Supporting self-regulated-learning in colonoscopy training-A comparison cohort trial.

Aim: This study aimed to demonstrate that using a self-regulated learning (SRL) approach can improve colonoscopy performance skills. Background: Colonoscopy is the gold standard for detecting colorectal cancer and removing its precursors: polyps. Acquiring proficiency in colonoscopy is challenging, requiring completion of several hundred procedures. SRL seems to be beneficial to help trainees acquire competencies in regulating their future learning processes and enhance the outcomes of current learning situations. SRL is a learner-centred approach that refers to a trainee's ability to understand and control their learning environment, including cognitions, motivations and emotions. The key abilities include self- and situational awareness, task analysis, and strategic planning. This study is the first to use an SRL approach for workplace-based colonoscopy training. Methods: In this comparison cohort trial, participants used two SRL supports: a self-review of videotaped performance, and an online learning platform with procedural and conceptual knowledge about colonoscopy. In the control cohort, participants performed patient-based colonoscopy as usual in their departments. Improvement was monitored via three video-based ratings (study start, end of the study period, and follow-up) using the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT). Outcomes were analysed using two-way analysis of variance with repeated measurements. Results: This study recruited 21 participants (12, intervention cohort; nine, control cohort); 58 videos were recorded. The intraclass correlation coefficient was 0.88 (95% CI 0.61-0.98; p < 0.001). The global rating scale (GRS) and checklist (CL) in GiECAT were analysed separately. No statistically significant main effects of cohort (GRS: F(1,16) = 2.84, p = 0.11; CL: F(1,16) = 1.06, p = 0.32), test (GRS: F(2,32) = 2.56, p = 0.09; CL: F(2,32) = 0.76, p = 0.48), or interactions between cohort and test were observed (GRS: F(2,32) = 1.16, p = 0.33; CL: F(2,32) = 1.01, p = 0.37). Conclusions: SRL in patient-based colonoscopy is feasible; however, no clear effect on performance scores was observed.

Development and validation of a simulation-based assessment tool in colonoscopy.

BACKGROUND: Colonoscopy is difficult to learn. Virtual reality simulation training is helpful, but how and when novices should progress to patient-based training has yet to be established. To date, there is no assessment tool for credentialing novice endoscopists prior to clinical practice. The aim of this study was to develop such an assessment tool based on metrics provided by the simulator. The metrics used for the assessment tool should be able to discriminate between novices, intermediates, and experts and include essential checklist items for patient safety. METHODS: The validation process was conducted based on the Standards for Educational and Psychological Testing. An expert panel decided upon three essential checklist items for patient safety based on Lawshe's method: perforation, hazardous tension to the bowel wall, and cecal intubation. A power calculation was performed. In this study, the Simbionix GI Mentor II simulator was used. Metrics with discriminatory ability were identified with variance analysis and combined to form an aggregate score. Based on this score and the essential items, pass/fail standards were set and reliability was tested. RESULTS: Twenty-four participants (eight novices, eight intermediates, and eight expert endoscopists) performed two simulated colonoscopies. Four metrics with discriminatory ability were identified. The aggregate score ranged from 4.2 to 51.2 points. Novices had a mean score of 10.00 (SD 5.13), intermediates 24.63 (SD 7.91), and experts 30.72 (SD 11.98). The difference in score between novices and the other two groups was statistically significant (p<0.01). Although expert endoscopists had a higher score, the difference was not statistically significant (p=0.40). Reliability was good (Cronbach's alpha=0.86). A pass/fail score was defined at 17.1 points with correct completion of three essential checklist items, resulting in three experts and three intermediates failing and one novice passing the assessment. CONCLUSION: We established a valid and reliable assessment tool with a pass/fail standard on the simulator. We suggest using the assessment after simulation-based training before commencing work-based learning.

Exploring adaptive expertise in residency: the (missed) opportunity of uncertainty.

Preparing novice physicians for an unknown clinical future in healthcare is challenging. This is especially true for emergency departments (EDs) where the framework of adaptive expertise has gained traction. When medical graduates start residency in the ED, they must be supported in becoming adaptive experts. However, little is known about how residents can be supported in developing this adaptive expertise. This was a cognitive ethnographic study conducted at two Danish EDs. The data comprised 80 h of observations of 27 residents treating 32 geriatric patients. The purpose of this cognitive ethnographic study was to describe contextual factors that mediate how residents engage in adaptive practices when treating geriatric patients in the ED. Results showed that all residents fluidly engaged in both adaptive and routine practices, but they were challenged when engaging in adaptive practices in the face of uncertainty. Uncertainty was often observed when residents' workflows were disrupted. Furthermore, results highlighted how residents construed professional identity and how this affected their ability to shift between routine and adaptive practices. Residents reported that they thought that they were expected to perform on par with their more experienced physician colleagues. This negatively impacted their ability to tolerate uncertainty and hindered the performance of adaptive practices. Thus, aligning clinical uncertainty with the premises of clinical work, is imperative for residents to develop adaptive expertise.

