The Journal of Continuing Education in Nursing

Original Article 

Promoting Teamwork for Rapid Response Teams Through Simulation Training

Nora Colman, MD; Abbie Patera, BSN, RN; Kiran B. Hebbar, MD, FCCM

Abstract

Use of teamwork skills during rapid response calls is important in the management of patient decompensation outside of the intensive care unit. The ability of a rapid response team (RRT) to influence patient outcomes depends on early team building and effective team performance. Simulation-based team training (SBTT) has been shown to be effective in teaching nontechnical teamwork skills. Rapid Cycle Deliberate Practice (RCDP) is becoming increasingly popular in simulation-based education. Emerging literature on the application of RCDP suggests this method may be superior to traditional reflective debriefing (TRD) in the acquisition of technical skills related to medical management, but fewer data exist that evaluate application of RCDP in teaching nontechnical teamwork skills. We describe a blended approach, using TRD with RCDP to hardwire teamwork behaviors including role assignment, task delegation, situational awareness, global assessment, and shared mental model to a nursing-led RRT. [J Contin Educ Nurs. 2019;50(11):523–528.]

Abstract

Use of teamwork skills during rapid response calls is important in the management of patient decompensation outside of the intensive care unit. The ability of a rapid response team (RRT) to influence patient outcomes depends on early team building and effective team performance. Simulation-based team training (SBTT) has been shown to be effective in teaching nontechnical teamwork skills. Rapid Cycle Deliberate Practice (RCDP) is becoming increasingly popular in simulation-based education. Emerging literature on the application of RCDP suggests this method may be superior to traditional reflective debriefing (TRD) in the acquisition of technical skills related to medical management, but fewer data exist that evaluate application of RCDP in teaching nontechnical teamwork skills. We describe a blended approach, using TRD with RCDP to hardwire teamwork behaviors including role assignment, task delegation, situational awareness, global assessment, and shared mental model to a nursing-led RRT. [J Contin Educ Nurs. 2019;50(11):523–528.]

Rapid response teams (RRTs) have been created by hospital systems in an effort to improve identification and response to clinical deterioration of patients outside of the intensive care setting (Jones, DeVita, & Bellomo, 2011). Creation of this system aligns with the Joint Commission's 2009 National Patient Safety Goals, which enables health care staff to “request additional assistance from a specially trained individual(s) when the patients' condition appears to be worsening” (The Joint Commission, 2009, p. 2). Ability of an RRT to influence patient outcomes depends on early team building and effective leadership identification, communication, and role clarity in order to manage patients during a medical crisis (Hunziker et al., 2011; Hunziker, Tschan, Semmer, & Marsch, 2013; Manser, 2009).

Simulation-based team training (SBTT) has been shown to be effective in teaching nontechnical teamwork skills (DeVita, Schaefer, Lutz, Wang, & Dongilli, 2005). Rapid Cycle Deliberate Practice (RCDP), a newer and innovative simulation training methodology, applies the concept of overlearning and automatization with the goal of acquiring skills in a short amount of time (Hunt et al., 2014; Kutzin & Janicke, 2015). Emerging literature on the application of RCDP suggests that this method is superior to traditional reflective debriefing (TRD) in the acquisition of technical skills with some showing benefit for nontechnical teamwork skills training (Cory, Colman, McCracken, & Hebbar, 2019; Lemke, Fielder, Hsu, & Doughty, 2019; Patricia, Arnold, & Lemke, 2017). Considering that this novel approach is attracting more interest in the field of education, there is a need to better understand its efficacy and appropriate application (Chancey, Sampayo, Lemke, & Doughty, 2019; Lemke et al., 2019; Taras & Everett, 2017).

Evaluation of our rapid response process highlighted an opportunity for our team to undergo formal training that would provide them with the leadership, teamwork, and communication skills necessary to manage a decompensating patient outside of the pediatric intensive care unit (PICU). We describe how we created and implemented an SBTT program that blended RCDP and TRD in order to teach teamwork performance skills to a nursing lead rapid response team (RRT).

Method

Setting

A SBTT workshop blending RCDP and TRD teaching techniques was implemented in the pediatric critical care division at our hospital in August 2017. Critical care nursing staff and respiratory therapists who respond to rapid response calls outside of the PICU participated in simulation training. The project was determined to be nonhuman subjects research by the institutional review board.

