RESEARCH ARTICLE
Dynamic and Routine Interprofessional Simulations: Expanding the Use of Simulation to Enhance Interprofessional Competencies Sharla King, PhD Michael Carbonaro, PhD Elaine Greidanus, PhD Dawn Ansell, RN, BN Colette Foisy-Doll, RN, BScN, MSN, CHSE Sam Magus, RTT
provide positive learning experiences for all participants, as demonstrated by these results. J Allied Health 2014; 43(3):169–175.
The purpose of this study was to develop, deliver, and assess relevant interprofessional (IP) simulation experiences for prelicensure students from multiple disciplines in certificate, diploma, and degree programs. Seventy-eight students from four post-secondary institutions participated in either a high-fidelity mannequin postoperative simulation experience (dynamic simulation) or a standardized patient homecare simulation experience (routine simulation). The University of West England Questionnaire was used pre- and postsimulation experience to determine the change in communication and teamwork. Overall, students’ perceptions of their communication and teamwork skills increased after completing either simulation. Students from certificate, diploma, and degree programs participating in the same simulations demonstrated improvements on self-report measures of communication and teamwork. The key was creating a simulation learning experience that reflected the realities of practice, rather than the participants’ credentials. Placing students in teams that are relevant for practice, rather than grouping them by academic credentials, is necessary and can
COLLABORATIVE PRACTICE has been identified as a critical approach for improving patient care and clinical practice within the health system. Interprofessional (IP) education is seen as a means to achieving collaborative practice. As a result, post-secondary health science education institutions, are increasingly integrating IP learning opportunities into their pre-licensure programs.1–3 A number of challenges to successfully implement IP education exist.4 These challenges include: 1) each discipline’s unique culture of practice; 2) disciplines that work together in practice are often not educated at the same institution, and when they are, timetabling, logistics, physical location, and traditionally defined curriculum are barriers; and 3) issues such as workload, reward systems, research, and teaching objectives vary within and across institutions for faculty members. Inter-institutional collaborations raise differences related to the awarding of credentials (certificate, diploma, degree), yet in certain environments the disciplines work together in the practice setting, regardless of the terminal credentials. To help overcome some of these challenges, IP educational “best practice” models have been proposed, such as didactic programming (teambuilding and knowledge of IP practice), community-based practice, and IP simulation.5 To operationalize these best practice models, it is often essential to: 1) develop cross-institutional relationships, because only a small percentage of schools offer a diverse range of programs,4 and 2) create relevant IP experiences that mirror students’ future practice.6 Previous research has demonstrated that IP simulations can provide relevant educational experiences prior to entry into clinical practice.5,7
Dr. King is Associate Professor, Department of Educational Psychology, Faculty of Education, and Director, Health Sciences Education and Research Commons, University of Alberta; Dr. Carbonaro is Professor, Department of Educational Psychology, Faculty of Education, University of Alberta; Dr. Greidanus is in Private Practice; Ms. Ansell is Head, Interdisciplinary Simulation Centre, Faculty of Health and Community Studies, NorQuest College; Ms. Foisy-Doll is Professional Resource Faculty, Clinical Simulation Centre, Robbins Health Learning Centre, MacEwan University; and Mr. Magus is Instructor—Respiratory Therapy, Preceptor Educator, School of Health Sciences, Northern Alberta Institute of Technology, Edmonton, Alberta, Canada. This project was made possible by funding from Access to the Future Innovation Fund, Government of Alberta. RA1346—Received July 4, 2013; accepted Oct 22, 2013. Address correspondence to: Dr. Sharla King, 2-263 HSERC, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB T6G 2G5, Canada. Tel 780-492-2333.
[email protected]. © 2014 Association of Schools of Allied Health Professions, Wash., DC.
