Simulation as a Vehiclefor EnhancingCollaborativePractice Models

Pamela R. Jeffries, DNS, RN, FAAN, ANEFa,*,Angela M. McNelis, PhD, RNb, CorinneA.Wheeler, PhD, RNb

KEYWORDS� Clinical simulation � Collaborative practice models� Educational technology � Interdisciplinary collaboration� Interdisciplinary learning

Health care professionals need to be prepared forsafe and efficient practice and for collaboratingeffectively with practitioners from other disci-plines. Faced with these challenges, educatorsmust explore innovative ways to teach medical,nursing, and other health care students and pro-fessionals how to work together to deliver carein real-world clinical practice. Developments ineducational technology make a wide array of op-tions available to facilitate this preparation. Thesedevelopments also create an advantageous envi-ronment for systematic and substantial change,including a focus on interdisciplinary, collabora-tive learning. Lectures and small-group work canimpart technical knowledge but are inadequateto prepare students for the complexities of thework place or for working collaboratively. Clinicalsimulation used in a collaborative practice ap-proach is a powerful tool to prepare health careproviders for shared responsibility for patientcare.1

Clinical simulations in professional curricula arebeing used increasingly to prepare providers forquality practice, but little is known about howthese simulations can be used to foster collabora-tive practice across disciplines. This article pro-vides an overview of what simulation is, whatcollaborative practice models are, and how to set

a Department of Adult Health, Indiana University Scho1111 Middle Drive, NU140, Indianapolis, IN 46202, USAb Department of Environments for Health, Indiana UniveNursing, 1111 Middle Drive, NU403H, Indianapolis, IN 46* Corresponding author.E-mail address: prjeffri@iupui.edu (P.R. Jeffries).

Crit Care Nurs Clin N Am 20 (2008) 471–480doi:10.1016/j.ccell.2008.08.0050899-5885/08/$ – see front matter ª 2008 Elsevier Inc. All

up a model using simulations. An example of a col-laborative practice model is presented, and nurs-ing implications of using a collaborative practicemodel in simulations are discussed.

SIMULATION DEFINITION, PURPOSES, AND USES

Simulation, in specific reference to health care, isan attempt to replicate essential aspects of a clini-cal scenario so that when a similar scenario occursin a clinical setting, the situation can be managedreadily and successfully.2 The educator decidesif the simulation will focus on the process of teach-ing–learning and progress toward an outcome(formative) or on the attainment of the learningobjectives (summative).

When simulations are used in a formative man-ner, as in a teaching–learning activity, the goal isto improve student performance. In this situation,students receive feedback from the educator andfrom peers, and they reflect on their knowledge,skills, and critical thinking relative to the simula-tion. When simulations are used in a collaborativepractice approach, students are exposed to theknowledge, skills, and critical thinking of practi-tioners outside their own discipline and can beginto appreciate the contributions each team mem-ber can make in patient care.

ol of Nursing, Indiana University School of Nursing,

rsity School of Nursing; Indiana University School of202, USA

rights reserved. ccnu

rsin

g.th

ecli

nics

.com

Jeffries et al472

When simulations are used summatively, feed-back about the attainment of learning objectivesand/or final competency goals is provided at theconclusion of the teaching–learning activity. Thesummative approach often becomes a componentof progression in a course or program. Summativesimulations address the charge by the Institute ofMedicine3 to improve patient care by increasingcollaboration among clinicians in practice settings.Educational initiatives that encourage teamworkamong the health care disciplines are critical toperforming this mission.

COLLABORATIVE PRACTICEMODELSOverview

In today’s health care system, no profession ordiscipline can operate alone. Interdisciplinary col-laboration is vital for creating a safe system ofcare. Health care providers need to understandthat teamwork and communication reduce errors.4

Quality client outcomes rely on professional team-work, and the level of collaboration that takesplace can affect safety outcomes directly.5

Studies among professional health science stu-dents have shown a strong relationship betweencommunication skills and teamwork training, withsuch skills leading to fewer errors, improvedpatient satisfaction, and more timely clinicaldecision-making in critical client events.6–8 To pro-mote a ‘‘culture of safety,’’ the Institute of Medi-cine (IOM), the Joint Commission (formerly theJoint Commission on Accreditation of HealthcareOrganizations), and others have encouragedhealth care professionals to improve communica-tion and teamwork.

Traditionally, the education of health care pro-fessionals has been from a discipline specific,rather than interdisciplinary approach. Faculty inthe health sciences now are adopting an evi-dence-based model of teaching in an integratedmanner that enables students to learn to commu-nicate and make clinical decisions collabora-tively.9 Communication among nurses andphysicians and others does not ‘‘just happen’’ ina clinical setting; it is a skill that must be taughtduring professional education.

