Simulation-based Learning Research Articles

Bringing competency-based communication training to scale: A multi-institutional virtual simulation-based mastery learning curriculum for Emergency Medicine residents

Purpose Serious illness communication skills are essential for physicians, yet competency-based training is lacking. We address scalability barriers to competency-based communication skills training by assessing the feasibility of a multi-center, virtual simulation-based mastery learning (vSBML) curriculum on breaking bad news (BBN). Methods First-year emergency medicine residents at three academic medical centers participated in the virtual curriculum. Participants completed a pretest with a standardized patient (SP), a workshop with didactics and small group roleplay with SPs, a posttest with an SP, and additional deliberate practice sessions if needed to achieve the minimum passing standard (MPS). Participants were assessed using a previously published BBN assessment tool that included a checklist and scaled items. Authors compared pre- and posttests to evaluate the impact of the curriculum. Results Twenty-eight (90%) of 31 eligible residents completed the curriculum. Eighty-nine percent of participants did not meet the MPS at pretest. Post-intervention, there was a statistically significant improvement in checklist performance (Median= 93% vs. 53%, p < 0.001) and on all scaled items assessing quality of communication. All participants ultimately achieved the MPS. Conclusions A multi-site vSBML curriculum brought all participants to mastery in the core communication skill of BBN and represents a feasible, scalable model to incorporate competency-based communication skills education in a widespread manner.

P.031 SMILES: Sunnybrook-St. Michael’s Integrated Leadership/QI in Endovascular Stroke care – enhancing hyperacute stroke protocols for optimized door-to-intervention times

Background: Hyperacute stroke care demands rapid, coordinated care. Traditional metrics like Door-to-Needle time are pivotal but insufficient for capturing the complexity of endovascular stroke interventions. The SMILES collaboration aims to standardize and optimize protocols for door-to-intervention times, incorporating Crew Resource Management (CRM). Methods: The multidisciplinary initiative integrates both hospitals, ED, neurology, and QI teams. We employed a comprehensive approach: stakeholder engagement, simulation-based learning, process mapping, and literature review. Emphasis was placed on enhancing situational awareness, triage and prioritization, cognitive load management, role clarity, effective communication, and debriefing. Results: The collaboration led to PDSA cycles and development of refined stroke protocols. Interventions included: 1) A ’zero point survey’ for team pre-arrival briefings, enhancing situational awareness and role clarity; 2) Streamlined patient registration to reduce cognitive load and improve triage efficiency; 3) Direct transfer of patients to imaging. Additionally, digital tools were implemented to facilitate communication. Simulation sessions reinforced CRM principles, leading to improved team cohesion and operational performance. Conclusions: The SMILES initiative is grounded in CRM principles by standardizing protocols and emphasizing non-technical skills crucial for high-stakes environments. This improves outcomes but also fosters a culture of safety and efficiency. Future directions include an evaluation of these protocols’ impact on patient factors.

Global consensus statement on simulation-based practice in healthcare

Simulation plays a pivotal role in addressing universal healthcare challenges, reducing education inequities, and improving mortality, morbidity and patient experiences. It enhances healthcare processes and systems, contributing significantly to the development of a safety culture within organizations. It has proven to be cost-effective and successful in enhancing team performance, fostering workforce resilience and improving patient outcomes. Through an international collaborative effort, an iterative consultation process was conducted with 50 societies operating across 67 countries within six continents. This process revealed common healthcare challenges and simulation practices worldwide. The intended audience for this statement includes policymakers, healthcare organization leaders, health education institutions, and simulation practitioners. It aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally. Key recommendations Advocating for the benefits that simulation provides to patients, staff and organizations is crucial, as well as promoting its adoption and integration into daily learning and practice throughout the healthcare spectrum. Low-cost, high-impact simulation methods should be leveraged to expand global accessibility and integrate into system improvement processes as well as undergraduate and postgraduate curricula. Support at institutional and governmental level is essential, necessitating a unified and concerted approach in terms of political, strategic and financial commitment. It is imperative that simulation is used appropriately, employing evidence-based quality assurance approaches that adhere to recognized standards of best practice. These standards include faculty development, evaluation, accrediting, credentialing, and certification. We must endeavor to provide equitable and sustainable access to high-quality, contextually relevant simulation-based learning opportunities, firmly upholding the principles of equity, diversity and inclusion. This should be complemented with a renewed emphasis on research and scholarship in this field. Call for action We urge policymakers and leaders to formally acknowledge and embrace the benefits of simulation in healthcare practice and education. This includes a commitment to sustained support and a mandate for the application of simulation within education, training, and clinical environments. We advocate for healthcare systems and education institutions to commit themselves to the goal of high-quality healthcare and improved patient outcomes. This commitment should encompass the promotion and resource support of simulation-based learning opportunities for individuals and interprofessional teams throughout all stages and levels of a caregiver’s career, in alignment with best practice standards. We call upon simulation practitioners to champion healthcare simulation as an indispensable learning tool, adhere to best practice standards, maintain a commitment to lifelong learning, and persist in their fervent advocacy for patient safety. This statement, the result of an international collaborative effort, aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

