A Scoping Review of Interprofessional Simulation-Based Team Training Programs
Interprofessional simulation-based team training is a form of interprofessional education (IPE), defined as “health professionals from 2 or more backgrounds learning with, from and about each other.” In 2011, an expert panel articulated outcomes of IPE as core competencies for collaborative practice (IPEC) across the following 4 domains: (1) demonstrating values and ethics for interprofessional practice while working with others, (2) understanding roles and responsibilities, (3) fostering interprofessional communication, and (4) performing effectively as a member of a team. Despite these clearly articulated competencies, the literature suggests that IPE programs are not universally successful in teaching the IPEC competencies. Paradis et al suggested that this may be due to insufficient engagement with theories of learning and interprofessional dynamics. It is unclear to what extent ISBTT programs are based in theories or theoretical frameworks that support effective interprofessional learning. Interprofessional simulation-based team training seems to be mostly grounded in principles of crisis resource management (CRM), adapted from cockpit or crew resource management training used in other high-risk industries, such as aviation. , This focus on crisis management explains the strong emphasis on algorithmic approaches to teamwork skill acquisition in ISBTT. , , While CRM skills include nontechnical skills, such as leadership, communication, and situational awareness, they do not encompass all competency domains of interprofessional collaborative practice; the domains “demonstrating values and ethics” and “understanding roles and responsibilities” are not explicitly represented. Thus, ISBTT programs may not teach the full range of IPEC competencies, especially those that predate the formulation of IPEC competencies. Understanding current practices can guide ISBTT program optimization and future research to study ISBTT effectiveness. We therefore performed a scoping review to examine how published ISBTT programs approach learning within the interprofessional context. We examined what theories informed ISBTT programs, their design features, and what collaborative behaviors were assessed. 