Exploring training needs of newly graduated medical doctors to inform the undergraduate simulation-based curriculum: a national Delphi consensus study.

PURPOSE: Mastering technical procedures is a key component in succeeding as a newly graduated medical doctor and is of critical importance to ensure patient safety. The efficacy of simulation-based education has been demonstrated but medical schools have different requirements for undergraduate curricula. We aimed to identify and prioritize the technical procedures needed by newly graduated medical doctors. METHODS: We conducted a national needs assessment survey using the Delphi technique to gather consensus from key opinion leaders in the field. In the first round, a brainstorm was conducted to identify all potential technical procedures. In the second round, respondents rated the need for simulation-based training of each procedure using the Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula (CAMES-NAF). The third round was a final elimination and prioritization of the procedures. RESULTS: In total, 107 experts from 21 specialties answered the first round: 123 unique technical procedures were suggested. Response rates were 58% and 64% in the second and the third round, respectively. In the third round, 104 procedures were eliminated based on the consensus criterion, and the remaining 19 procedures were included and prioritized. The top five procedures were: (i) insert peripheral intravenous catheter, (ii) put on personal protection equipment, (iii) perform basic airway maneuvers, (iv) perform basic life support, and (v) perform radial artery puncture. CONCLUSION: Based on the Delphi process a final list of 19 technical procedures reached expert consensus to be included in the undergraduate curriculum for simulation-based education.

Clinical decision-making and adaptive expertise in residency: a think-aloud study.

Clinical decision-making (CDM) is the ability to make clinical choices based on the knowledge and information available to the physician. It often refers to individual cognitive processes that becomes more dependent with the acquisition of experience and knowledge. Previous research has used dual-process theory to explain the cognitive processes involved in how physicians acquire experiences that help them develop CDM. However, less is known about how CDM is shaped by the physicians' situated cognition in the clinical environment. This is especially challenging for novice physicians, as they need to be adaptive to compensate for the lack of experience. The adaptive expert framework has been used to explain how novice physicians learn, but it has not yet been explored, how adaptive expertise is linked to clinical decision-making amongst novice physicians.This study aimed to analyse how residents utilize and develop adaptive expert cognition in a natural setting. By describing cognitive processes through verbalization of thought processes, we sought to explore their CDM strategies considering the adaptive expert framework.We used concurrent and retrospective think-aloud interviews in a natural setting of an emergency department (ED) at a university hospital, to query residents about their reasoning during a patient encounter. We analysed data using protocol analysis to map cognitive strategies from these verbalizations. Subsequently in a narrative analysis, we compared these strategies with the literature on adaptive expertise.Fourteen interviews were audio recorded over the course for 17 h of observation. We coded 78 informational concepts and 46 cognitive processes. The narrative analysis demonstrated how epistemic distance was prevalent in the initial CDM process and self-regulating processes occurred during hypothesis testing. However, residents who too quickly moved on to hypothesis testing tended to have to redirect their hypothesis more often, and thus be more laborious in their CDM. Uncertainty affected physicians' CDM when they did not reconcile their professional role with being allowed to be uncertain. This allowance is an important feature of orientation to new knowledge as it facilitates the evaluation of what the physician does not know.For the resident to learn to act as an adaptive decision-maker, she relied on contextual support. The professional role was crucial in decisional competency. This supports current literature, which argues that role clarification helps decisional competency. This study adds that promoting professional development by tolerating uncertainty may improve adaptive decisional competency.

The transferability of laparoscopic and open surgical skills to robotic surgery.

