Dr. Posmontier is Assistant Professor, Dr. Kymberlee Montgomery is Assistant Clinical Professor, Dr. Smith Glasgow is Professor and Associate Dean for Nursing, Undergraduate Health Professions & Continuing Nursing Education, Robert Wood Johnson Executive Nurse Fellow, Ms. Morse is Assistant Clinical Professor of Nursing, College of Nursing & Health Professions, Drexel University, and Dr. Owen Montgomery is Chairman and Associate Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania.
This study was funded by The Robert Wood Johnson Executive Nurse Fellows Program and 3PO1-82710-09.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Bobbie Posmontier, PhD, CNM, PMHNP-BC, Assistant Professor, College of Nursing & Health Professions, Drexel University, 245 N. 15th Street, Mail Stop 1030, Room 524, Philadelphia, PA 19102; e-mail: Bp98@drexel.edu.
Transdisciplinary teamwork simulation in health care education may be a key component in reducing medical error among future women’s health providers. Although the hierarchical model of medical care has prevailed thus far and has resulted in individual blame for adverse events, several research studies suggest that promoting a collaborative team approach, incorporating joint responsibility for care, fostering clear delineation of roles, and encouraging effective communication improves patient outcomes and satisfaction and reduces medical error related to health care system failure (Miller, Riley, Davis, & Hansen, 2008; Paige et al., 2009; Robertson et al., 2009). Findings from prior research and recommendations from the Agency for Healthcare Research and Quality (AHRQ) (2010) suggest that team-derived decisions result in less medical error than individual decisions (Freeth et al., 2009; Paige et al., 2009). In the United States, more than 22,000 reported adverse events occur in obstetrics in hospitals each year. Approximately 72% of these incidences have been attributed to failed communication and collaboration between the various members of women’s health teams (The Joint Commission, 2010; Miller et al., 2008). A recent Joint Commission (2010) report indicated that failures in situation monitoring of maternal vital signs and delayed diagnosis had resulted in preventable maternal deaths related to hypertension, pulmonary edema, and cesarean section.
Despite sharing common knowledge, values, and skills, current health care education promotes individual decision making through hierarchical models of care, where students are taught in separate educational silos; this further contributes to poor communication and collaboration (Margalit et al., 2009). In response to the concern for patient safety, the Institute of Medicine (IOM) (1999, 2001) and The Joint Commission (2010) advised implementing transdisciplinary simulated teamwork training experiences in health care education to facilitate provider communication and collaboration to improve patient outcomes.
The purposes of our transdisciplinary simulation education initiative, funded by the Robert Wood Johnson Executive Nurse Fellows Program, were to bridge educational silos and facilitate positive team attitudes based on these effective team competencies among a variety of women’s health care students. Because this was a student program evaluation, institutional review board approval was waived. Our intention of this simulation experience was to assist the students with a shift from individual reactive behaviors during adverse obstetric and gynecologic scenarios to a team consciousness, where each individual member listens to and acts in concert with the rest of the team to improve patient outcomes. In addition, our goal for the various women’s health care students was to minimize hierarchal inequity, which may prevent individual members from alerting each other about ineffective or harmful patient care. Our specific aim for this initial program evaluation was to assess whether a transdisciplinary teamwork simulation experience would improve collaborative attitudes among the following women’s health care providers: medical students, undergraduate nursing students, nurse practitioner students, physician assistant students, nurse anesthetist students, and obstetrics and gynecology residents. The conceptual framework for this simulation experience was based on the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), developed jointly by the AHRQ and the Department of Defense (AHRQ, 2010).
The students were presented with a simulated obstetric emergency scenario involving the management of an unanticipated shoulder dystocia and postpartum hemorrhage in a 25-year-old primigravida who had inadequate prenatal care. The patient was accompanied by her intrusive and verbally challenging mother. The students were charged to collaborate as a team to manage the obstetric emergency, as well as the mother’s behavior.
