Institutionalizing an interprofessional simulation education program: an organizational case study using a model of strategic change

ABSTRACT

Initiatives to implement interprofessional simulation education programs (ISEP) often fail due to lack of support, resources from management or proper integration into the organization system. This paper aims to identify factors that ensure the successful implementation of an ISEP. Further, the study explores the potential effects an ISEP can have on organizational processes and culture. The case study describes the implementation process of an ISEP in a non-academic community hospital using interviews, participative observations and archival data over six years. A thematic approach has been used to analyze the data guided by Kotter’s 8-step model for organizational change. Strategies for a successful implementation of an ISEP include: 1) make a case for interprofessional simulation-based education (SBE), 2) search for healthcare champions, 3) define where the ISEP will lead the organization, 4) spread the word about interprofessional SBE, 5) ensure that structures, skills and supervisors align with the change effort, 6) win over smaller entities, 7) enable peer feedback and create more change, 8) institutionalize the ISEP. Indicators of how the ISEP impacted hospital culture are presented and discussed. ISEPs – if implemented effectively – provide powerful opportunities to span boundaries between professional groups, foster interprofessional collaboration, and eventually improve patient care.

KEYWORDS:

• Interprofessional education
• continuing education
• debriefing
• simulation-based education
• simulation program
• change management

Introduction

Healthcare has become increasingly complex and intertwined. Therefore, healthcare workers (HCWs) from different professional backgrounds have to collaborate effectively to achieve the highest quality of healthcare (Gilbert et al., 2010). In order to work together, professionals also need to learn together. Interprofessional simulation-based education (SBE) has proven to be an effective training principle to foster collaborative practice (Cook et al., 2011; Hughes et al., 2016). Several reviews and meta-analyses have summarized the beneficial effects of interprofessional SBE in undergraduate and postgraduate programs (Gough et al., 2012; Granheim et al., 2018; Labrague, Petitte, Fronda et al., 2018; Martins & Pinho, 2020) as well as in professional development (Astbury et al., 2020; Fung et al., 2015; Zhang et al., 2011). There is overwhelming evidence that interprofessional SBE has positive effects on all levels of learning evaluation (Fung et al., 2015; Kirkpatrick, 1975; Welsch et al., 2018). Generally, HCWs are satisfied with SBE and report changes in attitudes following an intervention. This includes increased confidence, attitudes toward interprofessional collaboration, motivation and impression of safety (Welsch et al., 2018) and a knowledge increase in teamwork and other key concepts (Fung et al., 2015). In addition, interprofessional SBE translates to the workplace with increased team performance (Capella et al., 2010) and better interprofessional communication (Labrague & Petitte, Fronda et al., 2018). Finally, studies report benefits of interprofessional SBE for patients, namely reduced complications, adverse events and mortality (Capella et al., 2010; Riley et al., 2011).

However, implementing a hospital-wide interprofessional simulation education program (ISEP) poses significant challenges and requires money, time and expertise. These resources are especially limited in non-academic community hospitals, reserving the privilege of comprehensive ISEPs for large academic hospitals. As a result, community hospitals typically do not reap the positive benefits of ISEPs on acquiring complex skills (Dawe et al., 2014; Lorello et al., 2013) or team collaboration (Eppich et al., 2011; Schmutz & Manser, 2013; Weaver et al., 2014). Nonetheless, we often see a small number of simulation-enthusiasts in community hospitals overcome obstacles, even sacrificing their free time and advance SBE in their hospitals. Unfortunately, these initiatives based on the discretionary effort of a few often fail due to a lack of support, resources from management or proper integration of the program into the organization-wide system (Decker et al., 2012).

Background

Multiple authors provide guidance on how to implement simulation programs (Kumar et al., 2018; Lazzara et al., 2014; McGaghie et al., 2010; Seropian et al., 2004; Tuoriniemi & Schott-Baer, 2008; Wilford & Doyle, 2006). Generally, they describe long and difficult implementation processes and highlight the need for tight program integration into the context of broader health professions education efforts (McGaghie et al., 2010; Seropian et al., 2004). Common pitfalls include buying a simulator without sufficient planning, without having the necessary infrastructure, or without adequately trained instructors (Lazzara et al., 2014; Seropian et al., 2004).

These lessons learned are helpful but insufficient for new program development. The studies mentioned above target either a specific group (e.g., nurses) or view the simulation program as an isolated entity in the hospital. However, most studies agree that in order for a simulation program to be successful and sustainable, it needs to be integrated into organizational structures (Decker et al., 2012; Kotter, 2012; Lazzara et al., 2014). Therefore, the implementation process must take the organization’s ecosystem and its local context into account, requiring long-term commitment to organizational change with potentially positive effects on patient-related outcomes and overall hospital culture.

