'Just pretending': Narratives of professional identity transitions in internal medicine.

INTRODUCTION: Health professional identity transitions involve a dynamic period of liminality prompting a time of considerable uncertainty and self-doubt. For postgraduate trainees in the United Kingdom, the transition to medical registrar can be a significant deterrent to recruitment and retention. Narrative analysis offers insight into identity work during transitions with potential to inform strategies for developing professional identities. This study aimed to use narrative analysis to explore trainees' experiences and their sense of agency during the liminal phase of this transition. METHODS: Following ethical approval, internal medicine (IM) trainees in their second year of IM training were interviewed. Transcripts were audio recorded, transcribed verbatim and analysed to identify narratives describing liminality during the transition to the role of medical registrar, including examples of rejecting and claiming identity grants. Narrative analysis, as described by Riessman and influenced by James Gee's units of discourse, was undertaken, with an agentive lens applied to the data. RESULTS: Between January 2021 and February 2022, 19 IM trainees were interviewed. Given the in-depth analysis, four narratives were purposively selected to present, including trainees rejecting and claiming the medical registrar role. Trainees tended to describe negative experiences, but those with a higher sense of agency demonstrated positive reflection and identity construction through narrative. There was often identity dissonance between how trainees defined their stage in the transition to medical registrar and how their narrative illustrated their identity work. CONCLUSION: This study exemplifies narrative analysis' linguistic and agentive lenses in exploring the experience of the liminal identity transitional period. The findings reflect the identity dissonance experienced by trainees during this time and sheds light on their sense of agency throughout. It heralds a need to acknowledge the significant liminality experienced during transitions throughout medical training and to empower a sense of agency to support identity work.

The impact of simulation-based mastery learning, booster session timing and clinical exposure on confidence in intercostal drain insertion: a survey of internal medicine trainees in Scotland.

BACKGROUND: Intercostal chest drain (ICD) insertion is a skill that medical trainees lack confidence in performing. This study explores the impact of a national programme of Simulation-Based Mastery Learning (SBML) on procedural confidence, including the impact of time intervals between booster sessions and interim clinical experience. METHODS: Internal Medicine Trainees in Scotland were surveyed about confidence and clinical experience with ICD insertion before and immediately after SBML and booster session. Data were matched and analysed using paired sample t-tests. Short interval and long interval groups were compared using Student's unpaired t-test. The impact of interim clinical experience was assessed using Analysis of Variance. RESULTS: Mean confidence in ICD insertion rose following SBML, fell between initial and booster session, and increased again following booster session (P = < 0.001). 33 of 74 trainees had successfully inserted an ICD between sessions. Fall in confidence was unaffected by the time interval between training sessions, but was mitigated by interim clinical experience. CONCLUSIONS: SBML boosts trainee confidence in ICD insertion. However, there is evidence of confidence decay, possibly due to a lack of clinical experience between sessions. More research is needed to explore barriers to transfer of skills from simulated to real-world environments.

Transfer of training from an internal medicine boot camp to the workplace: enhancing and hindering factors.

BACKGROUND: The transfer of training to the workplace is the aim of training interventions. Three primary factors influence transfer: trainee characteristics, training design and work environment influences. Within medical education, the work environment factors influencing transfer of training remain underexplored. Burke and Hutchins' review of training transfer outlined five work environment influences: opportunity to perform, supervisor/peer support, strategic link, transfer climate and accountability. This study aimed to explore the ways in which work environment factors influence the transfer of training for medical trainees. METHODS: Internal Medicine Training in Scotland includes a three-day boot camp involving simulation-based mastery learning of procedural skills, immersive simulation scenarios and communication workshops. Following ethical approval, trainees were invited to take part in interviews at least three months after following their boot camp. Interviews were semi-structured, anonymised, transcribed verbatim and analysed using template analysis. Member checking interviews were performed to verify findings. RESULTS: A total of 26 trainees took part in interviews between January 2020 and January 2021. Trainees reported a lack of opportunities to perform procedures in the workplace and challenges relating to the transfer climate, including a lack of appropriate equipment and resistance to change in the workplace. Trainees described a strong sense of personal responsibility to transfer and they felt empowered to change practice in response to the challenges faced. CONCLUSIONS: This study highlights barriers to transfer of training within the clinical workplace including procedural opportunities, a transfer climate with challenging equipment availability and, at times, an unsupportive workplace culture. Trainees are driven by their own sense of personal responsibility; medical educators and healthcare leaders must harness this enthusiasm and take heed of the barriers to assist in the development of strategies to overcome them.

