Rapid Cycle Deliberate Practice to Facilitate “Nano” In Situ Simulation: An Interprofessional Approach to Just-in-Time Training

This quality improvement project, which was conducted at a large academic teaching hospital, was approved by the hospital’s institutional review board. The project was categorized as exempt given its nature and educational focus. The aims of the project were to (1) determine the feasibility of implementing multidisciplinary ISS training using the RCDP method of teaching in a busy ICU (participants electively participated during the busy workday); (2) increase identification and implementation of time-sensitive tasks in the management of a shock scenario; and (3) evaluate the learners’ confidence and satisfaction with the simulation training.

The participants in the ISS training were the available health care providers working in the ICU (n = 23). The faculty included a pediatric cardiac intensivist and an acute care pediatric nurse practitioner (PNP). A multidisciplinary group of ICU providers including a nurse, a respiratory therapist, and a pharmacist served as embedded actors in the scenarios. Embedded actors were incorporated into the educational intervention to enhance the realism of the simulation exercise. Although PICU nurses were learners in this exercise, different PICU nurses served as embedded actors who provided information to the team as they would in an actual patient event. This arrangement allowed us to evaluate all of the learners’ responses to this information based on their management decisions as a team.

All PICU team members were provided with an educational overview of the ISS program and informed that participation was voluntary. As these exercises were unannounced on the day of the simulation, consent was implied by voluntary participation in the program, which had been approved by the institutional review board. Furthermore, each group of participants was prebriefed that the simulation exercise would be recorded for educational research purposes (which is part of usual simulation center protocol at our institution) and that feedback on the value of the simulations would be requested. We also conducted our standard simulation introduction, in which we discuss psychological safety and maintenance of confidentiality. Each team was composed of a leader (either a physician or a PNP) and at least 1 nurse.

Training was conducted at the hospital in the combined PICU and pediatric cardiac ICU (PCICU). The training took place in a standard patient room that housed equipment typically available in this setting. To increase fidelity, the simulator (SimBaby [Laerdal Medical Corp]) underwent moulage (the art of applying fake injuries) with a central venous and arterial catheter, an endotracheal tube, a nasogastric tube, cerebral and somatic near-infrared spectroscopy probes, a chest dressing with chest tubes and transcutaneous pacing wires, and a functional pacer box (Figure 1).

The goal of the nano-ISS was to expose the maximum number of health care providers to a high-risk scenario in which early recognition and management of a low-cardiac-output state would have a significant effect on patient outcomes. The simulation scenario was designed, implemented, and piloted at a large-scale simulation-based boot camp for advanced practice nurses.¹¹  An expert opinion survey was used to develop a checklist to establish priorities for scenario tasks (see Table). This process involved content experts from the PCICU and the cardiac surgery department (physicians, nurses, and PNPs) who systematically evaluated the simulations before implementation to achieve consensus on the most critical time-sensitive tasks that were most likely to improve patient status. The base scenario and the checklist were then sent to outside reviewers to achieve consensus on the most critical time-sensitive tasks to be completed in the first 5 minutes. These tasks were used in the project to assess group performance.

The scenario involved a pediatric patient who had undergone a Norwood procedure with a Blalock-Taussig shunt who had pulmonary overcirculation and evidence of systemic hypoperfusion or shock in the initial postoperative period. This scenario was chosen because early identification and management of postoperative shock in a patient with congenital heart disease are crucial to prevent further deterioration, which can lead to cardiopulmonary arrest. Moreover, data obtained in a previous simulation boot camp training program for PNPs¹¹  revealed a deficiency in baseline knowledge of and preparedness for timely recognition and implementation of tasks necessary to care for a pediatric patient after complex surgery for a congenital heart defect. In that program, performance improved after RCDP simulation training.

The RCDP methodology (Figure 2) originally developed by Hunt et al⁸  has been well received owing to the ease of debriefing and the time-to-task type of training. The RCDP simulation curriculum was based on the model of expert performance and deliberate practice described by Ericsson et al.²⁰  Ericsson²¹  identified 3 essential conditions that must be met to facilitate improvement in learner performance: (1) an awareness of what aspects of performance require improvement; (2) immediate, detailed feedback on performance; and (3) opportunities to improve performance by practicing tasks repeatedly. Thus, deliberate practice is a model of training that involves repetitive performance coupled with assessment and feedback by an expert trainer or “coach.”²¹  In the Hunt et al⁸  model, Ericsson’s elements are combined with elements of mastery learning to ensure that learners achieve certain skills before advancing to the next level of skill acquisition.²²  With RCDP, both concepts are refined to augment the impact of the simulation experience in the allotted time frame.^8,11 

