Beruflich Dokumente
Kultur Dokumente
Grobbauer, Benedikt
Matriculation Nr.
07PMU03004
First Reader:
Dr. Andre Ewers, MScN
Second Reader:
Dr. Gerard Hogan, MScN
“There was a shift away from autocratic and individualist styles of aircraft
command to one that is more team-based with mutual interdependence and
shared responsibility.”
(Musson & Helmreich, 2004)
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Running head: WHY AND HOW TO TRAIN NURSES IN A SIMULATOR
Content
1. Preface .......................................................................................................... 3
2. Introduction .................................................................................................. 4
2.1. Background ............................................................................................. 4
2.2. Objectives................................................................................................ 5
2.3. Methods................................................................................................... 6
2.4. Goals ....................................................................................................... 6
6. Conclusion.................................................................................................. 38
7. References............................................................................................... 40
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Running head: WHY AND HOW TO TRAIN NURSES IN A SIMULATOR
1. Preface
This thesis presents the results of a literature review of articles related to human
patient simulation as a tool for the training of, especially anesthesia and
intensive care, nurses. The included information is structured from general to
detail.
Chapter five deals with the time, when the decision to pick up simulation is
already made and provides an answer to the question “How should anesthesia
and intensive care nurses be trained?” Next to the “essence of debriefing”, it
contains the most cited learning theories as well as the basics of Crew
Resource Management and other trainable protocols like SBAR (Situation,
Background, Assessment, Recommendation) CUS (I am concerned, This is
unsafe), or the World Health Organization proposed Stop-procedures, also
known as time-outs. Chapter six includes conclusions of this review and as an
appendix, there are useful Internet resources related to the topics discussed, as
well as simulation centers and providers of simulation systems.
Concluding this short preface I would like to acknowledge the support of Drs.
Andre Ewers and Gerard Hogan as well as Prof. Dr. John McDonough and Prof.
Dr. Juergen Osterbrink for supporting, reviewing and correcting my work,
whenever needed.
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2. Introduction
2.1. Background
The Institute of Medicine (IOM), the health arm of the United States National
Academy of Sciences stated in their 1999 report, entitled To Err is Human, that
„at least 44,000 people, and perhaps as many as 98,000 people, die in
hospitals each year as a result of medical errors that could have been
prevented” (IOM, 1999). Compared to the U.S death toll of 2006, these
numbers would somewhere rank in between deaths by septicemia and
pneumonia. Deaths by preventable errors in hospitals are still not stated in the
Center for Disease Control and Prevention reports (Heron, Hoyert, & Murphy,
2009).
In those areas of the hospital, which afford highly invasive treatment, namely
anesthesia and intensive care units, errors, no matter how small they might
seem, can have a highly adverse effect on the patients’ outcome. Valentin,
Cappuzzo, Guidet, Moreno, et Metnitz analyzed medication errors on 113
intensive care units in 27 countries over a period of 24 hours. There were 861
reported medication errors committed. Most consisted of medication being
given at the wrong time. However, they also included wrong patient, product,
dose, or even wrong route in seven percent of all counted errors. Some patients
experienced even two or more errors within a day. Assuming that most of the
medication can be harmful or even deadly, even when used correctly these data
indicate that dangerously emerging incidents are waiting to happen (Valentin et
al., 2009).
The IOM defines medical errors “as the failure of planned action to be
completed as intended or the use of a wrong plan to achieve an aim.” Further
on they say “High error rates with serious consequences are most likely to
occur in intensive care units and operating rooms” (IOM, 1999).
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In 1989 Gaba et. al. developed the first anesthesia simulation system, inspired
by aviation safety, and adopted the so called Cockpit Resource Management to
the formal training concept as Anesthesia Crisis Resource Management. They
developed a system of 15 key points to reflect on the medical aspects as well
as on general principles for crisis management that apply to the complexity of
emergency situations (Miller, 2009).
2.2. Objectives
For over 20 years now, there have been formal concepts known, that can be
applied to the complex field of crisis management in anesthesia and intensive
care. The skills and knowledge can be acquired in simulated environments,
without putting patients to risk. Human Patient Simulation is developing rapidly,
as the technical possibilities continue to expand. The purpose of this review is
to show what simulation can do for the training of anesthesia and intensive-care
nurses.
