The reliability of a portfolio of workplace-based assessments in anesthesia training.

PURPOSE: Competency-based anesthesia training programs require robust assessment of trainee performance and commonly combine different types of workplace-based assessment (WBA) covering multiple facets of practice. This study measured the reliability of WBAs in a large existing database and explored how they could be combined to optimize reliability for assessment decisions. METHODS: We used generalizability theory to measure the composite reliability of four different types of WBAs used by the Australian and New Zealand College of Anaesthetists: mini-Clinical Evaluation Exercise (mini-CEX), direct observation of procedural skills (DOPS), case-based discussion (CbD), and multi-source feedback (MSF). We then modified the number and weighting of WBA combinations to optimize reliability with fewer assessments. RESULTS: We analyzed 67,405 assessments from 1,837 trainees and 4,145 assessors. We assumed acceptable reliability for interim (intermediate stakes) and final (high stakes) decisions of 0.7 and 0.8, respectively. Depending on the combination of WBA types, 12 assessments allowed the 0.7 threshold to be reached where one assessment of any type has the same weighting, while 20 were required for reliability to reach 0.8. If the weighting of the assessments is optimized, acceptable reliability for interim and final decisions is possible with nine (e.g., two DOPS, three CbD, two mini-CEX, two MSF) and 15 (e.g., two DOPS, eight CbD, three mini-CEX, two MSF) assessments respectively. CONCLUSIONS: Reliability is an important factor to consider when designing assessments, and measuring composite reliability can allow the selection of a WBA portfolio with adequate reliability to provide evidence for defensible decisions on trainee progression.

RéSUMé: OBJECTIF: Les programmes de formation en anesthésie basés sur les compétences nécessitent de solides évaluations des performances des stagiaires et combinent habituellement des évaluations sur le lieu de travail (ÉLT) couvrant de nombreux aspects de la pratique. Cette étude a mesuré la fiabilité des ÉLT dans une grande base de données existante et a exploré comment elles pourraient être combinées pour accroître leur fiabilité pour des décisions sur les évaluations. MéTHODES: Nous avons utilisé la théorie de la généralisation pour mesurer un critère composite de fiabilité de quatre types d'ÉLT utilisés par les collèges d'anesthésiologistes d'Australie et de Nouvelle-Zélande : un exercice de mini-évaluation clinique (mini-CEX), l'observation directe des habiletés procédurales (DOPS), une discussion de cas (CbD) et une rétroaction de multiples sources (MSF). Nous avons alors modifié le nombre et la pondération des combinaisons d'ÉLT pour optimiser la fiabilité avec moins d'évaluations. RéSULTATS: Nous avons analysé 67 405 évaluations de 1 837 stagiaires et 4 145 assesseurs. Nous avons supposé une fiabilité acceptable pour les décisions intérimaires (enjeux intermédiaires) et définitives (enjeux élevés) à, respectivement, 0,7 et 0,8. Selon la combinaison des types d'ÉLT, 12 évaluations ont permis d'atteindre le seuil de 0,7 lorsqu'une évaluation de chaque type a le même poids, alors qu'il en a fallu 20 pour que la fiabilité atteigne 0,8. Si la pondération des évaluations est optimisée, la fiabilité acceptable pour les décisions intérimaires et finales est possible avec, respectivement, neuf évaluations (p. ex., deux DOPS, trois CbD, deux mini-CEX, deux MSF) et quinze évaluations (p. ex. deux DOPS, huit CbD, trois mini-CEX, deux MSF). CONCLUSIONS: La fiabilité est un facteur important dont il faut tenir compte quand on conçoit les évaluations et la mesure d'une fiabilité composite permet la sélection d'un éventail d'ÉLT avec une fiabilité adéquate pour l'obtention de données probantes et la défense de décisions sur les progrès des stagiaires.

Improved laparoscopic skills in gynaecology trainees following a simulation-training program using take-home box trainers.