Unfortunately, the guidance presented in the literature underdelivers in terms of needed specificity and lacks empirical data to back up key claims. This absence of detail leaves many open questions about how to implement such recommendations in specific contexts. Our field requires specific knowledge about the challenges, opportunities and potential outcomes of implementing an ISEP on a hospital-wide level. To address this gap, we need comprehensive descriptions of successful implementation processes that provide rich data about context-specific strategies to inform future implementation efforts.

General guidance on how to navigate organizational change processes provides Kotter’s 8-step model (Appelbaum et al., 2012; Kotter, 2012). This management model describes a stepwise approach to how change can be initiated and eventually anchored in the organization. The model has been used in several healthcare settings in the past (Baloh et al., 2018; Kumar et al., 2018; Vokes et al., 2018). Table 1 provides a summary of the eight steps that drive a change process. However, Kotter’s change model only provides general advice on how to structure change. Guidance on how the eight steps can be implemented in relation with an ISEP is still needed.

Table 1. Kotter’s 8-step change model (Kotter, 2012)

1	Establish a Sense of Urgency	Change often presents risks and uncertainty about the future and requires significant cooperation, initiative and willingness to make sacrifices from many people. A collective sense of urgency must precede the introduction of any change. A sense of urgency convinces people of the benefits and desired outcomes of the proposed change program. High urgency helps pull together a group with enough power and credibility to guide the effort.
2	Building a Powerful Guiding Coalition	Change often starts with one person, but this is not enough to sustain the process and change a whole organization. A guiding coalition is needed and should consist of a diverse group of members characterized by a) people in position with power, b) expertise, c) credibility and d) leadership. A good mix of managers and leaders is necessary. Managers are responsible for strategic thinking on an organizational level and allocation of resources. Leaders drive the change in everyday business and communicate the vision to the people.
3	Forming a Change Vision	A good vision is the driver for change and a basic component of all great leadership. A good vision should clarify the general direction for change, motivate and inspire people to take action in the right direction and help coordinating the actions of different people.
4	Communicating the Vision	A compelling vision needs to be communicated via all existing communication channels to create a shared understanding of its goals and directions. Communication comes in both words and deeds. The latter is often more powerful, and therefore important people have to lead by example.
5	Empower Others to Act by Removing Barriers	Obstacles will arise that represent a risk for the success of the change project. Four obstacles that often need to be addressed are structures, organizational systems, skills and supervisors. First, organizational structures and systems (e.g., recruiting, performance evaluation) need to support the change. Second, employees need to be trained so that the necessary skills are available and finally, supervisors in powerful positions need to be in favor of the change and not work against it.
6	Generating Short-Term Wins	It is just normal that the enthusiasm for change drops over time. Therefore it is important to plan for short-term wins that additionally empower people and keep the momentum going. In addition, short-term wins need to be visible to show that change is happening.
7	Consolidating Improvements and Produce More Change	Until the change sinks deeply into the companies culture, new approaches are fragile. Change leaders should use the credibility gained through short-term wins to tackle even bigger problems. In a company where change is increasingly the norm, people tend to be more open and more change becomes easier to implement.
8	Institutionalizing New Approaches	Institutionalizing the change in the culture should be the final goal of every change process. It needs to become “the way how we do things here.” Culture refers to the norms of behavior and shared values in a company. These norms and values often persist over time, even when group members change. Thus, changing a company’s culture requires a long time and only happens at the end of the change cycle not at the beginning.

Based on these considerations, the purpose of this study is two-fold. First, by conducting a detailed case study analysis of a non-academic community hospital, this study aims to identify factors that ensure the successful implementation of an ISEP. Under the assumption that ISEP implementation represents a change process, Kotter’s 8-step model for organizational change serves as a conceptual framework to guide and structure data analysis (Kotter, 2012). Second, the study aims to explore the potential effects of the ISEP on organizational processes and culture.

Methods

Study design

This paper presents a case study of a hospital-wide implementation of an ISEP. A case study methodology has been chosen for two reasons: (a) to generate an in-depth understanding of a single case in its real-world context and (b) to identify new insights about real-world phenomena and related behaviors (Bromley, 1986). The paper seeks to delineate factors in successful ISEP implementation, identify specific implementation steps and potential impact on the organization. The target of the investigation was a regional district hospital in Switzerland (details Table 2).

