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Featured Article

Interprofessional Simulation: An EffectiveTraining Experience for Health Care ProfessionalsWorking in Community Hospitals

Dawn Prentice, RN, PhDa, Karyn Taplay, MSN, RNCa,Elizabeth Horsley, RN, BScN, BAa, Sue Payeur-Grenier, RNb, Dan Belford, RRTb

aBrock University, St. Catharines, Ontario L2S 3A1, CanadabNiagara Health System, St. Catharines, Ontario L2R 5K3, Canada

KEYWORDSinterdisciplinarytraining;simulation;teaching methods;hospital;collaboration;interprofessionalcommunication

author: dprentice@broc

e front matter � 2010 Int

ns.2010.03.001

Background: This descriptive study measured the effectiveness of and participants’ satisfaction withan interprofessional simulation education workshop as a teaching strategy for health care professionals.

Abstract

Method: Health care professionals completed a 1-day clinical simulation workshop on interprofessionalcollaboration, after which they had the opportunity to fill out 4 evaluative instruments.Results: One hundred sixty-three participants completed the questionnaires. The majority were regis-tered nurses (73.6%). Subscale scores were calculated for 3 of the instruments, with the mean rangingfrom 3.99 to 4.61 out of a possible maximum rating of 5. Content analyses of the participants’ commentsresulted in 6 themes: (a) simulation as a learning experience, (b) the learning environment, (c) inter-professional collaboration learning continuum, (d) cohesiveness, (e) adapting to change, and (f) im-proved patient outcomes.Conclusions: Simulation was highly rated as an effective teaching strategy for interprofessionalcollaboration. Staff expressed satisfaction with simulation as a teaching strategy.

Cite this article:Prentice, D., Taplay, K., Horsley, E., Payeur-Grenier, S., & Belford, D. (2010, Month). Interprofessionalsimulation: An effective training experience for health care professionals working in communityhospitals.

� 2010 International Nursing Association for Clinical Simulation and Learning. Published by ElsevierInc. All rights reserved.

Introduction

Simulation is a teaching strategy that is gaining popularity innursing and in other allied health professions. Simulationtechnology provides the opportunity to develop realistic sce-narios for many different levels of learners, from undergrad-uate to postgraduate, in a safe environment (Morgan &

ku.ca (D. Prentice).

ernational Nursing Association for Clinica

Cleave-Hogg, 2002). Simulation activities can facilitate cog-nitive skills, critical thinking, and clinical reasoning and en-

hance psychomotor performance (Grady et al., 2008).

Following a simulation experience, learners are often given

the opportunity to debrief. Throughout the debriefing pro-

cess, learners reflect on the experience and receive feedback.In addition to practical applications, simulation experi-

ences provide learners with an opportunity to integrateknowledge, apply it, and examine the results of their

l Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Interprofessional Simulation: An Effective Training Experience e2

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actions (Baker et al., 2008). Learning can occur during thesimulation or the debriefing or when knowledge is trans-ferred from the simulation to the clinical setting (Bradley& Postlethwaite, 2003). The concept of simulation for pro-moting interprofessional practice was born of the need tosupport staffing changes and facilitate the adoption of an in-

Key Points� Clinical simulation is

an effective teachingstrategy used in inter-professional studenteducation.� Practicing health care

professionals expressedsatisfaction with simu-lation as a teachingstrategy for interprofes-sional collaboration.� Further research is

needed to determinewhether clinical simula-tion is an ongoing effec-tive teaching strategy toteach interprofessionalcollaboration to practic-ing health careprofessionals.

terprofessional collaborativemodel of care. This modelof care was implemented ina local health care systemconsisting of seven commu-nity hospitals. The healthcare system introduced fourregistered respiratory thera-pists, working to full scope,into the registered nurses’rotation to support the inter-professional collaborativecare model. In tandem withthese changes, the healthcare system participated inthe Health and Human Re-sources Demonstration SiteProject funded by the On-tario Ministry of Healthand Long-Term Care Nurs-ing Secretariat. This initia-tive focused on thedevelopment of best prac-tice staffing approaches andinterprofessional collabora-

tion (IPC) education initiatives to build capacity for sus-tainable human resources planning. Three keyinterprofessional care core competencies were developedas part of this initiative: (a) interpersonal and communica-tion skills, (b) client- and family-centered care, and (c) col-laborative practice.

