Comparison of three analgesic regimens in women undergoing cervical brachytherapy.

PURPOSE: Effective periprocedural analgesia is an important aspect of cervical brachytherapy delivery, with implications for patient comfort and attendance for subsequent fractions. We compared the efficacy and safety of three analgesic modalities: intravenous patient-controlled analgesia (IV-PCA), continuous epidural infusion (CEI) and programmed-intermittent epidural bolus with patient-controlled epidural analgesia (PIEB-PCEA). METHODS AND MATERIALS: Ninety-seven brachytherapy episodes involving 36 patients between July 2016 and June 2019 in a single tertiary center were retrospectively reviewed. Episodes were divided into two key phases: Phase 1 (while applicator remained in situ) and Phase 2 (following applicator removal until discharge or 4 h). For the primary endpoint, pain scores were retrieved and analyzed by analgesic modality with respect to median score and an internally defined "unacceptable" pain experience (>20% of scores being ≥4/10; i.e., moderate or greater). Total nonepidural oral morphine equivalent dose (OMED) and toxicity/complication events were reported as secondary endpoints. RESULTS: In Phase 1, there was a significantly higher median pain score (p < 0.001) and more episodes with unacceptable pain scores (46%) in the IV-PCA group compared with either epidural modality (6-14%; p < 0.001). In Phase 2, we observed a greater median pain score (p = 0.007) and higher proportion of patient episodes with unacceptable pain scores (38%) in the CEI group compared with both the IV-PCA (13%) and PIEB-PCEA (14%) groups (p = 0.001). There was a significant difference in median OMED used throughout all phases across the PIEB-PCEA (0 mg), IV-PCA (70 mg), and CEI (15 mg) groups (p < 0.001). CONCLUSIONS: PIEB-PCEA is safe and offers superior analgesia compared to IV-PCA or CEI for pain control after applicator placement in cervical brachytherapy.

Evaluation of the simulation based training quality assurance tool (SBT-QA10) as a measure of learners' perceptions during the action phase of simulation.

BACKGROUND: In an earlier interview-based study the authors identified that learners experience one or more of eight explicit perceptual responses during the active phase of simulation-based training (SBT) comprising a sense: of belonging to instructor and group, of being under surveillance, of having autonomy and responsibility for patient management, of realism, of an understanding of the scenario in context, of conscious mental effort, of control of attention, and of engagement with task. These were adapted into a ten-item questionnaire: the Simulation Based Training Quality Assurance Tool (SBT-QA10) to allow monitoring of modifiable factors that may impact upon learners' experiences. This study assessed the construct validity evidence of the interpretation of the results when using SBT-QAT10. MATERIALS AND METHODS: Recently graduated doctors and nurses participating in a SBT course on the topic of the deteriorating patient completed the SBT-QAT10 immediately following their participation in the scenarios. The primary outcome measure was internal consistency of the questionnaire items and their correlation to learners' satisfaction scores. A secondary outcome measure compared the impact of allocation to active versus observer role. RESULTS: A total of 349 questionnaires were returned by 96 course learners. The median of the total score for the ten perception items (TPS) was 39 (out of 50), with no significant difference between the scenarios. We identified fair and positive correlations between nine of the 10 items and the SBT-QA10-TPS, the exception being "mental effort". Compared to observers, active learners reported significantly more positive perceptions related to belonging to the team and interaction with the instructor, their sense of acting independently, and being focused. The questionnaire items were poorly correlated with the two measures of global satisfaction. CONCLUSION: Except for the item for mental effort, the QA10-TPS measures learners' experiences during the active phase of simulation scenarios that are associated with a positive learning experience. The tool may have utility to learners, instructors, and course providers by informing subsequent debriefing and reflection upon practice for learners and faculty. The relationship between these perceptions and commonly used measures of satisfaction remains poorly understood raising questions about the value of the latter.

Emotional Activation in Simulation: Measuring the Influence of Participant Roles and Scenario Design.

