- Email: [email protected]
High consequence infectious diseases training using interprofessional simulation and TeamSTEPPS
ARTICLE IN PRESS American Journal of Infection Control 000 (2019) 1−6
Contents lists available at ScienceDirect
American Journal of Infection Control journal homepage: www.ajicjournal.org
Major Article
High consequence infectious diseases training using interprofessional simulation and TeamSTEPPS Rachel Marrs DNP, RN, CIC a,*, Trisha Leann Horsley PhD, RN, CHSE, CNE b,c, Diana Hackbarth PhD, RN, FAAN b, Emily Landon MD a a b c
University of Chicago Medicine, Chicago, IL Loyola University Chicago Marcella Niehoff School of Nursing, Maywood, IL South Dakota State University College of Nursing, Sioux Falls, SD
Key Words: High consequence infectious diseases Interprofessional education Interprofessional teamwork Self-efficacy State anxiety
Background: The comfort level of health care workers to respond to an infectious disease outbreak or epidemic is likely directly related to the amount of education, training, and experience they have in responding to these events. Methods: A quasi-experimental study evaluated health care workers’ state anxiety, self-efficacy, and interprofessional teamwork when working with patients simulated to have a potentially high consequence infectious disease. Results: Pretest-posttest 1 scores revealed a significant decrease in state anxiety (P < .0001) and an increase in self-efficacy (P < .0001). Overall state anxiety preintervention (pretest) to postintervention (posttest 3) significantly decreased (P = .0265). Overall TeamSTEPPS knowledge significantly increased (P < .0001) from baseline. Conclusions: Simulation exercises are an effective strategy to increase self-efficacy and decrease state anxiety for health care workers. Positive teamwork scores indicate that the subjects value interprofessional teamwork. © 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Awareness of the potential for outbreaks of high consequence infectious diseases, pandemics, and bioterrorism has increased over the past 15 years. All health care workers have the potential for interacting with patients during such an event. The comfort level to respond to a high consequence infectious disease or emergency management event is likely directly related to the amount of education, training, and experience health care workers have in responding to these events.1 An infectious disease outbreak of any kind can have a devastating effect on morbidity, mortality, and costs for all patients.2 Emergency preparedness requires an all-encompassing plan that is reassessed periodically to ensure the plan is congruent with current evidencebased policies and guidelines, in addition, the plan must be updated/ adopted for current conditions in the institution. The required elements of emergency management plans are clearly defined by the APIC, World Health Organization, Centers for Disease Control and *Address correspondence to Rachel Marrs, DNP, RN, CIC, University of Chicago Medicine, 5841 S. Maryland Ave, Chicago, IL 60637. E-mail address: [email protected] (R. Marrs). Conflicts of interest: None to report.
Prevention (CDC), and the Office of the Assistant Secretary for Preparedness and Response.3-6 The American Nurses Credentialing Center offers an interprofessional certification for disaster health care professionals that focuses on all phases of the disaster cycle: mitigation, preparedness, response, and recovery to help promote successful outcomes for health care professionals involved in a disaster.7 However, readiness levels vary greatly throughout the nation and world.8 For example in 2015, 3,106 nurses from the United States were asked in an online survey about their perceptions of caring for persons under investigation or with confirmed Ebola virus disease in the United States. The survey revealed 20.5% of nurses believed there was a lack of preparedness/readiness; 16.2% felt a need for training, education, and communication; and 15.4% had a fear of infection transmission.8 The study took place in an academic medical center, and prior to the study, high consequence infectious disease training was conducted, which included practice and competency with personal protective equipment (PPE), practice of standard operating procedures, and clinical skills simulation, yet the potential of a body fluid exposure or equipment failure caused fear and anxiety in staff. Offering simulation-based exercises allowed the opportunity for deliberate
https://doi.org/10.1016/j.ajic.2019.10.007 0196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
ARTICLE IN PRESS 2
R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6
practice and interprofessional teamwork training to improve communication and competency. Here we describe using simulationbased exercises and interprofessional training methods and their effect on subjects’ state anxiety, self-efficacy, and interprofessional teamwork when caring for a patient with a high consequence infectious disease. LITERATURE REVIEW Simulation-based health care education is being used increasingly among both medical and nursing schools, and in hospitals for training, assessment, and research. There are important features of simulation methodologies that allow it to be an effective way to acquire health care knowledge and skills. A simulated environment allows for deliberate practice of procedures without harming actual patients, team members, or oneself. The reflective practice of simulation allows educators to bring theory into life in a setting in which it is safe for students to learn from mistakes without causing patient harm.9 Additionally, simulated patient care environments and scenarios that closely replicate real-life settings help engage the learner and facilitate the transfer of skills from the laboratory to clinical practice.10 In high-risk settings, such as unfamiliar infectious disease events, deliberate practice with challenging situations can better prepare health care workers to face the stress and risk. For example, when simulation-based learning has been added to crisis management, research suggested that most subjects feel better prepared to participate and lead future resuscitation events, and has also improved clinical management and teamwork.11 At University of Pittsburgh Medical Center, while preparing for Ebola virus disease, practice of clinical protocols, procedural skills, as well as analysis of failure modes related to clinical protocols and system responses were identified as key benefits of simulation.12 Professional growth is an important component for all health care disciplines practice. Competency is a mastery of knowledge and skills. Although very broadly defined, a level of competence can be achieved with an opportunity to practice and ultimately master skills. A simulated environment provides an opportunity for achieving mastery of skills.13,14 Historically, simulation-based learning was primarily used to increase knowledge and improve competency, but it is also being used to assess self-efficacy of health care professionals. Self-efficacy is the extent of one’s belief in one’s ability to complete tasks or reach goals. Several studies have assessed competency and self-efficacy, and have found a positive correlation between the 2 elements.15 The literature also suggests that health care professionals that have a higher level of self-efficacy will not shy away from difficult situations such as a code situation or critically ill patient with an infectious disease.16 After a crisis management resource training project that included simulation, the confidence level increased and subjects felt better prepared to lead future resuscitation events.11 In a study evaluating surgery and trauma residents, after a 3-day course of highfidelity simulation for emergent patient care scenarios, the confidence level increased for all objectives.17 Assessing state anxiety levels of health care professionals during simulation-based learning and evaluating strategies to decrease anxiety during simulation is newer to the simulation field. Research has demonstrated that some anxiety may actually improve performance but once it rises above the optimal level, anxiety could contribute to medical errors and unsafe patient care.18 Several studies have assessed self-reported anxiety levels,11,19 whereas other studies assessed heart rate and cortisol levels of subjects.20 When multidisciplinary teams participated in high-fidelity training of critical patients, their anxiety level decreased and comfort level increased postintervention.11
TeamSTEPPS 2.0 (Agency for Healthcare Research and Quality, Rockville, MD) training is an evidence-based teamwork system designed for health care professionals.21 The curriculum is used to improve communication and teamwork skills, improve patient safety, and integrate teamwork principles in health care systems.21 The 4 pillars of TeamSTEPPS include communication, leadership, situation monitoring, and mutual support. High performing teams share mental models, have a shared vision, a strong sense of collective trust and confidence, and have strong team leadership.21 TeamSTEPPS training is designed to increase team awareness and help clarify team roles and responsibilities, which is essential for health care workers who have the responsibility for caring for critically ill patients with high consequence infectious diseases.
THEORETICAL FRAMEWORK The theoretical framework used to guide this study was the NLN/ Jeffries Simulation Theory.22 All components within the theory were addressed in the study. The simulation scenarios were designed after past events that have anecdotally caused fear and panic for health care workers, and the simulated environment allowed subjects to problem solve and practice skills in a safe environment. Debriefing immediately after the simulation was guided by the advocacy inquiry model to facilitate the subjects’ reflection. Most health care providers are problem-solvers and learn best when the subject is of immediate use, effective instruction involves the learner in solving real-life problems.
