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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation
Clinical Simulation in Nursing (2013) 9, e163-e169
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Featured Article
Evaluating An Interprofessional Pediatrics Educational Module Using Simulation Marian Luctkar-Flude, RN, MScNa,*, Cynthia Baker, RN, PhDb, Jennifer Medves, RN, PhDc, Ellen Tsai, MD, MHSC, FRCPCd, Lauren Rivard, RN, MSce, Marie-Claude Goyer, RN, NP-PHC, MScf, Ana Krause, RN, BScNf a
Adjunct Professor, Nursing Lab Coordinator, Queen’s University, School of Nursing, Kingston, Ontario, Canada K7L 3N6 Executive Director, Canadian Association of Schools of Nursing, Ottawa, Ontario, Canada, K1S 5K4 c Director, Queen’s University, School of Nursing, Kingston, Ontario, Canada K7L 3N6 d Associate Professor, Department of Pediatrics, Queen’s University, Kingston, Ontario, Canada, K7L 3N6 e Clinical Educator, Obstetrics, Kingston General Hospital, Kingston, Ontario, Canada, K7L 2V7 f Queen’s University, School of Nursing, Kingston, Ontario, Canada K7L 3N6 b
KEYWORDS education; interprofessional; medicine; nursing; pediatrics; simulation; undergraduate
Abstract Background: High-fidelity simulation (HFS) has been shown to be effective in health sciences education for practicing team approaches to managing complex care. Interprofessional (IP) collaboration contributes to patient well-being. This prospective study was conducted to evaluate an interprofessional pediatrics educational module using HFS. Methods: Nursing and medical students (N ¼ 96) attended one asthma exacerbation simulation and a second on sepsis. Performance of basic pediatric skills and team skills was evaluated using a checklist. Participants (N ¼ 86) completed a survey regarding their confidence performing pediatric skills and their comfort with IP communication and collaboration. Fifty-three nursing students completed the scenarios in non-IP groups. Results: Team skills improved significantly for the IP groups between the two scenarios (p < .001), but not for the non-IP groups. Pediatric skills scores were lower than team scores in both sessions for all groups. Conclusion: HFS may be a useful strategy to teach interprofessional teamwork in pediatrics. Cite this article: Luctkar-Flude, M., Baker, C., Medves, J., Tsai, E., Rivard, L., Goyer, M.-C., & Krause, A. (2013, May). Evaluating an interprofessional pediatrics educational module using simulation. Clinical Simulation in Nursing, 9(5), e163-e169. doi:10.1016/j.ecns.2011.11.008. Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the International Nursing Association for Clinical Simulation and Learning. All rights reserved.
Background * Corresponding author: [email protected] (M. Luctkar-Flude).
A university school of nursing and school of medicine collaborated on a project to enhance patient welfare by
1876-1399/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the International Nursing Association for Clinical Simulation and Learning. All rights reserved.
doi:10.1016/j.ecns.2011.11.008
Evaluating An Interprofessional Pediatrics Educational Module Using Simulation developing and implementing interprofessional (IP) health education modules using human patient simulation. Highfidelity simulation (HFS) has been shown to be an effective and satisfying method for teaching clinical skills and team approaches to managing complex care (Laschinger et al., 2008). In pediatrics, seamless IP collaboration is parKey Points ticularly critical for optimal High-fidelity patient clinical outcomes; theresimulation can profore, pediatrics was chosen vide more consistent as the fourth educational pediatric learning exmodule in our IP simulation periences for undercurriculum. graduate nursing and Pediatric simulation is medical students, inthe reenactment of routine cluding common peor critical clinical events in diatric events and pediatric care. Because of rarer but more risky the low frequency of acute complications. incidents in childhood, it is High-fidelity patient difficult to assess knowlsimulation may be edge and skills of pediatric a useful strategy to trainees in emergent care, teach interprofessional an obstacle that can be teamwork in undermanaged through highgraduate health scifidelity human patient simences education. ulation (Adler et al., 2007). Participation in multiSimulation provides the opple interprofessional portunity to practice routine pediatric simulation or critical scenarios in an scenarios may be necenvironment where misessary to enhance learntakes can be made and iming of both clinical and mediate learning can occur teamwork skills. (Fiedor, 2004). Traditionally, health professional education has occurred in uniprofessional programs (Coates et al., 2008). IP education (IPE) educates learners about the roles of other health professionals and the key behaviors essential to health care team functioning (Cook, 2005). Team training has also been proposed as a strategy to reduce medical errors and improve patient safety (Institute of Medicine, 2000). Primarily because of short clinical rotations and a lack of patients, nursing and medical students completing pediatric rotations have inconsistent learning encounters. Simulation offers the opportunity for more consistency. Practice in the simulation laboratory may provide students with the knowledge and confidence to assist with a variety of common acute care events and rare potential complications.
Use of Simulation to Teach Pediatric Skills Research has shown the value of using simulation for training in acute pediatric emergencies (Eppich et al., 2006). Although the practice of pediatrics requires IP collaboration, most pediatric simulation training and evaluation has been conducted with uniprofessional groups
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and does not include teamwork training. Several studies have shown HFSs to be an effective tool for behavioral skill training (Nishisaki et al., 2009). Nursing students who practiced pediatric assessment during HFS reported lower anxiety levels before their first assessment of a hospitalized child (Megel et al., 2011). Gilfoyle et al. (2007) suggest that a simulation-based intervention improved pediatric residents’ resuscitation leadership skills. Repetitive practice is a key feature involving the use of HFS in medical education (Issenberg et al., 2005). Through repetitive practice of critical assessment and interventional skills on HFSs, first-year pediatric critical care fellows had improved clinical performance and self-confidence immediately after training and 6 months later (Nishisaki et al., 2009). Researchers evaluating a curriculum for pediatric emergency medicine residents involving simulation found limited benefits from a 1-day simulation-based pediatric emergency medicine curriculum, suggesting that frequent, focused instructional simulation modules may be more effective in achieving substantial performance improvements (Adler, 2009). Shilkofski et al. (2008) also revealed that simulation can be used to identify knowledge and skill deficiencies among learners, allowing for improvements in critical care and resuscitation training programs.
Interprofessional Use of Simulation to Teach Pediatric Team Skills Simulation has also been proposed to improve team performance in pediatric emergencies and to facilitate IP team training (Messmer, 2008). There is currently limited research evaluating the use of simulation with IP groups of pediatric practitioners. Most interdisciplinary studies have focused on procedural performance. Simulation-based team training in pediatric resuscitation was shown to increase self-efficacy in resuscitation skills among both residents and nurses (van Schaik et al., 2011). Few interdisciplinary studies have evaluated team skills, such as communication. Two studies evaluated both performance of team skills and pediatric procedural skills in IP simulation scenarios. Messmer (2008) evaluated the level of IP collaboration between nurses and pediatric residents during simulated critical care scenarios. Although participants perceived high levels of group interaction and collaboration throughout the module, video recordings revealed that initially, more uniprofessional collaboration was seen, ultimately shifting towards a more interdisciplinary style. Falcone et al. (2008) showed that overall team performance and completion of appropriate care measures improved significantly after pediatric trauma simulation training.
