Improving the relational aspects of trauma care through translational simulation

Translational simulation revisited: an evolving conceptual model for the contribution of simulation to healthcare quality and safety

The simulation community has effectively responded to calls for a more direct contribution by simulation to healthcare quality and safety, and clearer alignment with health service priorities, but the conceptual framing of this contribution has been vague. The term 'translational simulation' was proposed in 2017 as a "functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions" (Brazil V. Adv Simul. 2:20, 2017). Six years later, this conceptual framing is clearer. Translational simulation has been applied in diverse contexts, affording insights into its strengths and limitations. Three core concepts are identifiable in recently published translational simulation studies: a clear identification of simulation purpose, an articulation of the simulation process, and an engagement with the conceptual foundations of translational simulation practice. In this article, we reflect on current translational simulation practice and scholarship, especially with respect to these three core concepts, and offer a further elaborated conceptual model based on its use to date.

Debriefing Methods for Simulation in Healthcare: A Systematic Review

ABSTRACT

Debriefing is a critical component in most simulation experiences. With the growing number of debriefing concepts, approaches, and tools, we need to understand how to debrief most effectively because there is little empiric evidence to guide us in their use. This systematic review explores the current literature on debriefing in healthcare simulation education to understand the evidence behind practice and clarify gaps in the literature. The PICO question for this review was defined as "In healthcare providers [P], does the use of one debriefing or feedback intervention [I], compared to a different debriefing or feedback intervention [C], improve educational and clinical outcomes [O] in simulation-based education?" We included 70 studies in our final review and found that our current debriefing strategies, frameworks, and techniques are not based on robust empirical evidence. Based on this, we highlight future research needs.

Artificial intelligence in emergency medicine. A systematic literature review

Motivation and objective: Emergency medicine is becoming a popular application area for artificial intelligence methods but remains less investigated than other healthcare branches. The need for time-sensitive decision-making on the basis of high data volumes makes the use of quantitative technologies inevitable. However, the specifics of healthcare regulations impose strict requirements for such applications. Published contributions cover separate parts of emergency medicine and use disparate data and algorithms. This study aims to systematize the relevant contributions, investigate the main obstacles to artificial intelligence applications in emergency medicine, and propose directions for further studies.

METHODS

The contributions selection process was conducted with systematic electronic databases querying and filtering with respect to established exclusion criteria. Among the 380 papers gathered from IEEE Xplore, ACM Digital Library, Springer Library, ScienceDirect, and Nature databases 116 were considered to be a part of the survey. The main features of the selected papers are the focus on emergency medicine and the use of machine learning or deep learning algorithms.

FINDINGS AND DISCUSSION

The selected papers were classified into two branches: diagnostics-specific and triage-specific. The former ones are focused on either diagnosis prediction or decision support. The latter covers such applications as mortality, outcome, admission prediction, condition severity estimation, and urgent care prediction. The observed contributions are highly specialized within a single disease or medical operation and often use privately collected retrospective data, making them incomparable. These and other issues can be addressed by creating an end-to-end solution based on human-machine interaction.

CONCLUSION

Artificial intelligence applications are finding their place in emergency medicine, while most of the corresponding studies remain isolated and lack higher generalization and more sophisticated methodology, which can be a matter of forthcoming improvements.

Exploring the relationship between simulation-based team training and sick leave among healthcare professionals: a cohort study across multiple hospital sites

OBJECTIVE

Burnout and mental illness are frequent among healthcare professionals, leading to increased sick leave. Simulation-based team training has been shown to improve job satisfaction and mental health among healthcare professionals. This study seeks to investigate the relationship between simulation-based team training and sick leave.

DESIGN

Cohort study.

SETTING AND INTERVENTION

Five Danish hospitals.

PARTICIPANTS

A total of 15 751 individuals were screened for eligibility. To meet the eligibility criteria, individuals had to be employed in the same group (intervention or control) for the whole study period. A total of 14 872 individuals were eligible for analysis in the study.

INTERVENTION

From 2017 to 2019, a simulation-based team training intervention was implemented at two hospital sites. Three hospital sites served as the control group.

OUTCOME MEASURES

Data on sick leave from 2015 to 2020 covered five hospital sites. Using a difference-in-difference analysis, the rate of sick leave was compared across hospital sites (intervention vs control) and time periods (before vs after intervention).

