” behaviours that describe effective team functioning. The crisis resource management framework provides a foundation to explore a range of domain specific, team based, non-technical skills within an acute, inpatient, ward-based environment. 

Methods: A five step identification process was followed: Literature review; focus groups (n= 63); card sorting exercise (n=6); field observations (n=9); and final questionnaire evaluation and refinement. Field observations were conducted to assess the level of agreement among raters when using the TFAT tool to rate teams’ non-technical skills. Participants took part in a 1-day TFAT training session. The following day participants were asked to view video recordings of three multidisciplinary health care team meetings, and individually assess each team’s performance using the TFAT tool. 

Results: A qualitative analysis of focus group responses resulted in a taxonomy of behavioural elements structured into 5 categories. Overall, the Kappa coefficient results suggest moderate to very high correspondence between expert ratings and the apriori categorisation. A comparison of the one-on-one correspondence among the 3 subject matter experts who obtained the three highest Kappa coefficients against the solution-based categorisation revealed high levels of agreement ranging from .76 to .95. Qualitative feedback was also solicited from the 6 subject matter experts about the content categorisation that had been generated from the previous stage. Based on the results from the focus groups as well as a review of the behavioural marker methodology and the team effectiveness research, 59 behavioural exemplars were generated. Participants’ ratings of the video observations were also used to create a ranking of the 3 teams which varied slightly across the 10 participants. One-sample independent t-tests suggest that the majority of raters did not rate significantly differently from the other raters. The majority of inter-class correlation coefficients (ICC(1)) demonstrate a reasonable level of agreement between raters, especially in Video 1. Kendall’s Coefficient of Concordance W suggest a W concordance coefficient of .59 (Clinical Planning), .46 (Executive Tasks), .78 (Team Relations), and .59 (Overall TFAT), indicating that there is agreement in raters’ rankings of the 3 videos. 

Conclusions: We are currently testing the construct validity of the scale and its predictive validity in a broader model of team performance. At the time of submission, observations of 50 teams have been completed. 

References: 

1. Beaubien, J. M., & Baker, D. P. (2005). The use of simulation for training teamwork skills in healthcare: How low can you go? Quality and Safety in Healthcare, 13, i51-i56. 
2. Bleakley, A., Hobbs, A., Boyden, A., & Walsh, L. (2004). Safety in operating theatres: Improving teamwork through team resource management. Journal of Workplace Learning, 16, 1/2, 83-91. 
3. Borrill, C. S., Carletta, J., Carter, A. J., Dawson, J. F., Garrod, S., Rees, A., Richards, A., Shapiro, D., & West, M. A. (2002). The effectiveness of healthcare teams in the National Health Service - Report, Universities of Aston, Glasgow, Edinburgh, Leeds and Sheffield, available at http://research.abs.aston.ac.uk/achsor/aschor.html

Background: The study examines the potential of aviation-style CRM training to improve public health safety, by investigating attitude and behavioural changes in multidisciplinary teams resulting from implementation of a CRM intervention in the Australian health care field. Unlike in aviation, standalone classroom-based training is not widely used in health care simulation settings as a prelude to simulation training. 

Methods: Aviation CRM knowledge, skills and attitudes were translated to learning outcomes for health care, based on a combination of a pre-training needs analysis, a review of the current evidence base for team training, and an expert panel review¹. The resulting competencies were developed into a one day classroom based CRM course for health care professionals working in complex time-critical environments in an Australian area health service. A total of 157 recruits were randomised into one of four groups, consisting of three intervention groups and a control group. The intervention groups were then given one day of classroom CRM based training, one day of CRM style simulation training, or both. Pre- and post-test quantitative data were gathered on participant attitudes to working in teams, using a modified Safety Attitudes Questionnaire (SAQ)². Post-test quantitative data were gathered on trainee reactions via a course critique questionnaire, and on CRM knowledge via a pencil and paper test developed for this study. Post-test quantitative self assessed teamwork behaviour data were also gathered, using the Mayo High Performance Teamwork Scale (MHPTS)³. Ten participants who completed the classroom training (17%) were purposely selected with regard to achieving a balance of experience, position and gender, and interviewed at the conclusion of the evaluation. These interviews provided qualitative data to supplement and explicate the results. 

Results: A total of 94 doctors, nurses and midwives completed the pre-intervention attitude questionnaire, 59 participants completed the post-intervention attitude questionnaire, and 61 participants completed the post-intervention behaviour assessment. Evidence was gathered in support of the training using Kirkpatrick's framework⁴ (see Table 1). 

Contrary to the quantitative result, qualitative data supported the effectiveness of the training for all intervention groups. The research uncovered qualitative evidence in support of the importance of training health care teams in multidisciplinary groups, and the need to utilise multi-method approaches for future classroom and simulation training studies. 

Conclusions: The study revealed some positive benefits in providing classroom-based CRM training to health care workers, but was inconclusive in whether classroom and simulation training in combination enhance teamwork attitudes and behaviours. 

References:

1. Clay-Williams R, Braithwaite J. Determination of health-care teamwork training competencies: a Delphi study. Int J Qual Health Care 2009;21(6):433-440. 
2. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Services Research 2006;6:44. 
3. Malec JF, Torsher LC, Dunn WF, Wiegmann DA, Arnold JJ, Brown DA, et al. The Mayo High Performance Teamwork Scale: reliability and validity for evaluating key Crew Resource Management skills. Simulation in Healthcare 2007;2(1):4. 
4. Kirkpatrick DL. Evaluation of training. In: Craig RL, editor. Training and development handbook. 2nd ed. New York: McGraw-Hill, 1976:18-1 to 18-27.

Methods: Eight programs of inter-professionally led orientation training were individually organized by eight different institutions between May and October 2009 and conducted in a common simulation facility. A total number of 72 residents and 71 nurses participated as trainees. There were 40 training stations, including 22 for Injection and pumps, 12 for emergency procedures, 2 for physical assessment and 4 others. At the end of programs trainees were surveyed with a questionnaire, scaled 1 (low) to 4 (high) regarding their opinion of the training received. 

Results: Among the trainees, there are no significant differences in survey responses when asked about “self assessment of content", "self assessment of program feasibility", "overall facility satisfaction", "wish to use the facility again", or "recommend to colleagues”. However, there is a significant difference in "self assessment of attainment of goals" between first year residents and senior residents (<0.05 by Mann-Whitney test). 

Conclusions: These results demonstrate that inter-professional education may be an effective tool to conduct a resident orientation program. Self-assessment of attainment of goals may be differentiated by clinical experiences, when comparing first year and senior residents. This modality may be especially useful for small residency training programs that lack the manpower for large-scale orientation training using the traditional model of physician-only led education. 

Reference: 

1. An online inter-professional learning resource for physicians, pharmacists, nurse practitioners, and nurses in long-term care: benefits, barriers, and lessons learned. Macdonald CJ, Stodel EJ, Chambers LW. Inform Health Soc Care. 2008 Mar;33(1):21-38.

Video audit of the first 30 minutes of trauma resuscitations was used to score observable team behaviours and subsequent interview and focus group sessions examined the individual and cultural factors which drive these behaviours. A number of key aspects of team working that need to be supported were highlighted alongside recommendations for training.

Methods: From existing literature, consensus of a group of experts, and a systematic, progressive process of item refinement, we developed a rating instrument which three expert raters used to independently score 160 videos (480 scores). Exploratory Factor Analysis, Generalisability Theory and interviews of raters provided information on the psychometric properties of the instrument. Comparison of scores from the first to fourth scenario, and between teams led by junior and senior doctors, provided a measure of construct validity. 

Results: Items clustered into three factors: Leadership and Team Coordination; Mutual Performance Monitoring; and Verbalising Situational Information. Internal consistencies (Cronbach’s alpha) for these factors were 0.917, 0.915 and 0.893 respectively. G co-efficient for overall team behaviour was 0.78 and for the three factors, 0.85, 0.4 and 0.37 respectively. Variance components and interview data provided insight into individual item performance. Significantly improved performance over time supported construct validity. 

Conclusions: The instrument performed well as an overall measure of team behaviour and reflected three dimensions of teamwork. Triangulation of information on the instrument properties from the three different analyses will allow a methodical approach to the further development of the instrument. The ultimate goal is an instrument that can robustly evaluate interventions to improve teamwork in healthcare.

Methods: This was a cross-sectional observational study. Consultant surgeons from three hospitals observed higher surgical trainees operating as lead surgeon during n=49 general and vascular procedures. They rated trainees’ non-technical skills using NOTSS, and technical ability using the global rating form from OSATS (Objective Structured Assessment of Technical Skill) after each operation. Trainees self-rated using the same instruments.

Results: One way analysis of variance (ANOVA) was used to test for differences in ratings between trainees’ self-ratings and trainers’ ratings. Trainers rated the trainees consistently higher than trainees rated themselves for Decision Making (F=7.2, p<.01), Communication & Teamwork (F=9.63, p<.01), Leadership (F=9.23, p<.01), and Technical skills (F=5.90, p<.05). There was no difference for ratings of Situation Awareness. All Non-technical skills were significantly correlated with OSATS global judgements of technical performance so a hierarchical regression was conducted to test for prediction of non-technical skills on technical ratings. The value of adjR2 for the final model of non-technical skills predicting technical competence was .624 [F(2, 45)= 25.54, p<.01], but only decision making emerged as a significant predictor (ß =.593, p<0.01). 

Conclusions: There are differences in the way in which trainees and trainers rate performance, and ratings of decision making was the only significant predictor of technical ability. The extent and mechanism by which technical and non-technical skill ratings predict patient outcomes should be investigated, initially using simulation. The NOTSS tool now has enough background data to merit further use in simulated environments as a way of assessing surgeons, in line with the RACS competence framework. 

References: 

1. Dickinson I, Watters D, Graham I, Montgomery P, Collins J. (2009). Guide to the Assessment of Competence and Performance in Practising Surgeons. ANZ Journal of Surgery 79: 198-204 
2. Yule S, Rowley D, Flin R, Maran N, Youngson GG, Duncan J, Paterson-Brown S. (2009). Experience matters: Comparing novice and expert ratings of non-technical skills using the NOTSS system. ANZ Journal of Surgery 79: 154-160

The aim of this study was to determine if this method of recurrent and embedded teaching of communication skills actually improves teamwork and changes behaviours as observed in an immersive simulation scenario. The controlled environment of a simulation scenario provides the opportunity to use research methods that enable an objective and quantifiable measure of teamwork [3]. This method employs communication probes to track information sharing within a team and will be the focus of this presentation. 

Methods: After institutional ethics review, teams of students from a total of 168 students gave informed consent to participate. Five education days were spread over a 6-9 month period, during which the communication techniques were introduced as one of a number of learning topics. 

The same simulation scenario was presented on the first and final (fifth) days of the course, i.e. pre- and post-intervention. The scenario included a number of information 'probes' given to a limited number of participants [3]. These probes were pieces of information given discretely by means of telephone communication, from the clinical notes, or by looking at other items such as radiographs or wristbands. The students were then questioned at the end of the scenario to determine how widely the information had been spread among team members. Video data were recorded to ensure the probes had been placed correctly and not 'contaminated', for example by being discussed by the educator during the session.

Results: A total of 35 teams (176 students) were observed. There was a trend towards improved communication sharing that did not reach statistical significance:

Table 1 Characteristics of the control and intervention scenarios               

Conclusions: Communication sharing among medical students may be improved by extensive training. Further research will help determine the reliability of this quantifiable method of evaluating team-working skills through the use of a larger sample sizes and correlation with qualitative evaluation techniques. This research methodology has the potential to objectively quantify the effectiveness of teamwork and teamwork training and, in doing so, can help shape the development of meaningful education programs that actually change teamwork behaviours in practice. 

References: 

1. Flanagan, B., D. Nestel, and M. Joseph, Making patient safety the focus: Crisis resource management in the undergraduate curriculum. Med. Educ., 2004. 38: p. 56-66. 
2. Withheld for blind review purposes. 
3. Blum, R.H., et al., A method for measuring the effectiveness of simulation-based team training for improving communication skills. Anesthesia and Analgesia, 2005. 100(5): p. 1375-1380.

Background: Effective teamwork is increasingly recognized as important in healthcare outcomes¹. Accurate self-assessment of teamwork by team members is essential for reflective learning especially in the absence of external feedback. Self-assessment by individuals is known to be poor to moderate² but to our knowledge there is limited information on the assessment of team performance by individuals within the team. 

Methods: As part of our teamwork research programme, 40 intensive care teams, each comprising one doctor and three nurses, managed four standardised simulated crisis scenarios, two at the beginning and two at the end of a training day (160 scenarios). Scenario order was randomized. Team members rated their team's technical and behavioural performance on-line immediately after each scenario without discussion. Between the two initial and the two concluding scenarios, teams participated in a training workshop comprising skill-stations, discussions and three training scenarios. Facilitated expert debriefing occurred after all scenarios. Using the same rating instrument as team members, three expert assessors blinded to order of scenarios rated the four scenarios, generating 160 scenarios with self- ratings by four team members and three expert ratings. The technical rating instrument had 11 items plus a global score (GTS); the behavioural rating instrument⁵ had 23 items plus a global score (GBS); a global overall score (GOS) was also required. A seven point anchored Likert scale was used for rating all items. 

Results: Considering all 160 scenarios, the mean self-rated GTS, GBS and GOS were moderately correlated with the mean external ratings (correlation coefficients 0.49, 0.57 and 0.49 respectively). 

Additional training during the study day did not increase accuracy of global self-ratings.

The correlation between mean self-ratings and the difference between mean self and external ratings was positive and significant for GTS, GBS and GOS (0 .29, 0.30, and 0.24 respectively, p<.001).Thus the higher the self-rated score, the larger the difference between external and self assessment. 

Conclusions: We found that accuracy of self-assessment of team technical and behavioural performance by clinically experienced staff in immersive scenarios was only moderate and did not improve with additional training over a study day. Teams rating themselves highly had the least accuracy. These findings are consistent with the literature on accuracy of individual self-rating and have implications on the educational value of self-reflection by teams without external input. The effect of profession and duration of clinical experience on self-rating accuracy, including different aspects of teamwork, will be presented at SimTecT 2010.

References: 

1. Manser, T. (2009) "Teamwork and patient safety in dynamic domains of healthcare: a review of the literature." Acta Anaesthesiology Scandinavica, vol. 53, pp.143-51. 
2. Weller JM et al. (2005) "Psychometric characteristics of simulation-based assessment in anaesthesia and accuracy of self-assesed scores" Anaesthesia,vol. 60, pp. 245-50. 
3. Morgan PJ et al. (2007) "Evaluating teamwork in a simulated obstetric environment". Anesthesiology, vol. 106, pp. 907-15. 
4. Frengley R, Weller J et al. "The STRiCT Study" (In preparation)
5. Weller J et al. "Evaluation of an instrument to measure teamwork in multidisciplinary healthcare teams." (submitted for publication).

• To explore the concept of context in a simulated learning activities,
• To investigate what elements contribute to developing context in simulated learning and
• To discuss the effect context has on the learning processes of the participant including developing mental schema, coding and storage of knowledge and developing links between these stores.

Background: Context of learning can be defined as the “multilevel body of factors in which learning and performance are embedded” (Tessmer and Richey, 1997). The physical, social, commitment and instructional dimensions (Koens, Mann, Custers & Cate, 2005) of the learning situation play an important role in the learning outcomes of the student. Historically the context and activity in which learning takes places was regarded as ‘merely ancillary to the learning, … fundamentally distinct and even neutral with respect to what is learned” (Brown, Collins & Duiguid, 1989). However it is now argued that the activity for learning and the content of the learning are fundamentally linked (Brown et al., 1989) and that “people learn not from experience, but in it” (Hoffman & Donaldson, 2003).

Methods: The search terms context and learning were input into the CINAHL, MEDLINE, Proquest, JSTOR and SAGE databases. Articles retrieved were reviewed to enable an examination and discussion of the role of context in learning and how that context can effect learning processes in simulated learning activities.

Results: Learning can be considered from two perspectives the cognitive perspective – which explores the learners memory and thinking processes during learning, and the social and environmental perspective – that is the environment in which the learning places and the learner interaction with that environment (Mann, 2002). The simultaneous interaction of these elements together makes up the context of learning. The context of the learning environment shapes how the learner will look at, react to and interpret new information which will in turn influence their learning (Tessmer & Richey, 1997). For a nursing student to be able to access the intellectual resources that have been developed they need to be able to organize their resources in a systematic way but also be aware of those resources (Lauder, Reynolds and Angus, 1999). The organization of a learner’s knowledge base and the learners’ awareness of that organization can impact greatly on the ability of the learner to frame and solve clinical problems (Mann, 2002).

Conclusions: The context of the learning environment in simulation assists to engage the learner in the learning task and facilitates the use of reflection to promote metacognition which is required to assist the learner to organise and develop links between schema and and to create meaning from the situation for application to the real world (Koens et al, 2005). Effective education is context rich and the educators address the vital elements of a situation by deliberate design of the learning experience (Tessmer & Richley, 1997). 

References: 

1. Brown, J., Collins, A & Duguid, P. (1989) Situated cognition and the culture of learning. Educational Researcher. 18(1) 32-42 Hoffman, K. & Donaldson, J. (2004) Contextual tensions of the clinical environment and their influence on teaching and learning. Medical Education. 38(4), 448-454 
2. Koens, F., Mann, K., Custers, E & Cate, O. (2005). Analysing the concept of context in medical education. Medical Education. 39, 1243-1249. 
3. Mann, K. (2002). Thinking about learning: implications for principle-based professional education. The Journal of Continuing Education in the Health Professions. 22, 69-72. 
4. Tessmer,M & Richey,R. (1997) The role of context in learning and instructional design. ETR&D. 45(2) 85-115. Categories

Background: The Acute Illness Management (AIM©) course was developed by Greater Manchester Strategic Health Authority to provide large scale training in the management of acutely ill patients. The AIM© course was previously only available to multi-professionals, post-graduation and delivered using low-fidelity simulation. Despite the wealth of evidence to support the use of high-fidelity simulation training, its impact within the AIM© course had not been evaluated. The use of high-fidelity scenarios had never previously been utilised within AIM© courses. 

Methods: All 153, undergraduate Physiotherapy students undertaking the AIM© course in 2008-2009 were included within this study. Participants were recruited from the first three successive AIM© course cohorts (May, 2008 solely featured low-fidelity simulation) whereas November 2008, May and November 2009 cohorts utilised both low and high-fidelity simulation. All AIM© course participants completed all four standardised (peer reviewed) AIM© scenarios (breathlessness, cardiovascular, renal and altered consciousness). Scenarios were undertaken using either low-fidelity (role play with Laerdal Resusci® Anne) or high-fidelity simulation (Laerdal’s SimMan®). During the low fidelity scenarios, faculty provided verbal feedback/updates on the patient’s vital signs e.g. respiratory rate, blood pressure and heart rate, whereas in high-fidelity scenarios participants sought this information from the mannequin/display screen. Outcome measures: All participants completed course evaluations. Participants were invited to share their reflective simulation debriefing logs and peer reviews (formative assessment), using the AIM© summative assessment rubric. Local Ethics Review Committee approval was obtained. 

Data Analysis: Data analysis included thematic analysis of 72 reflective debrief logs and 56 peer reviewed formative assessments. Thematic analysis was similarly undertaken of the 153 qualitative course evaluations. All data sources were integrated to provide the overall analysis. Four key themes emerged from the data relating to relevancy, personal skills, clinical skills, enhanced experience. 

Results: All 153 students perceived the AIM© course to be relevant to undergraduate education. 

Relevancy - All students perceived the AIM© course to be relevant to their forthcoming final clinical placement, both acute and critical care environments postgraduation and physiotherapy on-call requirements. 

Personal skills - Students perceived the scenarios developed a wide range of transferable personal skills (effective communication, prioritisation, clinical reasoning, clinical decision making, self-confidence and reflection). 

Clinical skills - The AIM© scenarios facilitated linked theory to practice, providing essential clinical skills and knowledge relating the assessment, stabilisation and management of acutely unwell/deteriorating patients.

Enhanced experience - Both low and high-fidelity simulation resources were deemed appropriate, supported skill development, facilitated group participation, facilitated peer review and individual reflection. Participation in high-fidelity AIM scenarios added realism, allowed activists to learn from mistakes without compromising patient safety, whilst theorists were challenged to act quickly upon available clinical information. All learning styles improved clinical reasoning and decision making under pressure. High-fidelity simulation was preferable to low-fidelity. 

Conclusions: All students perceived the AIM© course to be relevant, promoting transferable skills relevant to both undergraduate and postgraduate practice. Low and high-fidelity simulations added value to the student experience, enhancing clinical practice skills, clinical reasoning, personal skills, facilitating reflection and peer review. The addition of high fidelity simulation has the potential to further enhance the student experience, providing additional realism and relevance to high-pressure clinical practice environments.

As a strategy to address these challenges Blended eLearning Solutions (BeLS) and the Nursing Skills Centre of Excellence (NSCE) at the Box Hill Institute are developing and applying such a blended learning model (BLM). While this approach is institute wide, BeLS and the NSCE have been working on a contextualised BLM to accommodate for the needs of nurses of the future with a curriculum driven flexible approach. 

This innovative activity has required a review of the curriculum and identification where each blended learning augmentation best fits and how it integrates with all other elements. As a result students are now provided with a matrix of face-to-face (F2F) content, on-line static and interactive e-learning activities, skills laboratory based clinical skills development, immersive, experiential simulation with guided reflection in a highly contextualised ‘virtual’ hospital and industry based clinical placements. With patient safety the underpinning clinical risk management driver this blended learning model is designed to positively reduce cognitive dissidence and close the theory-practice gap. 

As this approach is a recent activity that remains a ‘work in progress’ this report will identify the rationale and case for the BLM and will demonstrate how the various elements are linked to achieve both a better learning outcome for students and ultimately meet the needs of the emerging workforce and their potential employers.

