Review the 10 provided articles then write 3-4 pages to explore the impact of simulation on team training. Categorize the findings to themes e.g. Leadership, communication, patient safety, situational awareness, mutual support, participant attitude, confidence etc…

Review the 10 provided articles then write 3-4 pages to explore the impact of simulation on team training.

Categorize the findings to themes e.g. Leadership, communication, patient safety, situational awareness, mutual support, participant attitude, confidence etc…

cite information in APA 7th edition

319The Journal of Continuing Education in Nursing · Vol 50, No 7, 2019

A Collaborative Partnership for Improving Newborn Safety: Using Simulation for Neonatal Resuscitation Training Elizabeth Palmer, PhD, RN, CNE; Amy L. Labant, PhD, RN; Taylor F. Edwards, PhD, RN; and Johanna Boothby, DEd, MS, RN

The American Heart Association (AHA) and American Academy of Pediatrics (AAP) recom-mend biennial Neonatal Resuscitation Program® (NRP) recertification and training of all personnel at- tending deliveries. The sixth edition of this program released in 2011 shifted the training to team-based

training through the use of simulation (AAP & AHA, 2011). The seventh edition (AAP & AHA, 2016) of the NRP suggests changes in practice that reflect the latest research evidence and quality patient outcomes and rec- ommends more frequent training to ensure competency (Bellini, 2016). NRP also focuses on team-based train- ing with debriefing. Past research assessing the influence of simulation-based neonatal resuscitation trainings have produced variable results (Kaczorowski et al., 1998; Lin & Cheng, 2015). However, the literature does support the benefit of an organized approach to patient safety with opportunities to use simulation and debriefing to enhance communication, teamwork, skill development, and improve patient safety outcomes (Burke, Grobman, & Miller, 2013; Fialkow et al., 2014; Lin & Cheng, 2015). Furthermore, Clary-Muronda and Pope (2016) recommended psychometric testing of existing instru- ments to support their use in NRP training.

This project supports a professional collaborative train- ing project between a community hospital and an aca- demic nursing program. The purpose of this study is to evaluate the effects of simulation teaching strategies on the training and performance of the health care team at- tending deliveries at a community hospital. Health care workers’ ability to perform key interventions during life-

abstract Background: The latest Neonatal Resuscitation Pro-

gram® (NRP) guidelines suggest the use of team-based training using simulation. Furthermore, psychometric testing of instruments appropriate to measure team performance in NRP is needed. This study evaluated the effects of simulation on the training and perfor- mance of the health care team attending deliveries at a rural community hospital. Method: Twenty-three nurses and nurse anesthetists comprised the sample. A pre- and postintervention repeated measures design was used. Data were collected using the Background/ Experience Survey, Self-Assessment and Attitudes Survey, and two Agency for Healthcare Research and Quality TeamSTEPPS tools (the Teamwork Perceptions Questionnaire [T-TPQ] and the TeamSTEPPS Teamwork Attitudes Questionnaire [T-TAQ]), the Simulation Ef- fectiveness Tool–Modified (SET-M), and the Individual and Team Performance Survey. Results: Data analy- sis revealed significant findings in team functioning, situation monitoring, and communication. Prebrief- ing and debriefing were valuable as measured by the SET-M. Conclusion: This project supports the use of simulation to enhance team-based training, perfor- mance, and communication. [J Contin Educ Nurs. 2019;50(7):319-324.]

Dr. Palmer is Professor, Dr. Labant is Emeritus Faculty, Dr. Edwards is Assistant Professor, and Dr. Boothby is Assistant Professor, Department of Nursing and Allied Health Professions, Indiana University of Pennsylva- nia, Indiana, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Elizabeth Palmer, PhD, RN, CNE, Professor, Department of Nursing and Allied Health Professions, Indiana Univer- sity of Pennsylvania, 221 Johnson Hall, 1010 Oakland Ave., Indiana, PA 15705; e-mail: lpalmer@iup.edu.