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Running head: WHY AND HOW TO TRAIN NURSES IN A SIMULATOR
2.3. Methods
A literature review was undertaken on CINAHL, OVID and Pub MED to identify
articles from 1990 up to 2010 relating to the following keywords: simulation –
patient safety – CRM – Crew resource management – Crisis resource
management - anesthesia training – SBAR – high fidelity – intensive care -
emergency – human patient simulation - adverse events – medication errors –
errors. Furthermore related books were taken into review. Literature that did not
relate to simulation, learning, health-care or aviation was excluded.
2.4. Goals
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Many users of simulation technology are critically evaluating the teaching and
learning literature and are merging this body of knowledge with the practices
conducting simulation” (Harder, 2009).
3.1. Definition
Fidelity measures how “real” a simulation system is, meaning to which extent
conditions of reality can be represented. Low-fidelity simulation for example
may be a simple model of a limb, representing the vessel structure in a human
forearm, to train puncture techniques. Those models may be useful for the
training of a specialized skill, but they do not represent reality in its’ time-based,
interactive and dynamic nature. Low-fidelity simulation could also be a pen-and-
paper case-study (Jeffries & Rizzolo, 2006).
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The nursing students taking part in the full-scale, high-fidelity human patient
simulation had “a greater sense of being involved in diverse ways of learning,
and they valued this educational practice more than the two other groups”,
namely a group training on a static mannequin and a group trained with a pen
and paper case study only (Jeffries & Rizzolo, 2006).
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Another distinguishing feature defines the way processed data are influenced
by the instructor. Either the instructor has to indirectly manage the data via
fluids and drugs, based on a “physiologic-model” or enters a target value “on-
the-fly”, which means directly into the system, accepting that participants could
see an instant “unphysiologic” change in the mannequins’ parameters. No
literature could be found, if there is, or is not, influence on the learning
experience through the implementation of a “physiologic-model”. This aspect
awaits further research, although it does make a difference in “steering the
wheel”, meaning the way and effort for the instructors to get the intended
parameter values on screen (Jones, 2009).
Every person will bring his own frame of interpretation to the artificially-real
setting. Especially when people have the feeling of having failed, they might
want to reject the experience. Some may even identify the simulation as
“unreal”, because they are unhappy with their performance (Dieckmann, 2005).
The moment the participant begins to forget that this is not a real patient, is
when immersion takes over, so we are not so much talking about “role-playing”,
but more about “role-being”. They accept the reality of the simulation and start
to act like this experience was under real conditions.
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Jeffries et al. (2006) identified role assignment, (either primary nurse one or
secondary nurse) as a significant influencing factor on how successful a training
experience can be transferred into confidence and assertiveness to handle
future situations. In the Jeffries study 395 students were asked about their “self
perceived judgment performance, providing information about students’
perceptions of their clinical performance in the simulation”. From the four
available roles in the scenario, the role of nurse 1 and the significant other rated
themselves significantly higher than nurse 2 or the observer. There seemed to
be different grades of involvement by each individual depending on the
assigned role during simulation.
This may be the main advantage, that in contrast to pen and paper case studies
or part-task training, as “[high-fidelity] simulation can promote collaborative
learning among students, instructors and other health-care professionals to
provide an environment in which everyone works together, mimicking what is
actually done in real life” (Jeffries, 2004).
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“However, it appears from multiple accounts and the experience of our own and
other research groups the implementation of such programs is as complex a
question as what to train” (Musson & Helmreich, 2004). Therefore anesthesia
and intensive-care nurses should be trained in simulators, as part of the team
training together with their own colleagues and all other involved professionals,
resembling the daily working routine.
