Development of Content for a Virtual Reality Simulation to Understand and Mitigate Moral Distress in Healthcare Workers.

Background In high-stakes situations, healthcare workers are prone to suffer moral injury, the psychological, social, and spiritual impact of events involving betrayal or transgression of one's own deeply held moral beliefs and values. As a result, this may negatively impact their capacity to provide adequate levels of care to patients. There is a lack of educational resources catered to help healthcare workers navigate ethical situations in clinical settings that may lead to or worsen moral distress. The aim of this report is to describe the methodology of development and resulting outcomes in the form of an educational resource that includes a virtual reality (VR) simulation to help healthcare workers understand and mitigate moral distress as a result of internal and external constraints at their workplaces. Methodology A study using a method outlining a set of constraint parameters, followed by ideation utilizing design thinking (DT), and concluding with a consensus-building exercise using Delphi methodology (DM) with a group of 13 experts in healthcare simulation, VR, psychiatry, psychology, and nursing. The constraints parameters included technology use (VR), use of experiential learning theory, and duration of the intervention (15 minutes). A DT process was performed to generate and expand on ideas on the scenario and intervention of a possible VR simulation which were funneled into a three-round DM to define the foundations of the VR simulation. Average, standard deviations, and free-text comments in the DM were used to assess the inclusion of the produced requirements. Finally, a focus group interview was conducted with the same experts to draft the VR simulation. Results Within the specified constraints, the DT process produced 33 ideas for the VR simulation scenario and intervention that served as a starting point to short-list the requirements in Round 1. In Rounds 1 to 2, 25 items were removed, needed revising, and/or were retained for the subsequent rounds, which resulted in eight items at the end of Round 2. Round 2 also required specialists to provide descriptions of potential scenarios and interventions, in which five were submitted. In Round 3, experts rated the descriptions as somewhat candidate to use in the final VR simulation, and the open feedback in this round proposed combining the elements from each of the descriptions. Using this data, a prototype of the VR simulation was developed by the project team together with VR designers. Conclusions This development demonstrated the feasibility of using the constraints-ideation-consensus approach to define the content of a possible VR simulation to serve as an educational resource for healthcare workers on how to understand and mitigate moral distress in the workplace. The methodology described in this development may be applied to the design of simulation training for other skills, thereby advancing healthcare training and the quality of care delivered to the greater society.

Development of Simple and Advanced Adult Proximal Tibia Simulators for a Decentralized Simulation-Based Education Model to Teach Paramedics-in-Training the Intraosseous Infusion Procedure.

Introduction During the COVID-19 pandemic, public health had advised practicing social distancing which led to the temporary shutdown of simulation laboratories or centralized simulation-based education model, shared spaces that healthcare workers such as paramedics use to train on important hands-on clinical skills for the job. One such skill is intraosseous (IO) access and infusion, the delivery of fluids and medication through the marrow or medullary cavity of the bone which provides fast and direct entry into the central venous system. This skill is critical in emergencies when peripheral access is not immediately available. To continue the training of paramedics in life-saving skills like IO infusion in the post-pandemic era, a decentralized simulation-based education (De-SBE) model was proposed. The De-SBE relies on the availability of inexpensive and flexible simulators that can be used by learners outside of the simulation laboratory. However, to date, there is a paucity of simulation design methods that stimulate creativity and ideation, and at the same time, provide evidence of validity for these simulators. Our exploratory research aimed to test a novel approach that combines components of development-related constraints, ideation, and consensus (CIC) approach to develop and provide content validity for simulators to be used in a De-SBE model. Materials and methods The development of the IO simulators was constrained to follow a design-to-cost approach. First, a modified design thinking session was conducted with three informants from paramedicine and medicine to gather ideas for the development of two IO simulators (simple and advanced). Next, to sort through, refine, and generate early evidence of the content validity of the simulators, the initial ideas were integrated into a two-round, modified Delphi process driven by seven informants from paramedicine and medicine. In addition, we surveyed the participants on how well they liked the CIC approach. Results The CIC approach generated a list of mandatory and optional features that could be added to the IO simulators. Specifically, six features (one mandatory and four optional) for the existing simple IO simulator and eight (three mandatories and five optional) for the advanced IO simulators were identified. Following a design-to-cost approach, the features classified as mandatory for the simple and advanced IO simulators were integrated into the final designs to maintain the feasibility of production for training purposes. The surveys with the participants showed that the CIC approach worked well in the group setting by allowing for various perspectives to be shared freely and ending with a list of features for IO simulator designs that could be used in the future. Some improvements to the approach included flagging for potential users to determine what works best concerning the mode of delivery (online or in person), and duration of the stages to allow for more idea generation.  Conclusion The CIC approach led to the manufacturing of simple and advanced IO simulators that would suit a training plan catered to teach the IO access and infusion procedure decentrally to paramedics-in-training. Specifically, they have been designed in a manner that allows them to be made easily accessible to the trainees i.e., low costs and high mobility, and work cohesively with online learning management systems which further facilitates the use of a De-SBE model.