We elected to conduct a scoping review because this type of knowledge synthesis aims to map and summarize scholarship on a given topic and report on its depth and breadth. We followed recommended methodology for scoping reviews , and used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to our reporting. In this review, we define ISBTT as an educational activity that uses in-person simulation (as opposed to simulation in virtual environments only) with the explicit goal of training individuals from at least 2 health professions for collaborative practice. We use the term collaborative behaviors to encompass behaviors that map to the IPEC domains including teamwork and communication. Step 1: Identifying the Research Question It is crucial to consider reflexivity when conducting a scoping review because researchers draw on past experiences and areas of interest in their approach and sense-making of data. Two of the authors (N.B., B.O.) are qualitative researchers in health professions education and 2 (M.J., S.M.v.S.) are physician-educators involved in interprofessional simulation training at our institution. S.M.v.S. and M.J. have long-standing experience with curriculum development, program management, and research in simulation; S.M.v.S. was the founder of the ISBTT program at her institution's Children's Hospital with several related publications, – M.J. completed a simulation fellowship as well as a master’s in education and has published research on bias and power dynamics in healthcare. , Both these authors also have leadership roles in our institution's simulation center. All 4 authors have conducted research in topics related to interprofessional collaborative practice both within (simulation-based) educational contexts and in clinical practice. , , , – The authors were all familiar with ISBTT and formulated the following research questions based on their expertise and preliminary readings: What are the theoretical frameworks underlying published ISBTT programs? What are the design features of ISBTT programs and how do programs accomplish learning “with, from and about” each other? What collaborative behaviors do ISBTT programs include in their assessment of participants and to what extent do they map to the IPEC domains? With the third research question, we sought to examine whether current available studies provide insights into a potential gap between collaborative behaviors developed during ISBTT and their translation to clinical practice. Step 2: Identifying Relevant Articles We worked with a health sciences librarian to develop the search strategy and conduct searches. We performed preliminary searches of the literature on interprofessional simulation training to identify relevant key words and iteratively develop our search strategy, adding or eliminating keywords after each preliminary search until the results seemed to be inclusive without being too broad. We detail the final search strategy used for PubMed in Figure and used a similar strategy to search Embase, Web of Science, PsycINFO, Sociological Abstracts, ERIC, and CINAHL with adaptations for the functions of each database. We selected these databases to capture literature published in health and social sciences. We conducted our initial search on January 6, 2020, and updated the search twice, with the most recent search conducted on February 1, 2023. We also performed hand searches of the reference lists of included articles. Step 3: Selecting Articles We imported all references into EndNote (version X9; Clarivate, Philadelphia, PA) for automated deduplication and then imported the remaining references into Rayyan (HBKU Research Complex, Doha, Qatar), a web-based tool for title and abstract screening. We developed the following inclusion criteria in an iterative manner: Study must be in published in English. Study must use in-person ISBTT, defined as an educational activity using in-person simulation with the explicit goal of training individuals from at least 2 health professions for collaborative practice. ISBTT participants must include members of at least 2 different health professions or health professions students (eg, medicine, nursing, pharmacy, etc) who all participate as learners as opposed to scripted roles to aid in the education process, often referred to as confederates. Study must include observational data on collaborative behaviors related to ISBTT beyond self-assessment. We decided on this last inclusion criterion to address our third research question, what collaborative behaviors do ISBTT programs include in their assessment of participants, and excluded studies that relied on self-assessment only because prior literature suggests poor correlation between self-assessment and actual behavior. Two authors (N.B., S.M.v.S.) independently screened all titles and abstracts to identify articles for full-text review. Step 4: Charting the Data We iteratively developed a data charting instrument to extract information on the theoretical frameworks referenced, design features of the programs, and the reported behavioral outcomes. We used principles of interprofessional simulation-based education identified in the literature to chart design features and core competencies for IPE to chart outcomes. We imported the final version of the instrument (see word file, Supplemental Digital Content 1, which contains the questions included in the charting tool, http://links.lww.com/SIH/B59 ) into Smartsheet (Bellevue, WA) for consistent data charting. We piloted the charting instrument on a random sample of 10 articles to test the instrument before charting all articles. Each article was charted by 2 authors with either NB or S.M.v.S. serving as one of the 2 charters, who reviewed charting together to reconcile any discrepancies and ensure consistency in application of the charting tool. Step 5: Collating and Summarizing Findings We reviewed and qualitatively analyzed the data in the charting tool to compare and contrast how different programs enabled participants to learn “with, from and about” each other. We used descriptive statistics (total numbers and percentages) to summarize the data into tables and analyzed text from articles entered into our charting tool. We reviewed full manuscripts to provide context to our findings. Step 6: Consulting With Stakeholders We shared preliminary findings of this review with 2 different groups: (1) a group of physician-educators working on simulation at our institution who come together on a regular basis in a work-in-progress meeting and (2) members of the Society of Directors of Research in Medical Education (SDRME), which funded this work. While neither group was fully representative of all stakeholders this review targets, both groups expressed great interest in this work and found the topic important and of likely interest to others. Both groups also offered important insights for organizing and contextualizing our findings. 

It is crucial to consider reflexivity when conducting a scoping review because researchers draw on past experiences and areas of interest in their approach and sense-making of data. Two of the authors (N.B., B.O.) are qualitative researchers in health professions education and 2 (M.J., S.M.v.S.) are physician-educators involved in interprofessional simulation training at our institution. S.M.v.S. and M.J. have long-standing experience with curriculum development, program management, and research in simulation; S.M.v.S. was the founder of the ISBTT program at her institution's Children's Hospital with several related publications, – M.J. completed a simulation fellowship as well as a master’s in education and has published research on bias and power dynamics in healthcare. , Both these authors also have leadership roles in our institution's simulation center. All 4 authors have conducted research in topics related to interprofessional collaborative practice both within (simulation-based) educational contexts and in clinical practice. , , , – The authors were all familiar with ISBTT and formulated the following research questions based on their expertise and preliminary readings: What are the theoretical frameworks underlying published ISBTT programs? What are the design features of ISBTT programs and how do programs accomplish learning “with, from and about” each other? What collaborative behaviors do ISBTT programs include in their assessment of participants and to what extent do they map to the IPEC domains? With the third research question, we sought to examine whether current available studies provide insights into a potential gap between collaborative behaviors developed during ISBTT and their translation to clinical practice. 