Background: Manikins are great at simulating unconscious patients and allow invasive treatments. Standardised Patients (actors) are great at simulating conscious patients with limited pathology. Kneebone et al have pioneered Augmented Patients where actors wear ‘strap-on bits’ to allow invasive procedures such as IV cannulation, suturing or urinary catheterisation. We have developed a range of emulated diagnostic medical equipment that provides simulated information to the user rather than actual measurements. This allows an actor to exhibit abnormal clinical signs. These devices currently include: glucometer, thermometer, pulse oximeter, stethoscope, BP cuff, ECG/Defib and capnometer. Planned devices include: pulse collar/cuffs, CTG, ABG printer, vital signs monitor and foetal Doppler. In addition, several devices are used to supplement or control these devices such as: pressure sender, SP controller, coaching earpiece, point-of-view camera and central controller. Initial feasibility studies and opinion surveys conducted during development of the devices were very positive. Our current study is exploring how acute care simulations are different when using a manikin and an actor. 

Methods: Our fourth (final) year medical students undertake an “on-call” workshop and assessment in preparation for their impending release onto the public as interns being on-call in the hospital. As part of this workshop, they participate in several high fidelity simulations of relatively common medical emergencies such as bronchospasm, hypoglycaemia, chest pain, anaphylaxis, etc. Participants work either individually or in groups of 2 or 3 peers plus a nurse (collaborator). We routinely video record these sessions for use in debriefing and for inclusion in participant’s ePortfolios as evidence of competence. Video recordings of these sessions are analysed and tagged to quantify the quantity and duration of significant events. These events include both technical (i.e. checking vital signs, applying oxygen, administering medication) and non-technical skills (communication with patient, colleagues, other staff to direct, gather information, explain). We are looking for patterns in the tagged events to distinguish between manikin and actor simulations. We are also looking for quantitative changes such as time to recognise a change in condition or time to initiate treatment. There are 117 students in the available cohort. 75% of the students will have participated in this activity by the end of August 2010. Each student will experience either a manikin simulation or an actor simulation in both a group and individual setting. If they have a manikin for the group, they will have an actor individually and vice versa. The manikin groups will be compared with the actor groups to determine trends in the data. Group allocation was done by the students when they signed up for session dates without knowledge of which type of simulation they would encounter. 

Results: Data collection is underway, preliminary results will be available for presentation. 

Conclusions: Student reaction is very favourable as is generally the case with most simulation activities. The benefits of actor vs. manikin based simulations remains to be seen.

Methods: The curriculum for this programme is in alignment with the CHW evidence based tracheostomy care practice guidelines. The 'pilot' programme consisted of a one day course devised by a multidisciplinary group of clinical experts in consultation and collaboration with staff of the Simulation Centre at CHW. 

Prior to the course consultation with stake holders identified their expectations and resulted in organisational support at a senior management level for a 'pilot' programme. Course content included lectures, skill stations and immersive scenarios. Live video with feedback and debriefing was used enabling participants to reflect upon their performance. 

The aim of the initial 'pilot' programme was to establish learning modules which could be successfully transferred (from the simulation centre environment) into an 'in situ' session within the clinical arena. Each module can be conducted in sessions of a one hour time frame. 

Results: The pilot was conducted on March 23^rd 2010. Faculty on the day included representatives from Nursing, Medical and staff of the Simulation Centre. 

Evaluations included a self rated confidence questionnaires sent prior to the course and a Likert scale evaluation of each module on the day. The pilot course was highly evaluated with 91% of participants indicating they were able to manage the care of the paediatric patient with a tracheostomy in situ and identify clinical support if required. 

The use of multimodal teaching (including simulation) was highly evaluated: 91% found simulation an effective way to learn, thought the simulations were realistic and that feedback following the scenarios was useful. 

A post course evaluation will be conducted two months following the course. 

Conclusion / Discussion: The initial data has demonstrated a positive step towards 'filling' an educational gap and striving towards a safer culture. Recommendations include a repeat one day course to include external applicants and a transference process to 'in situ' sessions. Lesson learnt include challenges of evaluation. 

References:

1. Berry J G, Graham R J, Putney H L, et al, Predictors of Clinical outcomes and hospital resource use of children after tracheotomy: Pediatrics 2009, 124(2), 563-572 Wilson M. Tracheostomy management: Paediatric Nursing 2005, 17, 38-43. 
2. Wrightson F, Soma M, Smith J H, Anaesthetic experience of 100 pediatric tracheostomies: Pediatric anaesthesia 2009, 19, 659-666.

Objectives: To enhance realism through emulating the clinical environment, communication and decision making skills. 

Methods: This project aimed at evaluating the learning objectives within the simulation environment. Workshops were conducted in the KOAPSC using the Laerdal Simbaby and video replay for the debriefing process. The pilot workshop was held in May 2009 initially utilising the Laerdal Megacode kid. This later progressed to a higher fidelity with Simbaby. Use of this manikin enhanced the scenarios by providing participants with visual cues, for example increased work of breathing. The programme was developed using three scenarios mild, moderate and severe asthma based on actual presentations. The scripts included the necessity for clinical decision making and effective communication between staff and family members. Duration of the workshop was two hours and this included a familiarisation process to the environment and the manikins. In an effort to reduce anxiety participants were provided with an introductory fact sheet prior to attending the session. Results Participant attendance to date is n=24. Evaluation tools included a confidence questionnaire, process evaluation, participant and facilitator debriefing. The confidence questionnaire measured pre to post levels in respiratory assessment and clinical decision making. 

Results: The data were analysed in Statistical Package for Social Sciences, with a paired sample test confirmed a significant change. The process evaluation demonstrated that the workshop provided valuable information with the learning objectives met. 

Conclusions: The workshop has demonstrated increased participant confidence. Peer review and the facilitators observations on closed loop communication with scenario based learning provided the participants with an effective learning experience. The evolution of this programme in 2010 has progressed to a pause and discuss scenario of mild to severe asthma. It is our objective to introduce the use of a more structured debriefing methodology for sustainability of future facilitators. We have received positive feedback on post evaluation data. With ongoing clinical support we have achieved a successful process of accrediting RNs and enhancing patient safety.

Method: Eye tracking technology (IVIEW XTM HED, SensoMotoric Instruments) was used to record cognitive processes during a standardized simulated scenario (SimBaby, Laerdal) in the paediatric intensive care unit. Study participants were expert (staff specialist) or subexpert (registrar / fellow) physicians with a range of experience in paediatric and neonatal intensive care. Information acquisition during the first 90-seconds of the scenario was analysed. Expertise (number of fixations, mean fixation duration, frequency of blinks) and the dwell time associated with 6 areas of interest (AOI) were recorded. 

Results: Experts had a longer mean fixation time than subexperts [F(1, 10) = 7.61, p < .05], but did not differ significantly in the number of fixations or frequency of blinks. A significant interaction between AOI and expertise was observed [F(5, 72) = 3.331, p < .01], with experts spending significantly more time looking at the manikin’s head compared to subexperts [F(1, 12) = 15.273, p < .005]. 

Discussion / Conclusion: This research demonstrates a greater level of expertise amongst senior, experienced staff compared to trainees during a simulated emergency scenario in intensive care. Expert physicians spent significantly more time gazing at the manikin’s head, despite the absence of variability in cues from this area. The study results highlight the importance of facial or neurological cues in expert diagnosis and cast doubt on the ability of existing manikin technology to allow teaching of appropriate cue-based acquisition of expertise.

Background: Accurate clinical assessments are necessary for initiating correct medical interventions^{1 2}. During NR such assessments should be made every 30 seconds³. Although NR is a team effort, there is no formal teamwork training for it⁴. There is no guidance about who performs the clinical assessments and how assessments are discussed and shared among team members. Moreover, it is not clear who leads the intervention, how a leader carries out his/her role and what support is provided from other team members. Nonetheless, the Joint Commission⁵ recommends team training to make NR safer. There are no reliable measures of team training^{6 7}. In previous research, however, we showed that clinicians make more accurate clinical assessments after hands-on team training. 

Methods: The experiment took place in xxx (a simulation centre). Seventeen NR clinicians (nine doctors and eight nurses) from (a hospital) participated. In the base-line phase, clinicians reviewed 40 recordings showing simulated resuscitations of the SimNewB^TM (Laerdal Inc.) manikin. After each recording, each clinician individually assigned an Apgar score⁸. In the second phase, teams of three clinicians resuscitated the mannequin in 51 scenarios and after every scenario each clinician individually assigned an Apgar score. At each phase, we calculated an Accuracy Score⁹ (AS) to measure how closely each clinician's Apgar scores matched the actual Apgar score for the manikin (perfect match would be 1.0). Team leaders were identified as the person in charge of airway management. The AS for a leader was calculated only from scenarios that he or she led. The AS for a team member was calculated only from all the scenarios in which he or she participated.

Results: In the base-line phase the mean AS for the leaders was 0.90 (SD=0.04) and for team members it was 0.89 (SD=0.03). The two phases were significantly different (p<0.001) with a lower AS overall in the second, hands-on, phase. A post-hoc unequal-N Tukey test showed that the AS of the team members did not deteriorate significantly in the hands-on phase (0.79, SD=0.07, p=0.21), but it did for the leaders (0.72, SD=0.17, p<0.01). There was wide variability between leaders.

Conclusions: There is a trend for NR team leaders to find it more difficult to monitor the clinical condition of a manikin in a hands-on simulated NR than do the members of their teams. For leadership to be effective, leaders must be supported by the team members. Indeed, Apgar herself indicated that "It is preferred that the assessment will be made by an observer..."¹⁰. The AS is an objective measure presented on absolute scale and calculated algorithmically. Accordingly, researchers in future team training studies may find the AS to be useful for measuring and testing different aspects of trainees' performance.

References: 

1. Greenland P, Bonow RO, Brundage BH, Budoff MJ, Eisenberg MJ, Grundy SM, et al. ACCF/AHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain. Journal of the American College of Cardiology, 2007:378-402.
2. Thompson C, Bucknall T, Estabrookes CA, Hutchinson A, Fraser K, de Vos R, et al. Nurses' critical event risk assessments: a judgement analysis. Journal of Clinical Nursing 2009;18(4):601-612.
3. Kattwinkel J, Short J. Textbook of Neonatal Resuscitation. 5th edition ed: American Academy of Pediatrics, 2006.
4. Thomas EJ, Taggart B, Crandell S, Lasky RE, Williams AL, Love LJ, et al. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. Journal of Perinatology 2007;27(7):409-414.
5. (Editorial). Sentinel Event Alert Issue 30-July 21, 2004 - Preventing infant death and injury during delivery. Advances in Neonatal Care 2004;4(4).
6. Salas E, Wilson KA, Burke CS, Wightman DC. Does crew resource management training work? An update, an extension, and some critical needs. Human Factors 2006;48(2):392-412.
7. Salas E, Cooke NJ, Rosen MA. On Teams, Teamwork, and Team Performance: Discoveries and Developments. Human Factors 2008;50(3):540-547.
8. Apgar V. A proposal for a new method of evaluation of the newborn infant. Current researches in anesthesia & analgesia 1953;32(4):260-7.
9. Cooksey RW. Judgment analysis: Theory, methods and applications San Diego, Calif.: Academic Press, 1996.
10. Apgar V. Newborn (APGAR) scoring system - reflections and advice. Pediatric Clinics of North America 1966;13(3):645-

Background: Post-partum hemorrhage (PPH) is the leading cause of maternal mortality in Africa and Asia [1-4]. Despite an UN Millennium Development Goal to reduce maternal mortality rates, no significant impact has resulted to date, in large part because women in these areas give birth in rural communities with poor access to definitive care [5-6]. Traditional Birth Attendants (TBA) provide care for delivering mothers, however they are neither trained nor equipped to recognize or manage PPH as a life-threatening emergent condition. Simulation-based training could provide them with these life-saving skills. 

Methods: Clinicians in the USA and Ghana (N=10) were consulted to develop the engineering specifications, including: low cost, long lifetime, easy to use, portable, and high anatomical and procedural fidelity. Pugh charts were used to finalize the design from multiple concepts. The simulator was built and evaluated for validity by American and Ghanaian Obstetricians and professional nurse-midwives (N=96), to determine its effectiveness in providing an accurate representation of the relevant anatomy for the procedure using a 6-pt rating scale (1= completely inaccurate; 6=outstanding accuracy). Obstetricians, professional nurse-midwives, midwifery students and TBAs (N=130) performed bimanual uterine compression using the simulator and performance feedback was collected for each level of practitioner. The feasibility for using the simulator to train illiterate TBAs (N=16) was assessed by tracking their ability to perform the procedure using it. 

Results: A biomedical simulator was designed for the project that was low cost ($250US), light weight (<5.5kg), easily portable (modular design), durable (>60 uses) and providing objective performance feedback (6-lighted indicators). The 96 professional nurse-midwives and Obstetricians rated the simulator as very good for its effectiveness in providing an accurate representation of the clinical context for PPH from uterine atony (4.67+/- 0.36). The simulator was able to significantly discriminate between the performance of experts and novices in the use of bimanual compression with uterine massage; t(129) = 14.04, p = 0.000. The mean number of lights illuminated by the expert users was 4.00 (0.67) compared with the mean number of illuminated lights for the novice users of 1.36 (0.56). 

Conclusions: The low cost, portable simulator has the potential to reduce maternal mortality from PPH in the developing world. The potential impact of this simulator for reducing maternal mortality by assuring that all practitioners who attend to women during childbirth have an opportunity to learn these skills is significant. PPH remains a major cause of maternal death in the developing world, despite a Millennium Development Goal to significantly reduce this rate by 2015. As demonstrated by the Helping Babies Breathe project [7-8], simulation-based training has potential to help achieve that goal at relatively low cost. This simulator may provide a contextual building block from which to build a similar program for PPH. 

References: 

1. Ronsmans C, Graham WJ. Maternal mortality: Who, where, when, and why. Lancet 2006;368:1189–2000. 
2. Abdoulaye D. Maternal mortality in Africa. Internet J Health 2006:5. Available from: www.ispub.com/ostia/index.php?xmlFilePath=journals/ijh/vol5n1/africa.xml [Accessed March 8, 2010]. 
3. World Health Organization. Health action in crises: Liberia, 2004. Available from: www.who.int/hac/crises/lbr/background/2004/Liberia_Nov04.pdf [Accessed March 8, 2010]. 
4. Safe Motherhood. Available from: www.safemotherhood.org [Accessed March 8, 2010]. 
5. United Nations Statistics Division. DSG unveils Millennium Development Goals publication at midway point to 2015. New York: United Nations, 2007. Available from http://mdgs.un.org/unsd/mdg/News.aspx?ArticleId=21 [Accessed March 8, 2010]. 
6. Rosenfield A, Maine D, Freedman L. Meeting MDG-5: An impossible dream? Lancet 2006;368:1133–5. 
7. Niermeyer S, (Ed.) Helping Babies Breathe. American Academy of Pediatrics. http://www.helpingbabiesbreathe.org. Accessed 01/27/2010. 
8. Korioth T. Helping Babies Breathe in resource-limited countries. AAP News 2010 Feb;31(2):32

Aims: We set out to develop a device for providing feedback on applied force for physiotherapy students performing manual therapy techniques. The design criteria were that the device should 1) Be simple to use and calibrate, 2) Cost less than $100, 3) Not interfere significantly with performance of the technique, 4) Be able to provide real-time or archived feedback on both force magnitude and timing within +/- 20% for the intended range of forces and 5) Be available off-the-shelf or not require specialist knowledge to construct. 

Methods: Force Sensing Resistors (FSRs) are thin, low cost pressure sensors available in different sizes and sensitivities. We use standard computer sound cards present on most computers to output a raw signal and input a modified signal. A sound signal is sent from the computer headphone output, through the FSR, and returned to microphone’s input so the FSR essentially acts as a volume control. Custom made software quantifies the volume of the sound signal which is converted to a force equivalent which is displayed as a time series graph and as instantaneous values and if required, can be saved as a text file. We assessed the device against the design criteria. 

Results: 

1. Device plugs directly into the computer and calibration prior to each session takes less than one minute; 
2. Cost is under $30; 
3. Small (5 mm) sensors do not interfere with the technique, but due to only covering part of the contact area may provide more of a qualitative comparison between applied forces. Larger sensors (15 to 40 mm) can be used that more accurately indicate total applied force, but may restrict the performance of, or perception during, the technique. 
4. The accuracy to static loads or when loads were applied slowly to a variety of tissue types was within +/-20%. At high load rates, timing data remains accurate, but magnitude data was less accurate. 
5. The device is not available off-the-shelf, but can be constructed from readily available components without the need of specialized skills. 

Conclusions: A device is described that fulfils the design criteria for providing feedback for teaching physiotherapy students. It is anticipated that similar devices could be useful across a variety of applications. Advantages and disadvantages of alternative designs will be discussed. 

Bibliography:

1. Cook, C.E., Effectiveness of visual perceptual learning on inter-therapist reliability of lumbar spine mobilization. The Internet Journal of Allied Health Sciences and Practice, 2003. 1(2). 
2. Snodgrass, S.J., et al., Forces applied to the cervical spine during posteroanterior mobilization. J Manipulative Physiol Ther, 2009. 32(1): p. 72-83. 
3. Sran, M.M., et al., Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization. Spine, 2004. 29(21): p. 2382-8. 
4. Colloca, C.J., et al., Spinal manipulation force and duration affect vertebral movement and neuromuscular responses. Clinical Biomechanics, 2006. 21(3): p. 254-262. 
5. Chang, J.Y., et al., Effectiveness of two forms of feedback on training of a joint mobilization skill by using a joint translation simulator. Physical Therapy, 2007. 87(4): p. 418-30. 
6. Keating, J., T.A. Matyas, and T.M. Bach, The effect of training on physical therapists' ability to apply specified forces of palpation. Phys Ther, 1993. 73(1): p. 45-53. 
7. Lee, M., A. Moseley, and K. Refshauge, Effect of feedback on learning a vertebral joint mobilization skill. Physical Therapy, 1990. 70(2): p. 97-102; discussion 103-4. 
8. Enebo, B. and D. Sherwood, Experience and practice organization in learning a simulated high-velocity low-amplitude task. J Manipulative Physiol Ther, 2005. 28(1): p. 33-43.

Background: Post-partum hemorrhage (PPH) is the leading cause of maternal mortality globally [1-4]. Despite UN Millennium Development Goal to reduce maternal mortality rates, no significant impact has resulted to date [5-6], in large part because women give birth in rural communities with poor access to definitive care. Traditional Birth Attendants (TBAs) provide care for delivering mothers, however they are neither trained nor equipped to recognize or manage PPH as a life-threatening emergent condition. If definitive care is sought for a hemorrhaging woman, professional nurses, midwives and physicians, are often faced with caring for a patient who has de-compensated to a point where resuscitation efforts are ineffective. In industrialized countries, management of PPH includes active management of 3rd-stage labor using uterotonic agents and physical manipulation to help the uterus contract. In rural areas of developing nations drug therapy may not be possible, however physical methods for stimulating uterine contraction are highly practical and easily taught. The most effective form of physical manipulation is bimanual uterine compression to control hemorrhage resulting from atony. It is highly effective if performed correctly. A biomedical simulator with validated objective performance feedback was designed to teach professional and traditional birth attendants to perform the technique. 

Methods: Simulator-based training was conducted using a sample of physicians (N=5), nurse-midwifery students (N=22), professional nurse-midwives (N=89) and traditional birth attendants (N=14) at two regional medical centers (Kumasi, Tamale) and three rural district medical centers (Savelugu, Tolon, Sene). The training consisted of pre-test/post-test methodologies using the simulator feedback and a rating scale, as well as a component of applied outcomes assessment in one of the rural districts (Sene). Half of the sample completed post-tests within one day of training, the other half completed post-tests two-weeks after training. 

Results: All learners were able to significantly increase their bimanual uterine compression skills after training with the simulator t(124) = -19.882, p = 0.000. There were no significant differences in post-test performance between the immediate group and the two-week delayed group; t(123) = -.650, p = 0.52. Applied outcomes were reported for 30 days from nurse-midwives (2) and TBAs (N=8) in the Sene District using mobile phones. During that reporting period 175 cases were reported, including two cases of PPH managed using bimanual compression. Neither maternal nor neonatal mortality were reported in those cases. 

Conclusions: The results of this study demonstrate that the use of a bi-manual compression simulator provided significant training benefits for managing PPH from uterine atony for all levels of care providers (traditional and professional). Use of the simulator for training has the potential to increase the abilities of all levels of birth attendants in rural and urban communities to reduce the incidence of maternal mortality from PPH. 

References:

1. Ronsmans C, Graham WJ. Maternal mortality: Who, where, when, and why. Lancet 2006;368:1189–2000. 
2. Abdoulaye D. Maternal mortality in Africa. Internet J Health 2006:5. Available from: www.ispub.com/ostia/index.php?xmlFilePath=journals/ijh/vol5n1/africa.xml [Accessed March 8, 2010]. 
3. World Health Organization. Health action in crises: Liberia, 2004. Available from: www.who.int/hac/crises/lbr/background/2004/Liberia_Nov04.pdf [Accessed March 8, 2010]. 
4. Safe Motherhood. Available from: www.safemotherhood.org [Accessed March 8, 2010]. 
5. United Nations Statistics Division. DSG unveils Millennium Development Goals publication at midway point to 2015. New York: United Nations, 2007. Available from http://mdgs.un.org/unsd/mdg/News.aspx?ArticleId=21 [Accessed March 8, 2010]. 
6. Rosenfield A, Maine D, Freedman L. Meeting MDG-5: An impossible dream? Lancet 2006;368:1133–5.