RESULTS

Significant alterations in sick leave were evident when comparing the intervention and control groups. When comparing groups over time, the increase in sick leave was -0.3% (95% CI -0.6% to -0.0%) lower in the intervention group than in the control group. The difference-in-difference for the complete case analysis showed that this trend remained consistent, with analysis indicating a comparable lower increase in sick leave by -0.7% (95% CI -1.3% to -0.1%) in the intervention group.

CONCLUSION

The increase in sick leave rate was statistically significantly lower in the intervention group, implying that simulation-based team training could serve as a protective factor against sick leave. However, when investigating this simulation intervention over 5 years, other potential factors may have influenced sick leave, so caution is required when interpreting the results.

On the edge of decision-making in trauma care: A focus group study on radiographers' experiences of interprofessional collaboration

INTRODUCTION

The temporary trauma teams in trauma alerts consist of a diverse group of unique professionals requiring interprofessional collaboration and coordination to achieve efficient, high-quality care. The uncertain situation and complex care environment impose high demands on team dynamics such as individual attitudes and team behaviours. Within interprofessional teams, interaction and coordination reflect the collective success of collaboration and the achievement of goals. Interactions with radiographers have increased in trauma teams given computed tomography's prominent role in providing crucial knowledge for decision-making in trauma care. This study aimed to explore radiographers' experiences of interprofessional collaboration during trauma alerts.

METHOD

The study was designed with focus group methodology, including 17 radiographers participating in five focus groups, analysed with an inductive focus group analysis.

RESULTS

An overarching theme, "On the edge of decision-making", emerged along with three sub-themes: "Feeling included requires acknowledgement", "Exclusion precludes shared knowledge", and "Experience and mutual awareness facilitate team interaction".

CONCLUSIONS

Interprofessional collaboration from the radiographer's perspective within trauma teams requires a sense of inclusion and the ability to interact with the team. Exclusion from vital decision-making obstructs radiographers' comprehension of situations and thereby the interdependence in interprofessional collaboration.

IMPLICATIONS FOR PRACTICE

Common platforms are needed for knowledge sharing and team practices, including radiographers' areas of responsibility and relational coordination to foster interprofessional relationships. Through these means interdependence through awareness and shared knowledge can be facilitated on trauma teams.

Training for managing impacted fetal head at caesarean birth: multimethod evaluation of a pilot

BACKGROUND

Implementation of national multiprofessional training for managing the obstetric emergency of impacted fetal head (IFH) at caesarean birth has potential to improve quality and safety in maternity care, but is currently lacking in the UK.

OBJECTIVES

To evaluate a training package for managing IFH at caesarean birth with multiprofessional maternity teams.

METHODS

The training included an evidence-based lecture supported by an animated video showing management of IFH, followed by hands-on workshops and real-time simulations with use of a birth simulation trainer, augmented reality and management algorithms. Guided by the Kirkpatrick framework, we conducted a multimethod evaluation of the training with multiprofessional maternity teams. Participants rated post-training statements about relevance and helpfulness of the training and pre-training and post-training confidence in their knowledge and skills relating to IFH (7-point Likert scales, strongly disagree to strongly agree). An ethnographer recorded sociotechnical observations during the training. Participants provided feedback in post-training focus groups.

RESULTS

Participants (N=57) included 21 midwives, 25 obstetricians, 7 anaesthetists and 4 other professionals from five maternity units. Over 95% of participants agreed that the training was relevant and helpful for their clinical practice and improving outcomes following IFH. Confidence in technical and non-technical skills relating to managing IFH was variable before the training (5%-92% agreement with the pre-training statements), but improved in nearly all participants after the training (71%-100% agreement with the post-training statements). Participants and ethnographers reported that the training helped to: (i) better understand the complexity of IFH, (ii) recognise the need for multiprofessional training and management and (iii) optimise communication with those in labour and their birth partners.

CONCLUSIONS

The evaluated training package can improve self-reported knowledge, skills and confidence of multiprofessional teams involved in management of IFH at caesarean birth. A larger-scale evaluation is required to validate these findings and establish how best to scale and implement the training.

