Medical Science Educator (2018) 28:65–69 https://doi.org/10.1007/s40670-017-0497-y
ORIGINAL RESEARCH
Simulation-Based Learning Improves Anesthesiology Resident Self-Efficacy in Critical Skills: a Flipped Classroom Approach Kevin R Olsen 1 & Lucas Bannister 1 & Aneel Deshmukh 1 & David J Hall 2 & Juan Mira 2 & Rohit Patel 1,2,3 & Terrie Vasilopoulos 1,4 Published online: 16 November 2017 # International Association of Medical Science Educators 2017
Abstract We implemented a flipped classroom curriculum for our institution’s resident physicians entering their internship year. This curriculum included instructional videos on ACLS, supplemental oxygen delivery, trans-thoracic echocardiography, and line placement, followed by a 3-day simulation-based curriculum. Overall self-efficacy of interns increased following the curriculum. This increased self-efficacy, particularly in procedural ability, was similar to that of PGY-2 residents who had 1 year of experience. Our work suggests that a flipped classroom/simulation-based curriculum for interns can effectively teach a clinical skill set in a short period, yielding self-efficacy in implementing that skill set, particularly in procedural ability, comparable to that after 1 year of residency. Keywords Flipped classroom . Simulation . Medical education . Basic skills
Background Physicians entering residency after medical school have varying self-efficacy and knowledge of practical, specialtyspecific clinical skills [1, 2]. These skills include the workup and treatment of altered mental status, advanced cardiac life support (ACLS) and Brunning a code,^ and methods of supplemental oxygen delivery. Furthermore, new interns and residents are often the first physicians to respond to both common complaints and emergencies, sometimes without an attending present [3]. However, there is no standardized Electronic supplementary material The online version of this article (https://doi.org/10.1007/s40670-017-0497-y) contains supplementary material, which is available to authorized users. * Kevin R Olsen
[email protected] 1
Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254, Gainesville, FL 32610, USA
2
Department of Surgery, University of Florida College of Medicine, PO Box 100286, Gainesville, FL 32610, USA
3
Department of Emergency Medicine, University of Florida College of Medicine, PO Box 100186, Gainesville, FL 32610, USA
4
Department of Orthopedics and Rehabilitation, University of Florida College of Medicine, PO Box 112727, Gainesville, FL 32610, USA
curriculum for educating new interns on the appropriate workup and treatment of a variety of common floor complaints as well as emergencies with the exception of taking an ACLS course. To address this gap, our group developed an intern Bboot camp^ consisting of a combined flipped classroom, simulation-based model, taught by expert faculty that would give new interns a standardized skill set that they could apply to their new roles as care providers (Table 1). Flipped classroom and simulation-based approaches have garnered increasing support by medical educators [4–6]. Recent research has shown that flipped classroom and simulation-based education models are as effective as traditional lectures in teaching clinical skills to graduating medical students and new residents [7–10]. Furthermore, these clinical trainees have rated their flipped classroom and simulation experience positively and prefer this to other approaches [9, 11, 12]. The primary goal of this curriculum was to increase resident self-efficacy in areas relevant to clinical practice. Selfefficacy is one’s belief in their own agency and capabilities [13]. Increasing self-efficacy may lead to change in performance [14], which, in the case of residents, would be the clinical setting. Specifically, for the current study, we examined how self-efficacy in Anesthesiology interns increased following a combined flipped classroom/simulation-based
66 Table 1 interns
Med.Sci.Educ. (2018) 28:65–69 Components of the essential skill set taught to anesthesiology
Essential skill set for interns Basic life support (BLS) Advanced cardiac life support (ACLS) Vital sign monitor use (i.e., American Society of Anesthesiologists Standard Monitors) Supplemental oxygen delivery techniques (i.e., nasal cannula, venturi mask, bag-valve mask ventilation) Bedside transthoracic echocardiography (TTE) Intravenous line placement (IV) Central venous line placement (CVL) Placement and management of post-surgical devices (i.e., Jackson-Pratt drains, chest tubes, vacuum-assisted closure apparatus, nasogastric tubes)
Bboot camp.^ Furthermore, we wanted to examine if our short-term flipped classroom/simulation-based Bboot camp^ could instill levels of self-efficacy in Anesthesiology interns that were comparable to PGY-2 residents who already had a year of clinical experience.