Background: Collecting outcomes data from rural communities is an enormous global health challenge, especially in communities with low literacy, limited access to care and poor infrastructure. Consequently, it is difficult to assess the healthcare needs of these communities and the impact of any implemented interventions. Mobile phones have been used successfully among professional healthcare workers for telemedicine applications and patient monitoring, however their use as a means for collecting health-related outcomes within rural communities has not been evaluated. 

Methods: Ten traditional birth attendants from the remote Sene District in Ghana participated in the study. Mobile phones were selected for their simplicity and capability to send text messages to a pre-programmed number. A reporting protocol was developed to include: Reporter's pre-assigned ID number; maternal age; post-partum hemorrhage; bimanual uterine compression; maternal death; infant death; antenatal care; and antenatal care visits. Maternal age and antenatal care visits were reported as discrete numbers. All other data were reported as "1" for yes or "0" for no. Participants were asked to use the protocol to report all births they attended for one month to a pre-programmed number. 

Results: Nine of the ten birth attendants sent texts during the month following the training. All respondents followed the reporting protocol correctly. Data reported over the one-month period is summarized in Table 1. 

Table 1: Reported birth outcomes                 

Conclusions: The results of this study suggest that it is possible to train low literacy, community-based people to use mobile phones and report health-related outcomes data using a specified protocol. The use of rural-based providers for data reporting may provide a more accurate picture of what happens in remote communities because it is real-time, however any self-reported data is subject to under/over reporting. Reported outcomes may reflect proximity to excellent Sene District Medical Center, but may also reflect reporting biases of birth attendants. Future studies may require secondary monitoring to assure data accuracy. These findings are easily exportable to other applications (healthcare and other) where rural outcomes tracking is necessary for program evaluation or other population monitoring. The data reporting protocol could be expanded to include sending text requests and images to definitive care providers to secure rapid deployment of definitive care providers to remote areas. Additionally, a network-served centralized reporting database where texts could be sent and accessed by healthcare administrators could provide a powerful point for monitoring health trends and epidemiological concerns. Additional studies examining the uses of mobile phones for data reporting are underway in other rural communities in Ghana. 

References: 

1. Kahn JG, Yang JS, and Kahn JS. 'Mobile' health needs and opportunities in developing countries. Health Affairs. 2010; 29: 252-258. 
2. J. Lester Feder JL. Cell-phone medicine brings care to patients in developing nations. Health Affairs. 2010; 29: 259-263. 
3. Curioso WH, and Mechael PN. Enhancing 'M-Health' with south-to-south collaborations. Health Affairs. 2010; 29(2): 264-267.

Background: An important aspect of preparing students for Registered Nurse practice is offering experiential learning opportunities within the context of contemporary patient care issues. Opportunities for undergraduate students to observe or be involved in the care of a patient who is deteriorating cannot be guaranteed during the clinical component of their degree. Tailored simulations in the university clinical practice laboratory enable deliberate rehearsal of such situations and allow academics to model ideal practices, based on patient safety imperatives (Bremner, Aduddell, Bennett, & VanGeest, 2006; Corbridge et al., 2008; Gantt & Webb-Corbett, 2010; Ironside & Sitterding, 2009; Lasater, 2007; World Health Organisation, 2004). 

Methods: Final year Bachelor of Nursing students in an adult medical surgical subject engaged in a deteriorating patient simulation encounter. Local Ethics Review Committee approval was obtained for the study. Sixty two students agreed to participate in the study and completed consent and confidentiality forms. A pre-simulation survey consisting of ten questions, with a 4 point Likert scale response was completed immediately prior to the activity. Students participated either actively in predetermined roles or as observers with structured questions to address and discuss during the debriefing. A post-simulation survey, of identical questions, was completed immediately after the simulation encounter. Demographic data were also collected. 

Results: Overall, self-rated ability across all variables demonstrated significant improvement post simulation: total mean scores (pre and post respectively), from a possible range of 10 – 40, were 23.8 (SD 3.77) and 27.4 (SD 4.14) (p<0.01). Specific variables which showed significant differences post simulation (possible range of 1-4) were: assessing and recognising a deteriorating patient (2.42 Vs 2.67, p<0.01); approaching a medical officer for help (2.62 Vs 2.78, p=0.021); and approaching external services e.g. MET for help (2.35 Vs 2.73, p<0.01). Conclusions: Experiences within this immersive simulation encounter overall significantly improved self-rated ability across several clinical practice domains for final year nursing students. Most improvement was seen in the areas of assessing and recognising a deteriorating patient and approaching others for help. These results provide evidence of the positive impact such learning experiences can offer students in preparing them for the registered nurse role. Further, it may be inferred that other 3rd year students who participated in the same simulation gained similar benefits or have at least experienced a representation of a relatively common clinical situation which requires prompt analysis and timely intervention for best patient outcomes. 

References: 

1. Bremner, M., Aduddell, K., Bennett, D., & VanGeest, J. (2006). The use of human patient simulators: best practices with novice nursing students. Nurse Educator, 31(4), 170 - 174. 
2. Corbridge, S. J., McLaughlin, R., Tiffen, J., Wade, L., Templin, R., & Corbridge, T. C. (2008). Using simulation to enhance knowledge and confidence. Nurse Practitioner, 33(6), 12. 
3. Gantt, L., & Webb-Corbett, R. (2010). Using Simulation to Teach Patient Safety Behaviors in Undergraduate Nursing Education. Journal of Nursing Education, 49(1), 48. 
4. Ironside, P., & Sitterding, M. (2009). Embedding Quality and Safety Competencies in Nursing Education. Journal of Nursing Education, 48(12), 659. 
5. Lasater, K. (2007). High-Fidelity Simulation and the Development of Clinical Judgment: Students' Experiences. Journal of Nursing Education, 46(6), 269. 
6. World Health Organisation. (2004). World alliance for patient safety. Retrieved 31 March 2009, from http://www.who.int/patientsafety/en/

Problem: Communication is one of the essential elements in rapid response to in-hospital emergencies. While technical skill training is provided, a form of education to reinforce the communication of the findings to the colleagues and to the in-hospital emergency team is in need. 

Assessment of problem and analysis of its causes: In-hospital emergency team has been sent out for 31 pediatric emergency cases from the year of 2005 to 2008. 25 (80%) of these hospital records showed documented abnormalities of respiratory indices six to twenty-four hours prior to the calls, with the possibility of not being communicated promptly. 

Strategy for change: Clinicians in the patient safety department first developed a presentation material which describes the importance of patient assessment and the communication of the assessment when a provider is concerned. The material is in a Kamishibai (paper drama, a form of traditional storytelling in Japan) format, which is based on Power Point slides with digital illustrations and a vocal script provided by the patient safety department staff members. A few questions on the next action are included. Subsequently, a patient safety officer with the background of PICU and supervisor-level pediatric providers joined to develop a course utilizing the material. The course consists of five components.

1. Kamishibai presentation including Q&A's,
2. discussion on the actions and communication skills including SBAR based on the Kamishibai presentation,
3. simulation training with a low-fidelity manikin. Each participant is presented with a case that is modified from the emergency records with the goal to assess the patient and call for help using the skills discussed.
4. debriefing. The communication skills in the simulation were discussed. In addition, predicted actions immediately in need following the call were discussed.
5. The course evaluation by participants. 

Measurement of improvement: The course was held for 52 general pediatric and pediatric surgical nurses over three days. Pre- and post-course questionnaires on knowledge, skills and confidence level were performed. The number of pediatric in-hospital calls was tracked every month. 

Effects of changes: Pre-course questionnaire showed nurses' concerns including assessment of patients in 12 (23%) and communication and teamwork in 7 (13%). Post-course questionnaire showed acquisition of skills in 52(100%) and higher comfort level in 44 (84%) after taking the course. The number of pediatric in-hospital calls increased to 14 per year in 2009 from the average of 7.7 per year until 2008. 

Lessons learnt: The integration of Kamishibai-style material and the simulation is a good challenge to facilitate mental and behavioural change in patient safety education. Availability of this form of educational material and a support in structuring a course to supervising clinicians can promote patient safety activities at department levels. 

Message for others: The integration of Kamishibai-style educational materials and simulation for patient safety can be useful, and can be tailored to the needs of the department under limited resources.

1. the usefulness of a mechanical simulation of the cervical spine to assess skill in differentiating spinal stiffness and 
2. the effectiveness of an inexpensive take-home force-feedback device in training therapists to accurately reproduce target forces. 

Background: Short courses are important for postgraduate continuing education of physiotherapists. Assessment of stiffness during palpation is considered a core physiotherapy skill and experts, at least in some professions, are known to have a greater ability to discriminate stiffness than novices [1]. It is unclear whether the ability of therapists to discriminate stiffness can be improved by short course participation. 

Secondly, a consistent magnitude of force is necessary for safety and effectiveness of techniques, but forces applied by different therapists differ by up to 500% [2, 3]. Consistency of applied forces can be improved by real time feedback [4, 5], but most methods of providing feedback impact adversely on performance of the technique. The authors developed a novel method of providing feedback on applied forces. This study evaluates the usefulness of this device. 

Methods: Local ethics review committee approval was obtained. Twenty three qualified physiotherapists (between 2 and 6 years experience) participated who were undertaking a two day course focussing on manual assessment and treatment of the cervical spine. On completion of the course, participants were provided with a device for providing real-time feedback on applied forces. The participants ability to discriminate stiffness and reproduce target magnitudes of force were assessed immediately before, immediately after, and on follow-up two months after completion of the course. 

Accuracy of the participants’ ability to discriminate stiffness was assessed by their ability to correctly identify which of five suspended modules of a custom made spinal simulator had an altered level of stiffness. The accuracy of participants’ ability to reproduce target loads onto a patient of 1, 3 and 5 pounds force was assessed with the participants standing on a force platform. The change in reaction force on the force platform was compared to the target force. 

Results: The follow-up data has not been collected. It was hypothesized that at the conclusion of the course which focussed on discriminating stiffness in vivo, that the participants’ ability to discriminate stiffness on a simulated palpation task would improve and it was further hoped that continued improvement would be found at follow-up. The participants’ accuracy in applying a force of known magnitude on the other hand would only be expected to improve at the follow-up assessment after they had access to the novel feedback device. 

Conclusions: The results will begin to clarify the relationship between skills gained through clinical teaching and objective measures of skill in stiffness discrimination. Secondly the results will indicate the potential usefulness of a home device for improving consistency of force application during physiotherapy assessment and treatment. 

Bibliography:

1. Forrest, N., S. Baillie, and H. Tan, Haptic stiffness identification by veterinarians and novices: A comparison, in Third Joint Eurohaptics conference and Symposium on haptic interfaces for virtual environment and teleoperator systems. 2009: Salt Lake City, Utah, USA. p. 646-651.
2. Cook, C.E., Effectiveness of visual perceptual learning on inter-therapist reliability of lumbar spine mobilization. The Internet Journal of Allied Health Sciences and Practice, 2003. 1(2).
3. Snodgrass, S.J., et al., Forces applied to the cervical spine during posteroanterior mobilization. J Manipulative Physiol Ther, 2009. 32(1): p. 72-83.
4. Chang, J.Y., et al., Effectiveness of two forms of feedback on training of a joint mobilization skill by using a joint translation simulator. Physical Therapy, 2007. 87(4): p. 418-30. 5. Lee, M., A. Moseley, and K. Refshauge, Effect of feedback on learning a vertebral joint mobilization skill. Physical Therapy, 1990. 70(2): p. 97-102; discussion 103-4.

Background: The use of simulation activities in health care education has been continuing to increase and evolve. The use of high-fidelity mannequins' for "augmenting learning, teaching patient safety, enhancing clinical practice, teaching resuscitation, and teaching clinical judgment skills" (Parr & Sweeney, 2006, p. 188) is used mostly to meet the needs of small groups of participants. This form of simulation is incredibly resource intensive in term of staff, equipment, and time, which ultimately equals money. For many health care educators and facilities wishing to utilise simulation as an effective teaching methodology to educate a large number of staff, it becomes a logistical and financial impossibility. Observational simulation is one simulation typology that can be utilised as a means of meeting the education goals of the health sector, address their needs in relation to providing programs that are cost effective, incorporate the learning needs of large inter-professional learning audience, with course content that focuses on the non-technical skills such as communication and teamwork. 

Specific Aims of this study are to: 

1. Describe the experience of nurses and midwives learning through observational simulation. 
2. Discuss the effectiveness of observational simulation as a modality to increase knowledge or capability. 
3. Examine the effectiveness of observational simulation in incorporating any knowledge gained into their practice. 

Methods: A two phase method of data collection is being utilised to collect and analyse data using Kirkpatrick matrix for evaluating training programs. This included undertaking a quantitative descriptive survey and qualitative personal interviews. Both the survey and the interviews will be developed and analyses based on the work of Kirkpatrick and look at: 

1. Reaction of student - what they thought and felt about the training 
2. Learning - the resulting increase in knowledge or capability 
3. Behaviour - extent of behaviour and capability improvement and implementation/application 
4. Results - the effects on the business or environment resulting from the trainee's performance 

Conclusion: The aim of this discussion is to focus on the learning outcomes of observational simulation techniques and to identify if this model of education has value in the professional development of health care workers.

Premises: The premise is that doctors receive little or no communication education during their medical school training, nor during their hospital practice. Yet this part of their armamentarium forms a significant part of their clinical practice. Due to this lack of formal education, they have to find their own ways and means during their careers, to help them develop strategies to assist them in dealing with difficult communication scenarios. Simulation has shown promise as an adult learning tool, and the premise is that simulation with facilitated debriefing can assist in the learning and teaching of communication. However we do not know the actual cognitive processes by which health professionals actually attain education using simulation with facilitated debriefing. This study will use the topic of OD after medication error to address these questions. 

Research Plan: Based on a review of the current literature, the four main research questions are: 

1. What are the experiential learning techniques, that interns have utilised and developed in their first year of practice, which they perceive as having assisted them, when being involved in Open Disclosure Communication with patient's and their families 
2. What are the experiential learning techniques, that senior doctors have utilised and developed throughout their years of practice, which they perceive as having assisted them, when being involved in Open Disclosure Communication with patient's and their families 
3. What are the perceptions and experiences of students, staff and simulated patients, elicited during debriefing, when final year medical students are immersed in a medical simulation focussing on OD with a patient's family, after the occurrence of a medication error with significant sequelae. 
4. What are the differences in the perceptions, experiences and differences in experiential learning techniques, of medical interns involved in ODC scenarios, who have been involved in a simulation of ODC following medication error with facilitated debriefing as a medical student, compared with interns who have been involved in the same simulation with no facilitated debriefing 

Based on the research questions developed, the research plan involves five stages: 

1. Develop a theoretical framework as to how simulation is expected to impact on learning and teaching, in students and junior doctors. 
2. Interview junior doctors for their reflections on any critical incidents related to prescribing error 
3. Interview senior doctors for their perceptions of real cases of open disclosure after medication error, involving themselves or other medical staff. 
4. Run an immersive simulation in ODC / medication error. Debriefing after each scenario will be given to half the students and staffs, to discuss whichever issues arise. The participants who do not receive debriefing 
5. Follow up of students into internship, and their reflections on any critical incidents related to prescribing error, and the possible value of the simulation experience. 

The study will involve 24 participants, between the ages of 20-60 years old. The sex distribution will be roughly equal. Inclusion criteria are based on being a medical student or practicing doctor, and volunteering to take part. There are no exclusion criteria. 

Methods: Qualitative methods, using an interpretative paradigm. In particular using action research to generate simulation data, and thematic analysis as a methodology of analysing interview and observational data. Issues of validity and reliability will be addressed, and the methods utilized will be under the principle of 'fitness for purpose' 

Conclusion of the study: The conclusion will address the following areas: 

1. Summarise main the findings for each of the research questions 
2. Discuss implications of the research findings 
3. Theoretical framework development 
4. Recommendations for future learning and teaching in OD 

Scientific validity: OD is a new concept in healthcare and the literature on its use is small. Simulation is also a new concept in healthcare, and the literature suggesting its effectiveness, and the perceived benefits are based around quantitative analysis. Medication error is a common problem leading to significant mortality and morbidity in healthcare institutions. These three topics are closely linked in the overall setting of patient safety. At present there is no robust qualitative data on how physicians learn and develop professional values to assist them in situations of OD involving medication error. There is also no robust qualitative data on how simulation may assist in the learning and teaching of these professional values. This study will be the first study to address these issues. The results of this study could be highly influential in the development of curricula at medical schools and medical education within hospitals. It could also influence the methods by which this education is taught. 

References: 

1. Oedema, R. (2008). Open Disclosure: A Review of the Literature. A. C. o. S. a. Q. I. Healthcare. 
2. Kohn, L. (2000). To err is Human: Building a Safer Health System. Washington DC, National Academy Press. 
3. Kolb, D. (1975). Toward an Applied Theory of Experiential Learning. London, John Wiley. 
4. Barrett, L. (1999). "The Structure of Current Affect: Controversies and Emerging Consensus." Current Directions in Psychological Science 8(1): 10-14 
5. Rudolf, J (2007). "Debriefing with good judgement: Combining rigorous feedback with genuine inquiry" Anaesthesiology Clinics 25: 361-376

The Center for Medical Simulation (CMS) has almost 10 years experience in conducting simulation based team training for healthcare leaders and managers. This brief report will share key learnings from this innovative training program.

Background: There is evidence to suggest that good teamwork relates to patient safety (1). In the Critical Care environment, establishment and maintenance of a patent airway through Rapid Sequence Intubation (RSI), and the management of malignant arrhythmias are common emergent scenarios which require effective teamwork for successful patient care. Patient simulation using computerised manikins has been advocated as an effective means by which teams may be trained (4), however there is limited evidence to demonstrate its efficacy. 

Methods: Using a double-blind randomised cross-over study design (table 1). 40 intensive care teams (1 doctor, 3 nurses) were video-recorded and assessed in their management of four different, standardised immersive scenarios, two at the beginning and two a the end of the study day. Scenario order was randomized, with 1 RSI and 1 malignant arrhythmia at the beginning and 1 RSI and 1 malignant arrhythmia at the end of the study day. Between the two initial and two concluding assessment scenarios, teams participated in a training workshop consisting of skill-stations, followed by three case-based discussions and three immersive scenarios. For 20 teams the immersive scenarios necessitated RSI, and case-based discussions were around the management of a malignant arrhythmia (RSI intervention). For the other 20 teams the immersive scenarios necessitated management of a malignant arrhythmia, and case-based discussions were around RSI (Cardiac intervention). Facilitated expert debriefing occurred after both training and assessment scenarios. Using seven-point rating scales three blinded assessors assessed team performance based on 10 technical, 23 behavioural and 3 global (global technical, global behavioural, and global overall) measures. 

Results: Construct validity of the scenarios was demonstrated by improved performance of the teams over time (p<0.05) and superior performance of teams led by specialists versus trainees (p<0.05). Based on overall performance it was found that for the RSI Intervention group achieved larger improvement on RSI scenarios than on cardiac scenarios and this difference was statistically significant (p <0.05). The Cardiac Intervention group achieved larger improvement on Cardiac scenarios than on RSI scenarios with a trend towards statistically significance (p 0.07). Overall behavioural scores showed statistically significant improvement for the RSI scenarios irrespective of whether or not the team was RSI Intervention (p<0.05). On the other hand overall behavioural scores measured for the Cardiac scenarios showed statistically significant improvement for the Cardiac Intervention teams (p<0.05) but not for the RSI Intervention teams. 

Conclusions: In the context of our study, we demonstrated that both case-based learning and simulation based learning were effective, and we found evidence supporting an additional benefit of simulation based learning for improving performance of intensive care teams in the management of common and life-threatening emergencies. 

References:

1. Manser T. Teamwork and Patient Safety in Dynamic Domains of Healthcare: A Review of the Literature. Acta Anesthesiology Scand 2009; 53: 143-51.
2. Institute of Medicine. To Err is Human. Washington, D.C. : National Academy Press 2000 pg 173.

In NSW, where RCA is mandated for over 600 clinical incidents every year this presents a number of challenges: 

• How well is human error understood by those leading RCAs and what does that mean? 
• Is it reliable/possible/appropriate to expect clinical quality staff to separate themselves from their former clinical roles/silos and analyse their former peers’ behaviour? 
• Does RCA legislation really give permission to explore behaviours – how is it in the ‘real world’? 
• Are the other parts of the incident management process robust enough to support this? 

During 2010, the CEC has been trying a number of approaches to assist patient safety staff in gathering and understanding information about the human factors which may have contributed, both directly and indirectly to clinical incidents. This includes a trial of a coordinated, holistic early response to clinical incidents and targeted training. Early feedback suggests that education and permission are powerful influences within the organisational framework in NSW Area Health Services. 

We are keen to monitor how this translates into: 

• More comprehensive incident analysis in regard to human factors 
• Cultural spread of more open communication of human error recognition and ideally, sharing and celebrating of strategies to trap errors in our stressed and busy health system.

Methods: Technical (review of cardiac and airway algorithms) and behavioural objectives (teamwork dynamics and communication styles) were set. Course design utilised scenarios with debriefs, skills stations, games and lectures. ISBAR, task-unloading the leader and graded assertiveness were three key behaviours explored. Participants completed feedback questionnaires at the end of each day. 

Results: Four courses were delivered to a total of 38 anaesthetic assistants and all completed questionnaires. 80% felt the course material was relevant to their practice and all would recommend the course to others. Written comments on key learning points mentioned 50% more on the human factors learning than the technical skills. Specific comments related to the ‘importance of a shared language’, appreciating leadership difficulties and how to assist and understanding graded assertiveness. 

Conclusions: ATAC participants were enthusiastic and felt the content was relevant. Feedback indicated that participants felt that this exposure to human factors concepts such as language, leadership, teamwork and communication skills would benefit the whole team and thus patient safety. 

