Emergency manual implementation: can brief simulation-based or staff trainings increase familiarity and planned clinical use?

BACKGROUND: Emergency manuals (EMs)-context-relevant sets of cognitive aids such as crisis checklists-are useful tools to enhance perioperative patient care. Studies in high-hazard industries demonstrate that humans, regardless of expertise, do not optimally retrieve or deploy key knowledge under stress. EM use has been shown in both health care simulation studies and other industries to help expert teams effectively manage critical events. However, clinical adoption and use are still nascent in health care. Recognizing that training with, access to, and cultural acceptance of EMs can be vital elements for successful implementation, this study assessed the impact of a brief in situ operating room (OR) staff training program on familiarity with EMs and intention to use them during critical events. METHODS: Nine 50-minute training sessions were held with OR staff as part of a broader perioperative EM implementation. Participants primarily included OR nurses and surgical technologists. The simulation-based in situ trainings included why and how to use EMs, familiarization with format, simulated scenarios of critical events, and debriefings. A retrospective pre-post survey was conducted to determine participants' levels of EM familiarity and intentions to use EMs clinically. RESULTS: The 126 trained OR staff self-reported increases in awareness of the EM (p < .01), familiarity with EM (p < .01), willingness to use for educational review (p < .01), and intention to use during critical events (p < .01). Participants rated the sessions highly and expressed interest in more opportunities to practice using EMs. CONCLUSIONS: Implementing institutions should not only provide EMs in accessible places in ORs but also incorporate training mechanisms to increase clinicians' familiarity, cultural acceptance, and planned clinical use.

Simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia.

Introduction. Properly performing a subarachnoid block (SAB) is a competency expected of anesthesiology residents. We aimed to determine if adding simulation-based deliberate practice to a base curriculum improved performance of a SAB. Methods. 21 anesthesia residents were enrolled. After baseline assessment of SAB on a task-trainer, all residents participated in a base curriculum. Residents were then randomized so that half received additional deliberate practice including repetition and expert-guided, real-time feedback. All residents were then retested for technique. SABs on all residents' next three patients were evaluated in the operating room (OR). Results. Before completing the base curriculum, the control group completed 81% of a 16-item performance checklist on the task-trainer and this increased to 91% after finishing the base curriculum (P < 0.02). The intervention group also increased the percentage of checklist tasks properly completed from 73% to 98%, which was a greater increase than observed in the control group (P < 0.03). The OR time required to perform SAB was not different between groups. Conclusions. The base curriculum significantly improved resident SAB performance. Deliberate practice training added a significant, independent, incremental benefit. The clinical impact of the deliberate practice intervention in the OR on patient care is unclear.

Nurses' immediate response to the fall of a hospitalized patient: a comparison of actions and cognitions of experienced and novice nurses.

BACKGROUND: Falls represent a significant threat to patient safety for hospitalized patients throughout the world. Little is known, however, regarding nurses' immediate responses to the discovery of a fallen patient. OBJECTIVES: The objective of this study was to perform an experimental examination of experienced and novice nurses' reaction to the discovery of a fallen patient who has sustained a closed head injury. DESIGN: The study was based upon the expert performance approach, which utilizes a mixed methods approach to determining performance characteristics of individuals performing in a variety of domains. SETTING: The study was accomplished using a simulated task environment developed specifically for research concerning the performance of health professionals. PARTICIPANTS: The study included 12 experienced and 10 novice nurses, all of whom were currently employed in critical care settings. METHODS: The study used directly observed performance, which was quantified through the use of direct coding of clinical behaviors and the analysis of verbal reports of thought. RESULTS: The data indicate that experienced participants were not only more likely to call for help but that they were more likely to precede this action by checking for responsiveness, and then, after calling for help, establish the effectiveness of the patient's airway, breathing and circulation. These data confirmed that experienced participants were more likely to engage in the appropriate sequence of actions when faced with this unexpected and highly stressful situation. CONCLUSIONS: Novice nurses' superficial assessment of the situation and subsequent failure to react properly implied an overall pattern of superior performance by the experienced nurses. The results indicated that, compared with novice nurses, experienced nurses are more likely to initiate standard treatment protocols in situations such as the one reported in this study.

