Teamwork and team training in the ICU: Where do the similarities with aviation end?

Journal Club Article: Reader, T. W., & Cuthbertson, B. H. (2011). Teamwork and team training in the ICU: Where do the similarities with aviation end?Critical care15(6), 313.

Background

Comparing the lessons learnt and development of team training approaches in the aviation industry to the complex needs of the Intensive Care Unit (ICU). The importance of teamwork and the coordination of behaviours in terms of patient care provided and subsequent outcomes. Higher levels of doctor-nurse collaboration improve safety and mortality rates. The recognised importance of poor communication which has been identified as a factor in medical error.

Team input and team processes = team output

  • Teamwork

“Team skills are important for maintaining safety in both domains, as multidisciplinary teams must work effectively under highly complex, stressful, and uncertain conditions. ”

  • Active & Latent Failures

“team-related ‘active failures’ (for example, failures to communicate the proximity of nearby aircraft) and ‘latent failures’ (for example, lack of team training, poor ergonomic design, and organizational culture) that influence behavior and error in the cockpit.”

  • Decision Making Under Stress

“Techniques include exposing teams to high-stress situations, training pilots to facilitate team discussions before and after stressful team activities, and cross-training aircrew team members to understand the demands and needs of one another’s role. Teams are trained in a multidisciplinary environment…….”

  • Hierarchical Team Structures

The ability to understand other roles, so in stressful events still work together as a team and negative behaviours and attitudes don’t effect performance.

  • Environmental Factors

“Fatigue and stress are known to negatively influence performance in the ICU, and non-technical factors such as team communication, situation awareness, and decision making frequently underlie error.”

Developing a workplace culture based upon safety requires supporting and valuing staff in the high risk environment of ICU, with models of training and supervision that focuses not only on the norms of practice (normative) and educative training, but on restorative and supportive resources to improve stress and burnout, and aid personal development.

Keywords: Intensive Care Unit; Team Performance; Human FactorsTeam Training; Aviation Industry; Cognitive Load; Situation Awareness.

Relevant additional resources around some of the themes identified in this articles to aid collaborative educational teamwork:

 

 

 

The Rise of eSports

eSports 

Moving from the bedroom to filling out stadiums, welcome to eSports. Think this is just a hobby? Think again. With increasing sponsorship and media interest, this a rising sporting extravaganza. Take a read of this great review on the atmosphere and experience attending an eSports event by MishManners.

A little About eSports 

FIFA Interactive World Cup

 

The following is a list of eSports resources and tournaments.

ESPN. (2018). eSports.

FIFA.com (2018). FIFA eWorld Cup 2018.

MishManners. (2018). Australia takes Esports to the Next Level. Hackathon Queen.

Red Bull eSports. (2018). eSports.

Wikipedia. (2018). eSports.

Wikipedia. (2018). Lists of eSports leagues and tournaments.

From the Premier League, Manchester City and West Ham United have signed up an eSports player as member of their squad to represent them in eSports competitions.

 

The Celebrity Millionaires of Competitive Gaming

 

Resus Days

Practice Saving Lives While Playing a Game

Resus Days is a resuscitation game to help healthcare professionals practice some quick-thinking needed for care of cardiopulmonary emergencies. Using gamification to deliver a simulation game for cardiopulmonary resuscitation. Check the below resources, the first level is free to try it out.

The Blurb

Rehearse life-saving decision-making in a fun, game environment. Resus Days is a simulation game for healthcare professionals to practice some quick-thinking needed for care of cardiopulmonary emergencies. You are the team leader in the resuscitation team. Your task is resuscitate the patient until he is back to a normal heart rhythm (normal sinus rhythm). The game includes 7 levels covering cardiac arrest, bradycardia, tachycardia, and simulated megacode. The first level (cardiac arrest) is free to play. If you like it, an in-app purchase will unlock six additional levels.

Keywords: #resuscitology #gamification

The game homepage is: https://resusdays.com

 

 

 

Gaming Addiction: Disorders Due to Addictive Behaviours

As education continues with an increasingly e-learning approach to delivery, its worthwhile to consider some of the precautionary aspects. Gamification and social media may enhance and offer different learning opportunities but the potential to create or exacerbate disorders due to addictive behaviours from gaming addiction, will need to be considered when delivering the e-learning approach and consideration of the well-being of students. Patterns of gaming behaviour when interfering with normal daily activities, and any changes in physical or psychological health will need to be monitored.

