Learning Of Procedural Skills Research Articles

Factors Affecting Learning Essential Procedural Skills in Pediatric Residents: A Cross-sectional Study

Background: Clinical education is a vital component of physician education, where medical students learn by attending to patients and applying their knowledge and reasoning to solve their problems. However, many medical students struggle to acquire procedural skills, the ultimate goal of clinical education. Procedural skills are expected to be learned by the residents according to their academic year and are essential for providing better health services to children and families. Objectives: This study evaluates the status of the training provided and the level of learning the necessary procedural skills in pediatric residents based on standards. Methods: This research was a descriptive cross-sectional method from 1998 to 99. In the first part of the researcher-made questionnaire, the implementation of the educational program on all pediatric residents (115) of Mofid Children's Hospital was evaluated. In the second part, the residents' views on the current state of their learning of essential procedural skills were determined. Results: All residents from years one to four participated in the study. After assessing the status of skills acquired by residents with a questionnaire and comparing the average of each skill acquisition procedure with the desired standards, the average of all skills in all three methods was under the standards approved by the Ministry of Health, except for independent subcutaneous, intramuscular and intravenous injection skills and the skill of working with a ventilator. Also, according to the Friedman test, the lowest score for gaining skills in performing procedures was related to NG tube placement skills and subcutaneous, intramuscular, and intravenous injection skills. According to the statistical results obtained from the Spearman coefficient in all procedures, the level of subcutaneous, intramuscular, and intravenous injection skills had a significant correlation with independent skills. Conclusions: According to the specialized assistants of children participating in this study, the current training program of essential procedural skills implemented at Shahid Beheshti University of Medical Sciences was generally useful and effective. But there were also obstacles and limitations. Therefore, it is recommended to review the implementation of the training programs and implement effective measures, including providing more exposure conditions for independent procedures.

Systematic Review of Smart Classroom for Hard Skills Training in Augmented and Virtual Reality Environments

Advances in augmented and virtual reality (AVR) technology have allowed for the development of AVR interactive learning environments (AVR-ILEs) with increasing fidelity. When paired with a suitably capable computer tutor agent, such environments can permit adaptive and self-directed learning of procedural skills in some cases. We undertook a comprehensive review of published smart classroom (SC) solutions to facilitate hard skills training in AVR-ILEs. We established the learning context and implemented support for hard skills training for each of the seven solutions that qualified for the final analysis. Typically, AVR-ILEs mimic realistic work conditions or equipment. The aim of this study is to solutions featuring a smart classroom for hard skills training in an AVR-ILEs have been described. In the study, it is also aimed to types of AVR-ILEs from a smart classroom (SC) have been implemented to support hard skills training. This systematic review is based on the reporting criteria of PRISMA 2020 and the scope of the study consists of 9 academic studies including the keyword "smart classroom" and the keywords "augmented reality" or "virtual reality" in academic studies scanned in Scopus, IEEE Xplore, Eric, ScienceDirect and ACM Digital Library. In this study, the distribution of the studies used in the Smart Classroom for Hard Skills Training in Augmented and Virtual Reality Environments (SCHST-AVRE) by solution, domain, country, concept description, country, reviewed papers, learning objective(s), learning tasks, and the context of the technology used is included. In order to contribute to the research on the AVR-ILEs, it has been tried to determine the opportunities and risks that teaching in the SCHST-AVRE can offer to the field of education. In addition, it is thought that this study will shed a light on future studies.

Optimizing simulator-based training for emergency transesophageal echocardiography: A randomized controlled trial.

