Optimal team dynamics and leadership skills are important, trainable factors in patient resuscitations.1–3 Although patient physiology plays a big role in successful resuscitations, strong leadership, early planning, and role allocation benefit team performance,4,5 which has been correlated with improved medical outcomes.3,6 This is particularly important for rising trainees in emergency medicine, critical care, and other specialties that train for the code team leader role.
Multiple methods to quickly train trainees to an acceptable level of competency have been implemented to prevent the “July effect,”7 including boot camps and intensive orientation sessions.8,9 As part of the orientation exercise, we introduced a unique game modification using game cards that provided private information to participants. The content of the cards could specify a predetermined code team role—both in a constructive and in a destructive manner—as well as instructions on how to behave during the code. The game cards acted independent of the scenario, patient physiology, or medical outcome as they rapidly created communication problems that required problem solving in addition to the clinical care required. The purpose of this article was twofold: to summarize the theoretical underpinnings on why and how these game cards teach teamwork and communication and to describe our participant feedback when used with typical mannequin-based simulation scenarios.
Resuscitation team training is a common simulation exercise.8,10 The initial team assembly and the first minutes of a resuscitation tend to be very standardized: determination of a code leader, assignment of roles for other healthcare providers, and assessments of airway, breathing, and circulation.1,2 Insufficient team coordination and lack of early planning are associated with poor resuscitation outcomes,3 making the planning stage a critical construct for practice.
Confederates are used in simulation exercises for multiple reasons. Confederates are actor participants standardized for the scenario and are designed to contribute to the psychological fidelity of the scenario.11,12 A well-trained confederate can improve the quality of the scenario or assist poorly performing participants13 but requires significant personnel and preparation.14 When all participants within a scenario are engaged in role play, the shared experiences improve bonding among participants and facilitate reflection during debriefing.14 The use of cue cards to standardize confederates is common in simulation-based research but not necessarily in simulation-based education.15 We decided to use game cards to turn simulation participants into confederates, for the purpose of emphasizing problem solving in code team communication.
We proceeded to develop cards using principles of serious gaming, the branch of game development that seeks to maximize learning among participants.16,17 For example, successful learning through gaming requires several attributes as follows: relevance, incremental difficulty, and a fantasy element.16 Cards in each set designated a role, action, or a disruptive behavior for each participant to artificially disrupt team dynamics, thus simulating elements of failed teamwork described in the literature, including dual or unclear leaders,18 insufficient communication of plans,3,19 and inability to share information.19,20 All cards depicted a version of a real and known communication mishap or problem. We also purposefully chose the order in which the card sets progressed, so as to start with relatively simple communication problems and then escalate to pose incremental challenges.16,17,21 The fantasy element was provided by developing cards that added hyperbole or exaggeration that potentially improves engagement, attention, and learning.16,17 A controlled exaggeration of learning points has also been shown to improve pattern recognition and problem solving skills.22
The primary author (T.P.C.) initially drafted 40 card sets. Each set consisted of 7 cards that designated roles, actions, or behaviors for code team participants. Other authors provided iterative feedback, ultimately choosing 23 card sets divided into 5 series of increasing difficulty. We envisioned these cards for use in sequential fashion with similar teams. Each series introduced different types of barriers exemplified in resuscitation teams described in the literature.
- ○ Series 000–002 (3 sets) preassigns simple roles for code leader and airway.
- ○ Series 100–104 (5 sets) introduces geographical/temporal barriers.
- ○ Series 200–203 (4 sets) constrains typical communication strategies.
- ○ Series 300–303 (4 sets) forces leaders to address suboptimal or harmful performance.
- ○ Series 400–406 (7 sets) forces leaders to overcome disruptive team behaviors.
Example card sets for each series are shown in Table 1 (Supplemental Digital Content 1, http://links.lww.com/SIH/A216, which details all 23 card sets, each set was designed to have 7 cards).
