Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum

요약

The goal is to demonstrate how to apply the rapid cycle deliberate practice debriefing technique to the GRIEV_ING death notification curriculum.

초록

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners’ confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the “right way.” The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.

서문

Death notification is an important and challenging aspect of Emergency Medicine. An emergency medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. On average 270,000 patients die in United States emergency departments each year¹. This number is anticipated to increase as the population ages². Unskilled death notification can lead to the development of pathologic grief and posttraumatic stress disorder^3,4,5. It is paramount for emergency medicine physicians to be trained in and practice death notification.

Graduate and undergraduate medical educators employ a variety of death notification techniques when teaching residents and medical students to deliver bad news^6,7,8. One example is the GRIEV_ING curriculum. It provides medical personnel a conceptual framework for death notification. The curriculum has demonstrated improvement in learners’ confidence and competence when delivering bad news⁸.

Rapid Cycle Deliberate Practice (RCDP) is a simulation-based medical education technique that uses within-scenario debriefing⁹. This technique is based on the concepts of mastery learning and deliberate practice^9,10,11. It allows educators to pause a scenario, provide directed feedback, and then let learners rewind and continue the simulation scenario the “right way.” The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news¹².

In preparation for this curriculum, learners are given a 45-minute lecture on the principles of death notification and the GRIEV_ING conceptual framework. Prior to starting the simulation session, faculty perform a prebrief of the objectives, RCDP and simulation environment logistic details, establish a fiction contract with the learners and pledge to respect the learners^13,14,15. The learners are split into groups of 4-5 and assigned an examination room with a faculty member and standardized patient. Each learner is given a GRIEV_ING pocket card to reference during the simulation. To start, one learner is selected from each group to perform the first death notification scenario. This first death notification serves as a needs assessment for the faculty. It is allowed to run from start to finish without interruption. Next, the same learner performs a new death notification simulation using the same scenario, this time RCDP is used by the faculty to provide feedback throughout the death notification scenario. Faculty pause the scenario, provide directed feedback and then rewind the scenario 30-60 seconds. The scenario is then restarted by the standardized patient.

프로토콜

All methods described here were found to be exempt from review by the Indiana University Institutional Review Board.

1. Preparation

1. E-mail the GRIEV_ING pocket card (Figure 1) to all faculty one week prior to the scheduled simulation session.
2. E-mail the death notification simulation scenarios (Supplement 1), that include patient role and background history, to the standardized patients one week prior to the scheduled simulation session.
3. Prepare the simulation examination rooms prior to beginning the death notification simulation exercise.
   1. Place a chair for the standardized patient and a stool for the learner in each examination room.
   2. Print patient scenario information (Supplement 2), which includes name, age, gender, background, present condition and survivor present, and post outside each exam room for learners. Have faculty read death notification scenarios prior to the start of the session.

2. Rapid Cycle Deliberate Practice GRIEV_ING Simulation Exercise Pre-brief

1. Gather all faculty and learners in one room. Review the simulation session goals and objectives.
2. Review logistic details about RCDP and the simulation environment.
3. Form a fiction contract with the learners and pledge to respect the learners. 
   NOTE: A fiction contract is an agreement between the educators and learners. This creates the expectation that educators attempt to create as realistic of simulation environment as possible while the learners pretend that things are real and actively participate in the educational experience¹⁴.
4. Divide the learners into groups of no more than 4-5 learners.
5. Assign each learner group an examination room with a faculty member and standardized patient.
6. Give each learner a GRIEV_ING pocket card to reference during the simulation (Figure 1).

3. Rapid Cycle Deliberate Practice GRIEV_ING Simulation Exercise

1. Select one learner from each group to perform the initial death notification scenario.
2. Position the standardized patient in the exam room. Have the learners to review the simulation scenario case details posted outside the exam room.
3. Start the initial death notification scenario. Run the scenario from start to finish without interruption. Identify specific areas that necessitate feedback.
4. Perform a micro-debriefing at the conclusion of first scenario. Give succinct feedback to learners on initial performance in less than 5 minutes.
5. Reset the scenario and place the learners outside the room. Perform the same simulation scenario from the beginning. Begin with the same learner as the leader for the second round of the scenario.
6. Apply the RCDP technique during the scenario. Pause the scenario, provide directed feedback and then rewind the scenario 30-60 seconds. Have the standardized patient to restart the scenario.
   NOTE: In order to allow multiple students to participate in a single scenario, faculty can switch out the participating learner by “tagging in” observing students to continue the scenario. For example, if John started the scenario, faculty can stop, give feedback and rewind the scenario. Faculty then “tags in” Sam to resume the scenario as the new active participant from where John left off. Faculty should make sure all learners have an opportunity to be in the “hot seat” throughout the allotted training time.
7. Perform a micro-debriefing at the conclusion of the scenario training period. Provide constructive feedback to the learners.
8. Repeat the scenario again from the start and continue with the RCDP approach.
   NOTE: The goal is to need less interruptions each time the scenario is performed. The RCDP simulation exercise requires 45-50 minutes.

4. Rapid Cycle Deliberate Practice GRIEV_ING Wrap Up

1. Gather all faculty and learners in one room for a group wrap-up at the conclusion of the simulation training. Focus on key take-home points from the training and allow for learner feedback during the 15 minute wrap-up.

결과

As noted in Ahmed et al., the study involved 22 emergency medicine residents¹². Learners’ median self-efficacy and knowledge scores increased from 3 to 4 and 65 to 90, respectively, when comparing pre- and post-simulation results. In addition, pre- and post-intervention death notification performance scores improved (Table 1).

Qualitative themes from the post-curriculum surveys by Ahmed et al. were that this exercise was a great experience and pro...

토론

The RCDP death notification curriculum consists of several critical steps. First, the prebrief is critical to introduce the concept of RCDP and create psychological safety for learners. Learners who feel psychologically safe have less anxiety and feel more comfortable making mistakes, allowing for optimization of the learning experience^13,14,15. In addition, the curriculum requires that educators provide learners with an overvie...

자료

Name	Company	Catalog Number	Comments
Chair
Facial Tissues			Standardized patients will need for simulated crying
GRIEV_ING pocket card
Stool