Received: January 23, 2019; Accepted: February 6, 2019 doi:10.3928/00220124-20190612-07

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threatening situations can be enhanced by providing op- portunities for deliberate practice of these key skills.

Research Project Aims The aims of this study were:

• To improve the quality of care, patient safety, and the performance of the health care team attending deliver- ies by developing and using simulated neonatal stabi- lization training. Specifically, the study will focus on neonatal resuscitation biennial training that incorpo- rates high fidelity simulation scenarios.

• To evaluate the effectiveness of the simulated neonatal resuscitation training sessions on identified patient and team performance outcomes.

• To explore the perceptions of the effectiveness of the use of Simulation for Neonatal Resuscitation Train- ing as measured by the Simulation Effectiveness Tool– Modified (SET-M).

Hypotheses This study’s hypotheses were:

• Health care personnel will demonstrate increased lev- els of competence and confidence related to neona- tal resuscitation following the neonatal resuscitation emergency simulation drill as measured by the Self- Assessment and Attitudes Survey (S-AAS).

• Participants will identify that Simulation (prebrief, sce-

nario, and debrief ) had a positive effect on their learn- ing as measured by the SET-M.

METHOD Figure 1 presents the overview of the neonatal resuscita-

tion study design and data collection plan. Following insti- tutional review board approval at both the university and the hospital, participants were recruited via e-mail communica- tions sent by the researchers. A pre- and postintervention repeated measures design was used. The participants com- pleted online simulation training and a quiz required by NRP prior to attending. To make the training realistic, the simulation scenarios were conducted onsite using the hos- pital’s actual equipment, such as their radiant warmer and self-inflating bag. Participants were provided with current practices related to the NRP changes.

Table 1 presents a brief overview of each of the instru- ments used in this study. Instruments used in this study were selected based on a literature review examining exist- ing instruments to measure team performance and effec- tiveness when conducting team training using simulation. The framework and instruments used in this study are based on a similar study by Robertson et al. (2009) and TeamSTEPPS instruments (Agency for Healthcare Re- search and Quality, 2017). The SET-M tool was selected for evaluation of simulation effectiveness with permission for use obtained from the instrument’s author, Kim Leigh- ton (Leighton, Ravert, Mudra, & Macintosh, 2015).

The participants completed the Background/Experi- ence Survey, the S-AAS, TeamSTEPPS Teamwork Per- ceptions Questionnaire (T-TPQ), and the TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) prior to the intervention. All participants then participated in the in- tervention phase of the study. The intervention consisted of the high-fidelity simulation drills designed and writ- ten by the hospital unit educator and simulation specialist staff on the basis of NRP recommendations. Each training session consisted of three high-fidelity simulation scenar- ios with small groups of four to five participants each. An observer checklist was completed during the emergency simulation drill. The unit-based educator was responsible for completing the observer checklist as she is the NRP instructor responsible for evaluating staff participating in NRP training. Debriefing sessions were facilitated by the simulation specialist and unit-based educator immediately following each scenario. Debriefing with good judgment (Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007) was the debriefing stance used, which moves away from a judgmental approach to debriefing (What went right? What went wrong?) to a nonjudgmental approach. This approach is helpful when working with adult learners, as was our case with nursing personnel as participants, and

Figure 1. Overview of the neonatal resuscitation study design and data collection plan. (Note. IRB = institutional review board; NRP = Neonatal Resuscitation Program®.)

Questionnaire Questionnaire

Questionnaire Questionnaire

321The Journal of Continuing Education in Nursing · Vol 50, No 7, 2019

when the instructor wishes to focus on whether or how the group was able to achieve key learning objectives. De- briefing with good judgment explores participants’ frames, assumptions, and knowledge that led the groups toward learning, or in contrast may have contributed to less than ideal performances by the team. The instructor facilitates learning by engaging in sense-making dialogue which helps the group to see from an expert position whether achievement of key learning objectives occurred.

