Construction and validation of an interprofessional simulated scenario for the identification and management of sepsisABSTRACT
Objective: Build and validate a realistic interprofessional simulation scenario for the identification and management of sepsis by doctors and nurses.
Method: Methodological study developed in 2021, in two stages: construction of the guide and content validation by expert judges; and development of the simulation and validation of the scenario by doctors and nurses. 15 specialists participated in the research in the first stage and eight care professionals in the second stage. 0.8 was adopted as a parameter for the Content Validation Index (CVI).
Results: The scenario guide addressed nosocomial sepsis with an abdominal focus in an adult patient and its validation obtained a total CVI of 0.97. All areas evaluated in the simulation scenario obtained agreement indices greater than 0.8.
Conclusion: The construction and validation of the guide allowed the elaboration of guiding material for the development of an interprofessional simulated scenario, whose execution and validation process demonstrated its suitability in approaching the identification and management of sepsis by doctors and nurses. It is recommended to carry out future research evaluating its applicability to other situational contexts.
Descriptors:
Simulation training; Interprofessional education; Validation study; Sepsis; Nursing
RESUMO
Objetivo: Construir e validar um cenário de simulação realística interprofissional de identificação e manejo da sepse por médicos e enfermeiros.
Método: Estudo metodológico desenvolvido em 2021, dividido em duas etapas: construção do roteiro e validação do conteúdo por juízes especialistas; e desenvolvimento da simulação e validação do cenário por médicos e enfermeiros. Participaram da pesquisa 15 especialistas na primeira etapa e oito profissionais assistenciais na segunda etapa. Adotou-se 0,8 como parâmetro do Índice de Validação de Conteúdo (IVC).
Resultados: O roteiro do cenário abordou a sepse nosocomial com foco abdominal em paciente adulto e sua validação obteve IVC total de 0,97. Todas as áreas avaliadas no cenário de simulação obtiveram índices de concordância superiores a 0,8.
Conclusão: A construção e validação do roteiro permitiu a elaboração de material norteador para o desenvolvimento de cenário simulado interprofissional, cujo processo de execução e validação demonstrou a sua adequabilidade na abordagem da identificação e manejo da sepse por médicos e enfermeiros. Recomenda-se realizar pesquisas futuras avaliando sua aplicabilidade a outros contextos situacionais.
Descritores:
Treinamento por simulação; Educação interprofissional; Estudo de validação; Sepse; Enfermagem
RESUMEN
Objetivo: Construya y valide un escenario de simulación interprofesional realista para la identificación y el tratamiento de la sepsis por parte de médicos y enfermeras.
Método: Estudio metodológico desarrollado en 2021, dividido en dos etapas: construcción del guion y validación de contenido por jueces expertos; y desarrollo de la simulación y validación del escenario por parte de médicos y enfermeras. En la investigación participaron 15 especialistas en la primera etapa y ocho profesionales asistenciales en la segunda etapa. Se adoptó 0,8 como parámetro para el Índice de Validación de Contenido (CVI).
Resultados: El guión de escenario abordó la sepsis nosocomial con foco abdominal en un paciente adulto y su validación obtuvo un CVI total de 0,97. Todas las áreas evaluadas en el escenario de simulación obtuvieron índices de acuerdo superiores a 0,8.
Conclusión: La construcción y validación del guion permitió la elaboración de material orientador para el desarrollo de un escenario simulado interprofesional, cuyo proceso de ejecución y validación demostró su idoneidad en el abordaje de la identificación y manejo de la sepsis por parte de médicos y enfermeros. Se recomienda realizar futuras investigaciones evaluando su aplicabilidad a otros contextos situacionales.
Descriptores:
Entrenamiento simulado; Educación interprofesional; Sepsis; Estudio de validación; Enfermería
INTRODUCTION
Sepsis is considered a complex organic dysfunction caused by the body's exacerbated response to an infectious process1). In Brazil, in the period 2010-2019, more than one million hospitalizations and 463 thousand deaths from sepsis were recorded2; at a global level, the incidence was approximately 48.9 million cases and 11 million deaths in 2017 alone3. Identifying a septic condition is a complex process that requires up-to-date healthcare teams capable of intervening in a timely manner1.
The Latin American Sepsis Institute (ILAS) currently recommends the use of the Sequential Organ Failure Assessment (SOFA) tool to identify probable septic conditions4. The function of the tool is to evaluate the performance of the body's different systems and assign them a score. To achieve this, the following parameters are considered: systolic blood pressure (SBP) <100 mmHg; respiratory rate >22 bpm; and Glasgow <15, in which each variable is equivalent to one point and scores ≥ 2 indicate a higher risk of mortality4.
