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      Improving the relational aspects of trauma care through translational simulation

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          Major trauma care is complex and requires individuals and teams to perform together in time critical, high-stakes situations. Scenario-based simulation is well established as a strategy for trauma teamwork improvement, but its role in the relational and cultural aspects of trauma care is less well understood. Relational coordination theory offers a framework through which we aimed to understand the impact of an established trauma simulation programme.


          We studied simulation activities using a narrative survey of trauma providers from anaesthesia, emergency medicine, medical imaging, surgery, trauma service, intensive care, and pre-hospital providers at Gold Coast University Hospital, in conjunction with data from an ethnography. Data analysis was performed using a recursive approach—a simultaneous deductive approach using the relational coordination framework and an inductive analysis.


          Ninety-five of 480 (19.8%) staff completed free-text survey questions on simulation. Deductive analysis of data from these narrative survey results using the RC framework domains identified examples of shared goals, shared knowledge, communication and mutual respect. Two major themes from the inductive analysis—“Behaviour, process and system change” and “Culture and relationships”—aligned closely with findings from the RC analysis, with additional themes of “Personal and team learning” and the “Impact of the simulation experience” identified.


          Our findings suggest that an established trauma simulation programme can have a profound impact on the relational aspects of care and the development of a collaborative culture, with perceived tangible impacts on teamwork behaviours and institutional systems and processes. The RC framework—shared knowledge, shared goals and mutual respect in the context of communication that is timely, accurate, frequent and problem-solving based—can provide a common language for simulation educators to design and debrief simulation exercises that aim to have a translational impact.

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          Most cited references 23

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          A Relational Model of How High-Performance Work Systems Work

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            Establishing a safe container for learning in simulation: the role of the presimulation briefing.

            Summary statement: In the absence of theoretical or empirical agreement on how to establish and maintain engagement in instructor-led health care simulation debriefings, we organize a set of promising practices we have identified in closely related fields and our own work. We argue that certain practices create a psychologically safe context for learning, a so-called safe container. Establishing a safe container, in turn, allows learners to engage actively in simulation plus debriefings despite possible disruptions to that engagement such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes. Establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a "fiction contract" with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety. As instructors collaborate with learners to perform these practices, consistency between what instructors say and do may also impact learners' engagement.
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              In situ simulation: detection of safety threats and teamwork training in a high risk emergency department.

              Implement and demonstrate feasibility of in situ simulations to identify latent safety threats (LSTs) at a higher rate than lab-based training, and reinforce teamwork training in a paediatric emergency department (ED). Multidisciplinary healthcare providers responded to critical simulated patients in an urban ED during all shifts. Unannounced in situ simulations were limited to 10 min of simulation and 10 min of debriefing, and were video recorded. A standardised debriefing template was used to assess LSTs. The primary outcome measure was the number and type of LSTs identified during the simulations. Secondary measures included: participants' assessment of impact on patient care and value to participants. Blinded video review using a modified Anaesthetists Non-Technical Skills scale was used to assess team behaviours. 218 healthcare providers responded to 90 in situ simulations conducted over 1 year. A total of 73 LSTs were identified; a rate of one every 1.2 simulations performed. In situ simulations were cancelled at a rate of 28% initially, but the cancellation rate decreased as training matured. Examples of threats identified include malfunctioning equipment and knowledge gaps concerning role responsibilities. 78% of participants rated the simulations as extremely valuable or valuable, while only 5% rated the simulation as having little or no value. Of those responding to a postsimulation survey, 77% reported little or no clinical impact. Video recordings did not indicate changes in non-technical skills during this time. In situ simulation is a practical method for the detection of LSTs and to reinforce team training behaviours. Embedding in situ simulation as a routine expectation positively affected operations and the safety climate in a high risk clinical setting.

                Author and article information

                Adv Simul (Lond)
                Adv Simul (Lond)
                Advances in Simulation
                BioMed Central (London )
                21 May 2019
                21 May 2019
                : 4
                [1 ]ISNI 0000 0004 0405 3820, GRID grid.1033.1, Faculty of Health Science and Medicine, , Bond University, ; Robina, QLD Australia
                [2 ]ISNI 0000 0004 0625 9072, GRID grid.413154.6, Gold Coast Hospital and Health Service, ; Southport, QLD Australia
                [3 ]ISNI 0000 0004 1936 8331, GRID grid.410356.5, Queen’s University, ; Kingston, ON Canada
                [4 ]ISNI 0000 0004 0625 9072, GRID grid.413154.6, Emergency Department, , Gold Coast Hospital and Health Service, ; Southport, QLD Australia
                [5 ]ISNI 0000 0004 0625 9072, GRID grid.413154.6, Simulation Service, , Gold Coast Hospital and Health Service, ; Southport, QLD Australia
                © The Author(s) 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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                © The Author(s) 2019

                culture, ethnography, simulation, trauma care, teamwork


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