Athletic Training and Sports Health Care

Original Research 

Effects of Simulation-based Training for High School Sports Medicine Personnel on Emergency Response Confidence and Teamwork Behaviors

Daryl A. Rosenbaum, MD; Heath C. Thornton, MD; James E. Johnson, PhD; Ian Saunders, Cer. AT; Michael T. Fitch, MD, PhD

Abstract

This study aimed to determine whether a workshop emphasizing teamwork and simulation can improve confidence and nontechnical skills in multidisciplinary athletic emergency response teams. Thirty-five participants from 7 high schools completed the 1-day summer workshop. An individual confidence self-assessment questionnaire was administered preworkshop, immediately postworkshop, and delayed postworkshop (at the end of the school year). Two observers reviewed video of the preworkshop and postworkshop simulation exercises and used the Anesthetists’ Nontechnical Skills (ANTS) system to rate team performance. All 5 self-confidence ratings increased for both immediate and delayed postworkshop, compared with preworkshop. Most of this improvement is attributable to nonhealth care professionals. ANTS scores immediately postworkshop showed improvement in all categories: task management (P = .008), teamwork (P < .001), situation awareness (P = .001), and decision making (P = .001). Multidisciplinary team participation in a workshop emphasizing teamwork and simulation training increased confidence and observed teamwork skills.

Abstract

This study aimed to determine whether a workshop emphasizing teamwork and simulation can improve confidence and nontechnical skills in multidisciplinary athletic emergency response teams. Thirty-five participants from 7 high schools completed the 1-day summer workshop. An individual confidence self-assessment questionnaire was administered preworkshop, immediately postworkshop, and delayed postworkshop (at the end of the school year). Two observers reviewed video of the preworkshop and postworkshop simulation exercises and used the Anesthetists’ Nontechnical Skills (ANTS) system to rate team performance. All 5 self-confidence ratings increased for both immediate and delayed postworkshop, compared with preworkshop. Most of this improvement is attributable to nonhealth care professionals. ANTS scores immediately postworkshop showed improvement in all categories: task management (P = .008), teamwork (P < .001), situation awareness (P = .001), and decision making (P = .001). Multidisciplinary team participation in a workshop emphasizing teamwork and simulation training increased confidence and observed teamwork skills.

Dr Rosenbaum and Dr Thornton are from the Department of Family and Community Medicine, Dr Johnson and Mr Saunders are from the Center for Applied Learning, and Dr Fitch is from the Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.

This study was presented in part at the 19th Annual Meeting of the American Medical Society for Sports Medicine; April 21, 2010; Cancun, Mexico.

Dr Rosenbaum received funding as a Brooks Scholar at the Wake Forest School of Medicine. The authors have no financial or proprietary interest in the materials presented herein.

The authors thank Steve Davis for statistical analysis, as well as those who assisted with simulation production and course instruction: Serene Markis, Will Safrit, Dan Ozimek, Greg Collins, and Drs Monroe, Bockewitz, Poynter, Richards, and Cox. They also thank the Forsyth County and Stokes County school systems for their enthusiastic cooperation.

Address correspondence to Daryl A. Rosenbaum, MD, Department of Family and Community Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1084; e-mail: drosenba@wakehealth.edu.

Received: September 14, 2010
Accepted: August 10, 2011
Posted Online: September 30, 2011

Although it is important for individual health care providers to possess adequate knowledge, technical skill, and experience, these factors alone do not guarantee acceptable clinical outcomes. One retrospective study of emergency department malpractice cases found that more than half of the deaths and permanent disabilities that occurred were attributable not to individual errors but rather to teamwork failures.1 This realization has led to calls for the medical profession to incorporate teamwork as a core value and to train its members in teamwork principles.2,3 One such effort, the Emergency Team Coordination Course, resulted in a significant 26.5% decrease in the observable error rate for the participating emergency departments.4

Sports medicine shares important similarities with emergency medicine. Both involve processing scattered or incomplete information, quick decision making, time pressure, and high stakes. As an additional challenge, the group that typically responds to a medical crisis in an athletic setting is often diverse, with a variety of professions, levels of experience, and employers involved. It is unrealistic to expect this loose association of individuals to suddenly come together for an emergency and perform optimally in an uncontrolled and highly visible environment without prior teamwork training.

