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Background During a critical event in the labor and delivery operating room, it is crucial for team members responding to the situation to be aware of the designated leaders. Visual and verbal cues have been utilized to designate leadership in various healthcare settings; however, previous research has indicated mixed results using visual cues for role designation. Methods The purpose of this study was to explore the use of the red surgical hat as a visual cue of leadership during obstetric emergency simulation training. We used a mixed-methods design to analyze simulation-based education video and debriefing transcripts. Results There was a statistically significant difference in the proportion of participants who declared leadership vs. those who donned the red hat. Participants were more likely to visually declare leadership utilizing a red surgical bouffant hat than to verbally declare leadership. Most participants indicated that observing the red hat to detect leadership in the operating room was more effective than when leaders used a verbal declaration to inform others who was leading. Conclusions Our findings suggest that utilizing a visual cue of leadership with the red surgical bouffant hat improves participant perceptions of communication of the surgical team during an obstetrical critical event in a simulation environment.

Background Trainees in medical subspecialties lack validated assessment scores that can be used to prepare for their licensing examination. This paper presents the development, administration, and validity evidence of a constructed-response preparatory test (CRPT) administered to meet the needs of nephrology trainees. Methods Learning objectives from the licensing examination were used to develop a test blueprint for the preparatory test. Messick’s unified validity framework was used to gather validity evidence for content, response process, internal structure, relations to other variables, and consequences. Questionnaires were used to gather data on the trainees’ perception of examination preparedness, item clarity, and curriculum adequacy. Results There were 10 trainees and 5 faculty volunteers who took the test. The majority of trainees passed the constructed-response preparatory test. However, many scored poorly on items assessing renal pathology and physiology knowledge. We gathered the following five sources of validity evidence: (1) Content: CRPT mapped to the licensing examination blueprint, with items demonstrating clarity and range of difficulty; (2) Response process: moderate rater agreement (intraclass correlation = .58); (3) Internal structure: sufficient reliability based on generalizability theory (G-coefficient = .76 and Φ-coefficient = .53); (4) Relations to other variables: CRPT scores reflected years of exposure in nephrology and clinical practice; (5) Consequences: post-assessment survey revealed that none of the test takers felt “poorly prepared” for the upcoming summative examination and that their studying would increase in duration and be adapted in terms of content focus. Conclusions Preparatory tests using constructed response items mapped to licensure examination blueprint can be developed and used at local program settings to help prepare learners for subspecialty licensure examinations. The CRPT and questionnaire data identified shortcomings of the nephrology training program curriculum. Following the preparatory test, trainees expressed an improved sense of preparedness for their licensing examination.

Background Opportunities to practice procedural skills in the clinical learning environment are decreasing, and faculty time to coach skills is limited, even in simulation-based training. Self-directed learning with hands-on practice early in a procedural skill course might help maximize the benefit of later faculty coaching and clinical experience. However, it may also lead to well-learned errors if learners lack critical guidance. The present study sought to investigate the effects of a hands-on, self-directed “study hall” for central line insertion among first-year residents. Methods Learner cohorts before vs. after introduction of the study hall ( n  = 49) were compared on their pre- and post-test performance of key procedural behaviors that were comparable across cohorts, with all learners receiving traditional instructor-led training between tests. Results Study hall participants spent a median of 116 min in hands-on practice (range 57–175). They scored higher at pre-test (44% vs. 27%, p  = .00; Cohen’s d  = 0.95) and at post-test (80% vs. 72%, p  = .02; Cohen’s d  = 0.69). A dose–response relationship was found, such that 2 h of study hall were roughly equivalent to the performance improvement seen with four clinical observations or supervised insertions of central lines. Conclusions Self-directed, hands-on “study hall” supported improved procedural skill learning in the context of limited faculty availability. Potential additional benefits make the approach worth further experimentation and evaluation.

Background: When current workload demands exceed the cognitive capacity of nurses, tasks that are critical to early detection of clinical deterioration may be omitted. In many high-risk industries that require vigilance over sustained periods, such as the military, the cognitive resource theory of vigilance heavily guides systematic approaches. Yet, in research and policy on nursing failure to rescue, that same application of a cognitive science framework has been overlooked. Method: The nursing literature on failure to rescue was reviewed through the lens of the cognitive resource theory of vigilance. Fifteen articles met the inclusion criteria. Results: Four themes emerged: relationship between clinical judgment and failure to rescue, implicit reference to the cognitive resource theory of vigilance, benefits of simulation-based education, and caregiver fatigue. Conclusion: The use of cognitive science to target advancement of patient management strategies has the potential to lead to a decrease in failure to rescue and an increase in nursing cognitive task efficiency. [J Contin Educ Nurs. 2023;54(6):253–260.]