Table 2. Description of case, data from 2019

Beds:	500
Patients:	>250,000 visits/year (28,024 inpatient visits)
Employees:	3294
Departments:	Surgery, gynecology, obstetrics, pediatrics
Institutes:	Anesthesiology, Laboratory Medicine, Pathology, Therapy and Rehabilitation, Radiology and Nuclear Medicine, Radio-Oncology
Interdisciplinary Centers*:	Center for vascular systems, Tumor Center, Perinatal Center, Simulation Center
Faculty Simulation Center:	50 people including nurses, physicians and representatives from medical technology and electrical engineering; 42 of them are trained simulation instructors
Amount of high-fidelity simulation trainings per year:	83 interprofessional simulation trainings on all institutes except Radio-Oncology and Therapy and Rehabilitation
Amount of staff trained per year:	Approximately 900 healthcare workers

*The Interdisciplinary Centers are virtual units that consist of representatives from different disciplines and departments.

In 2013 the hospital had no simulation activities. After a 6-year change process, the hospital developed a robust ISEP with several key achievements that justify the exploration of success factors in this particular context:

• Recruitment, training, and retention of 50 active faculty members

• Training of around 900 HCWs in 2019

• 83 high-fidelity interprofessional simulation trainings in 2019 (See Table 3 for details)

  Table 3. Characteristics of the high-fidelity interprofessional simulation trainings

  Simulator:	High-fidelity simulation mannequins (adult, 5-year old and newborn), AV video system for recording and debriefing (SIMStation, Austria).
  Procedure:	Each group participated in a 2.5 h session. The session started with a 30 min teaching block, including introduction to the simulation environment and an introduction to CRM principles (Gaba et al., 2001). Then two simulations were conducted. Scenario duration was between 15–20 min each, followed by a 30–45 min debriefing.
  Scenario design:	Scenarios were chosen to correspond to the participant’s areas of expertise. The simulation center supported each department in the development of it's own simulation scenarios.
  Group characteristics:	5–10 participants, including nurses, residents and physicians from one department.
  Instructors:	At least two trained simulation instructors were leading the sessions and facilitating the debriefings. If requested, additional instructors joined the session to foster peer coaching for the instructors. An additional technician was present, responsible for controlling the simulation mannequin.
  Course objectives:	Getting to know and apply the CRM principles, especially in relation to interprofessional collaboration, was a learning objective of every session. In addition, each department formulated specific learning objectives in terms of technical skills.

• Official integration as an entity into the organization’s structure as an interdisciplinary center

Data collection

The case analysis arose from different data sources, including interviews, participative observations during simulation sessions and meetings and archival data. In addition, four semi-structured interviews have been conducted with the two change leaders, two in October 2018 and two in June 2020. Change leader 1 was a neonatologist with 25 years of professional experience, change leader 2 was a pediatric emergency physician with 32 years of professional experience. The two individuals have been chosen because they were the initiators of the implementation process and could provide detailed information about every stage of the process from 2013 onwards. Interviews lasted between 90 minutes and two hours. They focused on the implementation process of the simulation program from the start and the specific steps that lead to the establishment of an official simulation center. Interviews also covered obstacles they faced and detailed descriptions of how problems were solved during the implementation process. Further, the interviews covered aspects of potential changes in hospital procedures resulting from the interprofessional SBE.

Data collection also involved participative observations during simulation trainings and meetings. The author participated yearly in a total of six meetings from 2015–2020, where the evolving simulation activities were discussed and evaluated by leaders from different departments. His role during the meetings was to support the group with his expertise in interprofessional SBE. These meetings helped to monitor the development of the ISEP and to learn about the challenges. After each meeting, the author wrote down notes about the progress of the ISEP. From 2017 until 2020, he also attended eight full-day simulation sessions in four different departments. He actively participated as a simulation instructor, either debriefing teams after a simulation scenario or supervising other instructors and providing feedback for improving the training session. During or after each training, the author engaged in informal interviews with participants to follow up on the simulation session. These conversations aimed to gather information about the potential impact of the simulation activities on individual attitudes and behavior and potential change within their unit (e.g., implementation of new standard operating procedures, checklists). During these sessions, the author took field notes and transcribed them after each session.

Finally, archival information was gathered, including organizational charts, annual reports, internal reports about simulation activities and regulations and descriptions about the simulation center.

Data analysis

Using a thematic approach (Guest et al., 2011), data analysis sought to a) identify factors for a successful implementation of an ISEP and b) identify indicators that the ISEP had a broader impact on organizational processes and culture. In a first round, line-by-line coding was conducted to create focused codes for the interviews and field notes. In a second round, higher-order themes were identified that emerged from the data (i.e., success factors for ISEP implementation, indicators for culture change). During this process, it became evident that the emerging themes overlapped with Kotter’s 8-step model. Therefore, in a third round, a deductive approach has been used to identify success factors for ISEP implementation using Kotter’s model (Kotter, 2012) as a guiding framework. Additional coding has been done to identify indicators that the ISEP had a broader impact on the organization. The emerging concepts concerning cultural change are presented at the end of the results section. This process included repeated reading and coding of the data using MAXQDA (VERBI GmbH, Berlin).

