University of Ottawa Skills and Simulation Centre

BACKGROUND: Simulation-based medical education (SBME) has traditionally been conducted as off-site simulation in simulation centres. Some hospital departments also provide off-site simulation using in-house training room(s) set up for simulation away from the clinical setting, and these activities are called in-house training. In-house training facilities can be part of hospital departments and resemble to some extent simulation centres but often have less technical equipment. In situ simulation, introduced over the past decade, mainly comprises of team-based activities and occurs in patient care units with healthcare professionals in their own working environment. Thus, this intentional blend of simulation and real working environments means that in situ simulation brings simulation to the real working environment and provides training where people work. In situ simulation can be either announced or unannounced, the latter also known as a drill. This article presents and discusses the design of SBME and the advantage and disadvantage of the different simulation settings, such as training in simulation-centres, in-house simulations in hospital departments, announced or unannounced in situ simulations. DISCUSSION: Non-randomised studies argue that in situ simulation is more effective for educational purposes than other types of simulation settings. Conversely, the few comparison studies that exist, either randomised or retrospective, show that choice of setting does not seem to influence individual or team learning. However, hospital department-based simulations, such as in-house simulation and in situ simulation, lead to a gain in organisational learning. To our knowledge no studies have compared announced and unannounced in situ simulation. The literature suggests some improved organisational learning from unannounced in situ simulation; however, unannounced in situ simulation was also found to be challenging to plan and conduct, and more stressful among participants. The importance of setting, context and fidelity are discussed. Based on the current limited research we suggest that choice of setting for simulations does not seem to influence individual and team learning. Department-based local simulation, such as simulation in-house and especially in situ simulation, leads to gains in organisational learning. The overall objectives of simulation-based education and factors such as feasibility can help determine choice of simulation setting.

OBJECTIVE: To compare the effectiveness of an interprofessional within-team debriefing with that of an instructor-led debriefing on team performance during a simulated crisis. BACKGROUND: Although instructor-led simulation debriefing is considered the "gold standard" in team-based simulation education, cost and logistics are limiting factors for its implementation. Within-team debriefing, led by the individuals of the team itself rather than an external instructor, has the potential to address these limitations. METHODS: One hundred twenty subjects were grouped into 40 operating room teams consisting of 1 anesthesia trainee, 1 surgical trainee, and 1 staff circulating operating room nurse. All teams managed a simulated crisis scenario (pretest). Teams were then randomized to either a within-team debriefing group or an instructor-led debriefing group. In the within-team debriefing group, the teams reviewed the video of their scenario by themselves. The teams in the instructor-led debriefing group reviewed their scenario guided by a trained instructor. Immediately after debriefing, all teams managed a different intraoperative crisis scenario (posttest). All sessions were videotaped. Blinded expert examiners used the validated Team Emergency Assessment Measure scale to assess crisis resource management performance of all teams in random order. RESULT: Team performance significantly improved from pretest to posttest (P = 0.008) regardless of the type of debriefing. There was no significant difference in the degree of improvement between within-team debriefing and instructor-led debriefing (P = 0.52). CONCLUSIONS: Within-team debriefing results in measurable improvements in team performance in simulated crisis scenarios. This form of debriefing may be as effective as instructor-led team debriefing, which could improve resource utilization and feasibility of team-based simulation (NCT01067378).

Objective To investigate the effect of in situ simulation (ISS) versus off-site simulation (OSS) on knowledge, patient safety attitude, stress, motivation, perceptions of simulation, team performance and organisational impact. Design Investigator-initiated single-centre randomised superiority educational trial. Setting Obstetrics and anaesthesiology departments, Rigshospitalet, University of Copenhagen, Denmark. Participants 100 participants in teams of 10, comprising midwives, specialised midwives, auxiliary nurses, nurse anaesthetists, operating theatre nurses, and consultant doctors and trainees in obstetrics and anaesthesiology. Interventions Two multiprofessional simulations (clinical management of an emergency caesarean section and a postpartum haemorrhage scenario) were conducted in teams of 10 in the ISS versus the OSS setting. Primary outcome Knowledge assessed by a multiple choice question test. Exploratory outcomes Individual outcomes: scores on the Safety Attitudes Questionnaire, stress measurements (State-Trait Anxiety Inventory, cognitive appraisal and salivary cortisol), Intrinsic Motivation Inventory and perceptions of simulations. Team outcome: video assessment of team performance. Organisational impact: suggestions for organisational changes. Results The trial was conducted from April to June 2013. No differences between the two groups were found for the multiple choice question test, patient safety attitude, stress measurements, motivation or the evaluation of the simulations. The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group. Expert video assessment of team performance showed no differences between the ISS versus the OSS group. The ISS group provided more ideas and suggestions for changes at the organisational level. Conclusions In this randomised trial, no significant differences were found regarding knowledge, patient safety attitude, motivation or stress measurements when comparing ISS versus OSS. Although participant perception of the authenticity of ISS versus OSS differed significantly, there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes. Trial registration number NCT01792674.

