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Trauma Team (Hospital.: 6 Doctors in Japan) is a Wii game released in 2010 and the third Wii.
AuthorAffiliationElizabeth D. Rosenman, MDUniversity of Washington School of Medicine, Department of Emergency Medicine, Seattle, WashingtonMarie C. Vrablik, MD, MCRUniversity of Washington School of Medicine, Department of Emergency Medicine, Seattle, WashingtonSarah M.
Brolliar, BSUniversity of Washington School of Medicine, Department of Emergency Medicine, Seattle, WashingtonAnne K. Chipman, MD, MSUniversity of Washington School of Medicine, Department of Emergency Medicine, Seattle, WashingtonRosemarie Fernandez, MDUniversity of Florida College of Medicine, Department of Emergency Medicine, Gainesville, Florida. ABSTRACTIntroductionEffective team leadership is linked to better teamwork, which in turn is believed to improve patient care.
Simulation-based training provides a mechanism to develop effective leadership behaviors. Traditionally, healthcare curricula have included leadership as a small component of broader teamwork training, with very few examples of leadership-focused curricula. The objective of this work is to describe a novel simulation-based team leadership curriculum that easily adapts to individual learners.MethodsWe created a simulation-based team leadership training for trauma team leaders in graduate medical education. Participants included second- and third-year emergency medicine and surgery residents. Training consisted of a single, four-hour session and included facilitated discussion of trauma leadership skills, a brief didactic session integrating leadership behaviors into Advanced Trauma Life Support®, and a series of simulations and debriefing sessions.
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The simulations contained adaptable components that facilitated individualized learning while delivering set curricular content. A survey evaluation was administered 7–24 months following the training to assess self-reported implementation of trained material.ResultsA total of 36 residents participated in the training and 23 (64%) responded to the survey. The majority of respondents (n = 22, 96%) felt the training was a valuable component of their residency education and all respondents reported ongoing use of at least one behavior learned during the training. The most commonly cited skills for ongoing use included the pre-arrival brief (n = 21, 91%) and prioritization (n = 21, 91%).ConclusionWe delivered a leadership-focused, simulation-based training that 1) adapted to learners’ individual needs, and 2) was perceived to impact practice up to 24 months post-training. More work is needed to understand the impact of this training on learner knowledge and behavior, as well as patient outcomes. INTRODUCTIONLeadership is important in healthcare resuscitation teams, such as trauma teams, that function under complex, dynamic, and time-pressured conditions.
1, 2 Effective team leadership is linked to better teamwork, 3 which in turn is believed to improve patient care. 4 Despite consensus on the importance of leadership training, clinical team leadership is most frequently a small component of broader teamwork-focused training, with very few examples of leadership-focused curricula. 5 As a result, leadership skills can vary markedly within a cohort of trainees.Simulation-based training provides a mechanism to develop effective leadership behaviors.
However, structured implementation of a context-specific leadership curriculum, such as a trauma leadership curriculum, requires 1) authentic reproduction of the environmental components present during a trauma resuscitation, 2) re-creation of a large, multidisciplinary team with scripted roles, and 3) the ability to address individual learner needs.To address this gap in training practices, we designed a simulation-based, trauma team leadership curriculum intended for graduate medical education. This approach was novel in its use of simulation to individualize training in a dynamic setting. The objective of this article is to describe the team leadership curriculum.
We also present a self-report of trained leadership skill implementation 7–24 months following training. METHODS OverviewWe designed and implemented a novel, simulation-based team leadership training for trauma team leaders. The training was administered monthly, from June 2016–November 2017. We surveyed trained participants 7–24 months following training to determine the perceived value of this training.
The institutional review board at the University of Washington approved the study. Participants and SettingParticipants included second- and third-year emergency medicine (EM) and surgery residents rotating as the trauma team leader at a Level 1 trauma center within an academic healthcare system. To be eligible, the participants were required to a) be in good standing with the Office of Graduate Medical Education, b) have completed the Advanced Trauma Life Support ® (ATLS) course, and c) have at least four weeks prior experience in emergency department (ED) trauma care. Residents were approached and consented by a study coordinator. Participation was voluntary and participants were compensated with a $100 gift card for study participation. Leadership training took place at the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Institute for Simulation in Healthcare, an 8,000-foot simulation suite, using a SimMan ® human patient simulator (Laerdal Medical, Wappingers Falls, New York). Leadership BehaviorsA conceptual model for team leadership provided the foundation for the training.
6 Leadership behaviors were translated into “communication events” tightly linked to key time points during an ATLS-driven resuscitation. These communication events became the behaviors that were the focus of training. By linking leadership concepts (e.g., setting priorities) to key steps in ATLS, the training helped learners anchor new behaviors on an existing knowledge scaffolding. The learning objectives, organized by communication event, are provided in Table 1. Table 1Learning objectives for the trauma team leadership curriculum. Table 3Survey results for the perceived value and realism of the simulation-based leadership training. Most frequently implemented behaviors from the trauma team leadership curriculum.A total of 20 respondents (87%) answered one or more of the free-response questions.
The majority of respondents (n=13, 50%) felt the training should be a standard, or even mandatory, part of the residency curriculum. Several components of the training were identified as being useful, including the following: 1) small groups of learners; 2) the realism of the training environment; 3) the focus on non-clinical skills; and 4) cycling between simulation and debriefing. The most common suggestion for improving the training was to offer similar training opportunities more frequently. Other suggestions included allowing participants to review their own videos, and providing follow-up coaching in the clinical environment. Table 4 has examples of responses organized by theme.
