Using simulation-based interprofessional education to change attitudes towards collaboration among higher specialty trainee physicians and registered nurses: a mixed methods pilot study.

Interprofessional collaboration (IPC) is important for delivering safe patient care and can be enhanced through interprofessional education (IPE). In postgraduate medical education, the most effective model for delivering IPE remains unclear. A multi-site non-randomized mixed methods study was undertaken to investigate the effectiveness of a simulation-based IPE (SB-IPE) intervention on changing attitudes among higher specialty trainee (HST) physicians in general internal medicine and registered nurses (RNs). The intervention, underpinned by intergroup contact theory, is comprised of paired participants (HSTs:RNs) undertaking six simulated scenarios. The Jefferson Scale of Attitudes toward Interprofessional Collaboration (JeffSATIC) was administered pre-and-post intervention. Focus groups were conducted to explore participants' perceptions of IPC and the SB-IPE intervention. Fifty-six participants attended the SB-IPE intervention and 37 completed focus group interviews. Overall, attitudes toward IPC changed positively (p < .001), with greater change among HSTs (p = .001) compared to RNs (p = .12). Attitudes to "working relationships" significantly increased for HSTs (p < .001) but not RNs (p = .047). Focus group analysis identified three processes by which SB-IPE led to attitudinal change: 1) Shared vulnerability, 2) Positive affirmation, and 3) Negotiating professional hierarchies, mainly through relationship building. Further research is needed to investigate the long-term impact of attitudinal change, including the extent to which benefits transfer into practice.

GENESISS 2-Generating Standards for In-Situ Simulation project: a systematic mapping review.

BACKGROUND: In-situ simulation is increasingly employed in healthcare settings to support learning and improve patient, staff and organisational outcomes. It can help participants to problem solve within real, dynamic and familiar clinical settings, develop effective multidisciplinary team working and facilitates learning into practice. There is nevertheless a reported lack of a standardised and cohesive approach across healthcare organisations. The aim of this systematic mapping review was to explore and map the current evidence base for in-situ interventions, identify gaps in the literature and inform future research and evaluation questions. METHODS: A systematic mapping review of published in-situ simulation literature was conducted. Searches were conducted on MEDLINE, EMBASE, AMED, PsycINFO, CINAHL, MIDIRS and ProQuest databases to identify all relevant literature from inception to October 2020. Relevant papers were retrieved, reviewed and extracted data were organised into broad themes. RESULTS: Sixty-nine papers were included in the mapping review. In-situ simulation is used 1) as an assessment tool; 2) to assess and promote system readiness and safety cultures; 3) to improve clinical skills and patient outcomes; 4) to improve non-technical skills (NTS), knowledge and confidence. Most studies included were observational and assessed individual, team or departmental performance against clinical standards. There was considerable variation in assessment methods, length of study and the frequency of interventions. CONCLUSIONS: This mapping highlights various in-situ simulation approaches designed to address a range of objectives in healthcare settings; most studies report in-situ simulation to be feasible and beneficial in addressing various learning and improvement objectives. There is a lack of consensus for implementing and evaluating in-situ simulation and further studies are required to identify potential benefits and impacts on patient outcomes. In-situ simulation studies need to include detailed demographic and contextual data to consider transferability across care settings and teams and to assess possible confounding factors. Valid and reliable data collection tools should be developed to capture the complexity of team and individual performance in real settings. Research should focus on identifying the optimal frequency and length of in-situ simulations to improve outcomes and maximize participant experience.

GENESISS 1-Generating Standards for In-Situ Simulation project: a scoping review and conceptual model.