Collaborative practice has been defined as aninterprofessional process for communication anddecision-making that enables the separate andshared knowledge and skills of care providers toinfluence synergistically the client care provided.Essentials needed for collaborative work includeresponsibility, accountability, coordination,communication, cooperation, risk-taking, asser-tiveness, autonomy, and mutual trust and re-spect.5,7,10 According to Keleher,10 the

foundational components required to build a suc-cessful collaborative practice are a willingness tomove beyond basic information-sharing and theability to challenge distortions and assumptions,using a belief system based on critical self-reflection.

Purposes

Interdisciplinary education is a critical element inimproving patient safety.3 The IOM report identi-fied five essential competencies in this area neces-sary for health care providers: patient-centeredcare, interdisciplinary teamwork, evidence-basedpractice, quality improvement practices, and infor-matics. Core curricular content that targets patientsafety and the use of teaching strategies that facil-itate attainment of the five core competencies willprepare future health care providers to improvepatient safety in complex health care environ-ments. Unfortunately, educational gaps exist forpractitioners in many clinical venues, resulting inan increased frequency of medical errors.3 Im-mersing students in a collaborative practice envi-ronment where health care professionals learnand practice together would promote safer patientcare.

In 2003, the IOM released its recommendationson how health care professional education mustbridge the quality gap between the expectationsfor care and the actual quality of care deliveredin health care systems today. To build this bridge,skillful, well-educated, innovative health profes-sionals are needed. To begin this effort, educatorsneed to develop an interdisciplinary educationalmodel as a way of developing a sense of commu-nity and collaboration among all health care pro-fessionals. Key elements in building sucha community are communication, teamwork, trust,and collaboration.11

The National Patient Safety Foundation12 callsfor health care professionals to identify and createa core body of knowledge, to identify pathways toapply the knowledge, and to foster communica-tions about patient safety to improve patient out-comes. Meeting these standards will requirestrategic cooperation among health care organiza-tions, schools of nursing, schools of medicine, andother health care disciplines to develop a modelfor collaborative educational practice models andto conduct research in this area.

Challenges

Barriers to collaborative practice are many. Roleambiguity and confusion, hierarchical relation-ships, educational differences, gender issues,

Enhancing Collaborative Practice Models 473

and culture are all real barriers to creating collabo-rative relationships.

Role ambiguity and confusionSexton and colleagues13 report that sufficientlytrained critical care health professionals oftenfunction well individually but fail to work smoothlyas a team. The most difficult tasks encountered byan interdisciplinary team include leadership, com-munication, and cooperation.13,14 All three ofthese tasks are necessary for team members tounderstand better how members of each disci-pline function independently within their scope ofpractice but interdependently in a smoothly oper-ating team. Role ambiguity exists when the goalsof one’s job or the methods of performing it are un-clear. Ambiguity sometimes is characterized byconfusion about how work performance is valuedor what the limits of one’s authority and responsi-bility are. Certain team members may have unclearexpectations of another team member, or theymay aware of the expectations but personallyfind them difficult to accept. Role ambiguity canbe reduced by open communication and respectshown for the knowledge and skills brought byeach discipline.

Hierarchical relationshipsThe nurse–physician relationship historically hasbeen one of hierarchy and power, with the physi-cian assuming control. In the past, physiciansplayed a dominant role, and nurses playeda more subservient role by deferring all client-re-lated decisions to the physician and communicat-ing in a passive way. Even though advances havebeen made, economics and educational prepara-tion perpetuate this type of nurse–physicianrelationship.

Economics contributes to the hierarchy, be-cause physicians usually are the revenue genera-tors in health care systems. Physicians caninfluence the bottom line of organizations by con-trolling the number of client admissions or proce-dures done within that organization; thusphysicians have inherent power. Nurses often areconsidered a ‘‘cost’’ to the organization, becausetheir salaries and benefits are paid directly by theorganization.

Educational differencesIt has long been recommended that students needrole models of collaboration, and faculty membershave been encouraged to develop interprofes-sional training opportunities for socialization topromote interdisciplinary collaboration.15,16 Healthcare professionals still are being educated sepa-rately, however, and as a result may fail to recog-nize the important roles played by members of

other disciplines. Formal education to help teammembers understand the scope of their col-leagues’ practice is essential. Collaboration relieson respect and on trust that each person is doinghis or her best. Familiarity with the role, skills, andphilosophy of care of each discipline also en-hances the collaborative relationship.