References: 

1. Manser, T. (2009) “Teamwork and patient safety in dynamic domains of healthcare: a review of the literature.” Acta Anaesthesiology Scandinavica, vol.53, pp.143-51. 
2. Weller J, 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 Simulation in Healthcare, vol.1, pp. 209-214.

Background: The NSW Institute of Trauma and Injury Management (ITIM) and the Sydney Clinical Skills and Simulation Centre (SCSSC) has for the past 4 years been providing Trauma Team Training to the Area Health Services of greater metropolitan Sydney. Rural Area Health Services had not been included in these training activities. A program of seminar-based learning had been offered at various rural locations over the preceding years. 

A new, rural focussed program was developed to integrate the seminars with some clinical skills workshops on day one and a Trauma Team Training course on the following day. This initiative was called the Trauma Assessment Resuscitation and Transport (TART) program, a collaborative activity between NSW ITIM, the SCSSC and CareFlight NSW. Wagga Wagga Base Hospital was selected as the pilot site for a variety of reasons including; access to a well equipped clinical school, dedicated on-site clinical skills and medical coordinators, and previous experience running an on-site simulation course in this facility with the SCSSC. 

Methods: The aim of the programme was to provide simulation based trauma education activities at varying levels of participant involvement for any trauma clinician (ambulance paramedic, medical practitioner or nurse) in the area health service vicinity. A team of trauma clinicians and educators representing NSW ITIM, the SCSSC and CareFlight NSW joined with local faculty to facilitate the two days. 

The programme consisted of three separate events: 

1. Trauma Skills Day: 5 separate clinical skills workshops for up to 36 people coordinated by CareFlight NSW
• Initial Assessment & Resuscitation 
• Basic Airway Management 
• Rapid Sequence Induction (RSI) and Surgical Airways 
• Shock and Intravenous Access 
• Thoracic Drainage 
2. Trauma Evening: Two lectures, a local case presentation and networking supper coordinated by NSW ITIM 
3. Trauma team training for 12 doctors and nurses representing local trauma resuscitation teams provided by the SCSSC 

Results: The three TART components were evaluated separately using 5-point likert scaled and free text questions. The Skills Day had 28 participants with 27 completed evaluations; the Trauma Team Training had 12 participants with 12 completed evaluations and the Trauma Evening had 28 participants with only 16 evaluations completed. The poor response for the Trauma Evening group was due to the early departure of several registrants before the completion of the final session. The evaluations for all three components were highly rated with the free commentary reflecting those ratings. 

Conclusions: The pilot TART course structure, content and delivery modes were very successful and showed that this model could be delivered at other rural area health services in the future. The use of a multi-agency approach provided clear leadership and responsibilities for each session reducing the workload for the individual agencies. The congruence and cross population of materials and instructing faculty clearly demonstrated the multi-agency and multi-disciplinary nature of trauma management in NSW.

Background: Scarcity of clinical placements and heightened concern for patient safety have led to an increased focus on simulation methodologies for the early acquisition of clinical technical, human engagement and reasoning skills, in parallel with clinically-based learning opportunities in undergraduate medical education.(1) Students and clinical supervisors recognise that some clinical and reasoning skills are difficult to acquire solely through experiential learning in clinical settings, especially in shorter medical courses with shorter clinical placements. The Clinical Learning through Extended Immersion in Medical Simulation (CLEIMS) methodology combines the reasoning-development approach of Problem Based Learning(2) with high fidelity clinical simulation.(3) Students are divided into medical teams, each comprising 2-4 'interns' and a designated 'registrar', who manage a simulated patient through an evolving story over the period of a week. Innovative elements include extensive use of trained simulated patients and relatives, technological simulations for emergency management and simulated after hours ‘on call’ experiences. A pilot of the methodology was extremely positively received by learners but it is resource intensive and definitive evidence of educational effectiveness will be required for sustainability. 

Methods: Local ethics committee approval was obtained. 2010 Year 3 MBBS students were invited to enrol in the study and 65% of the cohort did (n = 98). Participants were randomised 1:1 to receive either the full CLEIMS methodology (intervention arm) or just the associated seminars and workshops without the contextualising extended simulation (control arm), during their one 'in-school week' in each of 2010 (Year 3) and 2011 (Year 4). The two arms will be compared in relation to knowledge and script concordance (reasoning) written tests, as well as a practical clinical skill test, at the end of each week, as the primary endpoint. Secondary endpoints will include performance in summative OSCEs and evidence of affective-domain learning on Interpretative Phenomenological Analysis of reflective journals.(4)

Results: 98 students have enrolled in the study, which will proceed during 2010. By the time of the conference it is anticipated that 82 participants (84%) will have completed the first study week and primary endpoint data will be available for interim analysis. 

Conclusions: First data from this randomised educational trial will be presented. 

References: 

1. Okuda Y, Bryson EO, DeMaria S, et al. The utility of simulation in medical education: What is the evidence? Mt Sinai Journal of Medicine 76(4):330-43, 2009. 
2. Spalding WB. The undergraduate medical curriculum (1969 model): McMaster University. Canadian Medical Association Journal 100(14):659-664, 1969. 
3. Flanagan B, Nestel D, Joseph M. Making patient safety the focus: Crisis Resource Management in the undergraduate curriculum. Medical Education 38:56-66, 2004. 
4. Smith JA. Beyond the divide between cognition and discourse: Using Interpretative Phenomenological Analysis in health psychology. Psychology and Health 11:261-71, 1996.

Method: An acronym was developed that covered the essential requirements upon arriving at the scene. SMASH required an intensive hour of demonstration, practice and participation in a simulated scenario in small groups (n=3). Skills acquired included; scene safety, calling for help, airway and c-spine management and controlling haemorrhage. Use of an adult sized patient manikin, moulage and a crashed car ensured authenticity of a smash scene. The students returned 4 weeks later and completed the simulated scenario without prompts. The time-based assessment consisted of manual assessment sheets and video evidence of the students demonstrating their retained knowledge; they were graded as ‘competent’ or ‘not competent’. Students also completed self assessments. 

Results: The data was analysed to determine how much information students had retained from the 1 hour training they had received 4 weeks prior. All students reached a satisfactory competency grading, with 93% achieving this result within a 3 minute timeframe. Students reported that they felt more confident to maintain an airway and control haemorrhage following the education. 

Conclusion: The positive results confirm that through the use of an authentic training scenario, appropriately focussed lifesaving manoeuvres can be taught and retained, through a brief training episode. 

References: 

1. Larsson E M, Martensson N L, Alexanderson K A E 2002, ‘First-aid Training and Bystander Actions at Traffic Crashes – A Population Study.’ Prehospital Disaster Medicine, 17(3), 134-141. 
2. Ashour A, Cameron P, Bernard S, Fitzgerald M, Smith K, and Walker T. ‘Could bystander first-aid prevent trauma deaths at the scene of injury.’ 2007; Emergency Medicine Australasia, Vol.19, pp.163-168.

Background: While much has been written about the use and the perceived benefits of simulation in nursing, current understanding of how nurse academics regard the use of simulation as a teaching strategy is slim. The adoption of any new teaching technique is closely aligned with educators’ attitudes towards that technique (Lewis & Watson 1997; King et al 2008) and as Leveson (2004:369) notes ‘there is an interpretable relationship between perceptions of the teaching environment and approaches to teaching’. Less however is known about the relationship between academics’’ perceptions of their teaching surroundings and methods and the way they choose to conduct their teaching. The introduction of any new teaching technology can be received by educators as a ‘threat or a challenge’, and this may be true for simulation, particularly immersive high fidelity simulation (Akhtar-Danesh et al 2009). It is recognised that simulation is emerging in nursing education as a key strategy for preparing undergraduate nursing students for professional practice. In particular, there is rapid growth in the use of computerised, interactive manikins to support the development of such areas as clinical skills and inter-professional teamwork in a safe and controlled learning environment. Notwithstanding the growth of simulation and its potential to enhance student outcomes, its uptake by academics is varied. Many influences shape nurse academics decisions to become, or not to become involved in simulation-based education. Understanding these factors is essential to the successful implementation of simulation based education. This paper reports the findings from a study that explored the factors influencing nurse academics’ choices around simulation based learning. 

Methods: In order to elicit the reasons nurse academics made particular choices relating to simulation, semi-structured interviews were conducted. Interviews were transcribed verbatim. Coding and a cross comparative analysis of the data, supported by NVivo, generated the key themes. 

Results: Three key themes were elicited from the data which indicated the presence of significant cultural, professional and resource related factors influencing academics’ attitudes towards, and choices around, simulation. While the participants supported the use of simulation and recognised its value in teaching and learning, the notion that simulation was a separate entity within a school of nursing was central to the findings. Participants also raised issues around the level of capital investment, the speed of implementation, specialised equipment, new teaching techniques, the nature of teaching using simulation and the establishment of an informal simulation ‘elite’. 

Conclusions: The complex, multi-layered and largely hidden context in which academics make decisions about simulation based education demands further attention if simulation is to be successfully integrated across nursing curricula. While this modest study relates to nurse academics, the themes arising may have relevance to other health disciplines. In order to fully integrate simulation into a university curriculum, the factors influencing nursing academics decisions around simulation must be understood and addressed to avoid fragmentation of teaching and learning and to support strong learning outcomes. 

References: 

1. Akhtar-Danesh, N. Baxter, P. Valaitis, R. Stanyon, W. Sproul, S. (2009), ‘Nurse faculty perceptions of simulation use in nursing education’, Western Journal of Nursing Research, 31, 312- 329. 
2. Griffin-Sobel, J. (2009), ‘The ENTRÉE model for integrating technologically rich learning strategies in a school of nursing’, Clinical Simulation in Nursing, 5, e73-e78. 
3. Kardong-Edgren, S. Starkweather, A. Ward, L. (2008), ‘The intergration of simulation into a clinical foundations of nursing course: student and faculty perspectives’, International Journal of Nursing Education Scholarship, 5(1), 1-16. 
4. King, C. Moseley, S. Hindenlang, B. Kuritz, P. (2008), ’Limited use of the human patient simulator by nurse faculty: an intervention program designed to increase use’, International Journal of Nursing Education Scholarship, 5(1), 1-17. 
5. Leveson, L. (2004). ‘The things that count: negative perceptions of the teaching environment among university academics’, The International Journal of Educational Management, 18(6), 368-373. 
6. Lewis, D. & Watson, J. (1997). ‘Nursing faculty concerns regarding the adoption of computer technology’, Computers in Nursing, 15(2), 71-76.

When considering health care costs, the numbers are staggering. Approximately half of the USD$2.4 trillion spent annually on US health care can be categorized as preventable costs, and USD$300 billion of this is attributable to medical mistakes and the defensive medicine they engender. 

Just as the use of flight simulators and system integration concepts revolutionized the aircraft industry decades earlier, similar concepts can be applied to improve the effectiveness and efficiency of the health care industry today. Our proposed approach is intended to leverage advanced modeling and simulation techniques to accurately represent complex clinical environments. By creating hierarchical simulated models of these systems and then validating these models against their real-world equivalents, we are able to develop a virtual system-of-systems integration laboratory for clinical environments. As with comparable tools in aviation, our goal is for simulation-based tools for health care to make analysis and training fast, safe, measurable, and reproducible. This will be a significant step forward in health care, which has trailed other fields in the adoption of software simulations, due to technological limitations and behavioral barriers. We believe that a holistic approach such as this will pave the way for the next generation of decision support aids, medical devices, and training systems for applications across the health care spectrum. In this paper, we will outline our approach with detailed examples of potential savings for a number of complex clinical scenarios.

Background: The ScaLe Project is funded by the Joint Information Systems Committee (JISC), a body that informs UK post-16 education institutions on how best to embed learning technologies. As an emerging icon of popular culture, Twitter is resonant with ‘the text generation’ permitting only 140 characters and has many possible applications, ranging from communicating to groups of learners or directing learners to relevant links, resources, scholarly groups or individuals. It has the potential to address the concern that health professional courses need to focus on producing reflective practitioners equipped with the tools for self-directed learning, knowledge synthesis and critical reasoning. Within this project is a bold statement which speculates that social media, and tools like Twitter, will increasingly influence the way in which learners engage with knowledge-based experiences. It is a project that breaks away from the ‘formal e-boundary’ of the institution, represented by the institutional Virtual Learning Environment, toward a more informal and customised (or customisable) space. The project is premised on the suggestion that the increased adoption of social media (augmented by its capture on mobile phones) will continue to blur the relationship between work/education and leisure in society. 

Methods: Applied with a high-fidelity human patient simulator, instructors construct a series of ‘tweets’ to illustrate a patient’s deteriorating, or improving, condition. Nursing and paramedic students on a BSc Critical Care Course at the University of Glamorgan, direct the course of a clinical scenario at appropriate assessment points and use Twitter’s review applications to highlight their clinical reasoning. A review of user logs and responses elicit information on whether learning has been ‘achieved’ (i.e. if a diagnosis has been correctly identified). Further qualitative data-gathering – via on-line forums, focus groups and interviews gauge the depth of feeling toward the new learning environment. 

Results and Conclusions: Data is in the process of being collected. Categories

Background: Nurses and allied health professionals working in the area of thoracic surgery often care for patients having limited in-depth knowledge of surgical procedures. Opportunities to observe surgery itself in the operating room are limited by time and resources, and may not provide the best learning environment. Lack of procedural knowledge may impact on patient care as it limits ability to convey information regarding patient condition, pre and postoperative care, and also impacts upon clinician clinical reasoning. Previously in the UK no thoracic surgery teaching course were available to address these issues. Thoracic surgery patients are at high risk for postoperative complications and clinician (and consequently patient) education may be important to optimise postoperative recovery with interventions proven to reduce complication rate (early mobility, physiotherapy). 

Methods: A multidisciplinary faculty developed a theoretical and simulation teaching programme which was taught in a centre with wetlab facilities. Educators were challenged to provide the unique opportunity to see and rehearse surgical procedures, and to provide an innovative training opportunity that could improve patient safety and experience. The delegates (24) attended lectures for the first half of the programme to prepare for the practical sessions that followed, where they rotated in small subgroups around 6 practical surgical stations to facilitate interaction with the Consultant surgeon trainers. Stations included incisions (thoracotomy, video assisted thorascoscopic surgery-VATS), common procedures (lung resection, bronchial surgery, use of glues, sealants and staples), and invasive postoperative interventions (mini-tracheostomy, chest drain insertion). For this we required products including sheep lungs, chest wall cavities and trachea/larynx specimens. We also relied upon links with industry to provide glues, sealants, staples and VATS equipment reflective of current products used in practice. 

Results: 74% of delegates strongly agreed that the content met their needs and 91% that the content was very interesting. There were no negative scores. Testimonials for the practical simulation include; ‘will be able to explain more to patients now’, ‘this will change the way I look after patients’, ‘increased awareness of the patients’ journey before, during and after surgery’, ‘I have learnt more in this day than in 20 years on the surgery ward’, ‘surgeons approachable in the small group situation’, ‘excellent link between theory and practice’. 

Conclusion: We successfully delivered a multidisciplinary, practical simulation programme for professionals working in thoracic surgical practice. Delegate reflection demonstrated that after accessing this programme their practice and approach to patient care would change, this may be due to enhanced clinical reasoning, team working and communication skills. Delegates also found this method of education delivery beneficial.

The paper will consider practical and pedagogical aspects of using these combined advanced educational technologies within the undergraduate nursing curriculum.

Aims: Utilising a simulated organ donation process, conducted over a single day, we aimed to introduce the processes and procedures related to DCD to Link Nurses, allowing for questions, feedback, and support. 

Methods: A half day planning session with Organ Donation New Zealand ensured agreed objectives. The day was co-ordinated around 4 simulated time-staged events in an Intensive Care and an Operating Room. The four events were: initial family meeting with intensivist and link nurse; signing paperwork and family goodbye; team planning; and withdrawal of treatment, death, and organ retrieval. Events were conducted on both METI and Simman simulators. A blend of faculty, including intensivists, surgeons and nursing staff experienced in organ donation, an operating retrieval team, and paid actors (as family members) were utilised for the scenarios. Each simulation was followed by debriefs with participants, and group discussion. Particular attention was paid to the emotional wellbeing of the large cast. Questionnaires were developed that explored Link Nurse’s understanding of, attitudes to, and willingness to perform DCD before and after the day; their perception of simulation as a method of introduction to DCD; and key learning points. 

Results: 45 of New Zealand’s (number) Link Nurses attended. All 45 completed questionnaires. Prior to the study day 22 (49%) nurses considered they had good or excellent understanding of DCD, 21 (47%) were willing to be involved in DCD, while 10 (22%) expressed reservations or were unsure about being involved in the education of DCD. Following the study day all (100%) considered they had good or excellent understanding of DCD, 40 (89%) were willing to be involved in DCD, while only 6 (13%) expressed reservations about being involved in the education of DCD. 38 (84%) considered the day to have demonstrated the procedures and processes around DCD very well. 

Conclusions: Intensive care and operating room Link Nurses were receptive to this form of simulation based education. Feedback supported this style of education as a realistic and positive experience. Link nurse were more confident at becoming involved in, disseminating information on, and supporting staff in the process of DCD. 

References:

1. McCall, J. (2007) “Organ Donation and Legislation”. Journal of the New Zealand Medical Association, 18-August-2006, Vol 119 No 1240
2. Protocol for Donation after Cardiac Death (DCD). Organ Donation New Zealand, 2007
3. Australasian and New Zealand Intensive Care Society, Statement on death and organ donation (3rd Edition). ANZICS, Melbourne 2007

Background: Prospective memory (PM) – the ability to remember future intentions – is important in healthcare because forgotten tasks might compromise patient safety [1-2]. However, a challenge when studying PM in field settings is to know when an intention is formed. One way of overcoming this challenge is to use full-scale simulation and to “control” intentions. For example, Dieckmann et al. [1] used a simulation to investigate PM in the context of medical student training. In this study, we constructed a representative scenario that would expose nurses to well-controlled PM-demanding situations to test whether adding visual cues helps nurses remember intentions. 

Methods: Twenty-four registered nurses participated. The study received local hospital and university approval. We used an isolation room in an ICU to provide participants with their usual environment. Equipment included a Laerdal SimMan®, a fully equipped patient-bay, running medication, patient history, and paper work. We created a scenario based on the busy first 45 minutes of a morning shift. Each participant was told to imagine it was 7 am and that they were about to start their shift. When the participant entered the bay, the night nurse (actor) told the participant that she had not finished writing her patient notes. This prompted the participant to start their safety check. 

The scenario had 5 phases:

1. bed side area safety check,
2. handover,
3. patient assessment,
4. family member phone call and doctor visit,
5. patient care tasks. 

Eight events representing different PM-demanding situations were spread out over the scenario. The independent variable visual cue (present, absent) was manipulated between participants. The dependent variable was frequency of remembered intentions. The scenario was video recorded and all participants wore a mobile eye-tracker. 

Results Simulation: When asked to rate how realistic the scenario was for the ICU under study (1=not realistic at all, 7=very realistic), participants’ median answer was 6. The patient manikin was the main reason why the simulation did not always feel fully realistic. When asked how immersed they were in the scenario (1=I was aware that this is not real all the time, 7=I was not aware this is not real all the time), participants’ median response was 5. Information that had to be delivered via a speaker (e.g., skin color) disrupted participants’ immersion. PM performance. In two events with strong visual cues, PM performance increased significantly or marginally significantly. In three events with more subtle cues, no cue effect was observed, but in one case the cue caused significantly more nurses to finish a task-at-hand before handling an interruption. The remaining events require further analysis of the eye-tracking data because remembering frequencies showed floor or ceiling effects. 

Conclusion: Using an embedded ICU simulator, we achieved a highly realistic and representative scenario to study PM in nursing. For a subset of the events, our results indicate that visual reminders help nurses remember future intentions.

References:

1. Dieckmann P, Reddersen S, Wehner T, Rall M. Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions. Ergonomics 2006;49:526-43.
2. Dieckmann P, Dyrlov M, Reddersen S, Rall M, Wehner T. Remembering to do things later and resuming interrupted tasks: prospective memory and patient safety. In: Flin R, Mitchell L, eds. Safer Surgery: Analysing Behaviour in the Operating Theatre Surray: Ashgate, 2009:339-52.

Background: Globally, more than 1400 childbirth-related deaths occur every 24 hours [1-4]. In 2000, The United Nations Millennium Development Goals (MDGs) targeted a 75% reduction in maternal mortality by 2015. To date sub-Saharan Africa and Southern Asia have made no progress, or a reversal in progress, with higher maternal mortality than in 2000 [5-6]. A leading cause of maternal mortality is post-partum hemorrhage (PPH), an unpredictable emergent condition that if uncontrolled can very quickly lead to maternal death. Bimanual uterine compression is a life-saving technique that can be used to control or arrest PPH from uterine atony. It is a particularly valuable skill for birth attendants caring for women in rural communities with limited access to definitive care. Bimanual uterine compression is performed by applying external pressure to the uterine fundus with one hand, and internal pressure on the cervix with the other to compress the uterus for 20-30 minutes. 

Methods: Obstetricians, nurse-midwives, community health nurses and traditional birth attendants (N=130) in Ghana participated in the study. All were asked to perform bimanual compression using a simulator designed to give objective feedback (6 lights) on the effectiveness of uterine compression. Each light corresponded to a specific point of compression on the uterus. The number and location of illuminated lights were tracked for each participant. We also tracked the amount of time the participants were able to maintain the compression without fatiguing. Fifteen pairs of birth attendants were asked to perform the technique as a team, and again, the time before fatiguing (up to 5 minutes) and the number and location of illuminated lights were tracked. 

Results: There were significant performance differences between novice and expert practitioners t(129) = 14.04, p = 0.000. Mean number of lights illuminated for experts was 4.00 +/- 0.67 and for novices 1.36 +/- 0.56. No individual was able to compress the uterus beyond the fundus and cervix. Practitioners were unable to maintain compression for more than 60 seconds without fatiguing; much less than 20-30 minutes. All paired teams were able to compress the uterus to illuminate 6 lights and were able to maintain the compression without fatiguing for the allotted 5 minutes. 

