Why simulation-based team training has not been used ... - Springer Link

Adv in Health Sci Educ (2012) 17:279–288 DOI 10.1007/s10459-011-9281-8 REFLECTIONS

Why simulation-based team training has not been used effectively and what can be done about it Italo Masiello

Received: 1 May 2010 / Accepted: 2 February 2011 / Published online: 11 February 2011 Ó Springer Science+Business Media B.V. 2011

Abstract Advanced medical education simulators are broadly used today to train both technical/procedural and team-based skills. While there is convincing evidence of the benefits of training technical skills, this is not the case for team-based skills. Research on medical expertise could drive the creation of a new regime of simulation-based team training. The new regime includes first the understanding of complex systems such as the hospital and the operating room; then the performance of work-place assessment; thirdly, the deliberate training of weaknesses and team performance skills; and lastly the understanding of the underlying mechanisms of team competence. A new regime of deliberate training proposed by the author, which would need to be evaluated and validated, could elucidate the underlying mechanisms of team competence while providing evidence of the effect of simulation-based team training. Keywords Deliberate practice
Medical simulation
Medical expertise
Team training
Teamwork
Human factors

Background Training of technical skills such as operative, surgical and anaesthesia competence has been demonstrated to be acquired through the use of medical simulators, such as the laparoscopic trainer (Aggarwal et al. 2007; Ahlberg et al. 2002; Grantcharov et al. 2001; McGaghie et al. 2006; Seymour et al. 2002) and anaesthesia simulator (Chopra et al. 1994). Research around the use of technical skills simulators has even gone a step further by proving that simulation training sessions with these instruments translate into competence in the clinical settings (Domuracki et al. 2009; Grantcharov et al. 2004; Naik et al. 2001; I. Masiello (&) Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Berzelius va¨g 3, 17177 Stockholm, Sweden e-mail: [email protected] I. Masiello Karolinska University Hospital, Clinical Skills and Simulation Center, Stockholm, Sweden

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Seymour et al. 2002). This research validates the use of simulators for the training of technical skills. Before going any further, it is necessary to define ‘team’, ‘teamwork’, and ‘team training’. A frequently quoted definition of a team is that of Katzenbach and Smith (1993), by which a team is defined as a small number of people who have complementary skills, work interdependently, are committed to a common purpose and goal, share relevant knowledge, and are likely accountable. Teamwork can be defined as a set of behavioural abilities, such as effective communication, anticipation and meeting of others’ demands, and inspiration to confidence, that facilitate effective interaction among team members (Smith and Cole 2009; Lerner et al. 2009). Team training is the utilization of instructional strategies to a specific set of competencies, that is, the assimilation of learning theory principles and team behaviours, the practice of these, and the provision of remedial feedback (Baker et al. 2005). In healthcare, teams are usually interprofessional, meaning that they are composed of two or more health professions. To date, there is little evidence of the benefits of team training in dynamic clinical domains to improve non-technical skills. Non-technical skills are classified into four components: task management and leadership, teamwork and collaboration, problemsolving and decision-making and finally situation awareness. One study reports that simulation-based not-technical skills training improves technical performance (McCulloch et al. 2009). Another study instead shows the transfer of simulation-based training on both technical and non-technical clinical performance (Bruppacher et al. 2010). Both studies have limitations such as personnel change, resources problems, population size, financial crisis and biased study design and raters; nonetheless they reinforce the use of simulation training. However, the current bulk of research evidence is ambiguous and in many cases only linked to the subjective recollection of trainees, the so called self-efficacy effect, which does not consistently link to observed measures of competence (Nishisaki et al. 2007). As with many studies, technical and non-technical outcomes are measured within the exercise of a research project or training opportunity and not in real life (Hunt et al. 2007; Moorthy et al. 2005; Yee et al. 2005). In this article the author intends to elucidate some of the reasons behind why research on simulation-based team training has failed to produce clear evidence of its effect in a dynamic domain of healthcare, such as the operating room. This will be done by building on theories of medical expertise, medical education and team training. In addition, the author proposes a new training regime for ensuring the effectiveness of team training. However, further studies are needed to evaluate its feasibility. Current simulated team training In 2000, the Institute of Medicine (Kohn et al. 2000) reported defective teamwork as one of several factors related to an excessive rate of preventable healthcare errors. After that report, teamwork and team training have become a major focus in healthcare. Thus, it has also been suggested, in a subsequent report (Baker et al. 2005), that effective teamwork and the development of team training performance are necessary to improve patient safety. Teamwork in healthcare is complicated by the fact that three or more people who have probably not previously worked with each other and might not even be familiar with each other have to collaborate for the benefit of the patient in a complex and dynamic environment. This means that team composition and context change constantly, which is one of the obvious explanations to why the evidence on the effective use of simulated medical team training is weak (more on the importance of context in the next section). This

