Interprofessional Teamwork Training in Neonatal Resuscitation using
TeamSTEPPS® and Event-based Approach Simulation:
Instructor’s Guides
Introduction:
Healthcare has been described as a ‘team sport’, and good teamwork is essential
to optimal patient care and patient safety.1 This is true in all areas of healthcare, but is
especially important during cardiopulmonary resuscitation.2 Up to 10% of all newborn
infants will require some amount of resuscitation at birth, with approximately 1%
needing intensive cardiopulmonary resuscitation, including manual ventilation, chest
compressions and medications.3 Good teamwork behaviors have previously been
correlated with higher quality of care during neonatal resuscitation.4 Thus, measures to
improve teamwork during neonatal resuscitation are critically important. Prior research
has shown that the addition of a teamwork and human error curriculum to the 5th
edition Neonatal Resuscitation Program (NPR) course resulted in more frequent
teamwork behaviors during simulated neonatal resuscitations.5,6 The newest edition of
the Textbook of Neonatal Resuscitation includes a discussion of teamwork/crisis
resource management skills.3
The purpose of this interprofessional training curriculum is to provide training in
teamwork and communication for medical providers engaged in neonatal resuscitation.
The curriculum includes a mix of simulation-based learning and didactic lecture.
Participants in the training could include physicians, nurses, respiratory therapists and
pharmacists.
The didactic teamwork and communication portion is comprised of the
TeamSTEPPS® training curriculum, which was developed by Department of Defense
(DoD) and the Agency for Healthcare Research and Quality (AHRQ).7 The TeamSTEPPS®
curriculum focuses on five core competencies of teamwork which include: team
structure, leadership, situational monitoring, mutual support, and communication.
TeamSTEPPS® is widely considered to be the national standard for medical team training.
The simulation-based training exercises utilizes an ‘event-based approach’ and
were designed to facilitate learning of the TeamSTEPPS® concepts by allowing students
to apply the competencies of teamwork during realistic neonatal resuscitation
scenarios. The simulations involve a neonatal resuscitation, wherein the physicians
orders an incorrect dose of epinephrine and nurses provide slow and ineffective
compressions. These performance errors were designed to elicit specific and observable
reaction from teammates- specifically, a challenge from the nurse concerning the
medication dose and a correction of chest compression technique by the physician
leading the resuscitation.
The entire training curriculum can be conducted in 4 to 6 hours. Based on our
preliminary results, we feel the training offers a valuable learning experience to
practitioners. In a small pilot study we were able to demonstrate significant
improvements in teamwork attitudes, knowledge and skills after participation in the
training. We feel others could easily conduct a similar course at their institution and
achieve similar results.
List of all the resource included here:
1. Interprofessional Teamwork Training in Neonatal Resuscitation using
TeamSTEPPS® and Event-based Approach Simulation: Instructor’s Guides
2. Interprofessional Teamwork Training in Neonatal Resuscitation Course Agenda
3. Neonatal Resuscitation Simulation Scenarios
4. Simulation Scenario Nurse Role
5. Simulation Scenario Physician Role
6. TeamSTEPPS® Fundamentals Course lecture - Module 1: Introduction
7. TeamSTEPPS® Fundamentals Course lecture - Module 2: Team Structure
8. TeamSTEPPS® Fundamentals Course lecture - Module 3: Leadership
9. TeamSTEPPS® Fundamentals Course lecture - Module 4: Situation Monitoring
10. TeamSTEPPS® Fundamentals Course lecture - Module 5: Mutual Support
11. TeamSTEPPS® Fundamentals Course lecture - Module 6: Communication
12. TeamSTEPPS® Learning Benchmarks
13. TeamSTEPPS® Teamwork Attitudes Questionnaire
14. Team Performance Observation Tool
Explanation of when, how, and the order in which to use each resource file:
The Interprofessional Teamwork Training in Neonatal Resuscitation course was
designed to be conducted in a large group composed of healthcare providers from
several specialties involved in neonatal care including nurses, respiratory therapist,
physicians and pharmacists. The course should be conducted as a half-day course. The
course will require a conference room, or meeting area, with capability of presenting a
Power Point presentation and a room in which to conduct neonatal resuscitation
simulations. Medical equipment required for neonatal resuscitation should be available
within the simulation area, as well as a neonatal simulation mannequin. The course is
composed of simulation-based exercises and didactic components from the
TeamSTEPPS® Fundamental course. See Figure 1 for an overview of the
Interprofessional Teamwork Training in Neonatal Resuscitation course.
