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Pediatr Qual Saf
Pediatr Qual Saf
PQS
Pediatric Quality & Safety
2472-0054
Lippincott Williams & Wilkins Hagerstown, MD

PQS-D-24-00022
00006
10.1097/pq9.0000000000000767
3
Patient/Employee Safety
Focused Team Engagements to Enhance Interprofessional Collaboration and Safety Behaviors among Novice Nurses and Medical Residents
Manuel Rosalyn MSN, BSN, CHSE *
Barber Aisha MD †
Kern Jeremy MD †
Myers Kristi MSN, RN, CPN ‡
Neary Tara MD §
Nicholson Laura MSN, RN, CHSE, CPN *
Walsh Heather MSN, RN, PCNS-BC, CHSE-A, CPN *
Zaveri Pavan MD, MEd, CHSE-A §
Dwivedi Pallavi MS, MPH ¶
Maggiotto Claire MD ‖
King Simmy DNP, MS, MBA, NI-BC, NE-BC, CHSE, FAAN *‡**
* Simulation Program, Children’s National Hospital, Washington, D.C.
† Division of Hospital Medicine, Children’s National Hospital, Washington, D.C.
‡ Nursing Education and Professional Development, Children’s National Hospital, Washington, D.C.
§ Division of Emergency Medicine, Children’s National Hospital, Washington, D.C.
¶ Division of Biostatistics & Study Methodology, Children’s National Hospital, Washington, D.C.
‖ Division of Pediatric Critical Care, Children’s Hospital of Wisconsin, Milwaukee, Wis.
** Division of Nursing, Children’s National Hospital and Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, D.C.
*Corresponding author. Address: Rosalyn Manuel, MSN, BSN, CHSE, Simulation Program, Children’s National Hospital, Washington, D.C. Email: rmanuel@childrensnational.org
Sep-Oct 2024
09 9 2024
9 5 e76720 2 2024
18 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background:

Team communication remains a challenge in hospital settings. Hospital-based teams are diverse, team composition changes daily, and team members are frequently not co-located. Novice nurses and medical residents entering the workforce during the coronavirus 2019 pandemic experienced higher communication challenges than before and lacked adequate opportunities for interprofessional learning and communication.

Method:

We evaluated perceptions of safety and communication among novice nurses and medical residents after a 1-hour focused team engagement consisting of an interprofessional virtual simulation and debrief. We conducted a retrospective pre/post survey to measure perceptions of interprofessional collaboration using the Interprofessional Socialization and Valuing Scale.

Results:

Sixty-eight pediatric nurse residents and medical residents participated in the survey. Overall, the focused team engagements significantly improve participants’ perceptions of interprofessional collaboration, with participants showing statistically significant improvement in seven of nine retrospective pre/post survey questions. When analyzing by discipline, nurse residents show stronger gains than medical residents.

Conclusions:

The interprofessional structured debriefings encourage nurses and medical residents to collaborate and discuss important safety topics away from bedside stressors. After completing the virtual simulation, the outcomes show improved perceptions of interprofessional collaboration and enhanced knowledge of safety techniques.

OPEN-ACCESSTRUE
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pmcINTRODUCTION

Frontline clinicians must be prepared to work collaboratively and effectively in interprofessional teams to recognize patient safety events and intervene as required. A primary challenge to optimal patient outcomes is communication between interprofessional team members in hospital settings.1 Hospital-based teams are diverse, team composition changes daily, and team members are frequently not co-located. This variability often results in poor team communication, leading to tragic consequences. Risk data shows that communication failures are a primary factor in 70% of adverse events and attributed to 37% of high-severity injury cases.2 The Joint Commission also reports that failures in communication, teamwork, and consistent policy adherence are the leading causes of sentinel events.3 Common barriers to effective team communication include varying communication styles, egos, and lack of confidence.4

Nurses and physicians are trained differently and often transition into practice-based environments with minimal interprofessional learning opportunities focused on teamwork and communication.4 During the coronavirus 2019 (COVID-19) pandemic, many schools halted in-person learning, including in-person clinical placements, which exacerbated communication challenges. As less experienced nurses and physicians entered practice, it became evident they struggled with effective communication with peers, interprofessional teams, and patients and families. This new challenge heightened the need to develop and implement effective interprofessional team training focused on patient safety, communication, building confidence, and addressing variations in communication styles and expectations among clinicians.