Compared to modern medical training, “where it can be said that the pursuit for
safe patient care and therefore the need to acquire competence […] has fueled
the development and implementation of educational techniques such as
simulation […] in nursing education, this progression does not appear to be as
natural or as succinct. A cohesive ideology is lacking for the very existence of
simulation in nursing education”. Schiavenato (2009) suggests some reasons,
why nurses should experience simulation:
€ Patient safety
€ Decreased opportunities for clinical practice
€ Nursing faculty shortage
€ Increased clinical complexity
€ Technology trend
Of course there are more aspects, which still await further research. Assuming
simulation training can be used to enhance nursing staff continuing
development, as a consequence adherence to clinical protocols, improved
symptom management, prevention and reduction of adverse events, reduction
in human resource costs due to improved retention of nurses may well result
(Covell, 2009).
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It takes quite some time until a nurse reaches the expert level, and all this
expertise is still gained by practicing on real patients. “Although progression
along the continuum is not time dependent, expert nurses typically have a
minimum of 5 years or more of experience. As a result, although patient care
needs demand an expert nurse, often, there is a non-expert at the bedside”
(Burrit & Steckel, 2009).
Considering nurses as adult learners they have the “readiness to learn and
grow orientation to the developmental tasks of their social roles” and “the
internal motivation to learn” as long as “they know why something should be
learned.” Further, it is most important, that the experience “does not focus on
evaluation, but instead on assessment that improves practice”, following the
concept of Malcolm Knowles’ andragogy (Clapper, 2010). The simulation
laboratory could eventually develop as the “interface”, the one place, where
the adult clinical expert catches up with the standards brought up and
developed by qualified facilitators’ valid research (Freshwater, 2003).
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In a recent New York Times article a young resident describes her first
experience in a simulator-based training, which reminded her of “the Three
Stooges, in white coats. One resident stood at the patient`s side, holding a
rubber tube in one hand and a syringe in the other, unsure of which to use
first. The other resident kept bumping into the nurses and the respiratory
therapist as he paced alongside the patient. I watched myself standing at the
head of the bed mumbling orders that no one could hear“.
Two questions from this newspaper article arise and remain unanswered.
First, why did the experienced nurse not take over leadership, and second,
why did efficient help not arrive earlier? Human factors are not related to our
scientific knowledgebase about encountered phenomena, but more how we
apply theory to a complex and dynamic environment. They are emerging from
our conditio humana, which means the limitations we experience by the fact
that we are “only” human beings (Green, 2004).
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Most of the reviewed literature treats the training of students in preparation for
their new jobs, so the main goal is often to train procedures, that the trainees
get exposed to on a seldom basis (Bantz, Dancer, Hodson-Carlton, & Van
Hove, 2007). The content of training is furthermore often directed by the
flexibility of the available equipment (Morgan, Pittini, & Regehr, 2007).
It seems quite seldom (Blum, 2004), (Sittner, Schmaderer, & Zinnerman, 2009)
that instructors have the possibility to design courses in an evaluation based,
self-reflected manner in the sense of a tailor-made solution for the individual
branch of the organization (Musson & Helmreich, 2004).
Scenario designers must be careful about that, because “considerations for the
application of simulation in nursing education must, at the very least, include its
conceptualization beyond a single product or technology, lest that product or
technology become the concept itself” (Schiavenato, 2009).
Hicks, Coke & Li emphasize in their study, that “in addition to the need for high
equipment-fidelity, simulation requires psychological fidelity. This reflects the
degree to which the trainee perceives the simulation to be a believable
representation of the reality it is duplicating. Students may not take it seriously,
since mistakes or errors have no real consequences on patient safety”.
Psychological fidelity is also important to avoid negative transfer. “Negative
Transfer occurs if the students learns something incorrectly due to imperfect
simulation […], because the instructor fails to make clear to the students the
differences between these training device and the real situation” (Hicks et al.,
2009).
When designing a scenario one should also take into consideration, that every
single twist and turn causes workload for faculty and participants and is a
source of error during conduction (Jones, 2009). Every recognizable “logical
break” in the simulations’ reference to reality carries the risk of reducing the
effect of immersion.
