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ARTICLE

Simulation Training

Improves Resuscitation Team Leadership Skills of Nurse Practitioners

Amy Ryan, MSN, RN, CPNP-AC, Raheel Rizwan, MD, Brenda Williams, MSN, RN, CPN, CCRN-K, Alexis Benscoter, DO, David S. Cooper, MD, PhD, & Ilias Iliopoulos, MD

Introduction: In the current era of limited physician trainee work hours, limited nurse practitioner orientation times, and highly spe- cialized care settings, frontline providers have limited opportunities for mentored resuscitation training in emergency situations. We aimed to evaluate the effectiveness of a pilot program to improve

Ryan, CICU Nurse Practitioner, Cardiac Critical Care, The rt Institute, Cincinnati Children’s Hospital Medical Center, innati, OH.

eel Rizwan, Cardiothoracic Surgery Research Fellow, Cardiac cal Care, The Heart Institute, Cincinnati Children’s Hospital ical Center, Cincinnati, OH.

da Williams, Simulation Education Specialist, Cardiac Critical , The Heart Institute, Cincinnati Children’s Hospital Medical ter, Cincinnati, OH.

is Benscoter, CICU Attending Physician, Cardiac Critical , The Heart Institute, Cincinnati Children’s Hospital Medical ter, Cincinnati, OH.

id S. Cooper, CICU Attending Physician, Cardiac Critical , The Heart Institute, Cincinnati Children’s Hospital Medical ter, Cincinnati, OH.

Iliopoulos, CICU Attending Physician, Cardiac Critical Care, Heart Institute, Cincinnati Children’s Hospital Medical Center, innati, OH.

flicts of interest: None to report.

espondence: Amy Ryan, MSN, RN, CPNP-AC, Cincinnati dren’s Hospital Medical Center, MLC 1002, 3333 Burnet Ave., innati, OH 45229; e-mail: [email protected]. diatr Health Care. (2019) 33, 280-287

1-5245/$36.00

yright © 2018 by the National Association of Pediatric Nurse titioners. Published by Elsevier Inc. All rights reserved.

lished online November 27, 2018.

s://doi.org/10.1016/j.pedhc.2018.09.006

Volume 33 � Number 3

resuscitation team leadership skills of nurse practitioners using sim- ulation-based training. Methods: Seven nurse practitioners underwent a 4-hour simula- tion course in pediatric cardiac emergencies. Pre- and post-course surveys were conducted to evaluate previous emergency leadership experience and self-reported comfort in the team lead role. The time to verbalization of a shared mental model to the team was tracked during the simulations. Results: The increases in self-reported comfort level in team lead- ing, sharing a mental model, and differential diagnosis were statisti- cally significant. Average time to shared mental model significantly decreased between simulations. Discussion: Simulation can improve code leadership skills of nurse practitioners. These preliminary findings require confirma- tion in larger studies. J Pediatr Health Care. (2019) 33, 280−287

KEY WORDS Advanced practice provider, leadership, nurse practitioner, resusci- tation, simulation, team leader

INTRODUCTION Cardiorespiratory arrest is uncommon in children admitted to hospital. Resuscitation teams are frequently led by front- line providers, such as pediatric physician trainees and nurse practitioners (NPs; de Mos, van Litsenburg, McCrindle, Bohn, & Parshuram, 2006). Cardiac arrests and resuscitation events require the medical team to perform in a time-sensi- tive, emotionally and physically stressful environment. Car- ing for pediatric cardiac patients who arrest requires the medical staff to have additional familiarity with complex car- diac physiology. Cardiac intensive care units (CICUs) are increasingly staffed by acute care−trained NPs who operate fully as frontline medical providers. These NPs typically have a strong background of caring for critically ill patients,

Journal of Pediatric Health Care

with either direct or indirect supervision of the attending physician, but may feel less comfortable leading a resuscita- tion team during an arrest (Hunt, Patel, Vera, Shaffner, & Pronovost, 2009; Hunt, Vera, et al., 2009).