Interprofessional workshops were implemented to pro-vide health care professionals with the knowledge andskills to learn about working collaboratively on interpro-fessional teams. The interprofessional project team fromthe local health care system partnered, with the nursingfaculty from the local university, to develop, implement,and evaluate the workshops. Simulation was chosen asa teaching strategy for three reasons: (a) it provides a safeenvironment in which learners can make decisions andevaluate outcomes without risk to patients (Bradley & Post-lethwaite, 2003), (b) it had previously been used for con-tinuing education with this population and was perceivedas a positive learning experience, and (c) the project teamwanted the staff members to experience learning in an ac-ademic environment outside their typical work setting.

The effectiveness of using high-fidelity simulation forinterprofessional student education has been previouslyreported (Baker et al., 2008; Fernandez, Parker, Kalus, Miller,& Compton, 2007; Mikkelsen Kyrkjebø, Brattebø, & Smith-

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Strøm, 2006). However, there is a paucity of research aboutthe use of clinical simulation for educating health care profes-sionals. Thus, the purpose of this descriptive study was tomeasure the effectiveness and satisfaction of simulation asa teaching strategy for health care professionals.

Development and Implementation of the Simula-tion Scenarios

The interprofessional practice leader from the health caresystem and the university nursing lab coordinator de-veloped the scenarios for use with a high-fidelity humanpatient simulator. The interprofessional practice leader isa registered respiratory therapist and experienced advancecardiac life support instructor who brought clinical exper-tise to the simulation design. The lab coordinator wasresponsible for programming the scenarios and setting upthe simulations to create a realistic environment. Theopening sequence for each scenario was preprogrammed;however, patient parameters were adjusted throughout thescenarios in response to participants’ actions.

Three scenarios were developed, two adult and one infant.Although the focus was IPC, scenarios that dealt with criticalor traumatic situations were chosen as the background to al-low staff to apply concepts of IPC to situations that mirrorwhat they encounter in their practice. Prior to the start ofthe simulations, participants were informed that this wasa learning session. They were assured that it was not a testand that they would not be graded on their clinical skills. Fa-cilitated debriefing sessions were conducted after each sce-nario by the interprofessional practice leader, the projectmanager, and three clinical educators, all of whom had expe-rience in debriefing techniques. The debriefing questionswere developed by the facilitators on the basis of the corecompetencies of interprofessional care and included guided,open-ended, and reflective questions. The purpose of the de-briefing was to promote the exchange of ideas and foster anopen and supportive learning environment.

Ethics Clearance

Ethics clearance was obtained from both the university ethicsreview board and the ethics review board for the health caresystem. Prior to commencement of the workshops, staffmembers from the clinical areas involved were given a letterof information about the study and an invitation to participate.As participation was voluntary, implied consent was obtainedif the participants chose to complete the surveys.

Method

This descriptive study incorporated four quantitative ques-tionnaires and qualitative content analysis of the partici-pants’ comments on the workshop evaluation. The fourquestionnaires included (a) the 20-item Simulation Design

