Learning practices of experienced healthcare teams and dyads in acute care settings: a scoping review

OBJECTIVES

To map the evidence on learning practices currently used by experienced healthcare teams and dyads. The hypothesis is that through reviewing the literature we will identify the number and array of current learning practices. Through the lens of collaboration, the authors' goal is to map current practice to guide future research, policy and practice.

SETTING

The review included studies from North America, Europe, Australasia and Asia. All studies were conducted in acute care settings such as operating rooms, emergency rooms, intensive care units and simulation centres.

PARTICIPANTS

The participants were experienced healthcare professionals who work in acute care settings of any age or any sex. The group was interprofessional including two or more disciplines and/or professions. Characteristics of the participants who were excluded were students, novices, healthcare professionals who work in non-acute care settings and single profession studies.

PRIMARY AND SECONDARY OUTCOME MEASURES

Aligned to the protocol quantitative and qualitative analyses were conducted. Thematic analysis was used to evaluate and categorise the study findings. Secondary outcome measures were the different types of learning practices used together to produce excellence.

RESULTS

Most empirical studies were qualitative studies (46%), 31% were mixed methods and 23% were quantitative studies. There were also 24 reviews and 10 commentaries. The most frequent learning practices were structured observation and case scenarios (21%) followed by audio/video analysis and surveys (17%). Next was interviews and didactic presentations (12%) followed by prebriefing/debriefing and checklists (11%). Other learning practices accounted for less than 10%. Overall, 84 of the 86 publications, examined learning practices of teams larger than two participants.

CONCLUSIONS

While the quality of studies was high, and there was a broad range of empirical studies, reviews and commentaries, there was no consensus on best practice in determining which learning practices to use and measurement of the effect of these practices.

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats

BACKGROUND

Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcomes. Frequency of cardiac arrest events differs by hospital location, which presents unique challenges in care due to variations in responding team composition and comfort levels and familiarity with obtaining and utilizing arrest equipment. The objective of this initiative is to utilize unannounced, in situ, cardiac arrest simulations hospital wide to educate, evaluate, and maximize cardiac arrest teams outside the traditional simulation lab by systematically assessing and capturing areas of opportunity for improvement, latent safety threats (LSTs), and key challenges by hospital location.

METHODS

Unannounced in situ simulations were performed at a city hospital with multidisciplinary cardiac arrest teams responding to a presumed real cardiac arrest. Participants and facilitators identified LSTs during standardized postsimulation debriefings that were classified into equipment, medication, resource/system, or technical skill categories. A hazard matrix was used by multiplying occurrence frequency of LST in simulation and real clinical events (based on expert opinion) and severity of the LST based on agreement between two evaluators.

RESULTS

Seventy-four in situ cardiac arrest simulations were conducted hospital wide. Hundreds of safety threats were identified, analyzed, and categorized yielding 106 unique latent safety threats: 21 in the equipment category, 8 in the medication category, 41 in the resource/system category, and 36 in the technical skill category. The team worked to mitigate all LSTs with priority mitigation to imminent risk level threats, then high risk threats, followed by non-imminent risk LSTs. Four LSTs were deemed imminent, requiring immediate remediation post debriefing. Fifteen LSTs had a hazard ratio greater than 8 which were deemed high risk for remediation. Depending on the category of threat, a combination of mitigating steps including the immediate fixing of an identified problem, leadership escalation, and programmatic intervention recommendations occurred resulting in mitigation of all identified threats.

CONCLUSIONS

Hospital-wide in situ cardiac arrest team simulation offers an effective way to both identify and mitigate LSTs. Safety during cardiac arrest care is improved through the use of a system in which LSTs are escalated urgently, mitigated, and conveyed back to participants to provide closed loop debriefing. Lastly, this hospital-wide, multidisciplinary initiative additionally served as an educational needs assessment allowing for informed, iterative education and systems improvement initiatives targeted to areas of LSTs and areas of opportunity.

Accreditation of Simulation Fellowships and Training Programs: More Checkboxes or Elevating the Field?