Exploring transformative learning when developing medical students' non-technical skills.

CONTEXT: Non-technical skills (NTS) training should be incorporated into medical students' education and simulation-based approaches are often utilised to facilitate this. Such experiences have the potential to foster transformative learning by facilitating a reassessment of one's prior assumptions and a significant shift in one's outlook, referred to as the process of perspective transformation. The aim of this research was to explore how NTS training might facilitate transformative learning in final-year medical students. METHODS: Following ethical approval, medical student volunteers from four medical schools (Aberdeen, Dundee, Edinburgh and Glasgow) participated in simulation sessions, were debriefed with an emphasis on NTS using a behavioural marker system and then took part in focus groups. Focus group discussions were semi-structured and questions were based on the phases of perspective transformation identified by Jack Mezirow. Focus group discussions were audiorecorded, transcribed verbatim, anonymised and analysed using template analysis. RESULTS: A total of 33 medical students took part in five focus groups. There was evidence of the following stages of perspective transformation: Phase 2 (self-examination with emotional disturbance, including fear, anxiety, guilt, shame and frustration); Phase 3 (critical assessment of assumptions, including the undervaluing of NTS, recognising that technical skills alone are insufficient, and recognising that it is possible to improve one's NTS); Phase 5 (exploring options for new roles, relationships and actions), and Phase 6 (planning a course of action for future simulations, as a medical student and as a doctor). CONCLUSIONS: This study deepens our understanding of how exposure to NTS training in simulation-based education influences the learning of medical students and shows that such exposure can result in the cognitive phases of transformative learning. It provides us with valuable insights into medical students' perspectives on their learning of NTS at a pivotal stage in training and represents an interesting way of assessing the educational impact of such sessions.

Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care.

BACKGROUND: Avoidable patient harm in hospitals is common, and doctors in training can provide underused but crucial insights into the influencers of patient safety as those working 'on the ground' within the system. This study aimed to explore the factors that influence safe care from the perspective of medical registrars, to identify targets for safety-related improvements. METHODS: This study used enhanced critical incident technique (CIT), a qualitative methodology that results in a focused understanding of significant factors influencing an activity, to identify practical solutions. We interviewed 12 out of 17 consenting medical registrars in Scotland, asking them to recount their observations during clinical experiences where something happened that positively or negatively impacted on patient safety. Data were analysed manually using a modified content analysis with credibility checks as per enhanced CIT, with data exhaustiveness reached after six registrars. RESULTS: A total of 221 critical incidents impacting patient safety were identified. These were inductively placed into 24 categories within 4 overarching categories: Individual skills, encompassing individual behavioural and technical skills; Collaboration, regarding how communication, trust, support and flexibility shape interprofessional collaboration; Organisation, concerning organisational systems and staffing and Training environment, relating to culture, civility, having a voice and learning at work. Practical targets for safety-related interventions were identified, such as clear policies for patient care ownership or educational interventions to foster civility. CONCLUSIONS: This study provides a rigorous and focused understanding of the factors influencing patient safety in hospitals, using the 'insider' perspective of the medical registrar. Safety goes beyond the individual and is reliant on safe system design, interprofessional collaboration and a culture of support, learning and respect. Organisations should also promote flexibility within clinical practice when patient needs do not conform to standardised care pathways. We suggest targeted interventions within educational and organisational priorities to improve safety in hospitals.