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Scale, (b) the 16-item Educational Practices in SimulationScale, (c) the 13-item Student Satisfaction and Self-Confidence in Learning, and (d) the 9-item Interprofes-sional Education and Clinical Simulation Workshop Eval-uation. The questionnaires were administered to theparticipants at the end of the workshop, after all debriefingsessions were completed. Demographic information (age,gender, professional designation, years of experience, andhighest level of education completed) was also obtained.The first three instruments were developed and tested forthe National League for Nursing (NLN; Jeffries & Rizzolo,2006), and permission was obtained to use them for thisstudy. Each instrument uses a 5-point Likert-type scale,with responses ranging from strongly agree to strongly dis-agree. Jeffries and Rizzolo (2006) reported good reliabilityfor the first three scales, with Cronbach’s alpha subscalesbetween .86 and .96. In original tests of the Simulation De-sign Scale, Cronbach’s alpha was .92 for presence of fea-tures and .96 for importance of features. Cronbach’salpha for the Educational Practices in Simulation Scalewas .86 for presence of specific practices and .91 for theimportance of specific practices. Cronbach’s alpha for theStudent Satisfaction and Self-Confidence in Learning In-strument subscales was .94 and .87, respectively (Jeffries& Rizzolo, 2006). The only modification to the tool wasthe substitution of the word learner for student. The Inter-professional Education and Clinical Simulation WorkshopEvaluation questionnaire was developed by one of the in-vestigators (KT) at the request of the project team. Thequestionnaire, which used a 5-point Likert-type scale withresponses ranging from not at all to excellent, solicited infor-mation about the overall objectives of the workshop andasked specific questions related to the content presented. Ad-ditionally, the questionnaire had three open-ended questions:How has the workshop caused you to think about interpro-fessional collaboration? What did you enjoy about the work-shop? What changes would you recommend? There was alsoan opportunity for participants to provide comments. Giventhat this was a workshop evaluation, it was not pilot tested.

Sample

The workshops were mandatory for staff and took place inthe university’s nursing simulation lab during a 2-weekperiod. All staff who attended the workshops were invitedto participate in the study. Participants included registeredrespiratory therapists, registered nurses, registered practicalnurses, social workers, personal support workers, dietitians,and pastoral care givers. The majority of participants wereregistered nurses. This was expected because the usualcomposition of acute care units consists of a high numberof nurses. The participants represented five of the sevenhospital sites within the local health care system. Each ses-sion consisted of 16 to 20 participants. At least three facil-itators were present at each workshop, and they took turnsfacilitating the debriefing sessions.

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Data Analysis

Data were analyzed with SPSS Version 16. Descriptivestatistics were obtained for the demographic variables andthe Interprofessional Education and Clinical SimulationWorkshop Evaluation questionnaire. Individual subscalescores were calculated for each of the three NLN ques-tionnaires. For example, the Simulation Design Scale wasdivided into five subscales, and the scores were calculatedfor each subscale, with a score of 1 indicating strongly dis-agree with the statement and a 5 indicating strongly agreewith the statement.

The Educational Practices in Simulation Scale and theSimulation Design Scale had a not applicable option foreach item. To facilitate scoring of the subscales, the not ap-plicable option was converted to a missing designation, andthis score was replaced with the mean score of the particu-lar item on the subscale. If 20% or more items were missingfrom a questionnaire, the questionnaire was not included inthe analysis (Tabachnick & Fidell, 1989). To maximize thesample size, all other data were used, which accounts forthe differences in sample size among the subscales. TheSimulation Design Scale and the Educational Practices inSimulation Scale also had a ranking component for eachof the items on the questionnaire, in which responsesranged from 1 ¼ not important to 5 ¼ very important. Fre-quency counts were calculated for these items.

Content analysis (Graneheim & Lundman, 2004) wasused to examine the data from the three open-ended ques-tions on the Interprofessional Education and Clinical Sim-ulation Workshop Evaluation questionnaire. Initially opencoding was conducted independently by each of the inves-tigators. Once this was completed, the investigators met andcollectively decided on nine codes. All data were then reex-amined individually by the principal investigators and allo-cated to the specific codes. Analysis continued among theprincipal investigators, and each piece of coded data wascompared for consistency. Any outlier results were dis-cussed, mutually agreed on, and then allocated to the suit-able code. Data that could not be coded within the codingsystem were further examined, resulting in an additionalcode. All data were then reexamined in light of the newcode. Analysis continued, resulting in six themes, as well asareas for improvement. Investigator triangulation as suggestedby Loiselle, Profetto-McGrath, Polit, and Beck (2004) was im-plemented to enhance credibility. Investigator triangulationwas achieved by the two principal investigators’ and the co-in-vestigator’s collecting and analyzing the data.

