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Introduction The informal curriculum—an essential complement to the formal curriculum—is delivered to medical trainees through learning outside the classroom. We sought to explore nurse-mediated aspects of trainee education in the informal curriculum in obstetrics and gynecology (OBGYN), as well as nursing perceptions of their role in medical trainee education. Methods Naturalistic, non-participant observations (40 h) were performed on a tertiary care birthing unit (BU) to document teaching and learning interactions. Insights gleaned from observations informed subsequent semi-structured interviews with BU nurses (n = 10) and focus group discussions with third-year medical students who had completed an OBGYN rotation (n = 10). Thematic analysis was conducted across data sets. Results Conceptions of nurse-mediated education differed considerably between nurses and trainees. Nurses were widely acknowledged as gatekeepers and patient advocates by both groups, although this role was sometimes perceived by trainees as impacting on learning. Interest and engagement were noted as mediators of teaching, with enhanced access to educational opportunities reported by trainees who modelled openness and enthusiasm for learning. Nurse-driven education was frequently tailored to the learner’s level, with nurses feeling well positioned to share procedural knowledge or hard skills, soft skills (i.e. bedside manners), and clinical insights gained from bedside practice. Discussion Nurses are instrumental in the education of medical trainees; however, divergence was noted in how this role is enacted in practice. Given the valuable teaching resource BU nurses present, more emphasis should be placed on interprofessional co-learning and the actualization of this role within the informal curriculum.

Hysterectomy is a common gynaecological procedure, and therefore online information is highly valuable to patients. Our objective was to evaluate the quality, readability, and comprehensiveness of online patient information on hysterectomy.The first 25 patient-directed websites on hysterectomy, identified using 5 online search engines (Google, Yahoo, AOL, Bing, Ask.com) as well as clinical professional societies, were assessed using validated tools for quality (DISCERN, JAMA benchmark), readability (Flesch-Kincaid Grade Level [FKGL], Gunning Fog, Simple Measure of Gobbledygook [SMOG], Flesch Reading Ease Score [FRES]), and completeness of information.We identified 50 websites for inclusion. Overall, websites were of good quality (median DISCERN score 53/80 [interquartile range {IQR} 47-61]; median JAMA score 3/4 [IQR 1-4]). Most websites described surgical risks (39, 78%), benefits (45, 90%), and types of hysterectomy (48, 96%). Content readability corresponded to grade 11 using FKGL (median 11.1 [IQR 10.2-13.0]) and SMOG (median 10.9 [IQR 10.2-12.4]), or 15 years education using Gunning Fog (median 14.7 [IQR 13.8-16.4]). Websites were assessed as difficult to read using FRES (median 45.6/100 [IQR 37.9-50.9]). No differences were observed in readability scores when we compared websites from clinical professional societies, government, health care, or academic organizations with other websites (P0.05).Online patient information on hysterectomy is of good quality and comprehensive. However, the content is above the American Medical Association's recommended grade 6 reading level. Website authors should consider readability to make their content more accessible to patients.

Objectives Emergency department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend on effective interactions between the health care team, the patient, and the environment. Resuscitation teams work in dynamic environments and strive to ensure the timely delivery of necessary treatments, equipment, and skill sets when required. However, systemic failures in this environment cannot always be adequately anticipated, which exposes patients to opportunities for harm. Methods As part of a new interprofessional education and quality improvement initiative, this prospective, observational study sought to characterize latent safety threats (LSTs) identified during the delivery of in situ, simulated resuscitations in our ED. In situ simulation (ISS) sessions were delivered on a monthly basis in the EDs at each campus of a large tertiary care academic hospital system, during which a variety of scenarios were run with teams of ED health care professionals. LSTs were identified by simulation facilitators and participants during the case and debriefing and then grouped thematically for analysis. Results During the study period, 22 ISS sessions were delivered, involving 58 cases and reaching 383 ED health care professionals. 196 latent safety threats were identified through these sessions (mean = 3.4 LSTs per case) of which 110 were determined to be "actionable" at a system level. LSTs identified included system/environmental design flaws, equipment problems, failures in department processes, and knowledge/skill gaps. Corrective mechanisms were initiated in 85% of actionable cases. Conclusions Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care. ISS, beyond its role as a training tool for developing intrinsic and crisis resource management skills, can be effectively used to identify system issues in the ED that could expose critically ill patients to harm.

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

Objectives Disaster-preparedness and response are a commonly overlooked aspect of hospital policy and can frequently be outdated and undertested. Simulation-based education has become a core education modality within Canadian medical training programs. We hypothesized that integrating in situ simulation (ISS) into a hospital-wide, mass-casualty response exercise would enhance realism and our ability to identify latent safety threats (LSTs). Methods Using ISS we created a simulated mass shooting scenario with 20 patients, played by actors in full moulage, presenting to a large tertiary care hospital over a 50-minute period. Results Integrating ISS into our exercise created a realistic experience for the participants involved and improved participant education, while imparting enough systemic stress to expose LSTs associated within patient care and hospital policy. Conclusion Overall, ISS was successfully used and enhanced a large-scale test of our hospital's mass-casualty response plan.

