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Intensive and Critical Care Nursing (2014) xxx, xxx—xxx
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ORIGINAL ARTICLE
Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study Randi Ballangrud a,b,∗, Marie Louise Hall-Lord a,b, Mona Persenius a, Birgitta Hedelin b a
Department of Health Sciences, Faculty of Health, Science and Technology, Karlstad University, 651 88 Karlstad, Sweden b Faculty of Health, Care and Nursing, Gjøvik University College, Teknologivn. 22, 2815 Gjøvik, Norway Accepted 17 March 2014
KEYWORDS Intensive care; Nursing; Patient safety; Simulation-based training; Team performance
Summary Objectives: To describe intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care. Background: Failures in team processes are found to be contributory factors to incidents in an intensive care environment. Simulation-based training is recommended as a method to make health-care personnel aware of the importance of team working and to improve their competencies. Design: The study uses a qualitative descriptive design. Methods: Individual qualitative interviews were conducted with 18 intensive care nurses from May to December 2009, all of which had attended a simulation-based team training programme. The interviews were analysed by qualitative content analysis. Results: One main category emerged to illuminate the intensive care nurse perception: ‘‘training increases awareness of clinical practice and acknowledges the importance of structured work in teams’’. Three generic categories were found: ‘‘realistic training contributes to safe care’’, ‘‘reflection and openness motivates learning’’ and ‘‘finding a common understanding of team performance’’.
∗
Corresponding author at: Faculty of Health, Care and Nursing, Gjøvik University College, Teknologivn. 22, 2815 Gjøvik, Norway. Tel.: +47 61 13 53 23; fax: +47 61135170. E-mail addresses: [email protected] (R. Ballangrud), [email protected] (M.L. Hall-Lord), [email protected] (M. Persenius), [email protected] (B. Hedelin). http://dx.doi.org/10.1016/j.iccn.2014.03.002 0964-3397/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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R. Ballangrud et al. Conclusions: Simulation-based team training makes intensive care nurses more prepared to care for severely ill patients. Team training creates a common understanding of how to work in teams with regard to patient safety. © 2014 Elsevier Ltd. All rights reserved.
Implications for Clinical Practice • Exploring the advantages of simulation-based team training for building patient safety in the ICU. • Highlighting the importance of structured work in team to ensure patient safety. • Focusing on organisational learning and improvement in intensive care nursing.
Introduction Although health care is expected to be safe and of a high quality, incidents caused by human factors are reported to be a problem, thereby generating steps to prevent errors and make improvements is important to healthcare institutions (Page, 2004). Team training has been proclaimed as a method for improving safety and quality in health care (Kohn et al., 2000; Salas and Rosen, 2013). In intensive care units (ICU), nurses work in both disciplinary and interdisciplinary teams in a high-tech environment with seriously ill patients in rapidly shifting conditions. These teams mostly have a dynamically changing membership or are brought together ad hoc, e.g. in emergency situations (Manser, 2009). Failures in team performance with regard to non-technical skills (NTS) are found to be contributory factors to incidents in the intensive care environment (Manojlovich and DeCicco, 2007; Reader et al., 2006). However, the development of team performance competencies has not been addressed in a systematic way by the educational institutions and health-care systems (Salas and Rosen, 2013).
Background The most commonly used team-training strategy in health care is Crew Resource Management (CRM) (Salas et al., 2009), which is designed to improve both individuals’ and teams’ competencies in NTS (Flin and Maran, 2004; Gaba et al., 2001). NTS includes situational awareness, decisionmaking, communication, teamwork, leadership and the management of stress and fatigue (Flin et al., 2010). This approach to team training, with a focus on the role of human factors (Helmreich, 2000), was transferred and modified to health care by Gaba et al. (1994), who adapted the use of human patient simulation into team training. CRM aims to achieve patient safety by focusing on applying optimal resources, preventing errors and minimising the consequences of error that may have occurred (Rall and Dieckmann, 2005a). Simulation-based team training (SBTT) based on CRM has been shown to be effective for improving NTS (Doumouras et al., 2012; Lewis et al., 2012). A SBTT programme based on CRM has to date no international standard (Haerkens et al., 2012). However, a strategy often chosen encompasses lectures concerning human factors, as well as
team performance training with regard to high fidelity simulation scenarios in which the team treats the simulator as a patient and practises challenging situations in a realistic environment. During the simulation scenario, the team members play active roles as leaders and followers solving a situation, followed by a debriefing with active and observer roles involved in the discussion (Gaba et al., 2001; Rall and Dieckmann, 2005b). Team process behaviour has an impact on clinical performance in patient care and training has resulted in increased performance (Schmutz and Manser, 2013). Even though the implementation of team training among operating room personnel has shown an association with lower surgical mortality (Neily et al., 2010), moderate effects for patientrelated outcomes have also been demonstrated (Cook et al., 2011). Team training has been found to result in transformational changes in safety culture when the work environment supports the learning of new behaviour (Jones et al., 2013), and to improve efficiency, morale and patient safety in nursing (West et al., 2012). In intensive care, the implementation of an evidence-based team training system has exhibited improvements in observed team performance and interviews with staff indicated the implementation to be effective (Mayer et al., 2011). Moreover, Sandahl et al. (2013), in interviews with ICU personnel after the implementation of a SBBT programme regarding interdisciplinary teamwork found that training had increased their awareness of the importance of effective communication for patient safety. Most studies focusing on the outcome of team training for patient safety are based on interdisciplinary teams. To acquire a deeper understanding of intensive care nurses’ perception of simulation-based disciplinary team training with regard to patient safety would be of great interest. Intensive care nurses constitute a large proportion of ICU personnel and work closely with the patients, which consequently makes them an important group in preventing errors and building patient safety within the ICU.
Methods Design The study uses a qualitative descriptive design based on individual interviews.
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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A descriptive qualitative study
Aim
3 Table 1
Descriptions of the participants (n = 18).
The aim of the study was to describe intensive care nurses’ perceptions of simulation-based team training for building patient safety in the ICU.
Characteristic
The simulation-based team training programme
Age
During a period of eight months, 53 registered nurses (RNs) from seven different ICUs participated in a SBTT programme, consisting of a half-day of introductory theory inputs on safe team performance based on CRM and a half-day of team training in a simulation laboratory created as an ICU environment at a university college in Norway. During the simulation training, two high fidelity human patient simulation scenarios were conducted that provided opportunities to practise team performance during emergency situations. The RNs were trained in teams of five persons. The teams were comprised of three RNs in active roles (one leader and two followers), while two held passive roles as observers. All team members were in active roles in at least one scenario. Following the simulation scenario, which lasted approximately 12—15 min, a 30-min debriefing was conducted in which both the active and passive roles contributed. The SBTT programme was developed by the authors, and led by experienced simulation- and CRM instructors with backgrounds as nurses, and with extensive experience from anesthesiology and intensive care.