Global consensus statement on simulation-based practice in healthcare.

Simulation plays a pivotal role in addressing universal healthcare challenges, reducing education inequities, and improving mortality, morbidity and patient experiences. It enhances healthcare processes and systems, contributing significantly to the development of a safety culture within organizations. It has proven to be cost-effective and successful in enhancing team performance, fostering workforce resilience and improving patient outcomes.Through an international collaborative effort, an iterative consultation process was conducted with 50 societies operating across 67 countries within six continents. This process revealed common healthcare challenges and simulation practices worldwide. The intended audience for this statement includes policymakers, healthcare organization leaders, health education institutions, and simulation practitioners. It aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally. Advocating for the benefits that simulation provides to patients, staff and organizations is crucial, as well as promoting its adoption and integration into daily learning and practice throughout the healthcare spectrum. Low-cost, high-impact simulation methods should be leveraged to expand global accessibility and integrate into system improvement processes as well as undergraduate and postgraduate curricula. Support at institutional and governmental level is essential, necessitating a unified and concerted approach in terms of political, strategic and financial commitment.It is imperative that simulation is used appropriately, employing evidence-based quality assurance approaches that adhere to recognized standards of best practice. These standards include faculty development, evaluation, accrediting, credentialing, and certification.We must endeavor to provide equitable and sustainable access to high-quality, contextually relevant simulation-based learning opportunities, firmly upholding the principles of equity, diversity and inclusion. This should be complemented with a renewed emphasis on research and scholarship in this field. We urge policymakers and leaders to formally acknowledge and embrace the benefits of simulation in healthcare practice and education. This includes a commitment to sustained support and a mandate for the application of simulation within education, training, and clinical environments.We advocate for healthcare systems and education institutions to commit themselves to the goal of high-quality healthcare and improved patient outcomes. This commitment should encompass the promotion and resource support of simulation-based learning opportunities for individuals and interprofessional teams throughout all stages and levels of a caregiver's career, in alignment with best practice standards.We call upon simulation practitioners to champion healthcare simulation as an indispensable learning tool, adhere to best practice standards, maintain a commitment to lifelong learning, and persist in their fervent advocacy for patient safety.This statement, the result of an international collaborative effort, aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

The effectiveness of simulation-based learning on enhancing anaphylactic shock management skills in standardized training for anesthesiology residents

The effectiveness of simulation-based learning on enhancing anaphylactic shock management skills in standardized training for anesthesiology residents

