Using machine learning to identify quality-of-care predictors for emergency caesarean sections: a retrospective cohort study.

OBJECTIVES: Emergency caesarean sections (ECS) are time-sensitive procedures. Multiple factors may affect team efficiency but their relative importance remains unknown. This study aimed to identify the most important predictors contributing to quality of care during ECS in terms of the arrival-to-delivery interval. DESIGN: A retrospective cohort study. ECS were classified by urgency using emergency categories one/two and three (delivery within 30 and 60 min). In total, 92 predictor variables were included in the analysis and grouped as follows: 'Maternal objective', 'Maternal psychological', 'Fetal factors', 'ECS Indication', 'Emergency category', 'Type of anaesthesia', 'Team member qualifications and experience' and 'Procedural'. Data was analysed with a linear regression model using elastic net regularisation and jackknife technique to improve generalisability. The relative influence of the predictors, percentage significant predictor weight (PSPW) was calculated for each predictor to visualise the main determinants of arrival-to-delivery interval. SETTING AND PARTICIPANTS: Patient records for mothers undergoing ECS between 2010 and 2017, Nordsjællands Hospital, Capital Region of Denmark. PRIMARY OUTCOME MEASURES: Arrival-to-delivery interval during ECS. RESULTS: Data was obtained from 2409 patient records for women undergoing ECS. The group of predictors representing 'Team member qualifications and experience' was the most important predictor of arrival-to-delivery interval in all ECS emergency categories (PSPW 25.9% for ECS category one/two; PSPW 35.5% for ECS category three). In ECS category one/two the 'Indication for ECS' was the second most important predictor group (PSPW 24.9%). In ECS category three, the second most important predictor group was 'Maternal objective predictors' (PSPW 24.2%). CONCLUSION: This study provides empirical evidence for the importance of team member qualifications and experience relative to other predictors of arrival-to-delivery during ECS. Machine learning provides a promising method for expanding our current knowledge about the relative importance of different factors in predicting outcomes of complex obstetric events.

The concept of errors in medical education: a scoping review.

The purpose of this scoping review was to explore how errors are conceptualized in medical education contexts by examining different error perspectives and practices. This review used a scoping methodology with a systematic search strategy to identify relevant studies, written in English, and published before January 2021. Four medical education journals (Medical Education, Advances in Health Science Education, Medical Teacher, and Academic Medicine) and four clinical journals (Journal of the American Medical Association, Journal of General Internal Medicine, Annals of Surgery, and British Medical Journal) were purposively selected. Data extraction was charted according to a data collection form. Of 1505 screened studies, 79 studies were included. Three overarching perspectives were identified: 'understanding errors') (n = 31), 'avoiding errors' (n = 25), 'learning from errors' (n = 23). Studies that aimed at'understanding errors' used qualitative methods (19/31, 61.3%) and took place in the clinical setting (19/31, 61.3%), whereas studies that aimed at 'avoiding errors' and 'learning from errors' used quantitative methods ('avoiding errors': 20/25, 80%, and 'learning from errors': 16/23, 69.6%, p = 0.007) and took place in pre-clinical (14/25, 56%) and simulated settings (10/23, 43.5%), respectively (p < 0.001). The three perspectives differed significantly in terms of inclusion of educational theory: 'Understanding errors' studies 16.1% (5/31),'avoiding errors' studies 48% (12/25), and 'learning from errors' studies 73.9% (17/23), p < 0.001. Errors in medical education and clinical practice are defined differently, which makes comparisons difficult. A uniform understanding is not necessarily a goal but improving transparency and clarity of how errors are currently conceptualized may improve our understanding of when, why, and how to use and learn from errors in the future.

[Portfolio - a tool for making learning and competence development visible]. / Portföljen synliggör lärandet och kompetensutvecklingen.

Portfolio used in education can be defined as a collection of documentation of performed learning activities, feedback, and progress. Currently, the documentation is electronic, hence the term e-portfolio is used. The portfolio must have a clear purpose and be aligned with the learning outcomes of the program. To be successfully implemented a portfolio must be an integral part of the education with defined tasks for both the students and the teachers. Students and teacher support in how to use the portfolio is essential especially in the beginning of the program. Learning analytics enables teachers to identify and develop support for students at risk of not achieving the outcomes.