Leading change in practice: how "longitudinal prebriefing" nurtures and sustains in situ simulation programs

In situ simulation (ISS) programs deliver patient safety benefits to healthcare systems, however, face many challenges in both implementation and sustainability. Prebriefing is conducted immediately prior to a simulation activity to enhance engagement with the learning activity, but is not sufficient to embed and sustain an ISS program. Longer-term and broader change leadership is required to engage colleagues, secure time and resources, and sustain an in situ simulation program. No framework currently exists to describe this process for ISS programs. This manuscript presents a framework derived from the analysis of three successful ISS program implementations across different hospital systems. We describe eight change leadership steps adapted from Kotter's change management theory, used to sustainably implement the ISS programs analyzed. These steps include the following: (1) identifying goals of key stakeholders, (2) engaging a multi-professional team, (3) creating a shared vision, (4) communicating the vision effectively, (5) energizing participants and enabling program participation, (6) identifying and celebrating early success, (7) closing the loop on early program successes, and (8) embedding simulation in organizational culture and operations. We describe this process as a "longitudinal prebrief," a framework which provides a step-by-step guide to engage colleagues and sustain successful implementation of ISS.

Hospital-based patient navigation programs for patients who experience injury-related trauma and their caregivers: a scoping review

OBJECTIVE

This review's objective is to map the literature on the characteristics, impact, barriers and facilitators of hospital-based patient navigation programmes that support patients who experience injury-related trauma and their caregivers. Patients who experience injury-related trauma frequently require support from multiple care teams and face many challenges to care, both in hospital and when transitioning across settings and services. Patient navigation can improve their care.

DESIGN

This review is conducted according to JBI methodology for scoping reviews. The initial database search took place on 6 June 2021 and the grey literature search took place between September and October 2021. The results are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews flow diagram.

SETTING

This review considered materials where the patient navigation programmes were delivered in hospital settings. There was no geographical limit to this study.

PARTICIPANTS

This review focused on hospital-based patient navigation programmes for patients who experience injury-related trauma and/or their caregivers.

RESULTS

This review captured 11 records that describe 10 programmes. All programmes were based in the USA. Most programmes provided education, care coordination, discharge planning, and referrals to resources, services, and programmes to assist patients and/or their families in the hospital or the community. Half the programmes were based in level 1 trauma centres. Common impacts included decreases in readmission rates and increases in satisfaction rates. Barriers included difficulty recruiting or enrolling patients with short hospital stays and hospital administrators' and healthcare providers' lack of understanding of the navigator role. Navigator background, either professional or experiential, was identified as a facilitator, as was flexibility in programme delivery and communication methods.

CONCLUSIONS

Eleven records show a small but distinct sample. Reported characteristics, impact, barriers and facilitators were consistent with findings from other patient navigation studies. The results can inform the development and implementation of similar programmes in trauma centres and support changes in policy to improve the delivery of care.

Psychological safety and emergency department team performance: A mixed‐methods study

OBJECTIVES

Team culture underpins team performance. Psychological safety - 'a shared belief held by members of a team that the team is safe for interpersonal risk taking' - is a critical component of team culture for high-performing teams across contexts. However, psychological safety in ED teams has not been well explored. We aimed to explore this core teamwork concept in the ED.

METHODS

This was a sequential mixed-methods study of nursing and medical staff at a large tertiary care ED in Australia from October 2020 to March 2021. First, participants completed the 'Team Learning and Psychological Safety Survey' and a narrative questionnaire. These findings informed semi-structured interviews. We determined median psychological safety and compared results across role and length of time working in the department. Qualitative results were analysed using a deductive thematic analysis using a previously generated framework for enablers of psychological safety at the individual, team and organisational levels.

RESULTS

The survey was completed by 72/410 participants and 19 interviews were conducted. The median psychological safety score was 37/49 (IQR 13). Psychological safety was not experienced universally, with nurses and new staff experiencing lower levels. Individual, team and organisational factors impacted psychological safety. The primary force shaping psychological safety was familiarity with colleagues and leaders.

CONCLUSION

Familiarity of team members and leaders was critical to the development of psychological safety within the ED. Fostering familiarity should be a focus for frontline leadership each shift and a priority in broader departmental decisions for those seeking to enhance the psychological safety of their teams.

Simulation versus reality: what can interprofessional simulation teach us about team dynamics in the trauma bay?

Purpose

Surgical consultation and the joint management of trauma patients is a common scenario in the emergency department. The goal of this study was to utilize interprofessional trauma team training to understand the role of simulation and its impact on the overall culture of trauma-related care.