We worked with a health sciences librarian to develop the search strategy and conduct searches. We performed preliminary searches of the literature on interprofessional simulation training to identify relevant key words and iteratively develop our search strategy, adding or eliminating keywords after each preliminary search until the results seemed to be inclusive without being too broad. We detail the final search strategy used for PubMed in Figure and used a similar strategy to search Embase, Web of Science, PsycINFO, Sociological Abstracts, ERIC, and CINAHL with adaptations for the functions of each database. We selected these databases to capture literature published in health and social sciences. We conducted our initial search on January 6, 2020, and updated the search twice, with the most recent search conducted on February 1, 2023. We also performed hand searches of the reference lists of included articles. 

We imported all references into EndNote (version X9; Clarivate, Philadelphia, PA) for automated deduplication and then imported the remaining references into Rayyan (HBKU Research Complex, Doha, Qatar), a web-based tool for title and abstract screening. We developed the following inclusion criteria in an iterative manner: Study must be in published in English. Study must use in-person ISBTT, defined as an educational activity using in-person simulation with the explicit goal of training individuals from at least 2 health professions for collaborative practice. ISBTT participants must include members of at least 2 different health professions or health professions students (eg, medicine, nursing, pharmacy, etc) who all participate as learners as opposed to scripted roles to aid in the education process, often referred to as confederates. Study must include observational data on collaborative behaviors related to ISBTT beyond self-assessment. We decided on this last inclusion criterion to address our third research question, what collaborative behaviors do ISBTT programs include in their assessment of participants, and excluded studies that relied on self-assessment only because prior literature suggests poor correlation between self-assessment and actual behavior. Two authors (N.B., S.M.v.S.) independently screened all titles and abstracts to identify articles for full-text review. 

We iteratively developed a data charting instrument to extract information on the theoretical frameworks referenced, design features of the programs, and the reported behavioral outcomes. We used principles of interprofessional simulation-based education identified in the literature to chart design features and core competencies for IPE to chart outcomes. We imported the final version of the instrument (see word file, Supplemental Digital Content 1, which contains the questions included in the charting tool, http://links.lww.com/SIH/B59 ) into Smartsheet (Bellevue, WA) for consistent data charting. We piloted the charting instrument on a random sample of 10 articles to test the instrument before charting all articles. Each article was charted by 2 authors with either NB or S.M.v.S. serving as one of the 2 charters, who reviewed charting together to reconcile any discrepancies and ensure consistency in application of the charting tool. 

We reviewed and qualitatively analyzed the data in the charting tool to compare and contrast how different programs enabled participants to learn “with, from and about” each other. We used descriptive statistics (total numbers and percentages) to summarize the data into tables and analyzed text from articles entered into our charting tool. We reviewed full manuscripts to provide context to our findings. 

We shared preliminary findings of this review with 2 different groups: (1) a group of physician-educators working on simulation at our institution who come together on a regular basis in a work-in-progress meeting and (2) members of the Society of Directors of Research in Medical Education (SDRME), which funded this work. While neither group was fully representative of all stakeholders this review targets, both groups expressed great interest in this work and found the topic important and of likely interest to others. Both groups also offered important insights for organizing and contextualizing our findings. 