Game Card Setup
We piloted the cards with a 2-hour simulation during our own pediatric emergency medicine fellows’ orientations in 2013 and 2014 with postgraduate year 4 to 6 fellows. We applied game card scenarios to emphasize team skills, not necessarily medical or procedural skills. Our scenarios used elements similar to rapid cycle deliberate practice23 with a very simple scenario requiring only chest compressions and/or bag-valve-mask ventilation. However, the cards are also apt for any longer or more complicated scenario because they are agnostic to the physiology within the resuscitation. Some cards had a preassigned role, for example, “Code Captain” or “Airway”; others had actions, for example, “You are not allowed to speak”; and the rest were left blank. Blank cards denoted no particular restriction or guidance regarding code performance, and participants behaved as they chose. Table 1 provides some examples of the card sets, and the full set is available as a Supplemental PDF, http://links.lww.com/SIH/A216.
Supervisors and debriefers chose the card set and card set order before initiating the scenarios. Each participant was instructed to randomly draw a card and follow all instructions on the card without sharing its contents. Participants drew their card, viewed it, and then silently returned the cards back to the simulation staff in preparation for the scenario briefing.
Debriefing Game Cards
After each scenario, we provided focused direct feedback that elicited reflection and feedback on the card limitations.24 All participants were required to disclose the game card content. The code captain was asked to comment on her performance, with strategies for improvement. Other team members described difficulties and solutions and how the limitations imposed by the game cards reflect real-life resuscitations.
In addition, the debriefers facilitated a broader summative debriefing on the overall experience,24,25 allowing participants to examine the cognitive and social frameworks of their actions. Participants and supervisors were asked to state 2 behavioral modifications to use in their subsequent clinical performances.
In our experience, multiple card sets with incremental difficulty should be used for multiple short scenarios because these provide opportunities to practice new communication techniques learned from a previous card set. Teamwork exercises that emphasize the complexity of a longer scenario require only one or a few relevant card sets.
Observations About Game Cards
As the scenarios progressed, participants noted faster assignments of roles and louder, more direct communication. In scenario 406, for example, all cards were labeled “Code Captain”: when the team realized that multiple code leaders were present within 3 seconds, new roles were rapidly assigned, and a normal resuscitation team assembled thereafter. They further reflected that confusion over the code team leadership role occurs quite frequently, particularly with groups of health care providers at the same rank.
For card sets 200–203, which established communication barriers (eg, code leader outside the room), code leaders counteracted by using closed-loop feedback to confirm findings and completed actions and used a stronger, more direct tone. Furthermore, it was noted that even in later scenarios, code leaders maintained this type of communication style despite the absence of obvious communication barriers.
We also noted increasing specificity of commands. In the 300-series card sets, which designated certain participants to sabotage the resuscitation, code leaders began to more readily identify “poor performers.” One participant became more aware of nearby idle participants who could help correct or take over for another participant performing poor bag-valve-mask ventilation; she reflected on the need for “situational awareness” of all participants.26,27
Another participant noted that in progressive scenarios, participants began to anticipate problems and barriers. In card set 404, when 2 participants maintained an unacceptable noise level, the code leader quickly instructed another team member to escort the distractors away while maintaining the resuscitation. They reflected on the need to quickly resolve impending barriers to functional teamwork.
Final remarks from debriefing concerned card set 401, in which no code captain was preassigned but any code captain who emerged had to close her eyes for the scenario. Participants reflected on the exaggerated but realistic foundation of the underlying problem: for example, real resuscitations in which captains were not tall enough to see the patient or in smaller teams which required code captains to participate in a focused task in addition to leading the code. One observed solution was to publicly acknowledge the barrier: “I cannot see; please tell me what you are finding.” Participants wrestled with the notion of acknowledging deficits as a code captain but eventually concurred that code captains should reveal any misunderstanding or uncertainty within the scene.