BACKGROUND: In-Situ Simulation (ISS) enables teams to rehearse and review practice in the clinical environment to facilitate knowledge transition, reflection and safe learning. There is increasing use of ISS in healthcare organisations for which patient safety and quality improvement are key drivers. However, the effectiveness of ISS interventions has not yet been fully demonstrated and requires further study to maximise impact. Cohesive programmatic implementation is lacking and efforts to standardise ISS terms and concepts, strengthen the evidence base and develop an integrated model of learning is required. The aim of this study was to explore the current evidence, theories and concepts associated with ISS across all areas of healthcare and develop a conceptual model to inform future ISS research and best practice guidance. METHODS: A scoping review was undertaken with stakeholder feedback to develop a conceptual model for ISS. Medline, OpenGrey and Web of Science were searched in September 2018 and updated in December 2020. Data from the included scoping review studies were analysed descriptively and organised into categories based on the different motivations, concepts and theoretical approaches for ISS. Categories and concepts were further refined through accessing stakeholder feedback. RESULTS: Thirty-eight papers were included in the scoping review. Papers reported the development and evaluation of ISS interventions. Stakeholder groups highlighted situations where ISS could be suitable to improve care and outcomes and identified contextual and practical factors for implementation. A conceptual model of ISS was developed which was organised into four themes: 1. To understand and explore why systematic events occur in complex settings; 2.To design and test new clinical spaces, equipment, information technologies and procedures; 3. To practice and develop capability in individual and team performance; 4. To assess competency in complex clinical settings. CONCLUSIONS: ISS presents a promising approach to improve individual and team capabilities and system performance and address the 'practice-theory gap'. However, there are limitations associated with ISS such as the impact on the clinical setting and service provision, the reliance of having an open learning culture and availability of relevant expertise. ISS should be introduced with due consideration of the specific objectives and learning needs it is proposed to address. Effectiveness of ISS has not yet been established and further research is required to evaluate and disseminate the findings of ISS interventions.

Using a comprehensive audit to identify local context prior to care bundle design and implementation for inadvertent perioperative hypothermia in colorectal surgery.

BACKGROUND: The first step in bundle design or implementation is to identify the problem being addressed. Several validated approaches are recommended to facilitate this. These include using systematic reviews, adverse event triggers and risk assessment tools. However, these methods do not fully take the local context into account, which will limit the effectiveness of the bundle. AIM: This study explores the potential benefit of using a comprehensive audit to identify an organisation's local context prior to designing and implementing a care bundle. METHOD: A comprehensive audit comprising observations of four patient journeys, interviews with 21 staff and clinical data was carried out at one large National Health Service trust in England. A patient warming care bundle was used as the exemplar. FINDINGS: Each of the three data collection methods identified specific local practices which would be addressed within the planning and implementation stages of a care bundle. These practices would not have been identified through other recommended methods. CONCLUSION: A comprehensive audit, comprising observations, interviews and clinical data is a successful method to identify local contextual issues prior to care bundle implementation.

The VOICE study - A before and after study of a dementia communication skills training course.

BACKGROUND: A quarter of acute hospital beds are occupied by persons living with dementia, many of whom have communication problems. Healthcare professionals lack confidence in dementia communication skills, but there are no evidence-based communication skills training approaches appropriate for professionals working in this context. We aimed to develop and pilot a dementia communication skills training course that was acceptable and useful to healthcare professionals, hospital patients and their relatives. METHODS: The course was developed using conversation analytic findings from video recordings of healthcare professionals talking to patients living with dementia in the acute hospital, together with systematic review evidence of dementia communication skills training and taking account of expert and service-user opinion. The two-day course was based on experiential learning theory, and included simulation and video workshops, reflective diaries and didactic teaching. Actors were trained to portray patients living with dementia for the simulation exercises. Six courses were run between January and May 2017. 44/45 healthcare professionals attended both days of the course. Evaluation entailed: questionnaires on confidence in dementia communication; a dementia communication knowledge test; and participants' satisfaction. Video-recorded, simulated assessments were used to measure changes in communication behaviour. RESULTS: Healthcare professionals increased their knowledge of dementia communication (mean improvement 1.5/10; 95% confidence interval 1.0-2.0; p<0.001). Confidence in dementia communication also increased (mean improvement 5.5/45; 95% confidence interval 4.1-6.9; p<0.001) and the course was well-received. One month later participants reported using the skills learned in clinical practice. Blind-ratings of simulated patient encounters demonstrated behaviour change in taught communication behaviours to close an encounter, consistent with the training, but not in requesting behaviours. CONCLUSION: We have developed an innovative, evidence-based dementia communication skills training course which healthcare professionals found useful and after which they demonstrated improved dementia communication knowledge, confidence and behaviour.

A qualitative evaluation of the role of simulation in policy development for service improvement.

Objective: To evaluate the efficacy of simulation-based techniques to prospectively assess developing polices prior to implementation. Methods: A self-selected sample of nursing staff from a local, acute hospital reviewed a draft intravenous drug administration policy before simulating drug administration of either an infusion or direct injection. The participants completed a postsimulation questionnaire regarding the new policy and simulation, took part in a semistructured interview and were observed during the simulation with their consent. Results: 10 staff attended the simulation. The emergent themes identified a wide range of factors relating to the everyday usability and practicalities of the policy. There were issues surrounding inconsistent language between different clinical teams and training requirements for the new policy. Conclusion: Simulation, using simple scenarios, allows the safe evaluation of new policies before publication to ensure they are appropriate for front-line use. It engages staff in user-centred design in their own healthcare system.

