Use of Simulated Learning Environments in ...

FINAL REPORT Use of Simulated Learning Environments in Radiation Science Curricula Submitted by the University of South Australia School of Health Sciences Investigators: Dr Kerry Thoirs (lead) Eileen Giles Wendy Barber

Educating Professionals

Creating and Applying Knowledge Lic6382

Engaging our Communities

Contents Executive Summary

2

Background

6

Summary of Medical Radiations Education in Australia

6

Project Approach/Methodology

7

Aims of Project

7

Methodology

7

Findings

9

Map of Simulated Learning Programs currently delivered by accredited Australian Radiation Science Education Providers

9

Literature Review

13

Report on the outcome of stakeholder consultation including responses and issues raised

23

The level of agreement from accredited schools and accreditation bodies

31

Recommendations

40

Priority elements of the curriculum that could be supported by the SLE national project

40

Approaches to address barriers to effective utilisation and expansion of the use of SLE’s in delivering the priority elements of the curriculum

41

References

42

Appendices

44

Use of Simulated Learning Environments in Radiation Science Curricula

1

Executive Summary This reports details a consultative phase of the Simulated Learning (SLE) national project which engaged Radiation Science training organisations, professional councils and accreditation bodies to investigate the current and possible future role of simulated learning in Radiation Science education. The SLE national project is part of a health workforce reform package initiated by the Council of Australian Governments to build and operate new or enhance current simulated learning environments. The tasks of the project included: -Exploring existing curricula for simulation activity -Establishing criteria for identifying where simulation can expand capacity -Identifying where commonality and differences exists in the use of simulation for each profession -Exploring potential opportunities for consistent approaches in each profession with simulation experts -Achieving a national agreement on aspects of professional entry curricula that can be delivered via simulation and that will contribute to expanding clinical training capacity -Working across professions to identify commonalities and identify opportunities for interprofessional learning Project work for the report commenced in early September and concluded in early November 2010. Representatives from all disciplines of the Australian Medical Radiation Science community were consulted by way of interviews, an online survey and face-toface meetings. Participants included university educators, representatives of professional and accrediting bodies, clinical education providers and Australian and international educators with experience in simulation. The report is presented in four sections.

Section 1: Background Provides context and background of radiation science education in Australia, and the stakeholder organisations which contribute to the accreditation process of these programs

Section 2: Project Approach/Methodology Outlines the aims and methodologies used in the data collection and the stakeholders involved in the consultation process.

Section 3: Findings Presents the results of the consultative activities.

Section 4: Recommendations Presents recommendations for priority elements of the curriculum that could be supported by the SLE national project and approaches to address barriers to effective utilisation and expansion of the use of SLE’s in delivering the priority elements of the curriculum.

References Includes all references cited in the literature reviews and elsewhere in the report

Appendices


2

Summary of findings Currently, simulation is widely implemented in Universities across Australia to deliver Radiation Science curriculum. Radiation Science includes the four disciplines of Medical Imaging, Radiation Therapy, Nuclear Medicine and Medical Sonography. The literature reveals few studies that have investigated the effectiveness of simulation compared to clinical training. University educators identified a range of simulation activities that could be developed or upgraded in radiation science education. Examples of simulation activities included simulation of clinical situations using real or virtual equipment, real and or standardised patients, phantoms, imaging software, digital imaging libraries, video demonstrations and computed assisted programs. A number of common curricula elements were identified where simulation activities could be delivered across the four disciplines. These curriculum elements included professional, ethical and safe work practices, quality assurance, image interpretation, image manipulation, critical thinking, care and clinical management, and communication. The radiation science community widely supported the use of simulation to improve the quality of education. It was also widely accepted that simulation had a role in developing clinical skills and delivering curriculum elements outlined by professional accrediting bodies. Despite this support, most educators and professional representatives, excepting a few strong advocates for simulation, were reluctant to accept a significant reduction in clinical training days if simulated learning environments (SLE’s) were integrated into the radiation science curriculum as a strategy to increase student capacity without clear evidence verifying its value in clinical education. Three overseas examples in Radiation Science education were identified where clinical training days were reduced after the introduction of a SLE. Two of these examples integrated VERTTM , a radiation therapy immersive virtual linear accelerator into their teaching program. At face to face meetings university educators and representatives of accrediting bodies agreed that the development of SLEs in teaching beyond what was currently being delivered, had the potential to advance the clinical skills of radiation science students. Agreement between university educators and accrediting bodies to use SLEs as a clinical placement setting for clinical training days was reached for the following disciplines, with an essential condition that the simulation must be of high quality, and supporting evidence for the effectiveness of the simulation should be provided.

Medical Imaging A maximum of 5 weeks (25 days, 10% reduction) over a four year degree program with a 50 week (250 days) clinical placement program.

Radiation Therapy A maximum of 10 weeks (50 days, 20% reduction) over a four year degree program with a 50 week (250 days) clinical placement program if VERTTM was integrated into the program.

Nuclear Medicine No reduction in clinical training days

Medical Sonography A maximum of 10-20 days (3-7% of a 2200 hour clinical training program). Representatives of the accrediting body was reserved in agreement, and concerned that quality of training may be downgraded with the SLE approach.


3

Summary of Recommendations Priority elements of the curriculum that could be supported by the SLE national project

Medical Imaging - The curricula elements of patient assessment, general radiography, digital radiography, image interpretation, peer mentoring, quality assurance, professional, ethical and safe work practices, team work, problem solving, critical thinking and care and clinical management can be supported with upgrades of existing SLEs. - The curricula elements of fluoroscopy, operating theatre radiography, emergency radiography and routine computed tomography, which are not easily accessed by students in the clinical environment can be supported by developing new simulators (including video demonstrations, virtual reality, remote laboratories) with existing simulation technologies.

Radiation Therapy - The foundation curricula elements of treatment simulation, treatment imaging, treatment planning, and treatment verification could be supported with the installation of a fully immersive virtual linear accelerator (VERTTM) at Australian universities.

Nuclear Medicine To meet the three core curricula elements of Nuclear Medicine training of data acquisition, data analysis, and data archiving can be supported by two options. Option 1 would be a faster, but more expensive option, and Option 2 may be less expensive, but needs time for development and testing. -Option 1 Install working gamma cameras and other working imaging and ancillary equipment in Australian universities, using small animals and phantoms to simulate real patients and meet the curricula elements of data acquisition, data analysis, and data archiving. -Option 2 Investigate technology from all vendors which can be applied to development of new simulators including video demonstrations, computer assisted tutorials, artificial intelligence, virtual reality, remote laboratories, scan image databases, and image processing software

Medical Sonography - skill development in transducer manipulation, instrumentation and performing examinations can be supported by providing up to date scanning equipment combined with the use of body part phantoms for lower level skills, and live scanning and standardised patients for higher level skills in university program. - image interpretation skills can be supported by developing with online tutorials and exercises which can be shared between universities and clinical tutors through shared image databases - to support the curricula elements of understanding the clinical question, professional, ethical and safe work practices, manual handling, communication, teamwork, critical thinking and care and clinical management simulation with virtual reality or worlds, video, actors and role play can be developed.


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Interdisciplinary Radiation Science Interdisciplinary Radiation Science education can be supported by: -sharing of resources across the universities delivering Radiation Science programs e.g. virtual reality programs/virtual worlds, software to develop computer assisted learning programs. -investigate sharing of video and video playback resources across all health disciplines within universities. -developing a comprehensive radiation science image library that can be shared across all universities delivering Radiation Science and other Health discipline education programs.

Approaches to address barriers to effective utilisation and expansion of the use of SLE’s in delivering the priority elements of the curriculum -engage the external stakeholders in a collaborative approach when developing simulation activities -provide external bodies with access to the resources to assist with professional development activities for qualified practitioners -careful curriculum planning will be required to maximise resources for delivering education with simulation, and to limit duplication of teaching between the clinical site and the university -careful evaluation (including student evaluation) of the simulation curriculum -perform research investigating the effectiveness of simulation to teach clinical learning objectives -use virtual reality, and computer programs to reduce student contact time, and heavy reliance on resources. -where simulation products are unavailable, research and development companies should be engaged to explore possibilities of development of simulations for particular applications -university educators to share resources where feasible and collaboratively investigate best practices in education of Radiation Science


5

Background Summary of Medical Radiations Education in Australia Medical Radiation Science education is provided in Australia across four distinct professional disciplines; Medical Imaging (or Radiography), Nuclear Medicine, Radiation Therapy and Medical Sonography. Entry level training for these health profession disciplines is provided across a range of Australian university programs. Programs range from undergraduate Bachelor degree to post graduate Diploma level. Table 1 summarises the range of Radiation Science programs across Australia. Graduates from some programs may be required to undertake a professional development year or program prior to becoming eligible for full accreditation by the relevant professional body. Clinical placement hours within undergraduate or graduate entry programs requiring a professional development year/program range from 110 -155 days. Clinical placement hours within undergraduate or graduate entry programs not requiring a professional development year/program range from 245-320 days. By comparison to the other disciplines, Medical Sonography programs are postgraduate with a minimum requirement of 288 days of clinical experience which is mostly gained through paid workplace experience. All accredited programs are delivered by universities, with the exception of one Medical Sonography program which is delivered through a professional body (Australasian Society for Ultrasound in Medicine). Accreditation of Radiation Science programs is currently undertaken by professional bodies (Table 2). From July 2012, three of the disciplines (Medical Imaging, Radiation Therapy and Nuclear Medicine) will join the National Registration and Accreditation Scheme for the Health Professions. As part of this process a National Accreditation Council will be elected to oversee program accreditation. Current accrediting bodies and Australian universities will have representation on this council for each professional discipline.

Table 1: Summary of entry level Radiation Science Programs across Australia

Central Queensland University (commences 2011) Charles Sturt University

Curtin University Monash University Queensland University of Technology RMIT University University of Newcastle University of South Australia University of Sydney Australasian Society for Ultrasound in Medicine James Cook University

Medical Imaging

Radiation Therapy

Nuclear Medicine

Sonography

Bach (4yr)

-

-

Grad Dip

GEM (2yr)

Bach(4yr) Commence s 2011 -

Grad Dip Grad Dip

Bach (3yr) *

Bach (3yr)*

-

Grad Dip

Bach(3yr) * GEM (2yr) * Bach (3yr) * Bach (4yr) Bach (3yr) * GEM (2yr) *

Bach (3yr) * GEM (2yr) * Bach (3yr) * Bach (4yr)

Bach(3yr) * GEM (2yr) * Bach (3yr) * Bach (4yr) *

GEM (2yr) *

GEM (2yr) *

-

-

-

-

Diploma

Planned for 2012

-

-

-

Bach (4yr) commence s 2011

-

Bach (4yr) Bach (4yr)

Grad Dipl

Grad Dip Grad Dip

KEY: *denotes that a professional development year is required before graduate is eligible for full professional accreditation; Bach: bachelor degree; GEM: graduate entry masters degree.


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Table 2: Summary of accrediting bodies for Radiation Science programs Radiation Science Discipline

Professional Body

Medical Imaging

Australian Institute of Radiography (AIR)

Radiation Therapy

Australian Institute of Radiography (AIR)

Nuclear Medicine

Australian and New Zealand Society of Nuclear Medicine (ANZSNM)

Medical Sonography

Australasian Sonographer Accreditation Registry*(ASAR)

KEY: *composite registry made up of representative members of Australian Universities, Australasian Society for Ultrasound in Medicine, Australian Institute of Radiography and Australian Sonographers Association and Cardiac Society Australian and New Zealand.

