Simulation in Nursing: Historical Analysis and Theoretical Modeling in Support of a Targeted Clinical Training Intervention

The use of simulation is widespread in healthcare education, and the potential impact of its use large. This is especially true for nursing education as we look to address problems with obtaining clinical experiences, develop critical thinking skills and create methods to measure the impact of simulation interventions. There is substantial empirical evidence in support of predictive relationships between simulation training interventions and knowledge acquisition. This has been extensively demonstrated with the use of a variety of simulation training modalities from standardized patients to human patient simulators. However, data to support changes in clinical practice and improved patient outcomes are quite limited, including attempts to measure the impact of simulation education on retention and transference of knowledge and skill for more complex healthcare process. Additionally, literature searches reveal that only a handful of authors have engaged in the types of foundational work that any emerging science needs. For example, while pieces of the simulation process have been examined in detail, few have attempted to describe what the process of simulation entails at a macro level. Within the past few years some researchers have begun to ask whether there is a causal or predictive relationship present, but few have explored what these associations may look like structurally and what the evidence for them is. The overall objectives of this current research were to: 1) perform an historical review of simulation in healthcare; 2) use this review to outline a new theoretical model of healthcare simulation; and, 3) conduct a small-scale study aimed at pilot-testing and describing part of that model. Hierarchical Task Analysis (HTA) was used to derive an optimum task set for the standard induction of general anesthesia (OTS-SIGA). New Student Registered Nurse Anesthetists (SRNAs) were trained to this task set, and their adherence to the process steps in the clinical setting was then assessed. We also attempted to measure whether repeating the HTA-derived OTS-SIGA simulation training would have an impact on knowledge and transference of simulation-developed skills to the clinical environment. These measures necessitated the development of associated data collection tools and processes for rater training

A Simulation-Based Teaching Strategy to Achieve Competence in Learners

Background: Simulation-based education has become the mainstay of clinical education in health sciences and medical education. A simulation-based education is a result of work hour restriction placed on graduate learners, increased number of students requiring clinical experience, decreased number of clinical sites and lack of the availability to perform certain procedures by learners. Research has demonstrated that integration of a simulation-based educational teaching strategy in a curriculum and throughout continued learning achieves competence in learners. Methods: The review of the literature highlighted the following topics: (a) history of medical simulation, (b) fidelity used in simulation training, devices and equipment, (c) learning theories associated with simulation-based education, (d) role of simulation training in medical and health sciences education, e) advantages and disadvantages of simulation training, f) competence in simulation-based education, g) debriefing/reflection in simulation. Results: An extensive review of the literature supports the use of a simulation-based teaching strategy in health sciences and medical education. Learning theories associated with simulation-based education allow educators to provide teaching strategies that align with learner’s ability to achieve competence in learning clinical and procedural skills required for their profession. Conclusion: A simulation-based education integrated in all stages of learner education that provides deliberate/repetitive practice and feedback achieves competence in learners throughout a life-time of learning