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One has to take into account, that although the simulated experience is unreal,
the participants’ reactions are real. Before and after the exposure there have to
be strategies to help people transform their emotional impressions to deepen
the learning experience (Arnold, 2009). This means that the “creation of an
environment in which trainees feel both challenged and psychologically safe
enough to engage in rigorous reflection” should be the mantra of all facilitators
“to allow trainees to explain, analyze, and synthesize information and emotional
states to improve performance in similar situations” (Rudolph, 2007).
5.2. Workload
“The goal for every session should be to promote a positive experience that
leads to better understanding” (Clapper, 2010). To facilitate a successful
experience it seems to be important to reflect on how adults learn. In synthesis
of “Knowles’s theory of andragogy and McClusky’s theory of margin, we would
be aware that they will be coming to the center with many other responsibilities
weighing heavily on their minds. Courses and simulation experiences have to
be timely, convenient, and accessible to ease the burden of moving to this
learning environment”, on the other hand we learn, “that overloaded adults will
do all they can, regardless of the load they carry, so long as they view those
activities as essential and meaningful” (Clapper, 2010).
That means that participants will give all their best, as long as the instructors
can facilitate useful learning experiences to improve practice. It also means that
you can design the scenarios as demanding as good as your skills are, in the
sense of linking the simulated experiences to the real world. Therefore it is most
important to use scenarios that match the participants’ skill level and learning
needs.
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As the actual proof of effectiveness for simulation based learning is still missing,
it seems even more important to spend resources on the actual identification of
learning goals and how to represent them within a valid simulated environment.
“Clarity about the objectives of any educational exercise is essential, and the
choice of educational method should be informed by the particular
characteristics of the task in question, not by the fact that one happens to own a
simulator” (Merry, 2007).
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Learning goals should be tied to CRM concepts (Dismukes, Jobe, & McDonnell,
1997) and therefore team-based, just as “professional sports team members do
not train individually and then get together only on game days; they train
together day in and day out so that they are prepared for the real thing”
(Kardong-Edgren, 2010).
As we have seen, participants bring their own set of experience and also
expectations to their center and it maybe that quite a proportion of them is in
fear of the judging through educators and colleagues (Savoldelli, Naik, &
Hamstra, 2005). Thus the instructors have the ethical (Fanning & Gaba, 2007)
and andragogical (Clapper, 2010) obligation to create a safe and protective
atmosphere facilitating and promoting learning, typically during pre-briefing.
“This pre-brief period is a time, when the facilitator illustrates the purpose of the
simulation, the learning objectives, the process of debriefing, and what it entails.
It is the period when the participants learn what is expected of them and sets
the ground rules for their simulation-based learning experience” (Fanning &
Gaba, 2007). Additionally, as an instructor you must “clarify your role and detail
your expectations for crew participation. You should provide a persuasive
rationale for why the debriefing should be crew-centered and tell the crew how
long the session will last” (Dismukes et al., 1997).
Contributing to the high educational value, standards seem essential and the
aviation-based ACRM (Anesthesia Crisis Resource Management) is seen as
the global standard concept for application of simulated clinical experiences in
anesthesia. Therefore “the most important part of simulator training is the self-
reflective video-assisted debriefing session after the scenarios. The debriefing
is most strongly influenced by the quality of the instructor, not the fidelity of the
simulator” (Miller, 2009).
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Whereas the simulated part may take up to 20 minutes only, at least 45 minutes
of each session are assigned under “debriefing”. This accounts to the
circumstance that the actual learning from an experience seems to be triggered
by reflecting on the management of the incident in hindsight. “Like good
scenario design, effective debriefing can substantially enhance the pedagogical
impact of simulation-based practice” (Freeman & Salter, 2004).
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Tone of voice, body language and other conscious and unconscious messages
may or may not invite trainees to share their state of mind with the other
crewmembers. “Their nonverbal language and the measure of their opportunity
for critical dialogue tell the story of the facilitator’s transformational abilities”
(Arnold, 2009). Input and topics should be generated by the crewmembers
themselves.
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The central dilemma facing instructors who want to move away from this
judgmental approach is how to deliver a critical message while avoiding
negative emotions and defensiveness, preserving social face, and maintaining
trust and psychological safety”. Rudolph et al. propose to let participants
recognize and share their fundamental “frames”, in the sense of mental
presumptions leading to certain actions. Based on the “reflective practice
model” the authors introduce the “debriefing with good judgment approach” and
therefore combine “rigorous feedback with genuine inquiry” (Rudolph, 2007).