Undergraduate Simulation Training in Pediatrics Although simulation is increasingly being used in pediatric training of postlicensure practitioners, few studies have
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation examined the use of simulation in undergraduate pediatric education. Nursing students who participated in one pediatric asthma scenario identified simulation as a useful tool for learning prioritization and enjoyed practicing communication with family members and health care professionals (Richard, 2009). Another study found that IP team training improved medical and nursing student knowledge of team and communication skills and attitudes toward working as teams (Robertson et al., 2010). Qualitative feedback from nursing and medical students completing an IP cardiac resuscitation skills module indicated that they were comfortable learning with students from other professions and valued IP simulation sessions (Luctkar-Flude et al., 2010). The purpose of this study was to evaluate an IP pediatric simulation module for undergraduate nursing and medical students in terms of learner confidence and ability to perform pediatric assessment and interventions, as well as communication and teamwork skills and comfort with IP learning. Repetition strengthens learning (Fitzgerald, 2003). If learning takes place during a simulation and debriefing, it is anticipated that students would show improved performance during subsequent learning opportunities. It was therefore hypothesized that learners participating in two IP simulations would exhibit improved communication and teamwork skills during the second simulation.
Methods Design and Methods This mixed methods, quasiexperimental study evaluated one component of a larger action research project to develop IP health educational modules through patient simulation. Congruent with action research, the evaluation is designed to develop knowledge to modify and improve an innovation as it is being implemented (Kemmis & McTaggert, 1990). Two simulation scenarios, asthma exacerbation and sepsis, were offered to third-year nursing and medical students in addition to their pediatric theory and clinical courses. The scenarios were adaptations of the Program for Nursing Curriculum Integration (PNCI) simulated clinical experiences (SCEs). The SCEs are evidence-based, while allowing faculty to modify the simulations to meet their individual objectives (METIÒ, 2011). Modifications included using Canadian terminology, medications, and laboratory values. Each session consisted of 30 minutes of participation in a scenario followed by 30 minutes of debriefing. Facilitators were experienced clinical faculty members. Clinical faculty assigned students to simulation groups according to their clinical rotations. Attendance was not mandatory. A nursing instructor and a medical preceptor
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co-taught each session. Participants were assigned the roles of registered nurse, nursing student, resident, medical student, and family members. Nursing students played nursing roles and medical students the medical roles. An experienced pediatric nurse used a researcher-devised checklist to evaluate performance of clinical and team skills. After the simulations, participants completed a survey regarding confidence performing pediatric skills and their perceptions of IP communication and collaboration.
Sample A convenience sample of 96 students, 90% of whom were enrolled in a pediatric rotation, participated in the scenarios. Of these, 79 were third-year nursing students and 17 were third-year medical students. The control group of 53 nursing students completed the scenarios in non-IP groups, whereas the remaining 26 nursing students and all of the 17 medical students completed the scenarios in IP groups.
Ethics This study received approval from the Queen’s University Health Sciences Research Ethics Board. Informed consent was obtained from all study participants.
Instruments Communication and Teamwork The Communication and Teamwork Scale of the University of the West of England, Bristol Entry Level Interprofessional Questionnaire (Pollard et al., 2004) was used in this study and involved participants self-assessment of teamwork and communication skills and attitudes towards IP learning and IP interaction. Negative statements were reverse-scored, with higher scores on each item indicating greater comfort with communication and teamwork items. Internal consistency for the scale was good (Cronbach’s alpha ¼ 0.79). Confidence Performing Pediatric Skills A survey consisting of 18 items on a 6-point Likert Scale was developed to measure learner confidence performing pediatric skills, based on course objectives. Higher scores indicate higher confidence with the associated skills. Internal consistency for the subscales were good (Cronbach’s alpha ¼ 0.83 and 0.87 for the asthma and sepsis subscales, respectively). Validity was established through peer review by the instructors teaching in the course. Interprofessional Learning A qualitative survey was developed by the project team asking students to respond to four open-ended questions related to their comfort with IP learning, challenges and benefits to IP learning, and suggestions to improve the IP pediatric educational module.
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation Performance Checklist A performance checklist, based on course objectives, was developed specifically for the two scenarios by nursing and medical faculty involved in the project. The pediatric skills subscale consisted of 10 assessment items for the asthma scenario, 11 assessment items for the sepsis scenario, 19 task items for the asthma scenario, and 13 task items for the sepsis scenario. The team skills subscale (Cronbach’s alpha ¼ 0.87) consisted of 21 items based on crisis resource management: role clarity (4 items), communication (5 items), personnel support (5 items), resources (3 items), and global team functioning assessment (4 items). Items were scored as not done (0 points), done poorly or with prompting (1 point), or done well (2 points).
Data Analysis Quantitative data were entered into a database (SPSS version 17; SPSS Inc., Chicago, IL) and verified by a second person. Standard univariate measures, such as means and standard deviations, were calculated to describe outcomes. Comparisons of groups were conducted using independent t tests for scale data and ManneWhitney U tests for ordinal data. Qualitative data analysis is in progress and involves thematic analysis.
Results Participants
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for the assessment skill: ‘‘complete head to toe assessment’’ on a pediatric patient, with 70.8% of students in the control group reporting feeling ‘‘confident’’ compared to only 21.4% of students in the experimental group being confident. Both groups had low confidence ratings for ‘‘caring for a child with sepsis.’’ In the control group, 25% of students indicated that they were ‘‘unconfident’’ and 58.3% of students rated themselves as only ‘‘somewhat confident.’’ In the experimental group, 42.8% of students rated themselves as ‘‘unconfident’’ and 38.1% of students indicated they were only ‘‘somewhat confident.’’ Similarly, students in the asthma control group had much higher confidence ratings than the experimental group for most skills. More than half (56%) felt confident ‘‘administering oral medications to a pediatric patient,’’ compared to only 26.3% of the experimental group. Both groups reported lower confidence ‘‘communicating with the parents of a pediatric patient’’ with 38% for the experimental group and 44% for the control group. The overall trend of lower confidence amongst the experimental group persisted for many of the skills in the asthma scenario. Interprofessional Learning Qualitative data analysis is ongoing using thematic analysis and will be reported elsewhere. Preliminary results indicate that feedback related to the IP module is positive, with students reporting they enjoy the IP scenarios and requesting more sessions.
Performance Checklist
Surveys were completed by 86 (90%) students who attended the simulations. Ages ranged from 20 to 29 years in the control group and 21 to 30 years in the experimental group. The majority of students in both the control group (95.8%) and the experimental group (69%) were female, and the ratio of nursing to medical students in the experimental group was 64% to 36%.
Communication and Teamwork Overall students were comfortable with IP collaboration, and only one item showed a strong between-group difference. For the statement ‘‘I feel comfortable explaining an issue to people who are unfamiliar with the topic,’’ 57.1% of students in the experimental group rated that they would ‘‘agree,’’ compared to only 32.6% of students in the control group. There were no significant differences between the control and experimental group responses, or asthma and sepsis scenarios.
