This study demonstrated that team training using high-fidelity simulation and debriefing for nurses and physicians promoted collaborative teamwork in a working environment in which dissatisfaction with the existing teamwork approach to patient care was high according to results from Professional Research Consultants (Omaha, NE) surveys and unit-based teamwork surveys. Moreover, after the training experience, participants perceived that significant improvements in the patient care decision-making process were sustained over time in the practice setting. A secondary effect of the team training was a better understanding by physicians of the challenges faced by nurses (and vice versa) and an overwhelming motivation to improve professional relationships through more effective communication in the future.
One of the major concerns in our work unit was that patients might be at increased risk of adverse effects when exchanged information was misunderstood or misinterpreted (ie, miscommunicated). For good outcomes in health care, collaborative practice whereby nurses and physicians make a concerted effort to combine their unique professional skills and knowledge base is crucial.16
Collaboration between team members has been clearly shown to increase awareness of each other's type of knowledge and skill, leading to continued improvement in decision making.2
Effective nurse-physician collaboration has been shown to reduce morbidity and mortality rates, cost of care, and errors and to improve job satisfaction and retention of nursing staff.3-6
According to McConaughey17
and Marshall and Manus,18
the Joint Commission identified communication problems as the root cause of 65% of sentinel events, with 74% resulting in death. Health care organizations can no longer ignore the role of failures in teamwork and communication if the goal is to create sustainable, safe environments.
Rarely do health care professionals train as teams, yet evidence shows that team training improves team performance and safety outcomes.19
Our study showed a statistically significant improvement in the perception by nurses and physicians of collaboration and decision making at 2 weeks after high-fidelity simulation team training. These improvements were sustained and continued to increase at 2 months, especially in the nursing staff. However, at 2 months, the physicians showed a slight decline in the areas of communication and cooperation. These results indicate that simulating or practicing team collaboration in this manner has the potential to improve patient care, but whether initial improvements can be sustained over longer periods of time is unknown.
Our study also demonstrated that nurses and physicians have significantly different perceptions of clinical decision making. These findings emphasize the importance of developing strategies to overcome these differences and optimize the nurse-physician relationship. In a multisite, evidence-based management practice initiative to identify structures that foster critical care nurse-physician relations, Schmalenberg et al5
described different levels of collaboration and stated that collaboration is best viewed as a relationship. According to their study, “The lowest level is characterized by the sequential reporting by each discipline without interaction or dialogue,” and was called multidisciplinary by interviewees. The highest level of collaboration, interdisciplinary, is described by “interaction and spirited dialogue” occurring between members of differing disciplines.5
Factors that enhance and impede the perceived level of interdisciplinary collaboration are examined by Fewster-Thuente and Velsor-Friedrich20
in the context of the King theory of goal attainment. Factors that impede collaborative relationships between those with differing professional roles are patriarchal relationships, time, lack of role clarification, sex, and culture. Time for interaction, a building block for trust, is an essential ingredient in collaborative relationships. Interventions that support these relationships include collaborative practice order sets and care plans. As a result of these interventions, health care professionals in differing roles converge on a common path to influence the best outcome for patients.
Interdisciplinary training has been shown to foster respect for the contributions of each discipline.21
Health care team members interact with each other in the clinical setting, but learning to problem-solve as a team in a collaborative manner can be done in a simulated environment. According to Rodehorst et al,22
simulation provides an alternative teaching strategy that allows individual team members to problem-solve and identify ways to work together given a particular clinical scenario.
Using simulation as a venue for interdisciplinary learning has been shown to enhance nurse-physician collaboration.19,23,24
Miller et al19
found that simulation training with pediatric residents and nurses during life-threatening scenarios enhanced relationships between the nurses and physicians. Similarly, Ker et al23
found that interdisciplinary learning between medical and nursing students allowed the students to recognize professional roles and contributions. The students came to understand the importance of collaboration and teamwork.
The current study has several limitations. Using only 1 specialty practice group from a single surgical nursing unit has inherent bias and does not address the ability of training to be widely applicable to other surgical nursing units. The residents who participated rotate to different units every 6 weeks, so some of the resident participants had rotated to different surgical services by the time the last survey was administered. Moreover, the length of resident experience was limited to 1 to 3 years, whereas the years of nursing experience ranged from less than 1 year to more than 10 years. Finally, our study may have been underpowered to detect differences in the secondary analysis or differences between nurses and physicians. Another limitation was that the study design did not include a control group. Without a control group, the findings may be attributed to learning or testing effects (participants do better on follow-up tests because they learned from the baseline test).25
The outcome could also have been affected by the Hawthorne effect (participants modify their behavior in response to being studied)26
and the Pygmalion effect (people perform better because of expectations placed on them).27
Nevertheless, the desired effect was achieved. Because our study used a convenience sample, the participants may not have represented all personality types. The study results are preliminary, and further research using a stronger design is needed to clarify if the positive results are reproducible.
Does one need to use a simulation center to achieve these results, or would the same results have occurred by another intervention? The simulation center offers staff the opportunity to perform patient care activities in a non-threatening environment. Future research should include randomizing staff for simulation team training or another type of problem-based learning.
As the complexity of patient care increases and more standardization of postoperative pathways occurs, good communication and collaboration between multidisciplinary teams of caregivers will be essential. Without a highly collaborative approach, outcomes cannot be optimized and our patients will be at increased risk of postoperative complications.