Health care team training and simulation-based education are important for preparing obstetrical services to meet the challenges of the COVID-19 pandemic. Priorities for training are identified in two key areas. First, the impact of infection prevention and control protocols on processes of care (e.g., appropriate and correct use of personal protective equipment, patient transport, preparation for emergency cesarean delivery with the potential for emergency intubation, management of simultaneous obstetric emergencies, delivery in alternate locations in the hospital, potential for increased decision-to-delivery intervals, and communication with patients). And second, the effects of COVID-19 pathophysiology on obstetrical patients (e.g., testing and diagnosis, best use of modified obstetric early warning systems, approach to maternal respiratory compromise, collaboration with critical care teams, and potential need for cardiopulmonary resuscitation). However, such training is more challenging during the COVID-19 pandemic because of the requirements for social distancing. This article outlines strategies (spatial, temporal, video-recording, video-conferencing, and virtual) to effectively engage in health care team training and simulation-based education while maintaining social distancing during the COVID-19 pandemic.

Patient outcome during an obstetrical emergency depends on prompt coordination of an interprofessional team. The cognitive aids with roles defined (CARD) is a cognitive aid that addresses the issue of teamwork in crisis management. This study evaluated the clinical impact of implementing the CARD cognitive aid during emergency Cesarean deliveries.We conducted a prospective before-and-after cohort trial at the maternity units of two Canadian academic hospital campuses. Both sites received didactic online training regarding teamwork during crises, which involved training on using CARD for the "CARD" campus (intervention) and no mention of CARD at the "no CARD" campus (control). The primary outcome was the total time to delivery after the call for an emergency Cesarean delivery. Secondary outcomes included specific intervals of time within the time to delivery and clinical outcomes for both the babies and mothers.We analyzed data from 267 eligible emergency Cesarean deliveries that occurred between January 11 2014 and December 31 2017. The use of CARD did not significantly change the median [interquartile range] time to delivery of the baby during an emergency Cesarean delivery from the pre-intervention to the post-intervention time period (17 [12-28] vs 15 [13-20], respectively; median difference, 2; 95% confidence interval, -1 to 5; P = 0.36). The clinical outcomes for the baby or the mother and other secondary outcomes also did not change.The CARD cognitive aid did not significantly improve time-based or clinical maternal and neonatal outcomes of emergency Cesarean delivery at our academic maternity unit.RéSUMé: OBJECTIF: Les devenirs des patientes pendant les urgences obstétricales dépendent de la coordination rapide d’une équipe interprofessionnelle. Le système CARD (Cognitive Aids with Roles Defined) est un outil de soutien cognitif qui est centré sur le travail d’équipe dans la gestion de crise. Cette étude a évalué l’impact clinique de la mise en œuvre d’un système CARD pendant les accouchements par césarienne d’urgence. MéTHODE: Nous avons réalisé une étude de cohorte prospective avant / après dans les services de maternité de deux campus hospitaliers universitaires canadiens. Les deux sites ont eu accès à une formation didactique en ligne portant sur le travail d’équipe pendant les crises; dans le campus « CARD » (groupe intervention), une formation sur l’utilisation du système CARD a été incluse, alors qu’aucune mention du système n’a été faite dans le campus « sans CARD » (groupe témoin). Le critère d’évaluation principal était le délai total jusqu’à l’accouchement après l’appel pour un accouchement par césarienne d’urgence. Les critères secondaires comprenaient les intervalles spécifiques de temps jusqu’à l’accouchement et les pronostics cliniques des bébés et de leurs mères. RéSULTATS: Nous avons analysé les données de 267 accouchements par césarienne d’urgence éligibles survenus entre le 11 janvier 2014 et le 31 décembre 2017. L’utilisation du système CARD n’a pas modifié de manière significative le délai médian [écart interquartile] jusqu’à l’accouchement du bébé pendant un accouchement par césarienne d’urgence tel que mesuré entre le moment pré-intervention et le moment post-intervention (17 [12–28] vs 15 [13–20], respectivement; différence médiane, 2; intervalle de confiance 95 %, −1 à 5; P = 0,36). Les pronostics cliniques des bébés et des mères et les autres critères d’évaluation secondaires n’ont pas non plus été modifiés. CONCLUSION: Le système CARD n’a pas amélioré de façon significative les pronostics maternels et néonatals fondés sur le temps ou la clinique en cas d’accouchement par césarienne d’urgence dans notre service de maternité universitaire.

Background Best practices in simulation-based education indicate that sessions should be facilitated by a trained simulation instructor. A large academic Canadian hospital required instructors to facilitate simulation-based education in a corporate nursing orientation program. Method The Plan-Do-Study-Act framework was used to develop a simulation facilitation curriculum using mixed methods to evaluate the program. Results The mean scores on the Observational Structured Assessment of Debriefing tool were greater than the target of three out of five. Themes identified from the qualitative analysis focused on a safe learning environment and use of a framework for debriefing. Conclusion A simulation faculty development curriculum for nurse educators with support from peers improved the quality of debriefing in a corporate nursing orientation program.