Wow, woo, win"- Healthcare students' and facilitators' experiences of interprofessional simulation in three-dimensional virtual world: A qualitative evaluation study.

BACKGROUND: In an age disrupted by COVID-19 pandemic, three-dimensional virtual world (3DVW) offers an opportunity for healthcare students from different higher education institutions to participate in interprofessional education. Despite its growing evidence, there is a need to unravel the complex learning process in order to ensure high quality of interprofessional education delivery. AIM: This study aimed to explore the experiences of healthcare students and facilitators on the use of 3DVW for interprofessional team-based virtual simulation. METHODS: Interprofessional teams, each comprising six different healthcare students (Medicine, Nursing, Pharmacy, Physiotherapy, Occupational Therapy, and Medical Social Work) and two clinicians who acted as facilitators, logged into the 3DVW from their own remote locations to participate in team-based care delivery that included an interprofessional bedside round and a family conference. A qualitative descriptive study was conducted on a purposive sample of 30 healthcare students and 12 facilitators using focus group discussions and individual interviews. RESULTS: Four themes emerged from their experiences: the "wow experience", authentic experience on collaborative care, ease of learning, and preeminent role of the facilitator. The simulation provided the "wow" experiences through contextual, collaborative and experiential learning approaches. Despite technical challenges, the participants were wooed by the comforts of learning from home and the psychological safety in virtual environment. The facilitators played a critical role in optimizing learning engagement to win learners over. CONCLUSION: Our study explicates how attention to the "wow, woo and win" trilateral factors can transform the interprofessional learning experiences offered by 3DVW simulation. Future developments in the use of this learning technology should include developing the clinicians' facilitation skills and the provision of technical support to make this 3DVW a success calls in winning students' learning engagement.

How supervision and educational supports impact medical students' preparation for future learning of endotracheal intubation skills: a non-inferiority experimental trial.

BACKGROUND: Professional education cannot keep pace with the rapid advancements of knowledge in today's society. But it can develop professionals who can. 'Preparation for future learning' (PFL) has been conceptualized as a form of transfer whereby learners use their previous knowledge to learn about and adaptively solve new problems. Improved PFL outcomes have been linked to instructional approaches targeting learning mechanisms similar to those associated with successful self-regulated learning (SRL). We expected training that includes evidence-based SRL-supports would be non-inferior to training with direct supervision using the outcomes of a 'near transfer' test, and a PFL assessment of simulated endotracheal intubation skills. METHOD: This study took place at the University of Toronto from October 2014 to August 2015. We randomized medical students and residents (n = 54) into three groups: Unsupervised, Supported; Supervised, Supported; and Unsupervised, Unsupported. Two raters scored participants' test performances using a Global Rating Scale with strong validity evidence. We analyzed participants' near transfer and PFL outcomes using two separate mixed effects ANCOVAs. RESULTS: For the Unsupervised, Supported group versus the Supervised, Supported group, we found that the difference in mean scores was 0.20, with a 95% Confidence Interval (CI) of - 0.17 to 0.57, on the near transfer test, and was 0.09, with a 95% CI of - 0.28 to 0.46, on the PFL assessment. Neither mean score nor their 95% CIs exceeded the non-inferiority margin of 0.60 units. Compared to the two Supported groups, the Unsupervised, Unsupported group was non-inferior on the near transfer test (differences in mean scores were 0.02 and - 0.22). On the PFL assessment, however, the differences in mean scores were 0.38 and 0.29, and both 95% CIs crossed the non-inferiority margin. CONCLUSIONS: Training with SRL-supports was non-inferior to training with a supervisor. Both interventions appeared to impact PFL assessment outcomes positively, yet inconclusively when compared to the Unsupervised and Unsupported group, By contrast, the Unsupervised, Supported group did not score well on the near transfer test. Based on the observed sensitivity of the PFL assessment, we recommend researchers continue to study how such assessments may measure learners' SRL outcomes  during structured learning experiences.

"It was great to break down the walls between patient and provider": liminality in a co-produced advisory course for psychiatry residents.

