The skin color and gender of high-fidelity simulation manikins in US simulation centers and their use in cultural humility training

IntroductionIt is important for physicians to learn how to provide culturally sensitive care. Cultural humility is defined as a lifelong process with a goal of fixing power imbalances and creating institutional accountability through learning about another’s culture as well as performing self-exploration about one’s own beliefs, identities, and biases. One way to teach cultural humility in medicine is simulation. However, there are no peer-reviewed published studies that examine whether the skin tone or gender of the high-fidelity simulation manikins (HFSM) used by emergency medicine (EM) residency programs reflects the US population nor whether high-fidelity simulation is used to teach cultural humility. We aimed to address that gap in the literature. Our primary objective was to evaluate what proportion of EM residency programs use HFS to teach cultural humility. Our secondary objective was to evaluate whether the skin tone and gender breakdown of the EM residency program HFSM is representative of the US population.MethodsWe conducted a simple random sample of 80 EM residency programs to characterize HFSM and cultural humility training. Selected programs were emailed a questionnaire. Key outcomes included HFSM skin tone and gender and whether cultural humility was taught via HFSM. We calculated point and interval estimates for the proportion of dark-, medium-, and light-toned skin and the proportion of female and male manikins. Confidence intervals were employed to test the null hypothesis that dark/medium/light skin tone was 20/20/60 and that the female/male ratio was 50/50. Both ratios were extrapolated from the US Census data.ResultsOur response rate was 74% (59/80). Fifty-five of 59 EM residency programs that had manikins (0.93, 95% confidence interval [CI] 0.88–0.99) reported data on a total of 348 manikins. Thirty-nine of the 55 programs with manikins reported using HFS to teach cultural humility (0.71, 95% CI 0.60–0.82). Proportions of light-, medium-, and dark-toned manikins were 0.52 (0.43–0.62), 0.38 (0.29–0.47), and 0.10 (0.07–0.14), respectively. Proportions of male and female HFSM were 0.69 (0.64–0.76) and 0.31 (0.24–0.36), respectively. The null hypotheses that skin tone follows a 60/20/20 split and gender follows a 50/50 split were rejected, as not all confidence intervals contained these hypothesized values.ConclusionWhile most EM residency programs surveyed use high-fidelity simulation to teach cultural humility, the manikins do not reflect either the skin tone or gender of the US population.

The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education

Improving cultural competency and practicing cultural humility in dermatologic training: Skin of color education and board certification

Background With technological advances in virtual reality (VR) it is now possible to deliver totally immersive VR scenarios via a smartphone. This has the benefit of addressing the cost issues of high-fidelity simulators and the number of faculty required to run simulations. VR also addresses the visual issue that plastic SIM manikins do not react like real patients, e.g. with a change in skin colour from hypoxia1. However, virtual reality loses the SIM manikin’s advantage of giving tactile feedback, e.g. in cardio-pulmonary resuscitation. Augmented reality (AR) can combine the two concepts of high fidelity simulation and VR, to give the best of both worlds. It does so by overlaying an image onto a low fidelity manikin which then looks like a real patient when viewed through a head set. The use of avatars in AR reduces the need for additional faculty, as pre-programmed AR scenarios can run independently without the need for tutor involvement. Furthermore, AR can be used on top of a simulator manikin to enhance tactile feedback. This technology can improve accessibility to learning opportunities, as it removes the limitations of faculty and simulation space. Summary of project Run a randomised control trial to assess AR scenarios compared to a high fidelity simulation manikin when teaching medical students about medical emergencies. The students will be randomised to the AR teaching or simulation manikin teaching session. Following the teaching session students will fill out a questionnaire about their teaching experience. The students will then be assessed on the learning outcome session by sitting a simulation assessment on a high fidelity manikin and a MCQ test. Quantitive outcome measures will be comparing the students’ performance on the MCQ test. As well as measuring time to carry out key events during the simulation. Qualitative outcomes will be measured using the student questionnaire, which will assess student engagement, enjoyment, and preparedness for clinical practice. The questionnaire will use a Likert scale to measure student responses. Summary of results The AR app is still under development with a number of scenarios being programmed on to the platform. However, our hypothesis is that AR technology will improve enjoyment and engagement in simulation teaching as well as improved performance Discussion and conclusion Once the app has been fully developed and tested on clinical educators it will be ready to use in a trial. The aim is to start the study at beginning of September 2018.

