Simulated settings; powerful arenas for learning patient safety practices and facilitating transference to clinical practice. A mixed method study

Nurse Education in Practice 21 (2016) 75e82

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Nurse Education in Practice journal homepage: www.elsevier.com/nepr

Clinical education

Simulated settings; powerful arenas for learning patient safety practices and facilitating transference to clinical practice. A mixed method study Marit Hegg Reime a, *, Tone Johnsgaard a, Fred Ivan Kvam a, Morten Aarflot a, b, Marit Breivik a, Janecke Merethe Engeberg c, Guttorm Brattebø c a

Department of Nursing, Faculty of Health and Social Sciences, Bergen University College, Inndalsveien 28, 5063, Bergen, Norway Department of Community Medicine, Faculty of Health Science, University of Tromsø e The Arctic University of Norway, Hansine Hansens Veg 18, 9019, Tromsø, Norway c Department of Anaesthesia & Intensive Care, Haukeland University Hospital, N 5021, Bergen, Norway b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 25 November 2015 Received in revised form 13 June 2016 Accepted 12 October 2016

Poor teamwork is an important factor in the occurrence of critical incidents because of a lack of nontechnical skills. Team training can be a key to prevent these incidents. The purpose of this study was to explore the experience of nursing and medical students after a simulation-based interprofessional team training (SBITT) course and its impact on professional and patient safety practices, using a concurrent mixed-method design. The participants (n ¼ 262) were organized into 44 interprofessional teams. The results showed that two training sequences the same day improved overall team performance. Making mistakes during SBITT appeared to improve the quality of patient care once the students returned to clinical practice as it made the students more vigilant. Furthermore, the video-assisted oral debriefing provided an opportunity to strengthen interprofessional teamwork and share situational awareness. SBITT gave the students an opportunity to practice clinical reasoning skills and to share professional knowledge. The students conveyed the importance of learning to speak up to ensure safe patient practices. Simulated settings seem to be powerful arenas for learning patient safety practices and facilitating transference of this awareness to clinical practice. © 2016 Elsevier Ltd. All rights reserved.

Keywords: Mixed method Patient safety Simulation-based interprofessional team training Video-assisted oral debriefing

1. Introduction Healthcare providers tend to be trained as individuals yet function almost exclusively as teams, creating a gap between training and reality (Hunt et al., 2007). Uniprofessional training is limited when it comes to equipping graduates with the knowledge, skills, and attitudes needed for interprofessional collaboration, and for working effectively as part of a complex healthcare team. Interprofessional teams that collaborate effectively value the unique contributions made by each professional group to highquality patient care (Lapkin et al., 2013). Well-functioning teams clearly play a major role in improving safety in patient care (FirthCozens, 2001; Gjeraa et al., 2014; Manser, 2009), and the * Corresponding author. E-mail addresses: [email protected] (M.H. Reime), tone.johnsgaard@hib. no (T. Johnsgaard), fi[email protected] (F.I. Kvam), morten.aarfl[email protected] (M. Aarflot), marit. [email protected] (M. Breivik), [email protected] (J.M. Engeberg), [email protected] (G. Brattebø). http://dx.doi.org/10.1016/j.nepr.2016.10.003 1471-5953/© 2016 Elsevier Ltd. All rights reserved.

establishment of interdisciplinary team-training programs is recommended to build a safer health-care system (WHO, 2012). Poor teamwork seems to contribute to the occurrence of critical incidents, and this is attributable mainly to lack of non-technical skills (Hobgood et al., 2010). Team training can be a key factor in preventing these incidents (Motola et al., 2013), by fostering shared mental models (Westli et al., 2010). Non-technical skills include interpersonal skills such as communication, teamwork and leadership, and cognitive skills related to task management, situation awareness and decision-making (Reader et al., 2006, 2009). Simulation-based team training is one way of developing such skills and is an effective educational strategy used to address the growing ethical issues associated with educational training on human patients (Bremner et al., 2006; McGaghie et al., 2010). Scenario-based simulation training is an interactive teaching and learning method that aims to replace or reinforce the essential features of the real world, bridging the gap between theory and practice (Gaba, 2004; Joseph et al., 2012).

