the impact of simulation on healthcare team training.

Clinical Simulation in Nursing (2018) 20, 1-6

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Research Brief

Using Simulation to Cross-Train Staff and Build Effective Teams

Shelley C. Moore, PhD, MSN, RNa,*, Michelle Finch, PhD, MSN, RNa, Susan K. MacArthur, EdD, MSN, FNP, RN-BCb, Karen S. Ward, PhD, MSN, RNc aAssociate Professor, Middle Tennessee State University, 1301 E. Main Street, Box 81, Murfreesboro, TN 37132 bDirector of Nursing Professional Development, Maury Regional Medical Center, 1224 Trotwood, Columbia, TN 38401 cProfessor, Middle Tennessee State University, 1301 E. Main Street, Box 81, Murfreesboro, TN 37132

KEYWORDS cross-training; quality and safety in nursing;

simulation; TeamSTEPPS; teamwork

ng author: shelley.moore

e front matter � 2018 Int .1016/j.ecns.2018.04.00

Abstract Background: Maximizing nursing resources is imperative for hospitals to meet budget. Merging units is often viewed as cost effective. Clinical simulation can be used to both cross-train staff and enhance perceptions of teamwork, thus contributing to patient safety. Sample: Fifteen nurses and eight technicians underwent simulation as part of a cross-training project. Four nurses and four technicians participated in a pre-posttest study as part of the project. Methods: Two simulation sessions were used to assist medical surgical nursing staff in caring for pe- diatric patients. The 35-item Teamwork Perceptions Questionnaire was used to measure teamwork. Results: Non-parametric Wilcoxon signed ranks test demonstrated a significant improvement in the Teamwork Perceptions Questionnaire situation monitoring subscale (p < .05; p ¼ .012). Conclusion: Successful simulation training was accomplished, as well as improved perception of one aspect of teamwork. During debriefing of the simulation exercises, an additional unexpected benefit of problem-solving transpired.

Cite this article: Moore, S. C., Finch, M., MacArthur, S. K., & Ward, K. S. (2018, July). Using simulation to cross-train staff and build effective teams. Clinical Simulation in Nursing, 20, 1-6. https://doi.org/10.1016/ j.ecns.2018.04.002.

� 2018 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Hospitals continuously trim budgets. Because staff salaries and benefits are the highest expenses, hospitals seek innovative ways to maximize nursing resources. Merging units is often viewed as cost-effective. For staff nurses involved in such mergers, the idea of working with unfamiliar patient populations can be intimidating. The use

@mtsu.edu (S. C. Moore).

ernational Nursing Association for Clinica

2

of high-fidelity human patient simulation with unfolding scenarios can be used to both cross-train staff and to enhance perceptions of teamwork. This professional devel- opment project was planned and implemented to assist medical surgical nurses experienced in caring for adults to become better skilled in caring for pediatric patients on a newly merged patient unit (pediatrics, adult oncology, and adult medical surgical), 3West.

l Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Cross-Training Teams Using Simulation 2

Background

Lack of teamwork is associated with adverse events. The benefits of good teamwork are well documented: increased patient safety through reduction in falls, fewer

Key Points � Simulation activities can successfully be used to cross-train nursing staff and build effective teams.

� Debriefing may lead to additional problem- solving beyond simply reviewing and evalu- ating the actual simu- lation.

clinical errors, performance improvement, quality end of life care, and improved pa- tient outcome (Figueroa, Sepanski, Goldberg, and Shah, 2013; Garbee et al., 2013; Kalisch and Lee, 2011; Klipfel et al., 2014; Paull et al., 2013). Both the Institute of Medicine and the American Associa- tion of Colleges of Nursing recommend educational in- terventions that engender teamwork (Goliat, Sharpnack,

Madigan, Baker, & Trosclair, 2013). Teamwork must be taught and learned; it requires

practice (Klipfel et al., 2014). Simulation offers effective, interactive clinical learning (Martin, Keller, Long, & Ryan-Wenger, 2016; Paull et al., 2013), providing a venue to practice working as a team. Experiential learning, in a ‘‘no-risk-for-harm’’ setting, has been shown to effectively influence critical thinking, self-efficacy, confidence, satis- faction, and control over practice (Goliat et al., 2013; Klipfel et al., 2014). Simulation has been linked to team- work and patient safety as associated with (a) assessing critical patient physiologic parameters through observation and accurate communication, (b) planning appropriate in- terventions based on current and changing patient informa- tion, (c) intervening to stabilize the situation, (d) evaluating the situation, and (e) becoming part of a team (Lisko & O’Dell, 2010).

