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Please cite this article in press as: Currey J, et al. Learner perceptions and reflections after simulation-based advanced life support training. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.01.002 ARTICLE IN PRESS G Model AUCC-230; No. of Pages 3 Australian Critical Care xxx (2014) xxx–xxx Contents lists available at ScienceDirect Australian Critical Care j ourna l h o mepage: www.elsevier.com/locate/aucc Learner perceptions and reflections after simulation-based advanced life support training Judy Currey RN, BN (Hons), Crit Care Cert, PhD a,, Julie Considine RN, RM, BN, GradDipNurs (AcuteCare), MNurs, PhD, FRCNA b , Josh Allen RN, BN(Hons), Grad Dip Crit Care a a School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, Australia b Eastern Health-Deakin University Nursing and Midwifery Research Centre, Eastern Health and School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, Australia a r t i c l e i n f o r m a t i o n Article history: Received 12 July 2013 Received in revised form 23 October 2013 Accepted 7 January 2014 Available online xxx Review article: Long-term Intended and Unintended Experiences after Advanced Life Support Training Maria Birkvad Rasmussen, Peter Dieckmann, S. Barry Issenberg, Doris Østergaard, Eldar Søreide, Charlotte Vibeke Ringsted. Resuscitation 2013; 84: 373–377. Objective The aim of this study was to identify long-term learner reactions, experiences and reflections after attending a simulation-based advanced life support (ALS) course. The simulation training had taken place in Denmark during 2009–2010 and was based on the European Resuscitation Council ALS principles and algorithms. Design Based on grounded theory, this qualitative research used semi-structured interviews to address the research aims. Semi- structured telephone interviews were conducted after simulation training (timeframe unspecified) for durations of between 8 and 20 min. Consistent with grounded theory, a priori themes from the literature and perceptions of interviewees influenced the interview guide and provided themes that informed the data analysis in an Corresponding author at: Faculty of Health, Deakin University, 221 Burwood Highway, Burwood 3125, Victoria, Australia. Tel.: +61 3 9244 6122; fax: +61 3 9244 6159. E-mail address: [email protected] (J. Currey). iterative manner until saturation was reached. Ethics approval was sought and gained for the conduct of this study. Setting and sample Of 74 (63 physicians, 11 nurses) Danish individuals who com- pleted the ALS simulation training in 2009–2010, 17 (14 physicians, 3 registered nurses) agreed to participate following an email invi- tation from the Chairman of the ALS steering committee. Sampling was purposive for completion of the course by residents of Copen- hagen. The average age of participants during the ALS training was 55 (range 54–56) years for nurses and 31 (range 28–40) years for physicians. The average years of clinical experience was greater for nurses (mean 25; range 22–30) than physicians (mean 4; range 1–11). The specialty experience of participants included 9 with internal medicine (including cardiology), 6 from anaesthetics and 2 from surgical units. Results Analysis revealed three major themes which were highly inter- related. These themes were: contextual adaptation, communities of practice and transfer of skills. Participants found being held accountable for implementing the algorithm correctly and receiv- ing negative feedback about their performance quite confronting. Not only did participants find learning by a structured approach initially difficult, but once learnt and appreciated, the application of this newly-found valuable approach was difficult to imple- ment clinically due to peer pressure to do otherwise. Thus the perceived lack of synchrony between simulation and real world clinical practice was a major contributor to contextual adaptation. http://dx.doi.org/10.1016/j.aucc.2014.01.002 1036-7314/© 2014 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

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ARTICLE IN PRESSG ModelUCC-230; No. of Pages 3

Australian Critical Care xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Australian Critical Care

j ourna l h o mepage: www.elsev ier .com/ locate /aucc

earner perceptions and reflections after simulation-based advancedife support training

udy Currey RN, BN (Hons), Crit Care Cert, PhDa,∗,ulie Considine RN, RM, BN, GradDipNurs (AcuteCare), MNurs, PhD, FRCNAb,osh Allen RN, BN(Hons), Grad Dip Crit Carea

School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, AustraliaEastern Health-Deakin University Nursing and Midwifery Research Centre, Eastern Health and School of Nursing and Midwifery, Faculty of Health, Deakinniversity, Melbourne, Australia

r t i c l e i n f o r m a t i o n

rticle history:eceived 12 July 2013eceived in revised form 23 October 2013

ccepted 7 January 2014vailable online xxx

eview article:

Long-term Intended and Unintended Experiences afterdvanced Life Support Training

Maria Birkvad Rasmussen, Peter Dieckmann, S. Barryssenberg, Doris Østergaard, Eldar Søreide, Charlotte Vibekeingsted. Resuscitation 2013; 84: 373–377.

bjective

The aim of this study was to identify long-term learner reactions,xperiences and reflections after attending a simulation-baseddvanced life support (ALS) course. The simulation training hadaken place in Denmark during 2009–2010 and was based on theuropean Resuscitation Council ALS principles and algorithms.