Confidence Performing Pediatric Skills Control group confidence ratings were much higher (nursing students only) compared to the experimental group for both scenarios. In the sepsis scenario, there was a significant difference between group confidence ratings
Learner performance as measured by the performance checklist was compared between the IP and non-IP groups (Table 1). In the sepsis scenarios, there was a significant difference in overall role clarity between the groups, with better role clarity amongst the IP teams. IP teams were better at allocating team roles than the nursing teams. Pediatric assessment skill differences between groups were insignificant in the sepsis scenario. However, the IP team completed head-to-toe assessments notably better than the nursing teams, and the nursing teams were better at documenting vital signs. There was no difference in overall team communication between the nursing and IP groups in the sepsis scenarios. In the asthma scenarios, nursing teams performed assessment skills significantly better, related to documentation and reassessing respiratory status when the pediatric patient worsened. IP teams were better at actually completing the head-to-toe assessment and monitoring oxygen saturation throughout the scenarios. Overall teams met only 60% of the pediatric skills objectives for the sepsis scenario and 65% for the asthma exacerbation scenario. Learners scored higher on performance of team skills, meeting 86% of the sepsis scenario team skills objectives and 78% for the asthma scenario. Because the performance checklists measured team
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation Table 1
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Pediatrics Team Skills Performance by Interprofessional Group Status
Score PEDS skills Assessment score Task score Total PEDS skills score Team skills Role clarity score Communication score Personnel support score Resources score Global assessment score Total team skills score Total PEDS team skills score
IP Groups, Mean (SD)
Non-IP Groups, Mean (SD)
52.71% (11.50) 66.21% (9.09) 60.62% (8.70)
64.66% (14.99) 66.54% (13.16) 64.84% (10.06)
87.50% 81.67% 86.67% 85.16% 78.47% 82.22% 71.06%
81.25% 85.71% 83.57% 90.48% 64.29% 80.95% 72.12%
(17.68) (16.54) (13.72) (12.63) (19.08) (14.15) (9.14)
(11.76) (12.23) (18.23) (14.18) (25.41) (10.97) (6.96)
t test for Equality of Means
Significance (2-Tailed)
2.47 0.08 1.25
.21 .94 .22
1.20 0.77 0.53 1.10 1.74 0.29 0.37
.24 .45 .60 .28 .10 .78 .71
Note. PEDS ¼ pediatrics; IP ¼ interprofessional.
performance only, it was not possible to measure differences between nursing and medical students’ performance. Learner performance was also compared between the first and second sessions. Some teams completed the asthma scenario first, whereas others completed the sepsis scenario first. Each scenario involved different clinical skills, while the team skills objectives remained the same. Table 2 presents the results of team performance by session for the non-IP and IP groups. There were no significant differences in performance of pediatric skills between the two sessions for either the non-IP or IP groups. There was also no significant difference in performance of total team skills between the two sessions for the non-IP groups. A significant improvement in global assessment scores between the two sessions was noted amongst the non-IP groups. There were also significant improvements amongst the IP groups in three of the five categories of team skills, the total team skills score, and the total pediatric team skills score.
Discussion The high 90% return rate for the study surveys suggests that students valued the IP simulation sessions. Not only were students working with learners from another health profession, they were also working with learners within a wide age range, which reflects the reality in most health care settings, further contributing to the fidelity of the simulations. Results from the communication and teamwork survey show that learners were comfortable with IP collaboration. There were few significant differences between IP and nonIP groups, suggesting that participation in two IP sessions on the same day did not decrease the value of the IP aspect of the sessions. It is unclear, however, how many previous encounters students may have had with IPE. Nursing students and some medical students had at least one previous IP laboratory skills session. Students may have also participated in elective IP experiences.
Students in the experimental group were less confident performing pediatric skills; however, results were nonsignificant except for one item. Students may have been more confident in the control group when they were already acquainted with each other, especially in the first scenario. Overall, nursing and medical students were not confident performing pediatric skills. This was to be expected, because only one session on asthma exacerbation and one session on sepsis in a pediatric patient were offered. In addition, learners were third-year nursing and medical students taking part in pediatric clinical rotations for the first time. Students completing the simulation scenarios near the beginning of the rotation may have had limited or no previous experience in the pediatric clinical setting. Because the study design did not incorporate a comparison of clinical skills learned through simulation with a control group who had received the usual teaching methods only, we were unable to assess whether learning pediatric skills was increased using this approach. Studies with medical residents have shown that those who participate in pediatric simulations, especially on a frequent basis, are more confident with pediatric skills than those who covered the material in a lecture only (Adler et al., 2009; Brett-Fleegler et al., 2008; Nishisaki et al., 2009). These results suggest that students in our study may have been even less confident had they not participated in the simulation scenarios, and would benefit from more pediatric simulation scenarios to increase their confidence further. Repetitive practice is a key feature of HFS leading to effective learning (Issenberg et al., 2005). As measured by the performance checklists, overall team performance of pediatric skills was low in both scenarios, regardless of whether the teams were IP or non-IP, which corresponds to their reported lack of confidence performing these skills. The significantly better performance of pediatric skills in the asthma scenarios amongst nursing teams also correspond with the higher confidence ratings of nursing students performing these
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation Table 2
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Pediatrics Team Skills Performance by Session for Non-Interprofessional and Interprofessional Groups Non-IP Groups
Score PEDS skills Assessment score Task score Total PEDS skills score Team skills Role clarity score Communication score Personnel support score Resources score Global assessment score Total team skills score Total PEDS team skills score
First Session, Mean (SD)
IP Groups Second Session, Mean (SD)
t test for First Equality Significance Session, of Means (2-Tailed) Mean (SD)
Second Session, Mean (SD)
t test for Equality Significance of Means (2-Tailed)
1.84 0.32 1.62
.09 .76 .13
47.38% (9.63) 58.03% (11.16) 2.17 62.57% (9.15) 69.84% (7.89) 1.81 56.52% (7.53) 64.72% (8.15) 2.22
.05 .09 .04
82.14% (9.83) 80.36% (14.17) 0.27 81.43% (14.64) 90.00% (8.16) 1.35
.79 .21
76.39% (19.21) 98.61% (4.17) 3.39 68.89% (9.28) 94.44% (11.30) 5.24
.001 .001
77.14% (19.76) 90.00% (15.28) 1.36
.20
76.67% (11.18) 96.67% (7.07) 4.54
.001
90.49% (16.25) 90.47% (13.11) 0.00 50.00% (27.00) 78.57% (13.91) 2.49
1.00 .04
79.59% (11.08) 90.73% (12.11) 2.04 72.22% (20.52) 84.72% (16.27) 1.43
.06 .17
75.86% (10.87) 86.04% (9.05) 1.91
.08
71.03% (9.74) 93.40% (7.01) 5.59
.001
71.86% (4.49) 72.39% (9.20) 0.14
.89
64.40% (5.74) 77.72% (6.69) 4.53
.001
71.43% (15.74) 57.90% (11.52) 67.70% (7.23) 65.37% (17.88) 68.96% (3.98) 60.73% (12.81)
Note. PEDS ¼ pediatrics; IP ¼ interprofessional.