In simulation-based education, there is growing interest in the effects of emotions on learning from simulation sessions. The perception that emotions have an important impact on performance and learning is supported by the literature. Emotions are pervasive: at any given moment, individuals are in one emotional state or another. Emotions are also powerful: they guide ongoing cognitive processes in order to direct attention, memory and judgment towards addressing the stimulus that triggers the emotion. This occurs in a predictable way. The purpose of this paper is to present a narrative overview of the research on emotions, cognitive processes and learning, in order to inform the simulation community of the potential role of emotions during simulation-based education.

OBJECTIVE: The aim of this study was to develop and critically appraise a global rating scale (GRS) for the assessment of individual paramedic clinical competence at the entry-to-practice level. METHODS: The development phase of this study involved task analysis by experts, contributions from a focus group, and a modified Delphi process using a national expert panel to establish evidence of content validity. The critical appraisal phase had two raters apply the GRS, developed in the first phase, to a series of sample performances from three groups: novice paramedic students (group 1), paramedic students at the entry-to-practice level (group 2), and experienced paramedics (group 3). Using data from this process, we examined the tool's reliability within each group and tested the discriminative validity hypothesis that higher scores would be associated with higher levels of training and experience. RESULTS: The development phase resulted in a seven-dimension, seven-point adjectival GRS. The two independent blinded raters scored 81 recorded sample performances (n = 25 in group 1, n = 33 in group 2, n = 23 in group 3) using the GRS. For groups 1, 2, and 3, respectively, interrater reliability reached 0.75, 0.88, and 0.94. Intrarater reliability reached 0.94 and the internal consistency ranged from 0.53 to 0.89. Rater differences contributed 0-5.7% of the total variance. The GRS scores assigned to each group increased with level of experience, both using the overall rating (means = 2.3, 4.1, 5.0; p < 0.001) and considering each dimension separately. Applying a modified borderline group method, 54.9% of group 1, 13.4% of group 2, and 2.9% of group 3 were below the cut score. CONCLUSION: The results of this study provide evidence that the scores generated using this scale can be valid for the purpose of making decisions regarding paramedic clinical competence.

PURPOSE: Physicians are expected to provide compassionate, error-free care while navigating systemic challenges and organizational demands. Many are burning out. While organizations are scrambling to address the burnout crisis, physicians often resist interventions aimed at enhancing their wellness and building their resilience. The purpose of this research was to empirically study this phenomenon. METHOD: Constructivist grounded theory was used to inform the iterative data collection and analysis process. In spring 2018, 22 faculty physicians working in Canada participated in semistructured interviews to discuss their experiences of wellness and burnout, their perceptions of wellness initiatives, and how their experiences and perceptions influence their uptake of the rapidly proliferating strategies aimed at nurturing their resilience. Themes were identified using constant comparative analysis. RESULTS: Participants suggested that the values of compassion espoused by health care organizations do not extend to physicians, and they described feeling dehumanized by professional values steeped in an invincibility myth in which physicians are expected to be "superhuman" and "sacrifice everything" for medicine. Participants described that professional values and organizational norms impeded work-life balance, hindered personal and professional fulfillment, and discouraged disclosure of struggles. In turn, participants seemed to resist wellness and resilience-building interventions focused on fixing individuals rather than broader systemic, organizational, and professional issues. Participants perceived that efforts aimed at building individual resilience are futile without changes in professional values and sustained organizational support. CONCLUSIONS: Findings suggest that professional and organizational norms and expectations trigger feelings of dehumanization for some physicians. These feelings likely exacerbate burnout and may partly explain physicians' resistance to resilience-building strategies. Mitigating burnout and developing and sustaining a resilient physician workforce will require both individual resistance to problematic professional values and an institutional commitment to creating a culture of compassion for patients and physicians alike.

