John T. Paige MD, Deborah D. Garbee PhD, APRN, ACNS- BC, Vadym Rusnak MD, Qingzhao Yu PhD, Richard DiCarlo MD, Alan Marr MD LSU Health New Orleans (NO) Health Sciences Center New Orleans, LA Surgical Education Week Association for Surgical Education Paper Session #1 Orlando, FL April 23, 2013

Funding support: LSU Academy for the Advancement of Educational Scholarship Educational Enhancement Grant ( ) Funding support: LSU Academy for the Advancement of Educational Scholarship Educational Enhancement Grant ( ) Disclosures: Co-editor for Simulation in Radiology Disclosures: Co-editor for Simulation in Radiology

Promote the adoption of simulation-based training (SBT) of inter-professional teams to enhance collaboration, teamwork, and patient safety Promote the adoption of simulation-based training (SBT) of inter-professional teams to enhance collaboration, teamwork, and patient safety

Discuss the current status of teamwork in healthcare and its impact on medical education Discuss the current status of teamwork in healthcare and its impact on medical education Describe our simulation-based team training of inter-professional students (TTIPS) program Describe our simulation-based team training of inter-professional students (TTIPS) program Demonstrate the impact of TTIPS on participants’ attitudes toward inter-professional learning and teamwork Demonstrate the impact of TTIPS on participants’ attitudes toward inter-professional learning and teamwork Review future directions for TTIPS Review future directions for TTIPS

TEAMWORK IN HEALTHCARE

What’s this? What’s this? What’s the consequence? What’s the consequence? Why? Why? How do we fix it? How do we fix it? Bleakley A, J Workplace Learning 2006;18: Gillespie BM et al, Qual Saf Health Care 2010;19:

Good teamwork Negates fatigue Negates fatigue Reduces stress Reduces stress Promotes high reliability Promotes high reliability Poor teamwork Lowers collaboration Lowers collaboration Increases stress Increases stress Becomes system liability Becomes system liability Firth-Cozens J, Qual Saf Health Care (supplI):ii26-ii31 and Baker DP et al, Health Serv Res :

Core Components Core Components ‒ Team leadership (S) 1 ‒ Mutual performance monitoring (S) ‒ Back-up behavior (S) ‒ Adaptability (S) ‒ Team orientation (A) 2 Coordinating Mechanisms Coordinating Mechanisms ‒ Shared mental model (K) 3 ‒ Mutual trust (A) ‒ Communication (S) Salas E et al, Small Gr Res : ; 1 S=skill; 2 A=Attitude; 3 K=Knowledge

POOR TEAMWORK TECHNICAL ERRORS MORBIDITY AND MORTALITY PATIENT SAFETY SENTINEL EVENTS Catchpole K et al, Ann Surg : ; Mazzocco K et al, Am J Surg : ; Christian CK et al, Surgery : ; Kwan et al, Arch Surg : ?

Funded by the Academy for Advancement of Educational Scholarship at LSU Health NO Funded by the Academy for Advancement of Educational Scholarship at LSU Health NO Educational Enhancement Grant Educational Enhancement Grant Outgrowth of prior inter-professional undergraduate team training work Outgrowth of prior inter-professional undergraduate team training work Target learners  L3 medical and senior undergraduate nursing students Target learners  L3 medical and senior undergraduate nursing students

What is the impact of inter-professional, scenario based high-fidelity simulation training of undergraduate nursing and medical students on team-based behaviors? How does inter-professional, scenario based high-fidelity simulation training of undergraduate nursing and medical students influence participants’ attitudes toward inter-professional collaboration and learning?

Quasi-experimental in character Quasi-experimental in character Matching of participants pre- and post-intervention using unique, self-generated personal identification number (PIN) Matching of participants pre- and post-intervention using unique, self-generated personal identification number (PIN) Inter-professional education (IPE) with teams of 5 to 8 students Inter-professional education (IPE) with teams of 5 to 8 students Incorporated into general surgery clerkship and senior undergraduate nursing intensive care course Incorporated into general surgery clerkship and senior undergraduate nursing intensive care course

Introduction Scenario 1 Scenario 2 Debrief

LSUHSC-NO Academy for the Advancement of Educational Scholarship Education Enhancement Grant High fidelity simulation Core courses Inter-professionalteams Virtual Room Four concept ATLS protocols Shared mental model Open communication Anticipatory response Situational awareness Resource management Cross monitoring Teamwork Attitudes Readiness for Inter- professional Learning Role clarity Flattened hierarchy Mental rehearsal Two hour sessions Two scenario format Deliberatepractice Clinicalcorrelation