Results

It follows a detailed description of how the ISEP has been implemented and key findings organized according to Kotter’s (Kotter, 2012) eight steps are presented, including the lessons learned. For each section, main findings are offered and then located within the existing literature. Table 4 summarizes the main results and recommendations gained from the case study. Further, indicators for cultural change will be presented.

Table 4. Recommendations to establish an interdisciplinary simulation education program

1	Make a case for interprofessional SBE	Make a case for simulation training being the means to improve individual skills as well as interprofessional collaboration resulting in better patient care Convince the management that an ISEP will make the hospital a more attractive workplace and, over the long run, will save money by lower turnover rates, shorter length of stay and increased quality of care Hire an outside company to conduct simulation trainings to get people interested and familiar with simulation. Invite people from various professions as well as management to experience simulation firsthand
2	Search for healthcare champions	Actively search and approach healthcare champions, preferably persons with power, to promote simulation that embody the desired culture and enthusiasm for simulation and change
3	Define where the ISEP will lead the organization	Formulate a change vision within your guiding coalition. Describe how an ISEP will change collaboration, hospital culture and patient safety
4	Spread the word about interprofessional SBE	Find ways to regularly talk about the simulation activities with HCWs as well as management Make simulation activities and the change vision part of formal and informal meetings
5	Ensure that structures, skills and supervisors align with the change effort	Ensure that structures, skills and supervisors are in line with the change effort Get additional resources so that simulations can be conducted during work hours Educate simulation facilitators in basics of simulation training (communication, debriefing techniques, psychological safety) Get leaders on board with well-designed scenarios relevant to the target group Conduct demonstrations of a simulated case to get people used to simulation and decrease fear of being exposed
6	Win over smaller entities	Apply a step-by-step approach winning over smaller entities (e.g., units, departments) one after the other
7	Enable peer feedback and create more change	Enable peer-feedback among simulation facilitators Use the momentum to create more change (e.g., implementing clinical event debriefings)
8	Institutionalize the ISEP	Encourage the exchange of simulation facilitators between departments to enable interdepartmental learning Establish an interdepartmental network (organizational entity) for simulation to monitor, supervise, support and further develop simulation activities representing and communicating the core values of collaborative practice

The change process started with a neonatologist (Change leader 1) and an emergency pediatrician (Change leader 2). These two newly recruited senior physicians initiated the change in 2013 after they assumed their new leadership positions. In their previous organizations, they had experienced simulation-based team training (SBTT) and were thus personally convinced of the beneficial effects of interprofessional SBE on communication, teamwork and clinical performance. However, they also had the vision that such an initiative would have the power to change the overall hospital culture.

Step 1: make a case for interprofessional SBE

The two change leaders established a sense of urgency on two levels: (a) frontline HCWs and (b) management. However, the arguments for these two groups to create a sense of urgency varied considerably.

By talking with HCWs from various disciplines about advanced simulation training, they realized that these HCWs desire more training, given anxiety about critical emergency situations and a lack of confidence in dealing with such cases:

“People are often afraid that a crisis (life-threatening emergency) will happen during their shift. Having trained a specific scenario before, during a simulation takes away the fear of such situations and people are more confident” (Change leader 1, 2018)

They learned that urgency for more training – especially emergencies – already existed. HCWs wished for more training to be better prepared as individuals and teams to deal with crisis situations. Therefore, the change leaders’ task was not so much creating a sense of urgency but more to frame simulation as a way to address the lack of confidence to deal with crisis situations and improve clinical performance, a strategy that was met with great interest among HCWs.

Organizational leaders at the management level required more convincing to create a sense of urgency to support such a program and invest money in it. The change leaders presented examples of poorly managed cases or data about adverse events. Further, they wrote a formal proposal to the hospital management asking for financial support to build an ISEP. This report included published empirical evidence about the effectiveness of SBTT and the potential benefits (Ross et al., 2012; Shapiro, Morey, Small et al, 2004; Wayne et al., 2008; Weaver et al., 2014). They highlighted the need for an ISEP to increase individual skills and interprofessional collaboration to improve patient safety. Further, an ISEP would prepare teams better for crisis situations resulting in higher self-efficacy (Meurling et al., 2013) which eventually should increase job satisfaction (Baik & Zierler, 2019). Finally, they argued that an ISEP will make the hospital a more attractive place to work for talented HCWs resulting in less turnover. This was a strong argument, especially because there is a wide shortage of skilled HCWs in Switzerland (Biernoth, 2016). They made clear that management has to invest money now but the organization would be able to save money over the long run due to lower turnover rates, shorter length of stay and increased quality of care (Kalisch et al., 2007; McGuire, 1994; Weaver et al., 2014).