Simulation-based educational activities are happening in the clinical environment but are not all uniform in terms of their objectives, delivery, or outputs. While these activities all provide an opportunity for individual and team training, nuances in the location, timing, notification, and participants impact the potential outcomes of these sessions and objectives achieved. In light of this, there are actually many different types of simulation-based activity that occur in the clinical environment, which has previously all been grouped together as "in situ" simulation. However, what truly defines in situ simulation is how the clinical environment responds in its' natural state, including the personnel, equipment, and systems responsible for care in that environment. Beyond individual and team skill sets, there are threats to patient safety or quality patient care that result from challenges with equipment, processes, or system breakdowns. These have been labeled "latent safety threats." We submit that the opportunity for discovery of latent safety threats is what defines in situ simulation and truly differentiates it from what would be more rightfully called "on-site" simulation. The distinction between the two is highlighted in this article, as well as some of the various sub-types of in situ simulation.

In this issue, Rogers et al1 present the results of a study looking at the interplay of emotions and learning during simulation-based education. The role of emotions in learning, particularly simulation, has been of growing interest to educators. Medical education involves significant emotional experiences for the learners, and these emotions can have important effects on the cognitive and learning processes of individuals. Given that stress has been associated not only with greater memory consolidation (process of solidifying transient memory traces into long-term memory) but also with greater biases and inaccuracies in what is recalled, simulation educators are increasingly concerned with understanding and quantifying stress for learners during simulations.2 The goal of this editorial is to highlight possible directions for future research building on the work of Rogers et al.1 I first present arguments for looking at the role of appraisals as well as motivation when studying emotions. Second, I discuss the potential importance of individual roles as potential modifiers of emotional responses during team-based simulation sessions. Finally, I discuss the possible benefits of physiological and behavioral measures in the study of emotions. Addressing the concerns of educators regarding stress reactions during simulation-based education, Rogers et al1 investigated whether participants in simulations had greater emotional responses than observers. As a secondary outcome measure, they examined the relationship between emotional arousal and learning. They found that participants, as expected, reported greater negative arousal than the observers. However, they also found that the participants reported greater positive arousal than the observers, a finding that is more unexpected. Finally, they did not find any relationship between emotional arousal or role (participants vs observer) and scores on a measure of learning. This study represents the early stages of an important research agenda for the field of simulation-based education: how does the construction of our simulation sessions affect the emotional experience of our learners, and how do these emotional experiences affect their learning? As discussed by Rogers et al,1 the results of this study raise more questions than answers, as would be expected from any early inquiry into a topic. Although readers might be tempted to interpret these results as indicating that emotions do not influence learning, there are other factors potentially at play that could influence the results. The relationship between types of simulation experiences, emotional experiences, and subsequent learning is a complex one that merits further inquiry. Hereinafter, I describe some possible venues for future inquiry. As highlighted by Rogers et al,1 participants in their simulation sessions experienced the co-existence of greater negative and positive emotions compared with the observers. This supports findings from the broader emotions domain that emotions can co-exist, with each emotion having a unique—and sometimes opposing effect - on cognitive processes.3 In their study, Rogers et al1 use the circumplex model of emotions4 to frame the emotional reactions of the learners. A commonly used model, the circumplex model's strength is that it parses out various emotions into two dimensions thought to be at the core of an emotional experience: arousal and valence. Dimensional models of emotion describe affective states as arising from overlapping neurophysiological systems thought to act in predictable ways on cognitive processes. Over the years, there has been some evidence in support of dimensional models of emotions.5–7 However, dimensional models such as the circumplex model have also been critiqued for being too simplistic to fully capture the complex relationship between emotions and cognitive processes.8 To better characterize the relationship between emotions and cognition, discrete models of emotions have been put forward. Distinct emotions are thought to organize behavior and physiology in a predictable fashion to allow the individual to deal with specific emotion-evoking events.9 In contradiction to dimensional models, discrete approaches argue that emotions of the same valence and arousal can have different effects on cognition. For example, fear and anger, though both negatively valenced high arousal