Social ties influence teamwork when managing clinical emergencies.

BACKGROUND: Our current understanding of medical team competence is traditionally influenced by an individualistic perspective focusing on individual team members' knowledge, skills as well as on effective communication within the team. However, team dynamics may influence team performance more than previously anticipated. In particular, recent studies in other academic disciplines suggest that social ties between team members may impact team dynamics but this has not been explored for medical teams. We aimed to explore intensive care staff's perceptions about teamwork and performance in clinical emergencies focusing particularly on the teams' social ties. METHODS: Semi-structured interviews were conducted with a purposive sample of intensive care staff. We used a thematic analysis approach to data interpretation. RESULTS: Thematic saturation was achieved after three group interviews and eight individual interviews. Findings demonstrated that social ties influenced teamwork by affecting the teams' ability to co-construct knowledge, coordinate tasks, the need for hierarchy, the degree to which they relied on explicit or implicit communication, as well as their ability to promote adaptive behavior. CONCLUSIONS: Social ties may be an important factor to consider and acknowledge in the design of future team training, as well as for work planning and scheduling of team activities during clinical practice. More research is needed into the causal effect of social ties on team performance and outcome.

Knowing How and Knowing Why: testing the effect of instruction designed for cognitive integration on procedural skills transfer.

Transfer is a desired outcome of simulation-based training, yet evidence for how instructional design features promote transfer is lacking. In clinical reasoning, transfer is improved when trainees experience instruction integrating basic science explanations with clinical signs and symptoms. To test whether integrated instruction has similar effects in procedural skills (i.e., psychomotor skills) training, we studied the impact of instruction that integrates conceptual (why) and procedural (how) knowledge on the retention and transfer of simulation-based lumbar puncture (LP) skill. Medical students (N = 30) were randomized into two groups that accessed different instructional videos during a 60-min self-regulated training session. An unintegrated video provided procedural How instruction via step-by-step demonstrations of LP, and an integrated video provided the same How instruction with integrated conceptual Why explanations (e.g., anatomy) for key steps. Two blinded raters scored post-test, retention, and transfer performances using a global rating scale. Participants also completed written procedural and conceptual knowledge tests. We used simple mediation regression analyses to assess the total and indirect effects (mediated by conceptual knowledge) of integrated instruction on retention and transfer. Integrated instruction was associated with improved conceptual (p < .001) but not procedural knowledge test scores (p = .11). We found no total effect of group (p > .05). We did find a positive indirect group effect on skill retention (B ab  = .93, p < .05) and transfer (B ab  = .59, p < .05), mediated through participants improved conceptual knowledge. Integrated instruction may improve trainees' skill retention and transfer through gains in conceptual knowledge. Such integrated instruction may be an instructional design feature for simulation-based training aimed at improving transfer outcomes.

Collaborative learning of clinical skills in health professions education: the why, how, when and for whom.

OBJECTIVES: This study is designed to provide an overview of why, how, when and for whom collaborative learning of clinical skills may work in health professions education. WHY: Collaborative learning of clinical skills may influence learning positively according to the non-medical literature. Training efficiency may therefore be improved if the outcomes of collaborative learning of clinical skills are superior or equivalent to those attained through individual learning. HOW: According to a social interaction perspective, collaborative learning of clinical skills mediates its effects through social interaction, motivation, accountability and positive interdependence between learners. Motor skills learning theory suggests that positive effects rely on observational learning and action imitation, and negative effects may include decreased hands-on experience. Finally, a cognitive perspective suggests that learning is dependent on cognitive co-construction, shared knowledge and reduced cognitive load. WHEN AND FOR WHOM: The literature on the collaborative learning of clinical skills in health science education is reviewed to support or contradict the hypotheses provided by the theories outlined above. Collaborative learning of clinical skills leads to improvements in self-efficacy, confidence and performance when task processing is observable or communicable. However, the effects of collaborative learning of clinical skills may decrease over time as benefits in terms of shared cognition, scaffolding and cognitive co-construction are outweighed by reductions in hands-on experience and time on task. CONCLUSIONS: Collaborative learning of clinical skills has demonstrated promising results in the simulated setting. However, further research into how collaborative learning of clinical skills may work in clinical settings, as well as into the role of social dynamics between learners, is required.

Association between endovascular performance in a simulated setting and in the catheterization laboratory.

