Interprofessional simulation education to enhance teamwork and communication skills among medical and nursing undergraduates using the TeamSTEPPS® framework

Abstract

Background

Learning in silos during the undergraduate years results in ineffective collaborative practice leading to adverse events. Simulation training using the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)® framework has been shown to be effective in enhancing teamwork skills among healthcare professionals. This study aims to evaluate an interprofessional simulation education (IPSE) module for undergraduate medical and nursing students on teamwork and communication skills using the TeamSTEPPS® framework.

Methods

An IPSE module was developed by an interprofessional team of faculty. A convenient sample of medical and nursing undergraduate interns participated in trauma simulation scenarios before and after a didactic session on interprofessional education (IPE) and TeamSTEPPS® 2.0. The pre-post performance was assessed by faculty and pre-post self-assessment of the IPSE training and interprofessional education collaborative (IPEC) competencies by the participants. Quantitative data were analysed using a paired t-test of the mean scores and analysis of variance. The themes that emerged from audio recordings of the debriefing, and written reflections of the participants, yielded data for qualitative thematic analysis.

Results

The scores of team performance, self-assessment of IPSE training, and IPEC competencies revealed statistically significant values. Themes that emerged included the need for IPSE in the curriculum, impact of structured tools for communication on patient safety, and awareness of the roles and responsibilities in interprofessional teamwork. A survey conducted two weeks after completion of the module showed positive feelings among participants about interprofessional collaboration.

Conclusion

The study specifically assessed the effectiveness of an IPSE module based on TeamSTEPPS® guidelines in improving communication and teamwork skills among medical and nursing undergraduates.

Introduction

Healthcare professionals practice in a complex environment requiring knowledge of the roles and responsibilities of other professionals and skills of teamwork and communication. Improved patient safety and quality of care depends on interprofessional collaborative practice among all health and social-care providers especially doctors and nurses. A review of the literature shows that a major share of adverse events in healthcare arise because of communication failures among healthcare team members. Simulation enhanced interprofessional training using the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)® framework is an effective way to enhance teamwork and communication skills.^1,2 The present medical and nursing curriculum in India does not include interprofessional team training. The medical and nursing fraternity undergoes their training in silos but on graduation work together as part of the healthcare team. Interprofessional simulation education can provide an ideal environment for teaching skills that health profession students need to enable them, on graduation, to function as practice ready team members.³ It is proposed that this will lead to a culture of a shared mental model of the plan of care for the patient, which will have a positive impact on patient safety and the quality of care.

This study aims to evaluate an interprofessional simulation education (IPSE) module for undergraduate medical and nursing students on teamwork and communication skills.

Material and methods

Context

The present medical and nursing curricula do not include interprofessional team training or training to develop effective skills for communication in practice.

Intervention

Develop and implement an IPSE module to enhance teamwork and communication skills among medical and nursing undergraduates.

Study design and sample

A mixed-methods, interventional study design was used. The sample included medical and nursing interns; the faculty were teachers engaged in the intern years. As a part of the needs assessment, an initial survey was undertaken to explore the perceptions and attitudes of these students and faculty toward Interprofessional Education (IPE), simulation, and teamwork concepts. Because study participants were volunteered from both medical and nursing interns after evaluating the survey results, convenience sampling was used, with twenty students over two sessions. The ratio of nursing interns to medical interns was 3:2.

Study setting and ethical considerations

The study was conducted at a simulation and skill centre in India. The participants included undergraduate interns and faculty of the medical and nursing college of the institute. The invitation to participate included information and consent details clearly stating that participation was voluntary and confidential. The study protocol received approval by the institution ethics and research committee.

Development and implementation of the IPSE module

Healthcare professionals must work as a collaborative team, competent to communicate effectively to ensure patient safety and high-quality healthcare. IPE with a simulation-based experiential learning approach allows for the development and mastery of these competencies, promoting collaborative teamwork. With no formal module present in the existing curricula, the IPSE module was conceptualised and developed by an interprofessional faculty team of twelve members from various specialities of medicine and nursing. The module was intended to improve interprofessional teamwork and communication skills among the participating team members and was based on the TeamSTEPPS® curriculum.⁴ The framework for the 4-h IPSE module is depicted in Fig. 1.

Fig. 1.