Global consensus statement on simulation-based practice in healthcare

Simulation plays a pivotal role in addressing universal healthcare challenges, reducing education inequities, and improving mortality, morbidity and patient experiences. It enhances healthcare processes and systems, contributing significantly to the development of a safety culture within organizations. It has proven to be cost-effective and successful in enhancing team performance, fostering workforce resilience and improving patient outcomes.Through an international collaborative effort, an iterative consultation process was conducted with 50 societies operating across 67 countries within six continents. This process revealed common healthcare challenges and simulation practices worldwide. The intended audience for this statement includes policymakers, healthcare organization leaders, health education institutions, and simulation practitioners. It aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.Key recommendations Advocating for the benefits that simulation provides to patients, staff and organizations is crucial, as well as promoting its adoption and integration into daily learning and practice throughout the healthcare spectrum. Low-cost, high-impact simulation methods should be leveraged to expand global accessibility and integrate into system improvement processes as well as undergraduate and postgraduate curricula. Support at institutional and governmental level is essential, necessitating a unified and concerted approach in terms of political, strategic and financial commitment.It is imperative that simulation is used appropriately, employing evidence-based quality assurance approaches that adhere to recognized standards of best practice. These standards include faculty development, evaluation, accrediting, credentialing, and certification.We must endeavor to provide equitable and sustainable access to high-quality, contextually relevant simulation-based learning opportunities, firmly upholding the principles of equity, diversity and inclusion. This should be complemented with a renewed emphasis on research and scholarship in this field.Call for action We urge policymakers and leaders to formally acknowledge and embrace the benefits of simulation in healthcare practice and education. This includes a commitment to sustained support and a mandate for the application of simulation within education, training, and clinical environments.We advocate for healthcare systems and education institutions to commit themselves to the goal of high-quality healthcare and improved patient outcomes. This commitment should encompass the promotion and resource support of simulation-based learning opportunities for individuals and interprofessional teams throughout all stages and levels of a caregiver’s career, in alignment with best practice standards.We call upon simulation practitioners to champion healthcare simulation as an indispensable learning tool, adhere to best practice standards, maintain a commitment to lifelong learning, and persist in their fervent advocacy for patient safety.This statement, the result of an international collaborative effort, aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

Nursing Student Perception of Different Simulation Methodologies Applied to Help First-Year Students Integrate Knowledge Acquired: A Cross-Sectional Study

BackgroundStandardized patient simulations are an effective method for acquiring skills and knowledge. The purpose of this study was to explore nursing students' perceptions of the learning methods used in clinical simulation. MethodsA cross-sectional study was conducted evaluating two different clinical simulations: 1) basic simulations, where the actor/patient was the teacher, the simulations were performed in pairs, and the rest of the students were present in the same classroom; and 2) simulation-based peer-assisted learning, where the actors/patients were third-year students, the simulations were performed individually, and the rest of the students watched them from another classroom via a video recording system. ResultsIn terms of their perceptions, both types of simulation scored 4.4 out of 5 on the Student Perception of Clinical Simulation tool (SD ±0.7 and ±0.8, respectively). In addition, the results of the characteristics of each simulation are presented. ConclusionsBasic simulations helped students to internalize theoretical knowledge and gain confidence. Peer-assisted learning based on simulations increased their self-confidence and ability to predict clinical changes in patients. As a result, they felt better prepared to care for real patients. The use of both simulation modalities is a flexible method that can be adapted to educational needs.

What makes a simulation-based learning environment for preservice teachers authentic? The role of individual learning characteristics and context-related features

To support professional competence development in teacher education, learning environments should allow learners to engage with professional tasks. It is crucial for knowledge and skill transfer in such learning environments to real-life context that preservice teachers perceive the task as authentic. However, due to a lack of prior knowledge, novices may have difficulties in recognizing relevant elements of practice. It is thus assumed that different factors may guide their perception of task authenticity independently of the task that has to be mastered. Such factors could be, for example, overt design features of the learning environments on a physical level or the familiarity with the learning context and learning prerequisites, which act as important links for knowledge acquisition. In this study, preservice teachers’ perception of task authenticity is contrasted between two implementation types (video vs. role-play) of the same simulation aiming to foster diagnostic competence. The two types differ in approximating real-life practice concerning the professional task that has to be mastered. In an experimental, longitudinal study, N = 119 mathematics preservice teachers participated online in one type of the simulation four times during one semester (n = 66 video, n = 53 role-play). Perceived task authenticity was higher for the video simulation type and increased with repeated participation in the simulation independently of the implementation type. Further, preservice teachers’ task utility value positively influenced their perception of task authenticity. The results illustrate the role of learning prerequisites as well as familiarity with the task for novices’ perception. Also, they could be an initial indication that, depending on the level of learners’ professional development, the way of approximating real-life practice in simulations might influence the perception of task authenticity.