Although the parameters of the Systemic Inflammatory Response Syndrome (SIRS) are no longer part of the current criteria for defining sepsis, they remain of clinical value for identifying patients with infection and potential risk of progression to a septic condition; therefore, they are still used by health institutions4. The parameters considered are: core temperature, or axillary equivalent, >38.3ºC or <36ºC; heart rate >90 bpm; respiratory rate >20 rpm or partial pressure of carbon dioxide <32 mmHg; total leukocytes >12,000/mm³ or <4,000/mm³ or left shift >10%, in which the presence of at least two positive parameters configures SIRS4.
Regardless of the tool used, it is essential that healthcare institutions invest in structuring initiatives capable of stimulating the continuous updating of their employees, since the ability to identify and intervene early in a septic condition is directly proportional to its clinical outcome4. The use of realistic simulation techniques can contribute in this regard, as it provides spaces for training and reflection in a safe and controlled environment, excluding the risks inherent in the development of skills in a real context and enabling the minimization of feelings of fear and anxiety when facing critical situations in clinical practice5,6.
Conceptually, realistic simulation is a technique that reproduces aspects of the real world through immersion in a practical scenario7; although its implementation does not necessarily depend on major technological contributions, it is developed with the greatest possible fidelity to reality8. According to the good practices recommended by the International Nursing Association for Clinical Simulation and Learning (INACSL), the technique should include the stages of briefing, scenario and debriefing9. The briefing is the moment that precedes the simulation, in which the participants receive the necessary guidance about the activity. The scenario, also called design or scene, is the actual simulation. Debriefing, in turn, occurs immediately after the simulation, when a guided reflection and discussion takes place on the conduct taken during the simulation9,10.
The use of the realistic simulation technique as a health education strategy allows the sharing of knowledge between different professional occupations, in order to exercise effective communication and improve the understanding of clinical practice issues, in addition to stimulating greater synergy between teams11,12. Such aspects are crucial when seeking to work on complex issues arising from the health context, reinforcing the attributes that govern work in an interprofessional team13. Based on this understanding, the present study aimed to build and validate a realistic interprofessional simulation scenario for the identification and management of sepsis by physicians and nurses.
METHOD
This is a methodological study14, developed in two stages: 1) construction of a guide and validation of its content by expert judges and 2) development of the simulation and validation of the scenario by doctors and nurses. The research was carried out in a realistic simulation center of a hospital institution in the southern region of Brazil in 2021.
There is no consensus in the literature regarding the minimum number of expert judges to compose samples in validation studies. Therefore, the characteristics of the data collection instruments, training, qualification and availability to participate were taken into consideration as primary foundations for establishing the minimum number of samples in the two stages of the study15.
This study followed the guidelines of the General Data Protection Law(16) and Resolution No. 466/12(17) by providing a Free and Informed Consent Form (FICF) to all participants, which contained the objectives of the study, probable benefits and risks involved in participation, the guarantee of anonymity and the freedom to decline participation at any time. The research was submitted to the Research Ethics Committee of the institution where the study was carried out and was approved under Protocol no. 4,577,927 and Certificate of Presentation of Ethical Appreciation (CAAE) no. 42741520.8.0000.5335, in March 2021.
Stage 1 - Construction of the guide and content validation
The guide content was constructed through research in the literature and in health institution protocols developed according to the levels of evidence proposed by the Latin American Sepsis Institute (ILAS) (4 and the Surviving Sepsis Campaign (SSC)1. The structure of the guide followed good practice guidelines for the development of guides1,18.
The theme defined was nosocomial sepsis with abdominal focus and the predictive parameters of Systemic Inflammatory Response Syndrome (SIRS) were used, in accordance with the current protocol at the institution where the research was carried out. The guide’s main objective was to identify and manage nosocomial sepsis, while the secondary objectives were to identify the parameters of Systemic Inflammatory Response Syndrome (SIRS), initiation of a sepsis protocol and management of the patient until the appropriate antimicrobial therapy is established.
The expert judges were selected by convenience sampling14 and the minimum number established was ten participants15). The judges were found through research in the area of activity specified in the Lattes Curriculum. The inclusion criteria used were having a higher education degree in medicine or nursing; a specialization degree, master's degree or doctorate; and experience in simulation, health education or hospital infection control. Invitation letters were sent by email to 30 expert judges; and for those who consented to participate, the ICF and the assessment instrument were sent. This collection stage took place between July and August 2021.
For data collection, an online instrument with a Likert-type scale was developed, consisting of 21 items distributed in three areas: objectives, structure/presentation and relevance, in which 1=No, 2=Maybe and 3=Yes; There was also space for the inclusion of comments and suggestions. For data analysis, only answers 3=Yes were considered15.