METHODS The setting for the study was a large academic medical center in the Midwest United States. All physicians, nurses, and infection control practitioners (ICPs) that were immediate responders in the adult emergency department were invited to participate during their annual training session. Annual training sessions are required and consist of computer-based training and training/competency with PPE. For participants who volunteered to participate in the study, they went on to complete simulation-based exercises, TeamSTEPPS training, and completion of pre/postsurveys on self-efficacy, state anxiety, and interprofessional teamwork. The study was submitted to the institutional review board, and they declared the study exempt. Before the training sessions began, the immediate responders participating in the required training were informed of the opportunity to participate in the research study. The training elements were required as part of preparedness for high consequence pathogens. The surveys on knowledge, skills, and attitudes were optional and part of the research study. They were assured that participation was voluntary, that they could decline participation at any time, and that whether or not they participate would not impact their employment. `The study used a quasi-experimental design to evaluate subjects’ knowledge, skills, and attitudes when working with patients with a high consequence infectious disease. The aim of the study was to determine the necessary elements including ideal order of interventions in a high consequence infectious disease training plan. Traditional education in past high consequence infectious disease events for immediate responders included hands-on training with PPE, competency assessment, and drills. This study offered traditional education with the addition of simulation-based exercises and TeamSTEPPS interprofessional education training. Training was offered in 2 different sequences to evaluate if there is a difference in subjects’ knowledge, skills, and attitudes depending on if they completed simulation-based exercises or TeamSTEPPS first in the training plan.
ARTICLE IN PRESS R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6
Training plan A computer-based training on the use of PPE was a prerequisite for participation in the training sessions. The computer-based training included the role of the trained observer who recorded observations on communication strategies, PPE donning and doffing exercises, and videos that pointed out common donning and doffing errors. Competency for donning and doffing PPE was evaluated by the trained observer who was the project facilitator using a PPE checklist created by the medical center in conjunction with CDC guidelines. A fluorescent glow powder that can be visualized with an ultraviolet flashlight was placed on subjects PPE to demonstrate contamination that can occur while caring for a patient. The design, implementation, and evaluation of the simulation experience met the International Nursing Association for Clinical Simulation and Learning Standards of Best Practice: Simulation.23,24 The scenarios validated by content and simulation experts included
events that previously caused discomfort and anxiety in past reallife events such as patients vomiting, bleeding, having diarrhea, or respirator battery dying when caring for patients with a potentially high consequence infectious disease. The simulation-based exercise sessions included 2 nurses, 1 physician, and 1 ICP per session. This matched the workflow for caring for a patient with a potentially high consequence infectious disease at the medical center. Each participant took part in 2 scenarios, prebriefing took place before each scenario, and debriefing took place after each scenario. Each training session was 2 hours in length. In both scenarios, the patient was suspected to have a high consequence pathogen and hemodynamically unstable while an acute stressor was added in each one. In the first scenario, the respirator battery died with one of the participants as the patient was decompensating. In the second scenario, the patient was vomiting and had diarrhea, which allowed the participants to practice containing body fluids while stabilizing the patient.
Complete pre-requisite (CBT) (30 mins)
1. 2. 3. 4.
All Participants (groups of 2-4) Training Session #1 Traditional Education Pre anxiety, satisfaction and self-efficacy PPE demonstration and practice. PPE Competency Post anxiety, satisfaction and self-efficacy (1 hour)
Divide participants in to Group A or Group B
Training Session #2 (Groups of 4) Simulation Exercises (2 hours)
Post anxiety, satisfaction, self- efficacy and teamwork
3
Training Session #2 (Groups of 8-16) Classroom/TeamSTEPPS® Education (1 hour)
Post anxiety, satisfaction, self- efficacy and teamwork
Training Session #3 (Groups of 8-16) Classroom/TeamSTEPPS® Education (1 hour)
Training Session #3 (Groups of 4) Simulation Exercises (2 hours)
Post anxiety, satisfaction, self- efficacy and teamwork
Post anxiety, satisfaction, self-efficacy and teamwork
Fig 1. Project design. CBT, computer-based training; PPE, personal protective equipment.
ARTICLE IN PRESS 4
R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6
TeamSTEPPS training sessions were designed to be interprofessional among nurses, physicians, and ICPs. Each training session was 1 hour in length. TeamSTEPPS training was included to increase team awareness and help clarify team roles and responsibilities, which is essential for health care workers who have the responsibility for caring for critically ill patients with high consequence infectious diseases. Figure 1 shows a clear description of the research design.
Instruments The Spielberger State-Trait Anxiety Inventory (STAI) 6-item short form was the tool used to collect the state anxiety score pre- and posttraining. The 6-item tool is designed to assess the presence or absence of anxiety. The reliability coefficient is a = 0.82.25 The correlation between the short form STAI and the standard STAI is r = 0.91.25 The STAI state anxiety 6-item short form score range is from 20-80. A normal score is noted to be between 34 and 36, a score higher suggests that some anxiety is present in the given moment or situation. The STAI tool has well established and documented reliability and validity.25 Self-efficacy (situational confidence) was assessed using the National League of Nursing satisfaction and self-confidence instrument, which was slightly modified so that it was relevant for health care workers and not students. The 13-item instrument is designed to measure student satisfaction (5 items) with the activity and selfconfidence in learning (8 items) using a 5-point scale. The score for self-efficacy ranged from 8-40. A higher score on the instrument suggests an increase in self-efficacy. The reliability of the instrument was tested using Cronbach’s alpha, satisfaction = 0.94 and selfconfidence = 0.87.26 TeamSTEPPS training knowledge transfer was assessed using a modified version of the Center for Health Science Interprofessional Education, Research and Practice Interprofessional team simulation training postassessment instrument.27 This instrument includes 24items on team function, leadership, situation monitoring, mutual support, and communication. The tool also includes 20-items to assess teamwork and knowledge transfer when used prior to and after TeamSTEPPS training. The score range for the questions regarding the 4 TeamSTEPPS pillars is 24-120. The before and after TeamSTEPPS knowledge questions each have a range of 10-50. A higher score on the TeamSTEPPS pillars question indicates a positive attitude or feelings about working to improve communication and interprofessional teamwork. A higher score on the before/after knowledge questions indicate increased knowledge after attending a TeamSTEPPS training session. Competency for donning and doffing PPE was evaluated by using a PPE checklist created by the medical center based on CDC PPE guidelines. As part of the competency assessment, the subjects had fluorescent glow powder placed on their PPE. They were examined with an ultraviolet light after doffing PPE to illuminate for any contamination. For the study, subjects were able to make multiple attempts but had to achieve a passing score in the PPE component to be deemed competent. A passing score meant that glow powder was absent after the participant doffed all PPE. Data were analyzed in STATA Release 13, 2015 (StataCorp, College Station, TX). The results from the state anxiety, self-efficacy, satisfaction, and interprofessional teamwork surveys were analyzed using independent and paired sample t tests. The mean score, confidence interval, P values, t values, and analysis of variance were calculated for each group of scores. The state anxiety and self-efficacy results were analyzed for all subjects pretest and posttest 1, posttest 2, and posttest 3. The mean score for each test was calculated for all subjects and within and between the 2 groups. The state anxiety and self-efficacy results were also analyzed comparing group A and group B.