Children’s National Hospital is a 323-bed free-standing academic Magnet-designated pediatric hospital in Washington, D.C. The nurse residency program has supported newly licensed registered nurses’ transition into practice since 2001. The program includes many learning opportunities to develop nurse resident interpersonal relationships, teamwork, and communication skills. In 2020, as nurse residents entered the workforce, the impact of school closures and limited clinical learning experiences was amplified when they began vocalizing their lack of confidence and comfort in communicating with interprofessional team members. These data were validated by the self-reported question on the Casey-Fink Graduate Nurse Survey (2006),5 which asks if the nurse resident feels confident communicating with physicians/nurse practitioners. Pre-data from the 2020–2021 cohorts showed that they disagreed with feeling confident (average score of 2.3 on a five-point Likert scale). In-class discussion revealed that many nurse residents did not know what to say to providers, especially when questioning or escalating care. Some shared that they had never spoken to a provider before joining the workforce because their learning had been exclusively virtual and/or simulation-based, a common trend during the pandemic.6 Similarly, the medical residency leadership team identified a need for the medical residents to better understand the nurse’s role, and how to improve interpersonal relationships between nurses and doctors. They also found that medical residents graduating during the pandemic were experiencing similar challenges with communication.

This gap led to the development and implementation of an interprofessional learning activity aimed at improving interprofessional relationships and confidence in interprofessional communication. This article will describe how a facilitated conversation among novice interprofessional clinicians about a patient safety event was used to evaluate and improve interprofessional socialization, communication, and teamwork.

INTERPROFESSIONAL LEARNING

The Interprofessional Education Collaborative (IPEC) is a common framework for interprofessional learning.7 This framework includes four core competencies for interprofessional collaborative practice: (1) Values/Ethics for Interprofessional Practices, (2) Roles/Responsibilities, (3) Interprofessional Communication, and (4) Teams and Teamwork.7 The core values serve as a foundation for interprofessional learning and aim to achieve interprofessional collaboration to advance patient outcomes. Additionally, teamwork can be fostered through interprofessional socialization, creating opportunities for understanding, and appreciating professional roles.

The National Collaborative for Improving the Clinical Learning Environment (NCICLE) Pathways to Excellence: Expectations for an Optimal Interprofessional Clinical Learning Environment to Achieve Safety and High-Quality Patient Care is another framework healthcare systems can use to improve the clinical learning environment.8 The pathways include: (1) Patient Safety, (2) Health Care Quality, (3) Teaming, (4) Supervision, (5) Well-Being, and (6) Professionalism,7 and emphasize the important interface between learners and healthcare settings. This framework and the IPEC framework serve as the foundation of our interprofessional education curriculum.

METHODS

Participant Eligibility/Institutional Review Board Approval

Eligible participants include nurses with less than 1 year of experience (nurse residents) who started after March 2021 and first-year physicians (medical residents) who started after July 2021. This study was reviewed and approved by the institutional review board as exempt.

Learner Strategy

One-hour team-engagement sessions are offered once per resident block (monthly) from December 2021–December 2022. We use an open-sourced team engagement case from the Global Network for Simulation in Healthcare for each session. Global Network for Simulation in Healthcare is an international organization dedicated to patient safety, workforce well-being, and healthcare quality.9 Each session focuses on collaboration and safety behaviors through socialization, team communication, and engagement skills.9 Nurses and medical residents review a prerecorded scenario of a safety event resulting in a patient’s demise, followed by a structured debriefing that allows participants to reflect on safety techniques that could have changed the outcome. Each session includes three to eight nurses and two to four medical residents. Medical residents are preassigned during an identified clinical rotation to maximize attendance and granted protected time to attend. Similarly, nurse residents attend a session as a requirement of the Nurse Residency Program.

