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Use of simulator-based medical procedural curriculum: the learner's perspectives Shanks, David; Wong, Roger Y; Roberts, James M; Nair, Parvathy; Ma, Irene W Nov 8, 2010

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RESEARCH ARTICLE Open AccessUse of simulator-based medical proceduralcurriculum: the learner’s perspectivesDavid Shanks1, Roger Y Wong1, James M Roberts1, Parvathy Nair1, Irene WY Ma1,2*AbstractBackground: Simulation is increasingly used for teaching medical procedures. The goal of this study was to assesslearner preferences for how simulators should be used in a procedural curriculum.Methods: A 26-item survey was constructed to assess the optimal use of simulators for the teaching of medicalprocedures in an internal medicine residency curriculum. Survey domains were generated independently by twoinvestigators and validated by an expert panel (n = 7). Final survey items were revised based on pilot survey anddistributed to 128 internal medicine residents.Results: Of the 128 residents surveyed, 106 (83%) responded. Most responders felt that simulators should be usedto learn technical skills (94%), refine technical skills (84%), and acquire procedural teaching skills (87%).Respondents felt that procedures most effectively taught by simulators include: central venous catheterization,thoracentesis, intubation, lumbar puncture, and paracentesis. The majority of learners felt that teaching should bedone early in residency (97%).With regards to course format, 62% of respondents felt that no more than 3-4 learners per simulator and aninstructor to learner ratio of 1:3-4 would be acceptable.The majority felt that the role of instructors should include demonstration of technique (92%), observe learnertechniques (92%), teach evidence behind procedural steps (84%) and provide feedback (89%). Commonly citedbarriers to procedural teaching were limitations in time, number of instructors and simulators, and lack of realismof some simulators.Conclusions: Our results suggest that residents value simulator-based procedural teaching in the form of small-group sessions. Simulators should be an integral part of medical procedural education.BackgroundSimulation is increasingly utilized in the education ofprocedural skills. Simulation offers several potentialadvantages over traditional methods of medical training.First, simulators allow for learning and practicing of tech-nical skills in a safe and controlled environment, withoutposing danger to patient well-being [1]. In addition,training on simulators improves technical skills [2-4]. Inan era of increasing awareness of medical errors and con-cern for patient safety [5,6], such opportunities areinvaluable. Secondly, simulators are flexible educationaltools. For example, the use of simulators in teachingtechnical skills can range from a bench-top skill station[4,7,8] to a more complex integrated clinical proceduralscenario [9]. Finally simulators allow learners the oppor-tunities for deliberate practice [10], an important factorin the acquisition of skills and expertise [11].Procedural training using simulation has a long history,dating as far back as 600 bc [12], and is increasingly usedin medical education. Despite better understanding of howbest to incorporate simulation technology into an educa-tional curriculum [10], little information exists on the useof simulators in procedural teaching from the learner’sperspective. Although the Accreditation Council for Grad-uate Medical Education stipulates that internal medicineresidency programs must provide residents with access totraining using simulation [13], no specific guidance orguidelines exist in terms of how to implement simulation-based education. Consistent with the principles of adultlearning theory, a better understanding of the learners’* Correspondence: ima@ucalgary.ca1Department of Medicine, University of British Columbia, Vancouver, BC,CanadaFull list of author information is available at the end of the articleShanks et al. BMC Medical Education 2010, 10:77http://www.biomedcentral.com/1472-6920/10/77© 2010 Shanks et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.perspective can assist educators in deciding how to imple-ment a simulation curriculum [14].Given the lack of guidelines on the implementation ofsimulation-based education, the aim of the currentstudy is to establish learner preferences in simulation-based procedural education in internal medicine. Thiswas done by the generation of a 26-item web-basedsurvey that was distributed to all internal medicine resi-dents at an academic institution.MethodsStudy PopulationAll 128 core internal medicine (PGY-1 to PGY-4) resi-dents at the University of British Columbia were invited toparticipate and complete a voluntary anonymous on-linesurvey in 2009. At the University of British Columbia,since 2007, all internal medicine residents were invited toattend 2-3 hour workshops on procedural simulationtraining on task trainers, in small groups of rangingbetween two to eight in size. Generally one to two instruc-tors were present per workshop. Procedural