1. education

An Interprofessional Acute Care Simulation Success Story:
Design and Implementation of the Experience
Melinda Rybski, PhD, OTR/L.
Occupational Therapy
Stephanie Burlingame, BSN ,RN
College of Nursing
Lisa Rohrig, BSN, RN
College of Nursing
Georgianna Sergakis, PhD, RRT,RCP
Respiratory Therapy Division
Stephanie Justice, MSN ,RN
College of Nursing
Erin M. Thomas, PT ,DPT
Physical Therapy Division
Carolyn McClerking, MS, RN,ACNP-BC
College of Nursing
Julie Legg, PharmD
College of Pharmacy
Marcia Nahikian-Nelms, PhD, RDN,LD,CNSC
Medical Dietetics Division
Janice Wilcox, MSN, RN,CNL
College of Nursing
AOTA SC 403
Objectives
1. Describe the benefits and challenges of developing
interprofessional and simulated multidisciplinary
learning experiences
2. Summarize the steps and supports needed to
implement an interprofessional simulation
3. Generate ideas for an interprofessional simulation
plan in participants’ own institution.
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Describe the benefits and
challenges of developing
Interprofessional education (IPE)
and Simulated multidisciplinary
learning experiences
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3
Topics relative to
IPE and
multidisciplinary
simulations
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1. What is IPE? Why is IPE
valuable?
2. What are simulated learning
experiences?
3. What are barriers and
influences of IPE and
simulation experiences?
What is
Interprofessional Education (IPE) and
Interprofessional Practice (IPP)
Interprofessional Education:
Defined as learning about, from and with each other to
enhance collaboration and improve health outcomes”
(Hopkins, 2010, pg.2)
Interprofessional collaborative practice:
“When multiple health workers from different
professional backgrounds work together with patients,
families, caregivers, and communities to deliver the
highest quality of care” (Hopkins, 2010, pg.2)
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Who Participates in ICP and ICE
Experiences?
Professions’ Participation in IPE and IPC studies
(Hopkins, 2010)
(Hopkins, 2010)
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Value of IPE?
Why is it needed?
IPE is an important approach for preparing students to work in a
collaborative team environment.
• The World Health Organization (1988, 2010), United Nations, and Institute of
Medicine (2003) are just a few of the organizations that support IPEWHO aims to
develop a “collaboration-ready workforce” to improve fragmented healthcare
delivery systems globally (Brandt, Lutfiyya, King, & Chioreso, 2014
• Findings from multiple studies support that IPE and collaborative team-based care
(IPC):
• Enhances professional practice, healthcare quality, and patient outcomes.
• Provides more cohesive practice
• Alleviates the fragmentation within the current health care system
• Increases client safety and improves health care delivery
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(D'Amour & Oandasan, 2005; McPherson, L. Headrick, & Moss, 2001)
Affordable Care Act (2010)ACA)
With passage of the Affordable Care Act of 2010 (ACA), care
coordination and interprofessional care teams were
identified in law as important to improving health outcomes,
preventing hospitalization, and reducing the cost of care for
older adults and the chronically ill.
Interprofessional care coordination is
a means to achieve the
Triple Aim of ACA
1. Quality of care
2. Improving the Experience of Care
3. Reducing per capita costs of
health care
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Barriers and Influences to
Interprofessional Education and Practice
If Interprofessionality is to be studied, it is necessary to
make a distinction between
•
Educational initiatives to enhance learner outcomes
•
Collaborative practice to enhance patient outcomes.