Methods

Interdisciplinary trauma simulation scenarios were completed by 12 groups of emergency medicine residents, general surgery residents, and emergency medicine nurses across two academic years. Following each simulation, a debriefing session was held to reflect on the scenario, focusing on team interactions. Debriefing sessions were audio-recorded, transcribed, deidentified, and independently, inductively coded by two members of the research team. Using the constant comparative method, a codebook was developed and refined until interrater reliability was confirmed with a kappa of > 0.9. Codes were organized into higher level themes.

Results

There were 72 participants, including 23 general surgery residents, 19 emergency medicine residents, and 30 emergency medicine nurses. 214 primary codes were collapsed into 29 coding categories, with 6 emerging themes. Pre-trauma bay impact describes how interactions prior to the trauma scenario can impact how team members communicate, trust one another, and ultimately care for the patient. Role and team identity explores the importance of one knowing their individual role in the trauma bay and how it impacts overall team identity. Resource allocation describes the balance of having appropriate resources to efficiently care for patients while not negatively impacting crowd control or role identity. Impact of the simulation experience highlights the impact of the lower stakes simulation scenario on learning and reflection as well as concerns with simulation fidelity. Trauma leader traits and actions outlines inherent traits and learned actions of trauma leaders that impact how the trauma scenario unfolds. Interprofessional team performance describes the overall performance of the trauma team, including but not limited to the type of communication used, teamwork behaviors, and transition of care of the patient.

Conclusions

Interdisciplinary trauma simulations and structured debriefing sessions provide insights into team dynamics and interprofessional relationships. Simulations and debriefing sessions can promote understanding, respect, and familiarity of team members' roles; recognition of key characteristics of high functioning leaders and teams; and discovery of conflict mitigating strategies for future interdisciplinary team improvement. Simulation sessions allow implementation of quality improvement measures and communication and leadership strategy practice in a safe, collaborative learning environment. The lessons learned from these sessions can encourage participants to reexamine how they interact and function as a team within the real-life trauma bay.

Wearing hats and blending boundaries: harmonising professional identities for clinician simulation educators

Many clinicians working in healthcare simulation struggle with competing dual identities of clinician and educator, whilst those who harmonise these identities are observed to be highly effective teachers and clinicians. Professional identity formation (PIF) theories offer a conceptual framework for considering this dilemma. However, many clinician simulation educators lack practical guidance for translating these theories and are unable to develop or align their dual identities.

An unusual experience involving the first author’s suspension of disbelief as a simulation facilitator sparked a novel reflection on his dual identity as a clinician and as a simulation educator. He re-framed his clinician and simulation ‘hats’ as cooperative and fluid rather than competing and compartmentalised. He recognised that these dual identities could flow between clinical and simulation environments through leaky ‘blended boundaries’ rather than being restricted by environmental demarcations.

This personal story is shared and reflected upon to offer a practical ‘hats and boundaries’ model. Experimenting with the model in both clinical and simulation workplaces presents opportunities for PIF and alignment of dual identities. The model may help other clinician simulation educators navigate the complexities of merging their dual identities.

A relational approach to improving interprofessional teamwork in post-partum haemorrhage (PPH)

Background

Post-partum haemorrhage (PPH) is an obstetric emergency that requires effective teamwork under complex conditions. We explored healthcare team performance for women who suffered a PPH, focusing on relationships and culture as critical influences on teamwork behaviours and outcomes.

Methods

In collaboration with clinical teams, we implemented structural, process and relational interventions to improve teamwork in PPH cases. We were guided by the conceptual framework of Relational Coordination and used a mixed methods approach to data collection and analysis. We employed translational simulation as a central, but not singular, technique for enabling exploration and improvement. Key themes were identified from surveys, focus groups, simulation sessions, interviews, and personal communications over a 12-month period.

Results

Four overarching themes were identified: 1) Teamwork, clear roles and identified leadership are critical. 2) Relational factors powerfully underpin teamwork behaviours—shared goals, shared knowledge, and mutual respect. 3) Conflict and poor relationships can and should be actively explored and addressed to improve performance. 4) Simulation supports improved team performance through multifaceted mechanisms.

One year after the project commenced, significant progress had been made in relationships and systems. Clinical outcomes have improved; despite unprecedented increase in labour ward activity, there has not been any increase in large PPHs.