training incentral venous catheterization had been mandatory since2008. Training in arterial blood gas sampling, intubation,lumbar puncture, paracentesis, thoracentesis, and kneearthrocentesis was made available as elective workshops.Our study was approved by the University of BritishColumbia Behavioural Research Ethics Board and theUniversity of British Columbia Internal Medicine Resi-dency Training Committee.Survey DevelopmentBased on review of the literature [10,15,16] and clinicalteaching experience, survey domains were generatedindependently by two investigators (DS, IM). Keydomains identified included learner background, experi-ence, motivation and attitude towards simulation; learn-ing environment, course content and format; instructorroles, skills and expertise. Survey items were generated toaddress topics within each of these domains. Feedbackfrom an expert panel (N = 7) supported content validityof survey domains. Members from the expert panel con-sisted of three clinician educators, two academic sur-geons, one intensivist, and one academic nephrologist.This expert panel rated relative importance of surveyitems and pilot survey items were modified based onexpert panel rating resulting in a 31-item survey. This31-item survey was then piloted to nine internal medi-cine trainees: five trainees were recent graduates of thecore internal medicine program (PGY-5s) at same insti-tution (University of British Columbia). Four traineeswere PGY-2s at other Canadian academic institutions.Survey items were revised based on input from this pilotsurvey with respect to question phrasing, clarity, flow,redundancy, and ease of use, resulting in a final 26-itemsurvey (additional file 1). Test-retest reliability of the26-item survey was assessed four weeks after the initialpilot and showed a Kappa score of 0.71 and r of 0.88, indi-cating good to substantial agreement [17]. This 26-itemon-line survey, administered using an electronic surveyinstrument (Survey Monkey, http://www.surveymonkey.com, accessed December 1, 2009) was distributed electro-nically in February 2009 to all 128 internal medicine resi-dents via a personalized invitation e-mail. Participantswere offered the opportunity to enter into a drawing forone of three book prizes in an attempt to maximize theresponse rate. Reminder e-mails were sent four weeks fol-lowing the initial invitation.Statistical AnalysisDescriptive statistics were presented for baseline charac-teristics. Test-retest agreement was assessed usingKappa score and Spearman correlation coefficient. Sta-tistical analyses were conducted using Stata version 11.0(StataCorp LP, College Station, TX) and SAS version 9.1(SAS Institute, Cary, NC).ResultsOf the 128 invited residents, 106 completed the survey(83%). Table 1 shows the baseline characteristics of theparticipants. The majority of the participants had priorexperience on simulators, primarily through attendingformal procedural simulator courses (88%). The majorityof participants (94%) felt that simulators are helpful inthe acquisition of procedural skills (Table 1). FewerTable 1 Characteristics of Participants Who CompletedSurvey (N = 106)Characteristic No. (%)SexMale 63 (59)Female 42 (39)Not reported 1 (0.9)Level of trainingPGY-1 35 (33)PGY-2 38 (36)PGY-3/4 32 (30)Prior Experience on simulatorsReceived prior formal training on simulators 93 (88)Received prior informal training on simulators 20 (19)No prior training on simulators 4 (4)Simulators are useful inAcquisition of procedural skills 100 (94)Learning teaching skills 92 (87)Refining procedural skills 89 (84)Assessment of procedural skills 70 (66)Shanks et al. BMC Medical Education 2010, 10:77http://www.biomedcentral.com/1472-6920/10/77Page 2 of 7participants (66%) felt that simulators are useful in theassessment of procedural skills.Course Content and FormatWith respect to course content, over 80% of participantswould opt to undergo training in the following proce-dures using simulators: central venous catheterization,ultrasound guided central venous catheterization, thora-centesis, intubation, lumbar puncture, and paracentesis(Table 2). Procedures that 50% or fewer participantswould opt to undergo training in included: peripheralintravenous access, peripherally inserted central catheter,and introductory course on sterile technique, suturing,hand-ties, and local anesthetic administration.Aspects of procedures the participants felt were besttaught using simulation included: use of ultrasound,review of anatomy, troubleshooting techniques, steriletechniques, and review of equipment (Figure 1). Forremaining aspects of the procedures (review of indica-tions, contraindications, diagnosis and treatment ofcomplications, consent, review of evidence, andprocedural notes), participants did not significantlyfavour the use of simulators over didactic lectures, web-based resources, and other modalities such as bedsideteaching and small-group sessions.Incorporating a clinical scenario into proceduralteaching using simulators was felt to be very useful orsomewhat useful by 83 of the participants, (Table 2).The majority of the participants (97%) felt that