•
Systematic influences
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Interprofessional Collaboration
Framework
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Goldman, J., M. Zwarenstein, et al. (2009)
Barriers:
Microlevel Factors
Macrolevel Factors
Mesolevel Factors
Microlevel Factors
•
Effect of Socialization/Professional Culture
• Attitudes, beliefs, understandings of students and faculty
• Differing types of professional knowledge creates different professional cultures
• Different use of terminology
•
Interactional processes
• Willingness of team members to work together
• Mutual trust and respect among the health professionals
• Must be familiar with each other’s conceptual models, roles and responsibilities
•
Pedagogical Requirements
•
Need experience in IP work
•
In-depth understanding of interactive learning
methods
•
Knowledge of group dynamics
•
Ability to role-model and mirror collaborative
learning
Oandasan,S. Reeves,2005
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Barriers:
Mesolevel
Macrolevel Factors
Mesolevel Factors
Institutional,
Administrative or
Logistical Influences
Internal inhibitors
• Inequalities in numbers of
students
• Geographical location or
isolation
• Differences in curricula and
timetable clashes
• Different academic schedules
(i.e., block vs. semester)
• Conflict resolution
• Shared decision making
practices
Microlevel Factors
External inhibitors
• Financial arrangements/funding
• Degree of integration between
different organizations
• Sufficient time and resources
• Governance models
• Protocols
• Personnel policies
• Management practices
• Administrative support
Oandasan,S. Reeves,2005
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Barriers:
Macrolevel
Macrolevel Factors
Mesolevel Factors
Systematic Influences
Microlevel Factors
Accreditation, certification, licensure
Structural and financial supports
• Financial supports for different disciplines can vary
• Stress of shifting health care systems driven by economic factors, turnover of staff, lack of
resources
• Lack of reimbursement for collaborative work
Defining scopes of practices
Dealing with issues of liability and accountability in practice
Oandasan,S. Reeves,2005
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What are simulated learning
experiences and standardized
patients?
Standardized Patients (SP's) are:
• actors playing the role of patients or actual patients coached to
present specific illnesses to the medical practitioner (Hubal, et.al., 2015)
• a healthy person trained to simulate a patient's illness in a
standardized way
Simulated Experiences
• emphasize learning by doing through practice, rehearsals and role
playing (Coleman, 2015)
•
•
•
•
Enable critical thinking and responding “in the moment”
Engage in the hands-on application of specific technical skills
Facilitates adjustment to the fast pace and complexity of clinical practice
Provides experiences that are social, collaborative, integrative and safe 1
Not all simulations require technology
(Knecht-Sabres, Kovic, Wallingford, & St.Amand, 2013; Hayword, Blackmer, , & Markowski, 2006)
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Value of Simulated Experiences and
Standardized Patients
C u r r i c u l a r Ad va n t a g e s
•
Student Benefits
Learning experiences that are both realistic and
relevant to healthcare students
Same standardized opportunities so students have
opportunity to deal with all of the curricular objectives
in each case
(Connections between classroom concepts and real
world application
Students can be exposed to a variety of clinical and
system situations.
•
Gain experience in problem solving and interpersonal
skills that would be difficult to otherwise simulate in
didactive environment
•
•
Standardized patients only provide information if
requested; will not offer information
Reflection with faculty helps critical analysis
•
Students get feedback from the standardized patient
•
Students take risks in safe environment
•
Improves knowledge acquisition
•
Valuable lessons without risk to patient’s well being
•
Improved technical skills
•
Permit direct faculty oversight of students
•
More control over students’ learning opportunities
•
Enhanced student satisfaction
•
Students report being able to “see the big picture”
•
Possible measure behavioral empathy
•
Instruction using simulation is student centered
•
Learner self-reports of increased confidence in their
ability to provide patient care
•
Controlled learning environment
•
•
•
(Bearnson & Wiker, 2005; Block, Lottenberg, Flint, Jakobsen, & Liebnitzky, 2002; Cleave-Hogg & Morgan, 2002; Euliano, 2000; Gilbart, Hutchinson, Cusimano, &
Regehr, 2000; Henrichs, Rule, Grady, & Ellis, 2002; Hravnak, Tuite, & Baldisseri, 2005; Jeffries, 2005; Laschinger et al., 2008; Lindstrom-Hazel & West-Frasier, 2004;
Lubitz et al., 2003; Marshall et al., 2001; Meier, Henry, Marine, & Murray, 2005; Morgan & Cleave-Hogg, 2002; O'Brien, Haughton, & Flanagan, 2001; Ohtake,
Lazarus, Schillo, & Rosen, 2013; Rhodes & Curran, 2005; Seybert & Barton, 2007; Teherani, Hauer, & O'Sullivan, 2008; Wayne et al., 2006; Weller, 2004; Wu & Shea,
2009)
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Limitations of Simulated experiences with
Standardized Patients
Simulation is constrained by the
degree it can mimic reality
The fast-paced, high stress
environment of a critical care is
difficult to simulate
Possibility that simulation may be used
a replacement for actual clinical
experience
Potential to lead to overconfidence on
the part of the learner
Learners in a simulation are probably
in a state of heightened awareness
and anticipation, waiting for
something to happen; not
necessarily true of daily practice
Anxiety on the part of the student and
possibly the faculty
Simulations might be heavily oriented
to the psychomotor skills
Cannot fully simulate humans
Monetary cost
Limited number of learners in a
simulated experience at one time
Time consuming
Space needed
Technical support required
Faculty development may be a
problem
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Characteristics of Simulation Design
1) Objectives to guide the student learning
2) Fidelity to ensure the simulation is what the students will
encounter in the clinical reality
3) Complexity to facilitate critical thinking and problem solving
4) Cues to provide students with information so that they can
assess the patient’s status or determine an appropriate
course of action
5) Debriefing to allow time for reflective learning.