BACKGROUND: Within the last decades, robotic surgery has gained popularity. Most robotic surgeons have changed their main surgical activity from open or laparoscopic without prior formal robotic training. With the current practice, it is of great interest to know whether there is a transfer of surgical skills. In visualization, motion scaling, and freedom of motion, robotic surgery resembles open surgery far more than laparoscopic surgery. Therefore, our hypothesis is that open-trained surgeons have more transfer of surgical skills to robotic surgery, compared to surgeons trained in laparoscopy. METHODS: Thirty-six surgically inexperienced medical students were randomized into three groups for intensive simulation training in an assigned modality: open surgery, laparoscopy, or robot-assisted laparoscopy. The training period was, for all study subjects, followed by performing a robot-assisted bowel anastomosis in a pig model. As surrogate markers of surgical quality, the anastomoses were tested for resistance to pressure, and video recordings of the procedure were evaluated by two blinded expert robotic surgeons, using a global rating scale of robotic operative performance (Global Evaluative Assessment of Robotic Skills (GEARS)). RESULTS: The mean leak pressure of bowel anastomosis was 36.25 (7.62-64.89) mmHg in the laparoscopic training group and 69.01 (28.02-109.99) mmHg in the open surgery group, and the mean leak pressure for the robotic training group was 108.45 (74.96-141.94) mmHg. The same pattern was found with GEARS as surrogate markers of surgical quality. GEARS score was 15.71 (12.37-19.04) in the laparoscopic training group, 18.14 (14.70-21.58) in the open surgery group, and 22.04 (19.29-24.79) in the robotic training group. In comparison with the laparoscopic training group, the robotic training group had a statistically higher leak pressure (p = 0.0015) and GEARS score (p = 0.0023). No significant difference, for neither leak pressure nor GEARS, between the open and the robotic training group. CONCLUSION: In our study, training in open surgery was superior to training in laparoscopy when transitioning to robotic surgery in a simulation setting performed by surgically naive study subjects.

Patient safety culture improvements depend on basic healthcare education: a longitudinal simulation-based intervention study at two Danish hospitals.

BACKGROUND: A growing body of evidence supports the existence of an association between patient safety culture (PSC) and patient outcomes. PSC refers to shared perceptions and attitudes towards norms, policies and procedures related to patient safety. Existing literature shows that PSC varies among health professionals depending on their specific profession and specialty. However, these studies did not investigate whether PSC can be improved. This study investigates whether length of education is associated with improvements in PCS following a simulation intervention. METHODS: From April 2017 to November 2018, a cross-sectional intervention study was conducted at two regional hospitals in Denmark. Two groups with altogether 1230 health professionals were invited to participate. One group included nurses, midwives and radiographers; the other group included doctors. A train-the-trainer intervention approach was applied consisting of a 4-day simulation instructor course that emphasised team training, communication and leadership. Fifty-three healthcare professionals were trained as instructors. After the course, instructors performed in situ simulation in their own hospital environment. OUTCOMES: The Safety Attitude Questionnaire (SAQ), which has 6 dimensions and 32 items, was used to collect main outcome variables. All employees from both groups were surveyed before the intervention and again four and nine months after the intervention. RESULTS: Mean baseline scores were higher among doctors than among nurses, midwives and radiographers for all SAQ dimensions. At the second follow-up, four of six dimensions improved significantly (p ≤ 0.05) among nurses, midwives and radiographers, whereas no dimensions improved significantly among doctors. CONCLUSION: Over time, nurses, midwives and radiographers improved more in PSC attitudes than doctors did.

Simulation-Based Emergency Team Training in Pediatrics: A Systematic Review.

OBJECTIVES: The rare event of handling critically ill children often challenge the emergency care team. Several studies have investigated effects of simulation-based team training to prepare for such events, but the body of evidence remains to be compiled. We performed a systematic review of the effects of simulation-based team training on clinical performance and patient outcome. METHODS: From a search of MEDLINE, Embase, CINAHL, and Cochrane Library, we included studies of team training in emergency pediatric settings with reported clinical performance and patient outcomes. We extracted data using a predefined template and assessed risk of bias using the Cochrane risk-of-bias tool for randomized trials 2.0 and the Newcastle Ottawa Quality Assessment Scale. RESULTS: We screened 1926 abstracts and included 79 studies. We identified 15 studies reporting clinical health care professional performance or patient outcomes. Four studies reported survival data, 5 reported time-critical clinical events, 5 reported adherence to guidelines, checklists or tasks, and 2 reported on airway management. Randomized studies revealed improved team performance in simulated reevaluations 2 to 6 months after intervention. A meta-analysis was impossible because of heterogeneous interventions and outcomes. Most included studies had significant methodological limitations. CONCLUSIONS: Pediatric simulation-based team training improves clinical performance in time-critical tasks and adherence to guidelines. Improved survival was indicated but not concluded because of high risk of bias. Team performance and technical skills improved for at least 2 to 6 months. Future research should include longer-term measures of skill retention and patient outcomes or clinical measures of treatment quality whenever possible.

