Ground-Breaking Innovations in General Psychology.

The article addresses two recently published books in General Psychology by Niels Engelsted and Jens Mammen. The two approaches offer in their own way solutions to the so-called 'crisis of psychology'. Mammen's new logical foundation for psychology is based on two different properties of the objects we relate to: those characterizing the objects appearances, and those characterizing the objects as unique substances or singulars distributed in time and space - the existence of the objects as opposed to the appearance of the objects. Engelsted makes a journey from Aristotle (384-322 BC) until today's psychology in his quest to identify the domain of psychology. He places the psyche in the natural world as a result of locomotion in the first, most simple animal life. The domain of psychology includes intentionality, mind and consciousness.

Defining a competency map for a practical skill.

BACKGROUND: In recent years there has been a move towards a competency-based model for assessing the performance of practical procedures in clinical medicine rather than the traditional assumption that competency is achieved with increasing experience. For such an assessment to be valid, the necessary competencies comprising that skill must be identified. Our aim was to map the individual competencies necessary to perform a given procedural skill using spinal anaesthesia as the example, and to explore the relationship of individual competencies with each other. METHODS: In the first part of the study an extensive hierarchical task analysis (HTA) was undertaken to determine the competencies necessary for the performance of spinal anaesthesia. Secondly, the concept of competency-based knowledge space theory (CbKST) was applied to the map. CbKST is based on the principle that acquisition of a specific skill is usually preceded by a number of dependent or prerequisite skills. Our aim was to map the individual competencies necessary to perform a given procedural skill RESULTS: The analysis yielded a comprehensive HTA of the skills necessary to perform spinal anaesthesia, comprising 509 individual competencies. Applying the concept of CbKST yielded 194 key competences with at least one dependent or prerequisite skill. DISCUSSION: We have defined a comprehensive HTA or competency map for use in the assessment of the performance of spinal anaesthesia. This CbKST approach will provide clinicians who undertake medical procedures to better understand their own performance, and to improve over time.

Preliminary evaluation of a virtual reality-based simulator for learning spinal anesthesia.

STUDY OBJECTIVE: To evaluate the influence of a simulation-based program on the initial performance of dural puncture by medical interns, and to refine the design of simulator-based teaching and competence assessment. DESIGN: Prospective interventional study. SETTING: Academic medical center. SUBJECTS: 27 medical interns inexperienced in the technique of spinal anesthesia or dural puncture and within 12 months of graduating from medical school, were randomly assigned to a conventional or a simulator-based teaching course of spinal anesthesia: 13 were recruited to the Conventional Group (CG) and 14 to the Simulator Group (SG). MEASUREMENTS: A SenseGraphic Immersive workbench and a modified Phantom desktop with shutter glasses were used to create a teaching environment. Outcomes of teaching were assessed in two phases within three weeks of the teaching course: Phase I consisted of a written examination followed by assessment on the simulator. A global rating scale and a task-specific checklist were used. Phase II (for those participants for whom a suitable opportunity arose to perform spinal anesthesia under supervision within three wks of the teaching course) consisted of structured observation of clinical performance of the procedure in the operating room. Participants were assessed by independent, study-blinded experts. Student's two-tailed impaired t-tests were used to compare the parametric outcomes (P < 0.05 was considered significant). MAIN RESULTS: All participants completed the written test successfully with no difference between groups. Ten participants from CG and 13 from SG completed the simulator-based testing performing similarly in terms of the global rating scale. Five participants in CG and 6 in SG proceeded to clinical testing. On the global rating scale, interns in SG scored higher than those in CG. They performed similarly according to the task-specific checklist. CONCLUSIONS: Overall, no difference was measured between those taught with traditional methods and those, by a simulator based program in regard to the performance of spinal anesthesia.

Virtual reality-based medical training and assessment: The multidisciplinary relationship between clinicians, educators and developers.

BACKGROUND: The current focus on patient safety and evidence-based medical education has led to an increased interest in utilising virtual reality (VR) for medical training. The development of VR-based systems require experts from different disciplines to collaborate with shared and agreed objectives throughout a system's development process. Both the development of technology as well as the incorporation and evaluation of relevant training have to be given the appropriate attention. AIM: The aim of this article is to illustrate how constructive relationships can be established between stakeholders to develop useful and usable VR-based medical training systems. METHODS: This article reports a case study of two research projects that developed and evaluated a VR-based training system for spinal anaesthesia. RESULTS: The case study illustrates how close relationships can be established by champion clinicians leading research in this area and by closely engaging clinicians and educators in iterative prototype design throughout a system's development process. CONCLUSION: Clinicians and educators have to strive to get more involved (ideally as champions of innovation) and actively guide the development of VR-based training and assessment systems. System developers have to strive to ensure that clinicians and educators are participating constructively in the developments of such systems.

Determinants of learning ultrasound-guided axillary brachial plexus blockade.