Project Approach/Methodology Aims of project The aim of this project was to engage training organisations, professional councils and accreditation bodies to explore the aspects of Radiation Science curriculum that can be delivered via simulated learning programs, and to achieve national agreement on aspects of professional entry curriculum that can be delivered by simulated learning programs. This report describes and summarises the results of this consultative process. Five stages were addressed: 1. Mapping of simulated learning environments currently being delivered at each accredited university where Radiation Science programs are offered. 2. Researching opportunities for expanded use of simulation to achieve learning outcomes of clinical placements using national and international examples. 3. Identifying curricula elements that could be delivered by accredited Australian Universities using simulation. 4. Gaining national agreement from each accredited university where Radiation Sciences education is delivered, on the impact of simulation in the delivery of curricula elements, including barriers, impact on clinical training days, and timeframes for implementation. 5. Gaining national agreement from the Radiation Sciences Accreditation bodies on the impact of simulation in the delivery of curricula elements, including barriers, impact on clinical training days, and timeframes for implementation.

Methodology Ethics approval to conduct this project was granted from the Human Research Ethics Committee of the University of South Australia. Representatives of accrediting and professional bodies, and university and clinical educators (including those with extensive experience with simulation) were invited to participate in this project. All participants (excepting participants responding to an online survey) provided written consent to participate in the project. Information on the use and perceptions of simulation in Radiation Science education was collected from participants using semi -structured telephone interviews, data from the National Health Workforce Taskforce (NHWT) university survey, and an online survey. A search of the literature was also undertaken. This information was collated and distributed to Australian participates to review and provide feedback on the accuracy of the report, and to provide any additional information relevant to the project. This report also provided participants with prior knowledge and insight before subsequent face to face meetings between university educators and accrediting body representatives.


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Semi structured telephone interviews (informing stages 1-3) Radiation Science professionals from the following groups were invited to participate in semi-structured telephone interviews: -Radiation Science educators in existing and future Radiation Science programs in Australia; -Radiation Science educators in Radiation Science programs in Australian and overseas teaching institutions who have considerable experience in teaching with simulation; and -Professional and accrediting bodies of the Radiation Science professions Participants were provided with interview questions one week before the interview so they could prepare their responses in advance. Themes of the interview questions included: -Curricula elements and learning objectives of clinical placements -Clinical placement objectives that are currently being delivered through simulation -Any planned future use of simulation and how they would be integrated into the curriculum to meet clinical placement objectives -How simulation may expand capacity for students -How simulation may improve the quality of learning outcomes

NHWT university survey (informing stage 1) Data from the NHWT university survey was analysed to identify where existing and potential simulation teaching could be used in Radiation Science curriculum for students to meet learning outcomes that are usually met by clinical placement.

Online survey to Radiation Science clinical providers (informing stages 2-3) An online survey using SurveyMonkeyTM was open for clinical supervisors of Radiation Science students across Australia from 7th September to the 29th September 2010. The survey was advertised at an international radiographer and radiation therapist’s conference in early September 2010 by distributing information cards to delegates. Some organisations (including one professional organisation, public health services, and one private radiology company) agreed to provide a web link for their employees to access the survey.

Search of the literature and simulation vendors (informing stages 2-3) A literature search for evidence to support the expanded use of simulation to achieve learning outcomes of clinical placements was undertaken on a national and international level. The literature review was supplemented with opinion from identified educators with considerable experience using simulation in Radiation Science. Vendor promotional material was also sourced.

Distribution of preliminary report for comment (informing stages 1-3) Information from the preceding activities was collated and a preliminary report was prepared and distributed to all project participants. Participants were invited to provide feedback on the accuracy of the report and to contribute any further information. The preliminary report also served to educate participants on simulation strategies currently used, and other possible simulation strategies which could be incorporated in Radiation Science education prior to their attendance at the subsequent consultative face-to-face meetings.


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Face to face meetings of university educators and accrediting body representatives (informing stages 2-3). Face to face consultative meetings were held on the 30th and 31st October 2010 at the Amora Jamison Hotel in Sydney. Medical Imaging and Radiation Therapy representatives from Australian universities and the Australian Institute of Radiography (accrediting body) were invited to attend on the 30th October. Nuclear Medicine and Medical Sonography representatives from Australian universities and professional bodies with an accreditation role (ANZSNM, ASUM, ASA, and ASAR) were invited to attend on the 31st October 2010.

Findings Map of Simulated Learning Programs currently delivered by accredited Australian Radiation Science Education Providers

Results of NHWT University Survey This survey provided de-identified information on simulation teaching techniques that were being utilised in Radiation Science education and the perceptions by academics of whether these activities met the learning objectives of clinical placements. It was difficult to determine which of the simulation activities were implemented across each of the four discrete disciplines. The use of phantoms or mannequins to develop technical skills, and the use of Radiation Therapy planning software to develop radiation therapy planning skills appeared to be the two simulation activities most strongly perceived to meet clinical learning objectives.

Table 3: Results of NHWT survey Does the simulation meet the objectives clinical placements in this skill area? Sometimes No Yes

Academic Year(s) that simulation activity is delivered 1 2 3 4

For non specific applications

10

1

2

√

√

√

For patient positioning

2

1

3

√

√

√

√ √ √ √

√ √

√ √

√ √

√ √

√ √

√

√

√

√

√

√

√

√ √

√

Simulation Activity

Role play/ scenarios/case studies

For history taking For communication skills For immobilisation techniques

1 1

Image critique Image interpretation Phantoms/mannequins for technical skills

1 1

2

Peer tutoring in lab

1

Treatment planning(RT)

1

Occupational Health and Safety Preparation of Radiopharmaceutical(NM) Practical red cell labelling(NM) Hands on with real equipment imaging and treatment Simulation of reconstruction of cold kit and ITLC (NM) Use of sonography transducer to get used to movements

1 1 1 1 10 6

√

1

√ √

1 1 1 1

√ √

1

√

KEY: NM; Nuclear Medicine, RT; Radiation Therapy


√

9

√

Results of interviews with university educators Structured interviews of academics across accredited university programs provided more detailed information on the simulation activities being utilised across Australia (Table 4).

Table 4: Simulation activities utilised across Australian accredited Radiation Science programs (data from semi-structured interviews Medical Imaging UniSA

RMIT

Monash

Charles

Curtin

QUT

Sydney







Newcastle

Sturt Anatomical models (body parts)







Full body phantom







Image analysis/ interpretation

















Interactive group work/role play





































Live actors Computed Radiography





PACS





Simulated clinical settings



Digital imaging software





X-ray machines









 

Digital Radiography





Computer assisted learning program



Digital image library (large data and image sets)





3D reconstructive software(multi modality)





Mammography equipment

 

 







Virtual reality software




















10

Table 4 (continued) Radiation Therapy UniSA

RMIT

Monash

Sydney

Case studies/role play/interactive group work









Planning system 3D





Image analysis







Dosimetry analysis and evaluation







Anatomic phantoms/ mannequins





Newcastle

QUT 





 





  

Image library Manufacture ancillary equipment







Reproduction of clinical environment









Virtual software programs Manual Handling







Positioning for treatment



Actors (with or without video replay)





Clinical site visit (no real patient interaction)











Nuclear Medicine UniSA

RMIT

Real-life scenarios/ role play/ group work





Image and data processing software (computer lab)





Injection and cannulation



Image evaluation and interpretation



Anatomic models/Phantoms

Charles Sturt

Sydney

Newcastle

 



















 

Live actors Radiopharmacy lab(hot lab/ cold lab or both)



Computer assisted instruction





 





Video /CD simulation (demonstrations) Stress testing simulation





Gamma camera





PET scanner






11



Table 4 (continued) Medical Sonography UniSA

Body Part Phantom

RMIT

Monash

Charles Sturt

Curtin

QUT Cardiac & general

ASUM





Image interpretation/analysis







Online Quizzes







Live scanning





Simulated biometry measurements









Online interactive group work KEY:

 Currently being used





 Planned in future

The interviews identified a range of simulation activities with potential to be implemented across all four of the disciplines. These included: -Realistic replication of the clinical environment with a range of modern equipment and mock reception areas and facilities for video recording to provide students with visual feedback on their performance and for critique in tutorial sessions. -Flexible multipurpose spaces that could be converted to a variety of settings including a ward or operating theatre. -Online tutorials, interactive programmes, case and situational scenarios that could be fashioned into teaching exercises with defined learning outcomes and assessment. These simulation tools were considered useful, but time consuming to build. -Virtual reality environments such as second life were also suggested where virtual scenarios, virtual hospitals or virtual departments could be constructed. -Real-life scenarios/ role play/ group work, live actors. -Digital imaging library, and use of a picture archiving system (PACS)

Medical Imaging Specific to the Medical Imaging discipline it was thought that current facilities could be upgraded and expanded to more realistically simulate the clinical environment including: high-level anthropometric phantoms, paediatric phantoms, phantoms suitable for use in Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scanners, image libraries, image analysis software, X-ray machines, digital imaging systems, and CT scanners.

Radiation Therapy Without exception, Radiation Therapy academics expressed a desire to have a VERT™ (VERTual Ltd) unit in their department. VERT is a fully immersive virtual linear accelerator, which assists students in developing planning and treatment skills. Other suggestions included software for electronic charting, image matching and verification, expansion of simulated treatment set-ups, which included rooms that were set up with lasers and treatment tables and upgrading of current image analysis and treatment planning software.


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Nuclear Medicine Suggestions for simulation in Nuclear Medicine included; the use of small animals in existing veterinary diagnostic services or small animal research projects to simulate Nuclear Medicine scanning techniques, data acquisition, data analysis and quality control, Nuclear reactor, cyclotron, SPECT scanner, CT/PET scanner, SPECT/CT scanner, and gamma cameras.

Medical Sonography Medical Sonography can be simulated with real people, with no harmful effects. Most respondents wanted up to date ultrasound machines to allow simulated teaching activities to occur. All radiation science disciplines can simulate professional tasks using equipment that is available at the clinical sites. Installing similar equipment in universities can be an expensive outlay with high maintenance costs, and which becomes outdated very quickly. An alternate approach to installing this equipment on campus would be to take students to clinical sites for sessions after normal working hours when these spaces were not being utilised for clinical work, or to use recently superseded equipment on campus that is no longer required at the clinical sites, or to establish real working clinics in the university environment. The benefit of having access to real or simulated equipment on campus is that it provides students with access to modern technology and the flexibility for simulation activities to be integrated more effectively into the curriculum.

Literature Review A preliminary search of the literature revealed that the topic of simulation in education was abundant in the nursing and medical literature, scarce in the Radiation Science literature. A two-phased approach was used to counter the lack of Radiation Science evidence, when searching for evidence to determine the effectiveness of simulation as a teaching tool to meet learning objectives of clinical placement in Radiation Science. Phase 1 would identify systematic reviews that investigated the effectiveness of simulation, to determine the highest available level of evidence in order to assess the value of teaching simulation in health and medical professions generally. Phase 2 would identify literature that was specific to Radiation Science. Due to the apparent lack of published journal articles for the use of simulation specific to Radiation Science, it was decided to supplement the Phase 2 literature review with anecdotal evidence from educators who had considerable experience in simulation.

Evidence in Systematic reviews of the effectiveness of simulation (Phase 1) Search terms used to identify systematic reviews in written English language that investigated the effectiveness of simulation in teaching medical or allied health students included ‘systematic reviews’, ‘evidence based reviews’ and ‘simulation’. The search revealed thirteen articles with six of these excluded for the following reasons. -A systematic review was not conducted [1, 2] -The systematic review did not assess the effectiveness of simulation in teaching [3-6] -The article was a replicate of an already included systematic review. [7] A summary of the included systematic reviews (n=7) are presented in Table 5. These reviews focussed on simulation used in teaching medical and health disciplines, medicine, nursing, urology and surgery and the findings are useful to provide insight into the applications of simulation in Radiation Science. Most reviews concluded that simulation was a valuable adjunct to clinical training. However, there was no firm


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evidence that simulation training was more effective than clinical training, with only a few studies identified within the reviews that had directly compared simulation training to clinical training. Overall, simulation appeared to be well received by students and there were a number of recommendations made on how simulation should be integrated into the curriculum to achieve quality outcomes.