University of Massachusetts Medical School

This study presents a cost-utility analysis that compared medium- vs. high-fidelity human patient simulation manikins in nursing education. The analysis sought to determine whether the extra costs associated with high-fidelity manikins can justify the differences, if any, in the outcomes of clinical reasoning, knowledge acquisition and student satisfaction. Investment in simulated learning environments has increased at an unprecedented pace. One of the driving forces is the potential for simulation experiences to improve students' learning and engagement. A cost-effectiveness analysis is needed to inform decisions related to investment in and use of simulation equipment. Costs associated with the use of medium- and high-fidelity manikins were calculated to determine the total cost for each. A cost-utility analysis using multiattribute utility function was then conducted to combine costs and three outcomes of clinical reasoning, knowledge acquisition and student satisfaction from a quasi-experimental study to arrive at an overall cost utility. The cost analysis indicated that to obtain equivalent clinical reasoning, knowledge acquisition and student satisfaction scores, it required $AU1·21 (US$ 1·14; €0·85) using medium-fidelity as compared with $AU6·28 (US$6·17; €4·40) for high-fidelity human patient simulation manikins per student. Based on the results of the cost-utility analysis, medium-fidelity manikins are more cost effective requiring one-fifth of the cost of high-fidelity manikins to obtain the same effect on clinical reasoning, knowledge acquisition and student satisfaction. It is important that decision-makers have an economic analysis that considers both the costs and outcomes of simulation to identify the approach that has the lowest cost for any particular outcome measure or the best outcomes for a particular cost.

Manikins and simulated patients (SPs) are commonly used in health care education and assessment. SPs appear to offer a more realistic experience for learners than 'plastic' manikins, and might be expected to engender interactions that approximate real clinical practice more closely. The analyses of linguistic patterns and touch are methodologies that could be used to explore this hypothesis. Our research aims were: (1) to compare verbal interactions and the use of procedural touch by health care workers (HCWs) in scenarios with SPs and with manikins; and (2) to evaluate the methodologies used to inform a large-scale study. We conducted a pilot preliminary comparative study on conversations and touch in two scenarios in emergency care training, each performed using an SP and a high-fidelity manikin. The setting was a simulation centre. Two scripted acute-care scenarios (chest pain and acute breathlessness) were performed using both an SP and a high-fidelity manikin. Audiovisual recordings were subsequently analysed. Two teams comprising a clinician (medical student), a senior nurse and a clinical support worker took part in the study. The linguistics research methodology integrated a multimodal corpus-based approach and discourse analysis. Simulated patients appearto offera more realistic experience forlearners than 'plastic' manikins Overall, HCWs had far more interactions with the SPs than with the manikins, and the utterances and behaviours were more akin to what one would expect in real clinical practice. HCWs used procedural touch without the patient's permission much more frequently with the manikin. These methodologies offer opportunities for further research projects studying interactions with SPs, manikins and real clinical practice.

