Educator's blueprint: A how-to guide for creating analog serious games for learning in medical education.

Serious games are an emerging tool for teaching and learning within medical education. These games can be used to facilitate learning or to demonstrate complex concepts in short bursts of interactive learning. This educator's blueprint will provide 10 strategies for creating a serious game, focusing on card and board games. These strategies include creating a project charter; determining the nature of the game; establishing game mechanics; selecting the best medium; prototyping and playtesting; reviewing sensitivity to equity, diversity, and inclusion; reviewing and refining content; funding game development, manufacture, and distribution; marketing and publicizing the game; and future-proofing the game. This blueprint hopes to help aspiring serious game designers and educators to conceptualize the steps for successfully creating a new serious game for medical education.

Comparing nurse leader and manager perceptions of and strategies for nurse engagement using a positive deviance approach: A qualitative analysis.

AIMS: To understand nurse leader and manager perspectives on employee engagement and their own role to foster engagement. To examine differences between managers of units with high versus low engagement. BACKGROUND: Health systems recognize the impact of employee engagement, yet alignment of leader and frontline-manager perspectives remains unclear. METHODS: A qualitative study at the Veteran Affairs New England Healthcare System. Leaders at five facilities (N = 13) and managers of units with high and low nurse engagement (N = 31) were interviewed. RESULTS: Nurse leaders almost universally conceptualized staff engagement as involvement in quality improvement service, while managers defined engagement as either commitment to excellence in direct patient care or involvement in quality improvement efforts. Intra- and interprofessional attitude contagion, and organisational factors of staffing-time-workload and senior leadership support were most common to support or detract from nurse engagement. A variety of strategies were identified, including protecting nurses as people and professionals. Differences in perceived roles and constraints to engaging nurse staff exist between managers of units with high versus low engagement. CONCLUSION: Nurse managers and leaders perceive engagement differently; strategies exist to facilitate engagement. IMPLICATIONS FOR NURSING MANAGEMENT: Leader and manager partnerships are needed to provide clarity on and resources for engagement.

National Burnout Trends Among Physicians Working in the Department of Veterans Affairs.

BACKGROUND: Heterogeneity of existing physician burnout studies impairs analyses of longitudinal trends, geographic distribution, and organizational factors impacting physician burnout. The Department of Veterans Affairs (VA) is one of the largest integrated healthcare systems in the USA, offering a unique opportunity to study burnout across VA sites and time. OBJECTIVE: To characterize longitudinal burnout trends of VA physicians and assess organizational characteristics and geographic distribution associated with physician burnout. DESIGN: Longitudinal study of the VA All Employee Survey during 2013-2017. PARTICIPANTS: Self-identified physicians practicing in one of nine clinical service areas at 140 VA sites nationwide. MAIN MEASURES: We identified burnout using a validated definition adapted from the Maslach Burnout Inventory and characterized burnout trends for physicians in different clinical service areas. We used clustering analysis to categorize sites based on their burnout rates over time, and compared organizational characteristics and geographic distribution of high, medium, and low burnout categories. KEY RESULTS: We identified 40,382 physician responses from 140 VA sites. Mean burnout rates across all physicians ranged from 34.3% in 2013 to a high of 39.0% in 2014. Primary care physicians had the highest burnout. High burnout sites were more likely to be rural and non-teaching, have lower complexity (i.e., offer fewer advanced clinical services), and have fewer unique patients per site. CONCLUSIONS: VA physician burnout was lower than previously described in many non-VA studies and was relatively stable over time. These findings may be due to unique characteristics of the VA practice environment. Nonetheless, with over a third of VA physicians reporting burnout, organizational interventions are needed. Primary care physicians and those practicing at small, rural sites have higher rates of burnout and may warrant more focused attention. Our results can guide targeted interventions to promote VA physician well-being and inform efforts to address burnout in diverse clinical settings.

Experiential Learning Through Local Implementation of a National Chief Resident in Quality and Patient Safety Curriculum.

The Clinical Learning Environment Review was created to evaluate quality improvement and patient safety (QIPS) beginning in 2013. Little guidance has been offered on implementing QIPS curricula for residency education. The aim was to provide a model QIPS residency curriculum from VA Boston Healthcare System (VABHS), wherein a chief resident in quality and patient safety (CRQS) participates in a national curriculum implementing skills and concepts locally. The CRQS mentors a patient safety resident with faculty oversight. The program involves case investigations, educational conferences, and experiential learning. Participants are residents from Beth Israel Deaconess Medical Center, Boston Medical Center, and Brigham and Women's Hospital and medical students from Boston University Medical School and Harvard Medical School. Local and national CRQS programs are evaluated. The patient safety rotation is evaluated locally. The local curriculum at VABHS augments the national curriculum and deploys a patient safety education that develops experiential learning skills.

Quality Improvement Virtual Practicum: The QI Simulator.