The next step was to get HCWs familiar with SBTT and reduce potential fears and skepticism (e.g., fear of being judged during a simulation). Since there was not enough know-how within the hospital, they worked with outside experts to conduct in-situ simulation over several months. Everyone was invited to participate and experience simulation firsthand. In case people were simulation skeptics, they were invited to observe without actually participating in the scenario. The change leaders also invited members of hospital management to experience the training first hand and explained what a potential hospital-wide ISEP would look like.

This is in line with other institutions that highlight the importance of involving the management level when promoting simulation. For example, the Center for Medical Simulation at Harvard Medical School offers simulation workshops targeted at non-clinicians for leadership and management teams (Center for Medical Simulation, 2021).

In 2014 the hospital management granted funding to the pediatric department to buy a complete simulation system. In the following years, the pediatric department then became the nucleus for spreading simulation across the hospital.

Step 2: search for healthcare champions

The change leaders recruited “champions” to promote simulation. These healthcare champions were preferably persons with power who could promote the importance of the program within their departments and inform organizational members about the purposes and benefits of simulation. Thus, for the change leaders SBTT embodies a culture of learning, collaboration, openness and feedback which in the long term should translate into everyday hospital routine.

“ … then it needs kindred spirits in our department but also from other departments with the same attitude and philosophy on how to lead (…) we searched for them (…) found them, and joined forces.” (Change leader 2, 2018)

This search for influential healthcare champions and join forces is a crucial step to consider before initiating the actual change that other authors have also highlighted (Lazzara et al., 2014).

Step 3: define where the ISEP will lead the organization

ISEPs should become one part of a larger campaign for clinical risk management (Gaba, 2004), including critical incident reporting systems and other measures increasing patient safety. Therefore the focus of the ISEP should lie on improving collaborative practice (Suter et al., 2009). For the guiding coalition, it was clear that SBTT itself was only a means to transform the way how teams interacted.

The vision was to use simulation to create opportunities for increased social interaction across professional, disciplinary and hierarchical boundaries. This increased intergroup contact should decrease conflict and prejudice by bringing people together from different teams and professions (Pettigrew & Tropp, 2006; Tajfel et ea, 1979).

“The idea was to improve the communication within the hospital, that you do not have to follow the hierarchies, but you can approach the people directly because you know each other. Also, in extreme situations [you] trust each other because you know each other better. We wanted to establish a culture of interdisciplinarity and interprofessionality.” (Change leader 1, 2018)

In line with existing recommendations (Gaba, 2010; Gaba et al., 2001) they made non-technical skills an essential part of every simulation. Crisis resource management (CRM) principles were the primary learning goal while reflecting on teamwork and leadership. The vision was to establish a common understanding of collaborative practice characterized by small hierarchical barriers, openness and respect.

“Through simulation, we want to transmit this idea of mutual respect and appreciation and make the teams stronger through the interactions between professions; among nurses, physicians, therapists and so on.” (Change leader 2, 2020)

Step 4: spread the word about interprofessional SBE

In 2015 only the pediatric department was conducting simulations regularly. From there, they communicated the vision of a hospital-wide ISEP to other departments by inviting guests to join their simulation activities. For the next six months, they spread the word that simulation training could benefit every department and promoted the vision to establish a hospital-wide ISEP.

The change leaders used every opportunity to publicize the simulation activities. For example, in collaboration with the communications department, they managed to publish several articles about the benefits of interprofessional simulation in the internal monthly newspaper. In addition, the guiding coalition used formal and informal meetings with other department heads and the management to update and inform them about all activities.

“We regularly informed the hospital director. Even when we shared an elevator, we used these six floors to update him about our progress and invited him to our training sessions.” (Change leader 2, 2018)

Step 5: ensure that structures, skills and supervisors align with the change effort

To accelerate their efforts, they needed to empower more people and include other departments by eliminating obstacles to adopting simulation activities. Structures, skills and supervisors needed to be aligned to enable a hospital-wide change effort (Kotter, 2012).

First, critical structural changes needed to be done related to staff scheduling during training days. The HCWs participating in simulation training were scheduled in addition to the normal staffing so that they could train during working hours. Thus, all participants could focus entirely on the simulation training and did not have to worry about getting called for real cases. Also, the simulation facilitators received extra work time to install and prepare the simulation facility. This demonstrates a significant commitment from management that communicates trust toward the change and illustrates how important it was to convince the management in the first step.

