Patient safety is defined as “the prevention of errors and adverse effects to patients associated with health care to an acceptable minimum” (World Health Organization, n.d., para. 3). Patient safety is a worldwide phenomenon, as evidenced by conferences being held by the World Health Organization such as the Patient Safety Global Action Summit held in London in 2016 or the conference hosted by the European Society of Intensive Care Medicine (ESICM) in 2010 that aimed to raise patient safety to the top of its scientific agenda. Clinical errors are the third highest cause of death in developed countries and it is estimated that 10% to 16% of people will experience a serious adverse event during their health care experience (Johnstone & Kanitasaki, 2006), with recent measurements suggesting that, adverse events may be the third leading cause of death in the United States (Makary & Daniel, 2016).
Adding to the complexity of adhering to best practices in patient safety is the fact that the United States is known as a cultural melting pot for the world. A recent U.S. Census Bureau report (2015) noted that as many as 350 different languages are spoken in homes throughout the United States, indicating the need for culturally sensitive care for individuals. Research has identified that clinical encounters that do not acknowledge and address cultural factors contribute significantly to adverse patient outcomes and health inequality (Johnstone & Kanitasaki, 2006). Thus, practical strategies for improving the delivery of culturally competent care are needed. There is a paucity of evidence to support best teaching and learning strategies to address cultural competence in undergraduate nursing education (Horvat, Horey, Romios, & Kis-Rigo, 2014). One strategy is known as Tag Team Patient Safety Simulation (TTPSS), which is an innovative strategy aimed to ensure that observers and participants remain actively involved and engaged throughout a simulation exercise.
The concept of TTPSS was first developed in 2014 to address the challenges associated with providing large numbers of learners with engaging simulation experiences, namely, ensuring active participation of all individuals (Levett-Jones et al., 2015). In 2016, TTPSS was extended to focus specifically on patient safety and is now known as Tag Team Patient Safety Simulation, or TTPSS (Levett-Jones et al., 2017).
TTPSS is underpinned by the tenets of Forum Theatre (Boal, 2002), experienced-based learning (Boud, 2000), and the social–cultural perspective of legitimate peripheral participation (Lave & Wenger, 1991). As noted in Table 1, although “Tag Team” does refer to the active tagging in and out, the acronym can be recalled from this elaborate mnemonic on which this framework is based. The TTPSS framework allows for an intervention through the use of antagonist cards and cue cards to initiate everyday challenging situations with the intent of empowering emerging professionals to reduce or prevent harm within a health care environment (Levett-Jones et al., 2015). TTPSS facilitates social relationship formation and provides opportunity for participative experience so each learner has a legitimate role in the simulation, ultimately fostering learning (Levett-Jones et al., 2015). Although research has shown that TTPSS in fact keeps participants and observers engaged in Australian classrooms, which can comprise up to 400 students, no such research has tested the effects of TTPSS on student learning within U.S. classrooms.
Tag Team Simulation
Finally, this simulation focused on communication and cultural assessment. Assessments underpin the delivery of safe practice (Boud, 2000). Although cultural assessments are equally important as other routine assessments, most nursing students have limited opportunities to apply the principles of competent cultural assessment during their learning. The ABCD mnemonic for cultural assessment by Kagawa-Singer and Backhall (2001) provides a structure for undertaking a cultural assessment that is easy to remember and apply to one's practice. The mnemonic stands for A = Attitudes, B = Beliefs, C = Context, and D = Decision-making style. This mechanism is used as a prompt for the assessor to inquire of the patient in the various domains. No specific question is scripted, although this tool is meant to foster culturally appropriate inquiry in a sensitive manner to the patient.
Given the importance of patient safety, the increased complexity of providing care for diverse populations, and the need to provide an engaging and effective way for students to achieve these tasks, this study implemented TTPSS in a palliative care situation in a U.S. nursing classroom and assessed its effects on student learning and understanding of providing optimal care to patients across diverse cultures by using the ABCD mnemonic device. Palliative care delivery often evokes feelings of uncertainty in undergraduate nursing students (Loerzel & Conner, 2016). The main questions this study tried to answer are:
- What effect does TTPSS have on student learning within the context of providing care to culturally diverse and sensitive populations?
- How do students rate their experience when participating in TTPSS?
This study is a replication of a study that originated in Australia and mimics an approach called TTPSS (Levett-Jones et al., 2017). After obtaining institutional review board approval to answer our research questions, a pretest–posttest design with nonequivalent groups was constructed. The participants consisted of 116 undergraduate nursing students across two sections of a required nursing course currently being taught within a traditional baccalaureate nursing program that focuses on examining values, cultural issues, code of ethics, and global and national health care policy as they relate to patient care. Students were invited into the study via the statistician who secured the informed consents. The scenario was then executed under the direction of the principal investigator/teacher. The exercise was a required, nongraded component of the course; however, signed consent was obtained to allow for data collection and publication. The simulation group (n = 43) received the simulation exercise plus the traditional classroom lecture, whereas the nonsimulation group (n = 73) received only the traditional classroom lecture. In both groups, the students were taught the ABCD mnemonic device. Both groups were also instructed to complete assigned readings prior to the intervention.