A simulação como recurso pedagógico no ensino médico

Background: The use of simulation in medical education ensures improved learning and an increase in experience without the risk of real events. The absence of previous training in the execution of technical procedures may involve risks to the patient, inseparable from the technique in question. Thus, medical education is decisive in preventing medical errors, and simulation has a critical role in this field. Different approaches, such as mixed-realism scenarios, high-fidelity mannequins, and virtual reality, are used in simulation as resources for medical education. Simulation can be used to train technical and non-technical skills such as team endeavor, team communication, and clinician-patient communication. The latter, which includes the disclosure of an adverse event to a patient, contributes to the increase in the clinician's confidence. Although the recognition of simulation as a fundamental resource in medical education has been increasing in the last years, there is a lack of implemented courses, as part of pre- and post-graduate medical training, and quantitative evaluation of the impact of these courses in residency and, at ultimately, in patient care improvement. Objectives: To increase anesthesiology training's efficacy and safety by including simulation training as a mandatory component of Anesthesiology Residency. To accomplish this primary objective, the work was divided into three aims: 1) to train and evaluate, through the construction of an evaluation instrument divided into two-parts: the participation in a clinical episode that triggered an adverse event in a simulation scenario in an Operating Room context and the dissemination of the same adverse event, in a hybrid simulation scenario; 2) to design a skill training program, in a simulation environment according to the programmatic contents included in the Portuguese Residency in Anesthesiology including technical and non-technical skills; 3) to implement and evaluate the program through the construction and validation of self-assessment questionnaires answered by the residents before and after each simulation module. Results: The comprehensive methodology involving mixed-realism simulation engaged 42 Anesthesiology residents in an adverse event and its disclosure to the patient. It allowed practicing to a range of patients’ answers through the different stages of a grief response. The instruments to assess the performance and the anesthesiology residents' disclosure practice showed excellent interrater reliability and high internal consistency (p<0.05). Three-hundred and forty individuals attended the competencies training program for Portuguese Anesthesiology residents, designed according to the programmatic contents defined by the Portuguese Board of Anesthesiology: 76 from the first year, 89 from the second, 82 from the third, and 93 from the fourth and last year. For the evaluation of this program, self-assessment questionnaires to be applied before and after each simulation module were designed, and the internal consistency was tested, indicating a high internal consistency of all questionnaires. Students assessed the importance attributed to several main technical concepts in Anesthesiology, and their training and experience before and after each simulation course. The results were statistically significant in almost all comparisons (p<0.05). Likewise, these questionnaires also included questions regarding non-technical skills such as need for help, making mistakes, self-efficacy over time, need for support, communication, and team attitude. Over time, the need for support and the number of mistakes increased from the residents' perspective (p<0.001). However, the students assumed that, through the residency, there was an improvement in the communication skills since they easily expressed their opinion, even if they disagreed with the consultant anesthesiologist. Unanimity is highlighted regarding the importance of non-behavioral competencies for clinical practice excellence, identified by 4th-year residents at the end of training with simulation. Finally, the residents rated all the programmatic contents addressed during the simulation modules as highly important. The last year's topics were the ones with numerically higher importance attributed by the trainees. Conclusions: The evaluation instrument divided into two parts demonstrated solid psychometric properties to evaluate the performance of communication to the patient of the occurrence of an adverse effect. The mixed concept of reality-simulation allowed residents to be involved in an adverse event and train their communication before direct contact with a patient. The construction of a simulation program according to the Anesthesiology Residency's pedagogical contents improves training in this area without putting patients at risk. It has repercussions on recognizing the error, enriching the value of self-confidence and the fundamental role of behavioral skills.In the end, this study showed that simulation also has repercussions on the identification of gaps that must be overcome before the residents become independent, culminating in improved patient safety. Together, the results obtained emphasize the positive impact of simulation as a learning instrument of the Medical Residency in Anesthesiology.Introdução: O uso da simulação no ensino médico assegura uma melhoria na aprendizagem e um acréscimo de