Resuscitative clinician-performed transesophageal echocardiography (TEE) is a relatively novel ultrasound application; however, optimal teaching methods have not been determined. Previous studies have demonstrated that variable practice (VP), where practice conditions are changed, may improve learning of procedural skills compared with blocked practice (BP), where practice conditions are kept constant. We compared VP and BP for teaching resuscitative TEE to emergency medicine residents using a simulator. Emergency medicine residents with no prior TEE experience were randomized to the BP or VP groups. The BP group practiced 10 repetitions of a fixed five-view TEE sequence, while the VP group practiced 10 different random five-view TEE sequences on a simulator. Participants completed a performance assessment immediately after training and a transfer test 2 weeks after training. Ultrasound images and transducer motion metrics were captured by the simulator for blinded analysis. The primary outcome was the percentage of successful views on the transfer test. Twenty-eight participants completed the study (14 in the BP group, 14 in the VP group). The BP group had a higher rate of successful views compared with the VP group on the transfer test (93.6% vs. 77.6%; p= 0.002). The BP group also had higher image quality on a 5-point scale (3.3 vs. 2.9; p= 0.01) and fewer probe angular changes (2982.5 degrees vs. 4239.8 degrees; p= 0.04). There were no statistically significant differences between the groups for the rate of correct diagnoses, confidence level, or scan time. Practicing a fixed sequence of views was more effective than a variable sequence of views for learning resuscitative TEE on a simulator. These results should be validated in TEE scans performed in the clinical environment.

Bridge2Practice: an interactive skills training e-tool which improves learning outcomes in university health students

Given the challenges with COVID-19 in the past two and a half years, clinical programs have struggled to find placements where students can get hands on experience assessing and working with real patients. Placements have switched to tele-practice or simulations each of which has a range of limitations. A key learning objective in healthcare programs is that students will be able to develop procedural skills, so reduced placement availability impacts students’ opportunity to practice these skills. Learning procedural skills also poses a problem for time-poor educators who must provide feedback to students and opportunities for students to practice in the classroom environment. An online learning tool aims to bridge these learning gaps and address the abovementioned educational challenges. Bridge2Practice (B2P), created by the School of Health Sciences, The University of Sydney, enables health students to practice identification of a range of specific features of clinical interventions and receive immediate feedback. B2P uses patient recordings for the learner to identify features of clinical interactions and procedures and subsequently receive immediate feedback and comparison of their assessment to that of their peers and experts. As such, it utilizes consensus learning and harnesses aspects of successful coaching such as reflection and explicit practice (Cushion et al., 2012; Cushion et al., 2003; Madill et al., 2020), to support the learning and teaching of motor and procedural skills to patients in clinical settings. B2P is freely available 24/7 and is utilised by over 7000 users from more than 14 institutions around the world for research and teaching purposes. It is currently used to support skill development in physiotherapy, sports science and speech pathology students and is integrated with online only and blended-learning educational programs. B2P incorporates features of Universal Design for Learning (UDL) (Dinmore, 2014), an approach to learning that involves embedding engaging and authentic learning opportunities into teaching and assessment using multiple modes of engagement. B2P also optimises relevance, value and authenticity, fostering collaboration and community and increasing mastery-orientated feedback. In a case example of clinical skills of entry-level speech pathology students, we will show B2P’s flexibility in supporting learning objectives and skill development based on a UDL perspective of learning. Students watch and rate a range of clinical videos in B2P to identify features relevant for clinical practice and receive immediate feedback of their ratings compared to experts’ and other students’ ratings of the same sample. This immediate feedback enables students to see the difference between novice and expert ratings, and observe the formation of a consensus answer by the student group. The benefits of practice via B2P is evidenced by a positive correlation between students who engaged with B2P and improved assessment results. Furthermore, B2P was of benefit to staff in saving them thousands of hours of marking and feedback. In the future, B2P will continue to be implemented to promote student engagement in skill development across a range of allied health settings with the capacity for application in other disciplines where interactive skill-based practice is required.

Focus on Radiation Protection Improves Both Correct Behavior and Procedural Performance During Simulation-Based Training – A Randomized Comparison

