Communication and Teamwork Focused Simulation-Based Education for Nursing Students

Simulation has become a common teaching method for healthcare providers, including nursing students. Until recently, the focus of simulation for nursing students has been on clinical skills. This study used a compilation survey to determine if knowledge and attitude scores improved in the bachelor degree nursing student after exposure to a simulation-based teamwork and communication training. Participants were 51 students from the senior leadership course of a bachelor’s degree in nursing program at a university in New Jersey. Control participants received normal clinical rotations with faculty led discussions, and intervention participants received a 4-hour simulation, focused on teamwork and communication. Intervention participants showed a significant difference in scores on one of five composite scores, demonstrating that simulation may be useful in improving knowledge of teamwork and communication related to teamwork and communication, but may not improve attitudes of nursing students related to teamwork and communication. COMMUNICATION SIMULATION IN NURSING EDUCATION 3 Statement of the Problem Poor teamwork and communication are barriers to successful nursing practice. The new nurse is particularly vulnerable to feeling increased amounts of stress, isolated, and dissatisfied with their job due to poor communication and teamwork both with other nurses and other healthcare professionals. Subsequently new nurses may leave their first job or the profession shortly after starting, adversely affecting the quality and safety of care and the financial stability of the hiring institution. Nursing schools have only recently started to implement human patient simulation training into their curriculum. Few, if any, nursing schools have implemented a simulationbased education program focusing on teamwork and communication. Nursing schools may be in a unique position to help prepare new nurses for successful transition to practice by teaching communication and teamwork concepts in a simulated environment. Evidence of the Problem A culture promoting teamwork is being produced in healthcare. Teamwork has been shown to improve the safety of healthcare, improve the environment that healthcare is provided in, improve the satisfaction of both patients and providers, and ultimately retain nurses (McConaughey, 2008; Sundar et al., 2007; IOM, 1999; Clark, 2009; Joint Commission, 2009). A culture of teamwork in healthcare is advocated for at all levels of healthcare, including government agencies (IOM, AHRQ), accrediting bodies (ACGME, AACN, Joint Commission), educational institutions, healthcare centers, and healthcare providers (ACGME, 2005; IOM, 1999; Joint Commission, 2009). A large component of this teamwork culture is the interpersonal communication and management of team members. As this culture of teamwork has gained momentum, grounded in the belief that teamwork leads to safer care, the innovation of high-fidelity simulation and crew resource management (CRM) also took hold in healthcare. Simulation is a technique that challenges novice and expert practitioners alike in a real world environment; while crew resource management training teaches teamwork concepts as well as situational awareness and interpersonal communication. The technological advances that have been adopted in other industries have made their way into healthcare and have slowly made their way into nursing education. However, the teamwork and COMMUNICATION SIMULATION IN NURSING EDUCATION 4 CRM concepts employed in the airline industry and in healthcare are yet to be fully integrated into nursing education. Literature Review The shortage of nurses is expected to reach 260,000 by 2025 (AACN, 2009). The nursing profession has long recognized the high attrition rate of nurses (Kramer, 1974) but is only beginning to address it. Orientation has been found to be the most stressful time in a nurses’ career (Delaney, 2003; Oermann & Moffitt-Wolff, 1997; Ackermann et al., 2007). Kovner et al. (2007) report that 41.5% of newly hired nurses would leave their current job if given the opportunity and 37% planned to leave their first job within 1 year. Other reports suggest that between 35% and 60% of new graduates change their place of employment during the first year (Williams, 1999) and 26.2% of nurses leave their first job within 2 years of starting (Kovner et al., 2007). Kovner et al. (2007) found that over 30% of nurses who left their current employment reported a stressful work environment as the reason for leaving. The workplace has been shown to have an effect on nurses’ morale, job satisfaction, commitment to the organization, and their intention to quit (Cangelosi, 1999; Revicki, 1989; Lim, 1998; Patrick, 2000; Rosenstein, 2002). Stressful work environments are caused by a myriad of factors, including poor communication and poor working relationships within the nursing profession and between nurses and other healthcare professionals (Nichols, 1981; McGrath, Reid, & Boore, 2003; Konstantinos, 2008). Recent attention of lateral, or horizontal, hostility has brought the issue of “unkind, discourteous, antagonistic interactions that occur between persons at the same organizational hierarchy level” to the forefront of the nursing profession (Alspach, 2007). Research (Rowell, 2008; Thomas, 2003; Ulrich et al., 2006; Simpson, 2008; Siu et al., 2008; Alspach, 2007) and a recent text, Ending Nurse to Nurse Hostility: Why Nurses Eat Their Young and Each Other (Bartholomew, 2006) demonstrate that horizontal hostility is a significant problem in the nursing profession. Stress is not only caused by difficult communication at the same organizational level, but by interactions between organizational levels. Studies (Cox, 1991; Anderson et al., 2009) demonstrate that disruptive behaviors, especially between nurses and physicians, inhibit teamwork and affect patient care in a number of ways. The disruptive behavior most frequently occurred after placing calls to physician, after questioning or clarifying orders, when physicians COMMUNICATION SIMULATION IN NURSING EDUCATION 5 thought their orders were not being carried out correctly or in a timely manner, after perceived delays in care, or after sudden changes in patient status (Rosenstein, 2002). the perceived disruptive behavior of select physicians led to confrontation and unease among those working with the physicians and caused frustration among staff members. The disruptive behavior most frequently occurred after placing