BACKGROUND AND OBJECTIVES: Training in medical procedural skills is currently undergoing important change. We set out to identify those factors, perceived by trainers and trainees, to be important determinants of learning ultrasound-guided axillary brachial plexus blockade (USgABPB). METHODS: We performed a structured, prospective, qualitative analysis of these determinants using a design-based approach. We collected data using focus groups, semi-structured interviews and questionnaires. RESULTS: Based on 113 responses to a detailed questionnaire, the most important determinants of learning USgABPB were access to and frequency of clinical learning opportunities in the presence of an appropriate trainer. Focus groups determined that meaningful learning opportunities required the coexistence of an appropriate patient, trainee, trainer and environment. Trainers and trainees perceived that the consistent provision of such opportunities required a formal structured training programme. CONCLUSIONS: Optimum training in USgABPB requires a formal structured training programme. We propose that these findings can be used to optimise the design of the curriculum, the training programme and assessment on performing the procedure.

Proactive error analysis of ultrasound-guided axillary brachial plexus block performance.

BACKGROUND: Detailed description of the tasks anesthetists undertake during the performance of a complex procedure, such as ultrasound-guided peripheral nerve blockade, allows elements that are vulnerable to human error to be identified. We have applied 3 task analysis tools to one such procedure, namely, ultrasound-guided axillary brachial plexus blockade, with the intention that the results may form a basis to enhance training and performance of the procedure. METHODS: A hierarchical task analysis of the procedure was performed with subsequent analysis using systematic human error reduction and prediction approach (SHERPA). Failure modes, effects, and criticality analysis was applied to the output of our SHERPA analysis to provide a definitive hierarchy to the error analysis. RESULTS: Hierarchical task analysis identified 256 tasks associated with the performance of ultrasound-guided axillary brachial plexus blockade. Two hundred twelve proposed errors were analyzed using SHERPA. Failure modes, effects, and criticality analysis methodology was applied to the output of SHERPA analysis to prioritize 20 errors. CONCLUSIONS: This study presents a formal analysis of (i) the specific tasks that might be associated with the safe and effective performance of the procedure and (ii) the most critical errors likely to occur as trainees learn to perform the procedure. Potential applications of these data include curricular development and the design of tools to teach and assess block performance.

Testing haptic sensations for spinal anesthesia.

BACKGROUND AND OBJECTIVES: Having identified key determinants of teaching and learning spinal anesthesia, it was necessary to characterize and render the haptic sensations (feeling of touch) associated with needle insertion in the lower back. The approach used is to match recreated sensations (eg, "pop" through skin or dura mater) with experts' perceptions of the equivalent clinical events. METHODS: The study was performed using a haptic device (Phantom Desktop) that simulated the tactile elements of predefined clinical events. Twenty-four experts (anesthetists) were invited to assess rendered versions of 3 basic sensations, which typically occur during the performance of spinal anesthesia with a 25-gauge pencil point needle: (1) touching different surfaces (skin, bone), (2) the "pop" sensations (skin, dura mater), and (3) the sensations associated with advancement of the spinal needle through particular tissues (subcutaneous tissue, ligaments, intrathecal space). The perceptions of each participant were recorded. The relationships between each rendered sensation and the corresponding participant's perception was modeled using standard random effects techniques. RESULTS: Experts seem to possess a specific haptic perception regarding most sensations. The coefficient of variation was less than 0.50 for all sensations with the exception of intrathecal space. However, there is considerable within-rater variation when experts are presented with the same haptic rendering on more than one occasion for bone surface, skin pop, dura pop, and subcutaneous tissue. CONCLUSIONS: The importance of this finding is that it demonstrates the feasibility of an "expert perception"-based approach to the design of medical simulators.

Teaching and learning spinal anaesthesia: anaesthetists' attitudes.

BACKGROUND: To identify the determinants of learning for one medical procedural skill, spinal anaesthesia, by eliciting the opinions of anaesthetists in Ireland and Hungary. This objective is one component of a research project, Medical Competence Assessment Procedure (MedCAP) funded by the EU Leonardo da Vinci Lifelong Learning Programme. METHODS: An electronic survey was circulated to anaesthetists in Hungary and Ireland. The survey was designed to identify and prioritise determinants of learning. Primary analysis was performed using the proportions of respondents that either agreed or strongly agreed with each question. A secondary analysis was performed comparing responses from Ireland with those from Hungary. RESULTS: A total of 180 of the 810 anaesthetists surveyed responded in Ireland, and 69 out of 225 responded in Hungary. In both countries, more than 90 per cent agreed or strongly agreed that acquisition of baseline knowledge, clinical demonstration, trainee motivation, feedback to the trainee, trainer motivation and communication skills were important determinants of learning. However, a greater proportion of Hungarian compared with Irish anaesthetists indicated that training should follow a problem-based approach [60/63 (95%) versus 54/124 (43%)]. A greater proportion of Irish anaesthetists indicated that trainee self-awareness was an important determinant of learning [89/122 (73%) versus 22/64 (34%)]. CONCLUSION: Anaesthetists in Ireland and Hungary believe that learning spinal anaesthesia is determined by factors related to the trainee (motivation, knowledge), the trainer (motivation, communication) and the training programme (feedback, demonstration prior to clinical performance). Differences between respondents from the two countries were identified in regard to attitudes towards problem-based learning and self-awareness. These findings can be used to inform the design of training programmes and simulators.