Healthcare leaders and managers are in pivotal positions for achieving improvements in patient safety, yet often lack essential training for providing safety leadership. Those in nonclinical roles often have little or no patient care experience. Clinicians who assume substantial administrative responsibilities spend considerably less time in actual patient care, so lack exposure to safety issues confronting frontline workers. In addition, clinician-managers may lack familiarity with clinical roles other than their own or may not have received substantial leadership training.
Healthcare managers often work in teams; yet for many reasons, those teams may not function effectively in leading their units or organizations to establish a high level of patient safety. Despite increased support among health care organizations for team training in general, management teams have traditionally not been exposed to training in teamwork.1 There is a large literature describing teamwork training methods across the entire spectrum of work domains and particularly in healthcare.2 Yet, few programs specifically address team training around issues of safety leadership for healthcare leaders, administrators, and managers.3
To address these gaps, we developed a safety leadership team training program to introduce managers and informal leaders of healthcare organizations to key concepts for teamwork, safety leadership, and simulation in the context of patient safety and to motivate them to act as leaders to improve safety climate and safety itself in their sphere of influence. More explanation of the underlying theory for developing this program is presented in a companion publication.4 We report here on the simulations and associated debriefings used in this program, which is an extension of an earlier, more narrowly focused program called Healthcare Adventures that has been operating for several years, targeting primarily nonclinician managers.5 The expectation underlying the program is that managers' collective involvement in a realistic, simulated experience involving a management dilemma would introduce the management team to basic concepts of teamwork and act as a springboard for them to examine their safety leadership. In addition, the simulation exercise introduced management teams to simulation, which we envisioned would help promote diffusion in their organization.
A chief distinction of the program from most training programs using simulation in healthcare is that it was applied to management teams, including both clinician and nonclinician managers. For the program, we developed two simulation exercises. The first is intended for use in training teams comprised heavily of clinicians who are called upon to act in the role of clinical managers. The second scenario, drawn from the original program, targets nonclinical teams. The program included several additional pedagogical elements and educational approaches for different learning styles, eg, presentation of theory and evidence supporting leadership behaviors targeted by the program, team-specific feedback from a safety climate survey comparing the team's results to the hospital overall, and practice of safety leadership through facilitated development of a plan for working to achieve one of the team's own safety initiatives (Table 1). The details and results of the entire safety leadership team training program are reported elsewhere.4 We focus here on the rationale and details of the simulations and associated debriefings used in the present program to illustrate this novel use of patient care simulation techniques. In addition, we present data on participants' perceptions and reactions about the simulation portion of the training program.
Participants in the Simulation Exercises
Twelve groups of managers, representing a spectrum of clinician and nonclinician management teams from one large academic medical center in New England, participated in the simulation exercises. To select the teams, the hospital's quality and safety leadership identified 39 teams throughout the hospital and solicited their interest in participating in the training program and related study. Of those, 5 declined to participate and 10 were excluded due to small size or overlap with other groups. Of the 24 remaining groups, we selected a stratified random sample of groups to participate in the training intervention, using the remaining groups as controls. Strata included groups representing nursing and other patient care services (n = 2 of 3), nonclinical areas (n = 2 of 3), groups described as hospital priorities because of their involvement in certain improvement projects (n = 2 of 3), and other (n = 6 of 15).
The participants in each team were identified by the QA chair and/or Department Chair of their respective department because of either their formal or informal role as managers or leaders. The teams varied in size from 6 to 12 members. For 10 teams, a substantial number of members were clinicians, currently or previously providing direct healthcare services, as well as managers. A typical team included several physicians, nurses, and other allied health professionals, eg, social worker, respiratory therapist, and one or more administrative managers from one hospital unit, center, or department. The two nonclinical teams comprised managers and administrators of varying backgrounds but none with any direct patient care training or experience.
The hospital's Institutional Review Board approved the evaluation of the program, of which the simulation exercise and debriefing were a part, and all program participants provided informed consent.
Objectives of the Simulation Exercise and Debriefing
The simulation exercise and the debriefing had several specific learning objectives. Our primary objective was the same as most healthcare simulations: to improve teamwork performance by involving participants in a situation that elicits teamwork behaviors of the type required of them in their usual work roles. Also, as with any single simulation exercise, we sought to address only a few specific behaviors. These simulation scenarios were designed to focus attention on management teams' responsibility for encouraging their own open communication, speaking up about safety issues, and workload management.