Sessions are held via videoconferencing platform and co-facilitated by a nurse and a physician, primarily nursing professional development specialists, simulation education specialists, and hospitalists. Facilitators have prior experience in debriefing, including participation in debriefing workshops, simulation consortia, and professional development opportunities. A comprehensive facilitator’s guide was developed to structure the sessions and debriefings. Facilitators participated in a facilitator training session to ensure comprehension of the guide and standardization of content delivery.

Educational Intervention

Participants are guided through the story of Lewis Blackman, who died tragically after routine surgery, resulting from his healthcare team’s failure to recognize his decline, lack of escalation, and general miscommunication. Then, facilitators lead a structured debriefing to reflect on preventing a comparable situation. Safety behaviors and techniques, such as closed-loop communication, the escalation algorithm, and shared mental models, are discussed as means to reduce mortality and rapid emergency transfers.10 The sessions also address distractions such as monitor alarms, phone notifications, and call bells, which can contribute to alarm fatigue and clinicians inadvertently ignoring important warnings.11 Facilitators use open-ended questions to ensure active engagement between nurses and medical residents and foster interprofessional socialization. The facilitator’s guide standardizes sessions and ensures consistency across classes and facilitators.12

Data Collection

The Interprofessional Socialization and Valuing Scale (ISVS-9A) is a refined version of the Interprofessional Socialization and Valuing Scale (ISVS-24) and measures perceptions of interprofessional collaboration.13 Refinement of the tool led to a condensed version, ISVS-21, with excellent measurement properties, Cronbach alpha of 0.988 and confidence interval of 0.985-0.991, and two short versions, ISVS-9A and ISVS-9B.13 Both versions have excellent agreement. The ISVS scale is predicated on three main factors: the self-perceived ability to work with others (beliefs), value in working with others (attitudes) and comfort in working with others (behaviors), which align with the IPEC competencies of Values, Teamwork, Communication, and Roles/Responsibilities and the NCICLE competencies for Patient Safety, Teaming, and Professionalism.7,8,13 Given our target audience of practicing first-year clinicians, we use the nine-item ISVS-9A in a single retrospective pre/post survey with question stems prompting learners to consider their responses before and after the session.

Participants complete the electronic survey immediately postsession. The survey does not collect personally identifiable data, and learners are unlikely to be identified based on survey responses. The questions assess participants’ agreement with statements regarding interprofessional collaboration on a Likert scale ranging from 0 to 6 (not at all/to a very small extent/ a small extent/to a moderate extent/to a fairly great extent/to a great extent/to a very great extent). Participants are asked to respond to the following questions:

I am able to share and exchange ideas in a team discussion.

I have gained an enhanced perception of myself as someone who engages in interprofessional practice.

I feel comfortable in speaking out within the team when others are not keeping the best interests of the client in mind.

I believe that the best decisions are made when members openly share their views and ideas.

I feel comfortable in describing my professional role to another team member.

I have gained an enhanced awareness of roles of other professionals on a team.

I have gained an appreciation for the importance of having the client and family as members of a team.

I am comfortable engaging in shared decision-making with clients.

I feel comfortable in accepting responsibility delegated to me within a team.

Participants answer four additional items regarding safety and communication techniques and are asked to select safety techniques used in our organization that could be applied to prevent the outcome in the scenario (Tables 2 and 3). We also include two free text questions: “what system-level interventions should be implemented to prevent an outcome like this in the future,” and “what makes it easier for you to use these [safety] techniques?”

