the impact of simulation on healthcare team training.

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Featured Article

Multidisciplinary Simulation-Based Team Training: Knowledge Acquisition and Shifting Perception

Melinda J. Cory, MDa,b,*, Kiran B. Hebbar, MDb, Nora Colman, MDb, Ashley Pierson, BSN, RN, CCRN, NPD-BCc, Shanelle A. Clarke, MDa aSibley Heart Center Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA bDivision of Critical Care, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA cThe Heart Center at Children’s Healthcare of Atlanta, Atlanta, GA, USA

KEYWORDS crisis resource management;

pediatric cardiology; pediatric intensive care; simulation; team training

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e front matter � 2020 Int 0.1016/j.ecns.2020.01.00

Abstract Background: A multidisciplinary simulation-based team training workshop was implemented to improve the knowledge and application of crisis resource management (CRM) principles in the pediatric cardiac intensive care unit. Methods: The workshop consisted of two scenarios followed by structured debriefing. The participants were asked to complete a survey, before and three months after the workshop, evaluating the knowl- edge base of CRM principles and perception of team dynamics. Results: The initial survey was completed by 144 participants; the follow-up was completed by 72 par- ticipants. There was a significant knowledge gap before the workshop, particularly in the areas of closed- loop communication and key principles for effective communication, which improved after the workshop. There was improvement in the perception of team performance three months after the workshop. Conclusions: This study shows that a multidisciplinary simulation-based team training in the pediatric cardiac intensive care unit improves knowledge of CRM principles in addition to improved perception of effective teamwork.

Cite this article: Cory, M. J., Hebbar, K. B., Colman, N., Pierson, A., & Clarke, S. A. (2020, April). Multidisciplinary simulation-based team training: Knowledge acquisition and shifting perception. Clinical Simulation in Nursing, 41(C), 14-21. https://doi.org/10.1016/j.ecns.2020.01.001.

� 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

ecific grant from funding agencies

fit sectors.

eview board (IRB) of Emory Uni-

ot require IRB review because it

with human subjects as set forth

federal rules. However, informed

ts completing the surveys.

.cory@emory.edu (M. J. Cory).

ernational Nursing Association for Clinic

1

The pediatric cardiac intensive care unit (pCICU) is a highly specialized unit that depends on a cohesive multi- disciplinary team. The patient population within the pCICU consists of both medical and surgical patients with varied and complex diagnoses, many at risk for rapid deterioration. A recent paper from the Pediatric Cardiac Critical Care Consortium registry reported a cardiac arrest rate of 3.1% in the pCICU with survival to hospital discharge after cardiac

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

Multidisciplinary Team Training 15

arrest of 47% (Alten et al., 2017). Deteriorating medical conditions in the pCICU are common and often times are more complicated to manage and can deviate from the Pe- diatric Advanced Life Support algorithm (Colman, Figueroa, McCracken, & Hebbar, 2019). Management of

Key Points � A simulation-based team training work- shop was successfully implemented in the pediatric cardiac intensive care unit in a multidisciplinary setting.

� All types of providers scored low in areas of communication, and the knowledge of these principles improved after the workshop.

� The workshop improved perceptions of actual team dy- namics and improved individual confidence levels, particularly in inexperienced providers.

such crises involves a multi- disciplinary team of health care providers where clear roles, effective communica- tion, and teamwork are imperative.

Ineffective teamwork and nontechnical skill errors are the root cause of nearly 70% of medical errors and a large contributor to morbidity and mortality in hospitalized patients (Kohn, Corrigan, & Donaldson, 2000; Stocker, Pilgrim, Burmester, Allen, & Gijselaers, 2016). Most health care providers do not receive formal training on effective teamwork, and a team of experts func- tioning as an expert team is more often the result of ongoing learning and training (Stocker et al., 2016). Keeping in line with other high-reliability indus- tries, including the aviation

and nuclear power, health care has incorporated crisis resource management (CRM) principles to train health care teams in an effort to create a culture of safety (Howard, Gaba, Fish, Yang, & Sarnquist, 1992). Simulation-based team training (SBTT) has been used to teach these important principles that are encapsulated in CRM including closed-loop communication, situational awareness, and shared mental models (Allan et al., 2010; Boling & Hardin-Pierce, 2016; Figueroa, Sepanski, Gold- berg, & Shah, 2013; Low, Horrigan, & Brewster, 2018; Stocker et al., 2016; Weaver et al., 2010). Studies have demonstrated that SBTT can instill confidence and pre- paredness for providers and improve team skills (Allan et al., 2010; Figueroa et al., 2013).