Strategies may mediate heritable aspects of memory performance: a twin study.

OBJECTIVE: This study examined use of strategies by twins during cognitive tasks to determine the effects of strategy-use on estimates of heritability. BACKGROUND: Performance on many cognitive tasks has been found to be more similar for monozygotic (MZ) than dizygotic (DZ) twins. The cognitive mechanisms mediating these similarities are largely unknown. METHODS: Think-aloud protocol analysis was used during 3 cognitive tasks typically considered to have high heritability and susceptibility to strategy-use. In addition, a battery of traditional paper tests was administered to examine potential effects of cognitive abilities. RESULTS: Performance on 3 cognitive tasks showed effects of strategies, and performance on 2 of the tasks showed a genetic influence. On 1 of these tasks differences in strategies explained a significant portion of the genetic influences. Measures of cognitive ability and metacognitive knowledge could not explain individual differences in strategy use. CONCLUSIONS: This is the first demonstration that the estimated heritability of performance on cognitive tasks is mediated, at least in part, by the use of specific cognitive strategies. Future studies using similar techniques will permit a description of the development of cognitive mechanisms mediating heritable cognitive abilities, and a deeper understanding of the integration of genetic and environmental factors at the level of cognitive strategies and processes.

Toward a science of exceptional achievement: attaining superior performance through deliberate practice.

Exceptional performance is frequently attributed to genetic differences in talent. Since Sir Francis Galton's book, Hereditary Genius, many scientists have cited heritable factors that set limits of performance and only allow some individuals to attain exceptional levels. However, thus far these accounts have not explicated the causal processes involved in the activation and expression of unique genes in DNA that lead to the emergence of distinctive physiological attributes and cognitive capacities (innate talent). This article argues on the basis of our current knowledge that it is possible to account for the development of elite performance among healthy children without recourse to innate talent (genetic endowment)--excepting the innate determinants of body size. Our account is based on the expert-performance approach and proposes that the distinctive characteristics of exceptional performers are the result of adaptations to extended and intense practice activities that selectively activate dormant genes that are contained within all healthy individuals' DNA. Furthermore, the theoretical framework of expert performance explains the apparent emergence of early talent by identifying factors that influence starting ages for training and the accumulated engagement in sustained extended deliberate practice, such as motivation, parental support, and access to the best training environments and teachers. In sum, our empirical investigations and extensive reviews show that the development of expert performance will be primarily constrained by individuals' engagement in deliberate practice and the quality of the available training resources.

Do clinical clerks provide candidates with adequate formative assessment during Objective Structured Clinical Examinations?

CONTEXT: Various research studies have examined the question of whether expert or non-expert raters, faculty or students, evaluators or standardized patients, give more reliable and valid summative assessments of performance on Objective Structured Clinical Examinations (OSCEs). Less studied has been the question of whether or not non-faculty raters can provide formative feedback that allows students to take advantage of the educational opportunity that OSCEs provide. This question is becoming increasingly important, however, as the strain on faculty resources increases. METHODS: A questionnaire was developed to assess the quality of feedback that medical examiners provide during OSCEs. It was pilot tested for reliability using video recordings of OSCE performances. The questionnaires were then used to evaluate the feedback given during an actual OSCE in which clinical clerks, residents, and faculty were used as examiners on two randomly selected test stations. RESULTS: The inter-rater reliability of the 19-item feedback questionnaire was 0.69 during the pilot test. The internal consistency was found to be 0.90 during pilot testing and 0.95 in the real OSCE. Using this form, the feedback ratings assigned to clinical clerks were significantly greater than those assigned to faculty evaluators. Furthermore, performance on the same OSCE stations eight months later was not impaired by having been evaluated by student examiners. DISCUSSION: While evidence of mark inflation within the clinical clerk examiners should be addressed with examiner training, the current results suggest that clerks are capable of giving adequate formative feedback to more junior colleagues.