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Simulation-based learning: Is it time for a paradigm shift in training postgraduates for crisis resource management? prospective interventional study

1 Department of Internal Medicine, St. John's Medical College Hospital; Department of Medical Education, St. John's Medical College Hospital, Bengaluru, Karnataka, India
2 Department of Medical Education, St. John's Medical College Hospital; Department of Anatomy, St. John's Medical College Hospital, Bengaluru, Karnataka, India
3 Department of Medical Education, St. John's Medical College Hospital; Department of Ophthalmology, St. John's Medical College Hospital, Bengaluru, Karnataka, India

Date of Submission16-Sep-2021
Date of Decision25-Nov-2021
Date of Acceptance04-Jan-2022

Correspondence Address:
Thenmozhi Nagarajan,
Department of General Medicine, St. John's Medical College Hospital, Sarjapur Road, Bengaluru - 560 034, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_751_21


Background: Crisis resource management (CRM) skills are nontechnical skills that are often neglected during the training of residents in the management of clinical emergencies. This study was conducted to assess the utility of high-fidelity simulation to enhance the learning of CRM among internal medicine postgraduates (PGs). Materials and Methods: After obtaining IEC approval, a total of ten (five 1st year and five 3rd year) internal medicine PG students were included by convenience sampling. Each student participated in four simulated emergencies in the simulation laboratory of a tertiary care hospital, one before and three after CRM training. They participated in groups of 3–5 at intervals of 15–30 days. All the scenarios were video graphed and viewed by the investigators and each student was assessed in each session for CRM using Ottawa global rating score (GRS). The outcome variable was an overall score (OS-ordinal from 1to 7). After the last session, a questionnaire was administered to assess the perceptions of the participants about the course. After 1 year, the participants self-assessed their CRM in a real emergency using GRS and also identified barriers for the application of CRM in real life. The statistical tests used were paired t-test, Student's t-test, and repeated measures ANOVA. Results: The mean OS at baseline was 3.9 ± 1.5 and after training, it improved to 4.6 ± 1.26 (P = 0.024). In the three posttraining sessions, the OS did not decline and this indicated good retention of CRM (P = 0.056). PGs had a consistently favorable opinion of this course. The self-assessed OS in a real emergency was 5.7 ± 0.82. The barriers to CRM application in real emergencies were lack of practice and lack of team training. Conclusions: High fidelity simulation is an effective and acceptable method of teaching CRM to internal medicine PGs and should be incorporated into the PG curriculum.

Keywords: Crisis resource management, high fidelity simulation, simulation in PG training

How to cite this URL:
Umesh S, Nagarajan T, Anantharaman LT, Joseph M. Simulation-based learning: Is it time for a paradigm shift in training postgraduates for crisis resource management? prospective interventional study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 20]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=339949

  Introduction Top

Simulations have been used for training various high-performance teams, especially those that require the processing of multiple inputs and quick responses. Examples of these include the military, maritime, and aeronautical fields.[1] Similarly, medical teams facing critical clinical events require rapid assessments and decisions to ensure patient safety. Effective management of these events often requires concerted multiprofessional and multidisciplinary teamwork.

Patient safety is dependent not only on technical skills but also on many nontechnical skills of the resuscitating teams. Crisis resource management (CRM) comprises a set of nontechnical skills that include leadership skills, problem-solving skills (PS), communication skills (CS), resource utilization skills (RUS), and situational awareness skills (SAS).[2] Each of these has an impact on the outcome of an emergency. Anesthesiologists worldwide were the first to recognize the importance of CRM and have consistently used it in their curriculum.[3],[4],[5] Pediatrics and emergency physicians have begun to test the utility of training CRM and are finding it to be effective and acceptable to students.[6],[7],[8] Simulation-based learning is gaining popularity in India and has been found acceptable to anesthesia postgraduates (PGs).[9]

PGs in internal medicine often manage high acuity and dynamic medical emergencies in the hospital. Despite this, simulations are not part of the internal medicine curriculum in India yet. Some of the concepts of CRM are taught to PGs in the mandatory advanced cardiac life support course, conducted at induction into their course. They also learn some concepts while working with their seniors as apprentices do. Therefore, these skills have remained a part of the hidden curriculum and are not explicitly taught or assessed. The roles of an Indian Medical Graduate as defined by competency-based medical education (CBME) include being an effective team leader, lifelong learner, clinician, communicator, and professional.[10] These roles have to be reinforced for PGs as well. Both simulation and CRM lend themselves to train students for all these roles. It is therefore imperative to teach and evaluate CRM performed by PGs using simulations.