Conclusions: The ability to control and arrest hemorrhage is a valuable life-saving skill for birth attendants caring for women in rural communities where access to definitive care may be delayed or unavailable. Although the technique is referenced and taught in training programs, the application of skills, even when correctly performed were inadequate to sufficiently compress the uterus for the recommended amount of time. The results of this study suggest that the technique would be more effective if performed with a partner applying external pressure to the uterine fundus while the birth attendant maintains internal pressure and monitors the patient’s condition. These findings would not have been possible without the use of the simulator providing objective performance feedback. 

References:

1. Ronsmans C, Graham WJ. Maternal mortality: Who, where, when, and why. Lancet 2006;368:1189–2000. 
2. Abdoulaye D. Maternal mortality in Africa. Internet J Health 2006:5. Available from: www.ispub.com/ostia/index.php?xmlFilePath=journals/ijh/vol5n1/africa.xml [Accessed March 8, 2010].
3. World Health Organization. Health action in crises: Liberia, 2004. Available from: www.who.int/hac/crises/lbr/background/2004/Liberia_Nov04.pdf [Accessed March 8, 2010].
4. Safe Motherhood. Available from: www.safemotherhood.org [Accessed March 8, 2010].
5. United Nations Statistics Division. DSG unveils Millennium Development Goals publication at midway point to 2015. New York: United Nations, 2007. Available from http://mdgs.un.org/unsd/mdg/News.aspx?ArticleId=21 [Accessed March 8, 2010].
6. Rosenfield A, Maine D, Freedman L. Meeting MDG-5: An impossible dream? Lancet 2006;368:1133–5.

Background: In 2008 with the support of the Queensland Health Skills Development Centre a pocket simulation centre was established in the PICU at the Mater Children’s Hospital (MCH). The Mater Children’s PICU is a 19 bed unit which has employed on average 30 new nursing staff per year over the past four years. The majority of these new staff members have no previous PICU experience. It is expected that within 12 months they will be caring for high acuity children with potential to deteriorate markedly. Training very junior staff to get to this level has traditionally been very difficult and has proven very stressful for the new staff members and the senior staff who have to support them. 

Methods: The MCH pocket simulation centre has animated the training requirements of the “staff development plan” for nursing staff new to PICU. Simulated PICU patients are utilized for skills training of tasks such as taping and suctioning an ET tube, sampling an arterial line or practising a respiratory assessment. PICU staff get experience at setting up and operating complex equipment like different ventilators, haemo filters and inhaled nitric oxygen delivery systems on a simulated patient. They get to rehearse managing a variety of both common and rare clinical emergencies. Many of the simulated clinical scenarios are managed by a multidisciplinary team of medical and nursing staff. These multidisciplinary scenarios provide excellent opportunity to train staff in effective teamwork and communication. Observation of staff performance in a simulated scenario has enabled educators to assess the progress of new staff members. 

Results: We have been able to provide new staff with experience managing clinical problems and complex equipment with no risk to real PICU patients. We believe simulation based training in the PICU has been successful in training staff to care for high acuity patients and to learn effective teamwork and communication in an emergency. 

Conclusions: Simulation has been invaluable in training new PICU staff and preparing them to safely care for acutely unwell children.

Background: As a statewide simulation based training centre, our institution trains thousands of clinicians from across the state and country. However, the geographical size of our state is substantial, and access to simulation based training for clinicians is restricted due to the cost and time involved in the travel to our metropolitan centre. With this in mind, we have developed the concept of "Pocket Simulation Centres": semi-permanent local facilities supported by our centre to deliver in situ simulation training to clinicians in their workplace. The benefits of in situ simulation include increased accessibility, effective team training and relevance to actual clinical practice, organisational change and relatively low start-up costs. 

Methods: The location of a Pocket Simulation Centre is determined by local need and enthusiasm, availability of a staff member for training and floor space to establish the facility and buy-in from local management. A Memorandum of Understanding (MOU) is reached by management locally and from our institution and any simulation equipment already in the hospital is asset transferred to our institution, ensuring that we are able to maintain and repair the equipment. Our institution trains a local staff member to be a Pocket Simulation Resource Facilitator (PSRF), equips the Pocket Centre with simulation and audio visual equipment as required and provides ongoing developmental, physical and technical support. The intensive training consists of sixteen days spent at our institution working with the existing Simulation Support Team, under the supervision of a Simulation Educator. The PSRF training is structured, competency based and includes preparing to deliver training, the moulage and operation of mannequins, use of part-task trainers, setting up and using of AV equipment, the basics of Crisis Recourse Management and scenario development. The program exposes PSRFs to a wide range of courses, across many specialties and equips them to develop, plan and deliver, in conjunction with local Faculty, high quality simulation based training that suits their local training needs. The PSRFs are subject to a midterm review to ensure that they are developing the skills required and a final competency based assessment is undertaken by a Simulation Educator who assesses their delivery of scenarios in their local Pocket Skills Centre. 

Results: To date we have fully established four pocket centres in rural and metropolitan hospitals statewide which have delivered approximately 300 hours of training this year. We have two pocket centres currently being established, three PSRFs about to start their training and at least ten units/hospitals waiting to come on board. 

Conclusions: The development of Pocket Simulation centres across the state will ensure that wherever they are, clinicians will have access to high quality simulation based training tailored specifically to their needs and in a manner which is available now, and sustainable into the future.

References / Notes:

1. http://www.health.qld.gov.au/publications/corporate/annual_reports/annualreport2009/AR08-09.pdf, pp 83, accessed 17 March 2010. 
2. Gaba, D.M., The future vision of simulation in healthcare, Quality and Safety in Healthcare, 2004:13 pp i5; Miller, K.K., Riley, W., Davis, S., Hansen, H.H., In Situ Simulation: A Method of Experiential Learning to promote Safety and Team Behaviour, Journal of Perinatal and Neonatal Nursing, 2008, Vol 22:2 (April/June), pp 106; Weinstock, P.H., Kappus, L. J., Garden, A., Burns, J.P., Simulation and the point of care: Reduced-cost in situ training via a mobile cart, Paediatric Critical Care Medicine, 2009, vol 10:2 pp177 
3. Hamman, W., Rutherford, W., Fuqua, W., Seiler, B., Beaubien, J., Rubinfeld, H., Lammers, R., Liang, B., Riley, W., In-situ Simulation: Moving Simulation to New Levels of Realism within Healthcare Organizations, presented at Safety Across High-Consequence Conference, St. Louis, March 13-15, 2007:2 
4. Weinstock, P.H., Kappus, L. J., Garden, A., Burns, J.P., Simulation and the point of care:Reduced-cost in situ training via a mobile cart, Paediatric Critical Care Medicine, 2009, vol 10:2 pp179
5. Data derived from January and February 2010 Equipment Usage reports of mannequin use compiled in our institution's Equipment Usage Database.

1. demographics of the director;
2. center organization and scope of work:
3. facilities; and
4. opportunities and challenges. 

Results will be exploratory and preliminary using both quantitative summaries and qualitative analysis of narrative comments. 

Discussion will focus on the meaning of the results and the next steps for improving the utility of the survey tool.

Background: There has been rapid development of simulation in healthcare as a teaching methodology. This has seen research focus on the effects of simulation training as compared to traditional teaching and its validity in the preparation of health care professionals for clinical practice. In contrast there has been very little research published on the training and development of immersive simulation instructors in Healthcare. This apparent lack of research is curious given the number of simulation instructor courses on offer around the world. There is also a published recognition that teaching in immersive simulation is a different teaching experience to other more traditional pedagogies. However, as to what exactly this different teaching experience requires in instructor skill sets and training in not well defined in the current health care literature. Moreover, it was intended that literature from other industries that utilise immersive simulation, such as aviation, maritime , military and education would provided further information and research on the preparation of their simulation instructors. Information from these industries could then be used to further develop health professional simulation instructors. 

Methods: A systematic structured literature review utilising Medline, Cinhal, ProQuest and ERIC (CSA) through search tools including MultiSearch has been undertaken. Multiple search terms have been utilised to identify published research and commentary / editorial pieces on immersive simulation instructor development and training. In addition, conference proceedings from a number of national and international simulation and medical education conferences have been analysed to ascertain what programs may be currently in development or implemented but as yet not published. Literature from other industries that utilise simulation has been sought using non medical data bases (ERIC, ProQuest) to compare current health related activities to other industries to identify simulation instructor training program research. This literature review is restricted to articles published in English in the last 15 years. 

Results: The review will outlines what is currently best practice both nationally and internationally in simulation in healthcare and how it could benefit from other industries using similar teaching methodology. 

Conclusions: Further research into the training and development of immersive simulation instructors in health professional education is necessary to better understand what skill set that is necessary and evident in current instructors. Healthcare would also benefit through continued links with other industries that utilise simulation teaching methods to ascertain what is being developed elsewhere. 

References:

1. Dieckmann, P. Molin Feriis, S. Lippert, A. Ostergaard, D. (2009) The art and science of debriefing in simulation: ideal and practise. Medial Teacher.31: e287 – e294.
2. Gaba, P.(2007)The future vision of simulation in Healthcare. Simulation in Healthcare 2(2):126-135
3. Riley, R. Grauze, A. Chinnery, C. Horley, R. Trewhella, N. (2003) Three years of “CASMS”; the world’s busiest medical simulation centre. MJA. 179 (11/12) 626 – 630.
4. McMillan, J.(2007). “Then you get a teacher”-Guidelines for excellence in teaching. Medical Teacher. 29: e209 – e218
5. Ali, A.(2006). Role and Importance of simulation instructor. Proceedings from the World Maritime University (WMA), Malmo, Sweden. Research Funding: This work was carried out with the support from the St. Vincent’s Hospital (Melbourne) Research Endowment Fund.

Background: An Australian Qualifications Framework (AQF) Level 7³ post graduate vocational qualification has been identified due to the need for clearly defined simulation roles, standards and assessment in geographically dispersed health facilities. Further, an agreed standard that identifies employability skills⁴, recognises clinical pre-requisites and offers flexible entry and exit⁵ to a training and development program is more likely to support industrial relations (IR) requirements for remuneration and progression in this new healthcare simulation role. 

A Vocational Graduate Certificate in Healthcare Simulation achieves these two drivers. Already accredited under the National Training Framework (NTF), the non-endorsed components of the qualification are being developed, conducted and evaluated for Australia wide delivery. 

Methods: The qualification comprises six modules, each with an interactive self directed work book, workshops and workplace assessment by a Registered Training Organisation (RTO) and subject matter expert (SME). The modules cover the knowledge, skills and workplace behaviours required to successfully discharge the role of simulation co-ordinator, and cross map to both existing AQF training packages and higher education sector tertiary qualifications. Many significant challenges were faced in developing this qualification, including developing learning strategies, assessment tools and materials that must accord with the Australian Quality Training Framework⁶ (AQTF) standards and principles. Engaging multi-disciplinary health teams as they transition from higher education delivery modalities to the more prescriptive vocational assessment models has required considerable cultural and educational change strategies. 

Results: The Vocational Graduate Certificate in Healthcare Simulation has been accredited as a nation wide training qualification. The pilot is underway, and will be completed by April 2010. It is planned to transition to a Vocational Graduate Diploma with articulation into a Masters Program. 

Conclusions: The challenges in determining workplace standards for new and emerging specialist fields in healthcare require considerable analysis. Designing an appropriate training and assessment program to ensure those standards articulate to a health facility must include a quality training system, appropriately trained and skilled assessors and facilitators, consideration of IR and Human Resource (HR) implications and an understanding of both the AQF and NTF.

References:

1. Higher Education Report 2008. Department of Education, Employment and Workplace Relations. Commonwealth Government, 2009, pp 10; 
2. Humels, Caroline and Frens, Joep Designing for the unknown: A design process for the future generation of highly interactive systems and products. Department of Industrial Design, Designing Quality in Interaction Group, 2008, pp 2; 
3. Australian Qualifications Framework Implementation Handbook Fourth Edition 2007. Australian Qualifications Framework (AQF) Advisory Board, Melbourne, 2007, pp 55; 
4. Down, Cathy Employability Skills in Training Packages: Final report. Brisbane, Australian National Training Authority, 2002, pp 6; 
5. Beckett, David Disembodied learning: how flexible delivery shoots higher education in the foot, well sort of. Melbourne: University of Melbourne, Dept. of Vocational Education and Training, 1999, pp 5; 
6. AQTF 2007 Building Training Excellence, Essential Standards for Registration. Department of Education, Science and Training. Commonwealth of Australia, 2007, pp 1.

Background: The existing ICU training program for junior physiotherapists at our hospital consists of five days of bedside teaching and supervised clinical practice in our ICU. Due to the high variability in workload, wide range of different patient presentations, and learning needs of the junior staff, it is difficult to provide consistency of training to these inexperienced staff before they are expected to work in the ICU independently. Anecdotally, staff report low levels of confidence with a number of ICU assessment and physiotherapy treatment techniques, as well as reporting higher levels of anxiety working on weekends in ICU. Before developing the modules, we needed to identify the areas of ICU care that are perceived as challenging and where confidence is low. 

Methods: A learning needs analysis was performed on junior physiotherapists (median 6-12 months since graduation) at our hospital, investigating topics which staff felt that they required further training in to improve their confidence and self-assessed competence. Topics included assessment and treatment techniques, as well as specific patient presentations. A similar survey was performed on a number of experienced ICU physiotherapists (median >10 years since graduation) from different hospitals around Australia. Assessment topics were ranked 1-6 in order of perceived importance for further training. Treatment techniques were listed, with participants selecting as many, or as few as they felt further training was required. Specific treatment techniques were grouped according to “positioning”, “manual techniques”, “hyperinflation techniques”, “suctioning”, and “mobilisation activities”. 

Results: 14/15 (93%) surveys were completed by junior physiotherapists. Results indicate that confidence appeared to be more closely related to level of independence when undertaking the task than to amount of experience. Assessment of intubated and ventilated patients (median ranking 1), assessment of haemodynamically unstable patients (median ranking 2.5), and prioritisation of ICU patients (median ranking 3) were the three highest ranked assessment topics. Hyperinflation techniques (86%), mobilisation activities (68%), and positioning (50%) were the most commonly selected treatment topics. 15/16 (94%) surveys were completed by experienced ICU physiotherapists. Most highly ranked assessment topics were assessment of haemodynamically unstable patients (median ranking 2.5), assessment of intubated and ventilated patient (median ranking 3), and assessment of acute head-injured/neurosurgical patient (median ranking 3). Most commonly selected treatment topics were mobilisation activities (80%), hyperinflation techniques (73%), and positioning (48%). 

Conclusions: Both junior and experienced therapists selected similar items on the learning needs analysis surveys. The simulation training modules currently being developed will focus on these identified areas.

Background: The Department of Health, Chief Medical Officer and National Patient Safety Agency have called for greater use, application and accessibility of simulation within UK healthcare education. Unlike the medical and nursing profession, to date, the Chartered Society of Physiotherapy (CSP) has yet to provide guidance on the use or application of simulation within physiotherapy. The potential use of simulation to aid physiotherapy clinical skill development (Blackstock and Jull, 2007), and competency development/assessment remains unknown. The use of simulation within physiotherapy, including provision, application and assessment within the NHS was previously unexplored. 

Methods: A national postal survey design was utilised featuring a customised questionnaire (with open and closed questions). All 280 UK NHS Hospitals providing EOC Physiotherapy Services in 2009 were included. Questionnaires were addressed to one EOC Service Lead per Hospital. A pilot study was undertaken in one NHS Trust. Results from the pilot were excluded from the main research findings. Quantitative data from closed questions was analysed using the SPSS V16.0. Content analysis was used to quantify the qualitative data generated by open-ended questions in the questionnaire. 

Local Ethics Review Committee deemed this study as service evaluation; therefore NHS ethical approval was not required. University ethical approval was obtained. 

Results: A useable response rate of 55% (155/280) was achieved, representing a range of Physiotherapy Service Leads. Sixty-one Trusts (39%) currently use simulation within their Trust for CPD activities relating to Acute Respiratory or EOC. Provision of simulation equipment varied with respect to type, fidelity and amount accessible to the physiotherapy service. Part-task trainer use was most common (72%) compared to low and high-fidelity simulators (66 and 38% respectively). Simulation featured in 75 % of EOC induction programmes and 92% of update training. More emphasis is currently placed on the use of simulation for development/practice of AR/EOC treatment skills (82%) compared to assessment skills (28%). Widespread variability exists between Trusts with respect to the scenario ‘range of competency’ (e.g. neurological/cardio-thoracic/multiple trauma/ventilated patients), patient assessment and patient treatment competencies as outlined by the Association of Chartered Physiotherapists in Respiratory Care (ACPRC, 2007). The range of simulation features utilised by Trusts for EOC training (initial/update) also varied. Seventy-four Trusts (48%) reported that their service used simulation scenarios in addition to part-task trainers for skills training. However, only 39% Trusts currently use simulation as a means of assessing professional competency. 

Conclusions: Two-fifths of the NHS Trusts provide simulation use for Physiotherapy AR/ EOC postgraduate education activities. National inconsistencies in simulation provisions and accessibility were identified. Guidance from the CSP is required on the use of simulation within postgraduate CPD. Further research is required to explore the application of simulation within the sub-speciality of Cardio-respiratory Physiotherapy. In addition, research is warranted to explore physiotherapy competency assessment and how simulation can be used to demonstrate achievement of core dimensions within the NHS Knowledge and Skills Framework.

Background: History taking is a vital and important component of patient assessment in nursing. Sound interviewing skills identify priorities for care (Roberts, 2004) and need for referral to other health professionals (Beck, 2007). Verbal and non verbal cues from patients provide triggers for nurses to follow-up with appropriate questions to fully explore key aspects during a health assessment and develop appropriate plans for care. This skill, however, is a difficult one for students to learn and develop. Students learned this skill in year one of their program and practiced on other students in laboratory situations, with neither taking the exercise very seriously. In clinical situations the access to this skill can be hit or miss with some students not extending this skill beyond a novice level. 

Methods: This project explored the value of video feedback, facilitated review and debriefing following a simulated patient experience to enhance final year nursing students' history taking and assessment skills. Scenarios with a number of predetermined cues imbedded within were developed, based upon specific and commonly encountered situations. Actors were employed as simulated patients from who the students then took a history while being videotaped. 

Following interviews with simulated patients, video-recordings were reviewed with each student and a lecturer to highlight missed cues or ways in which questioning could be further developed. All video-recordings were then analysed by the research team to explore cue identification. Finally, a focus group was held with participants to elicit detailed views of the experience. 

Results: Findings from the focus group suggested that the students found it a valuable exercise and believed that filming the interaction rewarding. The filming allowed the students to see themselves interact with a simulated patient that they did not know and who created a story that was believable and challenging for the student. Students thought it was important that they did not have an association with the simulated patient and that they were able to immerse themselves into a "real" situation. Students commented that when they had undertaken similar exercises with fellow students the outcomes were poor and no-one took the exercise seriously with poor learning an outcome. 

Conclusions: The study raises questions about whether history taking is being poorly developed in undergraduate students, implications for practice and how it can be more effectively interwoven into curricula and the value of simulated patients being used to enhance learning that may not be available in clinical placements. 

References:

1.  Beck, A. (2007) Nurse-led pre-operative assessment for elective surgical patients. Nursing Standard, 21(51), 35-38. 
2. Roberts, J.D. (2004) Senior student nurses information seeking skills: A comparative study. Nurse Education Today, 24, 211-218.

Background: One of the highest priorities in any clinical environment is safety – both for the patients, and for staff working in that area. This is particularly important with inexperienced staff, or in areas of high patient acuity or complexity. Anecdotally, junior physiotherapists at our hospital report low levels of confidence performing a number of ICU assessment and physiotherapy treatment techniques, as well as higher levels of anxiety working in ICU independently. Given the higher level of medical complexity and instability of patients in ICU, further training and education of junior staff is required to address these issues – to supplement our existing ICU orientation program. The current program for junior physiotherapists at our hospital consists of five days of bedside teaching and supervised clinical practice in ICU. 

Methods: Junior physiotherapists were surveyed regarding confidence and self-assessed competence across a number of different aspects of physiotherapy in ICU. An ICU skills training program – consisting of four short simulation-based modules on specific ICU physiotherapy topics – has been developed based on the learning needs analysis, and a similar survey of a number of experienced ICU physiotherapists from across Australia. Topics for the training program are: assessment of intubated and ventilated patients, assessment of haemodynamically unstable patients, positioning of patients in ICU, and lung hyperinflation techniques. Training modules utilise a combination of theory tutorials, part-task trainers for specific skills practice, medium-fidelity simulation practical workshops at the bed-side, and independent learning packages using computer-based simulators. Integration with the hospital’s clinical information system will allow use of simulated patient notes in the training program identical to those used in our ICU. 

Results: 14/15 (93%) surveys were completed by the junior physiotherapists at our hospital. Results prior to undertaking the training program indicate that confidence appeared to be more closely related to level of independence when undertaking the task than to amount of experience. Junior physiotherapists who undertake the ICU skills training program will be re-surveyed, following completion of the program in July 2010. This will provide data relating to the effect of the targeted training program on perceived confidence and self-assessed competence. 

Conclusions: A targeted program of simulation-based ICU skills training modules is being developed for junior physiotherapists to improve the level of confidence and perceived competence with those ICU physiotherapy topics felt most in need of further training.

