Improving the relational aspects of trauma care through translational simulation

Study setting

The Gold Coast University Hospital (GCUH) established a trauma service in 2013, concurrent with the opening of a new physical facility. Over 400 staff from a variety of disciplines and work groups participate in the care of major trauma patients in the hospital. In the financial year 2017–2018, there were 1739 trauma team activations, including 203 “Trauma Responds”, which is the highest acuity level at the institution.

There are key identifiable groups involved in the early phases of major trauma care and their inter-relationships for the initial phases of major trauma patient care are represented in Fig. 2. Each group is represented by function and/or geographic location, rather than professional discipline.

Trauma simulations

Over the last 4 years, the trauma and simulation services at GCUH have collaborated to improve trauma care at the hospital through monthly in situ simulation of trauma cases. These simulations are conducted involving providers from across the care continuum—paramedics, emergency department (ED) staff, medical imaging, operating theatre staff, surgery teams and intensive care teams, as well as support services such as blood bank, orderlies and security. These provider groups have voluntarily elected to join the trauma simulation process over that time. Staff are expected to participate in these simulations as part of their education, and as a standard part of trauma service delivery improvement.

Trauma simulations are scheduled at a consistent time each month. Participating staff are aware of simulation in advance and are emailed written preparatory information, including the broad clinical issues that will be the focus. Scenarios are designed based on common and important trauma presentations drawn from GCUH trauma database. Scenarios are presented using both manikin and simulated patient methodologies, according to the case and challenges designed. A 5–10-min pre-briefing is conducted in a conference room, followed by a 45-min scenario conducted in situ—initially in the ED ambulance bay and trauma room, and in some cases followed by transfer to computed tomography (CT) scanner or operating theatre. Between 8 and 30 staff participate in these simulations, with up to another 40 staff observing via video feed in the conference room, where the subsequent debrief is conducted for a further 30–45 min. The debrief is led by an experienced simulation debriefer who is also a senior clinician within the institution.

The large group debrief following the simulations are targeted towards practitioners involved in the simulated patient journey but with participation from observers also encouraged. The facilitator prompts reflection on the clinical processes and outcomes and enables discussion between providers to identify problems and proposed solutions. The debrief issues are summarised after each simulation in a quality activity report, provided to service leads from each department involved in the simulation. More recently, learning points have also been summarised in infographic format, which is then circulated to staff from the departments involved in trauma care.

Study design and data collection

As one aspect of a multi-phase quality improvement project aimed at understanding and supporting relationships between trauma care providers at our institution, we studied ongoing trauma simulation activities using a narrative survey in conjunction with data from a broader ethnography of the trauma care provision, which naturally included data related to simulation activities. The focused look at simulation reported here was performed in the context of a more extensive evaluation of how relationships affect the coordination of clinical trauma care at GCUH.

Staff from the key areas involved in the early phase of major trauma care at GCUH—emergency, trauma service, surgery, medical imaging, intensive care unit, paramedics and anaesthetics—were invited to participate. A link was provided via email to a survey that included 5 free-text questions related to their experience of in situ simulation in trauma care at GCUH (Fig. 3).

These narrative questions were one element of a survey that also included a quantitative relational coordination (RC) survey [17] comprising of Likert item questions related to the respondents’ perceptions of relationships between provider groups in trauma care at GCUH. Data from this quantitative part of the survey was not specifically related to simulation activities and is not reported here. Completion of the survey was voluntary and anonymous.

Concurrently, an ethnography of the trauma team and simulation programme was performed by author EP over a 3-month period. She conducted participant-observation of real and simulated traumas, educational activities of the trauma team, and the day-to-day activities of members from the core working groups for a total of approximately 75 h of participant-observation (16 h directly related to trauma simulations) and an additional 25 h of informal interviewing. [21] These activities informed field notes through a process similar to that described by Schensul and LeCompte [21]. Five formal interviews were performed with key personnel to further explore issues raised in the survey or through observation. Interviews were recorded and transcribed. Data from field notes, informal, and formal interviews generated from this process that related to trauma simulations are included in this review.