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Levett-Jones and colleagues found that the top three reasons for adverse patient outcomes were 1) failure to properly diagnose, 2) failure to institute appropriate treatment, and 3) inappropriate management of complications (Levett-Jones et al., 2010). According to the authors, each of these is related to poor clinical reasoning skills that can be broken down into the following steps: look, collect, process, decide, plan, act, evaluate, and reflect (Levett-Jones et al., 2010). Healthcare professionals with poor clinical reasoning skills often fail to detect impending patient deterioration, resulting in a failure to rescue the patient (Aiken et al., 2003). Nurses and doctors are partners in the healthcare system, and professions that work together should also meet to learn and train together during their education (WHO, 2012). A systematic review undertaken to investigate the effectiveness of university-based interprofessional education revealed that healthcare students’ attitudes towards interprofessional collaboration and clinical decision-making may improve through their education, but further studies are needed to explore the transferability of interprofessional education to clinical practice (Lapkin et al., 2013). Specifically, mixed-method studies are needed to provide greater clarity regarding the effects of this educational approach to professional practice and patient care (Ødegård and Bjørkly, 2012). The aim of the current study is to investigate the experiences of nursing and medical students who participated in a simulation-based interprofessional team-training (SBITT) course, and the impact of SBITT on professional and patient safety practices. 2. Methods 2.1. Study design A concurrent mixed-method design was chosen in which team performance was observed and scored on an observation form (Table 1), and focus group interviews were used to explore the participants’ overall experience. This methodology was chosen in order to illuminate the various facets of the research questions (Creswell, 2009; Tashakkori and Teddlie, 2010). 2.2. Participants Three categories of participants were included; bachelor and postgraduate nursing students and medical students. Postgraduate students studying anaesthesia, operating-room and critical-care nursing (n ¼ 61), and second-year bachelor nursing students (n ¼ 123) participated in the course on a compulsory basis. A bachelor's degree in nursing is a three-year program in Norway. The postgraduate program is 18 months, and the admission requirement is a minimum of 2 years of clinical experience in nursing. Fifth-year medical students were recruited to the course on a voluntary basis; only half of the invited students participated (n ¼ 78) due to clinical placements in other regions. Medical students study for six years followed by 18 months of clinical internship in hospitals (one year) and primary health services (6 months). Participant roles (hands on) and peer observer roles were allocated using simple randomisation (drawn from a hat by the researcher) within each profession group. The students worked in mixed-profession teams. One student from each profession acted as a participant and one as a peer observer in each team. One nursing student had the patient role (non-speaking), and a trained facilitator responded as the patient to standardize the scenarios. Prior to the simulation, the students from the different professions had not met. They had all completed their training in basic life support and were familiar with the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach to emergency situations.

