Translational simulation revisited: an evolving conceptual model for the contribution of simulation to healthcare quality and safety.

The simulation community has effectively responded to calls for a more direct contribution by simulation to healthcare quality and safety, and clearer alignment with health service priorities, but the conceptual framing of this contribution has been vague. The term 'translational simulation' was proposed in 2017 as a "functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions" (Brazil V. Adv Simul. 2:20, 2017). Six years later, this conceptual framing is clearer. Translational simulation has been applied in diverse contexts, affording insights into its strengths and limitations. Three core concepts are identifiable in recently published translational simulation studies: a clear identification of simulation purpose, an articulation of the simulation process, and an engagement with the conceptual foundations of translational simulation practice. In this article, we reflect on current translational simulation practice and scholarship, especially with respect to these three core concepts, and offer a further elaborated conceptual model based on its use to date.

Faculty development for translational simulation: a qualitative study of current practice.

BACKGROUND: Translational simulation is focused directly on healthcare quality, safety, and systems. Effective translational simulation design and delivery may require knowledge and skills in areas like quality improvement and safety science. How translational simulation programs support their faculty to learn these skills is unknown. We aimed to explore current faculty development practices within translational simulation programs, and the rationale for the approaches taken. METHODS: We used a qualitative approach to explore faculty development in translational simulation programs. We conducted semi-structured interviews with representatives who have leadership and/or faculty development responsibilities in these programs and performed a thematic analysis of the data. RESULTS: Sixteen interviews were conducted with translational simulation program leaders from nine countries. We identified three themes in our exploration of translational simulation faculty development practices: (1) diverse content, (2) 'home-grown', informal processes, and (3) the influence of organisational context. Collaboration beyond the historical boundaries of the healthcare simulation community was an enabler across themes. CONCLUSION: Leaders in translational simulation programs suggest a diverse array of knowledge and skills are important for translational simulation faculty and report a range of informal and formal approaches to the development of these skills. Many programs are early in the development of their approach to faculty development, and all are powerfully influenced by their context; the program aims, structure, and strategy.

Recommendations for embedding simulation in health services.

Aspirations to achieve quality and safety goals in health services through simulation have led to significant investments in simulation equipment, space and faculty. However, the optimal governance and operational models through which these resources are expertly applied in health services are not known. There is growing evidence supporting 'service' models for simulation. In these models, simulation activities are co-designed and delivered by a team of simulation experts in partnership with health service units, specifically targeting quality and safety goals. Embedded simulation specialist teams working within these programs offer benefits not fully captured by traditional models of health education or by traditional systems for quality and safety.In this article, we explore broad and specific recommendations for establishing a simulation consultancy service within an Australian metropolitan health service. We base these recommendations on a review of current Australian practice and healthcare simulation literature, and on a specific example within a large outer metropolitan health service. The broad domains discussed include (1) governance and leadership; (2) human resources; (3) principles and planning; (4) operationalise and evaluate and (5) look to the future.The recommendations recognise that healthcare simulation is moving beyond solely addressing individual learning outcomes. The value of simulation addressing organisation and system objectives through various simulation modalities is increasingly being explored and demonstrating value. There is a growing demand for translational simulation in these contexts, and a consequent requirement for organisations to consider how simulation services can be successfully operationalised. Recommendations included in this paper are discussed and described with the intent of facilitating a deeper appreciation of the complexities associated with, and opportunities afforded by, a well-integrated simulation service.

Developing residents' feedback literacy in emergency medicine: Lessons from design-based research.

