Collaboration, a type of teamwork aimed at accomplishing a common goal (Hassona & El-Aziz, 2017), is a component of the new American Association of Colleges of Nursing (AACN) essentials for entry-level professional nursing education: "Integrate the roles and responsibilities of healthcare professionals through collaborative practice" (AACN, 2021, p. 41). Much has been written about nurses' collaboration efforts with physicians and other members of the interdisciplinary team; however, there is a paucity of literature regarding intradisciplinary nurse-to-nurse collaboration.
In the clinical setting, it is often critical care nurses who respond to rapid response calls on other units, including obstetrics. There are also occasions when the obstetrical nurse assists in the care of a critically ill pregnant patient in the critical care unit. In nursing education, the focus of each specialty nursing course is for students to learn specific knowledge and skills about that particular area of nursing. The opportunity rarely presents itself for students to collaborate with students in different specialty courses on a single patient care experience. The COVID-19 global pandemic afforded just such an opportunity for baccalaureate nursing students in a small liberal arts university in the southeastern United States. Two seasoned nurse educators developed a pilot simulation experience designed to focus on collaboration between two high-risk nursing specialties: maternal/newborn care and critical care. The simulation ran approximately 16 times during the semester to allow all students in each cohort a chance to complete the scenario.
THE SIMULATION EXPERIENCE
The simulated patient was a 33-week pregnant primigravida who had tested positive for COVID-19. Having both gastrointestinal and respiratory symptoms, this patient was admitted to the critical care unit with increasing oxygen requirements and dehydration. Because of the patient's pregnancy, the patient was on continuous electronic fetal monitoring, therefore requiring the specialized knowledge of maternal/newborn nursing. Laboratory results and admission orders were available in the electronic health record.
In preparation for the simulation, both maternal/newborn and critical care nursing students were assigned an article to read about the clinical course of COVID-19 in pregnancy. Via the electronic health record, they were also given the patient's chart to review, along with a list of medications commonly given to patients with COVID-19. Students were placed in groups of six (three maternal/newborn students and three critical care students) to provide patient care in a multifaceted simulation.
The initial state of the simulated patient was one of a patient on 6 liters of high-flow nasal cannula with oxygen saturations of 87 percent, tachypnea, maternal and fetal tachycardia, decreased fetal heart rate variability, fever, and mild dehydration. Critical care nursing students were expected to recognize and manage maternal issues (tachypnea and hypoxia), and maternal/newborn students were expected to recognize and manage fetal heart rate issues and related causes. Students were given the simulation objectives, and a prebriefing was held to prepare them for the scenario and respond to questions.
Debriefing of the simulation utilized the Debriefing for Meaningful Learning(C) model for enhancing learning in simulation. The use of Socratic questioning as part of this model helps guide students' ability to integrate what they learned in the simulation experience into practice. Debriefing also helps students make adjustments when they encounter a similar situation in practice (Dreifuerst, 2009). Some of the questions asked during the debriefing included the following: 1) What went well for you in this simulation? 2) What would you do differently if you were to encounter this situation again? Why? 3) What challenges did you encounter in the scenario? 4) How did you feel as the simulation played out?
Once students had an opportunity to discuss how they thought the simulation played out, the nurse educators guided the dialog to integrating the experience into future practice. Students were asked to reflect on how their feelings impacted the care they gave the patient. Debriefing also provided an opportunity for the educators to guide the discussion toward how to improve collaboration when faced with similar situations in the clinical environment.
TEACHING MOMENTS
Multi-specialty collaboration was considered to be the main objective of this simulation experience. However, as students debriefed, faculty identified several teaching moments related to feelings of confidence/lack of confidence in interventions, physical discomfort clouding judgment, and "turf wars." The critical care students were a semester ahead of the maternal/newborn students in the nursing curriculum. During the debriefing, more than one critical care student noted that they were willing to try more interventions before calling a physician. These students reported they wanted as much information as possible before contacting the physician. Their actions speak to the students' confidence; these students already had the maternal/newborn content as well as much of the critical care content before taking part in the simulation. The maternal/newborn students were much quicker to call the physician but lacked appropriate assessment data to report to the physician. These students also tended to call the wrong physician; in this case, they called the pulmonologist instead of the obstetrician for obstetrical complications such as preterm contractions.
The maturity level of nursing judgment was observed as well. For example, during the scenario, the patient began to have late decelerations on the fetal heart monitor. In one group, the critical care students wanted to reposition the patient and check the fetal monitor positioning. The maternal/newborn students wanted to go straight to medications. Both cohorts reported difficulty combining the two aspects of nursing knowledge, seemingly lacking the foresight that the point of the simulation was to care for a pregnant patient in critical care. For example, many times ibuprofen is the drug of choice for fevers. However, in the pregnant patient, ibuprofen is contraindicated after 20 weeks. This is a detail that several critical care students had forgotten, but in the majority of simulations, the maternal/newborn students stopped the administration of the drug. These students reported that they felt comfortable speaking up in this situation but felt too intimidated to speak up at other times. For example, some maternal/newborn students wanted to turn the patient to treat late decelerations in the fetal heart rate but were afraid to speak up. When asked why they were intimidated, they reported that they felt that the critical care students were more competent at patient assessments and patient care.
Critical care students also seemed to have a lack of confidence in interventions that would be appropriate for the hypoxic pregnant patient. Even though the scenario began with the patient's oxygen saturation at 87 percent, no critical care student increased the oxygen delivery. If it was done at all, it was suggested by the maternal/newborn students. Maternal/newborn students expressed frustration with the critical care students when they did suggest an increase in oxygen and it was not done.
Another observation made during the collaborative scenario was that physical discomfort can cloud nursing judgment. For several students, this was the first time they had to don full airborne precaution personal protective equipment, and they became overheated within minutes. Nearly all the critical care students remarked about how physical discomfort and actual sweating made it hard for them to think through what should be done. This could be an excuse for poor performance during the simulation, or it could be an actual barrier to critical thinking.
A final observation made during the simulation was that of turf wars. Critical care students remarked that sometimes they knew that what the maternal/newborn students were doing was wrong, but they did not want to speak up because they did not want to seem like they were "superior." On the other hand, the maternal/newborn students reported that in some instances when they spoke up, the critical care students did not listen to them. Other critical care students reported that they felt "safer" having the maternal/newborn students there because they had forgotten some of the maternal/newborn material. This provided a teaching moment where students were reminded of the joint responsibility they share when providing care for a pregnant patient.
Other critical care students expressed feeling threatened when maternal/newborn students asked them to call the provider during the simulation. This could be related to the compartmentalization of students' minds when they successfully complete one specialty course and move on to another. The unwillingness to speak up is likely related to professional maturity. Students in both cohorts had been taught throughout the curriculum to always be patient advocates, and advocacy was emphasized as one of the objectives of the simulation.
FUTURE USE OF MULTISPECIALTY SIMULATION
This simulation experience received positive feedback from the students. Future simulations between cohorts are planned once an old curriculum is phased out and cohorts stabilize. COVID-19 restrictions in clinical led to the need for larger simulation groups, but consideration is being given to decreasing the size of simulation groups in the future. The nurse educators are also aware that they will need to change the simulation scenario as the pandemic ebbs. However, there are many scenarios in which an obstetrical patient would require critical care. Joint debriefing among multispecialty cohorts may encourage nurse-to-nurse collaboration.
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