To explore whether simulation-based endovascular training with focus on radiation safety could improve correct behavior without jeopardizing the learning of procedural skills. Twenty-four residents without previous endovascular experience completed 10 clinical scenarios on a virtual-reality endovascular simulator with software for peripheral endovascular interventions. Participants were randomized to receive feedback (n=12) or not (n=12) on radiation protection (RP) performance after each case. Expert assessments were done at the first, second, fourth, seventh, and 10th case on RP and endovascular skills (ES). Automatic simulator metrics on procedure time, contrast dose, handling errors, and estimated radiation exposure to patient and operator were registered. Outcome metrics were analyzed by two-way mixed analysis of variance pairwise comparisons with independent t-tests. Correlations were explored using Pearson's r for internal consistency reliability. The RP performance was similar in both groups at their first attempt (P=0.61), but the feedback group significantly outperformed the control group over time (P<0.001 for all comparisons). The feedback group was however slower to learn the ES at start (P=0.047 at second performance), but after 7 attempts no difference was shown (P=0.59). The feedback group used more time (19.5 vs. 15.3min; P=0.007) but less contrast (60 vs. 100mL; P<0.001). The number of errors was the same in both groups, but all metrics regarding radiation exposure favored the feedback group (P-values from 0.001 to 0.008). Simulation-based training (SBT) is effective to acquire basic endovascular intervention skills and concurrently learn RP behavior when feedback on radiation culture is provided.

Mastery versus invention learning: impacts on future learning of simulated procedural skills.

Invention and mastery learning approaches differ in their foundational educational paradigms, proposed mechanisms of learning, and potential impacts on learning outcomes. They also differ in their resource requirements. We explored the relative effects of 'invent and problem-solve, followed by instruction' (PS-I) learning compared to mastery learning (i.e., standards-based training) on immediate post-test and Preparation for Future Learning (PFL) assessments. PFL assessments measure learners' capacity to use their existing knowledge and strategies to learn about and solve novel problems. In this non-inferiority trial, pre-clerkship medical students were randomized to either PS-I, Mastery Learning (ML), or instruction then practice (CON) during simulation-based training of infant lumbar puncture (LP). After a 2-week delay, participants returned to learn and complete a PFL assessment of simulated Knee Arthrocentesis. Two independent raters assessed performances with a 5-point global rating scale. Based on our non-inferiority margin, analyses showed that for both the immediate post-test and the PFL assessment, the PS-I condition resulted in non-inferior outcomes relative to the ML condition. Results for the CON condition were mixed with respect to non-inferiority compared to either PS-I or ML. We suggest cautiously that the PS-I approach was not inferior to the ML approach, based on skill acquisition and PFL assessment outcomes. With ML anecdotally and empirically requiring more time, greater faculty involvement, and higher costs, our findings question the preference ML has received relative to other instructional designs, especially in the healthcare simulation community. We encourage researchers to study the educational and resource impacts of instructional designs using non-inferiority designs.

Transfer of training from an internal medicine boot camp to the workplace: enhancing and hindering factors

BackgroundThe transfer of training to the workplace is the aim of training interventions. Three primary factors influence transfer: trainee characteristics, training design and work environment influences. Within medical education, the work environment factors influencing transfer of training remain underexplored. Burke and Hutchins’ review of training transfer outlined five work environment influences: opportunity to perform, supervisor/peer support, strategic link, transfer climate and accountability. This study aimed to explore the ways in which work environment factors influence the transfer of training for medical trainees.MethodsInternal Medicine Training in Scotland includes a three-day boot camp involving simulation-based mastery learning of procedural skills, immersive simulation scenarios and communication workshops. Following ethical approval, trainees were invited to take part in interviews at least three months after following their boot camp. Interviews were semi-structured, anonymised, transcribed verbatim and analysed using template analysis. Member checking interviews were performed to verify findings.ResultsA total of 26 trainees took part in interviews between January 2020 and January 2021. Trainees reported a lack of opportunities to perform procedures in the workplace and challenges relating to the transfer climate, including a lack of appropriate equipment and resistance to change in the workplace. Trainees described a strong sense of personal responsibility to transfer and they felt empowered to change practice in response to the challenges faced.ConclusionsThis study highlights barriers to transfer of training within the clinical workplace including procedural opportunities, a transfer climate with challenging equipment availability and, at times, an unsupportive workplace culture. Trainees are driven by their own sense of personal responsibility; medical educators and healthcare leaders must harness this enthusiasm and take heed of the barriers to assist in the development of strategies to overcome them.