Results

Demographic

A total of 167 staff members from the health care systemparticipated in the Interprofessional Education and Clinical

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Table 1 Mean Subscale Scores for the Simulation DesignScale

Subscale N M SD

Objectives and information 156 4.06 .69Support 154 4.20 .66Problem solving 153 4.06 .67Feedback/guided reflection 152 4.35 .64Fidelity (realism) 154 4.22 .76

Table 2 Mean Subscale Scores for the Educational Practicesin Simulation Scale

Subscale N M SD

Active learning 157 4.23 .61Collaboration 157 4.61 .62Diverse ways of learning 159 4.08 .82High expectations 159 4.19 .88

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Simulation workshop. Of those, 163 completed the ques-tionnaires, yielding a response rate of 97.6%. The majorityof participants were female (88%) and registered nurses(73.6%). Registered respiratory therapists accounted for 9%of the participants, registered practical nurses 7%, socialworkers 4%, other allied health staff 4%, and health careaides 3%. Almost two thirds of participants were betweenthe ages of 36 and 55 (65.7%), and more than half reporteda college diploma as the highest level of educationcompleted.

Mean subscale scores for the five subscales within theSimulation Design Scale ranged from 4.06 to 4.35 out ofa possible 5, indicating that the respondents agreed with thestatements on the questionnaire (Table 1). This scale alsohad a ranking of not important to very important for eachitem on the scale. Overall, the items had an 83% or greaterranking of important to very important. The lowest rankeditem discussed goal setting for the patient, and this itemmay not be relevant for this particular setting or populationand may account for the lower ranking.

Mean subscale scores for the Educational Practices inSimulation Scale shows the mean score for each of the foursubscales was at least 4 (agree with the statement; Table 2).The subscales ranged from 4.08 to 4.61. The collaborationsubscale had the highest mean score, 4.61. All items on theEducational Practices in Simulation Scale were ranked asimportant or very important by 80% or more of respon-dents. Of the two highest ranked items, the first item wasin the collaboration subscale; 92.4% ranked ‘‘I had thechance to work with my peers during the simulation’’ asimportant or very important. Similarly, 91.7% ranked‘‘The simulation offered a variety of ways in which to learnthe material’’ as important or very important. The meansubscale scores for the Learner Satisfaction and Self-Confidence in Learning Scale indicated the satisfactionwith current learning subscale was 4.15, and the mean scorefor the self-confidence in learning subscale was 3.99(Table 3).

Results of the Interprofessional Education and ClinicalSimulation Workshop Evaluation showed that 73% of theparticipants reported that the stated learning objectiveswere met for the day and 74% reported that this workshophelped enhance their learning using simulation.

Qualitative Findings

Six major themes emerged from the qualitative analysis:simulation as a learning experience, the learning environ-ment, IPC learning continuum, cohesiveness, adapting tochange, and improved patient outcomes. The respondentsalso identified seven areas for improvement: (a) logistics,(b) simulation, (c) more information requested, (d) theevaluation tools, (e) interprofessional diversity, (f) theaddition of more professionals, and (g) ideas for futureeducational days.

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Simulation as a Learning Experience

The majority of the responses viewed the simulationlearning experience as positive. One participant stated,‘‘The simulation lab allowed me to experience the scenar-ios presented in a very realistic way, unlike previousmanikins’’. Many participants simply stated that the mostenjoyable aspect of the workshop was simulation. Simula-tion as a teaching strategy resonated with the majority ofthe participants.