Background: This study focuses on simulation education as a teaching strategy in educating postgraduate nurses’ in Papua New Guinea (PNG). Nurses in all areas of PNG require advanced knowledge and skills in early diagnosis, management and referral of patients with chest pain to major hospitals. Thus, the National Health Plan (2000) for Papua New Guinea challenges all cadres of the health workforce in up-skilling their knowledge and skills in competently diagnosing and treating patients with chest pain. Participants in this study consisted of postgraduate nurses from PNG, Vanuatu and Solomon Islands who were undertaking a 12 months Bachelor of Clinical Nursing at the University of Papua New Guinea (UPNG). The study site was located at the School of Medicine and Health Sciences, Taurama Campus just in the vicinity of Port Moresby, Capital city of Papua New Guinea. 

Methods: The study adapted Jeffries (2005) conceptual framework on simulation education use in developing, designing, delivering, and diffusing in educating nurses. A one-group pretested-post-tested experimental design is used. The study’s hypothesis was that simulation education has positively influenced the decision making in chest pain management. The improvement in knowledge and skills will be evident, immediately after the intervention, and after 5 weeks post intervention. A convenience sample of twenty two (n=22) nurses were recruited from the Division of Nursing, UPNG. Low fidelity simulation strategy was selected for this pilot study; firstly a one hour power point presentation on chest pain was conducted. Secondly, a 30 minutes problem solving of standardised patient presentation of chest pain acted by the ‘live actors ‘ staff emergency nurses of Port Moresby General Hospital. The participants were grouped into 2 groups of 5 and 2 groups of 6, attending 30 minutes each for a total of 2 hours. 

Results: The SPSS version 17.0 was used in undertaking statistical analysis. Descriptive frequencies on categorical variables will be tabulated and mean scores of the pretested, post-tested after intervention and post 5 weeks intervention will be the main discussion. The paired-samples t-test (repeated measures) was used to analyse the mean scores. The results are still under analysis but early indications are that the simulation methods have had a significant impact on the decisions made by the nurses. The results will be finalised by the date of announcement of acceptance of the abstract and can be included in the poster. 

Conclusion: The conclusion and recommendations will be drawn from the overall study after the completion of the analysis and readers are reminded that this is a preliminary study on a small sample and the findings should be interpreted with caution. 

References: 

1. Jeffries, P.R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26 (2), 96-103. 
2. Jeffries, P.R., & Rogers, K.J. (2007a). Evaluating Simulations. In P.R. Jeffries (Ed.), Simulation in nursing education: From conceptualization to evaluation (pp. 87-103). New York: National League for Nursing. National Health Plan (2000).

Methods: Quasi-experimental approach was used. 100 students in 50 pairs were enrolled for the study. The control group attended a paper based scenario, a medium fidelity simulation, and the paper based debrief. The experimental group attended a computer-based scenario, a high fidelity simulation, ended a brief video-based. The students were placed in group using the health sciences reasoning test (HRST) to place students in randomised stratified blocks. 

Evaluation Framework Assessment of clinical reasoning:

• The Health Sciences Reasoning Test (Facione and Facione)
• Video analysis
• Think aloud technique Assessment of knowledge application:
• Knowledge application tests – before, during and after the simulation experience Students’ perceptions of the value of the simulation experience:
• Student experience survey 

Results: Students collect and interpret cues to inform their clinical reasoning. The interpersonal communication of the student pair affected clinical reasoning. Dominant students ignored the knowledge and cue acquisition of their partner. This delayed and sometimes present prevented a good clinical decision being made, despite the partner understanding the clinical significance of the situation. These findings will be presented using transcripts from the think aloud data collection and the video analysis. 

Discussion: This poster will present the results of a quasi experimental study that examined how nursing students develop and demonstrate clinical reasoning skills using medium and high fidelity human patient simulation manikins. The simulation experiences were videoed and the resultant data subjected to content analysis. This poster will focus on the stage of clinical reasoning and demonstrate how student interpersonal communication effects the collection and interpretation cues to inform their clinical reasoning. 

References:

1. Hoffman, K. (2007).Unpublished PhD thesis, A comparison of decision-making by “expert” and “novice” nurses in the clinical setting, monitoring patient haemodynamic status post abdominal aortic aneurysm surgery. University of Technology, Sydney.
2. Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M. and Silber, J.H. (2003) Educational levels of hospital nurses and surgical patient mortality. JAMA. 290 (12), 1617–1620.
3. NSW Health (2006) Patient Safety and Clinical Quality Program: Third report on incident management in the NSW Public Health System 2005-2006, NSW Department of Health. Sydney.
4. del Bueno, D. (2005) A crisis in critical thinking. Nursing Education perspectives. 26, (5), 278-283.
5. Thiele, J.E. , Holloway, J., Murphy, D., Pendarvis, J., and Stucky M. 1991. Percieved and actual decision making by novice baccalaurete students. Western Journal of Nursing Research. 13 (5), 616-626.
6. Reischman,R. R. and Yarandi, H. N. 2002. Critical care cardiovascular nurse

Aims: To develop a low-budget, multidisciplinary in-situ simulation program to teach management of common ICU problems. 

Methods: A simulated ICU bed space was recreated using an existing MegaCode Kelly with Vital SimTM, supplemented by common ICU equipment and simple moulage. Junior and senior ICU doctors manage a simulated patient through realistic events for 5 consecutive days as part of their usual ward round. Prior to each review, nurses make an assessment then interact on the round. A management plan is reached as a team then a teaching debrief follows. A baseline global survey of staff perceptions regarding simulation-based learning was performed. Four initial patient cases were developed, each with specific learning objectives. Total material outlay costs have been approx. A$200 (excluding disposables from the ICU). 

Results: Staff envisaged simulation training could improve clinical decision making and interdisciplinary communication, especially on ward rounds. Simulated patients have reflected the ICU case mix and have included common Cardiac surgical, Neurosurgical and General ICU journeys, with classical crisis and maintenance issues. Early evaluation suggests the program is being well-received, is enjoyable and meeting its aims. 

Conclusions: Low-budget, multidisciplinary, in-situ simulation in an ICU is achievable. Innovative, creative approaches, for delivering high value programs to meet clear educational goals are needed in the current climate of stretched resources. This remains a work in progress. 

References:

1. Weinstock P, Kappus L, Garden A, Burns J. Pediatr Crit Care Med. 2009; 10: 176-81.
2. Kobayashi L, Patterson M, Overly F, et al. Acad Emerg Med. 2008; 15: 1166-74. 3. Weinstock P, Kappus L, Kleinman M, et al. Pediatr Crit Care Med. 2005; 6: 712-3.

1. To investigate the effectiveness of a training package to improve assertiveness demonstrated by medical students when faced with challenging situations during medical simulation exercises. 

2. To determine the attitudes of medical students towards teamwork before and after the training intervention. 

3. To evaluate the students’ views on the effectiveness of the training package and to generate themes for future investigation. 

Background: Patient safety is an aspect of medical care that is of increasingly recognised importance in the minimisation of errors and harm to patients. Effective teamwork, especially in urgent or crisis situations, is an important contributor to this (1). Good communication skills are one of the many factors that contribute to the development of effective teamwork. Teaching students how to speak up and to create the environment in which they can express their concerns is one method to enhance this process (2). Specific training in assertive communication has been reported in post-graduate anaesthesia environments, but not previously with medical students (3). 

A recent systematic review examined the existing literature on teamwork training interventions in medical student education (4). They noted several common study weaknesses, including lack of randomisation and controlled design, lack of clinical outcomes, and on over-reliance on self-assessment and short-term outcomes. Our study was designed to overcome some of these problems. 

Methods: 

Phase I 

• all students complete an ‘attitude to teamwork’ questionnaire (as a baseline prior to any simulation experience) 
• all students undertake their first simulation session 

Phase II 

• students are split randomly into 2 groups according to day of attendance
• both groups complete questionnaire again (to determine if the exposure to simulation in itself has had an effect on the baseline teamwork attitudes) 
• both groups undertake their second simulation session, in which an error by a more senior staff member is embedded. The videos from both groups are analysed to assess the student teams’ response to the challenge
• as part of the debriefing after the session, group 1 receives a specific assertiveness training intervention. This incorporates both theoretical and practical aspects of communication to improve assertiveness using the ‘two challenge rule’ as described by Pian-Smith et al (3).

Phase III - approximately 3 months after phase II 

• both groups complete the teamwork attitudes questionnaire again 
• both groups undertake their third simulation session. This will have a different error and challenge opportunity embedded 
• videos from both groups will be analysed for the response to the challenge. Our hypothesis is that the group 1 students will have a higher level of assertiveness as measured by how they behave in managing an error. All of the videos will be analysed after the conclusion of the study by an external blinded observer. 
• group 2 will then receive the specific assertiveness training as part of their debriefing after the simulation sessions are completed. 
• both groups will undertake a semi-structured interview as the final part of the debriefing to explore their learning from the intervention 

Results: The study is partially completed as of mid-March 2010 (Phase I and II). Phase III will occur in May 2010, and we expect the results to be analysed and the study completed in time to present the results at the SimTecT Conference. 

Conclusions: We will report our findings on the effectiveness of the training intervention in improving assertiveness and attitudes to teamwork in general. 

References:

1. WHO patient safety curriculum guide for medical schools. WHO 2009.
2. Leonard M et al. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004 13:i85-i90
3. Pian-Smith et al. Teaching residents the two-challenge rule: a simulation based approach to improve education and patient safety. Sim Healthcare 2009;4:84-91
4. Chakraborti C et al. A systematic review of teamwork training interventions in medical student and resident education. J Gen Intern Med 2008 23(6):846-53

The Diploma of Enrolled Nursing is a nationally recognised qualification which is based on the AQTF, Health Training Package HLT51607. This qualification consists of 26 compulsory units of competency and 5 elective competencies. The majority of these units require the critical aspects of the competency to assessment and evidence is required to demonstrate competency. 

Evidence guide for HltEN504A states:

Critical aspects for assessment and evidence required to demonstrate this competency unit:

• Observation of performance in a work context is essential for assessment of this unit
• Consistency of performance should be demonstrated over the required range of workplace situations and should occur on more than one occasion and be assessed by a registered nurse 

Context of and specific resources for assessment:

• This unit is most appropriately assessed in the clinical workplace or in a simulated clinical work environment and under the normal range of clinical environment conditions
• Where, for reasons of safety, access to equipment and resources and space, assessment takes place away from the workplace, simulations should be used to represent workplace conditions as closely as possible 

Therefore, the teaching staff at CIT have endeavoured to develop a simulation centre where we can evaluate the students in a realistic and safe environment that emulates the work place as closely as possible. CIT is currently using both high and low fidelity simulators in our practice/assessment scenarios; these include both manikins and human actors to achieve the required level of simulation. 

The Training package also requires that students are able to demonstrate competency over a range of workplace situations. As hospital placements are always an ongoing issue and students are not always given the opportunity to perform the skills they have learnt, we need to be able to provide an environment in which these competencies can be assessed. 

CIT is focused on developing quality simulation that reflects industry requirements, and provides the students with realistic situational learning. As directed by the training package, our students are being educated and assessed in the simulated work environment on manikins to enable them. 

We are currently gathering feedback information from both the students and industry on the effectiveness of the use of assessment of competency using simulation. 

CIT simulation environment is used across disciplines: Nursing, Aged Care, Disability and Community. 

CIT is striving to expand our simulation centre to include a multidisciplinary team approach. This will enable not only our students to use the facility, but to include all the health facilities in the surrounding area.

Background: Demands on Clinical placement increase annually as the number of training provider's increases and with this, the volume of students requiring valuable placement opportunities. Combine this with the possibility that a student will not have exposure to the required competency experiences to suit the focus of the placement. Training organisations therefore need to identify alternatives to ensure all students have exposure to the required clinical experiences that will ensure they 'connect the dots' between theory and practice. Regular, effective exposure to simulation could be the answer. Whilst not a complete replacement for the true clinical environment, simulation can be used to ensure the student is capable of working in that environment. 

Method: Introduced within the first few weeks of training, the Enrolled nurse is exposed to the simulated environment. Initially exposure is low fidelity, a combination of demonstration, practice, and performance as students develop foundation nursing skills. As the course progresses, the simulated environment becomes more complex with an expectation of a higher level of understanding and knowledge and the introduction of simulation activities that will increase progressively as the course moves through phases of training. Each student is exposed to a full day of simulation every week of their course from the sixth week of training with a gradual increase in fidelity as the course progresses. 

Prior to clinical placement, the student will be required to complete a 'clinical competence assessment' to determine the student's preparedness for clinical placement and probability to succeed. Students who are deemed to not have the theoretical and practical knowledge required to succeed prior to placement risk not being allocated a clinical placement until such as time where they are considered to demonstrate these qualities. 

Results: After six-months, there have been only two students which have not been cleared for clinical placement with their student cohort. 

Evaluations from each simulation demonstrated an improved level of understanding and cohesion between theory and practice although this result was determined by the student mix and phase of training. 

Follow up evaluation of the effectiveness of simulation as a preparedness tool for clinical ability is still being undertaken with the intent of performing an evaluation at six-months after course completion. The intent of this study will be to determine whether students who were exposed to regular simulation throughout their training demonstrated a higher standard of clinical competence. 

Conclusions: This study is on-going and the result of the new training implemented methodologies not to be finalised until the six-month evaluation has been completed. Evaluations prior to course completion showed an increased connection of the dots between theory and practice which were encouraging.

Background: The provision of early adequate chest compressions remains a standard of care for optimal outcome in cardiac arrest. In 2005, ILCOR recommended that rescuers deliver CPR in cycles of 30 chest compressions and 2 ventilations (30:2) at a rate of 100 compressions per minute with a compression depth of 4-5cm. Given this change from the previous CPR cycle of 15:2 to 30:2 there is now greater emphasis on pushing faster and deeper with minimal interruption which has led to speculation surrounding rescuer fatigue and compression efficiency. 

Methods: This was an observational pilot study investigating second year undergraduate paramedic students’ fatigue levels and quality of chest compressions following twenty minutes of simulated CPR on a Laerdal Resusci Anne mannequin. Data were collected at baseline and every 2 mins until the conclusion of the twenty minutes. Student fatigue was measured using the Borg Scale which is a validated fatigue rating instrument, and student heart rates using a wireless heart rate monitor. Chest compression rate and depth was measured using the Laerdal Resusci Anne CPR Skill Reporter™ connected to a laptop computer. 

Results: Seven students participated, with two being males and five between the age of 21 and 25 with the other two < 21 years of age. There was a statistically significant difference between the base heart rate (resting prior to commencing CPR) and heart rate at 14 minutes, p=0.045, for all students. There was a statistically significant difference between the Borg Scale at rest (prior to commencing the CPR) and at 2 minutes (p=0.001), at 6 minutes (p< 0.0001), at 10 minutes (p< 0.0001), at 14 minutes (p< 0.0001), and at 18 minutes (p=0.002). There was no statistically significant difference between compression rate and compression depth for all students. There was a statistically significant difference between the < 21 years group and 21-25 years group for compression rate, mean 113.4 chest compressions/minute to 136.1 chest compressions/minute, p< 0.001. For compression depth, student heart rate and Borg there was no statistically significant difference between the two age groups. There was a statistically significant difference between males and females for compression rate, 108.0 chest compressions/minute to 125.6 chest compressions/minute, p=0.006. For compression depth, student heart rate and Borg there was no statistically significant difference between the genders. 

Conclusion: This pilot study suggests that fatigue sets in early when undertaking CPR in a controlled setting with some of this fatigue possibly attributed to faster than recommended chest compression rates. Further research is required to identify if students fitness levels affect the rate of onset of fatigue

Background: Box Hill Institute introduced immersive simulation scenarios into the Certificate IV nursing curriculum in 2008. This was initially implemented into the timetable into identified gaps as a way of adding to the curriculum. It was during 2009 that this changed. Rather that fill a gap in the timetable with simulation, simulations opportunities were identified within the curriculum with the resulting timetabling evolving around the simulation activities. This enabled the theory and practical components to be further consolidated by the simulation activity. 

Methods: Initially six immersive scenarios were developed, tested and modified to suit the activity identified. One of the teachers had initially been identified as having simulation delivery as part of her portfolio. It was with limited understanding and exposure to simulation that these sessions were developed. Intensive training, support and mentoring also took place during this time to develop a greater understanding of how to deliver using this new teaching methodology. As the year progressed, a further three scenarios were implemented and incorporated into the curriculum. A number of tutorial sessions were also developed using part task trainers. Evaluation of each session was undertaken by the students as well as by the simulation educator and teacher involved in their delivery. 

Conclusions: As the students were more exposed to the immersive simulation sessions, their confidence and competence grew. Many reported that they felt more confident as they now know what to do. They could see alternative ways of doing and could identify some of the signs of deterioration. Analysis of the data from 2010 will be included and comparisons made between this and the data from 2008-2009.

Background: During simulations participants are subjected to stressful scenarios which can push them to the limits of their abilities. Adding an unfamiliar environment and a simulated patient can add further levels of stress. Participants being unsure of how to perform in the simulator can reduce realism and cause participants to perform in a manner which is different to their normal behaviour. If the participant is overstressed then the objectives of the scenario will not be met and possibly lead to a harmful experience. 

Before participants are exposed to any simulations, they are given a familiarisation. This introduces the participants to the patient simulator and the room in which they will be working. Besides identifying the features of the patient simulator and the room the familiarisation will also explain that the scenarios are scenario-objective focussed (not individual performance), how the debrief works, re-enforces the centre's confidentiality policy and introduces the faculty nurse. 

By performing this familiarisation in a non-threatening and informative manner the participants will feel more comfortable, take in more information and get more out of the scenario. 

Method: SimMan 3G (Laerdal Medical Corporation) is a medium fidelity patient simulator used in the SCSSC. Using the simulator with its accompanying software it was decided to develop a semi-automated familiarisation with interactive elements to produce a consistent, informative and fun familiarisation. 

The familiarisation uses SimMan 3G to describe its own features as well as that of the room and other points that the participants need to be aware of. Using SimMan 3G's scenario editor, feedback from the simulator makes the familiarisation interactive and automated, eg SimMan describes its pulses and waits for the pulses to be palpated before moving onto the next item. 

Conclusion: Using the SAIF we aim to produce a more informative and consistent familiarisation for our participants.

Students state that there are times when simulation teachers can assist or mire their learning experience. Qualities or characteristics such as professionalism, interpersonal skills, evaluative techniques, personality and methods of teaching are highlighted and valued by students. These qualities may not always be apparent when recruiting staff in the simulated learning environment, however it is essential that these virtues be admired, respected and valued so that students have a practical and beneficial learning experience.

This paper will explore some of the theoretical and practical issues related to achieving realism in human patient simulation based education. It will discuss the issue of authenticity drawing on theories such as Guliker’s five-dimensional theory of authentic assessment and Vygotsky’s zones of proximal development.

Background: It is not uncommon to see what appears to be a complete disconnect between theory and practice. Training has historically comprised the delivery of theory through a combination of delivery modalities and the use of practical laboratory activities which provide the student the opportunity to implement the skills required in a safe, protected, low risk environment. In Enrolled Nurse training this has perhaps been adequate for the knowledge standards required, however the Scope of Practice for the enrolled nurse now requires a higher level of knowledge and skill which must dictate higher expectations. 

Past simulation activities have incorporated the use of concurrent activities with the student cohort divided into three syndicate groups rotating through each activity which may be of varying fidelity and clinical focus. This remains a valuable delivery tool for students however it has been determined that the learning experience could be enriched with the use of consolidated activities. 

Method: Theory and practice will continue to be developed using a staged approach which includes the delivery of theory through a combination of face-to-face delivery, online learning and readings. This is followed with the use of low fidelity laboratory activities where theory is implemented in a highly supervised and facilitated activities followed by a medium level fidelity, guided simulation activity. Previously this would have been the end-point of training in the campus environment with a reliance on the 'broader picture' occurring in the clinical environment. 

This project will introduce a further level in campus delivery. The timetabling of regular 'ward practical activities' where the focus is not on one activity, but a combination activities, or more holistic approach to learning. 

Ward activities will require students to become more engaged as they progress through a series of linked simulated activities where the level of teacher engagement is decreased and the need to students to participate at a higher level which may lead to the end-point of the stimulation taking a positive or negative pathway. 

Results: Initial results after the implementation of one ward practical activity have been extremely positive with students making a stronger connection to the importance of communication which impacts on the outcome for each activity. 

Conclusions: Further use of this training methodology will hopefully show that providing a simulated environment that captures a number of learning outcomes where the student drives the potential outcome will improve the cohesion of knowledge and therefore improve learning outcomes.

Background: Two high-fidelity patient simulators were recently purchased by the university, with the intention to incorporate simulation into the undergraduate nursing education program. Second year acute care nursing was the first subject redeveloped using simulation, as part of curriculum renewal in 2009. Concept mapping and simulation activities were introduced to provide an opportunity for students to develop critical thinking skills in a simulated clinical environment. The lack of critical thinking skills in health care, particularly among nursing students and graduates, was identified by Luckowski (2003) as a major issue in nursing practice. Concept mapping has been endorsed as an educational strategy that promotes critical thinking, particularly in nursing literature (Abel & Freeze, 2006; Luckowski, 2003; Schuster, 2008; Wilgis & McConnell, 2008). 

Method: Second year student nurses completed a concept mapping exercise on a case scenario pre and post a simulation activity of the same scenario. The students were directed to identify and present learning concepts that related to the patient case; based on previous knowledge, past experiences, and the context of the case scenario. Students were asked to make graphical links between the concepts; and rank these according to the knowledge (skills/attitudes) relevant to this situation. Students were then invited to compare the pre and post concept maps as evidence of their own learning. The two concept maps were collected for comparative analysis. Focus group interviews were then conducted to gain further insight into the participants' views on the use of concept mapping and simulation. 