emotions, differ in terms of certainty and power appraisals. Fear is associated with appraisals of low certainty and low power over a situation. Anger is associated with high certainty and high power. As a result of these appraisals, anger is associated with more optimistic assessments of the future and lower risk perceptions than is fear.10–12 Similar research has shown that sadness (eg, negative-low arousal) is associated with more pessimistic assessments of the future, but less aversion to taking risks.12 These data suggest that even when emotions overlap in valence and/or arousal, they can have significantly different effects on how individuals think and act. In addition, emotions can have an impact on a learner's motivation and efforts toward understanding of educational materials, that is, their preparation, perseverance in the face of challenges, and strategies toward learning.13 According to Pekrun's control-value theory of emotions,14 achievement emotions are emotions directly tied to achievement activities (emotions experienced during an activity) and achievement outcomes (emotions experienced as a result of success or failure outcomes). Different emotions will affect one's motivation toward learning behaviors. Positive emotions, such as enjoying a task, can lead to greater interest and greater intrinsic motivation to engage in the task for its own sake.15,16 Negative emotions (eg, boredom, anxiety, anger) can decrease interest and intrinsic motivation in a task. However, negative emotions can also increase extrinsic motivation (motivation to engage in a task as a means to an end).17 For example, the fear of performing badly in front of colleagues may result in greater extrinsic motivation, thereby motivating learners to engage in behaviors to enhance their learning. As such, both positive and negative emotions can enhance motivation to learn and, as a result, subsequent performance.14 These effects may be different for specific emotions. For example, Zhao18 observed that fear did not have any significant impact on motivation to learn but had a direct negative effect on learning itself. In contrast, guilt and sadness were positively associated with motivation to learn but had no direct effects on learning from errors. Another study suggests that transient shame can lead to greater attention to feedback.19 In contrast, deactivating positive emotions, such as relief, can have a detrimental effect on learning motivation and behaviors.20 In a study of medical students' learning with a virtual patient simulation program, relief was negatively associated with attention to feedback.19 Together, these studies suggest that future studies looking at the relationship between emotions and learning from simulation sessions would benefit from considering the distinct emotions experienced by learners. Another aspect that merits further study would be to look at the effects of specific roles while participating in simulations. In their study, Rogers et al1 describe sessions in which 2 to 3 residents actively participated in the same scenario. In such cases, one individual would likely assume the role of leader with the others taking a more supporting role. As such, the emotional responses of all active participants might not be equivalent. In previous research by our group, we found that different roles were associated with different stress responses.21 Therefore, further work could look at the effect of different roles on participants' emotions as well as on subsequent learning. This study also looked at self-reported emotions. This is a common approach, given financial and logistical challenges of measuring physiological stress responses (eg, cortisol and heart rate variability). As addressed by Rogers et al,1 this is also a potentially contentious approach to measuring emotions. Although the collection of cortisol samples often requires constraints that do not accommodate well with simulation-based education sessions,22 recent development in the measurement of heart rate variability has made data collection more straightforward and affordable.23 Where possible, adding physiological measures to subsequent studies looking at stress responses would allow for greater understanding of the relative contributions of subjective (“feeling” stressed) and physiological responses. Although the physiological measurement of other distinct emotions is not as reliable, great advances have been done in facial and behavioral analyses.24 In conclusion, Rogers et al,1 in their study, begin to address an important question for simulation-based education. By further understanding the emotional responses of our learners to simulation sessions, and the effects of these various emotions on learning, educators will be better equipped to create simulation-based curricula that will best prepare learners for future clinical practice.

This article describes opportunities for scholarship in medical education, based on a brief overview of recent changes in medical education. The implications arising from these changes are discussed, with recommendations for focus, and suggestions and examples for making progress in this field. The author discusses 1) the historical context of the current shift toward competency-based medical education, 2) the potential contribution of social and behavioral sciences to medical education scholarship, 3) methods and approaches for supporting scholarship in medical education, and very briefly 4) trends in simulation. The author concludes with a call for quality in medical education scholarship and argues that the most promising and fruitful area of medical education scholarship for the future lies in the field of assessment of individual competence.