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Simulation is a standard instructional strategy in health science education, particularly in medicine and nursing.8,9 IP simulation learning experiences are increasingly more common with a focus on enhancing nontechnical skills, such as communication and collaboration.9–14 Brief and intense simulation-based scenarios can increase perceived confidence in communicating and working in impromptu teams of prelicensed students from multiple health science disciplines.15 The majority of IP simulation studies have focused on enhancing communication and team skills between nurses and physicians (prelicensed and postgraduate), residents, and specialists,12 typically in urgent care situations. Teamwork knowledge and attitudes significantly improved after medical and nursing students participated in one of four different modalities, including high-fidelity simulation.16 Unfortunately, details are lacking with respect to the type of simulations. A comprehensive study on the use of IP simulation with undergraduates from medicine, nursing, physiotherapy, radiography, and operating department practice from four different institutions was conducted.3 The IP simulation intervention consisted of half-day sessions with pre-post assessment of student perceptions of learning and attitudes to IP. Overall, the findings demonstrated positive improvements on students’ perceptions after the intervention. Working with other institutions allowed them to share expertise, effectively model complex teamwork, and increase the range of professions. Although five disciplines were represented, medicine and nursing students accounted for 82% of the participants. In this article, we describe a study that created and evaluated IP simulation experiences with students from multiple post-secondary institutions. Two types of relevant IP simulation experiences were created to address the broad range of disciplines participating: 1) anaphylaxis reaction (mannequin-based dynamic simulation); and 2) hospital-to-homecare transition (simulated patients routine simulation). Evaluation of the simulation-based learning interventions involved pre- and post-assessments of students’ communication and teamwork skills. The purpose of the study was to: 1) develop and deliver relevant IP simulation experiences for prelicensure students from multiple certificate, diploma, and degree programs; 2) examine the change in a self-report measure of communication and teamwork, IP relationships, and IP learning in students from these programs; and 3) determine the psychometric properties of the self-report measure. Specifically, the aim of this study was to determine the change in self-report communication and teamwork, IP relationships, and learning in students from four different degree, diploma, and certificate-granting institutions after two types of simulation learning experiences. 170
Methods THE INTER-INSTITUTIONAL LEARNING COMMUNITY Four post-secondary institutions and a health provider formed a learning community focused on developing, implementing, and evaluating IP education in simulation environments. The post-secondary institutions each represented different sectors of the post-secondary environment. These sectors are based not only on credentials offered and type of research activity at the institution, but also on the institutional strengths, strategic priorities, and client groups served. The four educational sectors represented by the institutions and the level of credentialing provided are: a) comprehensive academic and research [undergraduate and graduate (master and doctoral) degrees]; b) baccalaureate and applied studies (undergraduate degrees and diplomas); c) polytechnical (diplomas); and d) comprehensive community (diplomas and certificates).
Development of IP Simulation Experiences The first simulation was entitled “Post Operative Teamwork and Communication: Anaphylaxis.” The student health team works together to diagnose and treat a postoperative patient (high-fidelity mannequin) experiencing an anaphylaxis reaction. The simulation is 1 hour in duration and involves students from medicine, nursing, practical nursing, and respiratory therapy. The team debriefed with a trained facilitator at the conclusion of the experience. The second simulation was entitled “Hospital to Homecare.” The student health team participated in planning and completing a discharge planning conference with two simulated patients (SP) playing the roles of a geriatric patient and his wife. The team then debriefed the conference and prepared for the second half of the simulation where members of the home care team met with the patients in “their home.” Again, the team debriefed the home care visit with a trained facilitator and discussed how the home care team dealt with the patient’s diabetes management and high blood sugar in the scenario. The simulation was 3 hours in duration and included students from respiratory therapy, nursing, occupational therapy, physical therapy, recreational therapy, therapist assistant, health care aide, and pharmacy programs.
DESIGN The study was quasi-experimental, repeated measures design. A convenience sample of student participants volunteered from the four post-secondary institutions, as the learning experience was extracurricular. In order KING ET AL., Dynamic and Routine IP Simulations
TABLE 1. Disciplines and Program Type for Each Simulation Modality Simulation Modality
Discipline
Mannequin-based
Medicine Nursing Licensed practical nursing Respiratory therapy
Simulated Patient
Nutrition/dietetics Physical therapy Occupational therapy Nursing Pharmacy Health care aides Respiratory therapy Physical therapy and occupational therapy aides
to evaluate the effectiveness of the IP simulation, students completed a self-report measure before and after participation in the IP simulation. Demographic data were collected. Consent forms and a pre-questionnaire were completed immediately prior to the simulation. All students received a pre-briefing related to the appropriate simulation (e.g., orientation to the mannequin, equipment, and patient charts). Immediately following the simulation event, a debriefing occurred with two facilitators. In the SP scenario, a debriefing occurred after part 1 and part 2. For both simulations, the debriefing focused on the IP teamwork and communication skills, rather than the clinical skills. The simulation facilitators were trained in using the advocacy-inquiry framework for debriefing the simulations.17 After the debriefing, participants completed the questionnaire again.
QUESTIONNAIRE The University of the West of England Interprofessional Questionnaire (UWE)18 was used as a change measure. The UWE consists of four scales: Communication and Teamwork (CTS), Interprofessional Learning (ILS), Interprofessional Interaction (IIS), and Interprofessional Relationships (IRS). The CTS includes 9 items (scores range from 9–45) that relate to an individual’s assessment of their own IP communication and teamwork skills. The ILS contains 9 items (scores range from 9–45) that assess a student’s attitude toward learning in the IP context. The IIS also has 9 items (scores range from 9–45) and assesses student perception of health care professionals and their IP teamwork and communication capabilities, i.e., whether or not students see that other health care professionals can work collaboratively and respectfully as a team. The IRS includes 8 items (scores range from 8–40) relating to an individual’s Journal of Allied Health, Fall 2014, Vol 43, No 3
No. (Total in Cohort)
Type of Program
8 (130) 11 (200) 5 (30) 19 (30)
Degree Degree Diploma Diploma
6 (40) 3 (90) 2 (94) 6 (200) 1 (130) 6 (40) 3 (30) 3 (30)
Degree Degree Degree Degree Degree Certificate Diploma Diploma
perception of their professional relationships with both peers and non-peers. In the original version of the UWE, the scales were measured on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), except for the CTS scale which did not include a “neutral” option and so was on a 4point scale. In order to make the survey more readerfriendly, the authors utilized a 5-point scale throughout. Pollard et al.18,19 recommended reverse scoring items “when necessary.” We followed the method of Thomas20 (2007) for the CTS and reverse-scored items 3, 4, 6, and 7. For the remaining scales, none of the items were reverse-coded. Reliability of UWE from previous studies18,19 showed internal consistency across the four scales at 0.76 for the CTS, 0.84 for the ILS, 0.82 for the IIS, and 0.71 for the IRS, all in the acceptable range.21 SPSS (version 16; IBM-SPSS, Armonk, NY) was used to compute Cronbach’s alpha values for each subscale and the full instrument.