World Health Organisation: International Classification of Diseases (ICD)

Disorders due to addictive behaviours from gaming addiction:

“Gaming disorder is defined in the draft 11th Revision of the International Classification of Diseases (ICD-11) as a pattern of gaming behavior (“digital-gaming” or “video-gaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences” (WHO, 2018).

 

Symptoms to monitor:

  • impaired control over gaming (frequency, intensity, duration)
  • increased priority given to gaming
  • continuation or escalation of gaming despite negative consequences

Gamification

Some questions around gaming:

  • Keen gamer or problem with addiction, at what point is too much and does age/maturity need to be factored into the guidelines?
  • How does a sensible mix of connectivity with social media, gaming, work and social time look?
  • The developing technology such as augmented reality (AR), simulation technology and virtual reality (VR). How will they be introduced and controlled?

A quick Google Scholar search using ‘gaming addiction’ shows there are plenty of research papers on this topical subject.

References

Petry, N. M., & O’brien, C. P. (2013). Internet gaming disorder and the DSM‐5Addiction108(7), 1186-1187.

Woodward, A. (2018). The World Health Organization Identifies Gaming Disorder as a Mental Health Condition. Futurism.com

World Health Organisation. (2018). Gaming Disorders.

 

 

 

Simulation Resources To Follow

Simulation is a key component of nursing and healthcare training, and the knowledge base is continually increasing with research publications, conferences, online and social media resources. To aid knowledge translation, the nurse educator needs to embrace a global network of resources not just confined to local knowledge. To keep current on simulation focused research, here are some resources that may help (no conflict of interest to report). As ever please add any suggestions of other resources you know about in the comments section at the bottom of this post and I will update the below resource list.

This post supplements the recent Journals For The Nurse Educator To Follow  and these journals will also include simulation research.

Simulation Focused Journals

Online & Social Media Resources

Clinical Reasoning Cycle

Book Club: Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Clinical Reasoning Cycle

Define reasoning as “the process by which nurses (and other clinicians) collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process”.

“Clinical reasoning is often confused with the terms ‘clinical judgement’, ‘problem solving’, decision making’ and ‘critical thinking’. While in some ways these terms are similar to critical reasoning, clinical reasoning is a cyclical process that often leads to a series or spiral of linked clinical encounters” (pg.4 Levett-Jones, 2013).

Stages of the Clinical Reasoning Cycle

  1. Consider the patient
  2. Collect cues/information
  3. Process information
  4. Identify problems/issues
  5. Establish goals
  6. Take action
  7. Evaluate outcomes
  8. Reflect on process and new learning

Why is this book important?

For nurse training and education delivery, the stages of clinical reasoning can be incorporated into training sessions to discuss the clinical judgments and decision making during a care intervention and applying the ‘nursing process’.  Simulated nursing environments are an ideal educational approach to challenge clinical decision making and clinical reasoning skills. Nurses are the constant presence on the ward level, providing the monitoring and making judgments form the clinical reasoning encounters every shift over a patients hospital journey. Responding to complex and time critical events requires sophisticated abilities which expand further than pure theoretical knowledge, such as assessing and responding to clinical deterioration.

In the current economic drive for cost cutting measures across healthcare (nurses make up the majority of the healthcare workforce, so are often seen as a costly element), the drive to replace with lower skilled, trainees and eventually robots are factors for the nursing profession to consider. Nurses need to be able to understand and explain the role they play and have a voice to raise the profile of what it entails to be a nurse and the efficacy of such skills to maintain levels of care and safety.

Summary

Thinking on the go and decision making are skills to develop over time and with experience but need to be incorporated into nurse training. Nurses with effective clinical reasoning skills have a positive impact on patient outcomes (School of Nursing and Midwifery Faculty of Health, 2009). It’s important to remember, during all this consideration of the patient and reflective process that you (the nurse) are human and as such wont get everything correct all the time.

References

Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Alfaro-LeFevre, R. (2015). Critical Thinking, Clinical Reasoning, and Clinical Judgment E-Book: A Practical Approach. Elsevier Health Sciences.

Interprofessional Ambulatory Care Unit. Clinical Reasoning User Manual. Edith Cowan University.

School of Nursing and Midwifery Faculty of Health (2009) Clinical Reasoning Instructor Resources. University of Newcastle.

Peyton’s 4 Step Approach for Skills Teaching

We have all either delivered or been on the end of a “see one, do one” or “do one, teach one” approach to learning, often delivered in simulation with the aim for skill development. But maybe we should add another two-steps into the approach and follow Peyton’s four-step method. To aid the processing of information (learning) and then apply this new knowledge in context (situational awareness) the four-stage technique can be utilised.

