The most common learning point for IPE was the importance of learning the different roles and capabilities that different HCPs can play and the need to involve other HCPs to ensure an effective resuscitation effort. The learning points listed support change in perceptions related to interprofessional roles that the quantitative scale did not capture.

“The workshop improves knowledge of the roles that other healthcare professionals are able to perform, for example, a physiotherapist being qualified to help in CPR during resuscitation.”

(Nursing participant, ID 16)

B. Infection Prevention Knowledge and Practices

Although there were no statistically significant differences between the groups, better infection prevention scores were noted in the intervention group. The intervention group had a percentage increase of 3.2% (8.4% vs 5.2%) in self-evaluated infection prevention knowledge. The questions on infection prevention knowledge were supposed to be of similar difficulty, and we avoided repeating the same set of questions, as we did not want participants to discuss or look up the answers. For both groups, there was a decrease in infection prevention knowledge scores post-workshop; however, there was a smaller decrease in the intervention group (-17.1%) compared to the control group (-29.0%) (Table 3). We speculate that this may be due to the post-workshop questions being more difficult compared to the pre-workshop questions. Another reason that may have contributed to the decrease in scores is the limited number of questions (n=6), which may have confounded our results.

The participants shared a rich diversity of infection prevention learning points during the debrief session. Examples included correct steps in the donning of personal protective equipment, strategies to clean the intravenous (IV) injection hub quickly and effectively, and identification of threats that deterred proper infection prevention compliance during the simulation such as the lack of a disposable dish on the resuscitation trolley to keep intravenous drugs and intubation equipment clean. The most common learning point for infection prevention was the importance of adhering to infection prevention practices during resuscitation such as the accurate administration of parenteral medications. The learning points listed support change in perceptions related to interprofessional roles that the quantitative scale did not capture.

“The importance of practicing infection prevention measures such as the need for changing soiled gloves in between administering parenteral medications, but yet not compromising on resuscitation.”

(Physiotherapist, ID 8)

The clinical audit conducted after the simulation workshop showed that compliance rates in accurate parenteral medication administration improved by 50%, while compliance rates in ETT insertion improved by 60% post-workshop, compared to pre-workshop performance (Table 4).

Table 4. Comparison of compliance rates to infection prevention during real-time resuscitations pre- and post-workshop

IV. DISCUSSION

The study was designed, conducted and written before the COVID-19 pandemic. Since the pandemic, there had been some changes in infection prevention guidelines in aerosol general procedures such as tracheal intubation (Perkins, et al., 2020), which was not reflected in our study. Our study had highlighted the importance of using simulation and inter-professional collaboration to enhance infection prevention education, and these were also emphasised in many publications regarding infection prevention during the pandemic (Wong, et al., 2020). For example, there had been recommendations of using a buddy system for PPE donning and doffing, and using high fidelity simulation to prepare for the COVID-19 crisis (Bricknell, Hodgetts, Beaton, & McCourt, 2016). However, many of these publications were reviews and opinions rather than research studies (Foong, et al., 2020; Lim, Wong, Teo, & Ho, 2020).

To our knowledge, there are no publications on the use of in-situ simulation to teach infection prevention during resuscitations in an IPE setting. Current literature evaluating the impact of simulated IPE workshops in teaching infection prevention had mixed results with regards to the effectiveness of such workshops in improving attitudes towards inter-professional teamwork and enhancing compliance rates to infection prevention practices. In the study by Luctkar-Flude et al. (2016), there was significant improvement in infection prevention knowledge, but little change in inter-professional teamwork. Although knowledge related to aseptic technique improved significantly immediately post-workshop, long-term retention was poorer (Wagner, et al., 2011).

A. The Utility of Simulation in Improving Infection Prevention

Our results from the clinical audit conducted during actual resuscitations in the SICU demonstrated a large improvement after the workshop in accurate parenteral medication administration and ETT insertion. This finding supports the hypothesis that an inter-professional simulated workshop is more effective than traditional didactic web-based methods in improving adherence to infection prevention practices, which could be due to three added elements present in simulated workshops.