This study was conducted to assess the utility of high-fidelity simulation to enhance the learning of CRM in internal medicine PGs. Their perceptions regarding experiential learning with high fidelity simulation were also explored.

  Materials and Methods Top

We conducted a prospective interventional, before and after study in the simulation laboratory of a tertiary care teaching hospital after obtaining IEC approval for the study protocol numbered-365/November 2019. A total of ten (five 1st year and five final year) consenting internal medicine PGs with no prior training with simulations were included by convenience sampling. The study was conducted from November 2019 to November 2020.

Each PG participated in a total of four peer-validated scenarios, one before and three after the intervention. The PGs participated in the first simulated medical emergency using a high-fidelity mannequin called Sim Man 3G (Laerdal Medical). The session comprised a briefing of 5 min, a scenario of 10 min, and a structured debriefing of 20 min. The scenario was video graphed. The video graph was then viewed to assess the CRM using Ottawa Global Rating Scale.[11] The scale comprises an ordinal from 1 to 7 based on the worst to the best performance for LS, RUS, CS, PS, SAS, and overall score (OS). This OS was considered to be the outcome variable of scenario-1.

The intervention consisted of training by using an interactive lecture about the principles of CRM and its importance during resuscitations. The PGs viewed their video-graphed performances in the scenario and filled out worksheets that helped them to reflect and plan improvement of CRM in subsequent sessions.

The PGs then participated in three successive sessions at intervals of 15–30 days in groups of 3–5. The clinical events in each of the subsequent sessions were identical for all participants. Each time the leader was changed. All the scenarios were video graphed. All subsequent scenarios were viewed by the investigators and the OS of each PG during each of the three posttraining sessions was recorded.

A survey was conducted at the end of the third posttraining session using a questionnaire previously used in a similar study by Reznek et al. to determine the PG's perception of simulation-based learning for training in CRM.[12] The questionnaire was face validated by senior faculty of the Department of Medical Education.

A second survey was conducted after 1 year of the training. The participants were asked to self-assess their CRM skills in a real emergency that they had encountered. They used the Ottawa Global Rating Scale for self-assessment and entered their responses on a questionnaire administered on Google forms. Furthermore, an open-ended questionnaire was used at the same time to identify the barriers to the effective application of CRM in workplace emergencies. The PGs were asked to enumerate the three most important barriers. The first barrier was given a weightage of 3, the second 2, and the third 1. All responses were entered in a Microsoft Excel sheet (Windows 10). The responses were then collated and scores calculated.

Statistical analysis

Commercially available SPSS version 24 (IBM Corp., Armonk, NY) was used to analyze the data. All scores were represented as mean and standard deviation after ensuring normal distribution of the data. Mean OSs of the pretraining and the first posttraining session were compared using paired t-test. The difference in OS of the baseline and the first posttraining session between the first and final years was analyzed by Student's t-test. The difference between the OS in three posttraining sessions to assess retention was analyzed using repeated-measures ANOVA. P < 0.05 was considered significant.

The questionnaire on perceptions was marked on a Likert scale of 1-5 (1-worst rating, 5 best rating) and then analyzed.

  Results Top

The OS of PGs in the first session was 3.9 ± 1.5. The baseline score of the 1st year PGs was 3 ± 1.5 and the 3rd year PGs was 4.8 ± 0.83. In the first posttraining session, the OS of all the PGs improved significantly to 4.6 ± 1.26 (P = 0.024). The improvement occurred significantly because of better situational awareness and communication in the posttraining session (P 0.017, 0.015) as depicted in [Table 1].
Table 1: Crisis resource management scores of all postgraduate students before and after training

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When the mean OS between these two sessions was compared among the first and final-year PGs as separate groups, there was a significant improvement in the overall performance for 1st-year PGs (P 0.016). The scores improved for the 3rd-year PGs as well, but they did not have a statistical significance (P 0.304). These findings have been represented in [Table 2].
Table 2: Crisis resource management scores among the 1st and 3rd-year postgraduate students before and after training

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The final year PGs had outperformed their juniors in all sessions and all domains of CRM.