Peyton’s Four-Step Approach: 

1. “The teacher demonstrates the skill at his normal pace without any comments (Demonstration)

2. The teacher repeats the procedure, this time describing all necessary sub-steps (Deconstruction)

3. The student has to explain each sub-step while the teacher follows the student’s instructions (Comprehension)

4. The student performs the complete skill himself on his own (Performance)” (Nikendei et al, 2014).

There are clearly defined instructional steps to guide educator and student. Provides small group or a 1:1 teacher:student ratio for successful instructional training in skills learning sims.

Keywords: Simulation; skills labs; 4-step; experiential learning; technical skills.

References

Bullock, I., Davis, M., Lockey, A., & Mackway-Jones, K. (Eds.). (2015). Pocket Guide to Teaching for Clinical Instructors. John Wiley & Sons.

International Clinician Educators (ICE) Blog. (2017). Effective teaching of technical skills requires more than see one do one. KeyLime podcast No. 142. ICE blog.

Münster, T., Stosch, C., Hindrichs, N., Franklin, J., & Matthes, J. (2016). Peyton’s 4-Steps-Approach in comparison: Medium-term effects on learning external chest compression–a pilot studyGMS journal for medical education33(4).

Nikendei, C., Huber, J., Stiepak, J., Huhn, D., Lauter, J., Herzog, W., … & Krautter, M. (2014). Modification of Peyton’s four-step approach for small group teaching–a descriptive study. BMC medical education14(1), 68.

Walker, M., & Peyton, J. W. R. (1998). Teaching in theatre. Teaching and learning in medical practice. Rickmansworth, UK: Manticore Europe Limited, 171-180.

Wang, T. S., Schwartz, J. L., Karimipour, D. J., Orringer, J. S., Hamilton, T., & Johnson, T. M. (2004). An Education Theory–Based Method to Teach a Procedural Skill. Archives of dermatology140(11), 1357-1361.

 

 

The Stress Curve (Yerkes and Dodson Law)

Background History

“Yerkes-Dodson law from 1908 to the present. In its original form, the law was intended to describe the relation between stimulus strength and habit-formation for tasks varying in discrimination difficultness. But later generations of investigations and textbook authors have rendered it variously as the effects of punishment, reward, motivation, drive, arousal, anxiety, tension or stress upon learning, performance, problem-solving, coping or memory; while the task variable has been commonly referred to as difficulty, complexity or novelty, when it is not omitted altogether” (Teigen, 1994).

Stress Curve By Yerkes and Dodson 1908

OriginalYerkesDodson

Pressure & Performance

There are four main influencers related to pressure and performance:

  1. Skill Level.
  2. Personality.
  3. Trait Anxiety.
  4. Task Complexity.

The perception of stress from the individual can trigger the innate fight or flight response.

For The Educator

  • Remember stress can be both a negative and positive experience. This stress theory can link to ’emotional intelligence’ of the individual, well-being and potential for burnout.
  • Simulation sessions can be set up to challenge the learner along the stress curve. The educator must be aware of how they can positively or negatively influence the learners experience.
  • The environment can also impact on stress and perceived threats (culture, unsafe workplace such as violence).
  • For the educator. the question when to challenge the learner and when to step back is very difficult and will require regular review and feedback from the learner and the wider nursing team. Its good to provide a challenge, with the required supports but dropping the learner into an unsupported situation may backfire and effect confidence. Also learners (nurses) are people and have personal lives and so sometimes private life issues means the level of stress the person is experiencing renders learning negligible. This is the time to step off the learning curve, give an extension and put supports in place and to regroup at an appropriate time. Provide a personal approach to learning, not one fitted around traditional university semester timetables.

Keywords: Resilience, mindfulness, stress curve; burnout; Yerkes and Dodson Law.

References

Gibbons, C., Dempster, M., & Moutray, M. (2008). Stress and eustress in nursing students. Journal of Advanced Nursing, 61(3), 282-290.

Intensive (2017) Training for Stress.

Selye, H. (1956). The stress of life.

Teigen, K. H. (1994). Yerkes-Dodson: A law for all seasons. Theory & Psychology, 4(4), 525-547.

Watson, R., Gardiner, E., Hogston, R., Gibson, H., Stimpson, A., Wrate, R., & Deary, I. (2009). A longitudinal study of stress and psychological distress in nurses and nursing students. Journal of Clinical Nursing, 18(2), 270-278.

