Better communication, better care through high-fidelity simulation

The Institute of Medicine reports that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors.¹ Alhough it's often assumed that solid communication and teamwork skills come naturally to healthcare providers, this isn't always the case. Upholding patient safety is at the forefront of healthcare in our society today, but it's clear that more emphasis must be placed on how we share and use patient information.

High standards

Nursing organizations have heeded the call to advocate for change in the healthcare culture. The American Association of Critical-Care Nurses released Standards for Establishing and Sustaining Healthy Work Environments in January 2005.² Among the six standards is skilled communication, which states that nurses must be as proficient in their communication skills as they are in clinical skills. No longer can we excuse “excellent” clinicians who exhibit poor communication and teamwork skills.

Another standard is true collaboration, with the statement that nurses must be relentless in pursuing and fostering true teamwork. Unfortunately, there are many instances where collaboration hasn't occurred, resulting in suboptimal patient care and outcomes. Lack of teamwork and collaboration skills contribute heavily to low morale, high turnover, and low satisfaction, which can impact patient safety. So how do we effectively teach these skills? One way is through the use of simulation techniques, which can be much more engaging than a standard lecture format.

Role playing

One of the best ways to conduct education is in the unit in an efficient and fun manner. Over the course of 2 years, I've collaborated on a role-play skit called “How to Have a Great Shift!” This intriguing title draws people in to participate. In a nutshell, we role-play poor teamwork and communication skills, then ask the participants how they'd approach the situation differently.

One role-play simulation we conducted involved a busy nursing assistant and a nurse who lacked the situational awareness to notice how busy the nursing assistant was. The nurse tells the nursing assistant, “Come help me turn the patient in Room 10.” The nursing assistant, exhausted and running ragged, snaps at the nurse and says she can't. Neither of them solves the conflict, and both end up frustrated and angry.

By this time, all the participants are laughing because they recognize that they've been in this situation before. So, as educators, we facilitate discussion on ways that the nurse can better communicate with the nursing assistant and vice versa. After general discussion, we engage the participants to “replay” the role-play simulation with us to achieve more positive communication and teamwork outcomes.

Many of the scenarios we've developed revolve around the nurse and nursing assistant relationship. We did variations on this theme, always concluding that both individuals, regardless of their jobs, have a responsibility to be good communicators and team players. This addresses the “blaming” issue that often occurs when team members don't take personal responsibility for making their unit a better place to work.

Simulation techniques

Simple scenarios can also be conducted with high-fidelity simulation techniques, such as a human patient simulator. These lifelike simulators can talk and be programmed to have normal and abnormal breath sounds, nor-mal and abnormal heart sounds, blood pressures, pulses, and ECG rhythms. They can be hooked up to monitors and devices and have I.V. lines, nasogastric tubes, and practically anything else you'd like to equip the simulator. Because simulators are lifelike, they can be used for clinical skills and other care aspects such as communication and teamwork.

High-fidelity simulation has been used extensively in the aviation industry. Student pilots and certificated pilots can practice hands-on skills and critical thinking via realistic flight simulators in a controlled environment where there's no danger of crashing. Healthcare is now catching up to the use of high-fidelity simulation techniques and recognizing that it's unacceptable to have medical errors, just as aviation realized years ago that it's unacceptable to have plane crashes.

A basic scenario that can be used to practice communication, teamwork, critical thinking, and clinical skills could be a resuscitation attempt, similar to what is used in life-support courses such as advanced cardiac life support. Various healthcare providers could each practice their respective roles in carrying out CPR, defibrillation, and airway management; gathering necessary supplies; documenting; managing and administering medications; and communicating with each other using an organized and agreed-upon approach. The key to this scenario isn't only to ensure that hands-on clinical skills are performed correctly, but also that effective teamwork and true collaboration are displayed.

The debriefing part of the simulation, whether it's low-tech role-play simulation or high fidelity with a simulator, is the most essential part of the teaching and learning. A skilled facilitator is necessary to help the debriefing process progress adequately. After a scenario has ended, the facilitator should elicit comments from the participants on what went well with communication and teamwork. Often the participants will focus on some of the clinical aspects, as these can be their comfort zone. A skilled facilitator can steer the discussion to more of the nonclinical issues.

After discussion on what the group did well, the discussion needs to turn toward what the team could do better. Could they have communicated more clearly? Could they have demonstrated more respect? Could they have had more situational awareness? Again, the focus needs to be on the development of team skills.

In many simulation labs, camera equipment is installed to capture the simulation electronically. A wonderful teaching-learning tool is to facilitate a team through a simulation, debrief, and then play back the simulation so that participants can look at their own behavior, words, actions, and body language. It can be an enlightening experience for many people as they might never have seen themselves in action before.

Additionally, it's important for participants to feel safe in the simulation environment; i.e., they shouldn't be concerned that they're being evaluated or will look bad if they make a mistake. It's also essential to have a good facilitator who'll develop rapport with the learners and make them feel at ease. No one wants to be judged in the learning environment; if they feel threatened, learning won't occur.

Whatever works

As with all technology, it's crucial to weigh the pros and cons of its implementation and not just use it because it's new. Figure out what works best for you and your facility, and continue to develop strong collaboration and interaction abilities from there.