Micro productive failure and the acquisition of algebraic procedural knowledge

Productive failure has shown positive effects on conceptual and transfer measures, but no clear effects on procedural measures. It is therefore an open question whether, and to what extent, productive failure methods may be used to enhance the learning of procedural skills. A typical productive failure study focuses on a single, complex concept; in contrast, procedural knowledge generally consists of a series of less-complex procedural steps. In this study, failure occasions were adapted to specifically fit procedural knowledge by introducing procedural problems prior to the formal instruction of relevant principles. These procedural problems offered brief but multiple occasions for failure, which we call micro productive failure. A total of 85 sixth-graders were introduced to algebraic expression simplification by providing problem-solving prior to instruction (PS-I condition), compared to providing problem-solving after instruction (I-PS condition). Findings reveal a stable effect of offering micro productive failure occasions for procedural learning; however, as anticipated, there were no effects on conceptual or transfer measures.

Simulation-based training for early procedural skills acquisition in new anesthesia trainees: a prospective observational study

BackgroundIn a setting in which learning of basic procedural skills commences upon graduation from medical school, and as a first step towards integration of simulation-based learning into the anesthesiology training program, a preparatory course for new anesthesia trainees was designed. Three educational strategies were sequentially combined (e-learning, simulation-based hands on workshops, and on-site observational learning), and performance was assessed in a stepwise approach on five procedural skills considered essential for early anesthetic management (peripheral intravenous cannulation, sterile hand wash and gowning, anesthesia workstation preparation, face-mask ventilation, and orotracheal intubation). The primary aim of this study was to determine if this preparatory training course at the onset of anesthesiology residency is useful to achieve a competent trainee performance in the clinical setting.MethodsThis prospective study was carried out at a university-affiliated hospital in Buenos Aires, Argentina, from 2017 to 2019. The 24 participants, comprising three cohorts of 8 residents each, underwent a preparatory course at the onset of residency. Diverse, consecutive educational strategies, and assessments (three stages: 1, 2, 3) took place using task-specific tools (checklists) and global rating scales for five procedural skills. The primary outcome was achievement of competent scores (85%) in final assessments, and the secondary outcomes were performance improvement between assessment stages and compliance with predefined safety items.ResultsTwenty trainees (83.3%) were found to be globally competent (both assessment tools for all procedures) during final assessments (stage 3). Statistically significant improvement was found for all procedural skills between baseline and after workshop assessment scores (stages 1–2), except for orotracheal intubation in checklists, and for all procedural skills between stages 2 and 3 except for sterile hand wash and gowning in checklists.ConclusionsIn our single-center experience, the gap for competent trainee performance in essential early anesthetic management skills can be effectively covered by conducting an intensive, preparatory course using the combination of three educational strategies (e-learning, simulation-based hands on workshops, and observational learning) at the onset of residency. This course has allowed learning to be generated in a secure environment for both patients and trainees.

A Randomized controlled study to evaluate the effect of flipped classroom relative to a traditional demonstration method on learning of procedural skills in dermatology residents

To assess the effectiveness of flipped classroom on dermatology residents' learning of procedural skills, and to identify their perceptions about it. The case-control study was conducted at Dermatology department of Pak Emirates Military and Combined Military Hospital Rawalpindi from 1/3/2018 to 2/7/2018, and comprised post-graduate dermatology residents training at Pak Emirates Military and Combined Military Hospital, Rawalpindi, Pakistan. The residents were randomised into two equal groups. A pre-test consisting of multiple-choice questions was taken. Group A was emailed the related teaching material 1 week prior to the session. The in the subsequent week, both groups attended a 3-hour hands-on training session. In the first hour, Group A had small group discussion, while Group B attended interactive lecture utilising the same teaching material that was posted to Group A earlier. Both groups then participated in hands-on session with the same facilitators. The process was repeated next week for another topic. Finally, a post-test comprising multiple-choice questions and objectively structured clinical exam at 16 stations was conducted. Group A answered the flipped classroom perception instrument and three open-ended questions. Quantitative data was analysed using SPSS 21, while manual thematic analysis was done for qualitative data. Of the 40 subjects, there were 40(50%) in each of the two groups. There was a significant difference between median pre-test and post-test scores in both groups (p<0.001).. With respect to objectively structured clinical exam, the median score of Group A was significantly different from Group B (p=0.001). Flipped classroom was found to be an effective teaching strategy for procedural skills in dermatology residents.