We describe the implementation of game cards to encourage participants to become their own confederates. Our overarching goal was to provide a safe, educational setting for advanced trainees in pediatric emergency medicine to improve communication in resuscitation. The cards, however, can be extrapolated for use in situations and locales with different departments, participants, and team sizes. Suboptimal communication can threaten patient safety in any high-acuity environment where ad hoc teams with new or inexperienced staff are common.28 Code leaders who facilitate team input create safer patient environments, and the game cards can encourage this behavior in simulations.29,30 The relative safety of simulation and the competitive yet collaborative atmosphere provided by the game cards created an engaging interactive experience for our fellows. Based on subjective feedback, we noted improvements in communication, specifically closed-loop communication.9
The game cards worked well in our session because we outlined clear goals, creating easy opportunities for reflective feedback and engaging debriefing. This is because most teamwork building exercises and simulations rely heavily on reflective debriefing.19,28,29 Game cards provide an opportunity to experience a “bad communication event” in a safe, engaging arena.
We believe the experience level of the participants is a factor when considering the use of game cards. We used Dror’s concepts of exaggeration as a facilitation for learning,22 which is similar to the fantasy attribute described by Garris et al.16 Although blindfolds and other theatrical additions are not part of a real resuscitation, they are exaggerated symbols of the real communication problems that can be discussed in summative debriefing.19,20 Although the blindfold made the scenario “fun” and engaging, the participants were experienced enough to discover and implement practical solutions. This was possible because the 6 participants had experience with resuscitations and had encountered these barriers before; therefore, they were able to develop novel “scripts” and creative solutions. At their level, the learners are expected to develop pattern recognition and to correct or change plans in the face of new information, such as those introduced by the novel use of game cards in resuscitation simulations.31,32 A proficient learner is expected to develop communication solutions during the scenario, which are practical and applicable to real resuscitations, whereas a novice learner deficient in real resuscitation experience may not connect what is learned within the exaggerated framework with real-world situations. This is not to say that game cards should not be used in more novice or beginner learners—these attributes are still engaging and facilitate active participation16—but a different debriefing strategy may be required to connect their simulated performance to real performance. We decided to use 2 types of debriefing for our more advanced learners—the directive, rapid debriefing with the comprehensive, summative debriefing because of their complementary benefits.33
It is not expected that a single training session to mastery would last throughout the year and even their careers, even for simple procedural training.34 A more long-term model to improve retention is to perform high-frequency refreshers, as demonstrated by Sutton et al.35 Further study is needed to find actual performance changes in resuscitations from the use of these game cards.
We introduce the use of game cards for participants to become their own confederates as an additional method to teach and improve resuscitation communication, teamwork, and technical skills; it is grounded on the learning paradigms used in gaming and debriefing. It can also be used with any scenario or with any group of participants within a simulation. The use of game cards to modify simulation scenarios should be considered as a team-building exercise to target communication and teamwork skills.
1. Berg M, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation
2010; 122: S862–S875.
2. Berg R, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation
2010; 122: S685–S705.
3. Fernandez Castelao E, Russo SG, Reithmüller M, Boos M. Effects of team coordination during cardiopulmonary resuscitation: a systematic review of the literature. J Crit Care
2013; 28: 504–521.
4. Cooper S, Wakelam A. Leadership of resuscitation teams: “Lighthouse Leadership”. Resuscitation
1999; 42: 27–45.
5. Marsch S, Muller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation
2004; 60: 51–56.
6. Yeung J, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med
2012; 40: 2617–2621.
7. Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. “July effect”: impact of the academic year-end changeover on patient outcomes: a systematic review. Ann Intern Med
2011; 155: 309–315.
8. Cohen E, Barsuk JH, Moazed F, et al. Making July safer: simulation-based mastery learning during intern boot cAMP. Acad Med
2013; 88: 233–239.
9. Delac K, Blazier D, Daniel L, N-Wilfong D. Five alive: using mock code simulation to improve responder performance during the first 5 minutes of a code. Crit Care Nurs Q
2013; 36: 244–250.
10. Nishisaki A, Hales R, Biagas K, et al. A multi-institutional high-fidelity simulation “boot camp” orientation and training program for first year pediatric critical care fellows. Pediatr Crit Care Med
2009; 10: 157–162.