Statistical Analyses

Descriptive statistics (counts and percentages) are generated for the role of study participants and survey responses regarding safety and communication techniques. To examine the efficacy, retrospective pre- to postsurvey responses are analyzed. A paired t test is used to compare the mean response for the above questions. Survey responses are categorized as less than 4 (not at all/to a very small extent/ a small extent/to a moderate extent) and 4 or more (to a fairly great extent/to a great extent/ to a very great extent). Chi-square or Fisher exact test were used to compare the proportion of survey responses≥4 for each survey question between pre/post responses. Survey responses were compared pre to post for all survey participants and nurse and medical residents separately.

RESULTS

Twenty-six medical residents and sixty-five nurse residents participated in the focused team engagement sessions during the data collection period. Sixty-eight completed the retrospective pre/post survey, sixteen medical residents and fifty-two nurse residents. There is a statistically significant increase in mean responses in postsurvey results for all participants in seven of nine questions (Table 1). When analyzing the disciplines separately, nurse residents saw statistically significant increases in mean responses pre- to post for seven questions compared with four for the medical residents. We do not observe any statistically significant difference in the mean response among any of the survey participants for Q4. In addition, Q7 shows a statistically significant increase in the mean response postsurvey compared with the presurvey for medical residents (5.69 ± 0.60 versus 5.44 ± 0.89, P = 0.041) but not for nurse residents or the total participant group.

Table 1. Interprofessional Socialization and Valuing Scale (ISVS-9A): Pre–Post Data, Overall, and by Clinician Group

	All Participants (68)	Nurse Resident (52)	Medical Resident (16)	
Question	Pre Survey (Mean SD)	Post Survey (Mean SD)	P Value Based on Paired t Test	Pre Survey (Mean SD)2	Post Survey (Mean SD)2	P Value Based on Paired t Test2	Pre Survey (Mean SD)3	Post Survey (Mean SD)3	P Value Based on Paired t Test3	
I am able to share and exchange ideas in a team discussion.	4.78 (± 1.09)	5.12 (0.82)	0.003*	4.71 (1.16)	5.02 (0.85)	0.028*	5.00 (0.82)	5.44 (0.63)	0.004*	
I have gained an enhanced perception of myself as someone who engages in interprofessional practice.	4.75 (± 1.10)	5.10 (0.83)	0.001*	4.62 (1.12)	5.00 (0.86)	0.002*	5.19 (0.91)	5.44 (0.63)	0.104	
I feel comfortable in speaking out within the team when others are not keeping the best interests of the client in mind.	4.71 (± 1.09)	5.10 (0.90)	0.001*	4.60 (1.07)	5.00 (0.93)	0.003*	5.06 (1.12)	5.44 (0.73)	0.164	
I believe that the best decisions are made when members openly share their views and ideas.	5.35 (± 0.94)	5.44 (0.76)	0.347	5.31 (0.92)	5.37 (0.79)	0.606	5.50 (1.03)	5.69 (0.60)	0.27	
I feel comfortable in describing my professional role to another team member.	4.99 (± 1.00)	5.22 (0.81)	0.008*	4.85 (1.00)	5.12 (0.83)	0.012*	5.44 (0.89)	5.56 (0.63)	0.432	
I have gained an enhanced awareness of roles of other professionals on a team.	4.81 (± 1.03)	5.22 (0.83)	<0.0001*	4.69 (1.00)	5.15 (0.85)	<0.0001*	5.19 (1.05)	5.44 (0.73)	0.216	
I have gained an appreciation for the importance of having the client and family as members of a team.	5.26 (± 0.91)	5.46 (0.76)	0.07	5.21 (0.91)	5.38 (0.80)	0.192	5.44 (0.89)	5.69 (0.60)	0.041*	
I am comfortable engaging in shared decision making with clients.	5.00 (1.07)	5.29 (0.79)	0.004*	4.88 (1.06)	5.19 (0.82)	0.017*	5.38 (1.02)	5.62 (0.62)	0.041*	
I feel comfortable in accepting responsibility delegated to me within a team.	4.97 (1.01)	5.29 (0.79)	0.003*	4.88 (1.04)	5.19 (0.82)	0.022*	5.25 (0.86)	5.62 (0.62)	0.029*	