Table 1 Total sample mean and confidence intervals, n = 31 Variable
Mean
95% CI
Anxiety pretest Anxiety posttest 1 Anxiety posttest 3 Self-efficacy pretest Self-efficacy posttest 1 Self-efficacy posttest 3 Cumulative before knowledge TeamSTEPPS score Cumulative after knowledge TeamSTEPPS score
36.46 29.24 31.61 32.48 37.19 33.68 39.94 45.68
(32.81, 40.12) (25.99, 32.51) (28.30, 34.92) (30.85, 34.12) (35.84, 38.55) (32.19, 35.17) (38.08, 41.79) (44.40, 46.95)
CI, confidence interval.
RESULTS Each participant took part in 1 computer training module and 3 in-person training sessions. A total of 31 subjects completed all 4 elements of the training plan and all surveys: 19 emergency room nurses (61.3%), 6 emergency medicine physicians (19.4%), and 6 ICPs (19.4%). This sample represented 21% of nurses and 23% of emergency medicine physicians within the emergency department, as well as 100% of ICPs employed within the hospital. Of the 31 subjects, 9 were men and 22 were women. The subjects were assigned to each group using convenience sampling. There was a similar distribution of nurses, physicians, and ICPs in each of the groups. Fifteen of the subjects were in group A and 16 were in group B. The mean scores for all subjects taking the STAI state anxiety 6item short form were in the normal range throughout the study (Table 1). Group B had overall higher pretest state anxiety scores than group A, and a lower posttest 3 state anxiety score than group A (Table 2). When comparing the state anxiety pretest and posttest 1 for all subjects combined, there was a statistically significant decrease in anxiety (P < .0001) after the training modules were completed. The preintervention test was given immediately before PPE training and competency, and the postintervention test 1 was given immediately after PPE training and competency (Fig 1). When comparing the pretest to posttest 3, there was significantly less anxiety after training. The preintervention test was given immediately before PPE training and competency, and posttest 3 was given immediately after the third activity (5 points, P = .0265) (Table 3). The group B pretest to posttest 1, there was significantly less anxiety posttraining (P = .0311) (Table 4). The self-efficacy pretest and posttest 3 scores for both groups were similar before the study (pretest) and at the end of the study (posttest 3). When comparing the aggregate self-efficacy from the pretest and posttest 1, there was an increased self-efficacy score by 5 points, and it was statistically significant (P < .0001) (Table 3). The preintervention test was given immediately before PPE training and competency, and the postintervention test 1 was given immediately
Table 2 Group A and group B comparison of mean and confidence intervals Group A n = 15
Group B n = 16
Variable
mean
95% CI
mean
95% CI
Anxiety pretest Anxiety posttest 1 Anxiety posttest 2 Anxiety posttest 3 Self-efficacy pretest Self-efficacy posttest 1 Self-efficacy posttest 2 Self-efficacy posttest 3
36.01 30.89 30.44 33.33 32.13 36.47 35.93 33.67
(30.13, 41.90) (25.12, 36.66) (25.92, 34.96) (28.50, 38.17) (29.60, 34.69) (34.30, 38.63) (33.95, 37.91) (31.50, 35.83)
36.88 27.71 31.04 30 32.81 37.88 32.19 33.69
(31.75, 42.01) (23.89, 31.53) (26.75, 35.34) (25.06, 34.93) (30.45, 35.17) (36.03, 39.72) (30.22, 34.15) (31.38, 36.00)
CI, confidence interval.
ARTICLE IN PRESS R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6 Table 3 Total sample P and T values, n = 31 Variable
P value
T value
Anxiety test pretest to posttest 1 * Anxiety test pretest to posttest 3* Self-efficacy pretest to posttest 1* Self-efficacy pretest to posttest 3 TeamSTEPPS before to after knowledge test *
<.0001 .0265 <.0001 .2437 <.0001
4.9110 2.331 −6.4726 −1.1892 −7.1136
*Denotes statistical significance (P value < .05).
after PPE training and competency. When comparing the pretest to posttest 3, there was an increase in score by 1 point and the increase was not statistically significant (P = .2437) (Table 3). The posttest 3 was given immediately after the third activity the subject participated in. TeamSTEPPS training knowledge transfer was assessed using a modified version of the Center for Health Science Interprofessional Education, Research and Practice Interprofessional team simulation training postassessment instrument. TeamSTEPPS knowledge was assessed after TeamSTEPPS training, and participants were asked to access their knowledge and thoughts on interprofessional teamwork both before and after training. When comparing the TeamSTEPPS before knowledge to after knowledge, the mean score was significantly increased (5 points, P < .0001; Table 3). Overall, about 15% of subjects were contaminated with glow powder after doffing PPE. Of the 31 subjects that attended annual PPE training, 15% were unable to successfully demonstrate competence (as measured by glow powder contamination) after 1 session of training. The most common areas of contamination included their hands, shoes, or pant legs. All subjects who failed the initial assessment were able to successfully prove competency after a second round of training. No subjects required more than 2 rounds of PPE training.
DISCUSSION During the 2014-2016 Ebola outbreak, inadequate training led to transmission of infection to 2 health care providers, which in turn increased anxiety for health care workers. The results of this study suggest that simulation-based exercises and TeamSTEPPS could directly address this deficiency and enhance existing high consequence infectious diseases training plans by increasing health care worker self-efficacy and decreasing anxiety. Currently, most training for high consequence infectious diseases is based on guidelines,28,29 but these do not include any recommendation for simulation or communication tools like TeamSTEPPS. The simulation-based exercises allowed the health care team to practice unexpected situations while caring for critically ill patients with a high consequence infectious disease. In the previously discussed study, Miles10 highlighted that when simulated-based
5
exercises were included in a training plan the learners had more engagement and helped facilitate the transfer of skills. In previous research by Allan et al,11 it was identified that after participating in simulation-based exercises the participants had a decrease in anxiety level. The state anxiety results from pretest to posttest 3 showed a significant decrease in state anxiety cumulatively and in group B subjects that completed TeamSTEPPS prior to participating in simulation-based exercises. Both groups had similar pretest anxiety scores, but group B had a statistically significant decrease in state anxiety scores for posttest 3, which was not seen with group A scores. This indicates the ideal order for training to decrease state anxiety of subjects may be to have them complete TeamSTEPPS prior to simulation-based exercises. As previously mentioned in the study by Watters et al,15 this study also had a correlation between competency and self-efficacy. Subjects immediately after completion of PPE competency (posttest 1) had a statistically significant increase in self-efficacy scores compared with their pretest score. The self-efficacy score of the subjects at the end of the study (posttest 3) was only about 1 point higher than before the training. Although the self-efficacy results from pretest to posttest 3 did not show a statistically significant increase in self-efficacy, the scores did move in the hypothesized direction with the subjects’ self-efficacy increasing over time. The pretest and all posttest 3 scores for both groups were similar for self-efficacy. Simulation-based exercises may be the added activity that is needed to help health care workers feel prepared and less anxious when caring for patients with a high consequence infectious disease. Limitations Limitations were identified while implementing this study. The sample size was small reflective of a pilot study. A preinterprofessional teamwork score was not collected on any of the subjects. Although the score is positive and subjects seem to value interprofessional teamwork, it is unknown if there is a difference pre- to posttraining. The TeamSTEPPS training sessions were led by 2 different facilitators. One facilitator was a master trainer with extensive experience in TeamSTEPPS, and the other facilitator is new to facilitating TeamSTEPPS training. The training was standardized but there may have been slight differences in the delivery of the training with the 2 facilitators. More study is needed to answer important questions about how to correctly scale this kind of simulation and communication training in a strained health care system.