PROCEDURAL SKILLS;

Objective: To compare the effectiveness of Directly Observed ProceduralSkills (DOPS) and Traditional Method of Learning of Procedural Skills in Ophthalmology atundergraduate Level. Setting: Armed Forces Institute of Ophthalmology Rawalpindi. Period:Nov 2015 to June 2016. Study Design: It is an interventional study and is based on randomizedpre and post-test comparison of DOPS with Traditional method of teaching &amp; learning proceduralskills. Methods: After obtaining informed consent; a batch of 40 students were equally assignedto interventional and non interventional study groups through stratified randomization. TheObjective Structured Clinical Examination (OSCEs) was used as data collection instrument aftervalidation. Pre and post test were taken from both groups before and after intervention. Thedata were analyzed using SPSS version 20. Results: By comparison of means of post test oftwo groups it was found that Post test torch examination traditional group had a mean of 5.35and post test mean of DOPS group was 6.80 with a p value &lt;0.05 which was significant. Posttest Fundoscopy had a mean of 4.70 in traditional group and post test mean DOPS group was6.50 with p value &lt; 0.05. Conclusion: There is significant difference between the two groupsand the students in DOPS group performed better than their counterparts in traditional group.

Peer-assisted learning model enhances clinical clerk's procedural skills

BackgroundFailure to transfer procedural skills learned in a laboratory to the bedside is commonly due to a lack of peer support/stimulation. A digital platform (Facebook) allows new clinical clerks to share experiences and tips that help augment their procedural skills in a peer-assisted learning/teaching method. This study aims to investigate the effectiveness of the innovation of using the digital platform to support the transfer of laboratory-trained procedural skills in the clinical units. MethodsVolunteer clinical clerks (n = 44) were enrolled into the peer-assisted learning (PAL) group, which was characterized by the peer-assisted learning of procedural skills during their final 3-month clinical clerkship block. Other clerks (n = 51) did not join the procedural skills-specific Facebook group and served as the self-directed learning regular group. The participants in both the PAL and regular groups completed pre- and post-intervention self-assessments for general self-assessed efficiency ratings (GSER) and skills specific self-assessed efficiency ratings (SSSER) for performing vein puncture, intravenous (IV) catheter and nasogastric (NG) tube insertion. Finally, all clerks received the post-intervention 3-station Objective Structured Clinical Skills Examination (OSCE) to test their proficiency for the abovementioned three procedural skills. ResultsHigher cumulative numbers of vein punctures, IV catheter insertions and NG tube insertions at the bedside were carried out by the PAL group than the regular group. A greater improvement in GSERs and SSSERs for medical procedures was found in the PAL group than in the regular group. The PAL group obtained higher procedural skills scores in the post-intervention OSCEs than the regular group. ConclusionOur study suggested that the implementation of a procedural skill-specific digital platform effectively helps clerks to transfer laboratory-trained procedural skills into the clinical units. In comparison with the regular self-directed learning group, the peer-assisted learning characteristics of Facebook give additional benefits to the PAL group by enhancing their procedural skills.

P018: Blocked practice outperforms random practice for learning resuscitative transesophageal echocardiography: a randomized controlled trial