INTRODUCTION: The degree of emotional activation required for optimal learning in either hands-on or observer roles is unclear, as is the level of stress that impedes learning. Measuring emotional activation is time-consuming, and many scales measure threat or anxiety without considering pleasurable activation. This study examined emotional activation in the observer and hands-on roles in 2 different scenario designs. METHODS: This study was a 2-cohort, parallel study of graduate nurses and doctors completing 2 different courses in managing the deteriorating patient. We examined emotional activation by role across 2 scenario designs. We measured emotional activation on 3 anchored measures scales: the State Trait Anxiety Inventory, Cognitive Appraisal Index, and the Affect Grid with data analysis using analysis of variance and repeated measures. RESULTS: Hands-on learners experienced higher anxiety, threat, and arousal levels and less pleasure than observers in both scenario designs. There were no differences in pre-emotional and postemotional activation in immersive scenarios for either role and increased arousal and decreased threat and anxiety in the hands-on role in the pause-and-discuss scenario design. CONCLUSIONS: Hands-on learners were more emotionally activated than observers in both scenario designs. There was significant perceived anxiety, threat, and pleasurable arousal in both roles and both scenario designs. Pause-and-discuss scenarios demonstrated similar levels of activation as the immersive scenario design. The Affect Grid provided a quick subjective view of arousal and pleasure in simulation participants, potentially providing educators with an indication of whether emotional activation is positive (excitement) or negative (stressful) and may be helpful in educational planning and future research.

Two case studies of cardiac arrest occurring in medically fit patients undergoing radical hysterectomy for cervical cancer.

We report case histories of two young women who had an intraoperative cardiac arrest, potentially caused by preoperative emotional stress, while undergoing open radical hysterectomy for cervical cancer. Neither had any history of heart disease or other comorbidities. Takotsubo cardiomyopathy, a form of stress cardiomyopathy characterized by acute reversible ventricular dysfunction that can occur in the perioperative period, was the cause in one patient. A vasovagal episode during the exploration of the abdomen was the cause in the other. Successful resuscitation and stabilisation of both patients made it possible to continue the surgery and successfully complete both procedures. Takotsubo cardiomyopathy should be considered in any patient showing significant preoperative stress who has a cardiac arrest, even if there is no preoperative morbidity. It is difficult to differentiate from a vasovagal episode intraoperatively. Surgical and anaesthetic teams should be aware of importance of countering severe preoperative stress.

'It is a different type of learning'. A survey-based study on how simulation educators see and construct observer roles.

Background: Simulation is reported as an appropriate replacement for a significant number of clinical hours in pregraduate programmes. To increase access for learners, educators have looked to understanding and improving learning in observer roles. Studies report equivalent learning outcomes and less stress in observer roles. However, reports on the prevalence, use and perceived value of observer roles from the educator's perspective are lacking. Methods: An exploratory survey for Australian and New Zealand (ANZ) simulation educators based on literature findings was developed and piloted with a small sample (n=10) of like subjects for language, clarity, skip logic and completion time. The final survey comprised 36 questions. Quantitative data were analysed using Pearson's chi-squared test, Welch's ANOVA and exploratory factor analysis. Select qualitative data were analysed using content analysis and summarised with frequency counts and categorisation. Results: Two hundred and sixty-seven surveys were completed, with 221 meeting criteria for analysis. The observer role is widely used in ANZ and most learners experience both hands-on and observer roles. The location of observers is dependent upon several factors including facility design, learner immersion, scenario design and observer involvement. Verbal briefings and/or other guides are provided to 89% of observers to direct their focus and 98% participate in the debrief. Educators value observer roles but tend to believe the best learning is hands-on. Conclusions: The learning in observer roles is less valued by educators than hands-on roles. Focused observation provides opportunities for noticing and attributing meaning, an essential skill for clinical practice. Learning spaces require consideration of scenario design and learning objectives. Scenario design should include objectives for observer roles and incorporate the observer into all phases of simulation. Attention to these areas will help promote the value of the different type of learning available in observer roles.

Finding common ground: meta-synthesis of communication frameworks found in patient communication, supervision and simulation literature.