experiência, sem o risco dos eventos reais. A ausência de treino prévio na execução de procedimentos técnicos pode associar risco para o doente, indissociável da técnica em questão. Assim, a educação e o treino em segurança são decisivos para a prevenção do erro médico. Neste contexto, a simulação tem um papel determinante. Diferentes abordagens, como cenários híbridos realidade-simulação, manequins de altafidelidade e realidade virtual são usadas em simulação enquanto recurso de ensino médico. A simulação pode ser utilizada na aquisição de competências técnicas e competências não técnicas, como o trabalho de equipa, a comunicação em equipa e a comunicação médicodoente. A relação médico-doente pode também ser desenvolvida pelo treino de situações como a comunicação de um evento adverso a um doente ou familiar. Embora o reconhecimento da simulação como instrumento fundamental na educação médica tenha aumentado nos últimos anos, falta ainda a sua integração na formação médica pré e pós-graduada, tal como a avaliação quantitativa dessa integração no desempenho dos médicos internos e, em última instância, na melhoria assistencial do doente. Objetivos: Aumentar a eficácia e a segurança da formação em Anestesiologia através da inclusão do treino em simulação como componente obrigatória do programa de formação específica desta especialidade. Para atingir esse objetivo principal, o trabalho foi dividido em três objetivos secundários: 1) Treinar e avaliar, através da construção de um instrumento de avaliação dividido em duas partes: a participação num episódio clínico que desencadeou um efeito adverso num cenário de simulação em contexto de bloco operatório e a divulgação do mesmo evento adverso, num cenário híbrido de simulação; 2) desenhar um programa de formação de competências, em ambiente de simulação, de acordo com os conteúdos programáticos incluídos no Internato de Anestesiologia, incluindo competências técnicas e não técnicas; 3) implementar e avaliar o programa através da construção e validação de questionários de autoavaliação respondidos pelos internos antes e depois de cada curso de simulação. Resultados: A metodologia que envolveu a utilização da técnica de simulação mista realidade-simulação contou com a participação de 42 internos de Anestesiologia na simulação de um evento adverso e na sua comunicação ao doente. Este estudo permitiu a prática de um conjunto de respostas aos doentes ao longo das diferentes fases do luto. Os instrumentos para avaliar o desempenho e a prática da comunicação do efeito adverso pelos internos de Anestesiologia, apresentaram uma excelente fiabilidade e elevada consistência interna (p<0,05). O programa de formação de competências para internos portugueses de Anestesiologia, desenhado de acordo com os conteúdos programáticos definidos pelo Colégio de Anestesiologia da Ordem do Médicos, contou com a participação de 340 médicos: 76 internos do primeiro ano, 89 do segundo, 82 do terceiro e 93 do quarto e último ano. Para a avaliação deste programa foram construídos questionários de autoavaliação para serem aplicados antes e depois de cada módulo do programa de simulação. A consistência interna foi testada e considerada elevada em todos os questionários. Os participantes avaliaram a importância atribuída a diversos conceitos técnicos em Anestesiologia, e a sua formação e experiência antes e depois de cada curso de simulação. Os resultados foram estatisticamente significativos na maioria das comparações (p<0,05). Da mesma forma, os questionários permitiram autoavaliar a evolução do desempenho clínico e competências não técnicas, tais como a consciência situacional, o pedido de ajuda, a comunicação e o trabalho de equipa. Ao longo do tempo, na perspetiva dos internos, a necessidade de apoio e o número de erros aumentaram (p<0,001). Os médicos internos assumiram também que ao longo do internato houve uma melhoria da capacidade de comunicação, uma vez que mais facilmente expressam a sua opinião, mesmo discordando do anestesiologista sénior. Realça-se a unanimidade em relação à importância das competências não comportamentais para a excelência da prática clínica, identificada pelos internos do 4º ano no final das formações com simulação. Por fim, os participantes deram elevada importância a todos os conteúdos programáticos abordados durante os módulos de simulação, com maior relevância nos temas abordados no último ano. Conclusões: O instrumento de avaliação dividido em duas partes demonstrou fortes propriedades psicométricas para avaliar o desempenho da comunicação ao doente da ocorrência de um efeito adverso. O conceito misto de realidade-simulação permitiu que os internos estivessem envolvidos num evento adverso e treinassem a sua comunicação antes do contato direto com um doente. A construção de um programa de simulação de acordo com os conteúdos pedagógicos do Internato de Anestesiologia melhora não só a formação nesta área, sem colocar os doentes em risco, como tem repercussão no reconhecimento do erro, enriquecendo o valor da autoconfiança e o papel fundamental das competências comportamentais. No final, este estudo mostrou que a simulação também tem repercussão na identificação de lacunas que devem ser ultrapassadas antes que os internos se tornem independentes, culminando na melhoria da segurança do doente. Em conjunto, os resultados obtidos vêm enfatizar o impacto positivo da simulação como instrumento de aprendizagem do Internato Médico de Anestesiologia