In this project, simulation was used to assist experienced direct care staff in learning to care for a different patient population in a safe environment such as a simulation laboratory. Specific aims for the project were (a) to provide information and practice to medical surgical nurses in caring for pediatric patients and (b) to foster team building. A pretest/posttest design using a convenience sample was used.

Sample

This project took place in a 255-bed hospital in the mid- south United States. The sample comprised of 15 registered nurses and 8 nurse technicians assigned to the newly merged unit. Of the 23 people who cross-trained via simulation, all of them completed a pretest, and eight also completed a posttest that measured perceptions of

teamwork. Of these eight, four were registered nurses, and four were techs. These eight were studied for changes in perceptions of teamwork from pre-simulation to post- simulation.

Methods

Setting and Ethics

Institutional review board approval was obtained. Informed consent was acquired from the participants. Training took place in the hospital’s simulation laboratory. The staff had worked together on the new unit (3West) for approximately six months before simulation exercises were conducted. They had received didactic classroom sessions concerning pediatric care before 3West opening. Groups of three to four went through simulation together. They were oriented to the simulation room including the video equipment and the simulator, told briefly how the simulations would proceed, and informed that debriefing would occur after each case; then, the entire process would be debriefed after concluding both the sessions.

Measure

Immediately before the training, participants completed a 10-minute survey, Teamwork Perceptions Questionnaire (TPQ). The identifier used for later matching to a posttest was last four digits of the participant’s employee number.

The TPQ is a 35-item instrument designed and tested collaboratively by the Department of Defense and the Agency for Healthcare Research and Quality as part of a nationally recognized program called Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS 2.0, 2013). Constructs of the survey are team structure, leadership, communication, mutual support, and situation monitoring (Appendix 1). Cronbach’s alpha reliability coefficients for each construct range from 0.88 to 0.95.

Intervention

Project leaders consisted of two nursing faculty experi- enced in high-fidelity simulation using unfolding scenarios, the clinical educator for 3West, and the director of nursing professional development for the hospital. Many hours were spent preparing for the simulation, including (a) planning the flow, (b) checking equipment, (c) preparing the unfolding scenarios, (d) loading the fictitious patients into the simulated electronic record and the simulator, (e) working with 3West manager regarding staff scheduling, (f) making available the hospital’s policies, procedures, and standards of care, and (g) doing a ‘‘dry run’’ one day before the first scheduled session to practice and troubleshoot.

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Cross-Training Teams Using Simulation 3

A Gaumard pediatric simulator was used. HAL� is a life-like, fully responsive wireless simulator. Features include advanced airway management, breathing, circula- tion and color change, hypoxic modeling, active eyes, voice response, venous access, intraosseous infusion, blood pres- sure, and cardiopulmonary resuscitation feedback with defi- brillation, cardioversion, and pacing capabilities. The 3West educator and the director of nursing professional development were both very skilled in the use of this simu- lator. The educator had carefully programmed HAL. There were no conflicts of interest with Gaumard. This was considered a pilot project because of its fairly small scope and the fact that the nursing faculty had never worked with this nursing staff before the training.

The simulation experience took approximately 90 mi- nutes (45 minutes each scenario). Two unfolding patient scenarios were used: (a) a child with asthma exacerbation and (b) an infant with fever, dehydration, and rule out sepsis. The staff were assigned roles by the project leaders. For each scenario, one nurse was the patient’s primary nurse; the second nurse was the charge nurse. Project leaders played the roles of people to whom phone calls were placed, such as physician, laboratory, respiratory, and pharmacy. The tech played his/her customary role, assisting the nurses, taking vital signs, running to get supplies, and so forth. The third nurse played a key role as patient’s mother; this person was ‘‘scripted’’ and was intended to challenge and stress the caregivers. The particular scenarios used were chosen based on frequent diagnoses at this hospital. Full transcripts of the scenarios are available upon request to first author. The hospital’s current transfer forms and procedures were used.