Immediately following the drill, postintervention data collection was conducted using the S-AAS, Individual and Team Performance Survey, T-TPQ, T-TAQ, and the SET-M. Simulations were scheduled in groups with no more than seven participants. Each scheduled group par- ticipated in three different NRP scenarios with varying background information and outcomes.

RESULTS Descriptive statistics were used for demographic vari-

ables, attitudes toward simulation training, opinions about working in groups, performance during simulation, and the effects of simulation prebriefing and debriefing exercises. SPSS® version 24 was used to analyze the data.

Sample All invited participants agreed to participate in the

study. Twenty-three subjects participated in the study: 21 were obstetric nurses and two were nurse anesthetists.

Overall, ages ranged from 25 to 59 years (mean ± SD = 44.50 ± 10.27) and 100% were female. Years in current position ranged from 1 to 36 (13.48 ± 10.81). Three (13%) participants reported they had extensive simulation experience, 19 (82.6%) reported they had a little expe- rience, and 0% reported no experience with simulation. Participants were asked how often they had participated in obstetric emergencies. Five participants (21.7%) re- ported they had no experience participating in neonatal resuscitation with no pediatric support staff available. Six (26.1%) reported a little experience, eight (34.8%) re- ported moderate experience, and three (13%) stated ex- tensive experience. Participants had the least experience with amniotic embolism and reported the highest, moder- ate to extensive, experience with postpartum hemorrhage. The influence of using simulation training on confidence, competence, simulation technology, team attitudes, and perceptions were analyzed using Wilcoxon signed-rank test, with a significance level set at p < .05.

Hypothesis Testing and Results The first hypothesis was that health care personnel will

demonstrate increased levels of competence and confi- dence related to neonatal resuscitation following the emer- gency simulation drill. The S-AAS was used to measure current level of competence and confidence. A Wilcoxon signed-rank test determined the median score for level of competence for neonatal resuscitation, which increased

TABLE 1

DESCRIPTION OF INSTRUMENTS USED IN THE STUDY

Instrument Brief Description

Background and Experience Survey Six demographic-type questions

Self-Assessment and Attitudes Survey (S-AAS) Assesses current level of competence in the care/management of patients with various obstetrical emergencies (10 items), confidence in the care management of the same 10 items, attitudes toward the use of human simulation technology (6 items), and attitudes toward training (6 items) and feelings about working in groups (21 items).

TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) 30-item questionnaire that measures teamwork attitudes with subcategories on team structure, leadership, situational monitoring, mutual support, and communication with items such as “Staff are held accountable for their ac- tions” and “Staff monitors each other’s performance.”

TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) 30-item questionnaire that measures teamwork attitudes with subcategories on team structure, leadership, situational monitoring, mutual support, and communication with items such as “It is important for leaders to share infor- mation with team members” and “Effective team members can anticipate the needs of other team members.”

Individual and Team Performance Survey (Post only) Assesses team performance during simulation (35 items)

Simulation Effectiveness Tool–Modified (SET-M) (Post only) Measures effectiveness of entire simulation experience including prebrief- ing, scenario, and debriefing with items such as “I am more confident of my nursing assessment skills” and “Debriefing contributed to my learning.”

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from pretraining (Md = 1.00) to posttraining (Md = 2.00) but there was no statistically significant difference (z = -1.698, p = .090). The median score for confidence pre- training was (Md = 1.00) to posttraining (Md = 2.00) with no statistically significant difference (z = -1.705, p = .088). Although neither were statistically significant, the Wilcoxon signed rank test is a nonparametric method that has less power when used in small sample sizes.

The S-AAS also measured attitudes toward the use of human simulation technology, attitudes toward training, and feelings about working in particular groups. A 5-point Likert item scale from strongly agree to strongly disagree was used to evaluate these variables with a Cronbach’s alpha of .862 pretraining and .914 posttraining. A Wilcoxon signed-rank test determined that there was a statistically significant median increase in attitudes toward the use of human simulation technology pretraining (Md = 21.00) to posttraining (Md = 23.00; z = -2.807, p = .005).

