This journal club focuses on a scoping review of the literature on Rapid Cycle Deliberate Practice (RCDP) in Simulation-Based Medical Education (SBME).

Journal Club Article: Ng C, Primiani N, Orchanian-Cheff A. (2021). Rapid Cycle Deliberate Practice in Healthcare Simulation: a Scoping Review. Med Sci Educ. 2;31(6):2105-2120.

Key Findings:

This is the largest scoping review on the topic to date. It examines 23 published studies on RCDP in healthcare simulation and summarizes them. RCDP is a type of “within-event debriefing.” Learners repeatedly practice a skill and receive directed feedback until mastery is achieved. Only then do they move to the next learning objective. It builds on the principles of deliberate practice and mastery learning, originating from fields like music and sports.

Main Themes and Important Ideas:

Definition and Principles of RCDP:

• RCDP was introduced by Hunt et al. in 2014. It is consistently defined across the literature as a method that “rapidly cycle(s) between deliberate practice and directed feedback until skill mastery is achieved”.
• It incorporates within-event debriefing, where the simulation is paused for real-time coaching.
• Key principles of RCDP include:
• Applying overlearning and automatisation through multiple opportunities for repetitive practice to achieve “muscle memory”.
• Providing efficient expert or evidence-based feedback.
• Fostering an environment of psychological safety where learners feel comfortable receiving feedback.

Heterogeneity in Studies and Implementation Strategies:

• The included studies are diverse in design. The participant types are primarily residents and particularly pediatric. The simulation types are most commonly paediatric and adult resuscitation. The studies also have diverse outcome measures.
• While the core definition of RCDP is consistent, there are variations in its application. These variations include the use of a needs assessment, pause timing, and rewinding or restarting. Case progression and escalating difficulty also vary, making it difficult to draw general conclusions about RCDP.
• Implementation strategies varied, including:
• Using the first simulation run uninterrupted as a needs assessment (11 studies).
• Having pre-determined pauses in the scenario (9 studies).
• Pausing for error correction, praise, or feedback (10 studies).
• Short cases repeated multiple times (2 studies).
• Rewinding to the start (9 studies) or to the point of the pause (7 studies).
• Case progression through the scenario (15 studies), often with increasing difficulty (6 studies).

Positive Learner Outcomes:

• RCDP is consistently associated with positive outcomes at Kirkpatrick’s K1 (reaction) and K2 (learning) levels [more on Kirkpatrick Model of Evaluation]
• K1 Outcomes: “The most common K1 outcomes were increased learner confidence (11 studies) and learner satisfaction (11 studies)”.
• K2 Outcomes: RCDP was linked to improved knowledge and skills acquisition, evidenced by:
• Significantly increased multiple-choice question (MCQ) scores (4 studies).
• Increased checklist scores (8 studies).
• Decreased time to critical tasks (6 studies).
• Increased chest compression fraction (CCF) (2 studies).
• Studies demonstrated specific improvements. For example, there was a “significant decrease in median time from onset of pulseless v-tach to defibrillation.” The pre-shock pause was shorter compared to the pre-intervention group [5].

Application Beyond Technical Skills:

• While initially studied for technical resuscitation and procedural skills, RCDP simulation can teach nontechnical abilities. It can successfully include death notification and family communication.

Comparison with Other Instruction Methods (Mixed Results):

• Adding RCDP to standard curriculums appears “overall beneficial,” leading to improvements in K2 outcomes.
• However, comparisons between RCDP and traditional simulation yielded mixed results.
• While some studies showed immediate improvements with RCDP (e.g., decreased time to critical tasks, higher checklist scores), “three of the five studies that compared RCDP to traditional simulation did not show significant differences in all K2 outcome measures”.
• Importantly, studies with follow-ups (3-4 months) observed that checklist scores decreased in both RCDP and traditional simulation groups. RCDP groups experienced “greater decreases in scores.” This occurred despite initially showing higher scores immediately after training.

Unclear Long-Term Skills Retention:

• Scores decreased more at follow-up in RCDP groups than in traditional simulation groups. This indicates that RCDP has an immediate advantage in knowledge application. However, knowledge retention has not been demonstrated.
• This raises questions about the creation of long-term “muscle memory” with RCDP.
• One study suggested that RCDP training should occur more frequently. Training every 3 months helps maintain skills. It also prevents the decay observed at 6 months.

Lack of K3 and K4 Outcomes:

• Only two studies reported K3 outcomes, which involve the application of learned skills in clinical practice. These include perceived improvement in leadership and communication [14]. Additionally, nursing staff are better able to manage cardiac arrest [21].
• “No K4 outcomes [systemic outcomes such as improved patient outcomes, cost-savings, etc.] were reported.”

Knowledge Gaps and Future Research:

• Need for standardization of RCDP implementation and simulation design to facilitate more consistent research.
• More studies are needed. They should examine how RCDP interventions “translate to clinical practice.” These studies must have a demonstrable impact outside the learning environment (K3 and K4 outcomes).
• Further research is required to compare RCDP to other types of SBME, particularly regarding “long-term skills retention”.
• More high-quality, adequately powered randomized controlled studies are needed to definitively assess the superiority of RCDP over traditional simulation.

Limitations of the Review:

• Exclusion of grey literature, conference abstracts, and poster presentations.
• Limitation to English language studies.
• No critical appraisal of study quality due to the broad scope and heterogeneity of the included studies.
• Most studies were small and single-site, and many lacked comparisons, making it difficult to rule out confounders.

Overall Conclusion:

RCDP is a rapidly emerging technique in healthcare simulation. It is associated with immediate positive outcomes in learner satisfaction and confidence. It also enhances the acquisition of knowledge and skills for both technical and nontechnical abilities. Adding RCDP to standard curriculums appears beneficial. However, its superiority over traditional simulation is currently unclear. This is due to mixed results in comparative studies and the lack of evidence regarding long-term skills retention. Additionally, its translation to clinical practice is uncertain. Further standardized research is needed to clarify the long-term impact and comparative effectiveness of RCDP.

Resources

Nursing Education Network. (2019). Kirkpatrick Model of Evaluation.

Nursing Education Network. (2019). Kirkpatrick 10 Requirements for an Effective Training Program.

Kirkpatrick, D. L. (2009). Implementing the four levels: A practical guide for effective evaluation of training programs. ReadHowYouWant.com [excerpt].

Kirkpatrick Partners. (2019). The Kirkpatrick Model.

Kurt, S. (2016). Kirkpatrick Model: Four Levels of Learning Evaluation. Educational Technology.