The Learning Environment

The overarching sentiment of this theme spoke to thesatisfaction expressed by the majority of participants aboutthe learning environment. The location, atmosphere, andthe use of technology to enhance learning were amongsome of the aspects receiving positive comments. Althoughmost comments were positive, one participant stated‘‘didn’t understand the whole point of the day,’’ and anotherwrote ‘‘not too sure how SIM lab enhanced why we werehere. Could be better facilitated elsewhere. SIM labdistracts [from] the real reason we’re here. It’s not clinicalskills.’’ Follow-up from these comments could includeassessing the participants’ understanding of IPC andeliciting what participants would like to learn about IPC,such as scope of practice, roles, communication, or conflictresolution. As the goal of the project was to introduce aninterprofessional model of practice, some of the contentrelated to the components of that model may have beenbetter introduced in an alternative learning environmentprior to having the team of interdisciplinary professionalscome together for a simulation.

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Table 3 Mean Subscale Scores for the Learner Satisfactionand Self-Confidence in Learning Questionnaire

Subscale N M SD

Satisfaction with currentlearning

159 4.15 .57

Self-confidence in learning 158 3.99 .69

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Learning Continuum

The data represented a continuum of responses. Someparticipants said the workshop offered new learning aboutIPC, some said it reminded them about or reinforced theconcept of IPC, and some said it produced no change(‘‘I have always practiced this way’’). The new learningthat was shared by the participants included the importanceof IPC and a better understanding of the extent to whichprofessionals from different areas can work together.

The majority of the data supported the reminding andreinforcing section of the IPC learning continuum. Aheightened awareness of IPC was articulated by severalparticipants, and other comments supported IPC as a pro-cess. Additionally, participants shared their views of IPCprior to the workshop, acknowledged that the workshopserved to reinforce what they already knew, and suggestedactions as a result of their recent learning.

The concept of a learning continuum was further supportedby the remaining responses, in the already doing it category. Afew participants provided comments to suggest that they werealready practicing IPC. One participant stated ‘‘same as al-ways treat people the way you want to be treated.’’ Responsesranged from IPC as new learning, to reminding or reinforcing,through to indicating there was no change in their idea of IPC.Further analysis of an IPC learning continuum could beachieved by comparing the years of experience of the profes-sionals with where they were on the continuum.

Cohesiveness

Teamwork was a significant component within this theme.The word teamwork, as well as the concept of teamwork,was repeatedly shared. Participants expressed that thisworkshop caused them to ‘‘reinforce’’ or ‘‘rethink’’ theconcept of teamwork, and one suggested, ‘‘We need towork as a team, not on an individual basis.’’

Another element within the theme of cohesiveness wasappreciation of oneself within the team, as well as anappreciation of the whole team. Several participants statedthat the most enjoyable aspect of the workshop was‘‘sharing’’ and ‘‘working’’ as a team.

Adapting to Change

As with any change, actual or anticipated, voluntary orrequired, various responses are elicited. This was reflected

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in the development of this theme. One participant stated‘‘that it’s coming, we better get ready.’’ A few participantsrealized that changing to an interprofessional model of careis ‘‘the wave of the future,’’ and others indicated that thiseducational workshop served to alleviate some fears andoffer some support for the future.

Improved Patient Outcomes

Although much of the data pointed to themes about IPC andthe actual learning experience, the themes of cohesivenessand improved patient outcomes speak to potential outcomesof adopting an IPC model of care. Improved patientoutcomes are a goal for all health care professionals andwere clearly articulated by the participants of this study. Asone participant commented, this workshop ‘‘helped meunderstand the degree to which we can support each otherfor better patient outcomes.’’