Objectives To assess the current state of gynecology education in Canadian OBGYN residency programs with regards to: (1) transition to CBD, (2) teaching methods and infrastructure, (3) learner evaluation, (4) use of simulation, and (5) interest in a national educational database. Methods All OBGYN program directors in Canada were invited to participate in a 30-minute telephone interview. These took place from January to September 2020, and consisted of 20 standardized questions, focused on surgical education within their residency program. Results Of 16 program directors, 12 participated. The majority have completed curriculum mapping for CBD. CBD implementation has not led to major structural changes to existing 5-year curricula. Barriers to implementation mostly pertain to faculty engagement, resident uptake of frequent evaluations, and convenience of electronic platforms. In all programs, formal teaching is structured around academic half-days, which are largely not individualized to level of training. Simulation is utilized by all programs, though simulation modalities and frequency of sessions vary. Program director satisfaction with the current amount of simulation varied widely from 2/5 to 5/5, with most common barriers being cost, time and human resources. Interest in a national database of educational resources averaged 4.8/5. Conclusions CBD implementation has led to major changes in systems of assessment. However, despite its call for curricular innovation, CBD has not, as yet, resulted in substantial changes to curricula and teaching methods in postgraduate gynecology education. Participating program directors unanimously support the development of a national bank of educational resources to ease knowledge sharing and reduce burden on individual programs.

Objectives Hysterectomy is a common gynecological procedure, thus available online information is highly valuable to patients. The objective was to evaluate the quality, comprehensiveness, and readability of online patient information on hysterectomies. Methods The first 25 consecutive patient-directed websites on hysterectomy identified using five online search engines (Google, Yahoo, AOL, Bing, Ask.com), and clinical professional society and Healthwise websites, were assessed using validated tools for quality (DISCERN, JAMA benchmark), completeness of information, and readability (FKLG, Gunning FOG, SMOG, FRES). Results We identified 55 website for inclusion. Overall, websites were of good quality (DISCERN median 54, interquartile range [47-61]; JAMA 3[1-4]). Most websites described surgical risks (n=44, 80%), benefits (n=46, 84%), and alternatives (n=19, 35%). Content readability corresponded to Grade 11 using FKGL (11.0[9.9-12.9]) and SMOG (10.8[9.7-12.0]), or 14 years education using Gunning FOG (14.4[13.1-16.1]). Websites were assessed to be difficult to read using FRES (46.2[39.9-51.5]). No differences were observed in readability scores when we compared websites from clinical professional societies, government or healthcare or academic organizations, versus others (p>0.05). Websites with Healthwise designation were assessed to be have more appropriate readability scores (Grade 9 vs. 11, FKGL and SMOG; Gr 12 vs. 15 years education, Gunning FOG, p Conclusions Online patient information on hysterectomy is of good quality and contains the majority of required information. However, the content is above the American Medical Association's recommended grade six reading level. Website authors should consider readability to make their content more accessible to patients.

Study Objective Hysterectomy is a commonly performed procedure. Accessible online patient information is highly important due to associated risks, implications of the procedure and potential treatment alternatives. The study aims to evaluate quality, comprehensiveness and readability of commonly accessed online patient information on hysterectomies. Design We included websites whose purpose was to provide hysterectomy information for patients. The first 25 webpages on 5 search engines were assessed by two reviewers. Quality of websites was assessed by validated tools for online material (DISCERN and JAMA benchmark). We assessed whether the websites included information on alternatives (including minimally invasive approaches), risks, and benefits. Lastly, readability scores were calculated using standardized tools to assess the grade level or years of education needed to comprehend the material (FKLG, Gunning FOG, SMOG, FRES). Setting N/A Patients or Participants Women seeking online information on hysterectomy to inform their treatment choices. Interventions Hysterectomy (On-line patient information). Measurements and Main Results Forty-seven websites were included according to our selection strategy. On average, websites were of good quality (53.2 ± 10.7 of 80, DISCERN criteria; 2.8 ± 1.2 of 4, JAMA criteria). The majority of websites described alternatives to hysterectomy (33/47, 70.2%) including minimally invasive options (21/47, 44.7%), and also described surgical risks (36/47, 76.6%) and benefits (46/47, 97.9%). However, website article readability corresponded to a grade 12 reading level (FKGL= 11.9 ± 2.3) or reading levels of 11 or 15 years of education (SMOG= 11.1 ± 1.7, Gunning FOG= 14.9 ± 2.4) suggesting these websites are difficult to read for the general population (40.7 ± 12.0 FRES). Conclusion Online patient information on hysterectomy is overall of good quality and contains the majority of the required information. However, the content is more difficult to read than the American Medical Association's recommendation for a grade six level. Website content creators should consider readability to make the content more accessible to patients.