2.3. The interprofessional team-training course The course was arranged in a skills’ laboratory in a university hospital. The simulation room imitated a hospital patient room. A total of 44 teams (5e7 students each) were trained over a period of 7 weeks. Each student participated in two out of four emergency scenarios, either scenarios 1 (hypovolemic shock) and 2 (anaphylactic reaction), or scenarios 3 (child with fever seizure and hypoglycaemia) and 4 (trauma patient losing consciousness due to increasing intracranial pressure). The scenarios were piloted for face validity on six of the 44 participating teams who considered them realistic and well-suited to meet the learning outcomes defined for the course (Table 1). The scenarios integrated skills in patient observation, clinical reasoning, problem solving, leadership, teamwork, communication, prioritizing, and delegation and medication practices. In order to investigate whether team performance continued to improve, students who trained the first time on scenarios 1 and 2 were invited to train on scenarios 3 and 4 after three months. Eight teams (5e6 students each) participated in the second training session (Fig. 1). Each scenario ran for approximately 15 min and was videorecorded. To prevent “information leakage” about the scenarios between the groups, the students verbally consented to confidentiality. The interdisciplinary facilitator group consisted of six trained facilitators. Two facilitators (MB, JME) each facilitated half of the teams using the same simulation protocol, and the others were responsible for the video recordings. The facilitators briefed the participants prior to the simulation, and this included a patient handover report. During the simulation, the facilitator provided the vital parameters on request from the participants, and also gave critical cues to the team. Students acted in their professional roles, and no instructions were given as to who should take charge or perform specific tasks. Following each scenario, both participants and observers gathered for 30 min of video-assisted oral debriefing. They reflected on their performance, identifying both successes and opportunities for improvement. The debriefing incorporated process and outcome-based feedback from the participants, observers and facilitators, in order to obtain the most valid picture of performance (Weaver et al., 2010). This SBITT format has been widely used in Norway (Kyrkjebø et al., 2006; Wisborg et al., 2008). 2.4. Data collection 2.4.1. The observation form A six-item observation form was developed to assess the learning outcomes of the course, scored on a five-point Likert scale. The observing peers rated the teams’ performance on each scenario, using this form (Table 1). The Delphi method was employed to achieve consensus in the development of the form (Powell, 2003), with 100% agreement required for items to be included, thereby confirming construct validity. The assessment panel consisted of the six facilitators participating in the course (two MDs and four RNs), all experienced in interprofessional team training Table 1 Observation form. The team is able to:  Communicate clearly with other team members and demonstrate use of closed-loop communication  Collaborate with other team members and use each team member's expertise  Identify acute physiological derangements in the patient and formulate a symptom diagnosis  Prioritize treatment based on the assessment of ABCDE  Decide on and implement treatment agreed on by the team  Perform safe medication practices in emergency situations Scoring: 1 ¼ strongly disagree, 3 ¼ neither disagree nor agree, 5 ¼ strongly agree.

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Fig. 1. The simulation and evaluation design.

and part of the study team. The form was piloted on six teams and after minor adjustments considered suitable for the study. Focus groups were chosen as a suitable method in order to obtain data on how the participants experienced the SBITT. Kitzinger (1995) states that focus groups are well suited for identifying attitudes and experiences within a given context. Three interprofessional teams (n ¼ 15) were interviewed 3 months after their first simulation training. An open interview guide helped the moderator to structure the discussion, introducing topics such as “experiences regarding SBITT”, “non-technical skills”, “different roles”, “transferability to clinical studies”, and “suggestions for course improvement ”. The moderator introduced the topics, encouraged discussion, summarized the discussion after every question, and asked for participant validation (Kvale and Brinkmann, 2009). An assistant moderator took notes, capturing impressions that evolved during the discussions. All interviews were tape-recorded and transcribed verbatim. Each session lasted approximately 60 min. 2.5. Data analysis 2.5.1. Statistical analysis The quantitative data was analysed using the Statistical Package for the Social Science (SPSS) version 20. Demographic characteristics are reported as counts, proportions, means, and standard deviations. Chi-square tests were used to compare demographic variables (Table 2). The observation scale was tested for normality using the ShapiroeWilk test. The Wilcoxon signed-rank test for related samples was used to test for differences in team performance between the scenarios (Table 3). In addition, the ManneWhitney U test was employed to evaluate differences between training two times and training four times (described only in text). A significance level of p  0.05 was chosen. 2.5.2. Qualitative analysis The method employed in the analysis of the focus group data was qualitative content analysis as described by Graneheim and Lundman (2004), involving a process of meaning-unit identification, condensation and abstraction. The transcribed interviews were read independently several times by three researchers