skills. However, evaluation during the training program does not measure whether learning took place. Reevaluation at a later date using similar scenarios would be a better indicator of knowledge and skill acquisition and retention gained through simulation. Most pediatric simulation training described thus far in the literature used a preand post-training evaluation of skill performance, which showed significant improvements following simulation training (Brett-Fleegler et al., 2008; Nishisaki et al., 2009). Overall, learners performed better on team skills in both scenarios, which corresponded to their reported comfort with IP collaboration. Team skills scores improved significantly for the IP groups by the second session, suggesting that repeated exposure to IP sessions may enhance learners’ functioning within an IP team. One study found that pediatric team simulation training resulted in improved group cohesion and communication scores after simulation, a result that should positively enhance pediatric patient care in the long-term (Messmer, 2008). Several limitations in the study design may have influenced the findings. The scenario order differed between groups, with some participating in the asthma scenario before the sepsis scenario and vice versa; however, there were no significant differences found between the two methods of course delivery. Participants may have had different amounts of previous experience with IPE and/or with simulation; improvement in team performance scores observed in the second session may have resulted from increased comfort with simulation and not necessarily specific to the IP aspects of the scenarios. Evaluation of
postscenario debriefing sessions may be an important aspect to consider, because providing feedback is a key feature of HFS that leads to effective learning (Issenberg et al., 2005).
Conclusion Results from this evaluation indicate that HFSs increase IP team skills among nursing and medical students participating in pediatric clinical rotations for the first time. They are not confident performing pediatric skills and do not perform these skills well in a simulated setting when provided with only a single simulation session targeting a specific clinical skill set. Study results will inform ongoing restructuring of the IP pediatric simulations as defined by the action research process. Suggested improvements include better preparation of learners through online materials before each session and the introduction of additional scenarios to improve learning of clinical skills and further enhance development of teamwork skills. Preparatory online materials will include both written guidelines and interactive videos, allowing students to become familiar with both the pediatric environment and simulation. Barriers to the introduction of more scenarios include scheduling of students, availability of instructors, and associated financial costs. Future research should include pre- and post-test evaluation of learning and performance outcomes, along with the collection of data related to participants’ previous experience with IPE and simulation.
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation
Acknowledgments Supported by the Ontario Ministry of Health and LongTerm Care, Health Education Innovation Fund.
References Adler, M. D., Trainor, J. L., Jo Siddall, V., & McGaghie, W. C. (2007). Development and evaluation of high-fidelity simulation case scenarios for pediatric resident education. Ambulatory Pediatrics, 7(2), 182-186. Adler, M. D., Vozenilek, J. A., Trainor, J. L., Eppich, W. J., Wang, E. E., Beaumont, J. L., et al. (2009). Development and evaluation of a simulation-based pediatric emergency medicine curriculum. Academic Medicine, 84(7), 935-941. Brett-Fleegler, M. B., Vinci, R. J., Weiner, D. L., Harris, S. K., Shih, M. C., & Kleinman, M. E. (2008). Simulator-based tool that assesses pediatric resident resuscitation competency. Pediatrics, 121(3), 597-603. Coates, V., Andrews, J., Davies, M., Hart, P., Martin, S., McErlean, U., et al. (2008). An evaluation of multi-professional education in diabetes. Journal of Interprofessional Care, 22(3), 295-307. Cook, D. A. (2005). Models of interprofessional learning in Canada. Journal of Interprofessional Care, 19(Suppl 1), 107-115. Eppich, W. J., Adler, M. D., & McGaghie, W. C. (2006). Emergency and critical care pediatrics: Use of medical simulation for training in acute pediatric emergencies. Current Opinion in Pediatrics, 18(3), 266-271. Falcone, R. A., Daugherty, M., Schweer, L., Patterson, M., Brown, R. L., & Garcia, V. F. (2008). Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation. Journal of Pediatric Surgery, 43(6), 1065-1071. Fiedor, M. L. (2004). Pediatric simulation: A valuable tool for pediatric medical education. Critical Care Medicine, 32(2), 72-74. Fitzgerald, K. (2003). Instructional methods. In S. B. Bastable (Ed.), Nurse as educator: Principles of teaching and learning for nursing practice (pp. 355-388). Sudbury, MA: Jones and Bartlett Publishers. Gilfoyle, E., Gottesman, R., & Razack, S. (2007). Development of a leadership skills workshop in paediatric advanced resuscitation. Medical Teacher, 29(9), e276-e283. Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Gordon, D. L., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27(1), 10-28.
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Kemmis, S., & McTaggert, R. (1990). The action research planner. Geelong: Deakin University Press. Laschinger, S., Medves, J., Pulling, C., McGraw, R., Waytuck, B., Harrison, M. B., et al. (2008). Effectiveness of simulation on health profession students’ knowledge, skills, confidence and satisfaction. International Journal Evidence Based Healthcare, 6(3), 278-302. Luctkar-Flude, M., Baker, C., Pulling, C., McGraw, R., Dagnone, D., Medves, J., et al. (2010). Evaluating an undergraduate interprofessional simulation-based educational module: Communication, teamwork, and confidence performing cardiac resuscitation skills. Advances in Medical Education and Practice, 1(1), 59-66. Medical Education Technologies Inc. (METIÒ). (2011). PNCIÒ: Program for Nursing Curriculum Integration. Sarasota, FL: METI. Retrieved December 12, 2011 from http://www.meti.com/downloads/PNCI_White_ Paper.pdf Megel, M. E., Black, J., Clark, L., Carstens, P., Jenkins, L. D., Promes, J., et al. (2011). Effect of high-fidelity simulation on pediatric nursing students’ anxiety. Clinical Simulation in Nursing. doi:10.1016/j.ecns. 2011.03.006. Messmer, P. R. (2008). Enhancing nurse-physician collaboration using pediatric simulation. The Journal of Continuing Education in Nursing, 39(7), 319-327. Nishisaki, A., Hales, R., Biagas, K., Cheifetz, I., Corriveau, C., Garber, N., et al. (2009). A multi-institutional high-fidelity simulation ‘‘boot camp’’ orientation and training program for first year pediatric critical care fellows. Pediatric Critical Care Medicine, 10(2), 157-162. Pollard, K. C., Miers, M. E., & Gilchrist, M. (2004). Collaborative learning for collaborative working? Initial findings from a longitudinal study of health and social care students. Health and Social Care in the Community, 12(4), 346-358. Richard, J. J. (2009). Beginning experiences with simulation: Asthma in a pediatric patient. Clinical Simulation in Nursing, 5(1), e5-e8. Robertson, B., Kaplan, B., Atallah, H., Higgins, M., Lewitt, M. M., & Ander, D. S. (2010). The use of simulation and a modified TeamSTEPPS curriculum for medical and nursing student team training. Simulation in Healthcare, 5(6), 332-337. Shilkofski, N. A., Nelson, K. L., & Hunt, E. A. (2008). Recognition and treatment of unstable supraventricular tachycardia by pediatric residents in a simulation scenario. Simulation in Healthcare, 3(1), 4-9. van Schaik, S. M., Plant, J., Diane, S., Tsang, L., & O’Sullivan, P. (2011). Interprofessional team training in pediatric resuscitation: A low-cost, in situ simulation program that enhances self-efficacy among participants. Clinical Pediatrics (Philadelphia), 50(9), 807815.