The relatively low frequency and high-stakes nature of medical emergencies in the athletic setting makes a learn-on-the-job approach to training for these events impractical and unacceptable. Emergency preparation is not complete without at least annual rehearsal of the plan by the response team.5 The use of simulation is already a recommended method to train and assess the competence of resident physicians,6 and there is a strong association between time spent practicing in high-fidelity medical simulators and learning outcomes.7 Simulation training seems well-suited for exposing sports medicine teams to the stress and dynamic nature of an athletic emergency. It has also been shown to be an effective way for multidisciplinary medical teams to improve on learned crew resource management principles.8–10

We developed a 1-day workshop for high school sports medicine teams that emphasized teamwork training and group practice using high-fidelity simulation. This study sought to determine whether this workshop can improve participant confidence levels and teamwork behaviors regarding medical emergency responses in an athletic setting. The secondary goal was to obtain feedback from participants concerning the feasibility of instituting such a training program.

Method

Study Design

A quasi-experimental pretest–posttest design was used. Institutional Review Board approval was obtained prior to the study.

Participants and Setting

A convenience sample of multidisciplinary groups from 7 local high schools was used. Each participant was identified by the respective high school’s athletic director as someone who was expected to respond to a medical emergency in an athletic setting. Each school was invited to bring from 2 to 8 people to a 1-day educational workshop offered on a medical school campus during the summer before the start of the school and sports year. Three high school teams included personnel from their nearby middle school. Forty participants attended the workshop; however, not all attended on the same date. Four groups attended the workshop on the first date it was held, whereas 3 groups attended a workshop held 2 months later.

Procedure

Participants’ consent to participate was obtained prior to the beginning of the workshop. The program began with a brief verbal explanation of the simulation setting and the simulator capabilities. Each group then managed a simulated medical crisis event involving a high school football player. Digital video was used to record the team performance for later structured review.

This exercise was followed by a 1-hour didactic session about crew resource management based on the emergency medicine teamwork model developed by Fernandez.11 The lecture given by the lead instructor (D.A.R.), a certified sports medicine physician, included video vignettes that dramatized both proper and improper performance of teamwork principles in a sideline emergency setting. This instructor then led an interactive debriefing of the medical crisis simulations that included video analysis. The last session of the morning was a question-and-answer session with a director of local emergency medical services.

Each team then rotated through 4 separate 20-minute breakout sessions led by course faculty. These sessions were as follows: (1) Communication challenge, in which the task was to recreate, under a time restriction, a unique geometric color drawing in a separate room from where the drawing was placed, with participants not being allowed to move between rooms. The goals of this exercise were to optimize personnel resources and to understand the need for clarity in giving and receiving orders. (2) Trivia challenge, in which participants answered questions about sports medicine emergency knowledge, both individually and as a team. Goals of this exercise were to increase knowledge and to understand the benefits of identifying and utilizing the different strengths of team members to achieve a common goal. (3) Cervical spine immobilization “pit crew,” in which teams attempted to log-roll a prone actor, immobilize him on a spine board, and remove the facemask from his football helmet in as little time as possible, with 5-second penalties added for any error that compromised patient safety. The goals of this exercise were to increase dexterity with equipment, highlight need for role definition, and test the ability of a team to work together under pressure. (4) Practice with the high-fidelity patient simulator. The goals of this exercise were to increase knowledge, improve familiarity with equipment, and provide repeated exposure to emergency situations to decrease stress in subsequent situations.

At the end of the 1-day event, each team managed a second medical crisis scenario of equal difficulty (videotaped for later structured review), followed by a second debriefing session.

Simulation Details

The setting for the simulated medical crisis scenarios was a medical school lecture hall. Recorded crowd noise and public address announcements were played over the sound system to enhance participant immersion into the event. A cooler with ice, an automated external defibrillator, a cordless screwdriver, and towels were immediately available to participants if requested. Two local paramedics with a stretcher and response equipment waited outside a second door of the lecture hall and were available 3 minutes after being called by the initial response team. A faculty member dressed as a high school football game official called for each team to attend to “a player down” and then facilitated the scenario as indicated by predetermined protocols. The “player” was a wireless high-fidelity adult patient simulator mannequin (iSTAN; Medical Education Technologies Inc, Sarasota, Florida) wearing football attire (regulation helmet, shoulder pads, and jersey).

The 2 simulation scenarios of relatively equal difficulty were created following methods described by Bush et al.12 The common algorithm for both scenarios involved a high school football player found lying face down, responsive but confused. After initial evaluation by the response team, an unhelpful actor, playing the role of a spectator from the crowd, intruded into the scenario and attempted to challenge and distract the participants. Meanwhile, the simulated patient underwent an abrupt change in clinical condition, with decreased alertness and accompanying changes in pulse and respiratory status eventually leading to cardiopulmonary arrest. Only after a team had managed a particular scenario were its members allowed to observe other teams working through the same case.

