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Learning to Overcome Hierarchical Pressures to Achieve Safer Patient Care

An Interprofessional Simulation for Nursing, Medical, and Physician Assistant Students

Reeves, Susan A. EdD, RN; Denault, Deanna PhD, MA, MEd; Huntington, Jonathan T. MD, PhD, MPH; Ogrinc, Greg MD, MS; Southard, Douglas R. PhD, MPH, PA-C; Vebell, Renee MA, RN, CHSE

doi: 10.1097/NNE.0000000000000427
Feature Articles

To positively impact patient safety, the Institute of Medicine, as well as the Quality and Safety Education for Nurses initiative, has recommended clinician training in structured communication techniques. Such techniques are particularly useful in overcoming hierarchical barriers in health care settings. This article describes an interprofessional simulation program to teach structured communication techniques to preprofessional nursing, medical, and physician assistant students. The teaching and evaluation plans are described to aid replication.

Author Affiliations: Professor and Dean, School of Nursing and Health Professions, Colby-Sawyer College, New London (Dr Reeves); Assistant Professor and Associate Director of Didactic Education, Masters of Physician Assistant Program, Franklin Pierce University, Lebanon (Dr Denault); Hospitalist, Dartmouth-Hitchcock Medical Center, Lebanon (Dr Huntington); Assistant Professor of Medicine (Dr Huntington) and Senior Associate Dean for Medical Education, Interim, and Associate Chief of Staff for Education (Dr Ogrinc), Geisel School of Medicine at Dartmouth, Hanover; Professor and Director, Master of Physician Assistant Studies, Franklin Pierce University, Lebanon (Dr Southard); and Assistant Professor and Simulation & Learning Specialist, Colby-Sawyer College, New London (Ms Vebell), New Hampshire.

The authors declare no conflicts of interest.

Correspondence: Dr Reeves, Colby-Sawyer College, 541 Main St, New London, NH 03257 (

Accepted for publication: June 9, 2017

Much has been documented in the literature about the impact of hierarchical power on a clinician’s ability and willingness to raise concerns about patient care.1-6 Such pressure is felt even more acutely for students in health profession programs given their perceived status on the health care team as “outsider” or as the “low rung on the ladder.”7-9 Students, although often in a prime position to be aware of safety concerns because of their lack of embeddedness in a site’s care delivery culture, fall prone to self-doubt because of their novice status. Even more frequently, students shy away from raising safety concerns for fear of being humiliated, ignored, and poorly evaluated.

For the past decade, a nursing, medical, and physician assistant school in New England has collaborated to create a longitudinal, interprofessional curriculum that has patient safety, quality improvement, and teamwork and collaboration as its focus. This 3-year curriculum is grounded in the competencies promulgated by the Interprofessional Education Collaborative and involves both required sessions and elective options for students. The curriculum specifically addresses knowledge, skills, and attitudes articulated in the Quality and Safety Education for Nurses framework within the safety competency.

In year 1, the interprofessional sessions are centered on developing role appreciation, as well as team and teamwork skills. Year 2 curricular elements include activities, which build team and teamwork skills among the students while they practice structured communication in the face of an impending medical error. The final year’s sessions are scheduled 3 months before program completion and center on the competencies of values and ethics for interprofessional practice.

This article focuses on the required simulation-based, patient safety–focused learning session that is situated in the second year of the interprofessional curriculum. The session’s objectives are to introduce students to a variety of structured communication techniques with a focus on the CUS (I have a Concern, I am Uncomfortable, this is a Safety issue) and SBAR (Situation, Background, Assessment, Recommendation) models with an experiential learning component followed by formative and summative debriefing. The learning session involves prereading, a brief 20-minute theory burst taught by faculty, a case-based simulation incorporating a video clip in which students are confronted with a clear and imminent patient safety issue and need to act, and a planned unsuccessful interaction with a dismissive authority figure that is then followed by 2 progressively successful interactions using a structured communication technique. The lesson plan, tools, and techniques used for this session are described in detail along with evaluative data.