Implications Simulation has been studied and there is evidence that it is an effective way to acquire health care knowledge and skills. Incorporating simulation-based exercises in training and preparation of health care workers responsible for caring for patients with potentially high
Table 4 Group A and group B P and T values
Variable
Group A n = 15 P value
Group A n = 15 T value
Group B n = 16 P value
Group B n = 16 T value
Anxiety pretest Anxiety posttest 1 Anxiety posttest 2 Anxiety posttest 3 Self-efficacy pretest Self-efficacy posttest 1 Self-efficacy posttest 2 Self-efficacy posttest 3
.0516 .8787 .2200 .3844 .0034* .6118 .0190* .3041
2.1276 0.1555 −1.2841 −3.5141 −1.0669 0.519 2.6503 −1.0669
.0001* .3354 .6786 .0311* .0000* .0008* .0100* .5533
5.5277 −0.9953 0.4226 2.3784 −6.0340 4.1937 2.9474 −0.6064
*Denotes statistical significance (P value < .05).
ARTICLE IN PRESS R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6
6
consequence infectious diseases is becoming a necessary component for education. A simulated environment used in this program allowed subjects to practice clinical skills while donned in first responder PPE without harming actual patients, team members, or oneself. The scenarios used in the simulation-based exercises included events that previously caused discomfort and anxiety in past real-life events when caring for patients with a potentially high consequence infectious disease. The increase in self-efficacy and decrease in state anxiety after participating in this training program helps address the concern of many health care workers in not feeling confident in caring for patients with high consequence infectious diseases. CONCLUSIONS The high consequence infectious disease training program that included simulation and TeamSTEPPS showed an increase in selfefficacy (situational confidence) and a decrease in state anxiety for health care workers. The group B subjects that had interprofessional teamwork training before participating in simulation-based exercises had a greater decrease in state anxiety. Adding interprofessional teamwork training and simulation-based exercise significantly decreased state anxiety overall, and the results suggest it may be ideal to participate in teamwork training before simulation-based exercises. Although the results of the study are positive, a larger sample size is needed to be able to fully assess if simulation-based exercises and TeamSTEPPS training should be added as standard training for future high consequence infectious disease training plans at other academic medical centers. References 1. Miller JL, Rambeck JH, Snyder A. Improving emergency preparedness system readiness through simulation and interprofessional education. Public Health Rep 2014;129:129-35. 2. Rebmann T. APIC state-of-the-art report: the role of the infection preventionist in emergency management. Am J Infect Control 2009;37:271-81. 3. Rebmann T. Infectious disease disasters: bioterrorism, emerging infections and pandemics. In: Boston K, editor. Association of Professionals in Infections and Epidemiology. Arlington (VA): APIC; 2014. p. 120-1-120-22. 4. World Health Organization. Health emergency and disaster risk management framework. 2019. Available from: https://www.who.int/hac/techguidance/preparedness/health-emergency-and-disaster-risk-management-framework-eng. pdf?ua=1 Accessed November 3, 2019. 5. Centers for Disease Control and Prevention. Emergency preparedness and response. 2018. Available from: https://www.emergency.cdc.gov/. Accessed November 3, 2019. 6. Assistant Secretary for Preparedness and Response. The Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE). 2019. Available from: https://asprtracie.hhs.gov/technical-resources. Accessed November 3, 2019. 7. American Nurses Credentialing Center. ANCC national healthcare disaster certification. 2018. Available from: https://www.nursingworld.org/our-certifications/ national-healthcare-disaster/. Accessed November 3, 2019. 8. Speroni KG, Siebert DJ, Mallinson RK. Nurses’ perception on Ebola care in the United States, part 2: a qualitative analysis. J Nurs Adm 2015;45:544-50.
9. Morrison JB, Deckers C. Common theories in healthcare simulation. editors. In: Palaganas J, Maxworthy JC, Epps C, Mancini ME, editors. Defining excellence in simulation programs. Philadelphia (PA): Wolters Kluwer; 2015. p. 496-508. 10. Miles DA. Simulation learning and transfer in undergraduate nursing education: a grounded theory. J Nurs Educ 2018;57:347-53. 11. Allan CK, Thiagarajan RR, Beke D, Imprescia A, Kappus LJ, Garden A, et al. Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams. J Thorac Cardiovasc Surg 2010;140:646-52. 12. Phrampus PE, O’Donnell JM, Farkas D, Abernathy D, Brownlee K, Dongilli T, et al. Rapid development and deployment of Ebola readiness training across an academic health system: the critical role of simulation education, consulting, and systems integration. Simul Healthc 2016;11:82-8. 13. McGaghie WC, Harris IB. Learning theory foundations of simulation-based mastery learning. Simul Healthc 2018;13:15-20. 14. Reed T, Pirotte M, McHugh M, Oh L, Lovett S, Hoyt A, et al. Simulation-based mastery learning improves medical student performance and retention of core clinical skills. Simul Healthc 2016;11:173-80. 15. Watters C, Reedy G, Ross A, Morgan NJ, Handslip R, Jaye P. Does interprofessional simulation increase self-efficacy: a comparative study. BMJ Open 2015;5:e005472. 16. O’Leary J, Nash R, Lewis P. Standard instruction versus simulation: educating nurses in the early recognition of patient deterioration in pediatric critical care. Nurse Educ Today 2016;36:287-92. 17. Miyasaka KW, Martin ND, Pascual JL, Buchhloz J, Aggarwal R. A simulation curriculum for management of trauma and surgical critical care patients. J Surg Educ 2015;72:803-10. 18. Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation exercises as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:426-32. 19. Piquette D, Tarshis J, Sinuff T, Fowler RA, Pinto R, LeBlanc V. Impact of acute stress on resident performance during simulated resuscitation episodes: a prospective randomized cross-over study. Teach Learn Med 2014;26:9-16. 20. Harvey A, Bandiera G, Nathens AB, LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. J Trauma Acute Care Surg 2012;72:497-503. 21. Agency for Healthcare Research and Quality. TeamSTEPPSÒ 2.0. 2018. Available from: http://www.ahrq.gov/teamstepps/instructor/index.html. Accessed November 3, 2019. 22. Jeffries PR. The NLN Jeffries Simulation Theory. National League of Nursing (NLN). New YorkNY: Wolters Kluwer; 2015. 23. INACSL Standards Committee. INACSL standards of best practice: simulationSM simulation-enhanced interprofessional education (sim-IPE). Clin Sim Nurs 2016;12:S34-8. 24. INACSL Standards Committee. INACSL standards of best practice: simulationSM simulation design. Clin Sim Nurs 2016;12:S5-S12. 25. Marteau TM, Bekker H. The development of a six-item short form of the state scale of Spielberger state-trait anxiety inventory (STAI). Br J Clin Psychol 1992;31:301-6. 26. National League of Nursing. National league of nursing descriptions of available instruments. 2016. Available from: http://www.nln.org/professional-development-programs/research/tools-and-instruments/descriptions-of-available-instruments. Accessed November 3, 2019. 27. Chui CJ, Brock D, Abu-Rish E, Vorcick L, Wilson S, Liner D, et al. Performance Assessment of Communication and Training (PACT) tool set. .Center for Health Sciences Interprofessional Education Research and Practice 2011, Available from: https://collaborate.uw.edu/ipe-teaching-resources/evaluation-tools/. Accessed November 3, 2019. 28. Centers for Disease Control and Prevention. Guidance for donning and doffing personal protective equipment (PPE) during management of patients with Ebola virus disease in US hospitals. 2016. Available from: http://www.cdc.gov/vhf/ebola/hcp/ ppe-training/index.html. Accessed November 3, 2019. 29. World Health Organization. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. World Health Organization Guidelines 2014:1-133.