Data analysis

Data analysis was performed using a recursive approach, a simultaneous deductive and inductive approach to data interpretation. Data from the surveys, field notes and interviews was entered into NVivo software then coded by two authors (EP and CA) using the relational coordination framework (knowledge, goals, respect and communication), themes not accounted for by this framework were generated inductively. An independent inductive analysis of the free-text questions related to trauma simulation was also performed by VB and JM. All authors then met to compare findings and create agreement on relevant themes and subthemes. The association between the relational coordination themes and inductive interpretation of findings was compared and contrasted by authors to finalise the interpretative analysis presented.

Notes on the research team

Victoria Brazil (VB) is an emergency physician and simulation educator. She has led the trauma simulation programme at the institution since its inception and facilitates most of the debriefing sessions after trauma simulations. She participates as a trauma team leader at the institution in her role as an emergency physician. Eve Purdy (EP) is a master’s student in applied anthropology and an emergency medicine trainee from Canada, currently undertaking fellowship year at the institution. She has led the ethnographic component of a group of research projects focused on trauma care and emergency medicine at GCUH. She also works as a trauma team member. Charlotte Alexander (CA) is a provisional trainee in emergency medicine at the institution, and occasional trauma team member. She has been involved in the trauma simulations since 2014 as an assistant simulation educator, while still a medical student at Bond University. Jack Matulich (JM) is a registered nurse, currently working within the GCUH Simulation Service, who has been involved in delivery of trauma simulations over the last 6 months. JM and CA were both trained and received guidance in the analytical methods used in this study by EP.

The broader research team comprised an advisory group with members drawn from pre-hospital service, emergency medicine, anaesthesia, intensive care, medical imaging and the trauma service.

Consultant physicians, simulation team members and nurses outside of the research team, but familiar with the simulation exercises, were consulted for a member check of the findings.

Relational coordination analysis

During deductive analysis using the RC framework all domains of the construct were easily identified. The concept of simulation as an enabler of mutual respect was most predominant followed closely by its effect on the development of high-quality communication. The ability for simulation to facilitate shared goals and shared knowledge were less prominent but also readily recognised. We review each of these themes below.

Overall, we found that participants saw simulation both as a way to identify shared goals as a group, then practise and troubleshoot movement towards them.

In the final domain, communication, there were many generic comments such as, “I think it gives you a good chance to work on your communication skills with colleagues” (survey respondent). However, the relational coordination framework further divides communication down into four component parts (frequent, timely, accurate and problem-solving based). When comments were detailed enough for this analysis, we found that participants reflected most-often on the problem-solving-based aspect of communication. They identified simulation as a place to practise collaborative decision-making between specialties with one participant commenting, “I have found that those who participate in the sims incorporate the lessons into their practice, especially around communication and collaborative decision making” [survey respondent]. Consistent focus on accurate communication methods was noted as translating into practice by some participants in the survey and informal interviews, with one commenting, “communication has greatly improved across our trauma team. clear role allocation early, clear leader, close loop communication, etc.” (survey respondent). Comments related to frequent and timely communication were rarely identified; however, informal discussions and observations throughout the ethnographic process facilitated understanding that the simulation exercise itself serves to promote frequent communication—not only around a specific patient but as a system—by providing a space each month for specialties to come together for open dialogue. That facilitated space seemed to foster a frequent, respectful and problem-solving-based interdisciplinary conversation.

Inductive analysis

The inductive analyses of survey responses supported and extended the findings of analysis guided by the RC framework and are presented in Table 1. We identified four major themes: “Behaviour, process and system change”, “Culture and relationships”, “Personal and team learning” and “Impact of the simulation experience”.

