Improve Skill Acquisition Research Articles

Effective in-service training design and delivery: evidence from an integrative literature review.

BackgroundIn-service training represents a significant financial investment for supporting continued competence of the health care workforce. An integrative review of the education and training literature was conducted to identify effective training approaches for health worker continuing professional education (CPE) and what evidence exists of outcomes derived from CPE.MethodsA literature review was conducted from multiple databases including PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between May and June 2011. The initial review of titles and abstracts produced 244 results. Articles selected for analysis after two quality reviews consisted of systematic reviews, randomized controlled trials (RCTs) and programme evaluations published in peer-reviewed journals from 2000 to 2011 in the English language. The articles analysed included 37 systematic reviews and 32 RCTs. The research questions focused on the evidence supporting educational techniques, frequency, setting and media used to deliver instruction for continuing health professional education.ResultsThe evidence suggests the use of multiple techniques that allow for interaction and enable learners to process and apply information. Case-based learning, clinical simulations, practice and feedback are identified as effective educational techniques. Didactic techniques that involve passive instruction, such as reading or lecture, have been found to have little or no impact on learning outcomes. Repetitive interventions, rather than single interventions, were shown to be superior for learning outcomes. Settings similar to the workplace improved skill acquisition and performance. Computer-based learning can be equally or more effective than live instruction and more cost efficient if effective techniques are used. Effective techniques can lead to improvements in knowledge and skill outcomes and clinical practice behaviours, but there is less evidence directly linking CPE to improved clinical outcomes. Very limited quality data are available from low- to middle-income countries.ConclusionsEducational techniques are critical to learning outcomes. Targeted, repetitive interventions can result in better learning outcomes. Setting should be selected to support relevant and realistic practice and increase efficiency. Media should be selected based on the potential to support effective educational techniques and efficiency of instruction. CPE can lead to improved learning outcomes if effective techniques are used. Limited data indicate that there may also be an effect on improving clinical practice behaviours. The research agenda calls for well-constructed evaluations of culturally appropriate combinations of technique, setting, frequency and media, developed for and tested among all levels of health workers in low- and middle-income countries.

Does the Incorporation of Motion Metrics Into the Existing FLS Metrics Lead to Improved Skill Acquisition on Simulators? A Single Blinded, Randomized Controlled Trial

We hypothesized that training to expert-derived levels of speed and motion will lead to improved learning and will translate to better operating room (OR) performance of novices than training to goals of speed or motion alone. Motion tracking has been suggested to be a more sensitive performance metric than time and errors for the assessment of surgical performance. An institutional review board-approved, single blinded, randomized controlled trial was conducted at our level-I American College of Surgeons accredited Education Institute. Forty-two novices trained to proficiency in laparoscopic suturing after being randomized into 3 groups: The speed group (n = 14) had to achieve expert levels of speed, the motion group (n = 15) expert levels of motion (path length and smoothness), and the speed and motion group (n = 13) both levels. To achieve proficiency, all groups also had to demonstrate error-free performance. The FLS suture module (task 5) was used for training inside the ProMIS simulator that tracks instrument motion. All groups participated in transfer and retention tests in the OR. OR performance was assessed by a blinded expert rater using Global Operative Assessment of Laparoscopic Skills, speed, accuracy, and inadvertent injuries. Thirty (71%) participants achieved proficiency and participated in the transfer and retention tests. The speed group achieved simulator proficiency significantly faster than the other groups (P < 0.001). With the exception of a higher injury rate during the transfer test for the speed group (that reversed during the retention test), there were no significant performance differences among the groups on all assessed parameters. The incorporation of motion metrics into the time/accuracy goals of the FLS laparoscopic suturing curriculum had limited impact on participant skill transfer to the OR. Given the increased training requirements for such a curriculum, further study is needed before the addition of motion metrics to the current FLS metrics can be recommended.