Learning curves can support a competency-based approach to assessment for learning. When interpreting repeated assessment data displayed as learning curves, a key assessment question is: “How well is each learner learning?” We outline the validity argument and investigation relevant to this question, for a computer-based repeated assessment of competence in electrocardiogram (ECG) interpretation. We developed an on-line ECG learning program based on 292 anonymized ECGs collected from an electronic patient database. After diagnosing each ECG, participants received feedback including the computer interpretation, cardiologist’s annotation, and correct diagnosis. In 2015, participants from a single institution, across a range of ECG skill levels, diagnosed at least 60 ECGs. We planned, collected and evaluated validity evidence under each inference of Kane’s validity framework. For Scoring, three cardiologists’ kappa for agreement on correct diagnosis was 0.92. There was a range of ECG difficulty across and within each diagnostic category. For Generalization, appropriate sampling was reflected in the inclusion of a typical clinical base rate of 39% normal ECGs. Applying generalizability theory presented unique challenges. Under the Extrapolation inference, group learning curves demonstrated expert–novice differences, performance increased with practice and the incremental phase of the learning curve reflected ongoing, effortful learning. A minority of learners had atypical learning curves. We did not collect Implications evidence. Our results support a preliminary validity argument for a learning curve assessment approach for repeated ECG interpretation with deliberate and mixed practice. This approach holds promise for providing educators and researchers, in collaboration with their learners, with deeper insights into how well each learner is learning.

BackgroundThe Fundamentals of Endoscopic Surgery (FES) program became required for American Board of Surgery certification as part of the Flexible Endoscopy Curriculum (FEC) for residents graduating in 2018. This study expands prior psychometric investigation of the FES skills test.MethodsWe analyzed de-identified first-attempt skills test scores and self-reported demographic characteristics of 2023 general surgery residents who were required to pass FES.ResultsThe overall pass rate was 83%. “Loop Reduction” was the most difficult sub-task. Subtasks related to one another only modestly (Spearman’s ρ ranging from 0.11 to 0.42; coefficient α = .55). Both upper and lower endoscopic procedural experience had modest positive association with scores (ρ = 0.14 and 0.15) and passing. Examinees who tested on the GI Mentor Express simulator had lower total scores and a lower pass rate than those tested on the GI Mentor II (pass rates = 73% vs. 85%). Removing an Express-specific scoring rule that had been applied eliminated these differences.Gender, glove size, and height were closely related. Women scored lower than men (408- vs. 489-point averages) and had a lower first-attempt pass rate (71% vs. 92%). Glove size correlated positively with score (ρ = 0.31) and pass rate. Finally, height correlated positively with score (r = 0.27) and pass rate. Statistically controlling for glove size and height did not eliminate gender differences, with men still having 3.2 times greater odds of passing.ConclusionsFES skills test scores show both consistencies with the assessment’s validity argument and several remarkable findings. Subtasks reflect distinct skills, so passing standards should perhaps be set for each subtask. The Express simulator-specific scoring penalty should be removed. Differences seen by gender are concerning. We argue those differences do not reflect measurement bias, but rather highlight equity concerns in surgical technology, training, and practice.Graphic abstract

Background The Fundamentals of Endoscopic Surgery (FES) manual skills examination is a simulation-based assessment of five foundational skills in endoscopic surgery. With the FES skills exam becoming part of the board certification process in general surgery, continual investigation is needed to determine the validity with which the exam is supporting inferences and decision-making about examinees, as well as how it might be improved. Methods The present study retrospectively analyzed performance and demographic details for the initial 344 examinees completing the FES skills exam. Results The five tasks showed distinct degrees of difficulty, with Loop Reduction being especially difficult for examinees. Tasks related to one another positively but moderately, suggesting that the exam assesses both general and task-specific skills. The number of lower-endoscopic cases completed by an examinee strongly predicted performance, while upper endoscopy experience and career level (e.g., resident vs. fellow vs. practicing) did not. Hand dominance and the type of simulator used were not found to be related to scores. However, three demographic variables that related to one another—gender, glove size, and height—were also related to performance and pass/fail status. Conclusions This study’s results generally support the validity argument for the FES skills exam while pointing to additional investigations to be undertaken as the exam is applied more broadly.