ENVISIONING BETTER POLICE PERFORMANCE WITH SELECTIVE-FIDELITY TRAINING: LESSONS FROM SIMULATIONS AND VIRTUAL REALITY IN AVIATION AND MEDICINE

This thesis explores how technology-based, selective-fidelity training methods found in aviation and medicine can improve law enforcement training and performance. Professionals in aviation, medicine, and law enforcement all encounter high-risk and unpredictable situations. Within aviation and medicine, research has shown that simulation and virtual reality (VR) can improve performance at all levels—from beginner to advanced. This thesis reviews Bloom’s taxonomy, state- and context-dependent learning, and law enforcement training practices; assesses the efficacy of selective-training methods across the aviation and medical fields; and reviews real-world applications of simulation and VR. This research determined that certain technology-based, selective-fidelity training methods found in aviation and medicine may improve law enforcement training and performance. To best leverage simulation and VR, the law enforcement community should match the device’s fidelity (high or low) to the underlying learning objective; utilize both high- and low-fidelity training methods confidently; and mimic the medical sector’s standard, policy, and procedure development for technology-based, selective-fidelity training methods. Also, high-fidelity training methods may improve performance in novel situations. Finally, law enforcement trainers should use certain devices to mitigate stress, treat post-traumatic stress disorder, teach checklist material, and promote confidence.Civilian, City of Tulsa, Tulsa Police DepartmentApproved for public release. Distribution is unlimited

Roundtable Discussion (RTD03) - Is there a downside to using Simulated Patients to teach and assess communication skills?

Background Simulated Patients (SPs) are widely used to facilitate the learning of communication skills enabling students to receive detailed feedback on experiential practice in a safe environment. They are also used in the assessment of students’ communication skills in Objective Structured Clinical Examinations (OSCEs). We have observed that our most experienced SPs are highly conversant with medical jargon and consultation skills and have almost become ‘medical faculty’. Consultations can therefore lack the true patient perspective, with SPs focussing their feedback on process rather than giving a true patient perspective. Roundtable objectives To consider the challenges in ensuring that highly experienced SPs continue to respond from a true patient perspective To critique whether the use of SPs in OSCE stations is a valid way to assess students’ communication skills with real patients To consider whether using consultations with Simulated Patients is useful for students in the later years of an Undergraduate medical course who are learning to integrate the different components of a consultation and reasoning clinically in a real-life clinical context To share best practice with colleagues Roundtable A brief interactive presentation including the authors’ experiences of working with experienced Simulated Patients which will draw on current literature regarding the evidence for using Simulated Patients in the teaching and assessing of communication skills Delegates will have the opportunity to take part in three roundtable discussions • OSCE Stations using SPs assess how good students are at communicating with SPs but not with real patients • Experienced SPs are in danger of responding with a faculty not a patient perspective • By using SPs in teaching we over focus on process and forget the global picture

WS19. From pedagogy to practice: implementing transformative learning in clinical reasoning

BackgroundHealthcare professionals must provide high quality care that is both efficient and safe. Underpinning this requirement is a presumption that individuals are able to make accurate clinical decisions. Knowledge is not sufficient: judgment and reasoning are required to translate clinical information into accurate decisions to produce effective care. Clinical reasoning skills need to be developed in healthcare professionals in a way that produces change in behaviour. This is aplies to the spectrum of healthcare education: from undergraduate to postgraduate to lifelong practice. Though much is understood about clinical decision-making theory, direction for systematic implementation of teaching in both undergraduate and postgraduate medical education programmes is lacking. In particular, evidence describing transformative teaching methods is limited. This workshop will explore how to design effective spiral curricula in clinical reasoning, compare and contrast experiences from three medical schools in the UK, discuss challenges in implementation, share a variety of teaching methods, provide hands on demonstration of technological resources that have produced changes in learner behaviour and support attendees to adapt methodology to their programmes.Structure of workshopWe will briefly review current knowledge on clinical decision-making learning before sharing experiences from three UK medical schools.Attendees will participate in discussions supported by interactive exercises to explore each subtopic. These exercises will include role play, video and trial of electronic teaching tools used in our current practice. The session will conclude with a reflection on principles and ideas shared during the event