Introduction: Resuscitative clinician-performed transesophageal echocardiography (TEE) is a relatively new ultrasound application, however the optimal teaching methods have not been determined. Previous studies have demonstrated that random practice (RP), which increases the variability of training, may improve learning of procedural skills compared with blocked practice (BP). We compared RP and BP for teaching a resuscitative TEE protocol to emergency medicine residents using a simulator. Methods: We recruited emergency medicine residents with no prior TEE experience from a university-affiliated hospital. Participants completed a questionnaire and baseline skill assessment on a simulator, then were randomized to one of two groups. The BP group completed 10 repetitions of a fixed 5-view TEE sequence with instructor feedback, while the RP group completed 10 different random 5-view TEE sequences with feedback. Participants completed a simulation-based performance assessment immediately, and a transfer test consisting of a simulated patient encounter 1-2 weeks after training. Ultrasound images and transducer motion metrics were captured by the simulator for blinded analysis. Our primary outcome was the percentage of successful views on the transfer test, and secondary outcomes included participants confidence level, image quality, percentage of correct diagnoses, and efficiency of movement. We compared all scores using two-tailed, independent samples t-tests. Results: 22 participants completed the study (11 in the RP group, 11 in the BP group). There were no significant baseline differences between the groups. The BP group had a higher rate of successful views compared with the RP group on the transfer test (92.7% vs 80.9%, p=0.02). While not statistically significant, the BP group had higher image quality on a 5-point scale (3.2 vs 2.9, p=0.09), and fewer probe accelerations (297 vs 403, p=0.09). The groups did not differ in rate of correct diagnoses (77.3% vs 72.7%, p=0.73), confidence level on a 10-point scale (6.2 vs 6.2, p=1.0), or scan time (173 vs 199 seconds, p=0.28). Conclusion: Emergency medicine residents randomized to BP had a higher success rate on a transfer test, compared to RP when learning resuscitative TEE using a simulator. We consider this pilot work that can inform future studies in both simulation and real clinical settings.

Measuring cognitive load during procedural skills training with colonoscopy as an exemplar.

Few studies have investigated cognitive factors affecting learning of procedural skills in medical education. Cognitive load theory, which focuses on working memory, is highly relevant, but methods for measuring cognitive load during procedural training are not well understood. Using colonoscopy as an exemplar, we used cognitive load theory to develop a self-report instrument to measure three types of cognitive load (intrinsic, extraneous and germane load) and to provide evidence for instrument validity. We developed the instrument (the Cognitive Load Inventory for Colonoscopy [CLIC]) using a multi-step process. It included 19 items measuring three types of cognitive load, three global rating items anddemographics. We then conducted a cross-sectional survey that was administered electronically to 1061 gastroenterology trainees in the USA. Participants completed the CLIC following a colonoscopy. The two study phases (exploratory and confirmatory) each lasted for10weeks during the 2014-2015 academic year. Exploratory factor analysis determined the most parsimonious factor structure; confirmatory factor analysis assessed model fit. Composite measures of intrinsic, extraneous and germane load were compared across years of training and with global rating items. A total of 477 (45.0%) invitees participated (116 in the exploratory study and 361 in the confirmatory study) in 154 (95.1%) training programmes. Demographics were similar to national data from the USA. The most parsimonious factor structure included three factors reflecting the three types of cognitive load. Confirmatory factor analysis verified that a three-factor model was the best fit. Intrinsic, extraneous and germane load items had high internal consistency (Cronbach's alpha 0.90, 0.87 and 0.96, respectively) and correlated as expected with year in training and global assessment of cognitive load. The CLIC measures three types of cognitive load during colonoscopy training. Evidence of validity is provided. Although CLIC items relate to colonoscopy, the development process we detail can be used to adapt the instrument for use in other learning settings in medical education.

A systematic review and meta-analysis of selected motor learning principles in physiotherapy and medical education.

BackgroundLearning of procedural skills is an essential component in the education of future health professionals. There is little evidence on how procedural skills are best learnt and practiced in education. There is a need for educators to know what specific interventions could be used to increase learning of these skills. However, there is growing evidence from rehabilitation science, sport science and psychology that learning can be promoted with the application of motor learning principles. The aim of this review was to systematically evaluate the evidence for selected motor learning principles in physiotherapy and medical education. The selected principles were: whole or part practice, random or blocked practice, mental or no additional mental practice and terminal or concurrent feedback.MethodsCINAHL, Cochrane Central, Embase, Eric and Medline were systematically searched for eligible studies using pre-defined keywords. Included studies were evaluated on their risk of bias with the Cochrane Collaboration’s risk of bias tool.ResultsThe search resulted in 740 records, following screening for relevance 15 randomised controlled trials including 695 participants were included in this systematic review. Most procedural skills in this review related to surgical procedures. Mental practice significantly improved performance on a post-acquisition test (SMD: 0.43, 95 % CI 0.01 to 0.85). Terminal feedback significantly improved learning on a transfer test (SMD: 0.94, 95 % CI 0.18 to 1.70). There were indications that whole practice had some advantages over part practice and random practice was superior to blocked practice on post-acquisition tests. All studies were evaluated as having a high risk of bias. Next to a possible performance bias in all included studies the method of sequence generation was often poorly reported.ConclusionsThere is some evidence to recommend the use of mental practice for procedural learning in medical education. There is limited evidence to conclude that terminal feedback is more effective than concurrent feedback on a transfer test. For the remaining parameters that were reviewed there was insufficient evidence to make definitive recommendations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-016-0538-z) contains supplementary material, which is available to authorized users.