Conclusions

Teamwork, relationships, and the context of care can be actively shaped in partnership with clinicians to support high performance in maternity care. We present our multifaceted approach as a guide for leaders and clinicians in maternity teams, and as an exemplar for others enacting quality improvement in healthcare.

Strengthening networks for healthcare integration: A commentary

In their paper "Integrating Network Theory into the Study of Integrated Healthcare," Burns, Nembhard and Shortell set out to change how we think about healthcare, and ultimately how we design and deliver healthcare. They aim to do this by focusing attention on the networks through which care is delivered, with particular attention to the relational dimensions of those networks. Inspired by social network, care integration, and relational coordination theories, Burns et al. (2022) offer recommendations for moving the healthcare sector toward a fresh approach to care integration that reflects the realities of relationships and networks. In this commentary, we analyze the main recommendations by Burns et al. and present our view of the field's current standing with regards to each of them. We then suggest potential research questions, contexts and designs to move this proposed work forward, drawing upon insights from a conversation with the authors in addition to their original article. We end by recommending the formation of a research collaborative to carry out the work.

Critical Appraisal of Anesthesiology Educational Research for 2019

BACKGROUND

This study reviews and appraises the articles published about anesthesiology education in 2019. Through this critical appraisal, those interested in anesthesiology education are able to quickly review literature published during this year and explore innovative ways to improve education for all those involved in the practice of anesthesiology.

METHODS

Three Ovid MEDLINE databases, Embase.com, ERIC, and PsycINFO were searched followed by a manual review of articles published in the highest impact factor journals in both the fields of anesthesiology and medical education. Abstracts were double-screened and quantitative articles were subsequently scored by 3 randomly assigned raters. Qualitative studies were scored by 2 raters. Two different rubrics were used for scoring quantitative and qualitative studies; both allowed for scores ranging from 1 to 25. In addition, reviewers rated each article on its overall quality to create an additional list of top articles based solely on the opinion of the reviewers.

RESULTS

A total of 2374 unique citations were identified through the search criteria and the manual review. Of those, 70 articles met the inclusion criteria (62 quantitative and 8 qualitative). The top 12 quantitative papers and the top 2 qualitative papers with the highest scores were reported and summarized.Conclusions: This critical appraisal continues to be a useful tool for those working in anesthesiology education by highlighting the best research articles published over the year. Highlighting trends in medical education research in anesthesiology can help those in the field to think critically about the direction of this type of research.

Taking simulation out of its "safe container"-exploring the bidirectional impacts of psychological safety and simulation in an emergency department

BACKGROUND

Simulation facilitators strive to ensure the psychological safety of participants during simulation events; however, we have limited understanding of how antecedent levels of psychological safety impact the simulation experience or how the simulation experience impacts real-world psychological safety.

METHODS

We explored the experience of participants in an embedded, interprofessional simulation program at a large tertiary emergency department (ED) in Australia. We engaged in theoretical thematic analysis of sequential narrative surveys and semi-structured interviews using a previously derived framework of enablers of psychological safety in healthcare. We sought to understand (1) how real-world psychological safety impacts the simulation experience and (2) how the simulation experience influences real-world psychological safety.

RESULTS

We received 74 narrative responses and conducted 19 interviews. Simulation experience was both influenced by and impacted psychological safety experienced at the individual, team, and organizational levels of ED practice. Most strikingly, simulation seemed to be an incubator of team familiarity with direct impact on real-world practice. We present a model of the bidirectional impact of psychological safety and simulation within healthcare environments.

CONCLUSION

Our model represents both opportunity and risk for facilitators and organizations engaging in simulation. It should inform objectives, design, delivery, debriefing, and faculty development and firmly support the situation of simulation programs within the broader cultural ethos and goals of the departments and organizations.

Decision Making in Obstetric Anesthesia

Obstetric anesthesiologists provide care under unique conditions, where frequently unscheduled cases demand flexibility in thinking and acting. And although most obstetric patients may be healthy, they can quickly deteriorate, necessitating rapid team diagnostic and treatment interventions. Examining decision making is a critical step in improving care to these patients. This article reviews evidence-based models of decision making both with individuals and with teams, and presents strategies to improve decision making under any circumstance.