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Figure 1. Interprofessional Teamwork Training in Neonatal Resuscitation Course
Overview.
To begin the course, the participants should receive a brief introduction to the
course and a review of what will happen during the day, including a review of the
agenda. During this introduction a brief review of the TeamSTEPPS® Fundamentals
Course can be provided by using Module 1- Introduction. Next, the participants should
complete the pre-course Learning Benchmarks exam and Teamwork Attitudes
Questionnaire. The participants should then be divided into teams of 3 or 4 (comprised
of one physician, one respiratory therapist and 1 to 2 nurses) and go to the simulation
room to conduct the first (pre-course) neonatal resuscitation with their team. After
completing the pre-course exam, questionnaires and simulation the participants should
receive Modules 2 through 6 of the TeamSTEPPS® Fundamental course. This can be
conducted using the standard TeamSTEPPS® slides. Instructor training in how to
conduct the TeamSTEPPS® Fundamental course should be obtained by way of
attendance of a TeamSTEPPS® training course
(http://teamstepps.ahrq.gov/trainingEligibility.htm) prior to conducting this training.
After completion of the TeamSTEPPS® Fundamental course the participants should
complete the post-course Learning Benchmarks exam and Teamwork Attitudes
Questionnaire, and complete the second (post-course) neonatal resuscitation with their
same team. See the Interprofessional Teamwork Training in Neonatal Resuscitation
Course Agenda for an example of a course agenda.
The simulation-based training exercises utilizes an event-based approach and
were designed to facilitate learning of the TeamSTEPPS® concepts by allowing students
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to apply the concepts in realistic scenarios.8 The simulations involve a neonatal
resuscitation, wherein physicians are told by the course director to request an incorrect
dose of epinephrine and nurses are told by the course director to provide slow and
ineffective compressions. These performance errors were designed to elicit specific and
observable reaction from teammates- specifically, a challenge from the nurse
concerning the medication dose and a correction of chest compression technique by the
physician leading the resuscitation. During our pilot study we used the Laerdal
SimNewB (Laerdal Medical), but any neonatal mannequin would work. The Neonatal
Resuscitation Simulation Scenarios included here provide details on the history of the
infant in the scenarios and simple instructions on changing the physiologic state of the
mannequins during the simulations. Simulations should take place in a real, or
simulated, delivery room, equipped with standard neonatal resuscitation equipment. To
ensure psychological safety of participants during the scenarios the facilitator should
clearly state prior to the first (pre-course) simulations that the simulations are not
designed to assess medical management, but rather focus on teamwork and
communication skills, and that specific imbedded errors have been included in the
scenario. At the conclusion of the first (pre-course) simulation, no facilitated debriefing
should be conducted. Instead, the debriefing should be reserved until after the second
(post-course) simulation. Participants should be instructed to maintain confidentiality
regarding what happened during the first (pre-course) simulation, and directed not to
speak to others in their group about the simulation until the debriefing conducted after
the second (post-course) simulation. At the conclusion of the second (post-course)
simulation a facilitated debriefing should be conducted. The discussion should focus on
team performance during the two simulations, and compare and contrast team
performance between the two scenarios. At the conclusion of the second (post-course)
simulation the imbedded errors should be clearly identified and the abilities of the
participants who committed the errors in the simulation environment to correctly
perform those steps in a real neonatal resuscitation should be iterated to the team
members.
Explanation of course materials:
1. Interprofessional Teamwork Training in Neonatal Resuscitation Course Agenda –
example agenda for conducting the course.
2. TeamSTEPPS® Fundamental course - TeamSTEPPS® is a teamwork system developed
jointly by the DoD and AHRQ to improve institutional collaboration and
communication relating to patient safety. The Fundamentals Course highlights the
key principles and concepts of TeamSTEPPS®. The Fundamentals Course is divided
into 6 modules, including and introduction followed by a module on each of the 5
core competencies of teamwork.
Course Overview:
Module 1: Introduction
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Module 2: Team Structure
Module 3: Leadership
Module 4: Situation Monitoring
Module 5: Mutual Support
Module 6: Communication
3. Neonatal Resuscitation Simulation Scenarios – two neonatal resuscitation scenarios
with instructions on changing the physical state of the simulator.
