1. Park, Chan W. MD, FAAEM
  2. Holtschneider, Mary Edel MPA, BSN, RN-BC, NREMT-P, CPLP

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"[horizontal ellipsis](T)he desired outcome is not just about improving learning but improving the health of individuals and populations and enhancing the responsiveness of health systems to such nonhealth dimensions as respect for patients and families[horizontal ellipsis]." (Institute of Medicine [IOM], 2015, p. 2).


In our previous column on interprofessional (IP) simulation, we explored a debriefing strategy we called "debriefing from the learner's point of view." This strategy aims to look at the simulation debriefing through the lens of the learner to see how IP core competencies and competency domains can be enhanced during our debriefing sessions. To bridge some of these gaps, we explored alternative ways to pose debriefing questions that encourage learners to consider the relevance of Core Competency Domains involving Values/Ethics, Roles/Responsibilities, Communication, and Teams/Teamwork in their daily clinical practice (Core competencies for interprofessional collaborative practice, 2011). In this column, we draw attention to a slightly different perspective for our simulation debriefing-a perspective that is sometimes overlooked but remains highly relevant-"debriefing from the patient's point of view."


Nursing professional development (NPD) practitioners and learners uniformly agree that one of the highest goals of simulation practice and facilitation is to translate the simulation-based learning to improve patient-centered care. However, how can we hope to achieve this elusive goal if we have not stopped to consider the patient's perspective with respect to the outcomes of our IP training (IPT) sessions? Despite our commitment in achieving educationally driven metrics such as knowledge, skills, and abilities of learners, as simulation-based educators, we have yet to reliably or demonstrably link our training successes to important measurable patient-centered outcomes (IOM, 2015). So, how can NPD practitioners improve simulation debriefing to direct greater resources and attention to patient-centered care?


This type of inquiry provides us an excellent starting point to launch into a strategy we call "debriefing from the patient's point of view." We believe the time is right for us to reinstate the patient to the center of our clinical simulation training and debriefing. As learners' technical and nontechnical skills are being shaped and refined, the educational community needs to consider ways to help transition the primary source of motivation for training from that of self-improvement to patient benefit and patient outcomes. As you will see, when training is seen through the lens of the patient, the priorities of our existing goals and objectives for the learner may demand greater scrutiny and justification.


To illustrate this point, let us imagine for a moment that you, as an NPD practitioner, actually suffered a ventricular fibrillation cardiac arrest during a code response team training simulation session at your institution. As you lie there witnessing the responders coding you, what would matter most to your chance of survival and improved clinical outcome? How would you define excellent care? Would demonstration of closed loop communication, such as repeating back physician orders, or the gathering of information that has little direct impact to your care (i.e., your age, family history, and need for laboratory blood draws) take priority over early defibrillation and immediate high-quality compressions? Would slow and shallow chest compressions be called anything but ineffective? How would you feel about being ventilated if no oxygen was used or if none of the gas found its way to your lungs? What if you were being ventilated in excess of 50 breaths per minute?


Your responses to the questions above need to be reflected in the voracity and rigor of your simulation training and debriefing. We know from the body of resuscitation science literature that the most important interventions that impact survival after a witnessed ventricular fibrillation arrest are early defibrillation and continuous high-quality cardiopulmonary resuscitation. Ironically, these are two most often delayed and overlooked aspects during in-hospital cardiac arrests. Let's suppose that the team did not successfully resuscitate you. How then do you suppose you would feel during the team debriefing if everyone complimented one another on "great teamwork" and walked away feeling good about your resuscitation that went horribly awry? The patient would feel the same as you would, because from the perspective of the dying patient, debriefing that discusses "closed loop communication," "teamwork," and "leadership" must always be tightly linked to patient-centered outcomes; otherwise, it focuses too much on the learner and not enough on the patient.


Let's now see how NPD practitioners can use the patient's perspective paradigm to improve simulation debriefing and to help guide the learners' motivation toward improvement of patient-centered care. We will use the IOM's core competencies as the framework for our strategy (Figure 1).

Figure 1 - Click to enlarge in new windowFIGURE 1. Interprofessional teamwork and Institute of Medicine core competencies, 2011, by the National Academy of Sciences. Reprinted with permission from National Academies Press, Washington, DC.

First, when utilizing informatics, we need to carefully focus on metrics that satisfy the following three criteria: accurately measurable, objectively recordable, and clinically relevant.


Similar to our learners, our patients are demanding greater use of real-time data to determine effectiveness of the care provided and the types of training pursued. In order to provide useful and credible feedback to our sophisticated learners, a summary of their actual performance data must become a fundamental component of the debriefing discussion. This will ensure that the resulting analysis, reflection, and deliberate practice plan are based on the actual team performance and thus most likely to impact future behavior and performance. Relevant metrics that can be reported include quality of cardiopulmonary resuscitation (depth, rate, time off chest), ventilation (rate, volume delivered), and early use of defibrillation (time to availability, time to use).


Second, we must strive to incorporate evidence-based practice and guidelines into the training whenever possible. Given that most clinical guidelines are based on meta-analyses of randomized double-blinded and placebo-controlled trials or based on expert opinion when such studies are not available, this provides a solid foundation for the simulation exercise. Unfortunately, although most learners are familiar with the existence of various clinical guidelines, many fail to appreciate nuances and critical elements within each guideline that have inordinately high impact on patient outcomes. By helping the learners to gain greater insight and appreciation for these nuanced elements of the clinical guidelines during the debriefing, NPD practitioners can have material impact on the quality of interprofessional education (IPE) provided.