Thiel embalmed cadaveric tissue : a model for surgical simulation and research

Le Collège royal des médecins et chirurgiens du Canada met actuellement en place des curriculums basés sur les compétences, plutôt que sur le temps, dans toutes les spécialités médicales et chirurgicales. La transition devrait être complétée en 2022. Les programmes de formation en chirurgie plastique au Canada devront repenser leurs curriculums pour se plier aux directives nationales. La simulation est la pierre angulaire du modèle de formation des résidents basé sur les compétences puisqu'elle permet aux résidents d'apprendre et d'améliorer leurs compétences dans un contexte éthique, sécuritaire, et mesurable objectivement. Un consensus récent des directeurs de programme canadiens en chirurgie plastique a nommé 154 procédures essentielles de bases que les résidents doivent maîtriser avant la fin de leur formation. Nous proposons l'utilisation du modèle cadavérique Thiel pour la simulation haute fidélité des procédures en plastie. Les spécimens Thiel ont déjà été introduits dans une multitude de spécialités, incluant la plastie pour la dissection de lambeaux et la réparation de tendons. Nous nous sommes concentrés sur l'évaluation des spécimens Thiel pour la maîtrise des anastomoses vasculaires, la réparation des nerfs périphériques, et la réparation des tendons fléchisseurs. Par ailleurs, nous avons développé des instruments d'évaluation pour chacun de ces domaines de simulation. Des trois instruments, nous avons validé les échelles d'évaluation des anastomoses vasculaires et nerveuses. Ces deux échelles ont démontré d'excellents degrés de fiabilité et de reproductibilité et sont bien corrélés avec le niveau de formation et d'expérience des sujets. Le modèle de réparation des tendons fléchisseurs a démontré un degré plus élevé de variaiblité inter-évaluateur, et, quoique prometteur, il n'a pas pu être complètement validé basé sur les données actuelles. De plus, nous avons utilisé les vaisseaux Thiel comme un modèle de recherche pour l'investigation de nouvelles techniques microvasculaires. Notre expérience montre que les spécimens cadavériques Thiel sont un excellent modèle de simulation pour la chirurgie microvasculaire et la réparation des nerfs périphériques et des tendons fléchisseurs. Nous proposons des instruments d'évaluation pour assister à l'implémentation de ces modèles de simulation dans les curriculums basés sur les compétences en chirurgie plastique.The Royal College of Physicians and Surgeons is currently implementing a major shift from a time based to a competence based curriculum in all medical and surgical specialties. By 2022 the transition is to be complete. The plastic surgery training programs in Canada will have to rethink their curriculum in order to comply with the national directives. Simulation is a cornerstone of the competence based model of resident training as it not only allows residents to safely learn and hone their skill in a setting that is ethical and promotes patient safety, but it allows for objective evaluation of their performance. A recent consensus statement from the Canadian plastic surgery program directors identified 154 essential core procedures for residents to master by the end of their training. We propose the use of the Thiel cadaveric model for high fidelity simulation of plastic surgery procedures. While Thiel cadaveric specimens have been proposed for use in a multitude of specialties, including in plastic surgery for flap dissection and tendon repair, we focused on evaluating the use of the Thiel embalmed specimens on three core procedures: microvascular anastomoses, peripheral nerve repair, and flexor tendon repair. In addition, we designed evaluation instruments for each of these three simulation areas to help grade performance and aid in the feedback/debriefing process. Of the three evaluation instruments, we successfully validated the microvascular evaluation and micro-neurorrhaphy evaluation scales. Both of these scales showed excellent degrees of reliability and reproducibility and correlated well with the level of training and self-declared experience of the subjects. The flexor tendon evaluation scale showed a higher degree of inter-rater variability and, while it shows promise with a larger cohort of participants and additional calibration, it could not be validated fully based on the available data. Additionally, we used the Thiel embalmed cadaveric vessels as a research model for the investigation of new microvascular techniques. Our experience shows the Thiel cadaveric specimens to provide an excellent model for simulating microvascular, peripheral nerve and flexor tendon repairs. We propose evaluation instruments to assist in the implementation of these simulation models in a comprehensive, competence based curriculum in plastic surgery