Retention of learning was assessed by comparing the changes in OS from the first to third posttraining sessions. Since there was no statistical difference between the OSs from the first to the third posttraining sessions (repeated measures ANOVA P 0.056), it indicates that the initial improvement after training was sustained till the last session. PS and CS improved from the first to second posttraining session but decreased thereafter in the third posttraining session. (P = 0.041, 0.014) indicating a decay in retention in these components of training [Table 3].
Table 3: Crisis resource management scores of all postgraduate students (n=10) in the three posttraining sessions to assess retention

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The survey at the end of the last session to assess perceptions of students toward the course showed favorable results [Table 4]. The scoring was a Likert from 1 to 5 and almost all components scored ≥4.2 except the utility of this course in undergraduate training and whether the simulations prompted realistic responses from the participants.
Table 4: Perceptions of all postgraduate students regarding simulation.based learning as a tool to learn crisis resource management

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One year later, all the PGs had participated in at least one resuscitation in the hospital. The self-assessed scores using Ottawa global rating scale (1-7) showed a mean score of ≥5.5 in all components and the OS [Table 5]. The salient barriers to the effective application of CRM in real clinical events were lack of practice and the lack of team training [Table 6].
Table 5: Self-assessed crisis resource management scores of all postgraduate students in a real emergency

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Table 6: Barriers to the application of crisis resource management in an actual emergency

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  Discussion Top

Our study has found that simulation-based learning is effective in training internal medicine PGs in CRM. Studies conducted in other specialties like emergency medicine and pediatrics have demonstrated that training in simulated environments enhances student performance in CRM.[6],[11],[13] After the first training, CRM skills improved significantly among all PGs. However, the improvement was significant among the 1st-year PGs. The final year PGs did not show a statistically significant improvement as they already had a baseline higher score. The senior PGs had better scores in all domains and in all the subsequent sessions as they had more clinical experience. This finding concurs with other studies which found that the 3rd-year PGs significantly outperformed the 1st-year PGs.[11],[14]

The improvement in CRM skills was sustained in all posttraining sessions and during actual resuscitation in the hospital, indicating the retention of learning. Athough the scores of the real-life resuscitation were self-reported, they were comparable to the scores assigned by the investigators in the last simulated session. Statistical significance was not determined as the scores were investigator assigned in the simulated session and self-assigned in the latter real-life session.

There are many reasons for the effectiveness of training and retention of learning demonstrated in this study. First, this course seamlessly incorporated the primary principles of adult learning as described by Kearsley et al.[15] Participants planned their learning, used a problem-centered approach, learned this skill by experience, and this learning had immediate relevance to their regular activities in the hospital.

Second, the combined use of an interactive lecture and debriefing using videographs of the participant's performance in the scenario may have enabled effective learning. Debriefing allowed the teams to reflect on their performance, identify the gaps in learning and devise strategies to enhance future performance, under the guidance of a facilitator. Structured debriefing is considered the most important part of simulation-based training. This form of reflective learning facilitates critical thinking, deeper learning, and better retention.[16],[17]

The PGs opinion on the course was uniformly favorable. They found the sessions enjoyable, while being useful in their practice and recommended that it be incorporated into resident training. These findings resonate with findings in other studies.[12],[18] They did not find the applicability of this course for undergraduates' training. Several emergency medicine competencies have been delineated for the undergraduates including basic life support as a certifiable skill as part of the new CBME curriculum being implemented across our country. CRM training using simulation will be an ideal tool for this purpose, but it may have to be tailored for undergraduates using simpler scenarios.[10]

A year later, the PGs felt that the lack of practice and team training were the foremost obstacles to the optimal application during real-life emergencies. Other factors included greater complexity and intensity of real events, lack of appropriate resources, and difficulty in communicating with patient's relatives.

Thus, we have been able to demonstrate that CRM can be taught effectively in a structured fashion and assessed explicitly using validated tools. The limitation of our study is that the number of PGs is small. However, the effectiveness of training demonstrated by our study is bound to have profound impacts on patients during critical events.

Further studies with a larger sample size are required to identify the components of CRM which need focussed training and reinforcement.

  Conclusions Top

High-fidelity simulation is an effective and feasible tool to enhance the CRM skills of internal medicine PGs. This experiential and immersive method of training was acceptable and utilitarian in real-life situations to the participants. Therefore, it may be essential to incorporate simulation-based CRM training early in the medical PG curriculum in the interest of patient safety.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Cheng A, Donoghue A, Gilfoyle E, Eppich W. Simulation-based crisis resource management training for pediatric critical care medicine: A review for instructors. Pediatr Crit Care Med 2012;13:197-203.  Back to cited text no. 6
Parsons JR, Crichlow A, Ponnuru S. UC irvine: Integrating emergency care with population health title filling the gap: Simulation-based crisis resource management training for emergency medicine residents. West J Emerg Med 2018;19:205-10.  Back to cited text no. 7
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Reznek M, Smith-Coggins R, Howard S, Kiran K, Harter P, Sowb Y, et al. Emergency Medicine Crisis Resource Management (EMCRM): Pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med 2003;10:386-9.  Back to cited text no. 12
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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