In an effort to promote effective team dynamics and ultimately improve patient care, a unit-wide SBTT pro- gram was implemented in the pCICU. The aim of this program was to improve the knowledge and application of CRM principles and to have a positive effect on team dynamics in the pCICU. We hypothesized that the SBTT would improve CRM knowledge and improve team dynamics among providers.

Theoretical Framework

The educational framework for this simulation workshop was based on Kolb’s Experiential Learning Theory. The learners participated in the simulation providing concrete experience and then reflected on their actions during the structured debrief session, providing the opportunity for reflective observation. During the structured debrief, the learners were encouraged to think of different actions they could have taken and to generalize these topics to other situations they have been in, allowing for abstract concep- tualization. Finally, the participants were able to participate in a second simulation scenario that allowed the learners to use active experimentation on the concepts that were discussed (Kolb, 1984).

Materials and Methods

Clinical and Simulation Setting

An SBTT workshop was implemented in the pCICU from March to May 2017. The hospital where the study was conducted is a freestanding 272-bed pediatric teaching hospital with a 27-bed pCICU and approximately 600 cardiopulmonary bypass surgical cases annually. The institutional review board determined that this study was institutional review board exempt; however, informed consent was obtained from all participants completing the surveys.

Over the three-month training period, 26 workshops were conducted, each lasting approximately four hours. Every nurse (RN), respiratory therapist (RT), cardiology fellow, cardiothoracic advanced practice provider (APP), and attending cardiac intensivist who are involved in patient care in the pCICU were required to participate in the training. Each workshop consisted of a multidisci- plinary team of learners, including five to six RNs, one RT, one APP when available, and one physician (either a cardiology fellow or cardiac intensivist).

The simulations were conducted ‘in situ’ in a patient room in the pCICU with the equipment and supplies used for real patients in the pCICU (including ventilators, code cart, defibrillator, etc.). A high-fidelity manikin, Gaumard Super Tory (Gaumard Scientific, Miami, FL), was used. Basic vital signs, including intracardiac pressure tracings, pulse oximetry, and electrocardiography, were displayed on a bedside monitor. An electronic medical record was created for the scenario to display labs and radiographs and for real-time charting.

Each scenario was preprogrammed based on a detailed script including manikin settings, trained embedded partic- ipants, and facilitator triggers in an effort to standardize the training and minimize variation in participant experience. Scenarios were not videotaped. Three members of the

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Multidisciplinary Team Training 16

simulation team, two facilitators and one simulation techni- cian, conducted each workshop. The two facilitators con- sisted of one pediatric intensivist and one simulation educator. The facilitators have extensive experience in delivering simulation and underwent structured training in debriefing. The facilitators conducted the orientation, served as embedded participants in the scenarios (as ancillary personnel) based on the predetermined script, and conducted the debriefing after the scenarios. The simulation technician operated the manikin and made scripted phone calls to the learners. The scenarios were rehearsed and refined before implementing in the workshop.

Participant Orientation

Each session included a scripted 10-minute briefing, which included an introduction to simulation, objectives for the training session, clarification of participants’ and facilita- tors’ roles, logistics and timing of the session, and manikin introduction. Learners were able to examine the manikin during this time and were informed of the limitations of the manikin and that the physical examination findings would be described by the facilitator. Participants were also oriented to the location and availability of nursing equipment including syringe pumps, computers, medica- tions, and respiratory equipment.

