John T. Paige MD, Deborah D. Garbee PhD, APRN, ACNS-John T. Paige MD, Deborah D. Garbee PhD, APRN, ACNS-BC, Vadym Rusnak MD, Qingzhao Yu PhD, Richard DiCarlo BC, Vadym Rusnak MD, Qingzhao Yu PhD, Richard DiCarlo

MD, Alan Marr MDMD, Alan Marr MD

LSU Health New Orleans (NO) Health Sciences CenterLSU Health New Orleans (NO) Health Sciences Center

New Orleans, LANew Orleans, LA

Surgical Education WeekSurgical Education WeekAssociation for Surgical Education Paper Session #1Association for Surgical Education Paper Session #1

Orlando, FLOrlando, FLApril 23, 2013April 23, 2013

Funding support: LSU Academy for the Funding support: LSU Academy for the Advancement of Educational Scholarship Advancement of Educational Scholarship Educational Enhancement Grant (2011-2012)Educational Enhancement Grant (2011-2012)

Disclosures: Co-editor for Disclosures: Co-editor for Simulation in Simulation in RadiologyRadiology

Promote the adoption of simulation-based Promote the adoption of simulation-based training (SBT) of inter-professional teams to training (SBT) of inter-professional teams to enhance collaboration, teamwork, and patient enhance collaboration, teamwork, and patient safetysafety

Discuss the current status of teamwork in Discuss the current status of teamwork in healthcare and its impact on medical educationhealthcare and its impact on medical education

Describe our simulation-based team training of Describe our simulation-based team training of inter-professional students (TTIPS) programinter-professional students (TTIPS) program

Demonstrate the impact of TTIPS on participants’ Demonstrate the impact of TTIPS on participants’ attitudes toward inter-professional learning and attitudes toward inter-professional learning and teamworkteamwork

Review future directions for TTIPS Review future directions for TTIPS

TEAMWORK IN HEALTHCARETEAMWORK IN HEALTHCARE

What’s this?What’s this?

What’s the What’s the consequence?consequence?

Why?Why?

How do we fix it?How do we fix it?

Bleakley A, J Workplace Learning 2006;18:414-425

Gillespie BM et al, Qual Saf Health Care 2010;19:103-106

Good teamworkGood teamwork

Negates fatigueNegates fatigue

Reduces stressReduces stress

Promotes high Promotes high reliabilityreliability

Poor teamworkPoor teamwork

Lowers collaborationLowers collaboration

Increases stressIncreases stress

Becomes system Becomes system liabilityliability

Firth-Cozens J, Qual Saf Health Care 2001 10(supplI):ii26-ii31 and Baker DP et al, Health Serv Res 2006 41:1576-1598

Core ComponentsCore Components

‒ Team leadership (S)Team leadership (S)11

‒ Mutual performance Mutual performance monitoring (S)monitoring (S)

‒ Back-up behavior (S)Back-up behavior (S)

‒ Adaptability (S)Adaptability (S)

‒ Team orientation (A)Team orientation (A)22

Coordinating MechanismsCoordinating Mechanisms

‒ Shared mental model (K)Shared mental model (K)33

‒ Mutual trust (A)Mutual trust (A)

‒ Communication (S)Communication (S)

Salas E et al, Small Gr Res 2005 36:555-599; 1S=skill; 2A=Attitude; 3K=Knowledge

POOR TEAMWORKPOOR TEAMWORK

TECHNICAL ERRORSTECHNICAL ERRORS

MORBIDITY AND MORTALITYMORBIDITY AND MORTALITY

PATIENT SAFETYPATIENT SAFETY

SENTINEL EVENTSSENTINEL EVENTS

Catchpole K et al, Ann Surg 2008 247:699-706; Mazzocco K et al, Am J Surg 2009 197:678-685;Christian CK et al, Surgery 2006 139:159-173; Kwan et al, Arch Surg 2006 141:352-357

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Funded by the Academy for Advancement of Funded by the Academy for Advancement of Educational Scholarship at LSU Health NOEducational Scholarship at LSU Health NO

2011-2012 Educational Enhancement Grant2011-2012 Educational Enhancement Grant

Outgrowth of prior inter-professional Outgrowth of prior inter-professional undergraduate team training workundergraduate team training work

Target learners Target learners L3 medical and senior L3 medical and senior undergraduate nursing studentsundergraduate nursing students

What is the impact of inter-professional, scenario based high-fidelity simulation training of undergraduate nursing and medical students on team-based behaviors?