Results: Analysis of the 26 pre and post concept maps will be undertaken in line with the criteria used by Abel and Freeze (2006). Three focus group interviews of 6-8 students were conducted at the completion of the subject; and content analysis of the interview transcripts is in progress. Results from both analyses will be ready for presentation at the conference. From the preliminary focus group transcript analysis, it was evident that some students experienced feelings of frustration and apprehension about the concept mapping process. The data highlighted that whilst some students undertaking the simulation experience stated that it was realistic in its delivery and aided in the development of confidence in clinical practice; others voiced feelings of 'anxiety, pressure, stress and self-consciousness.' A strong emerging theme from the focus group responses was the strong links between the concept mapping exercise, the case study and the simulation experience. 

Conclusion: The outcomes of this research will inform the integration process of simulation into the acute care subject stream across the undergraduate nursing program. It is anticipated that the information gathered will assist academics to make changes to the curriculum, enhance the utilisation of the simulation mannequin and associated technology, as well as consolidate students' problem based learning and critical thinking skills. 

References:

1. Abel, W. M., & Freeze, M. (2006). Evaluation of concept mapping in an associate degree nursing program. Journal of Nursing Education, 45(9), 356-364. 
2. Luckowski, A. (2003). Concept mapping as a critical thinking tool for nurse educators. Journal for Nurses in Staff Development, 19(5), 225. 
3. Schuster, P. M. (2008). Concept mapping: a critical-thinking approach to care planning (2nd ed.). Philadelphia, PA: F.A. Davis. 
4. Wilgis, M., & McConnell, J. (2008). Concept mapping: an educational strategy to improve graduate nurses' critical thinking skills during a hospital orientation program. Journal of Continuing Education in Nursing, 39(3), 119-126.

Background: For the benefits of the learning produced in simulated learning activities to be useful, the learning in the cognitive, affective and psychomotor domain needs to be able to be applied to real clinical patient situations to enable appropriate and competent patient care to be implemented. There have a number of claims from researchers that participants in simulated learning activities should have an increased ability to apply knowledge, skills and attitudes learnt to patient situations in the clinical setting. Aliner et al., (2004) state that competence will ‘hopefully be able to be transferred to the clinical setting’ and Kneebone (2003) states that the improvement in “motor skills should lead to increased transfer to clinical practice”. So how does the context in simulated learning experiences effect learning outcomes and the transfer of learning of nursing students enrolled in either undergraduate or postgraduate programs? 

Methods: The terms simulation, nursing and education were inserted to gather data for the research question. To be included in the review articles had to:

•  Be published in English
•  Have participants from undergraduate or postgraduate nursing programs
•  Discuss the application of the learning from simulation in the classroom setting to the clinical environment. 

In the search the limit for publication dates included all articles published from 2003. 

Results: From the 64 articles returned in the search using the terms nursing, simulation and transfer 32 made reference to how the learning that resulted from simulation based education did or did not transfer to the clinical practice environment and were included in this review. Sample sizes in research articles ranged from 4 to 344 with the participants from undergraduate and postgraduate nursing programs. Articles were from a wide variety of countries with the USA featuring predominantly. Other countries included Australia, China, UK and Ireland and Canada. 

Conclusions: The literature regarding the effect of simulation on the ability of nursing students either postgraduate or undergraduate to transfer learning from the classroom to the clinical setting is limited. This literature review reveals that of the 64 articles reviewed from the CINAHL database only five articles documented significant research findings that support the claim that simulation positively effects the ability of the learner to transfer learning from the classroom to the clinical setting. Seven other articles had significant anecdotal evidence in the form of student feedback and preceptor reports that claim those students who experienced simulation performed better in the clinical setting that those who received traditional methods. However the small sample sizes in these articles make for the findings unable to be generalised. 

References: 

1. Alinier, G., Hunt.B., Gordon,R & Harwood,C. (2006). Effectiveness of intermediate fidelity simulation training technology in undergraduate nursing education. Journal of Advanced Nursing , 54 (3), 359-369. 
2. Kneebone, R (2005) Evaluating Clinical Simulations for Learning Procedural Skills: A Theory-Based Approach. Academic Medicine. 80(6), 549-553

Methods: The participants were 20 nurses and 1 registrar. The format included a lecture, review of new protocol and anaphylaxis kit simulation and debrief and later complete a worksheet. 

Outcomes:

1. Simulation: Evaluation from the workshop demonstrated that the nurses didn’t like simulation and verbal feedback was that they felt under prepared . This resulted in developing a formal “Introduction to Simulation” Power Point presentation which is now used in all simulation based workshops
2. Occupational Health and Safety Issues: In preparing for the workshop by performing a “dry run” of the scenarios it became clear that a lone nurse would have difficulty transferring a patient to floor. This resulted in a change of practice. Since carrying an Epi-pen was not an option( partly due to costs) drawing up 0.3ml of adrenaline from an ampoule was very difficult and wasted time and the dose due to spillage the actual dose to be given was changed

Conclusion: This workshop on implementation of guidelines for ambulatory nursing management for anaphylaxis in the home demonstrated how careful preparation in orientating participants to what is expected of them best facilitates the learning experience. Properly used simulation made the nurses clinical practice safer for them and the patient.

Background: Experience can be defined as knowledge of, or skill in, or practical wisdom, or the observation of something, or some event, by being involved in, or exposure to, that thing or event ("The Macquarie Dictionary Digital Edition," 2009). This basic definition of experience is important, because it raises to our attention that experiences means, “exposure to” or “involvement in” it does not exclude any site or type of experience. This places participation in simulation as an authentic site for experiences. As simulation is not excluded from the definition of experience then experiences gained during a simulation has validity. Often experiences are only considered valid if it occurred at the site of authentic practice in the authentic environment. But, authentic practice can and does occur in the pseudo-authentic workplace. These experiences provide an avenue to develop holistic competencies and not just focus on the behavioural model of competency-based training. 

However, to move beyond the “reductionist” model, the participants and educators need to engage at all levels and look beyond the simple checklists for skills attainment to determine if the actions undertaken during the “hot action” represent “wise” actions or as Beckett (2008) refers to as “judgment-in-context”. St. Pierre et. al argues that past experiences are our “main” interpretive frame for this new event, as a result there is a danger we will only see what we have always seen, and it is nearly impossible to move beyond that frame of reference. Simulation has the power broaden our experiences thus reducing the risk being blinkered by past experiences. 

Methods: This is a qualitative study involving educators and students from Nursing, Medicine, and Paramedicine. A total of 18 educators, and 18 students, were interviewed through semi-structured interviews. The findings were triangulated with observations and a search of curriculum documents. 

Results: Both the educator and the students agreed that simulation does provide for experiences that can have validity in the authentic workplace. Simulation can provided for the development of the skills in the context of a valid experience that can assist in the development of the participants’ schemata. There is a correlation of the effectiveness of simulation between the espoused views of the simulation and that the educator implies at time of the simulation. If the espoused view is that we are looking beyond the “know-how”, however, the educators’ actions and comments only focus on the “know-how” and there is little or no emphasis on the “know-why”, then the student will only focus on the theories-in-use, and not the espoused views, as a result some valuable learning can and will be lost. 

Conclusion: Simulation is a powerful learning and teaching pedagogy. Simulation can be considered as one of the active learning pedagogies, that is learner centred. Furthermore, if the simulation is well constructed and well executed, it can provide valid experiences for the participants. These experiences can provide for the development or the extension of the participants’ schemata, this in turn should aid them in the authentic workplace.

Background: Health simulation is well established as a learning tool for those working in emergency care and operating theatres. The increasing body of literature and both national and international exposure is resulting in simulation centres such as the Clinical Skills Development Service in Queensland now being approached by groups not traditionally associated with the higher fidelity end of this learning modality. It is essential that processes are developed and implemented that ensure meaningful scenarios can be developed, even if those charged with their development do not have direct knowledge and experience in the new field. 

Methods: A process has been developed to:

• determine the specific learning requirements
• review the feasibility of the request (timeframe, budget, resource requirements)
• identify suitability of simulation as a teaching modality
• allocate development of teaching content
• allocate scenario development
• pilot the newly developed program 

Results: Using a systematic approach, successful programs have been developed for:

• podiatrists treating patients with at risk diabetic feet
• dental teams dealing with emergencies in the dental clinic (both in the waiting room and in the dental chair)
• Australian Defence Force reservists (health professionals) pre deployment. 

Conclusion: Simulation has potential to improve patient care at all points in the patient care continuum. The process developed has enabled valuable learning tools to be developed across a diverse range of domains getting more bang for our buck.

Background: Prior to this study, Westmead Hospital, a major trauma centre in NSW, undertook a substantive review of their trauma service. One key recommendation was Trauma Team Training. A one day multi-professional course was subsequently provided for 25 clinicians at the Sydney Clinical Skills and Simulation Centre. This course addressed non-technical skills effective in the team management of seriously injured patients along with case management and rehearsal of NSW Health best practice guidelines. The course was contextualised to enable the teams to apply Westmead specific trauma practices. Evaluations of the course on the day indicated a perceived improvement in ability to manage specific trauma conditions and teamwork practices learnt in the course.

Methods: An anonymous, post course questionnaire was developed and sent to all 25 participants of the trauma team training courses twelve weeks after the initial course. The questionnaire asked participants to recall how many trauma resuscitations they had attended and to evaluate whether their clinical practice and teamwork had remained improved across the eleven domains previously measured. 

Results: There was 100% compliance in the three month, post course evaluation (n=25). The participants represented the spectrum of a typical Westmead Hospital trauma team. Only one person had not been part of a trauma team activation since their course. 52% (13) had been part of a trauma team on more than 5 occasions and 36% (9) on more than 10 occasions since their initial team training. 

Upon reflection of the course sessions and using a 5 point likert scale (1= strongly disagree, 3= can’t decide and 5= strongly agree), participants scored their perceived subsequent utilisation of skills and knowledge learned at the course during trauma activations. Across the four sessions there was a mean of 4 with a standard deviation of 0.62- 0.78. 

Participants considered whether the course had improved their practice in eleven non-technical skills. Across the domains there was a mean response of 4 – 4.4 (SD 0.44 – 0.9). Perceived improved ability to manage the clinical conditions portrayed in the scenarios scored a mean of 4 (SD 0.4 – 0.6). 

Participants reported that training as part of an inter-professional team (doctors and nurses) and a multi-disciplinary team (ED, trauma, anaesthesia, surgery and ICU) was highly useful, as shown by the likert scale mean of 5 (SD 0.4 – 0.45). The routine use of effective communication and team skills in trauma team management at the hospital scored 4 (range 2 – 5) with a standard deviation of 0.95. 

Conclusions: Participants report that initial benefits of a one day trauma team training course in terms of improved clinical practice and ability to participate effectively in the trauma team are retained at three months.

Methods: Medical students participating in simulated cardiac arrest scenarios were randomised to passive (P) or active (A) sessions. In each session, students were further randomised to simulation “1” or “2”. All students had participated in a two hour BLS/ALS refresher in the weeks prior to the simulations and all students participated in a one hour discussion on chest pain, shortness of breath and cardiac arrest management immediately prior to the simulations. P1 and A1 students performed their scenario, involving a simulated cardiac arrest, immediately following the discussion. No check lists were used by these groups. P2 students watched P1 teams live. A2 students watched A1 teams live while also completing a checklist based on the ARC algorithm for cardiac arrest management. All students then participated in a 30-45 minute debrief of the first scenario. P2 and A2 students then participated in a second simulated cardiac arrest scenario followed by another debrief session. Scenarios were recorded to DVD and were used to determine time to initiation of CPR, time to first defibrillation, interruptions to chest compressions and time between defibrillations. Times were compared between P2 and their control (P1), A2 and their control (A1) and between A2 (checklist) and P2 (no checklist) groups. 

Results: Eighty-two medical students in 28 teams participated in 14 passive and 14 active sessions. There was no significant difference between the groups in terms of demographics, group size or previous exposure to simulation, defibrillation or training for cardiac arrest. The mean time to defibrillation for P1 and P2 was 130 seconds (95% CI 90-171) and 74 seconds (95% CI 64-85) respectively with a mean difference of 56 seconds (95% CI 26-86) (P = 0.001). The mean time to defibrillation for A1 and A2 was 121 seconds (95% CI 96-146) and 84 seconds (95% CI 71-98) respectively with a mean difference of 36 seconds (95% CI 6-67) (P = 0.02). The mean difference between P2 and A2 was minus 10 seconds (95% CI -40-20)(P = 0.501). For each of the groups, there was no significant difference between time to initiation of CPR, time between first and second defibrillations or time where no chest compressions were performed. Chest compressions were not performed for approximately 30% of the arrest time for all groups. Time between defibrillations tended to be shorter in the second scenarios (P2, A2), though this did not reach statistical significance. 

Conclusions: Time to defibrillation is improved for medical students performing simulated cardiac arrest management after they have witnessed one such simulation and participated in a subsequent debrief. In the setting of a comprehensive teaching package with two hours of instruction prior to participation in a simulation, the use of this simple checklist does not seem to add to this improvement. Delay in initiation of and interruptions to CPR have been identified as needing further attention in future education sessions.

Methods: DVD recordings were made of medical students participating in simulated cardiac arrest scenarios. Total time spent not performing chest compressions, from the time of recognition of cardiac arrest to the time of successful defibrillation, were recorded. Successful defibrillation occurred with the second attempt at defibrillation. Periods of time where chest compressions were not being performed were categorised according to the stage of the arrest and likely reasons for lack of chest compression. 

Results: Eighty-two medical students in 28 teams had their cardiac arrest scenarios recorded resulting in a total of 5738 seconds of cardiac arrest time (median 201 seconds (IQ range 161-245)). The total time where no chest compressions were performed was 1687 seconds (29% (95% CI 28-31)), a median time of 58 seconds (IQ range 45-76). The total time between recognition of cardiac arrest and initiation of chest compressions was 848 seconds (median 29 seconds (IQ range 16-37)) and accounted for 50.3% (95% CI 47-53) of the total time where no chest compressions were performed. 

Conclusions: While other aspects of life support such as pulse checks, endotracheal intubation, drug administration and relieving rescuers performing chest compressions have been touted as reasons for interruptions to chest compressions in CPR, this study highlights that the biggest reason for “interruption” in this simulated environment is actually delay in the initiation of chest compressions once cardiac arrest has been identified. Further investigation is indicated to determine whether this finding relates to the delivery of the teaching program including its format, participant engagement and realism of the simulation, or whether it relates to lack of experience, knowledge or skills amongst the participants.

Methods: Our curriculum spreads 6 hours of BLS training into 4 sessions throughout first year and includes: 

• Small groups of 4 students 
• A printed reference booklet 
• A learning-needs-analysis conducted as the first activity to: 
• Determine the knowledge and skill of the class as a whole to guide curriculum evolution 
• Provide individual feedback to each participant to identify their needs and guide their learning 
• Video-based didactic lectures that introduce each session (~15 min *4 sessions) 
• Skills practice (~30 min * 4 sessions) 
• Scenarios using medium and high fidelity simulators (~30 min * 4 sessions) 
• Final assessment with visual and computer feedback on performance 
• The assessment is repeated until competency is achieved 
• Follow-up assessment in second year to determine retention 
• A website with: 
• Information from the booklet
• Links to official guidelines and current research
• Introduction lectures as streaming videos o Supplementary short how-to videos 
• Demonstration videos of good and bad CPR 
• ePortfolio to collect evidence of competency, encourage reflection and obtain expert feedback 

Students attend four sessions spaced approximately 6 weeks apart. Information and skills presented includes the following: 

• Recognition of a problem (unresponsiveness) 
• Calling for help
• Opening the airway
• Assessment of signs of life
• Management of foreign body obstruction
• Introduction to elements of a hospital room: Oxygen; Airway roll; Call bells; Bed controls

• Mouth to mouth
• Mouth to mask
• Bag and Mask
• Proper rate and depth of ventilation 

• Position, Rate, Depth 
• Controlling haemorrhage 

• Using an AED 

Key features of this curriculum include spreading contact time over the whole of first year at approximately 6 week intervals and use of an ePortfolio to collect evidence of competence. This evidence takes the form of video recordings, self-reflection of performance during simulations and real events, and feedback from experts and/or peers. 

Results: We have been collecting anecdotal evidence for several years regarding experiences students have had where they have used their BLS training. We are now collecting data regarding retention of BLS skills by second year medical students after taking this training at 4, 8 and 12 months following their initial assessment near the end of first year. Preliminary results of this validation will be available for presentation. 

Conclusions: We believe that this distributed curriculum provides a quality foundation in BLS skills and establishes a climate of personal reflection and continual professional development with approximately the same student contact time. Using small groups as is typical with simulation-based teaching increases the staff commitment. Improvements to retention of BLS skills using this curriculum remains to be seen.

An education program using simulation to encourage an improvement in identifying the deteriorating patient and initiating a MET call earlier was delivered in efforts to reduce unplanned admissions into ICU. 

The program incorporated a pre-simulation tutorial on the MET policy; an orientation to the manikin and surroundings; two clinically based immersive scenarios, debriefing using guided reflection; pre and post test surveys and post scenario and post program evaluations. 

A pre- and post-simulation education intervention audit on MET calls, Code Blue calls and unplanned admissions was carried out. The number of MET calls increased by 167% while the number of Code Blue calls were reduced by 40%. Unplanned ICU admissions increased significantly by 43%. 

A post-intervention survey of intensive care personnel who respond to MET and Code Blue calls was also conducted to identify what impact on human and organisation resources occurred. 

Post-simulation education data demonstrates nursing staff instigated an increase in MET calls which led to the increased unplanned admissions. Recommendations include: to ultimately reduce the number of unplanned admissions that existing MET criteria be reviewed, in efforts to encourage an earlier patient review. Also that a simulation education program is designed to facilitate both the clinical and contextual attributes required to identify earlier indicators of deterioration and the triggering of an appropriate response.

Background: Contemporary research into human factors has identified that when health professionals recognise their potential for error, develop systems and strategies to learn from mistakes, the subsequent effects will be minimised (Degos, Amalberti, Bacou, Cartlet, & Bruneau, 2009; Donchin, et al., 2003; Henriksen, Dayton, Keyes, Carayon, & Hughes, 2010; Martinez, et al., 2010; Spiess & Nussmeier, 2010). Developing human factor theory in health care has built on work from other high risk industries, such as aviation, and is now focussed on non technical (cognitive and social) skills that may contribute to accidents and error (Fletcher, McGeorge, Flin, Glavin, & Maran, 2002; Flin & Patey, 2009; Mitchell & Flin, 2008; Yule, et al., 2008). While there has been emerging research that examines the human factor phenomenon in clinical settings, and simulation, there are currently no studies that examine the impact of introducing these principles in an undergraduate nursing cohort.

Methods: A quasi experimental design was used. Thirty participants were conveniently recruited from a total sample of 170 third year nursing students. Volunteer participants were then divided into two distinct groups. Fifteen were purposively allocated to the experimental group, the remaining fourteen participants were allocated to the control group. One student withdrew from the study following the first episode of simulation. All 170 students were exposed to three episodes of simulation (two actively participating, one observing) focussing on a case of a deteriorating patient who progressed to cardiac or respiratory arrest. All students participated in pre brief and de brief of simulation sessions. Lectures delivered relevant theoretical content relating to course objectives with the addition of one that introduced the principles of human factors. 

The research participants followed the same process of students indicated above. The experimental group were provided further education in the form of one tutorial session exploring the specific features of human factors. The focus of these sessions related to non technical skills such as situation awareness, decision making, task management, communication, teamwork, and leadership. In addition all participants from the six groups (3 control and 3 experimental) took part in semi-structured focus group interviews to solicit their opinions related to the meaning of human factors, the contribution of human factors on their performance in the simulation session, and the impact on decision making and clinical performance. The first focus group session took place following the first simulation exercise and before the scheduled lecture on human factors. The second focus group interview was scheduled following the last simulation experience and following the intervention of the additional tutorial for the experimental group.

Results: Results have shown that introducing principles of human factors to undergraduate nurses, impacted on student self reported perceptions of non technical skills. Prior to exposure to human factor principles, both the experimental and control groups expressed notions that human factors were features of their own personality, knowledge, feelings and attitudes that affected their performance and actions in the simulation. Many participants also reported "being aware of your environment", "teamwork" and "good communication." Conversely following the human factors lecture, both the control and experimental groups reported an increased awareness of their impact on others, with communication and teamwork becoming a predominant feature. Of interest, during comparative analysis of the final focus groups, the experimental group, while sharing similar notions of teamwork and communication, also verbalised a clear link between human factors and the potential for error.

Conclusions: The results of this pilot study will contribute to debate regarding the relevance of introducing undergraduate nursing students to human factor principles. The intervention of the lecture material introducing human factors principles resulted in an increased awareness of impact on others in terms of communication and teamwork. Further tutorial work elicited even greater self awareness of individual features of human factors, and specifically linked these to the potential for error.

References: 

1. Degos, L., Amalberti, R., Bacou, J., Cartlet, J., & Bruneau, C. (2009). Breaking the mould in patient safety. British Medical Journal, 339, 82-85. 
2. Fletcher, G., McGeorge, P., Flin, R., Glavin, R., & Maran, N. (2002). The role of non-technical skills in anaesthesia: a review of current literature. British Journal of Anaesthesia, 88(3), 418-429. 
3. Flin, R., & Patey, R. (2009). Improving patient safety through training in non-technical skills. BMJ, 339(sep23_2), b3595-. 
4. Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2010). Understanding Adverse Events: A Human Factors Framework. In C. J. Huston (Ed.), Professional Issues in Nursing: Challenges & Opportunities (2nd ed.). Philadelphia: Wolters Kluwer / Lippincott Williams & Wilkins. 
5. Martinez, E. A., Marsteller, J. A., Thompson, D. A., Gurses, A. P., Goeschel, C. A., Lubomski, L. H., et al. (2010). The Society of Cardiovascular Anesthesiologists' FOCUS Initiaitve: Locating Errors Through Networked Surveillance (LENS) Project Vision. Anesthesia & Analgesia, 110(2), 302-311. 
6. Mitchell, L., & Flin, R. (2008). Non-technical skills of the operating theatre scrub nurse: literature review. Journal of advanced nursing, 63(1), 15-24. 
7. Spiess, B. D., & Nussmeier, N. A. (2010). Bring your life into FOCUS! Anesthesia & Analgesia, 110(2), 283-287. 
8. Yule, S., Flin, R., Maran, N., Rowley, D., Youngson, G., & Paterson-Brown, S. (2008). Surgeons' non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system. World journal of surgery, 32(4), 548-556.