Development and Initial Assessment of a Novel and Customized Bile Duct Simulator for Handsewn Anastomosis Training.

Simulation-based medical education allows for the training and maintenance of healthcare skills in a safe and controlled environment. In this technical report, the development and initial evaluation of a bile duct anastomosis simulator are described. The simulator was developed using additive manufacturing techniques such as three-dimensional (3D) printing and silicone work. The final product was produced by maxSIMhealth, a research lab at Ontario Tech University (Oshawa, ON, Canada), and included four individual silicone bile ducts, based on the expert opinions from surgeons at the Centre Hospitalier de l'Université de Montréal (Montreal, QC, Canada), and a 3D-printed maxSIMclamp, which was described in a previous report. The evaluation was conducted by nine individuals consisting of surgeons, surgical residents, and medical students to assess the fidelity, functionality, and teaching quality of the simulator. The results from the evaluation indicate that the simulator needs to improve its fidelity by being softer, thinner, and beige. On the other hand, the results also indicate that this simulator is extremely durable and can be used as a training tool for surgical residents with some minor improvements.

Hacking Intraosseous Infusion Skills Training With 3D Printing: maxSIMIO Drilling System.

Intraosseous (IO) infusion is an alternative way to access the vascular system to administer drugs and fluids, which is particularly helpful when the commonly used peripheral intravenous route is inaccessible. The IO procedure can be done using a drill that involves disinfecting the area, landmarking the insertion point, seating the needle in a firm and stable position in the bone, and then delivering a smooth fluid flush. However, in the current medical training landscape, access to commercially available IO drills such as the Arrow® EZ-IO® Power Driver (EZ-IO; Teleflex, Morrisville, North Carolina, United States) is difficult, especially for rural and remote areas, due to the high costs. Furthermore, the EZ-IO is not rechargeable and does not clearly indicate the remaining battery life, which could potentially put patients at risk during the IO procedure. This technical report aims to address these concerns by describing the development of an alternative, affordable, and reliable IO drilling system for training use: the maxSIMIO Drilling System. This system consists of a cordless and rechargeable IKEA screwdriver which connects to a conventional, hexagon-shaped 3D-printed drill bit needle adapter. Two needle adapters were created: Version A was designed to use a friction-based mechanism to couple the screwdriver with the EZ-IO training needle, while Version B relies on a magnetic mechanism. The major differences between the EZ-IO and the screwdriver are that a) the EZ-IO has only one rotation to advance the cannula while the screwdriver features both directions, b) the EZ-IO is not rechargeable while the screwdriver is, and c) the EZ-IO has a custom needle holder that can fit any EZ-IO training needle size while the screwdriver needs to have a custom needle adapter made to connect to the EZ-IO training needle. Overall, through this exploration, the features of the maxSIMIO Drilling System in comparison to the EZ-IO appear more accessible for IO training. Future considerations for this development include gathering clinical expertise through rigorous testing of this novel system.

Hands-On Practice on Sustainable Simulators in the Context of Training for Rural and Remote Practice Through a Fundamental Skills Workshop.

Simulation-based education (SBE) is a sustainable method to allow healthcare professionals to develop competencies in clinical skills that can be difficult to maintain in rural and remote settings. Simulation-based skills training is necessary for healthcare professionals that experience difficulties accessing skills development and maintenance courses to address the needs of rural communities. However, simulators, a key element of simulation, are often prohibitively expensive and follow a "one-size-fits-all" approach. Using additive manufacturing (AM) techniques, more specifically three-dimensional (3D) printing, to produce inexpensive yet functional and customizable simulators is an ideal solution for learners to practice and improve their procedural skills anywhere and anytime. AM allows for the customization of simulators to fit any context while reducing costs and is an economic solution that moves away from the use of animal products to a more ethical, sustainable method for training. This technical report describes the delivery of a fundamental skills workshop to provide hands-on training to rural and remote healthcare professionals using 3D-printed simulators purposefully designed following design-to-cost principles. The workshop was delivered at a three-hour session hosted at a rural and remote medicine course in Ottawa, Canada. The workshop consisted of four technical skills: suturing, cricothyrotomy, episiotomy, and intraosseous infusion (tibial) (IO) and used a blended learning approach to train healthcare professionals and trainees who practice in rural and remote areas. In addition, the learners were granted access to a custom-designed learning management system, which provided a repository of instructional materials, and enabled them to record and upload personal practice sessions, review other learners' practice sessions, collaborate, and provide feedback to other learners. The feedback collected from participants, instructors, and observations on the delivery of the workshop will help improve the structure and training provided to learners. The delivery of this workshop annually is an ideal solution to ensure parsimonious delivery of simulation training for rural and remote healthcare professionals.