Introduction: In recent years, undergraduate and graduate medical education has been rightfully emphasizing education in quality improvement and patient safety (QIPS). However, the best methods for teaching the foundational principles of QIPS and associated skills are unknown. Methods: In collaboration with the Institute for Healthcare Improvement Open School, we developed an approachable simulation for teams of health care trainees at any level and any discipline. The simulation is based on the investigation of a case regarding a psychiatric patient admitted to a fictional hospital for medical treatment who has eloped. In teams, participants investigate the incident by collecting data and using basic QI principles to brainstorm and design interventions. Participants are guided through this paper-based simulation by QI facilitators who have working knowledge of basic QI principles and techniques. Results: The simulation has been successfully used with hundreds of medical students and other health professional trainees. While working in teams, participants gained exposure to patient-safety incident reporting and investigation, process mapping, plan-do-study-act cycles, run charts, intervention design, and interactions with hospital administrators. Surveyed participants reported that they had learned QI principles, gained confidence in their ability to do QI work, and increased their likelihood of leading a QI initiative in the future. Discussion: Simulation has become a standard way to teach many clinical topics in undergraduate and graduate medical education, and QIPS should be no exception. This simulation has been shown to be effective in increasing understanding of and interest in QIPS.

The 60-Minute Root Cause Analysis: A Workshop to Engage Interdisciplinary Clinicians in Quality Improvement.

Introduction: We created a standardized workshop to engage residents in quality improvement (QI) using the root cause analysis model. The workshop allows for a robust learning experience while providing solutions derived from clinicians to address important local problems. No prerequisite knowledge or experience is required. Methods: The workshop is facilitated by one or more moderators, ideally with experience in QI. An interdisciplinary group of residents, medical students, nurses, and other attendees comprise an audience which actively engages in workshop activities. Facilitators follow a scripted model to teach important patient safety concepts with frequent break-outs for hands-on application of QI tools. During the workshop, participants create a process map and fishbone diagram, as well as develop and critically evaluate novel interventions. Results: Over the course of one academic year, the workshop has been implemented 17 times with roughly 25 internal medicine residents in attendance at each workshop. In addition, the workshop was run online for 126 participants with varied exposure to QI techniques. Forty percent of these participants completed a survey indicating that over 89% learned something new, 87% felt they could apply the material to their work, and 95% would recommend the workshop to a colleague. Discussion: This 60-minute workshop can provide hands-on QI experience in a standardized format to achieve the dual objectives of teaching QI to clinicians and allowing them to generate innovations. The module can be used for internal case development and trainee participation, but prepared cases are provided for facilitators without the resources for local case development.

Oculocardiac reflex in a medial orbital wall fracture without clinically evident entrapment.

In this report, we describe a patient with a medial wall orbital fracture, who presented with vasovagal-like symptoms secondary to an oculocardiac reflex. This case is unusual because the patient had no other clinical evidence of muscle entrapment. A 15-year-old male presented with daily 5-10 min episodes of dizziness, light headedness, and nausea consistent with a vasovagal reaction. On examination, the patient had full extra ocular motility and was orthotropic in all fields of gaze. On computed tomography a comminuted medial orbital wall fracture was identified. The adjacent medial rectus muscle was in normal position, but was "rounded" relative to the contralateral side. The patient underwent fracture repair with immediate resolution of all symptoms. Symptoms related to a vasovagal response may occur with orbital fractures despite normal extra ocular motility. Presumably this relates to tension or pulling on an extra ocular muscle, which is not to a degree that alteration in function is appreciable clinically.

Activation of the ciliary neurotrophic factor (CNTF) signalling pathway in cortical neurons of multiple sclerosis patients.

Neuronal and axonal degeneration results in irreversible neurological disability in multiple sclerosis (MS) patients. A number of adaptive or neuroprotective mechanisms are thought to repress neurodegeneration and neurological disability in MS patients. To investigate possible neuroprotective pathways in the cerebral cortex of MS patients, we compared gene transcripts in cortices of six control and six MS patients. Out of 67 transcripts increased in MS cortex nine were related to the signalling mediated by the neurotrophin ciliary neurotrophic factor (CNTF). Therefore, we quantified and localized transcriptional (RT-PCR, in situ hybridization) and translational (western, immunohistochemistry) products of CNTF-related genes. CNTF-receptor complex members, CNTFRalpha, LIFRbeta and GP130, were increased in MS cortical neurons. CNTF was increased and also expressed by neurons. Phosphorylated STAT3 and the anti-apoptotic molecule, Bcl2, known down stream products of CNTF signalling were also increased in MS cortical neurons. We hypothesize that in response to the chronic insults or stress of the pathogenesis of multiple sclerosis, cortical neurons up regulate a CNTF-mediated neuroprotective signalling pathway. Induction of CNTF signalling and the anti-apoptotic molecule, Bcl2, thus represents a compensatory response to disease pathogenesis and a potential therapeutic target in MS patients.