Violato Efrem, Stefura Jennifer, Patey Meredith, Witschen Brian
Centre for Advanced Medical Simulation Northern Alberta Institute of Technology.
School of Health & Public Safety Southern Alberta Institute of Technology.
Can J Respir Ther. 2024 Oct 23;60:152-163. doi: 10.29390/001c.124914. eCollection 2024.
Speaking up is an important yet challenging aspect of health professional communication. To overcome social-cognitive influences and improve speaking up, an intervention based on Kolb's experiential learning cycle was developed, which integrated Virtual Simulation, curriculum, and practice speaking up. The present study investigated if integrating Virtual Simulation influenced Respiratory Therapy students' ability to challenge a physician compared to a control condition at multiple time points during training.
A multi-institutional longitudinal randomized control trial was conducted. Students from two schools completed a Virtual Simulation or No Virtual Simulation before classroom instruction on speaking up and an in-person simulation requiring speaking up. After three-to-six months and post-clinical placement, students completed a second simulation requiring speaking up. The student's ability to speak up and use CUS (Concerned, Uncomfortable, Safety Issue) was measured.
No significant effects for the intervention were observed across time points, , with a small effect for using CUS, ϕ=.28. During the study, two unexpected findings emerged with theoretical and practical implications. The multi-institutional design created a natural experiment that allowed for the identification of instructor effects on speaking up and Bloom's Two-Sigma problem. Observations were also made related to perceptual limitations that diminish the ability to speak up.
Single speaking-up interventions continue to appear to be ineffective. To substantially influence behaviour, consistent mentorship through a "champion" is likely necessary to train for and create a culture of speaking up. Training in situational awareness is also likely needed to counter human perceptual limitations in complex situations.
直言不讳是医疗专业人员沟通中一个重要但具有挑战性的方面。为了克服社会认知影响并提高直言不讳的能力，开发了一种基于科尔布体验式学习循环的干预措施，该措施整合了虚拟模拟、课程以及直言不讳的实践。本研究调查了与对照条件相比，在培训期间的多个时间点整合虚拟模拟是否会影响呼吸治疗专业学生挑战医生的能力。
进行了一项多机构纵向随机对照试验。来自两所学校的学生在关于直言不讳的课堂教学和需要直言不讳的面对面模拟之前，完成了虚拟模拟或无虚拟模拟。在三到六个月以及临床实习后，学生完成了第二次需要直言不讳的模拟。测量了学生直言不讳和使用CUS（关心、不舒服、安全问题）的能力。
在各个时间点均未观察到干预的显著效果，使用CUS有较小效果，ϕ = 0.28。在研究过程中，出现了两个具有理论和实际意义的意外发现。多机构设计创造了一个自然实验，使得能够识别教师对直言不讳的影响以及布鲁姆的双西格玛问题。还观察到了与感知局限性相关的情况，这些局限性会削弱直言不讳的能力。
单一的直言不讳干预措施似乎仍然无效。为了对行为产生实质性影响，可能需要通过“倡导者”进行持续的指导，以培养并营造一种直言不讳的文化。可能还需要进行情境意识培训，以应对复杂情况下人类的感知局限性。