Wikipedia (2017) Yerkes-Dodson Law.

Tag Team Simulation: Journal Club

Journal Club Article: Levett-Jones, T., Andersen, P., Reid-Searl, K., Guinea, S., McAllister, M., Lapkin, S., … & Niddrie, M. (2015). Tag team simulation: An innovative approach for promoting active engagement of participants and observers during group simulations. Nurse education in practice, 15(5), 345-352. [abstract]

Rationale for the Study

The authors state that “when simulations are conducted in large groups, maintaining the interest of observers so that they do not disengage from the learning experience can be challenging. We implemented Tag Team Simulation with the aim of ensuring that both participants and observers had active and integral roles in the simulation.”

Background 

“However, in nursing programs, where there may be hundreds of students, resource limitations often lead to simulations being conducted as group activities. Evidence suggests that when this happens, learners who take on an observer role instead of being an actual participant in the simulation, can lose interest and disengage from the learning experience” (Kettlewell, 2012; Harder et al., 2013).

The importance of active participation in education and simulation is highlighted. However, in simulation an observing role from watching through one way glass, auditorium or via video conference is part of increasing engagement and providing an alternative view or ‘lens’ from the non-active members. Learning can occur from this observation aspect, but the authors highlight the issue of a passive role, less immersion and boredom ensuing.

One of the most innovative parts of this article is that the idea was taken from performative theatre. It’s really interesting to take ideas from other professional fields and try them in the nursing environment and take some risks and consider new approaches to education delivery.

Tag Team Simulation (TTS)

“TSS is designed for groups of approximately 20 learners, with each participant and observer having a specific, active and integral role in the simulation.

  1. The narrator/director (the educator).
  2. The protagonist  (leading character- trained simulator actor, student or educator).
  3. The actors (the students).
  4. The audience (active observers).
  5. The set ( an authentic learning environment with high level of fidelity).
  6. The play (simulation scenario)

One of the unique features of TTS is that there are no formal scripts. The TTS play is comprised of a prologue, two acts, an intermission, a debrief and an epilogue.”

Results

The Satisfaction with Simulation Experience Scale (SSES) was used to measure student’s perceptions.

444 second year nursing students submitted the surveys from a population of 536 giving a response rate of 83%.

“The results of an independent sample t test revealed that those who participated in the simulation experience (the actors) reported slightly higher satisfaction with the simulation experience than observers (audience). However, the difference was not statistically significant on the SSES or any of the three subscales.”

Take Home Messages from the Article:

  • Simulation observers can lose interest and disengage from the learning experience.
  • Tag Team Simulation ensures that both participants and observers have equally active and integral roles in simulation.
  • A Tag Team pain simulation implemented with second year nursing students revealed no significant difference in satisfaction scores.

Summary

The holy grail for the perfect education approach continues, but this is a reasoned approach to the very real challenge of large group sessions and how to improve the educational approach. One question that I would like to know in regards to nurse training, relates to the increasing deregulation on the number of nursing enrollments in higher education and universities and the impact on the quality of education (I presume this is becoming a global phenomena with the predicted global nursing shortage?). Many simulation courses provide a 1:6 or 2:6 instructor to participant ratio for a quality learning experience. Is this article just responding to changing times and the stretch on nurse education resources?

Keywords: Tag Team Simulation; TTS; Simulation;active participation

Reference

Levett-Jones, T., Andersen, P., Reid-Searl, K., Guinea, S., McAllister, M., Lapkin, S., … & Niddrie, M. (2015). Tag team simulation: An innovative approach for promoting active engagement of participants and observers during group simulations. Nurse education in practice, 15(5), 345-352. [abstract]

Minecraft & Gamification

Now I am not a gaming person but for skills of the future I have decided for my own personal development, that my aims for the coming 12- 24 months are to engage in gaming environments (Minecraft to start) and also learn some basic coding skills. Hopefully you find these resources useful when starting out, if you know of any others please post them in the comment section at the bottom of this post. When I somehow find some spare time to commence coding I will create a post with links to any of the resources I have used (I aim to learn using open access resources so it will all be free).

For those in school education, there is also a Minecraft Education edition that promotes an online world with collaboration and problem-solving in an immersive environment.

Keywords; gaming, immersive, problem-solving, collaboration, Minecraft.

Resources

DigMinecraft (2017) Getting started in Minecraft.

Minecraft (2017) Minecraft Official Site.

Minecraft Education Edition (2017) What is Minecraft Education.

Wikipedia (2017) Minecraft.