Gender issuesHistorically, physicians were men, and nurseswere women. Today, more women are becomingphysicians, and more men are becoming nurses.According to the American Medical Association,men and women are almost equally representedin medicine (2000), although nationally only about5.4% of registered nurses are men.17 Multiplestudies investigating gender and power foundthat male physicians maintain a dominant role. Astudy by Zelek and Phillips18 found that nurseswere less likely to speak up to a male physician,whereas the balance of power was more equaland collaborative when both nurse and physicianwere women. In a qualitative study by Wear andKeck-McNulty,19 female nurses reported a higherlevel of collaboration with female physicians thanwith male physicians.

CultureCulture describes a person’s way of life, includingknowledge, values, beliefs, and behaviors. Culturealso includes the way people think about and un-derstand the world and their own lives. A specificculture can be reflected in a nation, region, organi-zation, or in the communication and symbols usedby an individual.20 Contrasting values, beliefs, orunderstandings held by team members from dif-ferent cultures can be a barrier to successful col-laborative practice.

In some ways, nursing and medicine are rootedin different cultures. The respective philosophiesrepresent different priorities in providing care. Stu-dents in nursing and medicine are indoctrinated inthese diverging philosophies, values, and beliefsearly in their educational preparation, making col-laboration potentially difficult. Introducing interdis-ciplinary, collaborative learning into both nursingand medical curricula decreases this ethos disso-nance and promotes a culture of collaboration.

Organizations also have their own cultures. Anorganization that values teamwork and communi-cation provides an environment supportive of col-laboration among disciplines. Other organizationsmay have a rich tradition of social order thatsupports a hierarchical system.5

Benefits of the collaborative practice modelResearch has demonstrated positive outcomesfrom interdisciplinary collaboration for both health

Jeffries et al474

care providers and patients.6,21,22 Collaborativepractice models are known to improve patientsafety, patient satisfaction, care coordination,and health care provider working relationships.They also lead to more efficient use of time, de-creased length of hospital stays, and reducedcost.5,10 Collaborative practice allows the full skillsets of the team to be used and facilitates contin-ued learning for all team members.

SETTING UPA COLLABORATIVE PRACTICEMODEL USING SIMULATIONSCollaborative Learning with Simulations

Although communication skills may be learned bytrial and error in a clinical setting, a formal ap-proach to instruction has been shown to be moreefficient and to enhance student confidence.8 Col-laborative learning with simulations also has beenfound to increase a sense of collegiality and team-work.23 One way to develop mutual respect, toenhance communication, and to improve relation-ships among disciplines is to involve the membersof the various disciplines in a group-learning simu-lation experience.

Simulation Design Overview

The design for creating an interdisciplinary teach-ing simulation must be appropriate for all the disci-plines involved in the activity. Although course

OBJECTIVESDEBRIEFING

STUDENT SUPPORT

FIDELITYPROBLEMSOLVING

EVALUATION

EVALUATION

LEARNING

COLLABORATIVE

PRACTICE

goals and skill competencies may differ amongdisciplines, the learning outcomes of the simula-tion (eg, communication skills) may apply to all.Each simulation design, regardless of discipline,should include the following characteristics: ob-jectives, roles, fidelity, problem-solving, support,and guided reflection.24 The evaluation of eachsimulation process should include an assessmentof each of these design features as well as learningoutcomes related to collaborative practice. Fig. 1is an example of a collaborative model used atthe Indiana University Schools of Nursing andMedicine.

Characteristics of a Simulation Design

ObjectivesBefore participating in a simulation experience,learners need to be provided with information re-garding its purpose and objectives. Pre-simulationinformation can be sent to students several daysbefore the event to help them prepare for the ex-perience. Objectives for the activity need to beprovided clearly to the learner; they must statethe intended outcome(s) of the experience, ex-pected learner behaviors, and enough detail to al-low the learner to participate in the eventeffectively.24 It is best to limit each simulation tono more than two or three main objectives. Duringthe debriefing session following the simulation

ROLES

Fig.1. Characteristics of an inter-disciplinary teaching simulation.

Enhancing Collaborative Practice Models 475

event, the objectives can be revisited to explorewith the students how they felt the objectiveswere met.

RolesRegardless of the fidelity (realism) or complexity ofthe simulation, the two constant roles are those ofeducator and student. Depending on the simula-tion design, other roles may include actors playingthe part of a standardized patient or family mem-ber and support staff assisting with room set-upfor high-fidelity technology.