For this project, an equally important objective of the simulation and debriefing was to expose the team to a clinical situation that illustrated how unsafe conditions can arise during clinical care and to have them consider their role as leaders in reducing such hazards in their own sphere of influence. Through the simulation and debriefing, we specifically targeted four leadership elements addressed with each team as follows:
- Leadership really cares about safe patient care
- Leadership is welcoming and not defensive regarding safety concerns
- Leadership encourages staff to speak up about safety concerns
- Leadership facilitates good communication and teamwork among staff
The first was presented as an overarching goal and the remainder as specific behaviors or practices. A major goal of the debriefing was to promote dialogue about these issues. These objectives were reinforced (and three others were introduced) over the course of the full training program.
A third objective of the simulation exercise was to introduce the management teams to simulation as a vehicle for healthcare training, although this was not explicitly discussed during the program.
We describe the general approach here to each scenario. The details of each are available in the Appendix (Supplemental Digital Content 1, http://links.lww.com/SIH/A20).
Nonclinician Group Scenario
Participants are assembled in a conference room. After the introductory elements of the daylong program, they are told that their hospital has just purchased a small local hospital and they are the transition team for their department's functions. They will be touring the operating room (OR) to learn about the hospital. A lead facilitator enters the room in the character of an anesthesiologist who is going to lead the tour. The anesthesiologist begins a lecture on the basic elements of anesthesia. Within 10 minutes, the anesthesiologist is interrupted by a call. He takes the call and then tells the class that he has been called to the OR and that they should come with him.
In the OR, a confederate anesthesiologist explains that he needs to take another case and transfers responsibility for care of the patient to the anesthesiologist hosting the tour. The host then assigns various responsibilities to each participant, eg, listening to the heart, keeping the record, and injecting drugs. One participant assists in intubation. After the successful intubation, the confederate anesthesiologist is called out of the room on an emergency and tells the team that everything is stable and to simply keep monitoring the patient and call him if needed. Within a few minutes, the team learns that the surgeon has been operating on the wrong limb. They are drawn in to the discussion of what are the appropriate responses to this situation and must decide what to do in this case. The total time of the scenario is approximately 45 minutes.
Clinician Group Scenario
As in the nonclinician scenario, participants are told that their hospital has just purchased a small local hospital and they are the transition team. To learn about the hospital, they are taken on a tour of the emergency room (ER), by the ER Director (a confederate). There are two active ER bays, one with a standardized patient-actor and the other with a mannequin. In each bay, various clinical errors or inappropriate situations posing safety risks are unfolding.
After the visit to the ER, the team is taken to a different conference room. They are shown a video message from the hospital CEO who explains that the hospital is having serious safety and morale issues in the ER. He asks for their expert advice on how to deal with it. They are shown a clandestine video taken by the husband of the patient who they just saw in the ER. The video reveals serious problems in patient safety and safety culture. The program facilitator assigns them the task of developing advice for the CEO about how to deal with the situation he is facing. They are given a time limit of 45 minutes to complete the task. The team then is left to organize and prepare a plan.
The debriefing is led by an experienced simulation educator and one of two program facilitators, both trained organizational behavior professionals on the study team (each facilitated 6 of the 12 sessions). The debriefings are based on the model described by Rudolph et al6,7 “debriefing with good judgment” and use the same format as our crisis resource management programs for clinical teams. The general goal of the debriefing is to help participants understand, learn, and apply insights from the simulation experience to change their frames and behaviors regarding the learning objectives. The debriefing is conducted in a manner that maintains an environment that is safe for taking interpersonal risks8 and gives accurate evaluative feedback.
The three main phases of the debriefings include (1) reactions, (2) understanding, and (3) summary. First, facilitators invite participants to express their feelings and reactions to the scenario. While processing the reactions, they conduct a mini-needs assessment, so that they may match the learning objectives with participants' needs. The facilitators allow the reactions' phase to proceed until they determine that sufficient emotional and factual decompression has occurred.
One of the facilitators then redirects the conversation to the second debriefing phase, understanding. Facilitators explore participants' reactions to surface their “mental frames,” ie, their view of what was going on. They also combine advocacy and inquiry to enable the team to understand their behavior in the scenario relative to the learning objectives.9,10
During this phase, facilitators also teach and lead the group to understand how their teamwork and leadership skills and actions reflect the ways in which they lead others in their normal work activities and how they can help to address the problems they face in their patient safety responsibilities. Facilitators explicitly query the team about its safety leadership with regard to the four learning objectives for the simulation exercise. Specific attention is given to the issues of speaking up while observing in the ER or participating in the OR, likelihood that concerns offered were or would be welcomed had they been on the receiving end, and establishing processes to facilitate teamwork and communication during discussion of the ethical or managerial dilemma.