Objectives: Residents in emergency medicine have reported dissatisfaction with feedback. One strategy to improve feedback is to enhance learners' feedback literacy-i.e., capabilities as seekers, processors, and users of performance information. To do this, however, the context in which feedback occurs needs to be understood. We investigated how residents typically engage with feedback in an emergency department, along with the potential opportunities to improve feedback engagement in this context. We used this information to develop a program to improve learners' feedback literacy in context and traced the reported translation to practice. Methods: We conducted a year-long design-based research study informed by agentic feedback principles. Over five cycles in 2019, we interviewed residents and iteratively developed a feedback literacy program. Sixty-six residents participated and data collected included qualitative evaluation surveys (n = 55), educator-written reflections (n = 5), and semistructured interviews with residents (n = 21). Qualitative data were analyzed using framework analysis. Results: When adopting an agentic stance, residents reported changes to the frequency and tenor of their feedback conversations, rendering the interactions more helpful. Despite reporting overall shifts in their conceptions of feedback, they needed to adjust their feedback engagement depending on changing contextual factors such as workload. These microsocial adjustments suggest their feedback literacy develops through an interdependent process of individual intention for feedback engagement-informed by an agentic stance-and dynamic adjustment in response to the environment. Conclusions: Resident feedback literacy is profoundly contextualized, so developing feedback literacy in emergency contexts is more nuanced than previously reported. While feedback literacy can be supported through targeted education, our findings raise questions for understanding how emergency medicine environments afford and constrain learner feedback engagement. Our findings also challenge the extent to which this contextual feedback know-how can be "developed" purposefully outside of the everyday work.

You are in charge now: exploration of educational relationships between anaesthetic trainees and their supervising specialists.

Background: Much of the education during anaesthesia training occurs in the workplace where trainees work under the close supervision of a more senior anaesthetist. Trainee anaesthetists are exposed to multiple supervisors with whom they form educational and supervisory relationships over the course of their training. Surprisingly little research has been conducted to explore the factors behind the development and maintenance of these relationships. This study explores the process of how education occurs in the workplace by examining the relationship from the perspective of both trainees and specialists. Methods: This is an exploratory qualitative study. Eight trainee and 10 specialist anaesthetists participated in an individual semi-structured interview. The data were analysed thematically by each of the authors to generate themes. Results: Six themes were identified in the analysis: (1) sizing up; (2) negotiated autonomy; (3) working closely together; (4) workplace practices; (5) education being valued; and (6) gender. A conceptual model to illustrate the relationships between the six themes was developed. Conclusions: Supervisory relationships were viewed positively by participants despite impediments such as lack of continuity and busy clinical environments. But there were tensions, particularly in balancing trainee autonomy with patient safety. A nuanced 'sizing up' process, with negotiation of autonomy, was described by both supervisors and trainees. Our findings may support supervisory relationships to reach this ideal more effectively.

Exploring participant experience to optimize the design and delivery of stress exposure simulations in emergency medicine.

Objectives: Emergency department (ED) teams frequently perform under conditions of high stress. Stress exposure simulation (SES) is specifically designed to train recognition and management of stress responses under these conditions. Current approaches to design and delivery of SES in emergency medicine are based on principles derived from other contexts and from anecdotal experience. However, the optimal design and delivery of SES in emergency medicine are not known. We aimed to explore participant experience to inform our approach. Methods: We performed an exploratory study in our Australian ED with doctors and nurses participating in SES sessions. We used a three-part framework-sources of stress, the impacts of that stress, and the strategies to mitigate-to inform our SES design and delivery and to guide our exploration of participant experience. Data were collected through a narrative survey and participant interviews and analyzed thematically. Results: There were 23 total participants (doctors n = 12, nurses n = 11) across the three sessions. Sixteen survey responses and eight interview transcripts were analyzed, each with equal numbers of doctors and nurses. Five themes were identified in data analysis: (1) experience of stress, (2) managing stress, (3) design and delivery of SES, (4) learning conversations, and (5) transfer to practice. Conclusions: We suggest that design and delivery of SES should follow health care simulation best practice, with stress adequately induced by authentic clinical scenarios and to avoid trickery or adding extraneous cognitive load. Facilitators leading learning conversations in SES sessions should develop a deep understanding of stress and emotional activation and focus on team-based strategies to mitigate harmful impacts of stress on performance.