This article was migrated. The article was marked as recommended. Preparations for the COVID-19 pandemic required healthcare teams to practice known skills, such as intubation, with renewed consideration for safety, as well as develop new Standard Operating Procedures (SOPs) for health care delivery. In these conditions, translational simulation based-education (SBE) is a well-known tool that supports health care teams to improve the system using design thinking methods such as walkthroughs and team-based simulation. However, the pandemic has introduced two stressors on translational SBE simultaneously. Firstly, the need for rapid upskilling of front-line staff and rapid change to SOPs. Secondly, the need for social or physical distancing at work, such that it quickly became inappropriate for large groups of individuals to practice in-situ SBE and debrief together in close proximity. An educational approach that brings the best of translational SBE while minimizing contact and maximizing experiential learning is needed.Digital learning has been rapidly adopted by much of medical education during the pandemic. Focusing on a strong alignment between learning goals with intended clinical performance change outcomes we sought to leverage a digital education format that allowed for low barriers to adoption, yet supported the experiential, dynamic reality of translational SBE. In the absence of the ability to quickly train large numbers of people due to the need for social distancing, an immersive experience that can only be provided by virtual reality (VR) videos was the next best thing. VR, using 360-degree video, supported the creation of instructional videos from SBE events in the hospital which allow the learner to immerse and explore multiple points within the scenario. We describe how the very act of recording a video assisted in the rapid development of SOPs through translational simulation. We then describe the use of VR to stay true to the spirit of simulation for experiential learning and nearly hands-on training.

The science, conversation, and application of the terms fidelity, authenticity, and realism have evolved since the first edition of this textbook. This chapter will cover the newer lexicon behind these terms. It will provide key examples of the three types of realism, a short primer on authenticity, and an approach to understand how fidelity might be tailored through the concepts of realism and authenticity.

Applying for accreditation for your simulation center by a recognized institution is the ultimate program evaluation. Different specialty and simulation societies offer accreditation and require similar standards to be met. The most common standards are in the spheres of mission statement and governance, infrastructure, teaching and education, scholarship and research, and patient safety and healthcare system integration. Accrediting bodies try to add value to being recognized, and the benefits of each may be a driver for a center to choose one society over another. The process of applying for accreditation involves the completion of a questionnaire and assembly of the relevant documentation, followed by a site visit of qualified centers. Once accredited, the cycle of program evaluation continues; maintenance of accreditation requires continuous efforts to improve.

Postpartum hemorrhage (PPH) continues to be the leading cause of maternal mortality worldwide, occurring in about five percent of deliveries. The most common cause of PPH is uterine atony, and a number of medical and surgical management techniques are available to prevent morbidity and mortality associated with PPH in this context. Uterine compression sutures provide a more conservative surgical approach, allowing for the preservation of fertility. Obstetrics and Gynecology (Ob/Gyn) residents need to be adequately trained to competently perform this technique. The goal of this surgical skills training is for Ob/Gyn residents to be able to surgically manage PPH using uterine compression sutures. A uterine towel model for surgical skills training in the use of uterine compression sutures was developed. The simulator is explained and compared to similar models. Possible ways to implement and use the simulator in a simulation curriculum are also described. A performance-based assessment rubric was also developed in order to formatively aid with the learning and understanding of the technique. Much work is still needed to test the validity and reliability of this tool, but based on current literature, results may be promising.

As an educational methodology, simulation has been used by nursing education at the academic level for numerous years and has started to gain traction in the onboarding education and professional development of practicing nurses. Simulation allows the learner to apply knowledge and skills in a safe environment where mistakes and learning can happen without an impact on patient safety. The development of a simulation scenario to demonstrate the benefits of simulation education methodologies to a large group of nurse educators was requested by nursing education leadership at The Ottawa Hospital (TOH). Since the demonstration of this scenario in the fall of 2016, there has been significant uptake and adaptation of this particular scenario within the nursing education departments of TOH. Originally written to be used with a simulated patient (SP), "Alice" has since been adapted to be used with a hi-fidelity manikin within an inpatient surgery department continuing professional development (CPD) program for practicing nurses, orientation for nurses to a level 2 trauma unit and at the corporate level of nursing orientation using an SP. Therefore, this scenario is applicable to nurses practicing in an area of inpatient surgery at varying levels, from novice to expert. It could easily be adapted for use with medicine nursing education programs. The case presented in this technical report is of the simulation scenario used for the inpatient surgery CPD program. Varying adaptations of the case are included in the appendices.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (OB/GYN) and anesthesiology. Consultation with a nurse educator maintained the quality and relevance of objectives for nursing participants. The curriculum was prepared to train OB/GYN and anesthesiology residents and labor and delivery nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets in a four-year cycle to allow OB/GYN and anesthesiology residents exposure to all scenarios during a five-year residency, beginning in their second year. Prospective evaluative data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for “Was an effective use of my educational time” and “Will influence/enhance my future practice.” In this scenario, participants must evaluate and treat a postpartum preeclamptic woman who is being treated with magnesium sulfate for the purpose of seizure prophylaxis. The patient experiences magnesium sulfate toxicity and subsequent respiratory arrest. Any mannequin that can display vital signs can be used for this scenario. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

