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Updated on July 16th, 2014 at 2:12 pm

by Diana Taibi Buchanan, PhD, RN

Culture is a broad and pervasive concept.  It gives motivation and meaning to our actions and shapes our interactions.  Culture can bring richness and diversity, or conflict and misunderstanding.  Although culture saturates all human behavior, the impact of culture within the health care team is rarely given due attention.  It is well-accepted that healthy functioning of interprofessional health care teams improves patient outcomes and is crucial for patient safety.  New initiatives teach health care providers strategies to work as a team.  However, these strategies do not attend to the variety of cultural backgrounds represented by each team member.  Individuals’ use of strategies, such as those provided by TeamSTEPPS, occurs in the context of rich personal and cultural histories of the persons giving and receiving the communication.  Research to date on interprofessional education (IPE) suggests that IPE may not be effectively translated to ultimate goal of collaborative practice.  Training health care team members in cultural competence may be a way to bridge that gap by preparing persons who are self-aware of their own cultures and know how to be curious about and respectful of others’ cultures.

 What is culture?

The National Institutes of Health explains that culture is “the combination of a body of knowledge, a body of belief and a body of behavior.  It involves a number of elements, including personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are often specific to ethnic, racial, religious, geographic, or social groups.” (NIH, 2014). 

 In health care, team members bring both professional and personal cultural backgrounds that impact their views of care issues and their relational styles.  Below are some examples of culture at the personal level that might impact care. Several of these cultures may influence a person’s motivations and behaviors at any given time and to varying degrees.

  • Ethnic (e.g., African American, Italian American, Creole)
  • Religious/faith (e.g., atheist, Buddhist, Christian)
  • Geographic/regional (e.g., Southern U.S., Midwest)
  • Social (e.g., Republican, pacifist, Mountaineer)

 Health care team members also bring the culture of their professional backgrounds.  Health professionals may not consider that their professional group has a culture, but based on the definition of culture representing knowledge, belief, and behavior, health professions are indeed cultures.  Professions clearly have different bodies of knowledge, but they are also socialized to different behavioral norms, and may arrive at different beliefs about what is best in patient care. 

 Interprofessional Education for Cultural Competence

For teams to be effective, members must learn to navigate culture.  IPE is used with this intent, but IPE activities are often oriented toward group functioning rather than mutual understanding.  IPE is defined as “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010, p. 7).  However, students may not learn about each other effectively without being given a framework for understanding.   Cultural competence is an important framework for such understanding.  Accordingly, principles of cultural competence within the health care team are explicitly listed in the values/ethics domain of the Core Competencies for Interprofessional Collaborative Practice:

  • "VE3. Embrace cultural diversity and individual differences characterizing patients, populations, and health care teams.
  • VE4. Respect the unique cultures, values, roles/responsibilities, and expertise of other health professions.” (Interprofessional Educaton Collaborative Expert Panel, 2011, p. 19). 

 The National Center for Cultural Competence (NCCC) defines cultural competence as values and principles for working cross-culturally, as demonstrated through behaviors and attitudes (NCCC, nd).  The NCCC also states that cultural competence is a developmental process that occurs over time.  Therefore, principles of cultural competence should be taught early in pre-licensure education and applied throughout professional training. 

 Another helpful concept in developing cultural competence within the health care team is learning in a community of practice.  Communities of practice are when “people engage in a process of collective learning in a shared domain” (Wenger, 2011, p. 1).  This is the concept underlying IPE.  The health care team is a community of practice; therefore, health sciences students are best taught how to work as a team by being placed within that team/community.  The same could be said of cultural competence in team communication.  Interprofessional students will best learn to apply the principles of cultural competence by learning about it together. 

 Several frameworks for cultural competence are available.  The NCCC adopted the approach published by Cross, Bazron, Dennis, & Isaacs (1989).  Some approaches that these authors recommend for individual development of cultural competence include the following.  Although Cross and colleagues stated these points at the provider-patient level, I have expanded the statements to also encompass provider-provider interactions. 

  1. Acknowledge cultural differences and be aware of how these impact care.
  2. Recognize how one’s own culture impacts one’s thoughts and actions.
  3. Understand cultural differences at the practice level, when patients and providers bring unique histories.
  4. Make a conscious effort to understand the meaning of the other’s behavior within the context of his or her culture.
  5. Health care providers should gain information as they can, but comprehensive knowledge is not attainable.  Providers should how obtain information needed in the moment to reach a patient care goal.