BACKGROUND: Lack of time and access to equipment are recognised barriers to simulation training. AIM: To investigate the effect of a take-home laparoscopic simulator training program on the laparoscopic skills of gynaecology trainees. METHOD: Participants (n = 17 in 2015, n = 16 in 2016) were supplied with a box trainer, associated equipment and instructions on self-directed training. A program was designed and implemented in 2015 comprising of ten weekly laparoscopic skills tasks and modified in 2016 to eight monthly tasks. Half of the participants were randomly allocated a supervisor. Participants performed baseline and post-training assessments of laparoscopic skills in a box trainer task (thread transfer) and virtual reality simulator tasks (laparoscopic tubal ligation and bilateral oophorectomy). RESULTS: Trainees in 2015 demonstrated an improvement in the median time to complete the laparoscopic tubal ligation task (baseline 124 s vs post-training 91 s, P = 0.041). There was no difference in the number of tubal ligation bleeding incidents, or in the time taken to complete the box trainer thread transfer task. In 2016 trainees demonstrated improvement in tubal ligation time (baseline 251 vs 71 post-training, P = 0.021) and bilateral oophorectomy time (baseline 891 s vs 504 post-training, P = 0.025). There was no significant difference in other outcome measures. There was no difference found in performance when groups were compared by supervisor allocation. CONCLUSION: A take-home box trainer simulation-training program was associated with improvement in laparoscopic skills. This type of program may improve trainee access to simulation training.

Trainee Performance in Loop Electrosurgical Excision Procedure (LEEP) After Simulation Training.

OBJECTIVE: The aim of the study was to review the performance of trainees in loop electrosurgical excision procedure (LEEP) procedures after the introduction of a simulation training program. MATERIALS AND METHOD: A simulation training program was introduced in September 2016 for gynecology trainees at the study institution. Trainees were encouraged to perform at least 3 simulated LEEP procedures before operating. For a 12-month period after the introduction of training, data on operating time and specimen quality measures of clear margin status, adequate depth, and absence of fragmentation were reviewed. This was compared with a 12-month period before simulation training (from September 2014-September 2015). Trainees were surveyed for feedback on the training. RESULTS: In total, 135 LEEP procedures were reviewed: 68 before and 67 after simulator training. Trainee specimens after training were more likely to be nonfragmented (89.2% vs 55.9%, p = .003), have clear margins (72.2% vs 41.9%, p = .015), and meet "all criteria" (46% vs 20.6%, p = .043) than trainee specimens before training. There was no change in depth adequacy (70.3% vs 67.7%, p = .99). Median trainee procedure time reduced from 18 minutes (interquartile range = 11-24) before training to 8 minutes after training (interquartile range = 6-11) (p = <0.001). There was no significant change in operating time or specimen quality from LEEP procedures performed by attendings (who did not use the simulator). Trainee and attending procedural outcomes were similar after training. Trainees had mostly positive views on the training, though reported time constraints as a barrier to simulation. CONCLUSIONS: After the introduction of an LEEP simulation training program, operative time and specimen quality from trainee procedures seemed to improve.

Composite reliability of workplace-based assessment of international medical graduates.

OBJECTIVE: The fitness to practise of international medical graduates (IMGs) is usually evaluated with standardised assessment tests. The performance rather than the competency of practising doctors should, however, be assessed, for which reason workplace-based assessment (WBA) has gained increasing attention. Our aim was to assess the composite reliability of WBA instruments for assessing IMGs. DESIGN AND SETTING: Between June 2010 and April 2015, 142 IMGs were assessed by 99 calibrated assessors; each was assessed in the workplace over 6 months. The IMGs completed 970 case-based discussions (CBDs), 1741 mini-clinical examination exercises (mini-CEX), and 1020 multi-source feedback (MSF) assessments. PARTICIPANTS: 103 male and 39 female candidates from 28 countries (Africa, Asia, Europe, South America, South Pacific) in urban and rural hospitals of the Hunter New England Health region. MAIN OUTCOME MEASURES: The composite reliability across the three WBA tools, expressed as the standard error of measurement (SEM). RESULTS: In our WBA program, a combination of five CBD and 12 mini-CEX assessments achieved an SEM of 0.33, greater than the threshold 0.26 of a scale point. Adding six MSF results to the assessment package reduced the SEM to 0.24, which is adequately precise. CONCLUSIONS: Combining data from different WBA assessment instruments achieves acceptable reliability for assessing IMGs, provided that the panel of WBA assessment types are carefully selected and the assessors are calibrated.

A national training program for simulation educators and technicians: evaluation strategy and outcomes.

