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The aim of this study was to assess the feasibility of incorporating the Delphi process within the simplifying conditions method (SCM) described in elaboration theory (ET) to identify conditions impacting the complexity of procedural skills for novice learners.We generated an initial list of conditions impacting the complexity of lumbar puncture (LP) from key informant interviews (n = 5) and a literature review. Eighteen clinician-educators from six different medical specialties were subsequently recruited as expert panellists. Over three Delphi rounds, these panellists rated: (i) their agreement with the inclusion of the simple version of the conditions in a representative ('epitome') training scenario, and (ii) how much the inverse (complex) version increases LP complexity for a novice. Cronbach's α-values were used to assess inter-rater agreement.All panellists completed Rounds 1 and 2 of the survey and 17 completed Round 3. In Round 1, Cronbach's α-values were 0.89 and 0.94 for conditions that simplify and increase LP complexity, respectively; both values increased to 0.98 in Rounds 2 and 3. With the exception of 'high CSF (cerebral spinal fluid) pressure', panellists agreed with the inclusion of all conditions in the simplest (epitome) training scenario. Panellists rated patient movement, spinal anatomy, patient cooperativeness, body habitus, and the presence or absence of an experienced assistant as having the greatest impact on the complexity of LP.This study demonstrated the feasibility of using expert consensus to establish conditions impacting the complexity of procedural skills, and the benefits of incorporating the Delphi method into the SCM. These data can be used to develop and sequence simulation scenarios in a progressively challenging manner. If the theorised learning gains associated with ET are realised, the methods described in this study may be applied to the design of simulation training for other procedural and non-procedural skills, thereby advancing the agenda of theoretically based instruction design in health care simulation.

Context Learning complex procedural skills, such as bronchoscopy, through simulation training, imposes a high cognitive load on novices. Example-based learning has been shown to be an effective way to reduce cognitive load and enhance learning outcomes. Prior research has shown that modelling examples, in which a human model demonstrates the skill to a learner, were effective for learning basic surgical skills. However, principles derived from simple skills training do not necessarily generalise to more complex skills. Therefore, the present study examined the effectiveness of integrating modelling examples into simulation training for a more complex procedural skill – bronchoscopy. Moreover, this study extended previous simulation studies by using a physical demonstration rather than video-based modelling examples. Methods Forty-eight medical students were randomised into a modelling group and a control group. They all practised on eight bronchoscopy simulation cases individually, followed by standardised feedback from an instructor. Additionally, the modelling group watched three modelling examples of the simulated bronchoscopy, performed by the instructor. These modelling examples were interspersed between cases. Assessments were carried out at pre-, post- and 3-week retention tests with simulator-measured performance metrics. The primary outcome measure was the percentage of segments entered/minute. Other measures were wall collisions, red-out, the percentage of segments entered and the time to completion. Group differences were examined using repeated measures analysis of variance (anova). Results A clear learning curve was observed for both groups, but as hypothesised, the modelling group outperformed the control group on all parameters except the percentage of segments entered on the post-test and retained this superiority at the retention test. For the primary outcome measure, the percentage of segments entered/minute, the modelling group achieved a 46% higher score at the post-test and a 43% higher score at the retention test. Conclusions The present study shows, that integrating modelling examples into the curriculum of bronchoscopy simulation training optimises the role of the instructor and enhances novices' learning outcomes, presumably by optimising cognitive load during training.

Context A substantial proportion of medical students enter their intern year without any basic skills experience. Lack of experience is a significant source of stress for many junior doctors. Objectives To evaluate the effect of a basic procedural skills tutorial for Year 3 medical students on their competence in relevant skills at Year 5. Subjects The control group consisted of 93 medical students who completed Year 3 in 1996. The intervention group consisted of 92 medical students who completed Year 3 in 1997. The intervention group received a practical skills tutorial in Year 3; the control group did not. Both groups were assessed on their practical skills competence during Year 5. Methods A 3-hour practical tutorial on injection and suturing techniques was delivered to the intervention group. The effectiveness of the intervention was assessed by self-reported experience of giving injections, inserting sutures and sustaining needlestick injuries, and by teacher-rated competency in four basic procedural skills. Results Students who received the Year 3 tutorial were significantly more likely to record a satisfactory assessment for their performance in all four basic skills compared with students who did not receive the tutorial. They were less likely than controls to refuse invitations to give injections, but not invitations to insert a suture, during Years 4 and 5. Conclusions A single session of formalised teaching in procedural skills in the early stages of a medical degree can have long-term effectiveness in basic skills competence and may increase students' confidence to practise their skills.

Summary. An education programme in which preclinical medical students are introduced to common procedural skills is described. This programme is presented by a multidisciplinary health care team using short lectures, demonstrations, mannequin practice, and, in selected instances, practice on class-mate volunteers. The programme was evaluated by the students immediately following the presentation and for one class during their clinical activities one year later. The students' support for this programme was generally enthusiastic and remained undiminished upon reflection 12 months later.