Table 5: Systematic reviews looking at effectiveness of simulation in teaching in Health professions Review 1 [8] Aim of review

What are the features and uses of high-fidelity medical simulations that lead to most effective learning?

Summary of findings

High-fidelity medical simulations facilitate learning when used under the right conditions. Simulation-based medical education complements, but does not duplicate education involving real patients in genuine settings. It is best used to prepare learners for real patient contact.

Recommendations

For effective learning to occur using simulation, the following features should be integrated into the learning program: feedback during the learning experience, repetitive practice, careful integration of simulation into the overall curriculum, stratified learning with increasing levels of difficulty, the simulator should be adapted to complement multiple learning strategies, the simulation should provide for clinical variation, learning should occur in a controlled environment, team and individualised learning should occur, clearly defined learning outcomes and benchmarks to ensure the simulation is a valid learning tool.

Limitations

80% of the published research findings are equivocal and only 20% of the research publications that were reviewed report outcomes that are clear and probably true. Consequently, current research in simulation-based medical education prohibits strong inference and generalized claims about efficacy

Review 2 [9] Aim of review

To find quantitative evidence for medium to high fidelity simulation using manikins in nursing, in comparison to other educational strategies.

Summary of findings

Medium and/or high fidelity simulation using manikins is an effective teaching and learning method when best practice guidelines are adhered to. Simulation may have some advantage over other teaching methods, depending on the context topic and method. Further exploration is needed to determine the effect of team size on learning and to develop a universal method of outcome measurement

Recommendations

Use best practice guidelines for education curriculum, academic staff should be present throughout simulation, repeated simulation exposure in individual or team work settings. Use 3 stepped learning process based on (i) Briefing, (ii) Simulation and (iii) Debriefing

Limitations

Only one randomised controlled trial, inadequate sample size in some studies, several studies may have been confounded by the limited exposure to a simulation experience, which ranged from one 15–20 minute session to weekly simulation sessions each of 90 minutes over 5 weeks. The use of indirect outcome measures such


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as self-perceived confidence may not be as reliable as clinical observations or other validated instruments in assessing learning, thus restricting statistical outcomes. Review 3 [10] Aim of review

To identify the best available evidence on the effectiveness of using simulated learning experiences in pre-licensure health profession education.

Summary of findings

Inconclusive evidence of the effectiveness of simulators to prepare students for real-life experiences. At best, a simulation equivalent can be used as an adjunct for clinical practice, not a replacement for everyday practice. Student enthusiasm and confidence may potentially enhance student understanding of material through increased motivation and effort. There is evidence that using simulators improves the skill performance on OSCE; however, there is a diminishing effect over time. It is unclear whether the skills learned through a simulation experience are transferable to real-world settings.

Recommendations

Simulation may be a useful adjunct to learning new skills and practising skills used infrequently. In addition, team approaches to complex care may be a confidence builder for practitioners not usually confronted by these emergencies. The presence and intervention of a clinical instructor during the simulation and the debriefing session afterwards is essential to avoid the threat of negative learning, which occurs if the student incorrectly learns something due to an imperfect or less-than-ideal situation.


To assess whether skills acquired via simulation-based training transfer to the operative setting, to evaluate the effectiveness of surgical simulation compared with other methods of surgical training

Summary of findings

Only one study compared patient-based training with simulationbased training (for colonoscopy/sigmoidoscopy) and found that participants who received training in the assessment procedure exhibited better performance than those who had trained exclusively on a simulator without any mentoring or supervision. Computer simulation generally showed better results than no training at all but was not convincingly superior to standard training (such as surgical drills) or video simulation. Video simulation did not show consistently better results than groups with no training at all, and there were not enough data to determine if video simulation was better than standard training or the use of models. Model simulation may have been better than standard training, and cadaver training may have been better than model training.

Recommendations

Further research is needed in the transfer of skills acquired via simulation-based training to the patient setting to strengthen the current evidence base. Future studies could explore: • the nature and duration of training required to deliver the greatest transfer effect • the stage of training at which trainees receive maximum skill transfer benefits from different forms of simulation • the effect of different levels of mentoring during the training period on transfer rates, and changes in staff productivity as a


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result of simulation-based training Limitations

Determining the training methods used in some studies was difficult. Reporting of methodological detail in the included studies was generally inadequate, There were large variations in the length of time participants were trained.


To determine the effectiveness of multidisciplinary teamwork training in a simulation setting for the reduction of medical adverse outcomes in obstetric emergencies.

Summary of finding

Teamwork training in a simulation setting resulted in improvement of knowledge, practical skills, communication, and team performance in acute obstetric situations. Training in a simulation centre did not improve outcome compared with training in a local hospital.


To identify the evidence as to whether computer simulators are able to teach and assess arthroscopic skills in a valid and reliable manner and whether these skills can be transferred to the operating theatre

Summary of finding

Knee and shoulder arthroscopy computer simulators showed high levels of internal consistency and reliability. The studies also showed improvement of skill levels for inexperienced participants. The evidence suggests that knee arthroscopy simulator training may result in improved performance within the operating theatre.


Review of simulation in urology

Summary of findings

Different urology simulators showed improvements in performance, shortened learning curves, but were unable to override clinical practice experience, no evidence transferability, no mention of demonstrated construct validity (that simulator simulates exactly the skills required in real life).

Evidence for effectiveness of Radiation Science simulation techniques (Phase 2)

Literature search A literature search of written English journal articles from multiple data bases using a combination of search terms (simulation, teaching, medical, health effectiveness and increased capacity) with no limiters, and pearling of reference lists revealed a number of journal articles that reported on different simulation techniques suitable for Radiation Science.

Phantom/Mannequin simulators Most phantoms identified in the literature for Radiation Science have not been tested for their effectiveness in developing skills in comparison to a real life clinical experience. Two studies [15,16]were identified which reported on the use of a sonography simulator called Ultrasim (Ultrasim, MedSim, Ft. Lauderdale, Fla) which can be used to help develop the psychomotor skills required to perform sonography. This simulator consists of a simulated patient (body shell) with interchangeable real data sets of sonography images to represent normal and pathologic anatomy. The unit also replicates a real


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ultrasound unit with a simulated transducer and image control platform. Monsky et al [15] demonstrated that Ultrasim could be used successfully to perform objective assessments on students and Knudsen[16] found that students trained using the Ultrasim demonstrated better knowledge than clinically trained students. Neither study addressed the effectiveness of teaching psychomotor skills, which would be of primary interest to assess the value of the simulator in teaching clinical sonography skills. Other simulators have also been developed for more specific sonography applications such as echocardiography [17] and prostate sonography. [18] These simulators also have not been tested for their effectiveness in developing skills compared to real life clinical experience, but were assessed for the student’s perceptions of their educative value. The echocardiography simulator was rated highly by students for its ease of use, close replication of a real experience, and helped them understand a relationship between the images and the anatomy. Students rated the prostate phantom [18] highly for assisting them with three dimensional orientation and pathology recognition but were disappointed with some features of the simulator. These included the tactile properties of the simulated tissue that was not elastic and realistic, the limited range of possible transducer movements, the limited available range of pathology within the phantom and that the phantom could not be positioned on its side as would be required in clinical practice. A report describing a simulator replicating a Magnetic Resonance scanner [19] was also identified, but the description on this simulated scanner was limited and it was not evaluated for its effectiveness. Two reports were found providing evidence that the use of phantoms to teach ultrasound guided venous access is more effective than the real clinical training experience. [19, 20] Domenico [20] demonstrated that venous access improved with more practice using the phantom, and Andreatta [21] demonstrated that students trained with simulation were better when tested in the real environment than clinically trained students.

Live simulated scenarios One example of a live simulated scenario in the radiology context was found. [22] It involved a simulated scenario of a critical incident within the Computed Tomography suite. The report demonstrated that students performed better if they were given the opportunity to view and critique a staged simulated scenario before becoming immersed in that scenario. This observation highlights the importance of carefully staging simulation in a graded learning framework.

Online interactive tutorials A number of online interactive tutorial systems for radiation science were identified in the literature [23-26] ranging from exercises in image interpretation and evaluating the effect of variations of imaging parameters on image quality, but none of these appear to have been evaluated for their effectiveness on learning. Soman [26] evaluated their system for student acceptance, reporting it as well received and easy to use.

Virtual Reality One report of a virtual reality software program [27] was found, but it did not evaluate the effectiveness of the tool on student learning. The program simulated a mobile Carm fluoroscopy unit in an operating theatre with a virtual moveable patient.

VERT™ (VERTual Ltd) VERT™ is a virtual reality (VR) training platform for radiation therapy. VERT™ or Virtual Environment Radiotherapy Training was developed in the United Kingdom by the University of Hull and Hull and East Yorkshire Hospitals NHS Trust. The VERT™ training platform uses immersive visualisation technology to create a virtual radiation treatment room containing a linear accelerator. The VERT™ system comprises a virtual linear


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accelerator (treatment machine) and a real hand pendant to operate the virtual linear accelerator. The simulated Linear Accelerator responds in real time to the manipulation of the hand pendant, facilitating a ‘hybrid’ learning environment utilising real (the pendant) and virtual objects (the treatment machine, treatment room and the patient). Students view the virtual linear accelerator in three-dimensions by wearing 3D glasses with circular polarisation. VERT™ has the capacity to simulate linear accelerators from three different manufacturers. This system is widely used in the United Kingdom, Europe and North America to simulate workflow in a Radiation Therapy department, assist with skills training for radiation dose planning, and treatment delivery. Appleyard and Coleman [28] reported using the system to prepare first year students for clinical practice, to demonstrate and explore radiotherapy techniques with students, to integrate with in-house treatment planning systems and thereby enhance learning of plan evaluation. They also reported that VERT™ enhanced the learning and teaching of anatomy. Students like VERT™ because their learning occurs in a relaxed environment, their training is more uniform, and they gain understanding faster. [29] VERT™ also has the potential to increase student capacity by 50 per cent. [30] An extensive report of the use of VERT™ in the United Kingdom has recently been released with summary findings [31]. The report outlines that VERT™ enhances student’s knowledge, understanding, skills and confidence. Students found VERT ™ motivating and enjoyable. VERT™ is available in two training modes, ‘hands on’ mode and ‘demonstrator mode’. Hands on mode is designed to allow the student to acquire practical skills using the hand pendant, such as setting up the patient for radiotherapy on the treatment couch. Demonstrator mode is for classroom teaching or tutorials, and allows demonstration of concepts that may be difficult to understand or visualise without a linear accelerator. According to the report, students reported that they gained most benefit using the ‘hands on’ mode where they interacted individually; learned from mistakes made in a ‘safe’ environment; and received immediate, objective feedback on their performance via the software. The most common problem that students experienced was that they felt they had insufficient time in VERT™ prior to their first placement. Reports from clinical staff confirmed that pre-placement experience in VERT ™ led to increased confidence and improvement in psychomotor skills; and that the skills developed were transferable to the clinical environment. The general perception was that VERT ™ had the greatest impact on students' knowledge and understanding of fundamental concepts, simple techniques and anatomy, although VERT ™can also be used to prepare students for more complex set-ups.