Setting the stage for speaking up: psychological safety and directing care in acute care collaboration

Managing a safe and efficient anaesthetic induction within a team involves the challenge of when, if, and how to surface, discuss, and implement the best plan on how to proceed. The Lemke and colleagues study in this issue of the British Journal of Anaesthesia is a unique view into real-world conversations that naturally occur in anaesthesia teams in moments of high task and cognitive load, such as induction of anaesthesia. The study spotlights important small moments of physician, nurse, and trainee team coordination. It illuminates key patterns of conversation in naturally occurring anaesthesia teams, and raises important questions about what the speaking up standard should be and the psychological safety-shaping role consultants play in setting the norms for speaking up.

Optimising frontline learning and engagement between consultant-led neonatal teams in the West Midlands: a survey on the utility of an augmented simulation training technique

Background

In England, neonatal care is delivered in operational delivery networks, comprising a combination of the Neonatal Intensive Care (NICU), Local-Neonatal (LNU) or Special-Care Units (SCU), based on their ability to care for babies with different degrees of illness or prematurity. With the development of network care pathways, the most premature and sickest are mostly triaged for delivery in services linked to NICU. This has created anxiety for teams in LNU and SCU. Less exposure to sicker babies has resulted in limited opportunities to maintain expertise for when these babies unexpectedly deliver at their centre and thereafter require transfer for care, to NICU. Simultaneously, LNU and SCU teams develop skills in the care of the less ill and premature baby which would also be of benefit to NICU teams. A need for mutual learning through inter-unit multidirectional collaborative learning and engagement (hereafter also called neonatal networking) between teams of different designations emerged. Here, neonatal networking is defined as collaboration, shared clinical learning and developing an understanding of local systems strengths and challenges between units of different and similar designations. We describe the responses to the development of a clinical and systems focussed platform for this engagement between different teams within our neonatal ODN.

Method

An interactive 1-day programme was developed in the West Midlands, focussing on a non-hierarchical, equal partnership between neonatal teams from different unit designations. It utilised simulation around clinical scenarios, with a slant towards consultant engagement. Four groups rotating through four clinical simulation scenarios were developed. Each group participated in a clinical simulation scenario, led by a consultant and supported by nurses and doctors in training together with facilitators, with a further ~two consultants, as observers within the group. All were considered learners. Consultant candidates took turns to be participants and observers in the simulation scenarios so that at the end of the day all had led a scenario. Each simulation-clinical debrief session was lengthened by a further ~ 20 min, during which freestyle discussion with all learners occurred. This was to promote further bonding, through multidirectional sharing, and with a systems focus on understanding the strengths and challenges of practices in different units. A consultant focus was adopted to promote a long-term engagement between units around shared care. There were four time points for this neonatal networking during the course of the day. Qualitative assessment and a Likert scale were used to assess this initiative over 4 years.

Results

One hundred fifty-five individuals involved in frontline neonatal care participated. Seventy-seven were consultants, supported by neonatal trainees, staff grade doctors, clinical fellows, advanced neonatal nurse practitioners and nurses in training. All were invited to participate in the survey. The survey response rate was 80.6%. Seventy-nine percent felt that this learning strategy was highly relevant; 96% agreed that for consultants this was appropriate adult learning. Ninety-eight percent agreed that consultant training encompassed more than bedside clinical management, including forging communication links between teams. Thematic responses suggested that this was a highly useful method for multi-directional learning around shared care between neonatal units.

Conclusion

Simulation, enhanced with systems focussed debrief, appeared to be an acceptable method of promoting multidirectional learning within neonatal teams of differing designations within the WMNODN.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-021-00181-1.

Feeling the flow with a serious game workshop: GridlockED as Medical Education 2 study (GAME2 study)

OBJECTIVE

GridlockED gameplay workshops were delivered in Canada. This project investigated workshop attendees' experiences, seeking to identify learning points to inform improvement of the workshop.

METHODS

GridlockED sessions were held through 2018 and 2019. Workshops targeted medical trainees. After a standardized video, learners played for approximately 90 minutes. Learners completed a postgameplay survey with 7-point Likert scale questions about their experience.

RESULTS

Seventy-two participants responded to our survey (41 medical students, 13 physician assistant students, 12 emergency medicine residents, and six faculty members). Trainees rated GridlockED as both enjoyable and a meaningful educational experience, with a mean (±SD) rating of 6.53 (±0.96) of 7 for enjoyment and 6.17 (±1.13) for education. Attendees identified teamwork and communication (49%) as the most helpful learning domain, with patient flow (43%) being second and basics of how the ED worked (31%) being third. The respondents self-identified top areas of learning as resource management (38.9%), improved understanding of various provider roles in the ED (33%), and improved communication skills (33%).