Second, the necessary skills to facilitate simulation activities needed to be present in the organization. After identifying champions from all professions, they participated in instructor courses where they learned the basics of simulation, debriefings and non-technical skills and CRM (Flin et al., 2002; O’Dea et al., 2014). This training equipped simulation facilitators with the necessary skills to be leaders within their groups, including debriefing strategies, CRM and a basic understanding of psychological safety. Later in the process, they obtained funding to bring in three simulation and debriefing experts for an on-site advanced debriefing course to extend debriefing capabilities for all hospital simulation facilitators. This course additionally increased the visibility of the simulation efforts hospital-wide.

Third, the change leaders were keenly aware that team and department leaders needed to support change and had influence to promote simulation activities actively. Therefore, participation in simulation was never mandatory without complete buy-in from leadership. However, if they could not find any allies in a department, they offered to organize a full simulation training. Departments that already had the necessary know-how provided equipment and debriefers. In order to promote engagement, the change leaders meticulously designed the training cases so that the reluctant groups were drawn into the scenarios as the main actors whose expertise was required.

“For the less enthusiastic departments, we provided the simulation manikin and instructors for them and designed scenarios (…). They didn’t have to prepare anything, but they were the main players in the scenario. Without them, the patient wouldn’t survive the scenario. So we hoped we could inspire them and get them on board.” (Change leader 2, 2018)

Such a scenario for anesthesia could include an emergency that turns into an airway problem where the patient eventually has to be intubated.

Finally, one obstacle that the change team faced was fear of being observed, evaluated and judged by others. This form of training was new for most of the participants. Although, most HCWs acknowledged the training value of interprofessional SBTT some were still reluctant to expose themselves during a simulation training.

“During simulations, if people don't adhere to algorithms, we’ll see that and people are scared to embarrass themselves. These are the people you have to bring on board.” (Change leader 1, 2018)

Therefore, the coalition team conducted demonstrations in different departments (e.g., during team meetings). These demonstrations highlighted the potential for a culture focused on learning and improvement, not blame and shame. The change leaders were aware that a psychologically safe environment is crucial for success (Edmondson, 1999; Kolbe et al., 2020). The change leaders highlighted the importance of the very first impression of simulation on any ward. Rather than providing simulation scenarios of infrequent events, change leaders selected cases that HCWs experience daily or weekly. These relatively mundane cases provided a forum for HCWs to experience simulation with less fear about being “tested” on rare illnesses or infrequent complications. Examples included straightforward scenarios of a dehydrated child or a patient with garden-variety asthma. This again highlights the importance of well-educated simulation facilitators who know how to design scenarios, provide feedback and create a safe learning environment.

“Psychological safety is so important for us, and we need to ensure this. We had to demonstrate this (simulation training) to them without exposing anyone (…). We had to make clear that it’s ok to make mistakes and we all want to learn.“ (Change leader 1, 2018)

Step 6: win over smaller entities

Since establishing a hospital-wide ISEP represented a long-term process with the potential for waning enthusiasm, the change leaders approached each department step-by-step to generate and build on short-term wins. The first goal was to establish regular simulation trainings in the pediatric department since one of the change leaders held a leadership position there and could promote simulation activities. Second, they approached the anesthesia department since this department had the most interactions during clinical work with the pediatrics department. After that, they approached other departments step-by-step. So the change leaders could focus their efforts on one department at a time.

Step 7: enable peer feedback and create more change

In 2017 simulation training was officially integrated into the organization structure as one of four interdisciplinary centers. However, in some departments, the excitement leveled, resulting in fewer training. Here the interdisciplinary center for simulation provided support. The center consists of simulation experts from different professions. They were able to provide support with scenario design and debriefings and implemented a peer-learning approach. So they ensured that also the instructors would receive regular feedback. The peer-feedback rounds were designed to create an open environment where the instructors could reflect on their performance and receive feedback from other instructors. This structure ensured that the simulation activities were consolidated and the instructors could evolve their skills.

Over the years, regular interprofessional SBE resulted in more people being trained in non-technical skills, communication and debriefing techniques. Reflection about team collaboration was not a rare occasion anymore. Participants reported getting used to debriefings and were more open to receiving feedback.

The change coalition used this momentum to create more change. They pushed initiatives for clinical event debriefings, something that was not institutionalized in the hospital before. The establishment of regular simulation training and debriefings laid the groundwork for clinical event debriefings. The necessary skills were present and the ISEP established a safe and open culture where everyone can speak her/his mind. In May 2018, the hospital offered their employees the first workshop about clinical event debriefings with three experts in the field. In the future, the interdisciplinary center for simulation also became a contact point for departments that aim to establish regular clinical event debriefings.