The phase-wise implementation framework of the IPSE module. IPSE, interprofessional simulation education.

All participants were initially oriented to the five phases of the module. The participants were grouped into four interprofessional teams. Each team participated in trauma simulation scenarios. The team members initially completed a pre-training IPSE assessment checklist⁵ after which they entered Phase 1 in which they were immersed in simulated trauma scenarios wherein their teamwork and communication skills were assessed by faculty members using a performance checklist (TeamSTEPPS® 2.0 Performance Observation Tool).⁶ In Phase 2, participants engaged in team-building exercises and a didactic session to the IPE and TeamSTEPPS® 2.0 framework.⁶ Participants then completed the interprofessional education collaborative (IPEC) competency self-assessment tool⁷ and TeamSTEPPS® 2.0 learning benchmark⁶ to ensure adequate knowledge of the framework. In Phase 3, students were again immersed in simulated trauma scenarios and assessed for performance using the TeamSTEPPS® 2.0 Performance Observation Tool as used in Phase 1. After debriefing, students completed the post-training IPSE assessment checklist⁵ and the IPEC competency self-assessment tool. After the session, students completed an evaluation form.⁵ Phase 4 of the programme involved collation of the qualitative data, which included retrieving audio recordings of the debriefing sessions in which open-ended questions were posed, and reviewing written reflections of the students with regard to the entire training experience. The themes that emerged formed the data for qualitative thematic analysis. In Phase 5, conducted two weeks later, students were asked to complete a self-assessment behavioural checklist based on the Interprofessional Socialisation and Valuing Scale (ISVS).⁸

Data collection

The tools used for data collection were adapted from the literature with permission and are referenced in the following points.

• 1.UW Health Sciences Performance Assessment Communication and Teamwork Tools Set⁵ (used in Phase 1 and 3): The pre- and post-training assessment tools were used from this tool; both are similar in structure and content. The self-report tools (i.e. pre- and post-simulation training) included rating in 15 areas: familiarity working and training with teams, interprofessional training satisfaction, benefits of training, learning and performance, learning environments, skills, team structure, leadership, situation monitoring, mutual support, communication, interprofessional training experience, essential practice characteristics, understanding before and after training, and expectations. Most items have a five-point Likert-type scales ranging from very unfamiliar to very familiar or strongly disagree to strongly agree or never to frequently.
• 2.TeamSTEPPS® 2.0 framework tool kit⁶ (used in Phase 1 and 3): TeamSTEPPS™ curriculum was developed by the Department of Defense and the Agency for Health Research and Quality to train healthcare professionals. It has several assessment tools relevant for quality improvement. The Team Performance Observation Tool (TPOT) is an on-site observational tool which was used in this study to assess the performance during immersive simulation. The TPOT measures five domains: team structure, leadership, situational monitoring, mutual support, and communication. The overall average of items formed a score for the team.
• 3.IPEC competency assessment tool⁷ (used in Phase 2 and 3): The original tool measured four domains (to reflect the interprofessional education collaborative core competency domains), with each domain containing 8–11 specific competencies: values and ethics, roles and responsibilities, interprofessional communication, teams and teamwork. The revised tool was used in this study which measures two domains, with eight items each: interprofessional interactions and interprofessional values. Each item uses a five-point agreement scale ranging from strongly disagree (1) to strongly agree (5); mean and median scores were calculated for each domain.
• 4.ISVS tool⁸ (used in Phase 5): ISVS-21 is a self-report instrument designed to measure interprofessional socialisation among students and health practitioners and their readiness to function in interprofessional teams. The tool has positively worded statements regarding the extent to which a respondent holds certain beliefs, attitudes, or feels able to demonstrate certain behaviours. About half the items are worded in the past tense to reflect change after an educational intervention. All items are scored via a seven-point Likert-type scale: 7 = “to a very great extent,” 1 = “not at all”, or NA. These scores (0–7) were added together and divided by 21 to obtain an overall total score.
• 5.Qualitative data (used in Phase 4): The audio recordings were transcribed manually by an independent observer. These transcriptions and the written reflections were then coded and sorted, and themes were identified manually by two independent faculty members from medical and nursing within two rounds. The major themes were grouped into cognitive, affective, and social domains.