Exploring equity, diversity, and inclusion in a simulation program using the SIM-EDI tool: the impact of a reflexive tool for simulation educators.

BACKGROUND: There have been increasing calls for awareness and action related to equity, diversity, and inclusion (EDI) in simulation but a lack of practical guidance for how simulation delivery teams (SDTs) might move towards meaningful transformation. The gap between academic conversations about EDI and how to practically impact SDT attitudes, behaviors, and performance remains considerable. We designed a conversational tool, the SIM-EDI, to bridge the gap between theory and practice for SDTs by enhancing reflexivity and studied its impact locally. METHODS: We engaged in a collaborative autoethnography to explore EDI within our emergency department SDT shortly after implementing the SIM-EDI. The 12-month ethnography is informed by our team's collection and analysis of data about ourselves and our own experiences using the tool. Data included serial interviews, field notes from simulations and SDT meetings, SDT documents, and self-reflections. RESULTS: We found the SIM-EDI tool could be implemented with a team with a high level of readiness. Use of the tool had several meaningful impacts including enhanced team reflexivity, normalization of conversations related to EDI and increased confidence to engage in EDI conversations with participants. Key themes throughout the process included (1) individual and team growth, (2) fear of "getting it wrong", and (3) tension between bias towards action and need for slow reflection. CONCLUSION: The SIM-EDI tool can effectively promote reflexivity among faculty in an emergency department simulation program. The tool is easy to use and implement, impacts attitudes and behaviors, and facilitates individual and team growth.

Psychological safety and emergency department team performance: A mixed-methods study.

OBJECTIVES: Team culture underpins team performance. Psychological safety - 'a shared belief held by members of a team that the team is safe for interpersonal risk taking' - is a critical component of team culture for high-performing teams across contexts. However, psychological safety in ED teams has not been well explored. We aimed to explore this core teamwork concept in the ED. METHODS: This was a sequential mixed-methods study of nursing and medical staff at a large tertiary care ED in Australia from October 2020 to March 2021. First, participants completed the 'Team Learning and Psychological Safety Survey' and a narrative questionnaire. These findings informed semi-structured interviews. We determined median psychological safety and compared results across role and length of time working in the department. Qualitative results were analysed using a deductive thematic analysis using a previously generated framework for enablers of psychological safety at the individual, team and organisational levels. RESULTS: The survey was completed by 72/410 participants and 19 interviews were conducted. The median psychological safety score was 37/49 (IQR 13). Psychological safety was not experienced universally, with nurses and new staff experiencing lower levels. Individual, team and organisational factors impacted psychological safety. The primary force shaping psychological safety was familiarity with colleagues and leaders. CONCLUSION: Familiarity of team members and leaders was critical to the development of psychological safety within the ED. Fostering familiarity should be a focus for frontline leadership each shift and a priority in broader departmental decisions for those seeking to enhance the psychological safety of their teams.

Wearing hats and blending boundaries: harmonising professional identities for clinician simulation educators.

Many clinicians working in healthcare simulation struggle with competing dual identities of clinician and educator, whilst those who harmonise these identities are observed to be highly effective teachers and clinicians. Professional identity formation (PIF) theories offer a conceptual framework for considering this dilemma. However, many clinician simulation educators lack practical guidance for translating these theories and are unable to develop or align their dual identities.An unusual experience involving the first author's suspension of disbelief as a simulation facilitator sparked a novel reflection on his dual identity as a clinician and as a simulation educator. He re-framed his clinician and simulation 'hats' as cooperative and fluid rather than competing and compartmentalised. He recognised that these dual identities could flow between clinical and simulation environments through leaky 'blended boundaries' rather than being restricted by environmental demarcations.This personal story is shared and reflected upon to offer a practical 'hats and boundaries' model. Experimenting with the model in both clinical and simulation workplaces presents opportunities for PIF and alignment of dual identities. The model may help other clinician simulation educators navigate the complexities of merging their dual identities.