(Cross et al., 1989, pp. 32-35) 

Each of these principles can be used to plan interprofessional activities to understand culture in the context of the health care team.  As an early learning exercise, students might complete a group activity to understand culture.  They might take a few moments to write about aspects of their own professional culture and what they view as the culture of other profession.  Then they could share these and discuss how self-identified culture is similar or different to the other’s expectations of that culture.  The discussion should conclude with reflection on how understanding of culture could impact the functioning of the health care team.  A higher level exercise could be a simulated clinical case with a scripted cultural conflict.  For instance, two team members (acting from a script) engage in conflict over a misunderstanding based in cultural differences.  The other team members are students who must navigate this conflict to achieve the goals of patient care.  Debriefing would focus on understanding how culture contributed to the conflict, how individuals’ responses were impacted by their own culture, and what strategies could be effective or ineffective in navigating the conflict. 

“Team” as a Culture

It is important to recognize that creating a professional identity of “team” also creates a new culture with group norms for values and behavior.  The cultural values could be said to be those stated in the Core Principles & Values of Effective Team-Based Health Care (Mitchell, et al., 2012): shared goals, clear roles, mutual trust, effective communication, and measurable processes and outcomes (p. 6).  Another core value of this new culture is full inclusion of patients as team members (Mitchell, Hall, & Gaines, 2012).  Cultural competence training should encompass interactions with the patient in the context of the team, rather than individual interactions as is often the focus.  Such training could begin in a simulated setting with a standardized patient, but could also be accomplished in student experiences in the clinical setting in learning activities with objectives clearly focused on cultural competence.

To conclude, cultural competence is a core competency for effective health care team functioning.  Training health care professionals in this area involves teaching them to recognize culture as an influence on team interactions, respect diversity, and problem-solve difference from a shared approach. 

References

Cross, T. L., Bazron, B. J., Dennis, K. W., Isaacs, M. R. (1989).  Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed.  Washington,  D. C.: National Institute of Mental Health, Child and Adolescent Service System Program.

Interprofessional Education Collaborative Expert Panel. (2011) Core competencies for interprofessional collaborative practice: Report of an expert panel.  Washington, D.C.: Interprofessional Education Collaborative.

Mitchell, P., Hall, L., & Gaines, M.  (2012).  A social compact for advancing team-based high-value health care.  Health Affairs Blog.  Retrieved from http://healthaffairs.org/blog/2012/05/04/a-social-compact-for-advancing-team-based-high-value-health-care/

Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, E.,… Von Kohorn, I.  (2012).  Core principles & values of effective team-based health care.  Washington, D. C.: Institute of Medicine.

National Center for Cultural Competence. (nd). Conceptual frameworks/models, guiding values and principles.  Retrieved from http://nccc.georgetown.edu/foundations/frameworks.html#ccdefinition

National Institutes of Health. (June 3, 2014).  Cultural competency.  Retrieved from http://www.nih.gov/clearcommunication/culturalcompetency.htm

Wenger, E.  (2011). Communities of practice: a brief introduction. Retrieved from https://scholarsbank.uoregon.edu/xmlui/handle/1794/11736

World Health Organization.  (2010).  Framework for action on interprofessional education & collaborative practice.  Geneva, Switzerland: World Health Organization.

Updated on May 21st, 2014 at 4:05 pm

By: Diana Taibi Buchanan, PhD, RN

A colleague comes to you and says, “You work in the lab.  Simulation is big now.  Why don't you do simulation with our students?”  Where do you start?  What do you do first?

We at InCITE have provided a lot of information on simulation ranging from introductory materials to some advanced techniques. However, it is easy to get lost in the volume of information available on our website and the wider Internet. This blog post is a kind of quickstart, like you would get with your television.  I will provide a few tips to get you started with your first simulation experience.

STEP 1: Decide what clinical point you want to teach and write learning objectives.

As with any teaching activity, the first step is deciding what the purpose of the activity is and what are the learning objectives.  Don’t worry yet about the simulator or set-up.  Simulation is not about the technology.  Simulation is best used for teaching students to function in complex or distracting situations and to effectively apply clinical reasoning skills.  Therefore, good learning objectives are key.  Simulation is also not about gaining psychomotor skills.  Students should be able to perform technical skills adequately before using them in simulation.  Therefore, an appropriate learning objective could be:

Learner will interact with the patient using empathy while correctly inserting an indwelling urinary catheter using sterile technique.

The student should already have mastered catheter insertion on the task trainer before participating in the simulation.  Accordingly, the simulation and debriefing are not focused on the technical skill of catheterization, but rather on the patient-nurse interaction in the context of the task performance. 

