We compared the homogeneity of the CG and of the TG at pre-test with χ2 test and Fisher’s exact test for qualitative variables and with the Mann-Whitney U test for quantitative parameters. A generalized linear mixed model47 measured changes before and after the BBNSBT in self-efficacy, the SPIKES competence form and the mBAS. We adjusted the effects of time, group, and group-by-time by the study year as a confounding factor. GLMMs were performed with a covariance matrix of the compound symmetry type.We performed the McNemar’s test to compare the proportion of students who passed the SPIKES competence form and the mBAS cut-offs between pre-test and post-test within the groups. Furthermore, two further analyses were considered. First, we calculated the relative gains between pre-and post-test within the two groups by means of the following formula: [ / pre-test]. A Mann-Withney U test was used to compare relative gains. Second, we tested whether the BBNSBT could help fill the performance gap between participants with limited clinical experience in the TG and participants with clinical experience in the CG by means of a Mann-Whitney U test. Results were considered statistically significant at the 5% critical level .Traditional training is the common pedagogical method for learning clinical skills.Trainees rarely learn BBN in real clinical practice due to the paucity of opportunities and the fact that clinical preceptors are rarely available to give feedback.At pre-test,rolling benches for growing our study shows a low level of participant experience and a lack of BBN skills, especially in the TG.
Chiniara et al. define the “simulation zone” as areas in which simulation education may be better suited than other methods. BBN is an example of the HALO quadrant: high impact on the patient and low opportunity to practice. This feasibility study assessed the impact of a four-hour ED BBNSBT compared to clinical internship. It was hypothesized that BBNSBT would have the potential to increase participant self-efficacy in BBN communication and management, adherence to BBN stages and processes, and to improve communication skills during BBN. Our results revealed that this training increased self-efficacy perception. Participants had a low level of self-efficacy in pre-test. After the BBNSBT, the TG reported being more confident about their knowledge and application of BBN and about their ability to perform BBN compared to the CG. This confirms the results of another, smaller study , which showed an improvement in confidence and self-efficacy.52 These findings may be explained by Bandura’s social cognitive theory,53 which suggests four ways to enhance self efficacy that we identify in the BBNSBT: 1) enactive attainment ; 2) vicarious experience ; 3) verbal persuasion ; and 4) psychological safety during the simulations. Moreover, the perceived self efficacy of students in the CG with more clinical experience decreased. This result could have different potential explanations, notably that the pre-test may have led to introspection and reflection about their BBN and communication skills. Communication with patients and their families is one of the Accreditation Council for Graduate Medical Education Milestones for EM residents, specifically the fourth level of BBN.Our research used two validated assessment tools that allow for standardization of the evaluation and training. The results demonstrate that BBNSBT using role-playing and debriefing enhances participant BBN learning and performance compared with the traditional learning paradigm and direct immersion in acute clinical situations.
BBNSBT offers the opportunity to teach BBN and communication skills to students and young residents in a psychologically safe environment, preventing harm to patients and family members. It allows each participant to announce bad news and observe several BBN simulations with debriefings. By contrast, in the traditional curriculum role modeling at the bedside could have a negative impact on patients and relatives when medical students or residents engage in inappropriate communication behaviors,such as not keeping patients or family members adequately informed or using medical words they do not understand. More students in the TG reached the cut-off scores: 73% for SPIKES and 62.2% for the mBAS vs 45.2% and 35.5% in the CG. These results demonstrate the relevance of BBNSBT in communicating bad news in the ED. However, the difference between the groups for the mBAS cut-off score is not significant. BBNSBT probably focuses more on SPIKES than on communication behavior. It may be necessary to create an advanced course centered on communication skills rather than on SPIKES. Despite this, BBNSBT offers experiential learning for participants. From the simulation experience, the debriefing process leads students to explore their frames, incorporate new frames such as SPIKES skills, and re-practice these new skills. This process allows knowledge to be acquired through experience.56 Moreover, participants had access to ED BBN experts for four hours, which, unfortunately, is unlikely to happen in real clinical practice. Additional data analyses allowed us to address a new question: Is BBNSBT more useful for students with less than one year of clinical experience? We found a statistically significant difference in the pre-test. Students with limited clinical experience reached the same level of BBN skills as students with more clinical experience after the BBNSBT.