Preparing providers for advanced life support in the prehospital environment

Out-of-hospital cardiac arrest is a leading cause of death and Ambulance Victoria estimated over 30,000 cardiac arrests occur outside of hospital each year in Australia (1, 2). When an out-of-hospital cardiac arrest occurs, first responders, paramedics or other clinicians attached to ambulance, industrial or aeromedical services are often the first providers on scene with the skills and equipment to implement advanced life support (ALS). Despite the essential role of prehospital advanced emergency care in the treatment of out-of-hospital cardiac arrest, at the time this research was commenced, ALS training courses had been designed for those responding to cardiac arrests in controlled environments such as in hospitals. These courses emphasised methodology, processes and teamwork suitable for the controlled hospital environment. In contrast, prehospital clinicians typically face an uncontrolled and unpredictable environment, often working with lay responders, and with the added challenge of extricating and transporting the patient to hospital care. As a result, prehospital ALS providers were not trained in an environment that aligned with their workplace or the teams they regularly worked with. Ultimately, there is evidence that out-ofhospital cardiac arrest has a less than optimal patient survival rate when compared to in-hospital cardiac arrests (3, 4). The aim of this research was to review the characteristics of prehospital cardiac arrest ALS and identify gaps in the current ALS training courses in relation to preparation for the prehospital environment and then use this knowledge to develop and evaluate a pilot, standardised, prehospital ALS course. In terms of the potential broader benefits to society, a standardised prehospital ALS course could enhance healthcare professional preparedness to deliver prehospital resuscitation and have positive impacts on out-of-hospital survival rates within the community. A mixed method research design was implemented whereby both qualitative and quantitative data were collected. Using an iterative approach, a prehospital cardiac arrest ALS course congruent with the Australian Resuscitation Council (ARC) guidelines was developed, piloted, and evaluated. Finally, the course was validated by an expert advisory panel. The implementation of a standardised, validated prehospital cardiac arrest ALS training course may assist in improving patient survival rates from out-of-hospital cardiac arrest. The prehospital course designed from this research has tailored elements of leadership, teamwork, and resource management relevant to the prehospital clinicians working environment. However, whilst this research designed and validated a prehospital resuscitation course, further work is needed to determine whether such a course has an impact on prehospital cardiac arrest outcomes

Bridging the clinical experience gap: –using simulation to improve ventilation performance during neonatal resuscitation in a high-resource setting