Outcome Measures

Before the workshop, each participant completed a short questionnaire that contained demographic questions (gender; age; primary profession; years of experience in primary profession; and training and current certification in first aid, cardiopulmonary resuscitation, advanced cardiac life support or pediatric advanced life support, and advanced trauma life support; Table 1) and questions to assess confidence in the ability to respond to a medical emergency (Table 2). At the conclusion of the program, participants completed the confidence assessment questions and additional questions related to satisfaction with the course. Participants were then contacted via e-mail at the end of the school and sports year (7 months after attending the workshop for 3 schools, and 9 months after for 4 schools) and asked to again answer the same 5 confidence questions using an Internet-based survey tool
(http://www.surveymonkey.com).

Participant Demographics (N = 40)

Table 1: Participant Demographics (N = 40)

Confident Assessment Questions Used Preworkshop, Immediately Postworkshop, and Delayed Postworkshop

Table 2: Confident Assessment Questions Used Preworkshop, Immediately Postworkshop, and Delayed Postworkshop

Teamwork behaviors were assessed using the Anesthetist’s Nontechnical Skills system (ANTS) (Table 3), a tool found to be valid and reliable for assessing the behavioral competencies of anesthesiologists13 that has since been applied to multidisciplinary medical teams responding to a patient crisis.8 Two sports medicine-certified physicians first discussed what specific behaviors during a sideline medical emergency would exemplify both good and poor practice for each of the 15 ANTS elements. Then, they reviewed together the video recordings of the preworkshop and postworkshop scenarios for each team. The raters discussed the appropriate numerical rating from 1 to 4 on each of the specific elements to determine the final element rating. Averaged element ratings yielded an overall rating for each of the 4 main ANTS categories. Because the raters had served as faculty for the workshop, they were not blinded to whether a scenario was preworkshop or postworkshop.

Anesthetists’ Nontechnical Skills System

Table 3: Anesthetists’ Nontechnical Skills System

Statistics

SPSS version 17.0 software (SPSS Inc, Chicago, Illinois) was used for statistical analysis. Descriptive statistics were used to analyze the demographic information, confidence assessment scores, and workshop satisfaction. ANTS category scores for teams were compared using simple paired t tests. Significance was set at P < .05.

Results

Demographic data for the 40 participants are summarized in Table 1. The mean age was 40 years, and 67.5% (n = 27) were male. The most common primary profession reported was coach or administrator, and average experience in the profession was almost 14 years. Most participants had been trained and were currently certified in first aid and basic life support, but less than a quarter of the participants had been trained in advanced cardiac or trauma life support.

Five participants left the workshop prior to its conclusion, resulting in a response rate of 87.5% for the immediately postworkshop confidence self-assessment and course satisfaction questionnaires. All 5 participants who left early were coaches or administrators, with 4 citing other job responsibilities and 1 citing poor health. Twenty-six of 35 (74.3%) participants responded to the delayed postworkshop confidence survey administered at the end of the school year. Figures 15 show the preworkshop, immediately postworkshop, and delayed postworkshop self-confidence ratings. The percentage of strongly agree responses increased for all 5 questions immediately postworkshop. Only the “communicate” and “team ability” percentage of strongly agree responses decreased between immediate and delayed postworkshop questionnaires, by 11.6% and 7.7%, respectively. Further analysis by profession showed that those in the coach or administrator group accounted for a majority of the shifts to higher levels of agreement with confidence statements immediately postworkshop primarily because those in this group more frequently started at lower levels preworkshop.

Self-assessment of confidence in ability to prepare, by percentage of respondents (N = 26).

Figure 1: Self-assessment of confidence in ability to prepare, by percentage of respondents (N = 26).

Self-assessment of confidence in ability to communicate, by percentage of respondents (N = 26).

Figure 2: Self-assessment of confidence in ability to communicate, by percentage of respondents (N = 26).

Self-assessment of confidence in skills, by percentage of respondents (N = 26).

Figure 3: Self-assessment of confidence in skills, by percentage of respondents (N = 26).

Self-assessment of confidence in ability to promote teamwork, by percentage of respondents (N = 26).

Figure 4: Self-assessment of confidence in ability to promote teamwork, by percentage of respondents (N = 26).

Self-assessment of confidence in team ability, by percentage of respondents (N = 26).

Figure 5: Self-assessment of confidence in team ability, by percentage of respondents (N = 26).