Prior knowledge of final testing improves sensorimotor learning through self-scheduled practice

The elaboration of learning strategies has been considered a key factor to explain sensorimotor learning gains obtained in self-scheduled practice conditions. Nevertheless, the effect of prior knowledge of the testing context (i.e., the learning goal) on that process has been neglected. This study sought to determine whether: (a) learners in a self-controlled condition make different choices contingent on having or not having a learning goal; (b) providing a learning goal would modify the effects of a self-controlled practice condition, and (c) the effect of providing a learning goal would be due to the augmented cognitive effort or to the practice schedule resulting from the learning strategies. The results show that prior knowledge of a variable testing context affects the elaboration of learning strategies and improves skill acquisition in a self-scheduled practice condition. Furthermore, learning gains can be attributed to the self-imposed practice schedule resulting from the learning strategies, and not to the process of elaborating them.

An integrated theory for improved skill acquisition and retention in the three stages of learning

We introduce an integrated theory of learning and forgetting that has implications for training theory and practice. We begin with a review of skill acquisition research that argues that individuals employ different cognitive mechanisms when learning, which can be reliably associated with three stages of learning. This review leads to our proposed skill retention theory, which recommends a method to increase skill retention when designing systems, covering a range of system design issues, from interface design to training. We conclude with a discussion of how we might optimise skill retention based upon this approach. Specifically, we discuss how we might improve training by better spacing the iterations between training sessions to support proceduralisaion to improve skill retention.

Exploratory Visualization of Surgical Training Databases for Improving Skill Acquisition

A new visualization system analyzes multidimensional surgical performance databases of information collected via emerging surgical robot and simulator technologies. In particular, it has visualized force, position, rotation, and synchronized video data from 300 bimanual laparoscopic surgery tasks performed by more than 50 surgeons. To explore data, the system uses a multiple-coordinated-views framework. It provides techniques to select and filter multivariate time series data, visualize animated force plots in conjunction with contextual videos, encode multivariate bimanual tool trace data in 3D visualizations, and link visualizations to a database management system via a new generalizable data model. Insights and feedback from an interdisciplinary iterative design process and use case studies support the utility of visualization in this emerging area of data-driven surgical training.

Pre-service Teachers' Literacy Self-Efficacy and Literacy Competence

The impetus for the study reported in this paper was Queensland's poor performance on 2008's NAPLAN testing, the Queensland Education Performance Review(Department of Education and Training, [DET]2009b) that followed and the subsequent adoption of pre-registration tests for aspiring Primary and Early Childhood teachers(Queensland College of Teachers,[QCT] 2010). In response to this policy focus on pre-service teachers' levels of competence, this study was designed to provide a measure of their levels of literacy competence and confidence. The study was conducted at one of Australia's largest regional universities, where many pre-service teachers train each year in preparation to take up positions in rural education throughout Queensland and Australia. The study examined teacher confidence for English literacy by assessing their self-efficacy for items in three areas: personal literacy, literacy content knowledge and pedagogical knowledge in literacy. These three areas were flagged by the QCT as areas of importance and those which will be tested in 2011's pre-registration tests (QCT, 2010). We also assessed pre-service teacher competence in a small subset of English literacy skills to confirm that their levels of self-efficacy for literacy were reflected by their skills and competence. The sample comprised 180 pre-service teachers from First to Final Year students. We hypothesized and expected that their confidence (self-efficacy) for various aspects of literacy would increase as they gained experience and training, increasing in line with their improved skill acquisition through their study of English language subjects over the four years of training for a Bachelor of Education (BEd). Quantitative methods were employed and a survey instrument was constructed to be used across all years of the BEd (Primary and ECE) degree. Participants, who were volunteers, answered questions pertaining to their confidence in personal literacy as well as the teaching and assessment of literacy. They also completed a competence exercise which allowed comparison of confidence to competence on an individual, year and cohort level. In order to gain the pre-service teachers' perspectives about their preparation for English literacy, we also sought their views in an extended response question about their actual literacy training over the BEd degree, in particular any areas they believed they needed further help with. Preliminary findings obtained by comparing year levels indicate that although students are confident from the outset, this confidence is not always matched by their actual competence. There were some significant differences between the year levels, but increased experience in the BEd degree did not always translate to increased competence. Respondents' comments to the final, open-response, question of the survey flagged several literacy areas for which participants noted they required more instruction, such as grammar. In addition a high level of anxiety amongst students about the competence based pre-registration literacy tests was highlighted. We conclude that there may be scope for the BEd degree to include more English language units than it currently offers at this university to support pre-service teachers' literacy needs.