The gap between these groups could be filled by simulation training, without the pitfalls of stress and discomfort of direct clinical exposure. No study has previously focused on this question. In fact, BBNSBT used a step–by-step process involving novice participants to bring them to a higher level. The first step involved theoretical explanations given via video, discussions, and lectures. Each simulation, and especially each debriefing, further enhanced the participants’ skills. One strength of the study is that we paid special attention to the theoretical background upon which the training and evaluation were based, using the widespread SPIKES28 theoretical model and the INACSL Standards of Best Practice for SimulationSM.Moreover, the simulations were well designed, the debriefings were standardized, and the facilitators were trained and experienced. We believe that it is mandatory to meet the INACSL Standards of Best Practice, as well as work with simulation experts to obtain positive results with simulation training. The next steps for research and pedagogical method improvement can be identified based on these results. Further research is needed to investigate the role of an advanced course in BBN. As BBN is not a required skill for EPs, it would be interesting to investigate whether BBNSBT is feasible and effective in other areas such as obstetrics, intensive care units, etc. Finally, we think that e-learning preparation before BBNSBT, as described for a training on managing low urine output,58 could replace some of the in-person time.Myanmar, formerly Burma, and now administratively designated the Republic of the Union of Myanmar, is a sovereign state in Southeast Asia. Myanmar has a diverse—135 different ethnic groups—population of 53 million according to the United Nations Population Division.1 Recently, the military regime that long hampered the country’s development was replaced by a civilian government.2 Socioeconomic development in Myanmar lags far behind nearby countries,vertical farming system as does its healthcare system. There are shortcomings in maternal care, pediatric healthcare, and infectious disease treatment, as well as medical accessibility and quality.3 Strengthening medical systems by improving the standard of emergency care has been known to reduce the mortality and morbidity from both communicable and non-communicable diseases.A large proportion of the global mortality and morbidity rate from various diseases is found in low- and middle-income countries . Unfortunately, the emergency care systems required to address these shortcomings are not well established in most LMICs, including Myanmar.Formal emergency care in Myanmar is only available in hospitals located in urban areas. Rural hospitals can provide only limited emergency care to patients.While preparing for an international sporting event, the Myanmar government started to formalize efforts to develop a formal emergency medicine training program.
Apart from the formal EM training program in the capital city, Nay Pyi Taw, frontline healthcare facilities across the country are not capable of providing life-saving emergency care. In most rural hospitals, the outpatient department usually covers emergencies; there is no separate area or facility for emergency treatment. Rural hospitals offer access to few medical specialties with minimal, if any, laboratory services. Public prehospital ambulance transportation service is virtually unavailable in rural areas.Several tools have been used to evaluate emergency care capability. Most focused primarily on the availability of hardware or infrastructure rather than functional aspects of emergency care.Some researchers have tried to measure performance of EM practice in resource-limited settings, which has resulted in a demand for a comprehensive EM assessment tool for LMICs.Recently, a novel approach based on work in the field of obstetrics, called sentinel condition and signal function, was adapted for EM by the African Federation for Emergency Medicine .Based on this concept, the AFEM developed a standard preliminary tool called the Emergency Care Assessment Tool , which has been suggested to be more useful than previous evaluation tools in assessing EM systems.10 Our study incorporated the concept of ECAT as a tool to analyze Myanmar’s emergency care systems. We investigated the capability to deliver emergency care in different levels of hospitals located in several regions of Myanmar.This facility-based survey was conducted between February 7, 2018 –April 3, 2018. With the help of two Myanmar doctors and three nurses who were invited to Korea for training, survey sheets were distributed to the doctors in charge of emergency medical care at nine hospitals. Our primary criterion for selecting hospitals was access to e-mail and online messaging, at the time of survey, to allow for our interactions with them. The nine hospitals, including five at which our initial contacts were employed, were scattered in five states in Myanmar, and believed to partially represent both urban and rural regions . The nine hospitals were grouped into three levels, according to the bed capacity of the hospital and the number of physicians . Survey sheets were prepared in English using ECAT and delivered to responsible officers by e-mail. ECAT encompasses six sentinel conditions that threaten life , and the related signal functions that alleviate them. The researchers explained the meaning of each question in the survey to the original five Myanmar contacts, and they, in turn, conveyed this information to the Myanmar doctors who took part in the study. In the case of any questions that were initially omitted on the completed surveys, clarification was provided, and the questions were then revisited and answered by the respondents. The survey included questions about the general status of each hospital, such as the number of staff members, the number of hospital beds, and the annual patient load. The remaining questions addressed the performance of emergency signal functions, the products for signal functions , and the availability of emergency facility infrastructures. We coded data using standard descriptive analyses with Microsoft Excel 2015 . Qualitative research methods involved thematic analysis of answers. In performing signal functions for each of the sentinel conditions, basic-level hospitals were revealed to be weak in trauma care. Among the 12 signal functions related to trauma care that are deemed essential in basic-level hospitals, more than two functions were unavailable at all four hospitals. One hospital could not provide half of the trauma-related essential signal functions [Matupi Hospital– trauma protocol implementation , pelvic wrapping, cervical spine immobilization, basic fracture immobilisation , immediate cooling care for burns, fracture reduction]. None of the four basic-level hospitals had the resources to treat burn patients or provide pelvic wrapping. The survey questions regarding infrastructure revealed that none had a specialized resuscitation area for critical patients, and three of the hospitals did not have a triage area. There was neither trauma protocol nor a cervical immobilization device at any of the hospitals. Most signal functions for the other five sentinel conditions were generally available in these basic-level hospitals, with the exception of treatment for common toxidromes, which only half could provide. Two of the four intermediate-level hospitals indicated that they could provide all emergency signal functions. The other two hospitals, however, were found to provide a limited set of signal functions. They did not have a trauma protocol nor could they provide reduction for patients with bone fractures. Cervical immobilization, pelvic wrapping, burn care, and treatment of compartment syndrome were also unavailable. Moreover, one hospital could not perform defibrillation or mechanical ventilation support, nor administer intramuscular adrenaline, which is important for cardiopulmonary resuscitation.