Method: We fortified the pre-existing resident training and assessment program in Nov 2009 with simulator assisted learning. Each simulator crisis scenario was managed by a group of 2-3 residents with nurses experienced in simulator training. Another group of 2-3 residents observed and were tasked to feedback on the simulator management by their colleagues. This feedback and review session happened at the end of the scenario. Consultants supervised and steered this scenario including mannequin response, software control and provision of laboratory results, to create optimal realism. 

Results: The residents were very positive about their simulator assisted learning, with those who immersed themselves in the scenario being much more able to extract, reflect and evaluate their learning outcome more intensely and positively. The faculty also enjoyed this maiden experience though they admit there was plenty more to learn. They were keen to learn more. A big issue was the time, efforts, manpower and coordination needed to run this training program and to train the faculty too. 

Discussion: Simulator training can be a powerful teaching, learning tool especially if tailored and contextualized to the local training needs. Pivotal to the sustainability of our simulator program requires a multi-prongED and consistent approach to its planning, implementation, review and development in order to engender commitment to the program.

Background: Current difficulties associated with access to adequate quality clinical placements for undergraduate nursing students, along with the need to educate increasing numbers of health care professionals (Levett-Jones and Bourgeois, 2007), has provided a stimulus for increased government funding for simulation. This spending is further supported by both Australian and international studies, which have found that inadequate clinical reasoning and decision making by health professionals contributes to adverse patient outcomes (NSW Health, 2008; del Bueno, 2005). The Council of Australian Governments (COAG) has indicated that $96 million will be made available over the next four years for investment in clinical training in simulated learning environments. It is crucial that all institutions involved with the provision of the education and training to health professionals consider how this money can be best spent to provide quality education and thus best outcomes for patients. 

Method: Three stages of the group project are included in this poster presentation:

1. A cross sectional survey of Australian schools of nursing conducted in April- May 2009 to establish current usage of HPSM.
2. quasi-experimental study conducted April-September 2009 on the impact of medium and high fidelity HPSM use on undergraduate nursing students’ clinical reasoning
3. A Delphi study using a panel of international and Australian simulation experts, currently in progress, to establish indicators of quality use of HPSM. 

Results: The poster will present selected results from the above studies. Key points raised by the survey include the wide variations in physical resources available in different schools of nursing. At the time the survey was conducted 45% of nursing schools had access to a high fidelity manikin, and only 45% of schools using medium or high fidelity manikins had a specially designed laboratory for simulations. However, despite this, staffing issues were identified by participants as the greatest impediment to the integration of simulation into teaching curricula. Results from the quasi-experimental study indicated that there is no significant difference in students’ clinical reasoning with the use of medium or high fidelity manikins, given the learning objectives and scenarios that were utilised. This is supported by preliminary Delphi findings which emphasise the need for manikin selection and simulation design based on specified learning objectives, the impact of other aspects of fidelity apart from the technology level of the manikin, as well as the importance of adequate staffing and staff training to achieve curriculum integration and quality outcomes. 

Conclusion: Careful consideration of resource needs is crucial when funding simulation activities. Physical resources apart from the manikins, as well as adequate staffing to support simulation design, curriculum integration and ongoing conduct of simulation activities must be given due consideration in order to achieve quality outcomes. 

References:

1. del Bueno, D. (2005). A crisis in critical thinking. Nursing Education Perspectives, 26(5), 278-283.
2. Levett-Jones, T. and Bourgeois, S. (2007). The clinical placement: An essential guide for nursing students. Sydney: Elsevier. 
3. NSW Health. (2006). Patient safety and clinical quality program: Third report on incident management in the NSW Public Health System 2005-2006. Sydney: NSW Department of Health.

Background: Hollier Simulation Centre Heart of England Foundation NHS Trust teaching [Acute] hosts a Faculty of Education and a state of the art simulation centre ‘The Hollier Simulation Centre’. The simulation centre currently delivers medical education to 1400 FY1 and FY2 and undergraduate medical students. National Diploma The UK sector skills council for the health sector accredit a national diploma, ‘Society, Health and Development Diploma’ targeted at 14-19 years and identified an opportunity to design a programme to provide better progression routes into employment whilst developing personal learning and thinking skills which are fundamental to the students confidence and competence in the world of work. The diploma provides challenging academic study related to the sectors [health, social and justice] and enables students to progress to degree level qualification or career opportunities. 

The case for simulation in engaging tomorrow’s health workforce created an opportunity to develop a bespoke simulation programme targeted at a local community secondary school. In partnership with Bordesley Green Girls school, Hollier simulation centre hosted a simulation programme for 20 students, 15-16 year olds. This initiative was developed in collaboration with NHS Birmingham East and North Primary Care Trust [BENPCT] was designed to help the students meet key learning outcomes from the core dimensions of the diploma, in a simulated environment. 

Methods: A simulation programme was designed to utilise the high fidelity mannequin [METI iStan] typically used to recreate a highly realistic clinical scenarios for medical, nursing and allied health professionals. A simulation scenario was designed to incorporate the health typology model designed by BEN PCT, ‘segmentation model for addressing health inequalities by recognising and designing for the inherent differences that exist for individuals and communities’. For the scenario one of the health typologies for the school was pin pointed as Asthma and the scenario designed around this. The students spent a day in the Hollier Simulation Centre along with their teachers. The day was filled with experiences in simulated clinical situations where the students looked after a patient with Asthma supported by a nurse mentor. Full video and audio links enhanced the teaching capabilities by recording the simulation experience and provided live classroom streaming. The students were taught to adopt the ABCDE method of assessment and the day was punctuated by debriefings from experienced instructors supported by the video taped scenarios. 

Conclusion/Results: This simulation innovation provided the opportunity to apply skills and knowledge learnt within the diploma into a replicated clinical environment. The simulation programme created the opportunity for creative thinking, reflective learning and effective participation. Instilling the principle of communication and teamwork were central to the method of delivery.

Methods: First and second year residents participated in simulation education activities between March and October 2009. Each program was developed in collaboration between the academic institution and the industry partner. All programs were designed to maximize the advantages of a “Hospital Studio” that has realistic circumstances, a variety of currently available mannequins and/or novel hybrid simulators. Residents were surveyed at the end of the program, and scored their satisfaction levels on a 1 to 4 Likert scale (1=lowest, 4=highest). 

Results: A total of 365 residents and 46 trainers participated in a variety of programs. A total of 292 first-year residents participated in 18 individually designed programs. A total of 73 second-year residents from 20 institutions participated in programs including an advanced OCSE. Skill stations performed in the programs were categorized to include 56 stations for injection related procedures, 27 for basic and advanced emergency care, 2 devoted to the care of the pediatric patient, 12 for physical assessment, 2 for home healthcare and 18 others. At the end of the program, residents and trainers scored “assessment of content at 3.7 and 3.4, respectively. Scores for “assessment of feasibility” were 3.7 and 3.4; scores for “overall facility satisfaction” were 3.7 and 3.8; “wish to use the facility again” scored 3.4 and 3.8; “recommend to colleagues” scored 3.6 and 3.8. 

Conclusions: These educational activities demonstrate the success of a unique model for partnership between industry and academic medicine. Both residents and trainers who went through the programs reported a high level of satisfaction not only with the content of the programs, but also with the facility used. This model could provide the means for even small teaching hospitals to give their trainees the benefit of simulator-based educational programs.

Background: The idea of a Nursing Skills Centre of Excellence was first developed by Box Hill Institute’s CEO who had the opportunity to see a simulation centre in action while in Singapore. It was from this visit that the idea of developing a Nursing Skills Centre of Excellence was conceived. The journey has involved obtaining grants from the government for infrastructure and equipment and has seen the implementation of the Health and Wellness hub which also houses the Aveda Institute Melbourne at Box Hill Institute. As with all new ventures it is not just the infrastructure that is important. The personnel to make the concept become a reality are also vitally important. It was with this view that a Manager and a senior educator for the Nursing Skills Centre of Excellence were appointed. It was the main role of these people to develop a teaching and learning philosophy and pedagogy that was to be integrated into the nursing curriculum. Rather than embedding simulation into the curriculum an approach was taken to look at how and where the curriculum was applied around simulation activities. 

Methods: The aim for 2010 is for fifty percent of the program delivery will be undertaken using simulation. For this to occur there has been a large shift by the teachers from a traditional classroom lecture style teaching approach to one where the teachers feel empowered to try out and explore new ways of delivering the curriculum. This acceptance by the nursing teachers to embrace this new way of delivery has also itself been a journey. Through specialised training and education focusing on simulation, the nursing teachers are now exploring and developing ways in which simulation education is incorporated into their teaching practice on a daily basis. 

Conclusions: The Nursing Skills Centre of Excellence has taken a journey of immense proportions from its conception to inception. Without dedicated, passionate and highly motivated staff, this would not have come to fruition. Our next stage of development is the incorporation of simulation into other Health and Community Services programs such as children’s services.

Background: We recognised that there were hundreds of pieces of simulation equipment purchased and distributed around the State without a distribution model which correlated equipment usage, repairs, maintenance and current locations with the local contact. 

With demand increasing for the use of simulation equipment in districts, the implementation of a tracking system to provide data on equipment usage based on hours of training, the time it takes and the cost of parts for repairs and/or preventative maintenances became crucial to support distribution approval and provide a service to the districts. 

Prior to the equipment management and tracking system there was no actual data to confirm exactly how many types i.e. mannequins, part task trainers etc of equipment we had including the purchasing history and their exact locations. We were also unsure of the running costs of equipment including the cost to repair and unable to analyse equipment usage data to assess the need to increase purchases. 

Methods: A working group was assigned based on staff portfolios and worked towards an implementation deadline of 12 months. There was a need to review current possible locations and conduct a stock count for confirmation in areas State-wide based on historical purchasing data. Equipment owned by our institution was assigned barcodes to identify each piece individually and ensure accuracy. 

Individual equipment information was entered into the asset management database which incorporated tables to include financial history, repairs, maintenance, usage and ability to update the location as it changed. The implementation of usage and repair/work order forms provided officers State-wide to complete and submit manually or online for the action of those with the specific portfolios. 

We tested the database before implementation to ensure the system was accurate, relevant and captured the correct data. Communication to users throughout the State was done verbally and electronically informing users of the process to follow. 

Results: Based on the information captured in the asset management database reports are generated periodically on the usage by location to review and query a noticeable decrease in equipment usage, the request for repairs and maintenance to support budget forecasting and other reports required intermittently such as the quantity of equipment at current locations, the usage based on a certain type of equipment and ad-hoc report generation. 

Conclusions: Our institution can now generate measurable data to support future purchasing and distribution of equipment enabling the Centre to provide a service at a State-wide level to support simulation based training efficiently. 

References:

1. "A New Database on Physical Capital Stock: Sources, Methodology and Results" Nehru, V. & Dhareshwar, A (1993) 
2. "The Info Industry Growth Accounting Database - CESifo Working paper no. 1915" Roehn, O., Eicher, T. & Strobel, T (2007)

Background: Sydney Clinical Skills and Simulation Centre (SCSSC) runs various paediatric simulation courses, serving the Greater Sydney Metropolitan area. A need was recognised for wider dissemination of this training, to enhance the quality of children’s healthcare state-wide. With NSW’s area, the difficulty for health workers from remote regions travelling to Sydney has limited their access to this training. Mobile simulation provides a solution. The Greater Eastern and Southern Child Health Network (GESCHN) collaborated with SCSSC to develop a suitable program. 

Methods: 

• Needs Analysis: Conducted by the director of SCSSC, the director of Sydney Children’s Hospital (SCH) Emergency Department, rural and local stakeholders, and GESCHN representatives, with reference to available courses (PLS, APLS, ARC). 
• Format Development: Multiple previously trialed formats were considered- multi-day, single-day, half-day and 90 minute. 
• Curriculum Development: Focus included common and poorly managed conditions. 
• Site Selection: Population, target group presence, and hospital site availability/suitability were considered. 
• Pilot Implementation: Mona Vale Hospital- three 3.5 hour modules were delivered over two days, recruiting three local staff members as faculty, enrolling 31 participants. 
• Pilot Assessment: Participants questionnaires collected with Likert and free text elements. Appraisal of pilot completed by SCSSC instructors post-implementation. 
• Financial Sustainability Assessment: Discussion between SCSSC and GESCHEN 

Results: 

• Needs Analysis: Garling identification of need for training in management of acutely unwell children. Rural Doctor’s association statement of need for training infrastructure to support and retain rural staff. Under-utilisation of simulation by rural staff- multiple reasons. Underdeveloped current training strategies. Need to decentralise simulation and increase pool of instructors. Need for easily assimilated training for new instructors 
• Format Development: 3.5 hour stand alone and integratable modules chosen for utility, flexibility, and equity of access. 
• Curriculum Development: Three workshops: the deteriorating child, the child with trauma, and with respiratory problems. 
• Site Selection: Mona Vale, Nowra, Camden and Cantebury Hospitals were chosen after site review and discussion with local staff. 
• Assessment of Pilot: Education needs met in 94% of participants, and subjective improvement in human factors and management of presented medical conditions in 100% of participants. 
• Financial Sustainability Assessment: GESCHEN funding secured for program development and pilot implementation. Further funds allocated on recognition of program’s value. Yearly funding expected to be allocated. Small participant fees provided minimal revenue stream. Wider need and applicability recognised. 

Discussion / Future Directions: Distribution of pre-course reading material/references will allow increased immersive scenario and debrief time. Modules can be tailored to the target hospital/participant skill mix. Adaptation of this program is possible to suit wide range of situations including tertiary centres. Rural and urban development is required to improve sustainability. Local instructor training increases the likelihood of program survival and propagation.

Conclusions: This program successfully increases rural access to simulation training. Subjective participant satisfaction and improvement is high but objective improvement in paediatric healthcare is difficult to assess. 

References:

1. Advanced Paediatric Life Support manual, Fourth Edition, K. Mackway-Jones et al, Blackwell Publishing
2. NSW Health Clinical Practice Guidelines, 2006-2009, NSW Department of Health 3. Institute of Trauma and Injury Management Guidelines, 2008-2009, NSW Department of Health

Background: In 2009 the Medical Education unit was approached about assisting in developing a simulated training method for a cardiac surgeon to refine skills associated with endoscopic radial artery harvesting. This was in preparation for the first procedure to be conducted in Australia. 

Methods: Discussion regarding the conduct of the procedure in order to gain an insight as to what would be the most appropriate methodology. As a result a beef shin was selected and various lengths of cuts were experimented with. The endoscopic radial artery harvesting procedure was conducted a number of times utilising the various lengths in order to ascertain what was of greatest fidelity. Following this the procedure was repeatedly performed leading up to the Australian first harvesting. 

Results: A number of individual training sessions occurred specifically for the cardiac surgeon involved leading up to the first Australian procedure. Following on from this registrars within the hospital have been trained utilising the same methodology and a state wide training session has been conducted in February 2010 including 24 participants. From these sessions further areas of development have been identified and will be incorporated into future simulated training programs. 

Conclusions: Utilising beef shins as a simulated specimen provides an appropriate level of fidelity for training for endoscopic radial artery harvesting, allowing participants to learn and refine skills associated with the procedure that may not be possible on commercially purchased part task trainers.

Background: Environmental, equipment and psychological fidelity all contribute to the ability of participants to suspend disbelief. (1) Situating a learning experience within the clinical workplace utilising equipment, staff and procedures can help to maximise the transfer of learned behaviours. Vital signs monitoring used in simulated learning environments however typically relies upon proprietary equipment supplied by simulator manufacturers. 

Whilst the information provided by these devices approximates that used in the clinical setting, qualitative differences exist between these proprietary devices and actual medical monitors in at least three areas:

1. the order and range of vital signs and clinical information displayed,
2. the operation of the device,
3. the physical appearance of the monitor. 

Psychological fidelity is likely to be increased with the use of the actual clinical monitor and not a simulated substitute. 

Methods: The vital signs monitoring requirements extend to both the visual and aural modalities. In this particular case, a laptop running the 3G SimMan software was used to generate the vital signs information. This visual information was conveyed from the laptop via a VGA cable to the VGA port on the Datex monitor attached to the anaesthetic machine. The laptop display was then configured to 'extended desktop' mode through the Windows XP operating system to facilitate the display of simulated parameters, such as ECG, SPO2, NIBP, and percentage of inhaled and end-tidal anaesthetic agent. The aural component, namely the QRS beeps and alarm tones, was provided via an audio extension cable from the headphone output of the laptop to a stand-alone speaker located behind the anaesthetic machine. 

Results: The simple methodology used resulted in a monitor which displayed the 3G software-generated vital signs and clinical information via a familiar modality to the scenario participants. Extended-length cabling allowed the scenario director and simulation technician to be located in a side room and thus out of sight of the trainees. Both of these interventions allowed the participants to treat the "patient" in their own environment using their own equipment, including monitoring system. 

Conclusions: Increasing environmental and psychological fidelity, know to be important in transfer of learning, is possible through the use of in-situ monitoring systems. The methodology described here is likely to be easily adaptable to the monitoring systems used in critical care areas like intensive care units, operating theatres and emergency departments, provided they have a VGA input port. 

References:

1. Beaubien, JM and Baker, DP. (2004). The use of simulation for training teamwork skills in health care: how low can you go? Quality and Safety in Health Care; 13(suppl 1):i51-i56.

Background: Students and residents learn surgical skills in a number of environments, but the optimal role of each is not yet defined. Trainees should have a certain level of skill prior to animal laboratory experience. 

Methods: Ex-vivo animal tissue was obtained from animals used for other purposes. 

Students: In two separate years, senior medical students (N=56) received a series of lectures and dry lab training in gastrointestinal anastomoses. Students were randomized into a dry lab only (DL, N=29) group and a group that also used ex-vivo tissue (EXV, N=27). Both groups then performed animal surgery. Performance was measured by global scores and task scores evaluated by two faculty raters as well as self-assessment. 

Residents: Surgery residents (N=5) underwent training with ex-vivo tissue for gastrointestinal and vascular surgery followed by an animal laboratory and a self-assessment tool. 

Results: 

Students: Task scores were similar for both groups (DL 95.7±17.5, EXV 92.5±21.0, p>.05) as well as global rating scores (DL 31.3±5.6, EXV 30.4±6.8, p>.05). EXV students judged dry lab training as significantly less useful (p<.05) than DL students. EXV students felt significantly more confident (p<.05) than DL students to perform the animal laboratory. 

Residents: Of the 5 residents, 0/5 (0%) had performed gastrointestinal or vascular surgery on patients. All 5 residents (100%) felt that the EXV training was a valuable experience prior to animal surgery. 

Conclusions: These data demonstrate that ex-vivo tissue provides a valuable way to practice surgical skills at both student and resident levels and helps respect the 3R principle of animal ethics. Animal laboratories remain an important method of teaching certain surgical skills. Future research will further define the optimal role of ex-vivo tissue simulation in the surgical curriculum. 

References: 

1. Hishikawa S, Kawano M, Tanaka H, Konno K, Yasuda Y, Kawano R, Kobayashi E and Lefor AT. Simulation improves operator confidence but not performance of tube thoracostomy by medical students in a porcine model: A prospective controlled trial. The American Surgeon. 2010; 76:73-8. 
2. Bass BL. Fundamental changes in general surgery residency training. The American Surgeon, 73:109-113 (2007). 
3. Sutherland LM, Middleton PF, Anthony A et al. Surgical simulation: A systematic review. Ann Surg. 243:291-300 (2006).

Method: 52 medical students were randomised to receive instruction in laparoscopic (intracorporeal) suturing technique in a training box using either a cognitive method (utilizes explicit teaching methods to form mental template of the process) or directed training (the more traditional method). No students had previously used such training aids nor been instructed on laparoscopic surgical techniques. 1 student failed to complete a single suture after 90 minutes and elected to withdraw from the study - he was from the directed learning group. 

Students were randomised to the 2 study groups (26 to cognitive group, 25 to directed group) and were asked to watch a short video demonstrating the suture required with verbal descriptive cues for performance. Students were then taught using the appropriate method how to tie a single intracorporeal suture in a 20 minute supervised teaching session (maximal student to teacher ratio of 3:1). Videos were recorded of performance of 1st suture at this session, a distracted test and a final undistracted test. The knots were strength tested and the videos assessed for performance quality. 

Results: The 2 groups were quite similar with the exception of female predominance in the cognitive learning group (n=17/25 compared to 10/26) - age, hand dominance, year of medical school, age and suturing experience were equally distributed. There was no statistically significant difference between the 2 groups when times taken to perform the task or strength of the suture generated were compared. 

Conclusions: There is no demonstrated difference between students taught using a cognitive vs directed teaching method.

Aims: To evaluate the airways in the SimMan, iStan and Trucorp AirSim Advanced for the insertion of 6 different types of LMAs. 

Method: 20-30 consultant and special registrar anaesthetists experienced in LMA insertion will be asked to insert a Classic, Proseal, Unique, iGel, Supreme and Solus LMA in each manikin. Order of LMA insertion will be randomised. Ease of insertion, correctness of position and fit will be rate by each subject. LMA function will be assessed by chest movement and effectiveness of the seal by measuring carbon dioxide levels. In addition each subject will be asked for their subjective impression of the manikins’ airways for LMA insertion. 

Results: Subjects have been recruited and results will be available by the end of April.