Additional themes that were identified in the inductive analysis were Personal and team learning and the Impact of the simulation experience. The habits of shared reflection seemed to be as important as the learning from any specific simulation experience. As with the domain of shared knowledge from the RC framework, the personal and team learning related to both “technical” trauma care lessons, and those relating to team roles, functions and relationships. Many practical examples of translation to practice focused on communication and other teamwork behaviours, with relatively few relating to technical skills.

Respondents perceived the simulation experience (and its design, delivery and debriefing) to be relevant to the outcomes. The need for a high degree of task realism was clear, including technical and environmental aspects but even more important was the degree of realism of interactions, challenges and affective experience. The absence of comments relating to lack of realism of manikin was notable.

Both the RC and inductive framework were supported by local and more broad member checks, and no new themes were identified.

What this means for trauma providers and clinical leaders

Simulation should be considered as a tool to build and strengthen relationships between practitioners across traditional boundaries. A dedicated trauma simulation programme may offer wide-ranging opportunities to improve culture and relationships that are difficult to approach using other strategies. Health professionals providing trauma care perceive that trauma simulations affect relationships and culture, and that this translates to real-world practice. The learning from simulation is multi-faceted—including motivation, personal leadership, teamwork and communication behaviours, and local systems and protocols. Regular simulation affords practitioners the space to come together in an environment that stimulates the habits of reflection for both individuals and groups. Our participants suggest that this has an impact that extends well beyond simulation sessions.

What this means for simulation providers

The RC framework can be applied to the acute trauma setting, not only as a diagnostic tool for measuring team function as traditionally designed but also as a pillar for guiding the development of translational simulation interventions and structuring debriefing conversations for translational impact. Developing recognisable language to describe relational fundamentals in debriefing conversations—shared goals, shared knowledge and mutual respect—can complement existing language related to observable teamwork behaviours.

Simulation providers need to carefully support task realism for all provider roles involved in trauma simulations, including technical task alignment but also create realistic affective experience and team interactions. Having intact teams participate in trauma simulations, including leadership by senior clinicians, is an opportunity afforded more easily by using in situ delivery.

What this means for researchers

The novel application of the RC framework to analyse the impact of simulation can serve as an example for others interested in examining the role of simulation in affecting relationships and culture at their institution. We found that pairing the narrative surveys with an ethnography, to be uniquely informative in understanding the role of simulation within the overall trauma service and would encourage consideration of this embedded approach. As with many ethnographies, we are left with more questions than answers. Some relate to examining the “dose” of translational simulation required to have a relational impact, while others centre on understanding the granular elements of simulation design, delivery and debriefing that lead to relational outcomes.

Limitations

The most significant limitation of this work is that the effects of any simulation programme will be dependent on a number of factors including local context, pre-existing relationships, design and delivery. The findings we present are local to our institution and may not translate to other programmes already in existence or developed in the future. Our results show simulation driven movement towards positive relational outcomes but the opposite could also occur under different circumstances. We trust that simulation educators will apply our method, not just focus on our results, in an effort to thoughtfully consider the effect of their local programmes on culture and relationships.

Next, the respondents answered survey questions related to trauma simulations after completing the overall RC survey, which included questions focused on their relationships with other trauma providers. This may have primed respondents towards responses focused on relational aspects of care. However, this bias is simply towards the topic of relationships—the extent of positive relational impact and more collaborative culture stands independently. Furthermore, including a less bounded question about individuals’ experiences with trauma simulation might have added to our understanding.

Respondents may have undertaken their simulation experience at any time within the 4 years preceding the survey, and their experience may have been as few as one simulation or as many as 25. These results should therefore be regarded as a review of the programme, rather than any one specific simulation activity.

Finally, the study authors and simulation providers have been focused on relational aspects of care in the design and delivery of trauma simulations, and acknowledge they may be inclined towards interpretation of survey results and field notes in the light of these interests. However, the strength and consistency of those themes and enthusiastic support for the findings in member checks is suggestive that the findings stand on their own.