(Jeffries 2005)
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Summarize the steps and
supports needed to implement
interprofessional simulation
experiences.
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18
Initial Development
Built on success of IP experiences with 2 professions
• College of Nursing, Pharmacy: Acute myocardial infarction
case
• College of Nursing, Respiratory Therapy: Respiratory Failure
case
IP team developed in spring of 2012
• Represented 6 health science professions: Nursing (BSN,
ACNP), Medicine, Pharmacy, Respiratory Therapy, Physical
Therapy, Medical Dietetics
• Added Social Work ,Occupational Therapy, Dentistry
Member Recruitment
• Lisa Rohrig (College of Nursing) contacted each department
6 months of team planning
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Decide What Should be Taught
Determine collaborative competencies which
include team members sharing:
• Knowledge of each other’s roles
• Good communication including
negotiation skills
• A willingness to work together
• Trust related to self-competence and
competence in other’s abilities
• Mutual respect implying knowing other
health professionals and their
contributions to patient care. (Hall and
Weaver (2001)
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• Teamwork
• Communication
• Roles and Responsibilities
• Values and Ethics
Core Competencies for Interprofessional Collaborative Practice
(2011)
Decide what should be taught
• Should be consistent with curricular goals
• Cases should be complex and challenging to facilitate critical thinking and
problem solving
• Cases should involve realistic patients as seen in acute or ICU environments
• Students often do not feel prepared for ICU experiences (Shea,
2009:Ohtake, Lazarus, Schillo, & Rosen, 2013:Oss, Perez, & Hartmann,
2013))
• Cases should necessitate collaborative learning where students
• work together to solve problems
• share in decision making
• Cases need to help students learn to use time well and complete tasks on
time
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Determine Objectives for the
Experience
•
Create a climate of mutual respect and understanding.
•
Understand the roles and responsibilities of the other
professions participating in the simulation.
•
Develop inter-professional communication skills.
•
Develop a multidisciplinary team plan of care to
improve patient outcomes across the lifespan.
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Learning Environment and Learning
Considerations
• Create a nonthreatening learning environment (Knowles)
• This will help to create the climate of mutual respect and
understanding
• The environment must foster status-equal basis
(Interprofessional Care Coordination: Looking to the Future, 2013)
• Cultivate a reflective practitioner (Schön)
• Students learn not only about other professions but about how
their own profession works in partnership with others
• This enables greater cohesiveness and a more comprehensive
plan of care which can lead to better patient outcomes
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Oandasan,S. Reeves,2005
Learning Environment and Learning
Considerations
• Process-based method where learner is an active participant with
interactive learning opportunities (Jeffries 2005)
• Encourages connections between and among concepts learned in
one’s own profession and how that relates to others
• Engages students in the learning process as active participants
• Provide relevant learning experiences
 Use complex cases
 Cases may involve role blurring, leadership issue, decisionmaking, communication, and respect
• Provide relatively little information initially so that students are
allowed to investigate freely
 Use a variety of teaching and learning strategies
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Learning Environment and Learning
Considerations
• Collaborative learning
• Work together to solve problems, share in decision making
• Bring different ideas, bring course content to life, increased
confidence
• Help students to see that uniprofessional aims may contribute to
interprofessional outcomes for teams and clients.