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environment is usually characterized by quickly developing and confusing situations, information overload, time constraints, and high risks for patient well-being. Effective teams typically use shared knowledge, skills, attitudes, goals, and monitoring of own and others’ performance to achieve teamwork (Paris et al. 2000). The composition of effective teams though does not change as often as it does instead in clinical settings. In addition, researchers (Salas et al. 2009) state that successful team training programs can improve team performance if organizational aspects such as leadership support, a positive learning climate, and commitment to best-evidence change, are factored in. Those aspects though are seldom part of a healthcare environment in which caregivers are given flexible opportunities for learning. Crew resource management (CRM) (Helmreich and Musson 2000), a NASA method to train cockpit pilots, has been included in the training of team coordination and communication with the goal of improving teamwork. The argument of CRM is that a structured series of actions could minimize the risk of making errors that could be fatal for the patient or cause morbidity. Research has demonstrated the use of CRM as an effective team training method for successful transfer of team performance in high-reliability organizations such as aviation and nuclear power plants (Baker et al. 2006). However, health care hardly qualifies as such an industry, and to date there is little or no evidence that CRM programs for team training actually improve patient safety and outcomes (Hunt et al. 2007; Sundar et al. 2007). The existing evidence illustrates that even though non-technical skills improve after training, there is variation between teams studied (McCulloch et al. 2009; Salas et al. 2008a). This evidence is probably tied to the research on expertise which reveals that non-technical skills, such as communication and problem-solving, are not skills that can be generalized across contexts (Norman 2005a) that change as rapidly as the healthcare. Research on medical expertise In the early 1990s, Miller (1990) introduced a framework for the assessment of clinical performance of medical students. As in a pyramid-like structure, students are often tested on prerequisite knowledge and the application of it (the Knows and Knows How bottom blocks of a pyramid). Moving one step higher in the structure, Shows How, basic clinical skills can be measured by objective structured clinical examinations. Finally, at the top of the pyramid is the element most difficult to capture—Does, professionalism during actual patient care. This framework is today at the base of assessment methods of medical competency, and it is now incorporated in performance assessment of virtually all simulation-based team training. This dichotomy of knowledge and skills though has been challenged. The interdependency of knowledge and skills is highly content specific, making teaching of generalisable performance skills, such as communication and problemsolving, impractical (Eva 2003; Hodges 2006). Only after continuous practice/training and gaining of experience in a specific domain a student becomes then a professional and finally, after 10 years (Ericsson et al. 1993), is recognized as an expert or one who performs in a masterful way (Dent and Harden 2005). The study of this long development process and interdependency of knowledge and skills is outlined by research on medical expertise. A fairly recent volume of the Medical Education journal (Volume 41, Issue 12, pages 1113–1242, December 2007) has focused on clinical expertise research. Without going into the details of the articles or taking any position toward any research paradigm, it can be stated that one crucial aspect of this small body of research is that practice is central for the

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development of expertise; even more important than talent (Ericsson 2004). This acknowledges the importance of simulation-based training to improve clinical and teamwork performance. However, precisely this notion is the Achilles’ heel of simulation-based team training. According to Ericsson (2004), most professionals in any domain reach a stable and proficient level of performance—automaticity—within a short period of time and maintain this status for the rest of their careers. Only some will continue to develop and improve. Ericsson (ibid) dubs these expert performers, who offset automaticity by developing gradually more complex mental representations in order to achieve higher levels of performance, or deliberate practice. Simply stated, training on a well-defined task, with detailed and immediate feedback and ample opportunity for repetition, leads to improved performance (Ericsson 2008). However, at least two out of the three aspects just mentioned, if not all, are exactly the deficiencies of current medical team training practice (Rodriguez-Paz et al. 2009), Achilles’ heel. To reach the level of performance described by Ericsson it is necessary to repeatedly train teamwork, not once a year or every two years, as it happens currently with simulationbased team training in clinical skills centres (at least this is the case in the Stockholm area). It is necessary to focus on tasks of which each individual in a team needs gradual refinement, not on general CRM training aspects for all, as it happens today with simulation-based team training. It is necessary to receive immediate feedback on repeated variations of specific performance and not general feedback, which at times may even be the first experience with direct feedback for many, as it happens today with simulationbased team training. Simulation-based team training is not developed nor used effectively, and more of this training will probably not lead to better performance. What we can do to use simulation-based team training more effectively Healthcare professionals are highly competent and responsible experts who have been trained many years to function as individual professionals, while patient care is an activity that demands collaboration between professionals. At times, however, competent individual professionals can ‘‘combine to create an incompetent team’’ (Lingard 2009). The same researcher proposes a ‘‘collectivist discourse of competence’’ in medicine, with the premise that knowledge is constructed as the result of the social interaction which is shaped by the physical, social and organizational artefacts and not completely controlled by the teacher or learner. According to this premise, competence in team performance is the collective production of knowledge, and each individual is a crucial part of the system. Still to date, we measure competences of the individuals in a team instead of assessing team-skills competences. In addition, the results from the research on team-skills performance measures are confusing and inconsistent (Baker et al. 2005). Interprofessional education is making advances in health professional undergraduate curricula with the promise of offering a possible way to improve teamwork, communication and patient care, but its effectiveness is still debated (Reeves et al. 2008). According to Reeves et al. (2010), the more experimentally stringent studies have not provided the evidence of the impact of IPE on a number of outcomes. While others studies with more inclusive methodologies showed effectiveness of IPE on changes in learners’ attitude ‘‘towards one another’s professions, improvements in knowledge of interprofessional collaboration, enhancement of collaborative behaviour, and gains in the delivery of patient care.’’ The resulting dissimilarities derived from the use of different methods illustrate the challenge that IPE faces in demonstrating its evidence base. IPE is though a recent