esign

Based on grounded theory, this qualitative research usedemi-structured interviews to address the research aims. Semi-tructured telephone interviews were conducted after simulation

Please cite this article in press as: Currey J, et al. Learner perceptiontraining. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.0

raining (timeframe unspecified) for durations of between 8 and0 min. Consistent with grounded theory, a priori themes from the

iterature and perceptions of interviewees influenced the interviewuide and provided themes that informed the data analysis in an

∗ Corresponding author at: Faculty of Health, Deakin University, 221 Burwoodighway, Burwood 3125, Victoria, Australia. Tel.: +61 3 9244 6122;

ax: +61 3 9244 6159.E-mail address: [email protected] (J. Currey).

ttp://dx.doi.org/10.1016/j.aucc.2014.01.002036-7314/© 2014 Australian College of Critical Care Nurses Ltd. Published by Elsevier Au

iterative manner until saturation was reached. Ethics approval wassought and gained for the conduct of this study.

Setting and sample

Of 74 (63 physicians, 11 nurses) Danish individuals who com-pleted the ALS simulation training in 2009–2010, 17 (14 physicians,3 registered nurses) agreed to participate following an email invi-tation from the Chairman of the ALS steering committee. Samplingwas purposive for completion of the course by residents of Copen-hagen. The average age of participants during the ALS training was55 (range 54–56) years for nurses and 31 (range 28–40) years forphysicians. The average years of clinical experience was greater fornurses (mean 25; range 22–30) than physicians (mean 4; range1–11). The specialty experience of participants included 9 withinternal medicine (including cardiology), 6 from anaesthetics and2 from surgical units.

Results

Analysis revealed three major themes which were highly inter-related. These themes were: contextual adaptation, communitiesof practice and transfer of skills. Participants found being heldaccountable for implementing the algorithm correctly and receiv-ing negative feedback about their performance quite confronting.Not only did participants find learning by a structured approachinitially difficult, but once learnt and appreciated, the application

s and reflections after simulation-based advanced life support1.002

of this newly-found valuable approach was difficult to imple-ment clinically due to peer pressure to do otherwise. Thus theperceived lack of synchrony between simulation and real worldclinical practice was a major contributor to contextual adaptation.

stralia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

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ARTICLEUCC-230; No. of Pages 3

J. Currey et al. / Australian

he communities of practice theme reflected the limited under-tanding of other disciplines’ specific roles, responsibilities androfessional knowledge; and the beneficial sense of being a partf the specific ALS-trained community. In particular, being part ofhe community of ALS-trained staff provided strong feelings of pro-ciency and confidence that they could perform resuscitation the

right’ way. The third theme of transfer of skills reflected partici-ants’ usage of skills from one area to another. The use of algorithmsnd communication skills and processes inherent to ALS resus-itation measures were useful as a framework for usual clinicalractice. However, participants found limited use and applicationf this framework in clinical practice in situations and contextshen working with others who had not completed ALS simulation

raining.The authors concluded that while the simulation based course

esulted in a high degree of efficiency in applying the theoreti-al and practical components of ALS in the training setting, theontent of the course was insufficient in developing the commu-ication and teamwork skills necessary for transferring these skillsnd knowledge to the clinical setting.

ritique and discussion

The aim of this study was to identify long-term intended andnintended learner reactions, experiences and reflections afterttending the simulation based ALS course. Although long term wasot defined in this study, it appeared to be a timeframe between

and 24 months after the simulation-based training. It is knownhat practical skills and knowledge decay over time, with prac-ical skills decaying over about 6 weeks and knowledge over 18

onths,1–3 so variable time since training may have influenced par-icipant perceptions. This study is likely to be interesting to criticalare clinicians given the emphasis and expectations surroundingducation, assessment and ongoing competence in ALS. Researchnvestigating learner reflections and experiences of ALS training isot common, so an understanding of the finer nuances of these arealuable for informing instructional design and feedback to skilllinicians in ALS, and to identify barriers to transferring skills fromraining into clinical practice.

The current emphasis by some of our local and global col-eagues on simulation as the ideal model of education and training,reparation and ongoing professional development for health clini-ians warrants interest in this study’s findings. A recent systematiceview and meta-analysis of simulation in emergency medicine,hich included some studies of ALS, found unsurprisingly that sim-lation is favourable for learning over no education at all; however,e still have little understanding of how to best design simulation-

ased education to maximise learning efficiency and impact learnerehaviours.4

The clinical background of the 17 people interviewed was pro-ided but it would be useful to understand their level of exposureo resuscitation before and after the training, as well as theirurrent clinical environment. Participant reactions may vary con-iderably as a consequence of ALS exposure due to an expectedncrease in experiential knowledge and skill acquisition.5 A numberf studies have demonstrated that knowledge and skill acquisitionnd retention are improved with recent or sustained exposure toesuscitation.2,6,7 Indeed, regular practice is required after initialraining to maintain skills rather than annual assessment.8 Thistudy did not consider such ongoing exposure; but rather, it simplyxplored long term perceptions qualitatively. Likewise, ALS educa-

Please cite this article in press as: Currey J, et al. Learner perceptiontraining. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.0

ion received prior to this simulation training may positively impactlinicians’ performances during ALS practical sessions, althoughhis expectation is not always met because some clinicians doot demonstrate their knowledge verbally or through appropriate

PRESSl Care xxx (2014) xxx–xxx

actions.9 Participants in this study described a lacked of confidencein their own practice and skills in emergency situations that mayhave related to their clinical background or exposure to resuscita-tion.