STEP 2: Choose a clinical case that will be used to address the learning objectives

The easiest approach to this step is to find a pre-existing case. There are numerous simulations available online.  Even if a simulation does not address your objectives, many of the cases available can be used of modified for your objectives.  You don't even have to find these from simulation resources. I draw many of my cases from case study texts.

STEP 3: Plan how the scenario will flow.

I recommend planning a very short scenario for your first experience – perhaps 10 minutes, and certainly no longer than 20 minutes. Beyond that amount of time, it's very difficult to keep students focused on the learning objectives and to keep them in their assigned roles. The things you will plan are:

  • Learner roles.  At the minimum, you need a patient, nurse, and someone to operate the simulator.  It is preferable to have a tech or teaching assistant operate the simulator so the instructor can focus on the learners.  For your first simulation, you may find it easiest for to voice the patient yourself.  This gives you a degree of control if things don’t go as planned (and they often don’t).  Keep it simple.  The more roles, the more there is that can go in unplanned directions, which can distract from the learning objectives. 
  • Patient set-up and parameters.  Plan as much realism as possible.  This includes making the simulator the correct sex, using a wig and clothing, and setting up hospital equipment.  Note the patient parameters – vital signs, respiratory rate, heart and lung sounds, etc.
  • Events, in chronological order.  You’ll need to plan how the simulation begins, what events occur during the simulation, and how it ends.  Plan the transitions to be as natural as possible.  For example, you might begin the scenario with shift report or with the student nurse informing the patient that a procedure has been ordered.  Also plan a natural exit from the scenario.  I often inform the student nurse that there is a call at the nurse’s station or that another patient has requested care.  Finally, plan what events will move the scenario forward.  That is, what behaviors must the students do to get a different patient response (either physiological or verbal)?  Below is a simple example based on the catheter insertion scenario.  Realistically, this scenario would take about 20 minutes because of involving a complex skill.
  1. The scenario will begin by the student informing the patient that an indwelling urinary catheter has been ordered.  The student should explain the rationale for the procedure. If the rationale is not explained, the patient will refuse the procedure.
  2. The student will position the patient and set up the catheterization equipment in an appropriate manner that facilitates the task.
  3. The student will insert the indwelling catheter maintaining sterile technique.  Student will attend to the patient’s anxiety. If the student does not attend to the patient’s anxiety, the patient will vocalize discomfort and annoyance during the procedure.
  4. The “charge nurse” will inform the student that another patient requested pain medicine.  The student should attend to the patient and secure the catheter, then exit the room.
  • Debriefing.  Debriefing is the most important event in simulation.  This is where the students will get the chance for reflective learning.  To prepare, the instructor should have an overall approach selected.  I use the Plus-Delta approach – What went well? What would you do differently? Also have some questions prepared to stimulate reflection on the learning objectives.  Here are examples related to the catheterization scenario:

What statements during the scenario conveyed empathy for the patient?  How did the patient respond?

What were opportunities to convey empathy to the patient that you think you might have missed?  What would you do if you did the simulation again?

STEP 4. Plan and assign student preparation.

A simulation can be quickly derailed by unprepared students.  It is wise to give students homework before the simulation day, such as reviewing the steps in urinary catheterization.  It is also advisable to verify that the students have prepared.  This could be done in a formal manner such as a quiz, or informally in group discussion.  If students are not prepared, they should not participate in the simulation.

STEP 5.  Set up the actual simulation space.

Give yourself ample time to make sure you have the supplies you need and to be sure the space is set up properly.  Set up includes the physical space (e.g., what are the room boundaries, is there a med room or supply room, where is the patient chart), the manikin appearance and programming, and any other supplies such as catheterization equipment, gloves, and a patient chart.  If you can, run through the scenario with a volunteer to catch and glaring oversights.

STEP 6.  Run and debrief the scenario.

Now you are ready!  When you run the scenario, there are 3 steps: brief, do the scenario, debrief.  Don’t skip the first and last steps – these are crucial to learning!  Plan adequate time.  For our 20 minute scenario, I’d plan an hour session: about 15 minutes to brief, 20 minutes for the scenario, 20 minutes to debrief, and 5 minutes of padding for the unexpected.

Briefing involves reviewing the purpose of the exercise and the learning objectives, reviewing important information (e.g., steps in catheterization), and assigning learner roles.  When reviewing the objectives with the students, you don't have to reveal every aspect of the scenario. For example if an objective is to identify a specific abnormal findings, you might only reveal to the students in the objective the objective is to manage the changing patient situation.   Also, it’s okay to let the students know that this is your first simulation.  That will help reduce student anxiety when things don’t go as planned.