SUMMARY STATEMENT

As the field of healthcare simulation matures, formal accreditation for simulation fellowships and training programs has become increasingly available and touted as a solution to standardize the education of those specializing in healthcare simulation. Some simulation experts hold opposing views regarding the potential value of simulation fellowship program accreditation. We report on the proceedings of a spirited debate at the 20th International Meeting on Simulation in Healthcare in January 2020. Pro arguments view accreditation as the logical evolution of a maturing profession: improving training quality through standard setting, providing external validation for individual programs, and enhancing the program's return on investment. Con arguments view accreditation as an incompletely formulated construct; burdensome to the "financially strapped" fellowship director, misaligned with simulation fellows' needs and expectations, and confusing to administrators mistakenly equating accreditation with credentialing. In addition, opponents of accreditation postulate that incorporating curricular standards, practice guidelines, and strategies derived and implemented without rigor, supporting evidence and universal consensus is premature. This narrative review of our debate compares and contrasts contemporary perspectives on simulation fellowship program accreditation, concluding with formal recommendations for learners, administrators, sponsors, and accrediting bodies.

Optimising expert dyad performance in acute care settings: a scoping review protocol

INTRODUCTION

When there is miscommunication and poor coordination between experienced clinician dyads, teamwork suffers. Research on expert learning practices for the smallest team, and arguably the most important team, the healthcare dyad, is limited. The objective of this study is to map the extent and range of evidence available on learning practices which experienced dyads use, to achieve excellent performance, and to identify the gaps in effective practice. This will guide future research, policy and practice.

METHODS AND ANALYSIS

We are using the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews Extension Fillable Checklist, searching for literature that meets the inclusion criteria. The searches will be conducted using Maastricht University's Libsearch, which includes MEDLINE, Education Resources Information Center and PsycINFO and a second search on Web of Science online databases. We will search grey literature and references of selected sources. Search limits include sources from 2016 to 2021, using English language only. A data extraction tool was developed, and charting will use a thematic analysis approach.

IMPLICATIONS AND DISSEMINATION

This review will be the first to examine the learning practices that experienced dyads use, which ensures excellent performance in acute care settings. The findings will be used to develop best-practices and shared with New York City hospital system. Dissemination will occur through peer-reviewed publications and at healthcare conferences.

Embracing informed learner self-assessment during debriefing: the art of plus-delta

The healthcare simulation field has no shortage of debriefing options. Some demand considerable skill which serves as a barrier to more widespread implementation. The plus-delta approach to debriefing offers the advantages of conceptual simplicity and ease of implementation. Importantly, plus-delta promotes learners' capacity for a self-assessment, a skill vital for safe clinical practice and yet a notorious deficiency in professional practice. The plus-delta approach confers the benefits of promoting uptake of debriefing in time-limited settings by educators with both fundamental but also advanced skills, and enhancing essential capacity for critical self-assessment informed by objective performance feedback. In this paper, we describe the role of plus-delta in debriefing, provide guidance for incorporating informed learner self-assessment into debriefings, and highlight four opportunities for improving the art of the plus delta: (a) exploring the big picture vs. specific performance issues, (b) choosing between single vs. double-barreled questions, (c) unpacking positive performance, and (d) managing perception mismatches.

Debrief it all: a tool for inclusion of Safety-II

Safety science in healthcare has historically focused primarily on reducing risk and minimizing harm by learning everything possible from when things go wrong (Safety-I). Safety-II encourages the study of all events, including the routine and mundane, not only bad outcomes. While debriefing and learning from positive events is not uncommon or new to simulation, many common debriefing strategies are more focused on Safety-I. The lack of inclusion of Safety-II misses out on the powerful analysis of everyday work.

A debriefing tool highlighting Safety-II concepts was developed through expert consensus and piloting and is offered as a guide to encourage and facilitate inclusion of Safety-II analysis into debriefings. It allows for debriefing expansion from the focus on error analysis and “what went wrong” or “could have gone better” to now also capture valuable discussion of high yield Safety-II concepts such as capacities, adjustments, variation, and adaptation for successful operations in a complex system. Additionally, debriefing inclusive of Safety-II fosters increased debriefing overall by encouraging debriefing when “things go right”, not historically what is most commonly debriefed.

Early lessons learnt using simulation to rapidly deploy a trained observer programme during the COVID-19 pandemic in New York City

New York City became one of the epicentres of the COVID-19 pandemic in 2020. Simulation was used to establish the COVID-19 trained observer programme to mitigate healthcare workers’ infection risk during patient care. The members of the trained observer group consisted of 32 staff members. At the start of the training programme, they were provided donning and doffing guides with a step-by-step description of personal protective equipment (PPE) usage, followed by in-situ PPE simulation training. Later on, as PPE protocols evolved, additional educational modalities were used and included training videos, picture demonstrations of common PPE mistakes and repeated in-situ simulations. The early lessons which emerged from using simulation to train observers during the COVID-19 pandemic were the following: address PPE shortages during presimulation planning, prepare to perform updates for trained observers and use multiple educational modalities to train observers. Adequate amounts of PPE should be available to train observers. Repeated simulations are necessary to update observers on PPE protocols. Multiple learning modalities should educate the trained observers and equip them for their role in COVID-19 units.

