In-situ team training is just in time learning. It provides clinical staff the opportunity to practice in their own work environment with their own teams. The demand from leaders in organizations is that educators prove ROI. Here is a framework to proving team training works!

1. Melissa Powell BSN, MSHCA, RN

2. 
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I’m a novice to conducting research
I’ve made a few mistakes along the way
I’m eventually going to get there

3. 
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Late 2009 and early 2010, multiple anecdotal
stories of confusion and communication
problems
Post Code Quality Survey
Out of ICU/RRT debrief Committee meets
weekly.
Remediation and debrief process by educator
in place for failure to initiate early rescue and
RRS activation. Qualitative data collected after
each meeting.

4. 
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1.
“He or she {physician} is right here at the bedside with me. And that feels very
uncomfortable as though it says to the physician that I do not think they are capable.”
2.
“He or she went to medical school. I didn’t. I’m just a nervous new nurse. They
know what they are doing.”
3.
“I feel like I’m tattling on them.”
4.
“The doctor is responding to my concerns with orders.”
5.
“There is nothing anyone can do for this patient anyway.”
6.
“There is something not right about this patient but my vital signs are normal, I just
don’t want to call them over here and waste their time.”
7.
“There aren’t any critical care beds right now. The ED is on diversion. I know they
are busy.”
8.
“The {responder} nurses just roll their eyes at me and don’t do anything.”
9.
“The charge nurse thinks everything is okay so I don’t want to call and override her.”
10. “Multiple nurses at bedside: “I didn’t call because my charge nurse was there and
there were others with me and felt I had enough different people involved”.
11. “What else would RRT do, besides what we are already doing?”
12. If the patient wasn’t transferred they think that it wasn’t the right thing to do to call.
13. If the patients code status is DNR/DNI they do not think they should call, regardless
of goals of care or team knowledge.

5. 
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Authority gradient phenomenon
Inability to express concern clearly
Other staff discounting judgment
Lack of organization support
Issues of diminished culture of safety
Responder communication poor
Lack of knowledge
System and process failure

6. Ineffective communication is a root cause for
nearly 66 percent of all sentinel events
reported*
• (The Joint Commission Root Causes and Percentages for Sentinel
Events (All Categories) January 1995−December 2005)
•
Vanderbilt Innovation Pillar goal 2011: Innovate
with new approaches to Interprofessional learning.

7. 
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Experiential learning theory -- (Kolb, 2000)
Social Cognitive learning theory -- (Bandura,
1960)
Interprofessional team training evidence -Multiple studies (Salas, 2008) (Gaba, 2004)
(Miller, 2008) (Small, 2008)
 AHRQ TeamSTEPPS evidence (Salas, 2008)
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Diffusion through Innovations -- (Rogers,
1962)

8. 
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Will in situ team training improve team
member perceptions of “chaos” during acute
events?
Will in situ team training with TeamSTEPPS
improve team member perceptions of “good”
communication during acute events?
Will in situ team communication training with
TeamSTEPPS curriculum decrease delay and
failure to rescue?

9. • Participation
• Satisfaction - Learners reactions to the training
Level 1
Level 2
• 3a Declarative Knowledge - Modifications to knowledge, attitudes,
perceptions
• 3b Procedural Knowledge - Acquisition of procedural knowledge and skills
Level 3
• Competence - Demonstration of skill in training
Level 4
• Performance - Changes in workplace behavior, competencies
and attitudes
Level 5
• Patient Health – Changes in patient health or workplace
systems as a result
• Community Health – Changes in the health of a community
Level 6
Level 7

10. 
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Unit determined by the following VUH
standard:
Required Bi-annual AHA Training for all
staff delivered by VRP. (Policy 30-1.24)
Education regarding adherence to Rapid
Response System process (Policy 32.89.0)
received in orientation.
Required Bi-annual “Mock Code” simulation
in “Hands on Clinical Safety”.
All nurses debriefed about failure to rescue.