Using emergent stroke care as an example, the American Heart Association (Jauch et al., 2013) and the American Academy of Neurology have endorsed the expanded time window for the use of thrombolytic therapy (tPA) from 3 hours to 4.5 hours for patients who meet the criteria. Unfortunately, some providers view this change as a welcomed "time to relax" or "more time to work with" rather than working expediently to minimize the delay to tPA administration. We say, "time is brain," but do clinicians really count each second and each minute as if the delays were having deleterious effect on "their" brain? Does the average learner appreciate just how much of damage the patient's brain suffers for every second of unnecessary delay in tPA administration? This is highly unlikely, yet this information is available. Saver (2006) estimates the number of neurons destroyed for every second, minute, and hour that the brain is deprived of blood flow to be 19,000, 1.9 million, and 120 million neurons, respectively. So, does every second matter? It absolutely does to the patient!


Armed with this type of information, how might we modify the IPT debriefing? Using accurately measured and objectively recorded timestamps of the simulated interventions, we can help our learners appreciate the positive impact of a well coordinated team effort and point out the downsides of a poorly coordinated team effort. A sample debriefing question one might ask may be, "how did the use of a stroke activation algorithm check list impact the time to tPA administration?" or "what areas of delays could improve with better communication?" These types of debriefing questions can achieve two additional benefits. One, by simple redirection of the learners' primary motivation from that of self-improvement to patient outcome, they aim to shape our educational culture to place greater emphasis on patient-centered care. Second, these types of questions grant the learners permission to examine other aspects of the healthcare system where latent threats exist and pose unnecessary danger to our patients.


Third and finally, our simulation strategies need to explore ways to encourage learners to examine and reevaluate the overall healthcare system through the eyes of the patient. NPD practitioners are expected to welcome system-wide quality improvement (QI) initiatives and to integrate them into simulation-based IPT training whenever possible. Interestingly, this gives NPD practitioners an informal invitation from the executive leadership to help uncover potential or latent threats that exist throughout the healthcare system and to mitigate the negative impact of "unrehearsed" processes that plague even the best of our healthcare systems. Before we get into some real-life examples, remember that these types of QI or system issues may best be explored using an in situ-based simulation (i.e., simulation conducted in the clinical setting where the event likely takes place).


Because most facilities have a code response team protocol in place, let's use this as the framework for the QI example. During a code simulation, when someone calls out "activate the code response team," the simulation recorder notes the time of the code. All of a sudden, a team of providers instantaneously arrives at the scene with all of the necessary equipment. But does it happen like that at your institution? Sometimes, the first call for help falls on deaf ears. After a short period of chaos, a second and third request is made before someone picks up the phone to notify an operator who then activates the pagers of all code personnel. But what if the operator doesn't properly page all of the code team members? What if the code pagers have unexpected delays in transmission? What if there are dead spots throughout the facility where the pagers do not work? If this process has never been fully activated and rehearsed, how can we reasonably expect it to function correctly on the day of an emergency? Because simulation allows us to test systems and processes, we can uncover these latent threats that might have otherwise gone unnoticed.


Seen from the patient's perspective, a reasonable question may be, "how could a healthcare system allow such an important process to go unrehearsed?" Worse yet, how could NPD practitioners well versed in simulation overlook the importance of periodically testing the integrity of the code response activation system and focus solely on the code response training itself? In our experience, the reality is that this is far too common. In fact, one of the first and most common places where errors in code response occurs is with failure in the activation process. So, as the patient, how would you feel if the main reason for the delay in your resuscitation care was due to an oversight of the code activation system? Interestingly, when we frame the continuum of health care through the lens of the patient, all facets of simulation training (simulation center-based and in situ-based training, individual and team-based training, technical and nontechnical skills training, and QI and system process training) become increasingly relevant.


As the education experts in the simulated practice setting, NPD practitioners have an enormous responsibility to not only train our learners to improve their clinical skills, but also to help improve their understanding of the integral connection between improvements in IP behavior and achieving improved patient-centered care. By simply framing the debriefing questions to that of a patient's perspective, we can help shape the learners' motivation for learning and for interprofessionalism to be better aligned to the patient-centered care goal.


In this issue, we have introduced a debriefing strategy that employs the patient viewpoint and redefines the goal of the simulation training from learner-centered to patient-centered outcomes. We have also highlighted the relevance of the IOM's core competencies in IPE and team training in promoting better patient-centered care. By keeping our patient's well-being at the center of our educational endeavor, IPT communication, behavior, and performance will undoubtedly impact our patient outcomes in a positive manner.


As we continue to explore IP simulation, our future columns will focus on discussing creative options to incorporate IPE for teamwork training and ways that IPE can address ongoing and future needs in health care. We will continue to probe issues that we face in the practice setting and strategize on ways to optimize IP simulation to enhance the care of our patients.


How have you documented successes in implementing IPE in your workplace? What successes are you experiencing and what challenges are you facing? Please e-mail us at mailto:[email protected] and mailto:[email protected] to continue the conversation.




Core competencies for interprofessional collaborative practice. ( 2011). Retrieved from[Context Link]


Institute of Medicine. ( 2015). Measuring the impact of interprofessional education on collaborative practice and patient outcomes. Retrieved from


Jauch E. C., Saver J. L., Adams H. P. Jr., Bruno A., Connors J. J., Demaerschalk B. M., [horizontal ellipsis] Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. (2013). Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44, 870-947. [Context Link]


Saver J. L. ( 2006). Time is brain-Quantified. Stroke, 37( 1), 263-266. Epub 2005 Dec 8. [Context Link]