• Advanced Cardiac Life Support (ACLS) skills are a required competency for Internal Medicine trainees in Canada
• Clinical exposure to ACLS events among trainees is decreasing (Mickelson et al., 2011) 
• Existing ACLS training courses may lead to suboptimal skill acquisition and retention (Semeraro et al., 2006)
• Half of Internal Medicine residents surveyed felt they have inadequate training opportunities to develop ACLS skills (Hayes et al., 2007)
• Many Internal medicine residents are not able to demonstrate ACLS skills at the completion of their training (Wayne et al., 2006a)

Mastery Learning

• Mastery learning has been shown to significantly improve residents' ACLS skills (Wayne et al., 2006b)
• Mastery learning incorporates principles of deliberate practice to ensure all learners surpass the objectively set level of mastery performance (McGaghie et al., 2008)

Simulation

• Frequently used for ACLS skills training and mastery learning allowing for training of rare and critical events in a safe environment
• Defined as "a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion" (Gaba, 2004, p. 126)
• Cost is often a barrier to implementing simulation-based training 
• Cost is infrequently reported in simulation-based medical education research (Zendejas et al., 2013)

Directed Self Regulated Learning (DSRL)

• In DSRL, an educator designs and structures the learning process to direct trainees in their learning (Brydges et al., 2010)
• DSRL allows for scaffolding to support learning, while maintaining independence to enhance motivation and metacognitive activity
• DSRL effective in teaching procedural skills (Brydges et al., 2012, Jowett et al., 2007)
• DSRL can be applied to groups of learners with a shared identity and goals

Research Questions

• How does the ACLS skill performance of PGY1 Internal Medicine residents who participate in a DSRL simulation-based mastery learning course compare to residents who participate in an instructor regulated learning (IRL) mastery learning course?
• What is the cost effectiveness of a DSRL simulation-based mastery learning course?
• It was hypothesized that DSRL would be as effective as IRL and be more cost effective

Setting

• University of Toronto - SimSinai and Bloomberg School of Nursing Simulation Centre 
• Utilized full body mannequin (SimMan®) that could be preprogrammed to respond to real-time interventions 

Participants

• PGY1 Internal Medicine residents at the University of Toronto, Canada (n=40)
• University of Toronto REB approval obtained

Video - Introduction to simulation session 

Brydges, R., Dubrowski, A., & Regehr, G. (2010). A new concept of unsupervised learning: directed self-guided learning in the health professions. Academic Medicine, 85(10 Suppl), S49-55.

Brydges, R., Nair, P., Ma, I., Shanks, D., & Hatala, R. (2012). Directed self?regulated learning versus instructor?regulated learning in simulation training. Medical Education, 46(7), 648-656.

Gaba, D. M. (2004). The future vision of simulation in health care. Quality & safety in health care, 13 Suppl 1, i2-10.

Jensen, A. R., Wright, A. S., Levy, A. E., McIntyre, L. K., Foy, H. M., Pellegrini, C. A., . . . Anastakis, D. J. (2009). Acquiring basic surgical skills: Is a faculty mentor really needed? The American Journal of Surgery, 197(1), 82-88.

Jowett, N., LeBlanc, V., Xeroulis, G., MacRae, H., & Dubrowski, A. (2007). Surgical skill acquisition with self-directed practice using computer-based video training. The American Journal of Surgery, 193(2), 237-242.

McGaghie, W. C. (2008). Research opportunities in simulation?based medical education using deliberate practice. Academic emergency medicine, 15(11), 995-1001.

Mickelsen, S., McNeil, R., Parikh, P., & Persoff, J. (2011). Reduced resident “code blue” experience in the era of quality improvement: New challenges in physician training. Academic Medicine, 86(6), 726-730.

Semeraro, F., Signore, L., & Cerchiari, E. L. (2006). Retention of CPR performance in anaesthetists. Resuscitation, 68(1), 101-108.

Wayne, D. B., Butter, J., Didwania, A., Siddall, V., & McGaghie, W. C. (2009). Advanced Cardiac Life Support checklists for simulation-based education Retrieved June 6, 2012, from MedEdPORTAL www.mededportal.org/publication/1773

Wayne, D. B., Butter, J., Siddall, V. J., Fudala, M. J., Wade, L. D., Feinglass, J., & McGaghie, W. C. (2006a). Graduating internal medicine residents' self-assessment and performance of advanced cardiac life support skills. Medical Teacher, 28(4), 365-369.

Wayne, D. B., Butter, J., Siddall, V. J., Fudala, M. J., Wade, L. D., Feinglass, J., & McGaghie, W. C. (2006b). Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice.Journal of General Internal Medicine, 21, 251-256.

Zendejas, B., Wang, A. T., Brydges, R., Hamstra, S. J., & Cook, D. A. (2013). Cost: The missing outcome in simulation-based medical education research: A systematic review. Surgery, 153(2), 160-176.

Table 3 - Baseline demographic data, mean (standard error).  IRL = instructor regulated learning, DSRL = directed self-regulated learning

• On a post-course survey (1=strongly disagree, 5=strongly agree), residents in the DSRL group were significantly more likely to want to train in the IRL group (mean = 3.5), than residents in the IRL group were to have wanted to train in the DSRL group (mean = 2.2, p = .001) (Table 4)
  
• Both groups felt that participation in their assigned group was an effective way to learn ACLS, although those in the IRL group agreed with this more strongly (Table 4) 

Table 4 - Summary of post-course survey.  Mean score (standard error) on a 5-point Likert scale (1=strongly disagree, 5=strongly agree).  IRL = instructor regulated learning, DSRL = directed self-regulated learning

• Majority of residents did not feel that traditional training was sufficient preparation to lead a cardiac arrest team
• Despite equivalent efficacy in improving resident ACLS skills performance, residents in both groups were more likely to express a desire to learn in an instructor led group
• Trainee preference for instructor regulated learning has been noted previously (Jensen et al., 2009)
• Residents in this study may be more familiar and comfortable with the traditional model of didactic and instructor led learning because of their prior educational experiences

Limitations

• Impact of DSRL and IRL on skill retention or transfer to clinical practice was not examined
• Only 2 hours of deliberate practice provided, however, scope of material was narrow
• Different scenarios used for pre-test and post-test prevents direct comparison, but addresses potential for test-retest bias and was adjusted for using pre-test score as a covariate in analyses
• Checklist used in the study and minimum passing scores were not validated specifically in this setting

Future Work

• Assessment of retention of skills and transfer to clinical setting
• Determine how to optimize DSRL and what mechanisms make it effective
• Determine why residents prefer IRL over DSRL despite its effectiveness

Implications

• ACLS skills are taught to many health care providers
• DSRL represents a potentially cost-effective way to teach these skills
• Given apparent learner preference for IRL, educators who wish to engage learners in DSRL may need to acknowledge these preferences and outline the potential advantages of DSRL