In discussing the leadership team's ability to facilitate good communication and teamwork among staff, the team considers how they could have optimized their management of the simulation exercise using the basic principles of Crisis Resource Management: role clarity, using resources, communication effectiveness, time management, and structuring the group task.11,12
In discussing the leadership team's ability to be welcoming and nondefensive and to encourage staff to speak up about safety concerns, facilitators address the following issues:
- Recognizing the difference in perspectives between managers and clinicians.
- How to speak up to voice concerns specifically using the “two-challenge” model13; effects of power imbalance between physicians and nurses, usually with reference to Milgram's experiment on obedience to authority figures, demonstrating how individuals are prone to defer to authority, even when doing so presents a conflict with their personal conscience14; the possible negative effects of avoiding conflict; and organizational barriers to speaking up (especially a blame- rather than a learning-orientation) using examples of each item.
- How to use an advocacy/inquiry approach as a tool for speaking up and raising concerns effectively.6,7,15
- The need to balance reflection with action to welcome and explore ideas.
For the OR scenario, the team typically wishes to review what happened chronologically, answering questions about the model of care by the surgical team, time out process, surgical site marking, how the wrong side could have been blocked and operated on, and other clinical issues. For the ER scenario, the character of the debriefings varies considerably, in concert with the varied ways in which the team effectively or ineffectively addressed their managerial task.
In the final debriefing phase, the facilitator summarizes lessons learned, reviewing what worked, what did not, and what the participants can apply as leaders.
At the end of the daylong training, participants assessed the relevance and quality of the simulation and debriefing exercise along with other program elements through a questionnaire using an 11-point (0–10) scale. We summarized participants' quantitative evaluation of the simulation and debriefing for both scenarios by reporting high (score >5) and low (score 5 or lower) perception of relevance or quality. We excluded from this analysis data from the first two teams that participated in the ER scenario because we modified the scenario (see Results section) after we observed that they had difficulty accepting their simulation roles. We also extracted positive, negative, and neutral comments about the simulation program from written evaluations of participants from all 12 teams. Next, using ATLAS.ti qualitative research software, we identified quotations from transcripts illustrating various insights by teams and team members derived from the simulation experience. Three investigators reviewed the quotations and agreed on their organization by theme through iterative discussion and reflection on related literature. Finally, we also summarize verbal and written comments provided by facilitators to study team members after each training program and after administration of the training for all 12 teams about individuals' and teams' response to the simulation.
There were 108 participants in the 12 teams involved in the training program, 100 of whom completed training evaluations on the day of the simulation exercise. After excluding participants in the first two ER scenarios, 67 evaluated the ER scenario and 13 evaluated the OR scenario.
A summary of participants' perceptions of the simulation and its debriefing respectively is shown in Figure 1. Almost all participants rated both the relevance and quality of the simulation and debriefing portions of the training program highly (6 or higher on a 0–10 point scale). The ER simulation was rated highly by 55 of the 63 respondents to the relevance question and 62 of 66 for quality (87% and 94%, respectively). Among the 13 nonclinical managers who participated in the OR scenario, 9 of 11 respondents to the relevance question rated the simulation highly for relevance and all 13 respondents to the quality question rated it highly (82% and 100%, respectively). The debriefing received slightly higher scores than the simulation. For the ER scenario, 59 of 62 respondents scored it at least 6 for relevance (95%) and 64 of 66 scored it above 6 for quality (97%). For the OR scenario, 10 of 11 respondents gave scores of at least 6 for relevance (91%) and all 13 respondents rated the quality as high.
There were 38 comments about the simulation and debriefing from the 100 program evaluations for participants in the 12 teams. Representative comments about the simulation and debriefing are shown in Table 2. Twenty-five comments included positive and complementary comments about the program's perceived relevance or quality and 10 offered suggestions for improvements. Five comments included remarks that were critical about the perceived realism, quality, or relevance to the teams' goals or the perceived value of the program. Two of the five came from the first two teams that participated in the ER scenario, identified as “ER early session” in the table.