11. Sanko JS, Shekhter I, Kyle RR Jr, Di Benedetto S, Birnbach DJ. Establishing a convention for acting in healthcare simulation: merging art and science. Simul Healthc
2013; 8: 215–220.
12. Dieckmann P, Gaba D, Rall M. Deepening the theoretical foundations of patient simulation as social practice. Simul Healthc
2007; 2: 183–193.
13. Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a “reader?” improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study. Simul Healthc
2012; 7: 1–9.
14. Shapiro J, Hunt L. All the world’s a stage: the use of theatrical performance in medical education. Med Educ
2003; 37: 922–927.
15. Cheng A, Auerbach M, Hunt EA, et al. Designing and conducting simulation-based research. Pediatrics
2014; 133: 1091–1101.
16. Garris R, Ahlers R, Driskell JE. Games, motivation, and learning: a research and practice model. Simul Gaming
2002; 43: 118–132.
17. Wilson K, Bedwell WL, Lazzara EH, et al. Relationships between game attributes and learning outcomes: review and research proposals. Simul Gaming
2009; 40: 217–266.
18. Sarcevic A, Marcis I, Waterhouse LJ, Stockwell DC, Burd RS. Leadership structures in emergency care settings: a study of two trauma centers. Int J Med Inform
2011; 80: 227–238.
19. Sawyer T, Laubach VA, Hudak J, Yamamura K, Pocrnich A. Improvements in teamwork during neonatal resuscitation after interprofessional TesmSTEPPS training. Neonatal Netw
2013; 32: 26–33.
20. Kakatam L, Trickey AW, Thomas EJ. Speaking up and sharing information improves trainee neonatal resuscitations. J Patient Saf
2012; 8: 202–209.
21. Bedwell WL, Pavlas D, Heyne K, Lazzara EH, Salas E. Toward a taxonomy linking game attributes to learning: an empirical study. Simul Gaming
2012; 43: 729–760.
22. Dror I, Schmidt P, O’Connor L. A cognitive perspective on technology enhanced learning in medical training: great opportunities, pitfalls and challenges. Med Teach
2011; 33: 291–296.
23. Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, et al. Pediatric resident resuscitation skills improve after “rapid cycle deliberate practice” training. Resuscitation
2014; 85: 945–951.
24. Rudolph J, Simon R, Dufresne RL, Raemer DB. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc
2006; 1: 49–55.
25. Rudolph J, Simon R, Raemer DB, Eppich WJ. Debriefing a formative assessment: closing performance gaps in medical education. Acad Emerg Med
2008; 15: 1010–1016.
26. O’Leary F, McGarvey K, Christoff A, et al. Identifying incidents of suboptimal care during paediatric emergencies-an observational study utilising in situ and simulation centre scenarios. Resuscitation
2014; 85: 431–436.
27. Greig PR, Higham H, Nobre AC. Failure to perceive clinical events: an under-recognised source of error. Resuscitation
2014; 85: 952–956.
28. Risser D, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Ann Emerg Med
1999; 34: 373–383.
29. Eppich W, Brannen M, Hunt EA. Team training: implications for emergency and critical care pediatrics. Curr Opin Pediatr
2008; 20: 255–260.
30. Krug S, Frush K. Patient safety in the pediatric emergency care setting. Pediatrics
2007; 120: 1367–1375.
31. Carraccio C, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. 2008; 83: 761–767.
32. Croskerry P. The theory and practice of clinical decision-making. Can J Anesth
2005; 52: R1–R8.
33. Van Heukelom JN, Begaz T, Treat R. Comparison of postsimulation debriefing versus in-simulation debriefing in medical simulation. Simul Healthc
2010; 5: 91–97.
34. Kessler DO, Arteaga G, Ching K, et al. Interns’ success with clinical procedures in infants after simulation training. Pediatrics
2013; 131: e811–e820.
35. Sutton RM, Niles D, Meaney PA, et al. Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers. Pediatrics
2011; 128: e145–e151.