We identified a total of 4854 references after removing duplicates and based on our selection criteria included 58 in our final pool. Figure shows a flowchart of the article inclusion process and the Excel file in Supplemental Digital Content 2 shows extracted data (see document, Supplemental Digital Content 2, charting tool with information for all included articles, http://links.lww.com/SIH/B60 ). We did not specify a start date for our searches but found articles published as early as 1975, although the oldest article that met review criteria was published in 2004. Most articles (51, 87.9%) were published after the IPE Competencies were first introduced in 2011. As Table shows, most articles described programs in the United States (30, 51.7%). Twenty-one (36.2%) articles reported on ISBTT programs involving multiple institutions. Included articles were published in simulation journals, health professions education journals, discipline-specific journals such as pediatrics, quality of care journals, and in the Journal of Interprofessional Care. The 58 articles described 56 unique programs. Two programs were described in 2 articles each, reporting on different outcomes for each of those programs. – We found wide variations between programs, particularly in program structure, approaches to debriefing, and the number and levels of professions involved. In addition, we found substantial variation in the degree of detail provided about design features and outcomes. Few reports included information on all the elements of our charting tool. Theoretical Frameworks Underlying Published ISBTT Programs The articles included in this review rarely delved into theoretical underpinnings of the programs they reported on. They often approached ISBTT from a patient safety perspective and typically implicitly or explicitly referred to conceptual frameworks such as CRM (18 articles, 31%) and TeamSTEPPS (14 articles, 24.1%) that guided the content of the reported ISBTT program. Fifteen articles (25.9%) did not refer to any framework. We did not observe changes in programs' engagement with theories over time. In addition to determining the educational content, conceptual frameworks frequently provided program developers with tools, including assessment tools. Many reports referenced prior publications to justify the use of simulation as an educational strategy, but only 12 (20.6%) articles framed ISBTT in the context of IPE. While 51 (87.9%) of all 58 articles in this review were published after the IPEC competencies were first released in 2011, only 5 (8.6%) articles mentioned using these competencies to design the ISBTT program and/or assess participants, 2 of which reported on the same program. , Design Features of ISBTT Programs Design features of programs described in the included articles are summarized in Table . All articles described some level of representation across professions among simulation participants, although the majority included 3 or fewer professions. A large proportion of articles (27, 46.5%) reported on programs with participants from 2 professions, most frequently medicine and nursing together while other combinations, for example, nursing and dentistry, were less common. Approximately a third of the articles reported on programs with participants from 3 professional backgrounds, whereas programs with participants from 4 or more professional backgrounds were less common. Programs targeted a variety of participants in terms of training status and level, and approximately half of the articles described programs targeting learners from multiple levels, for example, a combination of trainees and practitioners (Table ). Most articles provided limited description of simulation facilitators, and a third did not describe facilitators' professional background. In the remaining articles, the facilitators often represented only 1 of the professions participating in the simulation. The majority of articles described 1-time training events organized in the context of a research study (42 articles, 72.4%), although 7 (12.1%) articles reported on longitudinal trainings occurring on a regular basis. The format for most ISBTT sessions included a prebriefing, 1 or more scenarios, and a debriefing. Prebriefings were described in the majority of articles (36, 62%) and focused on 1 or several of the following topics: goals for the session, collaborative practice, clinical aspects of the scenario, and orientation to the simulation setting and equipment. Only 7 articles (12.1%) referenced psychological safety as part of the prebriefing, – which refers to the ability to behave without fear of negative consequences and is thought to be critical for learning during ISBTT. Scenarios typically included crisis clinical situations (eg, cardiac arrests, intraoperative crises, obstetric emergencies). However, some programs targeting students involved lower-acuity situations (eg, an interprofessional patient interview). , , High-fidelity manikins and standardized patients were commonly used during scenarios (34 articles, 58.6%, and 9 articles, 15.5%, respectively). Most articles provided descriptions of debriefings (53, 91.4%), which ranged from short discussions to in-depth video-assisted feedback; 13 (22.4%) referred to previously published models for debriefing. Two articles compared different types of debriefings. Boet et al studied facilitator-led versus participant-led debriefings without a facilitator and found equal improvements in collaborative behaviors. Lemke et al studied postevent debriefings versus within-event debriefings in which facilitators interrupted the scenario to debrief on particular aspects before restarting the scenario; in this article, the within-event debriefing group showed more pronounced improvement in collaborative behaviors. Collaborative Behaviors and Interprofessional Competencies as Outcomes In mapping the assessed collaborative behaviors to IPEC domains, we found that 19 (32.8%) articles reported assessment of 1 competency; 15 (25.9%) assessed 2 competencies; 21 (36.2%) assessed 3 competencies; and 3 (5.2%) articles assessed all 4 competencies. , , All but one article described assessment tools that focused on teamwork, and 39 (67.2%) assessed communication, consistent with reliance on CRM and related frameworks by the majority of programs. While communication was commonly assessed, most assessment instruments did not specifically focus on communication between members from different professions. Assessment of some aspect of roles and responsibilities was described in 24 (41.4%) of the articles, whereas values and ethics for interprofessional collaboration were only assessed in 4 (6.9%). , , , Only 1 article used an existing instrument from the interprofessional literature (Interprofessional Team Observation Feedback Tool ), although 2 articles reporting on the same study developed a custom instrument informed by the IPEC , and 2 articles by the same group did not use an instrument but performed a qualitative analysis based on the IPEC. , Nine (15.5%) articles did not provide a description of the instrument used. Collaborative behaviors were observed before and after simulations in 49 (84.5%) articles. Thirty-nine (67.2%) of these articles reported some improvement in collaborative behaviors assessed and 10 (17.2%) articles did not report any change. Two (3.4%) articles reported an improvement between the first and second scenario (conducted on the same day). In 7 (12%) articles, collaborative behaviors were measured at a single time, making it difficult to evaluate the impact of the program. Eight (13.8%) articles measured longer-term outcomes, either through simulation , – and/or in clinical settings. , , – Fifteen (25.9%) articles included measures of the impact of the training on clinical outcomes, such as patient safety. Eleven (19%) of these articles showed improvements in clinical outcomes, and 4 (6.9%) did not show any impact. , , , In addition to measuring outcomes before and after simulations, 16 (27.6%) articles also compared different approaches to training. Three (5.2%) articles compared ISBTT training to no training and concluded that simulation led to improvements in collaborative behaviors. , , Four (6.9%) articles compared different types of training for interprofessional teams, such as didactic-only versus didactic and simulation. , – Of these, 3 (6.1%) articles showed greater improvements in groups that participated in simulation. , , Two articles compared teamwork among medical and nursing students after participation in interprofessional versus uniprofessional training; one of these found greater improvement in collaboration after the interprofessional course, whereas the other did not note any significant differences between groups. Seven articles (12.1%) compared different design features of ISBTT. Two (3.5%) articles , compared in situ sessions to sessions in simulation centers and found a similar beneficial effect on team performance between the 2 settings. Two (3.5%) articles compared in-person simulation to virtual simulation; one of these found that these 2 modalities led to similar improvements, whereas the other showed greater improvements for in-person sessions compared with virtual simulation. One article showed that simulation led to similar improvements in students' collaborative behaviors after participation in 2 versus 4 scenarios. 

