The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department.

OBJECTIVES: The emergency department (ED) has been recognized as a high-risk environment for workplace violence. Acutely agitated patients who perpetrate violence against healthcare workers represent a complex care challenge in the ED. Recommendations to improve safety are often based on expert opinion rather than empirical data. In this study we aim to describe the lived experience of staff members caring for this population to provide a broad perspective of ED patient violence. The findings of this study will contribute to the development of a comprehensive framework for ED agitated patient care that will guide safety interventions. METHODS: We conducted uniprofessional focus groups and individual interviews using a phenomenologic approach with emergency medicine resident physicians, ED staff nurses, patient care technicians, and hospital police officers at an urban hospital in New York City. Audio recordings were transcribed and coded for thematic analysis using the constant comparison method. RESULTS: We reached theoretical saturation with 31 interprofessional participants. Three broad themes emerged from our analysis: 1) ED healthcare workers provide high-quality care to a marginalized patient population that concurrently poses safety threats, creating a patient care paradox; 2) teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals; and 3) environmental challenges and systems issues both in and outside the ED exacerbate threats to safety. CONCLUSION: The experience of ED staff members while caring for agitated patients is complex and multidimensional. We identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment, and system levels. Future research is needed to determine applicability of our findings across institutions to build a comprehensive framework for ED agitated patient care.

Making an "Attitude Adjustment": Using a Simulation-Enhanced Interprofessional Education Strategy to Improve Attitudes Toward Teamwork and Communication.

INTRODUCTION: Health care providers must effectively function in highly skilled teams in a collaborative manner, but there are few interprofessional training strategies in place. Interprofessional education (IPE) using simulation technology has gained popularity to address this need because of its inherent ability to impact learners' cognitive frames and promote peer-to-peer dialog. Provider attitudes toward teamwork have been directly linked to the quality of patient care. Investigators implemented a simulation-enhanced IPE intervention to improve staff attitudes toward teamwork and interprofessional communication in the emergency department setting. METHODS: The 3-hour course consisted of a didactic session highlighting teamwork and communication strategies, 2 simulation scenarios on septic shock and cardiac arrest, and structured debriefing directed at impacting participant attitudes to teamwork and communication. This was a survey-based observational study. We used the TeamSTEPPS Teamwork Attitudes Questionnaire immediately before and after the session as a measurement of attitude change as well as the Hospital Survey on Patient Safety Culture before the session and 1 year after the intervention for program impact at the behavior level. RESULTS: Seventy-two emergency department nurses and resident physicians participated in the course from July to September 2012. Of the 5 constructs in TeamSTEPPS Teamwork Attitudes Questionnaire, 4 had a significant improvement in scores-6.4%, 2.8%, 4.0%, and 4.0% for team structure, leadership, situation monitoring, and mutual support, respectively (P < 0.0001, P = 0.029, P = 0.014, and P = 0.003, respectively). For Hospital Survey on Patient Safety Culture, 3 of 6 composites directly related to teamwork and communication showed a significant improvement-20.6%, 20.5%, and 23.9%, for frequency of event reporting, teamwork within hospital units, and hospital handoffs and transitions, respectively (P = 0.028, P = 0.035, and P = 0.024, respectively). CONCLUSIONS: A simulation-enhanced IPE curriculum was successful in improving participant attitudes toward teamwork and components of patient safety culture related to teamwork and communication.

"The Safety Dance": A Faculty Development Workshop Partnering IPE and Patient Safety Initiatives Using Simulation-Based Education.

INTRODUCTION: Interprofessional collaboration (IPC) is important for improving patient outcomes and patient safety; however, interprofessional education (IPE) is required to develop skills necessary for successful IPC. IPE is resource intensive and requires advance planning and negotiation of logistical challenges. The goal of this faculty development workshop is to train administrators and educators from academic health care institutions to address potential challenges faced during design and implementation of IPE programs. METHODS: This educational module presents best practices for implementing simulation-based IPE to enhance patient safety through an interactive workshop. We utilize hands-on practice with coaching through a facilitated small-group tabletop simulation followed by a large-group discussion driven by the case-based method to maximize learning and engage a diverse audience. The materials associated with the module include a workshop outline, a PowerPoint slide show, and a summary handout for the participants. To facilitate the tabletop simulation and the subsequent large-group discussion, we have included two versions of the small-group prompts, a worksheet for the participants to complete during the tabletop exercise, and a facilitator guide. RESULTS: We have received positive feedback regarding the learning value of the module from faculty attendees at a regional simulation conference as well as the International Meeting on Simulation in Healthcare in January of 2016. DISCUSSION: Implementing simulation-based IPE curricula to address patient safety initiatives comes with a unique set of challenges that require prior training and knowledge. We provide insight and evidence-based strategies in this module to help interested parties successfully implement their own programs.