Real-Time Audiovisual Feedback Training Improves Cardiopulmonary Resuscitation Performance: A Controlled Study Objective The aim of the study was to quantitatively measure the effect of teaching cardiopulmonary resuscitation (CPR) using a real-time audiovisual feedback manikin system on first-year medical student's CPR performance. Methods This is a prospective, manikin-based intervention study, including 2 consecutive classes of medical school students enlisted to a mandatory first aid course. One class (control group) was taught using manikin-based standard CPR education models. The second class (intervention group) was taught similarly, but with the addition of real-time CPR quality feedback provided by the manikins. Students' performance was assessed using a standardized Objective Structured Clinical Examination scenario, during which no real-time feedback was provided. Critical CPR parameters were measured including compression depth, chest recoil, ventilation volume, and “hands-off” time. Results A total of 201 participants were included in the study, 106 in the control group and 95 in the intervention group. Baseline demographic characteristics and previous medical knowledge were similar for the 2 groups. A significant improvement was observed for all primary study outcomes in favor of the real-time feedback group for median (interquartile range) chest compression fraction [57 (52.75%–60%) vs. 49 (43%–55%), P < 0.001], compressions with adequate depth [66.5 (19.5%–95.25%) vs. 0 (0%–12%), P < 0.001], ventilations with adequate volume [68.5 (33%–89%) vs. 37 (0%–70%), P < 0.00], and a simulator-derived composite “total CPR score” [39 (24%–61.25%) vs. 13 (3.5%–22%), P < 0.001]. In multiple regression analysis, the real-time feedback group's performance was significantly better than the control group in all primary outcomes, adjusting for participant's characteristics of age, sex, and body mass index. Conclusions The use of audiovisual feedback techniques to teach CPR improves skill acquisition with significant improvement in crucial prognosis-improving parameters, as tested in a “no-feedback” test scenario. Reprints: Ron Eshel, BSc, Ben-Gurion University of the Negev, Ha'machtarot 20 A Ra'anana, Israel (e-mail: Ron.Eshel@gmail.com). The authors declare no conflict of interest. Neither Laerdal nor any other commercial company revised, altered, or influenced the study protocol or this article at any stage. This study was conducted as part of the requirements for graduation from the medical school of the Faculty of Health Sciences, Ben-Gurion University of the Negev, Negev, Israel. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). © 2019 Society for Simulation in Healthcare

Evaluation of the Patterns of Learning in the Labor Cervical Examination Objective The aim of the study was to evaluate patterns of skill acquisition in the labor cervical examination in novice providers, such as the change in accuracy and overestimation and underestimation over time and the impact of dilation and effacement on accuracy. Methods In this descriptive longitudinal study, medical students each performed 120 simulated cervical examinations. Accuracy and how often students overestimated and underestimated dilation and effacement during was determined for each set of 10 repetitions. Accuracy data were grouped and compared by dilation (1–3, 4–6, and 7–10 cm) and effacement (90%, 75%, 50%, and 25%). Results Student accuracy in dilation significantly improved throughout the course of the study (P < 0.001). At the beginning of the study, students more often overestimated dilation, but this decreased over time (P < 0.001). In addition, the accuracy of the students' estimations was 84%, 62%, and 52% for dilations of 1–3, 4–6, and 7–10 cm, respectively (P < 0.001). Student accuracy in effacement significantly improved throughout the course of the study (P < 0.001). At the beginning of the study, students more often overestimated effacement, but as training progressed, more students tended to overestimate and underestimate equally often (P < 0.001). In addition, accuracy of the students' estimations was 93%, 88%, 81%, and 35% for effacements of 90%, 75%, 50%, and 25%, respectively (P < 0.001). Conclusions Knowing that students tend to overestimate cervical dilation and effacement early in training and that cervices of high dilation and low effacement are more difficult to assess will be helpful in designing more efficient cervical examination training regimens. Reprints: Joshua F. Nitsche, MD, PhD, Division of Maternal Fetal Medicine, Department of OB/GYN, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 (e-mail: jnitsche@wakehealth.edu). The authors declare no conflict of interest. An abstract of this article was presented at the annual meeting of the Association for Professors of Gynecology and Obstetrics/Council on Resident Education in Obstetrics and Gynecology, National Harbor, MD, February 28 to March 3, 2018. © 2019 Society for Simulation in Healthcare