Data analysis

Statistical Package for the Social Sciences Version 22.0 was used to analyse the data. The data were analysed using the paired t-test to compare mean scores and one-way analysis of variance test values. Significant differences between the groups were analysed using the Tukey's post-hoc test. The results were statistically significant (p < 0.05). Qualitative data were transcribed, coded, and analysed using a thematic analysis.

Results

Demographic data

A total of 40 students and eight faculties participated in the module in two sessions of 20 students and four facultieseach. The nurse to doctor student ratio was 3:2 in both sessions, and 75% were female students. All students completed the module.

Performance outcomes

Quantitative analysis of the pre- and post-mean scores of team performance during simulation assessed by the TPOT tool was highly significant (p < 0.001) which is interpreted as being strongly suggestive of improvement in teamwork and communication skills (Table 1). Pre- and post-session self-assessment scores of the training were highly significant (p < 0.001), which is interpreted as beingly strongly suggestive of an improved awareness and attitude towards the interprofessional simulation session (Fig. 2).

Table 1.

Team performance mean scores during simulation (Phase 1and 3 using Tool 2).

Team performance	Pre-test	Post-test	p-value
Team structure	3.5	4.25	<0.001
Communication	2.75	4.25	<0.001
Leadership	2.5	3.75	<0.001
Situation monitoring	2.5	4.5	<0.001
Mutual support	2	4.5	<0.001

Fig. 2.

Self-assessment of IPSE training scores (Phase 1 and 3 using Tool 1).

Attitudinal and behavioural outcomes

The IPEC competency scores after orientation to a didactic session on IPE and a post-immersive interprofessional simulation session revealed statistically significant values for the domains of interprofessional interactions and interprofessional values (Table 2). A session evaluation revealed that 86% of participants strongly agreed that the simulation scenario helped them learn interprofessional team communication skills. A survey two weeks after completion of the module revealed that, to a great extent, participants held positive feelings toward interprofessional teamwork (Fig. 3).

Table 2.

Self-assessment of IPEC competency scores (Phase 2 and 3 using Tool 3).

IPEC competency self-assessment tool	Pre-test	Post-test	p-value
I am able to choose communication tools and techniques that facilitate effective team interactions	3.761905	4.52381	<0.001
I am able to place the interests of patients at the centre of interprofessional healthcare delivery	3.904762	4.333333	0.008
I am able to engage other health professionals in shared problem -solving appropriate to the specific care situation	3.857143	4.47619	<0.001
I am able to respect the privacy of patients while maintaining confidentiality in the delivery of team- based care	4.333333	4.47619	<0.001
I am able to inform care decisions by integrating the knowledge and experience of other professions appropriate to the clinical situation	3.952381	4.333333	0.0182
I am able to embrace the diversity that characterizes the health care team	3.857143	4.095238	0.127
I am able to apply leadership practices that support effective collaborative practice	4	4.333333	0.038
I am able to respect the cultures and values of other health professions	4.428571	4.47619	0.747
I am able to engage other health professionals to constructively manage disagreements about patient care	3.333333	4.571429	<0.001
I am able to develop a trusting relationship with other team members	4.285714	4.380952	0.521
I am able to use strategies that improve the effectiveness of interprofessional teamwork and team-based care	3.714286	4.47619	<0.001
I am able to demonstrate high standards of ethical conduct in my contributions to team-based care.	3.666667	4.238095	<0.001
I am able to use available evidence to inform effective teamwork and team-based practices	3.857143	4.285714	0.008
I am able to act with honesty and integrity in relationships with other team members	4.285714	4.428571	0.369
I am able to understand the responsibilities and expertise of other health professions	4.238095	4.571429	0.038
I am able to maintain competence in my own profession appropriate to my level of training	4.190476	4.619048	0.008

Fig. 3.

Self-assessment scores of ISVS scale (Phase 5 using Tool 4).

Thematic analysis

Major themes that emerged from the qualitative analysis were the need for interprofessional simulation training in the curriculum, impact of structured tools for communication Identify Situation Background Assessment Recommendation (ISBAR) on patient safety, and awareness of the significance of the roles and responsibilities in interprofessional teamwork (Table 3).

Table 3.

Major themes that emerged (Phase 4 using Tool 5).