simula-tion should be offered early in residency (Table 3). Ofthe 103 participants who felt that simulation shouldbe offered early in residency, 74 (72%) felt that addi-tional sessions should be offered throughout residency.Small group format of ≤ 3 hour duration was favouredby the participants. Although 87% of participants feltthat simulator-based procedural training should bemade mandatory in a residency program, participantsdid not agree on which procedure should be mademandatory (Table 2).Instructor CharacteristicsWith respect to instructor characteristics, 74 partici-pants (70%) strongly disagreed or somewhat disagreedwith the statement that the role of a supervisor in asimulation-based procedural education session is super-fluous. The majority of participants felt that simulation-based procedural training should be taught by either anattending (82%) or senior resident (86%). Only 50% feltthat a trained technician would be a suitable instructor.Participants strongly agreed or somewhat agreed thatthe role of an instructor included demonstration oftechnique (92%), observe learner techniques (92%),teach evidence behind procedural steps (84%) and pro-vide feedback (89%).Barriers to Simulation-Based Procedural EducationLastly, 52 (49%) participants answered an open-endedquestion regarding perceived barriers to simulation-based procedural education. Time is the most commonlycited barrier to institution of simulation-based proceduraleducation (n = 31; 60%), followed by limited availabilityof simulators (n = 12; 23%), realism of simulators (n = 12;23%), number of available procedural teachers (n = 10;19%), and overall cost of program (n = 3; 6%).DiscussionSimulation is an attractive educational modality. Simula-tion allows for deliberate practice [18] and allows lear-ner to acquire technical expertise by advancing throughFitts and Posner’s three-stage theory of motor skillacquisition: cognition, integration, and automation[19,20]. While educational research has substantiallyadvanced our understanding in terms of what educa-tional elements in simulation best enhances learning[10], considerably less research has addressed simulationTable 2 Survey Results of 106 Participants’ View onCourse ContentCharacteristic No.(%)Number of participants interested in undergoing proceduraltraining on simulators inCentral venous catheterization 92 (87)Ultrasound-guided central venous catheterization 97 (92)Thoracentesis 95 (90)Intubation 93 (88)Lumbar puncture 90 (85)Paracentesis 89 (84)Peripherally inserted central catheter 61(38)Peripheral intravenous 53 (50)Arterial blood gas sampling 46 (43)Introductory course on sterile technique, suturing, hand-ties, local anesthetic administration53 (50)Number of participants who feel simulation training should bemandatory92 (87)Simulator training for these procedures should be mademandatoryCentral venous catheterization 45 (42)Ultrasound-guided central venous catheterization 42 (40)Intubation 38 (36)Lumbar puncture 36 (34)Arterial blood gas sampling 21 (20)Thoracentesis 32 (30)Paracentesis 29 (27)Incorporating a clinical scenario into procedural teaching usingsimulators would be very useful or somewhat useful83 (78)Shanks et al. BMC Medical Education 2010, 10:77http://www.biomedcentral.com/1472-6920/10/77Page 3 of 7from the view point of the learner. Consistent withadult learning theory, where adults are viewed as self-directed learners, a better understanding of the learners’perspectives on education can assist educators indesigning and implementing a simulation-based proce-dural curriculum [21]. In the absence of guidelines onhow to implement simulation-based procedural curricu-lum, establishing learner preferences is of paramountimportance.Results from our 26-item survey indicate that themajority of the 106 participants who responded to thesurvey felt that simulators are useful for the acquisitionof procedural skills. There was perceived utility in simu-lation-based procedural education for the followingmedical procedures: central venous catheterization, thor-acentesis, intubation, lumbar puncture and paracentesis.Participants favoured small-group teaching, led by eitheran attending or senior resident. Group sizes of no morethan 3-4 learners for every simulator and no fewer thanone instructor for every 3-4 learners were preferred.Duration of session of ≤ 3 hours was preferred. Partici-pants preferred protected teaching time, early imple-mentation of simulation-based procedural curriculum,with additional sessions offered throughout residency.Participants felt that simulation-based educational ses-sions should cover primarily technical aspects of theprocedure: use of equipment, review of anatomy, steriletechniques, troubleshooting techniques, and demonstra-tion of technique by instructors. Participants felt thatother cognitive or knowledge-based aspects of the pro-cedure (review of indications, contraindications, compli-cations, consent, procedural note, and review of currentevidence on the procedure) could be taught by a varietyof non-simulation-based teaching modalities. Partici-pants’ preferences for the use of simulators on technicalaspects