Training as imagined? A critical realist analysis of Scotland's internal medicine simulation programme.

BACKGROUND: Evaluating the impact of simulation-based education (SBE) has prioritised demonstrating a causal link to improved patient outcomes. Recent calls herald a move away from looking for causation to understanding 'what else happened'. Inspired by Shorrock's varieties of human work from patient safety literature, this study draws on the concept of work-as-done versus work-as-imagined. Applying this to SBE recognises that some training impacts will be unexpected, and the realities of training will never be quite as imagined. This study takes a critical realist stance to explore the experience and consequences, intended and unintended, of the internal medicine training (IMT) simulation programme in Scotland, to better understand 'training-as-done'. METHODS: Critical realism accepts that there is a reality to uncover but acknowledges that our knowledge of reality is inevitably our construction and cannot be truly objective. The IMT simulation programme involves three courses over a 3-year period: a 3-day boot camp, a skills day and a 2-day registrar-ready course. Following ethical approval, interviews were conducted with trainees who had completed all courses, as well as faculty and stakeholders both immersed in and distant from course delivery. Interviews were audio-recorded, transcribed verbatim and analysed using critical realist analysis, influenced by Shorrock's proxies for work-as-done. RESULTS: Between July and December 2023, 24 interviews were conducted with ten trainees, eight faculty members and six stakeholders. Data described proxies for training-as-done within three broad categories: design, experience and impact. Proxies for training design included training-as-prescribed, training-as-desired and training-as-prioritised which compete to produce training-as-standardised. Experience included training-as-anticipated with pre-simulation anxiety and training-as-unintended with the valued opportunity for social comparison as well as a sense of identity and social cohesion. The impact reached beyond the individual trainee with faculty development and inspiration for other training ventures. CONCLUSION: Our findings highlight unintended consequences of SBE such as social comparison and feeling 'valued as a trainee, valued as a person'. It sheds light on the fear of simulation, reinforcing the importance of psychological safety. A critical realist approach illuminated the 'bigger picture', revealing insights and underlying mechanisms that allow this study to present a new framework for conceptualising training evaluation.

"Ego massaging that helps": a framework analysis study of internal medicine trainees' interprofessional collaboration approaches.

INTRODUCTION: Patient care depends on collaborative practice. Debate remains as to the best approach to providing education for collaboration, with educational interventions often far removed from the realities of the clinical workplace. Understanding the approaches used for collaboration in clinical practice could inform practical strategies for training. For internal medicine trainees, this involves collaboration with other professions but also with other specialties. This study aimed to explore the approaches that internal medicine trainees use for interprofessional collaboration and the ways that these approaches vary when internal medicine trainees interact with different healthcare provider groups. METHODS: Following ethical approval and participant consent, interprofessional communication workshops between August 2020 and March 2021 were audio recorded and transcribed verbatim. Workshops involved groups of internal medicine trainees discussing collaboration challenges and the approaches they use in clinical practice. This framework analysis study used the interprofessional collaboration framework described by Bainbridge and Regehr (building social capital, perspective taking and negotiating priorities and resources), and cross-referenced the categorised data with the healthcare groups that trainees collaborate with, to look for patterns in the data. RESULTS: Seventeen workshops, involving 100 trainees, were included. Trainees described relationship building, perspective taking and negotiating priorities and resources. Relationship building was a modification to the original framework domain of building social capital. Themes of power and civility transcended domains with evidence of using hierarchy as leverage when negotiating and employing civility as a tactical approach throughout. DISCUSSION: This bi-dimensional analysis highlights patterns of perspective taking when collaborating with other specialties and professions, and the approaches to negotiation of courting favour and coercion when interacting with other specialties. This study provides evidence of the strategies currently utilised by internal medicine trainees, with different healthcare groups, and presents a modified framework which could inform the development of training for collaboration.