The articles included in this review rarely delved into theoretical underpinnings of the programs they reported on. They often approached ISBTT from a patient safety perspective and typically implicitly or explicitly referred to conceptual frameworks such as CRM (18 articles, 31%) and TeamSTEPPS (14 articles, 24.1%) that guided the content of the reported ISBTT program. Fifteen articles (25.9%) did not refer to any framework. We did not observe changes in programs' engagement with theories over time. In addition to determining the educational content, conceptual frameworks frequently provided program developers with tools, including assessment tools. Many reports referenced prior publications to justify the use of simulation as an educational strategy, but only 12 (20.6%) articles framed ISBTT in the context of IPE. While 51 (87.9%) of all 58 articles in this review were published after the IPEC competencies were first released in 2011, only 5 (8.6%) articles mentioned using these competencies to design the ISBTT program and/or assess participants, 2 of which reported on the same program. , 

Design features of programs described in the included articles are summarized in Table . All articles described some level of representation across professions among simulation participants, although the majority included 3 or fewer professions. A large proportion of articles (27, 46.5%) reported on programs with participants from 2 professions, most frequently medicine and nursing together while other combinations, for example, nursing and dentistry, were less common. Approximately a third of the articles reported on programs with participants from 3 professional backgrounds, whereas programs with participants from 4 or more professional backgrounds were less common. Programs targeted a variety of participants in terms of training status and level, and approximately half of the articles described programs targeting learners from multiple levels, for example, a combination of trainees and practitioners (Table ). Most articles provided limited description of simulation facilitators, and a third did not describe facilitators' professional background. In the remaining articles, the facilitators often represented only 1 of the professions participating in the simulation. The majority of articles described 1-time training events organized in the context of a research study (42 articles, 72.4%), although 7 (12.1%) articles reported on longitudinal trainings occurring on a regular basis. The format for most ISBTT sessions included a prebriefing, 1 or more scenarios, and a debriefing. Prebriefings were described in the majority of articles (36, 62%) and focused on 1 or several of the following topics: goals for the session, collaborative practice, clinical aspects of the scenario, and orientation to the simulation setting and equipment. Only 7 articles (12.1%) referenced psychological safety as part of the prebriefing, – which refers to the ability to behave without fear of negative consequences and is thought to be critical for learning during ISBTT. Scenarios typically included crisis clinical situations (eg, cardiac arrests, intraoperative crises, obstetric emergencies). However, some programs targeting students involved lower-acuity situations (eg, an interprofessional patient interview). , , High-fidelity manikins and standardized patients were commonly used during scenarios (34 articles, 58.6%, and 9 articles, 15.5%, respectively). Most articles provided descriptions of debriefings (53, 91.4%), which ranged from short discussions to in-depth video-assisted feedback; 13 (22.4%) referred to previously published models for debriefing. Two articles compared different types of debriefings. Boet et al studied facilitator-led versus participant-led debriefings without a facilitator and found equal improvements in collaborative behaviors. Lemke et al studied postevent debriefings versus within-event debriefings in which facilitators interrupted the scenario to debrief on particular aspects before restarting the scenario; in this article, the within-event debriefing group showed more pronounced improvement in collaborative behaviors. 

