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Why simulation-based team training might be a bad idea……

By: Victoria Brazil (@SocraticEM)

Healthcare teams improve if they practice in simulation, right?

Simulation is considered a great way to train healthcare teams, especially in acute care settings. But simulation programs require significant faculty expertise and institutional resources, and the paucity of ‘hard evidence’ for them is sometimes glossed over, with simulation faculty lamenting …. “it’s hard to prove.”

I remember my first experience of being a participant in a crisis resource management (CRM) simulation course. It was the first time I had experienced emergency medicine doctors and nurses learning together.It was scary but exciting. We were talking about stuff I knew was important but had never discussed in a resus room or education session – putting words to vague concepts of teamwork, leadership and communication. And bonding with the team!

I finished the course as a zealot for the cause.

But, 16 years on….. I begin to wonder.. Maybe there are there right and wrong ways to do simulation-based team training?

In that spirit, I offer six reasons why you shouldn’t do simulation-based team training!

  1. If your interprofessional team training is really just using nurses as props for doctor training?

All too often simulation scenarios (and entire curricula ) are designed around medical decision-making and ‘medical expert’ content, with debriefing conversations that match. Nursing and medical learning objectives are written separately (if at all), and designated nursing debriefers are asked for input on ‘nursing issues’. This is often well intentioned, but may impede progress toward true collective competence.

What does better look like?

It’s hard. Balanced contributions from an interprofessional delivery team, faculty development for doctor and nurse educators, and sharing in cleaning up and keeping the sim room in order! Design based on team challenges and departmental performance issues – not just difficult procedures or decisions for doctors. And evaluation that includes measures of Relational Coordination – shared knowledge, shared goals, and mutual respect.

We’ve all seen the perky team leader at the end of the bed in simulation scenarios – recapping, asking for team member suggestions, allocating roles, closed loop communicating – but all in an exaggerated, melodramatic manner. Often followed by a debriefing conversation which feels like we’re reading from a script – “Our team work was good….”, “I really liked Dr Eng’s leadership”.. “Our roles were clear” – while the patient quietly died without being defibrillated.  And this charade can be aided and abetted by debriefers who talk in ways that are weird – telling us “it’s a safe space”, and being endlessly ‘curious’…  The simulation has become a show of behaviours everyone has come to expect in simulation, but which don’t always translate to the real world.

What does better look like?

Maybe windingback the ‘sim voodoo’ and having real conversations. Blending sound debriefing principles into the kind of conversations we’d have on the floor or in the tea room. Engendering the learners with an expectation of deeper discussion – asking what they mean when they say “great leadership” and why….

Are your simulation debriefings limited to the list of CRM behaviours on the wall of your debrief room? Is that all there is to teamwork? Is your best move just exhortation to do more of situational awareness, closed loop communication or to ‘knowing your environment’?

What does better look like? Just because we work in teams does not mean we have a deep understanding of them. Crisis Resource Management is a great start to thinking about teamwork, but if we’re doing team training, we’re going to need a broader repertoire of concepts and reading.

 A bit of theory is also useful here. We shouldn’t desert our social constructivism just because the focus is teamwork. We know that simply ‘norming’ a team toward different behaviours is hard – change requires a big dose of simulation, together with a much smaller contextual gap to real world practice. ‘Making meaning’ is smarter, but much harder. Read more about organisational learning to consider better approaches.

Are you so keen for your learners to have a good experience in simulation that you demand to hear  ‘what went well’ in the debrief, don’t mention  any observed poor performance (or skirt around it), or offer your own excuses for the team’s performance gaps. Are you repeatedly telling your learners what a ‘safe space’ your debrief room is?

What does better look like? Psychological safety is critical for learning and improvement, but a little misunderstood. Create that psychological safety slowly and consistently – building trust with your clinical and simulation teams over time – and by actions as much as words. But also have the integrity to name performance gaps.  

Congratulations – you’ve got your in situ simulation program up and running and you’ve uncovered 600 latent safety threats in the first 2 months of running it… and sent the report off to your department chair. But you had to include some less positive outcomes of the program-  the medical emergency call that mistakenly went out for the sim, and which pulled the code team away from a real patient; the outdated nasogastric feed used as a sim prop that was given to a real baby after it was left out in the clinical area; the simulated patient who sustained a minor head injury after the behavioural emergency scenario that the security staff weren’t aware was a sim.

What does better look like? Get serious about having a simulation safety policy, a sim safety briefing, some ‘no-go’ criteria for your in situ sim, and a ‘safety first’ attitude from your sim team.

Where’s the debrief after your last (real) rapid sequence intubation? After your last procedural sedation? After your last ward round?. These are missed opportunities for reflecting on team performance, especially given your expensive debriefing qualifications, and hard acquired expertise. We know the problems – no time?, no one wants to do it?, ”But nothing bad happened, why do we need a debrief?

What does better look like? This is also hard. But ideally –a clear objective, and a carefully designed, consistent process for short conversations after specific ‘triggers’, and with leadership level support and frontline ability to lead these conversations.

So, should you be doing simulation-based team training?

Yes! Even if you (like me) are still making lots of these mistakes. But let’s commit to thoughtful and rigorous reflection on how we do it

~Victoria Brazil

With acknowledgements to Eve Purdy (@purdy_eve), Belinda Lowe (@Belinda_J_Lowe) and Warwick Isaacson (@WarwickIsaacson)  for their comments and feedback on this article.

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The Royal College of Physicians and Surgeons of Canada. For more details on our site disclaimers, please see our ‘About’ page

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