Next you will run the scenario. Try to interrupt as little as possible, but expect about your first simulation might be a little bit rocky.  If a scenario is rocky, I like to have a quick debriefing and then run it again, perhaps with different students participating in the as a learners.  Then we will do the full debrief afterwards.  This gives everyone the chance to perform a little better and feel okay about the simulation.

Debriefing is the time taken for reflective learning.  You should not do a simulation if you do not have time to debrief.  A good rule of thumb is that the time allotted for debriefing should be at least equal to the time spent in the scenario.  As I mentioned before, I find the easiest debriefing approach is to ask what went well and what could be improved (Plus-delta).  Don't let the students jump straight into criticism.  Encourage them to focus first on things that went well in the scenario.  An important thing to remember in debriefing is that it is not time to lecture.  An instructor might make notes of things to cover in the future, but in debriefing students should do the majority of the speaking with the instructor acting as a facilitator.

STEP 7.  Evaluation and planning.

I recommend getting student evaluations of the learning activity. This can be very helpful for planning the next simulation. I also recommend making modifications to your scenario and the entire learning activity while the simulation is fresh in your head.  Make these changes and save them for the future.

These steps should help you get started on your first simulation.  Remember to keep it simple the first time!  Have fun, encourage the student to have fun, and continue to build your skills over time.  Also remember to take advantage of the many resources on the InCITE Website:

Sample scenario

Scenario building tools

Teaching with Simulation educational modules

Simulation resources and publications

 

Updated on March 7th, 2014 at 9:11 am

By: Diana Taibi Buchanan, PhD, RN

Simulation is an important tool for teaching the health professions.  Various types of basic simulations have been used for many years, such as using an orange to practice injections.  In recent years, there has been growing interest in and use of high-fidelity simulation, meaning that the simulated learning environment closely resembles reality (Hayden, 2010; Kardong-Edgren, Willhaus, Bennett, & Hayden, 2012).  High-fidelity simulation activities tend to focus on management of a full clinical situation rather than development of psychomotor skills (for which high-fidelity is not necessary).  As this trend has grown, colleges and universities have acquired simulation equipment, but often remain stymied as to the use of these resources. 

To examine the simulation learning needs of health profession educators, InCITE (a HRSA grant awarded to UW to create faculty development in the use of technology) conducted an online survey in the northwestern United States, which will be appearing in an upcoming issue of Clinical Simulation in Nursing (Taibi & Kardong-Edgren, in press).  The majority of the 66 respondents instructed nursing students.   Although all respondents were interested in simulation, only 23% reported using clinical simulation in their teaching.

The areas in which training was most needed were:

·         teaching interprofessional communication in a simulation (highly rated by 80% of respondents)

·         leading a post-simulation debriefing (70%)

·         integrating simulation into course curricula (66%)

The lowest need was mechanically operating a simulator (49%).

These findings are encouraging in showing that instructors are focused on the uses of simulation for teaching rather than being concerned with the technology itself.  In addition, the survey results  show that educators have great interest in areas for which simulation is uniquely well-suited: interprofessional education (IPE) and reflective learning (debriefing).

To address these training needs, InCITE has developed free resources to help educators become more facile with simulation in education.  To meet the topmost survey need, the InCITE website offers an entire IPE toolkit: http://collaborate.uw.edu/resources-and-publications/ipe-resources.html.  The toolkit includes instructor guides, a video example of a real simulation, a TeamSTEPPS® training lesson, evaluation forms, and pre/post assessment tool to assess student learning.  The InCITE Simulation Workgroup also produced four basic and three advanced online courses on general simulation topics.  http://collaborate.uw.edu/faculty-development/teaching-with-simulation/teaching-with-simulation.html-0.  To date, these materials have been used by individuals in nine countries, across five continents.

In summary, our survey confirms the findings of other research studies that lack of adequate training remains a substantial barrier to the use of clinical simulation in education of the health professions (Adamson, 2010; Hayden, 2010; Jansen et al., 2009).  It is important for instructors to be aware of resources, such as our IPE toolkit and self-paced training modules, that can help simulation to become a more standard part of health professional education, for instructors as well as students.

References

Adamson, K. (2010). Integrating human patient simulation into associate degree nursing curricula: Faculty experiences, barriers, and facilitators. Clinical Simulation in Nursing, 6(3), e75-e81. doi:10.1016/j.ecsns.2009.06.002.