Consultation with educators experienced in simulation To supplement the literature, eleven radiation science educators with experience in simulation (five international educators and six Australian private sonography educators) were consulted.

Interview with a North American educator This educator described a simulation facility at his teaching institution that serviced programs in Medical Imaging, Radiation Therapy and Nuclear Medicine. The facility included four X-ray suites, a CT scanner, a C-arm mobile fluoroscopy unit, a Gamma camera, PACS, image processing workstations, a range of phantoms and VERT™. Multifunctional space was available to set up simulated environments to prepare the students for clinical workflow and provide real-life clinical scenarios. These spaces are not lead lined, therefore radiographs cannot be taken, but the required setups can be practised by students and actors were used at times to simulate patient responses. Scenarios that are replicated include portable radiography, operating theatre radiography, ICU unit radiography, emergency trauma radiography and geriatric radiography.


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Recently, the institution replaced an 8 week clinical placement with a full semester of simulation (12 hours/week for 12 weeks), reducing the total clinical placement time, from 38 weeks to 30 weeks. Students were able to use the simulation semester to develop their clinical placement skills prior to attending large blocks of clinical placement at the end of the program. The quality of the students graduating from this revised program has not been formally evaluated, but anecdotal feedback from students suggested that they lacked confidence upon graduating and were not ready for independent practice. Clinical supervisors were initially concerned that the students would not reach competence within the shorter period of clinical placement. However, students did achieve the required competencies, but were perceived to have not reached full proficiency. In response to this feedback further enhancement to both the simulation activities and the clinical practice are planned.

Interviews with educators using virtual simulation environments 1. Interview with United Kingdom educator with 4 years experience integrating a virtual radiography (medical imaging) system (virtual radiography TM Shaderware) into an undergraduate program. This educator was a strong proponent of using simulation in Radiation Science education because it allowed for more structured and consistent teaching and assessment and provides opportunities for students to see scenarios that they may not get much exposure to in clinical placement. He believed that simulation needs to be as real to clinical placement as possible. The educator was more interested in exploiting the acceleration of skill level to better prepare the students for clinical placement, rather than looking at reducing clinical hours (240 days). His view was that simulation allowed students to undertake a wider breadth of activities in their first clinical placement, resulting in efficiencies for the students because they can engage in more learning and can be challenged with more advanced skills in the clinical placement. He felt the main barrier to simulation was that clinicians do not like any suggestions of a reduction in placement time, although they welcome students with more advanced skills. From the university perspective, he thought graduates who have undertaken simulation during their degree, may have a competitive edge over graduates from other institutions. Student feedback is that they enjoy virtual simulation, in comparison to lectures, but they still prefer clinical placement compared to virtual simulation. Acceptance of the simulation by clinical supervisors has been facilitated by showcasing it at clinical liaison meetings which are held to introduce consistency into the teaching methods between the university and the clinical site. 2. Interview with Australian Medical Imaging educator using avatars on a virtual environment (‘reaction grid’) to create real life clinical scenarios Using avatars (or virtual participants) in a virtual environment to immerse students in a scenario that simulates the experience of the patient and clinician is an area for exploration in Radiation Science. The educator has trialled virtual reality with Medical Imaging students using a mammography scenario, an imaging modality which many students do not get experience in when on clinical placement. The virtual reality scenario serves to heighten the students’ appreciation of professional roles and interactions through ‘acting them out’ in a virtual clinical environment. The learning objectives described for this simulation activity were communication skills, verbal listening skills, history taking, and developing strategies to respond to patients in distress. The activity promotes learning of these objectives by constructing and scripting


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the role-play in student pairs, acting the role-play out through avatars, and then reflecting on their experiences. The concept of virtual reality could be expanded to promote interdisciplinary learning by establishing a polyclinic or virtual hospital, and following a patient’s journey through the clinic. Students in the future may take their avatar down a pathway with consequence. It can also be used to expose students to situations that may be less accessible for them to see in clinical practice e.g. portable x-rays, operating theatre, and paediatric communication. Virtual scenarios can prepare students, give them a better understanding of what is expected of them, and provide them with an outline of the processes that are involved in different examinations. Virtual simulation is no different to face-to-face role-playing that mimics what happens in real life. Avatars may have an advantage in that students feel some anonymity when using avatars, as they can hide behind the character of the avatar. This is especially important when discussing embarrassing topics such as sexual dysfunction. Evidence needs to be collected to determine the potential scope of the virtual environments and the impact on learning that occurs in clinical placement. Anecdotal opinion of the educator is that students are more informed when they attend clinical practice, as they are not seeing things for the first time.

Summary of interviews with sonography educators using simulation environments A number of private sonography training sites in Australia use simulation in their teaching and it was considered to be beneficial to consult with them. The following is a summary of their accounts. These educators saw the benefit of simulation outside of the clinical environment to provide scaffolded learning and assessment in a safe environment, where students could make mistakes and observe the consequences without impacting adversely on a real patient. The teacher can incrementally advance the student through their learning using skill milestones. If the student fails a skill milestone, there is opportunity for students to go back and learn what they missed. Simulation also allows professional assessment and safe feedback on performance. Phantoms were widely used and valued as tools for teaching skills in a non-intrusive setting, providing good initial scanning instruction of the mechanical aspects of scanning, and improving student confidence. The limitations of phantoms are that they cannot reproduce the variable anatomy of real people. A wide range of real patients would be required to expose the student to variable levels of difficulty in recognising and demonstrating anatomic structures. Real models are often used to develop scanning skills for non-invasive sonography examinations because sonography does not utilise ionising radiation and is not harmful. Using real life models is more realistic than using phantoms, and exposes the student to a different range of body types, and encourages them to be flexible in their approach. Real life models have limitations in representing the complete spectrum of cases that students would see in the clinical setting. Role-play and live actors also appear to be widely used in private sonography schools. The use of role play and live actors avoids the potential awkwardness of a novice student between patient and student in a clinical environment and allows for more time and space to teach. Role-play/live actors help teach communication skills. This can be blended with phantom scanning so that while the student performs their scan on a phantom, the live actor presents a simultaneous communication scenario. This helps the student develop clinical skills in conjunction with the patient interaction so they could form an interconnection between the skill and the patient. Live patients or actors also provide feedback to the student on their manner and communication skills that may not be forthcoming from a real patient. Role-play can challenge students with ‘patients’ that have severe impairments and also develop their interactions with other


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medical or health professionals. It is useful to record these sessions and review later to provide students with visual feedback. These strategies will facilitate an enormous uptake of skills in a short time (2 to 3 times more so than in clinical practice) in the early phases of learning. Live patients with real pathology can also be used to develop clinical skills. Large databanks are available of live simulated patients who have had professional training. These patients present with a set of symptoms, and a portfolio of biochemistry, imaging procedures, and other data sets that the students can draw on. Image analysis and case reviews using real image sets are employed to assist students understand the range of normal and pathologic appearances that may be encountered in real clinical practice. These image sets could be further developed into training sets with outlined learning objectives and tasks. There was variation in responses from educators when asked whether simulated activities could reduce the clinical time that students require to reach full competency. Interviewees drew on personal experience rather than research evidence when responding. Most educators thought that clinical practice time could not be reduced in the student’s training regime because: -Simulation cannot replace the real pressure of the clinical setting, even if time constraints are applied to the simulation activity -Clinical practice provides wide case mix range, with patient presentations ranging from complex cases, to cases with very subtle pathologies. -Feedback from clinical supervisors of students who have undertaken simulation training note that the students are very well prepared for clinical practice but they were underprepared in recognising focal pathology, preparation of the patient, and lack the experience of the urgency that occurs in the clinical setting. -Student feedback was that after simulation training they were nervous about transitioning to the workplace. It was thought that the savings from simulation were not so much in reducing clinical time, but that simulation converted to efficiencies in training within the clinical environment. Efficiencies in clinical training could also be achieved by preparing individual learning plans for their clinical placement. One educator conceded that clinical placement time could be reduced if you were training sonographers in specialised areas, suggesting that the breadth of clinical experience required in general training was the barrier to reducing clinical time. In contrast, one educator had strong views that if learning tasks and objectives could be deconstructed using simulation in the initial training period, and then gradually reconstructed with increasing complexity as the trainee progressed, most sonography training could be provided using either simulated live patients or phantoms (part task trainers). This approach was also justified as an ethical approach for safe learning and safe health care delivery. This view was supported by another educator who reviewed the impact of their training course on student performance at clinical placement and thought that after their two-week intensive training program students were at about the level of where they would have been if they had been in a clinical placement setting for three months. All respondents agreed that the quality of learning outcomes were dependent on the quality of the learning experience in both the clinical setting and the simulated environment. Clinical training is heterogeneous across Australia, with some sites using good models of clinical training, but many training with little attention to sound teaching pedagogy. Collectively, interviewees put the following principles of simulation training forward: -The simulation must be valid and relevant to learning objectives of clinical placement. -Educators should supervise the simulation activity, they should debrief the student, be available to stop a student and change the way the activity is being delivered.


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-Educators should be trained in simulation, as it is a very different learning domain than the clinical one. -Learning objectives for the tasks need to be clearly defined, with no more than three learning objectives per task. -The slowest part of the education process is in the early stages when tasks need to be deconstructed and taught linearly. -As the student progresses, the complexity of the learning objectives increase and the integration and scaffolding of different learning objectives is increased. -Good simulated patients that have been professionally trained from educational providers increase the quality of the simulation. -The student should be provided with a visual example of skill before they attempt the task. This can be achieved through video demonstrations. -Students and clinicians should be provided with a progress report with suggestions on how their training is best affected when the student is on clinical placement. -Students should be given the freedom to practise their new skills after simulation training,in the clinical environment.

Summary of Interviews with Radiation Therapy educators who are using VERT™ Three international radiation therapy educators recognised as leaders in using VERT™ were interviewed to explore the impact VERT™ had on Radiation Therapy curriculum, opportunities for inter-professional education and the impact on the quality of clinical learning objectives and clinical training time. As with other simulators, VERT™ aims to enhance theoretical and clinical education, and provide a more comprehensive clinical training experience. VERT™ allows students to apply theoretical concepts to skill development without time pressures, enhances the understanding of physical, anatomical and imaging anatomy concepts, and provides a learning environment where students can focus on their psychomotor skills with freedom to practise and make mistakes. The interviewees provided more specific examples of curricula elements that could be delivered using VERT™ including: -Radiation Therapy terminology -Skills associated with operating hand control pendant -Creating and applying treatment plans, and comparing different treatment plans -Allow students to develop an understanding of the isocentre-Image matching -Quality assurance -Demonstrating impact of treatment planning errors -Demonstrating positioning errors -Problem solving -Teaching students emerging techniques -Limited in developing communication skills with patient VERT™ has the potential to impact on the quality of clinical learning objectives by providing students with a ‘safe’ environment to learn clinical skills. It exposes students to the required quality and variety of treatment techniques ranging from simple to complex and to consistent teaching and assessment. VERT™ can be linked to the imaging and planning equipment so students can use real clinical cases for their training. Respondents thought that VERT™ accelerated the students’ learning of clinical skills. One had undertaken a pilot project to seek feedback from clinical tutors on the impact


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of VERT™ on student learning. All tutors thought that the students were very good at understanding dose planning and explaining those plans to the patient –far better than they were when they did not have the VERT™ simulation. The government funding for VERT™ in the United Kingdom was introduced to reduce the training burden on clinical departments, to increase the marketing potential of Radiation Therapy courses to prospective students, and to reduce attrition and support students ‘at risk’ of failing clinical placement in Radiation Therapy programs. Reducing the training burden on clinical departments may have an indirect impact on clinical training capacity by potentially allowing more students to attend clinical training. Three examples were given by educators where training capacity had been increased using VERT™ in conjunction with using simulated planning systems. One institution increased capacity by 20% (from 30 to 36 students), and two institutions doubled capacity. In one example where capacity was doubled, this was achieved by dividing the year into 2 halves. In the first year half, the students had 12 weeks of ordinary theoretical learning and 13 weeks of VERT™. The second year half was based in the clinic. Plans are being made to further improve the quality of the program, by making further adjustments to the timing (but not amount) of VERT™ and clinical time. Part of the enhancement to quality will be more collaboration with the clinical tutors so they are aware of the level the students have reached. Another educator had not yet used VERT™ to increase student capacity, but was sure that students were better prepared for clinical practice. She thought that in order to increase capacity, problem based learning around VERT™ could be used to take students away from clinical time on radiation treatment units. Feedback was that students were happy to use VERT™, but the acceptance by clinicians was variable, with some quite enthusiastic and some quite negative. Negative perceptions were alleviated once the clinicians had been briefed on how the system works and what it does. VERT™ works best if there is a motivational and enthusiastic leader to lead the simulator. Inter-professional learning opportunities for the wider professional community exist using VERT™. Areas which were described by the educators included education for nursing students and for medical secretaries to introduce them to radiation therapy and how it relates to the patient, for physiotherapists treating lymphoedema in breast cancer to have an appreciation of the patient’s treatment, and to teach technicians and engineers why precision is important clinically, when making laser adjustments. VERT™ is also used to teach anatomy, and is used in multidisciplinary team meetings to develop treatment plans.