Simulation Scenarios

Each workshop consisted of two scenarios, which were designed based on real-life emergencies encountered in the pCICU. The first case consisted of a 5-day-old infant with pulmonary atresia with ventricular septal defect, postop from Blalock-Taussig shunt placement earlier in the day, intubated with an open chest that develops cardiac tampo- nade. For this case, an open chest patch was created with a setup for fluid to be infused to create the perception of a bulging patch. The second case consisted of a 3-month-old with hypoplastic left heart syndrome s/p Norwood with Sano shunt presenting from home with fever, vomiting, and diarrhea who became hypotensive and bradycardic, ulti- mately resulting in cardiac arrest.

After the participant orientation, the first scenario was conducted, lasting 10 minutes. The first scenario was followed by a structured debrief. Then the second scenario was conducted, lasting 15 minutes, which was then followed by a second structured debrief. All learners participated in both scenarios. Physicians, APPs, and RTs maintained their roles in both scenarios, whereas the RNs rotated between being a primary patient nurse and resource nurse. The team leader (TL) assigned the specific roles of the resource nurses during the scenario.

The team members were asked to assess and act on the information obtained from examining the manikin and from the vital signs as they would in an actual clinical scenario.

The progression of the scenario was controlled by the simulation technician in real time in response to the interventions made by the care team.

Specific teamwork objectives were preidentified for each scenario related to principles of CRM and included identifi- cation of TL, role assignment, role clarity, flattened hierarchy, sharing mental model, and closed-loop communication.

Debriefing

Each of the scenarios was followed by structured debriefing led by two facilitators. The debrief script included a short introduction to the content of the debrief and provided the facilitators with the learning objectives for each scenario. The debriefing consisted of three phases: (1) reaction phase (5- 10 minutes) where participants were asked to share their initial feelings after the scenario, (2) descriptive phase (5 minutes) where the primary nurse and physician were asked to give a one-line summary of what had occurred clinically in the scenario, and (3) the analysis phase (15- 20 minutes) where facilitators aimed to assess the learners’ frame and close any performance gaps. The facilitators used the PEARLS debriefing framework (Eppich & Cheng, 2015). Debriefings allowed for learner-focused facilitation, which allowed the facilitators to adapt the discussion to the needs of the learner. In addition to learner-focused facilitation, directive feedback and facilitator-focused discussion ensured consistency and that the key objectives were discussed. Con- tent of the debriefings were focused on teamwork behaviors based on the learning objectives which included (1) identifi- cation of TL, (2) leadership qualities, (3) role assignment, (4) role clarity, (5) flattened hierarchy, (6) sharing mental models, (7) closed-loop communication. Any medical errors that were made during the scenario were addressed; however, the medical decision-making was not the focus of the debrief- ing session but rather on team skills.

Program Assessment

Participants were asked to complete a survey before and three months after the workshop. The survey was the same at each time point and consisted of six demographic questions, ten questions assessing knowledge of CRM principles, and eleven questions pertaining to perception of current team dynamics. The survey was investigator-created. The ques- tions were created using a previously validated clinical assessment tool based on CRM components as inspiration (Colmanet al., 2019; Guise et al., 2008). The perceptionques- tions were weighted with a 5-point Likert scale and were in- tended to assess each person’s confidence level and their perception of how the members were functioning as a team during actual patient care in the pCICU. The knowledge- based questions were fill-in-the-blank questions and graded as either correct or incorrect by two blinded experts in

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Multidisciplinary Team Training 17

CRM principles. The two experts agreed on all graded re- sponses except for one response. For this disagreement, a tiebreaker was completed by a third expert. The survey did not have mandatory questions and could be exited at any time.

Statistical Analysis

Cardiology fellows, APPs, and attending cardiac intensivist were combined into one group, the TLs, as this is the role that these participants filled in the scenarios. Participants who made no effort on the knowledge-based assessment were excluded from that portion of the analysis. If a participant filled out one of the questions, the blank questions were counted as incorrect.