Statements from participants during the training demonstrated insight arising from the simulation (see examples in Table 3). The simulation helped participants recognize problems with speaking up. Several recognized that they themselves had difficulty speaking up. For example, one participant admitted, “I felt like a coward during the entire event .... Why didn't I say what I was thinking? Partly because I was not sure I needed to as part of the simulation and partly it was just a failure to speak up” (Clinician, ER scenario). Some participants commented on what was their failure as leaders to invite speaking up. Others acknowledged the need to shift to a learning-oriented culture. One participant said, “The creaking sound you heard was us thinking about taking an event like this and taking an approach that is not blame-focused but learning-focused” (Clinician, ER scenario). Still others recognized the need to improve teamwork and communication.
Participants made other self-reflections as well. In this example, the participant wondered aloud about the advantages and disadvantages of passively observing rather than intervening as a leader: “I kept thinking about why we were there and I wanted to comment on a lot of things because we were observers but I thought the less I talk the less I contribute to chaos” (Nonclinician, OR scenario).
The facilitators observed that the teams reacted in various ways to the two simulations. The OR scenario (two teams) was well developed, having been used extensively before this project. The script was stable, and the simulation staff were practiced at executing it. Yet, only one of the teams became fully engaged with the clinical tasks, as had been the experience in all the prior uses of the scenario before this new program. The participants of this team began with a slightly humorous effect, not deeply suspending disbelief perhaps partly because they were in an OR but only with a surgical cap and mask. As they engaged in their assigned tasks, almost all assumed an air of seriousness that became more pronounced when the wrong-sided surgery was identified and they found themselves in the position of allowing it to continue or acting to intervene. The other of the two teams trained using the OR scenario refused to do any clinical tasks, saying that would be a violation of HIPAA, the federal Health Insurance Portability and Accountability Act of 1996, and other hospital policies. They nevertheless acted consistent with visiting in a real clinical setting, showing concern for the patient and trying to be helpful in permissible ways, eg, calling for assistance. While this scenario did not flow as planned, it still provided a rich experience for the debriefing including about the commitment of the team to its ethics and to the dynamics of influence within the group.
In one of the two OR scenario sessions, one participant became quite emotionally affected and left the room and the course for the remainder of the day. On follow-up, we learned that the sight of an OR triggered disturbing memories for this person of a recent hospital experience with a family member. Professional counseling was offered and declined. The participant's concerns appeared to resolve after a private conversation with the person's group leader.
As noted earlier, during the first two sessions applying the ER scenario, participants had difficulty adopting their role as visitors and then as consultants to the CEO. Based on their feedback, we modified the scenario by devoting more time to explain their role beforehand and being explicit that they should act as much as possible as they would in real life. Facilitators introduced the session by speaking explicitly about a “full value contract,” which established participants' agreement to engage in the simulation in ways that would allow them to get the most out of the experience by making it to seem real.16 Even with these improvements, we observed that the participants in the ER scenario were more resistant than those in the OR scenario to the discussion around defensiveness, claiming that they were guests and therefore should not have been expected to speak up.
It was the subjective impression of the facilitators while observing teams during the simulation and subsequent review of transcript data that clinician-managers often had trouble stepping out of their clinician role when faced with a situation that required them to act as managers more than clinicians. Many of the clinicians appeared to have difficulty acting as managers in responding to the challenge posed to them. Their attention frequently remained focused on the immediate needs of the simulated patient. In addition, few teams were able to structure their conversation in a way that efficiently facilitated communication and teamwork.
This use of simulation for teams of leaders, administrators, and managers has objectives that are somewhat different than most other applications of high-realism simulations in healthcare. We are not trying to teach clinical or technical skills. Rather, we are using clinical simulations, both with and without engagement in simulated patient care, to elicit reflection about patient safety, about the teams' usual style of interaction among its members, and about their individual and collective leadership. The team's simulation experience can also aid those who support extending the use of simulation through greater understanding and appreciation for how effective it can be for clinician teams. Generally, the programs in this study were fairly effective in meeting those objectives, with some notable exceptions. Both the successes and failures provide information about how best to use this type of simulation to achieve the intended effect.
The simulations were generally effective at engaging the teams in discussion about their own teamwork and safety leadership and introducing nonclinician teams to patient safety challenges. For the ER/clinician-manager scenario, clear introductory remarks outlining expectations of participants during their visit appeared to enable sufficient immersion into the simulation to provide the necessary experience for useful debriefing.