Report on the outcome of stakeholder consultation including responses and issues raised Consultation across Australian stakeholders (university educators and professional bodies) was sought through semi-structured telephone interviews. Clinicians were consulted through an online questionnaire. The dominant themes explored in stakeholder consultation were 1) increasing student capacity, 2) effect on quality of clinical learning objectives, 3) barriers, and 4) opportunities for Inter-professional learning through simulation. Thirty-eight participants were interviewed (n=32 university educators, n=6 representatives of professional bodies).

Increasing student capacity using simulation in Radiation Science education Interviews with university educators Most educators found it difficult to address the question of increasing student capacity using simulation in teaching, recognising that simulation comes in many different forms, and that students learn at different rates. Most educators understood that an increase in student capacity could be potentially achieved by two mechanisms:


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-Reducing the time the student spends in clinical placement, which translates to an increased number of students being able to undergo clinical training within a finite number of placement sites. -Increasing student skill level when they are at clinical placement to reduce the supervision burden on clinical sites. This may encourage sites to accept more student places. With more developed skills students have a contributory effect rather than a disruptive effect on clinical workflow. No educator believed that any simulation could completely replace clinical placement, and most thought that the optimal time to deliver simulation was in the early stages of skill development. Estimates of possible reduction in clinical hours ranged from 10-50%, with most leaning to more conservative estimates of 10-20%, or 2-5 weeks across an entire program. These estimates were qualified with the view that for this reduction in clinical placement to occur, resources should be available to deliver high quality simulation. Most academics thought that simulation would have a greater impact on the level of the skills that students could reach before attending clinical placement, rather than decreasing the required clinical training. Therefore, it may be possible to increase student capacity by elevating students to a higher level in preclinical education, although this argument can be countered by the observation that supervision has to be provided regardless of the student’s level of skill. Some educators questioned the need to increase student capacity when limits on graduate jobs and clinical placements cause a bottleneck. This is especially true when a professional development year is required for students to become registered or accredited, and there are limitations on the availability of these positions.

Interviews with representatives from accrediting and professional bodies Accrediting and professional bodies are not always prescriptive in defining the time a student is required to spend in clinical practice, but do weight the clinical experience as an important component of the education of radiation science students. All interviewees recognised simulation as a component of the education process. One respondent illustrated the value of simulation, by observing that the current student capacity would be reduced if the existing simulation used in teaching Radiation Science programs was removed. While there was an acceptance of simulation as a valuable teaching tool, there was a reluctance to accept a reduction in clinical hours, with qualifying statements that simulation should be quality assured and research based, with adequate checks and balances to ensure that students can practise safely at the completion of their education. Reluctance to accept a decrease in clinical training may be related to a perceived erosion of clinical placement hours over time, evidenced by a repeated comment that they thought students did not engage in enough clinical practice in their training. The benefit of adding simulation to an education program was viewed as increasing quality of learning outcomes and increasing the breadth of experience, rather than accelerating the time taken to achieve learning outcomes. The value of simulation was seen to be of most value as a pre-clinical tool, to prepare students for clinical practice. Any impact on the time spent in clinical training would occur in the early stages of skills training rather than in the advanced stages. Most representatives were closed to the idea of reducing clinical placement time, even if simulation accelerated different phases of learning, with only one representative receptive to increasing student capacity if simulation resulted in accelerated progression of a student through skill development and learning objectives.


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Effect on Quality of clinical learning objectives using simulation Interviews with university educators Simulation was viewed favourably as a complimentary training method to clinical placement. The perceived benefits included: -The alleviation of student anxiety compared to the real situation which could be stressful. -Allowing the student to develop confidence and competence in a safe environment (this is especially relevant where ionising radiation is used). One respondent felt educators had an ethical responsibility to use simulation to prepare students for clinical placement, to protect both the student and the patient from trauma. -Consistency of learning and assessment experiences -The use of remedial training and feedback -Repetition to help the student retain knowledge and accelerate the learning process (this would be particularly useful if the simulation activities are portable or freely accessible to students) -Student self‐assessment Simulation was seen as a useful tool for developing problem solving, management skills and practical clinical skills that could enable higher order learning in the more complex clinical site. Student acceptance is one method of measuring teaching quality. One educator thought that her experience with increased enquiries for course registration since introducing online simulation activities, indicated student support for those activities as quality teaching.

Interviews with representatives from accrediting and professional bodies Most representatives agreed that simulation would have a positive outcome on clinical learning objectives by providing transition experiences prior to clinical placement and a non-threatening environment that could enhance learning outcomes. It was recognised that techniques such as video playback of scenarios, e-learning simulation, and live models could be used successfully to address curricula elements such as patient interaction, anatomy, inter-professional engagement, equipment optimisation, identification of common and not so common pathology, and to teach critical thinking skills. Simulation was not seen as a replacement of clinical placement because it was not perceived to have the capability to allow the student to gain experience in dealing with the unknown or to think laterally. It was however thought to be very good for developing skills, such as task orientation in the early learning phases, to provide experience in examinations or situations that are not commonly encountered, for consistency and standardisation of teaching and assessment, to bridge the gap between theoretical knowledge and clinical practice and helpful to provide learning in progressive logical steps. Interviewees thought that quality of the simulation learning experience would be optimised with good collaboration between universities and clinical sites. Simulation also needed to be integrated into the program so that students and teachers had a clear understanding of the learning outcomes and marking criteria.


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Barriers to delivery of clinical curricula elements using simulation Interviews with university educators Educators were most concerned about the resources available to both introduce and maintain simulation activities. Identified required resources included academic staff capacity and expertise, space, support for maintenance of programs, and the time inefficiencies that it may bring. The perceptions of the accrediting and professional bodies were consistently raised, with most respondents expressing it would be difficult to convince professional and accrediting bodies of the value of simulation. This may be a cultural barrier, as many radiation science professionals did not believe that simulation could replace the learning that occurs across a range of unexpected real life scenarios, with real consequences. Academics and the students would also have to have confidence in simulation, and see simulation as a valid tool for them to invest their energy into the experience. This barrier can be possibly overcome as indicated by one academic who had experience in using simulation in an overseas institution, stating that once the improvements of student performance in clinical were evident, then the simulation was accepted as a valid technique. The VERTTM Radiation Therapy simulator is a simulation tool that may be readily accepted as it uses very sophisticated technology, and its existence and applications are widely known in the Australian Radiation Therapy community. The issue of student equity was raised. As most simulation activities are conducted in a physical location this may exclude students who are studying externally from accessing the simulation learning activities. It was also highlighted that some universities provide more external and online delivery reducing student contact time. Simulation requires increased contact time and participation and therefore may conflict with curricula philosophy. Where on-line simulation delivery is used barriers include long download time of large image files, firewalls, and available broadband speed.

Interviews with representatives from accrediting and professional bodies Representatives of professional and accrediting bodies identified a number of barriers to simulation: -Agreement on who bears cost of equipment; university or the clinical site; difficult to see how simulation could be delivered economically -The time and resources required to simulate the wide range of complex clinical aspects. -Determining the balance between clinical placement and simulation. -Difficulties in delivering simulation in external programs.

Opportunities for Inter-professional learning with simulation Interviews with university educators, face to face consultative meetings Most respondents provided favourable and positive responses in relation to opportunities for inter-professional learning using simulation activities. There were only two negative comments about the implementation of inter-professional learning; that it is often seen as a means of reducing teaching time, and that it may cause competition between professional groups for simulation resources and timetabling. It was identified that a strength of simulation is it’s potential to provide consistent interdisciplinary experiences, in comparison to clinical placement. Curricula elements that were identified for delivery by inter-professional learning models included: -Manual handling -Patient history taking -Radiation safety


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-Communication skills -Research into best practice for diagnosis and treatment -Problem solving in the medical team/critical thinking -Patient care -Professional and ethical behaviour -Team work -Image fusion (within disciplines of radiation science) A number of simulation techniques were identified to engage students across multiple disciplines in these curricula elements. -Multi disciplinary scenario based learning or case studies -Simulated settings of hospital wards, operating theatres and emergency departments -Virtual worlds -Role play -Video recording and replay -Large medical radiation image database that can be used to develop case studies, quizzes, radiology image interpretation exercises, image analysis -Computer simulation Specific examples were given where there were opportunities for other health professionals to access radiation science simulation learning activities: -Allied health workers who use sonography for specific applications -Speech therapists who perform radiographic swallowing studies -Allied health workers who are required to have image interpretation skills -Medical physicists who work with medical imaging and radiation therapy equipment; i.e. in developing anatomic knowledge and image fusion skills.

Implementation of simulated learning activities Interviews with university educators There was clear reference throughout the interviews that simulation should be implemented with strong curriculum design, be of high quality, be delivered in a structured and controlled environment to enable consistency, be introduced at the appropriate times and be integrated with clinical placement so students can translate their simulated experience to the clinical environment. The learning outcomes in the curriculum may not need to change significantly, but it was suggested that a quality framework should be implemented so that Australian Quality standards are met, and to ensure that the simulation allows students to meet or exceed the current clinical learning objectives. Quality measures would include educating academics in simulation learning techniques, gaining commitment from universities to providing resources, and undertaking pre and post evaluation of students. Challenges will exist for effective timetabling, and clinicians should be educated on how simulation works in teaching. Opportunities exist for collaborative research to provide supporting evidence that will also help convince clinicians of the value of simulation. A number of comments were also received suggesting that simulation infrastructure could also be used to assist qualified professionals in updating their knowledge and skills.