Evidence-based medicine has become the standard of care in clinical practice. In this study, our objectives were to (1) determine the type of epidemiology and/or biostatistical training being given in Canadian obstetrics and gynaecology post-graduate programs, (2) determine obstetrics and gynaecology residents' level of confidence with critical appraisal, and (3) assess knowledge of fundamental biostatistical and epidemiological principles among Canadian obstetrics and gynaecology trainees.During a national standardized in-training examination, all Canadian obstetrics and gynaecology residents were invited to complete an anonymous cross-sectional survey to determine their levels of confidence with critical appraisal. Fifteen critical appraisal questions were integrated into the standardized examination to assess critical appraisal skills objectively. Primary outcomes were the residents' level of confidence interpreting biostatistical results and applying research findings to clinical practice, their desire for more biostatistics/epidemiological training in residency, and their performance on knowledge questions.A total of 301 of 355 residents completed the survey (response rate=84.8%). Most (76.7%) had little/no confidence interpreting research statistics. Confidence was significantly higher in those with increased seniority (OR=1.93), in those who had taken a previous epidemiology/statistics course (OR=2.65), and in those who had prior publications (OR=1.82). Many (68%) had little/no confidence applying research findings to clinical practice. Confidence increased significantly with increasing training year (P0.001) and with formal epidemiology training during residency (OR=2.01). The mean score of the 355 residents on the knowledge assessment questions was 69.8%. Increasing seniority was associated with improved overall test performance (P=0.02). Poorer performance topics included analytical study method (9.9%), study design (36.9%), and sample size (42.0%). Most (84.4%) wanted more epidemiology teaching.Canadian obstetrics and gynaecology residents may have the biostatistical and epidemiological knowledge to interpret results published in the literature, but lack confidence applying these skills in clinical settings. Most residents want additional training in these areas, and residency programs should include training in formal curriculums to improve their confidence and prepare them for a lifelong practice of evidence-based medicine.

Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications.Retrospective, multicenter, cohort study (Canadian Task Force classification II-2).Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites.Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012.ACS-NSQIP database.Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p .001), urinary tract infection (5.27% vs 2.64%, p .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality.Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (OB/GYN) and anesthesiology. Consultation from a nurse educator maintained quality and relevance of objectives for nursing participants. The curriculum was prepared to train OB/GYN and anesthesiology residents and nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations, and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets on a four-year cycle to allow OB/GYN and anesthesiology residents exposure to all scenarios during a five-year residency beginning in their second year. Prospective evaluative data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 with comments, such as "Was an effective use of my educational time" and "Will influence/enhance my future practice". In this scenario, participants must recognize and manage fetal distress resulting from umbilical cord prolapse in a labouring patient and respond with urgent operative delivery. This scenario requires adult and fetal mannequins with presenting umbilical cord for pelvic examination as well as equipment for fetal monitoring, general anesthetic, and emergency cesarean section. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (ob/gyn) and anesthesiology. Consultation with a nurse educator maintained quality and relevance of objectives for nursing participants. The curriculum was prepared to train ob/gyn and anesthesiology residents and nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets on a four-year cycle to allow ob/gyn and anesthesiology residents exposure to all scenarios during a five-year residency beginning in their second year. Prospective evaluation data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for “Was an effective use of my educational time” and “Will influence/enhance my future practice”. In this scenario, participants must recognize and manage a parturient with spinal cord injury in active labour who develops autonomic dysreflexia. The fetal heart tracing becomes abnormal and the team must respond with urgent delivery. This scenario requires a mannequin for a pelvic exam and a pregnant abdomen. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

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

Simulation-based education has gained popularity, yet many faculty members feel inadequately prepared to teach using this technique. Fellowship training in medical education exists, but there is little information regarding simulation or formal educational programs therein. In our institution, simulation fellowships were offered by individual clinical departments. We recognized the need for a formal curriculum in educational theory. Kern’s approach to curriculum development was used to develop, implement, and evaluate the Foundational Elements of Applied Simulation Theory (FEAST) curriculum. Needs assessments resulted in a 26-topic curriculum; each biweekly session built upon the previous. Components essential to success included setting goals and objectives for each interactive session and having dedicated faculty, collaborative leadership and administrative support for the curriculum. Evaluation data was collated and analyzed annually via anonymous feedback surveys, focus groups, and retrospective pre-post self-assessment questionnaires. Data collected from 32 fellows over five years of implementation showed that the curriculum improved knowledge, challenged thinking, and was excellent preparation for a career in simulation-based medical education. Themes arising from focus groups demonstrated that participants valued faculty expertise and the structure, practicality, and content of the curriculum. We present a longitudinal simulation educator curriculum that adheres to a well-described framework of curriculum development. Program evaluation shows that FEAST has increased participant knowledge in key areas relevant to simulation-based education and that the curriculum has been successful in meeting the needs of novice simulation educators. Insights and practice points are offered for educators wishing to implement a similar curriculum in their institution.