The specifics of the faculty role are determinedby whether the simulation is designed for studentlearning or evaluation. When the goal is learning,the faculty member is involved more actively insupporting the student by providing informationbefore the simulation or by providing ‘‘cues’’ dur-ing the actual simulation activity. If the goal is eval-uation, the faculty takes on the role of observer.Whether for learning or evaluations, faculty re-sponsibilities are the same for the design andimplementation of the simulation (Table 1).

Student roles vary depending on the simulationdesign. According to Cioffi,25 clinical student rolesare either process-based or response-based. Ina process-based role, the student is an active par-ticipant and influences the sequence of events (eg,when using a simulator or role-playing in a sce-nario). The student in a response-based role

Table1Simulation roles and responsibilities

Faculty Role

Stude

Caregiver Actor

Provide learnersupportthroughoutsimulation activityand debriefing

Responsible forown learning

Responsibown lea

Design simulation

Provide informationto the studentsbefore thesimulation

Engage activelya as health careprovider

Engage acas an acdesigna

Equipment set-up Give cues

Program high-fidelity technology

Self reflectionand evaluation

Self reflecand eva

Observation

Evaluate alldimensions of thesimulation

Can rotate through assignedabout the roles during d

does not become actively involved in controllingthe event. An example of a response-based roleis reviewing a standardized case report and dis-cussing the findings.

In an interdisciplinary simulation, students takeon process-based roles. During the simulation ac-tivity, a role might be that of the health care pro-vider in one’s discipline, or the design might callfor a student to take on a role of actor or an ob-server. Whatever the role assigned, all participantsmust be prepared for their parts before the activity.It also is expected that each student will be en-gaged actively throughout the simulation activityand debriefing process.

FidelityHuman mannequin simulators can perform atthree levels of fidelity and sophistication (high,moderate, and low).26 Fidelity is the extent towhich a simulation mimics reality. The high-fidelitymannequin can mimic a real-life situation with in-teractive features (eg, the mannequin speaks, thechest moves up and down, skin color changes).A moderate-fidelity mannequin may produce audi-ble heart and lung sounds but does not have ashigh a level of technical sophistication. The low-fidelity mannequin is sometimes referred to asa ‘‘static mannequin.’’ It may appear real but hasno mechanical features such as voice or lungand heart sounds.27

nt Role

OtherObserver

le forrning

Responsible for ownlearning

Participate as anactor orobserver

tivelytor inted role

Observe silently,take notes duringsimulation activity

Providetechnologysupport

Assist withequipmentset-up

tionluation

Self reflection andevaluation

roles in addition to talkingebriefing and reflection.

Jeffries et al476

In a discussion of teaching teamwork skills inhealth care, researchers Beaubien and Baker28

state that high-fidelity simulation is only one ofmany tools that may be effective. They describethree dimensions of fidelity: environment, equip-ment, and psychologic, and they propose thatpsychologic fidelity is the most important forteam training. A focus on realism in all aspectsof the simulation, not just on the realism of themannequin, is important.

Health care educators must consider factorsbeyond providing realistic equipment when de-signing the collaborative clinical simulations.Learners quickly can become engaged in caringfor a human patient mannequin with lung sounds,chest tubes, and real-life heart sounds, but thereis more to a successful simulation than the manne-quin. What learners are thinking and feeling duringthe simulation must be considered also. Thesimulation scenario must call for the use ofevidence-based findings, critical thinking, andproblem-solving skills related to patient care.

Problem-solvingThe design of the simulation ranges from simple tocomplex and should correspond to the level ofproblem-solving and decision-making expectedof the student. The simulation activity is designedto be aligned with the learner’s current knowledgeand skill level and to incorporate different levels ofuncertainty. The simulation needs to challenge thelearner but be attainable. If the level of complexityor problem-solving is too high for the learner, theresult will be an unfavorable learning experience.In a complex collaborative practice simulation,the learners have an opportunity to communicate,prioritize assessment findings, initiate care withintheir scope of practice, and perform team andself-evaluations. For example, in a simulation sce-nario with the focus on collaborative communica-tion and teamwork involving both medical andnursing students, the simulation provides an op-portunity to work with members of the other disci-pline, to respect each other, and to communicatewith each other while focusing on patient-centeredcare. During the debriefing, the simulation partici-pants can reflect on the experience, self-evaluate,and discuss with the instructor what went right andwrong.