Participants Eighteen registered nurses (RNs) working in seven ICUs in one hospital trust in Norway were recruited from the sample of 53 RNs who had attended the SBTT programme. A strategic sampling was carried out with regard to variation in gender, age, area of intensive care, education level, years as RN, years as postgraduate intensive care nurse, scenario roles and simulation experience (Table 1). A request was sent to one or two RNs in each of the participating teams about a week after the completion of the SBTT programme, and out of a total of 21 requests, 18 RNs gave their consent to participate in the study.
Data collection The data collection took place from May to December 2009. The individual interviews were conducted by the first author three-four weeks after the RNs had completed the SBTT programme, and took place according to the participants’ wishes, either at the hospitals or at the university college. The interview started with a clarification of the aim of the study, and was followed up with the open-ended question: ‘‘Can you please describe how you perceive simulationbased team training with regard to building patient safety in intensive care’’? The interview took the form of a dialogue in which follow-up questions were used (Kvale, 2007), lasted from 26 to 47 minutes (mean = 39 minutes), and was digitally recorded and transcribed verbatim.
Category
Nurses (n)
Female Male
15 3
Gender
≤40 years 41—50 years ≥51 years
6 7 5
G-ICU M-ICU GM-ICU
7 7 4
Area of intensive care
Educational level Graduate Postgraduate
3 15
≤5 years 6—15 years ≥16 years
1 5 12
≤5 years 6—15 years ≥16 years
7 4 4
Years as RN
Years as PG-RN
Simulation experience Yes No
11 7
Leader Assistant Helper Observer
6 7 9 14
Scenario roles
G-ICU, general intensive care unit; M-ICU, medical intensive care unit; GM-ICU, general/medical intensive care unit; PG-RN, postgraduate registered nurse.
Ethical approval The study was approved by the Norwegian Social Data Services, accepted by the hospitals’ administrative heads and conducted according to the ethical guidelines for nursing research (Northern Nurses Federation, 2003). Invitations and information about the study were given to the RNs in both written and oral form. The information included confidentiality policy, that participation was voluntary and that the participants could withdraw from the study at any time. Written consent was obtained from the RNs who agreed to participate.
Data analysis Based on Elo and Kyngäs (2008), a manifest inductive content analysis was implemented. The content analysis processes contained a preparation-, organising- and reporting phase.
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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R. Ballangrud et al. The preparation phase:
• The unit of analysis was selected on the basis of the aim of the study. • The written transcript was repeatedly read through in order to grasp the content and obtain a sense of its entirety.
to seeing clinical practices in a new way, creating reflections about what is good and what can be done better in daily work to help ensure patient safety. Additionally, SBTT helps to articulate team performance and create awareness of the importance of structure with regard to communication and different roles and responsibilities within the team.
Realistic training contributes to safe care The organising phase: • An open coding with written headings was performed. • The headings were collected on coding sheets. • The coding sheet headings were grouped by gathering those with a similar content into higher order subcategories covering the meaning. • Similar sub-categories were grouped together in higher order generic categories. • A main category was generated from the generic categories in order to give a general description of the content of the written material. The reporting phase • An overview of the abstraction process with the generation of categories was made (Fig. 1).
Trustworthiness Lincoln and Guba’s (1985) four criteria of credibility, dependability, confirmability and transferability were used in this study to ensure trustworthiness. Credibility was established with regard to variation in RNs’ area of ICU practice, gender, age, education level and years as practising as nurses to give a broad description of the phenomenon (Sandelowski, 2000). An open-ended interview question encouraged the participants to talk openly, follow-up questions were posed in order to avoid misunderstandings. Moreover, a pilot interview was conducted, and a detailed description of the data collection- and analysis process was given. To ensure dependability, the same introductory openended question was posed to each participant, and all the interviews were conducted by the first author. Confirmability was achieved by a systematic treatment of the data, with repeated readings to help grasp the content and careful generation of categories reflecting the participants’ voices. Quotations were used to enhance and illuminate the content of the categories and agreement within the research team was addressed in order that the data correctly represented the information the participants provided. To ensure transferability, we have presented the participants’- and study’s results in a trustworthy way, with some short quotations used to clarify the interviewees’ perceptions (Graneheim and Lundman, 2004).
Results One main category generated from three generic categories and six sub-categories (Fig. 1). The main category, ‘‘Training increases awareness of clinical practice and acknowledges the importance of structured work in teams’’, describes that organised SBTT yields experiences that may contribute
The generic category concerns the fidelity in the human patient simulation training with respect to real-life situations, and how training with the use of a simulator is related to ensuring patient safety. Conducting simulation scenarios that deal with common and expected situations from the ICU makes nurses more prepared to ensure critically ill patients receive safe care. The category consists of two subcategories: ‘‘Not putting the patient at risk’’ and ‘‘Transferable to clinical practice’’. Not putting the patient at risk The participants pointed out that the advantage of SBTT was that it provided a safe arena for training that facilitated learning without affecting a highly critically ill patient. Training could make intensive care nurses more prepared and confident to handle different emergency situations. They described that SBTT could contribute to managing stress both in emergencies and in their daily work in the ICU since the same feelings of stress were recognised during simulation-based situations. These feelings were related to managing the situation and demonstrating their competencies to others. Even though rarely occurring situations were particularly emphasised, simulations of common situations were also found necessary to practise. The participants perceived that SBTT should be performed on a regular basis to achieve improvement, and one participant expressed the importance of SBTT with regard to patient safety in this way: We are practising on living people, and some of them die because we are not prepared well enough. So it is absolutely crucial for patient safety that you are capable of doing your job before you actually have to do it. (No.15) Transferable to clinical practice The simulated scenarios were experienced as realistic, useful and transferable to clinical practice. Being able to observe its measurable parameters such as heart rate, electrocardiogram, blood pressure and oxygen saturation was expressed as important and enabled the nurses to recognise and compensate for failures in the patients’ vital functions. Although it was a simulated situation, they focused on solving the emergency situation similarly to a real situation in the ICU. The different roles in the scenario reflected the division of responsibility in their daily work. One participant said: I found it to be very practical in the sense of being very close to real-life practices. Being able to communicate with a patient was especially important, [. . .] suffice it to say that it was then when I felt that it became very realistic and close [to real life]. (No.13) Some of the nurses experienced the simulation as being less realistic, mostly because of the absence of any
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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Sub-category • •
• •
• •
Generic category
Main category
Not pung the paent to risk Transferable to clinical pracce
Realisc training contributes to safe care
Focusing on one’s own- and others’ competence Debriefing facilitates improvement
Reflecon and openness movates learning
Responsibility in roles and use of human resources Importance of clear communicaon
Finding a common understanding of team performance
Figure 1
Training increases awareness of clinical pracce and acknowledges the importance of structured work in teams
An overview of generation of categories.
physicians in the team. Although positive experiences among participants with regard to training in a simulation laboratory were expressed, SBBT in situ in their own unit with physicians as a part of the team was thought to provide an even greater degree of realism and transferability.