of the procedure are consistent with the use ofsimulators for experiential learning [22]. Instructorswere felt to play an important role in simulation-basedprocedural education. Participants felt that the instruc-tors should demonstrate techniques, observe learners,and provide feedback to learners. The majority of parti-cipants felt simulation would be useful for the acquisi-tion of teaching skills. Lastly, commonly cited barriersto the implementation of simulation-based proceduraleducation included limitations in time, realism of simu-lators, and resources.Our results are consistent with current available evi-dence. For instance, participants favoured small groupsessions. In a randomized trial examining the optimalteacher-to-learner ratio for suturing technique, optimalinstructor-to-learner ratio was found to be 1 instructorfor 4 students [23]. Small group size allows time fordeliberate practice and feedback, elements previouslydemonstrated to be of educational value [10]. Secondly,participants valued protected teaching time and imple-mentation of simulation sessions throughout residency.Integration of simulation teaching into a curriculum isan essential feature previously demonstrated to lead toFigure 1 Content of Curriculum and Percent Favouring Teaching Modality. Bar graph of percent of participants favouring teachingmodality.Shanks et al. BMC Medical Education 2010, 10:77http://www.biomedcentral.com/1472-6920/10/77Page 4 of 7effective learning [10]. Ongoing training throughoutresidency, rather than delivering simulation-based edu-cation as a one-time intervention may be particularlyimportant for procedural skill retention [24]. Thirdly,the majority of participants (89%) felt that instructorsshould provide feedback. Consistently demonstrated inthe literature is the value of feedback as an importantfeature of simulation-based education [10]. Fourthly,despite not having had prior exposure to incorporatinga clinical scenario into procedural teaching, 78% of par-ticipants felt that this teaching technique would be use-ful. The Integrated Procedural Performance Instrument(IPPI), by integrating bench-top models to standardizedpatients in order to recreate clinical encounters, hasbeen successfully used for assessment and teaching pur-poses [25,26].Our study has several limitations. It was conducted ata single institution. However, we were able to achieve ahigh response rate of 83% and therefore, were able tocapture responses from most of our trainees. Despite ahigh response rate, there remains a possibility of aresponse bias being present. The majority of participantshad been previously exposed to simulator training andhad generally high satisfaction with simulators, based onour previous experience [4]. Our survey results thereforemay not be generalizable to learners with no prior expo-sure or those with predominantly negative prior experi-ence with simulators. How the quality and amount ofbaseline experience with simulators influence learners’opinion is beyond the scope of our current study butdoes deserve further study. Secondly, because we wereevaluating opinions from our learners, we were unableto evaluate whether incorporating trainees’ stated prefer-ences will necessarily lead to a more effective curricu-lum. In addition, preferences stated by the trainees maysimply be a reflection of what simulator experience theyhave had to date and not based on comparing differenteducational experiences. A variety of simulator experi-ences were possible for our trainees, ranging from one-on-one teaching experience to one instructor per 6-8trainees. We did not seek information about the specifictype of experience our trainees may have had prior tocompleting the survey. Within the confines of our sur-vey, we were unable to further explore reasons for ourparticipants’ stated preferences. Third, although our sur-vey was constructed based on results from a literaturescan on Pubmed using the following MeSH terms: simu-lation; education; learning; teaching; and teach$, we didnot conduct a systematic review and therefore may haveomitted important domains.To our knowledge, our study provides a detailedexamination of the learner’s perspective on simulation-based procedural education, covering domains ofinterest to educators, including educational format andcontent. Our survey was rigorously developed [27] andhad a high response rate. Our study indicates that lear-ners are in favour of small-group simulation-basedTable 3 Survey Results of 106 Participants’ View onCourse Format and Instructor CharacteristicsCharacteristic No.