Needs Assessment

The structure of our RRT is unique in that it is a nursing-led team, consisting of one PICU nurse and one respiratory therapist. Non-ICU–based care team members who respond to a rapid response call include the general care area bedside nurse, floor charge nurse or advanced nurse manager, patient care technician, and respiratory therapist. Unlike code blue events, PICU physicians at our institution do not go on rapid response calls routinely and the RRT nurse serves as the team leader. Expectations of the rapid response nurse include patient assessment, communication with the floor team, handoff to the ICU or non-ICU physician, care escalation, or hands-on tasks that may include intravenous catheter placement, fluid administration, and blood draws. Evaluation of the role of the rapid response team members highlighted an opportunity for improvement in teamwork and communication. Prior to implementation of this project, education for RRT members did not include formal training in teamwork.

Identification of Learning Objectives

Specific teamwork objectives were preidentified for each scenario based on the literature describing teamwork skills that are essential to team performance and those thought to be most deficient during rapid response calls (Catchpole, Mishra, Handa, & McCulloch, 2008; Nadkarni et al., 2018). After learning objectives were identified, each was categorized into a hard stop or a soft stop. Hard stop objectives for this training were identified as those thought to be most difficult to learn and essential to hardwire. These objectives were centered around skills needed to be an effective resuscitation leader, which required the nurses to take a step back from the patient, maintain global assessment, anticipate the needs of their team, assign roles, and communicate effectively (Nadkarni et al., 2018). An additional hard stop included a scripted set of questions used to guide the telephone conversation at the initiation of each rapid response call. Soft stops were identified as adjunct skills related to effective gathering of information and shared mental model. Each individual learning objective was anchored to a debrief script to ensure consistency in the language used to teach each skill. A summary of learning objectives is provided in Table 1.

Scenario Description and Learning Objectives

Table 1:

Scenario Description and Learning Objectives

Scenario Development

Scenarios were based on real-life frequently encountered cases, designed with specific learning objectives, and intended to reflect three levels of acuity frequently encountered during rapid response calls at our institution: a patient who required interventions and transport to the ICU, a patient who required intervention but did not meet criteria for an ICU transfer, and a patient who did not require an intervention or escalation of care (Table 1).

Simulation Event

During a 1-month training period, 23 SBTT workshops were conducted. Each workshop was 3 hours and consisted of three scenarios. Each workshop consisted of three PICU nurses and one to two respiratory therapists. Participants attended one single training session. All staff that respond to rapid response calls were required to participate as part of their advanced care competencies.

Debriefing Method

RCDP applies the concept of overlearning and automatization where learners practice a sequence of pre-identified skills repeatedly (deliberate practice) over a short amount of time (rapid cycle) (Hunt et al., 2014). The format of training has been well received by learners who report that frequent interruptions and coaching allow for more optimal skill acquisition and learning through repetition and practice (Chancey et al., 2019; Kutzin & Janicke, 2015). This training method involved use of hard stops and soft stops to hardwire learning objectives. Hard stops occurred throughout the scenario and required the learner to repeat a preidentified critical step in management until they performed the objective to expectation. Soft stops allowed for periods of coaching without requiring the learner to repeat the objective (Hunt et al., 2014; Taras & Everett, 2017).

TRD allowed facilitators to assess the learners' frame and close any performance gaps, allowing for discussion to be tailored to the needs of each learner group. Facilitator-focused discussions concentrated on key objectives including global assessment, identification of team members, role clarity, and positioning of team members around the bedside. TRD provided an opportunity to further discuss these particular concepts, their importance, and application to rapid response calls, in the hopes to generate more buy-in from learners.

Instructional Design

The same three scenarios were conducted in each training session and presented to the teams in the same order. One nurse and one respiratory therapist completed each scenario at a time to reflect the true composition of our RRT. Scenario refers to one clinical simulated scenario, and the cycle refers to the number of times that same scenario was repeated. For the first, most complex scenario (scenario 1), one nurse and one respiratory therapist participated in the scenario uninterrupted. The same learners then repeated the scenario but in an RCDP format where they were paused and coached by the facilitators, based on the predetermined learning objectives. The scenarios were repeated in cycles until all learning objectives were met. Although two learners participated in the scenario, the others observed the simulation as a passive learner. A TRD followed scenario one only. Scenarios two and three were run only in the RCDP format and were not followed by traditional reflective debriefing. Learners rotated roles as the primary nurse in scenarios two and three.

The number of hard and soft stops was consistent among each SBTT session. There was a total of 27 predetermined hard stops for each session. Eight of the hard stops addressed the same teamwork skill and were a required learning objective in all three scenarios. As scenario progression decreased in complexity, the number of hard stops also decreased from 10 in scenario 1, nine in scenario 2, and eight in scenario 3. As the patient required fewer interventions, role assignment and positioning of team members were not included as hard stops.