We used a pretest–posttest comparative design to measure changes in collaborative attitudes among students before and after the transdisciplinary simulation. Collaborative attitudes were measured by the Team Attitudes Questionnaire (TAQ), derived from the AHRQ TeamSTEPPS model (Baker, Krokos, & Amodeo, 2008).The TAQ consists of five collaborative domains, including structure, leadership, situation monitoring, mutual support, and communication. The structure domain measures understanding of role clarity and shared vision. Leadership measures understanding of the leader’s responsibility to provide direction and coordination of team activities. Situation monitoring measures understanding of the need to monitor teammate performance, identify mistakes, and provide constructive feedback. Mutual support measures understanding of anticipating teammate needs. Communication measures understanding of effective exchange of information. Data analysis consisted of descriptive analysis, paired t tests, and post hoc item analysis.
Simulation faculty, consisting of seven physician faculty, 12 nursing faculty, and one physician assistant faculty, received 4 to 6 hours of instruction and orientation, as well as instruction on prebriefing before and debriefing after student participation. Student simulation preparation consisted of a series of discipline-specific online and live faculty lectures, as well as case studies on various obstetric and gynecological conditions. During the simulation prebriefing, students were oriented to the simulation laboratory, which consisted of 10 outpatient rooms and two inpatient urgent care rooms monitored by faculty via in-room cameras, one-way mirrors, or both. Life-sized highfidelity mannequin simulators, anatomic models, computerized patient simulation vital sign monitors, trained live interactive standardized patients, and videotaping of simulated scenarios were used in the transdisciplinary simulation experience. Key faculty members from nursing, medicine, and physician assistant disciplines were trained to critically review both clinical and interpersonal transdisciplinary student team skills, as well as to provide group debriefing after the simulation experience.
A total of 42 transdisciplinary women’s health students participated in the simulation, but seven did not complete the post-test, including one obstetric resident, one nurse practitioner student, four physician assistant students, and one undergraduate nursing student, leaving 35 participants with complete data and reflecting a 21% dropout rate. No reasons were given for student dropout. No significant differences in demographics were noted between those who did and did not complete the posttest. Two thirds of the participants were nurse practitioner (34.3%) and physician assistant (31.4%) students; the remainder represented undergraduate nursing, medical students, and obstetrics-gynecology residents. Most participants were women (82.9%), and many identified themselves as White (68.6%) or African American or Black (25%). Approximately half rated their trans-disciplinary collaboration expertise as well developed (48.6%), and the other half rated their expertise as limited (51.4%).
Findings from analysis of the TAQ suggest significant increases in collaborative attitudes for mutual support (mean [SD], 18.5 [3.4] to 21.2 [4.6], p = 0.001) and communication (mean [SD] 23.3 [2.6] to 25.0 [3.1], p = 0.001), but no significant increases were noted in attitudes about structure, situation monitoring, or leadership from pretest to posttest. No significant differences in results were found between groups on any of the subscales.
Post hoc item analysis of the TAQ found a significant increase in collaborative attitudes for five categories:
- Monitoring the emotional and physical well-being of team members.
- Repeating patient safety concerns until acknowledged.
- Decreasing medical error by increasing information exchange between patients and families.
- Using a standardized method for sharing patient information among team members.
- Preferring to work with team members who ask questions about patient information.
Significant increases were also seen in the rejecting of ideas that team members who ask for help are not competent, providing assistance to another team member is a sign of not enough work to do, and that personal conflict does not affect patient safety.
The pretest Cronbach’s alphas were 0.71 for team structure, 0.83 for leadership, 0.81 for situation monitoring, 0.72 for mutual support, and 0.52 for communication. The Cronbach’s alphas for the posttest were 0.85 for team structure, 0.93 for leadership, 0.93 for situation monitoring, 0.71 for mutual support, and 0.63 for communication.
The findings of this study support the value of a transdisciplinary simulation experience in increasing collaborative attitudes among women’s health care students consisting of medical students, undergraduate nursing students, nurse practitioner students, physician assistant students, nurse anesthetist students, and obstetrics and gynecology residents on mutual support and communication. The results of our study also highlight the need to improve team structure, leadership, and situation monitoring in transdisciplinary simulation education for women’s health care students in future simulations.