Anti-Lemons: School Reputation, Relative Diversity, and Educational Quality

Friedman (1962) observed that the ability of firms to acquire and maintain reputations for is a key ingredient for the efficient provision of goods and services in a market economy. This paper explores the implications of school reputation for skill acquisition and labor market outcomes in an otherwise competitive market. We find that reputation effects can explain several puzzling findings in the economics of education, including the fact that competition can, but does not always, improve skill acquisition. This result follows from an anti-lemons effect (in contrast to Akerlof's lemons effect) that arises when schools can enhance their reputation by positively selecting their students. This leads to excess demand for high quality selective schools that drive out non-selective schools. This in turn reduces relative diversity, a measure of ability dispersion in a school, leading to lower skill acquisition.

Simulator Training to Automaticity Leads to Improved Skill Transfer Compared With Traditional Proficiency-Based Training

We hypothesized that novices will perform better in the operating room after simulator training to automaticity compared with traditional proficiency based training (current standard training paradigm). Simulator-acquired skill translates to the operating room, but the skill transfer is incomplete. Secondary task metrics reflect the ability of trainees to multitask (automaticity) and may improve performance assessment on simulators and skill transfer by indicating when learning is complete. Novices (N = 30) were enrolled in an IRB-approved, blinded, randomized, controlled trial. Participants were randomized into an intervention (n = 20) and a control (n = 10) group. The intervention group practiced on the FLS suturing task until they achieved expert levels of time and errors (proficiency), were tested on a live porcine fundoplication model, continued simulator training until they achieved expert levels on a visual spatial secondary task (automaticity) and were retested on the operating room (OR) model. The control group participated only during testing sessions. Performance scores were compared within and between groups during testing sessions. : Intervention group participants achieved proficiency after 54 ± 14 and automaticity after additional 109 ± 57 repetitions. Participants achieved better scores in the OR after automaticity training [345 (range, 0-537)] compared with after proficiency-based training [220 (range, 0-452; P < 0.001]. Simulator training to automaticity takes more time but is superior to proficiency-based training, as it leads to improved skill acquisition and transfer. Secondary task metrics that reflect trainee automaticity should be implemented during simulator training to improve learning and skill transfer.

Simulation and skills training in mitral valve surgery

Limited exposure and visualization and technical complexity have affected resident training in mitral valve surgery. We propose simulation-based learning to improve skill acquisition in mitral valve surgery. After reviewing instructional video recordings of mitral annuloplasty in porcine and plastic models, 11 residents (6 integrated and 5 traditional) performed porcine model mitral annuloplasty. Video-recorded performance was reviewed by attending surgeon providing audio formative feedback superimposed on video recordings; recordings were returned to residents for review. After 3-week practice with plastic model, residents repeated porcine model mitral annuloplasty. Performance assessments initially (prefeedback) and at 3 weeks (postfeedback) were based on review of video recordings on 5-point rating scale (5, good; 3, average; 1, poor) of 11 components. Ratings were averaged for composite score. Time to completion improved from mean 31 ± 9 minutes to 25 ± 6 minutes after 3-week practice (P = .03). At 3 weeks, improvement in technical components was achieved by all residents, with prefeedback scores varying from 2.4 ± 0.6 for needle angles to 3.0 ± 0.5 for depth of bites and postfeedback scores of 3.1 ± 0.8 for tissue handling to 3.6 ± 0.8 for suture management and tension (P ≤ .001). Interrater reliability was greater than 0.8. In this sample, composite scores of first-year integrated and traditional residents were lower than those of senior level residents; comparatively, third-year integrated residents demonstrated good technical proficiency. Simulation-based learning with formative feedback results in overall improved performance of simulated mitral annuloplasty. In complex surgical procedures, simulation may provide necessary early graduated training and practice. Importantly, a "passing" grade can be established for proficiency-based advancement.