• Students should receive prompt feedback and reinforcement
• l
• Formal and informal settings
• It may be important to set aside time in the structured learning
environment in order to create informal learning opportunities.
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Learning Environment and Learning
Considerations
• Awareness of group dynamics
• Group balance: an equal mix of professionals
• Recommended group size: 8– 10 members
• Our group size varies depending upon how many
students are involved from each profession at any one
session
• Groups may be as large as 15 students
• Up to 10 professions
• Many professions have more than one student; some have only one
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Team Planning
Communication: How to encourage this in the scenarios?
•
•
We built this into the case complexity
We decided to have the students round twice with each patient to facilitate
communication and case discussion
Cases were built to include distinct interactions between professions;
there is a reason for each profession to consult with each other
•
•
Ex: Respiratory therapy can assess the patient for extubation but must consult with the
nurse regarding sedation; then Medical Dietetics will need to be consulted about post
extubation nutrition
Uniform documentation system: ISBAR
•
•
•
Standardized approach for verbal and written communication
I (introduction), S (situation) B (background), A (Assessment), R
(recommendation)
Would like to use electronic documentation in future (possibly EPIC)
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Team Planning
Rounding
• Timing of rounds was considered carefully
• First rounds begin 30 minutes into the experience
• Second round begins 60 minutes later
IRB approval
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Team Planning
Resolve issues of
• Dissimilar student levels (undergraduate and graduate students)
•
•
•
Incongruent student schedules
•
•
•
We focused on the importance of communication rather than what our students were doing to
the patient
Reassurance to the students that it was not about their performance
We had “stand ins” or scripts for professions not represented
We realized that it is not perfect anytime we do it!!!
How to account for missing “players”
• The “chart” would have notes from those professions not present
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Team Planning
• How much preparation for the experiences? Equipment? Materials?
•
•
•
•
Based on case specifics
Each profession’s role in the case determines equipment needs
Initially just one standardized patient and one simulator (now we have 2
standardized patients)
There is an expectation that students will be self-directed learners
Student Preparation
• Varies by profession
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Building the Scenarios
Incorporate each profession
Our faculty built in experiences that would emulate typical issues and
teaching opportunities
Develop cases that necessitate collaboration
The cases needed to be complicated enough so the team needs to
collaborate to create the plan of care
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Building the Scenarios
Make clinical environments that have high fidelity
• Use authentic and realistic equipment in a realistic environment
• Level of fidelity is the degree to which the simulation mimics
reality
• Equipment fidelity
• Environmental fidelity
• Psychological fidelity
(Ohtake, Lazarus, Schillo, & Rosen, 2013; Wu & Shea, 2009)
Low fidelity: learn, practice and achieve a skill
High fidelity: develop critical thinking skills
(Rothgeb, 2008)
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Building the Scenarios
Create cases are complex
• Cases that require students to problem solve “on their feet”
• Requires use of knowledge and skills in a contextually accurate
environment
• Need for creativity to deal with complex problems
Task complexity can be increased if:
• a patient has a number of problems
• problems that are in relationship to each other (ex: comorbidities)
• cases where clinical information is available but irrelevant
• require social interactions between team members of varying levels of
authority and experience.
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Building the Scenarios
Cues
• Determine how information will be provided to students
• Faculty will provide if students become “stuck”
• Cases will provide cues as well as irrelevant information
Debriefing
• Debriefing most often takes place at the end of the session
• The group discusses the process, outcome, and application of the
scenarios
• The process reinforces the positive aspects of the experience
• Encourages reflective learning, which allows the participant
•
to link theory to practice and research,
•
to think critically,
•
To discuss bow to intervene professionally in very complex situations
(Jeffries, 2010, pg. 101)
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Logistics
•
2.5 hour
simulations
•
Simultaneous
sessions in 2
rooms
•
10 time slots
scheduled over a
3-4 days
•
9 professions
participating
AOTA SC 403
Our two simulations
An n Ar b o r
Jill Shuman
•
25 Year old MVA- unrestrained/ejected
from vehicle- ETOH involved
•
Right transfemoral amputation, stump
infected
•
Post op ORIF femur, spleen lac,
respiratory failure
•
PEG tube in place, on hold for antibiotic
•
Unemployed, uninsured, single, diabetic
•
Addicted to benzodiazepines and ETOH
•
Pt orally intubated on ventilator, chest
tube to LWS, arterial line, OG and post
pyloric feeding tube in place
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Jill Shuman Supplies and Set Up:
To ensure Fidelity
Equipment, Supplies, and Standardized Patient Setup Notes:
Dressed in hospital gown, G-tube in abdomen. Enteral pump with tube feed and tubing
hanging, but not infusing. ID band on patient. HOB @ 25 degrees. > 200 mL tube feeding
residual in abdomen. R transfemoral amputation with dressing in the bed with small to
moderate amount of greenish fruity smelling drainage, propped on pillow. Foley catheter lying
on bed with balloon inflated (pt. pulled out). Saline well in one forearm.
