From in-situ simulation to beyond : improving paediatric trauma care

Abstract: Background: In-situ-simulation (ISS) has been adopted across the globe as an educational tool to enhance the quality of care provided to severely injured children. As an intervention that trains individuals where they work, when they work, and with whom they work, ISS is well positioned to overcome many of the challenges of paediatric trauma care. Recent reviews however indicate that ISS has yet to reach its potential. Barriers to progress include the lack of an effective way to disseminate learning post ISS across organisations. This is compounded by an incomplete understanding of the complexity of paediatric trauma care and a lack of definition of what constitutes of high-quality care and how to measure it. Multi-level empirical studies at the individual, team, and organisational levels, extending from the pedagogy of ISS may inform future theoretical and research directions. Resilience engineering (RE) has concepts that embrace complexity, focuses on context, and explores human adaptations resonating across complex systems. As such, RE may illuminate a path and stimulate ideas of how to enhance multi-level learning in both simulations and real-life. Aim: The aim of this thesis is twofold: To deepen the understanding of the context of acute stabilisation of severely injured children from a multilevel perspective of individuals, teams, and organisations. To apply this understanding to the design of simulation-based interventions to improve paediatric trauma care. Methods: This thesis uses a series of different approaches to reach its aims. These include phenomenography, Design-Based Research (DBR), Functional Resonance Analytical Methodology (FRAM), and thematic analysis. The studies were situated in a simulated setting using ISS, and in the real life setting of a mass casualty incident. Study I explored the relationships and hierarchy between the contrasting perceptions of quality and evaluation of quality in the context of the stabilisation of a severely injured child, using phenomenography. Thirty-six individuals, six trauma team members of all disciplines and roles and six administrators, two from the executive board, two from administrator director positions and two clinical directors in each of three hospitals took part in semistructured interviews. Study II employed an iterative DBR approach to design, test, and re-design a tool to feed back the performances at individual, team, and system levels during ISSs across three hospital organisations. Semi structured interviews and other data were collated from three hospitals. Study III explored the novel modification of FRAM and its application to ISS for the first time. Empirical data from twenty ISSs was modelled to permit the visualisation of human adaptations as they propagated across the complex systems of paediatric trauma stabilisations. Study IV was situated in the real world. A diverse sample of forty members of staff from a paediatric major trauma center, were interviewed in the immediate aftermath of a mass casualty incident. A thematic analysis provided insights on how innovations and adaptations catalysed the resilient response of the hospital during the incident. Findings: Study I indicated a novel framework for the joint understanding of what quality means in the context of the acute stabilisation of traumatically injured children, and how to measure this. This shared framework from the perspective of trauma team members and administrators highlighted system, team, process, individual, data and culture, as delineating quality. A hierarchy of perspectives was evident from the simple, system, team, process to the complex, with all elements of the framework added. Great emphasis was placed upon team working, although this is not currently measured in clinical practice. The findings redefined both classical and current thinking of quality as a key and attainable measure of human performance in the center of a complex interconnected system of care provision. Study II highlighted the challenges of disseminating ISS learning across organisations to impact change using a tool to capture and promote reflection post the debrief. Conducting standardised ISSs one year apart, with such a tool, did not improve performance in the three hospitals studied. The iterative design approach embedded in the study highlighted the need for a performance analysis tool to provide knowledge transfer in an understandable and contextualised format. This study also illuminated theoretical conceptions and directions for empirical studies to explore how learning post the ISS debrief can overcome the complexity of multilevel learning in hospitals. One such theoretical consideration was how to embrace complexity as had been conceptualised in the science of resilience engineering. The guiding principle of Study II was to capture and disseminate not only that that did not go well but as much as possible of that which went well also. The study illuminated how Safety I and Safety-II information can be disseminated. The findings of Study III indicated that it was possible to model and visualise how things went and not so well using ISS in the context of paediatric trauma care. Using human adaptations as a base unit of variability, FRAM modelled comparisons of “work as imagined” and “work as done”, permitted visualisations of the propagation of variability across the complexity of trauma care systems. The case series of variations and the added value to ISS of observing and reflecting on the mundane normal adaptations of when things go well, and how this may promote second order learning was demonstrated. The findings of Studies II and III, the position of humans in the center of a complex sociotechnical system continually adapting to the environmental ecology in which they found themselves, lead to theoretical conceptions of how knowledge post ISS may disseminate across organisations in the face of complexity. The findings of this thesis transitioned from the simulated world to the real world of a mass casualty incident. In doing so, the unit of analysis remained the same that of human adaptations. In this case the adaptations to the hospital major incident plan. Analysis through the lens of resilience engineering, identified five themes of 1. team-working, 2. psychological support, 3. reconfiguration of infrastructure, 4. information and technology workarounds and 5. the preservation of key critical safety functions. Conclusion: By extending the pedagogy of ISS into RE, this thesis deepens the understanding of the context of acute stabilisation of severely injured children from a multilevel perspective of individuals, teams, and organisations. The complexity of the system of paediatric trauma care provision is analysed and described in detail from several perspectives. Quality of care is delineated and positioned as a key outcome measure across organisational levels, that can be measured in future studies of ISS & RE. The depth of the complexity of the clinical complex adaptive system of trauma care is described. However, the challenges posed by a second complex system, that of disseminating knowledge across the multiple levels of an organisation to improve care is also illuminated. The two interventions described in this thesis, the FACT report tool, and the SWI-FRAM approach both have the potential to improve future paediatric trauma care. The iterative design and re-design of the FACT tool indicated the potential of a performance analysis approach to transferring Safety-I and Safety-II information across organisational levels. The SWI-FRAM resilience engineering approach has illuminated human adaptation as a visible unit of variation for analysis. This approach provides the opportunity to learn not only from errors but also mundane often unnoticed adaptations that improve care. The development of these tools has also afforded the opportunity to consider theoretical concepts of how to empirically study adaptations of care as units of analysis and the transfer of knowledge across organisations as they evolve.