Activity This study protocol was reviewed and approved by the University of Florida IRB-02 committee under no. 2016U-0425. Interns in the Department of Anesthesiology at the University of Florida who were entering a 4-year categorical residency were selected as participants. For the flipped classroom portion of the intervention, participants were asked to review instructional videos from the University of Florida Department of Anesthesiology, American Thoracic Society, and the New England Journal of Medicine in addition to Advanced Cardiac Life Support Algorithms (Appendix 1) prior to attending simulation sessions. They were then given a pre-simulation survey (Appendix 2) to determine their selfefficacy in technical skills and patient management. The survey included 21 questions, focusing on self-efficacy in three areas: Procedures, Autonomy, and Medical Knowledge. Briefly, Procedures questions included questions on the ability to use common medical devices (e.g., ventilators) and perform common techniques (e.g., IV placement). Autonomy questions focused on the ability to work independently in the clinical setting, such as navigating the electronic medical record and working with the nursing staff. Medical knowledge questions assessed the interns’ ability to interpret and assess common clinical measures and results, including interpreting EKGs and management of post-operative complications.
The simulation-based portion of the curriculum was conducted over 3 days by expert faculty in the Departments of Emergency Medicine, Surgery, Anesthesiology, and Critical Care. Simulated scenarios utilized the Human Patient Simulator (CAE Healthcare, Sarasota, FL) at the University of Florida Center for Safety, Simulation, and Advanced Learning Technologies. On the 1st day, interns focused on ACLS with three case-based scenarios specifically tailored to the experience of the ward intern. They were provided with a case vignette and tasked with evaluating and treating a simulated patient in real time. They were provided with an emergency crash cart stocked with the same implements as those found on the hospital floors and standard monitors (defined here as non-invasive blood pressure, pulse oximetry, 5-lead electrocardiogram, and end-tidal CO 2 monitoring). Parameters of the scenario, including patient responses and vital signs, would change in response to the team’s clinical decisions. Each scenario had a defined end point or hard stop that the team would have to reach prior to termination of the scenario. At the end, the intern cohort underwent a debriefing in which they were provided with the opportunity to discuss their perceived strengths and weaknesses during the experience followed by the instructor’s feedback on the team’s performance and review of learning objectives. The ACLS session was followed by a procedure workshop and simulation session where interns first received basic instruction on the indications and techniques of inserting central venous lines, arterial lines, peripheral IVs, and EKG monitoring. Then, under instructor supervision, students were given the opportunity to practice these skills on patient simulator mannequins and specialized demonstration models. They were given a chance to try again and improve their technique based on constructive feedback. The 2nd day included didactic sessions (no simulation) focused on the identification, management, and operation of common surgical devices found in surgical units, including Jackson-Pratt drains, chest tubes, vacuum-assisted closure apparatus, and nasogastric tubes. Clinical instructors from the Department of Surgery presented these sessions. On day 3, a simulator session covering the management of trauma, medication overdose, and supplemental oxygen was held. Participants were provided with standard monitors (as previously described) and crash carts identical to those found in the ED trauma bays and were expected to demonstrate correct operation of these devices. Each scenario was preceded by an outline of the case vignette and followed by a debriefing session in which the teams would discuss their perceived strengths and weaknesses and receive feedback and clinical instruction from a faculty facilitator. A post-simulation survey was conducted at the end of the 3-day period (Appendix 2). This survey was also administered
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to 2nd-year (PGY-2) residents who had completed a year of training at the University of Florida in the Department of Anesthesiology. These PGY-2 residents received standard didactics as interns (not specifically designed to focus on the above skill set, Table 1) and clinical experience in rotations, but had not undergone any flipped classroom or simulationbased education during their intern orientation. Responses to the survey were averaged to create summary scores within each area (Procedures, Autonomy, and Medical Knowledge) and for the entire survey (Overall Self-efficacy). One-way ANOVA was used to compare self-efficacy across three groups: presimulation PGY-1 interns, post-simulation PGY-1 interns, and PGY-2 residents. The Holm-Sidak test was used for post hoc multiple pairwise comparisons. p < 0.05 was considered statistically significant. All analyses were performed in SigmaPlot 13.0 (Systat Software, Inc., San Jose, CA).