Step 8: institutionalize the ISEP

With an interdisciplinary center for simulation anchored in the organization’s structure, they managed to institutionalize the ISEP. This center plays a crucial part in maintaining long-term success. Today, the center consists of representatives from all departments and professions and is responsible for monitoring, supervision, support and further development of simulation activities across the hospital. Every other month representatives meet and discuss past and upcoming simulation activities. The center also constantly recruits new simulation champions, coordinates training activities and conference visits targeted at SBE.

Indicators for cultural change

The data revealed several indicators that the ISEP influenced internal processes and hospital culture.

Change in interprofessional collaboration

Over the years, the ISEP has transformed collaboration. The focus on CRM in the interprofessional simulation training led to a noticeable transfer to real cases. Teams reported after training sessions that they increasingly apply the 10-seconds-for-10-minutes principle (Rall et al., 2008) and closed-loop communication (Härgestam et al., 2013) during real emergencies. Also, leadership was increasingly discussed and more explicitly defined in teams.

“Everyone now knows the 10-seconds-for-10-minutes principle and closed-loop-communication and we apply these principles during emergencies. Also, people explicitly ask who the leader is. The people demand in real life scenarios what we train in simulations.” (Emergency resident, 2018)

Document analysis revealed that the regular simulation sessions lead to the design of a speaking-up algorithm published internally. All employees independent from profession or rank are encouraged to apply it. Using interprofessional SBE to introduce and establish teamwork principles helped develop a shared understanding of how to work together and improved collaboration in everyday activities.

Change of interprofessional and multidisciplinary exchange

The hospital established an interdepartmental exchange of simulation instructors. More experienced facilitators went to other departments to support training sessions. This exchange resulted in several benefits. Departments that do not yet have the necessary skills to conduct simulation training received support from more experienced staff. Also, simulation facilitators from other departments guiding debriefings provided an outside view and did not have to fear potential negative consequences after giving feedback. This interdepartmental exchange fostered communication between departments and opened the door for interdepartmental learning. Also, the exchange further supported the establishment of the before mentioned teamwork principles by implementing the same processes in different departments (e.g., CRM, speaking up).

Change in feedback and debriefing culture

Participants during the informal interviews reported that the ISEP was able to transform the way tensions between professions are discussed and solved over the years.

“If we look at the collaboration with anesthesia, back in the days they rushed into the room, pushed us (pediatrics) away, and overwhelmed us. We didn’t know how to deal with that. Today, we have a culture where we can address this, it’s normal to ask for debriefings after cases and discuss issues together because we know each other; we train together.” (Pediatrician, 2018)

Various factors have enabled this change. First, as the quote illustrates, regular interprofessional training reduced barriers between professions, making it easier to speak up if tensions arise. Second, HCWs during the SBTT participated in debriefings. During the debriefings, facilitators prompted the participants to reflect on their work collectively. Reflection can be uncomfortable and is not something that comes naturally in a team. However, it is a skill that can be learned (Schmutz & Eppich, 2017). Over the years, team reflection in the form of debriefings has become more popular, and teams got used to reflecting together. HCWs from multiple departments reported that they increasingly demand shorter or longer debriefings and feedback sessions after clinical cases since the ISEP demonstrated the value of collective reflection. Third, the 42 trained simulation instructors acquired specific skills in guiding debriefings and feedback techniques through their training and practice in leading SBE. By being part of the simulation center, leading regular interprofessional training, and teaching CRM principles, these HCWs internalized collaborative practice. As a result of their active participation in the ISEP, this influenced their way of working in their departments. These HCWs became essential role models, especially for younger generations which will further establish a more inclusive interprofessional culture.

Discussion

This paper outlined the implementation process of an ISEP of a regional hospital over six years. The case study presented in this paper and especially the specific strategies described should encourage hospitals to adopt a long-term organizational lens and view simulation programs as an engine to drive culture change.

A recurring theme in the ISEP of our case is creating various opportunities for collaboration between professions and disciplines. Besides the interprofessional SBE itself, there is the exchange of simulation facilitators between departments or creating an interdisciplinary center that creates opportunities for interprofessional and interdisciplinary collaboration. Increased interaction is an effective way to span boundaries between groups and minimize conflict (Burford, 2012; Eppich & Schmutz, 2019). The ISEP in our case study created opportunities for social interactions across professional, disciplinary, and hierarchical boundaries.