Crisis resource management (CRM) was first developed in the aviation industry as crew resource management and was adapted (and renamed) according to health care needs (Ornato & Perberdy, 2014). There is ample experimental evidence that the majority of medical catastrophes result from system or pro- cess failures that do not account for human error (Cheng, Donoghue, Gilfoyle, & Eppich, 2012). Rather than focusing on human errors, CRM attempts to identify system and pro- cess failures to improve safety using standardized communica- tion tools. It has been used extensively to train emergency health care teams to mitigate human errors and prevent patient harm (Reznek et al., 2003; Weinstock et al., 2005). Applying CRM to code team training provides a framework for teaching nontechnical skills required to lead a team but may not be taught elsewhere in medical training. These skills include information search and structuring, situational awareness,

Rather than focusing on human errors, CRM attempts to identify system and process failures to improve safety using standardized communication tools.

problem solving, clear and explicit communi- cation, and resource management (Hunziker et al., 2011). It has been shown that teaching CRM principles to med- ical residents through the use of simulation can teach communica- tion skills better than lecture-based training.

This, in turn, can lead to improvement in team and event man- agement (Burden et al., 2014).

Simulation is a realistic and safe way to reproduce critical events. It is perfectly suited for presentation of rare but serious events that require rapid and coordinated response. It has gained acceptance in medical training to the point that is con- sidered by some to be superior to traditional experiential train- ing (Kory et al., 2007). It has been suggested that the old practice of “See one, do one, teach one” has now evolved into “See one, simulate many, do one competently and teach every- one” (Vozenilek, Huff, Reznek, & Gordon, 2004, p. 1153).

Despite widespread use of simulation, little is known about its effectiveness in preparing NPs for the role of clini- cal resuscitation team leader. Thus, a high-fidelity simulation course was designed using the concepts of CRM to improve the resuscitation team leadership skills of CICU NPs. It was hypothesized that this course would improve the NPs’ com- fort and confidence levels while leading pediatric emergen- cies and, ultimately, lead to improved code leadership skills.

MATERIALS AND METHODS This study was developed as part of a quality improvement project. It was reviewed and acknowledged by the institu- tional review board of our institution as nonhuman subjects research.

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The NPs evaluated in this project work in a 25-bed CICU caring for medical and surgical cardiac patients ranging from neonates to adults. The unit is staffed 24 hours a day by either a pediatric intensive care fellow or a cardiology fellow, an NP, and an in-house attending physician. There were seven NPs who participated in this study, all of whom are acute care trained. The expe- rience level of these NPs ranged from less than 1 to 9 years. They were all certified in basic and advanced pediatric and adult life support and showed a proactive interest in improving skills relating to leading the resusci- tation of a complex cardiac patient. In response to their request, we developed the “Resuscitation for Advanced Providers” course as a pilot program. The program is specifically designed to enhance team-leading resuscita- tion skills of the NPs in the CICU.

Before introduction of the course, a formal needs assessment was completed with questionnaires filled by the seven NPs. Based on the results, the primary course objective was to improve level of comfort and compe- tence in performing as code team leader. To achieve this objective, we developed the course with a focus on prac- ticing established safety behaviors, team leadership, and teamwork techniques. As secondary objectives, our aim was to identify obstacles to teamwork and communica- tion, increase awareness of resources available for resus- citation emergencies, and identify team level knowledge deficits and latent threats.

The course took place at an offsite simulation center and was conducted from June through August 2016. Each 4-hour course consisted of 30 minutes of didactic education and four simulated cardiac emergencies scenarios. Each NP led four consecutive scenarios. The didactic lecture focused on principles of CRM as described previously. Emphasis was placed on techniques of leadership and principles of team functioning, particularly effective communication. The hope was that improving team leader communication would promote safe and efficient operations, group problem solv- ing, and optimal use of all available resources (Ornato & Peberdy, 2014). The principles of effective communication taught in the course were information sharing though ver- balization of a shared mental model, the use of affirmative and concise statements from the code team leader, and closed-loop communication from all code team members. Additional leadership training included assigning clear roles to each member of the team and prioritization of tasks. Although no education regarding medical management was shared with participants before the simulations, specific leadership behaviors pertaining to management strategies were provided. Leaders were encouraged to monitor for effective cardiopulmonary resuscitation, establish a differen- tial diagnosis, and share their mental model of what was happening in the scenario with the team. Leaders were also required to request and synthesize any data they believed was necessary to diagnose patient and manage care. These data included laboratory study and imaging results; real-time feedback from the course staff; and a rapid, real-time

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All participants reported increased levels of comfort in sharing mental model and in having a team- leading role after the course.

evaluation of the events leading up to the code. Finally, lead- ers were required to verbalize an exit strategy if return of spontaneous circulation did not occur.