Purpose: Rectal thermometry has been the best practice for recognizing exertional heat stroke (EHS) since 2015, but many certified athletic trainers fail to utilize this technique. Recent studies identified a barrier to implementation is a lack of self-confidence due to not having hands-on practice opportunities. To improve the adoption of rectal thermometry, the Commission on Accreditation of Athletic Training Education (CAATE) began requiring athletic training programs to train students in rectal thermometry in 2020. Providing authentic practice opportunities for low-incidence conditions such as EHS poses a challenge to some athletic training programs. Therefore, the purpose of this study was two-fold: 1) to identify the effect of high-fidelity simulation vs. mid-fidelity simulation on athletic training students’ self-confidence when performing rectal thermometry; 2) to determine if there were any differences in self-confidence between genders. Method: This study used an explanatory, mixed methods, two-group repeated measures research design. Participants were thirty-nine first-year professional Master of Athletic Training students. These students completed a simulated EHS encounter with either a high-fidelity simulation manikin (HFSM) (n=19) or a standardized patient (SP) (n=20). The outcome measures were The Athletic Trainer’s Self-Confidence Scale (ATSCS) and qualitative semi-structured open-ended interviews. Eight participants from each group (n=16) participated in qualitative interviews. Results: A repeated measures ANOVA with one within-subjects factor and two between-subjects factors revealed a statistically significant improvement from participants’ pre-intervention ATSCS score to the post-intervention ATSCS score regardless of group assignment. There were no statistically significant differences between groups or genders. We identified three major themes of athletic training students’ self-confidence that align with three sources of self-efficacy in Bandura’s Social Cognitive Theory: 1) past performance accomplishments, 2) verbal persuasion, and 3) imaginal future experiences performing rectal thermometry. Conclusions and Recommendations: A simulated EHS encounter with a standardized patient or a high-fidelity manikin is equally effective for improving first-year athletic training students’ self-confidence with performing rectal thermometry. Future research is needed to determine the effect of these encounters on a larger population and the long-term adoption of rectal thermometry in clinical practice.

Introduction The theatre environment is fast-paced and we identified it is logistically challenging for many theatre staff to access centre-based simulation training during normal hours. Therefore we designed a short recurrent, in-situ, multi-professional simulation programme. Simulation-based training is a valuable learning tool and there is a growing body of evidence supporting its integration into everyday healthcare education. Aim Our aim is to provide in-situ simulation training to a multidisciplinary theatre team during normal working hours, with minimal interruptions to theatre flow, in a familiar and safe environment, using a high-fidelity manikin from our dedicated Simulation Centre. The scenarios were selected based on common emergencies that manifest in recovery. Method We liaised with department managers to facilitate this in-situ recovery simulation. The anaesthetic secretary allocated an anaesthetist for the day we chose, the theatre co-ordinator nominated an operating department practitioner (ODP), the recovery nurse in charge selected 2 available recovery nurses and a South West Elective Orthopaedic Centre (SWELEOC) nurse. Pre-course material and an online survey was emailed out in advance to provide us with a baseline level of participant information. On the day we transferred the manikin on a trolley, with all necessary equipment and relevant hospital guidelines to the theatre recovery room for a 9 am start. Following a brief introduction to set psychological safety and introduce human factors, we ran through a single 15 min scenario e.g. management of anaphylaxis. After the simulation, participants re-convened to the simulation centre for a 30 min diamond debrief whilst we provided refreshments. Finally we collected instant post-course feedback. Results 30 members of staff have participated in six sessions over a nine month period from 2017–2018. The emphasis on a small multidisciplinary group meant that there was minimal disruption to the running of theatre, for 1.5 hours of teaching and learning centred on individual concerns in a safe environment. The feedback also highlighted that many felt more comfortable within the familiar theatre environment compared to the simulation centre. Comparing pre- and post-course survey results candidate’s confidence increased by 25%. Individual feedback was overwhelmingly positive with a senior nurse suggesting, ‘Theatre staff need more opportunities to do sim,’ and one anaesthetic trainee emphasised, ‘I’m more leading in real life after practicing in-situ sim.’ We continually develop our in-situ simulation course at Epsom based on real-life incidents and aim to expand by including our sister site St Helier’s Hospital recovery staff in 2018. References Issenberg SB, Mcgaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher2005;27:1:10–28. doi:10.1080/01421590500046924 Jaye P, Thomas L, Reedy G. The diamond: A structure for simulation debrief. Clin Teach2015;12:171–5.