Discussion

An interprofessional model of care was mandated by senioradministration in the health system. The anticipation ofresistance to this change created a quandary for theinterprofessional project team members. They searchedfor the best method to introduce and implement this newmodel. As this workshop was one of the first steps in theimplementation process, a positive learning experience wasdesired. The results from the NLN questionnaires indicatethat simulation was an effective strategy for teaching IPC,and staff was satisfied with simulation as a teachingstrategy. Although the findings from this study are similarto those of other studies that have reported simulation to bea useful strategy for team training in acute care areas suchas the operating room (Shapiro et al., 2004) and the emer-gency department (Paige et al., 2007), there is a paucity ofstudies related to the effectiveness of this type of teachingstrategy for health care professionals. Because this work-shop was the first component in the introduction of a newmodel of patient care, the desire was to create a positivelearning environment and facilitate the change process.This study revealed that simulation was highly rated bythe participants as a positive learning experience. There-fore, simulation could be used as a teaching strategy forhealth care professionals when one is implementingchange. Further research is warranted to determine whethersimulation as a teaching strategy can facilitate the changeprocess among health care professionals and whether sim-ulation is an effective way to teach practicing health careprofessionals.

The findings from the content analysis indicate thatparticipants viewed improved patient outcomes as a positiveaspect of adopting an IPC model. Emphasizing improvedpatient outcomes of care as a result of implementing an IPC

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model may help facilitate this change for those practicesettings planning to introduce this model in the future. Tounderstand what constitutes improved patient outcomes,further research with the staff is necessary. This researchmay help articulate the specific patient outcomes that canbe improved as a result of integrating an IPC model of care.

To the best of the researchers’ knowledge, the NLNinstruments have been used only in academic settings andonly with students. We purposely chose to use theseinstruments with health care professionals in order todetermine their effectiveness in a different population. Inreviewing comments from the participants, we found therewas some duplication of items across the instruments. Inaddition, some of the items on the instruments may not beappropriate for nonacademic settings. Further research withthese instruments is suggested in order to ascertainmodifications that might eliminate some of the duplicationand make the instruments more suitable to various healthcare disciplines.

Participants used the Interprofessional Education andClinical Simulation Workshop Evaluation questionnaire tosuggest several areas for improvement of future simula-tions. One suggestion was to develop scenarios that are less‘‘crisis focused.’’ Another recommendation was to createdifferent scenarios that provide greater opportunity tosimulate team collaboration. An additional suggestionwas to have a more diverse representation of healthprofessionals, including physicians. When future educa-tional workshops using simulation are planned, thesesuggestions should be considered.

Limitations

There are several limitations to this study that may affect thegeneralizability of the results. A convenience sample wasused, and the data were collected from one health care systemat one time. Moreover, with a self-report survey, there isalways a chance of a reporting bias (Polit & Beck, 2004).

During the presentation on simulation, a small numberof participants mentioned that they had minimal exposureto interdisciplinary learning or simulation training; how-ever, this information was not tracked formally in our study.Prior exposure to simulation may have influenced satisfac-tion scores.

Conclusion

This study was an innovative use of simulation and a novelapproach to interprofessional education. Additionally, thesimulation workshop provided the context to integrate thekey interprofessional care core competencies: interpersonaland communication skills, client- and family-centered care,and collaborative practice in a safe or nonthreateninglearning environment. Although the results from this study

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showed that simulation was an effective teaching strategyfor staff members to learn about IPC and that staff wassatisfied with simulation as a teaching strategy, furthermultisite health system research within the province andacross the country is necessary to improve generalizabilityof the results. Given that the majority of the participantswere nurses, future research should include a more diverserepresentation of professionals In addition, informationrelated to prior exposure to interdisciplinary learning orsimulation training needs to be collected.

It would be interesting to evaluate staff satisfaction withIPC 1 year after the respiratory therapists have been in-tegrated into the health care team. Finally, further develop-ment, implementation, and evaluation of interprofessionalscenarios need to be conducted in order to advance the use ofsimulation as a teaching strategy for IPC.

Acknowledgments

This study was supported by Health Force Ontario,Ministry of Health and Long-Term Care Nursing Secretar-iat Demonstration Site Project for Nursing Human Re-sources Planning.

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