Reflection and openness motivates learning This generic category concerns the pedagogical method used for learning during SBTT, which was perceived as strengthening human resources development, and as building competencies for patient safety in daily work. The debriefing with open group discussions and reflections concerning the team performance during the simulation scenarios was experienced as positive. This generic category consisted of two subcategories: ‘‘Focusing on one’s own- and others’ competence’’ and ‘‘Debriefing facilitates improvement’’. Focusing on one’s own and others’ competence SBTT helps nurses to be aware of what they do well and what can be improved, what they need to practise and what they have to study, all with the intention of preventing mistakes as well as making improvements in clinical situations. One of the participants expressed: Yes, it was definitely useful. Something that you think you have done well for many years [. . .] and then you suddenly get surprised when undergoing simulation-based training. (No.5) In particular, participating in the training could be useful in building competencies because the participants had to articulate the reasons for their own actions and give feedback to each other, which required reflection. One participant said: It is quite good that while you normally just work as you are used to [without thinking too much about it], in a simulation you have to somehow think the situation
through, usually more than once, because you will have to give feedback about it. (No.7) By using SBTT on a regular basis, the participants believed that intensive care nurses will be more familiar with their own reactions when handling various emergencies. Moreover, an awareness of the team’s performance will be increased, thereby strengthening the team’s preparedness. Some participants experienced that a team member could have vastly different perceptions of a situation, which also was conducive to learning. One participant stated: I was a bit surprised about how different the various group members had experienced the very same scenario [. . .]. Things were mentioned that I completely did not think of at all — both things to improve and things that were positive. I think every single one of us who participated saw things from a different angle and had a different focus; it was actually exciting. (No.6) The participants found it important to know that the team members complemented each other and worked well together ahead of a real patient situation, so they therefore considered it of importance that all in the unit participate in SBTT. Debriefing facilitates improvement Regular use of SBTT was perceived to increase the use of structured debriefing after difficult situations in clinical practice. The constructive feedback during the debriefing after the scenarios made the nurses aware of areas for improvements, and the participants experienced that they seldom gave each other feedback during daily work since they have no tradition of doing so. As one participant put it: It is actually not so easy to correct [people], or somehow give them feedback on how they communicate or function in such a situation. (No.8) The discussions and reflections related to leadership, resource management and communication, in which each team member had the opportunity to give reasons for their
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own actions and priorities were perceived as being of great importance. It was important to provide debriefings, both in emergency and in more common patient situations, in the daily work in practice. One participant stated: I think that in cases of patient safety, it is important to have some debriefing, to sit down and take some time [to reflect on] what we did, [and] what we could have done better in this special situation. (No.7)
Finding a common understanding of team performance This generic category concerns how team training based on CRM gives new insight and knowledge of how to work in teams. An awareness of the use of human resources, responsibilities and team communication was experienced to be improved through training using simulation. The generic category consisted of two subcategories: ‘‘Responsibility in roles and use of human resources’’ and ‘‘The importance of clear communication’’. Responsibility in roles and use of human resources SBTT was experienced as creating an awareness of the importance of clarifying roles and responsibility within a team. The nurses expressed that they had limited knowledge of structured teamwork prior to the SBTT, and in clinical practice they experienced an unsystematic approach to teamwork that was dependent on the nurse’s or physician’s competence, as well as whether the team had experience in working together. One participant pointed out the advantage of SBTT: Simulations create consciousness about the role oneself and other people play. Since I was observing, I could see how the others functioned, which I can learn from too. I can see how I should not do things, as well as how I should do them. Moreover, I see that some [people] are very fit to be leaders while others are not; some create chaos. (No.17) The participants’ perceptions were that SBTT had a great potential for improvement, especially concerning the importance of the team’s leadership and followership. They described a clinical practice in which these roles were rarely clarified or verbalised. One said: I think that training is important, because if no one assumes leadership in a situation [. . .] it gets very disorganised. I like to have things organised—yes, and I think there is much that can be improved by that. I think that the more simulations one experiences, the better one can get. (No.11) It was considered important that the nurses mastered leadership; however, in emergency situations they perceived it most appropriate for the physician to take the leading role. Interdisciplinary team training is described as crucial in order to clarify roles and responsibilities together with the physicians, although nurses and physicians currently have no tradition of training together as a team. Optimising personnel resources in teams was characterised by the participants as being an area of which clinical practice needs to be
more aware. The participants described emergency situations during daytime that often became chaotic, which was due to the fact that too many nurses and physicians wanted to help. The participants experienced that they performed best at night when fewer staff were present. People somehow start running around and try to do something, [. . .] and then you think that someone did something that he/she actually did not do after all. So if one had trained [how to behave in such a situation], one would know much better what to do if such a scenario became real. (No.8) Importance of clear communication Both verbal- and non-verbal communication were perceived by the participants as being most important to teamwork in the ICU, since distinct communication that had been emphasised in the simulation-based training should also be integrated into clinical practice. You are much more conscious [about what you are doing] during simulations, and when you are more conscious about it, then the quality of the service you provide increases. If you communicate clearly, constantly checking that the person you talk to understands what you’re saying and acts accordingly, higher quality assurance for the patient will be provided. (No.11) Inadequate communication was perceived as causing a lowering in team performance. The participants referred to various clinical situations in which well-trained communication techniques could contribute to proper patient care, and they considered it important to give clear messages, e.g. in CPR situations. When exposed to a high level of stress, structured and proper verbal- and non-verbal communication in the team might help to calm the situation down and introduce accountability, which was exemplified by one nurse: [....] Through the way she [physician] behaves, she communicates calmness. You can see in her determined gaze that she is in control. She knows what she is doing. [...] And then there is someone else, you can see he is somehow restrained, and maybe looks around a little and you can see his uncertain gaze, giving you the impression that he wonders about what is happening on the scene, and you find yourself asking if he actually knows what he is doing right there. (No.3) Having knowledge of structured and clear communication with regard to leadership was emphasised by the participants, in addition to having a follower in a team requiring training to communicate observations in a satisfactory manner. They emphasised the importance of open communication across the team. Nonetheless, the participants described some reservations about open communication when physicians were part of the team. This was found to be a typical phenomenon, which again supports the need for interdisciplinary team training.
Discussion The aim of the study was to describe intensive care nurses’ perceptions of SBTT for building patient safety in intensive care. The results showed that intensive care nurses
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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A descriptive qualitative study experienced that training created awareness about clinical practice, and also acknowledged the importance of structured work in teams as a contribution for building patient safety.
