Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches

BMJ Qual Saf. 2016 Apr;25(4):281-94. doi: 10.1136/bmjqs-2014-003518. Epub 2015 Nov 5.


Importance: Optimal approaches to teaching bedside procedures are unknown.

Objective: To identify effective instructional approaches in procedural training.

Data sources: We searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014.

Study selection: We included research articles that addressed procedural training among physicians or physician trainees for 12 bedside procedures. Two independent reviewers screened 9312 citations and identified 344 articles for full-text review.

Data extraction and synthesis: Two independent reviewers extracted data from full-text articles.

Main outcomes and measures: We included measurements as classified by translational science outcomes T1 (testing settings), T2 (patient care practices) and T3 (patient/public health outcomes). Due to incomplete reporting, we post hoc classified study outcomes as 'negative' or 'positive' based on statistical significance. We performed meta-analyses of outcomes on the subset of studies sharing similar outcomes.

Results: We found 161 eligible studies (44 randomised controlled trials (RCTs), 34 non-RCTs and 83 uncontrolled trials). Simulation was the most frequently published educational mode (78%). Our post hoc classification showed that studies involving simulation, competency-based approaches and RCTs had higher frequencies of T2/T3 outcomes. Meta-analyses showed that simulation (risk ratio (RR) 1.54 vs 0.55 for studies with vs without simulation, p=0.013) and competency-based approaches (RR 3.17 vs 0.89, p<0.001) were effective forms of training.

Conclusions and relevance: This systematic review of bedside procedural skills demonstrates that the current literature is heterogeneous and of varying quality and rigour. Evidence is strongest for the use of simulation and competency-based paradigms in teaching procedures, and these approaches should be the mainstay of programmes that train physicians to perform procedures. Further research should clarify differences among instructional methods (eg, forms of hands-on training) rather than among educational modes (eg, lecture vs simulation).

Keywords: Evidence-based medicine; Patient safety; Simulation.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Clinical Competence*
  • Curriculum
  • Female
  • Humans
  • Male
  • Methods
  • Patient Care / standards*
  • Point-of-Care Testing*
  • Practice Guidelines as Topic / standards*
  • Randomized Controlled Trials as Topic