Transformative Landscape of Anesthesia Education: Simulation, AI Integration, and Learner-Centric Reforms: A Narrative Review

This article examines the intersection of simulation-based education and the AI revolution in anesthesia medicine. With AI technologies reshaping perioperative management, simulation education faces both challenges and opportunities. The integration of AI into anesthesia practice offers personalized management possibilities, particularly in preoperative assessment and monitoring. However, the ethical, legal, and social implications necessitate careful navigation, emphasizing patient data privacy and accountability. Anesthesiologists must develop non-technical skills, including ethical decision-making and effective AI management, to adapt to the AI era. The experience-based medical education (EXPBME) framework underscores reflective learning and AI literacy acquisition, fostering lifelong learning and adaptation. Learner-centered approaches are pivotal in anesthesia education, promoting active engagement and self-regulated learning. Simulation-based learning, augmented by AI technologies, provides a dynamic platform for technical and non-technical skills development. Ultimately, by prioritizing non-technical skills, embracing learner-centered education, and responsibly leveraging AI technologies, anesthesiologists can contribute to enhanced patient care and safety in the evolving perioperative landscape.

Utilisation of simulation-based learning to decrease student anxiety and increase readiness for clinical placements for speech-language pathology students

Purpose To investigate the use of two versions of a simulation-based learning experience (SBLE) to decrease speech-language pathology (SLP) students’ anxiety and increase their confidence and sense of preparedness for clinical placements. Method Two cohorts of third-year SLP students (n = 33) participated in a mixed-methods study with each cohort completing one version of the SBLE. Participants completed pre- and post-program quantitative ratings of anxiety, confidence, and preparedness for clinical placements and participated in focus groups. Three clinical educators also provided qualitative data in debriefs and interviews. Result Significant decreases in student ratings of anxiety, and increases in confidence and sense of preparedness, were found for participants from both versions of the SBLE. No significant differences were found between changes in each measure between the two groups. Qualitative data from the student focus groups and clinical educator interviews described affective changes in the students, which concurred with the quantitative results. Conclusion Results suggest this SBLE can be used to improve SLP students’ self-perceptions of readiness for clinical placements. Comparable outcomes can be achieved for students using the shorter, less resource intensive version of the SBLE program, with reduced costs, to overcome barriers to its implementation.

“The Air Is Being Sucked Out of the Room”: Experiences of Social Work Students of Color with Antiracism Education in the Classroom and Practicum

Abstract This study explores the experiences of social work students of color (SOC) and their antiracism education within a school of social work at a public university. Twenty-one SOC participated in focus groups where they described their experiences with antiracism education. Several key themes were identified: (a) finding community through affinity groups, (b) SOC interactions with White students, (c) differentiating internalized racism and anti-Black racism, (d) the impact of White instructors and the lack of mentors and supervisors of color, (e) microaggressions and incidents of racism, and (f) taking up space. As this is an exploratory study, authors make recommendations for social work schools to pilot in the future. These recommendations include assessing White students’ skill level with antiracism education and practice before placing them in classes with SOC, assessing faculty’s skill set with antiracist teaching and providing ongoing support, creating sustained affinity spaces for SOC as a way to booster wellness, designing and piloting antiracist outcomes for social work students, and developing simulation-based learning with simulated patients as a tool to measure antiracist practice competencies.

The Pathway to Developing a Competency-based Tool for Entry-level Nursing Simulation: A Delphi Study

BackgroundSimulation-based learning experiences allow undergraduate nursing students to develop competence and confidence through deliberate practice with immediate feedback on the learner's performance through debriefing. With the transition to competency-based nursing education, nursing faculty need more guidance in implementing competency-based evaluations in the simulation setting. PurposeThis Delphi study aims to inform the future development of a competency-based tool – SimComp – based on the American Association of Colleges of Nursing (AACN) Essentials. MethodsA Delphi framework was used to recruit expert nursing faculty to complete the surveys via an online platform. Data analysis occurred through open-ended questions and quantitative methods to ensure that the responses from expert panelists were used to form the results. ResultsAfter four rounds of this Delphi study, a consensus was achieved on 111 appropriate items for assessing competence in the simulation-based learning environment. ConclusionWhile further research is warranted, this study provides insight for nursing institutions considering implementing or increasing the use of simulation within their program for competency-based evaluations.

