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Journal ArticleDOI

Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review

01 Jan 2005-Medical Teacher (Taylor & Francis)-Vol. 27, Iss: 1, pp 10-28
TL;DR: While research in this field needs improvement in terms of rigor and quality, high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings.
Abstract: SUMMARY Review date: 1969 to 2003, 34 years. Background and context: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. Objectives: Review and synthesize existing evidence in educational science that addresses the question, ‘What are the features and uses of high-fidelity medical simulations that lead to most effective learning?’. Search strategy: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the ‘grey literature’ were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. Inclusion and exclusion criteria: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. Data extraction: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. Data synthesis: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. Headline results: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following:

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Citations
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Journal ArticleDOI
TL;DR: This article reviews and critically evaluates historical and contemporary research on simulation‐based medical education (SBME) and presents and discusses 12 features and best practices that teachers should know in order to use medical simulation technology to maximum educational benefit.
Abstract: Objectives This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit. Methods This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969–2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003–2009. Results The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record. Conclusions Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts. Medical Education 2010: 44: 50–63

1,459 citations

Journal ArticleDOI
07 Sep 2011-JAMA
TL;DR: In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.
Abstract: Context Although technology-enhanced simulation has widespread appeal, its effectiveness remains uncertain. A comprehensive synthesis of evidence may inform the use of simulation in health professions education. Objective To summarize the outcomes of technology-enhanced simulation training for health professions learners in comparison with no intervention. Data Source Systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. Study Selection Original research in any language evaluating simulation compared with no intervention for training practicing and student physicians, nurses, dentists, and other health care professionals. Data Extraction Reviewers working in duplicate evaluated quality and abstracted information on learners, instructional design (curricular integration, distributing training over multiple days, feedback, mastery learning, and repetitive practice), and outcomes. We coded skills (performance in a test setting) separately for time, process, and product measures, and similarly classified patient care behaviors. Data Synthesis From a pool of 10 903 articles, we identified 609 eligible studies enrolling 35 226 trainees. Of these, 137 were randomized studies, 67 were nonrandomized studies with 2 or more groups, and 405 used a single-group pretest-posttest design. We pooled effect sizes using random effects. Heterogeneity was large (I2>50%) in all main analyses. In comparison with no intervention, pooled effect sizes were 1.20 (95% CI, 1.04-1.35) for knowledge outcomes (n = 118 studies), 1.14 (95% CI, 1.03-1.25) for time skills (n = 210), 1.09 (95% CI, 1.03-1.16) for process skills (n = 426), 1.18 (95% CI, 0.98-1.37) for product skills (n = 54), 0.79 (95% CI, 0.47-1.10) for time behaviors (n = 20), 0.81 (95% CI, 0.66-0.96) for other behaviors (n = 50), and 0.50 (95% CI, 0.34-0.66) for direct effects on patients (n = 32). Subgroup analyses revealed no consistent statistically significant interactions between simulation training and instructional design features or study quality. Conclusion In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.

1,420 citations


Cites background or methods from "Features and uses of high-fidelity ..."

  • ...Criterion B was fulfilled if (1) a randomized study concealed allocation or (2) an observational study controlled for another baseline learner characteristic....

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  • ...We sought to answer 2 questions: (1) To what extent are simulation technologies for training health care professionals associated with improved outcomes in comparison with no intervention? and (2) How do outcomes vary for different simulation instructional designs? Based on the strength of the theoretical foundations and currency in the field, we selected 5 instructional design features(2,9) (curricular integration, distributed practice, feedback, mastery learning, and range of difficulty) for subgroup analyses (see eBox for definitions; available at http://www ....

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  • ...Beyond descriptive analysis (2) 560 (91....

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  • ...When authors reported multiple measures of a single outcome (eg, multiple measures of efficiency), we selected in decreasing order of priority (1) the authordefined primary outcome; (2) a global or summary measure of effect; (3) the most clinically relevant measure; or (4) the mean of the measures reported....

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  • ...cComparability of cohorts criterion A was fulfilled if the study (1) was randomized or (2) controlled for a baseline learning outcome....