Table 4Examples of survey free-text responses organized by themes. Themes (Number of related comments)Examples of commentsTraining should be required (13)Should be mandatory.Please incorporate this in our training! It is one of the single most helpful things I have done in residency regarding leadership. This has absolutely changed my practice.Mandatory for all residents before leading a code.Excellent training which gives a framework for myriad roles in daily clinical medicine. Should be a component of every resident’s training.Excellent, should be provided to all EM residents in all residency programs, it helps the quality of care in our specialty.Useful components of the trainingRealism of the simulations (SIM) (3)This was very helpful, and far more realistic than the average SIM. It would be valuable for all residents to receive this training!The authenticity and stressful environment made this great training.Non-clinical focus (1)This was one of the most valuable simulations I participated in and made me a much more confident leader in these situations. Prior to the simulation I was a bit of a wallflower but this gave me some basics with which to take command and fall back on in difficult situations.
Rather than focusing on the basics of resuscitation the emphasis on teamwork was key. I recently had a very difficult code and was able to take command with many of the specific skills that I learned in this training.Small learner group (1)Nothing to make it better, but the very small group (two people) was very helpful.Repetition of simulations and debriefings (1)Opportunity to do multiple SIMs after discussing how the first one went, and getting a second chance to incorporate the teachings.Opportunity for improvementCoaching and performance review (5)Ability to see feedback videos. Real-time feedback in a real clinical scenario.More check-ins after the training to see how things were going.More frequent training (4)We need more of this kind of training.
One day spent doing this training drastically changed my performance during traumas and medics codes and really helped with my confidence.More of it. More repetitions.Timing of training (4)If it had happened earlier in my training, at the end of R1 or beginning of R2, before I had certain set habits.Ideal for junior residents to set them on the correct path.Other (6)Critical training, not covered elsewhere. Made me a better team leader.EM, emergency medicine; R1, first-year resident; R2, second-year resident. DISCUSSIONWe created a four-hour, simulation-based team leadership training for trauma team leaders in graduate medical education. Survey results showed nearly universal support for the training program. We acknowledge that the 36% of participants who did not respond to the survey may have viewed the training less favorably.
The time interval between training and the evaluation ranged from 7–24 months. This timing meant all participants had completed at least two years of postgraduate training, with some respondents having completed residency training. Despite this time interval, and the concurrent learning opportunities, the evaluations suggest the training had a meaningful and lasting impact for most learners.We believe the strength of the training was the learner-focused content, facilitated by small groups of learners and cycling between multiple simulations and debriefings. The facilitated discussion provided instructors with insight into the participants’ baseline level of knowledge and their individual challenges. The initial simulations were targeted to the learner based on prior knowledge of the learner and the facilitated discussion.
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Finally, the pre-scripted options for the second round of simulations facilitated rapid scenario modification to individualize the training. Together, this structure provides a semi-standardized approach to delivering team leadership training that can adapt to the learner.Although not cited by the learners, we felt there was also value in incorporating peer observations and feedback, and using cognitive aids to help maintain focus on team leadership rather than clinical care. We were initially uncertain whether our learners would feel comfortable discussing their perceived strengths and challenges, or participating in peer-to-peer feedback. Ultimately, the addition of peer observers and peer-guided feedback was beneficial, allowing learners to observe strengths and weaknesses of different leadership styles exhibited by their peers. Furthermore, it augmented the realism of the scenarios by adding an element of stress that replicated the stress of performing in a crowded resuscitation bay.Several participants suggested the training should be provided early in residency (eg, beginning of second year, prior to leading a code).
However, determining the “right” time to administer this type of training is complicated. It was our impression that more senior residents, who were more clinically confident, seemed to get more immediate benefit out of the training. They were less likely to get distracted by the medicine, allowing them to focus more on leadership skills. It may be, however, that more junior learners actually achieve more long-term value from this type of training, even if it isn’t immediately apparent in the simulation lab. There is an argument for introducing teamwork and team leadership training earlier in medical education, 10 rather than waiting to introduce leadership skills until the individual is already in a formal leadership role. Learning good habits from the start may be better than trying to add or modify them later.
LIMITATIONSThere are several limitations to this work. Most importantly, the evaluation of the training was limited to learner perception, which is a level one outcome in Kirkpatrick’s framework. 11 Further work is needed to determine the impact of this training, however well received, on learner knowledge, behavioral change, and clinical care. In addition, our response rate was 64%. We intentionally delayed survey assessments to gain learner insight into skill implementation, knowing the trade-off would be a decrease in response rate. While this response rate is within the range of previously reported response rates for surveys of phyisicians, 12, 13 it introduces the possibility of a selection bias favoring the training. CONCLUSIONWe designed and implemented an adaptable, simulation-based team leadership training that had a lasting impact on the learners, as demonstrated by participant survey responses up to two years post-training.
Given the resource-intensive nature of the training, more work is needed to understand the impact of this training on learner knowledge and behavior, and patient outcomes, and to understand the optimal timing for delivery of the training. Supplementary InformationFootnotesSection Editor: Michael Epter, DOFull text available through open access at for Correspondence: Elizabeth Rosenman, MD, University of Washington School of Medicine, Department of Emergency Medicine, 325 9th Ave Box 359702, Seattle, WA 98104. 5 / 2019; 20:520 – 526Submission history: Revision received October 24, 2018; Submitted February 6, 2019; Accepted February 22, 2019Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. Funding and support for this project was provided by the Agency for Healthcare Research and Quality (1R18HS022458-01A1RF, EDR). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, approval, or decision to submit the manuscript. REDCap at ITHS is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1 TR002319.
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A guide for the design and conduct of self-administered surveys of clinicians. Can Med Assoc J. Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department.
The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.
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