Type of supplies
Medication area
IV supplies
I & O supplies
Genitourinary
supplies
Miscellaneous
# requested
1 table or cart per
room
1 set per room
Description
Supplies for administering Cipro tablets 500 mg to be crushed for enteral
administration: Crusher, slicer, 220 mL graduated cups, sterile H2O bottles,
tongue blades, Toomey syringe, towel
Saline well
Feeding pump, bag and tubing.
1 per room
Label bag: Glucerna 1.2 (1200 kcal /liter)
Foley cath with 150 mL of clear yellow urine to straight drain. Catheter with
inflated balloon on bed.
Patient ID band on manikin, boxes of gloves, sharps box
Walker, crutches,SCDs, wedge pillow, BSC, Therban
Dressing
supplies
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Dry sterile dressing supplies available. Wound culture supplies available.
Ann Arbor Supplies and Set Up:
To ensure Fidelity
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Dress in hospital gown and wig
Place a bra with simulated breasts on the simulator. Individual
breast exam models or socks may be used inside bra
Insert OG tube with green drainage
Small amount of simulated green tinged nasogastric drainage.
Place the simulated drainage in the nasogastric suction
canister; do not allow solution to enter the simulator airway.
Label the output according to I/O’s documentation.
Simulate serosanguinous drainage in pleurovac and place to
waterseal. Mark output according to I/O’s documentation.
Prior to starting the simulated clinical experience:
Insert urinary catheter with small amount of amber urine
draining
Apply ECG monitor with leads attached
Intubate the simulator and place on ventilator (If no ventilator
available, attach ventilator tubing to endotracheal tube to
simulate ventilator use)
Insert triple lumen central venous catheter on right internal
jugular and apply dressing.
Attach to 1000 mL 0.9NS with 20KCl at 50 ml/hour into distal
port.
Insert arterial line in right radial and apply dressing. Attach to
500 mL 0.9 NS with pressure bag
Insert CT in right side to underwater seal.
Have clean dry dressings in place over abdomen and left femur
and CT. Splint on left forearm
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IV Supplies
Oxygen
Supplies
Suction
Supplies
Medications
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CVC in the right internal jugular with 0.9 NS with 20 KCl infusing at 50 mL/hr into the
distal port
IV tubing
Sterile water 1000mL (label 0.9 NS with 20mEq KCl)
Triple lumen central venous catheter
IV pump
Arterial line – R radial
Pressurized flush system tubing or 3-in-1 pressurized flush system tubing
Transparent dressing
Sterile water 250mL (label 0.9% NS) [one bag if using 3-in-1 pressurized flush system]
Pressure bag
Ventilator
Endotracheal tube 7.0
Ventilator tubing
1
1
1
1
1
1
1
1
1
1
3
1
Resuscitation bag
Closed system endotracheal suction catheter
Oral gastric to low wall suction
Suction collection canister
Suction tubing
Endotracheal suction (Ballard suction system)
Pleuravac
Chest tube to water seal
Sterile water 250mL (label D5W with norepinephrine 8mg)
Sterile water prefilled syringe (label morphine 10mg/mL, promethazine 25 mg/mL,
famotidine 10mg /mL)
16 Fr urinary catheter with urimeter
1
1
1
1
1
1
1
14 Fr Salem sump tube
Catheter tip syringe
Irrigation tray
Sterile water bottle
Feeding pump, bag and tubing labeled Oxepa
Bra
Simulated breast
Wig
Hospital gown
50 mL surgical lubricant or foam soap for NG drainage
Yellow, red, blue food color
2” surgical tape
Genitourinary
Supplies
Gastrointestinal 1
Supplies
1
1
1
Miscellaneous
Format for each session
Purpose of
experiences
PostSimulation
Survey
•Professional
Obtain
consent
Review
of
patient
cases,
Debriefing
ofRound
Bedside
Review
Re-Round:
Complete
of
rounding
postPlan
of
Implementation of of
and
complete
patient
assessment
and
rounding
experience
Debriefing
Debriefing
by
individual
in full
interobjectives/overview
patients