Data were summarized using descriptive statistics such as medians and interquartile ranges (IQRs) or counts and percentages as appropriate. Categorical variables such as years of experience in the pCICU and experience with team training were compared among level of profession groups using chi-square tests. Continuous variables such as the Likert responses for the perception of team dynamic questions were compared among the profession groups using the KruskaleWallis test. If KruskaleWallis tests demonstrated significance, pairwise comparisons were conducted using the Dwass-Steel-Critchlow-Fligner method to determine pairwise group differences. Statistical analyses were performed using SAS v. 9.4 (SAS Institute, Cary, NC), and significance was assessed at the 0.05 level.

Results

One hundred forty-four participants completed the pre- workshop survey, consisting of 99 RNs, 18 RTs, and 27 TLs (5 APPs, 12 fellows, 10 attending physicians). The baseline

Table Baseline Experience of Participants

Characteristics N (%)

Total (N ¼ 144)

Registered N (N ¼ 99)

Experience in role <1 year 13 (9%) 7 (7%) 1-5 years 52 (36%) 37 (37%) 5-10 years 30 (21%) 24 (24%) >10 years 49 (34%) 31 (31%)

Experience in pCICU <1 year 27 (19%) 15 (15%) 1-5 years 48 (33%) 40 (40%) 5-10 years 30 (21%) 22 (22%) >10 years 39 (27%) 22 (22%)

Prior experience with team training 60 (42%) 36 (36%) Prior experience with simulation 115 (80%) 86 (87%)

Note. pCICU ¼ pediatric cardiac intensive care unit. Team leaders ¼ cardiology fellows, advanced practice providers, and attending * Categorical variables analyzed with chi-square tests.

experiences of the participants in their respective role, in the pCICU and in simulation, are summarized in Table. Seventy-two (50%) participants completed the postwork- shop survey, consisting of 51 RNs, eight RTs, and 13 TLs (1 APP, six fellows, six attending physicians). There was no significant difference in the years of experience in their respective professional roles between the profession groups for the preworkshop or postworkshop survey.

Knowledge of Crisis Resource Management Principles

One hundred twelve of the 144 (78%) participants in the preworkshop survey and 40 of the 72 (56%) participants in the postworkshop survey completed the knowledge assess- ment. There were significant knowledge gaps before the course. The median score for all participants before the workshop was 7 (IQR: 5-9), which increased to 8 (IQR: 5.5-9) after the workshop out of 14 possible points. Although this change in score was not statistically signif- icant, there were significant increases in the percentage of correct responses by question (Figure 1). Specifically, the three questions with the lowest initial percentage of correct responses (defining closed-loop communication, identifica- tion of the key principles of effective teamwork, defining target fixation) increased significantly after the workshop.

Before the SBTT workshop, there were discrepancies in correct responses between profession groups. Subgroup analysis demonstrated that the TL group had more correct responses in defining transparent thinking (RN: 81%, RT: 58%, TL: 92%, p ¼ .049), situational awareness (RN: 69%, RT: 42%, TL: 96%, p ¼ .002), and target fixation (RN: 17%, RT: 17%, TL: 44%, p ¼ .020). The remaining questions were answered similarly between the three groups. After the SBTT workshop, there was less

urse Respiratory Therapist (N ¼ 18)

Team Leaders (N ¼ 27) P-Value*

1 (6%) 5 (19%) 3 (17%) 12 (44%) 0.073 4 (22%) 2 (7%) 10 (55%) 8 (30%)

4 (22%) 8 (30%) 2 (11%) 6 (22%) 0.054 3 (17%) 5 (18%) 9 (50%) 8 (30%) 3 (17%) 21 (78%) <0.0001 10 (56%) 19 (70%) 0.004

cardiac intensivists.

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Figure 1 Knowledge of crisis resource management principles for all participants. Change in correct response rate to the fill-in-the-blank questions for all participants before and after the simulation-based team training workshop. Bars represent the percentage of correct re- sponses for each question. The Y-axis displays the principle that was tested in each question.

Multidisciplinary Team Training 18

discrepancy between the profession groups with similar correct response rates.