Realistic training contributes to safe care The intensive care nurses emphasised the importance of realistic training without exposing patients to any unnecessary risk, which may prepare them in a better way to manage difficult situations in daily practice. Their views, which describe a need for this type of training, may be explained by the significant changes that have occurred in the ICU over the past few years with regard to more severe patients and an extensive increase in advanced technology equipment as well as workload. A high workload (Scott et al., 2006; Stone et al., 2007) and stress (Berland et al., 2008) were found to be associated with intensive care nurses’ risk of making mistakes. Over a period of several years, there have been reports that patient safety is often at risk in ICUs (Donchin et al., 1995; Rothschild et al., 2005), which was also recently confirmed by two European multicentre studies (Merino et al., 2012; Valentin et al., 2013). According to Salas et al. (2008), it is essential for a successful outcome that the training is undertaken in a psychologically safe environment in which errors can be seen as opportunities for learning. The result confirmed that most of the participants experienced the SBTT as realistic and thus transferable to practice. This result is in accordance with Sandahl et al. (2013), who also stated that this perception was also shared by the observers. Critical and acute care nursing practice is described as intellectually and emotionally challenging in that it requires quick decisions in life-threatening situations in which little margin for errors exists (Benner et al., 2011), and high simulation validity is emphasised as important to help learners sharpen their responses to critical incidents (Hamilton, 2005; Issenberg et al., 2005). Some of the nurses experienced the simulation as being less realistic, mostly because of the absence of a physician in the team. Our programme was never planned to deal with interdisciplinary team training and lack of real medical input may have been a limitation to provide realistic simulation even though they had the opportunity to call a physician acted by a simulation instructor. However, it is the nurses who most often identify the first sign of deterioration in the critically ill patient’s condition and have to manage the situation until the physician arrives (Benner, 2001), which also require disciplinary team training. According to Sandahl et al. (2013), several participants saw the advantage of in situ training, while the participants in our study also appreciated being in a simulation laboratory, which may offer benefits such as avoidance of job-related interruption.
Reflection and openness motivates learning Developing nursing competence within the area of intensive care practices requires experiential learning under pressure and constant thinking linked to action in ongoing situations (Benner et al., 2011). In this study, the participants experienced that training helped to build competencies. Strengths and weaknesses concerning their own and others’
7 actions were exposed to evaluation, as they had to articulate the reasons for their own actions and give feedback to each other, which may create learning. Feedback and communication about errors among intensive care nurses are documented as an area for improvement (Ballangrud et al., 2012). In this way, SBTT may help to make clinical judgement and clinical knowledge development more visible, and may be considered as a well-adjusted method to give them experiential learning without endangering patient safety. The use of simulation enabled self-reflection and feedback on personal performance, and according to Rall and Dieckmann (2005b), this ‘‘eye-opening effect’’ described by the participant is also voiced by other participants. Team training demonstrates the importance of the performance in terms of safe management and exemplifies how teamwork may malfunction, thereby facilitating learning (Rall and Dieckmann, 2005b). Moreover, training in team performance has also been shown to increase nurses’ and physicians’ self-efficacy (Meurling et al., 2013). As stated by the participants, the ad hoc simulation of a small group of personnel from a unit is considered as fruitless in bringing about changes. To attain shared knowledge, attitudes and skills, it is important that all in the unit with a dynamically changing membership participate in SBTT. Team training may initiate a transformational change in safety culture when the intervention is supported by the work environment (Jones et al., 2013). In the present study, the participants perceived that regular SBTT may strengthen nurses in relation to practising debriefing after difficult situations in clinical practice, which has also been reported by Sandahl et al. (2013). Debriefing is seen as a crucial tool for improving teamwork and creating an environment of continuous learning (Leonard et al., 2013), and is found to be a factor that influences the quality of nursing practice in intensive care in a positive way (Storesund and McMurray, 2009). Furthermore, the result may indicate an overall perception of SBTT as being an important contribution to ICU’s organisational learning. As documented by Ballangrud et al. (2012), organisational learning is an area in intensive care nursing that requires improvements and development.
Finding a common understanding of team performance In accordance with the staff’s perception in ICU environments in the United States (Mayer et al., 2011), team role clarity was highlighted by our participants as an area in need of improvement, and that training may help facilitate changes. This may support Salas and Rosen (2013) assertion that team performance competencies have not been addressed in a systematic way by health-care systems. However, the CRM strategy is considered to be a promising tool for cultural changes in an ICU setting (Haerkens et al., 2012). The participants in the present study saw the importance of mastering team leadership, hence practising this through simulation training, while team leadership is shown as a key factor in developing new ways for team members to interact and communicate with each other (Reader et al., 2009). Nevertheless, nurses do not have a cultural or professional tradition in taking leadership in teamwork, which is considered to inhibit them from participating in
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decision-making processes, e.g. in emergencies (Andersen et al., 2010), even though they are responsible for doing that (Hancock and Easen, 2006). Interdisciplinary team training was seen as essential in building patient safety. Thus far, the participants expressed that nurses and physicians had no tradition of training together as a team, although this fact has been found to limit the success of the training outcome (Sandahl et al., 2013). Today, however, interdisciplinary teamwork is seen as one of the key processes in the safe delivery of patient care (Kohn et al., 2000). According to Reader et al. (2009), this cross-professional nature of ICUs makes them particularly vulnerable to problems with team communication, which can affect patient safety. Team communication failure has led to patient harm (Pronovost et al., 2002, 2006), and the importance of focusing on communication in SBTT to ensure patient safety was supported by the participants. In this study, they emphasised the focus of clear and open communication with regard to both disciplinary and interdisciplinary teams, and that training may help to strengthen role clarity and communication between the disciplines. Some reservations about open communication had been experienced when physicians were part of the team. This may be explained by the traditional hierarchies in health care, which are characterised as barriers to team action in emergencies (Andersen et al., 2010; Hunziker et al., 2011). Team training based on CRM aims to flatten hierarchies of authority to achieve greater respect and foster open communication to help ensure quality and patient safety (Powell and Kimberly Hill, 2006).
Limitations of the study The results may be influenced by participants who agreed to participate in the study based on their initially positive perceptions of the phenomenon. Additionally, a less skewed gender distribution with a larger male sample could have raised different perceptions. A lack of a physician in the team might have been a limitation for providing realistic simulation.
Conclusion Intensive care nurses perceive that SBTT has advantages for building patient safety in the ICU and that realistic training makes them more prepared to care for severely ill patients. The pedagogical methods which focus on reflection and openness motivate learning, and team training creates a common understanding of team work. In addition to disciplinary team training, interdisciplinary team training is also considered to be important. Further research is needed in order to achieve a deeper understanding of ICU staffs’ perceptions concerning interdisciplinary teamwork for patient safety. Evaluation research with regard to interdisciplinary SBTT would be of great interest.
Conflict of interest The authors declare they have no competing interest and no financial disclosures.
Funding We will thank the Laerdal Foundation for Acute Medicine for their financial support.
Acknowledgements The authors would like to thank the registered nurses for their participation. In addition, we want to express our deepest gratitude to the simulation instructors, Viktor Haugom, Tore Karlsen, Christer Eriksson and Terje Ødegården.