The course scenarios were developed by the course fac- ulty and were reviewed by at least one other CICU staff phy- sician. The “Resuscitation for Advanced Providers” course faculty team consisted of a CICU staff physician, CICU NP, and simulation educator. The simulation educator was an individual who had significant previous experience as both a bedside nurse and a nurse educator in our CICU. All mem- bers of the faculty team received formal education in simula- tion training and debriefing before participating as course faculty. Each scenario ran for 20 minutes and was followed by a 30-minute structured debriefing. A standardized debriefing tool was used during all debriefs. Cases were as follows:

� A neonate with hypoplastic left heart syndrome on Postoperative Day 1 after Norwood palliation with acute severe desaturation;

� A neonate with transposition of the great arteries after an arterial switch operation who develops pericardial tamponade;

� A child with newly diagnosed dilated cardiomyopathy who experiences ventricular fibrillation during intuba- tion; and

� An infant with unrepaired tetralogy of Fallot having a hypercyanotic spell.

Two high-fidelity patient simulation mannequins (Sim- Man and SimBaby; Laerdal Medical Inc., Stavanger, NY) were used for these simulations, and vital signs were dis- played on a bedside monitor. Vital signs provided included heart rate, invasive and noninvasive blood pressure, and oxygen saturation. Other physiologic data provided on the monitor included electrocardiogram, end-tidal carbon diox- ide tracing, and central venous pressure. The course facilita- tors controlled the clinical progression according to participating team interventions. The participating team resembled the composition of a clinical team. It consisted of a bedside nurse and other nursing staff, respiratory therapist, and a NP. All team members were expected to deliver care to the standard of a real-life emergency within the limitations of the mannequin. Examples of this are drawing up and administering medications, providing chest compressions when necessary, and advanced airway management.

All NPs who participated as team leaders were asked to complete pre- and post-course questionnaires (Figures 1 and 2). The pre-course questionnaire was designed to assess their experience and the level of comfort in leading resusci- tation events and exercising standard communication techni- ques, such as mental modeling sharing. The post-course questionnaire had similar questions regarding self-percep- tion of performance during the course. Participants were also asked questions to evaluate the course. For both ques- tionnaires, a 5-point (range = 1−5) Likert scale was used. Debriefing sessions had a structured approach and were

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constructed with three elements. For the initial part, partici- pants reflected on individual and team performance. During the second part, the course facilitators prompted discussions about gaps identified in leader and team performance relat- ing to the principles of CRM. The final part focused on issues of medical management and scenario-specific knowl- edge and skills. Efforts were made to avoid lecture-type approaches and to offer critique in a nonjudgmental and safe environment. When performance gaps were identified, an explicit discussion was triggered regarding the drivers (thoughts, assumptions, knowledge gaps) behind subpar performance. Facilitators lead discussions with a series of questions designed to prompt participants to formulate sol- utions using a critical thinking approach to the issues identi- fied during the particular scenario. A standardized debriefing tool was used to maintain constituency between different facilitators. Time to shared mental model was defined as the time from the onset of code event to the time that the team leader clearly and specifically shared his/her thought process regarding causes/next steps and overall action plan in an effective way that resulted in a common understanding by the majority of the resuscitation team. It was tracked in real time to the second by the simulation facilitators.

Statistical Analysis Summary statistics are presented as mean § standard deviated and count (%). Continuous data were compared using the paired t test. Comparison of categoric data was not needed. The data analysis was performed with IBM SPSS, version 24.

RESULTS All seven NPs participated in the course and completed pre- and post-course questionnaires. Self-reported comfort levels were rated on a Likert scale from 1 to 5 (1 = none, 2 = low, 3 = moderate, 4 = high, 5 = expert). Five of seven had less than 5 years of experience in their role and had led less than three real-life resuscitation events. Pre-course, the self-reported comfort level in team leading role and sharing mental model were both rated low to moderate. The self-reported comfort level score in team leading increased from (mean § standard deviation) 2.4 § 0.5 to 3.0 § 0.0 ( p = .03). Time to sharing mental model was tracked for the six of seven NPs who participated in the course. The average time to mental model

sharing decreased from (mean § stan- dard deviation) 3.83 minutes § 0.75 in the first scenario to 2.33 minutes § 0.52 ( p = .017) in the fourth scenario. The self-reported comfort level score (scale = 1 −5) in sharing mental

model increased from 2.4 § 1.0 to 3.5 § 0.5 ( p = .008) and in sharing differential diagnosis from 2.3 § 0.8 to 3.4 § 0.5

Journal of Pediatric Health Care

FIGURE 1. Cardiac resuscitation for advanced providers: Pre-course questionnaire

How many simulations have you participated in?

0 1-3 3-5 5-10 >10

How many times have you functioned as the team lead in a simulation?