From Centralized to Decentralized Model of Simulation-Based Education: Curricular Integration of Take-Home Simulators in Nursing Education.

In a centralized model of simulation-based education (Ce-SBE), students practice skills in simulation laboratories, while in a decentralized model (De-SBE), they practice skills outside of these laboratories. The cost of "take-home" simulators is a barrier that can be overcome with additive manufacturing (AM). Our objective was to develop and evaluate the quality of education when year one nursing students practiced clinical skills from home following normal curricular activities but in the De-SBE format. A group of expert educators, designers, and researchers followed a two-cycle, iterative design-to-cost approach to develop three simulators: wound care and urethral catheterization (male and female). The total cost of manufacturing all three simulators was USD 5,000. These were sent to all year one nursing students who followed an online curriculum. Twenty-nine students completed the survey, which indicated that the simulators supported the students' learning needs, and several changes were requested to improve the educational value. The results indicate that substituting traditional simulators with AM-simulators provided an acceptable alternative for nursing students to learn wound care and urethral catheterization off-campus in De-SBE. The feedback also provided suggestions to improve each of the simulators to make the experience more authentic.

The Development and Initial End-Point User Feedback of a 3D-Printed Adult Proximal Tibia IO Simulator.

Intraosseous infusion (IO) remains an underutilized technique for obtaining vascular access in adults, despite its potentially life-saving benefits in trauma patients. In rural and remote areas, shortage of training equipment and human capacity (i.e., simulators) are the main contributors to the shortage of local training courses aiming at the development and maintenance of IO skills. Specifically, current training equipment options available for trainees include commercially available simulators, which are often expensive, or animal tissues, which lack human anatomical features that are necessary for optimal learning and pose logistical and ethical issues related to practice on live animals. Three-dimensional (3D) printing provides the means to create cost-effective, anatomically correct simulators for practicing IO where existing simulators may be difficult to access, especially in remote areas. This technical report aims to describe the development of maxSIMIO, a 3D-printed adult proximal tibia IO simulator, and present feedback on the design features from a clinical co-design team consisting of 18 end-point users.  Overall, the majority of the feedback was positive and highlighted that the maxSIMIO simulator was helpful for learning and developing the IO technique. The majority of the clinical team responders also agreed that the simulator was more anatomically accurate compared to other simulators they have used in the past. Finally, the survey results indicated that on average, the simulator is acceptable as a training tool. Notable suggestions for improvement included increasing the stability of the individual parts of the model (such as tightening the skin and securing the bones), enhancing the anatomical accuracy of the experience (such as adding a fibula), making the bones harder, increasing the size of the patella, making it more modular (to minimize costs related to maintenance), and improving the anatomical positioning of the knee joint (i.e., slightly bent in the knee joint). In summary, the clinical team, located in rural and remote areas in Canada, found the 3D-printed simulator to be a functional tool for practicing the intraosseous technique. The outcome of this report supports the use of this cost-effective simulator for simulation-based medical education for remote and rural areas anywhere in the world.

Development and Initial Assessment of a Novel Customized Deep Laceration Simulator for Suturing Training.

Suturing of different layers, such as deep lacerations, is a challenging clinical skill for residents. Currently, there is a lack of general suturing instructions and practice in undergraduate medicine curricula which would add to the education required during residency and could be impactful to patient safety. Therefore, in order to adequately prepare trainees for clinical practice, training in suturing needs to be made more robust and executable. One way to facilitate this is to provide easy access to equipment that can offer good educational value while allowing for adequate repetition of suturing deep lacerations outside of clinical settings, similar to how it has been done for superficial lacerations. Simulation-based medical education addresses this by training residents in healthcare skills in a safe and controlled environment. Our technical report aims to describe the development and initial evaluation of a deep laceration simulator designed to train residents in suturing. The simulator was made using additive manufacturing techniques such as three-dimensional printing and silicone. Feedback on the simulator was provided by Centre Hospitalier de l'Université de Montréal clinicians from various specialties and residents. The simulator was assessed mainly as being easy to use, durable, and having anatomically accurate characteristics. The main improvements suggested were to make the skin thinner, divide the epidermis and dermis, add a fascia, and create a looser and friable layer of fat. Overall, the respondents rated the simulator as a good educational tool with a few minor adjustments.