ANALYSIS OF CHANGE Repeated measures analyses was completed for each subscale and for the total UWE score crossed with gender, program, program year, institution, and simulation module. Item statistics were also investigated and reported. Missing data were not used in the analysis.
Results The sample consisted of 78 students from post-secondary health science programs in Edmonton, Alberta, Canada (Table 1). Fifty-seven females and 19 males with an average age of 28 years (range 18–58 yrs) completed both a pre- and post-simulation UWE questionnaire. Most students were in the senior years of their programs. Table 1 lists the disciplines present. 171
TABLE 2. Internal Consistency Rates No. of Items Cronbach’s α
Scale Communication and Teamwork (CTS) Interprofessional Learning (ILS) Interprofessional Interaction (IIS) Interprofessional Relationship (IRS) Full assessment
9 9 9
0.84 0.56 0.59
8 35
0.24 0.66
score. Post hoc analysis, using Scheffé, indicated that the CTS scores were significantly higher with students in year 2 than in year 4. This may be due to an interaction with institution. However, the sample size was not large enough to investigate a three-way interaction. One significant interaction effect was revealed with the repeated measures ANOVA between the type of simulation module and CTS scores (Fig. 1). This shows a greater increase in total CTS score for those students who completed the simulation module with the simulated patients compared to the mannequin.
UWE RELIABILITY
Discussion
Results of the reliability testing of UWE indicated that only the CTS had an internal consistency in the acceptable range (Table 2).21 The IRS had a particularly poor alpha value. Because of the poor reliability on three of the four subscales, change analyses were performed only on the CTS (total and item scores), and therefore only these scores are discussed. Table 3 presents paired t-tests for each of the nine items on the CTS and total CTS score. Only items 4 and 8 and the total score significantly increased after the simulation. Item 4 relates to the student’s comfort level with speaking up, and item 8 relates to the student’s confidence in assimilating quickly into a new group. Overall, students’ perceptions of their communication and teamwork skills increased after completing either simulation.
REPEATED MEASURES Repeated measures ANOVA results (Table 4) indicated that program year had a significant effect on the CTS
The purpose of the study was to: 1) develop and deliver relevant IP simulation experiences for prelicensure students from multiple certificate, diploma, and degree programs; 2) examine the change in a self-report measure of communication and teamwork, IP relationships, and IP learning in students from these programs; and 3) determine the psychometric properties of the self-report measure. There were two main findings. First, psychometric testing of the UWE discovered that of the four scales, the CTS appeared to be the most reliable. It also may be the most valid of the subscales, as it demonstrated a change from pre to post. Second, the results indicated that overall, students’ perceptions of their communication and teamwork skills increased after completing a simulation-based learning experience. In addition to the overall CTS scale, two items of the CTS were significant: the ability to a) express alternative opinions within the group and b) become involved quickly in a new group during problem-solving.
TABLE 3. Paired t-Test for Each CTS Item and Total CTS
CTS Items 1. I feel comfortable justifying recommendations/advice face to face with more senior people. 2. I feel comfortable explaining an issue to people who are unfamiliar with the topic. 3. I have difficulty in adapting my communication style (oral and written) to particular situations and audiences. (R) 4. I prefer to stay quiet when other people in a group express opinions that I don’t agree with. (R) 5. I feel comfortable working in a group. 6. I feel uncomfortable putting forward my personal opinions in a group. (R) 7. I feel uncomfortable taking the lead in a group. (R) 8. I am able to become quickly involved in new teams and groups. 9. I am comfortable expressing my own opinions in a group, even when I know that other people don’t agree with them. CTS total score
Mean Mean Pre Scores Post Scores (n=74) (n=74)
t Value
p-Value
Effect Size
3.490
3.62
–1.297
0.199
–0.151
3.850
4.040
–2.162
0.034
–0.250
3.467
3.440
0.231
0.818
0.027
3.300 3.960
3.608 4.120
–3.113 –1.883
0.003* 0.064
–0.362 –0.217
3.480 3.333 3.570
3.600 3.427 3.830
–0.922 –0.926 –3.137
0.359 0.357 0.002*
–0.107 –0.107 –0.362
3.430 31.932
3.520 33.260
–1.123 –2.987
0.265 0.004*
–0.130 –0.350
Item scores ranged from 1–5. (R) indicates an item’s reverse score is reported Asterisk (*) indicates significant at p