11. 
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Convenience sample
Required Bi-annual AHA Training for all
staff. (Policy 30-1.24)
Education regarding adherence to Rapid
Response System process (Policy 32.89.0)
Blended Learning Intervention:
◦ Online education regarding teamwork and
communication
◦ On unit setting with interprofessional team
◦ Briefing before simulation
◦ High fidelity Interprofessional simulation of patient
decline and cardiopulmonary arrest requiring early
activation of rapid response system and BLS
◦ Debrief using Rudolph’s “non-judgmental” process

12. Post code data
& # failure to
rescue events
Intervention
group (100%
unit) Level 1
Online
education
(Level 3a)
Simulation
(Level 3b, Level
4)
Debrief (Level
4)
Survey (Level
2)
Real event
(Level 5)
Post code
quality survey
(Level 5) &
# Failure to
rescue events
(Level 6)

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Participation was mandatory for intervention unit.
100% completion.
Most staff was excited to have an opportunity to
be a part of simulation training and signed up
early for sim times.
Few staff had anxiety. Reassurance and
encouragement was necessary for a few staff
members.
Satisfaction: Initial paper survey response rate
very highly rated simulation experience: 63
surveys received: 92% rated unit based training
with simulation “very satisfactory” as a learning
method.

14. Strongly agree
strongly disagree

15. Excellent
poor

16. 
All complete AED Heartsaver or BLS course
 Performance of CPR
 Pass a test on AHA guidelines for rescue
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All staff are communicated to about RRS
 All new hires are verified that they were informed and
read policy about RRS.
 Signs in all patient rooms and staff break room
 Cultural awareness
 No formal test of knowledge

17. 
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BLS skills (80%)
Procedural knowledge (50%)
Equipment knowledge (unable to assess during
due to SimMan3G barriers)
Assessment and Intervention (99%)
Recognizing and Initiating RRT immediately (55%)
Communication skills
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SBAR (20%)
CUS (.1%)
Check Back (34%)
Two-Challenge Rule (0%)
Situation Monitoring including Shared Mental Model
knowledge (34%)
***This data is based on video
observation and very rough and unable
to validate fully.

18. Strongly agree
strongly disagree

19. 
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Post RRT and Code event data obtained from
team members obtained through convenience
and ability to discover who would voluntarily
complete online survey.
No systematic process in place currently to
identify and contact all or some members of
an acute event.
The sample frame or the population size is
unknown and varies event to event.

20. Pre July
2010
Post
Intervention
Dec 2010
difference
Post
intervention
Confidence
Intervals
Intervention
Unit
8%
8.3%
0.3%
+/- 8%
Control Unit
9%
9.5%
0.5%
+/- 8%
With 90% confidence 8% of the participants in the survey sample answered
“strongly agreed," we could be sure that between 1% and 18% of the
members of the entire target population would also say “strongly agreed"
when asked the same question. The confidence interval, in this case,
is +/- 8%.
My sample is not random so my ability to report
is not accurate.

21. Pre July
2010
Post Dec
2010
difference
Intervention
Unit
20%
0%
20%
Control Unit
19%
4.8%
14.2%
Confidence
Intervals
+/- 6%
+/- 6%

22. 
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Interviewed 6 team leaders of STATS obtained
through ability to identify and meet.
Questions asked:
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Tell me how the code went that occurred on (unit)?
How was the communication?
What could the team have done better?
Did you all debrief afterward?
Unable to record conversations completely. Some
situations were random. Information regarding
team work was consistently very satisfactory in
regards to teamwork on intervention unit.
Additionally, this approach yielded the highest
quality feedback.

23. 
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Data obtained from Out of ICU meetings and
review of events
There were fewer delay and failure to rescue.
The behavior is still occurring.

24. Jan 2010 to
July 2010
Jan 2011 to
July 2011
Intervention
Unit
23
6
Control Unit
18
12
Delay to rescue is determined by patient meeting
a rapid response trigger criteria for more than 60 minutes.
Failure to rescue is determined by patient declining over more than 6
hours before RRS activated.