To assess learning, a modified 10-item knowledge acquisition questionnaire was given to participants via Qualtrics® online survey platform before and after the intervention and in both groups (Levett-Jones et al., 2011). The questionnaire included questions such as:
- When seeking health care, refugees are at an increased risk of all of the following except: (a) medication errors, (b) misdiagnosis, (c) racism and stereotyping, or (d) hospital-acquired infectious disease.
- In the Kagwa-Singer and Backhall ABCD mnemonic for cultural assessment “A” refers to: (a) a person's acceptance of illness, death, and dying; (b) a person's attitude toward illness, death, and dying; (c) a nurse's ability to address the concerns of a person about illness, death, and dying; or (d) a nurse's attitude toward people from CALD background.
One item, which in its original version was specific to the Australian population, was modified to assess knowledge of adverse patient outcomes for limited-English-speaking patients in the United States. Furthermore, the questionnaire for the simulation group also included a 27-item section that assessed participants' experience with the simulation, (i.e., briefing, patient safety, clinical practice, and the debriefing). The Simulation Experience Satisfaction Survey (SSES), a 27-item instrument, adapted for the TTPSS, is composed of four subsets—the briefing subscale (four items), the patient safety subscale (seven items), the clinical practice subscale (six items), and the debriefing subscale (10 items)—which were administered to both groups. The items are rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). In a previous manuscript by Levett-Jones et al. (2011), the psychometric integrity of the SSES revealed it had a Cronbach's alpha of .77 for the total scale, with .94 for the debriefing and reflection subscale, .86 for the clinical reasoning subscale, and .85 for the clinical learning subscale, attesting to its validity and reliability.
One scenario was enacted in a classroom setting that focused on the cultural needs of Nasifah, a 67-year-old woman with advanced metastatic liver cancer requiring home-based palliative care. For this experiment, we focused only on the initial scenario due to time constraints and expertise of students. The scenario is as follows: Nasifah was born in the Kurdish region of Iraq. During the Iran–Iraq war, her family experienced toxic gas attacks and many members of her extended family perished. Before she came to the United States, Nasifah taught economics at the local university; therefore, she speaks fluent English. Nasifah and her family are from a Muslim background. An RN who recently joined the local community-based palliative care team has been asked to conduct an initial home visit and undertake a cultural assessment of Nasifah. Because the RN is new to this role, she is accompanied by a mentor with more experience.
Briefings occurred at three time points. The first was a prebriefing that included all of the class to allow them to have a shared mental model of where this scenario was situated, psychological safety for all, and what the objectives were for this experience. Then, targeted prebriefings were individualized to small groups as classmates volunteered into specific roles. This allowed them to take on the role and prepare for role enactment. Debriefing occurred then at time one, approximately 15 minutes into the scenario. It was done adhering to an advocacy/inquiry model and the author used the PAAIL model specifically to foster learning within the class. The PAAIL is a mnemonic to assist with application for an advocacy-inquiry approach. PAAIL was developed by those at the Center for Medical Simulation and stands for Preview, Advocacy1, Advocacy2, Inquiry, and following up with Listen. It is especially useful for those who engage in learning conversations (Buttimer, n.d.). The scenario was restarted and debriefing then concluded the exercise once again using the PAAIL model.
The hypotheses were:
- The simulation group will have greater effects on knowledge acquisition than the nonsimulation group.
- Treatment participants will have positive attitudes about the simulation experience.
The nonsimulation group (n = 73, M = 5.2877, SD = 1.4670) and the simulation group (n = 43, M = 5.1860, SD = 1.5469) scored similarly on the pretest knowledge assessment questionnaire. An independent sample t test confirmed that there was no significant difference between groups on the pretest. The nonsimulation group (n = 73, M = 6.2740, SD = 1.8124) and the simulation group (n = 43, M = 6.1163, SD = 1.4834) also scored similarly on the posttest. An independent sample t test confirmed there was no significant difference between groups on the posttest (p > .05). Results from paired sample t tests revealed that average scores on the knowledge assessment questionnaire significantly improved for the nonsimulation group (n = 73, M = 0.98630, t [5.781], p = .000, 95% CI [.646, 1.326]) and the simulation group (n = 43, M = 0.93023, t [4.243], p = .000, 95% CI [.4878, 1.37263]). An analysis of covariance confirmed there was no significant difference between the non-simulation and simulation groups, while controlling for pretest scores, on posttest scores.
A factorial analysis of covariance also confirmed there was no significant difference between the groups and whether the participants completed their assigned readings prior to the class, while controlling for pretest scores, on posttest scores. In fact, whether a participant completed the assigned reading prior to class had no statistically significant influence on pretest scores, posttest scores, nor was there any improvement on pre- to post-test scores. All explanatory variables yielded no differences, but, overall, participants improved from pre- to posttest regardless of simulation participation/observation or whether students completed the assigned reading prior to class.