Additional subgroup analysis demonstrated that the participants with less than five years of experience had a

Figure 2 Change in perceptions of team dynamics based on Role. (A) work in a well-coordinated team before and after the simulation-based ipants who agree that it is easy to identify team members’ roles before a in the percentage of participants who agree that communication break training workshop. (D). Change in the percentage of participants who a the simulation-based team training workshop. * indicates p < .05. Note

significant increase in the correct response rate on how to use closed-loop communication (3.9% to 23.8%, p ¼ .009), otherwise there was no difference based on years of experience.

. Change in the percentage of participants who agree that providers team training workshop. (B). Change in the percentage of partic- nd after the simulation-based team training workshop. (C). Change downs are common before and after the simulation-based team gree that it is difficult to identify the team leader before and after . TL, team leaders.

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Multidisciplinary Team Training 19

Perception of Team Culture and Individual Confidence

Therewere two categories ofperceptionsquestions: individual confidence and team dynamics. Before the SBTT workshop, the overall perceptions of the team dynamics were positive, and this was consistent after the workshop. There was also an overall positive response for individual confidence with an increase in participants that reported being able to effectively delegate responsibilities for tasks (p ¼ .021).

Before the SBTTworkshop, the RN group was more likely to have a positive perception of team dynamics compared with the TL group. After the SBTT workshop, there was no longer a difference between the perceptions of the RN group and TL group (Figure 2AeD). The RT group generally re- sponded similarlyto theRN group,except fora more unfavor- able response to the existence of a flattened hierarchy after the SBTT workshop (p ¼ .004). The perceptions of individual confidence did not differ between the groups before or after the SBTT workshop and were in general positive.

There was a notable difference in reported confidence based on experience level. The participants with greater than five years of experience were more likely to score higher on the individual confidence questions before the workshop. After the SBTT workshop, these differences

Figure 3 Change in individual confidence based on years of experience are effective at delegating responsibilities before and after the simulatio participants who agree that it is easy to identify their role on the team b Change in the percentage of participants who agree that they have c simulation-based team training workshop. * indicates p < .05.

were no longer present because of an increase in the individual confidence of the participants with less than five years of experience (Figure 3AeC).

Discussion

Creating a culture of safety in health care is necessary for reducing errors and improving patient care (Institute of Medicine, 2001; Nieva & Sorra, 2003). Despite the rising awareness, health care providers do not consistently report the perception of a safety culture, and this has been demon- strated in the area of pediatric cardiology and cardiotho- racic surgery (Bognar et al., 2008). CRM principles have been successfully implemented in health care with the goal of creating and improving a culture of safety (Howard et al., 1992). We report the effective implementa- tion of a SBTT workshop, teaching CRM principles in the pCICU for a large group of participants. We demonstrated not only improved perception in team dynamics and indi- vidual confidence but also knowledge acquisition of CRM principles. The improved perception of team dynamics and individual confidence in the pCICU after SBTT is similar to other studies (Allan et al., 2010; Boling & Hardin-Pierce, 2016; Emani et al., 2018; Figueroa et al.,

. (A). Change in the percentage of participants who agree that they n-based team training workshop. (B). Change in the percentage of efore and after the simulation-based team training workshop. (C). onfidence performing their role in a code before and after the

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Multidisciplinary Team Training 20

2013). With team training, it can be difficult to show objec- tive measures of improvement. In this study, we showed improvement in cognitive knowledge surrounding the prin- ciples of CRM with the knowledge-based test. This is important, as understanding these principles is the first step in being able to use them effectively.

