|SYMPOSIUM: SIMULATION IN MEDICAL EDUCATION
|Year : 2017 | Volume
| Issue : 1 | Page : 104-109
Putting the pieces together: The role of multidisciplinary simulation in medical education
Jason M Stroud1, Kimberly D Jenkins1, Sujatha P Bhandary2, Thomas J Papadimos1
1 Department of Anesthesiology, The University of Toledo Medical Center, Toledo, OH, USA
2 Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
|Date of Web Publication||7-Jul-2017|
Jason M Stroud
Department of Anesthesiology, The University of Toledo Medical Center, 3000 Arlington Avenue, Mailstop #1137, Toledo, OH 43614
Source of Support: None, Conflict of Interest: None
Simulation is becoming an increasingly important tool in medical education. Specifically, multidisciplinary team-based simulation exercises are being used to promote teamwork and communication among various members of care teams. Similar to its use in the aviation industry, this type of team building simulation has shown promising results in improving teamwork and improving patient safety outcomes. Several key players in the health-care setting, including hospitals and malpractice insurance providers, have recognized these benefits and are promoting the use of multidisciplinary simulation for staff training. Despite several barriers to implementation, the use of multidisciplinary simulation will be an important part of a new emerging model of medical education.
The following core competencies are addressed in this article: Patient care, Interpersonal and communication skills, Systems-based practice.
Keywords: Medical education, multidisciplinary, patient safety, simulation
|How to cite this article:|
Stroud JM, Jenkins KD, Bhandary SP, Papadimos TJ. Putting the pieces together: The role of multidisciplinary simulation in medical education. Int J Acad Med 2017;3:104-9
|How to cite this URL:|
Stroud JM, Jenkins KD, Bhandary SP, Papadimos TJ. Putting the pieces together: The role of multidisciplinary simulation in medical education. Int J Acad Med [serial online] 2017 [cited 2020 Sep 26];3:104-9. Available from: http://www.ijam-web.org/text.asp?2017/3/1/104/209848
| Introduction|| |
The use of simulation as a supplement to traditional medical education continues to expand. The results of a recent survey of medical schools and teaching hospitals revealed that over ninety percent of these institutions are using simulation as part of their curricula for both medical students and residents. In fact, simulation use has become such an integral part of modern medical education that the Accreditation Council for Graduate Medical Education has made it a requirement of some residency programs. Conventionally, simulation exercises have been carried out within a single department and involved learners from a single discipline. Increasingly, however, simulation exercises have been expanded to include health-care professionals from multiple disciplines and across multiple locations within a hospital. This type of multidisciplinary simulation aims to enhance patient safety in several ways, namely improved communication among members of the care team, increased confidence and assertiveness of team members, and rehearsal of protocols for rare or high acuity events. Such benefits have already been demonstrated in the field of aviation, a profession that was an early adopter of simulation training. Here, we review the evidence for and potential benefits of multidisciplinary simulation education in healthcare.
| What Is Driving the Push for Multidisciplinary Simulation Training?|| |
The push for an increase in multidisciplinary simulation has been coming from multiple players in the healthcare setting including hospital system administrators, insurance carriers, and academic departments [Figure 1]. Hospital systems administrators have used multidisciplinary simulation in several different ways to educate staff and improve patient safety. First, they have used these types of exercises to improve communication between members of a care team. The basis for such simulations comes from evidence in the aviation industry demonstrating that team-based simulation can facilitate teamwork and improve team performance. Published examples from the healthcare industry have included a wide array of settings, teams, and contexts including operating room emergencies, labor and delivery, intensive care units, trauma bays, and even out-of-hospital disasters.,,,,,,, In general, these exercises have simulated emergency situations or rare events and have focused on team communication. However, hospitals have also employed this technique to train teams during the implementation of new care protocols. Figueroa et al. demonstrated successful development and implementation of a simulation-based team training program to train members of a pediatric cardiac intensive care unit on a newly-developed postpediatric cardiac surgery cardiac arrest protocol. They report that team members receiving this type of training showed improved communication and increased confidence during crisis scenarios. This type of protocol-specific multidisciplinary simulation training has also been used to improve the management of difficult airways outside of the operating room. Mark et al. employed simulation as a part of the educational component of a comprehensive program to improve emergency airway management in their hospital. Further, simulation-based team training does not need to be limited to one specific protocol or event. Adler and his team report the use of team-based simulation to prepare employees for new workflows related to the opening of a new hospital.