PP11.4 – 2523: Developmental coordination disorder: The tip of the iceberg

Objective To describe clinical features, cognitive profile and pharmacological treatment of a group of children diagnosed with developmental coordination disorder (DCD). Methods We retrospectively searched for a diagnosis of DCD following DSM-IV-TR in 432 children referred to paediatric neurologist due to clumsiness, learning deficit and/or attention difficulties in a period of four years (2010–2013). Clinical criteria proposed by Crespo-Eguilaz and Narbona (2009) were also applied. Results 10% were diagnosed with DCD (n=44). The mean age was 9 years (6–14), 52% of them were male. The reasons for consultation were learning difficulties (52%), attention problems (32%) and clumsiness (16%). They presented the following characteristics: motor control deficit (100%), learning disorder (95%), ADHD (91%, mostly inattentive subtype), low social achievement (86%) and low performance in constructive praxis (70%). It was found a significantly higher verbal IQ than performance IQ score using WISC-R (61%). When using WISC-IV, a lower processing speed index was remarkable compared to normal verbal comprehension index. The improvement of academic achievement after pharmacological treatment was noteworthy in only 48% of the children treated, independently of the drug administered (Methylphenidate, 65%; atomoxetine, 14%). Conclusion Most children with a DSM-IV-TR diagnosis of DCD also met criteria for ADHD inattentive subtype. However, the response to pharmacological treatment was lower than expected as having ADHD alone. The learning of procedural skills of children with DCD is impaired, increasing the risk for low academic achievement but also for emotional and peer relationship outcomes.

Models to teach lung sonopathology and ultrasound-guided thoracentesis.

Lung sonography allows rapid diagnosis of lung emergencies such as pulmonary edema, hemothorax or pneumothorax. The ability to timely diagnose an intraoperative pneumothorax is an important skill for the anesthesiologist. However, lung ultrasound exams require an interpretation of not only real images but also complex acoustic artifacts such as A-lines and B-lines. Therefore, appropriate training to gain proficiency is important. Simulated environment using ultrasound phantom models allows controlled, supervised learning. We have developed hybrid models that combine dry or wet polyurethane foams, porcine rib cages and human hand simulating a rib cage. These models simulate fairly accurately pulmonary sonopathology and allow supervised teaching of lung sonography with the immediate feedback. In-vitro models can also facilitate learning of procedural skills, improving transducer and needle positioning and movement, rapid recognition of thoracic anatomy and hand – eye coordination skills. We described a new model to teach an ultrasound guided thoracentesis. This model consists of the experimenter's hand placed on top of the water-filled container with a wet foam. Metacarpal bones of the human hand simulate a rib cage and a wet foam simulates a diseased lung immersed in the pleural fluid. Positive fluid flow offers users feedback when a simulated pleural effusion is accurately assessed.