Managing psychological safety in debriefings: a dynamic balancing act

Debriefings should promote reflection and help learners make sense of events. Threats to psychological safety can undermine reflective learning conversations and may inhibit transfer of key lessons from simulated cases to the general patient care context. Therefore, effective debriefings require high degrees of psychological safety—the perception that it is safe to take interpersonal risks and that one will not be embarrassed, rejected or otherwise punished for speaking their mind, not knowing or asking questions. The role of introductions, learning contracts and prebriefing in establishing psychological safety is well described in the literature. How to maintain psychological safety, while also being able to identify and restore psychological safety during debriefings, is less well understood. This review has several aims. First, we provide a detailed definition of psychological safety and justify its importance for debriefings. Second, we recommend specific strategies debriefers can use throughout the debriefing to build and maintain psychological safety. We base these recommendations on a literature review and on our own experiences as simulation educators. Third, we examine how debriefers might actively address perceived breaches to restore psychological safety. Re-establishing psychological safety after temporary threats or breaches can seem particularly daunting. To demystify this process, we invoke the metaphor of a ‘safe container’ for learning; a space where learners can feel secure enough to work at the edge of expertise without threat of humiliation. We conclude with a discussion of limitations and implications, particularly with respect to faculty development.

Working memory is limited: improving knowledge transfer by optimising simulation through cognitive load theory

This analysis explores how to optimise knowledge transfer in healthcare simulation by applying cognitive load theory to curriculum design and delivery for both novice and expert learners. This is particularly relevant for interprofessional learning which is team-based, as each participant comes to the simulation experience with different levels of expertise. Healthcare simulation can offer opportunities to create complex and dynamic experiences that replicate real clinical situations. Understanding Cognitive Load Theory can foster the acquisition of complex knowledge, skills and abilities required to deliver excellence in patient care without overwhelming a learner's ability to handle new materials due to working memory limitations. The 2 aspects of working memory that will be explored in this paper are intrinsic load and extrinsic load. These will be addressed in terms of the learner's level of expertise and how to consider these elements to enhance the learning environment in simulation scenario development and delivery. By applying the concepts of Cognitive Load Theory, this paper offers educators a method to tailor their curricula to navigate working memory and optimise the opportunity for knowledge transfer.

Social pairing and female mating fidelity predicted by restriction fragment length polymorphism similarity at the major histocompatibility complex in a songbird

Female birds often copulate outside the pair-bond to produce broods of mixed paternity, but despite much recent attention the adaptive significance of this behaviour remains elusive. Although several studies support the idea that extra-pair copulations (EPCs) allow females to obtain 'good genes' for their offspring, many others have found no relationship between female mating fidelity and traits likely to reflect male quality. A corollary to the good genes hypothesis proposes that females do use EPCs to increase the quality of young, but it is the interaction between maternal and paternal genomes - and not male quality per se - that is the target of female choice. We tested this 'genetic compatibility' hypothesis in a free-living population of Savannah sparrows (Passerculus sandwichensis) by determining whether females mated nonrandomly with respect to the major histocompatibility complex (Mhc). During both the 1994 and 1995 breeding seasons, female yearlings (but not older birds) avoided pairing with Mhc-similar males (P < 0.005). The Mhc similarity between mates also predicted the occurrence of extra-pair young in first broods (P < 0.007) and covaried with estimates of genome-wide levels of similarity derived from multilocus DNA fingerprinting profiles (P = 0.007). The overall genetic similarity between adults tended to predict female mating fidelity, but with less precision than their Mhc similarity (P = 0.09). In contrast, females appeared insensitive to the size, weight or age of males, none of which explained variation in female mating fidelity. Taken together, these results are consistent with the hypothesis that females sought complementary genes for their offspring and suggest either that the benefits of heterozygosity (at the Mhc) drive female mating patterns or that the avoidance of inbreeding is an ultimate cause of social and genetic mate choice in Savannah sparrows.