Evaluations for New Healthcare Environment Commissioning and Operational Decision Making Using Simulation and Human Factors: A Case Study of an Interventional Trauma Operating Room.

PURPOSE: The aim of this article is to provide a case study example of the preopening phase of an interventional trauma operating room (ITOR) using systems-focused simulation and human factor evaluations for healthcare environment commissioning. BACKGROUND: Systems-focused simulation, underpinned by human factors science, is increasingly being used as a quality improvement tool to test and evaluate healthcare spaces with the stakeholders that use them. Purposeful real-to-life simulated events are rehearsed to allow healthcare teams opportunity to identify what is working well and what needs improvement within the work system such as tasks, environments, and processes that support the delivery of healthcare services. This project highlights salient evaluation objectives and methods used within the clinical commissioning phase of one of the first ITORs in Canada. METHODS: A multistaged evaluation project to support clinical commissioning was facilitated engaging 24 stakeholder groups. Key evaluation objectives highlighted include the evaluation of two transport routes, switching of operating room (OR) tabletops, the use of the C-arm, and timely access to lead in the OR. Multiple evaluation methods were used including observation, debriefing, time-based metrics, distance wheel metrics, equipment adjustment counts, and other transport route considerations. RESULTS: The evaluation resulted in several types of data that allowed for informed decision making for the most effective, efficient, and safest transport route for an exsanguinating trauma patient and healthcare team; improved efficiencies in use of the C-arm, significantly reduced the time to access lead; and uncovered a new process for switching OR tabletop due to safety threats identified.

Simulation and Active Learning Decreases Training Time of an Emergency Triage Assessment and Treatment Course in Pilot Study in Malawi: Implications for Increasing Efficiency and Workforce Capacity in Low-Resource Settings.

OBJECTIVES: The aim of the Emergency Triage Assessment and Treatment (ETAT) plus trauma course is to improve the quality of care provided to infants and children younger than 5 years. The curriculum was revised and shortened from 5 to 2.5 days by enhancing simulation and active learning opportunities. The aim of this study was to examine the feasibility and value of the new short-form ETAT course by assessing postcourse knowledge and satisfaction. METHODS: We delivered the short-form ETAT course to a group of interdisciplinary health workers in Malawi. Precourse and postcourse knowledge was assessed using a standardized 20 questions short answer test used previously in the 5-day courses. A 13-statement survey with 2 open-ended questions was used to examine participant satisfaction. RESULTS: Participants' postcourse knowledge improved significantly (P < 0.001) after the shorter ETAT course. Participants reported high levels of satisfaction with the short-form ETAT. CONCLUSIONS: Simulation and other active learning strategies reduced training time by 50% in the short-form ETAT course. Participants with and without previous ETAT training improved their knowledge after participating in the short-form ETAT course. Reduced training time is beneficial in settings already burdened by scarce human resources, may facilitate better access to in-service training, and build capacity while conserving resources in low-resource settings.

Rater training for standardised assessment of Objective Structured Clinical Examinations in rural Tanzania.

OBJECTIVES: To describe a simulation-based rater training curriculum for Objective Structured Clinical Examinations (OSCEs) for clinician-based training for frontline staff caring for mothers and babies in rural Tanzania. BACKGROUND: Rater training for OSCE evaluation is widely embraced in high-income countries but not well described in low-income and middle-income countries. Helping Babies Breathe, Essential Care for Every Baby and Bleeding after Birth are standardised training programmes that encourage OSCE evaluations. Studies examining the reliability of assessments are rare. METHODS: Training of raters occurred over 3 days. Raters scored selected OSCEs role-played using standardised learners and low-fidelity mannikins, assigning proficiency levels a priori. Researchers used Zabar's criteria to critique rater agreement and mitigate measurement error during score review. Descriptive statistics, Fleiss' kappa and field notes were used to describe results. RESULTS: Six healthcare providers scored 42 training scenarios. There was moderate rater agreement across all OSCEs (κ=0.508). Kappa values increased with Helping Babies Breathe (κ=0.28-0.48) and Essential Care for Every Baby (κ=0.42-0.77) by day 3 of training, but not with Bleeding after Birth (κ=0.58-0.33). Raters identified average proficiency 50% of the time. CONCLUSION: Our study shows that the in-country raters in this study had a hard time identifying average performance despite moderate rater agreement. Rater training is critical to ensure that the potential of training programmes translates to improved outcomes for mothers and babies; more research into the concepts and training for discernment of competence in this setting is necessary.

A Simulation Scenario Focused on Resuscitation of a Young Infant (Neonate) for Nurses and Midwives in Malawi, a Limited Resource Country.

Despite the improvement in neonatal and infant mortality rates in Malawi, statistics still identify 27 neonatal mortalities per 1,000 live births and 42 infant mortalities per 1,000 live births. These figures are still unacceptably high. The common causes of neonatal death are prematurity (37%), intrapartum-related complications (28%), and severe infection (24%). These causes create an opportunity to further improve the mortality rates in both populations with a focus on improving the clinical skills of nursing and midwifery students in Malawi. Training to recognize when an infant requires resuscitation, as well as how to perform resuscitative and post-resuscitative care, may help to reduce Malawi's infant mortality rate in the future.