Teamwork perception and attitudes were analyzed pretraining and posttraining using the T-TPQ and T- TAQ. Both questionnaires use a 5-point Likert scale ranging from strongly agree to strongly disagree. The T- TPQ has 35 items that assess health professionals’ per- ceptions of interprofessional teamwork within a hospital and group-level team skills and behaviors (Baker, Kro- kos, & Amodeo, 2008). The T-TPQ had a high level of reliability with this sample, as determined by a Cron- bach’s alpha of .942 (pretraining) and .954 (posttrain- ing). A Wilcoxon signed-rank test revealed a statistically significant reduction in perception following participa- tion in the neonatal resuscitation simulation, with a me- dian score for perception pretraining (Md = 41.0000) to posttraining (Md = 36.0000; z = -3.257, p = .001). The T-TPQ is divided into five categories: team func- tion, leadership, situation monitoring, mutual support, and communication. As shown in Table 2, the catego- ries that were statistically significant were team function, situation monitoring, and communication.

The T-TAQ assessed the influence of interprofessional education on health professionals’ attitudes, knowledge, and team skills (Baker et al., 2008). The T-TAQ had a Cronbach’s alpha of .864 (pretraining) and .971 (post- training) with this sample and was not statistically sig- nificant, pretraining (Md = 88.0000) to posttraining (Md = 89.0000; z = -1.188, p = .235).

The Individual and Team Performance, administered posttraining only, assessed perceptions of individual and team performance following the neonatal resuscitation simulation drill. Descriptive statistics were used to assess perceptions of individual and team performance and had a Cronbach’s alpha of .965 with this sample. The major- ity of the participants reported they strongly agree or some- what agree that they functioned individually well within the team and that the overall team performed effectively during the neonatal resuscitation simulation drill.

The second hypothesis was that participants will iden- tify that simulation had a positive effect on their learning as measured by the SET-M. The SET-M was administered posttraining only, using a 3-point Likert item scale from strongly agree to somewhat agree to do not agree. The reli- ability for the 19-item SET-M for this sample was a Cron- bach’s alpha of .978. Participants identified prebriefing and debriefing as a valuable experience (Table 3).

Anecdotal comments from participants about their performance were positive. For example, following the simulation, participants stated they were pleased with their ability to communicate better with repeated rehears- als. They also expressed excitement toward completing the simulation drill within the expected time frame outlined in the NRP guidelines.

DISCUSSION The findings from this study provide support for the

use of a high-fidelity simulation experience during NRP recertification. Several tools were used in this study. The S-AAS was administered before and after the intervention

TABLE 2

TEAMWORK PERCEPTIONS

Category Pretraining Median Score Posttraining Median Score Test Statistics

Team functiona 8.00 6.00 z = -3.331, p = .001

Leadership 9.00 8.00 z = -1.720, p = .085

Situation monitoring 8.00 7.00 z = -2.653, p = .008

Mutual support 9.00 8.00 z = -1.184, p = .236

Communication 8.00 7.00 z = -2.488, p = .013 a Lower number indicates stronger teamwork perception.

323The Journal of Continuing Education in Nursing · Vol 50, No 7, 2019

to assess competence, confidence, attitudes toward the use of human simulation technology, and pretest to assess attitudes toward training and feelings about working in groups. Although median scores increased for both com- petence and confidence, the increase was not statistically significant. The S-AAS revealed a significant increase with attitudes toward human simulation technology following the intervention. This finding supports the use of simula- tion when conducting NRP training sessions for hospital personnel. Having a positive attitude toward the simula- tion may indicate that this simulation-based training cre- ated a meaningful learning experience for the participants. In the preassessment of attitudes toward simulation train- ing, the group reported a range of responses on “worrying about how others will view my work performance” during simulation training. This shift to perhaps a more positive attitude toward simulation is helpful for staff development personnel who may wish to incorporate more simulation into training, despite nurses’ varied attitudes toward simu- lation initially.