BACKGROUND: Effective communication between patients-clinicians, supervisors-learners and facilitators-participants within a simulation is a key priority in health profession education. There is a plethora of frameworks and recommendations to guide communication in each of these contexts, and they represent separate discourses with separate communities of practice and literature. Finding common ground within these frameworks has the potential to minimise cognitive load and maximise efficiency, which presents an opportunity to consolidate messages, strategies and skills throughout a communication curriculum and the possibility of expanding the research agenda regarding communication, feedback and debriefing in productive ways. METHODS: A meta-synthesis of the feedback, debriefing and clinical communication literature was conducted to achieve these objectives. RESULTS: Our analysis revealed that the concepts underlying the framework can be usefully categorised as stages, goals, strategies, micro-skills and meta-skills. Guidelines for conversations typically shared a common structure, and strategies aligned with a stage. Core transferrable communication skills (i.e., micro-skills) were identified across various types of conversation, and the major differences between frameworks were related to the way that power was distributed in the conversation and the evolution of conversations along the along the path of redistributing power. As part of the synthesis, an overarching framework "prepare-EMPOWER enact" was developed to capture these shared principles across discourses. CONCLUSIONS: Adopting frameworks for work-based communication that promote dialogue and empower individuals to contribute may represent an important step towards learner-centred education and person-centred care for patients.

Learners' Perceptions During Simulation-Based Training: An Interview Study Comparing Remote Versus Locally Facilitated Simulation-Based Training.

INTRODUCTION: Remotely facilitated simulation-based training (RF-SBT) is less positively appraised than face-to-face, locally facilitated simulation-based training (LF-SBT), despite being considered as an acceptable alternative. This study compared the perceptions of learners after RF-SBT and LF-SBT to explain differences between the two and identify relevant theories that would guide future practice. METHODS: Telephone interviews were conducted with 21 newly graduated doctors and nurses who completed a standardized simulation course delivered in both RF-SBT and LF-SBT formats. RESULTS: Participants reported that both SBT formats to be highly beneficial, however, were less positive about RF-SBT. They described a range of psychosocial and cognitive responses that explained their positive and negative attitudes to different aspects of the training. These perceptions, occurring across both formats, included a sense of the following: belonging to instructor and group, surveillance, responsibility, realism, contextual understanding, conscious mental effort, control of attention, and engagement with task. Participants associated these perceptions and ensuing attitudes to SBT with factors arising during, and/or existing before, the SBT as if in an input-output process model. The former 'enabling' factors related to human interaction, technology, and instructional design, whereas the latter 'precursor' factors reflected pre-existing attributes of the participants and instructors. These findings are supported by several theoretical models of which the technology acceptance model is arguably the best fit. CONCLUSIONS: Locally facilitated simulation-based training is easier to use and experience than RF-SBT; however, the latter's negative impact may be concealed by SBT's overarching very high perceived value. The technology acceptance model is an appropriate conceptual model to explain these processes.

Observer roles that optimise learning in healthcare simulation education: a systematic review.

BACKGROUND: Simulation is widely used in health professional education. The convention that learners are actively involved may limit access to this educational method. The aim of this paper is to review the evidence for learning methods that employ directed observation as an alternative to hands-on participation in scenario-based simulation training. We sought studies that included either direct comparison of the learning outcomes of observers with those of active participants or identified factors important for the engagement of observers in simulation. We systematically searched health and education databases and reviewed journals and bibliographies for studies investigating or referring to observer roles in simulation using mannequins, simulated patients or role play simulations. A quality framework was used to rate the studies. METHODS: We sought studies that included either direct comparison of the learning outcomes of observers with those of active participants or identified factors important for the engagement of observers in simulation. We systematically searched health and education databases and reviewed journals and bibliographies for studies investigating or referring to observer roles in simulation using mannequins, simulated patients or role play simulations. A quality framework was used to rate the studies. RESULTS: Nine studies met the inclusion criteria. Five studies suggest learning outcomes in observer roles are as good or better than hands-on roles in simulation. Four studies document learner satisfaction in observer roles. Five studies used a tool to guide observers. Eight studies involved observers in the debrief. Learning and satisfaction in observer roles is closely associated with observer tools, learner engagement, role clarity and contribution to the debrief. Learners that valued observer roles described them as affording an overarching view, examination of details from a distance, and meaningful feedback during the debrief. Learners who did not value observer roles described them as passive, or boring when compared to hands-on engagement in the simulation encounter. CONCLUSIONS: Learning outcomes and role satisfaction for observers is improved through learner engagement and the use of observer tools. The value that students attach to observer roles appear contingent on role clarity, use of observer tools, and inclusion of observers' perspectives in the debrief.

