Pre-learning
The lumbar puncture procedure will be used as an example of the enhancement of the SBML programme.
A pre-reading LP pack was made available online for the boot camp participants several weeks in advance. Participants had the option to download the reading pack onto their personal or work devices for asynchronous learning. The pack consisted of a comprehensive, evidence-based document compiled by a core group of physicians and anaesthetists which had been quality assured through an iterative process conducted by a selection of subject matter experts. The reading pack included an overview of the mastery skills programme (Additional file 1), learning outcomes, indications and risk assessment, patient safety considerations and potential complications. It also included a brief overview of the relevant anatomy, physiology and equipment. The procedure was divided into six procedural phases (Additional file 2), and the SBML LP assessment checklist was included (Additional file 3).
Two videos, whose design was consistent with the principles described by Dong and Goh, were included in the pre-learning [12]. The first video was 20 min in duration and featured an exemplar skill performance of lumbar puncture. This video was filmed in the skills lab and features a simulated patient with a part-task simulation trainer for the procedure itself. The procedure was aligned to the six phases described in the reading pack. These phases, used as a framework for all the SBML resources, were ‘Preparation, Assistance and Positioning’, ‘Procedural Pause’, ‘Asepsis and Anaesthetic’, ‘Insertion’, ‘Anchoring and Dressing’ and finally ‘Completion’ (Additional file 2).
The second video, with a duration of 30 min, was an example of a mastery skills session. It demonstrated ‘what will happen on the day’ and shows the learner making some common errors during the procedure, receiving feedback and then repeating the procedure to a higher standard before passing the assessment. Completion of the pre-learning was highlighted as being mandatory for attendance at the boot camp. Each of the boot camp attendees reported that they had completed the LP pre-learning.
Peer learning
Peer-assisted deliberate practice
A period of 2 h was allocated for the SBML LP session within the 3-day boot camp. Learners entered the lumbar puncture training suite in groups of six and were then placed in pairs before being randomly allocated to one of three members of faculty. The LP faculty included clinicians experienced in both lumbar puncture and the process of SBML. Each faculty member then demonstrated the equipment which had been made available to the learners. The pairs of learners were given time to familiarise themselves with the equipment and to practice the technical aspects of the procedure prior to their assessment. This constituted the peer-assisted deliberate practice section. During this period, the faculty had the option of observing their allocated pair of learners through one-way glass. They also had the opportunity for further informal discussion about the equipment or correction of the learners’ technique if they considered this desirable or necessary. The period of peer-assisted deliberate practice, which was an average of 20 min, was subsequently followed by a period of facilitator feedback and further practice if necessary. This ended when both learners in the pair felt that they were sufficiently familiar with the equipment and technique to be able to proceed to the next stage.
Peer observation of assessment and feedback
This commenced with the faculty member presenting the pair of learners with a basic clinical scenario which required them to perform a lumbar puncture on a patient. Each learner addressed the clinical scenario individually whilst the other member of the pair observed.
The faculty were provided with a checklist which detailed all of the points to be considered and actions to be taken by the learner being assessed. These included confirming the patient’s identity, reviewing the clinical findings, excluding contraindications and obtaining informed consent.
The faculty then acted as the learner’s ‘skilled assistant’ during the simulated lumbar puncture procedure. Following completion of a surgical scrub, the learners were required to include a safety pause before commencing the procedure and obtaining a sample of ‘cerebrospinal fluid’. Learners were assessed on their ability to perform the procedure safely and effectively whilst communicating with their assistant and the patient (represented by the LP part-task trainer). Learners were scored against a 23-point checklist (Additional file 3) created and standard set by a group of subject matter experts using a Mastery Angoff method [21].
Following each learner’s performance, the faculty member provided several minutes of feedback and determined whether or not the learner had completed the SBML LP to the required standard. If the standard was not met time was available for the learner to immediately repeat the performance, assessment and feedback process. Should the learner still not complete the procedure satisfactorily, arrangements were made for them to have further local training.
Data collection and analysis
A total of fifty learners were asked to complete both pre-course and post-course questionnaires. These related to the pre-learning and peer learning experiences respectively. The post-course questionnaires were completed immediately following the SBML LP session. All fifty questionnaires were returned; however, two of these were only partially completed but still taken into consideration. A combination of quantitative and qualitative data was collected.
Likert scales were used to generate quantitative data on all four sections of the enhanced programme. Qualitative data, in the form of short answers from the learners which explained their Likert scale rating, were obtained and subjected to a thematic analysis.
Thematic analysis was based on the approach of Braun and Clarke [22] and included the stages of familiarisation with data, generation of initial codes, searching for and reviewing themes, and defining themes. This process culminated in the learners’ responses being allocated to specific themes.