Simulation-Based Teaching and Learning in Respiratory Care Education: A Narrative Review.

Simulation-based pedagogy has become an essential aspect of healthcare education. However, there is a significant gap in the literature regarding the application of simulation-based modalities in respiratory care education. This review aims to address this gap by providing insight into the theory and current uses of simulation, its effectiveness in respiratory care education, and strategies to enhance faculty development. The study utilizes a narrative synthesis approach to review relevant literature and provide a comprehensive understanding of the topic. The research involved comprehensive searches of electronic databases, including PubMed and Google Scholar, to identify relevant literature, encompassing original articles, reviews, and other pertinent content, focusing on simulation-based teaching and learning in respiratory care education published between 1990 and 2022. Findings suggest that simulation-based education is an effective tool for improving respiratory care education and can enhance the clinical skills of learners. The study concludes by discussing the future of simulation in respiratory care education and the potential benefits it may offer.

A Simulation-Based Mastery Learning Curriculum Ensures Competency in Discussing Goals of Care for ICU Clinicians

A Simulation-Based Mastery Learning Curriculum Ensures Competency in Discussing Goals of Care for ICU Clinicians

Evaluation of Medical Students' Satisfaction With Using a Simulation-Based Learning Program as a Method for Clinical Teaching.

Objectives This cross-sectional analytical study aims to evaluate medical students' awareness and satisfaction regarding the utilization of simulation-based learning (SBL) as a method for clinical teaching at King Saud University (KSU) over the past 12 months. It seeks to understand how such learning methods enhance students' self-satisfaction and clinical skills, facilitate the application of learned knowledge, and assess the role of instructors in providing ample practice opportunities in the skills laboratory. Furthermore, the study aims to assess the satisfaction levels of students in both preclinical and clinical years regarding the time allocated for skills laboratory sessions and the integration of high-fidelity technology in simulation-based training programs at KSU. Methods In this cross-sectional study, a total of 306 male and female medical students from the College of Medicine at KSU participated, comprising 196 preclinical students (first, second, and third years) and 110 clinical students (fourth and fifth years). Quantitative data was collected through a structured questionnaire on a 5-point Likert scale that showed degrees of satisfaction. The satisfaction was measured based on a 5-point Likert scale that shows the degree of satisfaction from (very dissatisfied, dissatisfied, neither dissatisfied nor satisfied, satisfied, and very satisfied), and we calculated the p-value based on an independent t-test, and the percentage represented the percentage of students who chose satisfied and very satisfied. Results The results showed overall satisfaction with SBL (mean: 3.98, 71.10%), and it was recognized as a useful and effective method of learning skills. It is reported that it helped the students implement what they learned. At the same time, lower satisfaction was identified in areas with less allocated time for skill labs. Moreover, lack of accessibility and lack of trained staff were reported, and they should be addressed by providing staff with proper training. Conclusion The results of the study will help to understand how students' learning needs should be addressed. Moreover, providing simulation-based training is a pathway compliant with the best educational standards that should be adapted according to each institution's singularities. Besides offering further results, the study presents suggestions for further research.

Playing to learn? Analyzing participants' framing of competition and professional conduct in maritime simulations

This study scrutinizes how a simulated scenario framed as a competition is discussed in a post-simulation debriefing, where students reflect on game-like play in the context of professional education. This study draws on Erwin Goffman's (1974/86) analytical concept of framing. In particular, the analysis focuses on the instructor's and students' authentic conversations during a debriefing session and explores how these conversations open up negotiations of professional and playful learning. The research design is ethnographically informed and based on observations, field notes, and 34 h of video data from a navigation course in which 35 bachelor's students from a Norwegian university participated. Our analytical findings reveal that the activity undergoes continuous negotiation between two framings: professional and competitive. In professional framing, students are held accountable for adhering to professional rules, regulations, and norms of “good seamanship.” In the competition framing, students were competing to win the race. Moreover, as the competition mode intensified, students prioritized winning the race over adhering to the rules and regulations of the profession. Consequently, the findings illustrate how a competition framing within a professional education context has engaged the students, letting them demonstrate their knowledge and skills in a playful manner. Furthermore, the findings emphasize the need for an additional exploration of the opportunities and challenges of competition on professional decision making and ethical conduct in settings where simulation-based learning is utilized for training, particularly in domains that train students in high safety standards.