<sec><st>Background</st> High fidelity simulation uses technologically-advanced manikins to simulate complex clinical situations to train professionals in technical skills and human factors in a multidisciplinary group. We have expanded the use of simulation training (SIM) to educate about end of life care (EOLC). </sec> <sec><st>Aims</st> To evaluate the impact SIM training at Epsom and St Helier University Hospitals NHS Trust (ESTH) has on participant confidence, understanding and skills in EOLC and their perception of their role in end of life care. </sec> <sec><st>Methods</st> A 1 day end of life care course was initially designed by The Simulation and Interactive Learning Centre at Guy’s and St Thomas’ Hospital and subsequently delivered twice at ESTH. The ESTH Team adapted the scenarios and held a further 6 courses from January 2015 to June 2016. Five scenarios covered subjects including the 5 priorities for care of the dying person, individualised care planning, cultural beliefs, the Mental Capacity Act, compassion and communication. The courses took place in the Simulation Centre, allowing a realistic ward or home setting, utilising a professional actor to enhance the scenarios. Participants were given pre and post course questionnaires with free text sections. Information from these was used to identify themes. </sec> <sec><st>Results</st> 63 nurses and doctors of varying seniority attended the courses. Over half of the participants had worked in the NHS for at least a decade. Analysis of the data revealed that high fidelity simulation had a significant impact on the participants’ confidence, understanding and skills in EOLC and their perception of their role in EOLC. Additionally, the free text sections identified learning in patient centred care, communications skills, honesty and the importance of cultural factors. </sec> <sec><st>Conclusion</st> Use of high fidelity simulation to teach EOLC had a positive impact on the participants. We are now looking to expand the course into community settings. </sec>

Background Principles of pharmacology form the basis of many healthcare professional undergraduate curricula. They are essential for pharmacists who need this knowledge to inform their practice. Pharmacology has traditionally been taught using a didactic approach. High-fidelity simulation manikins are commonly used to train healthcare professionals but there are limited reports of use in pharmacy training or to reinforce principles of pharmacology. This feasibility study examined the use of a high-fidelity simulation manikin (SimMan3G) to support the teaching of pharmacology to pharmacy students. Summary of work The undergraduate pharmacy curriculum was reviewed alongside the SimMan3G capabilities in order to identify pharmacological concepts suitable for simulation. A scenario template was developed to deliver defined learning objectives. A total of 24 pharmacy students (years 2 and 3 of a four year programme) participated in a SimMan3G simulation centred on opioid analgesia and management of overdose with reference to the theories of receptor pharmacology. All students had received underpinning lecture-based introductions to these concepts as part of their existing curriculum. Student knowledge was determined with a 12 question pre- and post-session test based on the learning objectives. Pre- and post-test scores were analysed using a paired t-test. The session was evaluated by all participants. Summary of results Average scores for pre- and post-session tests were 52% and 90% respectively demonstrating a mean overall improvement of 38% (p Discussion and conclusions This study demonstrates the feasibility of using high-fidelity simulation manikins to reinforce the concepts of pharmacology to undergraduate healthcare professionals. Manikin-based simulation was well received and improved student’s short-term knowledge of pharmacotherapeutics. The practical application of knowledge and interactive learning improved understanding and stimulated student interest. Further scenarios will be developed and future work will look to confirm these pilot findings and assess long-term knowledge retention. Currently, healthcare professionals may encounter high-fidelity manikin-based simulation as part of a post-graduate multidisciplinary team to develop clinical decision making and communication. We recommend that it should be introduced earlier, in the undergraduate programmes, to demonstrate pharmacotherapeutic principles and reinforce traditional lecture-based learning.

Clinical Scenario: Athletic trainers must be confident when performing life-saving skills, such as a cardiovascular assessment and cardiopulmonary resuscitation. Learning and performing skills on high-fidelity simulation manikins may improve athletic training students’ self-confidence and self-efficacy. Clinical Question: What are the effects of high-fidelity manikin simulation on athletic training students’ self-confidence and self-efficacy in performing emergency cardiovascular care? Summary of Key Findings: Three good-quality cohort studies were included. Two studies assessed the effect of high-fidelity cardiopulmonary resuscitation simulation, and one study assessed the effect of high-fidelity cardiovascular assessment. Two studies evaluated self-confidence, while the other study evaluated self-efficacy. All three studies found that high-fidelity simulation improved athletic training students’ self-confidence and self-efficacy. Clinical Bottom Line: There is currently consistent, good-quality evidence that supports the use of high-fidelity manikin simulation to improve athletic training students’ self-confidence and self-efficacy in performing cardiovascular skills and assessment. Future research should examine the effects of high-fidelity manikin simulation on the same academic levels of athletic training students to ensure generalizability of results. Strength of Recommendation: The grade of B is recommended by the Strength of Recommendation Taxonomy for consistent, good-quality evidence.