The T-TPQ, which assessed perceptions toward team- work, had a high level of reliability with the sample, which gives the researchers confidence when interpreting this data. Pre- and postsimulation data reveal a significant finding related to team function, situation monitoring, and communication. The T-TAQ that assessed attitudes toward teamwork did not reveal significant findings. The Individual and Team Performance Survey also reveals positive perceptions regarding individual and team per- formance during the simulation drills. This data support the continued use of simulation as a strategy to improve staff attitudes and perceptions of working in teams, es- pecially during drills as critical as neonatal resuscitation

training. Given that the timing of nursing activities dur- ing a resuscitation procedure is critical to the effectiveness of the team, using simulation to train the staff to perform in the required time frames appears to be a realistic strat- egy for use by staff development personnel. This finding supports the use of Ericsson’s (2004, 2008) deliberate practice framework as a guide for staff development per- sonnel. This study’s findings are consistent with the litera- ture, which identifies the benefit of an organized approach to patient safety with opportunities to use simulation and debriefing to enhance communication, teamwork, and skill development in an effort to improve patient safety outcomes (Burke et al., 2013; Fialkow et al., 2014; Lin & Cheng, 2015).

In addition to the above findings, participants’ re- sponses indicate that simulation had a positive effect on learning, as evidenced by the results of the SET-M as- sessment. All three aspects of the simulation (prebriefing, simulation, and debriefing) were positively evaluated. The SET-M has been shown to be a valid and reliable method of evaluating perceptions of the effectiveness of learning through simulation (Leighton et al., 2015).

As noted earlier, Clary-Muronda and Pope (2016) have identified the need for further psychometric testing of ex- isting instruments for use in simulation training for NRP. This study found that both the T-TPQ, the T-TAQ, Indi- vidual and Team Performance Survey, and the SET-M had a high level of reliability with this sample, adding to the confidence of the researchers when interpreting this data.

Overall, the results of this study indicate that simu- lation use during NRP recertification results in positive teamwork perceptions, as well as improved attitudes to- ward simulation. Although there was not a statistically

TABLE 3

SIMULATION LEARNING

Prebriefing or Debriefing Strongly Agree,

n (%) Somewhat

Agree, n (%) Do Not Agree,

n (%) M (SD),

Posttraining Only

Prebriefing increased my confidence. 14 (60.9) 8 (34.8) 0 (0) 1.64 (.492)

Prebriefing was beneficial to my learning. 15 (65.2) 7 (30.4) 0 (0) 1.68 (.477)

Debriefing contributed to my learning. 17 (73.9) 5 (21.7) 0 (0) 1.77 (.429)

Debriefing allowed me to verbalize my feelings before focusing on the scenario.

15 (65.2) 7 (30.4) 0 (0) 1.68 (.477)

Debriefing was valuable in helping me improve my clinical judgement.

16 (69.6) 6 (26.1) 0 (0) 1.73 (.456)

Debriefing provided opportunities to self-reflect on my performance during simulation.

16 (69.6) 6 (26.1) 0 (0) 1.73 (.456)

Debriefing was a constructive evaluation of the simulation.

17 (73.9) 5 (21.7) 0 (0) 1.77 (.429)

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significant difference in competence and confidence with neonatal resuscitation following the emergency simulation drill, the data suggest that competence and confidence scores increased. Perhaps a larger sample size or expanded use of simulation would result in statistically significant pre- and posttraining levels of competence. Future re- search plans include multisite studies to increase sample size and to collect postdata on feelings about working in groups (teamwork).