The Rubik's cube of doing and being: Factors influencing professional identity transition to the medical registrar.

BACKGROUND: Professional identity transitions, such as the transition to medical registrar, are challenging. How minoritised identities influence transitions during medical training requires further study. This study aimed to explore the factors influencing the transition to the medical registrar in Scotland to guide support during training. METHODS: Interviews exploring this transition with internal medicine trainees were audio recorded, transcribed verbatim and double-coded using template analysis. We applied an initial coding template informed by multiple and multidimensional transition theory of individual, interpersonal, systemic and macro-level factors. Using a critical theory lens, a further template analysis specifically sought to understand how trainees' social identities interacted with the various levels. FINDINGS: Nineteen IM trainees were interviewed between January 2021 and February 2022. Influential factors reflected a parallel process of competence (doing) and identity (being) development. The interaction of social identities, such as gender (being a woman) and country of origin (being an international medical graduate), occurred across levels. This can be conceptualised as a Rubik's cube with the interplay between doing and being from an individual to a macro level with trainees' social identities interacting at all levels. CONCLUSION: The transition to the medical registrar is multifaceted; with a challenging balance between support and independence in providing opportunities to perform (doing) whilst identity develops (being). Identity transitions involve multiple Rubik's-cube-like rotations between the facets of 'doing' and 'being,' until these align. Taking heed of influential factors and the interaction of minoritised social identities could guide a trainee-centred and smoother transition.

Online non-technical skills faculty training.

BACKGROUND: The Medical Students Non-Technical Skills (Medi-StuNTS) system is a behavioural marker system (BMS) designed to identify and debrief non-technical skills (NTS) for medical students during immersive simulation. Educators must be adequately trained in using the BMS. This study aimed to design and implement an online platform to deliver a faculty development course on using Medi-StuNTS and evaluate the feasibility of this platform in training faculty to identify and debrief NTS. APPROACH: The online platform was developed by faculty with expertise in NTS, based on guidance for faculty training programme requirements and the multimodal model for online education. Content was arranged in modules, using presentations, videos of simulation scenarios and interactive discussion boards. EVALUATION: Fifteen participants completed the course and feedback over a two-month period. A feedback form was completed to assess feasibility, based on a feasibility framework. The areas of focus were acceptability, demand, implementation, practicality, adaptation, integration, expansion and limited efficacy. Feedback indicated that the course shows promise in improving the ability of faculty to identify and debrief NTS. IMPLICATIONS: The platform was successfully developed and implemented and was able to reach a national audience due to its online nature. Specific strengths include increased flexibility and accessibility compared to in-person training. Feasibility assessment suggests that this newly developed online platform can work as an effective method for faculty development in order to increase skills in identifying and debriefing NTS using Medi-StuNTS. Future work will focus on expansion of the online platform and dissemination to an international audience.

The development of a marker system for Pharmacists' Behavioural Skills.

OBJECTIVES: Pharmacists increasingly require complex behavioural skills to fulfil enhanced roles within healthcare teams. Behavioural marker systems are used to assess behavioural (or non-technical) skills during immersive simulation. This study aimed to develop a marker system for pharmacists' behavioural skills in patient-focussed care scenarios, and to investigate its content validity. METHODS: Literature describing existing marker systems and the requisite behavioural skills of pharmacists were presented to two expert panels, alongside video examples of pharmacists in patient-focussed care simulations. The expert panels used this information to develop a new behavioural marker system. A third expert panel assessed the content validity, and the item- and scale-content validity indices were calculated. KEY FINDINGS: The resulting tool contains four categories, each with three or four skill elements: situation awareness (gathering information; recognising and understanding information; anticipating, preparing and planning), decision-making and prioritisation (identifying options; prioritising; dealing with uncertainty; implementing or reviewing decisions), collaborative working (involving the patient; information sharing; leadership or followership), self-awareness (role awareness; speaking up; escalating care; coping with stress). The scale-content validity index was 0.95 (ideal) and the only item below the acceptable cut-off was 'leadership or followership' (0.7). CONCLUSIONS: This tool is the first marker system designed to assess the behavioural skills of pharmacists in patient-focussed care scenarios. There is evidence of good content validity. It is hoped that once validated, the Pharmacists' Behavioural Skills marker system will enable pharmacy educators to provide individualised and meaningful feedback on simulation participants' behavioural skills.