Background The transition between undergraduate and postgraduate medicine has been recognised as a target for simulation based education initiatives. We designed a programme to improve confidence of doctors starting their Foundation Year 1 (FY1) post in a trust of 3 district general hospitals. The programme was designed to allow the training of all 54 FY1 doctors within 6 days, to allow its integration into the mandatory shadowing period and minimise the necessity to release trainees after starting work. Summary of work Ten scenarios were developed by the trust simulation team to expose the candidates to a number of tasks they may be expected to perform in an out-of-hours setting. Each candidate had a direct experience of one scenario. These scenarios were mapped to the Foundation Programme Curriculum. Scenarios were delivered in a simulation centre using a high fidelity manikin (SimMan 3G/Classic, Laerdal) with a member of faculty acting as a senior ward nurse. Scenarios were designed to be feasibly managed by the FY1 doctor alone with the help of the nurse and senior advice over the telephone, to improve confidence in working independently. Each scenario was followed by a structured debrief led by a trained facilitator. Debriefs covered technical and non-technical skills. In the pilot of this course, we were unable to access the FY1 doctors during their shadowing period and so the course was delivered over 6 days during the first 3 months of their post. Summary of results All 54 FY1 doctors attended the course over the 6 days. Post course feedback indicated that the majority perceived that the course was realistic, relevant and useful. Participants were asked to indicate their perceived confidence in carrying out ‘on-call’ duties on a visual analogue scale before and after the course. Analysis revealed a statistically significant increase in median confidence, from 51% to 69%, with larger increases in earlier cohorts. Discussion and conclusions This study shows that an SBE intervention of this type is useful to improve confidence at the transition from medical student to FY1 doctor. Furthermore, the intervention is appreciated by participants and can be delivered to large numbers in a short time period. Recommendations The intervention will be delivered to the next intake of FY1 doctors within their shadowing period. Further work is required to ascertain whether the increase in confidence is retained in the long term and whether there are any improvements in patient outcome or safety. References Cleland J, Patey R, Thomas I, et al.Supporting transitions in medical career pathways: The role of simulation-based education. Adv Simul (Lond) 2016;1:14. UK Foundation Programme Office. The Foundation Programme Curriculum 2016. Available at: http://www.foundationprogramme.nhs.uk/

Objective: To assess the impact of a high-fidelity manikin chemotherapy infusion simulation on student pharmacists' confidence in applying clinical knowledge and perception of oncology pharmacy practice. Methods: One cohort of third professional year student pharmacists completed a high-fidelity manikin simulation during the last week of their didactic training. The 10-minute manikin experience simulated an acute paclitaxel infusion reaction, requiring students to apply their knowledge on how to provide patient care during a chemotherapy-induced infusion reaction. A pre- and post-survey was administered to determine whether there was a change in students' confidence and perception. Results: Thirty-three student pharmacists (62%) completed the pre- and post-surveys and manikin simulation. A statistically significant improvement was seen in median confidence scores when comparing pre- and post-questions of all 10 survey items (P < 0.001). Students' perception of oncology pharmacy and the manikin simulation had mean of 4.4 on a 0- to 5-point Likert scale. Conclusion: The high-fidelity manikin experience improved student pharmacists' post-survey confidence of applying clinical skills. In addition, students' perception of oncology pharmacy improved and the use of a manikin simulation to support didactic learning was seen as an additional avenue for delivering didactic curriculum. This study explored the feasibility of introducing a manikin simulation into the oncology pharmacy curriculum and the benefit of providing hands-on application of clinical skills to support didactic concept-based learning.

Developing a Multidisciplinary Simulation Course to Address the Physical Health Agenda in Mental Health: Recognising and Assessing Medical Problems in Psychiatric Settings (RAMPPS)