In each ISS in this project, the facilitator had 30 minutes to teach the scenario checklist and convey the RCDP teaching method. Each 30-minute session involved cycling between simulation and deliberate practice and debriefing time. The checklist included tasks or actions that are expected to be performed in this specific scenario; thus, the facilitator focused debriefing on items included in the checklist. The first 5-minute simulation was used as a needs assessment and was uninterrupted (time 1); the facilitator then debriefed the learners and provided specific evidence-based feedback. The facilitator focused on the identification of shock given the patient data, including vital signs, near-infrared spectroscopy, end-tidal carbon dioxide, and patient-specific information obtained during the simulation. Learners then performed the scenario again (time 2). The facilitator paused when key performance gaps were observed. Additional debriefing time focused on the differential diagnosis and rapid management of the situation. The teaching session concluded with a final 5-minute simulation (time 3) followed by a final debriefing (Figure 2).

The ISS sessions were conducted over 2 days with a mixed provider group of 4 to 5 participants per session. The expert-guided checklist mentioned previously was used to determine the most critical tasks to perform in the first 5 minutes. This checklist enabled the facilitator to focus on the most critical skills necessary to alleviate the patient’s condition. We compared the proportion of completed checklist items in the first 5-minute simulation with that in the final 5-minute simulation using a χ² test to determine whether performance improved. A total of 5 groups participated in this project. Each group was evaluated for completion of the 5 predetermined time-sensitive clinical tasks. Thus, 5 groups performed the simulation and were evaluated for the 5 tasks, yielding a denominator of 25. Performance is reported for the group and not the individual. We evaluated the learners’ satisfaction and confidence after each education session with a modified version of the Student Satisfaction and Self-Confidence in Learning tool.²³  We used 12 of the 13 items from this instrument. The instrument, which was developed by the National League of Nursing, was designed to measure satisfaction with the simulation experience and self-confidence in learning using a 5-point Likert scale, with higher scores indicating higher degrees of satisfaction and confidence.²³  The results are presented as mean (SD). The educational project methods adhered to the reporting guidelines for health care simulation research developed by Cheng et al.²⁴ 

A total of 23 health care providers participated in the ISS training: 12 critical care nurses, 5 pediatric residents, 2 pediatric critical care fellows, 2 respiratory therapists, 1 PNP, and 1 medical student. Time-sensitive clinical tasks for this scenario included appropriate fluid volume administration, vasoactive agent management, ventilator adjustments, and calcium and sodium bicarbonate administration (see Table). The proportion of time-sensitive clinical tasks completed within a 5-minute time frame increased significantly between the first 5-minute scenario and the last 5-minute scenario (52% [13 of 25] vs 100% [25 of 25]; P ≤ .001). Vasoactive medication adjustment and calcium administration were the most common tasks that were performed by teams in the first 5 minutes. However, none of the teams considered a second agent for vasoactive administration until it was discussed during RCDP debriefing. All teams were able to make adjustments to current vasoactive agents for the simulated patient by the last 5-minute scenario, including adding a second vasoactive agent. During the first 5-minute session, none of the teams considered sodium bicarbonate administration as a temporary adjunct for management of shock while addressing the underlying contributing causes such as anemia and pulmonary overcirculation. By the last 5-minute session, all teams included sodium bicarbonate administration as a management strategy. Additionally, 40% of teams did not consider adjusting either oxygenation or ventilation during the first 5 minutes. The remaining teams considered only weaning of oxygen and ventilator rate adjustments in the first 5 minutes. By the last 5-minute scenario, however, all of the teams asked for adjustments to oxygen, as well as adjustments to ventilator rate, peak inspiratory pressure, and/or positive end-expiratory pressure. The participants reported a high level of performance confidence (mean, 4.42; SD, 0.20) and satisfaction with the ISS experience (mean, 4.96; SD, 0.12).

The use of simulation, particularly in the current era of high provider turnover and workforce restrictions for physician trainees, provides increased exposure to clinical scenarios involving complex team management.²⁵  The use of ISS in this quality improvement project facilitated provider involvement during a busy workday, minimizing the negative impact of time constraints, cost, and personnel needs associated with simulations performed in simulation centers or other defined areas outside of the actual clinical environment. Furthermore, use of RCDP methodology was effective for teaching time-sensitive tasks. Implementing an expert-guided checklist enabled the facilitator to focus on the critical skills necessary to improve the patient’s condition. Overall, our project demonstrates the feasibility of using ISS with RCDP involving a checklist-based debriefing to create an effective learning environment.

