Our findings suggest that an established trauma simulation programme can have a profound impact on the relational aspects of care and the development of a collaborative culture, with perceived tangible impacts on teamwork behaviours and institutional systems and processes. This effect was observed in simulations with a perceived high degree of team and task realism, and with explicit simulation design, preparation and debriefing approach targeted towards relational aspects of care. To what extent the impact is attributable to each individual factor is not known, but overall, study respondents recognise a significant impact of the simulation experience on their learning and development of relationships with other care providers and teams.
Over half of trauma providers who answered the overall RC survey had participated in trauma simulations, evidence of significant engagement of these provider groups with the simulation process. The extent to which this level of engagement, over a sustained period, is required for this impact is also not known nor is whether that engagement is cause or effect of the relational impact and developing collaborative culture. As Mannion et al. point out “any relations between culture and health service outcomes are likely to be mutual and recursive: that is, perceived performance is as likely to shape local healthcare cultures as culture is to shape local healthcare performance” [9].
The straightforward application of the RC framework to the simulation experience data, and strong alignment of inductively generated results with the RC framework, provide compelling evidence that simulation has the ability to target and bolster fundamental domains of high functioning teams—shared knowledge, shared goals and mutual respect in addition to high-quality communication. These relational outcomes are stepping stones towards an improvement in organisational culture and go below the surface of previously documented benefits of simulation [14, 15, 22]. Furthermore, our results provide support for application of RC theory to inform the design, delivery and debriefing of simulation activities focused on achieving relational goals within clinical trauma care practice.
The findings specific to the simulation experience are instructive. The subtheme “facilitated debrief creating safe space for discussion/ disclosure/ reflection” strongly supports the concept of psychological safety “as an emergent property of the collective, that describes the level of interpersonal safety experienced by people in a particular group” [23]. Simulation educators have focused on establishing psychological safety for simulation activities [24], and our findings raise the possibility of translation into clinical practice—such that a simulation programme, through enhancing relationships and fostering mutual respect, can support the development of psychological safety for providers beyond the simulation exercise and positively affect real clinical practice.
With respect to practical simulation delivery, there was broad agreement on the high degree of realism within the simulations. Consistent with recent literature, the basis of that realism was rarely cited as physical resemblance and more commonly related to functional task alignment [25]. As such, translational simulation applied to a trauma patient journey with involvement of diverse provider groups presents a design challenge—being able to print an ECG may be a key element of realism for one staff member, while another requires a high degree of realistic stress as a trauma team leader.
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.