Survey results: clinical educators Clinical education providers were recognised as a stakeholder in this project, and were given the opportunity to provide comment through an online survey. The results of this survey should be interpreted with caution, with only a small proportion of the radiation


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science community responding. While the survey questions did not differentiate between the four disciplines, it appears that all disciplines were represented in the responses. Respondents to the survey supported the use of simulation, but most viewed it as an adjunctive teaching aid, not something that could replace or reduce clinical placement time. Many clinicians stated that they used simulation in their clinical teaching. This ranged from using phantoms, software, group work, live actors, image analysis, computer enhanced mannequins, simulated clinical environments, practical skill development and case studies. 18/38 respondents thought that they would like to develop these simulated teaching activities further, with the use of phantoms, VERT™, cadavers and live actors. Open ended comments demonstrated that clinicians viewed simulation to provide a safe teaching environment, allowing students to develop confidence, learn at their own place, practise with repetition, ask questions and learn about workflow. Simulation was viewed to be most valuable in developing preliminary skills and making the transition to clinical easier. Only 14/43 respondents believed that simulation could replace clinical practice. The barrier to simulation replacing clinical was that clinical placement exposes students to more complex skills, and allows students to develop communication and efficiencies with real life situations. The respondents who supported simulation to replace clinical placement, qualified their responses with comments that simulation needs to be carefully integrated into the curriculum. The clinician’s perception of simulation in clinical practice and simulation in the university environment needs further exploration. The survey suggests that clinicians are willing to implement simulation when teaching within the clinical environment, but do not value it with equivalence if delivered in the university environment. Many clinicians indicated they were using simulation, and therefore reducing the time students spent interacting with ‘real’ patients, without recognising it as a reduction in clinical time. The converse is that these simulation activities could be undertaken in the university environment and be valued as a clinical placement learning activity. Summary of responses to survey Do you employ any simulation techniques/programs when training Medical Radiation Science students (medical imaging, radiation therapy, nuclear medicine or sonography) in the clinical environment?


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What are you using?

Are you aware of any simulation techniques/aids or programs that you would like to integrate into clinical training if you had the funding and resources?

Do you think student clinical placement hours could be reduced if simulation activities were more integrated into university programs/courses?


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Do you think the use of simulated learning programs would affect the quality of clinical learning outcomes if they replaced some of the clinical placement?

Curricula elements that could be delivered via simulation The semi-structured interviews with academics and representatives of professional bodies identified curricula elements perceived to meet clinical placement objectives and which could be delivered via simulation and possibly contribute to increased clinical placement capacity. These curricula elements were mapped against the curricula elements identified in the competency standards for each radiation science discipline [32-34] (Table 6).

Table 6: Curricula elements identified in interviews that could be delivered via simulation to meet clinical placement objectives Skill development (identified from competency standards)[32-34] Medical Imaging Patient assessment General radiography Digital radiography Fluoroscopy Operating theatre imaging Emergency imaging Routine CT imaging Quality Assurance Image interpretation Image manipulation Peer mentoring Professional, ethical and safe work practices Communication Team work Problem solving Critical thinking Care and clinical management Radiation Therapy Patient assessment Patient positioning Patient immobilisation Manufacture or construction of ancillary equipment Simulation Treatment imaging Treatment planning Treatment verification

Additional comment

          

 

Clinical reasoning Patient management



Patient palpation

  

Patient contouring, anatomical matching Image matching


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Table 6 (continued) Quality Assurance Professional, ethical and safe work practices communication Team work Problem solving Critical thinking

  

Care and clinical management



Nuclear Medicine Preparation of radiopharmaceuticals



Administration of radiopharmaceuticals Acquisition of data Analysis of data Archiving data Quality assurance advocacy Professional, ethical and safe work practices communication Team work Problem solving Critical thinking Care and clinical management Medical Sonography Image interpretation Understanding the clinical question Obstetrics Abdominal Pelvic Obstetric Superficial parts Vascular Professional, ethical and safe work practices communication Team work Problem solving Critical thinking Care and clinical management



Patient handling

Interpretation of referral letters & patient history taking

Including spill cleanup, blood taking and labelling

   

Manual handling, radiation safety

  

Workflow

 





KEY:: Curricula elements perceived by university educators and representatives of professional bodies that could be delivered via simulation to meet clinical placement objectives; shaded areas represent curriculum elements that are common across all disciplines

The level of agreement from accredited schools and accreditation bodies Discussion and consensus agreement on the following items was sought between university educators of accredited programs and professional accrediting bodies at face to face consultative meetings. -The curricula elements in Radiation Science that can be delivered using simulation -Likely impact on training days should these curricula elements be delivered by simulation -Perceived barriers in using simulation to deliver the curriculum elements -Likely timeframes for implementation should these curricula elements be adopted Twenty-seven delegates including representatives from all Australian universities with Radiation Science programs, and professional and accrediting bodies (ASUM, ASA,


31

ANZSNM, AIR and ASAR) attended the meetings. The preliminary report was summarised at the commencement of the meeting to inform delegates of the findings to date and to inform discussion. Delegates were asked to perform tasks where they made judgements on the skills levels that could be attained using simulation activities in teaching for curricula elements identified in competency based standards documentation for each discipline. The meetings provided dialogue between and within professions that was collaborative and forward thinking of existing and future endeavours to reach learning outcomes with simulation.

The curricula elements identified in Table 6 that could be integrated into the curricula and that would meet the accreditation standards Medical Imaging After discussion at the consultative meetings, there was agreement that in addition to curricula elements identified in the interviews (Table 6), all other curricula elements outlined in the AIR competency standards for the accredited practitioner [32]could be delivered using simulation. Using the Dreyfus model of skill acquisition [35](Appendix 6), delegates determined that the overall skills level of students when students entered their first clinical placement was at beginner level. Expectations for students were that when graduating from a three year degree they would be at a competent level and when graduating from a four year degree or a professional development year they should be at a proficient level. Table 7 outlines the simulation activities that delegates thought could be integrated into the curricula, and the skills levels that could be reached using simulation in teaching. It was thought that simulation could be used to develop skills to a either a beginner or competent level in all curricula elements, excepting digital radiography skills which could be taken to proficiency. Most universities were already integrating simulation into their teaching programs, including interactive group work and role play, anatomic models and phantoms, image analysis, PACS systems, digital imaging software, and simulated clinical settings. Simulated clinical settings included using real radiographic equipment and phantoms for routine radiographic training. There is potential for these facilities to be upgraded. There was little simulation teaching occurring for other curricula elements of radiography training, which also are difficult for students to access in clinical practice (fluoroscopy, operating theatre radiography, emergency radiography, and routine CT imaging). There appear to be no products available to simulate these aspects of the curriculum, but there is potential to develop such tools. Suggestions included using video demonstrations, virtual reality, and remote laboratories. Remote laboratories are a concept supported by ‘Labshare’, a national project backed by Australian Government's Diversity and Structural Adjustment Fund and initiated by universities amongst the Australian Technology Network. Labshare’s mission is to create a nationally shared network of remote laboratories. This project has promise to effect large efficiencies in teaching students of professional disciplines such as Radiation Science, who use equipment that has high installation and maintenance costs. Digital radiography equipment, while becoming more widely used in clinical environments, is also not currently available in undergraduate Medical Imaging programs. Installing such systems to simulate clinical settings has the potential to take students from a novice level to a proficient level. Image interpretation and Quality assurance are large curricula elements in Australian Medical Imaging programs. A range of digital imaging software is currently being used in universities, but there is capacity to upgrade these facilities to more closely replicate the clinical setting. There is also no comprehensive diagnostic electronic imaging library available. A comprehensive diagnostic imaging electronic library, which could be shared across all universities, and which can be accessed with high quality imaging software would have great benefit to simulate the curricula elements of image interpretation and quality assurance.


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The benefits of using virtual worlds such as ‘second life’ and ‘reaction grid’ were also discussed as addressing the curriculum elements of communication, teamwork, problem solving, critical thinking, care and clinical management. These elements could also be delivered using interactive group work, but virtual worlds had the advantage of being remotely accessible and could be shared across universities.

Radiation Therapy At the consultative meetings there was agreement that in addition to curricula elements identified in the interviews (Table 6), all other curricula elements outlined in the AIR competency standards for the accredited practitioner [32] could be delivered using simulation. Using the Dreyfus model of skill acquisition [35](Appendix 6), delegates determined that the overall skills level of students when students entered their first clinical placement was at beginner level. Expectations for students were that when graduating from a three year degree they would be at a competent level and when graduating from a four year degree or a professional development year they should be at a proficient level. Table 8 outlines the simulation activities that delegates thought could be integrated into the curricula, and the skills levels that could be reached using simulation in teaching. It was thought that simulation could be used to develop skills to either a beginner or competent level in all curricula elements, with the exception of treatment planning skills which could be taken to proficiency. Most universities were currently using planning systems, image analysis, dosimetry, and role play or interactive group work. Curricula areas which were not well covered using simulation included patient assessment, patient positioning, patient immobilisation, manufacture of ancillary equipment, treatment simulation, treatment Imaging, treatment planning, and treatment verification. While interactive group work and role play, including live actors as standardised patients were valuable in teaching the curricula elements of patient assessment, professional, ethical and safe work practices, communication, team work, problem solving and critical thinking, the group thought that the most significant simulation in a Radiation Therapy program would be VERTTM . VERTTM was viewed to be the simulation tool that could most closely replicate clinical practice, and would have the greatest impact on teaching the foundation clinical skills (treatment simulation, treatment Imaging, treatment planning, and treatment verification) that could only otherwise be addressed in a clinical setting.

Nuclear Medicine At the consultative meetings, there was agreement that in addition to curricula elements identified in the interviews (Table 6), all other curricula elements outlined in the ANZSNM competency standards [33] could be delivered using simulation. Using the Dreyfus model of skill acquisition [35] (Appendix 6), delegates believed that the overall skills level of students entering clinical practice for the first time was at novice to beginner level. Expectations for students were that when graduating they would be at a competent level. Table 9 outlines the simulation activities that delegates thought could be integrated into the curricula, and the skills levels that could be reached using simulation in teaching. It was thought that simulation could be used to develop skills to either a beginner or competent level, excepting ‘analysis of data’, which could be taken to proficiency. Most universities were using simulation activities using real life scenarios/group work/role play, image and data processing software, venous injections and cannulations and radiopharmacy laboratories. Curricula elements that were not currently well covered by simulation included data acquisition, data analysis, archiving data, quality assurance, problem solving and critical thinking.


33

Data acquisition, data analysis and data archiving is a large curricula component in Nuclear Medicine clinical training and can be facilitated by simulation if working gamma cameras or other imaging equipment were available in universities. It was felt that collectively that data processing skills could be facilitated across all universities if nuclear medicine software vendors could contribute to a common educational platform with multiple log in licences. Animal imaging could also integrated into teaching to simulate functional imaging, which is not possible using innate phantoms, or real patients due to radiation exposure. As Nuclear Medicine imaging equipment is very expensive, there were other suggestions of simulation activities that could be developed in lieu of a real gamma camera, and ancillary equipment. These included the development of computer assisted tutorials, artificial neural network, virtual reality, video demonstrations, VIRAD (virtual reality injection software) scan image and QA outcome databases, and upgrading of image processing software.

Medical Sonography From the consultative meetings there was agreement that in addition to curricula elements identified in the interviews (Table 6), all other curricula elements outlined in the ASAR competency standards [34] could be delivered using simulation. Two other curricula elements were identified in the discussions; transducer manipulation and instrumentation, which are regarded as important foundation skills. Using the Dreyfus model of skill acquisition [35](Appendix 6), delegates believed that the overall skills level of students entering clinical practice for the first time was at novice level, and the skills level of students graduating from program was at competent level. Table 10 outlines the simulation activities that delegates of consensus meetings thought could be integrated into the curricula, and the skills levels that could be reached using simulation in teaching. It was thought that simulation could be used to develop skills to a novice or beginner level, but not to a competent or proficient level. Most universities deliver medical sonography programs in external mode/ distance education, therefore minimising opportunities for simulation unless web-based or online simulations are used, or changing the delivery mode of the program. Most universities reported using live scanning simulation, but students have limited exposure, with most development of skills in performing complete examinations, transducer manipulation, and instrumentation occurring in clinical practice. The group agreed that development of these psychomotor skills could be facilitated by simulation using body part phantoms for lower level skills, and live scanning and standardised patients for higher level skills. Animal scanning was also suggested for limited applications such as scanning the fetal heart. Image Interpretation is an important curricula element which appeared not to be well covered with simulation. Simulation exercises in this domain can be developed and adapted to suit online delivery. Image Interpretation could be facilitated by access to a comprehensive online image library, which could be made available to all universities. Other elements of the curricula that were not well covered using simulation, included image interpretation, understanding the clinical question, professional, ethical and safe work practices, manual handling, communication, teamwork, critical thinking and care and clinical management. These elements could be addressed using simulation with virtual reality or worlds, videos, actors and role play.