(MHR, TJ, MB) to obtain a sense of the whole. The natural meaning units of the text were identified by each researcher, and then condensed into a description that was close to the text, the manifest content. The three researchers then gathered to discuss how the manifest content should be interpreted, the latent content. Based on reflections and discussions amongst the researchers, abstractions of the latent content revealed several subthemes and finally one main theme. The process of analysis as presented in Table 4 was not a linear process, but involved movement back and forth between the whole and the parts of the text. 2.6. Ethical considerations The students had the option to participate only in the interprofessional simulation-training course, without participating in the study. Students were informed that study participation was voluntary one month prior to the course and again on the course day. All of the students gave their written consent to participate in the study. They were guaranteed confidentiality; the data would be anonymized, and the videotapes would be deleted at the end of the study. The Norwegian Social Science Data Services approved the study (No. 23713), as did the academic institutions. 3. Results 3.1. Quantitative results We obtained 260 (99%) questionnaires from the 262 participating students. Demographic details are shown in Table 2. There were more females than males in all groups: 87% in the nursing groups, and 60% among the medical students. This is in accordance with national figures (Hofstad, 2012; Høie, 2006). Most medical and nursing students were in the 20e29-year age category; the ages of the postgraduate students varied more due to the professional experience admission requirement. A larger proportion of the nursing students had the observer role because they also had the non-speaking patient role and thereby took the observer's perspective.

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Table 2 Characteristics of participants according to profession (N ¼ 262). Demographic information

Gender Age (y)

Professional experience

Role

Male Female 20e29 30e39 40 <1 y 1e6 y 7 y Participant Observer

Total

Nursing students

Postgraduate nursing students

Medical students

All

n

%

n

%

n

%

N

%

15 108** 101 14 8 23 90 10 50 71* 123

12.2 87.8 82.1 11.4 6.5 18.7 73.2 8.2 41.3 58.7 46.9

8* 53 29** 20 12 2 27** 32** 40 21 61

13.1 86.9 47.5 32.8 19.7 3.3 44.3 52.5 65.6 34.4 23.3

31 47 74 4** 0 16 53 9 44 34 78

39.7 60.3 94.9 5.1

54 208 204 38 20 41 170 51 134 126 262

20.6 79.4 77.8 14.6 7.6 15.6 64.9 19.5 51.1 48.1 100.0

Note. Chi-squared test used to compare each variable between the professions; *p  0.05;

3.1.1. Team performance scores relative to the number of simulation exposures The observing peers rated the team performance of those teams that first trained on scenarios 1 and 2 significantly higher on four learning outcomes. Those teams that trained first on scenarios 3 and 4 were rated significantly higher on three learning outcomes (Table 3). A comparison of the teams that trained on scenarios 3 and 4 in the first session and those that trained on these scenarios three months later in the second session, the ability to diagnose patient (p ¼ 0.029) was higher in the second session, on scenario 4.

20.5 68.0 11.5 56.4 43.6 29.8

**

p < 0.001.

I noticed that I was caught up in thinking professionally all the time and making a diagnosis and starting the right treatment, without thinking about the way I was behaving and the way I was conveying my message, and how I used the resources around me (postgraduate student). Video-assisted debriefing was also an important tool to make the team aware of how each team member's competence was used: I saw that I only discussed (things) with the postgraduate student, and we were reluctant to include the nursing

Table 3 Peer observer ratings on changes in team performance between first and second scenario training. Learning outcomes

p*

n ¼ 62 Scenario 1

Closed-loop communication Team cooperation Diagnose patient Prioritize treatment (ABCDE) Decide on and implement treatment Safe medication practice Note.

*

Scenario 2

p*

n ¼ 28 Scenario 3

Mean

SD

Mean

SD

3.61 4.06 3.89 3.62 4.28 3.82

1.08 0.83 0.83 0.91 0.66 1.19

4.10 4.32 4.45 3.90 4.44 3.64

0.84 0.67 0.88 0.88 0.72 1.25

<0.01 0.04 <0.01 0.03 ns ns

Scenario 4

Mean

SD

Mean

SD

3.18 3.75 3.65 2.92 4.18 3.42

1.06 0.89 0.98 1.06 0.77 1.02

3.75 4.25 4.27 4.00 4.39 3.89

1.15 0.70 0.87 0.75 0.69 0.88

0.02 0.03 ns 0.01 ns ns

Wilcoxon signed-rank test, ns ¼ non-significant; SD ¼ standard deviation.