ABSTRACT 572

Background and aims: Extracorporeal membrane oxygenation is a high-risk and low-volume procedure whose management requires quick and decisive application of knowledge as well as technical and behavioral prowess to solve multiple problems. A variety of simulation modalities can facilitate the learning of procedural skills and promote evidence-based practice guidelines. Aims: 1) To establish a nurse led simulation-based extracorporeal membrane oxygenation education program for CTSD PICU nurses; 2) To evaluate the competency of nursing care for paediatric patients with ECMO therapy. Methods: From September 2012 to December 2013, our department initiated a nurse led simulation-based ECMO education program which was a 1-day in-service training and development. We recruited 45 nurses who were working in CTSD PICU. The program included a pre-test and post-test, ECMO demonstration, return demonstration, case discussion and simulation scenarios. Debriefing introduced after post-test. Evaluation was completed at the end of the program. Results: 45 CTSD PICU nurses were recruited to participate in the program. Pre-test was finished and found that they were lacking knowledge in looking after critically ill paediatric patients with ECMO therapy. In the pre-test, all nurses achieved an average of 47.5% whereas 90% in the post-test. Of 45 nurses who joined the program, 87% enjoyed the program, 88% found it useful, 92% facilitated their professional development and 95% enjoyed the team work with instructors. Conclusions: Nurse led simulation-based ECMO education program proved to be effective and provided a safer clinical ECMO service to enhance better patient outcomes. All nursing staff attained good competency with simulated clinical ECMO management.

Directed self‐regulated learning versus instructor‐regulated learning in simulation training

Simulation training offers opportunities for unsupervised, self-regulated learning, yet little evidence is available to indicate the efficacy of this approach in the learning of procedural skills. We evaluated the effectiveness of directed self-regulated learning (DSRL) and instructor-regulated learning (IRL), respectively, for teaching lumbar puncture (LP) using simulation. We randomly assigned internal medicine residents in postgraduate year 1 to either DSRL ('directed' to progress from easy to difficult LP simulators during self-regulated learning) or IRL (in groups of four led by an instructor). All participants practised for up to 50 minutes and completed a pre-test, post-test and delayed (by 3 months) retention test on the simulator. Pairs of blinded trained experts independently rated all videotaped performances using a validated global rating scale and a modified version of a validated checklist. Participants provided measures of LP experience and self-reported confidence. We analysed the pre-post (n = 42) and pre-post-retention performance scores (n = 23) using two separate repeated-measures analyses of variance (anovas) and computed Pearson correlation coefficients between participants' confidence and performance scores. Inter-rater agreement was strong for both performance measures (intra-class correlation coefficient > 0.81). The groups achieved similar pre-test and post-test scores (p > 0.05) and scores in both groups improved significantly from the pre- to the post-test (p < 0.05). On retention, a significant interaction (F(2,42) = 3.92, p = 0.03) suggests the DSRL group maintained its post-test performance, whereas that in the IRL group dropped significantly (p < 0.05). Correlations between self-reported confidence and post-test performance were positive and significant for the DSRL group, and negative and non-significant for the IRL group. Both IRL and DSRL led to improved LP performance immediately after practice. Whereas the IRL group's skills declined after 3 months, the DSRL group's performance was maintained, suggesting a potential long-term benefit of this training. Participants in the DSRL group also developed a more accurate relationship between confidence and competence following practice. Further research is needed to clarify the mechanisms of self-regulated learning and its role in simulation contexts.

Strong agents and weak systems: University support for school level improvement

This study examined individual and school level factors that advance and suppress the traits of high performing schools. Based on action plans and reflective journals of 28 school level practitioners in 14 schools across 10 school districts, researchers tracked the progress of each practitioner from participation in a university-based school improvement institute through the initial 5 months of action plan implementation at the school site. This study also presents a conceptual model for a strong system, based on an extensive literature review. Findings are as follows: (1) Internal, school-level change agents who are knowledgeable and skillful with the traits of strong systems were able to make significant inroads within weak systems. (2) School and district level leadership knowledgeable and skillful with the traits of strong systems were crucial to the sustainability of improvement efforts. (3) The effectiveness of change agents in initiating improvement did not necessarily align with positional power, confirming prior complexity research findings that posit non-linearity of change. (4) Effective change agents focused in their work with colleagues on the cultivation of intellectual dispositions and complex skills. Such activity stands in contrast to much contemporary Professional Learning Community (PLC) work (so called) that focuses on “training” teachers in scripted procedures and suggests that much contemporary PLC work needs to be redirected from the learning of procedural skills to the cultivation of intellectual dispositions and complex skills. University colleges of education, whose signature traditions include inquiry, analysis, and reflection, are well-positioned to support such work.