Although rhetoric abounds about the importance of patient-, person- and relationship-centered approaches to health care, little is known about how to address the problem of dehumanization through medical and health professions education. One promising but under-theorized strategy is to co-produce education in collaboration with health service users. To this end, we co-produced a longitudinal course in psychiatry that paired people with lived experience of mental health challenges as advisors to fourth-year psychiatry residents at the University of Toronto. The goal of this study was to examine this novel, relationship-based course in order to understand co-produced health professions education more broadly. Using qualitative interviews with residents and advisors after the first iteration of the course, we explored how participants made meaning of the course and of what learning, if any, occurred, for whom and how. We found that the anthropological theory of liminality allowed us to understand participants' complex experiences and illuminated how this type of pedagogy may work to achieve its effects. Liminality also helped us understand why some participants resisted the course, and how we could more carefully think about co-produced, humanistic education and transformative learning.

The myth of ivory tower versus practice-oriented research: A systematic review of randomised studies in medical education.

CONTEXT: A long-standing myth in medical education research is a divide between two different poles: research aiming to advance theory with little focus on practical applications ('ivory tower' research) and practically oriented research aiming to serve educators and decision-makers with little focus on advancing theory ('in-the-trenches' practice). We explored this myth in a sample of randomised medical education studies using Stokes' four-quadrant framework for the classification of research perspective. METHODS: We searched MEDLINE, Embase, CINAHL, PsychINFO, ERIC, Web of Science and Scopus for studies in medical education using a randomised design that were published between 1 January 2018 and 31 December 2018. We used Stokes' four-quadrant framework to categorise the studies according to their use of theory, concepts and their justification for practical use. We compared medical education research published in medical education journals and clinical journals. RESULTS: A total of 150 randomised studies were included in the analysis. The largest segment of studies (46.7%) was categorised as use-inspired basic research (Pasteur's Quadrant), closely followed by pure applied research (40.7%, Edison's Quadrant). Only a few studies were categorised as aiming to advance knowledge with no thought for practical educational application (2.0%, Bohr's Quadrant). The proportion of studies that included educational concepts and theory differed according to publication in clinical journals or medical education journals: 40.5% vs 71.8%, respectively, P < .001. There were no differences between journals with regard to the proportion of studies that included a practical educational or clinical rationale (P = .99). CONCLUSION: In a large sample of studies using randomised designs, we found no evidence to support the myth that medical education research divides between two singular poles represented by 'ivory tower research' and 'in-the-trenches practice'. We did confirm prevailing assumptions regarding an emphasis on non-theoretical medical education research in clinical journals.

Video cases as tricksters, in medical students´ transition to psychiatric clerkship. A liminal perspective.

This article was migrated. The article was marked as recommended. OBJECTIVE: This study introduced a lens of liminal theory, drawn from anthropological classical ritual theory, to explore how a preparatory teaching format using video casesinfluenced medical students' patient approaches in their subsequent psychiatric clerkship. The video cases portrayed simulated patient-doctor encounters in diagnostic interview situations and were hypothesized to function as a liminal trickster. METHODS: The study applied a qualitative explorative design using individual rich picture interviews. We asked the students to draw their experiences, which we investigated using a semi-structured interview guide designed to capture and unfold the students' perspectives. We explored how students navigated insights from the preparatory teaching in their clerkship using liminal theory concepts in a mixed inductive and deductive thematic analysis. RESULTS: The results from 8 rich picture interviews demonstrated that students' ability to navigate insight gained from the video cases in their clerkship varied according to their roles in the clinical diagnostic interview situations. Students having active roles in the diagnostic interview situation adopted a patient-centred focus demonstrating empathic engagement and self-reflexivity related to their learning experiences with the video cases. Students with passive roles described a focus on how to adopt an appropriate appearance and copied the behaviour of the simulated doctors in the video cases. CONCLUSION: The liminal ritual theory perspective to explore the influence of preparatory teaching was useful for demonstrating how video cases could affect students' patient-centred learning. Without guidance and active roles in clerkship, medical students' learning experiences may lead to a prolonged liminal phase and may not capitalise on the potentially positive effects of the preparatory teaching. Liminal theory may further inform our understanding of students' learning considering patient cases in educational technology arrangements as tricksters.

Prehospital emergency nurses' experiences of care in critical incidents.