Objective As obstetrics and gynaecology (Ob/Gyn) residency training programs move towards a competence-based approach to training and assessment, the development of a national standardized simulation curriculum is essential. The primary goal of this study was to define the fundamental content for the Canadian Obstetrics and Gynecology Simulation curriculum. Methods A modified Delphi technique was used to achieve consensus in three rounds by surveying residency program directors or their local simulation educator delegates in 16 accredited Canadian Ob/Gyn residency programs. A consensus rate of 80% was agreed upon. Survey results were collected over 11 months in 2016. Results Response rates for the Delphi were 50% for the first round, 81% for the second round, and 94% for the third round. The first survey resulted in 84 suggested topics. These were organized into four categories: obstetrics high acuity low frequency events, obstetrics common events, gynaecology high acuity low frequency events, and gynaecology common events. Using the modified Delphi method, consensus was reached on 6 scenarios. Conclusion This study identified the content for a national simulation-based curriculum for Ob/Gyn residency training programs and is the first step in the development of this curriculum.

Introduction: The hidden curriculum is a set of ethical, moral, and value-based teachings communicated to doctors-in-training, providing a basis for their future interactions with patients, peers, and colleagues. The aim of our study is to introduce the concept of the hidden curriculum to a cohort of third-year medical students and to subsequently evaluate their understanding. In particular, we sought to measure and benchmark the degree of hidden curriculum recognition within a Canadian medical education context. With the help of student feedback, we elicited ideas for future directions. Methods: One hundred and fifty-four third-year medical students completing their obstetrics and gynaecology core clinical rotation attended a workshop on the hidden curriculum. Students completed two sets of evaluations; a voluntary anonymous pre- and post-workshop questionnaire evaluating their knowledge and opinions regarding the hidden curriculum, and a mandatory workshop evaluation. Answers to pre- and post-workshop questionnaires were compared using Mann-Whitney U test, and thematic analysis was used to code the students’ comments to identify common themes. Results: A standardized workshop on the hidden curriculum significantly improved students’ understanding and highlighted the importance of the hidden curriculum. Voluntary student comments (N = 108) were categorized according to five themes: 1) Students who were not sensitized to the hidden curriculum (8; 7.4%); 2) students who were sensitized but unaware of the hidden curriculum (12; 11.1%); 3) students who were sensitized and aware of the hidden curriculum (34; 31.5%); 4) comments on teaching methodologies/environment (43; 39.8%); and 5) suggestions for enhancement (11; 10.2%). Conclusions: A simple, cost-effective intervention, such as a workshop, can effectively assess and address the hidden curriculum. Many students are highly sensitized to and are aware of the positive and negative effects of role modeling on their development. The students are calling for similar interventions to be directed at the postgraduate and faculty level.

Objective To describe the effectiveness of an electronic consultation (eConsult) service by examining the number of traditional referrals that were avoided as a result of the service, to characterize the type and content of the clinical questions being asked, and to describe the time required for the specialist to complete each eConsult. Methods This is a retrospective electronic chart review study. All eConsults directed to obstetrics and gynecology from July 2011 to January 2015 were reviewed. Each eConsult was categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults. The amount of time reported by the specialist to answer each eConsult was analyzed. Results A total of 394 of 5,597 eConsults were directed to obstetrics and gynecology (7.0%). In 34.3% of eConsults, primary care providers indicated that a traditional consult was avoided. Pregnancy issues and gynecologic cancer screening issues were the most common queries. Primary care providers highly valued the eConsult and the majority of eConsults were completed within 15 minutes (98.8%). Conclusion Electronic consultations were effective at reducing the number of traditional consults requested over 3.5 years. This initiative has potential to reduce current wait times for traditional consultation in Canada and to make the consultation process more effective. The service was feasible and well-received by primary care providers.

Introduction Disclosing adverse events to patients after a poor outcome is an essential task involving both communication skills and professionalism, but one that is difficult to teach and assess during clinical rotations. Beyond ensuring clinical competency, these skills are essential in minimizing medico-legal risk. An objective structured clinical examination (OSCE) station with a standardized patient allows an opportunity to evaluate these skills. Our objective was to assess residents' communication skills involving the disclosure of a poor outcome to a standardized patient using a standardized patient encounter, and to compare their performance before and after formal teaching on disclosure. Methods Fourteen obstetrics and gynaecology residents (PGY-2 to PGY-5) were evaluated in a two-station OSCE. In the first station, they obtained a history and counselled an obstetrical patient, and in the second station they met with the same patient to discuss an adverse outcome that had occurred. The residents were evaluated using guidelines for the disclosure of adverse events developed by the Canadian Patient Safety Institute and published by the Canadian Medical Protective Association. The residents then participated in a workshop on disclosure and were retested. Results The mean score in the pre-workshop disclosure OSCE was 59.1% (12.4/21, SD 2.7), while the mean score in the postworkshop OSCE was 80.1% (16.9/21, SD 2.1). Using the paired Student t test, the scores differed significantly with P Conclusion Residents' performance in disclosure improves after formal teaching and the OSCE is an effective technique for testing communication skills.