Background: Up to 10% of newborn babies need help to establish regular breathing at birth. Those who do breathe, and who are not fortunate enough to receive prompt and effective help, will die. The burden of neonatal mortality is highest in sub-Saharan Africa and Central-Southern Asia. However, the burden of morbidity in those babies who survive is proportionately a greater problem in middle-income, but also in high-income, countries. Many non-breathing babies respond to stimulation. For those who need more help, positive pressure ventilation of the lungs via a facemask is by far the most important intervention. Training midwives in low-resource settings using simulation training has led to better simulated performance, improved parameters of real-life facemask ventilation, and reduced early neonatal mortality. In high-resource settings like Norway, where paediatricians perform most neonatal facemask ventilation, infrequent simulation training does not replace the lack of clinical experience for midwives and other medical professionals working with women giving birth. It is not known if more frequent simulation training for healthcare providers (HCPs) in a high-resource setting can train and maintain ventilation skills, nor whether it has the potential to change practice in the clinical setting, or impact neonatal outcomes. Aim: The aim of this thesis was to study methods of using simulation training to bridge the clinical experience gap in ventilation of non-breathing babies at birth in a high-resource setting. The specific aims of the individual papers were to: - 1) determine the realism of simulated ventilation using the high-fidelity manikin NeoNatalie Live; 2) evaluate the effects of a low-dose, high frequency simulation training (LDHFST) programme using NeoNatalie Live on the ventilation competence of multidisciplinary HCPs; and 3) determine the optimal simulation training load to maintain ventilation competence in these HCPs. Method: A prospective observational study of HCPs from six different professions involved in neonatal resuscitation, with a randomised controlled study arm. Following baseline testing (T1) of simulated ventilation performance, participants attended an educational session, after which their ventilation performance was re-tested (T2). Participants were randomised to one of two training-frequency groups and asked to train independently for nine months, receiving targeted feedback from the simulator to guide their training. These groups were a) intervention group aiming for two training sessions per month and b) control group permitted to choose their own training frequency. After nine months of independent training, participants’ simulated ventilation performance was re-tested a final time (T3). Parallel to the simulation study, all real neonatal ventilation was recorded using a respiratory function monitor (RFM). To evaluate the realism of the simulated ventilation experience (study I, observational), we used panel data regression analysis of RFM data. We compared ventilation data obtained from the manikin when ventilated by paediatricians, with data obtained from real resuscitations performed by the same group of HCPs. The educational benefit of the simulation training programme (study II, randomised controlled study) was assessed by Kruskal-Wallis testing to compare T3 scores for the two training frequency groups. The same test was used to analyse the effect of the ventilation performance test scores, T1, 2 and 3, for the different professions. Finally, we used generalized linear mixed effects models to correlate ventilation competence scores, obtained by participants during their nine months of independent training, with training load (frequency and dose) (study III, observational). Estimated marginal probabilities of successful outcomes identified training loads predictive of high scores. Results: Study I - We found similarities in three important ventilatory parameters and their inter-relationships, and the same frequency of upper airway obstruction, in the manikin and neonates, supporting the fidelity of the simulated ventilation experience. Study II - 187 HCPs from paediatric, obstetric and anaesthesia services completed the simulation study. Those randomised to the intervention group trained on average 8 sessions in 9 months, while those in the control group trained 2.8 sessions. There was no difference in T3 scores between these two groups. Subgroup analysis comparing T3 scores for those performing no sessions versus those performing 9 or more sessions in 9 months showed a significant difference in favour of training. Paediatricians scored significantly higher at T1 than the other five professions. For the paediatricans, there was no difference in scores at T1, 2 or 3. Overall, scores improved significantly from T1 to T2 and to T3. At T3 there was no difference in the scores for all six professions. Study III - During the 9 months of independent training, 4348 simulation cases were performed. Training on average 0.6 sessions per month was predictive of high ventilation competence scores for all 187 participants. Conclusion: NeoNatalie Live effectively simulates conditions encountered during real-life neonatal ventilation. Ventilation competence can be trained through simulation, and brief, frequent sessions maintain competence despite a lack of on-going clinical opportunities to practice this skill. For this multidisciplinary group of healthcare providers, training on average once every other month maintains competence

Artificial Reversible Skin

This project aims to improve the realism of medical simulation mannequins by developing an adaptable system for the skin that is capable of displaying physiological changes in the skin caused by conscious and unconscious perturbations. A design of an artificial skin is developed, which uses organic light emitting diode (OLED) displays implanted underneath the skin of a medical simulation mannequin. After performing fatigue analysis and constructing a proof of concept, it is shown that the use of strategically placed displays can realistically simulate color changes similar to the human physiology