BACKGROUND: Simulation-based education (SBE) has seen a dramatic uptake in health professions education over the last decade. SBE offers learning opportunities that are difficult to access by other methods. Competent faculty is seen as key to high quality SBE. In 2011, in response to a significant national healthcare issue--the need to enhance the quality and scale of SBE--a group of Australian universities was commissioned to develop a national training program--Australian Simulation Educator and Technician Training (AusSETT) Program. This paper reports the evaluation of this large-scale initiative. METHODS: The AusSETT Program adopted a train-the-trainer model, which offered up to three days of workshops and between four and eight hours of e-learning. The Program was offered across all professions in all states and territories. Three hundred and three participants attended workshops with 230 also completing e-learning modules. Topics included: foundational learning theory; orientation to diverse simulation modalities; briefing; and debriefing. A layered objectives-oriented evaluation strategy was adopted with multiple stakeholders (participants, external experts), methods of data collection (end of module evaluations, workshop observer reports and individual interviews) and at multiple data points (immediate and two months later). Descriptive statistics were used to analyse numerical data while textual data (written comments and transcripts of interviews) underwent content or thematic analysis. RESULTS: For each module, between 45 and 254 participants completed evaluations. The content and educational methods were rated highly with items exceeding the pre-established standard. In written evaluations, participants identified strengths (e.g. high quality facilitation, breadth and depth of content) and areas for development (e.g. electronic portfolio, learning management system) of the Program. Interviews with participants suggested the Program had positively impacted their educational practices. Observers reported a high quality educational experience for participants with alignment of content and methods with perceived participant needs. CONCLUSIONS: The AusSETT Program is a significant and enduring learning resource. The development of a national training program to support a competent simulation workforce is feasible. The Program objectives were largely met. Although there are limitations with the study design (e.g. self-report), there are strengths such as exploring the impact two months later. The evaluation of the Program informs the next phase of the national strategy for simulation educators and technicians with respect to content and processes, strengths and areas for development.

Simulation training in obstetrics and gynaecology: What's happening on the frontline?

BACKGROUND: Despite evidence supporting simulation training and awareness that trainee exposure to surgery is suboptimal, it is not known how simulation is being incorporated in obstetrics and gynaecology (O&G) training across Australia and New Zealand. AIM: To investigate the current availability and utilisation of simulation training, and the attitudes, perceived barriers and enablers towards simulation in Australia and New Zealand. METHOD: A survey was distributed to O&G trainees and fellows in Australia and New Zealand. The survey recorded demographic data, current exposure to simulation and beliefs about simulation training. RESULTS: The survey returned 624 responses (24.3%). Most trainees had access to at least one type of simulation (87%). Access to simulators was higher for trainees at tertiary hospitals (92% vs 76%). Few trainees had a simulation curriculum, allocated time or supervision for simulation training. 'Limited access' was the highest rated barrier to using simulation. Lack of time, other training priorities and cost were identified as further barriers. More than 80% of respondents believed simulation improves surgical skills, skills transfer to the operating theatre, and the addition of simulation to the RANZCOG curriculum would benefit trainees. However, a minority of respondents believed simulator proficiency should be shown prior to performing surgery. The need for a curriculum and supervision were highlighted as necessary supports for simulation training. CONCLUSIONS: Despite simulator availability, few trainees are supported by simulation training curricula, allocated time or supervision. Participants believed that simulation training benefits trainees and should be supported with a curriculum and teaching.

Medical school benchmarking - from tools to programmes.

BACKGROUND: Benchmarking among medical schools is essential, but may result in unwanted effects. AIM: To apply a conceptual framework to selected benchmarking activities of medical schools. METHODS: We present an analogy between the effects of assessment on student learning and the effects of benchmarking on medical school educational activities. A framework by which benchmarking can be evaluated was developed and applied to key current benchmarking activities in Australia and New Zealand. RESULTS: The analogy generated a conceptual framework that tested five questions to be considered in relation to benchmarking: what is the purpose? what are the attributes of value? what are the best tools to assess the attributes of value? what happens to the results? and, what is the likely "institutional impact" of the results? If the activities were compared against a blueprint of desirable medical graduate outcomes, notable omissions would emerge. CONCLUSION: Medical schools should benchmark their performance on a range of educational activities to ensure quality improvement and to assure stakeholders that standards are being met. Although benchmarking potentially has positive benefits, it could also result in perverse incentives with unforeseen and detrimental effects on learning if it is undertaken using only a few selected assessment tools.

Making sense of work-based assessment: ask the right questions, in the right way, about the right things, of the right people.