Contents lists available at ScienceDirect
American Journal of Infection Control journal homepage: www.ajicjournal.org
Major Article
High consequence infectious diseases training using interprofessional simulation and TeamSTEPPS Rachel Marrs DNP, RN, CIC a,*, Trisha Leann Horsley PhD, RN, CHSE, CNE b,c, Diana Hackbarth PhD, RN, FAAN b, Emily Landon MD a a b c
University of Chicago Medicine, Chicago, IL Loyola University Chicago Marcella Niehoff School of Nursing, Maywood, IL South Dakota State University College of Nursing, Sioux Falls, SD
Key Words: High consequence infectious diseases Interprofessional education Interprofessional teamwork Self-efficacy State anxiety
Background: The comfort level of health care workers to respond to an infectious disease outbreak or epidemic is likely directly related to the amount of education, training, and experience they have in responding to these events. Methods: A quasi-experimental study evaluated health care workers’ state anxiety, self-efficacy, and interprofessional teamwork when working with patients simulated to have a potentially high consequence infectious disease. Results: Pretest-posttest 1 scores revealed a significant decrease in state anxiety (P < .0001) and an increase in self-efficacy (P < .0001). Overall state anxiety preintervention (pretest) to postintervention (posttest 3) significantly decreased (P = .0265). Overall TeamSTEPPS knowledge significantly increased (P < .0001) from baseline. Conclusions: Simulation exercises are an effective strategy to increase self-efficacy and decrease state anxiety for health care workers. Positive teamwork scores indicate that the subjects value interprofessional teamwork. © 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Awareness of the potential for outbreaks of high consequence infectious diseases, pandemics, and bioterrorism has increased over the past 15 years. All health care workers have the potential for interacting with patients during such an event. The comfort level to respond to a high consequence infectious disease or emergency management event is likely directly related to the amount of education, training, and experience health care workers have in responding to these events.1 An infectious disease outbreak of any kind can have a devastating effect on morbidity, mortality, and costs for all patients.2 Emergency preparedness requires an all-encompassing plan that is reassessed periodically to ensure the plan is congruent with current evidencebased policies and guidelines, in addition, the plan must be updated/ adopted for current conditions in the institution. The required elements of emergency management plans are clearly defined by the APIC, World Health Organization, Centers for Disease Control and *Address correspondence to Rachel Marrs, DNP, RN, CIC, University of Chicago Medicine, 5841 S. Maryland Ave, Chicago, IL 60637. E-mail address: [email protected] (R. Marrs). Conflicts of interest: None to report.
Prevention (CDC), and the Office of the Assistant Secretary for Preparedness and Response.3-6 The American Nurses Credentialing Center offers an interprofessional certification for disaster health care professionals that focuses on all phases of the disaster cycle: mitigation, preparedness, response, and recovery to help promote successful outcomes for health care professionals involved in a disaster.7 However, readiness levels vary greatly throughout the nation and world.8 For example in 2015, 3,106 nurses from the United States were asked in an online survey about their perceptions of caring for persons under investigation or with confirmed Ebola virus disease in the United States. The survey revealed 20.5% of nurses believed there was a lack of preparedness/readiness; 16.2% felt a need for training, education, and communication; and 15.4% had a fear of infection transmission.8 The study took place in an academic medical center, and prior to the study, high consequence infectious disease training was conducted, which included practice and competency with personal protective equipment (PPE), practice of standard operating procedures, and clinical skills simulation, yet the potential of a body fluid exposure or equipment failure caused fear and anxiety in staff. Offering simulation-based exercises allowed the opportunity for deliberate
https://doi.org/10.1016/j.ajic.2019.10.007 0196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
ARTICLE IN PRESS 2
R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6
practice and interprofessional teamwork training to improve communication and competency. Here we describe using simulationbased exercises and interprofessional training methods and their effect on subjects’ state anxiety, self-efficacy, and interprofessional teamwork when caring for a patient with a high consequence infectious disease. LITERATURE REVIEW Simulation-based health care education is being used increasingly among both medical and nursing schools, and in hospitals for training, assessment, and research. There are important features of simulation methodologies that allow it to be an effective way to acquire health care knowledge and skills. A simulated environment allows for deliberate practice of procedures without harming actual patients, team members, or oneself. The reflective practice of simulation allows educators to bring theory into life in a setting in which it is safe for students to learn from mistakes without causing patient harm.9 Additionally, simulated patient care environments and scenarios that closely replicate real-life settings help engage the learner and facilitate the transfer of skills from the laboratory to clinical practice.10 In high-risk settings, such as unfamiliar infectious disease events, deliberate practice with challenging situations can better prepare health care workers to face the stress and risk. For example, when simulation-based learning has been added to crisis management, research suggested that most subjects feel better prepared to participate and lead future resuscitation events, and has also improved clinical management and teamwork.11 At University of Pittsburgh Medical Center, while preparing for Ebola virus disease, practice of clinical protocols, procedural skills, as well as analysis of failure modes related to clinical protocols and system responses were identified as key benefits of simulation.12 Professional growth is an important component for all health care disciplines practice. Competency is a mastery of knowledge and skills. Although very broadly defined, a level of competence can be achieved with an opportunity to practice and ultimately master skills. A simulated environment provides an opportunity for achieving mastery of skills.13,14 Historically, simulation-based learning was primarily used to increase knowledge and improve competency, but it is also being used to assess self-efficacy of health care professionals. Self-efficacy is the extent of one’s belief in one’s ability to complete tasks or reach goals. Several studies have assessed competency and self-efficacy, and have found a positive correlation between the 2 elements.15 The literature also suggests that health care professionals that have a higher level of self-efficacy will not shy away from difficult situations such as a code situation or critically ill patient with an infectious disease.16 After a crisis management resource training project that included simulation, the confidence level increased and subjects felt better prepared to lead future resuscitation events.11 In a study evaluating surgery and trauma residents, after a 3-day course of highfidelity simulation for emergent patient care scenarios, the confidence level increased for all objectives.17 Assessing state anxiety levels of health care professionals during simulation-based learning and evaluating strategies to decrease anxiety during simulation is newer to the simulation field. Research has demonstrated that some anxiety may actually improve performance but once it rises above the optimal level, anxiety could contribute to medical errors and unsafe patient care.18 Several studies have assessed self-reported anxiety levels,11,19 whereas other studies assessed heart rate and cortisol levels of subjects.20 When multidisciplinary teams participated in high-fidelity training of critical patients, their anxiety level decreased and comfort level increased postintervention.11
TeamSTEPPS 2.0 (Agency for Healthcare Research and Quality, Rockville, MD) training is an evidence-based teamwork system designed for health care professionals.21 The curriculum is used to improve communication and teamwork skills, improve patient safety, and integrate teamwork principles in health care systems.21 The 4 pillars of TeamSTEPPS include communication, leadership, situation monitoring, and mutual support. High performing teams share mental models, have a shared vision, a strong sense of collective trust and confidence, and have strong team leadership.21 TeamSTEPPS training is designed to increase team awareness and help clarify team roles and responsibilities, which is essential for health care workers who have the responsibility for caring for critically ill patients with high consequence infectious diseases.
THEORETICAL FRAMEWORK The theoretical framework used to guide this study was the NLN/ Jeffries Simulation Theory.22 All components within the theory were addressed in the study. The simulation scenarios were designed after past events that have anecdotally caused fear and panic for health care workers, and the simulated environment allowed subjects to problem solve and practice skills in a safe environment. Debriefing immediately after the simulation was guided by the advocacy inquiry model to facilitate the subjects’ reflection. Most health care providers are problem-solvers and learn best when the subject is of immediate use, effective instruction involves the learner in solving real-life problems.