The transferability of the minimal invasive surgeon's skills to open surgery.

BACKGROUND: Robot-assisted laparoscopic surgery has gained popularity, which has contributed to a decrease in the number of open procedures. Hence a growing concern regarding the ability of laparoscopically trained surgeons to perform open surgery (e.g. due to bleeding complications) has been raised. The aim of the study was to investigate the ability of conversion to open surgery following exclusively robotic or laparoscopic training. METHODS: Thirty-six medical students were randomized into three groups: Open surgery, laparoscopy, and robot-assisted laparoscopy. All underwent intensive simulation training in the allocated surgical modality. Subsequently, all study subjects performed an open bowel anastomosis in a pig model where anastomoses were tested for resistance to pressure and leak as a surrogate marker of surgical quality. RESULTS: The primary endpoint was the surgical quality of an open surgery model assessed as, leak pressure, which was 80.01 ± 36.16 mmHg in the laparoscopic training group, 106.57 ± 23.03 mmHg in the robotic training group, and 133.65 ± 18.32 mmHg in the open surgery training group (mean, SD). We found that there were no significant differences between the open surgery training group and the robotic training group whereas a significant difference was found when comparing laparoscopic and open surgery training groups in favor of open procedure training (p < 0.001). CONCLUSION: In a surrogate open surgery model based on bowel anastomosis, we found that skills acquired through practice on robotic simulation platforms were not significantly worse when compared to skills acquired through training in open surgery, whereas skills acquired from laparoscopic training were significantly poorer when compared to open surgery practice.

Identifying technical skills and clinical procedures in surgery for a simulation-based curriculum: a national general needs assessment.

BACKGROUND: The efficacy of simulation-based training in surgical education is well known. However, the development of training programs should start with problem identification and a general needs assessment to ensure that the content is aligned with current surgical trainee needs. The objective of the present study is to identify the technical skills and clinical procedures that should be included in a simulation-based curriculum in general surgery. METHODS: A national, three-round Delphi process was conducted to achieve consensus on which technical skills and clinical procedures should be included in a simulation-based curriculum in general surgery. In total, 87 key opinion leaders were identified and invited to the study. RESULTS: Round 1 of the Delphi process had a response rate of 64% (56/87) and a total of 245 suggestions. Based on these suggestions, a consolidated list of 51 technical skills or clinical procedures was made. The response rate in Delphi round 2 was 62% (54/87) resulting in a pre-prioritized order of procedures for round 3. The response rate in Delphi round 3 was 65% (35/54). The final list included 13 technical skills and clinical procedures. Training was predominantly requested within general open surgical skills, laparoscopic skills, and endoscopic skills, and a few specific procedures such as appendectomy and cholecystectomy were included in the final prioritized list. CONCLUSION: Based on the Delphi process 13 technical skills and clinical procedures were included in the final prioritized list, which can serve as a point of departure when developing simulation-based training in surgery.

Cardiopulmonary Resuscitation Training for Healthcare Professionals: A Scoping Review.

SUMMARY STATEMENT: The optimal strategy for training cardiopulmonary resuscitation (CPR) for healthcare professionals remains to be determined. This scoping review aimed to describe the emerging evidence for CPR training for healthcare professionals.We screened 7605 abstracts and included 110 studies in this scoping review on CPR training for healthcare professionals. We assessed the included articles for evidence for the following topics: training duration, retraining intervals, e-learning, virtual reality/augmented reality/gamified learning, instructor-learner ratio, equipment and manikins, other aspects of contextual learning content, feedback devices, and feedback/debriefing. We found emerging evidence supporting the use of low-dose, high-frequency training with e-learning to achieve knowledge, feedback devices to perform high-quality chest compressions, and in situ team simulations with debriefings to improve the performance of provider teams.

The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis.