The findings for hypothesis two suggest that the SET-M is an effective tool for measuring simulation effectiveness. This finding adds to the body of literature on the SET-M tool’s effectiveness and suggests that educators wishing to evaluate the effectiveness of the simulation could use the SET-M tool in their own simulation drills.

Measuring attitudes over time may yield significant changes as participants have the opportunity for further reflection and experience with simulation team train- ing. Finally, it would be helpful to perhaps streamline the number of tools used in future studies. Several tools administered pre- and posttest may have caused survey fatigue. Additionally, a longitudinal study to assess for skill decay over time for such critical interventions as NRP may provide further insights into the timing of and frequency needed for NRP trainings and simula- tions.

CONCLUSION This research demonstrated support for the use of high-

fidelity simulation for hospital training for NRP. This academic practice partnership proved beneficial for the participants in this study. Hospital personnel had access to training methods that were previously not available to them. Hospitals at academic institutions looking for valid and reliable instruments to measure team performance during NRP training may find these research findings, in- cluding the psychometrics of the instruments involved, to be useful.

REFERENCES Agency for Healthcare Research and Quality. (2017). TeamSTEPPS® in-

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American Academy of Pediatrics, & American Heart Association. (2011). Textbook of neonatal resuscitation (6th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

American Academy of Pediatrics, & American Heart Association. (2016). Textbook of neonatal resuscitation (7th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Baker, D.P., Krokos, K.J., & Amodeo, A.M. (2008). TeamSTEPPS teamwork attitudes questionnaire (T-TAQ) manual. Washington, DC: American Institutes for Research.

Bellini, S. (2016). A primer on updates to the neonatal resuscitation pro- gram. Nursing for Women’s Health, 20, 305-308.

Burke, C., Grobman, W., & Miller, D. (2013). Interdisciplinary collabo- ration to maintain a culture of safety in a labor and delivery setting. Journal of Perinatal & Neonatal Nursing, 27, 113-123.

Clary-Muronda, V., & Pope, C. (2016). Integrative review of instruments to measure team performance during neonatal resuscitation simula- tions in the birthing room. Journal of Obstetrics, Gynecologic, and Neo- natal Nursing, 45, 684-698.

Ericsson, K.A. (2004). Deliberate practice and the acquisition and main- tenance of expert performance in medicine and related domains [Sup- plemental material]. Academic Medicine, 79(10), S70-S81.

Ericsson, K.A. (2008). Deliberate practice and acquisition of expert perfor- mance: A general overview. Academic Emergency Medicine, 15, 988-994.

Fialkow, M.F., Adams, C.R., Carranza, L., Golden, S.J., Benedetti, T.J., & Fernandez, R. (2014). An in situ standardized patient-based simu- lation to train postpartum hemorrhage and team skills on a labor and delivery unit. Simulation in Healthcare, 9, 65-71.

Kaczorowski, J., Levitt, C., Hammond, M., Outerbridge, E., Grad, R., Roth- man, A., & Graves, L. (1998). Retention of neonatal resuscitation skills and knowledge: A randomized controlled trial. Family Medicine, 30, 705-711.

Leighton, K., Ravert, P., Mudra, V., & Macintosh, C. (2015). Updating the simulation effectiveness tool: Item modifications and reevaluation of psychometric properties. Nursing Education Perspectives, 36, 317-323.

Lin, Y., & Cheng, A. (2015). The role of simulation in teaching pediat- ric resuscitation: Current perspectives. Advances in Medical Education and Practice, 6, 239-248.

Robertson, B., Schumacher, L., Gosman, G., Kanfer, R., Kelley, M., & DeVita, M. (2009). Simulation-based crisis team training for multi- disciplinary obstetric providers. Simulation in Healthcare, 4, 77-83.

Rudolph, J.W., Simon, R., Rivard, P., Dufresne, R.L., & Raemer, D.B. (2007). Debriefing with good judgment: Combining rigorous feed- back with genuine inquiry. Anesthesiology Clinics, 25, 361-376.

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