In Obstetrics and Gynecologic operating room emergencies, the surgeon cannot both operate and lead a suddenly expanded and redirected team response. However, one of the most often used approaches to interprofessional continuing education designed to improve teams’ ability to respond to unanticipated critical events still emphasizes surgeon leadership. We developed Explicit Anesthesia and Nurse Distributed (EXPAND) Leadership to imagine a workflow that might better distribute emergency leadership task responsibilities and practices. The purpose of this exploratory study was to investigate teams’ responses to distributing leadership during an interprofessional continuing education simulated obstetrical emergency. We used interpretive descriptive design in a secondary analysis of teams’ post-simulation reflective debriefings. One-hundred sixty providers participated, including OB-Gyn surgeons, anesthesiologists, CRNAs, scrub technicians, and nurses. Using reflective thematic analysis, we identified three core themes: 1) The surgeon is focused on the surgical field, 2) Explicit leadership initiates a nurse transition from follower to leader in a hierarchical environment, and 3) Explicit distributed leadership enhances teamwork and taskwork. Continuing education which uses distributed leadership to improve teams’ ability to respond to an obstetric emergency is perceived to enhance team members’ response to the critical event . The potential for nurses’ career growth and professional transformation was an unexpected finding associated with this continuing education which used distributed leadership. Our findings suggest that healthcare educators should consider ways in which distributed leadership may improve teams’ response to critical events in the operating room.

Visual diagnosis of radiographs, histology and electrocardiograms lends itself to deliberate practice, facilitated by large online banks of cases. Which cases to supply to which learners in which order is still to be worked out, with there being considerable potential for adapting the learning. Advances in statistical modeling, based on an accumulating learning curve, offer methods for more effectively pairing learners with cases of known calibrations. Using demonstration radiograph and electrocardiogram datasets, the advantages of moving from traditional regression to multilevel methods for modeling growth in ability or performance are demonstrated, with a final step of integrating case-level item-response information based on diagnostic grouping. This produces more precise individual-level estimates that can eventually support learner adaptive case selection. The progressive increase in model sophistication is not simply statistical but rather brings the models into alignment with core learning principles including the importance of taking into account individual differences in baseline skill and learning rate as well as the differential interaction with cases of varying diagnosis and difficulty. The developed approach can thus give researchers and educators a better basis on which to anticipate learners’ pathways and individually adapt their future learning.

BackgroundAnalysis of the Fundamentals of Endoscopic Surgery (FES) performance exam showed higher scores for men than women. Gender differences have been reduced with task-specific practice. We assessed the effect of simulation-based mastery learning (SBML) on FES performance exam differences by gender.MethodsForty-seven surgical trainees [29 men (m), 18 women (w)] completed a SBML curriculum and were assessed by FES. Fourteen trained on the GI Mentor 2, 18 on the Endoscopy Training System, and 15 using the Surgical Training for Endoscopic Proficiency curriculum. Performance of male and female trainees was compared.ResultsOn the pre-training assessment, there were large differences between genders in FES pass rates (m 77%, w 15%, p < 0.001), total scores (m 69 ± 11, w 50 ± 12; p < 0.001), and in four of five FES sub-task scores (Navigation, m 73 ± 19, w 55 ± 22, p = 0.02; Loop reduction, m 34 ± 29, w 14 ± 22, p = 0.02; Retroflexion, m 81 ± 17, w 47 ± 27, p < 0.001; Targeting, m 89 ± 10, w 66 ± 23, p = 0.002). No differences were discernible post training (Pass rate, m 100%, w 94%, p = 0.4; Total score, m 77 ± 8, w 72 ± 12, p = 0.2; Navigation, m 91 ± 13, w 80 ± 13, p = 0.009; Loop reduction, m 49 ± 26, w 46 ± 36, p = 0.7; Retroflexion, m 82 ± 18, w 81 ± 15, p = 0.9; Targeting, m 92 ± 15, w 86 ± 12, p = 0.12). Time needed to complete curricula was not discernably different by gender (m 3.8 ± 1.7 h, w 5.0 ± 2.6 h, p = 0.17).ConclusionsGender-based differences are nearly eliminated through task-specific SBML training. This lends further evidence to the validity argument for the FES performance exam as a measure of basic endoscopic skills.