Analysing voice quality and pitch in interactions of emergency care simulation.

Background/aims: In emergency care, healthcare professionals (HCPs) interact with both a patient and their colleagues at the same time. How HCPs regulate the two distinct interactions is our central interest. Focusing on HCPs' use of their voice quality and pitch, a multimodal analysis of the interaction in a simulation training session was conducted. Our aims are (1) to compare the use of HCPs' voice quality and pitch in HCP-patient and HCP-HCP interactions, (2) to examine how different voice quality and pitch function in interaction, and (3) to develop the research methodology so as to integrate multimodal features in emergency care interaction for analysis. Methods: Three HCPs performed a scripted acute care scenario (chest pain) at the simulation centre. The multimodal corpus-based approach was applied to analyse the varying voice pitch and quality of the HCPs, in interactions with a simulated patient (SP) and with two other HCPs, in emergency care training. Results: The HCPs tended to use a clear voice when they talk to an SP and a 'shattered' voice to colleagues in the team. The pitch was raised to talk to an SP, by Helen (a nurse) and Mike (a doctor). Conclusion: This indicates that the HCPs strategically change their voice quality and pitch according to the addressees, regulating the interaction.

Assessing the impact of the introduction of an electronic hospital discharge system on the completeness and timeliness of discharge communication: a before and after study.

BACKGROUND: Hospital discharge summaries are a key communication tool ensuring continuity of care between primary and secondary care. Incomplete or untimely communication of information increases risk of hospital readmission and associated complications. The aim of this study was to evaluate whether the introduction of a new electronic discharge system (NewEDS) was associated with improvements in the completeness and timeliness of discharge information, in Nottingham University Hospitals NHS Trust, England. METHODS: A before and after longitudinal study design was used. Data were collected using the gold standard auditing tool from the Royal College of Physicians (RCP). This tool contains a checklist of 57 items grouped into seven categories, 28 of which are classified as mandatory by RCP. Percentage completeness (out of the 28 mandatory items) was considered to be the primary outcome measure. Data from 773 patients discharged directly from the acute medical unit over eight-week long time periods (four before and four after the change to the NewEDS) from August 2010 to May 2012 were extracted and evaluated. Results were summarised by effect size on completeness before and after changeover to NewEDS respectively. The primary outcome variable was represented with percentage of completeness score and a non-parametric technique was used to compare pre-NewEDS and post-NewEDS scores. RESULTS: The changeover to the NewEDS resulted in an increased completeness of discharge summaries from 60.7% to 75.0% (p < 0.001) and the proportion of summaries created under 24 h from discharge increased significantly from 78.0% to 93.0% (p < 0.001). Furthermore, five of the seven grouped checklist categories also showed significant improvements in levels of completeness (p < 0.001), although there were reduced levels of completeness for three items (p < 0.001). CONCLUSION: The introduction of a NewEDS was associated with a significant improvement in the completeness and timeliness of hospital discharge communication.

Simulated patients versus manikins in acute-care scenarios.

BACKGROUND: Manikins and simulated patients (SPs) are commonly used in health care education and assessment. SPs appear to offer a more realistic experience for learners than 'plastic' manikins, and might be expected to engender interactions that approximate real clinical practice more closely. The analyses of linguistic patterns and touch are methodologies that could be used to explore this hypothesis. Our research aims were: (1) to compare verbal interactions and the use of procedural touch by health care workers (HCWs) in scenarios with SPs and with manikins; and (2) to evaluate the methodologies used to inform a large-scale study. METHODS: We conducted a pilot preliminary comparative study on conversations and touch in two scenarios in emergency care training, each performed using an SP and a high-fidelity manikin. The setting was a simulation centre. Two scripted acute-care scenarios (chest pain and acute breathlessness) were performed using both an SP and a high-fidelity manikin. Audiovisual recordings were subsequently analysed. Two teams comprising a clinician (medical student), a senior nurse and a clinical support worker took part in the study. The linguistics research methodology integrated a multimodal corpus-based approach and discourse analysis. Simulated patients appear to offer a more realistic experience for learners than 'plastic' manikins RESULTS: Overall, HCWs had far more interactions with the SPs than with the manikins, and the utterances and behaviours were more akin to what one would expect in real clinical practice. HCWs used procedural touch without the patient's permission much more frequently with the manikin. DISCUSSION: These methodologies offer opportunities for further research projects studying interactions with SPs, manikins and real clinical practice.