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Featured Article
Evaluating An Interprofessional Pediatrics Educational Module Using Simulation Marian Luctkar-Flude, RN, MScNa,*, Cynthia Baker, RN, PhDb, Jennifer Medves, RN, PhDc, Ellen Tsai, MD, MHSC, FRCPCd, Lauren Rivard, RN, MSce, Marie-Claude Goyer, RN, NP-PHC, MScf, Ana Krause, RN, BScNf a
Adjunct Professor, Nursing Lab Coordinator, Queen’s University, School of Nursing, Kingston, Ontario, Canada K7L 3N6 Executive Director, Canadian Association of Schools of Nursing, Ottawa, Ontario, Canada, K1S 5K4 c Director, Queen’s University, School of Nursing, Kingston, Ontario, Canada K7L 3N6 d Associate Professor, Department of Pediatrics, Queen’s University, Kingston, Ontario, Canada, K7L 3N6 e Clinical Educator, Obstetrics, Kingston General Hospital, Kingston, Ontario, Canada, K7L 2V7 f Queen’s University, School of Nursing, Kingston, Ontario, Canada K7L 3N6 b
KEYWORDS education; interprofessional; medicine; nursing; pediatrics; simulation; undergraduate
Abstract Background: High-fidelity simulation (HFS) has been shown to be effective in health sciences education for practicing team approaches to managing complex care. Interprofessional (IP) collaboration contributes to patient well-being. This prospective study was conducted to evaluate an interprofessional pediatrics educational module using HFS. Methods: Nursing and medical students (N ¼ 96) attended one asthma exacerbation simulation and a second on sepsis. Performance of basic pediatric skills and team skills was evaluated using a checklist. Participants (N ¼ 86) completed a survey regarding their confidence performing pediatric skills and their comfort with IP communication and collaboration. Fifty-three nursing students completed the scenarios in non-IP groups. Results: Team skills improved significantly for the IP groups between the two scenarios (p < .001), but not for the non-IP groups. Pediatric skills scores were lower than team scores in both sessions for all groups. Conclusion: HFS may be a useful strategy to teach interprofessional teamwork in pediatrics. Cite this article: Luctkar-Flude, M., Baker, C., Medves, J., Tsai, E., Rivard, L., Goyer, M.-C., & Krause, A. (2013, May). Evaluating an interprofessional pediatrics educational module using simulation. Clinical Simulation in Nursing, 9(5), e163-e169. doi:10.1016/j.ecns.2011.11.008. Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the International Nursing Association for Clinical Simulation and Learning. All rights reserved.
Background * Corresponding author: [email protected] (M. Luctkar-Flude).
A university school of nursing and school of medicine collaborated on a project to enhance patient welfare by
1876-1399/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the International Nursing Association for Clinical Simulation and Learning. All rights reserved.
doi:10.1016/j.ecns.2011.11.008
Evaluating An Interprofessional Pediatrics Educational Module Using Simulation developing and implementing interprofessional (IP) health education modules using human patient simulation. Highfidelity simulation (HFS) has been shown to be an effective and satisfying method for teaching clinical skills and team approaches to managing complex care (Laschinger et al., 2008). In pediatrics, seamless IP collaboration is parKey Points ticularly critical for optimal High-fidelity patient clinical outcomes; theresimulation can profore, pediatrics was chosen vide more consistent as the fourth educational pediatric learning exmodule in our IP simulation periences for undercurriculum. graduate nursing and Pediatric simulation is medical students, inthe reenactment of routine cluding common peor critical clinical events in diatric events and pediatric care. Because of rarer but more risky the low frequency of acute complications. incidents in childhood, it is High-fidelity patient difficult to assess knowlsimulation may be edge and skills of pediatric a useful strategy to trainees in emergent care, teach interprofessional an obstacle that can be teamwork in undermanaged through highgraduate health scifidelity human patient simences education. ulation (Adler et al., 2007). Participation in multiSimulation provides the opple interprofessional portunity to practice routine pediatric simulation or critical scenarios in an scenarios may be necenvironment where misessary to enhance learntakes can be made and iming of both clinical and mediate learning can occur teamwork skills. (Fiedor, 2004). Traditionally, health professional education has occurred in uniprofessional programs (Coates et al., 2008). IP education (IPE) educates learners about the roles of other health professionals and the key behaviors essential to health care team functioning (Cook, 2005). Team training has also been proposed as a strategy to reduce medical errors and improve patient safety (Institute of Medicine, 2000). Primarily because of short clinical rotations and a lack of patients, nursing and medical students completing pediatric rotations have inconsistent learning encounters. Simulation offers the opportunity for more consistency. Practice in the simulation laboratory may provide students with the knowledge and confidence to assist with a variety of common acute care events and rare potential complications.
Use of Simulation to Teach Pediatric Skills Research has shown the value of using simulation for training in acute pediatric emergencies (Eppich et al., 2006). Although the practice of pediatrics requires IP collaboration, most pediatric simulation training and evaluation has been conducted with uniprofessional groups
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and does not include teamwork training. Several studies have shown HFSs to be an effective tool for behavioral skill training (Nishisaki et al., 2009). Nursing students who practiced pediatric assessment during HFS reported lower anxiety levels before their first assessment of a hospitalized child (Megel et al., 2011). Gilfoyle et al. (2007) suggest that a simulation-based intervention improved pediatric residents’ resuscitation leadership skills. Repetitive practice is a key feature involving the use of HFS in medical education (Issenberg et al., 2005). Through repetitive practice of critical assessment and interventional skills on HFSs, first-year pediatric critical care fellows had improved clinical performance and self-confidence immediately after training and 6 months later (Nishisaki et al., 2009). Researchers evaluating a curriculum for pediatric emergency medicine residents involving simulation found limited benefits from a 1-day simulation-based pediatric emergency medicine curriculum, suggesting that frequent, focused instructional simulation modules may be more effective in achieving substantial performance improvements (Adler, 2009). Shilkofski et al. (2008) also revealed that simulation can be used to identify knowledge and skill deficiencies among learners, allowing for improvements in critical care and resuscitation training programs.
Interprofessional Use of Simulation to Teach Pediatric Team Skills Simulation has also been proposed to improve team performance in pediatric emergencies and to facilitate IP team training (Messmer, 2008). There is currently limited research evaluating the use of simulation with IP groups of pediatric practitioners. Most interdisciplinary studies have focused on procedural performance. Simulation-based team training in pediatric resuscitation was shown to increase self-efficacy in resuscitation skills among both residents and nurses (van Schaik et al., 2011). Few interdisciplinary studies have evaluated team skills, such as communication. Two studies evaluated both performance of team skills and pediatric procedural skills in IP simulation scenarios. Messmer (2008) evaluated the level of IP collaboration between nurses and pediatric residents during simulated critical care scenarios. Although participants perceived high levels of group interaction and collaboration throughout the module, video recordings revealed that initially, more uniprofessional collaboration was seen, ultimately shifting towards a more interdisciplinary style. Falcone et al. (2008) showed that overall team performance and completion of appropriate care measures improved significantly after pediatric trauma simulation training.