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Intensive and Critical Care Nursing (2014) xxx, xxx—xxx
Available online at www.sciencedirect.com
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ORIGINAL ARTICLE
Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study Randi Ballangrud a,b,∗, Marie Louise Hall-Lord a,b, Mona Persenius a, Birgitta Hedelin b a
Department of Health Sciences, Faculty of Health, Science and Technology, Karlstad University, 651 88 Karlstad, Sweden b Faculty of Health, Care and Nursing, Gjøvik University College, Teknologivn. 22, 2815 Gjøvik, Norway Accepted 17 March 2014
KEYWORDS Intensive care; Nursing; Patient safety; Simulation-based training; Team performance
Summary Objectives: To describe intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care. Background: Failures in team processes are found to be contributory factors to incidents in an intensive care environment. Simulation-based training is recommended as a method to make health-care personnel aware of the importance of team working and to improve their competencies. Design: The study uses a qualitative descriptive design. Methods: Individual qualitative interviews were conducted with 18 intensive care nurses from May to December 2009, all of which had attended a simulation-based team training programme. The interviews were analysed by qualitative content analysis. Results: One main category emerged to illuminate the intensive care nurse perception: ‘‘training increases awareness of clinical practice and acknowledges the importance of structured work in teams’’. Three generic categories were found: ‘‘realistic training contributes to safe care’’, ‘‘reflection and openness motivates learning’’ and ‘‘finding a common understanding of team performance’’.
∗
Corresponding author at: Faculty of Health, Care and Nursing, Gjøvik University College, Teknologivn. 22, 2815 Gjøvik, Norway. Tel.: +47 61 13 53 23; fax: +47 61135170. E-mail addresses: [email protected] (R. Ballangrud), [email protected] (M.L. Hall-Lord), [email protected] (M. Persenius), [email protected] (B. Hedelin). http://dx.doi.org/10.1016/j.iccn.2014.03.002 0964-3397/© 2014 Elsevier Ltd. All rights reserved.
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R. Ballangrud et al. Conclusions: Simulation-based team training makes intensive care nurses more prepared to care for severely ill patients. Team training creates a common understanding of how to work in teams with regard to patient safety. © 2014 Elsevier Ltd. All rights reserved.
Implications for Clinical Practice • Exploring the advantages of simulation-based team training for building patient safety in the ICU. • Highlighting the importance of structured work in team to ensure patient safety. • Focusing on organisational learning and improvement in intensive care nursing.
Introduction Although health care is expected to be safe and of a high quality, incidents caused by human factors are reported to be a problem, thereby generating steps to prevent errors and make improvements is important to healthcare institutions (Page, 2004). Team training has been proclaimed as a method for improving safety and quality in health care (Kohn et al., 2000; Salas and Rosen, 2013). In intensive care units (ICU), nurses work in both disciplinary and interdisciplinary teams in a high-tech environment with seriously ill patients in rapidly shifting conditions. These teams mostly have a dynamically changing membership or are brought together ad hoc, e.g. in emergency situations (Manser, 2009). Failures in team performance with regard to non-technical skills (NTS) are found to be contributory factors to incidents in the intensive care environment (Manojlovich and DeCicco, 2007; Reader et al., 2006). However, the development of team performance competencies has not been addressed in a systematic way by the educational institutions and health-care systems (Salas and Rosen, 2013).
Background The most commonly used team-training strategy in health care is Crew Resource Management (CRM) (Salas et al., 2009), which is designed to improve both individuals’ and teams’ competencies in NTS (Flin and Maran, 2004; Gaba et al., 2001). NTS includes situational awareness, decisionmaking, communication, teamwork, leadership and the management of stress and fatigue (Flin et al., 2010). This approach to team training, with a focus on the role of human factors (Helmreich, 2000), was transferred and modified to health care by Gaba et al. (1994), who adapted the use of human patient simulation into team training. CRM aims to achieve patient safety by focusing on applying optimal resources, preventing errors and minimising the consequences of error that may have occurred (Rall and Dieckmann, 2005a). Simulation-based team training (SBTT) based on CRM has been shown to be effective for improving NTS (Doumouras et al., 2012; Lewis et al., 2012). A SBTT programme based on CRM has to date no international standard (Haerkens et al., 2012). However, a strategy often chosen encompasses lectures concerning human factors, as well as
team performance training with regard to high fidelity simulation scenarios in which the team treats the simulator as a patient and practises challenging situations in a realistic environment. During the simulation scenario, the team members play active roles as leaders and followers solving a situation, followed by a debriefing with active and observer roles involved in the discussion (Gaba et al., 2001; Rall and Dieckmann, 2005b). Team process behaviour has an impact on clinical performance in patient care and training has resulted in increased performance (Schmutz and Manser, 2013). Even though the implementation of team training among operating room personnel has shown an association with lower surgical mortality (Neily et al., 2010), moderate effects for patientrelated outcomes have also been demonstrated (Cook et al., 2011). Team training has been found to result in transformational changes in safety culture when the work environment supports the learning of new behaviour (Jones et al., 2013), and to improve efficiency, morale and patient safety in nursing (West et al., 2012). In intensive care, the implementation of an evidence-based team training system has exhibited improvements in observed team performance and interviews with staff indicated the implementation to be effective (Mayer et al., 2011). Moreover, Sandahl et al. (2013), in interviews with ICU personnel after the implementation of a SBBT programme regarding interdisciplinary teamwork found that training had increased their awareness of the importance of effective communication for patient safety. Most studies focusing on the outcome of team training for patient safety are based on interdisciplinary teams. To acquire a deeper understanding of intensive care nurses’ perception of simulation-based disciplinary team training with regard to patient safety would be of great interest. Intensive care nurses constitute a large proportion of ICU personnel and work closely with the patients, which consequently makes them an important group in preventing errors and building patient safety within the ICU.
Methods Design The study uses a qualitative descriptive design based on individual interviews.
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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Aim
3 Table 1
Descriptions of the participants (n = 18).
The aim of the study was to describe intensive care nurses’ perceptions of simulation-based team training for building patient safety in the ICU.
Characteristic
The simulation-based team training programme
Age
During a period of eight months, 53 registered nurses (RNs) from seven different ICUs participated in a SBTT programme, consisting of a half-day of introductory theory inputs on safe team performance based on CRM and a half-day of team training in a simulation laboratory created as an ICU environment at a university college in Norway. During the simulation training, two high fidelity human patient simulation scenarios were conducted that provided opportunities to practise team performance during emergency situations. The RNs were trained in teams of five persons. The teams were comprised of three RNs in active roles (one leader and two followers), while two held passive roles as observers. All team members were in active roles in at least one scenario. Following the simulation scenario, which lasted approximately 12—15 min, a 30-min debriefing was conducted in which both the active and passive roles contributed. The SBTT programme was developed by the authors, and led by experienced simulation- and CRM instructors with backgrounds as nurses, and with extensive experience from anesthesiology and intensive care.