CONTEXT: Historically, assessments have often measured the measurable rather than the important. Over the last 30 years, however, we have witnessed a gradual shift of focus in medical education. We now attempt to teach and assess what matters most. In addition, the component parts of a competence must be marshalled together and integrated to deal with real workplace problems. Workplace-based assessment (WBA) is complex, and has relied on a number of recently developed methods and instruments, of which some involve checklists and others use judgements made on rating scales. Given that judgements are subjective, how can we optimise their validity and reliability? METHODS: This paper gleans psychometric data from a range of evaluations in order to highlight features of judgement-based assessments that are associated with better validity and reliability. It offers some issues for discussion and research around WBA. It refers to literature in a selective way. It does not purport to represent a systematic review, but it does attempt to offer some serious analyses of why some observations occur in studies of WBA and what we need to do about them. RESULTS AND DISCUSSION: Four general principles emerge: the response scale should be aligned to the reality map of the judges; judgements rather than objective observations should be sought; the assessment should focus on competencies that are central to the activity observed, and the assessors who are best-placed to judge performance should be asked to participate.

Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals.

BACKGROUND: The introduction of Web-based education and open universities has seen an increase in access to professional development within the health professional education marketplace. Economic efficiencies of Web-based education and traditional face-to-face educational approaches have not been compared under randomized controlled trial conditions. OBJECTIVE: To compare costs and effects of Web-based and face-to-face short courses in falls prevention education for health professionals. METHODS: We designed two short courses to improve the clinical performance of health professionals in exercise prescription for falls prevention. One was developed for delivery in face-to-face mode and the other for online learning. Data were collected on learning outcomes including participation, satisfaction, knowledge acquisition, and change in practice, and combined with costs, savings, and benefits, to enable a break-even analysis from the perspective of the provider, cost-effectiveness analysis from the perspective of the health service, and cost-benefit analysis from the perspective of the participant. RESULTS: Face-to-face and Web-based delivery modalities produced comparable outcomes for participation, satisfaction, knowledge acquisition, and change in practice. Break-even analysis identified the Web-based educational approach to be robustly superior to face-to-face education, requiring a lower number of enrollments for the program to reach its break-even point. Cost-effectiveness analyses from the perspective of the health service and cost-benefit analysis from the perspective of the participant favored face-to-face education, although the outcomes were contingent on the sensitivity analysis applied (eg, the fee structure used). CONCLUSIONS: The Web-based educational approach was clearly more efficient from the perspective of the education provider. In the presence of relatively equivocal results for comparisons from other stakeholder perspectives, it is likely that providers would prefer to deliver education via a Web-based medium. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN): 12610000135011; http://www.anzctr.org.au/trial_view.aspx?id=335135 (Archived by WebCite at http://www.webcitation.org/668POww4L).

Student centredness in clinical learning: the influence of the clinical teacher.

AIM: This article reports a longitudinal study examining how nursing students learn on clinical placements in three cohorts of undergraduates at a large Australian university. BACKGROUND: Preceptorship models of clinical learning are increasing in popularity as a strategy to maximize collaboration between university and healthcare organizations. A clinical education model, underpinned by preceptorship, was offered by an Australian university in partnership with a tertiary healthcare organization to some students. DESIGN: The study utilized a mixed method approach of surveys and interviews. METHOD: It was hypothesized that students participating in the preceptorship partnership model would have more positive perceptions of the clinical learning environment than students participating in other models of clinical education. Data were collected over 3 years, from 2006-2008, using a modified Clinical Learning Environment Inventory from second (n = 396) and third (n = 263) year nursing students. Students were classified into three groups based on which educational model they received. RESULTS: On the inventory factor, 'Student centredness', a Welch test indicated an important difference between the responses of students in the three groups. Games-Howell post hoc test indicated that students in the clinical preceptorship partnership model responded more positively than students who had both a clinical teacher and a preceptor in a non-preceptorship partnership model. CONCLUSION: Developing sustainable approaches to enhance the clinical learning environment experience for student nurses is an international concern. The significance of continuity of clinical teachers to the contribution of student centredness is an important aspect to be considered.

Measuring the Impact of a Faculty Development Program on Clinical Educators.