Management of an Obstructed Tracheostomy in a Limited-Resource Setting.

Obstruction of a tracheostomy tube is a common cause of respiratory compromise in adults and pediatric patients, which can lead to a life-threatening emergency if it is not properly managed. Compromised airway patency has many potential etiologies; however, the scenario described in this technical report focuses specifically on the management of tracheostomy obstruction through the presence of a mucus plug, blood clot, or highly viscous secretions. The simulation described in this technical report was written to be conducted as an in-situ simulation within the intensive care unit (ICU) at Mzuzu Central Hospital, Malawi. The novel aspect of this report is that it depicts the integration of low-tech simulation with a deteriorating patient scenario educational methodology. This integration enables the use of affordable and sustainable simulation materials in Malawi context to deliver learning objectives that are otherwise not achievable. It was designed to train nurses, clinical officers, and nursing students from the ICU and male/female surgical wards. It can be utilized to train similar learners in other resource-poor regions of the world, as well as remote areas of the more developed countries.

The "Empty Chairs" Approach to Learning: Simulation-Based Train the Trainer Program in Mzuzu, Malawi.

Together, a group of Canadian colleagues from St. John's, Newfoundland, Calgary, Alberta (some via Doha) and London, Ontario introduced the first Train the Trainer in Simulation-Based Learning (TTT-SBL) program in Mzuzu Central Hospital and Mzuzu University in Malawi. The team led by Elaine Sigalet (Doha) and consisting of Ian Wishart (Calgary), Faizal Haji (London) and Adam Dubrowski (St. John's) was invited to Malawi by Norman Lufesi to conduct a two-day TTT-SBL course for facilitators who teach an Emergency Triage, Assessment and Treatment (ETAT) plus Trauma course. The following technical report describes this course.  All trainees-facilitators who took part in the first iteration of the TTT-SBL course were asked to participate in teaching an ETAT course and modify it to include elements of simulation. The new format of ETAT resulted in a reduction of time necessary to conduct the course from four days (based on historical data) to 2.5 days.

Insight into team competence in medical, nursing and respiratory therapy students.

This study provides information for educators about levels of competence in teams comprised of medical, nursing and respiratory therapy students after receiving a simulation-based team-training (SBT) curriculum with and without an additional formalized 30-min team-training (TT) module. A two-group pre- and post-test research design was used to evaluate team competence with respect to leadership, roles and responsibilities, communication, situation awareness and resource utilization. All scenarios were digitally recorded and evaluated using the KidSIM Team Performance Scale by six experts from medicine, nursing and respiratory therapy. The lowest scores occurred for items that reflected situation awareness. All teams improved their aggregate scores from Time 1 to Time 2 (p < 0.05). Student teams in the intervention group achieved significantly higher performance scores at Time 1 (Cohen's d = 0.92, p < 0.001) and Time 2 (d = 0.61, p < 0.01). All student teams demonstrated significant improvement in their ability to work more effectively by Time 2. The results suggest that situational awareness is an advanced expectation for the undergraduate student team. The provision of a formalized TT module prior to engaging student teams in a simulation-based TT curriculum led to significantly higher performances at Time 1 and 2.

A simulation-based intervention teaching seizure management to caregivers: A randomized controlled pilot study.

OBJECTIVES: To examine the effect of simulation-based seizure management teaching on improving caregiver competence and reported confidence with managing seizures. The authors hypothesized that simulation-based education would lead to a higher level of demonstrated competence and reported confidence in family members and caregivers. Simulation has not been previously studied in this context. METHODS: A two-group pre- and post-test experimental research design involving a total of 61 caregivers was used. The intervention was a simulation-based seizure curriculum delivered as a supplement to traditional seizure discharge teaching. Caregiver performance was analyzed using a seizure management checklist. Caregivers' perception of self-efficacy was captured using a self-efficacy questionnaire. RESULTS: Caregivers in the experimental group achieved significantly higher postintervention performance scores than caregivers in the control group in both premedication and postmedication seizure management (P<0.01). Additionally, they achieved significantly higher scores on the self-efficacy questionnaire including items reflecting confidence managing the seizure at home (P<0.05). CONCLUSION: Caregivers receiving the supplemental simulation-based curriculum achieved significantly higher levels of competence and reported confidence, supporting a positive relationship between simulation-based seizure discharge education, and caregiver competence and confidence in managing seizures. Simulation sessions provided insight into caregiver knowledge but, more importantly, insight into the caregiver's ability to apply knowledge under stressful conditions, allowing tailoring of curriculum to meet individual needs. These findings may have applications and relevance for management of other acute or chronic medical conditions.