Student supportThe educator supports student learning differentlyduring each phase of the simulation. In the pre-simulation phase, faculty members preparestudents directly for the simulation experience.During this pre-phase period, students learn thepurpose of the simulation, the learning objectives,

the process, and what the simulation entails.The student experience during this phase will influ-ence how effective the simulation-based trainingwill be.29

During the simulation activity, faculty memberssupport students’ learning less directly. Facultymembers incorporate a number of cues or hintsinto the design of the scenario that help the stu-dents progress to the next step. The cues shouldoffer enough information for the students to con-tinue without interfering with independent orteam problem-solving. Cues can take many forms,such as a telephone call, a laboratory report, orstatements from a family member or the voice-programmed human simulator. Most importantly,the cues need to be realistic to the case andprompt the participant toward certain actions.During the final phase of the simulation, the educa-tor supports students through guided reflection,also referred to as ‘‘debriefing.’’

Guided reflectionOne of the core elements of the simulation experi-ence is the debriefing session. Immediately afterthe simulation activity, students and faculty en-gage in a facilitated discussion. The goal of de-briefing is to promote reflective thinking and forlearning and discussion to occur in a nonthreaten-ing and organized way.30 To ensure a successfuldebriefing process and learning experience, theeducator or facilitator must provide a supportiveenvironment in which students feel respected, val-ued, and free to speak openly. The debriefing pro-cess allows students to evaluate and assess thesituation using their own self-analysis as well asfeedback from others. The debriefing also isa time when elements of a scenario’s evolutioncan be tied to theory, practice, and research.

Principles in Promoting Collaborative Work

The implementation of collaborative practicemodels is expected by many health care organiza-tions and health care regulatory agencies. Thestructures, systems, and processes within a col-laborative practice model are designed to facilitatecommunication, cooperation, coordination, andteamwork, with trust and equality being pivotalcomponents. Collaborative practice is not intui-tive, however. It involves a philosophy that needsto be learned and practiced by all members ofthe team. Institutions offering health serviceseducation recognize this need and are beginningto integrate collaborative practice models intothe educational preparation of nurses, physicians,and other health care providers. Hospitals and or-ganizations are transforming the work culture,

Enhancing Collaborative Practice Models 477

especially in critical care areas, by training healthprofessionals in collaborative practice.

EXAMPLEOFA CURRENT COLLABORATIVEPRACTICEMODEL

The demands on health care professionals havebecome more complex because of advances intechnology and increased patient acuity in the clin-ical agencies. Health care providers face increas-ingly complex patient-care situations; oftendecisions must be made rapidly in an atmosphereof conflicting or incomplete information. Given thissituation, the need for members of the health careteam to collaborate effectively is imperative.31

Such realities challenge nurse educators to de-velop teaching –learning activities that focus oncollaborative care. One strategy suggested byhealth care educators for developing collaborativepractice competencies is the scenario-basedsimulation.32 An example of how such simulationshave been used to teach interdisciplinary teamsusing a collaborative practice model is theAmerican Heart Association’s model of teachingadvanced cardiac life support (ACLS).

ACLS was developed in 1974 as a course to ad-dress the need to integrate knowledge and skills incardiac resuscitation. The ACLS course is one ofthe oldest multidisciplinary medical training pro-grams in the United States. The course tradition-ally is taught in 1 or 2 days, the equivalent of 8 to16 instructional hours Enrollment in the course in-cludes different health professionals includingnurses, physicians, respiratory therapists, andothers. Since the course began, the advent ofthe International Guidelines on CardiopulmonaryResuscitation (CPR) and Emergency CardiacCare Conference in 2000 resulted in internationalguidelines for resuscitation. The new guidelinesincorporate evidence-based practice using collab-orative teams to learn and perform ACLS. Withthese new guidelines developed for CPR andACLS courses, a difference in survival rates afterCPR has been demonstrated.33–35

For ACLS training, teamwork and collaborativepractice are incorporated throughout the course.For example, different health care participantswork together to learn to perform a successfulcode, in which a patient has a cardiac arrest ordysrhythmia resulting in a life-or-death situation.Moretti and colleagues36 reported a studyfocusing on patients who had a return ofspontaneous circulation after resuscitation byACLS-trained health care providers. The moreACLS-trained members there were participatingin the team, the higher was the likelihood of a returnof spontaneous circulation in the patients studied.

In addition, the researchers found that with in-creased numbers of ACLS-trained rescue squads,survival to hospital discharge increased from20.6% to 31.7%, and long-term survival increasedfrom 0% to 21.9% 1 year after discharge. The re-sults in this research emphasize the importanceof health care professionals learning ACLS andalso how the collaborative team effort affectsin-hospital and long-term survival rates.