INTRODUCTION: An Academy of Clinical Educators (ACE) was established at the University of Newcastle, to support and build capacity among existing and prospective medical educators. ACE established a Certificate of Clinical Teaching and Supervision (CCTS) program, the final assessment of which was a reflective piece on how the course has affected participants' practice as clinical teachers or supervisors and how changes are expected to impact learner achievement. We conducted a qualitative evaluation of these to explore the impact of the CCTS on participants' teaching. METHODS: Thirty-one participants (of 90 completers to date) consented for their written reflections to undergo qualitative thematic analysis and completed a survey exploring their preparation for, and experience of the program, and application of skills learnt. RESULTS: Most participants reported applying the skills gained through the CCTS to their teaching practice to a large (n=23; 72%) or very large (n=5; 16%) extent. Four themes emerged from the qualitative data, aligned with the topics of the CCTS: teaching structure; feedback; orientation; and assessment. Participants described application of more structured approaches to orientation, teaching and feedback, positive student responses, and self-reported satisfaction with adopted changes. DISCUSSION: The CCTS has motivated change in the teaching practice of participants. Although evidence presented here is limited by the self-reported nature, descriptions of actual changes in practice were detailed and specific enough to suggest they could act as a proxy for objectively measured change in behaviour and outcome. CONCLUSION: A faculty development program delivered to clinicians with a range of teaching and education-related roles, from varied clinical disciplines and professions, can promote improved, structured teaching and feedback.

Effectiveness of Web-based versus face-to-face delivery of education in prescription of falls-prevention exercise to health professionals: randomized trial.

BACKGROUND: Exercise is an effective intervention for the prevention of falls; however, some forms of exercises have been shown to be more effective than others. There is a need to identify effective and efficient methods for training health professionals in exercise prescription for falls prevention. OBJECTIVE: The objective of our study was to compare two approaches for training clinicians in prescribing exercise to prevent falls. METHODS: This study was a head-to-head randomized trial design. Participants were physiotherapists, occupational therapists, nurses, and exercise physiologists working in Victoria, Australia. Participants randomly assigned to one group received face-to-face traditional education using a 1-day seminar format with additional video and written support material. The other participants received Web-based delivery of the equivalent educational material over a 4-week period with remote tutor facilitation. Outcomes were measured across levels 1 to 3 of Kirkpatrick's hierarchy of educational outcomes, including attendance, adherence, satisfaction, knowledge, and self-reported change in practice. RESULTS: Of the 166 participants initially recruited, there was gradual attrition from randomization to participation in the trial (n = 67 Web-based, n = 68 face-to-face), to completion of the educational content (n = 44 Web-based, n = 50 face-to-face), to completion of the posteducation examinations (n = 43 Web-based, n = 49 face-to-face). Participant satisfaction was not significantly different between the intervention groups: mean (SD) satisfaction with content and relevance of course material was 25.73 (5.14) in the Web-based and 26.11 (5.41) in the face-to-face group; linear regression P = .75; and mean (SD) satisfaction with course facilitation and support was 11.61 (2.00) in the Web-based and 12.08 (1.54) in the face-to-face group; linear regression P = .25. Knowledge test results were comparable between the Web-based and face-to-face groups: median (interquartile range [IQR]) for the Web-based group was 90.00 (70.89-90.67) and for the face-to-face group was 80.56 (70.67-90.00); rank sum P = .07. The median (IQR) scores for the exercise assignment were also comparable: Web-based, 78.6 (68.5-85.1), and face-to-face, 78.6 (70.8-86.9); rank sum P = .61. No significant difference was identified in Kirkpatrick's hierarchy domain change in practice: mean (SD) Web-based, 21.75 (4.40), and face-to-face, 21.88 (3.24); linear regression P = .89. CONCLUSION: Web-based and face-to-face approaches to the delivery of education to clinicians on the subject of exercise prescription for falls prevention produced equivalent results in all of the outcome domains. Practical considerations should arguably drive choice of delivery method, which may favor Web-based provision for its ability to overcome access issues for health professionals in regional and remote settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number: ACTRN12610000135011; http://www.anzctr.org.au/ACTRN12610000135011.aspx (Archived by WebCite at http://www.webcitation.org/63MicDjPV).

The SOMERS Index: a simple instrument designed to predict the likelihood of rural career choice.