Firstly, simulation provides interaction amongst different HCPs and enables collaborative learning in small groups (Dolmans, Michaelsen, van Merriënboer, & van der Vleuten, 2015). Secondly, the debriefing process promotes reflective learning and provides real-time feedback (Ziv, Wolpe, Small, & Glick, 2003). Thirdly, the learning is contextualized as participants learn infection prevention principles that are embedded in authentic clinical scenarios, and simulated cardiac arrest in an infectious patient is a common scenario that reflects the reality of practice (Morison & Jenkins, 2007).

Simulation also enables participants to discover innovative solutions, thereby enabling optimal adherence to infection prevention protocols while ensuring a timely resuscitation response with limited manpower. An example of one of the interesting solutions discussed include the designation of specific roles during resuscitation, such as assigning one HCP to be in charge of the airway and another to be in charge of administering intravenous drugs so as to avoid contamination.

B. Encouraging Inter-Professional Teamwork Through Simulation

Simulated scenarios with a focus on IPE also encourage active engagement and collaboration amongst participants, which had been demonstrated to result in improved attitudes towards teamwork (Huitt, Killins, & Brooks, 2015). During the debriefing process, study investigators facilitated the discussion to allow HCPs from different specialties to give feedback and volunteer information on how they could better contribute to the resuscitation effort and work more cohesively as a team, thereby enabling HCPs to discover more about the capabilities of their fellow colleagues. This discussion helps to create a sense of shared purpose within teams (Freytag, Stroben, Hautz, Eisenmann, & Kammer, 2017), which is a defining characteristic of an effective team (Drinka & Clark, 2000), and also reinforces the idea that a team can often achieve what an individual cannot.

In our debriefing, the participants noted the importance of learning the different roles and capabilities that different HCPs can play and the need to involve other HCPs to ensure an effective resuscitation effort, which can subsequently translate to a positive change in patient care and collaborative practice (Hammick, Freeth, Koppel, Reeves, & Barr, 2007). For example, the nursing and medical participants did not realise that physiotherapists, pharmacists and speech and language therapists are BCLS trained and can perform effective chest compression, and the medical participants did not realise nurses can perform cardiac defibrillation during a cardiac arrest. Better collaboration and understanding of other HCPs’ roles can improve task delegation to fully maximise available manpower, and aids in crisis resource management.

C. Debriefing–An Essential Component of a Simulated Workshop

According to the experiential learning style theory (Kolb & Fry, 1975), reflective practice is an integral component that allows learners to fully integrate the learning experience. It allows HCPs to transit from merely experiencing the simulation to deriving critical learning points (Savoldelli, et al., 2006), as constructive discussion and feedback allow participants to better understand potential areas of improvement and reinforces proper infection prevention practice (Gerolemou, et al., 2014). The importance of feedback and discussion is aptly demonstrated in our study, with participants noting that accurate parenteral medication administration was one of their main takeaways from the debriefing process, and there being a subsequent 50% improvement in parenteral medication administration in our observational study.

An effective debriefing process was facilitated through the creation of a non-threatening environment by using open-ended questions, positive reinforcement, constructive feedback and active engagement of all HCPs present (Fanning & Gaba, 2007). While there are many debriefing tools present such as the Organ Specific Autoimmune Disease (OSAD) debriefing tool (Ahmed, et al., 2012), and Advocacy Inquiry (Gururaja, Yang, Paige, & Chauvin, 2008), we believe that the cornerstone of a successful debrief is through the creation of an environment that allows participants to freely voice their queries and concerns, and subsequent discussion to tease out relevant learning points that serve as important takeaway messages.

D. Other Observations

Interestingly, we noted significant differences in Team Structure and Leadership between the Intervention and Control groups in the pre-test questionnaire. This could be due to difference in number of years that the intervention and control groups have worked in SICU, with the intervention group having worked a mean number of 3.78 years compared to the control group’s 5.13 years, although this difference was not statistically significant. Studies have shown that HCPs who have worked together for longer periods of time and on a daily basis are more likely to develop trust and confidence in their teams (Bosch & Mansell, 2015). Less-experienced healthcare staff may feel more uncomfortable with inter-professional teamwork compared to more experienced staff, further highlighting the importance of increasing exposure to IPE for younger HCPs.