INTRODUCTION: Real-time assessment of operator performance during procedural simulation is a common practice that requires undivided attention by 1 or more reviewers, potentially over many repetitions of the same case. OBJECTIVE: To determine whether reviewers display better interrater agreement of procedural competency when observing recorded, rather than live, performance; and to develop an assessment tool for pediatric rapid sequence intubation (pRSI). METHODS: A framework of a previously established Objective Structured Assessment of Technical Skills (OSATS) tool was modified for pRSI. Emergency medicine residents (postgraduate year 1-4) were prospectively enrolled in a pRSI simulation scenario and evaluated by 2 live raters using the modified tool. Sessions were videotaped and reviewed by the same raters at least 4 months later. Raters were blinded to their initial rating. Interrater agreement was determined by using the Krippendorff generalized concordance method. RESULTS: Overall interrater agreement for live review was 0.75 (95% confidence interval [CI], 0.72-0.78) and for video was 0.79 (95% CI, 0.73-0.82). Live review was significantly superior to video review in only 1 of the OSATS domains (Preparation) and was equivalent in the other domains. Intrarater agreement between the live and video evaluation was very good, greater than 0.75 for all raters, with a mean of 0.81 (95% CI, 0.76-0.85). CONCLUSION: The modified OSATS assessment tool demonstrated some evidence of validity in discriminating among levels of resident experience and high interreviewer reliability. With this tool, intrareviewer reliability was high between live and 4-months' delayed video review of the simulated procedure, which supports feasibility of delayed video review in resident assessment.

INTRODUCTION: As residency training requirements increasingly emphasize a competency-based approach, novel tools to directly evaluate Canadian Medical Education Directives for Specialists (CanMEDS) competencies must be developed. Incorporating simulation allows residents to demonstrate knowledge and skills in a safe, standardized environment. We describe a novel hybrid simulation station for use in a urology resident in-training Objective Structured Clinical Exam (OSCE) to assess multiple CanMEDS competencies. METHODS: An OSCE station was developed to assess Communicator, Health Advocate, Manager, and Medical Expert (including technical skills) CanMEDS roles. Residents interviewed a standardized patient, interacted with a nurse, performed flexible cystoscopy and attempted stent removal using a novel bladder/stent model. Communication was assessed using the Calgary-Cambridge Observational Guide, knowledge was assessed using a checklist, and technical skills were assessed using a previously validated global rating scale. Video debriefing allowed residents to review their performance. Face and discriminative validity were assessed, and feasibility was determined through qualitative post-examination interviews and cost analysis. RESULTS: All 9 residents (postgraduate years [PGY] 3, 4, 5) completed the OSCE in 15 minutes. Communicator and knowledge scores were similar among all PGYs. Scores in technical skills were higher in PGY-5 compared with PGY-3/4 reside nts (mean score 79% vs. 73%). Residents and exam personnel felt the OSCE station allowed for realistic demonstration of competencies. Equipment cost was $218 for the exam station. CONCLUSIONS: We developed and implemented a hybrid simulation-based OSCE station to assess multiple CanMEDS roles. This approach was feasible and cost-effective; it also provided a framework for future development of similar OSCE stations to assess resident competencies across multiple domains.

A working group at the 2012 Academic Emergency Medicine consensus conference on education research in emergency medicine (EM) convened to develop a curriculum for dedicated postgraduate fellowships in EM education scholarship. This fellowship is intended to create future education scholars, equipped with the skills to thrive in academic careers. This proceedings article reports on the consensus of a breakout session subgroup tasked with defining a common core content for education scholarship fellowships. The authors propose that the core content of an EM education scholarship fellowship can be categorized in four distinct areas: career development, theories of learning and teaching methods, education research methods, and educational program administration. This core content can be incorporated into curricula for education scholarship fellowships in EM or other fields and can also be adapted for use in general medical education fellowships.