34

Table 7: Curricula elements of medical imaging that could be delivered with simulation Curricula elements in Medical Imaging Simulation activities

Achievable skills level with simulation

A B

2

1-3

C

34

D E

2

3

F

3

G H I

3

3

Anatomical models (body parts)

√

Full body phantom

√

Image analysis/ interpretation

√

√

√

√

Interactive group work/role play

√

Live actors

√

PACS Simulated clinical settings

√

Computer assisted learning program

√

M N O

P

2 3

2

2

2

2

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√ √

√

Technical

Proced -ural

Health and safety

Human

2

3

3

2

Elements

√

√

√

√

√

√

√

Digital image library (large data and image sets) Virtual reality software

K

√

√

Digital imaging software

L

2

J

√

√

√

√

√

√

√

√

Remote lab simulation

√

√

√

√

Video demonstrations

√

√

√

√

√

√

√

√

KEY 1: novice; 2: beginner; 3: competent; 4: proficient; A: Patient assessment; B: General radiography; C:Digital radiography; D: Fluoroscopy; E: Operating theatre imaging; F:Emergency imaging; G: Routine CT imaging; H: Image interpretation; I: Peer mentoring; J: Quality Assurance; K: Professional, ethical and safe work practices; L: Communication; M: Team work; N: Problem solving; O: Critical thinking; P: Care and clinical management


35

Table 8 Curricula elements of Radiation Therapy that could be delivered with simulation Curricula elements Radiation Therapy Simulation

A

B

C

D

E

F

G

H

I

J

K

L

M

1-3

1-3

N

activities Positioning for treatment

14

2

Planning system 2D

2

1-4

1-3

1-3

Planning system 3D

2

1-4

1-3

1-3

Image analysis

3

1-3

1-3

1-3

1-3

1-3

1-3

1-3

1-3

1-3

1-3

1-3

3

Dosimetry

3 1-4

Automatic phantoms

3

Image library

2

2

Manufacture ancillary equipment

2

2

3

Reproduct-

3

3

1-4

1-4

3

3

ion of clinical environment Virtual software programs

3

VERTTM

3

3

1-4

3

Video replay

2

1-3

1-3

Actors with or without video replay

3

1-3

1-3

1-2

1-3

1-3

1-3

1-2

1-2

1-2

1-3

1-3

1-2

1-3

1-3

1-3

1-3

1-3

1-2

1-2

1-3

1-3

1-2

Real-life scenarios / role-play /group work Replicated clinical environment (with suite of equipment) Real patients in a university clinic Virtual reality

2

3

3

1-4

3

1-2

KEY: 1: novice; 2: beginner; 3: competent; 4: proficient; A: patient assessment; B: Patient positioning; C: Patient immobilisation D: Manufacture of ancillary equipment; E: Simulation; F: Treatment Imaging; G: Treatment planning; H: Treatment verification; I: Professional, Ethical and safe work practices; J: communication; K: Team work; L: Problem solving; M: critical thinking; N: care and clinical management


36

Table 9 Curricula elements of Nuclear Medicine that could be delivered with simulation Curricula elements in Nuclear Medicine Simulation Activities A B C Real-life scenarios/role play/ group work Image and data 2 processing software (computer lab) Anatomic 2 models/Phantoms Live actors 2 Radio pharmacy lab(hot 1- 2 lab/ cold lab or both) 3 Computer assisted 1instruction 3 Video/CD simulation (demonstrations) Gamma camera 3 Animals

2

Virtual reality Real clinics Image data base/image Evaluation Artificial intelligence

2 2

2

D

E

F

G x

H

I X

J 23

K

L

2-3

23

2-3

23

M 2+

2

2 X

2 34 34 2

1-2

2

1-2 2

2

3-4 X

2 34

1-2 1-2

KEY: 1:novice; 2: beginner; 3: competent; 4:proficient; x:no skills level determined; A: Preparation of radiopharmaceuticals; B:Administration of radiopharmaceuticals; C: Acquisition of data (parameters + analysis); D:Analysis of data; E:Archiving data; F:Quality assurance; G:advocacy; H:Professional, ethical and safe work practices; I:Communicaion; J:teamwork; K:Problem solving; L:critical thinking; M: care and clinical management

Table 10 Curricula elements of Medical Sonography that could be delivered with simulation Curriculum elements Medical Sonography Simulation A B Body Part Phantom Online Quizzes 1-2 Live scanning Simulated biometry measurements Online interactive group work/computer programs PACS/image library 1-2 Virtual reality 1-2 2 Videos 2 Actors 2 Standardised patient Role play 2 Animal

C 1

D

E

F

G

H

I

1-2

J 2

K 2

2 2

2

2

1-2 1-2 1-2

1-2 1-2 1-2

1-2 1-2 1-2

1-2 1-2 1-2

1-2 1-2 1-2

1-2 1-2 1-2

1-2

1-2

1-2

1-2

1-2

1-2

1.5

2 2 2

2 2 2 2

KEY 1:novice; 2: beginner; 3: competent; 4= proficient; A: image interpretation; B: understanding the clinical question; C: performing complete examinations; D: Professional, ethical and safe work practices; E: manual handling; F: communication; G: teamwork, H: critical thinking; I: care and clinical management; J: instrumentation; K: transducer manipulation


37

Interdisciplinary Radiation Science Common curriculum elements were identified across each of the four radiation science discipline (Table 6). These were: -Professional, ethical and safe work practice -Communication -Team work -Problem solving -Critical thinking -Care and clinical management From the consultative meeting it was agreed that simulation resources could be developed and shared across the Radiation Science disciplines (and other allied health and medical disciplines) to meet these common curriculum elements. Examples of simulation activities that could be developed included: -Comprehensive radiation science image library (available to share across universities) -Virtual reality programs/virtual worlds (potential for sharing across universities) -Software to develop computer assisted learning programs (potential for sharing across universities) -Video resources (potential for sharing across universities) -Video playback facilities

Any perceived barriers to this curriculum being recognised and adopted for clinical training purposes The delegates at the consultative meetings across all disciplines identified a number of barriers to introducing a curriculum with simulation used for clinical teaching. The ongoing support for simulation resources and their maintenance by the teaching institutions was seen as a barrier that would need to be overcome. Resource issues that would need to be addressed by the universities included dedicated space for the simulation, and ongoing maintenance of the equipment. Timetabling was also seen as an issue which is complicated by the available spaces and required attendance at non –simulation teaching sessions for students and teachers. Virtual or online simulations were one strategy of overcoming some of these issues, and also of addressing another barrier of equity for external or distance education students. Simulation was thought to add to teaching loads, and would require additional teaching staff, who should be trained in the delivery of teaching with simulation. Careful planning would be required to bring the curricula elements together to address the complexities of clinical practice. The perceptions of the students, the professions and their accrediting bodies were also possible barriers. The confidence of these stakeholders in the teaching mode is important and pivotal in the success of curriculum changes. The evidence collected in this report suggests that simulation is perceived by stakeholders as an adjunct and not a replacement to clinical placement and evidence to support simulation needs to be collected to convince the stakeholders.

The likely impact on clinical training days required in the course should these curricula elements be delivered through SLP’s There was general reluctance for accrediting bodies to accept a reduction in clinical training days with the introduction of simulation or further development of existing simulation in teaching. The reasons for this, despite an agreement that simulation can


38

elevate skills levels, and improves the quality of the student entering clinical placement, is most likely the perception that clinical placement gives students a broad exposure to a wide range of complex situations. They are not prepared to accept simulation on face value, but wanted to see evidence that it could take students to the level of professional accreditation standards at the end of the program, in the interest of safety to the public.

Medical Imaging Agreement between university educators and accrediting bodies to use SLEs as a clinical placement setting for clinical training days was reached. The AIR representative agreed with universities that based on a four year degree program, a 50 week (250 days)clinical placement program could be reduced by a maximum 5 weeks (25 days, 10%) with a high quality simulation program. A submission to the accrediting body would be required, demonstrating how the simulation program would meet learning objectives, and evidence that at the end of the program students meet the accreditation standards.

Radiation Therapy Agreement between university educators and accrediting bodies to use SLEs as a clinical placement setting for clinical training days was reached. The AIR representative agreed with universities that based on a four year degree program, a 50 week (250 days)clinical placement program could be reduced by a maximum 10 weeks (50 days, 20%) with a high quality simulation program (this would include VERTTM). A submission to the accrediting body would be required, demonstrating how the simulation program would meet learning objectives, and evidence that at the end of the program students meet the accreditation standards.

Nuclear Medicine It was agreed between university educators and the representatives of the ANZSNM (accrediting body) that SLEs as a clinical placement setting could not replace any clinical training days (i.e. no reduction in clinical training days).

Medical Sonography Agreement between university educators and representatives of the accrediting body (ASAR) to use SLEs as a clinical placement setting for clinical training days was reached. A maximum of 10-20 days (3-7%) was conceded as possible if high quality simulation was used. Despite this agreement, the accrediting body was very reserved, with concerns that training quality would be compromised using SLEs.

The likely timeframes for implementation should these curricula elements be adopted. Timeframes for implementation are dependent on: - Time taken to install simulation equipment -Time taken for university curricula changes to be approved through university processes. -Time taken for accrediting bodies to approve the curricula changes Installation time would depend on the simulation technology. Upgrades to existing equipment may be instant or have a lead in time of up to 6 months. Time frames for new simulation equipment can be sourced quickly, and depending on availability may have a lead in time of up to 6 months. The availability of space, and creating spaces, also is variable. VERTTM is known to have a rapid installation time.


39

The time taken to process curricula changes through the university quality processes depends on the degree of changes to me made. Minor curricula amendments can mostly be implemented within weeks, but major curricula changes may have up to a 18 month lead in time. Accrediting bodies would need to be advised of curricula changes in advance, with bilateral dialogue between the university and accrediting body. The AIR would consider a group submission, if all universities were making similar changes. Time frames for accrediting body processing are variable, but a minimum of three months was considered to be required to allow for review and discussion around submitted documents, and if major revisions are required to a program the reaccreditation process could take up to 18 months.

Recommendations Priority elements of the curriculum that could be supported by the SLE national project Medical Imaging -Upgrading of existing SLEs with expanded suites of imaging phantoms, digital radiography facilities, advanced imaging software and comprehensive image libraries would facilitate the development of clinical skills of patient assessment, general radiography, digital radiography, Image interpretation, peer mentoring, quality assurance, professional, ethical and safe work practices, team work, problem solving, critical thinking and patient care and clinical management. - to meet the curricula elements of fluoroscopy, operating theatre radiography, emergency radiography and routine computed tomography, which are not easily accessed by students in the clinical environment, the development of existing technologies to develop new simulators (including video demonstrations, virtual reality, remote laboratories)should be investigated.

Radiation Therapy - the foundation curricula elements of treatment simulation, treatment imaging, treatment planning, and treatment verification could be met with the installation of a fully immersive virtual linear accelerator (VERTTM) at Australian universities.