Far too frequently, a colleague or superior may say something inappropriate in the operating room while a patient is anaesthetized. Remaining silent is akin to condoning the behaviour, and often we may even find ourselves getting in on the joke. As medical professionals, we must curb this behaviour, which is disrespectful of our patients, harmful to our trainees, and derogatory towards our colleagues. Our first action must be to accept that this is a real problem; this should be followed by constructive support through education about our current behaviour. Leaders in the OR must speak up, and all staff members in the OR should be made to feel that they can express their concerns without retribution.

Objective The Royal College of Physicians and Surgeons of Canada requires that residents demonstrate competence in health advocacy (HA). We sought to develop and implement a national educational module for obstetrics and gynaecology residents to address the role of HA. This pilot program was centred on cervical cancer prevention, which lends itself to applying the principles of advocacy. Methods An educational module was developed and disseminated to all obstetrics and gynaecology residency programs in Canada. The module describes options for HA involving cervical dysplasia screening, such as an outreach clinic or a forum for public/student education, which were to be implemented during Cervical Cancer Awareness Week. The measures of success were the number of programs implementing the curriculum, number of residents who participated, diversity of projects implemented, individuals (patients or learners) reached by the program, and the overall experience of the trainees. Results Three programs implemented the curriculum in 2011, one in 2012, and seven in 2013. After three years, the module has involved seven of 16 medical schools, over 100 residents, and thousands of women either directly or indirectly. Additionally, attributes of HA experienced by the residents were identified: teamwork, leadership, increased systems knowledge, increased social capital within the community, creativity, innovation, and adaptability. Conclusion We have demonstrated that an educational module can be implemented nationally, helping our residents fulfill their HA requirements. Other specialties could use this module in building HA into their own programs.

Answering telephone calls and pagers is common distraction in the operating room. We sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance. We conducted a randomized crossover study of obstetrics and gynecology residents. After studying a patient sign-out list, subjects performed a virtual salpingectomy. They were randomized to a distraction phase followed by quiet phase or vice versa. In the distraction phase, a pager beeped and subjects were asked questions based on the sign-out list. Accuracy of responses and the number of unsafe responses were recorded. In the quiet phase, trainees performed the task uninterrupted. Measures of surgical performance were successful task completion, time to task completion and operative blood loss. The mean score for correct responses to clinical questions during the distracted phase was 80 % (SD ±14 %). Nineteen residents (63 %) made at least 1 unsafe clinical decision while operating on the simulator (range 0–3). Subjects were more likely to successfully complete the surgical task in the allotted time under the quiet compared to distraction condition (OR 11.3, p = 0.03). There was no difference between the conditions in paired analysis for mean time (seconds) to task completion [426 (SD 133) vs. 440 (SD 186), p = 0.61] and mean operative blood loss (mL) [73.14 (SD 106) vs. 112.70 (SD 358), p = 0.47]. Distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents’ ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.

Performance of transesophageal echocardiography (TEE) requires the psychomotor ability to obtain interpretable echocardiographic images. The purpose of this study was to determine the effectiveness of a simulation-based curriculum in which a TEE simulator is used to teach the psychomotor skills to novice echocardiographers and to compare instructor-guided with self-directed online delivery of the curriculum. After institutional review board approval, subjects inexperienced in TEE completed an online review of TEE material prior to a baseline pre-test of TEE psychomotor skills using the simulator. Subjects were randomized to two groups. The first group received an instructor-guided lesson of TEE psychomotor skills with the simulator. The second group received a self-directed slide presentation of TEE psychomotor skills with the simulator. Both lessons delivered identical information. Following their respective training sessions, all subjects performed a post-test of their TEE psychomotor skills using the simulator. Two assessors rated the TEE performances using a validated scoring system for acquisition of images. Pre-test TEE simulator scores were similar between the two instruction groups (9.0 vs 5.0; P = 0.28). The scores in both groups improved significantly following training, regardless of the method of instruction (P