Clinical Impact of the Introduction of Pediatric Intussusception Air Enema Reduction Technology in a Low- to Middle-Income Country Using Low-Cost Simulation-Based Medical Education Introduction Pediatric intussusception is a common cause of bowel obstruction in infants. Air enema (AE) reduction is routine first-line management in many countries; however, there is a high rate of operative intervention in low- and middle-income countries. The aims of the study were to use simulation-based medical education with an intussusception simulator to introduce AE reduction to Myanmar and to assess its effect on provider behaviors and the resulting clinical care. Methods Clinical evaluation was conducted by comparing clinical outcomes data for children with intussusception 12 months before implementation with that from 12 months subsequent to implementation. These included the following: AE success rates, recurrence rates, length of stay, intestinal resection, and operative intervention rates. An educational workshop was developed that used a low-cost mannequin to facilitate practice at the reduction of intussusception using AE. Curriculum evaluation was performed through 5-point rating scale self-assessment in several domains. Data analysis was performed with Mann-Whitney U test, Student t test, or Wilcoxon signed-ranks test as appropriate; a P value of less than 0.05 was considered to be significant. Results After implementation, there was a significant reduction in the overall operative intervention rates [82.5% (85/103) vs. 58.7% (44/75), P = 0.006]. Intestinal resection rates increased [15.3% (13/85) vs. 35.9% (14/39), P = 0.02]. The success rate with attempted AE reduction was 94.4% (34/36), with a recurrence rate of 5.6% (2/36). The simulation-based medical education workshop was completed by 25 local participants. There was a significant difference in the confidence of performing (1.9 vs. 3.6, P ≤ 0.0001) or assisting (2.8 vs. 3.7, P = 0.018) an AE reduction before and after the workshop. Conclusions Simulation-based educational techniques can be successfully applied in a low- and middle-income country to facilitate the safe introduction of new equipment and techniques with significant beneficial impact on provider behaviors and the resulting clinical care. Reprints: Ramesh Mark Nataraja, MBBS BSc (Hons), GCCS (Hons), GDipSurgEd FRCSEd (Paed.Surg), FFSTEd, FRACS (Paeds), Department of Paediatric Surgery, Monash Children's Hospital, Monash University, 246 Clayton Rd, Clayton, Melbourne, Australia, 3168 (e-mail: ram.nataraja@monashhealth.org). The authors declare no conflict of interest. Supported by the Australian Government and the Royal Australasian College of Surgeons. © 2019 Society for Simulation in Healthcare

A Conceptual Framework for the Development of Debriefing Skills: A Journey of Discovery, Growth, and Maturity Summary Statement Despite the critical importance of debriefing in simulation-based education, existing literature offers little guidance on how debriefing skills develop over time. An elaboration of the trajectory through which debriefing expertise evolves would help inform educators looking to enhance their skills. In this article, we present a new conceptual framework for the development of debriefing skills based on a modification of Dreyfus and Dreyfus' model of skill development. For each of the 3 stages of debriefing skill development—discovery, growth, and maturity, we highlight characteristics of debriefers, requisite knowledge, and key skills. We propose how faculty development experiences map to each stage of debriefing skill development. We hope the new conceptual framework will advance the art and science of debriefing by shaping future faculty development initiatives, research, and innovation in debriefing. Reprints: Adam Cheng, MD, FRCPC, University of Calgary, KidSim-ASPIRE Research Program, Alberta Children's Hospital, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, 28 Oki Drive NW, Calgary, Alberta, Canada T3B 6A8 (e-mail: chenger@me.com). A.C., V.G., and M.M. are faculty for the Debriefing Academy, which runs debriefing courses for healthcare professionals. M.K. is faculty at the Simulation Center of the University Hospital and the Debriefing Academy, both providing debriefing faculty development training. W.E. receives salary support from the Center for Medical Simulation and the Debriefing Academy to teach on simulation educator courses; he also receives per diem honorarium from PAEDSIM e.V. to teach on simulation educator courses in Germany. K.B. is faculty at the NYC Health + Hospitals/Simulation Center, which provides debriefing faculty development training. © 2019 Society for Simulation in Healthcare