Undergraduate Simulation Training in Pediatrics Although simulation is increasingly being used in pediatric training of postlicensure practitioners, few studies have
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation examined the use of simulation in undergraduate pediatric education. Nursing students who participated in one pediatric asthma scenario identified simulation as a useful tool for learning prioritization and enjoyed practicing communication with family members and health care professionals (Richard, 2009). Another study found that IP team training improved medical and nursing student knowledge of team and communication skills and attitudes toward working as teams (Robertson et al., 2010). Qualitative feedback from nursing and medical students completing an IP cardiac resuscitation skills module indicated that they were comfortable learning with students from other professions and valued IP simulation sessions (Luctkar-Flude et al., 2010). The purpose of this study was to evaluate an IP pediatric simulation module for undergraduate nursing and medical students in terms of learner confidence and ability to perform pediatric assessment and interventions, as well as communication and teamwork skills and comfort with IP learning. Repetition strengthens learning (Fitzgerald, 2003). If learning takes place during a simulation and debriefing, it is anticipated that students would show improved performance during subsequent learning opportunities. It was therefore hypothesized that learners participating in two IP simulations would exhibit improved communication and teamwork skills during the second simulation.
Methods Design and Methods This mixed methods, quasiexperimental study evaluated one component of a larger action research project to develop IP health educational modules through patient simulation. Congruent with action research, the evaluation is designed to develop knowledge to modify and improve an innovation as it is being implemented (Kemmis & McTaggert, 1990). Two simulation scenarios, asthma exacerbation and sepsis, were offered to third-year nursing and medical students in addition to their pediatric theory and clinical courses. The scenarios were adaptations of the Program for Nursing Curriculum Integration (PNCI) simulated clinical experiences (SCEs). The SCEs are evidence-based, while allowing faculty to modify the simulations to meet their individual objectives (METIÒ, 2011). Modifications included using Canadian terminology, medications, and laboratory values. Each session consisted of 30 minutes of participation in a scenario followed by 30 minutes of debriefing. Facilitators were experienced clinical faculty members. Clinical faculty assigned students to simulation groups according to their clinical rotations. Attendance was not mandatory. A nursing instructor and a medical preceptor
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co-taught each session. Participants were assigned the roles of registered nurse, nursing student, resident, medical student, and family members. Nursing students played nursing roles and medical students the medical roles. An experienced pediatric nurse used a researcher-devised checklist to evaluate performance of clinical and team skills. After the simulations, participants completed a survey regarding confidence performing pediatric skills and their perceptions of IP communication and collaboration.
Sample A convenience sample of 96 students, 90% of whom were enrolled in a pediatric rotation, participated in the scenarios. Of these, 79 were third-year nursing students and 17 were third-year medical students. The control group of 53 nursing students completed the scenarios in non-IP groups, whereas the remaining 26 nursing students and all of the 17 medical students completed the scenarios in IP groups.
Ethics This study received approval from the Queen’s University Health Sciences Research Ethics Board. Informed consent was obtained from all study participants.
Instruments Communication and Teamwork The Communication and Teamwork Scale of the University of the West of England, Bristol Entry Level Interprofessional Questionnaire (Pollard et al., 2004) was used in this study and involved participants self-assessment of teamwork and communication skills and attitudes towards IP learning and IP interaction. Negative statements were reverse-scored, with higher scores on each item indicating greater comfort with communication and teamwork items. Internal consistency for the scale was good (Cronbach’s alpha ¼ 0.79). Confidence Performing Pediatric Skills A survey consisting of 18 items on a 6-point Likert Scale was developed to measure learner confidence performing pediatric skills, based on course objectives. Higher scores indicate higher confidence with the associated skills. Internal consistency for the subscales were good (Cronbach’s alpha ¼ 0.83 and 0.87 for the asthma and sepsis subscales, respectively). Validity was established through peer review by the instructors teaching in the course. Interprofessional Learning A qualitative survey was developed by the project team asking students to respond to four open-ended questions related to their comfort with IP learning, challenges and benefits to IP learning, and suggestions to improve the IP pediatric educational module.
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation Performance Checklist A performance checklist, based on course objectives, was developed specifically for the two scenarios by nursing and medical faculty involved in the project. The pediatric skills subscale consisted of 10 assessment items for the asthma scenario, 11 assessment items for the sepsis scenario, 19 task items for the asthma scenario, and 13 task items for the sepsis scenario. The team skills subscale (Cronbach’s alpha ¼ 0.87) consisted of 21 items based on crisis resource management: role clarity (4 items), communication (5 items), personnel support (5 items), resources (3 items), and global team functioning assessment (4 items). Items were scored as not done (0 points), done poorly or with prompting (1 point), or done well (2 points).
Data Analysis Quantitative data were entered into a database (SPSS version 17; SPSS Inc., Chicago, IL) and verified by a second person. Standard univariate measures, such as means and standard deviations, were calculated to describe outcomes. Comparisons of groups were conducted using independent t tests for scale data and ManneWhitney U tests for ordinal data. Qualitative data analysis is in progress and involves thematic analysis.
Results Participants
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for the assessment skill: ‘‘complete head to toe assessment’’ on a pediatric patient, with 70.8% of students in the control group reporting feeling ‘‘confident’’ compared to only 21.4% of students in the experimental group being confident. Both groups had low confidence ratings for ‘‘caring for a child with sepsis.’’ In the control group, 25% of students indicated that they were ‘‘unconfident’’ and 58.3% of students rated themselves as only ‘‘somewhat confident.’’ In the experimental group, 42.8% of students rated themselves as ‘‘unconfident’’ and 38.1% of students indicated they were only ‘‘somewhat confident.’’ Similarly, students in the asthma control group had much higher confidence ratings than the experimental group for most skills. More than half (56%) felt confident ‘‘administering oral medications to a pediatric patient,’’ compared to only 26.3% of the experimental group. Both groups reported lower confidence ‘‘communicating with the parents of a pediatric patient’’ with 38% for the experimental group and 44% for the control group. The overall trend of lower confidence amongst the experimental group persisted for many of the skills in the asthma scenario. Interprofessional Learning Qualitative data analysis is ongoing using thematic analysis and will be reported elsewhere. Preliminary results indicate that feedback related to the IP module is positive, with students reporting they enjoy the IP scenarios and requesting more sessions.
Performance Checklist
Surveys were completed by 86 (90%) students who attended the simulations. Ages ranged from 20 to 29 years in the control group and 21 to 30 years in the experimental group. The majority of students in both the control group (95.8%) and the experimental group (69%) were female, and the ratio of nursing to medical students in the experimental group was 64% to 36%.
Communication and Teamwork Overall students were comfortable with IP collaboration, and only one item showed a strong between-group difference. For the statement ‘‘I feel comfortable explaining an issue to people who are unfamiliar with the topic,’’ 57.1% of students in the experimental group rated that they would ‘‘agree,’’ compared to only 32.6% of students in the control group. There were no significant differences between the control and experimental group responses, or asthma and sepsis scenarios.