INTRODUCTION: Little is known about the optimal simulation-based team training in obstetric emergencies. We aimed to review how simulation-based team training affects patient outcomes in obstetric emergencies. MATERIAL AND METHODS: Search Strategy: MEDLINE, Embase, Cochrane Library, and Cochrane Central Register of Controlled Trials were searched up to and including May 15, 2021. SELECTION CRITERIA: randomized controlled trials (RCTs) and cohort studies on obstetric teams in high-resource settings comparing the effect of simulation-based obstetric emergency team training with no training on the risk of Apgar scores less than 7 at 5 min, neonatal hypoxic ischemic encephalopathy, severe postpartum hemorrhage, blood transfusion of four or more units, and delay of emergency cesarean section by more than 30 min. DATA COLLECTION AND ANALYSIS: The included studies were assessed using PRISMA, EPCO, and GRADE. RESULTS: We found 21 studies, four RCTs and 17 cohort studies, evaluating patient outcomes after obstetric team training compared with no training. Annual obstetric emergency team training may reduce brachial plexus injury (six cohort studies: odds ratio [OR] 0.47, 95% CI 0.33-0.68; one RCT: OR 1.30, 95 CI% 0.39-4.33, low certainty evidence) and suggest a positive effect; but it was not significant on Apgar score below 7 at 5 min (three cohort studies: OR 0.77, 95% CI 0.51-1.19; two RCT: OR 0.87, 95% CI 0.72-1.05, moderate certainty evidence). The effect was unclear for hypoxic ischemic encephalopathy, umbilical prolapse, decision to birth interval in emergency cesarean section, and for severe postpartum hemorrhage. Studies with in situ multi-professional simulation-based training demonstrated the best effect. CONCLUSIONS: Emerging evidence suggests an effect of obstetric team training on obstetric outcomes, but conflicting results call for controlled trials targeted to identify the optimal methodology for effective team training.

Simulation-Based Neonatal Resuscitation Team Training: A Systematic Review.

CONTEXT: Several neonatal simulation-training programs have been deployed during the last decade, and in a growing number of studies, researchers have investigated the effects of simulation-based team training. This body of evidence remains to be compiled. OBJECTIVE: We performed a systematic review of the effects of simulation-based team training on clinical performance and patient outcome. DATA SOURCES: Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library. STUDY SELECTION: Two authors included studies of team training in critical neonatal situations with reported outcomes on clinical performance and patient outcome. DATA EXTRACTION: Two authors extracted data using a predefined template and assessed risk of bias using the Cochrane risk-of-bias tool 2.0 and the Newcastle-Ottawa quality assessment scale. RESULTS: We screened 1434 titles and abstracts, evaluated 173 full texts for eligibility, and included 24 studies. We identified only 2 studies with neonatal mortality outcomes, and no conclusion could be reached regarding the effects of simulation training in developed countries. Considering clinical performance, randomized studies revealed improved team performance in simulated re-evaluations 3 to 6 months after the intervention. LIMITATIONS: Meta-analysis was impossible because of heterogenous interventions and outcomes. Kirkpatrick's model for evaluating training programs provided the framework for a narrative synthesis. Most included studies had significant methodologic limitations. CONCLUSIONS: Simulation-based team training in neonatal resuscitation improves team performance and technical performance in simulation-based evaluations 3 to 6 months later. The current evidence was insufficient to conclude on neonatal mortality after simulation-based team training because no studies were available from developed countries. In future work, researchers should include patient outcomes or clinical proxies of treatment quality whenever possible.

Patient safety culture improves during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites.

OBJECTIVES: This study aimed to investigate staff's perceptions of patient safety culture (PSC) in two Danish hospitals before and after an in situ simulation intervention. DESIGN: A repeated cross-sectional intervention study. SETTING: Two Danish hospitals. Hospital 1 performs emergency functions, whereas hospital 2 performs elective functions. PARTICIPANTS: A total of 967 healthcare professionals were invited to participate in this study. 516 were employed in hospital 1 and 451 in hospital 2. Of these, 39 were trained as simulation instructors. INTERVENTION: A 4-day simulation instructor course was applied. Emphasis was put on team training, communication and leadership. After the course, instructors performed simulation in the hospital environment. No systematic simulation was performed prior to the intervention. MAIN OUTCOME MEASURES: The Safety Attitude Questionnaire investigating PSC was applied prior to the intervention and again 4 and 8 weeks after intervention. The proportion of participants with a positive attitude and mean scale scores were measured as main outcomes. RESULTS: The response rate varied from 63.6% to 72.0% across surveys and hospitals. Baseline scores were generally lower for hospital 1. The proportion of staff with positive attitudes in hospital 1 improved by ≥5% in five of six safety culture dimensions, whereas only two dimensions improved by ≥5% in hospital 2. The mean scale scores improved significantly in five of six safety culture dimensions in hospital 1, while only one dimension improved significantly in hospital 2. CONCLUSIONS: Safety attitude outcomes indicate an improvement in PSC from before to after the in situ simulation intervention period. However, it is possible that an effect is more profound in an acute care hospital versus an elective setting.