25. 
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Debriefing nurses post intervention yield
stronger self reflective ability and that
learning occurred
Using concepts such as authority gradient to
communicate what they experienced
Staff now often identifies their own barriers
and role in early activation and failure to
rescue
Did not continue qualitative data collection of
debriefs

26. 
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In Situ Simulation Team Training is effective. I
recommend Vanderbilt leaders take a look at
equipping unit educators with the skills.
Communication skills are a hard skill. Best
methodology is not a power point but simulation.
Culture of safety is important and must take
multiple angles to address.
To get to “zero” delay and failure to rescue, we
must improve process, system, education and
communication skills of providers.
Diffusion of Innovation is occurring

27. 
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Researcher bias, confounded by known identity
of intervention group
Training works versus no training. Team
Training works with multiple levels of evidence
for the last 10 years.
Teams that are trained in team communication
rate themselves lower after training.
No triangulation of observed effects. No
independent raters of performance.
Inability to train all educators to level of
competence for intervention
Doesn’t inform beyond existing research
literature. Must find measurable outcomes.

28. 
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Pilot idea, discussed in multiple meetings
with leaders and experts in simulation team
training.
Held initial simulations with team training
experts and received training in event based
scenario development, team observation,
checklist development and rating, and
debriefing skills.
Ran 68 simulations in a 10 month period.
Videoed simulations and debriefs to improve
and practice observation skills and debrief
skills.

29. 
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July 2012, acquired TeamSTEPPS Master
Trainer training and status through AHRQ.
Continue to refine process through improved
coordination of departments and leadership
buy in.
Created a temporary unit simulation space in
a large equipment room.
Refined data collection methods and survey
instrument. NO MORE SLIDER SCALES.
LIKERT ONLY.
Begin collaboration with other units.

30. 
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Bandura. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52(1),
1.
Clancy, C. M. (2007). TeamSTEPPS: assuring optimal teamwork in clinical settings. American journal of
medical quality, 22(3), 214.
Gaba, D. M. (2004). The future vision of simulation in health care. Quality & Safety in Health Care,
13(suppl 1), i2.
Holzman, R. S. (1995). Anesthesia crisis resource management: real-life simulation training in
operating room crises. Journal of clinical anesthesia, 7(8), 675.
Kolb, D. A. (1983). Experiential Learning: Experience as the Source of Learning and Development (1st
ed.). Prentice Hall.
Miller, K. K. (2008). In situ simulation: a method of experiential learning to promote safety and team
behavior. The Journal of perinatal & neonatal nursing, 22(2), 105.
Moore, D. E., Green, J. S., & Gallis, H. A. (2009). Achieving desired results and improved outcomes:
Integrating planning and assessment throughout learning activities. Journal of Continuing Education
in the Health Professions, 29(1), 1–15. doi:10.1002/chp.20001
Nunnink, L. (2009). In situ simulation-based team training for post-cardiac surgical emergency chest
reopen in the intensive care unit. Anaesthesia and intensive care, 37(1), 74–8.
Peberdy, M. A., Callaway, C. W., Neumar, R. W., Geocadin, R. G., Zimmerman, J. L., Donnino, M.,
Gabrielli, A., et al. (2010). Part 9: Post–Cardiac Arrest Care 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation,
122(18 suppl 3), S768–S786. doi:10.1161/CIRCULATIONAHA.110.971002
Rogers, E. M. (1995). Diffusion of innovations. Free Press.
Rudolph, Jenny, W. (2006). There’s No Such Thing as “Non-judgmental” Debriefing: A Theory and
Method for Debriefing with Good Judgement. Simulation in Healthcare, 49–55.
Salas, E., DiazGranados, D., Klein, C., Burke, C. S., Stagl, K. C., Goodwin, G. F., & Halpin, S. M. (2008).
Does Team Training Improve Team Performance? A Meta-Analysis. Human Factors: The Journal of the
Human Factors and Ergonomics Society, 50(6), 903–933. doi:10.1518/001872008X375009
Small, S. D. (2008). Demonstration of high‐fidelity simulation team training for emergency medicine.
Academic emergency medicine, 6(4), 312.
Vanderbilt Policy Rapid Response Team Activation Policy number CL 30-08.16
Vanderbilt Policy Cardiopulmonary Resuscitation Policy number CL 30-08.21.