Psychological safety during a large-scale simulation-based learning event

Psychological safety (PS) is currently endorsed as best practice in simulated learning environments. PS refers to the belief that a student can express their ideas and concerns without fear of negative consequences. Students who participate in simulation-based scenarios often experience psychological distress during such events if they are immersed in an environment that is not psychologically safe. This phenomenon has been researched in the field of nursing during both the briefing and debriefing phases of simulation. The aim of this study was to determine the level of PS of emergency care students at a large-scale simulation rescue training exercise. A quantitative survey design was used on student participants at an annual rescue training exercise in 2021. Students who participated in a high-fidelity rescue event scored a mean PS score of 48.76. Reluctance to take interpersonal risks and fear of making mistakes in a team setting were identified as areas of concern. When PS is understood and improved, the learning experience for students will be enhanced and they will be able to participate without fear of humiliation.

Developing simulation-based learning application for radiation therapy students at pre-clinical stage

IntroductionSimulation-based education has been particularly valuable as a preclinical training method that adequately prepares students for clinical practice, including simulation in educational programs enhances the quality of learning outcomes. However, relevant previous research has exhibited several crucial limitations, with most of them having focused solely on the setup procedures. This study aimed to outline the development of an educational application in radiationtherapy and emphasizes the essential factors that radiation therapist technologists(RTTs) must consider in the treatment room from the perspective of experienced RTTs. MethodWe connected the virtual pendants to the linear accelerator components using C# programming and Unity. Customized scripts were assigned to specific linear accelerator (LINAC) functions, and the patient and RTT avatars were developed. We also included audio feedback for the realistic gantry movement sounds. ResultThis study outlines various aspects of radiotherapy procedures duringtreatment, such as the simulation of patient positioning, treatment fields, and pendantfunctions, aimed toward enabling the effective use of virtual reality technology inradiation therapy. DiscussionThis study explores the potential of an avatar-based app for radiotherapy education, providing foundational data for future trials. ConclusionSimulation learning is the most advantageous pre-clinical instrument for equipping students with the skills necessary for clinical practice. This study’s resultsare expected to facilitate radiotherapy students’ adoption of clinical replacement applications and improve collaborative partnerships and knowledge sharing. Notably, this application complements traditional learning methods, further enhancing the overall educational experience.

Advances in remote and cloud-based simulation through web conferencing platforms.

Simulation-based learning has become an essential element in entry-level perfusion education. While the use of simulation has been demonstrated to improve patient outcomes, few institutions possess the budgetary resources to build and maintain a high-fidelity simulation environment. This project aims to identify novel uses of web conferencing platforms to support in-person, remote, and virtual simulation exercises. The Zoom Virtual Meeting platform (Zoom Video Communications, Inc.) was incorporated into the perfusion simulation curriculum at the Medical University of South Carolina CVP Program. Among the observed benefits of incorporating meeting platform software included high-definition audio/visual outputs and recording capabilities, 3-D remote simulation, remote simulation proctoring, and classroom-based learning. Additional Zoom features included remote controlled screen access and sharing, annotations, and break-out rooms and activities. The combination of high-fidelity simulation with virtual and remote features may enhance the learning experience in healthcare education. Future developments in technology and software, simulation education, and instructions through virtual/remote learning may provide a pathway for the future of cardiovascular perfusion education.

Twelve tips for developing simulation-based mastery learning clinical skills checklists

Simulation-based mastery learning is a powerful educational paradigm that leads to high levels of performance through a combination of strict standards, deliberate practice, formative feedback, and rigorous assessment. Successful mastery learning curricula often require well-designed checklists that produce reliable data that contribute to valid decisions. The following twelve tips are intended to help educators create defensible and effective clinical skills checklists for use in mastery learning curricula. These tips focus on defining the scope of a checklist using established principles of curriculum development, crafting the checklist based on a literature review and expert input, revising and testing the checklist, and recruiting judges to set a minimum passing standard. While this article has a particular focus on mastery learning, with the exception of the tips related to standard setting, the general principles discussed apply to the development of any clinical skills checklist.