Stage 2 - Development of the simulation and validation of the scenario
The planning and development of the simulation followed the guidelines of the International Nursing Association for Clinical Simulation and Learning9 and its organization had the following structure: five-minute briefing, 15-minute simulation and 20-minute debriefing. The simulation center where the research was carried out had a high-fidelity mannequin, multi-parameter monitor and tablet to control the simulator's actions. Observation of the simulation was carried out through a room attached to the simulation environment, which had a mirrored wall and an audio reception system.
The simulation scenario was facilitated by one of the authors of the research, trained in realistic simulation instruction and who was a nurse hired by the Institution and was authorized to access the Laboratory due to restrictions imposed during the pandemic. This nurse worked in the Hospital Infection Control Service, without working directly with the professionals participating in the simulation scenario. The facilitator controlled the mannequin's responses through a control room equipped with a mirrored wall and an audio and video system.
Convenience sampling was used14 and the minimum number of eight professionals was established15. The selection criteria included being a clinical nurse who performs his/her activities in clinical and surgical inpatient units or being an internal medicine resident physician, as well as having completed previous training on sepsis through the institutional continuing education program. Invitations were sent by email to eight professionals belonging to the institution's staff and working in units that provide care for patients discharged from the Emergency Service. After accepting to participate in the research, at the simulation center, participants were informed about the purpose of the activity and then FICF was read, delivered and signed. The simulation scenario took place in September 2021.
The Simulation Design Scale, developed by the National League for Nursing (NLN) and validated for Portuguese19, was used for data collection. Its purpose is to enable the assessment of the structuring of realistic simulation scenarios. This is a Likert-type scale and consists of 20 items, distributed in five areas: objectives/information”; “support”; “problem solving”; “feedback/reflection”; and “realism”, in which 1=strongly disagree, 2=disagree, 3=neutral, 4=agree and 5=strongly agree. For data analysis, only the answers 4=agree and 5=strongly agree were considered15.
During data collection, given the health recommendations in force at the research institution due to the COVID-19 pandemic, access to shared teaching areas, as well as the number of simultaneous participants, were restricted. At that time, the Specialized Service in Safety Engineering and Occupational Medicine (SESMT) and the Hospital Infection Control (CIH) established a restriction to a maximum of four participants when carrying out realistic simulations, as well as the use of personal protective equipment and physical distancing.
To analyze the data collected in stages 1 and 2 of the research, the Content Validation Index (CVI) was used, which expresses the proportion of agreement between experts on certain aspects of an instrument15. The CVI calculation is carried out by adding the number of responses considered in the evaluation, followed by dividing the result by the total number of respondents. The minimum agreement value established in this research was 0.80, respecting the recommendations for studies with six or more expert judges15.
RESULTS
Stage 1 - Construction of the guide and content validation
The structure of the guide included a detailed description of the necessary materials, ambiance, simulation dynamics and specific actions expected according to the participating professional occupation (Chart 1). The clinical case of the simulation was a 49-year-old male patient weighing 75 kg, in the postoperative period of colectomy for diverticulitis, admitted for 10 days to a surgical inpatient unit. The patient had acute abdominal pain, purulent drainage oozing from a surgical wound, axillary temperature of 39ºC, change in bowel habits and no urine output for the past eight hours, with no history of allergies.
Fifteen of the invited participants agreed to participate in the study, of which 10 (67%) were nurses and five (33%) were doctors. Regarding academic qualifications, two (13%) had a doctorate; three (20%) had a master's degree; and seven (47%) had a lato sensu specialization or medical residency. Five (33%) stated that they had experience in hospital infection control, four (26%) in health education and three (20%) in realistic simulation. Two specialists (13%) worked in hospital infection control services and one (7%) in health education. All (100%) had institutional links with different hospital or teaching institutions in the southern region of Brazil and declared that they were aware of the guidelines for identifying and managing sepsis, in addition to the care protocols on the subject.
The guide obtained a total CVI of 0.97 (Table 1). The “objectives” area obtained a CVI of 0.94, with the lowest agreement rates related to the scientific nature of the information and scope of the content, both with 0.86. The “structure/presentation” area obtained a CVI of 0.98, with the lowest agreement values related to the items referring to the attractions of the scenario for maintaining the attention of participants and the evidence provided for the timely identification and management of sepsis, both with 0.93. The “relevance” area obtained maximum agreement among experts, with CVI 1.0.
The experts’ comments and/or suggestions were organized according to the occupation in which they were made (Chart 2).
Stage 2 - Development of the simulation and validation of the scenario
Four (50%) professionals with a nursing degree and four (50%) professionals with a medical degree participated in this stage. All (100%) denied having previous experience in simulation at any level of education. Two meetings were held to develop the simulation and the participants were organized into two groups: one of actors and the other of observers. Each simulation had a doctor and a nurse acting and a doctor and a nurse as observers, with the order defined by the professionals themselves.