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Instructional Methods


As with all interprofessional education (IPE) undertakings, the second-year hierarchical communication simulation exercise required significant logistical planning, which began 4 to 6 months before the annual sessions. Two faculty members from each of the participating programs met regularly and served as the activity’s leaders. Their assignment was to coordinate all aspects of the learning exercise.

Because of the size of the student groups (± 150 students each year), 5 to 6 evenings were required using 2.5-hour sessions per evening. Because of competing schedule pressures for the programs, all sessions were conducted in the evening, which necessitated coordination with the simulation center staff who provided logistical support to the sessions.

The most time-intensive preplanning activity involved the recruitment of both faculty coaches (5-6 per session) for the formative debriefs and actors (5-6 per session) who played the role of the harried, dismissive senior clinician who interacted with the students in the scenario. Faculty from each of the schools, as well as residents and fellows from the nearby academic medical center, were recruited for this purpose. In early years, all actors were required to attend a prebriefing for this simulation activity; however, this has been largely replaced by allowing them to view a previously produced demonstration tape and providing just-in-time instruction on the night of the simulation. For the faculty coaches, simple debriefing techniques for the intersessions were similarly reviewed on the evenings of the simulations.

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Participants and Setting

The simulation session was conducted in the Patient Safety Training Center at the nearby academic health center in which all 3 academic programs train during their clinical education. Preprofessional students came from 3 institutions: a medical school (approximately 80-95 second-year students per year), a 4-year nursing school (24-40 third-year students per year), and a physician assistant program (22-24 second-year students per year). Although these schools each use the same academic health center for clinical education, they are not co-located on grounds of the academic health center. The medical school is located in a small college town approximately 3 miles from the academic health center campus, the physician assistant program is approximately 5 miles from the academic medical center campus, and the nursing school is most distant at 24 miles away. At the time of the simulation sessions, the nursing students were in the intensive clinical phase of their education, whereas both the medical and physician assistant students were in the didactic (preclinical intensive) phase. Student participation was required for all students.

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Table 1 provides a summary of the session objectives, as well as a specific outline of the specific learning activities including time allotments for each activity within the simulation. Each session uses the same objectives and time schedule. Two weeks before the scheduled simulations, via the respective school’s learning management Web sites, the students received prereadings, as well as an online readiness quiz, which was designed by the lead faculty and administered through the learning management system of the participating schools. The readings discussed the patient safety risks of poor teamwork, as well as the specific pressures of hierarchical communication. Structured communication techniques were also outlined in the readings. A presession readiness quiz was administered. Students need to achieve an 80% score on the quiz. Completion was verified by faculty and provided the “ticket” to the learning session.

Table 1

Table 1

As students checked in for the simulation, they were assigned to a small group to which they would belong for the entire session. Preassigned interprofessional teams consisted of at least 1 medical, nursing, and physician assistant student. For each session, 5 teams (15 students) were scheduled to complete the 1.5-hour activity. Each session consisted of several activities to address the sessions’ 4 learning objectives.

The sessions began with a check-in activity that allowed students to introduce themselves to their teammates. This activity was followed by a brief theory burst presented in the form of a several questions taken from the readings where teams competed with one another via an audience response system. The students were then shown a video that depicted a surgical team failing to properly perform a valid informed consent for a bedbound, elderly man with diabetes. The patient in the video was hard of hearing and believed that he was being scheduled for a debridement of his infected large toe; however, he was actually being scheduled for a below-knee amputation. The scenario was designed specifically to showcase a gross error in the consent process so that preclinical students could easily comprehend the patient safety issue at hand.

The student groups then moved to a room in the PTSC where they had to work together to call a senior clinician to explain that the patient was not aware of the impending surgical procedure and ask that the clinician stop the procedure. The clinician arrived, was quickly and rudely dismissive of the students’ concerns, and left the room. The students then had to regroup and try a different approach, with the goal of using one of the structured communication techniques. When the clinician returned (obviously frustrated), the team tried again to be heard about their concerns. This interaction proved more successful than the initial one. Most teams fared better during this second round, and the clinician agreed to alert the on-call surgeon. When this surgeon arrived, the teams had 1 last opportunity to communicate their concerns.