METHODS The setting for the study was a large academic medical center in the Midwest United States. All physicians, nurses, and infection control practitioners (ICPs) that were immediate responders in the adult emergency department were invited to participate during their annual training session. Annual training sessions are required and consist of computer-based training and training/competency with PPE. For participants who volunteered to participate in the study, they went on to complete simulation-based exercises, TeamSTEPPS training, and completion of pre/postsurveys on self-efficacy, state anxiety, and interprofessional teamwork. The study was submitted to the institutional review board, and they declared the study exempt. Before the training sessions began, the immediate responders participating in the required training were informed of the opportunity to participate in the research study. The training elements were required as part of preparedness for high consequence pathogens. The surveys on knowledge, skills, and attitudes were optional and part of the research study. They were assured that participation was voluntary, that they could decline participation at any time, and that whether or not they participate would not impact their employment. `The study used a quasi-experimental design to evaluate subjects’ knowledge, skills, and attitudes when working with patients with a high consequence infectious disease. The aim of the study was to determine the necessary elements including ideal order of interventions in a high consequence infectious disease training plan. Traditional education in past high consequence infectious disease events for immediate responders included hands-on training with PPE, competency assessment, and drills. This study offered traditional education with the addition of simulation-based exercises and TeamSTEPPS interprofessional education training. Training was offered in 2 different sequences to evaluate if there is a difference in subjects’ knowledge, skills, and attitudes depending on if they completed simulation-based exercises or TeamSTEPPS first in the training plan.
ARTICLE IN PRESS R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6
Training plan A computer-based training on the use of PPE was a prerequisite for participation in the training sessions. The computer-based training included the role of the trained observer who recorded observations on communication strategies, PPE donning and doffing exercises, and videos that pointed out common donning and doffing errors. Competency for donning and doffing PPE was evaluated by the trained observer who was the project facilitator using a PPE checklist created by the medical center in conjunction with CDC guidelines. A fluorescent glow powder that can be visualized with an ultraviolet flashlight was placed on subjects PPE to demonstrate contamination that can occur while caring for a patient. The design, implementation, and evaluation of the simulation experience met the International Nursing Association for Clinical Simulation and Learning Standards of Best Practice: Simulation.23,24 The scenarios validated by content and simulation experts included
events that previously caused discomfort and anxiety in past reallife events such as patients vomiting, bleeding, having diarrhea, or respirator battery dying when caring for patients with a potentially high consequence infectious disease. The simulation-based exercise sessions included 2 nurses, 1 physician, and 1 ICP per session. This matched the workflow for caring for a patient with a potentially high consequence infectious disease at the medical center. Each participant took part in 2 scenarios, prebriefing took place before each scenario, and debriefing took place after each scenario. Each training session was 2 hours in length. In both scenarios, the patient was suspected to have a high consequence pathogen and hemodynamically unstable while an acute stressor was added in each one. In the first scenario, the respirator battery died with one of the participants as the patient was decompensating. In the second scenario, the patient was vomiting and had diarrhea, which allowed the participants to practice containing body fluids while stabilizing the patient.
Complete pre-requisite (CBT) (30 mins)
1. 2. 3. 4.
All Participants (groups of 2-4) Training Session #1 Traditional Education Pre anxiety, satisfaction and self-efficacy PPE demonstration and practice. PPE Competency Post anxiety, satisfaction and self-efficacy (1 hour)
Divide participants in to Group A or Group B
Training Session #2 (Groups of 4) Simulation Exercises (2 hours)
Post anxiety, satisfaction, self- efficacy and teamwork
3
Training Session #2 (Groups of 8-16) Classroom/TeamSTEPPS® Education (1 hour)
Post anxiety, satisfaction, self- efficacy and teamwork
Training Session #3 (Groups of 8-16) Classroom/TeamSTEPPS® Education (1 hour)
Training Session #3 (Groups of 4) Simulation Exercises (2 hours)
Post anxiety, satisfaction, self- efficacy and teamwork
Post anxiety, satisfaction, self-efficacy and teamwork
Fig 1. Project design. CBT, computer-based training; PPE, personal protective equipment.
ARTICLE IN PRESS 4
R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6
TeamSTEPPS training sessions were designed to be interprofessional among nurses, physicians, and ICPs. Each training session was 1 hour in length. TeamSTEPPS training was included to increase team awareness and help clarify team roles and responsibilities, which is essential for health care workers who have the responsibility for caring for critically ill patients with high consequence infectious diseases. Figure 1 shows a clear description of the research design.
Instruments The Spielberger State-Trait Anxiety Inventory (STAI) 6-item short form was the tool used to collect the state anxiety score pre- and posttraining. The 6-item tool is designed to assess the presence or absence of anxiety. The reliability coefficient is a = 0.82.25 The correlation between the short form STAI and the standard STAI is r = 0.91.25 The STAI state anxiety 6-item short form score range is from 20-80. A normal score is noted to be between 34 and 36, a score higher suggests that some anxiety is present in the given moment or situation. The STAI tool has well established and documented reliability and validity.25 Self-efficacy (situational confidence) was assessed using the National League of Nursing satisfaction and self-confidence instrument, which was slightly modified so that it was relevant for health care workers and not students. The 13-item instrument is designed to measure student satisfaction (5 items) with the activity and selfconfidence in learning (8 items) using a 5-point scale. The score for self-efficacy ranged from 8-40. A higher score on the instrument suggests an increase in self-efficacy. The reliability of the instrument was tested using Cronbach’s alpha, satisfaction = 0.94 and selfconfidence = 0.87.26 TeamSTEPPS training knowledge transfer was assessed using a modified version of the Center for Health Science Interprofessional Education, Research and Practice Interprofessional team simulation training postassessment instrument.27 This instrument includes 24items on team function, leadership, situation monitoring, mutual support, and communication. The tool also includes 20-items to assess teamwork and knowledge transfer when used prior to and after TeamSTEPPS training. The score range for the questions regarding the 4 TeamSTEPPS pillars is 24-120. The before and after TeamSTEPPS knowledge questions each have a range of 10-50. A higher score on the TeamSTEPPS pillars question indicates a positive attitude or feelings about working to improve communication and interprofessional teamwork. A higher score on the before/after knowledge questions indicate increased knowledge after attending a TeamSTEPPS training session. Competency for donning and doffing PPE was evaluated by using a PPE checklist created by the medical center based on CDC PPE guidelines. As part of the competency assessment, the subjects had fluorescent glow powder placed on their PPE. They were examined with an ultraviolet light after doffing PPE to illuminate for any contamination. For the study, subjects were able to make multiple attempts but had to achieve a passing score in the PPE component to be deemed competent. A passing score meant that glow powder was absent after the participant doffed all PPE. Data were analyzed in STATA Release 13, 2015 (StataCorp, College Station, TX). The results from the state anxiety, self-efficacy, satisfaction, and interprofessional teamwork surveys were analyzed using independent and paired sample t tests. The mean score, confidence interval, P values, t values, and analysis of variance were calculated for each group of scores. The state anxiety and self-efficacy results were analyzed for all subjects pretest and posttest 1, posttest 2, and posttest 3. The mean score for each test was calculated for all subjects and within and between the 2 groups. The state anxiety and self-efficacy results were also analyzed comparing group A and group B.