Participants Eighteen registered nurses (RNs) working in seven ICUs in one hospital trust in Norway were recruited from the sample of 53 RNs who had attended the SBTT programme. A strategic sampling was carried out with regard to variation in gender, age, area of intensive care, education level, years as RN, years as postgraduate intensive care nurse, scenario roles and simulation experience (Table 1). A request was sent to one or two RNs in each of the participating teams about a week after the completion of the SBTT programme, and out of a total of 21 requests, 18 RNs gave their consent to participate in the study.
Data collection The data collection took place from May to December 2009. The individual interviews were conducted by the first author three-four weeks after the RNs had completed the SBTT programme, and took place according to the participants’ wishes, either at the hospitals or at the university college. The interview started with a clarification of the aim of the study, and was followed up with the open-ended question: ‘‘Can you please describe how you perceive simulationbased team training with regard to building patient safety in intensive care’’? The interview took the form of a dialogue in which follow-up questions were used (Kvale, 2007), lasted from 26 to 47 minutes (mean = 39 minutes), and was digitally recorded and transcribed verbatim.
Category
Nurses (n)
Female Male
15 3
Gender
≤40 years 41—50 years ≥51 years
6 7 5
G-ICU M-ICU GM-ICU
7 7 4
Area of intensive care
Educational level Graduate Postgraduate
3 15
≤5 years 6—15 years ≥16 years
1 5 12
≤5 years 6—15 years ≥16 years
7 4 4
Years as RN
Years as PG-RN
Simulation experience Yes No
11 7
Leader Assistant Helper Observer
6 7 9 14
Scenario roles
G-ICU, general intensive care unit; M-ICU, medical intensive care unit; GM-ICU, general/medical intensive care unit; PG-RN, postgraduate registered nurse.
Ethical approval The study was approved by the Norwegian Social Data Services, accepted by the hospitals’ administrative heads and conducted according to the ethical guidelines for nursing research (Northern Nurses Federation, 2003). Invitations and information about the study were given to the RNs in both written and oral form. The information included confidentiality policy, that participation was voluntary and that the participants could withdraw from the study at any time. Written consent was obtained from the RNs who agreed to participate.
Data analysis Based on Elo and Kyngäs (2008), a manifest inductive content analysis was implemented. The content analysis processes contained a preparation-, organising- and reporting phase.
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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R. Ballangrud et al. The preparation phase:
• The unit of analysis was selected on the basis of the aim of the study. • The written transcript was repeatedly read through in order to grasp the content and obtain a sense of its entirety.
to seeing clinical practices in a new way, creating reflections about what is good and what can be done better in daily work to help ensure patient safety. Additionally, SBTT helps to articulate team performance and create awareness of the importance of structure with regard to communication and different roles and responsibilities within the team.
Realistic training contributes to safe care The organising phase: • An open coding with written headings was performed. • The headings were collected on coding sheets. • The coding sheet headings were grouped by gathering those with a similar content into higher order subcategories covering the meaning. • Similar sub-categories were grouped together in higher order generic categories. • A main category was generated from the generic categories in order to give a general description of the content of the written material. The reporting phase • An overview of the abstraction process with the generation of categories was made (Fig. 1).
Trustworthiness Lincoln and Guba’s (1985) four criteria of credibility, dependability, confirmability and transferability were used in this study to ensure trustworthiness. Credibility was established with regard to variation in RNs’ area of ICU practice, gender, age, education level and years as practising as nurses to give a broad description of the phenomenon (Sandelowski, 2000). An open-ended interview question encouraged the participants to talk openly, follow-up questions were posed in order to avoid misunderstandings. Moreover, a pilot interview was conducted, and a detailed description of the data collection- and analysis process was given. To ensure dependability, the same introductory openended question was posed to each participant, and all the interviews were conducted by the first author. Confirmability was achieved by a systematic treatment of the data, with repeated readings to help grasp the content and careful generation of categories reflecting the participants’ voices. Quotations were used to enhance and illuminate the content of the categories and agreement within the research team was addressed in order that the data correctly represented the information the participants provided. To ensure transferability, we have presented the participants’- and study’s results in a trustworthy way, with some short quotations used to clarify the interviewees’ perceptions (Graneheim and Lundman, 2004).
Results One main category generated from three generic categories and six sub-categories (Fig. 1). The main category, ‘‘Training increases awareness of clinical practice and acknowledges the importance of structured work in teams’’, describes that organised SBTT yields experiences that may contribute
The generic category concerns the fidelity in the human patient simulation training with respect to real-life situations, and how training with the use of a simulator is related to ensuring patient safety. Conducting simulation scenarios that deal with common and expected situations from the ICU makes nurses more prepared to ensure critically ill patients receive safe care. The category consists of two subcategories: ‘‘Not putting the patient at risk’’ and ‘‘Transferable to clinical practice’’. Not putting the patient at risk The participants pointed out that the advantage of SBTT was that it provided a safe arena for training that facilitated learning without affecting a highly critically ill patient. Training could make intensive care nurses more prepared and confident to handle different emergency situations. They described that SBTT could contribute to managing stress both in emergencies and in their daily work in the ICU since the same feelings of stress were recognised during simulation-based situations. These feelings were related to managing the situation and demonstrating their competencies to others. Even though rarely occurring situations were particularly emphasised, simulations of common situations were also found necessary to practise. The participants perceived that SBTT should be performed on a regular basis to achieve improvement, and one participant expressed the importance of SBTT with regard to patient safety in this way: We are practising on living people, and some of them die because we are not prepared well enough. So it is absolutely crucial for patient safety that you are capable of doing your job before you actually have to do it. (No.15) Transferable to clinical practice The simulated scenarios were experienced as realistic, useful and transferable to clinical practice. Being able to observe its measurable parameters such as heart rate, electrocardiogram, blood pressure and oxygen saturation was expressed as important and enabled the nurses to recognise and compensate for failures in the patients’ vital functions. Although it was a simulated situation, they focused on solving the emergency situation similarly to a real situation in the ICU. The different roles in the scenario reflected the division of responsibility in their daily work. One participant said: I found it to be very practical in the sense of being very close to real-life practices. Being able to communicate with a patient was especially important, [. . .] suffice it to say that it was then when I felt that it became very realistic and close [to real life]. (No.13) Some of the nurses experienced the simulation as being less realistic, mostly because of the absence of any
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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Sub-category • •
• •
• •
Generic category
Main category
Not pung the paent to risk Transferable to clinical pracce
Realisc training contributes to safe care
Focusing on one’s own- and others’ competence Debriefing facilitates improvement
Reflecon and openness movates learning
Responsibility in roles and use of human resources Importance of clear communicaon
Finding a common understanding of team performance
Figure 1
Training increases awareness of clinical pracce and acknowledges the importance of structured work in teams
An overview of generation of categories.
physicians in the team. Although positive experiences among participants with regard to training in a simulation laboratory were expressed, SBBT in situ in their own unit with physicians as a part of the team was thought to provide an even greater degree of realism and transferability.
