*3.2. SMB*

The multidisciplinary champion team at SMB was comprised of a neonatologist, clinical nurse specialist, a NICU supervisor and respiratory therapist. A total of 15 HCPs completed the online video training. The team developed a variety of custom NICU scenarios based on actual code events that occurred in Labor and Delivery and in the NICU. Beginning in July 2018, the team began video recording of simulations and debriefings. A timeline of the progression of the project is depicted in Figure 4. Simulation and debriefing events were held monthly for both day shift and night shift. Neonatologists and neonatal nurse practitioners were encouraged to participate in at least one simulation. Initial survey results demonstrated overwhelmingly positive results from HCPs who participated in these simulation and debriefing events. Forty-two HCPs responded to the initial survey; nurses and respiratory therapists represented 85% of the respondents. These respondents had moderate level of experience in their specialty (14.0 years + 11.7). Results demonstrated that participants had increased confidence in communicating during an emergency, increased ability to function as an essential team member during a code, and increased ability to voice a concern during a critical situation (Appendix B).

**Figure 4.** SMB Simulating Success project timeline.

Early in the implementation phase, the core team realized the need for additional simulation/debriefing facilitators and champions. The core team used a "train-the-trainer" approach to onboard additional facilitators. The train-the-trainer approach was not su fficient—additional preparation specific to e ffective debriefing was necessary. NICU nurses and respiratory therapists, mostly NRP instructors and advanced life support nurses who attend high-risk deliveries, volunteered to participate as champions. They each completed the CAPE online training course, "Strategies for Debriefing Health Care Scenarios".

### 3.2.1. SMART Aim #1

SMART Aim #1: Increase participation. A total of 100% of nurses (*n* = 205) and respiratory therapists (*n* = 40) participated in at least two simulation events within the first year. Participation in a minimum number of simulation and debriefing events were added to the annual competency requirements for both nurses and respiratory therapists which enabled achievement of this SMART aim. Throughout the 18 month participation in the collaborative, SMB utilized the PDSA process for the quality improvement framework.

### 3.2.2. Lessons Learned

The use of video to enhance CAPE's debriefing techniques allowed everyone to speak up and recognize areas for improvement. The debriefing technique which was new to SMB involved a flipped approach where the debriefers ask prompting questions or statements to elicit discussion from the participants thereby allowing the participants to identify strengths and opportunities for themselves. As a team, they critique their own performance and identify behaviors that they should reinforce and opportunities for improvement. Building effective, realistic scenarios using real-life events that have occurred at SMB helped staff identify and intervene with changing patient conditions. Strategies were identified to increase interdisciplinary team participation including adaptations to various provider schedules.

Effective debriefing has been key for successful learning. Some focus areas identified were the need for increased communication, consistently designating a team leader, knowledge of when to call for help and closed loop communication. Less experienced staff, especially on night shift, have expressed an increased confidence in ability to respond during an emergency. They have also increased their ability to recognize patient deterioration through simulation. Staff comments have been very positive. For example, staff comments include "This is the best mock code I have ever participated in; it is so realistic"; "This is such a grea<sup>t</sup> learning environment"; and "I really like how realistic this mock code is." In addition to the monthly simulation and debriefing sessions, newly learned debriefing skills have been incorporated into the review and evaluation of video-recorded neonatal resuscitations.

For more than 15 years, the SMB NICU team has used video resuscitation review as an ongoing quality improvement project to improve delivery room resuscitation. Using the debriefing model to discuss areas for improvement identified by the team has been highly effective. This process has proven beneficial in identification of a team leader, effective communication, and delegation of tasks. It has created an atmosphere that focuses more on team processes as opposed to individual performance. Given the technical components of simulation and debriefing (running video equipment, high-fidelity mannequin, and time commitment for set up and tear down), the goal was to have at least two facilitators at each debriefing. After initial experience, three facilitators were found to be ideal: one to direct the scenario and debriefing, one to control the high fidelity simulator, and one that manages the technical aspects of the debriefing with video equipment. In addition, the third person acted as a confederate as needed or as an additional debriefer.