|Figure 1: Who is driving the demand for multidisciplinary simulation education in healthcare?|
Click here to view
Increasingly, malpractice insurance carriers are joining hospital systems in embracing team-based simulation to decrease the incidence of adverse events and more specifically, limit liability. A pilot test of an insurer-driven, large-scale multicenter simulation program for operating room teams was recently reported. The model focused on principles of communication, assertiveness, and use of the World Health Organization Surgical Safety Checklist. The participants, including nurses, anesthesiologists, and surgeons found the simulations to be both challenging and realistic. The exercise revealed that surgeons, more often, found communication to be their area of the greatest potential improvement, whereas nurses and anesthesiologists reported a need to improve personal assertiveness. Both of these important aspects of team dynamics can directly improve patient safety if they are addressed in simulated learning environments like this. In addition to playing a role in developing team training simulation programs for their customers, insurance companies have also begun to offer incentives such as decreased premiums to physicians who participate in other forms of team building such as computer-based simulation.
While large hospital systems and insurance carriers are driving some use of multidisciplinary simulation, the majority of the demand for this type of teaching is coming from academic medical centers. As noted earlier, simulation is becoming a standard and sometimes, required part of modern medical education. Potential medical students and residents applying to programs now expect to see a robust clinical simulation program at almost every major program or school to which they would apply. This pertains not only to physicians in training, but increasingly to nurses, therapists, and first responders. Many larger centers have invested in free-standing simulation centers capable of running multiple exercises simultaneously using state of the art equipment. However, others have taken an interest in simulated team training as demonstrated by the development of a low-cost obstetric simulation in a rural hospital.
| What Types of Simulation Have Been Used for Team Training?|| |
As simulation-based team training becomes for ubiquitous, the types of simulation and ways in which it is used to educate will become more widely varied. Already there are a number of ways in which different types of simulation can be used to accomplish different educational goals. The large-scale high-fidelity exercises commonly thought of when one refers to “simulation” are not the only way that multidisciplinary teams can be taught. For example, Lary et al. described a multidisciplinary approach to improving teamwork between students in dental hygiene, physical therapy, and physician assistant using a problem-based learning (PBL) approach. Teams discussed a simulated case in a PBL format before moving on to care for real patients as a group. Survey results of the participants demonstrated that PBL simulation was an effective means of presenting multidisciplinary material, enhanced their problem-solving abilities, improved their ability to work as a group, and furthered their understanding of the other disciplines.
In situ simulation
In situ simulations (those taking place in a real working environment rather than a separate simulation center) have also shown potential as a means of improving teamwork. An in situ simulation program consisting of simulated traumas taking place in a real trauma bay with all members of the trauma team represented was developed and evaluated. Results showed that both teamwork and communication during real traumas were improved among member of the trauma team who had received the in situ simulation training. Importantly, however, the benefit was not shown to last once the training period was stopped, highlighting the need for ongoing team training as part of routine continuing medical education. Another benefit of in-situ simulation is the opportunity it provides for testing care delivery systems and discovering potential safety concerns. A report from a high-risk pediatric emergency department described the use of unannounced in situ simulations with multidisciplinary teams during their normal workday. The primary goal of this exercise was to uncover latent safety threats including malfunctioning equipment, lack of knowledge, and lack of clarity regarding roles and responsibilities among others. The authors report the discovery of greater than one latent safety threat identified for every simulation run. In addition, they report that the exercises were well received by the participants, with 78% rating them extremely valuable or valuable. A study by Wetzel et al. demonstrated a similar effect of in situ simulation in discovering latent safety threats in a neonatal intensive care unit. This study further reported that, in addition to discovering the threats, they were able to document nineteen clinical improvements as a result of the exercises.