Reflection and openness motivates learning This generic category concerns the pedagogical method used for learning during SBTT, which was perceived as strengthening human resources development, and as building competencies for patient safety in daily work. The debriefing with open group discussions and reflections concerning the team performance during the simulation scenarios was experienced as positive. This generic category consisted of two subcategories: ‘‘Focusing on one’s own- and others’ competence’’ and ‘‘Debriefing facilitates improvement’’. Focusing on one’s own and others’ competence SBTT helps nurses to be aware of what they do well and what can be improved, what they need to practise and what they have to study, all with the intention of preventing mistakes as well as making improvements in clinical situations. One of the participants expressed: Yes, it was definitely useful. Something that you think you have done well for many years [. . .] and then you suddenly get surprised when undergoing simulation-based training. (No.5) In particular, participating in the training could be useful in building competencies because the participants had to articulate the reasons for their own actions and give feedback to each other, which required reflection. One participant said: It is quite good that while you normally just work as you are used to [without thinking too much about it], in a simulation you have to somehow think the situation
through, usually more than once, because you will have to give feedback about it. (No.7) By using SBTT on a regular basis, the participants believed that intensive care nurses will be more familiar with their own reactions when handling various emergencies. Moreover, an awareness of the team’s performance will be increased, thereby strengthening the team’s preparedness. Some participants experienced that a team member could have vastly different perceptions of a situation, which also was conducive to learning. One participant stated: I was a bit surprised about how different the various group members had experienced the very same scenario [. . .]. Things were mentioned that I completely did not think of at all — both things to improve and things that were positive. I think every single one of us who participated saw things from a different angle and had a different focus; it was actually exciting. (No.6) The participants found it important to know that the team members complemented each other and worked well together ahead of a real patient situation, so they therefore considered it of importance that all in the unit participate in SBTT. Debriefing facilitates improvement Regular use of SBTT was perceived to increase the use of structured debriefing after difficult situations in clinical practice. The constructive feedback during the debriefing after the scenarios made the nurses aware of areas for improvements, and the participants experienced that they seldom gave each other feedback during daily work since they have no tradition of doing so. As one participant put it: It is actually not so easy to correct [people], or somehow give them feedback on how they communicate or function in such a situation. (No.8) The discussions and reflections related to leadership, resource management and communication, in which each team member had the opportunity to give reasons for their
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own actions and priorities were perceived as being of great importance. It was important to provide debriefings, both in emergency and in more common patient situations, in the daily work in practice. One participant stated: I think that in cases of patient safety, it is important to have some debriefing, to sit down and take some time [to reflect on] what we did, [and] what we could have done better in this special situation. (No.7)
Finding a common understanding of team performance This generic category concerns how team training based on CRM gives new insight and knowledge of how to work in teams. An awareness of the use of human resources, responsibilities and team communication was experienced to be improved through training using simulation. The generic category consisted of two subcategories: ‘‘Responsibility in roles and use of human resources’’ and ‘‘The importance of clear communication’’. Responsibility in roles and use of human resources SBTT was experienced as creating an awareness of the importance of clarifying roles and responsibility within a team. The nurses expressed that they had limited knowledge of structured teamwork prior to the SBTT, and in clinical practice they experienced an unsystematic approach to teamwork that was dependent on the nurse’s or physician’s competence, as well as whether the team had experience in working together. One participant pointed out the advantage of SBTT: Simulations create consciousness about the role oneself and other people play. Since I was observing, I could see how the others functioned, which I can learn from too. I can see how I should not do things, as well as how I should do them. Moreover, I see that some [people] are very fit to be leaders while others are not; some create chaos. (No.17) The participants’ perceptions were that SBTT had a great potential for improvement, especially concerning the importance of the team’s leadership and followership. They described a clinical practice in which these roles were rarely clarified or verbalised. One said: I think that training is important, because if no one assumes leadership in a situation [. . .] it gets very disorganised. I like to have things organised—yes, and I think there is much that can be improved by that. I think that the more simulations one experiences, the better one can get. (No.11) It was considered important that the nurses mastered leadership; however, in emergency situations they perceived it most appropriate for the physician to take the leading role. Interdisciplinary team training is described as crucial in order to clarify roles and responsibilities together with the physicians, although nurses and physicians currently have no tradition of training together as a team. Optimising personnel resources in teams was characterised by the participants as being an area of which clinical practice needs to be
more aware. The participants described emergency situations during daytime that often became chaotic, which was due to the fact that too many nurses and physicians wanted to help. The participants experienced that they performed best at night when fewer staff were present. People somehow start running around and try to do something, [. . .] and then you think that someone did something that he/she actually did not do after all. So if one had trained [how to behave in such a situation], one would know much better what to do if such a scenario became real. (No.8) Importance of clear communication Both verbal- and non-verbal communication were perceived by the participants as being most important to teamwork in the ICU, since distinct communication that had been emphasised in the simulation-based training should also be integrated into clinical practice. You are much more conscious [about what you are doing] during simulations, and when you are more conscious about it, then the quality of the service you provide increases. If you communicate clearly, constantly checking that the person you talk to understands what you’re saying and acts accordingly, higher quality assurance for the patient will be provided. (No.11) Inadequate communication was perceived as causing a lowering in team performance. The participants referred to various clinical situations in which well-trained communication techniques could contribute to proper patient care, and they considered it important to give clear messages, e.g. in CPR situations. When exposed to a high level of stress, structured and proper verbal- and non-verbal communication in the team might help to calm the situation down and introduce accountability, which was exemplified by one nurse: [....] Through the way she [physician] behaves, she communicates calmness. You can see in her determined gaze that she is in control. She knows what she is doing. [...] And then there is someone else, you can see he is somehow restrained, and maybe looks around a little and you can see his uncertain gaze, giving you the impression that he wonders about what is happening on the scene, and you find yourself asking if he actually knows what he is doing right there. (No.3) Having knowledge of structured and clear communication with regard to leadership was emphasised by the participants, in addition to having a follower in a team requiring training to communicate observations in a satisfactory manner. They emphasised the importance of open communication across the team. Nonetheless, the participants described some reservations about open communication when physicians were part of the team. This was found to be a typical phenomenon, which again supports the need for interdisciplinary team training.
Discussion The aim of the study was to describe intensive care nurses’ perceptions of SBTT for building patient safety in intensive care. The results showed that intensive care nurses
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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A descriptive qualitative study experienced that training created awareness about clinical practice, and also acknowledged the importance of structured work in teams as a contribution for building patient safety.