In another study by Gilligan and colleagues37 theresearchers found that ACLS-trained nurses per-formed as well as ACLS-trained emergency seniorhouse officers in a scenario-based simulation ofa cardiac arrest. The researchers recommendedthat if a physician were not present, the ACLS-trained nurse should act as a team leader. Accord-ing to the researchers, empowering experiencednurses who have had ACLS training to take overand lead the team until the physician arrives andthen work as part of a collaborative team actuallycan increase survival rates, because in most casesthe team begins compressions and defibrillationbefore the physician arrives. This finding empha-sizes the need for collaborative practice that hasbeen started in the learning environment whereACLS is being taught. This example serves asa model of collaborative practice in which inter-disciplinary groups work together to improveoutcomes and patient survival rates.

NURSING IMPLICATIONS OF USINGA COLLABORATIVE PRACTICEMODELIN SIMULATIONS

Physicians, nurses, and other health care profes-sionals must be prepared to create and establishsafer and more efficient practice environments.Faced with many challenges today in health careeducation, educators must explore innovativeways to teach medical, nursing, and other healthcare professional students the skills they willneed in real-world clinical practice in a cost-effective, productive, and high-quality manner.Discoveries and developments in educationaltechnology make a wide array of options availableto faculty to facilitate experiential learning (eg, us-ing sophisticated simulators). Such developmentsalso create an environment ripe for systematic andsubstantial change. Providing students with lim-ited clinical experiences and immersing them inlecture content and small-group work may impartthe requisite technical knowledge; however, thismode of instruction is inadequate to prepare stu-dents for the complexities of the work place. Clin-ical simulation based on a collaborative practicemodel, as discussed, clinical experience, and ex-periential teaching methods are powerful tools to

Jeffries et al478

prepare competent health care professionals forclinical practice.1 Health care providers such ashospitals have noted gaps in communication andteamwork. Teamwork solutions are available, buteducators must be prepared to develop andimplement solutions using a collaborative model.

Teaching strategies and opportunities for imple-menting collaborative practice models in educa-tion are shown in Table 2. In accordance withthe IOM 2003 recommendations,3 collaborativepractice should be incorporated into the educa-tional arena before students graduate and beginto practice in a real-world environment where col-laborative working relationships are imperative.Educators of health care professionals shouldconsider incorporating interdisciplinary simula-tions into the laboratory and/or clinical practicumexperiences. Content and interdisciplinary experi-ences can be included in student clinical experi-ences, orientations, and staff development athealth care institutions both to promote a culture

Table 2Teaching strategies to implement a collaborative practice

Teaching Strategy Concept

Develop an interdisciplinarysimulation to focus oncommunication skills andcollaborative teamwork.

Interdisciplinary coand collaboratio

Develop an interdisciplinarycourse in which medicalstudents and nursing studentsare enrolled to study commonconcepts and content.

Example of healthstudying the priethics and discudilemmas and is

Set up lunch times, eveningevents, or other selected timeswhen multidisciplinarystudents can mix, discussdifferent concepts, anddevelop a respect for eachdiscipline and individual.

Mutual respect foand the disciplinabout the otherthe knowledge aother team mem

Incorporate Web-baseddiscussion forums in whicha collaborative team ofprofessionals respond toa specific issue or scenario

Collaborative praconline platformconsider interdispractice and pat

Develop and implementWeb-based modules oncontent that are similar forall health care professionals(eg, patient safety) and havethe students complete themodules before simulations orother clinical practice

Concepts includedWeb-based modvary according tof the course, thcompetencies, avariables, but idinclude patientcommunication,care ethics

of patient safety and interdisciplinary collaborationand also to improve other patient outcomes. Fac-ulty development also must be considered whenintegrating models of collaborative practice. Fac-ulty members need knowledge and skills to createexperiences that include working in partnershipwith other disciplines, instructors, and studentsin health care professions. Four key faculty devel-opment elements that need to be consideredwhen using simulations are

1. Developing knowledge in designing, deve-loping, and implementing interdisciplinarysimulations

2. Establishing guidelines and procedures on howthe collaboration will work, taking into accountall stakeholders involved (eg, equal partners indecision-making, scheduling laboratory time,sharing resources)