INTRODUCTION: The ambulance care setting is complex and unpredictable and the personnel must prepare for upcoming assignments. Prehospital emergency care nurses (PENs), are frequently exposed to critical incidents (CIs). There are, to our knowledge, no prior studies describing experiences of requirements for management of caring for a patient during a CI in the ambulance care context. Therefore, the aim of the study was to explore PENs' experiences of care in CIs. METHOD: A qualitative research design with content analysis has been used, based on semi-structured interviews with eleven PENs in Sweden. RESULTS: PENs' experiences can be described as: "In a critical incident, personal ability based on experiential knowledge is central to patient care". Three generic categories underpinned the main category: "Clinical expertise", "Professional approach" and "Broad knowledge base". CONCLUSIONS: The care given during a CI in the ambulance care setting depends on PENs' personal ability based on experiential knowledge. Employers need to build an organization providing prerequisites and support during an CI. Suggested activities are to create forums for PENs to share experiences with each other, possibility to get feedback on completed assignments and continued training to develop new knowledge and be prepared for the unpredictable environment that characterizes CI.

Social ties influence teamwork when managing clinical emergencies.

BACKGROUND: Our current understanding of medical team competence is traditionally influenced by an individualistic perspective focusing on individual team members' knowledge, skills as well as on effective communication within the team. However, team dynamics may influence team performance more than previously anticipated. In particular, recent studies in other academic disciplines suggest that social ties between team members may impact team dynamics but this has not been explored for medical teams. We aimed to explore intensive care staff's perceptions about teamwork and performance in clinical emergencies focusing particularly on the teams' social ties. METHODS: Semi-structured interviews were conducted with a purposive sample of intensive care staff. We used a thematic analysis approach to data interpretation. RESULTS: Thematic saturation was achieved after three group interviews and eight individual interviews. Findings demonstrated that social ties influenced teamwork by affecting the teams' ability to co-construct knowledge, coordinate tasks, the need for hierarchy, the degree to which they relied on explicit or implicit communication, as well as their ability to promote adaptive behavior. CONCLUSIONS: Social ties may be an important factor to consider and acknowledge in the design of future team training, as well as for work planning and scheduling of team activities during clinical practice. More research is needed into the causal effect of social ties on team performance and outcome.

Correction to: "Getting Everyone on the Same Page": Interprofessional Team Training to Develop Shared Mental Models on Interprofessional Rounds.

This capsule commentary, Capsule Commentary on Liaw et al., "Getting everyone on the same page": interprofessional team training to develop shared mental models on interprofessional rounds," was to have accompanied the article, DOI: https://doi.org/10.1007/s11606-019-05320-z, which appeared in the December 2019 issue.

Making the best of the worst: Care quality during emergency cesarean sections.

OBJECTIVE: This study aimed to identify factors influencing mothers' and their partners' perceptions of care quality, and to identify associated clinical factors. METHODS: Questionnaires were developed based on eight interviews with couples after emergency Cesarean Sections (ECS). The internal structure of the questionnaires was examined using Rasch analysis. Cronbach's alpha was calculated to evaluate internal consistency of questionnaire items. Finally, associations between questionnaire scores and ECS characteristics were determined. RESULTS: Thematic analysis of interview data demonstrated that team-dynamics, professionalism, information, safety, leadership and mother-child continuity of care are important to patient- perceived quality of care. Questionnaire responses from 119 women and 95 partners were included in the validation and demonstrated satisfying fit to the Rasch model. The questionnaires had acceptable internal consistency with Cronbach's alpha 0.8 and 0.7 for mothers and partners, respectively. Perceived quality of care was negatively associated with increasing urgency of the CS. Spearman rank correlation coefficients were -0.34 (p <0.001) and -0.32 (p = 0.004) for mothers and partners, respectively. Perceived quality of care differed significantly across CS indications for both mothers (p = 0.0006) and their partners (p<0.0001). CONCLUSION: Team-dynamics, professionalism, information, safety, leadership and mother-child-continuity affect patients' perceptions of care. Perceptions of care were highly influenced by CS indications and urgency.

Co-producing Psychiatric Education with Service User Educators: a Collective Autobiographical Case Study of the Meaning, Ethics, and Importance of Payment.