Care
#2simulation
Advanced
developed
by
interPlan
interventions and treatment
pre-simulation
planning
#1
– full groupprofessional
professional
groups
group
of
professional
of
session
questionnaire
schedule
group
plans Care Developed
survey
optional
Presimulation
Survey
Debriefing
Session
Chart Review
Second
Rounds:
Advanced
Plan of Care
Developed
Patient
Assessment
First Round:
Plan of Care
developed
Debrief
Appropriate
Care
delivered
AOTA SC 403
Format for each session
• Obtain consent pre-simulation survey
• Review of objectives/overview of session schedule
• Review of patient cases, patient assessment and
planning
• Bedside rounding of patients by inter-professional
group
• Implementation of interventions and treatment
plans collaboratively
• Debriefing by individual professional groups
• Debriefing of rounding experience 1 (optional but it
does happen at times)
• Re-round: Round #2
• Debriefing in full inter-professional group
• Complete post-simulation questionnaire
AOTA SC 403
Select Student Comments regarding the
Interdisciplinary Simulated Experiences with
Standardized Patients
Interprofessional communication
•
•
•
“I learned what the other professions do and I feel more
comfortable approaching them with questions”
“I will not hesitate to communicate with other disciplines!”
“ISBAR tool improved communication:
Roles and responsibilities
•
•
•
“Rounds helped see what other professions do”. “Rounds
helped us know what questions we can ask other
professions”.
“I would hope that everyone from this takes away a greater
respect for the other professions now that we do
understand what everyone does”.
“Unaware of expertise from other professions”
Values/ethics
•
•
•
Increased Trust and Confidence
“You can get a chance to make mistakes and learn from
them.
Motivated the students to strive for pharmacy expertise
AOTA SC 403
Select Student Comments regarding the
Interdisciplinary Simulated Experiences with
Standardized Patients
Teamwork and team based practice
•
•
•
•
•
•
•
“You can see how you fit in the picture because when we
do nursing sims it’s just all nurses so now you can see the
bigger picture.”
“It’s nice to know I can depend on other people to help me
with what I do not know much about. It was humbling but
also a confidence booster.”
“Something I have learned over the years is that nobody
can do what they do without the other people. Yea sure I’m
the doctor, but I can’t do my job without the rest of you
guys.”
Recognition of how relationships are built between
practitioners
“All the pressure of patient care is not just on me”
“I was surprised by how much we all knew. It felt good to
come together as a team.”
“So it’s kind of nice to hear everything that’s going on with
the patient, to get more of an overview of everything that’s
going on.”
AOTA SC 403
Generate ideas for an
interprofessional simulation
plan in participants’ own
institution.
43
AOTA SC 403
Now…your turn!
If you are an educator:
If you are a clinician:
Do you feel IPE will prepare students to meet •
the challenges of the healthcare system
and complex client care?
Do you feel a part of an IPC? Why or
why not?
•
Did you have IPE experiences in your
educational program?
•
What would you change about the
working relationships you have as it
relates to IPC?
•
Do you feel that greater IPC would
enhance your practice?
Describe the IPE opportunities for your
students
What barriers do you see that prevent further
IPE
What supports do you have to facilitate
greater IPE experiences?
What ideas do you have about implementing •
IPE in clinical facilities or with other
disciplines?
How do you see your team and facility
working with educators to develop IPE in
your facility?
Other thoughts and items for discussion
Other thoughts and items for discussion
AOTA SC 403
•
Any questions?
Thank you for your attention.
Any Questions?
Thank you for your
attention and
attendance!
AOTA SC 403