'Us versus them': A social identity perspective of internal medicine trainees.

INTRODUCTION: Silos and group boundaries in the clinical workplace can result in interprofessional conflict which can be a source of anxiety for doctors in training. The social identity perspective (SIP) incorporates theories of social identity and self-categorisation, and may provide a useful lens to understand the socialisation and identity development of doctors. This study aimed to determine if and how the SIP may provide insight into intergroup relations as experienced by internal medicine (IM) trainees in Scotland. METHODS: Interprofessional communication workshops hosted as part of an IM boot camp between August 2020 and March 2021 were audio recorded and transcribed verbatim. Subsequent individual interviews with consenting trainees further explored social identity and intergroup relations. Data analysis employed template analysis and deductive independent coding with the SIP informing the initial coding template and new codes added inductively. RESULTS: Seventeen workshops, involving 100 trainees, and ten subsequent individual interviews were included. Trainees related to the social identity of an IM doctor and to stereotypes within the workplace. They described intergroup tensions resulting from a perception of differing priorities. They experienced outgroup derogation and the impact of role modelling those in their social group during their identity development. DISCUSSION: The SIP provides a useful lens to understand the social phenomena at play for IM trainees. It confirms the expectation of conflict between specialties and negative perceptions of outgroups. There is a need to consider the hidden curriculum of socialisation in the workplace during training and the influence of the learning environment on identity development.

Investigating how interprofessional simulation influences tolerance of ambiguity.

INTRODUCTION: Decision making in clinical practice is only possible if we are able to understand the limits of our own knowledge and manage the associated uncertainty. Tolerance of ambiguity is therefore an important attribute for trainee pharmacists and medical students to develop. This study aimed to explore the impact of an interprofessional simulation on the tolerance of ambiguity of trainee pharmacists and medical students. METHODS: Trainee pharmacists and final year medical students participated in interprofessional simulation in two regions of Scotland. Participants completed pre- and post-session tolerance of ambiguity questionnaires. Analysis included differences between the pre-session scores of the two groups; the trainee pharmacists' pre- and post-session scores; and the medical students' pre- and post-session scores. RESULTS: A total of 15 trainee pharmacists and 15 medical students participated. Baseline tolerance of ambiguity was slightly higher in medical students than trainee pharmacists (56.9 vs. 52.6), but the study was insufficiently powered to detect whether this was a true difference (P = .21). Trainee pharmacists showed a statistically significant increase in self-reported tolerance of ambiguity (52.6 to 60.8, P = .004), but medical students did not (56.9 to 63.8, P = .04). CONCLUSIONS: Trainee pharmacists' tolerance of ambiguity was improved following participation in an interprofessional simulation. Further research could establish whether the improvements differ between professional groups, and explore the reasons why tolerance of ambiguity may be affected by interprofessional simulation.

Exploring transformative learning for trainee pharmacists through interprofessional simulation: a constructivist interview study.