INTRODUCTION: This study evaluated delivery of immersive simulation-based training (SBT) by distance education. Newly graduated health professionals' experience of and learning outcomes from videoconference-enabled remotely facilitated (RF) were prospectively compared with a locally facilitated (LF) format within a course addressing management of the deteriorating patient. METHODS: Participants were exposed to both RF and LF formats in an intervention course (IC). The primary outcome measure was a questionnaire detailing participants' experience of 1 RF scenario and 1 LF scenario. The 16-item questionnaire measured perceived learning, comfort, interaction with other learners and instructor, as well as quality of instruction, factors that are considered essential in both SBT and distance education. As a secondary outcome measure, learning outcomes, measured as precourse and postcourse scores and pass rates in multiple-choice question tests, were also measured and compared with those of participants completing control courses, in which only the LF format was used. RESULTS: The study was conducted between April 2013 and April 2014. Among the 155 participants who participated in ICs, questionnaire results revealed a small, significantly higher median total score (25-75 interquartile range) for LF versus RF format scenarios [78 (72-80) vs. 76 (68-80), P = 0.01]. Multiple-choice question test scores compared between 155 IC and 150 control course participants showed no significant differences. CONCLUSIONS: Participants' experience of SBT using the RF format was slightly less positive than the LF format; however, it had no measured impact on knowledge. The impact of RF-SBT on more complex training applications remains poorly understood. Instructors could potentially optimize learner comfort and engagement by improving their interactive skills.

Healthcare organizations strive to deliver safe, high-quality, efficient care. These complex systems frequently harbor gaps, which if unmitigated, could result in harm. Systems-focused simulation (SFS) projects, which include systems-focused debriefing (SFD), if well designed and executed, can proactively and comprehensively identify gaps and test and improve systems, enabling institutions to improve safety and quality before patients and staff are placed at risk.The previously published systems-focused debriefing framework, Promoting Excellence and Reflective Learning in Simulation (PEARLS) for Systems Integration (PSI), describes a systematic approach to SFD. It includes an essential "pre-work" phase, encompassing evidence-informed steps that lead up to a SFD. Despite inclusion in the PSI framework, a detailed description of the pre-work phase, and how each component facilitates change management, was limited.The goal of this paper is to elucidate the PSI "Pre-work" phase, everything leading up to the systems-focused simulation and debriefing. It describes how the integration of project and change management principles ensures that a comprehensive collection of safety and quality issues are reliably identified and captured.

Abstract Introduction Paramedicine is experiencing significant growth in scope of practice, autonomy, and role in the health care system. Despite clinical governance models, the degree to which paramedicine ultimately can be safe and effective will be dependent on the individuals the profession deems suited to practice. This creates an imperative for those responsible for these decisions to ensure that assessments of paramedic competence are indeed accurate, trustworthy, and defensible. Purpose The purpose of this study was to explore and synthesize relevant theoretical foundations and literature informing best practices in performance-based assessment (PBA) of competence, as it might be applied to paramedicine, for design or evaluation of assessment programs. Methods A narrative review methodology was applied to focus intentionally, but broadly, on purpose relevant, theoretically derived research that could inform assessment protocols in paramedicine. Primary and secondary studies from a number of health professions that contributed to and informed best practices related to the assessment of paramedic clinical competence were included and synthesized. Results Multiple conceptual frameworks, psychometric requirements, and emerging lines of research are forwarded. Seventeen practice implications are derived to promote understanding as well as best practices and evaluation criteria for educators, employers, and/or licensing/certifying bodies when considering the assessment of paramedic competence. Conclusions The assessment of paramedic competence is a complex process requiring an understanding, appreciation for, and integration of conceptual and psychometric principles. The field of PBA is advancing rapidly with numerous opportunities for research. Tavares W , Boet S . On the assessment of paramedic competence: a narrative review with practice implications . Prehosp Disaster Med . 2016 ; 31 ( 1 ): 64 – 73 .

Abstract This 2012 Academic Emergency Medicine consensus conference breakout session was devoted to the task of identifying the history and current state of faculty development in education research in emergency medicine ( EM ). The participants set a future agenda for successful faculty development in education research. A number of education research and content experts collaborated during the session. This article summarizes existing academic and medical literature, expert opinions, and audience consensus to report our agreement and findings related to the promotion of faculty development.