Evaluation

Data on team performance during the most complex scenario (scenario 1) were collected during simulation training using the Clinical Training Scale (CTS) tool (11-point Likert scale, with 0 = unacceptable and 10 = perfect) (Guise et al., 2008). Both simulation facilitators scored the team's performance following the first uninterrupted cycle and following the final RCDP cycle for scenario one only.

Frequency of hard stops was monitored throughout training. Each time the learner did not meet the objective and required feedback, the facilitator marked a circle on their script identifying which learner, cycle, and objective was being coached.

Postintervention surveys were used to evaluate the learners' simulation experience. Six months following SBTT, learners were asked to describe the frequency in which they applied teamwork skills during rapid response calls. Pre- and postintervention surveys of general care area floor staff were used to evaluate any perceived changes in teamwork following training.

Results

During a 1-month training period, twenty-five 3-hour SBTT workshops were conducted. Seventy-six learners (43 nurses and 33 respiratory therapists) participated. Learners were resource-level staff who were required to have a minimum of 2 years of ICU experience. Mean composite scores for each individual teamwork skill measured on the CTS tool demonstrated that scores improved from a mean prescore of poor (mean range = 1.7 to 3.8) to average/good (mean range = 6.6 to 7.6) following RCDP coaching in scenario 1.

The mean percentage of hard stops was evaluated for the uninterrupted cycle of scenario 1 and each subsequent RCDP cycle (scenario 1, cycle 1 and 2; scenario 2, cycle 1; scenario 3, cycle 1). With each subsequent scenario and cycle, participants required less coaching (Figure 1). Each session generally required three cycles of scenario 1, one cycle of scenario 2, and no cycle of scenario 3.

Mean percentage of hard stops requiring coaching. Note. TRD = traditional reflective debriefing (refers to uninterrupted scenario); S1C1 = scenario 1, cycle 1; S1C2 = scenario 1, cycle 2; S2C1 = scenario 2, cycle 1; S3C1 = scenario 3, cycle 1.

Figure 1.

Mean percentage of hard stops requiring coaching. Note. TRD = traditional reflective debriefing (refers to uninterrupted scenario); S1C1 = scenario 1, cycle 1; S1C2 = scenario 1, cycle 2; S2C1 = scenario 2, cycle 1; S3C1 = scenario 3, cycle 1.

Postintervention survey results indicated that RCDP was well perceived by the learners. Biggest takeaways included identifying the team, delegating tasks, sharing of mental models, global assessment, and improved positioning of team members around the bedside. Postintervention surveys also demonstrated that rapid response team members applied the skills they acquired in simulation to the bedside during rapid response calls. Pre- and postintervention surveys completed by general care area staff members indicated there was a perceived improvement in leadership, role identification, communication, and flattened hierarchy following training.

Discussion

This is the first study to describe a blended approach to SBTT incorporating RCDP with TRD to teach nontechnical teamwork skills to a nursing-led rapid response team. Anecdotal results demonstrate that learners were able to quickly acquire teamwork skills taught during SBTT. Improvement in teamwork skills from a rating of poor to average/good, along with data showing that less coaching was required to achieve learning objectives with each subsequent scenario cycle, demonstrate skill acquisition during training.

Postintervention surveys suggest that RRT members incorporated learned teamwork concepts into their practice and standardized their approach to rapid response calls. Pre- and postintervention surveys assessing the floor staff perception of teamwork behaviors before and after training demonstrated that a greater percentage of staff perceived improvement in the areas of leadership, overall communication, and role clarity.

Most studies have used RCDP to effectively teach technical skills and algorithmic based management (Cory et al., 2019; Hunt et al., 2014; Magee, Farkouh-Karoleski, & Rosen, 2018). Fewer studies have investigated the application of RCDP to teaching teamwork skills, and no studies have yet to blend both techniques. Therefore, this project adds to the limited literature that supports application of RCDP to teach nontechnical teamwork skills (Lemke et al., 2019). In addition, as many RCDP studies evaluate physician learners, this study further supports the application of RCDP in nursing education (Kutzin & Janicke, 2015).

During a rapid response call, a coordinated and efficient exchange of information is essential in the early phase of response to an emergent situation. Yet, application of teamwork skills in an unfamiliar environment with an ad hoc team, where members do not routinely work with each other, is extremely challenging. The RRT's lack of familiarity with the general care area environment, location of supplies, and availability of resources, coupled with anxiety and stress associated with the decompensation of a patient outside of the ICU, increases likelihood of breakdown in teamwork and communication. Teamwork skills essential to the management of medical crises had not been incorporated into advanced competency training up until this point at our institution (Marsch et al., 2004; Roberts et al., 2014). Therefore, the ability to refine, practice, and perform these skills within the context of rapid response calls was prioritized to more effectively manage decompensating patients outside of the ICU.