The findings of our study also support the results from previous research. Several transdisciplinary simulation research studies also found that the simulation experience improved communication, teamwork, interpersonal skills, and role clarity among participants (Baker, Gustafson, Beaubien, Salas, & Barach, 2005; Baker, Pulling, et al., 2008; Dillon, Noble, & Kaplan, 2009; Freeth et al., 2009; Paige et al., 2009; Robertson et al., 2009). On the basis of our results, we surmise that working alongside others with disparate roles may have increased student sensitivity to the needs of individual members. Rather than imagining interaction with other health care professionals in a distant future, students enjoyed the opportunity to interact and brainstorm in real time, preparing them for more effective interactions after graduation. Students also may have realized that team tasks will not be accomplished without effective communication. In addition, nursing students who are socialized to use caring behaviors when interacting with patients and staff may have provided some measure of influence on physician students and physician assistant students to improve mutual support attitudes.
We also found that group debriefing after participation in simulation exercises is critical to acknowledge the students’ perspective, explore participant decisions and actions in greater detail, and link the experience to authentic patient care. Our multidisciplinary faculty debriefing team was used to contribute to the richness of the transdisciplinary simulation experience and offer another opportunity for role-modeling and learning. Limitations of the study included a small sample size, a convenience sample, self-report, a 21% participant dropout rate, and a lack of validated collaboration measures for physician assistant students.
To improve future simulation scenarios, we plan to incorporate leadership training, as outlined by the AHRQ, in student preparation and prebriefing, as well as embed more leadership opportunities in the simulated case scenarios. We plan to use seven fundamental course modules offered by AHRQ, consisting of PowerPoint® presentations, videos, and group exercises to assist students to fully understand team structure, leadership, situation monitoring, mutual support, and communication prior to the simulation experience (AHRQ, 2010).
On the basis of the findings in the literature, we also plan to further improve student attitudes and understanding of team structure, leadership, and situation monitoring using repetitive distributive training opportunities with interval breaks during future transdisciplinary educational simulations. Results of a large meta-analysis found that repetitive training with interval breaks (distribution effect) may improve team performance compared with massed training without such intervals (Donovan & Radosevich, 1999). In addition, a systematic review of Best Evidence Medical Education—an international group of universities, individuals, and organizations committed to moving medical education from opinion-based to evidence-based practice—cites distributed versus mass education as one of the 10 critical components in high-fidelity simulation to improve teamwork attitudes (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005). However, repetitive training has been used thus far only with health care professional versus health care education students. Because our transdisciplinary simulation has occurred only once thus far, repetitive exposures to transdisciplinary simulation education with interval breaks may facilitate team structure improvement and allow for more self-reflection and subsequent self-correction.
Situation monitoring may also be enhanced by the addition of a perinatal task checklist and a team performance observation tool. In a study by Robertson et al. (2009), in which 22 health care providers participated in Obstetric Crisis Team Training, a perinatal task completion checklist was used to monitor team-work progress in handling a series of mock obstetric emergencies over a 3-day period. Use of the perinatal checklist resulted in progression from 24% to 43% task completion during the first three scenarios to 80% to 100% task completion during the fourth scenario. The perinatal checklist helped the team focus on critical tasks and allowed group reflection, resulting in increased member confidence, competence, team organization, and timely notification of the rapid response team. Simulation participants could also use the perinatal checklist to facilitate orientation to the simulation scenario and simulation equipment, as well as prompt students to identify team mistakes. Finally, exploration of the effects of stress on executive functioning and situation monitoring may help to elucidate how environmental, patient, and situational cues are missed among health care students during mock obstetric emergencies. In a study of 222 anesthetists in Australia, respondents stated that personal stress occurred with poor team communication and that poor communication in turn resulted in procedural delays (Elks & Riley, 2009).
Transdisciplinary simulation educational experiences among women’s health care students may enhance mutual support and communication, which, in turn, could promote better patient outcomes. Because more research has been conducted with health care professional teams, future research should focus on mechanisms to facilitate improvements in collaborative behaviors and attitudes in team structure, leadership, and situation monitoring among transdisciplinary women’s health students.
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