Realistic training contributes to safe care The intensive care nurses emphasised the importance of realistic training without exposing patients to any unnecessary risk, which may prepare them in a better way to manage difficult situations in daily practice. Their views, which describe a need for this type of training, may be explained by the significant changes that have occurred in the ICU over the past few years with regard to more severe patients and an extensive increase in advanced technology equipment as well as workload. A high workload (Scott et al., 2006; Stone et al., 2007) and stress (Berland et al., 2008) were found to be associated with intensive care nurses’ risk of making mistakes. Over a period of several years, there have been reports that patient safety is often at risk in ICUs (Donchin et al., 1995; Rothschild et al., 2005), which was also recently confirmed by two European multicentre studies (Merino et al., 2012; Valentin et al., 2013). According to Salas et al. (2008), it is essential for a successful outcome that the training is undertaken in a psychologically safe environment in which errors can be seen as opportunities for learning. The result confirmed that most of the participants experienced the SBTT as realistic and thus transferable to practice. This result is in accordance with Sandahl et al. (2013), who also stated that this perception was also shared by the observers. Critical and acute care nursing practice is described as intellectually and emotionally challenging in that it requires quick decisions in life-threatening situations in which little margin for errors exists (Benner et al., 2011), and high simulation validity is emphasised as important to help learners sharpen their responses to critical incidents (Hamilton, 2005; Issenberg et al., 2005). Some of the nurses experienced the simulation as being less realistic, mostly because of the absence of a physician in the team. Our programme was never planned to deal with interdisciplinary team training and lack of real medical input may have been a limitation to provide realistic simulation even though they had the opportunity to call a physician acted by a simulation instructor. However, it is the nurses who most often identify the first sign of deterioration in the critically ill patient’s condition and have to manage the situation until the physician arrives (Benner, 2001), which also require disciplinary team training. According to Sandahl et al. (2013), several participants saw the advantage of in situ training, while the participants in our study also appreciated being in a simulation laboratory, which may offer benefits such as avoidance of job-related interruption.
Reflection and openness motivates learning Developing nursing competence within the area of intensive care practices requires experiential learning under pressure and constant thinking linked to action in ongoing situations (Benner et al., 2011). In this study, the participants experienced that training helped to build competencies. Strengths and weaknesses concerning their own and others’
7 actions were exposed to evaluation, as they had to articulate the reasons for their own actions and give feedback to each other, which may create learning. Feedback and communication about errors among intensive care nurses are documented as an area for improvement (Ballangrud et al., 2012). In this way, SBTT may help to make clinical judgement and clinical knowledge development more visible, and may be considered as a well-adjusted method to give them experiential learning without endangering patient safety. The use of simulation enabled self-reflection and feedback on personal performance, and according to Rall and Dieckmann (2005b), this ‘‘eye-opening effect’’ described by the participant is also voiced by other participants. Team training demonstrates the importance of the performance in terms of safe management and exemplifies how teamwork may malfunction, thereby facilitating learning (Rall and Dieckmann, 2005b). Moreover, training in team performance has also been shown to increase nurses’ and physicians’ self-efficacy (Meurling et al., 2013). As stated by the participants, the ad hoc simulation of a small group of personnel from a unit is considered as fruitless in bringing about changes. To attain shared knowledge, attitudes and skills, it is important that all in the unit with a dynamically changing membership participate in SBTT. Team training may initiate a transformational change in safety culture when the intervention is supported by the work environment (Jones et al., 2013). In the present study, the participants perceived that regular SBTT may strengthen nurses in relation to practising debriefing after difficult situations in clinical practice, which has also been reported by Sandahl et al. (2013). Debriefing is seen as a crucial tool for improving teamwork and creating an environment of continuous learning (Leonard et al., 2013), and is found to be a factor that influences the quality of nursing practice in intensive care in a positive way (Storesund and McMurray, 2009). Furthermore, the result may indicate an overall perception of SBTT as being an important contribution to ICU’s organisational learning. As documented by Ballangrud et al. (2012), organisational learning is an area in intensive care nursing that requires improvements and development.
Finding a common understanding of team performance In accordance with the staff’s perception in ICU environments in the United States (Mayer et al., 2011), team role clarity was highlighted by our participants as an area in need of improvement, and that training may help facilitate changes. This may support Salas and Rosen (2013) assertion that team performance competencies have not been addressed in a systematic way by health-care systems. However, the CRM strategy is considered to be a promising tool for cultural changes in an ICU setting (Haerkens et al., 2012). The participants in the present study saw the importance of mastering team leadership, hence practising this through simulation training, while team leadership is shown as a key factor in developing new ways for team members to interact and communicate with each other (Reader et al., 2009). Nevertheless, nurses do not have a cultural or professional tradition in taking leadership in teamwork, which is considered to inhibit them from participating in
Please cite this article in press as: Ballangrud R, et al. Intensive care nurses’ perceptions of simulation-based team training for building patient safety in intensive care: A descriptive qualitative study. Intensive Crit Care Nurs (2014), http://dx.doi.org/10.1016/j.iccn.2014.03.002
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decision-making processes, e.g. in emergencies (Andersen et al., 2010), even though they are responsible for doing that (Hancock and Easen, 2006). Interdisciplinary team training was seen as essential in building patient safety. Thus far, the participants expressed that nurses and physicians had no tradition of training together as a team, although this fact has been found to limit the success of the training outcome (Sandahl et al., 2013). Today, however, interdisciplinary teamwork is seen as one of the key processes in the safe delivery of patient care (Kohn et al., 2000). According to Reader et al. (2009), this cross-professional nature of ICUs makes them particularly vulnerable to problems with team communication, which can affect patient safety. Team communication failure has led to patient harm (Pronovost et al., 2002, 2006), and the importance of focusing on communication in SBTT to ensure patient safety was supported by the participants. In this study, they emphasised the focus of clear and open communication with regard to both disciplinary and interdisciplinary teams, and that training may help to strengthen role clarity and communication between the disciplines. Some reservations about open communication had been experienced when physicians were part of the team. This may be explained by the traditional hierarchies in health care, which are characterised as barriers to team action in emergencies (Andersen et al., 2010; Hunziker et al., 2011). Team training based on CRM aims to flatten hierarchies of authority to achieve greater respect and foster open communication to help ensure quality and patient safety (Powell and Kimberly Hill, 2006).
Limitations of the study The results may be influenced by participants who agreed to participate in the study based on their initially positive perceptions of the phenomenon. Additionally, a less skewed gender distribution with a larger male sample could have raised different perceptions. A lack of a physician in the team might have been a limitation for providing realistic simulation.
Conclusion Intensive care nurses perceive that SBTT has advantages for building patient safety in the ICU and that realistic training makes them more prepared to care for severely ill patients. The pedagogical methods which focus on reflection and openness motivate learning, and team training creates a common understanding of team work. In addition to disciplinary team training, interdisciplinary team training is also considered to be important. Further research is needed in order to achieve a deeper understanding of ICU staffs’ perceptions concerning interdisciplinary teamwork for patient safety. Evaluation research with regard to interdisciplinary SBTT would be of great interest.
Conflict of interest The authors declare they have no competing interest and no financial disclosures.
Funding We will thank the Laerdal Foundation for Acute Medicine for their financial support.
Acknowledgements The authors would like to thank the registered nurses for their participation. In addition, we want to express our deepest gratitude to the simulation instructors, Viktor Haugom, Tore Karlsen, Christer Eriksson and Terje Ødegården.
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