E. Challenges Encountered in the Implementation of a Simulated Infection Prevention IPE Workshop

The conception and organisation of an infection control workshop that incorporates both simulation and IPE improved our understanding of existing challenges to the development of a coherent curriculum and implementation of simulated workshops (Buckley, et al., 2012). There were numerous challenges encountered in the implementation of such workshops.

Examples include:

1. Simulated workshops are resource intensive. Monthly faculty meetings were held for five months before the workshop, and each workshop required the presence of a HCP from at least five different specialties. In addition, beds in the SICU had to be specially set aside for the workshop to take place.
2. Learning outcomes had to be crafted carefully to ensure that all HCPs could benefit from an effective IPE session.
3. Faculty development was crucial and the faculty was trained to ensure that the post-simulation debriefing could take place effectively and learning outcomes were met.
4. Scheduling conflicts were encountered as implementation of the workshop required HCPs with different work schedules to be present at the same time.

The effectiveness of the workshop could be better evaluated with multiple SICU audits of resuscitations pre- and post-workshop, as this would truly demonstrate translation of learning to real-life practice. However, it is difficult to coordinate logistically. Whenever a real-time resuscitation in the SICU occurred, our hospital-based infection prevention team had to be mobilised within a few minutes without advanced notice to the SICU to conduct the audit on infection prevention compliance during resuscitation, which proved to be challenging.

Nevertheless, these challenges can be resolved if HCPs are strongly committed to better healthcare and our study showed that it is possible to overcome the above-mentioned challenges (Byakika-Kibwika, et al., 2015). We hope that our experience would help shed light on future barriers to implementation of similar in-situ simulated IPE workshops.

 F. Plans for the Future

Our study showed that simulation IPE workshops encouraged mutual support amongst different HCPs and improved infection prevention practices during resuscitation. However, implementation of the workshop was costlier and more labour intensive compared to current online video infection prevention education. Currently, we now run in-situ simulations in SICU every month on crisis resource management, and infection prevention is one of the important learning outcomes. 

This workshop was conducted before the COVID-19 pandemic and there was no limitation on the maximum number of participants. In the future, with the SICU roster having changed to shift work, the workshop will only be conducted amongst HCPs within a particular shift to avoid cross-contamination with other shifts. A larger debrief room may be needed to allow for social distancing as well.

G. Limitations of our study

Limitations of our study include the small sample size, making it difficult to draw generalisations, as the study cannot show any statistically significant difference when comparing the control and intervention groups even though positive trends were observed. Furthermore, longer follow-up is required to evaluate long-term changes in behaviour, attitudes and retention of knowledge.

V. CONCLUSION

Our study showed that learning infection prevention through simulated IPE workshops is an innovative way to teach infection prevention and may lead to increased infection prevention compliance in clinical settings, as demonstrated by the clinical audit conducted. In light of the ongoing COVID-19 pandemic, use of a simulated scenario may help enhance infection prevention practices to limit the spread of transmission-based infections. Simulation may also help improve attitudes towards inter-professional teamwork and collaboration, which are crucial in resuscitations.

Notes on Contributors

Kah Wei Tan is a Medical Officer working with Ministry of Health Holdings (MOHH). Kah Wei Tan performed data collection and data analysis, reviewed the literature and wrote the manuscript.

Hwee Kuan Ong is a Senior Principal Physiotherapist in the Department of Physiotherapy, Singapore General Hospital. Hwee Kuan Ong performed data collection and data analysis and wrote the manuscript.

May Un Sam Mok is a Senior Consultant in the Division of Anaesthesiology and Peri-operative Medicine, Singapore General Hospital. May Un Sam Mok developed the methodological framework for the study, designed the study, reviewed the literature and wrote the manuscript.

Ethical Approval

The study is approved by SingHealth Centralised Institutional Review Board (CIRB reference: 2016/3001).

Acknowledgement

We would like to acknowledge the SICU staff for providing assistance in conducting the survey.

Funding

Funding was obtained from the Academic Medicine Education Institute (AMEI) grant.

Declaration of Interest

There is no conflict of interest to declare.

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*Kah Wei Tan
1 Maritime Square,
#11-25 HarbourFront Centre,
Singapore 099253
Email address: kahwei.tan@mohh.com.sg