CONCLUSION

Medical learners identified GridlockED to be an educational and enjoyable learning experience. Attendees reported that playing this serious game assisted with learning about health systems and communication.

A Guide for Medical Educators: How to Design and Implement In Situ Simulation in an Academic Emergency Department to Support Interprofessional Education

In situ simulation (ISS) put simulation training directly into the clinical practice environment. Although ISS creates opportunities to identify latent system threats, understand culture, and improve team dynamics, there are limited resources for medical educators to guide the development and implementation of ISS at academic (or community-based) emergency departments (EDs). We describe the implementation of ISS in a high-volume urban ED to help educators understand the requirements and limitations of successful program design. During an academic year, 66 individual learners participated in at least one of our 22 training sessions, a cohort that included 37 nurses, 17 physicians, eight physician assistants, and four allied health professionals. Feedback from these participants and case facilitators informed our iterative process of review and development of program guidelines and best practices. We share these key technical points and the themes we found to be essential to the successful implementation of an ISS program: consideration of session timing, participant buy-in, flexibility, and threats to professional identity. Overall, our report demonstrates the feasibility of implementing an ISS program in a high-volume urban ED and provides medical educators with a guide for creating an ISS program for interprofessional education.

Translational simulation: from description to action

This article describes an operational framework for implementing translational simulation in everyday practice. The framework, based on an input-process-output model, is developed from a critical review of the existing translational simulation literature and the collective experience of the authors' affiliated translational simulation services. The article describes how translational simulation may be used to explore work environments and/or people in them, improve quality through targeted interventions focused on clinical performance/patient outcomes, and be used to design and test planned infrastructure or interventions. Representative case vignettes are used to show how the framework can be applied to real world healthcare problems, including clinical space testing, process development, and culture. Finally, future directions for translational simulation are discussed. As such, the article provides a road map for practitioners who seek to address health service outcomes using translational simulation.

Doing our work better, together: a relationship-based approach to defining the quality improvement agenda in trauma care

Background

Trauma care represents a complex patient journey, requiring multidisciplinary coordinated care. Team members are human, and as such, how they feel about their colleagues and their work affects performance. The challenge for health service leaders is enabling culture that supports high levels of collaboration, co-operation and coordination across diverse groups. We aimed to define and improve relational aspects of trauma care at Gold Coast University Hospital.

Methods

We conducted a mixed-methods collaborative ethnography using the relational coordination survey—an established tool to analyse the relational dimensions of multidisciplinary teamwork—participant observation, interviews and narrative surveys. Findings were presented to clinicians in working groups for further interpretation and to facilitate co-creation of targeted interventions designed to improve team relationships and performance.

Findings

We engaged a complex multidisciplinary network of ~500 care providers dispersed across seven core interdependent clinical disciplines. Initial findings highlighted the importance of relationships in trauma care and opportunities to improve. Narrative survey and ethnographic findings further highlighted the centrality of a translational simulation programme in contributing positively to team culture and relational ties. A range of 16 interventions—focusing on structural, process and relational dimensions—were co-created with participants and are now being implemented and evaluated by various trauma care providers.

Conclusions

Through engagement of clinicians spanning organisational boundaries, relational aspects of care can be measured and directly targeted in a collaborative quality improvement process. We encourage healthcare leaders to consider relationship-based quality improvement strategies, including translational simulation and relational coordination processes, in their efforts to improve care for patients with complex, interdependent journeys.

Rapid cycle system improvement for COVID-19 readiness: integrating deliberate practice, psychological safety and vicarious learning

Introduction

In the face of a rapidly advancing pandemic with uncertain pathophysiology, pop-up healthcare units, ad hoc teams and unpredictable personal protective equipment supply, it is difficult for healthcare institutions and front-line teams to invent and test robust and safe clinical care pathways for patients and clinicians. Conventional simulation-based education was not designed for the time-pressured and emergent needs of readiness in a pandemic. We used ‘rapid cycle system improvement’ to create a psychologically safe learning oasis in the midst of a pandemic. This oasis provided a context to build staff technical and teamwork capacity and improve clinical workflows simultaneously.