OBJECTIFS: Examiner l'effet de l'enseignement de la prise en charge des convulsions par simulation pour améliorer les compétences des soignants et leur confiance déclarée à traiter les convulsions. Les auteurs postulent que l'enseignement par simulation accroîtrait les compétences démontrées et la confiance déclarée des membres de la famille et des soignants. La simulation n'a jamais été étudiée dans ce contexte. MÉTHODOLOGIE: Une méthodologie de recherche expérimentale en deux groupes avant et après le test a été privilégiée auprès de 61 soignants. L'intervention consistait en un cours par simulation sur les convulsions donné en plus de l'enseignement habituel sur les convulsions présenté au congé. Le rendement des soignants a été analysé au moyen d'une liste de vérification de la prise en charge des convulsions. La perception d'auto-efficacité du soignant a été saisie au moyen d'un questionnaire d'auto-efficacité. RÉSULTATS: Les soignants du groupe expérimental ont obtenu des indices de rendement considérablement plus élevés après l'intervention que ceux du groupe témoin, tant avant qu'après la prise en charge des convulsions par médication (P<0,01). De plus, ils ont obtenu des indices considérablement plus élevés au questionnaire d'auto-efficacité, y compris les questions reflétant la confiance à soigner les convulsions à domicile (P<0,05). CONCLUSION: Les soignants qui avaient eu un cours par simulation ont obtenu des taux de compétence et de confiance déclarée beaucoup plus élevés. Ces résultats corroborent la relation positive entre l'enseignement sur les convulsions par simulation au congé et la compétence et la confiance des soignants envers la prise en charge des convulsions. Les séances de simulation donnaient un aperçu des compétences des soignants, mais, surtout, de leur capacité à appliquer leurs connaissances dans des conditions stressantes, ce qui permet d'adapter le cours à leurs besoins. Ces observations peuvent être utiles et pertinentes pour la prise en charge d'autres maladies aiguës ou chroniques.

Development of a team performance scale to assess undergraduate health professionals.

PURPOSE: Interprofessional simulation-based team training is strongly endorsed as a potential solution for improving teamwork in health care delivery. Unfortunately, there are few teamwork evaluation instruments. The present study developed and tested the psychometric characteristics of the newly developed KidSIM Team Performance Scale checklist. METHOD: A quasi-experimental research design engaging a convenience sample of 196 undergraduate medical, nursing, and respiratory therapy students was completed in the 2010-2011 academic year. Multidisciplinary student teams participated in a simulation-based curriculum that included the completion of two acute illness management scenarios, resulting in 282 independent reviews by evaluators from medicine, nursing, and respiratory therapy. The authors investigated the underlying factors of the performance checklist and examined the performance scores of an experimental and a control team-training-curriculum group. RESULTS: Participation in the supplemental team training curriculum was related to higher team performance scores (P < .001). All teams at Time 2 achieved higher scores than at Time 1 (P < .05). The reliability coefficient for the total performance scale was α = 0.90. Factor analysis supported a three-factor solution (accounting for 67.9% of the variance) with an emphasis on roles and responsibilities (five items) and communication (six items) subscale factors. CONCLUSIONS: When simulation is used in acute illness management training, the KidSIM Team Performance Scale provides reliable, valid score interpretation of undergraduates' team process based on communication effectiveness and identification of roles and responsibilities. Implementation of a supplementary team training curriculum significantly enhances students' performance in multidisciplinary simulation-based scenarios at the undergraduate level.

Undergraduate students' perceptions of and attitudes toward a simulation-based interprofessional curriculum: the KidSIM ATTITUDES questionnaire.

INTRODUCTION: Existing attitude scales on interprofessional education (IPE) focus on students' attitudes toward the concepts of teamwork and opportunities for IPE but fail to examine student perceptions of the learning modality that also plays an important role in the teaching and learning process. The purpose of this present study was to test the psychometric characteristics of the KidSIM Attitude Towards Teamwork in Training Undergoing Designed Educational Simulation (ATTITUDES) questionnaire developed to measure student perceptions of and attitudes toward IPE, teamwork, and simulation as a learning modality. METHODS: A total of 196 medical, nursing, and respiratory therapy students received a 3-hour IPE curriculum module that focused on 2 simulation-based team training scenarios in emergency and intensive care unit settings. Each multiprofessional group of students completed the 30-item ATTITUDES questionnaire before participating in the IPE curriculum and the same questionnaire again as a posttest on completion of the high-fidelity simulation, team-based learning sessions. RESULTS: The internal reliability of the ATTITUDES questionnaire was α = 0.95. The factor analysis supports a 5-factor solution accounting for 61.6% of the variance: communication (8 items), relevance of IPE (7 items), relevance of simulation (5 items), roles and responsibilities (6 items), and situation awareness (4 items). Aggregated and profession-specific analysis of students' responses using paired sample t tests showed significant differences from the pretest to the posttest for all questionnaire items and subscale measures (P < 0.001). CONCLUSIONS: The KidSIM ATTITUDES questionnaire provides a reliable and construct valid measure of student perceptions of and attitudes toward IPE, teamwork, and simulation as a learning modality.