Confidence Performing Pediatric Skills Control group confidence ratings were much higher (nursing students only) compared to the experimental group for both scenarios. In the sepsis scenario, there was a significant difference between group confidence ratings
Learner performance as measured by the performance checklist was compared between the IP and non-IP groups (Table 1). In the sepsis scenarios, there was a significant difference in overall role clarity between the groups, with better role clarity amongst the IP teams. IP teams were better at allocating team roles than the nursing teams. Pediatric assessment skill differences between groups were insignificant in the sepsis scenario. However, the IP team completed head-to-toe assessments notably better than the nursing teams, and the nursing teams were better at documenting vital signs. There was no difference in overall team communication between the nursing and IP groups in the sepsis scenarios. In the asthma scenarios, nursing teams performed assessment skills significantly better, related to documentation and reassessing respiratory status when the pediatric patient worsened. IP teams were better at actually completing the head-to-toe assessment and monitoring oxygen saturation throughout the scenarios. Overall teams met only 60% of the pediatric skills objectives for the sepsis scenario and 65% for the asthma exacerbation scenario. Learners scored higher on performance of team skills, meeting 86% of the sepsis scenario team skills objectives and 78% for the asthma scenario. Because the performance checklists measured team
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation Table 1
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Pediatrics Team Skills Performance by Interprofessional Group Status
Score PEDS skills Assessment score Task score Total PEDS skills score Team skills Role clarity score Communication score Personnel support score Resources score Global assessment score Total team skills score Total PEDS team skills score
IP Groups, Mean (SD)
Non-IP Groups, Mean (SD)
52.71% (11.50) 66.21% (9.09) 60.62% (8.70)
64.66% (14.99) 66.54% (13.16) 64.84% (10.06)
87.50% 81.67% 86.67% 85.16% 78.47% 82.22% 71.06%
81.25% 85.71% 83.57% 90.48% 64.29% 80.95% 72.12%
(17.68) (16.54) (13.72) (12.63) (19.08) (14.15) (9.14)
(11.76) (12.23) (18.23) (14.18) (25.41) (10.97) (6.96)
t test for Equality of Means
Significance (2-Tailed)
2.47 0.08 1.25
.21 .94 .22
1.20 0.77 0.53 1.10 1.74 0.29 0.37
.24 .45 .60 .28 .10 .78 .71
Note. PEDS ¼ pediatrics; IP ¼ interprofessional.
performance only, it was not possible to measure differences between nursing and medical students’ performance. Learner performance was also compared between the first and second sessions. Some teams completed the asthma scenario first, whereas others completed the sepsis scenario first. Each scenario involved different clinical skills, while the team skills objectives remained the same. Table 2 presents the results of team performance by session for the non-IP and IP groups. There were no significant differences in performance of pediatric skills between the two sessions for either the non-IP or IP groups. There was also no significant difference in performance of total team skills between the two sessions for the non-IP groups. A significant improvement in global assessment scores between the two sessions was noted amongst the non-IP groups. There were also significant improvements amongst the IP groups in three of the five categories of team skills, the total team skills score, and the total pediatric team skills score.
Discussion The high 90% return rate for the study surveys suggests that students valued the IP simulation sessions. Not only were students working with learners from another health profession, they were also working with learners within a wide age range, which reflects the reality in most health care settings, further contributing to the fidelity of the simulations. Results from the communication and teamwork survey show that learners were comfortable with IP collaboration. There were few significant differences between IP and nonIP groups, suggesting that participation in two IP sessions on the same day did not decrease the value of the IP aspect of the sessions. It is unclear, however, how many previous encounters students may have had with IPE. Nursing students and some medical students had at least one previous IP laboratory skills session. Students may have also participated in elective IP experiences.
Students in the experimental group were less confident performing pediatric skills; however, results were nonsignificant except for one item. Students may have been more confident in the control group when they were already acquainted with each other, especially in the first scenario. Overall, nursing and medical students were not confident performing pediatric skills. This was to be expected, because only one session on asthma exacerbation and one session on sepsis in a pediatric patient were offered. In addition, learners were third-year nursing and medical students taking part in pediatric clinical rotations for the first time. Students completing the simulation scenarios near the beginning of the rotation may have had limited or no previous experience in the pediatric clinical setting. Because the study design did not incorporate a comparison of clinical skills learned through simulation with a control group who had received the usual teaching methods only, we were unable to assess whether learning pediatric skills was increased using this approach. Studies with medical residents have shown that those who participate in pediatric simulations, especially on a frequent basis, are more confident with pediatric skills than those who covered the material in a lecture only (Adler et al., 2009; Brett-Fleegler et al., 2008; Nishisaki et al., 2009). These results suggest that students in our study may have been even less confident had they not participated in the simulation scenarios, and would benefit from more pediatric simulation scenarios to increase their confidence further. Repetitive practice is a key feature of HFS leading to effective learning (Issenberg et al., 2005). As measured by the performance checklists, overall team performance of pediatric skills was low in both scenarios, regardless of whether the teams were IP or non-IP, which corresponds to their reported lack of confidence performing these skills. The significantly better performance of pediatric skills in the asthma scenarios amongst nursing teams also correspond with the higher confidence ratings of nursing students performing these
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation Table 2
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Pediatrics Team Skills Performance by Session for Non-Interprofessional and Interprofessional Groups Non-IP Groups
Score PEDS skills Assessment score Task score Total PEDS skills score Team skills Role clarity score Communication score Personnel support score Resources score Global assessment score Total team skills score Total PEDS team skills score
First Session, Mean (SD)
IP Groups Second Session, Mean (SD)
t test for First Equality Significance Session, of Means (2-Tailed) Mean (SD)
Second Session, Mean (SD)
t test for Equality Significance of Means (2-Tailed)
1.84 0.32 1.62
.09 .76 .13
47.38% (9.63) 58.03% (11.16) 2.17 62.57% (9.15) 69.84% (7.89) 1.81 56.52% (7.53) 64.72% (8.15) 2.22
.05 .09 .04
82.14% (9.83) 80.36% (14.17) 0.27 81.43% (14.64) 90.00% (8.16) 1.35
.79 .21
76.39% (19.21) 98.61% (4.17) 3.39 68.89% (9.28) 94.44% (11.30) 5.24
.001 .001
77.14% (19.76) 90.00% (15.28) 1.36
.20
76.67% (11.18) 96.67% (7.07) 4.54
.001
90.49% (16.25) 90.47% (13.11) 0.00 50.00% (27.00) 78.57% (13.91) 2.49
1.00 .04
79.59% (11.08) 90.73% (12.11) 2.04 72.22% (20.52) 84.72% (16.27) 1.43
.06 .17
75.86% (10.87) 86.04% (9.05) 1.91
.08
71.03% (9.74) 93.40% (7.01) 5.59
.001
71.86% (4.49) 72.39% (9.20) 0.14
.89
64.40% (5.74) 77.72% (6.69) 4.53
.001
71.43% (15.74) 57.90% (11.52) 67.70% (7.23) 65.37% (17.88) 68.96% (3.98) 60.73% (12.81)
Note. PEDS ¼ pediatrics; IP ¼ interprofessional.