How does inter-professional, scenario based high-fidelity simulation training of undergraduate nursing and medical students influence participants’ attitudes toward inter-professional collaboration and learning?

Quasi-experimental in characterQuasi-experimental in character

Matching of participants pre- and post-intervention Matching of participants pre- and post-intervention using unique, self-generated personal identification using unique, self-generated personal identification number (PIN)number (PIN)

Inter-professional education (IPE) with teams of 5 Inter-professional education (IPE) with teams of 5 to 8 studentsto 8 students

Incorporated into general surgery clerkship and Incorporated into general surgery clerkship and senior undergraduate nursing intensive care senior undergraduate nursing intensive care coursecourse

LSUHSC-NO Academy for the Advancement of Educational Scholarship LSUHSC-NO Academy for the Advancement of Educational Scholarship Education Enhancement Grant 2011-2012Education Enhancement Grant 2011-2012

High fidelityHigh fidelitysimulationsimulation

Core coursesCore courses

Inter-Inter-professionalprofessionalteamsteams

Virtual RoomVirtual RoomFour conceptFour concept

ATLS protocolsATLS protocolsShared mental modelShared mental modelOpen communicationOpen communicationAnticipatory responseAnticipatory response

Situational awarenessSituational awarenessResource managementResource managementCross monitoringCross monitoring

Teamwork AttitudesTeamwork AttitudesReadiness for Inter-Readiness for Inter-professional Learningprofessional Learning

Role clarityRole clarityFlattened hierarchyFlattened hierarchyMental rehearsal Mental rehearsal

Two hourTwo hoursessionssessions

Two scenarioTwo scenarioformatformat

DeliberateDeliberatepracticepractice

Clinical Clinical correlationcorrelation

Team-based attitudes Team-based attitudes TeamSTEPPS TeamSTEPPSTMTM Teamwork Attitude Questionnaire (TTAQ)Teamwork Attitude Questionnaire (TTAQ)‒ Given to entire class in June 2011 with f/u June 2012Given to entire class in June 2011 with f/u June 2012‒ Five subscalesFive subscales

Inter-professional learning attitudes Inter-professional learning attitudes Readiness for Interprofessional Learning Readiness for Interprofessional Learning (RIPL) Questionnaire(RIPL) Questionnaire‒ Given to participants immediately before and at the Given to participants immediately before and at the

end of each simulation sessionend of each simulation session‒ Nineteen questionsNineteen questions

Fall 2011 Session Date 9/ 1 9/8 9/15 9/22 10/6 10/13 10/27 11/3 11/10 11/17 Total (N)

Medical Students (N)Session 1 (1-3pm)Session 2 (3-5pm)

43

33

42

23

33

33

32

21

34

24

57

Undergraduate Nursing Students (N)Session 1 (1-3pm)Session 2 (3-5pm)

22

22

22

22

22

22

22

22

22

22

40

Total (N) 11 10 10 9 10 10 9 7 11 10 97

Spring 2012 Session Date

1/19 1/26 2/2 2/9 2/16 2/23 3/1 3/8 3/15 3/22 4/19 Total (N)

Medical Students (N)Session 1 (1-3pm)Session 2 (3-5pm)

32

34

44

33

32

33

64

43

32

43

12

69

Undergraduate Nursing Students (N)Session 1 (1-3pm)Session 2 (3-5pm)

22

22

22

22

22

22

22

22

22

22

22

44

Total (N) 9 11 12 10 9 10 14 11 9 11 7 113

TTAQ Subscales

N (matched) Pre-Training Score, June

2011 (Mean [std dev])

Post-Training Score, June 2012 (Mean [std dev])

∆: June ’12 – June ’11 (Mean

[std dev])

p value

Team structure 122 4.46 (0.36) 4.55 (0.37) 0.10 (0.43) .012

Leadership 122 4.68 (0.38) 4.72 (0.35) 0.04 (0.50) .326

Situation monitoring

121 4.44 (0.45) 4.45 (0.50) 0.01 (0.53) .896

Mutual support 119 3.20 (0.62) 3.47 (0.75) 0.26 (0.72) .000

Communication 118 4.07 (0.40) 4.14 (0.47) 0.08 (0.49) .086

RIPL Questionnaire Itema N (matched)