OBJECTIVE: Co-production involves service providers and service users collaborating to design and deliver services together and is gaining attention as a means to improve provision of care. Aiming to extend this model to an educational context, the authors assembled a diverse group to develop co-produced education for psychiatry residents and medical students at the University of Toronto over several years. The authors describe the dynamics involved in co-producing psychiatric education as experienced in their work. METHODS: A collaborative autobiographical case study approach provides a snapshot of the collective experiences of working to write a manuscript about paying service users for their contributions to co-produced education. Data were collected from two in-person meetings, personal communications, emails, and online comments to capture the fullest possible range of perspectives from the group about payment. RESULTS: The juxtaposition of the vision for an inclusive process against the budgetary constraints that the authors faced led them to reflect deeply on the many meanings of paying service user educators for their contributions to academic initiatives. These reflections revealed that payment had implications at personal, organizational, and social levels. CONCLUSION: Paying mental health service user educators for their contributions is an ethical imperative for the authors. However, unless payment is accompanied by other forms of demonstrating respect, it aligns with organizational structures and practices, and it is connected to a larger goal of achieving social justice, the role of service users as legitimate knowers and educators and ultimately their impact on learners will be limited.

Social ties between team members affect patient satisfaction: a data-driven approach to handling complex network analyses.

Research from outside the medical field suggests that social ties between team-members influence knowledge sharing, improve coordination, and facilitate task completion. However, the relative importance of social ties among team-members for patient satisfaction remains unknown. In this study, we explored the association between social ties within emergency teams performing simulated caesarean sections (CS) and patient-actor satisfaction. Two hundred seventy-two participants were allocated to 33 teams performing two emergency CSs in a simulated setting. We collected data on social ties between team-members, measured as affective, personal and professional ties. Ties were rated on 5-point Likert scales. In addition, participants' clinical experience, demographic data and their knowledge about team members' roles were surveyed. Perceived patient satisfaction was measured on a 5-point Likert scale. Data was analysed with a linear regression model using elastic net regularization. In total, 109 predictor variables were analysed including 84 related to social ties and 25 related to clinical experience, demographics and knowledge test scores. Of the 84 variables reflecting social ties, 34 (41%) had significant association with patient satisfaction, p < 0.01. By contrast, a significant association with patient satisfaction was found for only one (4%) of the 25 variables reflecting clinical experience, demographics and knowledge of team roles. Affective ties and personal ties were found to be far more important predictors in the statistical model than professional ties and predictors relating to clinical experience. Social ties between emergency team members may be important predictors of patient satisfaction. The results from this study help to enhance our conceptual understanding of social ties and their implications for team-dynamics. Our study challenges existing views of team-performance by placing emphasis on achieving collective competence through affective and personal social ties, rather than focusing on traditional measures of expertise.

Evaluating the effectiveness of video cases to improve patient-centeredness in psychiatry: a quasi-experimental study.

OBJECTIVES: To evaluate the effectiveness of including interactive video-based patient cases in preparatory lectures on medical students' patient-centredness and attitudes towards psychiatry. METHODS: This study was designed as a quasi-experimental intervention study. A preparatory lecture on diagnostic interviewing was given to 204 fourth-year medical students before a 4-week psychiatry clerkship. The students were divided into two groups. One group (n=102) received a preparatory lecture including an interactive video case portraying a doctor performing a diagnostic interview with a simulated patient (intervention group). The other group (n=102) received a conventional preparatory lecture using text-based instructional material (control group). We conducted a paired sample t-test to compare the students' confidence in exhibiting patient-centred communication and their attitudes towards psychiatry before receiving the preparatory lecture and after having completed a minimum of three weeks of clerkship training. RESULTS: A total of 102 students, 51 in each group, completed a questionnaire at both measurement points. In the intervention group, we found a statistically significantly difference for the students' patient-centredness before (M=69.4, SD=10.0) and after (M=73.8, SD=8.6) the intervention t(97)=2.38, p= 0.02, but no changes in attitudes t(98) =1.07, p=0.28. In the control group, we found no changes in patient-centredness or attitudes. CONCLUSIONS: Video cases in preparatory lectures appear to be better than text-based material at improving students' patient-centredness in psychiatry. However, neither video cases nor text-based material seem to influence the students' attitudes.

"Getting Everyone on the Same Page": Interprofessional Team Training to Develop Shared Mental Models on Interprofessional Rounds.