In anticipation and consideration that the delivery of the treatment may have masked and/or inhibited any treatment effects, participants reported their experience with the simulation. Regarding this process measure, participants exposed to the simulation generally had positive attitudes about the simulation. For example, simulation participants generally had positive attitudes about the briefing (n = 42, M = 4.1429, SD = 0.7286), patient safety (n = 42, M = 3.9802, SD = 0.7679), clinical practice (n = 42, M = 3.9802, SD = 0.78532), and the debriefing (n = 42, M = 4.1061, SD = 0.67939). It is important to note that the Cronbach's alpha for briefing (α = .919), patient safety (α = .942), clinical practice (α = .928), debrief (α = .978), and with a total scale of α = .985 were all greater than .90, indicating that these subscales demonstrated internal consistency among simulation participants within this sample.
Discussion and Conclusion
Ample evidence suggests that students learn best by integrating simulation into the learning process (Doherty-Restrepo et al., 2018; Kaltman et al., 2018). However, what is not clear is what part of simulation is most influential in the learning process. Research suggests that learning outcomes achieved in simulation may have a delayed effect. Because of this evidence, it should be considered that future evaluation might best come from having students run through the low-fidelity simulation at least three times, whereby additional between and within measurements of outcomes and process could be collected.
Our study has several limitations. First, the intervention, although standardized to some extent, relies on the actions/voices of students. This may not be representative of the “working nurse.” Furthermore, generalizability is limited due to the nature of our nonprobability convenience sampling strategy. It is noted that further development of facilitators and multisite studies should be implemented to assess this intervention. Although no significantly greater immediate learning effects were observed between simulation and nonsimulation groups, the possibility exists that more than one simulation and/or additional types of learning measures are needed to better assess learning. Thus, measuring learning in future applications is suggested such that a minimum of three simulation sessions are used and alternative knowledge assessments (e.g., prompts with essay writing) are implemented.
Finally, additional measures to assess onset and delayed effects of learning should also be included in future studies. Research shows that retention may be an issue and was not captured due to the one-time implementation of the session. It may be that significant learning occurred but was not captured; thus, it is recommended that 6-month and 1-year postintervention data be captured to note whether the learning occurred. Ideally, it would be helpful to know if application learning was noted so that after 1 year postgraduation, data could be collected about where students are employed to note whether learning was instilled. Overall, the goal is to provide optimal patient care to all in need, regardless of background. Although challenges and barriers may exist when providing care to patients from diverse cultural backgrounds, simulations that are refined and implemented rigorously may offer a valuable way for nursing students to learn how to navigate these barriers and challenges and thus provide better patient care, increase patient safety, and reduce errors when working with patients from backgrounds dissimilar to their own.
- Boal, A. (2002). Games for actors and non-actors (2nd ed.). New York, NY: Routledge.
- Boud, D. (2000). Sustainable assessment: Rethinking assessment for the learning society. Studies in Continuing Education, 22, 151–167. doi:10.1080/713695728 [CrossRef]
- Buttimer, M. (n.d.). PAAIL: A conversational strategy. Retrieved from https://harvardmedsim.org/blog/paail-a-conversational-strategy/
- Doherty-Restrepo, J., Odai, M., Harris, M., Yam, T., Potteiger, K. & Montalvo, A. (2018). Students' perception of peer and faculty debriefing facilitators following simulation-based education. Journal of Allied Health, 47, 107–112.
- Horvat, L., Horey, D., Romios, P. & Kis-Rigo, J. (2014). Cultural competence education for health professionals. Cochrane Database of Systematic Reviews, 5(5), CD009405.
- Johnstone, M. & Kanitasaki, O. (2006). Culture, language, and patient safety: Making the link. International Journal for Quality in Health Care, 18, 383–388. doi:10.1093/intqhc/mzl039 [CrossRef]16956931
- Kagawa-Singer, M. & Backhall, L.J. (2001). Negotiating cross-cultural issues at end of life: “You got to go where he lives.”Journal of American Medical Association, 286, 2993–3001. doi:10.1001/jama.286.23.2993 [CrossRef]
- Kaltman, S., Talisman, N., Pennestri, S., Syverson, E., Arthur, P. & Vovides, Y. (2018). Using technology to enhance teaching of patient-centered interviewing for early medical students. Simulation in Health-care, 13, 188–194. doi:10.1097/SIH.0000000000000304 [CrossRef]
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- Levett-Jones, T., Dwyer, T., Reid-Searl, K., Heaton, L., Flenady, T., Applegarth, J. & Andersen, P. (2017). The patient safety competency framework for nursing students. Retrieved from http://www.proftlj.com/wp-content/uploads/2017/07/UTS_PSCF_Brochure_2.pdf
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Tag Team Simulationa
|T = Theatrical, embracing the dramatic contribution of acting to education|
|A = Applied and directly relevant to clinical practice|
|G = Guided by a “director” and “narrator” who facilitates the learning experience|
|T = Tactical and strategically designed to achieve predefined learning outcomes|
|E = Engaging through immersions of participants and observers in authentic learning experiences|
|A = Active involvement in dynamic and unfolding simulation experiences|
|M = Meaningful, memorable, and designed to empower learners to become agents of change|