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As the value of simulated training is strongly connected to the quality and nature
of the debriefing, the design of the training is to follow the function of the
debriefing. Fritzsche, Leonard, & Boscia (2009) propose, as a result of a panel
discussion a classification of debriefing procedures by the way topics are
addressed and the way questions are formed. Furthermore this is a good
example how the participants’ attention and mood can be guided by the nature
of questions the debriefer uses.
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As “health care education is much more formal and rank driven than other
disciplines and as “even in hospitals dedicated to teaching, patients in an
operating room are not there with the purpose of being a clinical teaching
resource for students”, simulated environments may allow educators to provide
a more personalized learning experience taking various learning styles into
account (McDonough, Loriz, & Macha, 2009), (McDonough & Osterbrink, 2005).
In the late 1970’s commercial airlines started to realize “that 70% of commercial
flight accidents stemmed from communication failures among crew members,
CRM sought to standardize communication and teamwork” (Leonard, Graham,
& Bonacum, 2010).
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Although the whole concept of CRM is distilled within 15 key principles, “almost
anyone who uses simulation to teach or reinforce teamwork or crisis resource
management (CRM, or Crew Resource Management) has encountered
students who say they altered their fundamental way of doing things and
working with their colleagues” (Cooper, 2004). Applying CRM in simulated
trainings as a core concept means “to tie CRM concepts and techniques to
operational issues” (Dismukes et al., 1997). This means, that the instructors as
well as the crew, should be able to identify, categorize and analyze CRM key
principles, when debriefing the simulated event. As a facilitator one could
prepare and send out an article as a pre-read, in the case the participants are
not yet familiar with CRM key points.
One of the main features of CRM is that it is there to avoid the crisis in the first
place, so its’ application begins before the crisis. Rall & Dieckmann define, that
CRM is there to “coordinate, utilize and apply all available resources to optimize
patient safety and outcomes”. The authors recommend to “think through the
principles and ask yourself for each key point (Rall & Dieckmann, 2005):
€ How does it apply to your job and work environment?
€ Which problems have you experienced in your work related to the key
points?
€ Which problems have you observed in other people’s work?
€ How could you improve that using the key point?
€ How did you apply the key point so far?
€ How could you improve your ability to use this key point?
€ What problems or obstacles could you face in your real world?”
When looking at the 15 key points of CRM in detail, there are multiple ways to
do so. It is obvious that the concept as a whole was created for application in
real practice to raise patient safety. However the method and theory implied is
mostly taught in simulation centers, so it could be that participants do not fully
transfer the principles to their daily life.
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Most important seems to state out that not the application of one of the
principles alone will save the patient from harm, but “fundamental, lasting,
outcome-altering organizational change cannot come with single interventions
of one type” (Cooper, 2004). Furthermore “using simulation to improve safety
will require full integration of its applications into the routine structures and
practices of health” (Gaba, 2004).
Without the full implementation of CRM within a clinical facility, the simulation
training cannot have full effect. It`s like a participant is somebody who went to a
foreign country, which was indeed interesting, but his (and his families) own
cultural progress will stay untouched from these exotic experiences in a trusting,
while cross-checking environment. CRM implies to speak up, when concerned,
no matter of hierarchy. “All too frequently, effective communication is situation
or personality dependent” and this seems, culturally-dependent, problematic.
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Each of the CRM key points can be seen as an integral piece of a puzzle, which
pictures an organizations’ cultural approach towards human factors, patient
safety and the management of critical incidents. There has to be a clear
commitment from all levels of the organization to minimize “power distances”
and other distracters, which keep people from saying “something’s wrong, I`m
not sure what it is, but I need you here now” (Leonard et al., 2010). So CRM is
not actually about memorizing 15 key principles by heart. It is rather about
“lowering the threshold to obtain help, and treating the request respectfully”.
