457CHAPTER 39
Interdisciplinary Education in Simulation: Bridging the Gap Between Academic and Career Competencies
In contemporary health care dialogues about health professional graduates, educators often hear from their clinical associates about the challenges that new professional graduates face when entering the workforce. Moreover, educators of prelicensure health care professionals are challenged to teach to practice in a health care system that appears to be slowly shifting focus from discipline-specific care (e.g., nursing care) to the provision of safe and effective patient care of clinically complex patients. Adding to this shifting landscape is a recent move in Canada toward a business-model approach to health care whereby governmental funding and health care expenditures call for the most effective and the least expensive approach to safe and effective patient care. One might expect that health professional educators may feel overwhelmed by the increasing pressure to provide clinically competent practitioners who are job ready in a constantly changing environment, if they are not set up to compete for resources among each other to deliver their individual health education programs. However, a compelling argument may be made that efficient health care systems rely on collaboration among clinicians working from diverse fields of practice. Thus, we propose that the education of clinicians also rely on the collaboration among educators for student learning opportunities that better prepare them to meet the complexities of patient care provision: interprofessional education (IPE).
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Our nursing students attend the University of Victoria (UVic)’s School of Nursing 4-year baccalaureate program to meet the competencies as outlined by the College of Registered Nurses of British Columbia, including successfully passing the NCLEX-RN. Similarly, medical students must meet competencies as described by the Medical Council of Canada in order to meet their professional licensing objectives (LMCC part I) following completion of the University of British Columbia (UBC)’s Faculty of Medicine Island Medical Program (IMP) located at UVic. In addition, we have other health professional students who practice at the Island Health Authority (IHA) as part of their prelicensure clinical practice education.
Developing an Interprofessional Simulation Center
In 2011, a simulation center in Victoria was envisioned among three partner organizations, the UVic School of Nursing, UBC’s Island Medical Program, and the IHA. The idea of simulation 458education, particularly high-fidelity complex care patient cases, has been on the curriculum agenda for the School of Nursing and the Island Medical Program for several years. Moreover, IHA was investigating new ways to foster staff development, aid in recruitment and retention, and address patient care issues that came to the attention of quality and safety committees’ professional practices concerns.
As part of this development, in 2012 a curriculum-working group (CWG) was formed with a faculty lead from the School of Nursing and the Island Medical Program and a lead from the Professional Practice Office at the IHA. The CWG members were trained as simulation trainers through a certificate program at the Centre for Excellence in Simulation Education and Innovation (CESEI), Vancouver, Canada; the Simulation Educator Training (SET) course offered by the Royal College of Physicians and Surgeons; and the Debriefing Assessment for Simulation in Healthcare (DASH) workshop.
Over the following 2 years, the CWG members championed simulation learning at their respective organizations to train as trainers and curriculum revisionists. Each member conducted a needs assessment targeting how simulation would augment current education practices in his or her institution. They piloted simulation projects that followed best practice standards put forth by the International Nursing Association for Clinical Simulation Learning Standards for Best Practice: Simulation (International Nursing Association for Clinical Simulation and Learning [INACSL], 2013/2016) with a view to enahncing prelicensure students’ preparation to successfully complete the NCLEX-RN alongside the Standards for Accredited Simulation Activities as set the Royal College of Physicians and Surgeons of Canada (2013). Evaluation of the demonstration project for nursing included pre- and posttest questions, an objective assessment via a checklist, and a follow-up survey. At the end of the first year, from the evaluation data we (across discipline facilitators) were asked: “Why are we, students, playing the role of another health professional student during the simulation?” This question was followed by: “We really do not know what the scope of practice is for other health professional students or why they make the decisions they do.”
As a result of student feedback, an interprofessional simulation pilot project ensued over the subsequent year led by Drs. Maureen Ryan, RN, PhD (nursing), and Brian Farrell, MD, CCFP (emergency medicine). The pilot project work was informed by the Canadian Interprofessional Health Collaborative (CIHC) National Interprofessional Competency Framework (NICF), which outlines competencies required for effective interprofessional collaboration within six practice domains: role clarification, team functioning, patient/client/family/community-centered care, collaborative leadership, interprofessional communication, and interprofessional conflict resolution (CIHC, 2010). The pilot project focused on role clarification and interprofessional team communication in the debriefing in response to the student questions about roles and how to communicate effectively.
Student volunteers from the health professional schools of respiratory therapy, pharmacy, and nursing attended the medical student and medical resident simulations sessions. The sessions were cofacilitated by nursing and medical faculty from the CWG, and four cases from the UBC-IMP curriculum with a mix of trauma and general medicine were used with attention to how students understood, enacted, and communicated roles (e.g., closed-loop communication). The cofacilitators collected feedback from students following each session debriefing in a face-to-face group setting. The results were analyzed thematically, presented as illustrative case study to key stakeholders across discipline faculty, and presented as a poster at the Simulation Summit sponsored by the Royal College of Physicians and Surgeons Canada in 2013. A decision was made to continue engaging in research projects to formally evaluate the IPE programs.