The top safety techniques that the participants feel could have changed the scenario outcome are escalating care (91.18%), SBAR (73.53%), and ask a question, make a request, voice a concern (73.53%; Table 2). System-level interventions that could prevent a similar future outcome include monitoring guidelines, early warning scores, early escalation, rapid responses, team huddles, and parent involvement. Participants cite lack of confidence (67.65%) and being afraid of giving wrong information (64.71%), intimidating doctors (61.76%), and anxiety (61.76%) as top barriers to using safety/communication techniques (Table 3). Conversely, participants list knowing other members of the team, feeling comfortable to share, feeling heard, and having confidence as enablers to using safety techniques.

Table 2. What Safety/Communication Techniques If Applied Could Have Changed the Outcomes in This Scenario?

Safety/Communication Techniques	Percentage of Participants’ Response	
Escalating care	91.18%	
SBAR	73.53%	
Ask a question, make a request, voice a concern	73.53%	
Stop, Think, Act, Review (STAR)	64.71%	
Use chain of command (ARCC)	61.76%	
Closed loop communication	61.76%	
Creating a shared mental model	55.88%	
Assertive statements	54.41%	
Clarifying questions	48.53%	
Thinking out loud	47.06%	
Establishing situational awareness	44.12%	
Validate and verify	39.71%	
Avoiding task fixation	25.00%	
Prioritize Tasks	22.06%	
Establishing a team leader	22.06%	
Identifying roles and responsibilities	20.59%	
Repeat backs	19.12%	
Callouts	16.18%	

Table 3. What Do You Perceive As Barriers to Using Safety/Communication Techniques?

Barrier to Using Safety/Communication Techniques	Percentage of Participants’ Response	
Lack of confidence	67.65%	
Afraid of giving wrong information	64.71%	
Intimidating doctors/nurses	61.76%	
Anxiety	61.76%	
Chaotic environment	54.41%	
Trouble speaking up	50.00%	
Pride and fear in appearing incompetent	50.00%	
Being dismissed by ICU staff	47.06%	
Lack of time	45.59%	
Lack of open communication	39.71%	
Lack of role clarity	25.00%	
Working with team members from off-service teams	23.53%	
New environments	23.53%	
Cultural differences	11.76%	
Lack of crowd control	11.76%	
Too many leaders	10.29%	

DISCUSSION

These outcomes align with the IPEC competencies and framework for interprofessional learning to achieve optimal patient outcomes. Participants’ perceptions of interprofessional collaboration improve after the session, and they are also able to identify applicable safety techniques. These findings also support the NCICLE Pathways to Excellence: Expectations for an Optimal Interprofessional Clinical Learning Environment to Achieve Safe and High-Quality Patient Care (2021). The focused team engagements show that experiential, interprofessional learning on safety principles and practices improves perceptions of interprofessional collaboration and emphasizes the importance of teamwork to high performance in the clinical space. Results from this study support the idea that purposeful interactions in which team members can identify one another’s strengths allow clinicians to capitalize on those strengths to improve patient safety.

Additionally, data-free text responses identify five enablers/barriers to confidence and comfort in communication and, subsequently, optimal patient care (Fig. 1).

Fig. 1. Factors that influence confidence and comfort in communication and quality patient outcomes.

Role Clarity: “Knowing who is the leader in the situation and knowing the roles of the people that are involved.”

Team Variability: “Knowing who the residents are-sometimes with the residents so frequently rotating its harder to have open communication with someone I’m not as familiar with. It’s really helpful when the doctors take the time to introduce themselves to me and tell me to reach out if I need anything.”

Environment and Culture: “Working in an environment where it is encouraged to speak up when you think something is wrong. This eliminates any hesitation to escalate concerns.”

Perception of what others think: “Team members who are receptive to my concerns and can explain why or why not they are also concerned, kindness and respect towards all team members to make me feel less intimidated in talking with physicians, having peers who can help validate my concerns.”