3. Developing a conceptual collaborative modelwith goals and direction (see Fig. 1)

model

Potential OutcomeMeasures

mmunicationn

Collaboration ScaleCommunication Scale (IUSM,2008)27

care ethics,nciples ofssing ethicalsues

Focus groups, pre/post testing;develop a simulation dealingwith an ethical dilemma andreview for selectedcompetencies desired

r each othere; learn morediscipline andnd skill sets ofbers

Respect instrument measuringrespect for other disciplines;conduct focus groups andreview reflective journals forconcepts desired

tice using anto discuss andciplinaryient care

Online learning as a platform forteaching interdisciplinaryconcepts and collaborativepractice

in theule couldo the needse programnd othereas couldsafety,and health

Online learning and modulecompetencies defined withinthe Web-based module couldevaluate the concepts via aninterdisciplinary simulationdesigned to assess the concepttaught, (eg, culture of safety,authority gradient)

Enhancing Collaborative Practice Models 479

4. Establishing dates and meeting times for thecollaborative work, goals, and activities to bediscussed and reflected upon

Current college students, sometimes referred toas the ‘‘net generation’’ or ‘‘millennials’’ are morehands-on and active learners, multitaskers, andcollaborators who embrace technology as a wayof learning and communicating. Millennials like towork in teams with peer-to-peer collaboration.38

As faculty members learn more about developingsimulations and building experiences around a col-laborative practice model, it is important to under-stand learners’ characteristics so that educationalneeds, learning styles, and teaching modalitiesare considered. With the need for collaborativepractice models and the desire to promote betterpatient outcomes and safer patient care environ-ments, faculty development related to simulationpedagogy is important. To promote collaborativepractice, educators must be encouraged and sup-ported in designing and implementing innovationssuch as simulations in the health professionalcurriculum.

SUMMARY

Collaborative practice models that embrace simu-lation as a vehicle for improving patient care aretimely and necessary. Interdisciplinary educationis critical to delivering safe and holistic patientcare.3 Simulations that enhance collaborativepractice models facilitate knowledge and appreci-ation of the contributions each discipline brings tothe patient care arena. Moreover, understandingthe expertise and abilities of each health careprovider improves the likelihood that patients willreceive comprehensive, quality care. Interdisci-plinary simulations provide students and practic-ing professionals an opportunity to gather andsynthesize information about the patient, aboutthemselves, and about other members of thehealth care team. This valuable information thenforms the basis for effective communication, criti-cal thinking, and problem-solving that contributesto interdisciplinary collaboration and a safepractice environment.

REFERENCES

1. Morton P. Using a critical care simulation laboratory

to teach students. Crit Care Nurse 1999;17(6):66–8.

2. Morton PG. Creating a laboratory that simulates the

critical care environment. Crit Care Nurse 1995;

16(6):76–81.

3. Institute of Medicine. Patient safety, achieving a new

standard of care. Available at: Washington, DC: Na-

tional Academy Press; 2003 http://www.iom.edu/

CMS/3809/4629/16663.aspx. Accessed May 30,

2008.

4. Sherwood G, Thomas E, Bennett DS, et al. A team-

work model to promote patient safety in critical care.

Crit Care Nurs Clin North Am 2002;14(4):333–40.

5. Fewster-Thuente L, Velsor-Friedrich B. Interdisciplin-

ary collaboration for healthcare professionals. Nurs

Adm Q 2008;32(1):40–8.

6. Baggs JG, Schmitt MH, Mushlin AL, et al. Nurse-

physician collaboration and satisfaction with the

decision-making process in three critical care units.

Am J Crit Care 1997;6(5):393–9.

7. Griffiths M, Ibarra D, de Gonzalez A, et al. Attitudes

toward physician-nurse collaboration: a cross-

cultural study of male and female physicians and

nurses in the United States and Mexico. Nurse Res

2001;50(2):123–8.

8. Lanning SK, Ranson SL, Willett RM. Communication

skills instruction utilizing interdisciplinary peer

teachers: program development and student per-

ceptions. J Dent Educ 2008;72(2):172–82.

9. Allen KL, More FG. Clinical simulation and founda-

tion skills: an integrated multidisciplinary approach

to teaching. J Dent Educ 2004;68(4):468–74.

10. Keleher KC. Collaborative practice: characteristics,

barriers, benefits, and implications for midwifery.

J Nurse-Midwifery 1998;43(1):8–11.

11. Ziner-Wagler K. Asset-building and trust in interdis-

ciplinary teamwork. Doctoral dissertation, Indiana

University School of Nursing, 2006.

12. National Patient Safety Foundation. Available at:

http://www.npsf.org. Accessed May 10, 2006.

13. Sexton JB, Thomas EJ, Helmreich RL. Error, stress,

and teamwork in medicine and aviation: cross

sectional surveys. Br Med J 2002;320(7237):745–9.