Team-based attitudes  TeamSTEPPS TM Teamwork Attitude Questionnaire (TTAQ) Team-based attitudes  TeamSTEPPS TM Teamwork Attitude Questionnaire (TTAQ) ‒ Given to entire class in June 2011 with f/u June 2012 ‒ Five subscales Inter-professional learning attitudes  Readiness for Interprofessional Learning (RIPL) Questionnaire Inter-professional learning attitudes  Readiness for Interprofessional Learning (RIPL) Questionnaire ‒ Given to participants immediately before and at the end of each simulation session ‒ Nineteen questions

Fall 2011 Session Date9/ 19/89/159/2210/610/1310/2711/311/1011/17 Total (N) Medical Students (N) Session 1 (1-3pm) Session 2 (3-5pm) Undergraduate Nursing Students (N) Session 1 (1-3pm) Session 2 (3-5pm) Total (N) Spring 2012 Session Date 1/191/262/22/92/162/233/13/83/153/224/19 Total (N) Medical Students (N) Session 1 (1-3pm) Session 2 (3-5pm) Undergraduate Nursing Students (N) Session 1 (1-3pm) Session 2 (3-5pm) Total (N)

TTAQ Subscales N (matched) Pre-Training Score, June 2011 (Mean [std dev]) Post-Training Score, June 2012 (Mean [std dev]) ∆: June ’12 – June ’11 (Mean [std dev]) p value Team structure (0.36)4.55 (0.37)0.10 (0.43).012 Leadership (0.38)4.72 (0.35)0.04 (0.50).326 Situation monitoring (0.45)4.45 (0.50)0.01 (0.53).896 Mutual support (0.62)3.47 (0.75)0.26 (0.72).000 Communication (0.40)4.14 (0.47)0.08 (0.49).086

RIPL Questionnaire Item a N (matched) Pre-Session Score b Post-Session Score b ∆ (post – pre) b p value c Learning with other students will help me become a more effective member of a health-care team (0.54)4.77 (0.43)0.19 (0.55).000 Patients would ultimately benefit if health-care students worked together to solve patient problems (0.48)4.79 (0.42)0.10 (0.49).013 Shared Learning with other health-care students will increase my ability to understand clinical problems (0.60)4.77 (0.44)0.27 (0.55).000 Learning with other health-care students before qualification would improve relationships after qualification (0.61)4.77 (0.44)0.30 (0.58).000 Communication skills should be learned with other health-care students (0.54)4.78 (0.45)0.18 (0.53).000 Shared learning will help me think positively about other professionals (0.62)4.76 (0.43)0.31 (0.63).000 Team-working skills are essential for all health-care students to learn (0.51)4.79 (0.41)0.14 (0.49).001 Shared learning will help me to understand my own limitations (0.68)4.73 (0.53)0.29 (0.67).000 I don’t want to waste my time learning with other health-care students (0.85)1.41 (0.93)-0.16 (0.88).027 It is not necessary for undergraduate health-care students to learn together (0.84)1.48 (0.94)-0.23 (0.95).004 Clinical problem solving skills can only be learned with students from my own department (0.90)1.61 (1.07)-0.11 (1.08).200 Shared learning with other health-care students will help me communicate better with patients and other professionals (0.67)4.56 (0.86)0.15 (1.02).066 I would welcome the opportunity to work on small-group projects with other health-care students (0.86)4.61 (0.75)0.46 (0.80).000 Shared learning will help to clarify the nature of patient problems (0.69)4.70 (0.55)0.41 (0.68).000 Shared learning before qualification will help me become a better team worker (0.61)4.73 (0.46)0.29 (0.60).000 The function of nurses and therapists is mainly to provide support for doctors (1.13)2.40 (1.40)0.02 (1.38).858 I’m not sure what my professional role will be (1.09)2.29 (1.24)-0.05 (1.03).524 I have to acquire much more knowledge and skills than other health-care students (1.09)2.78 (1.25)-0.27 (1.06).002 a Scale: 1-strongly disagree, 2-disagree, 3-neutral, 4-agree, 5-strongly agree b Mean (standard deviation) c Paired 2 tail t-test √ √ √ √ √ √ √ √ √ √

Significant change in 10/19 items N ranged from 127 to to 129

Simulation-based IPE improves team-based attitudes related to team structure and mutual support in third year medical students Simulation-based IPE improves team-based attitudes related to team structure and mutual support in third year medical students Simulation-based IPE improves both medical and undergraduate nursing students’ attitudes toward inter-professional learning. Simulation-based IPE improves both medical and undergraduate nursing students’ attitudes toward inter-professional learning. Future directions include correlating improvement in each measurement with individual learning Future directions include correlating improvement in each measurement with individual learning

Vadym Rusnak, MD Vadym Rusnak, MD Richard DiCarlo MD Richard DiCarlo MD Alan Marr MD Alan Marr MD Qingzhao Yu, PhD Qingzhao Yu, PhD Megan Bronson Megan Bronson Deborah Garbee PhD, APRN Deborah Garbee PhD, APRN John Paige MD John Paige MD

To improve teamwork, we must target... those in practice, and… those coming up!