3.1.2. Comparing total mean scores for the different scenarios To investigate whether the different scenarios affected team performance, we compared total mean scores for the different scenarios. Scenario 2 had significantly higher mean scores than both scenarios 1 and 3, while scenario 4 had significantly higher mean scores than scenario 3 (Fig. 2).

student. The postgraduate student had a lot of knowledge and experience; I noticed that quickly, so I completely forgot about the nursing student who placed herself on the sideline. There were many tasks that could have been delegated to her, which would have made the work much easier for all of us. It's something one observes in retrospect (medical student).

3.2. Qualitative findings The analysis of the focus group data revealed one main theme: SBITT seems to be a powerful method for raising awareness about patient safety practices that includes three sub-themes (Table 4). These are elaborated below. 3.2.1. Sub-theme 1: learning interprofessional teamwork from video-assisted oral debriefing Although several of the students felt a bit uneasy about being videotaped the first time, they gave positive feedback during the debriefing process when they watched themselves and the interaction within the team. The video debriefing allowed the students to watch the scenario and how the team worked together from a different perspective:

Video-assisted debriefing also made it possible to see and reflect on both verbal and non-verbal communication and body language: I learned a lot about how you communicate with patients and colleagues by just seeing myself. I was not completely happy with it. I also saw that I stood with my back to you, so I excluded you quite effectively (medical student). In addition, the students discussed the importance of learning good interprofessional team communication. Video-assisted oral debriefing made them more aware of how to cooperate effectively in teams by sharing professional knowledge to achieve a common understanding of the patient's situation. Medical simulation as an educational tool also gave the students the opportunity to practise

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Table 4 Overview of meaning units, condensed meaning units, sub-themes and theme from the content analysis of the focus group interviews. Meaning units

Condensed meaning unit Description close to the text

Condensed meaning unit Interpretation of the underlying meaning

Sub-theme

Theme

It was very helpful to watch the video, because then you can see the scenario from a different perspective, and how you work together. You may be more aware then. I learned a lot about how you communicate with patients and colleagues just by seeing myself. I was not completely happy with it. I also saw that I stood with my back to you, so I excluded you quite effectively. What is inside my head is not inside the other persons head, so you have to communicate. No one can read your thoughts. I even had to stop a doctor when he ordered an adult dose of digitoxin for a child. The patient's safety is the most important, and if you don't dare to speak up then …. The doctor had ordered 25 mg verapamil iv. I told the doctor “I think you need to put a comma here”. This could have been fatal. I really got hit, I had even checked the name, I thought, but had not done it well enough. This experience was a real wake-up call e it is so easy to make mistakes. I have become more aware overall since, and have been more thorough when checking IDs

Video allows learning about how to work together and communicate with patients and colleagues by watching oneself. I was not happy with how I stood with my back to you.

Video makes one more aware of the body language and how one interacts and communicates

Learning interprofessional teamwork from video-assisted oral debriefing

SBITT seems to be a powerful method for raising awareness about patient safety practices

No one can read your thoughts, so you have to communicate.

To think aloud is essential for developing clinical reasoning skills

I had to stop the doctor from prescribing a wrong dose of medication. The patient's safety is the most important, so one has to speak up.

To go beyond the hierarchy is essential to ensure patient safety practices

Learning to speak up to ensure safe patient practices

I really got hit, because I had not checked the patient's ID well enough. This experience made me more aware and thorough when checking IDs.

Making mistakes leaves one with strong emotions which make one more alert

Making mistakes promotes transference of patient safety practices

voicing their thoughts, or “thinking loud”, to increase their clinical reasoning skills: One often assumes that everyone is thinking and understanding things the same way; however, what is inside my head is not inside the other person's head, so you have to communicate. No one can read your thoughts (medical student).