Self-perception of clinical competence: “Think about the safety of your patients, work together as a team to create an open communication environment, and don’t be afraid to state your ideas even if they are differing opinions or you may not be fully correct in your suggestions or ideas.”

Risk data have shown that communication among team members is often the primary cause of adverse events.2 Knowing who is leading and who is on the team facilitates effective communication, especially among variable teams.7 Clinicians must also possess self-perceived competence, and there must be an openness amongst team members where communication is encouraged and ideas welcomed.8 This openness creates a feeling of inclusiveness and belonging on the team, establishing the ideal environment for shared decision-making. It results in high-performing teams that are confident and comfortable communicating openly to achieve optimal patient outcomes.

Stronger gains in nursing residents versus medical residents could be attributable to several factors. There were more nurse participants during the data collection period, and nurses may feel more comfortable sharing among primarily other nurses. There are two to three times as many nurses as doctors in any given class. Additionally, many participants completed their formal education during the COVID-19 pandemic, creating new challenges and losing some clinical learning opportunities. The impact on clinical learning experiences was, in some cases, profound, with many nurses experiencing challenges with anxiety, integrating with the team, defining their professional role, and feeling insecure about their level of competence.14 These experiences could contribute to more significant findings among the nurse resident group than the medical residents. Another contributing factor may be that the medical residents who attend concurrently care for patients, whereas most nurses are not working clinically while attending, or even in the hospital during the sessions.

Clinical care in our organization is aligned with the principles of patient and family-centered care. This approach to care requires a culture that includes the patient and family in the planning, delivering, and evaluating care and aligns with these data findings.15 These data did not show statistically significant pre/post improvement for the questions about appreciating the client (patient) and family as team members and that the best decisions are made when team members’ views and ideas are openly shared. Given that the initial predata scores were already high (>5), the findings support our teams’ interprofessional culture and recognition that patient and family-centered care and an openness to sharing lead to better care outcomes, and improved patient and family experience.

LIMITATIONS

The study’s limitations include having more nurse residents than medical residents. It also focused on novice nurses and medical residents and did not include experienced clinicians, which could impact psychological safety and overall team performance. Because this study took place away from the bedside, the dynamic between nurses and medical residents may not have been realistic compared with the typically hierarchical relationships that exist in clinical settings.

Another study limitation was the pre/postsurvey methodology, which may have introduced bias during the evaluation process. However, the retrospective pre/post design can be useful in evaluating interventions that aim to impact participants’ beliefs, such as initial beliefs, but may be subject to ceiling effects. A ceiling effect in measurement occurs when most participants respond to the upper limit of the scale.16 Another explanation for the ceiling effect may be that respondents randomly select the highest responses in the survey regardless of their application to their learning. When participants consistently choose the higher response, it reduces variability. It limits the sensitivity of the evaluation tool in reflecting the actual learning experience, making it challenging to detect changes accurately.17 A retrospective design can allow participants to respond to belief-related items in a way that better reflects changes in their beliefs.17

CONCLUSIONS

Nurses and medical residents engage in many educational opportunities in their first year, although most are not interprofessional. The focused team engagements create a formal opportunity for novice first-year clinicians to learn together in discussing a patient safety event, team dynamics, shared mental models, and safety and communication techniques. The structured debriefing facilitates interprofessional learning and provides a platform for learners to explore patient safety and team communication in a safe environment. The strong outcomes of this activity resulted in embedding the content in the nurse resident and medical resident first-year curricula and, subsequently, including advanced practice providers to diversify the discussion and advance safe, high-quality interprofessional patient care.

Published online September 9, 2024.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

To cite: Manuel R, Barber A, Kern J, Myers K, Neary T, Nicholson L, Walsh H, Zaveri P, Dwivedi P, Maggiotto C, King S. Focused Team Engagements to Enhance Interprofessional Collaboration and Safety Behaviors among Novice Nurses and Medical Residents. Pediatr Qual Saf 2024;9:e767.
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