“It's Not an Acting Job… Don't Underestimate What a Simulated Patient Does”: A Qualitative Study Exploring the Perspectives of Simulated Patients in Health Professions Education Introduction Simulated patients (SPs) are individuals who have learned to realistically portray patient roles in health professional education. Program recommendations are increasing for simulation programs, and as key stakeholders, SPs' perspectives seem underrepresented. The aim of the study was to explore the experiences, perspectives, and practices of SPs to gain insights on topics of importance to SPs and inform program recommendations. Methods An interpretivist research paradigm and qualitative design were adopted. Eighteen SPs participated in 2 focus groups that were audio recorded, transcribed, and deidentified. Three researchers completed inductive thematic analysis. Institutional ethical approval was obtained. Results Three themes represented the different elements of SP practice: becoming and being a SP, preparing for a SP role, and performing a SP role. Simulated patients identify as educated specialists with unique responsibilities and attributes. Simulated patients are committed to representing the perspectives of real patients, while simultaneously supporting learners and educators. Simulated patients can feel unprepared to perform a role but have innovated responsive strategies. Conclusions Simulated patients considered 3 primary aspects to their practice and shared ways that they might be well supported. Simulated patients represent a community of practice, characterized by mutual engagement, joint enterprise, and a shared repertoire. Ongoing SP input in SP programs may benefit SPs and lead to higher-quality educational experiences for learners. Reprints: Shane A. Pritchard, BPhysio, Department of Physiotherapy, Monash University, PO Box 527, Frankston, Victoria, Australia 3199 (e-mail: shane.pritchard@gmail.com). The authors declare no conflict of interest. Supported by funding from Health Workforce Australia (CTR12-010) and an Australian Government Research Training Program (RTP) scholarship. © 2019 Society for Simulation in Healthcare

Benefits and Limitations of Transurethral Resection of the Prostate Training With a Novel Virtual Reality Simulator Purpose Profound endourological skills are required for optimal postoperative outcome parameters after transurethral resection of the prostate (TURP). We investigated the Karl Storz (Tuttlingen, Germany) UroTrainer for virtual simulation training of the TURP. Materials and Methods Twenty urologists underwent a virtual reality (VR) TURP training. After a needs analysis, performance scores and self-rated surgical skills were compared before and after the curriculum, the realism of the simulator was assessed, and the optimal level of experience for VR training was evaluated. Statistical testing was done with SPSS 25. Results Forty percent of participants indicated frequent intraoperative overload during real-life TURP and 80% indicated that VR training might be beneficial for endourological skills development, underlining the need to advance classical endourological training. For the complete cohort, overall VR performance scores (P = 0.022) and completeness of resection (P < 0.001) significantly improved. Self-rated parameters including identification of anatomical structures (P = 0.046), sparing the sphincter (P = 0.002), and handling of the resectoscope (P = 0.033) became significantly better during the VR curriculum. Participants indicated progress regarding handling of the resectoscope (70%), bleeding control (55%), and finding the correct resection depth (50%). Although overall realism and handling of the resectoscope was good, virtual bleeding control and correct tissue feedback should be improved in future VR simulators. Seventy percent of participants indicated 10 to 50 virtual TURP cases to be optimal and 80% junior residents to be the key target group for VR TURP training. Conclusions There is a need to improve training the TURP and VR simulators might be a valuable supplement, especially for urologists beginning with the endourological desobstruction of the prostate. Reprints: Gerald B. Schulz, MD, Department of Urology, Ludwig-Maximilians-University Marchioninistr, 15, 81377 Munich, Germany (e-mail: gerald.schulz@med.uni-muenchen.de). The authors declare no conflict of interest. F.J. and A.K. share the last authorship. The authors state that the study was performed in complete accordance with the local ethical requirements. The internal review board exempted the study protocol of ethical review. No patients or animals were involved within this study. © 2019 Society for Simulation in Healthcare

Medical Student Skill Retention After Cardiopulmonary Resuscitation Training: A Cross-sectional Simulation Study Introduction The retention of cardiopulmonary resuscitation skills and the ideal frequency of retraining remain unanswered. This study investigated the retention of cardiopulmonary resuscitation skills by medical students for up to 42 months after training. Methods In a cross-sectional study, 205 medical students received 10 hours of training in basic life support in 3 practical classes, during their first semester at school. Then, they were divided into 4 groups, according to the time elapsed since the training: 73 after 1 month, 55 after 18 months, 41 after 30 months, and 36 after 42 months. Nineteen cardiopulmonary resuscitation skills and 8 potential technical errors were evaluated by mannequin-based simulation and reviewed using filming. Results The mean retention of the skills was 90% after 1 month, 74% after 18 months, 62% after 30 months, and 61% after 42 months (P < 0.001). The depth of chest compressions had the greatest retention over time (87.8%), with no significant differences among groups. Compressions performed greater than 120 per minute were less likely to be done with adequate depth. Ventilation showed a progressive decrease in retention from 93% (n = 68) after 1 month to 19% (n = 7) after 42 months (P < 0.001). All 205 students were able to turn the automated external defibrillator on and deliver the shock. Conclusions The depth of chest compressions and the use of an automated external defibrillator were the skills with the highest retention over time. Based on a skills retention prediction curve, we suggest that 18 to 24 months as the minimum retraining interval to maintain at least 70% of skills. Reprints: Rafael Saad, MD, PhD, Dr. Arnaldo Ave, 455, Room 1210, Sao Paulo, Brazil (e-mail: rafaelsaad89@gmail.com). Supported by School of Medicine, University of Sao Paulo. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). © 2019 Society for Simulation in Healthcare