After this final round, the faculty coaches who were observing from an adjacent control room facilitated a rapid formative debriefing for reaction defusing, as well as an initial discussion of the students’ understanding and analysis of events. Students then once again came together as a large group joined by all faculty and engaged in a summative debriefing of the experience.

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Learning Outcomes and Evaluation

All students received an electronic feedback survey immediately after the simulation. The survey contained both Likert scale rating and free text items. In addition, students received a similarly structured follow-up survey 1 to 2 years after the simulation to assess whether they had used or observed any of the communication skills in their clinical settings. The follow-up survey was reviewed and deemed exempt by the medical school’s institutional review board.

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Postsession Survey

The postsurvey evaluation was conducted after the completion of all sessions held in 2014 to 2016. In all, postsession surveys were sent electronically to 437 students in all 3 participating programs via an electronic survey link and had a completion rate of 67% (n = 293). Students rated elements of the sessions highly (Table 2). This was most evident in their assessment of the quality of their interactions with interprofessional student colleagues and faculty. On average, students expressed agreement that this session increased their appreciation of the existence and impact of communication breakdowns in health care and also their confidence in applying communication strategies in unsafe patient situations. Furthermore, students rated their effectiveness of their team functioning as well to very well.

Table 2

Table 2

An opportunity for free text commentary was provided. Comments included appreciation for the time devoted to meeting their interprofessional team members and attention to learning about the similarities and differences in each other’s professional roles. Most teams displayed an initial shock at the exaggerated, dismissive behavior that served as a significant barrier to communicating their concern, forcing them to work together as a team while learning to use effective communication strategies. The teams were also able to consider factors that might lead to ineffective communication in the clinical setting. For example, 1 student wrote, “I learned how aggressive communication does not work in the health care setting, but sometimes people shutdown and resort to it. It showed me how important it is to keep an open mind to other people because they may have just been having an ‘off day’ and may not have been intending to be so aggressive in their communication.”

Many students expressed surprise that communication barriers still exist in health care. In both the debrief sessions and evaluations, students reflected on the importance of communication brevity, use of key words that direct attention to patient safety concerns, and how interprofessional team preparation can help in difficult conversations. The comments also reflected an overwhelming appreciation for the opportunity to experience this IPE in the relative safety of a simulated clinical environment to positively impact their professional practice. One student offered, “I liked the idea of making us go through this in a safe environment. I feel that I am better prepared to deal with this when I encounter it in a real setting.”

Students repeatedly commented on the need for individual and team advocacy to protect patient safety and appreciated the usefulness of team collaboration to make improvements after each attempt at communication in the simulation. Student feedback along this theme included:

I think my group got better and more efficient with each round during the session. I think the most valuable lesson learned was by discussing after each round what worked well and didn’t, and then compiling all the feedback to prepare for the next round. Each individual had really important feedback that we could use.

Suggestions for improvement included modifying the time of day of the sessions from evenings to earlier in the day and providing students with more simulation attempts, preferably with the same person to gauge individual learning.

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Follow-up Survey

To assess whether students recalled, used, or observed the skills from the simulation during clinical experiences, a follow-up survey was sent to students 1 to 2 years after the simulation experience. The survey contained basic yes/no questions, as well as provided the opportunity for free text comments. Surveys were sent to 254 students who participated in the simulation in the fall of 2015 and 2016. Of the follow-up survey participants, 54% of the students attended the simulation exercise in 2015, and 45% attended in 2016. Eighty-five responses were received for a completion rate of 33%. The survey participants represented roughly the proportions of the students participating in the simulation exercise (35% nursing, 9.5% physician assistant, 47% medical).

Students overwhelming responded that they recalled the hierarchical communication simulation (93%) and were able to correctly identify the learning objectives (91.5%) and structured communication techniques highlighted in the experience (70%). Slightly more than half of the students indicated that they had used one of the structured communication techniques in their own practice. Approximately the same number of students observed the use of the techniques by other clinicians.