While PBL simulation and in situ simulation offer their own unique benefits, high-fidelity simulation using mannequins and simulated environments remains the hallmark of simulation education. This type of educational exercise offers benefits for team training not seen with other methods. For example, the ability to record the simulation exercises on video is available in many centers. Not only does this allow the evaluators to carefully examine the learners' actions after the fact, it also provides the opportunity for the learner to self-evaluate by watching the video. Further, designers of simulation curricula can use the information gathered from these records to design new learning objectives for future simulations based on a review of the simulation. Another benefit specific to high-fidelity team-based simulation is the opportunity for the team members to practice using real equipment that has been designated for simulation use and can be reused for multiple team training scenarios. Such exercises, if done in situ, may prove too costly as the materials used would need to either be discarded and replaced or reprocessed at great cost.
| What Are the Proposed Benefits of Multidisciplinary Simulation?|| |
Crew resource management
Multidisciplinary simulation education, in any form, has many proposed benefits. Perhaps one of the most important is the idea of crew resource management adapted from the aviation industry. This from of multidisciplinary simulation focuses on improving teamwork and communication during crises. Simulation allows teams to rehearse their responses to events which are critical but happen rarely in real life. Further, it allows these events to be broken down into discreet steps, stopped and restarted, and repeated to enhance learning and retention. Simulations of crisis situations focused on team training have been reported widely in the literature and include examples of a simulation involving trauma, labor and delivery, neonatal care, and the operating room.,,, While each simulated crisis has its own learning objective for the teams involved, there are several general goals common to all such team-based exercises; namely improved communication among team members, clarification of roles within the team, and further understanding and appreciation of the roles of other team members [Figure 2]. Multidisciplinary simulation has been shown to improve each of these facets of team dynamics in the health-care setting.,,,,,,,
|Figure 2: Simulation education involving two or more disciplines presents the opportunity to practice as a team and improve patient safety|
Click here to view
Communication and transfers of care
The potential benefits of multidisciplinary simulation training extend beyond crisis management. Transfers of patient care are another source of potential errors that can be improved using this teaching tool. A recent study by Cumin et al. and is team using simulation to assess communication between members of a multidisciplinary operating room team revealed that even when formal communications such as the time out are appropriately delivered they are often missing pieces of information and are contributed to unequally by members of the team. Appropriately, therefore, team-based simulation has been used not only to assess the quality of communication taking place between team members but also as a tool to improve it. Several studies have demonstrated that simulated exercises focusing primarily on communication skills can improve these interactions., This benefit is not limited to communication between hospital-based providers. Simulation training involving communication between prehospital and hospital providers has also shown promise in improving these critical transfers of care.
In addition to its role in training teams of established health-care providers, multidisciplinary simulation may have an important role in educating future healthcare providers before they begin clinical practice. Several authors have investigated possible strategies and benefits of this type of team training during the formative years. A review by Kiesewetter et al. examined the current literature regarding the teaching of leadership skills to undergraduate medical students. They conclude that a strong focus on behavioral training is needed and propose that simulation-based team training should be part of the solution. Other authors have studied the learner's response to integrated team training between nursing students and medical students. Their results indicate that both nursing and medical students found combined simulation training to be a positive experience that enhanced their learning. As multidisciplinary simulation education becomes an increasingly common part of continuing education for medical professionals of all disciplines, it will be vitally important for learners to be accepting of this form of teaching. Introducing multidisciplinary simulation education early on in the educational process will not only improve acceptance of simulation in general but also familiarize all involved with the concept of learning in the same kinds of teams in which they will ultimately be working.
| What Are the Barriers to Multidisciplinary Simulation?|| |
Despite the mounting evidence of the benefits of team-based multidisciplinary simulation, widespread implementation of programs such as the ones described here faces many challenges. One of the primary forces countering the push for greater use of this technique is a lack of time. Large-scale simulations, even relatively simple ones, necessarily involve lost man-hours as personnel is temporarily displaced from their normal roles in patient care to participate in simulation scenarios. In addition, the creation and coordination of these types of educational events require many hours to develop and prepare. While large academic institutions may be equipped to devote an entire staff position to such tasks and can easily cover staffing shortages during these simulations, many smaller institutions will not be able to devote the valuable human capital necessary.