There was a statistically significant improvement in ANTS scores for all 4 categories (Table 4). The mean difference was 1.45 for task management (P = .008), 1.37 for teamwork (P < .001), 1.61 for situation awareness (P = 0.001), and 1.34 for decision making (P = .001).

Individual Participant Scores for Confidence Self-assessment Preworkshop Versus Immediate Postworkshop

Table 4: Individual Participant Scores for Confidence Self-assessment Preworkshop Versus Immediate Postworkshop

Workshop assessment results are summarized in Table 1. Feedback was highly positive, and all participants who completed the workshop agreed they were glad they had attended and would recommend the program to colleagues. Nearly all participants were interested in attending this workshop again in the future.

Discussion

Our workshop emphasized the teaching of teamwork principles and hands-on experience in high-fidelity simulation settings to prepare multidisciplinary groups from 7 high schools to perform optimally in a sports medicine crisis situation. There was improvement in all postworkshop participant self-confidence measures, both immediate and delayed, compared with preworkshop. The fact that this confidence persisted until the end of the school year indicates that the workshop benefits are durable. Assuming little turnover in a team, refresher training at a minimum of once yearly could be expected to maintain acquired self-confidence.

Self-confidence is a subjective and nonclinical outcome, but it is recognized as one of the key attributes that, along with knowledge, technical ability, communication skills, adaptability, and risk tolerance, are necessary for expertise.14 Higher confidence levels may also result in increased job satisfaction and in turn less staff turnover, both being highly desirable outcomes for target organizations.

The improvement in the confidence of the coach or administrator group is noteworthy. It suggests that a training program that includes a simulation experience and teamwork instruction may be an effective way to prepare nonhealth care personnel to assist in the response to a medical emergency.

Teamwork is widely recognized by the aviation, military, and medical industries to be as valuable as knowledge and technical skill. Team performance of nontechnical skills during the simulated emergency scenarios also improved significantly in all categories. Although teamwork training improves clinical outcomes in emergency medicine,4 it is not clear whether the increased ANTS scores we observed would translate into improved clinical outcomes in athletic medical emergencies. Despite this limitation, observable behaviors such as preparation, communication, and coordination are readily apparent to onlookers during public medical emergencies; thus, a display of optimal teamwork during a highly visible medical crisis is desirable. Furthermore, improved teamwork can increase the professionalism and pride of team members and their perception of institutional support, thereby increasing morale and job satisfaction.

Because of the workshop design, we cannot say from this feasibility study whether the teamwork training or the use of high-fidelity patient simulation was responsible for the observed improvements in confidence and nontechnical skills by workshop participants. However, it is known that a significant number of high schools in the United States do not rehearse their response to an athletic medical emergency at the recommended frequency, if at all.15,16 A course such as this allows the members of a multidisciplinary group to interact in simulated conditions, which fulfills some goals for planned practice of emergency protocols.

In assessing the workshop, participants placed an equally high value on both teamwork training and simulation. Future work will aim to determine the relative effect of course components on outcomes and may lead to adjustments in program design to optimize the financial cost–benefit ratio of such training.

Limitations

This study involved a small sample size (N = 40) from a specific geographic area, which may limit the ability to generalize its findings. The confidence rating questions were not validated. Only 26 participants completed the delayed postworkshop self-confidence survey. Those with more confidence in their skills may have been more likely to complete the workshop or respond to the delayed survey. However, comparing those who did not complete both the immediate and delayed postworkshop assessments with those who did showed the distribution of percentages to be similar for the preworkshop and immediate postworkshop assessments.

Although the use of a validated and structured evaluation tool was intended to standardize the evaluation of videotaped sessions, some bias may have been introduced into the teamwork behavior ratings applied via the ANTS, given that reviewers were not blinded to the identity of the teams or whether the sessions were preworkshop or postworkshop. The simulation experience was designed to be as realistic as possible, but it is not known whether the improved teamwork behaviors and participant confidence would have been the same in a genuine crisis. Practice effect in this artificial environment may also have improved results but may not fully translate to an actual emergency. It cannot be determined from this study how long the improvements in teamwork behavior will persist after the workshop event.

Conclusion

Teamwork is a critical element necessary to achieve successful outcomes in clinical medicine. Simulation may be an effective method to improve individual skill and team behavior. A workshop emphasizing teamwork education and simulation practice shows promise in helping multidisciplinary sports medicine groups prepare to respond effectively to medical emergencies in the athletic setting. We met our goal of determining whether the workshop was feasible (ie, would participants attend) and judged of value by them. Subsequent study in this area should attempt to determine the relative importance of teamwork training and simulation and further assess the durability of these confidence and skill gains. The ideal frequency and nature of refresher training could then be established.