A relational approach to improving interprofessional teamwork in post-partum haemorrhage (PPH).

BACKGROUND: Post-partum haemorrhage (PPH) is an obstetric emergency that requires effective teamwork under complex conditions. We explored healthcare team performance for women who suffered a PPH, focusing on relationships and culture as critical influences on teamwork behaviours and outcomes. METHODS: In collaboration with clinical teams, we implemented structural, process and relational interventions to improve teamwork in PPH cases. We were guided by the conceptual framework of Relational Coordination and used a mixed methods approach to data collection and analysis. We employed translational simulation as a central, but not singular, technique for enabling exploration and improvement. Key themes were identified from surveys, focus groups, simulation sessions, interviews, and personal communications over a 12-month period. RESULTS: Four overarching themes were identified: 1) Teamwork, clear roles and identified leadership are critical. 2) Relational factors powerfully underpin teamwork behaviours-shared goals, shared knowledge, and mutual respect. 3) Conflict and poor relationships can and should be actively explored and addressed to improve performance. 4) Simulation supports improved team performance through multifaceted mechanisms. One year after the project commenced, significant progress had been made in relationships and systems. Clinical outcomes have improved; despite unprecedented increase in labour ward activity, there has not been any increase in large PPHs. CONCLUSIONS: Teamwork, relationships, and the context of care can be actively shaped in partnership with clinicians to support high performance in maternity care. We present our multifaceted approach as a guide for leaders and clinicians in maternity teams, and as an exemplar for others enacting quality improvement in healthcare.

Self-assessment: With all its limitations, why are we still measuring and teaching it? Lessons from a scoping review.

INTRODUCTION: Self-Assessment (SA) is often assumed to be essential for learning, however, this assumption has been extensively rebutted. Research shows SA has significant limitations, including its lack of correlation with competence. METHOD: We undertook a scoping review of SA in medical education (2011-2021) and surprisingly discovered substantial research where SA was erroneously assumed to be a valid measure of successful learning, or a skill needing to be taught. Although the initial intent of our scoping review was to explore where SA is being effectively used to advance lifelong learning, we paused to explore the extent of the problem of its misuse and resulting in wasted research, by examining excluded studies. RESULTS: From 1151 articles, we identified 207 which ignored the documented limitations of SA. Thirty-nine studies explored SA of learning. This research has limited utility: increasing the accuracy of SA does not improve performance or lifelong learning. One hundred and sixty-eight used SA as an outcome measure to assess a program or intervention, including 63 where self-assessed improvement in knowledge/skills was the sole measure. SA of self-confidence was measured in 62 studies. When confidence was compared with an objective measure of performance, both invariably increased, but confidence did not always align with competence when measured. DISCUSSION: Many researchers mistakenly assume the ability to accurately self-assess is essential for learning, so focus on teaching self-calibration rather than evidence-based methods of advancing learning. Other researchers incorrectly suppose that self-reported improvements in knowledge/skills provide evidence of the efficacy of a program/intervention. This is particularly troubling with regards to novices, who may believe that because they self-assess to have improved/gained confidence, they are now competent. CONCLUSION: Our findings highlight the significant volume of research being done where SA is misunderstood and/or misused as a measurement. We posit reasons that such research continues to take place and suggest solutions moving forward.

The Purpose, Design, and Promise of Medical Education Research Labs.

Medical education researchers are often subject to challenges that include lack of funding, collaborators, study subjects, and departmental support. The construct of a research lab provides a framework that can be employed to overcome these challenges and effectively support the work of medical education researchers; however, labs are relatively uncommon in the medical education field. Using case examples, the authors describe the organization and mission of medical education research labs contrasted with those of larger research team configurations, such as research centers, collaboratives, and networks. They discuss several key elements of education research labs: the importance of lab identity, the signaling effect of a lab designation, required infrastructure, and the training mission of a lab. The need for medical education researchers to be visionary and strategic when designing their labs is emphasized, start-up considerations and the likelihood of support for medical education labs is considered, and the degree to which department leaders should support such labs is questioned.