Leonard et al. therefore propose the adoption of “critical language” models as
very effective. “[..] derived from the CUS program at United Airlines. CUS
stands for ‘I am concerned, I am uncomfortable, this is unsafe […] and is
adopted within the culture as meaning ‘We have a serious problem, stop and
listen to me” (Leonard et al., 2010) and is a very effective tool to be integrated
as a standardized cue for re-evaluation and, if needed, the initiation of an
emergency protocol.
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In the following all 15 key points are listed and briefly commented on how
factors can influence simulation and the following debriefing. A general
interpretation of the key principles is already formulated in many sources
including Rall & Dieckmann (Rall & Dieckmann, 2005).
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7. Communicate effectively
Communication is the central aspect of CRM, because it is the means of
transportation for most of the other tasks. Information is passed on by
communication between team members, workload is distributed and resources
are mobilized that way. Communication can be seen as the “backbone” of CRM.
To standardize communication is the main aim of CRM. It is apparent, that
stress, especially the one of an emergency situation, affects our sensorium, so
that “normal” communication is endangered. Under the influence of stress
people tend to overhear each other, so in CRM it is sought to “close the loop”,
meaning that the sender of a message makes sure, that the content of the
message is received, understood and considered. “Meant is not said, said is not
heard, heard is not understood, understood is not done” (Rall & Dieckmann,
2005).
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3. “Everything is o.k.!”
When all the alarms keep ringing or are constantly pushed away without any
visible reaction, the participants might have got stuck with their mantra of
“everything is ok!” No matter what, the patient is safe and there is no need for
action. For this and all the other cases of fixation, meaning the team cannot
establish productive effort to save the scenario, there should be scripted
“scenario life-savers”, that either let the instructed actors or the instructors
themselves interfere and give cues.
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Situation:
The description of the situation should explain what happened and triggered the
emergency protocol: “The patient collapsed!”
Background:
Quickly drafts the patients’ history, like relevant preexisting conditions: “He`s is
a 45 year old diabetic Type II.”
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Assessment:
Consists of what signs and symptoms does the patient present now? “He is
unconscious, but still breathing and I can feel a pulse.”
Recommendation:
Are there any suggestions on how to progress? “We should measure the
patients’ blood pressure and blood sugar. We could stabilize his position or lift
the legs of the patient to raise the blood pressure.”
5.6.6. Stop-Procedures
Within all of the single interventions and concepts to raise patient safety, none
has proven as effective as setting standardized “stop-procedures” at certain
critical points during the operational procedure, like proposed by the World
Health Organization. Before induction of anesthesia, before skin incision and
before the patient leaves the OR the whole team stops the routine tasks to
verify certain aspects following a standardized check-list. This makes sure,
more than any else single intervention, that “everybody is in the same movie,
and no surprises” (Leonard et al., 2010). It is also a good example, that training
on a sole basis will not affect patient safety very likely, but that in a simulator
new and innovative approaches can be blended with tried and true principles to
create an adequate safety culture in an explaining environment.
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6. Conclusion
Although those who conduct simulation may like to hear from participants, that
they liked the simulation experience, the question remains: How do they go on
from there? Did they really grasp the concepts we want them to apply? What
about CRM? Are they going to close the loop? What happens the first time they
hear, that they sounded like parrots, when repeating orders? Could the
participant really raise his/her level of confidence/assertiveness? Will they have
the possibility to speak up, when concerned? At this point there are no firm
answers to such questions.
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As the word “training” implies, this has to be a repeated process to have lasting
impact on daily practice alongside with changes in the organizations’ safety
culture and approach to errors. Simulation cannot fulfill all the hopes it is
brought to, but maybe in combination with all the other measurements, like
stop-procedures, checklists, Critical Incidents Report Systems, awareness of
Human Factors and so on, it could be, that one day hospital care will fulfill “six-
sigma” criteria, meaning that only one in a million goes wrong.
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7. References
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Erklärung
Hiermit erkläre ich, dass ich die vorliegende Arbeit selbstständig und ohne
fremde Hilfe angefertigt, sowie die verwendeten Quellen und Hilfsmittel in
einem vollständigen Umfang angegeben habe.
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