(%)COURSE FORMATLocation favoredCenter away from hospital 2 (2)Center within hospital 74 (70)Directly on ward 20 (19)Doctor’s lounge 4 (4)Other or no opinion 6 (6)When should simulator courses be offeredAt beginning of residency, with additional sessionsthroughout residency74 (70)At beginning of residency 29 (27)Later in residency (PGY-2/3) 1 (1)No opinion 2 (2)Training session times should be specified and protected 74 (70)Training session times should be specified but unprotected 24 (23)Simulators should be freely available 67 (63)Maximum acceptable learner to simulator ratioNo more than 1-2 learners per simulator 29 (27)No more than 3-4 learners per simulator 66 (62)No more than 5-6 learners per simulator 9 (8)>6 learners per simulator is acceptable 1 (1)Minimum acceptable instructor to learner ratioNo fewer than 1 instructor per 1-2 learners 20 (19)No fewer than 1 instructor per 3-4 learners 68 (64)No fewer than 1 instructor per 5-6 learners 16 (15)1 instructor for > 6 learners is acceptable 1 (1)Optimal duration of a simulator sessionOne hour 21 (20)Two hours 56 (53)Three hours 20 (19)>3 hours 2 (2)Full day session (with breaks) 5 (5)INSTRUCTOR CHARACTERISTICSMedical simulator sessions should be taught byAn attending physician 87 (82)A senior resident (or fellow) 91 (86)A trained technician 53 (50)The instructor shouldDemonstrate technique 98 (92)Observe my procedure 98 (92)Teach evidence behind procedural steps 89 (84)Provide feedback 94 (89)Shanks et al. BMC Medical Education 2010, 10:77http://www.biomedcentral.com/1472-6920/10/77Page 5 of 7educational sessions for the acquisition of proceduralskills in a number of procedures. Our participants assertthat teaching sessions should be of short-duration,introduced early in residency with additional sessionsthroughout residency. Instructors should focus the useof simulation on the technical aspects of the proceduresand provide feedback. These learner preferences shouldbe considered in the development of simulation-basedprocedural curriculum.Lastly, barriers to the implementation of simulation-based procedural education should be addressed. Morerecently, program requirements for Internal Medicinefrom the Accreditation Council for Graduate MedicalEducation mandate that institutions provide residentswith access to training using simulation [13]. Residencytraining programs, therefore, should ensure adequateprotected time in the curriculum and an adequate sup-ply of procedural teachers.ConclusionOur results suggest that residents value simulator-basedprocedural teaching in the form of small-group sessions.Protected teaching time, implementation of teachingearly in residency, with additional teaching sessionthroughout residency are favoured by participants.Implementation of a procedural curriculum may benefitboth from taking learners’ preferences into considerationand from available empirical evidence.Additional materialAdditional file 1: Appendix A - Survey Administered to Participants.Survey items administered to participants.AcknowledgementsThis work is supported by funding from the Department of Medicine,University of British Columbia, Canada. There are no financial disclosuresrelated to the design and conduct of the study, collection, management,analysis, and interpretation of the data, or preparation, review or approval ofthis manuscript. This study was presented in abstract form at the 2009International Conference on Residency Education in Victoria, BC, Canada.Author details1Department of Medicine, University of British Columbia, Vancouver, BC,Canada. 2Department of Medicine, University of Calgary, Calgary, AB, Canada.Authors’ contributionsDS: participated in research design, acquired, analyzed and interpreted data;drafted the paper. RYW: participated in research design and revised thepaper critically. JMR: participated in research design, assisted in theacquisition of data, and revised the paper critically. PN: participated inresearch design and revised the paper critically. IWYM: conceived of thestudy, participated in research design, acquired, analyzed and interpreteddata, drafted the paper, and revised the paper critically. All authors read andapproved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 1 June 2010 Accepted: 8 November 2010Published: 8 November 2010References1. Ogden PE, Cobbs LS, Howell MR, Sibbitt SJ, DiPette DJ: Clinical simulation:importance to the internal medicine educational mission. Am J Med2007, 120(9):820-4.2. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB: Use ofsimulation-based education to reduce catheter-related bloodstreaminfections. Arch Intern Med 2009, 169(15):1420-3.3. Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB: Use ofsimulation-based mastery learning to improve the quality of centralvenous catheter placement in a medical intensive care unit. J Hosp Med2009, 4(7):397-403.4. 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Kneebone R, Nestel D, Yadollahi F, et al: Assessing procedural skills incontext: exploring the feasibility of an Integrated ProceduralPerformance Instrument (IPPI). Med Educ 2006, 40:1105-14.27. Burns KEA, Duffett M, Kho ME, et al: A guide for the design and conductof self-administered surveys of clinicians. CMAJ 2008, 179(3):245-52.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/10/77/prepubdoi:10.1186/1472-6920-10-77Cite this article as: Shanks et al.: Use of simulator-based medicalprocedural curriculum: the learner’s perspectives. BMC Medical Education2010 10:77.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitShanks et al. BMC Medical Education 2010, 10:77http://www.biomedcentral.com/1472-6920/10/77Page 7 of 7


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