OBJECTIVE: The World Health Organization has drawn up a set of strategies to encourage health workers to live and work in remote and rural areas. A comprehensive instrument designed to evaluate the effectiveness of such programs has not yet been tested. Factors such as Stated rural intention, Optional rural training, Medical sub-specialization, Ease (or self-efficacy) and Rural Status have been used individually or in limited combinations. This paper examines the development, validity, structure and reliability of the easily-administered SOMERS Index. DESIGN: Limited literature review and cross-sectional cohort study. SETTING: Australian medical school. PARTICIPANTS: A total of 345 Australian undergraduate-entry medical students in years 1 to 4 of the 5-year course. MAIN OUTCOME MEASURES: Validity of the factors as predictors of rural career choice was sought in the international literature. Structure of the index was investigated through Principal Components Analysis and regression modelling. Cronbach's alpha was the test for reliability. RESULTS: The international literature strongly supported the validity of the components of the index. Factor analysis revealed a single, strong factor (eigenvalue: 2.78) explaining 56% of the variance. Multiple regression modelling revealed that each of the other variables contributed independently and strongly to Stated Rural Intent (semi-partial correlation coefficients range: 0.20-0.25). Cronbach's alpha was high at 0.78. CONCLUSIONS: This paper presents the reliability and validity of an index, which seeks to estimate the likelihood of rural career choice. The index might be useful in student selection, the allocation of rural undergraduate and postgraduate resources and the evaluation of programs designed to increase rural career choice.

Clinical learning environment inventory: factor analysis.

AIM: This paper is a report of the psychometric testing of the Clinical Learning Environment Inventory. BACKGROUND: The clinical learning environment is a complex socio-cultural entity that offers a variety of opportunities to engage or disengage in learning. The Clinical Learning Environment Inventory is a self-report instrument consisting of 42 items classified into six scales: personalization, student involvement, task orientation, innovation, satisfaction and individualization. It was developed to examine undergraduate nursing students' perceptions of the learning environment whilst on placement in clinical settings. METHOD: As a component of a longitudinal project, Bachelor of Nursing students (n = 659) from two campuses of a university in Australia, completed the Clinical Learning Environment Inventory from 2006 to 2008. Principal components analysis using varimax rotation was conducted to explore the factor structure of the inventory. RESULTS: Data for 513 students (77%) were eligible for inclusion. Constraining data to a 6-factor solution explained 51% of the variance. The factors identified were: student-centredness, affordances and engagement, individualization, fostering workplace learning, valuing nurses' work, and innovative and adaptive workplace culture. These factors were reviewed against recent theoretical developments in the literature. CONCLUSION: The study offers an empirically based and theoretically informed extension of the original Clinical Learning Environment Inventory, which had previously relied on ad hoc clustering of items and the use of internal reliability of its sub-scales. Further research is required to establish the consistency of these new factors.

How does moulage contribute to medical students' perceived engagement in simulation? A mixed-methods pilot study.

INTRODUCTION: Moulage is used frequently in simulation, with emerging evidence for its use in fields such as paramedicine, radiography and dermatology. It is argued that moulage adds to realism in simulation, although recent work highlighted the ambiguity of moulage practice in simulation. In the absence of knowledge, this study sought to explore the impact of highly authentic moulage on engagement in simulation. METHODS: We conducted a randomised mixed-methods study exploring undergraduate medical students' perception of engagement in relation to the authenticity moulage. Participants were randomised to one of three groups: control (no moulage, narrative only), low authenticity (LowAuth) or high authenticity (HighAuth). Measures included self-report of engagement, the Immersion Scale Reporting Instrument (ISRI), omission of treatment actions, time-to-treat and self-report of authenticity. In combination with these objective measures, we utilised the Stimulated Recall (SR) technique to conduct interviews immediately following the simulation. RESULTS: A total of 33 medical students participated in the study. There was no statistically significant difference between groups on the overall ISRI score. There were statistically significant results between groups on the self-reported engagement measure, and on the treatment actions, time-to-treat measures and the rating of authenticity. Four primary themes ((1) the rules of simulation, (2) believability, (3) consistency of presentation, (4) personal knowledge ) were extracted from the interview analysis, with a further 9 subthemes identified ((1) awareness of simulating, (2) making sense of the context (3) hidden agendas, (4) between two places, (5) dismissing, (6) person centredness, (7) missing information (8) level of training (9) previous experiences). CONCLUSIONS: Students rate moulage authenticity highly in simulations. The use of high-authenticity moulage impacts on their prioritisation and task completion. Although the slower performance in the HighAuth group did not have impact on simulated treatment outcomes, highly authentic moulage may be a stronger predictor of performance. Highly authentic moulage is preferable on the basis of optimising learning conditions.