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Journal ArticleDOI
TL;DR: The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is.
Abstract: The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is. A recent systematic

1,351 citations

Journal ArticleDOI
TL;DR: Although the number of reports analyzed in this meta-analysis is small, these results show that SBME with DP is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals.
Abstract: Purpose This article presents a comparison of the effectiveness of traditional clinical education toward skill acquisition goals versus simulation-based medical education (SBME) with deliberate practice (DP). Method This is a quantitative meta-analysis that spans 20 years, 1990 to 2010. A search strategy involving three literature databases, 12 search terms, and four inclusion criteria was used. Four authors independently retrieved and reviewed articles. Main outcome measures were extracted to calculate effect sizes.

1,311 citations

Journal ArticleDOI
10 Sep 2008-JAMA
TL;DR: Internet-based learning is associated with large positive effects compared with no intervention and with non-Internet instructional methods, suggesting effectiveness similar to traditional methods.
Abstract: Context The increasing use of Internet-based learning in health professions education may be informed by a timely, comprehensive synthesis of evidence of effectiveness. Objectives To summarize the effect of Internet-based instruction for health professions learners compared with no intervention and with non-Internet interventions. Data Sources Systematic search of MEDLINE, Scopus, CINAHL, EMBASE, ERIC, TimeLit, Web of Science, Dissertation Abstracts, and the University of Toronto Research and Development Resource Base from 1990 through 2007. Study Selection Studies in any language quantifying the association of Internet-based instruction and educational outcomes for practicing and student physicians, nurses, pharmacists, dentists, and other health care professionals compared with a no-intervention or non-Internet control group or a preintervention assessment. Data Extraction Two reviewers independently evaluated study quality and abstracted information including characteristics of learners, learning setting, and intervention (including level of interactivity, practice exercises, online discussion, and duration). Data Synthesis There were 201 eligible studies. Heterogeneity in results across studies was large (I2 ≥ 79%) in all analyses. Effect sizes were pooled using a random effects model. The pooled effect size in comparison to no intervention favored Internet-based interventions and was 1.00 (95% confidence interval [CI], 0.90-1.10; P Conclusions Internet-based learning is associated with large positive effects compared with no intervention. In contrast, effects compared with non-Internet instructional methods are heterogeneous and generally small, suggesting effectiveness similar to traditional methods. Future research should directly compare different Internet-based interventions.

1,241 citations

References
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Journal ArticleDOI
TL;DR: The data demonstrate that the CPS enhances learning both the knowledge and the skills necessary to perform a bedside cardiovascular evaluation and that the skills obtained from use of the simulator are transferable to use with patients.
Abstract: A total of 208 fourth-year students at five medical schools participated in an evaluation of a cardiology patient simulator (CPS). One group (116 students) used the CPS during a fourth-year cardiology elective, while another group (92 students) completed a cardiology elective that did not include use of the CPS. There were no differences between the two groups on a multiple-choice test on cardiology and a skills test on the CPS at the beginning of the clerkship. After the clerkship, the students in the CPS group achieved significantly higher scores on a multiple-choice test, a skills test on the CPS, and a skills test on cardiology patients. Both the students and faculty members expressed very favorable attitudes toward the CPS, but the patients perceived no differences between the two student groups. These data demonstrate that the CPS enhances learning both the knowledge and the skills necessary to perform a bedside cardiovascular evaluation and that the skills obtained from use of the simulator are transferable to use with patients.

143 citations

Journal ArticleDOI
TL;DR: Educational interventions using simulation technology that engage learners in deliberate practice of clinical skills produce large improvements in a relatively short time, with little faculty involvement.
Abstract: Background: Objective evaluations of residents' clinical skills reveal serious deficits. Purpose: To develop, implement, and evaluate outcomes from a review course in cardiology bedside skills for internal medicine residents. Methods: We used a 1-group pretest-posttest design with historical comparisons.The study was conducted at the University of Miami School of Medicine as part of the internal medicine residency program from July 1999 to June 2000. A total of 67 2nd- and 3rd-year medicine residents received an educational intervention involving deliberate practice using simulation technology. A total of 155 4th-year medical students in one intervention and one comparison group (n = 53) served as historical comparisons. Outcome measures were a reliable computer-delivered pretest and posttest that evaluate cardiology bedside skills. Results: Residents who received the review course and medical students who received a comparable educational intervention showed large and statistically significant pretest-to...