Another student had a similar example: The doctor had ordered 25 mg verapamil iv, and I had to say “I think you need to put a comma here”. This mistake could have been fatal (postgraduate student).

3.2.2. Sub-theme 2: learning to speak up to ensure safe patient practices The students stressed the importance of speaking up to ensure safe patient practices. They pointed out that healthcare providers are legally required to intervene when patients are at risk of adverse events and stressed the need to develop the habit of speaking up during training. The students’ reflections regarding patient safety practices brought up former experiences and the postgraduate students shared several examples from their own clinical experience: If a physician starts giving the wrong drug dose, it is important that someone on the team alerts them of the error and that they in turn take this into account and do not get angry or upset. I even had to stop a doctor when he prescribed an adult dose of digitoxin for a child (postgraduate student).

Fig. 2. Total mean scores for the different scenarios, based on results using the ManneWhitney U test.

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3.2.3. Sub-theme 3: making mistakes promotes transference of patient safety practices Regarding patient safety matters, the participants in the second sequence recalled in detail their experiences of making mistakes during the medical simulations three months earlier. Several of the teams gave an incorrect blood transfusion to the patient in scenario 1, due to not having checked the patient ID correctly, and the strong emotions associated with this experience promoted awareness of this issue. Participants stated that they had learned how important it is to be fully attentive to patient situations and have transferred this experience to clinical settings: I really got hit, I had even checked the name, I thought, but had not done it well enough. This experience was a real wake-up call that it is so easy to make mistakes. I have become more aware overall since then and have been more thorough in checking IDs and ensuring that double-control procedures for drug doses are followed (nursing student). There were also discussions about patient safety with regard to dosage of medication: We learn a lot about pharmacology and how drugs work, but dosage, what is too little and what is too much, we don't learn. So I had to ask the postgraduate student how much morphine I should order for the patient (medical student). One postgraduate student had been more aware of dosage of medication when returning to work: I had a patient last weekend who had received epinephrine 1 mg, and not 5 mg like the medical student in our team was going to give the last time we trained on the anaphylaxis scenario.

4. Discussion One of the challenges of simulation training has been the lack of evidence of patient benefits and improved quality of care (Gosai et al., 2015). The focus group interviews reveal that the strong emotions that arise in simulation training have a lasting effect, showing the impact making mistakes had on participants; they remembered their experience in detail several months after the episodes. Similarly, Fischer et al. (2006) found that trainees believe they learn more from their own errors and those that cause harm to patients, and attributed this to the increased emotional impact of such events. This can be related to the concept of embodiment, which Draper (2014) defines as the experience of living in and through our bodies. According to Merleau-Ponty (2012:244), the body is the general instrument of our understanding. Another study by Reilly and Spratt (2007) found that the students, after returning to clinical settings, recalled experiences from simulation scenarios, which lead them to take action to support the patient. Examining this issue from another perspective, Gardner et al. (2015) compared an error-focused training program with a traditional training methodology, and found that the incorporation of error-based activities and discussions in training programs can be beneficial for both skill retention and transfer. This illustrates the important role simulation-based learning may play in transferring knowledge and skills to practice. Our study supports the view that making mistakes can be beneficial because it made the students more aware and alert when they returned to clinical settings.