Commensurate with temporal constraints are financial ones. Although, as previously noted, team-based simulation can be performed relatively economically, there remain many financial barriers. First, high-fidelity simulation equipment including mannequins, monitors, and software may be prohibitively expensive for smaller departments and hospitals. In addition, the cost of medical supplies and equipment wear must be factored in since no reimbursement for these items. Finally, the cost of shift coverage or overtime pay may become part of the financial calculus depending on which staff is involved and when the simulation exercises are performed.
While financial and temporal barriers are certainly relevant, they are both relatively easily overcome by appropriate allocation of resources. Obtaining administrative approval for such resources requires buy-in from hospital leadership which, itself, may be the biggest barrier to implementation. Hospital administrators and senior leadership must recognize the value in and potential benefits of multidisciplinary simulation and be willing to support it. Furthermore, the participants in the simulations must also realize the value of the exercise and perform as willing and eager participants in order to maximize the educational gains for the entire team. For each of these things to happen will require a simulation champion to promote it within the institution as well as clear and measurable educational goals so that both administrators and learners can feel confident that they are seeing a return on the investment of their time and money.
| What Is the Future of Multidisciplinary Simulation?|| |
As acceptance and use of team-based multidisciplinary simulation grow, there will need to be changes and improvements to maximize gains. More validated tools for assessment of teamwork will need to be developed and standardized so that research into the utility of this type of educational tool may be properly compared across many different programs. Both survey-based and outcome-based will be needed to determine the translation of educational efforts to the clinical setting. Institutions will need to develop more standardized curricula to ensure that all vital staff, not just those already interested in simulation, benefit from this type of training. Further, as simulation becomes an increasingly standard part of medical education, potential students will expect to see a robust, well-organized curriculum designed to enhance their learning.
| Conclusion|| |
The face of medical education across all disciplines is changing. Gone are the days of “see one, do one, teach one.” Memorization of facts from a text followed by on-the-job learning on real patients is becoming less acceptable. In its place is a focus on emotional intelligence, communication, and teamwork designed to promote patient safety while simultaneously providing real-world experience. Simulation, and more specifically team-based simulation that spans medical disciplines, is an emerging and important tool that will be a cornerstone of this new educational model.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Passiment M, Sacks H, Huang G. Medical Simulation in Medical Education: Results of an AAMC Survey. Washington, DC: Association of American Medical Colleges; 2011.
ACGME Program Requirements for Graduate Medical Education in Anesthesiology [Electronic document]. (2016). Retrieved from https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/040_anesthesiology_2016.pdf.
Arora S, Cox C, Davies S, Kassab E, Mahoney P, Sharma E, et al.
Towards the next frontier for simulation-based training: Full-hospital simulation across the entire patient pathway. Ann Surg 2014;260:252-8.
Littlepage GE, Hein MB, Moffett RG 3rd
, Craig PA, Georgiou AM. Team training for dynamic cross-functional teams in aviation: Behavioral, cognitive, and performance outcomes. Hum Factors 2016;58:1275-88.
Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: A simulation-based observational study. BMJ Qual Saf 2017;26:209-16.
Acero NM, Motuk G, Luba J, Murphy M, McKelvey S, Kolb G, et al.
Managing a surgical exsanguination emergency in the operating room through simulation: An interdisciplinary approach. J Surg Educ 2012;69:759-65.
Porteous J. Evacuating an OR is a complex process: Who does what? ORNAC J 2013;31:15, 17-9, 30-2.
Dadiz R, Weinschreider J, Schriefer J, Arnold C, Greves CD, Crosby EC, et al.
Interdisciplinary simulation-based training to improve delivery room communication. Simul Healthc 2013;8:279-91.
Higgins M, Kfouri J, Biringer A, Seaward G, Windrim R. Teaching an experienced multidisciplinary team about postpartum hemorrhage: Comparison of two different methods. J Obstet Gynaecol Can 2015;37:824-8.
Figueroa MI, Sepanski R, Goldberg SP, Shah S. Improving teamwork, confidence, and collaboration among members of a pediatric cardiovascular Intensive Care Unit multidisciplinary team using simulation-based team training. Pediatr Cardiol 2013;34:612-9.