Table 1 Total sample mean and confidence intervals, n = 31 Variable
Mean
95% CI
Anxiety pretest Anxiety posttest 1 Anxiety posttest 3 Self-efficacy pretest Self-efficacy posttest 1 Self-efficacy posttest 3 Cumulative before knowledge TeamSTEPPS score Cumulative after knowledge TeamSTEPPS score
36.46 29.24 31.61 32.48 37.19 33.68 39.94 45.68
(32.81, 40.12) (25.99, 32.51) (28.30, 34.92) (30.85, 34.12) (35.84, 38.55) (32.19, 35.17) (38.08, 41.79) (44.40, 46.95)
CI, confidence interval.
RESULTS Each participant took part in 1 computer training module and 3 in-person training sessions. A total of 31 subjects completed all 4 elements of the training plan and all surveys: 19 emergency room nurses (61.3%), 6 emergency medicine physicians (19.4%), and 6 ICPs (19.4%). This sample represented 21% of nurses and 23% of emergency medicine physicians within the emergency department, as well as 100% of ICPs employed within the hospital. Of the 31 subjects, 9 were men and 22 were women. The subjects were assigned to each group using convenience sampling. There was a similar distribution of nurses, physicians, and ICPs in each of the groups. Fifteen of the subjects were in group A and 16 were in group B. The mean scores for all subjects taking the STAI state anxiety 6item short form were in the normal range throughout the study (Table 1). Group B had overall higher pretest state anxiety scores than group A, and a lower posttest 3 state anxiety score than group A (Table 2). When comparing the state anxiety pretest and posttest 1 for all subjects combined, there was a statistically significant decrease in anxiety (P < .0001) after the training modules were completed. The preintervention test was given immediately before PPE training and competency, and the postintervention test 1 was given immediately after PPE training and competency (Fig 1). When comparing the pretest to posttest 3, there was significantly less anxiety after training. The preintervention test was given immediately before PPE training and competency, and posttest 3 was given immediately after the third activity (5 points, P = .0265) (Table 3). The group B pretest to posttest 1, there was significantly less anxiety posttraining (P = .0311) (Table 4). The self-efficacy pretest and posttest 3 scores for both groups were similar before the study (pretest) and at the end of the study (posttest 3). When comparing the aggregate self-efficacy from the pretest and posttest 1, there was an increased self-efficacy score by 5 points, and it was statistically significant (P < .0001) (Table 3). The preintervention test was given immediately before PPE training and competency, and the postintervention test 1 was given immediately
Table 2 Group A and group B comparison of mean and confidence intervals Group A n = 15
Group B n = 16
Variable
mean
95% CI
mean
95% CI
Anxiety pretest Anxiety posttest 1 Anxiety posttest 2 Anxiety posttest 3 Self-efficacy pretest Self-efficacy posttest 1 Self-efficacy posttest 2 Self-efficacy posttest 3
36.01 30.89 30.44 33.33 32.13 36.47 35.93 33.67
(30.13, 41.90) (25.12, 36.66) (25.92, 34.96) (28.50, 38.17) (29.60, 34.69) (34.30, 38.63) (33.95, 37.91) (31.50, 35.83)
36.88 27.71 31.04 30 32.81 37.88 32.19 33.69
(31.75, 42.01) (23.89, 31.53) (26.75, 35.34) (25.06, 34.93) (30.45, 35.17) (36.03, 39.72) (30.22, 34.15) (31.38, 36.00)
CI, confidence interval.
ARTICLE IN PRESS R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6 Table 3 Total sample P and T values, n = 31 Variable
P value
T value
Anxiety test pretest to posttest 1 * Anxiety test pretest to posttest 3* Self-efficacy pretest to posttest 1* Self-efficacy pretest to posttest 3 TeamSTEPPS before to after knowledge test *
<.0001 .0265 <.0001 .2437 <.0001
4.9110 2.331 −6.4726 −1.1892 −7.1136
*Denotes statistical significance (P value < .05).
after PPE training and competency. When comparing the pretest to posttest 3, there was an increase in score by 1 point and the increase was not statistically significant (P = .2437) (Table 3). The posttest 3 was given immediately after the third activity the subject participated in. TeamSTEPPS training knowledge transfer was assessed using a modified version of the Center for Health Science Interprofessional Education, Research and Practice Interprofessional team simulation training postassessment instrument. TeamSTEPPS knowledge was assessed after TeamSTEPPS training, and participants were asked to access their knowledge and thoughts on interprofessional teamwork both before and after training. When comparing the TeamSTEPPS before knowledge to after knowledge, the mean score was significantly increased (5 points, P < .0001; Table 3). Overall, about 15% of subjects were contaminated with glow powder after doffing PPE. Of the 31 subjects that attended annual PPE training, 15% were unable to successfully demonstrate competence (as measured by glow powder contamination) after 1 session of training. The most common areas of contamination included their hands, shoes, or pant legs. All subjects who failed the initial assessment were able to successfully prove competency after a second round of training. No subjects required more than 2 rounds of PPE training.
DISCUSSION During the 2014-2016 Ebola outbreak, inadequate training led to transmission of infection to 2 health care providers, which in turn increased anxiety for health care workers. The results of this study suggest that simulation-based exercises and TeamSTEPPS could directly address this deficiency and enhance existing high consequence infectious diseases training plans by increasing health care worker self-efficacy and decreasing anxiety. Currently, most training for high consequence infectious diseases is based on guidelines,28,29 but these do not include any recommendation for simulation or communication tools like TeamSTEPPS. The simulation-based exercises allowed the health care team to practice unexpected situations while caring for critically ill patients with a high consequence infectious disease. In the previously discussed study, Miles10 highlighted that when simulated-based
5
exercises were included in a training plan the learners had more engagement and helped facilitate the transfer of skills. In previous research by Allan et al,11 it was identified that after participating in simulation-based exercises the participants had a decrease in anxiety level. The state anxiety results from pretest to posttest 3 showed a significant decrease in state anxiety cumulatively and in group B subjects that completed TeamSTEPPS prior to participating in simulation-based exercises. Both groups had similar pretest anxiety scores, but group B had a statistically significant decrease in state anxiety scores for posttest 3, which was not seen with group A scores. This indicates the ideal order for training to decrease state anxiety of subjects may be to have them complete TeamSTEPPS prior to simulation-based exercises. As previously mentioned in the study by Watters et al,15 this study also had a correlation between competency and self-efficacy. Subjects immediately after completion of PPE competency (posttest 1) had a statistically significant increase in self-efficacy scores compared with their pretest score. The self-efficacy score of the subjects at the end of the study (posttest 3) was only about 1 point higher than before the training. Although the self-efficacy results from pretest to posttest 3 did not show a statistically significant increase in self-efficacy, the scores did move in the hypothesized direction with the subjects’ self-efficacy increasing over time. The pretest and all posttest 3 scores for both groups were similar for self-efficacy. Simulation-based exercises may be the added activity that is needed to help health care workers feel prepared and less anxious when caring for patients with a high consequence infectious disease. Limitations Limitations were identified while implementing this study. The sample size was small reflective of a pilot study. A preinterprofessional teamwork score was not collected on any of the subjects. Although the score is positive and subjects seem to value interprofessional teamwork, it is unknown if there is a difference pre- to posttraining. The TeamSTEPPS training sessions were led by 2 different facilitators. One facilitator was a master trainer with extensive experience in TeamSTEPPS, and the other facilitator is new to facilitating TeamSTEPPS training. The training was standardized but there may have been slight differences in the delivery of the training with the 2 facilitators. More study is needed to answer important questions about how to correctly scale this kind of simulation and communication training in a strained health care system.