Implications for Clinical Practice

Teamwork skills are as important as technical medical skills in improving outcomes in a variety of high-stakes situations, including medical emergency response. Simulation can acclimatize personnel to the stress and dynamic nature of emergency situations. Training emphasizing teamwork principles and high-fidelity simulation improved the emergency response confidence and teamwork behaviors of multidisciplinary sports medicine teams. Much of this improvement was attributable to nonmedical personnel. It cannot be determined from this study whether the simulation or the teamwork training was more or less responsible for the improvements observed.

References

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  6. Accreditation Council on Graduate Medical Education/American Board of Medical Specialties Joint Initiative. Toolbox of Assessment Methods, Version 1.1. http://www.acgme.org/Outcome/assess/Toolbox.pdf. Published September 2000. Accessed August 23, 2011.
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  15. Monroe A, Rosenbaum DA, Davis S. Emergency planning for sudden cardiac events in North Carolina high schools. N C Med J. 2009;70(3):198–204.
  16. Olympia RP, Dixon T, Brady J, Avner JR. Emergency planning in school-based athletics: a national survey of athletic trainers. Pediatr Emerg Care. 2007;23(10):703–708. doi:10.1097/PEC.0b013e318155adfc [CrossRef]

Participant Demographics (N = 40)

VARIABLE RESULT
Age (mean±SD) (y) 39.97±11.20
Gender (male/female) 27/13
Primary profession
  Athletic trainer 3
  First responder 4
  Physician 4
  EMT 2
  Paramedic 3
  Coach or administrator 24
Experience in primary profession (mean±SD) (y) 13.77±10.17
Ever been trained/currently certified
  First aid 35/25
  Cardiopulmonary resuscitation 38/31
  Advanced cardiac life support or pediatric advanced life support 9/8
  Advanced trauma life support 3/3

Confident Assessment Questions Used Preworkshop, Immediately Postworkshop, and Delayed Postworkshop

PLEASE RATE YOUR LEVEL OF AGREEMENT WITH THE FOLLOWING STATEMENTSa

I am confident in my ability to properly prepare for a medical emergency at an athletic event.

I am confident in my ability to communicate with my team during a medical emergency at an athletic event.

I am confident in my clinical/technical skills needed to respond to a medical emergency at an athletic event.

I am confident in my ability to promote teamwork during a medical emergency at an athletic event:

I am confident in the ability of my assigned team to respond to and appropriately handle a medical emergency at an athletic event.

Anesthetists’ Nontechnical Skills System

CATEGORY ELEMENT RATINGa CATEGORY AVERAGE
Task management Planning and preparing
Prioritizing
Providing and maintaining standards
Identifying and using resources
Teamwork Coordinating activities with team
Exchanging information
Using authority and assertiveness
Assessing capabilities
Supporting others
Situation awareness Gathering information
Recognizing and understanding
Anticipating
Decision making Identifying options
Balancing risks and selecting options
Re-evaluating

Individual Participant Scores for Confidence Self-assessment Preworkshop Versus Immediate Postworkshop

OUTCOME Na PREWORKSHOPb IMMEDIATE POSTWORKSHOPb DIFFERENCEc Pd
Prepare 35 3.80±0.9 4.54±0.6 0.74 (0.46, 1.02) .000
Communicate 35 4.03±0.9 4.69±0.5 0.66 (0.37, 0.95) .000
Skills 35 3.57±1.1 4.34±0.6 0.77 (0.46, 1.08) .000
Promote teamwork 35 4.03±1.0 4.66±0.5 0.63 (0.33, 0.93) .000
Team ability 35 4.06±0.8 4.57±0.6 0.51 (0.26, 0.77) .000
Authors

Dr Rosenbaum and Dr Thornton are from the Department of Family and Community Medicine, Dr Johnson and Mr Saunders are from the Center for Applied Learning, and Dr Fitch is from the Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.

This study was presented in part at the 19th Annual Meeting of the American Medical Society for Sports Medicine; April 21, 2010; Cancun, Mexico.

Dr Rosenbaum received funding as a Brooks Scholar at the Wake Forest School of Medicine. The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Daryl A. Rosenbaum, MD, Department of Family and Community Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1084; e-mail: drosenba@wakehealth.edu

10.3928/19425864-20110930-02

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