Context The competent performance of a female pelvic examination requires both technical proficiency and superlative communication skills. However, the ideal medium with which to assess these skills remains to be elucidated. Part-task trainers (PTTs) offer an effective and affordable means of testing technical skills, but may not allow students to demonstrate their communication skills. Hybrids involving standardised patients (SPs) (SP–PTT) offer a more realistic assessment of communication, but students may feel awkward when examining the female genitalia. Objective The objective of this study was to compare the use of PTTs with that of SP–PTT hybrids in the assessment of technical and communication skills in the female pelvic examination. Methods A total of 145 medical students were randomised to one of three conditions during their summative objective structured clinical examination (OSCE) at the completion of clerkship. Students performed the female pelvic examination on: (i) a PTT alone (‘plastic’ condition); (ii) an SP–PTT hybrid with an SP who did not engage in any superfluous conversation (‘perfunctory’ condition), or (iii) an SP–PTT hybrid with an SP who was trained to offer small talk and banter, which was judged to better reflect the typical doctor–patient interaction (‘pleasant’ condition). Results Communication skills did not differ significantly among the three groups (p = 0.354). There was a significant difference among groups in technical skills scores (p = 0.0018). Students in the ‘plastic’ condition performed best, followed by those in the ‘perfunctory’ and ‘pleasant’ conditions, respectively. Conclusions Medical students demonstrate equivalent communication skills whether they work with a PTT or an SP–PTT hybrid, but their technical skills suffer in the presence of an SP. Working with the PTT alone does not appear to disadvantage students in terms of communication skills, but may offer better conditions for performing technical aspects of the procedure. Whether the ‘plastic patient’ is the most meaningful and valid means of predicting overall competence in the clinical setting is still a matter for debate.

Objective The skill of disclosing adverse events is difficult to assess. Assessment of this competency in medical trainees is commonly achieved via the objective structured clinical examination (OSCE) using a standardized patient (SP). We hypothesized that the addition of a simulated clinical adverse event prior to the SP encounter could increase trainees' engagement and empathy, thereby improving performance. The objective of this study was to explore whether experiencing a simulated adverse event prior to an SP encounter alters resident performance on a disclosure OSCE. Methods Sixteen obstetrics and gynaecology residents participated in this mixed methods study. Prior to disclosing the complication in an SP encounter, residents were randomized either to receive a written description of an adverse event, or to experience a mannequin simulation of an adverse event. Mean OSCE scores from blinded examiners were compared in each group. Focus group discussions elicited residents' reflections on the experience of disclosing the adverse event. Results The mean score was 16.6/23 ± 2.9 (range 10 to 20) for the traditional OSCE group and 16.9/23 ± 1.7 (range 15 to 20) for the simulation group. Analysis of the focus group data revealed several themes, such as the type of context the residents desired, the emotional involvement they felt, and their insights about their experience of the simulation scenario or with the SP. Conclusion The assessment of adverse event disclosure was not enhanced by the addition of a simulated experience. Study participants reported that the simulation did not provide the contextual information required to elicit empathy and a sense of being emotionally invested in the adverse event.

The following is a description of a simulation-based workshop for undergraduate medical students during their first week of clerkship in Obstetrics. This workshop was developed to complement the didactic lectures that medical students receive as part of their clerkship and addresses the basics of intrapartum management so that students can feel more like part of the team during their first days in the case room. There are several reasons why medical students may have limited exposure to aspects of obstetrics during their clerkship. The short duration of the rotation, the reduced availability of patients willing to have medical students observe and perform obstetrical techniques, and the potential for unpredictable, serious complications to occur in seconds are all conditions that conspire to create reduced learning opportunities for clerks. Unfortunately, it is the very same practical opportunities that medical students are excluded from that serve to increase their understanding and interest in the speciality. Given the successful implementation simulation education in residency programs, its use in undergraduate medical education may serve as a practical solution to the marginalization of medical students during their obstetrics rotation. The current curriculum was designed for a simulation-based workshop during the first week of the obstetrics clerkship to instruct students in the diagnosis of labour and gain an appreciation for the decisions that are made as part of intra-partum management. Prior to the development of this curriculum, formal teaching for clerkship students in obstetrics and gynaecology at our institution consisted solely of didactic lectures. The objective of this simulation-based innovation was to alleviate the students' anxiety at the beginning of their rotation through providing opportunities to practice clinical skills necessary for success during clerkship. Furthermore, it was thought that engaging the students early on in their clinical training could help to foster an interest in pursuing postgraduate training in obstetrics and gynecology. This workshop was developed in accordance with the educational objectives described in the US-based Association of Professors of Gynecology and Obstetrics (APGO). This simulation follows a single obstetrical patient whose clinical course is followed by the students from presentation to the obstetrical assessment unit until spontaneous vaginal delivery and immediate postpartum care. Through use of a high-fidelity mannequin, this simulation provides students the opportunity to examine the patient throughout the course of her labour to assess dilation and ultimately perform a vaginal delivery. The workshop also incorporates elements of interactive teaching and round table discussion that encourages student participation. You will find a full curriculum document which can be used as an instructors manual, as well as a pre- and post-test which can be used to assess learning during the workshop, and a hand-out for students summarizing the objectives of the session. This workshop has been in use at our institution since the 2008–2009 and has been incredibly well-received by students, as evidenced by anonymous written evaluations. Their confidence and knowledge-base during their first days on service in labour & delivery are noticeably improved, and we documented successful learning on a pre- and post-test comparison, as published in “Medical Education” in 2010.