Clinical Impact of Epidural Anesthesia Simulation on Short and Long-term Learning Curve: High Versus Low-fidelity Model Training

Background and Objectives: Epidural anesthesia is a technically challenging regional anesthetic technique that can be difficult to teach to novices. Epidural simulators are now available to allow realistic training within a safe and controlled environment before attempting the procedure on patients. Potentially, this may improve skill acquisition by novice residents. The purpose of this study was to examine the effect of a high-fidelity epidural anesthesia simulator on residents9 ability to perform their first labor epidurals and on their learning curve compared with a group having training with a low-fidelity model. Methods: Second-year anesthesia residents were recruited. Subjects were randomized into 2 groups and practiced epidural needle insertion on a high-fidelity epidural simulator or on a low-fidelity model. Subjects were then repeatedly videotaped performing epidural anesthesia over a 6-month period. Two blinded examiners graded each session, using a previously validated Global Rating Scale and Manual Skill Checklist to judge the skill level. Results: Seventy-two sessions performed by 24 residents were recorded. Manual Skill Checklist and Global Rating Scale total scores were compared across the 2 study groups at baseline (first epidural), middle (31-90 epidurals) and late (>90 epidurals) time points using independent-samples t tests. No significant differences in scores were detected at either one of these time points. Conclusion: Our study shows that a simple model can be as useful for learning how to place an epidural catheter as an expensive anatomically correct simulator. New and more technologically advanced simulators should be compared against lower fidelity models to establish their utility and cost-effectiveness.

Clinical Impact of Epidural Anesthesia Simulation on Short- and Long-term Learning Curve

Epidural anesthesia is a technically challenging regional anesthetic technique that can be difficult to teach to novices. Epidural simulators are now available to allow realistic training within a safe and controlled environment before attempting the procedure on patients. Potentially, this may improve skill acquisition by novice residents. The purpose of this study was to examine the effect of a high-fidelity epidural anesthesia simulator on residents' ability to perform their first labor epidurals and on their learning curve compared with a group having training with a low-fidelity model. Second-year anesthesia residents were recruited. Subjects were randomized into 2 groups and practiced epidural needle insertion on a high-fidelity epidural simulator or on a low-fidelity model. Subjects were then repeatedly videotaped performing epidural anesthesia over a 6-month period. Two blinded examiners graded each session, using a previously validated Global Rating Scale and Manual Skill Checklist to judge the skill level. Seventy-two sessions performed by 24 residents were recorded. Manual Skill Checklist and Global Rating Scale total scores were compared across the 2 study groups at baseline (first epidural), middle (31-90 epidurals) and late (>90 epidurals) time points using independent-samples t tests. No significant differences in scores were detected at either one of these time points. Our study shows that a simple model can be as useful for learning how to place an epidural catheter as an expensive anatomically correct simulator. New and more technologically advanced simulators should be compared against lower fidelity models to establish their utility and cost-effectiveness.

What is the ideal interval between training sessions during proficiency-based laparoscopic simulator training?

Background The aim of this study was to identify the ideal interval between training sessions in a proficiency-based laparoscopic suturing simulator curriculum. Methods We analyzed performance data from 3 randomized controlled trials of novices (n = 66) who followed a similar proficiency-based simulator curriculum in laparoscopic suturing on the Fundamentals of Laparoscopic Surgery model. The change in performance and intertraining interval were correlated. Results Overall participant performance improved from 530 ± 58 seconds at baseline to 81 ± 14 seconds at training completion ( P < .001). Intertraining intervals ranged from 1 to 43 days and performance change between training sessions varied widely. There was no correlation of performance change with intertraining interval ( r = .05, P = .30). Performance deterioration was similar at different intertraining intervals. Shorter intervals were associated, however, with shorter training duration ( r = .35, P = .005). Conclusions No association was found between intertraining interval and change in performance during proficiency-based laparoscopic simulator training but shorter intervals were associated with improved skill acquisition. Further study is needed to confirm these findings.