According to Kirkpatrick and Kirkpatrick (2007) evaluation model, which is widely used to classify outcomes of training programs, transfer of learning to the workplace is the next highest level, and can, in turn, lead to benefits for patients at the highest level in the model. Dewey (1938) claims that experiential learning involves the personal experience of the situation, including thoughts, actions and feelings. Our study showed that simulated settings appear to be powerful arenas for learning patient safety issues and that the resultant awareness seems to transfer to clinical practice. This finding is in accordance with the results of Lewis et al. (2012), who suggested that simulation-based education appears to prevent students from making mistakes by providing a set of clinical circumstances that allows them to make mistakes and learn from them. Reports suggest that about 70% of errors leading to patient injury are related to inadequate communication (Kohn et al., 2000). The students in this study recognized that thinking aloud and communicating with each other are vital for ensuring patient safety. Banning (2008) also stresses that the think-aloud approach is a useful educational tool to develop and assess the clinical reasoning skills that are vital in detecting impending patient deterioration. In addition, professional practice requires not only psychomotor and affective skills, but also complex thinking processes (Levett-Jones et al., 2010). SBITT can meet all of these requirements if the scenarios are developed to stimulate these skills, as was the case with our scenarios. The fact that scenario 3 had a lower total mean scores than the other scenarios may indicate that the participants’ lacked experience in handling sick children, and that there is a need to practice more often using scenarios involving this patient group. Another aspect of patient safety practices related to team training emphasizes that each team member is equally important, addressing the potential problems associated with hierarchies that prevent team members from speaking up about issues that may harm patients (Calhoun et al., 2014). ‘Hierarchy’ is defined as the presence of a significant gradient in authority between practitioners within a healthcare team, and a strong hierarchy has been identified as a threat to patient safety (Cosby and Croskerry, 2004). Examples from the focus group interviews revealed errors regarding the drug doses prescribed and highlighted the importance of speaking up when patient safety is at risk. Our study showed that reflection on patient safety practices brought up former experiences of the postgraduate nursing students. Sharing experiences of dealing with these situations has the potential to develop the professional practice role of students with less experience. In this way, mixing student groups with different levels of clinical experience can support experiential learning. Furthermore, it can contribute to developing both professional and patient safety practices. There are many different views on learning. In a traditional behavioural perspective, learning occurs when a person does something observable that she or he could not do before learning, indicating a change in behaviour. The observers’ ratings of team performance are based on such a perspective, where significant improvements were found on four of the learning outcomes relating to scenarios 1 and 2 and on three of the learning outcomes relating to scenarios 3 and 4. This result is in contrast to findings from Endacott et al. (2015), where team behaviour did not improve as the team progressed through three scenarios. Their findings were explained on the grounds that team communication is difficult to change because it takes time and repeated sessions to develop. In our study, we also wanted to investigate whether team performance further improved after three months; there was an improvement in only one of six learning outcomes. A limitation with our study is the rather low number of teams that participated

M.H. Reime et al. / Nurse Education in Practice 21 (2016) 75e82

in the second session, making it more difficult to detect significant improvements. Although actions are observable, drivers such as thoughts, beliefs, assumptions and knowledge base are often invisible to the facilitator without skilful questioning (Cheng et al., 2012). Furthermore, Merleau-Ponty (1996) states that inner processes, such as quiet reflection, are decisive in the acquisition of knowledge, and that awareness is an important key to change. The participants exemplified this when they described how they had become more aware of their own team behaviour and their contribution to the team during the debriefing, and in this way experienced the importance of non-technical skills in patient safety practices. With regard to the effectiveness of simulation debriefing, a systematic review found that video-assisted debriefing offers no statistically significant educational advantages over oral debriefing (Levett-Jones and Lapkin, 2014). However, in our study videoassisted debriefing was an important tool for strengthening team behaviour, since watching the video enhanced the participants' awareness of body language and of what it conveys. It also made the team members aware of the importance of using each team member's competence more effectively. Furthermore, it gave participants the opportunity to reflect on communication and mistakes related to safe medication practices. Perhaps this learning effect may also be related to the debriefing time allowed, since there was sufficient time for oral debriefing as well. Emphasis on developing safety-conscious practitioners is increasing, yet opportunities to acquire clinical competencies are limited by growing student numbers and increasing restrictions on practising on patients. In actual healthcare settings, learning is in a sense a by-product of care. The patients' need for healthcare must always take priority over the educational needs of students. The simulated environment provides opportunities for reflection on care-related episodes that contribute to acquiring clinical judgement skills (Berragan, 2014); simulation can offer the opportunity € n, 1995). to support “reflective transfer” to clinical settings (Scho Clinical judgement may be summarized as the thinking-in-action skills of three steps; noticing, interpreting, and responding, followed by a fourth step, the thinking-on-action skill of reflection €n, 1987). Peer assessment after responding to the situation (Scho can uncover areas for improvement that would remain undiscovered by self-assessment alone (Maas et al., 2014; Sargeant et al., 2011). In addition, peer assessment contributes to the development of a variety of skills, such as self-directed learning, critical reasoning, reflection, negotiation, professional judgement, teamwork and self-awareness (Casey et al., 2011; Kritikos et al., 2011; Krogh et al., 2014; Weidner and Popp, 2007). This may help students to learn clinical skills as well as interpersonal skills (Rush et al., 2012), and benefits teaching staff by reducing their workload (Falchikov, 2003). In addition, peer assessment encourages staff members to open for greater transparency regarding assessment objectives and grading criteria (Papinczak et al., 2007). Peer assessment may also prepare students to audit their colleagues’ performance after graduation, advocating a wider use of peer assessment in simulation training. Indeed, a Cochrane review has concluded that providing feedback can lead to improvements in healthcare professional practices (Ivers et al., 2012).