Developing an Interprofessional Simulation Education Community
Although faculty and organizational leads at the Center for Interprofessional Clinical Simulation Learning (CICSL) recognized the inherent value of IPE, they were also aware of the necessary work needed to reduce discipline-specific educational silos and the concurrent individual and organizational challenges this presents. Hall and Zierler (2015) propose that two organizational 459challenges must be overcome in order to be successful: the provision of IPE education opportunities and the exposure to clinical settings where IPE is well practiced. Moreover, they suggest that the complexity of scheduling, flexibility of curriculum, competing demands, and the changes that IPE bring to health care often invite organizational resistance. This brings to light the importance of faculty development and the ongoing practice of IPE with students using an IPE competency framework alongside supportive organizational leadership and infrastructures within which faculty and students to teach and learn.
Our organizational leadership supported two independently facilitated workshops that invited members of existing working groups and stakeholders and/or decision makers from each of the partner institutions to participate in shaping the operations of the CICSL.
Two key workshops supported by organizational leadership allowed for interprofessional and interinstitutional contributions to CICSL’s core functions. In Exhibit 39.1, we outline the CICSL’s vision, mission, and values developed by the group and its commitment to IPE.
Recent publications through the Cochrane Collaboration (Zwarenstein, Reeves, Barr, et al., 2005; Zwarenstein, Reeves, & Perrier, 2005) call for the adoption of a framework to guide IPE efforts, and a decision to continue to use the framework we piloted (NIHC) along with building resources for faculty development necessary to implement the program. As a result, we can now describe two developing research and development programs at the CICSL: The Interprofessional Simulation Educator Pathway, highlighted as one of the innovative approaches to simulation- based faculty development in Chapter 5, and The Interprofessional Communication Curriculum described in the following section.
Introducing an Interprofessional Competency Framework Into Simulation Research and Practice
Using simulation to learn with, from, and about each other is at the heart of the CICSL partnership. In addition, driven by the belief that IPE and collaborative patient-centered practice are central to building effective health care teams and improving the experience and outcomes of patients, in 2010, the CIHC released the NICF. The framework describes the competencies required for effective interprofessional collaboration. Six competency domains highlight the knowledge, skills, attitudes, and values that together shape the judgments that are essential for interprofessional collaborative practice: role clarification, team functioning, patient/client/family/community care, collaborative leadership, interprofessional communication, and interprofessional conflict resolution (CIHC, 2010).
Within each of the domains is a list of competencies that the health professional can self-assess or use to have his or her performance assessed objectively. A full tutorial of the quality indicators within each domain goes beyond the scope of this chapter, interested parties can find more at the CIHC website (CIHC, 2010).
Exhibit 39.1 CICSL’s Vision, Mission, and Values
Vision | Mission | Values |
Improved patient and provider experience Excellence in training and in practice Advanced health education Leader in research and innovation | Provide a sustainable, safe, and supportive learning environment Foster interprofessional and inter-institutional collaboration Improve simulation education through evidence-informed practice | Excellence Interprofessionalism Patient focus Integrity Innovation Collaboration Transparency Trust |
CICSL, Center for Interprofessional Clinical Simulation Learning.
460An interprofessional team at CICSL is currently implementing an IPE research project examining safe patient handover within and among interprofessional teams using this framework and a communication curriculum. The communication curriculum is an online module created by Elspeth McDougall and colleagues (including author Maureen Ryan). This module teaches participants the importance of effective interprofessional communication, team functioning, role clarification, collaborative leadership, and interprofessional conflict resolution. The participants are introduced to two patient handover tools—SBAR (situation, background, assessment, recommendations) and IDRAW (identify, diagnosis, recent changes, anticipated changes, what to watch for) to assist them. In Exhibit 39.2, the SBAR template outlines information expected within each of the steps required to communicate information in an urgent or unusual situation. The SBAR is ideal for urgent circumstances such as urgent physician orders, advice required by ICU outreach teams, and when the patient is deteriorating.
Similarly, in Exhibit 39.3, the required steps for patient transfer following the IDRAW method (Hill, 2012) are outlined. The IDRAW is ideal for patient handovers, including changes in the level of care (routine transfer), temporary transfer of responsibility of care to another caregiver (e.g., staff breaks or diagnostic procedures), discharge, and change of shift report.
These tools were adopted into our communication curriculum following a review for applicability by our interprofessional team with the intent to foster safe patient care. Our intent with this project was to answer the call to develop educational strategies that guide safe practices for prelicensure students that would transfer into postgraduate practice (Emanuel et al., 2011; Kohn, Corrigan, & Donaldson, 2000).
In our study, interprofessional teams made up of medical students, nursing students, respiratory therapy students, and pharmacy students in their third year of study take part in emergency-based simulated scenarios before and after taking the online communication curriculum module. They observed and assessed their communication, teamwork, and handover skills during both simulation sessions to determine whether taking the communication curriculum improves patient handover techniques. Students will also be asked to evaluate themselves, their team, and the curriculum itself following each simulation, and again 3 months after completion. Our aim is to give students an experience of working as part of an interprofessional team and to provide them with skills and knowledge, and a place to practice safe patient handover. This project is a collaboration of Dr. Maureen Ryan (UVic School of Nursing), Dr. Brian Farrell (UBC Island Medical Program), and Dr. Anna Macdonald (CICSL), and is based on the pilot project originally spearheaded by Drs. Ryan and Farrell in 2013.
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