During simulation training, staff were less comfortable announcing themselves when they entered the room, clarifying the roles of other team members, delegating tasks, positioning themselves at the foot of the bed, maintaining global assessment, and sharing their mental model. Coaching the RRT to announce themselves as the team leader, delegate tasks, clarify and assign roles, stand at the foot of the bed to maintain global assessment, and share their thoughts were difficult concepts initially. However, with repeated practice they began to see the value in these team leadership skills and how taking on the role of the team leader allowed for more efficient care of the patient. RCDP gave our learners the opportunity to practice and hardwire team performance skills, refining these behaviors until they became more comfortable and almost second nature. Multiple scenario cycles also allowed for passive learning, where those not actively participating in the scenario were able to hear feedback and observe the active learner. This may have contributed to skill acquisition by lowering the cognitive load—a benefit reported by learners who participate in RCDP (Chancey et al., 2019). Incorporation of TRD worked synergistically with RCDP and allowed for open discussion to further explore limitations staff perceived in being open to adopting certain skills, in what manner those skills may improve teamwork, and how they could be applied during rapid response calls in particular.

Implementation of an SBTT training program that integrates RCDP with TRD can be tailored to individual institutional needs and used as a methodology to teach teamwork skills to rapid response teams. Benefits to using RCDP as a vehicle for skill acquisition during SBTT is that this training is easier to reproduce, compared with TRD, which requires facilitator training to apply advocacy and inquiry techniques during debriefings. Detailed scripting of objectives allows those with minimal training to conduct future simulations, helping to maintain sustainability of this type of program.

Conclusion

This study describes a blended approach using RCDP and TRD to teach nontechnical teamwork, leadership, and communication skills to a nursing-led rapid response team. Further research is needed to compare RCDP to TRD in terms of superiority in technical and nontechnical skill acquisition, skill retainment, and translation of skills from the simulation environment to bedside practice.

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Scenario Description and Learning Objectives

Scenario DescriptionTeamwork Concepts
Scenario 1: Respiratory failure Case scenario: 5-year-old boy with left middle lobe pneumonia. Rapid response is called for increased work of breathing, desaturations, and tachycardia. Patient is in respiratory failure with hypoxia and is hypotensive. Patient requires initiation of CPAP and an IV fluid bolus by rapid response team. Patient requires transfer to the PICU.Leader identification, role assignment, role clarity, information gathering, situational awareness, global assessment, positioning of team members around the bedside
Scenario 2: Hypotension Case scenario: 4-year-old old boy with ALL admitted for neutropenic fever. Rapid response called for tachypnea and tachycardia. Patient requires initiation of high flow nasal cannula and IV fluid bolus by Rapid Response team. Patient status is discussed with primary care team and does not require transfer to the PICU.Leader identification, information gathering, role clarity, positioning of team members around the bedside, global assessment, situational awareness, resource utilization
Scenario 3: Pain control Case scenario: 3-year-old boy who had surgery for perforated appendicitis. Rapid response is called for pain and tachycardia. Patient requires increased pain medication. Rapid response assists bedside nurse in contacting primary medical team. Patient does not require transfer to the PICU.Leader identification, role clarity, communication, information gathering
Hard StopsSoft Stops
Initial intake questions taken when a rapid response telephone call is made Identification of rapid response by RN and RT Know my team, identification of team members at the bedside Obtains history from bedside nurse RT clarifies who will manage the airway RN and RT communicate their assessment with each other Shares mental model with floor team Uses SBAR to give report to the ICU physician Assigns roles to bedside nurse Identifies a charter and runner Positions the bedside nurse next to the rapid response nurse Clarifies the role of each person in the room Reviews medical decision making and disposition algorithmIntroduction to the family Identifies specific concerns of bedside nurse Performs hands-on assessment and physical examination Rapid response nurse delegates tasks to bedside nurse Shares plan with the floor nurse Provides step back and summarizes plan
Authors

Dr. Colman is Assistant Professor, Ms. Patera is Simulation Educator, and Dr. Hebbar is Associate Professor, Department of Pediatric Critical Care, Medical Director of Simulation, Division of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Nora Colman, MD, Assistant Professor, Department of Pediatric Critical Care, Division of Pediatrics, Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322; e-mail: Nora.Colman@choa.org.

Received: February 21, 2019
Accepted: June 24, 2019

10.3928/00220124-20191015-09

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