Methods

At the Department of Anaesthesia and Intensive Care in Prince of Wales Hospital, a tertiary institution, in situ simulations were carried out in the operating theatres and intensive care unit (ICU). The translational simulation design leveraged principles of psychological safety, rapid cycle deliberate practice, direct and vicarious learning to ready over 200 staff with 51 sessions and achieve iterative system improvement all within 7 days. Staff evaluations and system improvements were documented postsimulation.

Results/Findings

Staff in both operating theatres and ICU were significantly more comfortable and confident in managing patients with COVID-19 postsimulation. Teamwork, communication and collective ability to manage infectious cases were enhanced. Key system issues were also identified and improved.

Discussion

To develop readiness in the rapidly progressing COVID-19 pandemic, we demonstrated that ‘rapid cycle system improvement’ can efficiently help achieve three intertwined goals: (1) ready staff for new clinical processes, (2) build team competence and confidence and (3) improve workflows and procedures.

Translational simulation for rapid transformation of health services, using the example of the COVID-19 pandemic preparation

Healthcare simulation has significant potential for helping health services to deal with the COVID-19 pandemic. Rapid changes to care pathways and processes needed for protection of staff and patients may be facilitated by a translational simulation approach-diagnosing changes needed, developing and testing new processes and then embedding new systems and teamwork through training. However, there are also practical constraints on running in situ simulations during a pandemic-the need for physical distancing, rigorous infection control for manikins and training equipment and awareness of heightened anxiety among simulation participants. We describe our institution's simulation strategy for COVID-19 preparation and reflect on the lessons learned-for simulation programs and for health services seeking to utilise translational simulation during and beyond the COVID-19 pandemic. We offer practical suggestions for a translational simulation strategy and simulation delivery within pandemic constraints. We also suggest simulation programs develop robust strategies, governance and relationships for managing change within institutions-balancing clinician engagement, systems engineering expertise and the power of translational simulation for diagnosing, testing and embedding changes.

Effects of Gender and Race/Ethnicity on Perioperative Team Performance

We judge each other every day using demographic characteristics (such as gender and race/ethnicity), and these social identities shape our lives in profound ways. The impacts of demographic diversity in perioperative teams are poorly understood, and mixed results are reported in other team-based work settings. Drawing from decades' worth of organizational behavior literature, the authors propose a model of critical factors related to interplays between diversity, communication, and conflict, all which take place in a hierarchical environment influenced by power differences. Evidence-based recommendations are provided, aimed at maximizing benefits of diversity in perioperative teams while minimizing negative consequences.

Front-line nurses' perceptions of intra-hospital handover

AIM AND OBJECTIVE

To explore nurses' perceptions of factors that help or hinder intra-hospital handover.

BACKGROUND

Miscommunication during clinical handover is a leading cause of clinical incidents in hospitals. Intra-hospital nursing handover between the emergency department and inpatient unit is particularly complex.

DESIGN

A descriptive, qualitative study. This research adheres to the consolidated criteria for reporting qualitative research.

METHODS

Forty-nine nurses participated in group interviews, which were analysed using inductive content analysis.

RESULTS

Three categories emerged: (a) "lacking clear responsibilities for who provides handover"; (b) "strategies to ensure continuity of information"; and (c) "strained relationships during handover."

CONCLUSIONS

Intra-hospital handover requires clear processes, to promote high-quality information sharing. Ensuring these processes are broad and acceptable across units may ensure nurses' needs are met. Relational continuity between nurses is an important consideration when improving intra-hospital handover.

RELEVANCE TO CLINICAL PRACTICE

Nursing managers are optimally positioned to enhance intra-hospital handover, by liaising and enforcing standardisation of processes across units. Nurse managers could promote intra-unit activities that foster front-line nurses' communication with each other, to encourage problem-solving and partnerships.

Robotic Liver Resection

Robotic surgery has rapidly evolved. It is particularly attractive as an alternative minimally invasive approach in liver surgery because of improvements in visualization and articulated instruments. Limitations include increased operative times and lack of tactile feedback, but these have not been shown in studies. Considerations unique to robotic surgery, including safety protocols, must be put in place and be reviewed at the beginning of every procedure to ensure safety in the event of an emergent conversion. Despite the lack of early adoption by many hepatobiliary surgeons, robotic liver surgery continues to evolve and find its place within hepatobiliary surgery.