Learning Impacts of Pretraining Video-Assisted Debriefing With Simulated Errors or Trainees' Errors in Medical Students in Basic Life Support Training: A Randomized Controlled Trial Background Previous studies demonstrated that pretraining video-assisted debriefing (VAD) with trainees' errors (TE) videotaped in a skills pretest improved skill learning of basic life support (BLS). However, conducting a pretest and preparing TE video examples is resource intensive. Exposing individual trainee's errors to peers might be a threat to learners' psychological safety. We hypothesized pretraining VAD with simulated errors (SE, performed by actors) might have the same beneficial effect on skills learning as pretraining VAD with TE, but avoid drawbacks of TE. Methods Three hundred twenty-two third-year medical students were randomized into 3 groups (the control [C], TE, SE). A videotaped BLS skills pretest was conducted in 3 groups. Then, group C received traditional training with concurrent feedback. Video-assisted debriefing with TE in the pretest or SE was delivered in groups TE or SE, respectively, followed by BLS training without any feedback. Basic life support skills were retested 1 week later (posttest). Students completed a survey to express their preference to TE or SE for VAD in the future. Results Higher BLS skills scores were observed in groups TE (85.7 ± 7.0) and SE (86.8 ± 7.5) in the posttest, compared with group C (68.7 ± 13.3, P < 0.001). No skills difference was observed between group TE and SE in the posttest. More trainees (65.8%) preferred SE for VAD. Conclusions Pretraining VAD with SE had an equivalent beneficial effect as VAD with TE on BLS skills learning in medical students. More trainees preferred SE for VAD with regard to psychological safety. Reprints: Hong Xiao, MD, Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China (e-mail: 619526767@qq.com). The authors declare no conflict of interest. Supported by the following research grants: National Key R&D Program of China (2018YFC2001800); a Medical Education Research Grant from Medical Education Committee of Chinese Medical Association and Medical Education Association of High Education Society of China in 2018 (2018-N07004); and a Key Project of Innovation in New Centurial High Education in Sichuan University in 2017 (SCU8052). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). © 2019 Society for Simulation in Healthcare

Evaluating Best Methods for Crisis Resource Management Education: Didactic Teaching or Noncontextual Active Learning Introduction Health care training traditionally focuses on medical knowledge; however, this is not the only component of successful patient management. Nontechnical skills, such as crisis resource management (CRM), have significant impact on patient care. This study examines whether there is a difference in CRM skills taught by traditional lecture in comparison with low-fidelity simulation consisting of noncontextual learning through team problem-solving activities. Methods Two groups of multidisciplinary preclinical students were taught CRM through lecture or noncontextual active learning. Both groups were given a cardiopulmonary resuscitation simulation and clinical performance assessed by basic life support (BLS) checklist and CRM skills by Ottawa Global Rating Scale. The groups were reassessed at 4 months. A third group, who received no CRM education, served as a control group. Results The mean BLS scores after CRM education were 18.9 and 24.9 with mean Ottawa Global Rating Scale (GRS) scores of 22.4 and 29.1 in the didactic teaching and noncontextual groups, respectively. The difference between intervention groups was significant for BLS (P = 0.02) and Ottawa GRS (P = 0.03) score. At 4-month follow-up, there was no statistically significant difference in BLS (P = 1.0) or Ottawa GRS score (P = 0.55) between intervention groups. In comparison with the control group, there was a marginally significant difference in Ottawa GRS score (P = 0.06) at 4-month follow-up. Conclusions Noncontextual active learning of CRM using low-fidelity simulation results in improved CRM performance in comparison with didactic teaching. The benefits of CRM education do not seem to be sustained after one education session, suggesting the need for continued education and practice of skills to improve retention. Reprints: Sandy Widder, MD FRCSC, Department of Surgery, University of Alberta Hospital, 8440-112 St NW, 2D4.27 Walter C MacKenzie Health Sciences Centre, Edmonton, AB T6G 2B7, Canada (e-mail: Sandy.Widder2@albertahealthservices.ca). The authors declare no conflict of interest. © 2019 Society for Simulation in Healthcare

Educational Interventions to Enhance Situation Awareness: A Systematic Review and Meta-analysis Summary Statement We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I2 = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I2 = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes. Reprints: Nuala Walshe, RN, MTLHE, School of Nursing and Midwifery, Brookfield Health Science Complex, University College Cork, Cork T12 K8AF, Ireland (e-mail: n.walshe@ucc.ie). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). © 2019 Society for Simulation in Healthcare