BACKGROUND: The expanding roles of UK pharmacists have prompted substantial changes to the initial pharmacy education and training, including increasing recognition of the value of learning alongside other professional groups in acute settings. Interprofessional immersive simulation training appears to represent a useful educational tool to meet the evolving needs of the profession, but the impact of such training on workplace behaviour and relationships has not been explored. This study aimed to explore how interprofessional simulation training facilitates transformative learning in pre-registration pharmacists. METHODS: Across three different locations in Scotland, pre-registration pharmacists were paired with medical students to participate in immersive simulation scenarios with post-scenario debriefs. Pre-registration pharmacists were individually interviewed shortly after their simulation session, using a semi-structured interview schedule based on the transformative learning framework. Transcripts were analysed using template analysis, with Mezirow's phases of perspective transformation forming the initial coding template. RESULTS: Fifteen interviews following five simulation sessions at three different sites were undertaken. Phases 1-6 of the transformative learning framework all resonated with the pre-registration pharmacists to varying degrees. Two prominent threads became evident in the data: a change in participants' perceptions of risk, and deepened understanding of their role within an acute context. These themes were woven throughout phases 2-6 of the transformative learning framework. CONCLUSIONS: Interprofessional immersive simulation training involving acute clinical scenarios has been found to be helpful for pre-registration pharmacists and can foster transformative learning. Through this powerful process, they developed new ways to see the world, themselves and their professional relationships. Positive future actions and roles were planned. As the patient-facing roles of pharmacists expand, educational practices that translate into meaningful change to workplace behaviour and relationships become increasingly important. Carefully constructed interprofessional immersive simulation training should be utilised within pharmacy education more widely.

Exploring the impact of the COVID-19 pandemic on doctors' core workplace needs: a qualitative study of internal medicine trainees in Scotland.

OBJECTIVES: This study aimed to explore how the COVID-19 pandemic has impacted the workplace core needs of internal medicine (IM) trainees in Scotland. DESIGN: This qualitative study used an observational approach of interprofessional workshops combined with subsequent individual interviews with IM trainees. Workshops and interviews were audiorecorded, transcribed verbatim and analysed utilising NVivo software. Template analysis was used with the Autonomy/control, Belonging and Competence (ABC) of doctors' core needs outlined in the 2019 General Medical Council report Caring for doctors, caring for patients as a conceptual lens for the study. SETTING: The national IM boot camp in Scotland includes a 2-hour interprofessional workshop which is trainee led and explores current challenges in the workplace, including the impact of the pandemic on such relationships. PARTICIPANTS: Twelve workshops, involving 72 trainees, were included with ten trainees taking part in the subsequent interview process. Trainees representing all four regions in Scotland were involved. RESULTS: Trainees described all core needs having been impacted by the pandemic. They described a loss of autonomy with emergency rotas but also through a pervasive sense of uncertainty. The data revealed that work conditions improved initially with additional resources which have since been removed in some areas, affecting trainees' sense of value. Analysis found that belonging was affected positively in terms of increased camaraderie but also challenged through inability to socialise. There were concerns regarding developing competence due to a lack of teaching opportunities. CONCLUSIONS: Using the ABC of doctor's core needs as a conceptual framework for this study highlighted the impact of the COVID-19 pandemic on all domains for IM trainees in Scotland. It has highlighted an opportunity to foster the renewed sense of camaraderie among healthcare teams, while rebuilding work conditions to support autonomy and competence.

Reliability of assessment of medical students' non-technical skills using a behavioural marker system: does clinical experience matter?

Introduction: Non-technical skills are recognised to play an integral part in safe and effective patient care. Medi-StuNTS (Medical Students' Non-Technical Skills) is a behavioural marker system developed to enable assessment of medical students' non-technical skills. This study aimed to assess whether newly trained raters with high levels of clinical experience could achieve reliability coefficients of >0.7 and to compare differences in inter-rater reliability of raters with varying clinical experience. Methods: Forty-four raters attended a workshop on Medi-StuNTS before independently rating three videos of medical students participating in immersive simulation scenarios. Data were grouped by raters' levels of clinical experience. Inter-rater reliability was assessed by calculating intraclass correlation coefficients (ICC). Results: Eleven raters with more than 10 years of clinical experience achieved single-measure ICC of 0.37 and average-measures ICC of 0.87. Fourteen raters with more than or equal to 5 years and less than 10 years of clinical experience achieved single-measure ICC of 0.09 and average-measures ICC of 0.59. Nineteen raters with less than 5 years of clinical experience achieved single-measure ICC of 0.09 and average-measures ICC 0.65. Conclusions: Using 11 newly trained raters with high levels of clinical experience produced highly reliable ratings that surpassed the prespecified inter-rater reliability standard; however, a single rater from this group would not achieve sufficiently reliable ratings. This is consistent with previous studies using other medical behavioural marker systems. This study demonstrated a decrease in inter-rater reliability of raters with lower levels of clinical experience, suggesting caution when using this population as raters for assessment of non-technical skills.