There was a significant discrepancy between how the participants perceived the team dynamics and the actual knowledge of CRM principles before the SBTT workshop, which is similar to a study showing a disconnect between perception and performance in cardiopulmonary resuscita- tion skills (Cheng et al., 2015). The overestimating of the perception of team performance has been previously re- ported and is thought to be due to the lack of knowledge sur- rounding the true definition of these teamwork concepts (Colman et al., 2019). Overall in our study, the participants had positive perceptions of how teams were functioning in the pCICU. However, it is concerning that despite the posi- tive perceptions, the correct response rates and the applica- tion of many of the CRM principles in simulation were relatively low, suggesting that these important concepts were not actually being applied during critical events in the pCICU. Two of the questions that focus on how to effectively communicate within a team, closed-loop communication, and the key principles of effective communication were among the lowest correctly answered questions (Figure 1). After the workshop, we saw an increase in correctly answered questions, particularly in the three questions with the lowest scores. Notably, this knowledge acquisition was maintained over time, as we retested the participants 3 months after the training. This is suggestive that the SBTT course met the learning objectives of teaching CRM principles. Based on the follow-up survey results, the partic- ipants continued to have a positive perception of how teams operated in real situations in the pCICU, even with the gained knowledge of ideal CRM principles after the SBTT work- shop. This is suggestive that the participants were translating what was learned in SBTT into actual practice.

Although the SBTT workshop focused primarily on nontechnical skills, the need to use technical skills during the scenario was instrumental in maintaining realism for the participants. The stress of providing care in real time is necessary to transfer the principles to real-life situations (Weaver et al., 2010). Providers have to be able to use the CRM principles for effective team communication while also performing the technical skills to make the scenario more realistic and thus more likely to transfer to real life.

With our subgroup analyses, two important concepts were noticed. First, SBTT should be multidisciplinary. Each respective profession group has a different back- ground and is coming with a different perspective on team dynamics (Huang et al., 2007). For example, the TL group had a higher percentage of participants reporting previous team training (Table). Before the workshop, we demon- strated that nurses in general had more positive perceptions

of how the teams were functioning than the TL group, which may be related to the differences in their previous team training experiences. The SBTT course was equally effective for all of the groups, as there was little difference in how each group reported perceptions of team dynamics after the course. Second, the participants with less experi- ence had a greater increase in their individual confidence after the SBTT. It is not surprising that the providers with less experience feel less prepared to perform their role in a code or to delegate responsibilities, as these are often skills that develop over time. However, providers of all experience levels are expected to care for these complex patients in the pCICU. The SBTT course was effective in improving confidence during crisis situations, particularly for the providers with less than five years of experience.

Limitations

There are some important limitations that must be noted. There is an inherent subjectivity to the questions about perception, and participants may have felt compelled to respond favorably. We attempted to reduce this bias by deidentifying all surveys. In addition, two of the course facilitators were from the pediatric intensive care unit, which is separate from the pCICU at our institution. The partici- pants taking the course do not work with the providers in the pediatric intensive care unit, so this should have also helped reduce the bias. In addition, this survey was not validated. The topics of the questions were based on a previously validated clinical assessment tool using CRM components (Colman et al., 2019; Guise et al., 2008). We attempted to reduce bias by asking both ‘‘positive’’ and ‘‘negative’’ perception questions. For the knowledge-based portion, we specifically used fill-in-the-blank questions to reduce bias. However, the time commitment that comes with fill-in-the- blank-questions likely resulted in the lower response rate we saw with this portion of the survey. The response rate of approximately half at the three-month follow-up survey is also not insignificant and may have affected our results. Finally, we were unable to link the results of our survey to actual patient care and outcomes in the pCICU.

Conclusions

In summary, we have described the effectiveness of a multidisciplinary SBTT in the pCICU in improving both knowledge of CRM principles and in individual confidence during crisis situations. At baseline, there can be a big discrepancy how someone perceives team dynamics and in their knowledge of CRM principles based on their individ- ual background and training. In addition, we have shown that while the perception of good team dynamics may exist in a group, the actual knowledge and application of CRM principles may be low without formal team training. These

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Multidisciplinary Team Training 21

results suggest that repeated SBTT courses, in a multidis- ciplinary setting, to reinforce these principles would be beneficial for optimizing teamwork and improving the culture of safety in the pCICU.

Acknowledgment

The authors would like to acknowledge the simulation educa- tors for the time they committed to this workshop, as well as the simulation technicians who helped program and deliver the scenario. Additionally, we wish to acknowledge the Pediatrics Biostatistics Core for their statistical support of this study.

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