Simulation-based education often involves learners or teams attempting to manage situations at the limits of their abilities. As a result, it can elicit emotional reactions in participants. These emotions are not good or bad, they simply are. Their value at any given moment is determined by their utility in meeting the goals of a particular situation. When emotions are particularly intense, or a given emotion is not aligned with the situation, they can impede learners' ability to engage in a simulation activity or debriefing session, as well as their ability to retain knowledge and skills learned during the session. Building on existing guidance for simulation educators seeking to optimize the learning state/readiness in learners, this paper explores the theory and research that underpins the practical application of how to recognize and support learners' emotions during simulation sessions. Specifically, we describe the impact of various emotions on the cognitive processes involved in learning and performance, to inform practical guidance for simulation practitioners: (1) how to recognize and identify emotions experienced by others, (2) how to determine whether those emotional reactions are problematic or helpful for a given situation, and (3) how to mitigate unhelpful emotional reactions and leverage those that are beneficial in achieving the goals of a simulation session.

PURPOSE: Although one proposed solution to the problem of fatigued medical trainees is the implementation of work hours regulations, concerns about the effectiveness of these regulations are growing. Canada remains one of the few Western jurisdictions without legislated regulation. Recent research suggests that fatigue is a complex social construct, rather than simply a lack of sleep; thus, the authors explored how regulations and fatigue are understood in countries with established work hours frameworks to better inform other jurisdictions looking to address trainee fatigue. METHOD: Using constructivist grounded theory methodology, the authors conducted individual, semistructured interviews in 2015-2016 with 13 postgraduate medical trainees from four European countries with established work hours regulations. Data collection and analysis proceeded iteratively, and the authors used a constant comparative approach to analysis. RESULTS: Trainees reported that they were commonly fatigued and that they violated the work hours restrictions for various reasons, including educational pursuits. Although they understood the regulations were legislated specifically to ensure safe patient care and optimize trainee well-being, they also described implicit meanings (e.g., monitoring for trainee efficiency) and unintended consequences (e.g., losing a sense of vocation). CONCLUSIONS: Work hours regulations carry multiple, conflicting meanings for trainees that are captured by three predominant rhetorics: the rhetoric of patient safety, of well-being, and of efficiency. Tensions within each of those rhetorics reveal that managing fatigue within clinical training environments is complex. These findings suggest that straightforward solutions are unlikely to solve the problem of fatigue, assure patient safety, and improve trainee well-being.

BACKGROUND: Although peer-assisted learning is known to be effective for reciprocal learning in medical education, it has been understudied in simulation. We aimed to assess the effectiveness of peer-led compared to instructor-led debriefing for non-technical skill development in simulated crisis scenarios. METHODS: Sixty-one undergraduate medical students were randomized into the control group (instructor-led debriefing) or an intervention group (peer debriefer or peer debriefee group). After the pre-test simulation, the participants underwent two more simulation scenarios, each followed by a debriefing session. After the second debriefing session, the participants underwent an immediate post-test simulation on the same day and a retention post-test simulation two months later. Non-technical skills for the pre-test, immediate post-test, and retention tests were assessed by two blinded raters using the Ottawa Global Rating Scale (OGRS). RESULTS: The participants' non-technical skill performance significantly improved in all groups from the pre-test to the immediate post-test, with changes in the OGRS scores of 15.0 (95% CI [11.4, 18.7]) in the instructor-led group, 15.3 (11.5, 19.0) in the peer-debriefer group, and 17.6 (13.9, 21.4) in the peer-debriefee group. No significant differences in performance were found, after adjusting for the year of medical school training, among debriefing modalities (P = 0.147) or between the immediate post-test and retention test (P = 0.358). CONCLUSIONS: Peer-led debriefing was as effective as instructor-led debriefing at improving undergraduate medical students' non-technical skill performance in simulated crisis situations. Peer debriefers also improved their simulated clinical skills. The peer debriefing model is a feasible alternative to the traditional, costlier instructor model.

A plenary panel session at the 2012 Academic Emergency Medicine consensus conference "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" discussed barriers educators face in imagining, designing, and implementing studies to address educational challenges. This proceedings article presents a general approach to getting started in education research. Four examples of studies from the medical education literature that illustrate a distinct way to approach specific research questions are discussed. The study designs used are applicable to a variety of education research problems in emergency medicine (EM). Potential applications of studies are discussed, as well as effects and lessons learned.