Implementing human factors in clinical practice.

OBJECTIVES: To understand whether aviation-derived human factors training is acceptable and useful to healthcare professionals. To understand whether and how healthcare professionals have been able to implement human factors approaches to patient safety in their own area of clinical practice. METHODS: Qualitative, longitudinal study using semi-structured interviews and focus groups, of a multiprofessional group of UK NHS staff (from the emergency department and operating theatres) who have received aviation-derived human factors training. RESULTS: The human factors training was evaluated positively, and thought to be both acceptable and relevant to practice. However, the staff found it harder to implement what they had learned in their own clinical areas, and this was principally attributed to features of the informal organisational cultures. CONCLUSIONS: In order to successfully apply human factors approaches in hospital, careful consideration needs to be given to the local context and informal culture of clinical practice.

The temporal rating of emergency non-technical skills (TRENT) index for self and others: psychometric properties and emotional responses.

BACKGROUND: To enhance the non-technical skills (NTS) assessment literature by developing a reliable and valid peer and self-assessment tool for NTS in a simulated ward setting to include emotional reactions: the Temporal Rating of Emergency Non-Technical skills (TRENT) Index. The paper aims to document (1) the psychometric properties of the TRENT index (e.g., reliability, idiosyncrasy biases) and (2) its validity in terms of performance-emotional associations in the high fidelity simulated ward environment. METHODS: Two samples of doctors (Ns =150 & 90) taking part in emergency simulations provided both self and peer-assessment of NTS, with the second sample also providing self-assessments of mood. The psychometric properties of the TRENT were explored for self- and peer-assessment, and pre- and post-simulation environment mood was used to assess validity. RESULTS: A psychometrically reliable and valid 5-factor assessment of NTS was developed. While there was evidence for both intra-rater and inter-rater reliability, inter-rater idiosyncrasy was also observed. Self-rated, but not peer-rated, negative performance was positively associated with post simulation negative mood. CONCLUSION: These are the first results that pertain to inter-, intra-rater reliability as well as idiosyncratic biases in NTS assessment and the first to show that simulator performance can influence mood after assessment. Potential clinical carry-over effects of mood are discussed.

Teaching patient safety and human factors in undergraduate nursing curricula in England: a pilot survey.

Patient safety is a key priority for all healthcare systems, and there is growing recognition for the need to educate tomorrow's nurses about the role of human factors in reducing avoidable harm to patients. A pilot survey was sent to 20 schools of nursing in England to explore the teaching of patient safety and human factors. All 13 schools that responded (65% response rate) stated that patient safety was covered in their curricula and was allocated more than 4 hours; all the classes included human factors. Only two respondents indicated their teaching to be multi-professional. Awareness of the World Health Organization's multiprofessional patient safety curriculum guide was poor. Faculties also seemed unaware that the Institute for Healthcare Improvement provides free online patient safety modules for students and that there is a global network of student patient safety chapters.

Efficacy of transversus abdominis plane blocks in laparoscopic colorectal resections.

BACKGROUND: The increasing use of laparoscopic techniques for colorectal resections means that the issue of postoperative analgesia needs to be reassessed. This nonrandomized comparative study aimed to assess the efficacy of the transversus abdominis plane (TAP) block in laparoscopic colorectal resections. METHODS: Prospectively collected data from consecutive patients undergoing laparoscopic colorectal resections were used. Analgesia usage and outcome data for patients who had a TAP block and a postoperative morphine patient-controlled analgesia pump (PCA) were compared with those for patients who had a PCA alone. RESULTS: Data for 74 patients were used in the final analysis (40 TAP/PCA and 34 PCA alone). There was a significant reduction in overall intravenous opiate use in the TAP/PCA group (31.3 vs. 51.8 mg; P = 0.03). The TAP/PCA group showed a slight trend toward a shorter hospital stay (3 vs. 4 days; P = 0.17) but no difference in postoperative complications or any other outcome measure. There was no procedure-related morbidity relating to the use of TAP blocks. CONCLUSIONS: It appears that TAP blocks reduce postoperative analgesia use of patients undergoing laparoscopic colorectal resections within an enhanced recovery program, and this may have an impact on their postoperative hospital length of stay.