Multidisciplinary nano-ISS enables the simulation instructor to create an environment that emphasizes active learning and problem solving within a short time frame.^9,10  The ISS training sessions can emphasize rapid identification and initial management of the patient’s condition, allowing all team members to practice and improve their skills. It has been theorized that learners build new comprehension based on past experiences, knowledge, and existing attitudes.^26–28  Preexisting misconceptions can serve as barriers to the development of new, more effective mental models. Effective learning requires the learner to uncover and address preexisting knowledge and misconceptions. These nano-ISS sessions can help reveal and address misconceptions or latent patient safety threats²⁹  as well as highlight and reinforce prior knowledge, with the simulation debriefing ultimately focusing on concepts that need the most attention.

The use of RCDP is particularly useful in scenarios requiring time-specific tasks, such as identification and initial management of shock, as in this project. Delayed recognition and management of shock or other similar crucial events in a critically ill patient can have devastating consequences. Early identification of complications and timely implementation of appropriate treatment by a multidisciplinary team of providers may prevent further deterioration, cardiac arrest, or death.^30,31  Such multidisciplinary involvement is not unique to PCICU patients. Indeed, this type of training could be applied to a variety of critical care scenarios.

Nano-ISS scenarios could be developed based on the needs of specific patients currently in the ICU. Thus, practitioners who are working in that ICU could train in a scenario that requires potentially time-sensitive or task-oriented skills specific to an actual patient. Such real-time, real-patient application may increase provider engagement. Just-in-time simulation training has been used to refresh time-sensitive skills such as cardiopulmonary resuscitation, technical skills such as intubation, and sterile procedures such as central venous catheter dressing changes. These brief in situ RCDP simulations can take this concept a step further by incorporating the multidisciplinary team in a scenario that is unexpected but potentially applicable to an actual patient in real time.

Implementing a checklist of expected tasks, as in this project, helps not only to define the objectives but also to focus the debriefing on tasks included on the checklist. The checklist is easy to use and provides consistency across different facilitators, thereby providing the learners with more standardized education. During the debriefing, the facilitator can highlight checklist actions that were never performed and discuss why the task was important. Debriefing can also highlight checklist actions performed well by the team. When specific checklist tasks are used with RCDP simulation scenarios, the necessary time limits of ISS can be observed while improving learner skill and confidence.

A major limitation of this project is that we used a onetime training event without further evaluating the retention of knowledge. Additional research is needed to establish how often ISS training sessions are needed to maintain knowledge. Also, a larger-scale study with more participants should be conducted to help determine the educational significance of RCDP teaching methodology.

We recognize that the modification of the National League of Nursing tool for evaluating confidence and satisfaction is a limitation. Also, since this project was carried out, many other instruments have been developed to evaluate learners’ experience.

One limitation of simulation research in general relates to the authenticity of the clinical environment. An altered or low-fidelity environment may adversely affect specific learner behaviors. Furthermore, the responses of the mannequin are controlled by an operator and may or may not accurately reflect those of an actual patient. To mitigate these potential limitations, we incorporated a realistic room setup in an actual PICU room and used equipment that trainees would encounter in an actual patient experience. Moreover, the responses of the mannequins are standardized.

The main difficulty with using ISS is the interruption to patient care and workflow in busy hospital units. This is especially true in ICUs, where patient care often requires a 1:1 provider-to-patient ratio. However, it is often difficult to arrange off-site simulation training for a multidisciplinary group of providers. We hypothesized that “nano” (brief) ISS might be plausible if the training session could be completed in 30 minutes. However, conducting a simulation with a debriefing in such a short time may be inadequate to meet learning objectives. To compensate for this potential limitation, we used the RCDP method of teaching to ensure that specific learning objectives were met.

Simulation training is an effective strategy for educating critical care providers.^1,11  This ISS program trained a multidisciplinary group of providers in the rapid identification and management of postoperative shock, for which improvement in time to task may be lifesaving. Other noncardiac scenarios that require time-sensitive actions, such as septic shock or status asthmatics, could use the same format as in this project. The use of RCDP simulation and a specific checklist to guide debriefing allowed for successful implementation of this project in a busy ICU where time for activities other than patient care is limited. This program was feasible and well received by the participants. In the critical care setting, simulation-based education can be an effective tool for teaching or improving skills in a relatively short time frame. Use of this educational method to train providers on the early recognition and management of postoperative shock and other similar ICU scenarios may help to reduce the incidence of complications in vulnerable patient populations.