INTRODUCTION: Simulation-based assessment studies have related simulator performance to clinical experience instead of actual clinical performance. This study validates a novel rating scale for coronary angiography (CA) performance and at the same time explores the association between CA performance in a simulated setting and in the catheterization laboratory. METHODS: Ten cardiologists and cardiology residents with varying degrees of CA experience performed 2 CAs in the catheterization laboratory and 2 CAs in a simulated setting. The residents had prior simulator experience opposite cardiologists. Two raters assessed the operators' video-recorded performances using the novel CA rating scale (CARS). RESULTS: The correlation between CARS scores in the catheterization laboratory and the simulated setting was R = 0.20 (P = 0.195). Residents' scores were higher in the simulated setting than in the catheterization laboratory. The correlation between operators' previous clinical experience in CA and CARS scores was R = 0.65 (P = 0.005) in the catheterization laboratory and R = 0.11 (P = 0.353) in the simulated setting. CONCLUSIONS: The association between CA performance in a simulated setting and actual performance in the catheterization laboratory is not linear. The novel rating scale for CA (CARS) seems to be a valid proficiency assessment instrument in the catheterization laboratory. Familiarity with the simulator may overestimate proficiency, which means that simulator performance as a predictor of clinical performance should be interpreted with caution.

Factors relating to the perceived management of emergency situations: a survey of former Advanced Life Support course participants' clinical experiences.

BACKGROUND: This study explored individual, team, and setting factors associated with the quality of management of in-hospital emergency situations experienced by former Advanced Life Support (ALS) course participants. METHODS: This study was a survey of former ALS course participants' long-term experience of management of in-hospital, emergency situations. The survey was carried out in 2012 in Denmark and Norway. RESULTS: A questionnaire was send to 526 potential responders and (281/479 × 100) 58.7% responded. The results demonstrated that 75% of the emergency situations were perceived as "managed well". In general, the responders' confidence in being ALS providers was high, mean 4.3 (SD 0.8), scale 1-5. Significant differences between the perceived "well" and "not well" managed situations were found for all questions, p<0.001. The largest differences related to perception of co-workers' ability to apply ALS principles, the team atmosphere and communication. Responders' ratings of quality of management of emergency situations increased with intensity of setting. However, the 'clinical setting' was rated significantly lower as attributor to ability to apply ALS principles compared to 'co-workers familiarity with ALS principles', 'own confidence as ALS-provider' and 'own social/inter-personal skills'. CONCLUSION: The results of this survey emphasise that ALS providers' perceived ability to apply ALS skills were substantially affected by teamwork skills and co-workers' skills. Team related factors associated with successful outcome were related to clear role distribution, clear inter-personal communication and attentive listening, as well as respectful behaviour and positive team atmosphere. Although intensity of setting was attributed to ability to apply ALS principles, this did not affect management of emergency situations to the same extent as individual and team factors.

Medical students' perception of dyad practice.

Training in pairs (dyad practice) has been shown to improve efficiency of clinical skills training compared with single practice but little is known about students' perception of dyad practice. The aim of this study was to explore the reactions and attitudes of medical students who were instructed to work in pairs during clinical skills training. A follow-up pilot survey consisting of four open-ended questions was administered to 24 fourth-year medical students, who completed four hours of dyad practice in managing patient encounters. The responses were analyzed using thematic analysis. The students felt dyad practice improved their self-efficacy through social interaction with peers, provided useful insight through observation, and contributed with shared memory of what to do, when they forgot essential steps of the physical examination of the patient. However, some students were concerned about decreased hands-on practice and many students preferred to continue practising alone after completing the initial training. Dyad practice is well received by students during initial skills training and is associated with several benefits to learning through peer observation, feedback and cognitive support. Whether dyad training is suited for more advanced learners is a subject for future research.

A study of the effect of dyad practice versus that of individual practice on simulation-based complex skills learning and of students' perceptions of how and why dyad practice contributes to learning.