skills. However, evaluation during the training program does not measure whether learning took place. Reevaluation at a later date using similar scenarios would be a better indicator of knowledge and skill acquisition and retention gained through simulation. Most pediatric simulation training described thus far in the literature used a preand post-training evaluation of skill performance, which showed significant improvements following simulation training (Brett-Fleegler et al., 2008; Nishisaki et al., 2009). Overall, learners performed better on team skills in both scenarios, which corresponded to their reported comfort with IP collaboration. Team skills scores improved significantly for the IP groups by the second session, suggesting that repeated exposure to IP sessions may enhance learners’ functioning within an IP team. One study found that pediatric team simulation training resulted in improved group cohesion and communication scores after simulation, a result that should positively enhance pediatric patient care in the long-term (Messmer, 2008). Several limitations in the study design may have influenced the findings. The scenario order differed between groups, with some participating in the asthma scenario before the sepsis scenario and vice versa; however, there were no significant differences found between the two methods of course delivery. Participants may have had different amounts of previous experience with IPE and/or with simulation; improvement in team performance scores observed in the second session may have resulted from increased comfort with simulation and not necessarily specific to the IP aspects of the scenarios. Evaluation of
postscenario debriefing sessions may be an important aspect to consider, because providing feedback is a key feature of HFS that leads to effective learning (Issenberg et al., 2005).
Conclusion Results from this evaluation indicate that HFSs increase IP team skills among nursing and medical students participating in pediatric clinical rotations for the first time. They are not confident performing pediatric skills and do not perform these skills well in a simulated setting when provided with only a single simulation session targeting a specific clinical skill set. Study results will inform ongoing restructuring of the IP pediatric simulations as defined by the action research process. Suggested improvements include better preparation of learners through online materials before each session and the introduction of additional scenarios to improve learning of clinical skills and further enhance development of teamwork skills. Preparatory online materials will include both written guidelines and interactive videos, allowing students to become familiar with both the pediatric environment and simulation. Barriers to the introduction of more scenarios include scheduling of students, availability of instructors, and associated financial costs. Future research should include pre- and post-test evaluation of learning and performance outcomes, along with the collection of data related to participants’ previous experience with IPE and simulation.
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Evaluating An Interprofessional Pediatrics Educational Module Using Simulation
Acknowledgments Supported by the Ontario Ministry of Health and LongTerm Care, Health Education Innovation Fund.
References Adler, M. D., Trainor, J. L., Jo Siddall, V., & McGaghie, W. C. (2007). Development and evaluation of high-fidelity simulation case scenarios for pediatric resident education. Ambulatory Pediatrics, 7(2), 182-186. Adler, M. D., Vozenilek, J. A., Trainor, J. L., Eppich, W. J., Wang, E. E., Beaumont, J. L., et al. (2009). Development and evaluation of a simulation-based pediatric emergency medicine curriculum. Academic Medicine, 84(7), 935-941. Brett-Fleegler, M. B., Vinci, R. J., Weiner, D. L., Harris, S. K., Shih, M. C., & Kleinman, M. E. (2008). Simulator-based tool that assesses pediatric resident resuscitation competency. Pediatrics, 121(3), 597-603. Coates, V., Andrews, J., Davies, M., Hart, P., Martin, S., McErlean, U., et al. (2008). An evaluation of multi-professional education in diabetes. Journal of Interprofessional Care, 22(3), 295-307. Cook, D. A. (2005). Models of interprofessional learning in Canada. Journal of Interprofessional Care, 19(Suppl 1), 107-115. Eppich, W. J., Adler, M. D., & McGaghie, W. C. (2006). Emergency and critical care pediatrics: Use of medical simulation for training in acute pediatric emergencies. Current Opinion in Pediatrics, 18(3), 266-271. Falcone, R. A., Daugherty, M., Schweer, L., Patterson, M., Brown, R. L., & Garcia, V. F. (2008). Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation. Journal of Pediatric Surgery, 43(6), 1065-1071. Fiedor, M. L. (2004). Pediatric simulation: A valuable tool for pediatric medical education. Critical Care Medicine, 32(2), 72-74. Fitzgerald, K. (2003). Instructional methods. In S. B. Bastable (Ed.), Nurse as educator: Principles of teaching and learning for nursing practice (pp. 355-388). Sudbury, MA: Jones and Bartlett Publishers. Gilfoyle, E., Gottesman, R., & Razack, S. (2007). Development of a leadership skills workshop in paediatric advanced resuscitation. Medical Teacher, 29(9), e276-e283. Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Gordon, D. L., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27(1), 10-28.
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Kemmis, S., & McTaggert, R. (1990). The action research planner. Geelong: Deakin University Press. Laschinger, S., Medves, J., Pulling, C., McGraw, R., Waytuck, B., Harrison, M. B., et al. (2008). Effectiveness of simulation on health profession students’ knowledge, skills, confidence and satisfaction. International Journal Evidence Based Healthcare, 6(3), 278-302. Luctkar-Flude, M., Baker, C., Pulling, C., McGraw, R., Dagnone, D., Medves, J., et al. (2010). Evaluating an undergraduate interprofessional simulation-based educational module: Communication, teamwork, and confidence performing cardiac resuscitation skills. Advances in Medical Education and Practice, 1(1), 59-66. Medical Education Technologies Inc. (METIÒ). (2011). PNCIÒ: Program for Nursing Curriculum Integration. Sarasota, FL: METI. Retrieved December 12, 2011 from http://www.meti.com/downloads/PNCI_White_ Paper.pdf Megel, M. E., Black, J., Clark, L., Carstens, P., Jenkins, L. D., Promes, J., et al. (2011). Effect of high-fidelity simulation on pediatric nursing students’ anxiety. Clinical Simulation in Nursing. doi:10.1016/j.ecns. 2011.03.006. Messmer, P. R. (2008). Enhancing nurse-physician collaboration using pediatric simulation. The Journal of Continuing Education in Nursing, 39(7), 319-327. Nishisaki, A., Hales, R., Biagas, K., Cheifetz, I., Corriveau, C., Garber, N., et al. (2009). A multi-institutional high-fidelity simulation ‘‘boot camp’’ orientation and training program for first year pediatric critical care fellows. Pediatric Critical Care Medicine, 10(2), 157-162. Pollard, K. C., Miers, M. E., & Gilchrist, M. (2004). Collaborative learning for collaborative working? Initial findings from a longitudinal study of health and social care students. Health and Social Care in the Community, 12(4), 346-358. Richard, J. J. (2009). Beginning experiences with simulation: Asthma in a pediatric patient. Clinical Simulation in Nursing, 5(1), e5-e8. Robertson, B., Kaplan, B., Atallah, H., Higgins, M., Lewitt, M. M., & Ander, D. S. (2010). The use of simulation and a modified TeamSTEPPS curriculum for medical and nursing student team training. Simulation in Healthcare, 5(6), 332-337. Shilkofski, N. A., Nelson, K. L., & Hunt, E. A. (2008). Recognition and treatment of unstable supraventricular tachycardia by pediatric residents in a simulation scenario. Simulation in Healthcare, 3(1), 4-9. van Schaik, S. M., Plant, J., Diane, S., Tsang, L., & O’Sullivan, P. (2011). Interprofessional team training in pediatric resuscitation: A low-cost, in situ simulation program that enhances self-efficacy among participants. Clinical Pediatrics (Philadelphia), 50(9), 807815.
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