Virtual On-Call: Use of Low-Fidelity Simulation to Improve Preparedness for Practice

Abstract

Background Many newly qualified doctors feel unprepared for clinical practice. The literature identifies themes including difficulties with clinical reasoning, emergency management, handover, and prioritization of tasks. Although there is an expected level of anxiety for newly qualified doctors, this appears to be amplified with respect to the first on-call shifts that encompass these themes. Materials and methods Virtual on-call (VOC) is a low-fidelity, ward-based simulation for senior undergraduate medical students designed to simulate an on-call in a supported environment with high psychological fidelity. Sessions were provided across two hospital sites for students to attend voluntarily. Three simulation sessions were created, each composed of five medical and surgical scenarios of differing complexity. Students responded to simulated bleeps (pager messages) and attended relevant wards to find patient notes and complete paper-based tasks. A student-led handover concluded the simulation followed by facilitator-led structured feedback and debrief. Students completed pre- and post-session questionnaires collecting quantitative and qualitative feedback. Facilitators received feedback on their teaching. A total of 30 resident doctors volunteered to teach, and 39 students attended at least one session. Results Pre-session questionnaires highlighted that 91% of respondents (n=32) felt scared/nervous/petrified about the idea of their first on-call. Prior to the first VOC session, the baseline assessment highlighted a lack of confidence among medical students regarding on-call working. Post-session results (session one) showed statistically significant increases in confidence in all the themes assessed (paired t-test with statistical significance considered at p<0.05). Forty-seven percent of first-session participants (n=14) felt positive about on-call working after attending VOC. Students who completed multiple sessions continued to have significant increases in their overall confidence levels between sessions. All students who attended three sessions were left feeling positive about their first on-call (n=2). About 95% (n=38) reported a constructive learning environment which was useful to improve preparedness for practice and time management skills. Although students reported finding the experience stressful at times, they remarked how it was beneficial to have "the opportunity to practice a wide range of skills while in an on-call simulation, how to manage acute situations, how to prioritize, and how to escalate to a senior." They reported feeling "more confident holding the bleep, finding guidance, and seeking guidance." Conclusion This program fills an unmet educational need. Feedback was overwhelmingly positive, displaying significantly increased confidence in multiple skills associated with being a safe and successful on-call doctor. We hope that the confidence gained from the on-call program will translate to improved practice when the participants qualify as doctors with a positive impact on patient care.

Keywords: bleep; junior doctor confidence; low fidelity; on-call handover; on-call shift; preparedness training; residency preparedness; simulation in medical education; surgical-education; undergraduate medical student.

Figure 1. Virtual on-call intended learning outcomes

Figure 2. Participant self-rated attitudes toward their first on-call shift prior to their first VOC session (n=35)

VOC: virtual on-call

Figure 3. Participant self-rated attitudes towards their first on-call shift following to their first VOC session (n=30)

VOC: virtual on-call

Figure 4. Pre- and post-session mean overall self-rated confidence (all on-call task ratings combined), divided by session (session 1 in light blue, session 2 in dark blue, session 3 in purple). Vertical bars denote the range. Asterisks denote statistically significant percentage increase in mean self-rated confidence following the session. First session (n=29 pairs): 54% increase, p<0.0001; Second session (n=6 pairs): 36% increase, p<0.0001; Third session (n=2 pairs): 12% increase, p=0.01

Figure 5. Pre- and post-session mean self-rated confidence with multiple on-call shift tasks (prioritizing tasks, collecting information, constructing a jobs list, and managing acutely unwell patients), divided by session (session 1 in light blue, session 2 in dark blue). Vertical bars denote the range. Asterisks denote statistically significant percentage increase in mean self-rated confidence following the session. First session (n=29 pairs): ‘Prioritizing tasks’ (62% increase, p<0.0001), ‘Collecting information’ (62% increase, p<0.0001), ‘Constructing a jobs list’ (88% increase, p<0.0001), ‘Managing acutely unwell patients’ (52% increase, p<0.0001); Second session (n=6 pairs): ‘Prioritizing tasks’ (21% increase, p=0.1), ‘Collecting information’ (39% increase, p=0.03), ‘Constructing a jobs list’ (39% increase, p=0.04), ‘Managing acutely unwell patients’ (49% increase, p=0.01)

Figure 6. Pre- and post-session mean self-rated confidence with multiple on-call shift tasks, (‘Prescribing’, ‘Finding and using guidelines’, ‘Seeking senior help’ and ‘Handing over’), divided by session (session one in light blue, session two in dark blue). Vertical bars denote the range. Asterisks denote statistically significant percentage increase in self-rated confidence following the session: First session (n=29 pairs): ‘Prescribing’ (58% increase, p<0.0001), ‘Finding and using guidelines’ (37% increase, p<0.0001), ‘Seeking senior help’ (36% increase, p<0.0001), ‘Handing over’ (49% increase, p<0.0001). Second session (n=6 pairs): ‘Prescribing’ (47% increase, p=0.0009), ‘Finding and using guidelines’ (39% increase, p=0.0009), ‘Seeking senior help’ (22% increase, p=0.04), ‘Handing over’ (39% increase, p=0.04)

Figure 7. Examples of student white space responses to the question 'What did you gain from this session?'

Figure 8. Example scenario (post-fall review)

Figure 9. Example student schedule

Figure 10. Pre-session survey 1/2

VOC: virtual on-call

Figure 11. Pre-session survey 2/2

NICE: National Institute for Health and Care Excellence; SBAR: situation, background, assessment, recommendation

Figure 12. Post-session survey 1/3

VOC: virtual on-call

Figure 13. Post-session survey 2/3

VOC: virtual on-call; SBAR: situation, background, assessment, recommendation

Figure 14. Post-session survey 3/3

VOC: virtual on-call