Steinemann S, Berg B, Skinner A, DiTulio A, Anzelon K, Terada K, et al. In situ
, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ 2011;68:472-7.
Hutchinson SW, Haynes S, Parker P, Dennis B, McLin C, Welldaregay W. Implementing a multidisciplinary disaster simulation for undergraduate nursing students. Nurs Educ Perspect 2011;32:240-3.
Mark LJ, Herzer KR, Cover R, Pandian V, Bhatti NI, Berkow LC, et al.
Difficult airway response team: A novel quality improvement program for managing hospital-wide airway emergencies. Anesth Analg 2015;121:127-39.
Adler MD, Mobley BL, Eppich WJ, Lappe M, Green M, Mangold K. Use of simulation to test systems and prepare staff for a new hospital transition. J Patient Saf 2015Epub ahead of print.
Arriaga AF, Gawande AA, Raemer DB, Jones DB, Smink DS, Weinstock P, et al.
Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams. Ann Surg 2014;259:403-10.
Hanscom R. Medical simulation from an insurer's perspective. Acad Emerg Med 2008;15:984-7.
Chichester M, Hall NJ, Wyatt TL, Pomilla R. A cost-effective approach to simulation-based team training in obstetrics. Nurs Womens Health 2014;18:500-7.
Lary MJ, Lavigne SE, Muma RD, Jones SE, Hoeft HJ. Breaking down barriers: Multidisciplinary education model. J Allied Health 1997;26:63-9.
Miller D, Crandall C, Washington C 3rd
, McLaughlin S. Improving teamwork and communication in trauma care through in situ
simulations. Acad Emerg Med 2012;19:608-12.
Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ
simulation: Detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf 2013;22:468-77.
Wetzel EA, Lang TR, Pendergrass TL, Taylor RG, Geis GL. Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams. Jt Comm J Qual Patient Saf 2013;39:268-73.
Greidanus E, King S, LoVerso T, Ansell LD. Interprofessional learning objectives for health team simulations. J Nurs Educ 2013;52:311-6.
Daniels K, Auguste T. Moving forward in patient safety: Multidisciplinary team training. Semin Perinatol 2013;37:146-50.
Gettman MT, Pereira CW, Lipsky K, Wilson T, Arnold JJ, Leibovich BC, et al.
Use of high fidelity operating room simulation to assess and teach communication, teamwork and laparoscopic skills: Initial experience. J Urol 2009;181:1289-96.
Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JD, van Wijk KP. Interventions to improve team effectiveness: A systematic review. Health Policy 2010;94:183-95.
Fung L, Boet S, Bould MD, Qosa H, Perrier L, Tricco A, et al.
Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: A systematic review. J Interprof Care 2015;29:433-44.
Paige J, Kozmenko V, Morgan B, Howell DS, Chauvin S, Hilton C, et al.
From the flight deck to the operating room: An initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation. J Surg Educ 2007;64:369-77.
Tofil NM, Morris JL, Peterson DT, Watts P, Epps C, Harrington KF, et al.
Interprofessional simulation training improves knowledge and teamwork in nursing and medical students during internal medicine clerkship. J Hosp Med 2014;9:189-92.
Cumin D, Boyd MJ, Webster CS, Weller JM. A systematic review of simulation for multidisciplinary team training in operating rooms. Simul Healthc 2013;8:171-9.
Dojmi Di Delupis F, Pisanelli P, Di Luccio G, Kennedy M, Tellini S, Nenci N, et al.
Communication during handover in the pre-hospital/hospital interface in Italy: From evaluation to implementation of multidisciplinary training through high-fidelity simulation. Intern Emerg Med 2014;9:575-82.
Kiesewetter J, Schmidt-Huber M, Netzel J, Krohn AC, Angstwurm M, Fischer MR. Training of leadership skills in medical education. GMS Z Med Ausbild 2013;30:Doc49.
Reese CE, Jeffries PR, Engum SA. Learning together: Using simulations to develop nursing and medical student collaboration. Nurs Educ Perspect 2010;31:33-7.
[Figure 1], [Figure 2]