14. Fletcher GCL, McGeorge P, Flin RH, et al. Effect of

a voluntary trauma system on preventable death

and inappropriate care in a rural state. J Trauma

2002;54:663–70.

15. Croen LG, Hamerman D, Goetzel RZ. Interdisciplin-

ary training for medical and nursing students: learn-

ing to collaborate in the care of geriatric patients.

J Am Geriatr Soc 1984;32(1):56–61.

16. Wessell ML. Learning about interdisciplinary collab-

oration. J Nurs Educ 1981;20(3):39–44.

17. Williams D. Recruiting men into nursing school.

Available at: Minoritynurses.com. 2008; http://

www.minoritynurse.com/features/men/03-21-06e.html.

Accessed May 19, 2008.

18. Zelek B, Phillips SP. Gender and power: nurses and

doctors in Canada. Int J Equity Health 2003;2(1):

1–5. Available at: http://www.equityhealthj.com/

content/2/1/1. Accessed May 1, 2008.

19. Wear C, Keck-McNulty C. Attitudes of female nurses

and female residents toward each other: a qualitative

study in one U.S. teaching hospital. Association of

American Medical Colleges 2004;79(4):291–301.

Jeffries et al480

20. Merriam Webster online dictionary 2008. Avai-

lable at: http://www.merriam-webster.com/dictionary/

culture. Accessed May 1, 2008.

21. Higgins LW. Nurses’ perceptions of collaborative

nurse-physician transfer decisions as a predictor

of patient outcomes in a medical intensive care

unit. J Adv Nurs 1999;29(6):1434–43.

22. Vahey DC, Aiken LH, Sloane DM, et al. Nurse burn

out and patient satisfaction. Med Care 2004;42(2):

57–66.

23. Gibbons S, Adamo G, Padden D, et al. Clinical eval-

uation in advanced practice nursing education: us-

ing standardized patients in health assessment.

J Nurs Educ 2002;41:215–21.

24. Jeffries PR. A framework for designing, implement-

ing, and evaluating simulations used as teaching

strategies in nursing. Nurs Educ Perspect 2005;

2(26):96–103.

25. Cioffi J. Clinical simulations: development and

validation. Nurse Educ Today 2001;21:477–86.

26. Seropian M, Brown K, Gavilanes J, et al. Simula-

tion: not just a manikin. J Nurs Educ 2004;43(4):

164–9.

27. Jeffries PR. Simulation in nursing education: from

conceptualization to evaluation. New York: National

League for Nursing; 2007.

28. Beaubien JM, Baker DP. The use of simulation for

training teamwork skills in healthcare: how low can

you go? Qual Saf Healthcare 2004;13(Suppl 1):

i51–6.

29. Savoldelli GL, Naik VN, Hamstra SJ, et al. Barriers to

the use of simulation-based education. Can J Anaesth

2005;52(9):944–50.

30. Seropian M. General concepts in full scale simulation:

getting started. Anesth Analg 2003;97:1695–705.

31. Hammond J. Simulation in critical care and trauma

education and training. Curr Opin Crit Care 2004;

10(5):325–9.

32. Moyer-Childress R, Jeffries PR, Feken-Dixon C. Using

collaboration to enhance the effectiveness of simu-

lated learning innursing education. In: Jeffries P, editor.

Simulations in nursing education: from conceptualiza-

tion to evaluation. New York: The National League for

Nursing; 2007. p. 123–59.

33. American Heart Association and International Liai-

son Committee on Resuscitation. Guidelines 2000

for cardiopulmonary resuscitation and emergency

cardiovascular care: an international consensus on

science. Circulation 2000;102(Suppl):I1–11.

34. Awar MM, Walinsky P. Advanced cardiac life sup-

port: reviewing recommendations from the AHA

guidelines. Geriatrics 2003;58(11):30–4.

35. Dager WE. Achieving optimal antiarrhythmic therapy

in advanced cardiac life support. Crit Care Med

2006;34(6):1825–6.

36. Moretti MA, Cesar LAM, Nusbacher A, et al. Ad-

vanced cardiac life support training improves

long-term survival from in-hospital cardiac arrest.

Resuscitation 2007;72:458–65.

37. Gilligan P, Bhatarcharjee C, Knight G, et al. To lead

or not to lead? Prospective controlled study of emer-

gency nurses’ provision of advanced life support

team leadership. Emerg Med J 2005;22:628–32.

38. Skiba D. The millennials: have they arrived at your

school of nursing? Nurs Educ Perspect 2005;26(6):

370–1.