Case 1 A 12-month old presenting with lethargy, fever, and history of vomiting for 12 hours was admitted directly to 3West. Her young mother had no family support. As the staff worked together at the bedside assessing and admitting this patient to 3West, they demonstrated pedi- atric care principles. While the nurses performed proced- ures such as intravenous insertions and collecting specimen, the infant became progressively ill, needing treatment for symptoms of dehydration, fever, and vom- iting. More physician orders were needed, requiring phone calls. The anxious mother needed emotional support. A spinal tap was ordered; the staff demonstrated how to prepare for and accomplish this. A straight catheterization was performed. The staff was expected to think of possible etiology of symptoms as they were assessing the situation and delivering care and asked to verbalize rationale aloud as they made decisions. The project leaders called out vital signs and laboratory and other results as the team responded to the situation. The entire exercise was audio and video recorded. After the infant simulation, the group reviewed their video and then debriefed. The faculty merely guided the discussion.

Case 2 An 11-year old with history of asthma had been admitted to 3West via the emergency room two days before because he had an exacerbation uncontrolled with hourly nebulizers at home. Now he had improved enough to be discharged today. The scenario began with the mother ready to receive discharge instructions.

Roles were switched for the same three nurses and one tech who participated in the infant scenario. The primary nurse worked through the discharge instructions. At one point during the scenario, the patient’s mother went to the parking lot to meet her boyfriend and to smoke. When the mom returned, the cigarette smoke triggered an asthma attack; the boy became dyspneic and began to cough. The situation escalated into severe respiratory distress. The director of respiratory therapy played the respiratory therapist. She used teachable moments regarding the use of the pediatric emergency kit. The child went into respi- ratory failure despite all correct interventions, and the team was required to prepare for and facilitate transfer to the nearest Level I center. After this scenario, debriefing of Case 2 and the overall simulation experience followed. Participants were asked how they felt during the simulation, what they did well, and what they felt needed improvement.

Results

A posttest TPQ survey was distributed to participants two months later. Eight prepost pairs could be matched. Nonparametric Wilcoxon signed ranks test was conducted using SPSS, version 23. Four of the five subscales showed no significant difference in the posttest from pretest. A fifth subscale, situation monitoring, did have a statistically significant change (p < .05; p ¼ .012). A parametric paired samples t-test was conducted and supported this statisti- cally significant difference as well (p ¼ .000).

Discussion

The situation monitoring subscale consists of the following items: (a) effectively anticipating each other’s needs, (b) monitoring each other’s performance, (c) exchanging relevant information as it becomes available, (d) continu- ously scanning the environment for important information, (e) sharing information regarding potential complications, (f) reevaluation of patient care goals when aspects of the situation change, and (g) correcting each other’s mistakes to ensure that procedures are followed properly.

Purposes of this project were to augment cross-training and to foster teamwork. Goals for the project were met. Through video analysis and debriefing, the staff were observed to (a) identify critical patient physiologic param- eters through assessment and accurate communication, (b) plan appropriate interventions based on evolving patient

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Cross-Training Teams Using Simulation 4

information, (c) intervene to stabilize the situation, (d) reevaluate, and (e) become part of a team.

During debriefing, the participants were asked how they felt during the simulation, what they did well, and what they felt needed improvement. The discussion among the staff and the educator was dynamic and exciting. They solved problems together. The staff freely discussed educational needs and actual problems encountered on 3West. One example is that the examination room where children were brought for procedures such as a spinal tap was not well located or equipped. Together, the group brainstormed on how to resolve issues that had arisen since opening 3West. The educator mapped out a plan to address each issue. This was a serendipitous benefit of the debrief- ing sessions.

Conclusions

Although statistical results of the TPQ cannot be general- ized to all populations of nurses because of the small sample in a narrow setting, the value of this experience was tremendous. Recommendations for future research include larger sample, multicentered studies, and deeper explora- tion of situation monitoring.

Quantitative results found during this project reflected what was qualitatively observed by the project leaders and verbalized by the staff participants. During the simulation exercises, the team members anticipated each other’s needs, monitored each other’s performance, exchanged relevant information, continuously scanned the environment for important information, shared information regarding po- tential complications, reevaluated patient care goals when aspects of the situation changed, and corrected each other’s mistakes (situation monitoring). In addition, the group did extra problem-solving regarding the environment of care on 3West. This was a positive, unexpected process outcome and one that is likely to occur in other settings after the merging of units and opening of new units. Key stake- holders were engaged in this process-improvement project,

contributing to lasting ownership and commitment. Project objectives of learning and team building were accom- plished, whereas the additional benefit of meaningful problem-solving regarding 3West environment of care transpired.

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Appendix

Cross-Training Teams Using Simulation 5

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Cross-Training Teams Using Simulation 6

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