After the definition of the groups, the briefing stage for the acting participants would begin, with the presentation of the physical structure of the scenario and the clinical case, which was limited to the patient's current state, vital signs and context. The observers followed the explanations in the room attached to the simulation environment. At the end of the simulation, all participants gathered in the observation room, together with the facilitator, and the debriefing stage began. After the debriefing, the professionals who participated as actors answered the Simulation Design Scale.
The Simulation Design Scale obtained a total CVI of 0.98 (Table 2). The areas “objectives/information”, “support”, “problem solving” and “feedback/reflection” obtained maximum agreement among professionals, with a CVI of 1.0. The “realism” area obtained a CVI of 0.93. In the debriefing, participants addressed some counterpoints between the simulation and the reality experienced by them in their daily contexts, such as weaknesses in the identification of SIRS parameters by nursing technicians and in the identification and management of sepsis by non-clinical medical teams.
DISCUSSION
The challenges inherent in the context of health care require the development and maintenance of interprofessional and permanently qualified care teams, capable of acting in the most diverse situations, making it essential to structure permanent education strategies that stimulate continuous improvement and the development of different skills11,13. Therefore, active methodologies, such as realistic simulation, can contribute to the improvement of technical and non-technical skills in a safe and controlled context. However, the development of these methodologies requires methodological rigor in order to achieve their educational purposes11,20,21. Therefore, it is essential not only to develop simulation scenarios, but also to validate them with experts and the target audience, in order to guarantee their integrity and alignment with best practices22-24.
In validating the simulation guide for this research, the agreement rates closest to the established cut-off value are related to the scientific subsidies used and the scope of the scenario employed. Such evaluations are based on the divergence between the currently recommended sepsis diagnostic methods and the methods used as a basis for constructing the guide. Although the current guidelines of the Latin American Institute of Sepsis (ILAS) recommend the use of the Sequential Organ Failure Assessment (SOFA) (4, guided by the prediction of mortality, the health institution where the research was carried out uses the parameters of the Systemic Inflammatory Response Syndrome (SIRS) as a protocol for diagnosing sepsis. Therefore, it was necessary to adapt the theoretical support used in the development of the simulation guide, to develop the technique as close as possible to the reality experienced by the participating professionals25.
In validating the structure and presentation of the simulation guide, the experts were unanimous in evaluating the guide as capable of favoring the construction and sharing of interprofessional knowledge. This corroborates the importance of planning considering the environment, equipment and inputs available, as well as the construction of the patient's clinical history, enabling physical assessment, skills training, critical thinking and handling of the simulated situation23,26.
In the process of validating the simulation scenario, its objectives and the information provided during the development of the technique were agreed upon by all participants, who stated that the scenario was coherent, clear and provided all the necessary guidance in line with the proposed objectives. Furthermore, participants felt supported during the simulation, which favored their learning process and encouraged them to explore all the possibilities of the scenario, which was assessed as appropriate to the level of knowledge and skills of the professionals. Such results are similar to those in the literature regarding the use of simulation in health education, which evaluate the technique as a tool that enables the expansion of the relationship between theory and practice, optimizing skills and abilities and, thus, consolidating knowledge and increasing the satisfaction levels of the participants27,28.
In realistic simulation, debriefing is a fundamental step in the learning process, as it is a moment of reflection that explores the emotions and clinical reasoning experienced during the simulation29. Therefore, planning and structuring this stage is essential, aiming to provide feedback to participants through an approach that enables the perception of collective and individual actions, with a view to developing and improving skills within a safe and non-judgmental context.
The ability of simulation to reproduce reality is one of the aspects that favors immersion in the activity28,30. However, there may be inconsistencies between daily reality and that reproduced by the technique. When evaluating the similarity of the scenario to a real situation, there was a perception of low reliability of the simulation, the background of which were the divergences in the therapeutic possibilities available in the simulation and those used in the daily routine of professionals in their work units, exposing the participants' lack of knowledge of the current institutional protocol for the management of sepsis.
A limitation of this study is the fact that the simulation was carried out only with nursing and medical professionals, and it is possible to expand it to other professional occupations. Another aspect that deserves consideration is the fact that the research was carried out with experts geographically restricted to the southern region of Brazil. Thus, as a recommendation for future studies, it is suggested that the guide for the realistic simulation scenario be planned and validated, encompassing the other professional occupations involved in the sepsis diagnosis and management process, in addition to the geographical expansion of the specialists included in the sample. It should be noted that during the execution of this study there were restrictions on access to the simulation laboratory due to the COVID-19 pandemic, which made it impossible for another professional to participate as a facilitator.
CONCLUSION
The construction and validation of the guide allowed the preparation of material that leads the development of an interprofessional simulated scenario. The implementation and validation process, in turn, demonstrated its suitability in approaching the identification and management of sepsis by physicians and nurses. However, further studies are needed to assess its applicability to other situational contexts.
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