The motivations to nurse: an exploration of factors amongst undergraduate students, registered nurses and nurse managers.

AIM: To identify what motivates individuals to engage in a nursing career. BACKGROUND: Recruitment and retention of nurses is a worldwide concern that is associated with several compounding factors, primarily the high attrition of its new graduates and an ageing workforce. Given these factors, it is necessary to understand why individuals choose to nurse, what keeps them engaged in nursing, and in what ways healthcare systems can support career development and retention. METHOD: This paper presents initial interview data from a longitudinal multi method study with 29 undergraduate student nurses, 25 registered nurses (RNs), six Nurse Unit Managers (NUMs) and four Directors of Nursing (DoNs) from four hospitals across a healthcare organization in Australia. RESULTS: Thematic analysis yielded four key themes that were common to all participants: (1) a desire to help, (2) caring, (3) sense of achievement and (4) self-validation. CONCLUSIONS: These themes represented individuals' motivation to enter nursing and sustain them in their careers as either nurses or managers. IMPLICATIONS FOR NURSING MANAGEMENT: Managers need to be cognisant of nurses underlying values and motivators in addressing recruitment and retention issues. Strategies need to be considered at both unit and organizational levels to ensure that the 'desire to care' does not become lost.

Expert opinions on the authenticity of moulage in simulation: a Delphi study.

BACKGROUND: Moulage is a technique in which special effects makeup is used to create wounds and other effects in simulation to add context and create realism in an otherwise fabricated environment. The degree to which moulage is used in the simulated environment is varied; that is, there is no guide for how authentic it is required to be. To objectively assess whether a higher level of authenticity in moulage influences engagement and better outcomes, a common model to assess authenticity is required. The aim of this study was to explore expert opinions on moulage in simulation and develop an instrument for the classification of moulage in simulation. METHODS: The instrument was developed in 3 phases: expert panellist recruitment, domain identification, and consensus rounds. A Delphi technique was used to explore themes of authenticity using Dieckmann's Theory of Realism as a frame of reference. An initial list of elements was raised by a panel of international experts. The experts participated in a further four rounds of questioning, identifying and then ranking and/or rating elements of authenticity in moulage. A priori consensus threshold was set at 80%. RESULTS: In round 1, 18 of 31 invited panellists participated, and a total of 10 completed round 5 (attrition 44%). As a result of the Delphi, the Moulage Authenticity Rating Scale was developed. Under the three domains of realism, 60 elements were identified by experts. A total of 13 elements reached the consensus threshold, whilst tensions regarding the necessity for authentic moulage were identified throughout the rounds. CONCLUSION: This study demonstrates the complexity of moulage in simulation, with particular challenges surrounding the experts' views on authenticity. A prototype instrument for measuring moulage authenticity is presented in the form of the Moulage Authenticity Rating Scale (MARS) to further aid progress in understanding the role of authentic moulage in simulation.

Simulation can offer a sustainable contribution to clinical education in osteopathy.

Background: Clinical education forms a substantial component of health professional education. Increased cohorts in Australian osteopathic education have led to consideration of alternatives to traditional placements to ensure adequate clinical exposure and learning opportunities. Simulated learning offers a new avenue for sustainable clinical education. The aim of the study was to explore whether directed observation of simulated scenarios, as part replacement of clinical hours, could provide an equivalent learning experience as measured by performance in an objective structured clinical examination (OSCE). Methods: The year 3 osteopathy cohort were invited to participate in replacement of 50% of their clinical placement hours with online facilitated, video-based simulation exercises (intervention). Competency was assessed by an OSCE at the end of the teaching period. Inferential statistics were used to explore any differences between the control and intervention groups as a post-test control design. Results: The funding model allowed ten learners to participate in the intervention, with sixty-six in the control group. Only one OSCE item was significantly different between groups, that being technique selection (p = 0.038, d = 0.72) in favour of the intervention group, although this may be a type 1 error. Grade point average was moderately positively correlated with the manual therapy technique station total score (r = 0.35, p < 0.01) and a trivial relationship with the treatment reasoning station total score (r = 0.17, p = 0.132). Conclusions: The current study provides support for further investigation into part replacement of clinical placements with directed observation of simulated scenarios in osteopathy.