Remotely Versus Locally Facilitated Simulation-based Training in Management of the Deteriorating Patient by Newly Graduated Health Professionals: A Controlled Trial.

INTRODUCTION: This study evaluated delivery of immersive simulation-based training (SBT) by distance education. Newly graduated health professionals' experience of and learning outcomes from videoconference-enabled remotely facilitated (RF) were prospectively compared with a locally facilitated (LF) format within a course addressing management of the deteriorating patient. METHODS: Participants were exposed to both RF and LF formats in an intervention course (IC). The primary outcome measure was a questionnaire detailing participants' experience of 1 RF scenario and 1 LF scenario. The 16-item questionnaire measured perceived learning, comfort, interaction with other learners and instructor, as well as quality of instruction, factors that are considered essential in both SBT and distance education. As a secondary outcome measure, learning outcomes, measured as precourse and postcourse scores and pass rates in multiple-choice question tests, were also measured and compared with those of participants completing control courses, in which only the LF format was used. RESULTS: The study was conducted between April 2013 and April 2014. Among the 155 participants who participated in ICs, questionnaire results revealed a small, significantly higher median total score (25-75 interquartile range) for LF versus RF format scenarios [78 (72-80) vs. 76 (68-80), P = 0.01]. Multiple-choice question test scores compared between 155 IC and 150 control course participants showed no significant differences. CONCLUSIONS: Participants' experience of SBT using the RF format was slightly less positive than the LF format; however, it had no measured impact on knowledge. The impact of RF-SBT on more complex training applications remains poorly understood. Instructors could potentially optimize learner comfort and engagement by improving their interactive skills.

Contextual information influences diagnosis accuracy and decision making in simulated emergency medicine emergencies.

BACKGROUND: It is well documented that adaptations in cognitive processes with increasing skill levels support decision making in multiple domains. We examined skill-based differences in cognitive processes in emergency medicine physicians, and whether performance was significantly influenced by the removal of contextual information related to a patient's medical history. METHOD: Skilled (n=9) and less skilled (n=9) emergency medicine physicians responded to high-fidelity simulated scenarios under high- and low-context information conditions. RESULTS: Skilled physicians demonstrated higher diagnostic accuracy irrespective of condition, and were less affected by the removal of context-specific information compared with less skilled physicians. The skilled physicians generated more options, and selected better quality options during diagnostic reasoning compared with less skilled counterparts. These cognitive processes were active irrespective of the level of context-specific information presented, although high-context information enhanced understanding of the patients' symptoms resulting in higher diagnostic accuracy. CONCLUSIONS: Our findings have implications for scenario design and the manipulation of contextual information during simulation training.

Effective management of anaesthetic crises: development and evaluation of a college-accredited simulation-based course for anaesthesia education in Australia and New Zealand.

The Effective Management of Anesthetic Crises (EMAC) course is a joint initiative between the Australian and New Zealand College of Anesthetists (ANZCA) and simulation centers. This standardized 2.5-day course has become an integral component of training for Fellowship of ANZCA and as such is an innovative development on the global anesthesia scene.Since its inception in 2002, over 600 anesthetists, with equal numbers of specialists and trainees, have attended EMAC throughout Australia, New Zealand, and Hong Kong. Course evaluations from 499 anesthetists and a follow-up survey showed strong support for the course and its relevance to clinical practice. The course is perceived by participants as changing their practice and improving their management of anesthetic crises.Exposure to the concepts of effective crisis management is now widespread in the anesthetic community in the region and should contribute to improved patient safety.

High stakes assessment using simulation -- an Australian experience.

The use of simulation for high stakes assessment has been embedded in the New South Wales Medical Practice Act and has been used for high stakes assessment on a number of occasions. Simulation has rarely been used in this manner elsewhere in the world. We outline the use of simulation in particular focussing on its relationship to a performance assessment programme featuring performance focus, peer assessment of standards, an educative, remedial and protective framework, strong legislative support and system awareness.