Major themes	Domains
The need for interprofessional simulation training in curriculum	Affective
Impact of structured tools for communication (ISBAR) on patient safety	Cognitive
Awareness of the significance of the roles and responsibilities in interprofessional teamwork	Social

ISBAR, identify situation background assessment recommendation.

Discussion

Background

The IPSE module conceptualisation and development process were aligned to the recommendations of World Health Organization (WHO) for the creation of multiprofessional patient safety education.⁹

“Interprofessional education occasions when members or students of two or more professions learn with, from and about each other to improve collaboration and the quality of care and services”. (Centre for the Advancement for Interprofessional Education (CAIPE), 2016) Retrieved fromhttps://www.caipe.org/about-us.¹⁰,¹¹

The present Indian health profession undergraduate curriculum does not include IPE as a requirement, and this study was initiated as an attempt to introduce IPE into the medical and nursing curricula. Healthcare simulation provides a safe and protected learning environment in an artificially created setting that mimics the real-time clinical environment.¹² It involves a wide range of learning modalities and covers teaching in the cognitive (knowledge), psychomotor (procedural), and affective (attitudinal) domains. The undergraduates of the study centre were familiar with simulation sessions and regularly participate in silos as part of their speciality postings. This module was based on an established teamwork and communication curriculum, TeamSTEPPS® 2.0 framework⁷ in teaching interprofessional collaborative skills using high-fidelity simulators. Simulation-enhanced interprofessional team training using the TeamSTEPPS® framework has been widely documented with favourable outcomes in patient safety.¹³ A recent literature review advocates, and integrates, simulation-enhanced TeamSTEPPS® training into IPE.¹⁴ A lack of documented outcomes using this approach within the Indian context gave rise to this study. The IP team sought to develop trauma case scenarios during the first two sessions of this module because they are interesting, relevant, realistic, and readily applicable to practice by both professions.

Strengths

The initial challenge for executing this module was overcoming the major challenge faced that was scheduling the sessions amidst the already-packed academic activities of both professions. Improvement in the team performance scores after participating in the interprofessional team training shows the effectiveness of incorporating the simulation-enhanced TeamSTEPPS® framework into the module. The initial ice-breaker activities during the IPE didactic sessions and the trauma case scenarios were successful in engaging the participants, who had not previously attended any interprofessional sessions. The students and facilitators enthusiasm to participate in this innovative voluntary module and the advocacy of IPSE was one of the study's strengths. The acceptance of, and advocacy for, learning about teamwork and communication with other professions was reflected in the improved attitude scores after the session, as represented in the following observations:

“… …. I never realized how a simple workshop like this could make such a huge impact on my attitude towards patient safety. These type of team trainings should be given to all doctors and nurses and we should make it part of our curriculum …. ” (Medical Student during debriefing)

“… …. As a nursing student, I was hesitant to speak up and involve myself in the first scenario, but after the TeamSTEPPS and IPE orientation, I was more comfortable in performing my role for the second scenario. I hope to apply SBAR tool in my clinical work from now. We should have more such workshops with doctors to make us more confident.” (Nursing student written reflection)

Limitations

The sample size was small and represented only two professions. The study design was a single group pre- and post-assessment method, without a control group. Outcomes related to behavioural change after training were documented from self-assessment tools, rather than by direct observation within a clinical setting. Although significant positive performance outcomes were achieved, as observed during immersive simulation, there were unmeasured confounding factors such as effects due to voluntary enrolment for this module and effects of students and facilitators within each team on the overall learning experience.

Future directions

To longitudinally integrate this module into the curriculum, there is a need to recruit more faculties and to conduct train-the-trainer sessions with regards to IPE, simulation education and TeamSTEPPS® curriculum, and to develop and validate specific assessment tools within the context of each session.

Conclusion

This research was not designed to provide unequivocal evidence for the effectiveness of the module. The aim of the research was to provide educational researchers with a model to develop and create best-practice simulation using enhanced interprofessional education modules. This study specifically assessed the effectiveness of a pioneering interprofessional simulation module based on the TeamSTEPPS® framework in improving communication and teamwork skills among medical and nursing undergraduates within an Indian context. The lessons learnt from this study have the potential to facilitate implementation of this module in undergraduate curricula to promote a culture of patient safety and high-quality healthcare.

Disclosure of competing interest

The authors have none to declare.