4. Simulation Scenario Nurse Role – directions which should be provided to the nurses
participating in the simulation.
5. Simulation Scenario Physician Role - directions which should be provided to the
physician participating in the simulation.
6. TeamSTEPPS® Learning Benchmarks- used to measure teamwork knowledge before
and after TeamSTEPPS® training.
7. TeamSTEPPS® Teamwork Attitudes Questionnaire – used to measure teamwork
attitudes before and after TeamSTEPPS® training.
8. Team Performance Observation Tool – used to evaluate teamwork skills during
simulation-based training. Teamwork skills during the simulations are measured in
each of the five core competencies on a scale from 1 (very poor) to 5 (excellent).
Challenges to the incorrect medication dose and correction of ineffective chest
compressions can also be recorded during the simulations (yes/no).
The purpose/goal of the resource (including educational objectives):
The purpose of this course is to provide training in interprofessional teamwork and
communication for medical providers engaged in neonatal resuscitation.
Learning Objectives:
1. After completing the course participants will demonstrate improvements in
teamwork knowledge, as measured by increased scores on the TeamSTEPPS®
Learning Benchmarks exam.
2. After completing the course participants will demonstrate changes in attitudes
towards teamwork, as measured by changes in scores on the TeamSTEPPS®
Teamwork Attitudes Questionnaire.
3. After completing the course participants will demonstrate improvements in
teamwork skills during simulated neonatal resuscitations, as measured by team
scores on the TeamSTEPPS® Team Performance Observation Tool.
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4. At the conclusion of the course the student will be able to apply what they have
learned during the course to real life neonatal resuscitations.
The conceptual background:
The Interprofessional Teamwork Training in Neonatal Resuscitation course
includes a mix of didactic and simulation-based learning activities. Participants in the
course should include physicians, nurses, pharmacist, and respiratory therapists. The
didactic teamwork and communication portion involves the TeamSTEPPS® Fundamentals
Course curriculum, which focuses on five core competencies of teamwork that include:
team structure, leadership, situational monitoring, mutual support, and communication.
The simulation-based training exercises utilizes an event-based approach and was
designed to facilitate learning of the TeamSTEPPS® concepts by allowing students to
apply the concepts in a realistic scenario. The simulations involve neonatal
resuscitations which include scripted performance errors. These performance errors
were designed to elicit specific and observable reaction from teammates- specifically, a
challenge from the nurse concerning a medication dose and a correction of chest
compression technique by the physician leading the resuscitation. The entire course can
be conducted in 4 to 6 hours.
Practical implementation advice:
Participant number:
We have found that limiting course participants to 12 to 16 allows for better
small-group learning and fosters better discussion during the didactic portion of the
course.
Simulations:
Depending on the number of participants, conducting several simulations
simultaneous may be needed in order to allow all participants to complete the
simulation-based portion in a timely manner. Each simulation takes approximately 1015 minutes to complete. The debriefing after the second (post-course) simulation takes
an additional 10-15 minutes to complete.
Measuring learning outcomes:
By measuring teamwork attitudes, knowledge and skills before and after the
course learning outcomes can be easily analyzed using a prospective, pretest-posttest
design and statistical analysis with simple parametric and non-parametric comparisons.
Psychological safety:
During the event-based simulation training some students are called upon to
make intentional errors. Some individual may find this difficult to do in front of
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colleagues as it may give the impression of a lack of knowledge or a deficiency in clinical
skills. Thus, it is very important to ensure the psychological safety and confidentiality of
the participants at both the beginning and end of the training by assuring them that
their performance during simulations would have no adverse effects, and that their
individual performance would not be discussed outside the simulations and facilitated
debriefings. Additionally, every effort should be made to ensure that the scripted
behaviors are clearly revealed to all team members during the post-simulation
debriefing session to alleviate any concerns about perceived knowledge or performance
deficiencies due to the scripted behaviors.
How has it been successfully deployed?
We have performed a pilot study of the course at our institution with very
positive results.9 Forty two participants completed the course, including 29 nurses, 10
physicians (4 attendings, 6 fellows) and three respiratory therapists. Attitudes towards
teamwork improved significantly from the pretest to the posttest (P <0.001).