Fig. 1 Mean self-efficacy levels pre- and post-simulation for PGY-1 residents and for PGY-2 residents who had not undergone simulation, for overall self-efficacy and for each area. Error bars indicate 95% self-
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Results and Discussion A total of n = 20 PGY-1 interns pre-simulation, n = 17 PGY-1 interns post-simulation (n = 3 opted out of taking the post-simulation survey), and n = 10 PGY-2 residents completed the survey. There were statistically significant group differences in self-efficacy for Procedures (F(2,44) = 4.57, p = 0.016), Autonomy (F(2,44) = 411.45, p < 0.001), Medical Knowledge (F (2, 44) = 8.20, p < 0.001), and Overall (F (2,44) = 8.96, p < 0.001) (see Fig. 1). Selfefficacy in PGY-1 interns was higher post-simulation compared to pre-simulation for Procedures (p = 0.025), Autonomy (p = 0.011), and Overall (p = 0.015). Postsimulation interns had similar self-efficacy to PGY-2 residents for Procedures (p = 0.885) and Overall (p = 0.119). However, for Autonomy (p = 0.042) and Medical Knowledge (p = 0.035), PGY-2 residents had higher selfefficacy than that of post-simulation interns.
efficacy intervals. p values are from Holm-Sidak test for post hoc multiple comparisons. Bold indicates p < 0.05, italics indicate p < 0.10
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Our study found that interns’ self-efficacy increased following our flipped classroom, simulation-based curriculum, supporting prior research in this field. Flipped classroom and simulation-based curricula for senior medical students, interns, and junior residents have been shown to increase self-efficacy in a variety of clinical skills and overall preparedness to contribute to their clinical team, as well as increase self-efficacy and preparedness in topics specifically related to ACLS [12, 15–17]. Our study is unique in that it compared the self-efficacy level of interns to that of PGY-2 residents. While it was unsurprising that PGY-2 residents felt more confident on autonomy and medical knowledge, as these relate to skills, experiences, and training obtained while in the hospital and interacting with other hospital staff, it was interesting that we found similar levels of self-efficacy in procedural ability for post-simulation interns and PGY-2 residents. This supports the utility of our simulation curriculum in teaching and reinforcing self-efficacy in interns’ ability to perform a variety of common tasks expected of anesthesiologists, such as line placement, use of defibrillators, and management of post-surgical devices. Some limitations should be considered while reviewing our findings. First, we had a convenience sample limited to residents at one institution. Although it is unlikely that our surveyed residents deviated from the mean knowledge and ability of other anesthesiology residents nationwide, it is possible our group may have had an unexpectedly advanced or, conversely, insufficient knowledge compared to residents at other programs. Next, we did not measure the long-term effects of our curriculum. However, prior research has shown that the knowledge and self-efficacy acquired from flipped classroom and simulation-based education can be maintained for 6 months to 1 year [17, 18]. If the effects of the simulation did not last for a significant period of time, further simulation could be easily performed at regular intervals to maintain self-efficacy. The flipped classroom and simulation-based curriculum is beneficial in increasing self-efficacy levels for hands-on procedures and familiarity with life-saving skills. Teaching through simulation prior to putting skills to the test in real-world situations may also lead to fewer mistakes and improved quality of patient care. For our interns who received the simulation-based education, they had self-efficacy levels in procedural ability similar to that of PGY-2 residents after just 3 days of simulation, which makes this an easily implemented and effective curriculum for most institutions and programs. Future studies need to be performed to evaluate the duration of this effect and the utility of holding periodic repeat simulations to restore the effect on self-efficacy levels.
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