PURPOSE: The aims of this study were (1) to explore the effectiveness of dyad practice compared with individual practice on a simulator for learning a complex clinical skill and (2) to explore medical students' perceptions of how and why dyad practice on a simulator contributes to learning a complex skill. METHOD: In 2011, the authors randomly assigned 84 medical students to either the dyad or the individual practice group to learn coronary angiography skills using instruction videos and a simulator. Two weeks later, participants each performed two video-recorded coronary angiographies on the simulator. Two raters used a rating scale to assess the participants' video-recorded performance. The authors then interviewed the participants in the dyad practice group. RESULTS: Seventy-two (86%) participants completed the study. The authors found no significant difference between the performance scores of the two groups (mean±standard deviation, 68%±13% for individual versus 63%±16% for dyad practice; P=.18). Dyad practice participants noted that several key factors contributed to their learning: being equal-level novices, the quality of the cooperation between partners, observational learning and overt communication, social aspects and motivation, and meta-cognition. CONCLUSIONS: Dyad practice is more efficient and thus more cost-effective than individual practice and can be used for costly virtual reality simulator training. However, dyad practice may not apply to clinical training involving real patients because learning from errors and overt communication, both keys to dyad practice, do not transfer to clinical practice.

Use of performance curves in estimating number of procedures required to achieve proficiency in coronary angiography.

BACKGROUND: Current guidelines in cardiology training programs recommend 100-300 coronary angiography procedures for certification. We aimed to assess the number of procedures needed to reach sufficient proficiency. METHODS: Procedure time, fluoroscopy time, dose area product (DAP), and contrast media volume were used as indicators of quality of performance. We analyzed data from 4,200 coronary angiographies. Performance curves of seven trainees were compared with recommended reference levels and to those of seven interventional cardiologists. RESULTS: On average, the number of procedures needed for trainees to reach recommended reference levels was estimated as 226 and 353, for DAP and use of contrast media, respectively. After 300 procedures, trainees' procedure time, fluoroscopy time, DAP, and contrast media volume were significantly higher compared with experts' performance, P < 0.001 for all parameters. To approach the experts' level of DAP and contrast media use, trainees need 394 and 588 procedures, respectively. Performance curves showed large individual differences in the development of competence. CONCLUSION: On average, trainees needed 300 procedures to reach sufficient level of proficiency, and this is in accordance with current guidelines. However, because of large individual differences, performance curves might be useful in monitoring individual trainees' progress and ensure documentation of sufficient competence when dealing with patients at risk.

[Assessment of physicians' competence. The continuous professional development]. / Kompetenceevaluering af speciallaeger. Den kontinuerlige professionelle udvikling.

Several stakeholders now request some sort of continuous assessment of physician performance. In the assessment of physicians it must be acknowledged that physicians often work in teams and systems, rendering it impossible to attribute quality of practice to a single person. The challenge is to design a concept that is a meaningful contribution to the development of quality of practice. There is a need to rethink the traditional discourse known from undergraduate and postgraduate specialist educations when applying concepts of assessment to the continuous professional development.

[Are some of the challenging aspects of CanMEDS roles valid in a non-Canadian setting? Secondary publication]. / Er nogle af de udfordrende aspekter af CanMEDS-rollerne valide uden for Canada? Undersøgelse af validiteten af vaesentlige elementer i CanMEDS-rollebeskrivelserne.

A questionnaire survey among 8749 Danish physicians about how the CanMEDS roles apply in an international context. Response rate 42.8% (3,476). The mean rating of importance of competence was 4.2 (SD 0.6). Ratings of confidence increased from interns to specialists. Differences between specialty groups' evaluation of importance and confidence were evident. This study provides an outline of the validity of the CanMEDS roles in a non-Canadian setting. More research in how these aspects of competence are best taught across countries and specialties is needed.

[Interprofessional communication and cooperation training in ward rounds for medical and nursing students: a pilot project]. / Traening af tvaerfaglig kommunikation og samarbejde omkring stuegang for laege- og sygeplejestuderende: et pilotprojekt.

This study reports on a pilot study of the effect of an inter-professional course for medical and nursing students in how to collaborate in the conduct of a ward round. A mixed group of 13 medical and 12 nursing students attended a one-day course. They worked together in small groups training in communication and collaborative skills using a framework for ward rounds in a simulated clinical ward environment. The course was evaluated on standard evaluation forms and through focus group interviews. The programme was highly rated by both of the groups and considered most relevant, well situated and efficient. Next term the training course will be extended to include twice as many students.

[Focused clinical rotations in the postgraduate specialist training in Denmark]. / Fokuserede ophold som laeringsmetode i speciallaegeuddannelsen.

Focused clinical rotations are a new concept introduced in the education of specialists in Denmark. A focused rotation is a short exposure to a subspecialty or a contiguous specialty with the aim of acquiring specific areas of competence. The aim of this study is to report on the extent of focused rotation across specialties and discuss the rationale and possible impact based on a literature search.