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students allows the researcher to ask questions which might not otherwise have been posed. Another methodological issue relates to possible sample bias. Participation in the course was not mandatory for all students, and those who volunteer may have had a more positive attitude towards the teaching program, giving rise to a risk of selection bias. In addition, few teams trained in a second session, and a higher number would have strengthened the study. Another issue relates to the scoring of team performance by peers. To comprehensively evaluate team performance, designers of simulation programs must employ multiple measurements that capture the behavioural, cognitive and attitudinal components of performance at the team level (Rosen et al., 2010). In our study, the peers mainly captured the behavioural level of team performance. The fact that the students acted in their own professional roles, reduced the risk of biasing the behaviour as scripted roles might have done, thereby increasing the ecological validity of the intervention (Boet et al., 2013). Regarding the simulation sessions, two of the facilitators were each responsible for half of the teams, and used the same simulation protocol during briefing, simulation and debriefing. This served to standardize the different phases of the simulation and decrease the confounding effect of multiple facilitators. With regard to the focus groups, the moderator's role was to ensure that all members had the opportunity to express their views. As researchers, we are aware that the presence of dominant members in a focus group may cause conformity or polarization within the group (Kitzinger, 1995; Morrison and Peoples, 1999). The students in these focus groups did not know each other before the course, but they seemed to be honest and open in their reflections. The assistant moderator noted this positive atmosphere. The qualitative analysis process illustrates how meaning units, condensation and abstractions were established. In addition, quotations serve to illustrate our findings, giving the reader the opportunity to consider alternative interpretations. In sum, this makes it easier to judge the credibility of the findings (Graneheim and Lundman, 2004). 5. Conclusion Our study shows that simulated settings seem to be powerful arenas for learning patient safety practices and for facilitating the transfer of this awareness to clinical practice. Video-assisted oral debriefings provided an opportunity to strengthen good team performance and made the participants more aware of how they interact and behave in teams. It also provided an opportunity to reflect on mistakes. Making mistakes during SBITT appeared to improve the quality of patient care by making the students more aware when they returned to clinical practice. SBITT gave the students the opportunity to practice thinking aloud, promoting clinical reasoning skills and sharing professional knowledge to achieve a common understanding of the patient's situation. The students stressed the importance of learning to speak up in order to ensure patient safety. Research documenting the use of simulation to strengthen patient safety in clinical practice in interprofessional education is still scarce, and quality observational studies would contribute to strengthening knowledge on this topic.

4.1. Methodological considerations Conflict of interest The data collection methods employed in this study combined observation and focus groups, and the researchers were actively involved both as facilitators in the simulations and as moderators in the focus groups. This involvement may give rise to bias, such as “eager to please”. On the other hand, this feature may also have strengthened the study, since involvement in the same arena as the

The authors declare that there is no conflict of interest. Acknowledgements The authors thank the informants who participated in the study,

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