OBJECTIVE To develop generic criteria for the global assessment of clinical procedural competence and to quantify the extent to which existing checklists allow for holistic assessment of procedural competencies. METHODS We carried out a systematic review and qualitative analysis of published clinical procedural skills assessment checklists and enumerated the contents of each. Source materials included all English-language papers published from 1990 to June 2005, identified from 18 databases, which described or referred to an assessment document for any clinical procedural skill. A pair of reviewers identified key generic themes and sub-themes through in-depth analysis of a subset of 20 checklists with iterative agreement and independent retesting of a coding framework. The resulting framework was independently applied to all checklists by pairs of reviewers checking for the emergence of new themes and sub-themes. Main outcome measures were identification of generic clinical procedural skills and the frequency of occurrence of each in the identified checklists. RESULTS We identified 7 themes ('Procedural competence', represented in 85 [97%] checklists; 'Preparation', 65 [74%]; 'Safety', 45 [51%]; 'Communication and working with the patient', 32 [36%]; 'Infection control', 28 [32%]; 'Post-procedural care', 24 [27%]; 'Team working', 13 [15%]) and 37 sub-themes, which encapsulated all identified checklists. Of the sub-themes, 2 were identified after the initial coding framework had been finalised. CONCLUSIONS It is possible to develop generic criteria for the global assessment of clinical procedural skills. A third and a half of checklists, respectively, do not enable explicit assessment of the key competencies 'Infection control' and 'Safety'. Their assessment may be inconsistent in assessments which use such checklists.

BACKGROUND The assessment of clinical procedural skills has traditionally focused on technical elements alone. However, in real practice, clinicians are expected to be able to integrate technical with communication and other professional skills. We describe an integrated procedural performance instrument (IPPI), where clinicians are assessed on 12 clinical procedures in a simulated clinical setting which combines simulated patients (SPs) with inanimate models or items of medical equipment. Candidates are observed remotely by assessors whose data are fed back to the clinician within 24 hours of the assessment. This paper describes the feasibility of IPPI. RESULTS A full-scale IPPI and 2 pilot studies with trainee and qualified health care professionals has yielded an extensive data set including 585 scenario evaluations from candidates, 60 from clinical assessors and 31 from simulated patients (SPs). Interview and questionnaire data showed that for the majority of candidates IPPI provided a powerful and valuable learning experience. Realism was rated highly. Remote and real-time assessment worked effectively, although for some procedures limited camera resolution affected observation of fine details. DISCUSSION IPPI offers an innovative approach to assessing clinical procedural skills. Although resource-intensive, it has the potential to provide insight into individual's performance over a spectrum of clinical scenarios and at no risk to the safety of patients. Additional benefits of IPPI include assessment in real time from experts (allowing remote rating by external examiners) as well as provision of feedback from simulated patients.

Objectives: To describe our experience of teaching clinical skills to first-year medical students in a new problem-based curriculum. Design: Prospective evaluation of clinical skills acquisition using objective measures. Setting: Students were taught in a purpose-designed clinical skills resource centre in weekly structured sessions. Subjects: All 210 first year medical undergraduates in the first year of a new problem-based and clinically oriented course. Results: Student performance in structured objective examinations improved over 1 year. In all but one of nine matched stations, involving history, examination and procedural skills, improvements were significant. Ninety-three per cent thought that the appropriateness of the skills training course to other course elements was 'good' or 'very good'. Conclusions: First-year medical students can learn a wide range of clinical skills. Integrated teaching of clinical skills improves satisfaction with undergraduate studies.

AIM: To identify the core content for the new undergraduate medical curriculum in Manchester. METHOD: The initial step was to produce a list of 'index clinical situations' (ICSs), for which a newly graduated doctor must have a required level of competence. Using repeated consultation with consultants and general practitioners involved in medical education in the North-West of England, a list of 215 ICSs was agreed. Specialists and generalists were then asked to identify the components of the knowledge base and the performance (skills) base for each ICS. The knowledge base was divided into technical (biomedical facts/concepts) and contextual (effect/management of disease within the individual, family and society) domains. The performance base was divided into intellectual (problem solving and decision making) and interpersonal (history, examination, communication and procedural skills) domains. RESULTS: Forty specialties were consulted and 11,021 items (defined as a piece of knowledge, a concept or a skill) were identified. There was considerable overlap in the items listed, such that when the returns for each ICS were amalgamated, the 215 ICSs contained 6434 items with a mean of 34 +/- 14.2 per situation (range 6-85). UTILISATION: We have used the defined ICSs in the design of the trigger material used in the weekly problem-based learning sessions. Over 4 years almost all (207/215, 96%) of the ICS are covered, with many being revisited at several points in the curriculum.