An opportunity to include free text comments was provided, and students were encouraged to describe the opportunities they had to use the skills they learned in the simulation. Although there was wide variation in student use of the specific communication techniques, many students commented that they either used the techniques routinely themselves or observed clinicians using them. Some described that the simulation improved communication not only with clinicians but also with their patients. Other comments attributed an improvement in student empowerment and confidence to raise challenging issues with more senior clinicians. The follow-up survey prompted 1 student to muse, “I have been in a few situations where, retrospectively, I wish I had used them [structured communication techniques].”

The timing of the follow-up survey was such that many students were nearing the end of their preprofessional education experience. Such timing seemed to inspire a level of retrospective reflection on the simulation and its usefulness in the overall curriculum. One student offered:

I have completed most of my rotations here at the medical center and been fortunate to have worked with amazing residents/attendings thus far who take the time to listen to students like myself without being aggressive or condescending. I have had situations where I felt my voice mattered and spoke up to ensure we were appropriately following a patient’s blood sugars, for example. In those instances, I felt the teams I’ve worked with had been very receptive and interested to hear my thoughts. Despite not running into more unsavory experiences, I know I will have those experiences at some point in my career as a medical student, intern, senior resident, etc., and I am thankful to have had the opportunity to review these difficult situations/barriers with the exercise we did last year.

Another noted, “This gave me the confidence to talk to students from other disciplines. Practicing advocating for patient safety was a valuable experience and gave me the confidence so that I feel comfortable speaking up in the future.”

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A common lament of students who participate in IPE-designed sessions is that they wish they could experience more IPE in real clinical practice. This simulated learning experience, although not conducted in an active clinical setting, is a move toward that goal and away from classroom-only–based IPE activities, which can often experience a sense of being disconnected from direct clinical practice. Through its design, the session provides a way to efficiently engage large numbers of students in interprofessional, experiential learning using small groups. In addition, by placing the IPE competencies of roles, teams, and teamwork in the background of the experience, the students were able to work collaboratively to solve a real problem while learning a discreet set of skills. As such, the value of working together was able to emerge from the experience more organically as opposed to when IPE competencies are in the foreground of a learning session.

When initially designed, the simulation used senior and retired attending physicians as the actors. These individuals would often relate stories from the “old days.” Such anecdotes often failed to resonate with the current experience of students; thus, in 2015, a change was made to use resident physicians and fellows as actors. This change in the scenarios gave a realistic feel to the exercise and allowed students to place the experience in context with their daily clinical training and work. The faculty team has had conversations about whether the use of surgical resident physicians as actors may be perpetuating the stereotype of surgeon as a “difficult and arrogant communicator.” However, the integration of these residents-in-training into the simulation has introduced the collateral benefit of a providing a mechanism for co-training them on the importance of nonhierarchical responses to structured communication designed to promote patient safety. The potential for confronting a difficult communication in any discipline was consistently addressed during the summative debrief sessions.

An interesting feature of the simulation is that, by design, the nursing students are further along in their actual clinical training than are the medical and physician assistant students. Such developmental timing allows the nursing students more experience with which to initially guide the student groups into the structured communication techniques, which they have learned and practiced in their clinical work. The experience has tended to empower the undergraduate nursing students to be active in teaching their older, graduate student colleagues. The combination of these perspectives in the large-group debriefing session at the end of the exercise has been powerful to observe and reinforces the need for communication skill-building throughout one’s professional career.

As is always the case with the use of simulation as a teaching tool, the use of a skilled certified healthcare simulation educator debriefer is essential. The role of the debriefer in helping to make connections between the emotions experienced in the simulation with the learning is paramount in the students’ retention of the knowledge, skills, and attitudes gleaned in the experience. There also exists the added benefit of having faculty observe a skilled debriefer’s techniques because they can be used with students in other educational settings.

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This interprofessional simulation, which teaches nursing, medical, and physician assistant students different methods to communicate across hierarchical power structures in support of patient safety, has been near universally identified as a valuable learning experience by students. Similarly, nearly all students are able to recall the experience, some more than 24 months after the simulation. Students report feeling more empowered and confident in their communication skills. Although the planning for the learning experience is intensive and requires significant (after-hours) resources to properly conduct, the benefits have more than justified the investment.

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communication; interprofessional education; patient safety; Quality and Safety Education for Nurses; simulation; structured communication

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