Simulation-based team training in time-critical clinical presentations in emergency medicine and critical care: a review of the literature.

BACKGROUND: The use of simulation-based team training has increased over the past decades. Simulation-based team training within emergency medicine and critical care contexts is best known for its use by trauma teams and teams involved in cardiac arrest. In the domain of emergency medicine, simulation-based team training is also used for other typical time-critical clinical presentations. We aimed to review the existing literature and current state of evidence pertaining to non-technical skills obtained via simulation-based team training in emergency medicine and critical care contexts, excluding trauma and cardiac arrest contexts. METHODS: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Before the initiation of the study, the protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database. We conducted a systematic literature search of 10 years of publications, up to December 17, 2019, in the following databases: PubMed/MEDLINE, EMBASE, Cochrane Library, and CINAHL. Two authors independently reviewed all the studies and extracted data. RESULTS: Of the 456 studies screened, 29 trials were subjected to full-text review, and 13 studies were included in the final review. None of the studies was randomized controlled trials, and no studies compared simulation training to different modalities of training. Studies were heterogeneous; they applied simulation-training concepts of different durations and intensities and used different outcome measures for non-technical skills. Two studies reached Kirkpatrick level 3. Out of the remaining 11 studies, nine reached Kirkpatrick level 2, and two reached Kirkpatrick level 1. CONCLUSIONS: The literature on simulation-based team training in emergency medicine is heterogeneous and sparse, but somewhat supports the hypothesis that simulation-based team training is beneficial to teams' knowledge and attitudes toward non-technical skills (Kirkpatrick level 2). Randomized trials are called for to clarify the effect of simulation compared to other modalities of team training. Future research should focus on the transfer of skills and investigate improvements in patient outcomes (Kirkpatrick level 4).

An in situ simulation program: a quantitative and qualitative prospective study identifying latent safety threats and examining participant experiences.

OBJECTIVE: To explore the impact of in situ simulation training in regard to identification of latent safety threats and participant experiences. DESIGN: A prospective study including quantitative and qualitative measures. SETTING: A Danish hospital shifted from simulation training in centers outside the hospital to training where simulation was conducted where the situations normally took place and with the normal working teams. PARTICIPANTS: A total of 58 local instructors were educated and subsequently conducted in situ simulations in own departments. After each simulation, a log file was completed containing information on location, the scenario, who took part, time, learning points and findings. Furthermore, interviews were conducted with leaders, instructors and simulation participants. MAIN OUTCOME MEASURES: Identified latent safety threats and participant experiences. RESULTS: From June 2017 until December 2018, 323 simulations were conducted representing 35 different wards. They consisted of 40 different scenarios and had both technical and non-technical learning goals. A total of 35 organizational issues were uncovered via the in situ simulation and practice was adjusted accordingly. A total of 11 interviews were conducted. Four themes emerged from the analysis: practice-orientation, endorsement, sense of security and additional impact. CONCLUSION: Transferring simulation to in situ training resulted in a substantial number of organizational findings. The subsequent follow-up and changes in practice made awareness of what could be latent safety threats. Leaders, instructors and simulation participants experienced in situ simulation as relevant and profitable.

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.

Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine.

BACKGROUND: Clinical decision-making (CDM) is an important competency for young doctors especially under complex and uncertain conditions in geriatric emergency medicine (GEM). However, research in this field is characterized by vague conceptualizations of CDM. To evolve and evaluate evidence-based knowledge of CDM, it is important to identify different definitions and their operationalizations in studies on GEM. OBJECTIVE: A scoping review of empirical articles was conducted to provide an overview of the documented evidence of findings and conceptualizations of CDM in GEM. METHODS: A detailed search for empirical studies focusing on CDM in a GEM setting was conducted in PubMed, ProQuest, Scopus, EMBASE and Web of Science. In total, 52 publications were included in the analysis, utilizing a data extraction sheet, following the PRISMA guidelines. Reported outcomes were summarized. RESULTS: Four themes of operationalization of CDM emerged: CDM as dispositional decisions, CDM as cognition, CDM as a model, and CDM as clinical judgement. Study results and conclusions naturally differed according to how CDM was conceptualized. Thus, frailty-heuristics lead to biases in treatment of geriatric patients and the complexity of this patient group was seen as a challenge for young physicians engaging in CDM. CONCLUSIONS: This scoping review summarizes how different studies in GEM use the term CDM. It provides an analysis of findings in GEM and call for more stringent definitions of CDM in future research, so that it might lead to better clinical practice.