calls to physicians, after questioning or clarifying orders, when physicians thought their orders were not being carried out correctly or in a timely manner, after perceived delays in care, or after sudden changes in patient status (Rosenstein, 2002). Recent studies find that physicians and nurses’ experience increased frustration with poor professional communication and that dysfunctional work environments are a significant contributor to stress and burnout (Anderson et al., 2008; Thomas, 2009). Research (Siu, 2008) related to Deutsch’s theory of constructive conflict management and magnet hospital designation suggests that professional practice environments (magnet designated facilities) create cooperative work contexts that influence the nurses’ ability to engage in effective conflict management strategies and their units ability to work effectively. Professional practice environments, have been shown to be affected by, as well as foster, effective teamwork by creating a shared community where perspectives are respected, support for collaboration is common, and communication and teamwork are used to achieve mutual goals (Siu, 2008). In addition, the magnet hospital attributes have been associated with increased job satisfaction (Aiken, 2000; Laschinger, 2001). The use of simulation to teach interdisciplinary groups about teamwork and communication is becoming common in healthcare. Both researchers and accrediting bodies suggest that medical education should include communication training for future healthcare providers (Glavin & Maran, 2003; Haller et al., 2008; Hunt, Shilkofski, Stavroudis, & Nelson, 2007; Jankouskas et al., 2007; Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009; McConaughey, 2008; Sundar et al., 2007, Boss, Hutton, Donohue, & Arnold, 2009; ACGME, 2005; AACN, 2009). The aviation industry has successfully used simulation for decades to teach the concepts of crew resource management to cockpit personnel, as was demonstrated by the actions of the crew of US Airways flight 1549. Crew resource management has been defined by Lauber, as “using all available sources – information, equipment, and people – to achieve safe and efficient flight operations.” (Pizzi, 2001). Initially, the airline industry used simulation to train pilots in procedures, to avoid catastrophic mishaps. However, accidents still occurred, and COMMUNICATION SIMULATION IN NURSING EDUCATION 6 the program was revised to look beyond individual pilot’s error to teamwork and communication, using principles of crew resource management (McConaughey, 2008). Gaba and others, developed the anesthesia crisis resource management program in the 1980’s based on the airline industries cockpit resource management programs. The anesthesia crisis resource management program was the first use of CRM in healthcare (McConaughey, 2008). The use of CRM programs has now expanded beyond the operating room and anesthesiology, to the emergency department, obstetrics units, and other healthcare providers (Pizzi, 2001). Boss et al. (2009) reports that neonatologists must learn the skills of communication as listed by the Accreditation Council for Graduate Medical Education (ACGME, 2005). The study found that during their fellowship year, only 25% of neonatologist fellows had a simulation experience that taught the concepts of communication. Even less, six percent had a clinical rotation focused on communication skills (Boss et al., 2009). However, the minimal number of neonatologists reportedly taught communication skills, still outnumber the number of nursing students reported to be taught similar concepts using simulation. Even though, the American Association of Colleges of Nursing lists interprofessional communication as a standard in the Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2009). Universities and schools of nursing have quickly adopted simulation as a tool to enhance student education (Schiavenato, 2009). However, there is a belief that the adoption of simulation has occurred in such a fast manner, that the utility of the technique is questioned and a theory or ideology supporting simulation use is missing in nursing education (Schiavenato, 2009). Simulation in nursing education has been used in many capacities, including teaching psychomotor (Hravnak, Beach, & Tuite, 2007) and critical thinking skills (Rhodes & Curran, 2005); evaluating nursing competencies (Ebbert & Connors, 2004); remediating clinical performance deficiencies (Haskvitz & Koop, 2004); developing clinical judgment (Lasater, 2007a, Lasater, 2007b); and practicing with infrequent, high-risk patient situations that cannot be scheduled in the clinical setting (Nehring, Lashley, & Ellis, 2002; Parr and Sweeney, 2006). However, skills that fall in the affective domain receive far less attention in the literature. Perhaps, highlighting a lack of material in this domain, or an increased emphasis on the cognitive and psychomotor skills, which have until recently, been perceived to be of greater importance in the education of future nurses. Rarely discussed, are programs to improve teamwork or COMMUNICATION SIMULATION IN NURSING EDUCATION 7 communication skills in the undergraduate nursing population. However, some hospitals have experimented with incorporating teamwork based simulations into their nursing orientations and nursing schools have started to incorporate TeamSTEPPS training into their curriculums (Anderson, 2009; Grbach, 2009). TeamSTEPPS is an evidence-based program based on CRM principles to improve teamwork, communication, and the safety and quality of healthcare. Research (Bradley & Postlethwaite, 2003; Gaba, 2004; Weller, 2004) has described the potential role of simulation in bridging the theory–practice gap that is seen in healthcare education. Simulation-based learning can be an experience that connects classroom-based and work-based learning. It can incorporate not only the acquisition of knowledge and skills, but also the cultural practices that are present in actual healthcare work environments (Bligh & Bleakley, 2006). Simulation might also be effective for professional identity construction and socialization of the participants (Bligh & Bleakley, 2006). Incorporating teamwork and communication training into the nursing student curriculum can help students adjust to the complex clinical world they will enter. It will enable them to speak with confidence, especially in challenging circumstances to their co-workers and superiors and build the feeling of teamwork that new nurses need to be successful and remain in their positions.