Participant teamwork knowledge scores also improved significantly (pretest 86.8% ±SD
7.5 vs. posttest 92.6% ±SD 6.3; P <0.001). Teamwork skills during the simulated neonatal
resuscitations improved also significantly. Improvements were seen in team structure
(pretest 2.5 ± SD 1.3 vs. posttest 4.2 ±SD 0.9; P <0.001), leadership (pretest 2.6 ± SD 1.3
vs. posttest 4.4 ± SD 0.8; P <0.001), situation monitoring (pretest 2.5 ± SD 1.1 vs.
posttest 4.3 ±SD 0.7; P <0.001), mutual support (pretest 2.9 ±SD 1.4 vs. posttest 4.3 ± SD
0.9; P <0.001) and communication (pretest 3.0 ± SD 1.1 vs. posttest 4.4 ±SD 0.9; P
<0.001). Challenges by the nurses to the incorrect dose of epinephrine double from
38.4% before the training to 76.9% after the training (P= 0.063). Before the training,
fellow’s ordering an incorrect dose were challenged 55% of the time but no attending
neonatologists were challenged (OR = 11). After the training, fellows were challenged
77% of the time and attendings were challenged 75% of the time (OR = 1.1). Inadequate
compressions were corrected by the resuscitation leader 61.5% of the time before the
training and 84.6% of the time after the training (P=0.248).
We feel this half-day interprofessional teamwork training offers a valuable
experience to providers involved in neonatal resuscitation. We believe others could
easily conduct similar training at their institution and achieve similar results. The basic
teamwork concepts taught during the course are universally applicable throughout
medicine, and the simulation-based activities could easily be modified to include
pediatric and/or adult resuscitations. Thus, using the basic course framework,
educators could simply modify the simulation-based training and the course could be
adapted to any type of cardiorespiratory resuscitation scenario.
Limitations of the resource and ideas for improving/expanding it:
During the didactic portion in our pilot study we completed a full 4 hour
TeamSTEPPS® Fundamentals course with all participants. This included all the
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TeamSTEPPS®Power Point slides available on the AHRQ website along with the
imbedded video vignettes and several additional videos on teamwork. Based on input
from the students it may be beneficial to limit the didactic portion of the course and
focus more time on the simulation-based training. Additionally, a newer version of
TeamSTEPPS® is due for release from the AHRQ and including that didactic content may
prove beneficial.
References:
1. Baker, D.P., Day, R., Salas, E. (2006). Teamwork as an essential component of
high-reliability organizations. Health Serv Res. 2006;41:1576–1598.
2. Hunziker, S., Johansson, A.C., Tschan, F., Semmer, N.K., Rock, L., Howell, M.D., et
al. (2011). Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll
Cardiol. 57(24);2381-2388.
3. Kattwinkle, J. (ed)..Textbook of Neonatal Resuscitation. Elk Grove Village, IL:
American Academy of Pediatrics and American Heart Association. 2010.
4. Thomas, E.J., Sexton, J.B., Lasky, R.E., Helmreich, R.L., Crandell, D.S., Tyson, J.
Teamwork and quality during neonatal care in the delivery room. J Perinatal.
2006; 26:163-169.
5. Thomas, E.J., Taggart, B., Crandell, D.S., Lasky, R.E., Williams, A.L., Love, L.J., et al.
Teaching teamwork during the Neonatal Resuscitation Program: a randomized
trail. J Perinatal. 2007;27:409-414.
6. Thomas, E.J., Williams, A.L., Reichman, E.F., Lasky, R.E., Crandell, S., Taggart,
W.R. Team training in Neonatal Resuscitation Program for interns: teamwork and
quality of resuscitations. Pediatrics. 2010;125(3): 539-546.
7. Agency for Healthcare Research and Quality. TeamSTEPPS home page.
Accessed 3/26/2013 at http://teamstepps.ahrq.gov/index.htm
8. American Institute for Research. Training Guide: Using Simulation in
TeamSTEPPS® Training. Publication No. 11-0041-EF. Agency for Healthcare
Research and Quality. 2011
9. Sawyer T, Laubach VA, Hudak J, Yamamura K, Pocrnich A. Improvements in
teamwork during neonatal resuscitation after interprofessional TeamSTEPPS
training. Neonatal Network. 2013;32(1):26-33.
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