Test-enhanced learning improves learner attendance during a laparoscopic box trainer simulation program.

BACKGROUND: Laparoscopy is the gold standard approach for many surgical procedures, but it is a complex skill to learn. Laparoscopic simulation training may help, but it is unclear how to best engage trainees in these programs. Test-enhanced learning (TEL) uses regular, well-defined assessments of performance throughout the training phase of learning. AIM: The aim of this study was to assess the effects of TEL on a laparoscopic simulation program involving a cohort of medical student volunteers. MATERIALS AND METHODS: A prospective cohort study was performed with a convenience sample of 40 medical students. Students were recruited to participate in a ten-week laparoscopic simulation program. Twenty students participated in a laparoscopic surgical program with TEL ('TEL group'), and 20 students participated in a standard laparoscopic simulation program ('control group'). RESULTS: Attendance in the TEL group was significantly higher than in the standard group (71 vs 51.5%, P = 0.03). There was no difference between groups in mean time scores. Four themes were identified in qualitative data drawn from student surveys - personal traits and motivators, training context, clear goals and feedback enabling understanding of one's own performance. CONCLUSION: Testing laparoscopic skills throughout a learning program, in conjunction with individualised feedback and tracking of learning trajectory, increases trainee attendance. Laparoscopic simulation training programs are encouraged to reflect on the pedagogic framework in which their procedural skills training operates.

Taking simulation out of its "safe container"-exploring the bidirectional impacts of psychological safety and simulation in an emergency department.

BACKGROUND: Simulation facilitators strive to ensure the psychological safety of participants during simulation events; however, we have limited understanding of how antecedent levels of psychological safety impact the simulation experience or how the simulation experience impacts real-world psychological safety. METHODS: We explored the experience of participants in an embedded, interprofessional simulation program at a large tertiary emergency department (ED) in Australia. We engaged in theoretical thematic analysis of sequential narrative surveys and semi-structured interviews using a previously derived framework of enablers of psychological safety in healthcare. We sought to understand (1) how real-world psychological safety impacts the simulation experience and (2) how the simulation experience influences real-world psychological safety. RESULTS: We received 74 narrative responses and conducted 19 interviews. Simulation experience was both influenced by and impacted psychological safety experienced at the individual, team, and organizational levels of ED practice. Most strikingly, simulation seemed to be an incubator of team familiarity with direct impact on real-world practice. We present a model of the bidirectional impact of psychological safety and simulation within healthcare environments. CONCLUSION: Our model represents both opportunity and risk for facilitators and organizations engaging in simulation. It should inform objectives, design, delivery, debriefing, and faculty development and firmly support the situation of simulation programs within the broader cultural ethos and goals of the departments and organizations.

Developing a simulation safety policy for translational simulation programs in healthcare.

Healthcare simulation may present risks to safety, especially when delivered 'in situ'-in real clinical environments-when lines between simulated and real practice may be blurred. We felt compelled to develop a simulation safety policy (SSP) after reading reports of adverse events in the healthcare simulation literature, editorials highlighting these safety risks, and reflecting on our own experience as a busy translational simulation service in a large healthcare institution.The process for development of a comprehensive SSP for translational simulation programs is unclear. Personal correspondence with leaders of simulation programs like our own revealed a piecemeal approach in most institutions. In this article, we describe the process we used to develop the simulation safety policy at our health service, and crystalize principles that may provide guidance to simulation programs with similar challenges.

The revised Approved Instructional Resources score: An improved quality evaluation tool for online educational resources.

BACKGROUND: Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. OBJECTIVES: We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. METHODS: As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. RESULTS: Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). CONCLUSIONS: We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.