1. 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

2. Funding support: LSU Academy for the Advancement of Educational Scholarship Educational Enhancement Grant (2011-2012) Funding support: LSU Academy for the Advancement of Educational Scholarship Educational Enhancement Grant (2011-2012) Disclosures: Co-editor for Simulation in Radiology Disclosures: Co-editor for Simulation in Radiology

3. 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

4. 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

6. TEAMWORK IN HEALTHCARE

7. 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;18:414-425 Gillespie BM et al, Qual Saf Health Care 2010;19:103-106

8. 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 2001 10(supplI):ii26-ii31 and Baker DP et al, Health Serv Res 2006 41:1576-1598

9. 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 2005 36:555-599; 1 S=skill; 2 A=Attitude; 3 K=Knowledge

10. POOR TEAMWORK TECHNICAL ERRORS MORBIDITY AND MORTALITY PATIENT SAFETY SENTINEL EVENTS Catchpole K et al, Ann Surg 2008 247:699-706; Mazzocco K et al, Am J Surg 2009 197:678-685; Christian CK et al, Surgery 2006 139:159-173; Kwan et al, Arch Surg 2006 141:352-357 ?

12. 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 2011-2012 Educational Enhancement Grant 2011-2012 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

13. 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?

14. 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

16. Introduction Scenario 1 Scenario 2 Debrief

17. LSUHSC-NO Academy for the Advancement of Educational Scholarship Education Enhancement Grant 2011-2012 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

18. 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

20. 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) 4343 3333 4242 2323 3333 3333 3232 2121 3434 2424 57 Undergraduate Nursing Students (N) Session 1 (1-3pm) Session 2 (3-5pm) 2222 2222 2222 2222 2222 2222 2222 2222 2222 2222 40 Total (N)1110 9 97111097 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) 3232 3434 4444 3333 3232 3333 6464 4343 3232 4343 1212 69 Undergraduate Nursing Students (N) Session 1 (1-3pm) Session 2 (3-5pm) 2222 2222 2222 2222 2222 2222 2222 2222 2222 2222 2222 44 Total (N)91112109 14119 7113

21. 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 structure1224.46 (0.36)4.55 (0.37)0.10 (0.43).012 Leadership1224.68 (0.38)4.72 (0.35)0.04 (0.50).326 Situation monitoring 1214.44 (0.45)4.45 (0.50)0.01 (0.53).896 Mutual support1193.20 (0.62)3.47 (0.75)0.26 (0.72).000 Communication1184.07 (0.40)4.14 (0.47)0.08 (0.49).086

22. 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 1494.57 (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 1494.68 (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 1484.50 (0.60)4.77 (0.44)0.27 (0.55).000 Learning with other health-care students before qualification would improve relationships after qualification 1494.48 (0.61)4.77 (0.44)0.30 (0.58).000 Communication skills should be learned with other health-care students 1494.60 (0.54)4.78 (0.45)0.18 (0.53).000 Shared learning will help me think positively about other professionals 1484.45 (0.62)4.76 (0.43)0.31 (0.63).000 Team-working skills are essential for all health-care students to learn 1494.64 (0.51)4.79 (0.41)0.14 (0.49).001 Shared learning will help me to understand my own limitations1494.44 (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 1491.57 (0.85)1.41 (0.93)-0.16 (0.88).027 It is not necessary for undergraduate health-care students to learn together 1491.71 (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 1481.73 (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 1494.40 (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 1484.16 (0.86)4.61 (0.75)0.46 (0.80).000 Shared learning will help to clarify the nature of patient problems1494.29 (0.69)4.70 (0.55)0.41 (0.68).000 Shared learning before qualification will help me become a better team worker 1464.43 (0.61)4.73 (0.46)0.29 (0.60).000 The function of nurses and therapists is mainly to provide support for doctors 1472.38 (1.13)2.40 (1.40)0.02 (1.38).858 I’m not sure what my professional role will be1482.34 (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 1493.05 (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 √ √ √ √ √ √ √ √ √ √

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

24. 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

25. 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

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