Assessing Technical Skill in Surgery and Endoscopy: A Set of Metrics and an Algorithm (C-PASS) to Assess Skills in Surgical and Endoscopic Procedures

Historically, the performance of surgeons has been assessed subjectively by senior surgical staff in both training and operating environments. In this work, the position and motion of surgical instruments are analyzed through an objective process, denoted C-PASS, to measure surgeon performance of laparoscopic, endoscopic, and image-guided procedures. To develop C-PASS, clinically relevant performance characteristics were identified. Then measurement techniques for parameters that represented each characteristic were derived, and analytic techniques were implemented to transform these parameters into explicit, robust metrics. The metrics comprise the C-PASS performance assessment method, which has been validated over the last 3 years in studies of laparoscopy and endoscopy. These studies show that C-PASS is straightforward, reproducible, and accurate. It is sufficiently powerful to assess the efficiency of these complex processes. It is likely that C-PASS and similar approaches will improve skills acquisition and learning and also enable the objective comparison of systems and techniques.

P.1.001 Insertion/deletion polymorphism of the angiotensin I-converting enzyme gene in migraine patients

There has been recent interest in adding interventions that aid in skill generalization to standard social skills training programs for schizophrenia. Some of these adjunctive interventions are very comprehensive and clearly promising (e.g., IVAST; Liberman, Glynn, Blair, Ross, & Marder, 2002), but their overall cost-effectiveness and feasibility in communities with limited financial and staffing resources are of concern. Few studies have investigated the viability of such programs in small communities with few resources. This article reports on the development, implementation, and evaluation of two types of social skills training programs over an 8-month period: weekly group social skills training (based on the manual of Bellack, Mueser, Gingerich, & Agresta, 1997) and weekly training with the addition of individual supplementary coaching in the community. Evaluation of this pilot program suggests potential benefits of the adjunctive individualized coaching for clients, particularly in terms of improved skill acquisition and performance, as well as overall social functioning. Client case studies are presented, as are details of the nature of the coaching sessions, with an evaluation of the specific effects of these two social skills training programs. Factors involved in the implementation of these interventions inexpensively in a rural setting are also discussed.

Modelling skill acquisition in acquired brain injury

Acquired brain injury (ABI) is a debilitating condition often requiring extensive rehabilitation. Although cognitive rehabilitation is concerned with overcoming a skills deficit, the application of skill acquisition research in this context has been non-existent. Examining post-injury learning in terms of the qualitative variables associated with different phases of skill acquisition is likely to be beneficial in assessing patient status and monitoring progress, as well as identifying changing needs over the course of learning. However, current models of skill acquisition overlook the potential impact of variables such as emotion, implicit learning, metacognition, motivation, and strategies that can be leveraged to improve skill acquisition. The current paper attempts to lay the groundwork for modelling and improving skill acquisition in ABI.

Optimal refresher training intervals for AED and CPR skills: A randomised controlled trial

To determine the optimal refresher training interval for lay volunteer responders in the English National Defibrillator Programme who had previously undertaken a conventional 4-h initial class and a first refresher class at 6 months. Subjects were randomised to receive either two additional refresher classes at intervals of 7 and 12 months or one additional refresher class after 12 months. Greater skill loss had occurred when the second refresher class was undertaken at 12 compared with 7 months. Skill retention however, was higher in the former group, ultimately resulting in no significant difference in final skill performance. There was no significant difference in performance between subjects attending two versus three refresher classes. On completion of refresher training all subjects were able to deliver countershocks, time to first shock decreased by 17s in both groups, and the proportion of subjects able to perform most skills increased. The execution of several important interventions remained poor, regardless of the total number of classes attended or the interval between them. These included CPR skills, defibrillation pad placement, and pre-shock safety checks. Refresher classes held more frequently and at shorter intervals increased subjects' self-assessed confidence, possibly indicating greater preparedness to use an AED in a real emergency. This study shows that the ability to deliver countershocks is maintained whether the second refresher class is held at seven or 12 months after the first. To limit skill deterioration between classes, however, refresher training intervals should not exceed 7 months. The quality of instruction given should be monitored carefully. Learning and teaching strategies require review to improve skill acquisition and maintenance.