Pre-Session Scoreb Post-Session Scoreb ∆ (post – pre) b p valuec

Learning with other students will help me become a more effective member of a health-care team

149 4.57 (0.54) 4.77 (0.43) 0.19 (0.55) .000

Patients would ultimately benefit if health-care students worked together to solve patient problems

149 4.68 (0.48) 4.79 (0.42) 0.10 (0.49) .013

Shared Learning with other health-care students will increase my ability to understand clinical problems

148 4.50 (0.60) 4.77 (0.44) 0.27 (0.55) .000

Learning with other health-care students before qualification would improve relationships after qualification

149 4.48 (0.61) 4.77 (0.44) 0.30 (0.58) .000

Communication skills should be learned with other health-care students

149 4.60 (0.54) 4.78 (0.45) 0.18 (0.53) .000

Shared learning will help me think positively about other professionals

148 4.45 (0.62) 4.76 (0.43) 0.31 (0.63) .000

Team-working skills are essential for all health-care students to learn

149 4.64 (0.51) 4.79 (0.41) 0.14 (0.49) .001

Shared learning will help me to understand my own limitations 149 4.44 (0.68) 4.73 (0.53) 0.29 (0.67) .000

I don’t want to waste my time learning with other health-care students

149 1.57 (0.85) 1.41 (0.93) -0.16 (0.88) .027

It is not necessary for undergraduate health-care students to learn together

149 1.71 (0.84) 1.48 (0.94) -0.23 (0.95) .004

Clinical problem solving skills can only be learned with students from my own department

148 1.73 (0.90) 1.61 (1.07) -0.11 (1.08) .200

Shared learning with other health-care students will help me communicate better with patients and other professionals

149 4.40 (0.67) 4.56 (0.86) 0.15 (1.02) .066

I would welcome the opportunity to work on small-group projects with other health-care students

148 4.16 (0.86) 4.61 (0.75) 0.46 (0.80) .000

Shared learning will help to clarify the nature of patient problems

149 4.29 (0.69) 4.70 (0.55) 0.41 (0.68) .000

Shared learning before qualification will help me become a better team worker

146 4.43 (0.61) 4.73 (0.46) 0.29 (0.60) .000

The function of nurses and therapists is mainly to provide support for doctors

147 2.38 (1.13) 2.40 (1.40) 0.02 (1.38) .858

I’m not sure what my professional role will be 148 2.34 (1.09) 2.29 (1.24) -0.05 (1.03) .524I have to acquire much more knowledge and skills than other health-care students

149 3.05 (1.09) 2.78 (1.25) -0.27 (1.06) .002

aScale: 1-strongly disagree, 2-disagree, 3-neutral, 4-agree, 5-strongly agreebMean (standard deviation)cPaired 2 tail t-test

√

√

√

√

√

√

√√√

√

Significant Significant change in 10/19change in 10/19itemsitems

N ranged fromN ranged from 127 to 129127 to 129

Simulation-based IPE improves team-based Simulation-based IPE improves team-based attitudes related to team structure and mutual attitudes related to team structure and mutual support in third year medical studentssupport in third year medical students

Simulation-based IPE improves both medical Simulation-based IPE improves both medical and undergraduate nursing students’ attitudes and undergraduate nursing students’ attitudes toward inter-professional learning.toward inter-professional learning.

Future directions include correlating Future directions include correlating improvement in each measurement with improvement in each measurement with individual learningindividual learning

Vadym Rusnak, MDVadym Rusnak, MD Richard DiCarlo MDRichard DiCarlo MD Alan Marr MDAlan Marr MD Qingzhao Yu, PhDQingzhao Yu, PhD Megan BronsonMegan Bronson

Deborah Garbee PhD, APRNDeborah Garbee PhD, APRN John Paige MDJohn Paige MD

To improve teamwork,To improve teamwork,

we must target...we must target...

those in practice,those in practice,and…and…

those coming up!those coming up!