Much of the success of the ISEP in this case study can be explained by the contact hypothesis. This theory states that increased intergroup contact has the power to decrease intergroup conflict and prejudice by bringing people from different groups together (Allport et al., 1954; Pettigrew & Tropp, 2006). The contact hypothesis has been identified as one of the key theoretical perspectives on interprofessional education (IPE; Carpenter & Dickinson, 2016; Thistlethwaite, 2012). The basic assumption is that we all derive our identity from the membership of social groups (e.g., profession), and we perceive members of our group (in-group) more positively than members of other groups (out-group; Tajfel & Turner, 1986). Therefore the goal of an ISEP is to bring together members from different social groups to have common experiences that will reduce prejudice against the out-group and improve collaboration. However, simply putting together members of different professions is not enough. The literature highlights necessary conditions for IPE to positively affecton collaborative practice, namely equal status, cooperation, a common goal and institutional support (Allport et al., 1954; Hewstone & Brown, 1986). The case presented in this study provides some first-hand experience of how these necessary conditions can be implemented so that an ISEP will succeed.

Different professions should have equal status in the ISEP. This includes how training sessions are planned (e.g., giving all professional groups equal time during debriefings to reflect). Also the members of the simulation faculty need to represent all professional groups equally with equal sayings in curriculum design. Further, different professional groups should work on a common goal and cooperate. This can be achieved by designing simulation scenarios where the teams have to collaborate. Each member of a professional group contributes to the outcome in equal parts with his or her expertise. In addition, training scenarios need to be challenging but not too difficult. The complexity of the scenarios has to correspond to the team’s skills. Training scenarios that are too difficult will result in frustration and will not have the desired effect. Shared experiences of success are essential and further forges bonds between members of different groups. Finally, a successful ISEP needs institutional support. Authorities and hospital management need to demonstrate their support for the ISEP and interprofessional collaboration in general (Carpenter & Dickinson, 2016). The results of this study highlight the importance of that point in Step 1. One of the change leaders’ very first activities was convincing hospital management to support an ISEP.

Limitations and future directions

In order to accurately understand the results of this study, it is important to recognize several limitations. The qualitative approach provides rich data on how the ISEP has been implemented. However, a change process always has to deal with unique and specific challenges specific to the organization, local regulations or culture. Therefore this study is not proposing one way to go. Instead it aims to provide lessons learned from a successful case that hopefully will inform future change plans. Also the ISEP implemented in a medium-sized non-academic hospital might have been an advantage. In larger organizations, processes might be more rigid, and due to the size, it might be more challenging to implement a change hospital-wide. Further, this study does not provide quantitative data about the impact of the ISEP on culture. The results are mainly based on self-report data, and a hindsight bias cannot be ruled out (Roese & Vohs, 2012). Future studies are encouraged to apply a pre-posttest design assessing cultural variables to provide more substantial evidence about the effects an ISEP has on collaboration and organizational culture. Participative observation was used – a method commonly used in case studies (Yin, 2017). This allowed to get an in-depth understanding of organizational processes. However a bias cannot be ruled out since the researcher was directly involved in some simulation activities. Finally, Kotter’s model has been used as a framework to analyze the data (Kotter, 2012). While this is the most prominent model in the change literature, it is not without criticism (By, 2005). In general, there is very little evidence in support of all existing change theories and approaches (By, 2005; Guimaraes & Armstrong, 1998). However, the framework used in this manuscript was a suitable approach for the purpose of this study.

Despite these limitations, this study provided valuable first-hand insight into the implementation process of a successful ISEP institutionalized over six years. Hopefully, this study will inspire future change efforts to adopt the outlined strategies to their own specific needs to drive change.

Conclusion

Change management has been defined as “the process of continually renewing an organization’s direction, structure, and capabilities to serve the ever-changing needs of external and internal customers.” (Moran & Brightman, 2001). Healthcare organizations are faced with changing needs from patients, new technology or regulations. In order to meet these challenges, hospitals need to push for more patient-centered collaborative practice (Kumar et al., 2018; Suter et al., 2009). In most hospitals, the true potential of interprofessional education is not yet fully exploited. ISEPs – if implemented effectively – provide powerful opportunities to span boundaries between professional groups, foster collaboration, and eventually improve patient care.

Declaration of interests

The author received a one-time honorarium for teaching on a two-day advanced debriefing course at the hospital that was the subject in this case study.  The author alone is responsible for the content and writing of this article.

Ethics approval

This project has been approved by the ethics committee of ETH Zurich (EK 2020-N-85).

Acknowledgments

The author thanks Walter Eppich  and Tanja Manser for their insights on the topic and a critical review of the manuscript. The author also thanks the interview partners and hospital for sharing their experiences and providing access to the organization, documents and all relevant information about the implementation of the simulation program.

Data availability statement

Data includes qualitative interviews, observation data and documents in German. Data is available upon reasonable request from the author.

Additional information

Notes on contributors

Jan B. Schmutz

J. B. Schmutz, PhD is a senior researcher and lecturer at the Department of Management, Technology and Economics, ETH Zurich, Zurich, Switzerland.