Table 3 Themes with representative quotes

Changed conversation during the debriefing

Before the implementation of guidelines

The physician facilitator talks about how one can be hesitant to administer intramuscular epinephrine and discusses the distinction between an anaphylactic reaction and an allergic reaction. Then they ask the resident who was team leader in the scenario what her reasoning process was and she answers. The physician facilitator starts a discussion about oxygen delivery, nurses explain what they have access to and describe the tools they have available. (Observation Pre-implementation Session 5)

A participant brings up noticing a discrepancy between the medication dose initially ordered and eventually given (due to two different physicians giving orders, though the participant does not mention it). The participant says: “Maybe I should have said something.” The nurse facilitator says that speaking up is definitely useful, but there is no discussion of why the participant did not speak up. (Observation Pre-implementation Session 2)

After the implementation of guidelines

“I think sometimes it gets into like very teachy, especially with, depending on the residents that are on, they ask a lot of clinical questions with the physicians. So sometimes this [the guidelines] helps kind of say, “Okay, we can talk about this, but not right now. We're going to focus on these points right now with the whole team" (Interview 1, Nurse Facilitator)

The physician facilitator gives feedback about the interactions between the bedside nurse and resident in the scenario. She says the resident was reasoning out loud, the bedside nurse offered suggestions, so she asks why they did so. The bedside nurse says he was just looking at what was happening, recommended things he was sure of. The physician facilitator asks the bedside nurse if there is anything that made him feel safe to make suggestions. He hesitates, then says “it was just the way that we were talking to each other, it didn’t feel like, as if he’s coming into the picture… And just thinking about past actual codes, where you feel like it’s an inconvenience that the code is happening or that you called the doctor. Just in this dynamic, in this specific scenario, I felt comfortable to say ok, this is what is going on.” (Observation Post-implementation Session 5)

Nurse facilitator talks about power and hierarchy, uses her own words and gives examples of how to create collaborative environments and speak up. (Observation Post-implementation Session 1)

[…] “bringing attention to the power and hierarchy actually has been really useful in my opinion. People have had multiple opportunities to bring that up in a really organic way because it comes up every single time. Like someone being hesitant to voice their opinion. And we're like, all right, let's unpack this, let's talk about why. Even though the script feels kind of stiff when you're doing it at first, the content that comes up naturally out of mock code just leads you to go into that a lot more naturally.” (Interview 9, Nurse Facilitator)

Nurse observer: “Can I just thank you, and everybody actually, for acknowledging the power dynamics. Because again, in this group, this is a very strong group of nurses, and I know, I’ve been working with these guys [points to the medical team] for three days and I know the resident from before, so I think it’s not necessarily at play in this room, but it will be in real life. And so I think it’s really important to acknowledge that and to talk about it because that will help to bring that down outside and in the real world.” (Observation Post-implementation Session 4)

“And [the guidelines] gives good probing questions, I saw RN Facilitator 7 used it to ask about teamwork and power and dynamics, which I don't know if we would feel as comfortable talking about without having those words on a paper to read.” (Interview 7, MD Facilitator)

Improved interprofessional learning

Before the implementation of guidelines

The physician facilitator starts a discussion about oxygen delivery. Nurse participants explain what they can typically do, go through the emergency equipment they have access to give oxygen to patients. The nurse facilitator adds more specifics about what nurses are allowed to do and what they should know. (Observation Pre-implementation Session 5)

After the implementation of guidelines

The physician facilitator says that in this scenario, what was going on with the patient was less clear than in the first scenario, so how do people feel about teamwork and hierarchy? The senior resident answers that in situations like that she always sees the bedside and charge nurses as her main resources, so she turns to them for questions about the patient and if she is not sure what to do. She says: “Often, the nurses will say ‘are you sure?’ and I’m like, ‘no!’” (…) The nurse facilitator says that she also noticed that the senior resident asked the room for ideas and suggestions, talks about how people often expect the physician to know everything but asking the room was good to get input and elicit speaking up from team members. (Observation Post-implementation Session 5)

The resident talks about when they were trying to decide whether to run or push the medication, says that she was about to make a decision when the nurses asked if she was sure, which she says was good, but she says she also realized that the nurses would have done whatever she decided despite knowing that she was wrong. The physician facilitator asks questions to elicit more perspective from the resident, gives her an opportunity to explain more. The resident answers: “I fully trust my nurses, like, yeah, let’s do what you have been doing for the last 20 years, I’ve only been here for two.” (Observation Post-implementation Session 7)

Nurse facilitator asks if people noticed any communication breakdowns. Someone answers they struggled with medications, explains what he did to communicate better since information sometimes didn’t make it clearly to the code cart. Pharmacist says she could not find labels so when they were asking for medication she was holding what they wanted but could not give it because she did not have labels. (Observation Post-implementation Session 2)