AIM: This study aimed to evaluate the effect of a team training program to support shared mental model (SMM) development in interprofessional rounds. DESIGN AND PARTICIPANTS: A three-arm randomized controlled trial study was conducted for interprofessional teams of 207 health profession learners who were randomized into three groups. PROGRAM DESCRIPTION: The full team training program included a didactic training part on cognitive tools and a virtual simulation to support clinical teamwork in interprofessional round. Group 1 was assigned to the full program, group 2 to the didactic part, and group 3 (control group) with no intervention. The main outcome measure was team performance in full scale simulation. Secondary outcome was interprofessional attitudes. PROGRAM EVALUATION: Teamwork performance and interprofessional attitude scores of the full intervention group were significantly higher (P < 0.05) than those of the control group. The two intervention groups had significantly higher (P < 0.05) attitude scores on interprofessional teamwork compared with the control group. DISCUSSION: Our study indicates the need of both cognitive tools and experiential learning modalities to foster SMM development for the delivery of optimal clinical teamwork performances. Given its scalability and practicality, we anticipate a greater role for virtual simulations to support interprofessional team training.

Common core content in education for nurses in ambulance care in Sweden, Finland and Belgium.

There is no consensus regarding the required education content and competence needed for professionals working in the emergency medical services and only a few countries in Europe staff ambulances with registered nurses. This study aimed to identify common core content in Swedish, Finnish and Belgian university curricula in the education on advanced level for registered nurses in ambulance care and to describe the teachers' perception of the necessary content for the profession as a registered nurse in ambulance care. A deductive research design was used. Three Universities, one from each country; Sweden, Finland and Belgium, participated. Data was generated from curricula and interviews with teachers and analyzed with different approaches of qualitative content analysis. The results showed commonness with respect to core content; the emphasis was mainly on medical knowledge but the content concerning contextual subjects differed between the three universities. The teachers, however, aimed for the students' to acquire a broad competence in clinical reasoning by implementing theory into practice, as well as developing the students' personal aptitude and instilling a scientific awareness. The results suggest that it is possible to create a common curriculum for training of RNs for working in ambulance care.

Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process.

OBJECTIVES: There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore initiated to define priorities in health care simulation that contribute the most to improve patient safety. METHODS: An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies for these problems. RESULTS: The expert group agreed on the following topics: technical skills, nontechnical skills, system probing, assessment, and effectiveness. For each topic, 5 patient safety problems were suggested that each topic might contribute to solve. Solutions to these problems and implementation strategies for these solutions were identified for technical skills, nontechnical skills, and system probing. In the case of assessment and effectiveness, the expert group found it difficult to suggest solutions and implementation strategies mainly because of lacking consensus on metrics and methodology. CONCLUSIONS: The expert group recommends that the 5 topics identified in this consensus process should be the main focus when health care simulation is implemented in patient safety curricula.

Do One Then See One: Sequencing Discovery Learning and Direct Instruction for Simulation-Based Technical Skills Training.

PURPOSE: When teaching technical skills, educators often include a mix of learner self-regulation and direct instruction. Appropriate sequencing of these activities-such as allowing learners a period of discovery learning prior to direct instruction-has been shown in other domains to improve transfer of learning. This study compared the efficacy of learners trying a novel simulated suturing task before formal instruction (Do then See) versus the more typical sequence of formal instruction, followed by practice (See then Do) on skill acquisition, retention, and transfer. METHOD: In 2015, first-year medical students (N = 36) were randomized into two groups to learn horizontal mattress suturing. The See then Do group had access to instructors before independent practice, whereas the Do then See group explored the task independently before accessing instructors. Participants were assessed at the transition between interventions, and as training ended. Skill retention, and transfer to a novel variation of the suturing task, were assessed after one week. Performance was scored on a five-point global rating scale by a blinded rater. RESULTS: The groups did not differ significantly on immediate posttest or retention test (F[1,30] = 0.96, P < 0.33). The Do then See group (N = 16) outperformed the See then Do group (N = 16) on the transfer test; 2.99 versus 2.52 (F[1,28] = 10.14, P < 0.004, η(2) = 0.27). CONCLUSIONS: Sequencing discovery learning before direct instruction appeared to improve transfer performance in simulation-based skills training. Implications for future research and curricular design are discussed.