Nuclear Medicine To meet the three core curricula elements of Nuclear Medicine training of data acquisition, data analysis, and data archiving there are two general options. Option 1 would be a faster, but more expensive option, and Option 2 may be less expensive, but needs time for development and testing. -Option 1 Install working gamma cameras and other working imaging and ancillary equipment in Australian universities, using small animals and phantoms to simulate real patients and meet the curricula elements of data acquisition, data analysis, and data archiving. -Option 2 Investigate technology from all vendors which can be applied to development of new simulators including video demonstrations, computer assisted tutorials, artificial intelligence, virtual reality, remote laboratories, scan image databases, and upgrading of image processing software


40

Medical Sonography - skills in transducer manipulation, instrumentation and performing examinations can be developed if up to date scanning equipment combined with the use of body part phantoms for lower level skills, and live scanning and standardised patients for higher level skills is introduced into university courses where possible. - image interpretation skills can be developed with online tutorials and exercises which can be shared between universities and clinical tutors through shared image databases - to meet the curricula elements of understanding the clinical question, professional, ethical and safe work practices, manual handling, communication, teamwork, critical thinking and care and clinical management simulation with virtual reality or worlds, video, actors and role play can be developed.

Interdisciplinary Radiation Science -investigate sharing of resources across the universities delivering Radiation Science programs: virtual reality programs/virtual worlds, software to develop computer assisted learning programs. -investigate sharing of video and video playback resources across all health disciplines within universities. -develop a comprehensive radiation science image library that can be shared across all universities delivering Radiation Science and other Health discipline education programs.

Approaches to address barriers to effective utilization and expansion of the use of SLE’s in delivering the priority elements of the curriculum To improve the perception and understanding of simulation amongst stakeholders, educators will need to engage the external stakeholders in a collaborative approach by involving clinical sites when developing simulation activities, and providing external bodies with access to the resources to assist with professional development activities for qualified practitioners, including using simulation to provide clinical supervisors with education based on proven educational principles. The effectiveness of the simulation in meeting clinical learning objectives should be investigated with rigorous research, which would best be achieved by university educators pooling information and using shared resources where possible. Careful curriculum planning will be required to maximise resources for delivering education with simulation, and to limit duplication of teaching between the clinical site and the university. The simulation curriculum should undergo careful evaluation, including student evaluation. Virtual reality and computer programs have the potential to reduce student contact time, and be less resource intensive. Where simulation products are unavailable, research and development companies should be engaged to explore possibilities of development of simulations for particular applications


41

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Appendices Appendix 1: List of Participants who informed the report Appendix 2: Outline of Interview questions for university educators Appendix 3: Outline of Interview questions for representatives of professional and accrediting bodies. Appendix 4: Outline of Interview questions for individuals experienced in simulation in Radiation Science education Appendix 5: Outline of survey questions for clinical supervisors. Appendix 6: Dreyfus model of skill development Appendix 7: Agenda of face to face consensus meetings


44

Appendix 1: List of Participants who informed the report Wendy Barber

Shane Dempsey

Michelle Pedretti

Luke Barclay

Louise Deshon

Roger Phillips

Annette Boejen

Wendy Forrest

Karen Pollard

Sharon Brackenridge

Diana Gentilcore

John Robinson

Vicki Braithwaite

Eileen Giles Geoff Rof

Julie Burbery

Chris Hicks

Pam Rowntree

Tony Buxton

Daphne James

Elaine Ryan

Louise Coleman

Peter Kench

Sock Bee Sia

Margaret Condon

Paul Lombardo

Jenny Sim

Simon Cowell

David Lyall

Debbie Starkey

Cynthia Cowling

Jonathon McConnell

Pam Stronach

John Atyeo

Jan McKay

Faye Temple

Jenny Cox

Rob McGregor

John Tessier

Geoff Currie

Delwyn Nicholls

Kerry Thoirs

Rob Davidson

Suean Pascoe

Elaine Trevaskis

Sue Davies

Heather Patterson

Caroline Wright


45

Appendix 2: Outline of Interview questions for university educators 1. Please provide some background on your program to provide some context for your answers 2. Which medical radiation modality do you teach? 3. Does the program involve clinical placement or do students undertake workplace training? How much clinical placement or workplace training do they undertake across the entire program? 4. Is the program delivered online, face to face or a mixture of both? 5. Do you already imbed simulation into your teaching program, in addition to the clinical placement or work experience? What techniques are you using? Consider online or face to face examples of simulation. Simulation can be defined as any teaching activity that is made to resemble clinical practice as closely as possible. Anatomic models for task training (phantoms) Software programs (virtual reality) Interactive group work Live actors Image analysis (on archived images) Computer enhanced mannequins Simulated clinical environments (employing realistic equipment and tasks) Any other? 6. Do these simulation teaching activities meet any of the curricula elements (content) and learning objectives of clinical placement/workplace training? 7. Do you think you could expand currently used or introduce new simulation techniques/aids or programs to meet the curriculum elements and learning objectives currently being delivered through clinical placement/work place training if you had the funding and resources? (wish list question) 8. Do you think simulation has a role in increasing your student capacity/numbers without affecting the quality of clinical learning outcomes? If so, and if there were no barriers to using simulation (i.e. prescribed clinical hours, costs, resources) how would you integrate simulated learning programs into your program to expand student capacity? With no barriers, how much do you think you could increase your capacity (estimate percentage increase)? 9. What do you see as the barriers to integrating simulated learning programs to expand student capacity? 10. What comments do you have about simulated teaching activities affecting the outcome of the quality of clinical learning outcomes? 11. What opportunities are there (if any) for interprofessional learning using simulated learning environments? Interprofessional learning can be across medical radiation disciplines or be broader across other allied health/medical disciplines. 12. Of the simulation activities that you have identified, can these be used for teaching across other health disciplines?


46

Appendix 3: Outline of Interview questions for representatives of professional and accrediting bodies. 1. What curriculum elements and learning objectives do you think should be included in clinical placements/work place training of professional entry university programs? 2. Are you aware of any of these curriculum elements and learning objectives that are currently being delivered through simulation teaching activities in university programs? 3. What simulation have you seen being used? Anatomic models for task training (phantoms) Software programs (virtual reality) Interactive group work Live actors Image analysis (on archived images) Computer enhanced mannequins Simulated clinical environments (employing realistic equipment and tasks) Any other? 4. Please expand on what curriculum elements and learning objectives could be addressed with the above techniques. 5. Are you aware of any other simulation techniques/aids or programs that you think would be of value to meet the curriculum and learning objectives of clinical placement/workplace training that are not being used in university programs? 6. How could simulated learning programs be integrated into professional entry university programs to meet the curriculum elements and learning objectives currently being delivered through clinical placement/work experience? 7. What comments do you have about simulated teaching activities affecting the outcome of the quality of clinical placement/workplace training learning outcomes? 8. What do you see as the barriers to integrating simulated learning programs to meet the curricula and learning outcomes of clinical placement/work experience?


47

Appendix 4: Outline of Interview questions for individuals experienced in simulation in Radiation Science education 1. Do you know of examples where curriculum elements and learning objectives of clinical placements/workplace training are currently being delivered through simulation learning programs? 2. What types of simulation are you familiar with and what curriculum elements and learning objectives can be addressed with those techniques. Anatomic models for task training (phantoms) Software programs (virtual reality) Interactive group work Live actors Image analysis (on archived images) Computer enhanced mannequins Simulated clinical environments (employing realistic equipment and tasks) Any other? 3. Do you use/have you seen simulation techniques been used to successfully meet the curriculum elements and learning objectives that are traditionally being delivered through clinical placement? What impact does it have on quality of learning outcomes? What are the barriers? 4. Do you think you could expand simulation techniques/aids or programs that you are currently using to meet the curriculum elements and learning objectives currently being delivered through clinical placement? 5. Do you use/have you seen any good models of integrating simulation with clinical placement/workplace training for best learning outcomes. 6. Do you use/have you seen good models of simulation for inter-professional learning?

Appendix 5: Outline of survey questions for clinical supervisors. 1. Do you employ any simulation techniques/programs when training Medical Radiation Science students (medical imaging, radiation therapy, nuclear medicine or sonography) in the clinical environment? 2. What are you using? 3. How do these simulation activities assist your students in developing clinical skills? 4. How do these simulation activities assist your students in developing clinical skills? 5. Are you aware of any simulation techniques/aids or programs that you would like to integrate into clinical training if you had the funding and resources? 6. Do you think student clinical placement hours could be reduced if simulation activities were more integrated into university programs/courses? 7. Do you think the use of simulated learning programs would affect the quality of clinical learning outcomes if they replaced some of the clinical placement?


48

Appendix 6: Dreyfus model of skill acquisition Knowledge

1. Novice

2. Beginner

3. Competent

4. Proficient

5. Expert

Standard of work Unlikely to be satisfactory unless closely supervised

Autonomy

Working knowledge of key aspects of practice

Straightforward tasks likely to be completed to an acceptable standard

Good working and background knowledge of area of practice

Fit for purpose, though may lack refinement

Depth of understanding of discipline and area of practice

Fully acceptable standard achieved routinely

Authoritative knowledge of discipline and deep tacit understanding across area of practice

Excellence achieved with relative ease

Minimal, or 'textbook' knowledge without connecting it to practice

Coping with complexity Little or no conception of dealing with complexity

Perception of context Tends to see actions in isolation

Able to achieve some steps using own judgment, but supervision needed for overall task Able to achieve most tasks using own judgment

Appreciates complex situations but only able to achieve partial resolution

Sees actions as a series of steps

Copes with complex situations through deliberate analysis and planning

Sees actions at least partly in terms of longer-term goals

Able to take full responsibility for own work (and that of others where applicable) Able to take responsibility for going beyond existing standards and creating own interpretations

Deals with complex situations holistically, decisionmaking more confident Holistic grasp of complex situations, moves between intuitive and analytical approaches with ease

Sees overall 'picture' and how individual actions fit within it

Needs close supervision or instruction

Sees overall 'picture' and alternative approaches; vision of what may be possible

From the professional standards for conservation, Institute of Conservation (London) 2003 based on the Dreyfus model of skill acquisition [36]


49

Appendix 7 Agenda of face to face consensus meetings Timetable Time

Session

Content

9.30am – 10.30am

Session 1

Introductions and outline

10.30am – 11.30am

Session 2 (break out groups)

Group 1 (Sunday)

Medical Imaging (Saturday), Nuclear Medicine

Group 2 Radiation Therapy (Saturday), Medical Sonography (Sunday) Consensus discussion and agreement: Overall skills level of students at beginning of their first clinical placement Mapping: Map assessment curricula elements against simulation activities (curriculum elements have been derived from competency based standards for each profession)

11.30am – 11.45am

Morning tea

11.45am – 1.00pm

Session 3 (combined session)

Group 1 presents findings of Session 2 Discussion and consensus agreement on Group 1 findings in Session 2 Using skills level information, what is the potential impact of simulation on clinical training days. Can it replace/supplement traditional clinical placement delivery? What are the perceived barriers in adopting the identified simulation activities? If simulation activities adopted, what would be the likely timeframe for adoption to occur?

1.00pm – 1.45pm

Lunch Session 4 (combined session)

Group 2 presents findings of Session 2 Discussion and consensus agreement on Group 2 findings in Session 2 Using skills level information, what is the potential impact of simulation on clinical training days. Can it replace/supplement traditional clinical placement delivery? What are the perceived barriers in adopting the identified simulation activities? If simulation activities adopted, what would be the likely timeframe for adoption to occur?

3.00pm – 3.15pm

Afternoon tea

3.15pm – 4.15pm

Session 5

Inter-professional

4.15pm – 5.00pm

Session 6

Summary

5.00pm

Close


50

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