Emergency and critical care pediatrics: use of medical simulation for training in acute pediatric emergencies

Recent data suggest that pediatric trainees receive insufficient training to manage acute pediatric emergencies. This review addresses the use of medical simulation as a way for medical learners to acquire and maintain skills needed to manage pediatric resuscitations. Recent work highlights the value of deliberate practice in the context of simulated medical environments to promote development of medical expertise. Several studies demonstrate the benefit of simulation-based training for improved skill acquisition in advanced life support, emergency airway management, and nontechnical skills. Work in other fields of medicine supports the integration of simulation into pediatric training programs. Medical simulation holds great promise to enhance existing pediatric training curricula by increasing skills and expertise in resuscitation. Future research is needed to identify best methods of pediatric simulation-based training.

Generalization of skills through the addition of individualized coaching: Development and evaluation of a social skills training program in a rural setting

There has been recent interest in adding interventions that aid in skill generalization to standard social skills training programs for schizophrenia. Some of these adjunctive interventions are very comprehensive and clearly promising (e.g., IVAST; Liberman, Glynn, Blair, Ross, & Marder, 2002 ), but their overall cost-effectiveness and feasibility in communities with limited financial and staffing resources are of concern. Few studies have investigated the viability of such programs in small communities with few resources. This article reports on the development, implementation, and evaluation of two types of social skills training programs over an 8-month period: weekly group social skills training (based on the manual of Bellack, Mueser, Gingerich, & Agresta, 1997 ) and weekly training with the addition of individual supplementary coaching in the community. Evaluation of this pilot program suggests potential benefits of the adjunctive individualized coaching for clients, particularly in terms of improved skill acquisition and performance, as well as overall social functioning. Client case studies are presented, as are details of the nature of the coaching sessions, with an evaluation of the specific effects of these two social skills training programs. Factors involved in the implementation of these interventions inexpensively in a rural setting are also discussed.

Self-assessment in simulation-based surgical skills training

Background Simulation-based training provides minimal feedback and relies heavily on self-assessment. Research has shown medical trainees are poor self-assessors. The purpose of this study was to examine trainees’ ability to self-assess technical skills using a simulation-trainer. Methods Twenty-one medical students performed 10 repetitions of a simulated task. After each repetition they estimated their time and errors made. These were compared with the simulator data. Results Task time ( P < 0.0001) and errors made ( P < 0.0001) improved with repetition. Both self-assessment curves reflected their actual performance curves ( P < 0.0001). Self-assessment of time did not improve in accuracy ( P = 0.26) but error estimation did ( P = 0.01) when compared with actual performance. Conclusions Novices demonstrated improved skill acquisition using simulation. Their estimates of performance and accuracy of error estimation improved with repetition. Clearly, practice enhances technical skill self-assessment. These results support the notion of self-directed skills training and could have significant implications for residency training programs.

Bringing order from chaos: The challenge of training lay responders to use automated external defibrillators and provide cardiopulmonary resuscitation

Each minute's delay to treatment for out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation (VF) reduces the likelihood of survival by ten per cent. Automated external defibrillators (AEDs) were developed to make rapid definitive treatment more widely available.AEDs use a computer algorithm to diagnose the collapsed patient's heart rhythm and determine the need for a defibrillatory electric shock. This requires no intellectual input from the operator, whose actions are directed by simple written and recorded vocal prompts. Increasing the number of members of the public with the ability to access and use AEDs and provide cardiopulmonary resuscitation (CPR) is a cost-effective strategy for reducing deaths from OHCA. However, conventional training often results in inadequate skill acquisition and fails to ensure skill retention beyond three to six months. Classes without instructors and which use computer-assisted learning or automated voice-advisory manikins have resulted in competence similar to that achieved with traditional training, and may be more cost-effective and convenient. Simplified staged CPR classes offer improved skill acquisition and have a moderate benefit for skill retention. Short self-instructional video training classes or frequently repeated brief practice sessions with feedback from a voice-advisory manikin (both in the absence of an instructor) offer the greatest benefit for CPR skill acquisition and retention, but have not been used for AED instruction. Further research is required to determine the optimal method for training lay members of the public to use AEDs. It seems, however, that the ideal teaching strategy is unlikely to utilise a conventional instructor-led model.