The ER scenario (10 teams) was created for this training program. It was practiced but was not piloted with naïve subjects due to scheduling challenges. Thus, the early sessions were less developed and had less consistent scripting. In particular, comments from participants of the first two teams suggested that initial instructions were insufficiently clear about their role in visiting the ER. By unfortunate coincidence, the first two teams were the most senior of the 12 participating teams. The debriefings for those two teams were also uncharacteristically charged, especially around the issue of why the teams had not spoken up during the ER observation in the face of breaches in safety. These two teams, and some others, argued that it was unrealistic to expect them to speak up either because their role had not been adequately defined or because it would be unrealistic to expect anyone to speak up on such a consulting visit. This complaint was reflected in slightly more low quality scores from participants for the ER scenario than for the OR scenario.
While it is reasonable to attribute the critical reaction of these first two teams to imperfections in design or implementation of the scenario, it is also possible that the problem was associated with actual deficiencies in the performance of the team, and their reaction was a form of defensive behavior. In evaluating these teams' simulation performance, facilitators noted that these teams had difficulty in separating their clinical and leadership roles and in organizing themselves to facilitate the communication and teamwork necessary to form a coherent safety plan. This finding is striking in relation to prior research, which found differences in safety climate perceptions among senior managers and frontline workers.17 Those investigators suggested that the differences, which were greater among nurses than physicians, may have been because managers (especially nurses) tend to stop performing clinical work after promotion. Clinician-managers in our study perhaps had difficulty assuming their managerial role in the simulation because the scenario may have primed them to assume a clinical mindset. Under these conditions, their clinical training may have caused them to focus more on promoting technical remedies than on the management tasks necessary to maintain safe patient care.3
We have no firm evidence on which to draw a strong conclusion about the cause of the reactions from these first two teams. Still, as a result of the reactions from these first two teams, we altered the script to more explicitly instruct participants to act as members of the staff of the acquiring hospital charged to look at the functioning of the ER of the acquired hospital. Most of the subsequent teams participating in this simulation became engaged, either intervening during the visit in some way or at least, in retrospect, wishing they had become engaged.
For many participants, the simulation provided value in the form of insights about themselves and their leadership. Most teams used the simulations as a bridge to discussing the topic of speaking up, both by themselves and also by how much they encourage their staff to do so. Participants also gained understanding about shifting from blame- to learning-oriented leadership, facilitating communication and teamwork, being welcoming rather than defensive, and other self-reflections.
The resources and experience to conduct these simulations are not fundamentally different than clinical scenarios used for simulation-based crisis resource management programs. Our sense is that only relatively experienced simulation instructor teams should attempt to duplicate a program like this. Yet, there is no fundamental reason that it cannot be duplicated in any well-equipped simulation facility with access to experienced debriefers and confederate actors. While we are not aware of publications describing this type of program, especially one so comprehensive in its objectives and teaching modalities, we are aware of some simulation programs that conduct simulation experiences similar to what we described as demonstrations of simulation for public relations.
We used fairly realistic OR and ER settings employing both mannequin and standardized patients. The scenarios were relatively personnel-intensive in that each used several confederates. The video used to stimulate discussion after the ER visit was easy to create with our simulation faculty and staff. Even with amateur acting, the video was effective in providing the triggers and evidence for the consulting challenge presented in the ER scenario.
Two different facilitators led the ER and OR scenarios. Both were very experienced, amateur actors in simulation. We believe that having some confidence and acting ability is necessary to be convincing in this role. Yet, these qualities are likely available at most simulation programs with experience in conducting relatively realistic clinical simulations.
The debriefings used the style common for debriefing in simulation. The high organizational status of some participants presented some challenges, but these were similar to those of senior clinicians who may be skeptical or resentful of being placed in a potentially embarrassing situation in front of their peers or subordinates.
The instance in which a participant had an intense reaction and left the training session illustrates the risk of emotional trauma from simulation. Our center retains a psychiatrist on retainer to be available for such situations. In the case presented, the trauma appears to have had no lasting effect. However, we must recognize the risk and do what we can to ameliorate it and also be prepared to act when situations do arise.
There are several limitations to this study. There were a limited number of teams and they were all from the same institution. We were not testing any specific hypothesis about the use of scenarios or whether the use of simulations like these was a main determinant of behavior change or the teams' success in carrying out their projects. Rather, we consider this to be a pilot to help further develop the larger safety leadership program based on an intuitive interpretation of the qualitative and survey results. Thus, we do not propose that firm conclusions can be drawn about the impact of the simulation scenarios on the participants or their organizations. We do, however, infer from participant comments that nonclinicians and mixed clinician/nonclinician teams can benefit from participation in a simulated patient care experience. Simulation can convey critical issues about leadership for patient safety, motivate improved teamwork, and demonstrate excitement and the potential impact of simulation on improving quality and safety, all with existing resources and teaching techniques.