Participants also described several expectations or prejudicesabout colleagues from other professions/specialties and from thosewith different experiences as well as conflicts arising from power-relations or confusion about roles and responsibilities. Ways ofimproving resuscitation training should include considerationsabout the experience of team leaders and communication struc-tures and issues specific to resuscitation.10 Of note, the clinicalbackgrounds of the ‘ALS team’ created during training did not reflectusual practice for these clinicians; however, the clinical reality ofresuscitation is that ALS teams have to form anytime anywherein acute or community settings, so the instructors may have cho-sen team diversity deliberately. These issues illustrate the needto teach teamwork, communication skills and appreciation of dif-ferent professional backgrounds during resuscitation training. Itis only through dialogue that role clarification, expectations andbiases can be realised and dealt with appropriately to enable coor-dination. Ultimately, an understanding of others’ knowledge andskills contributes positively to teamwork and collaborative decisionmaking. Indeed, teamwork skills are critical to effective resuscita-tive efforts.10–13

Comments by participants about having clear right and wronganswers required a contextual explanation by authors. On the onehand, the use of highly structured simulation with clear ‘wrong’and ‘right’ is not reflective of real clinical environments, does notteach clinicians to make decisions under conditions of uncertainty;these are key factors required for decision making in a resuscitationcontext. On the other hand, if simulation instructors were seekingparticipants to adhere strictly to the ERC ALS algorithm, then theright and wrong feedback may well have been justified. It seemsapparent that the right/wrong responses from instructors were notattributable to the simulation per se; but rather, the need to adhereto the algorithm. As such, any form of instruction regarding ALStraining would engender this response from clinicians.

The divide between instructors and participants is worthy offurther exploration. For example, it is unclear what the educa-tional andragogy underpinning the course was or how instructorswere prepared for their role. Further, the teaching style used bythe instructors was not explained. Likewise, the professional back-grounds of instructors were not described. Authors commentedthat “In these situations, the participants found it difficult, frus-trating and sometimes impossible to apply the things they hadlearned.” This suggests an instructor style that was not conduciveto participants’ application of knowledge in a stressful situation.Attention to details about these aspects of instructional design iscritical to ensure participants’ acquire intended learning outcomes.

Although conducted overseas, amongst a cohort of cliniciansunlikely to be reflective of the composition of ALS teams in theAustralian context, this paper helps us to understand some ofthe facilitators and barriers to transferring skills and knowledgelearned in a simulation setting to the clinical environment. Anunderstanding of participant’s reflections might shed light on theimpact of attitude on future clinical behaviour and compliance withongoing ALS training, which has traditionally been poor amongstcritical care nurses.14

The limitations of this study included only 17 of 74 professionalswho completed ALS simulation training participated in the studyand that these individuals self-selected to be interviewed. It is likelyfindings in relation to reflections would always be highly indivi-dualised given the diversity of roles, discipline and experiences of

s and reflections after simulation-based advanced life support1.002

participants. The paper also identifies that the clinicians involvedwere self-motivated to undertake the training to improve skills. Incontrast, the experience in Australia is that despite the expectation

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o undertake regular ALS training, compliance is low, suggestive ofow self-motivation.14

Overall, this study’s findings are useful to prompt our owneflections of our experiences during ALS training, how trainingeams are composed, instructional andragogy, feedback contentnd styles and skills one gains that transfer to usual clinical practice.

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3. Soar J, Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, et al. Part 12: Education,implementation, and teams: 2010 international consensus on cardiopulmonaryresuscitation and emergency cardiovascular care science with treatment rec-ommendations. Resuscitation 2010;81(October (Suppl. 1)):e288–330. PMID:20956038 (Epub 2010/10/20).

4. Ilgen JS, Sherbino J, Cook DA. Technology-enhanced simulation in emer-

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gency medicine: a systematic review and meta-analysis. Acad Emerg Med2013;20(2):117–27.

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7. Jensen ML, Lippert F, Hesselfeldt R, Rasmussen MB, Mogensen SS, Jensen MK,et al. The significance of clinical experience on learning outcome from resusci-tation training – a randomised controlled study. Resuscitation 2009;80(February(2)):238–43. PMID: 19058890 (Epub 2008/12/09).

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9. Perkins G, Fullerton J, Davis-Gomez N, Davies R, Baldock C, Stevens H, et al.The effect of pre-course e-learning prior to advanced life support training: arandomised controlled trial. Resuscitation 2010;81(7):877–81.

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