Validity of the Medi-StuNTS behavioural marker system: assessing the non-technical skills of medical students during immersive simulation.

Background: The Medical Students' Non-Technical Skills (Medi-StuNTS) behavioural marker system (BMS) is the first BMS to be developed specifically for medical students to facilitate training in non-technical skills (NTS) within immersive simulated acute care scenarios. In order to begin implementing the tool in practice, validity evidence must be sought. We aimed to assess the validity of the Medi-StuNTS system with reference to Messick's contemporary validity framework. Methods: Two raters marked video-recorded performances of acute care simulation scenarios using the Medi-StuNTS system. Three groups were marked: third-year and fourth-year medical students (novices), final-year medical students (intermediates) and core medical trainees (experts). The scores were used to make assessments of relationships to the variable of clinical experience through expert-novice comparisons, inter-rater reliability, observability, exploratory factor analysis, inter-rater disagreements and differential item functioning. Results: A significant difference was found between the three groups (p<0.005), with experts scoring significantly better than intermediates (p<0.005) and intermediates scoring significantly better than novices (p=0.001). There was a strong positive correlation between the two raters' scores (r=0.79), and an inter-rater disagreement of more than one point in less than one-fifth of cases. Across all scenarios, 99.7% of skill categories and 84% of skill elements were observable. Factor analysis demonstrated appropriate grouping of skill elements. Inconsistencies in test performance across learner groups were shown specifically in the skill categories of situation awareness and decision making and prioritisation. Conclusion: We have demonstrated evidence for several aspects of validity of the Medi-StuNTS system when assessing medical students' NTS during immersive simulation. We can now begin to introduce this system into simulation-based education to maximise NTS training in this group.

Assessing Medical Students' Nontechnical Skills Using Immersive Simulation: What Are the Essential Components?

INTRODUCTION: Nontechnical skills (NTS) have been acknowledged to be important for medical students and can be linked to improved clinical performance. However, existing tools to evaluate these within a simulated setting address only a limited number of NTS. The Medical Students' Nontechnical Skills (Medi-StuNTS) behavioral marker system (BMS) outlines 5 categories of NTS for medical students. This study aimed to seek evidence for completeness and content validity to refine the BMS and to ascertain which NTS are essential for medical students. METHODS: We asked 128 workshop participants if they felt there were any missing or irrelevant items in Medi-StuNTS system. A subject matter expert panel (n = 10) rated how essential they considered each item in the BMS. An Item-Content Validity Index was calculated for each skill element and the Scale-Content Validity Index was calculated as a measure of content validity of the full system. RESULTS: Of the workshop participants, 78.9% felt that there were no missing items and 93% felt that there were no irrelevant items. Potentially missing items highlighted were as follows: "working in a hierarchy," "leadership," "awareness of the emotional state of other team members," and "nonverbal communication." Fourteen of 16 skill elements achieved the recommended level for content validity (Item-Content Validity Index ≥ 0.78), and the Scale-Content Validity Index was higher than the acceptable level (≥0.8). CONCLUSIONS: Evidence for completeness and content validity of Medi-StuNTS has been demonstrated. There is a far wider range of NTS that seem to be essential for medical students than those assessed by tools developed before Medi-StuNTS. Medi-StuNTS provides comprehensive cover of the essential NTS required by medical students, with specific reference to the skill categories "self-awareness" and "escalating care," which do not feature in other tools for assessing NTS in this group.