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educational model for learning together, or as in Lingard’s (ibid) terms ‘‘collectivist discourse of competence’’, and as such it needs time to mature and prove its effects. To support the importance of IPE and team training from early undergraduate health professional education, 10 universities around the world are now testing the WHO curriculum on patient safety (www.who.int/patientsafety/education/medical_curriculum/en/ index.html). Eleven areas are identified as relevant to improving safety, including human factors, teamwork, intercommunication and patient safety issues and system thinking (Ellis 2009). The results should soon be published. Nonetheless, it should not come as a surprise if the first thing we can do to use simulation-based team training more effectively during the professional career is to expose the trainees to non-technical skills much earlier in their early career, that is, during the undergraduate curriculum, and not as late as in the expert performer phase where professional attitudes are fully formed and difficult to change (Flin and Patey 2009). This is in line with the evidence from research on expertise, where exposure to multiple and continuous representations in memory is associated with expertise (Norman 2005b). However, this first step relates to students during their educational pursuit. A much larger group of professionals is though now in need of team training in order to do teamwork. Therefore, in the following sections the author elucidates how teamwork could be made effective after deliberate training of expert individuals. Again, as research on expertise tells us it is a futile exercise to lift-up behaviour from its context. Individuals’ personal characteristics are context-dependent, although we would like to think that we have general personality traits (Eva 2003). This suggests that errors and patient safety in healthcare, and the operating room, are dictated by the individuals’ features and the contextual factors, e.g., operating room’s culture, goals, staff, user needs, practices, organizational characteristics, etc. (Holden and Karsh 2007). One-size-fit-all solutions to team training seem after all unsuitable. In this case, what we need to do first then is try to understand the contextual factors of the operating room in its larger and complex context of the hospital. Human factors engineering suggests doing a function and task analyses of the system and human needs, discover potential human/system mismatches, include personnel in redesigning their jobs, optimize the jobs, and use valid ergonomic techniques to measure human performance and well-being. Those are just the tip of the iceberg of human factors engineering solutions applicable to healthcare in order to provide system safety and design solutions for complex systems (Gawron et al. 2006). Once we have a basic understanding of the complex hospital, we can start looking to the operating room. The above basic principles are valid here as well. The operating room is a complex system within a larger complex system. Finally, from the system we would then need to move and understand the behaviour of the single person. The recent WHO advance on safe surgery provides us with an opportunity, place and time to test the author’s idea to create a new regime of simulation-based team training and of deliberate practice, which would then need to be evaluated and validated. During the ‘Sign Out’ phase (one of three, according to the WHO | Safe Surgery Saves Lives initiatives http://www.who.int/patientsafety/safesurgery/en/index.html), meaning before the operating room team leaves the room, each team member is instructed to take a time out (no pan intended with the second phase of the WHO initiatives) and do a work-place based assessment of aspects of teamwork and communication that are strongly believed to need improvement (see Fig. 1a). At the same time, each individual is instructed to highlight the positive aspects on which good teamwork is built for that specific operation. These two steps go hand-in-hand. One, as Carthey et al. (2001) have suggested, is essential because error recovery strategies are just as important as error prevention measures, and the other is

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Research on medical expertise

A Individual/team LEARNING

Individual/team TRAINING

NEW TRAINING REGIME

Real practice WHO – ”Sign Out” Score cards - Team-skills weaknesses - Positive team-skills behaviours

B