Hayden, J. (2010). Use of simulation in nursing education: National survey results. Journal of Nursing Regulation, 1(3), 52-57.

Jansen, D. A., Johnson, N., Larson, G., Berry, C., & Brenner, G. H. (2009). Nursing faculty perceptions of obstacles to utilizing manikin-based simulations and proposed solutions. Clinical Simulation in Nursing, 5(1), e9-e16. doi: 10.1016/j.ecns.2008.09.004.

Kardong-Edgren, S., Willhaus, J., Bennett, D., & Hayden, J. (2012). Results of the National Council of State Boards of Nursing National Simulation Survey: Part II. Clinical Simulation in Nursing, 8(4), e117-e123. doi:10.1016/j.ecns.2012.01.003.

Taibi, D. M. & Kardong-Edgren, S.  (In press).  Healthcare educator training in simulation: a survey and website development.  Clinical Simulation in Nursing.

Updated on October 22nd, 2013 at 12:44 pm

by Diana Taibi Buchanan

In September 2013, I had the amazing opportunity of teaching 26 students from across various health sciences schools... in India!  These students participated in one of our university's "Exploration Seminars", a three-week study abroad experience.  The purpose of the program was for students to learn about the challenges and strengths of healthcare in a developing nation and to observe health practices in a cultural environment substantially different from the U.S.  The University of Washington School of Nursing offers many Exploration Seminars in locations including Korea, Thailand, and Italy.  Each of these programs is attended by students in non-nursing health fields as well as nursing, and sometimes by student in fields outside of the health professions altogether.  I have taught such programs twice now (in Switzerland and India), and only recently noted the opportunities for interprofessional training that could be intentionally addressed.

According to Senninger’s well-known Learning Zone model, individuals learn best when they are outside their comfort zone, but not so far beyond comfort that they panic (Vrouwenfelder, Milligan, Merrell, 2012). Accordingly, rich learning opportunities arise from the removal of familiar social cues (Comfort Zone) during study abroad, but with supervision and mentorship that avoids the Panic Zone.  Being in an unfamiliar setting where practices and norms may be different, or sometimes surprisingly similar, provides the opportunity for reflective learning.  Study abroad students usually arrive in the field with preconceived notions about the culture they will experience as well as preconceived notions about the roles of various healthcare providers.  In order to contrast health professionals' roles in the U.S. to those in other countries, students must confront what they have observed about roles in the U.S. and what this has lead them to believe.  Such analysis provides the opportunity to confront assumptions, address gaps in knowledge, and encourage sharing among the students of different health professions.  

A useful guideline for interprofessional training is the following six competency domains: (1) interprofessional communication; (2) patient/client/family/community-centred care; (3) role clarification; (4) team functioning; (5) collaborative leadership; and (6) interprofessional conflict resolution (Canadian Interprofessional Health Collaborative, 2010).  In India, we addressed many of these areas during the times when we debriefed with students about their daily experiences, and individual reflection was further evident in the students’ journals.  Below is a quote from one student demonstrating interprofessional learning across multiple competencies (noted by me throughout the quote).  With proper planning, students could be guided to intentionally focus their observations on the interprofessional competencies.  

As a (pre)nursing student I always believed heavily in patient centered care. I approached this by trying to examine the patient as a “holistic” person and understand how multiple facets of their lives are interplaying with each other to determine their health outcomes. I felt like I had a strong understanding of how one puts the patient at the center before I studied abroad in India. However in India I was encountered with [sic] the common idea of “I have so much more to learn” On my study aboard trip, I had the privilege to work with a handful of pharmacy students and a pharmacy faculty member. With this group of people I was able to shift my perception of pharmacy from the people who gave me drugs at the grocery store to an influential person important to delivering effective health care [addressing Role Clarification]. I realized how often the ego can interfere with what’s most important, the patient [Patient-centered Care]. It’s not just nurses and doctors that need to work fluidly with one another, but also the pharmacist, the physical therapist, the nutritionalist, the PA. Health care is a team effort, and I am beginning to better understand this through my experience working with other professions in India [Team Functioning].

As a teacher, it is tremendously fulfilling to see the accelerated personal growth that study abroad ignites in students.  In the future, I plan to more deliberately incorporate activities to facilitate awareness, collaboration, and respect among the health professions.  Rather than simply debriefing on what students happened to see, I would assign them specific observational roles pertaining to the competencies listed above.  Interprofessional education on this trip was more seredipitous than deliberate; however, that reinforces the potential for powerful learning opportunities that could be achieved with good planning.  

References

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