0 1-3 3-5 5-10 >10

How many times have you function as the team lead in real code situations?

0 1-3 3-5 5-10 >10

Rate your comfort level functioning in the team lead role in emergent situations

1

None

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Rate your comfort level in sharing your mental model with the team in emergent situations

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Rate your comfort level with determining and sharing you differential diagnosis during emergent situations

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( p = .008). All participants reported increased levels of com- fort in sharing a mental model and in having a team-leading role after the course. The training was believed to be both extremely useful and realistic (both 5/5 on a 5-point Likert scale) by 5 out of 7 (71%) participants and highly recom- mended (5/5 on a 5-point Likert scale) by 6 out of 7 NPs (85%). The results are summarized in the Table and Figure 3.

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DISCUSSION Leading a specialized multidisciplinary team during a resus- citation emergency is a challenging task even for the most experienced of providers. They are required to perform spe- cialized and coordinated tasks rapidly in an evolving situa- tion and in an environment that is emotionally and physically stressful. NPs are increasingly forming the core of

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FIGURE 2. Cardiac resuscitation for advanced providers: Post-course questionnaire

Rate your comfort level functioning in the team lead role in emergent situations

1

None

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Low

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Moderate

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Expert

Rate your comfort level in sharing your mental model with the team

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Moderate

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High

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Expert

Rate your comfort level with determining and sharing you differential diagnosis during emergent situations

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To what extent do you think this course will affect your clinical practice when functioning in the team lead role?

1

Not At All

2

Slightly

3

Somewhat

4

Moderately

5

Significantly

How useful did you find the scenarios?

1

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2

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3

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4

Very

5

Extremely

How realistic did you find the scenarios?

1

Not At All

2

Slightly

3

Somewhat

4

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5

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How likely is it that you would recommend taking this simulation course to other advanced providers in the CICU?

1

Not At All

2

Slightly

3

Somewhat

4

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5

Extremely

frontline providers in highly specialized medical units (Jones & Tucker, 2016). Our study shows that simulation-based training improves the comfort level of NPs in leading a mul- tidisciplinary resuscitation team. Every one of our study par- ticipants reported perceived improvements in their ability to act as team leader, and the average self-reported score increased significantly after the training. Although there are other studies that evaluated simulation as a tool to train NPs

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to effectively manage emergencies in the CICU (Allen et al., 2010; Brown et al., 2018), to our knowledge this is the first study to show that simulation training can effectively teach code leadership skills to pediatric critical care NPs. Pascual et al. (2011) also used simulation to teach leadership skills to NPs; however, no formal didactic education was prepared; instead, the leader observed other NPs in the leadership role between their first and last simulations.

Journal of Pediatric Health Care

TABLE. Average self-reported comfort level of study participants, mean § SD Self-reported comfort level Before training After training p

Team leadership 2.4 § 0.5 3.0 § 0.0 .03 Sharing mental model 2.4 §1.0 3.5 § 0.5 .008 Sharing differential diagnosis 2.3 § 0.8 3.4 § 0.5 .008

Note. All study participants (N = 7) completed pre- and post-training questionnaires. Scale range = 1−5. SD, standard deviation.

FIGURE 3. NP's change in time to shared mental model between first simulation scenario and last. SMM, shared mental model.

(This figure appears in color online at www.jpedhc.org.)

This study used CRM principles to improve the communi- cation and leadership skills of NPs as team leaders in code sce- narios. Previous simulation studies focused on CRM principles during code scenarios and showed improved code leader skills in resident and fellow physicians (Burden et al., 2014; Fernandez Castelao, Boos, Ringer, Eich, & Russo, 2015). Other studies showed improvement in resuscitation performance in simulated emergencies between residents who received CRM training and those who did not (Blackwood, Duff, Nettle-Aguirre, Djogovic, & Joynt, 2014). Finally, CMR training has been shown to improve the ability of the team leader to verbally direct the team during a code by giving direct orders, verbalizing plans, and assigning specific tasks to the team (Fernandez Castelao, Boos, Ringer, Eich, & Russo, 2015). Consistent with previous studies, these results indicate that verbalization by the NPs improved, as indicated by a sig- nificant decrease in the average time to shared mental model from the first simulation to the last. Mental model sharing is a fundamental team communication tool. It creates a common pool of critical information and enables team cognition and coordinated action (McComb & Simpson, 2014). Medical cat- astrophes frequently happen because of lack of full recogni- tion of clinical deterioration. Therefore, the practice of verbalizing a shared mental model early, and ideally before the onset of cardiopulmonary arrest, is strongly recommended for all critical situations. This study indicates that simulation train- ing is an effective way to improve the ability of the resuscita- tion team leader to efficiently share a mental model in a timely manner with the team.