142 citations

Journal ArticleDOI
TL;DR: A virtual reality-based simulator that addresses the problems of digital rectal examination (DRE) and allied care personnel training and the need to improve the virtual prostate model realism.
Abstract: Prostate malignancies are the second leading cause of cancer deaths among men. The most common method of detecting this disease is digital rectal examination (DRE), Current DRE training is inadequate, since the number of patients that students can practice on is limited. Furthermore, allied care personnel do not train in screening for prostate cancer. Finally, there is no objective way to follow the improvement in DRE skills for medical personnel. This paper presents a virtual reality-based simulator that addresses the above problems. The prototype consists of a PHANToM haptic interface which provides feedback to the trainee's index finger, a motion restricting board, and an SGI workstation, which renders the patient's anatomy. Four types of prostates were modeled-normal, enlarged with no tumor, incipient malignancy (single tumor), and advanced malignancy (tumor cluster). Human factors studies were conducted on both nonmedical students and urology residents in order to quantify the system usefulness. After only five minutes of training, nonmedical students had a 67% correct diagnosis rate of malignant versus nonmalignant cases. This compared with 56% for urology residents in the same trials. Subjective evaluation by the residents pointed out the need to improve the virtual prostate model realism. A control group formed of urology residents performed the same trials on a modified Merck Procar simulator. The control group scored significantly better (96% correct diagnosis of malignancies). It is concluded that the virtual prostate palpation simulator, while promising, needs significant improvement in both model realism and haptic interface hardware.

139 citations

Journal ArticleDOI
TL;DR: Training on a virtual reality simulator such as MIST VR helps laparoscopic novices adapt to the fulcrum effect faster.
Abstract: Background: The fulcrum effect of the body wall on instrument handling poses a major obstacle to the mastery of instrument coordination for junior laparoscopic surgeons. This study evaluated three types of laparoscopic simulator training to assess their ability to promote the user's adaptation to the fulcrum effect. Methods: Thirty-two participants with no previous experience in laparoscopic surgery were randomly assigned to one of four groups representing different training conditions. One group was assigned to use a virtual reality simulator (MIST VR); two others were given a laparoscopic Z or U maze-tracking task. The control group received no training. Subjects were asked to perform a 2-min laparoscopic cutting task under normal laparoscopic imaging conditions first before and then after training. Results: In the test trial, subjects who trained on MIST VR made significantly more correct incisions (p <0.0001) and fewer incorrect incisions (p <0.0001). Conclusion: Training on a virtual reality simulator such as MIST VR helps laparoscopic novices adapt to the fulcrum effect faster.

135 citations

Journal ArticleDOI
TL;DR: All three stressors led to impaired dexterity and an increase in the incidence of errors inRight-handed surgeons with varying levels of laparoscopic experience.
Abstract: Background: The availability of objective means for assessment of surgical skills has made it possible to evaluate the effect of adverse environmental conditions on surgical performance. Methods: Participants performed a laparoscopic transfer task under five conditions: a simple verbal mathematical task (M), operating theatre background noise at 80 to 85 dB (N), performance as quickly as possible (T), all three stressors combined (A), and quiet conditions (Q). The effect of these conditions on performance was evaluated by using a motion analysis system and an error score. Results: The study included 13 right-handed surgeons with varying levels of laparoscopic experience. There was a significant increase in the path length per movement of the right hand (p = 0.001) under T and a significant increase in the path length per movement of the left hand under M (p = 0.002), T (p = 0.0l), and A (p = 0.02). A significantly higher number of errors occurred under all four stress-inducing conditions. The effect was more pronounced when all the stressors were applied in combination (p = 0.001) followed by performance under M (p = 0.005), then T (p = 0.01) and N (p = 0.03). Conclusions: All three stressors led to impaired dexterity and an increase in the incidence of errors.

134 citations