Implications Simulation has been studied and there is evidence that it is an effective way to acquire health care knowledge and skills. Incorporating simulation-based exercises in training and preparation of health care workers responsible for caring for patients with potentially high
Table 4 Group A and group B P and T values
Variable
Group A n = 15 P value
Group A n = 15 T value
Group B n = 16 P value
Group B n = 16 T value
Anxiety pretest Anxiety posttest 1 Anxiety posttest 2 Anxiety posttest 3 Self-efficacy pretest Self-efficacy posttest 1 Self-efficacy posttest 2 Self-efficacy posttest 3
.0516 .8787 .2200 .3844 .0034* .6118 .0190* .3041
2.1276 0.1555 −1.2841 −3.5141 −1.0669 0.519 2.6503 −1.0669
.0001* .3354 .6786 .0311* .0000* .0008* .0100* .5533
5.5277 −0.9953 0.4226 2.3784 −6.0340 4.1937 2.9474 −0.6064
*Denotes statistical significance (P value < .05).
ARTICLE IN PRESS R. Marrs et al. / American Journal of Infection Control 00 (2019) 1−6
6
consequence infectious diseases is becoming a necessary component for education. A simulated environment used in this program allowed subjects to practice clinical skills while donned in first responder PPE without harming actual patients, team members, or oneself. The scenarios used in the simulation-based exercises included events that previously caused discomfort and anxiety in past real-life events when caring for patients with a potentially high consequence infectious disease. The increase in self-efficacy and decrease in state anxiety after participating in this training program helps address the concern of many health care workers in not feeling confident in caring for patients with high consequence infectious diseases. CONCLUSIONS The high consequence infectious disease training program that included simulation and TeamSTEPPS showed an increase in selfefficacy (situational confidence) and a decrease in state anxiety for health care workers. The group B subjects that had interprofessional teamwork training before participating in simulation-based exercises had a greater decrease in state anxiety. Adding interprofessional teamwork training and simulation-based exercise significantly decreased state anxiety overall, and the results suggest it may be ideal to participate in teamwork training before simulation-based exercises. Although the results of the study are positive, a larger sample size is needed to be able to fully assess if simulation-based exercises and TeamSTEPPS training should be added as standard training for future high consequence infectious disease training plans at other academic medical centers. References 1. Miller JL, Rambeck JH, Snyder A. Improving emergency preparedness system readiness through simulation and interprofessional education. Public Health Rep 2014;129:129-35. 2. Rebmann T. APIC state-of-the-art report: the role of the infection preventionist in emergency management. Am J Infect Control 2009;37:271-81. 3. Rebmann T. Infectious disease disasters: bioterrorism, emerging infections and pandemics. In: Boston K, editor. Association of Professionals in Infections and Epidemiology. Arlington (VA): APIC; 2014. p. 120-1-120-22. 4. World Health Organization. Health emergency and disaster risk management framework. 2019. Available from: https://www.who.int/hac/techguidance/preparedness/health-emergency-and-disaster-risk-management-framework-eng. pdf?ua=1 Accessed November 3, 2019. 5. Centers for Disease Control and Prevention. Emergency preparedness and response. 2018. Available from: https://www.emergency.cdc.gov/. Accessed November 3, 2019. 6. Assistant Secretary for Preparedness and Response. The Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE). 2019. Available from: https://asprtracie.hhs.gov/technical-resources. Accessed November 3, 2019. 7. American Nurses Credentialing Center. ANCC national healthcare disaster certification. 2018. Available from: https://www.nursingworld.org/our-certifications/ national-healthcare-disaster/. Accessed November 3, 2019. 8. Speroni KG, Siebert DJ, Mallinson RK. Nurses’ perception on Ebola care in the United States, part 2: a qualitative analysis. J Nurs Adm 2015;45:544-50.
9. Morrison JB, Deckers C. Common theories in healthcare simulation. editors. In: Palaganas J, Maxworthy JC, Epps C, Mancini ME, editors. Defining excellence in simulation programs. Philadelphia (PA): Wolters Kluwer; 2015. p. 496-508. 10. Miles DA. Simulation learning and transfer in undergraduate nursing education: a grounded theory. J Nurs Educ 2018;57:347-53. 11. Allan CK, Thiagarajan RR, Beke D, Imprescia A, Kappus LJ, Garden A, et al. Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams. J Thorac Cardiovasc Surg 2010;140:646-52. 12. Phrampus PE, O’Donnell JM, Farkas D, Abernathy D, Brownlee K, Dongilli T, et al. Rapid development and deployment of Ebola readiness training across an academic health system: the critical role of simulation education, consulting, and systems integration. Simul Healthc 2016;11:82-8. 13. McGaghie WC, Harris IB. Learning theory foundations of simulation-based mastery learning. Simul Healthc 2018;13:15-20. 14. Reed T, Pirotte M, McHugh M, Oh L, Lovett S, Hoyt A, et al. Simulation-based mastery learning improves medical student performance and retention of core clinical skills. Simul Healthc 2016;11:173-80. 15. Watters C, Reedy G, Ross A, Morgan NJ, Handslip R, Jaye P. Does interprofessional simulation increase self-efficacy: a comparative study. BMJ Open 2015;5:e005472. 16. O’Leary J, Nash R, Lewis P. Standard instruction versus simulation: educating nurses in the early recognition of patient deterioration in pediatric critical care. Nurse Educ Today 2016;36:287-92. 17. Miyasaka KW, Martin ND, Pascual JL, Buchhloz J, Aggarwal R. A simulation curriculum for management of trauma and surgical critical care patients. J Surg Educ 2015;72:803-10. 18. Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation exercises as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:426-32. 19. Piquette D, Tarshis J, Sinuff T, Fowler RA, Pinto R, LeBlanc V. Impact of acute stress on resident performance during simulated resuscitation episodes: a prospective randomized cross-over study. Teach Learn Med 2014;26:9-16. 20. Harvey A, Bandiera G, Nathens AB, LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. J Trauma Acute Care Surg 2012;72:497-503. 21. Agency for Healthcare Research and Quality. TeamSTEPPSÒ 2.0. 2018. Available from: http://www.ahrq.gov/teamstepps/instructor/index.html. Accessed November 3, 2019. 22. Jeffries PR. The NLN Jeffries Simulation Theory. National League of Nursing (NLN). New YorkNY: Wolters Kluwer; 2015. 23. INACSL Standards Committee. INACSL standards of best practice: simulationSM simulation-enhanced interprofessional education (sim-IPE). Clin Sim Nurs 2016;12:S34-8. 24. INACSL Standards Committee. INACSL standards of best practice: simulationSM simulation design. Clin Sim Nurs 2016;12:S5-S12. 25. Marteau TM, Bekker H. The development of a six-item short form of the state scale of Spielberger state-trait anxiety inventory (STAI). Br J Clin Psychol 1992;31:301-6. 26. National League of Nursing. National league of nursing descriptions of available instruments. 2016. Available from: http://www.nln.org/professional-development-programs/research/tools-and-instruments/descriptions-of-available-instruments. Accessed November 3, 2019. 27. Chui CJ, Brock D, Abu-Rish E, Vorcick L, Wilson S, Liner D, et al. Performance Assessment of Communication and Training (PACT) tool set. .Center for Health Sciences Interprofessional Education Research and Practice 2011, Available from: https://collaborate.uw.edu/ipe-teaching-resources/evaluation-tools/. Accessed November 3, 2019. 28. Centers for Disease Control and Prevention. Guidance for donning and doffing personal protective equipment (PPE) during management of patients with Ebola virus disease in US hospitals. 2016. Available from: http://www.cdc.gov/vhf/ebola/hcp/ ppe-training/index.html. Accessed November 3, 2019. 29. World Health Organization. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. World Health Organization Guidelines 2014:1-133.