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All study participants found the course scenarios both use- ful and realistic. The course took place in a dedicated high- fidelity simulation center. It was conducted outside normal working hours and flow to deliver uninterrupted, condensed training. Every effort was made to imitate a realistic clinical resuscitation environment. The groups of participants resem- bled clinical practice in terms of clinical composition, equip- ment used, and actions performed. This has been shown to increase emotionality and enhance acquisition of skills and modeled behaviors (Driskell, Johnston, & Salas, 2001). Although only the performance of the team leader was evalu- ated, the education was delivered to the entire participating team (nurses, respiratory therapists, and allied staff). Modern medical practice is based on highly specialized and increas- ingly interdependent health care professionals (McComb & Hebdon, 2013). The CICU is the epitome of such an environ- ment where excellent performance is increasingly dependent on interprofessional collaboration. Clearly, individual compe- tence and accountability is a prerequisite, but research has consistently shown that clinical teams that are focused on individual autonomy lack important coordinated mechanisms and promote the development of silos of specialization (Baker, Day, & Salas, 2006). Despite increased recognition of the significance of interprofessional teamwork, evidence shows that on many occasions it remains problematic (Rob- erts, Madsen, Desai, & Van Stralen, 2005). Multidisciplinary simulation training has been shown to promote effective behaviors such as mutual performance monitoring, collabora- tion, and adaptability (Clements, Curtis, Horvat, & Shaban,

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2015). It is our belief that the multidisciplinary approach and the realism of the scenarios and resuscitation environ- ment offered an added value to the team function, supple-

the multidisciplinary approach and the realism of the scenarios and resuscitation environment offered an added value to the team function, supplementing the improved performance by the team leader.

menting the improved performance by the team leader. A best practice of a resuscitation leader is to promote a style of flat- tened hierarchy, empower the team to share their thoughts, and encourage the team to speak up immediately if there is concern or suggestions regarding actions carried being out (Hunt, Shilkof- ski, Stavroudis, & Nel- son, 2007; Ornato & Peberdy, 2014).

This study has several limitations. It is a small

pilot study from a single institution. Therefore, the results should be viewed with caution. As mentioned, this study was initially developed as a quality improvement project with the objective of providing training and improving per- formance of the entire CICU NP team. Therefore, no provi- sions for a control group were made. However, it sets the groundwork for larger controlled studies to confirm the validity and generalizability of these findings.

Assessment of leadership performance during resuscita- tion is very challenging and is a limitation of this study. Fur- thermore, the training was offered to the entire team, rendering improved team performance as a potential con- tributor to improved leader performance. It is known that changing performance expectations of otherwise lower-sta- tus team members can successfully change team behavior (Hunt et al., 2007). The aim was to provide a realistic resus- citation environment and used real clinical team members rather than actors. The participants’ self-monitoring of per- formance, which has been previously shown to be feasible and valid, was used despite inherent subjectivity (Stocker et al., 2013). Nonetheless, the objective that measured data of performance on a vital communication tool, such as time to sharing mental model, points to improved performance and provides reasonable confidence that what was observed was a real effect.

Finally, this study does not establish a relationship of improved performance during resuscitation with improved patient outcomes. It evaluated performance at only one point in time and provided no information on sustainability of observed improvement. However, in the era of lifelong learning, simulation can be offered as an ongoing educa- tional program to ensure acquisition and consolidation of skills over time. It can serve as an important educational tool to provide a critical threshold of skills and knowledge. It can also provide a safe transition to mentored, supervised learning in real-life clinical situations.

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This study reports the findings from a pilot study of acute care pediatric NPs. A combination of didactic educa- tion and simulation training can be used for teaching resus- citation skills for providers who aim to operate in the team leader role. Simulation-based training might enable pediatric health care providers to train to perfection and increase the chances of optimal delivery of care under emotionally chal- lenging and high-risk conditions. These preliminary findings need to be tested in a larger cohort of providers to deter- mine generalizability.

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Pascual, J. L., Holena, D. N., Vella, M. A., Palmieri, J., Sicoutris, C., Selvan, B., . . . Schwab, C. W. (2011). Short simulation training improves objective skills in established advanced practitioners managing emergencies on the ward and surgical intensive care unit. Journal of Trauma-Injury Infection & Critical Care, 71, 330–338.

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