In mapping the assessed collaborative behaviors to IPEC domains, we found that 19 (32.8%) articles reported assessment of 1 competency; 15 (25.9%) assessed 2 competencies; 21 (36.2%) assessed 3 competencies; and 3 (5.2%) articles assessed all 4 competencies. , , All but one article described assessment tools that focused on teamwork, and 39 (67.2%) assessed communication, consistent with reliance on CRM and related frameworks by the majority of programs. While communication was commonly assessed, most assessment instruments did not specifically focus on communication between members from different professions. Assessment of some aspect of roles and responsibilities was described in 24 (41.4%) of the articles, whereas values and ethics for interprofessional collaboration were only assessed in 4 (6.9%). , , , Only 1 article used an existing instrument from the interprofessional literature (Interprofessional Team Observation Feedback Tool ), although 2 articles reporting on the same study developed a custom instrument informed by the IPEC , and 2 articles by the same group did not use an instrument but performed a qualitative analysis based on the IPEC. , Nine (15.5%) articles did not provide a description of the instrument used. Collaborative behaviors were observed before and after simulations in 49 (84.5%) articles. Thirty-nine (67.2%) of these articles reported some improvement in collaborative behaviors assessed and 10 (17.2%) articles did not report any change. Two (3.4%) articles reported an improvement between the first and second scenario (conducted on the same day). In 7 (12%) articles, collaborative behaviors were measured at a single time, making it difficult to evaluate the impact of the program. Eight (13.8%) articles measured longer-term outcomes, either through simulation , – and/or in clinical settings. , , – Fifteen (25.9%) articles included measures of the impact of the training on clinical outcomes, such as patient safety. Eleven (19%) of these articles showed improvements in clinical outcomes, and 4 (6.9%) did not show any impact. , , , In addition to measuring outcomes before and after simulations, 16 (27.6%) articles also compared different approaches to training. Three (5.2%) articles compared ISBTT training to no training and concluded that simulation led to improvements in collaborative behaviors. , , Four (6.9%) articles compared different types of training for interprofessional teams, such as didactic-only versus didactic and simulation. , – Of these, 3 (6.1%) articles showed greater improvements in groups that participated in simulation. , , Two articles compared teamwork among medical and nursing students after participation in interprofessional versus uniprofessional training; one of these found greater improvement in collaboration after the interprofessional course, whereas the other did not note any significant differences between groups. Seven articles (12.1%) compared different design features of ISBTT. Two (3.5%) articles , compared in situ sessions to sessions in simulation centers and found a similar beneficial effect on team performance between the 2 settings. Two (3.5%) articles compared in-person simulation to virtual simulation; one of these found that these 2 modalities led to similar improvements, whereas the other showed greater improvements for in-person sessions compared with virtual simulation. One article showed that simulation led to similar improvements in students' collaborative behaviors after participation in 2 versus 4 scenarios. 

Findings from this scoping review of 58 articles suggest that most published ISBTT programs draw on established frameworks for crisis management but lack grounding in theories of learning and team dynamics. Most articles provided limited descriptions of how these programs enable simulation participants from different professions to learn “with, from and about each other,” making it difficult to understand whether and how such learning is accomplished. In addition, reported training outcomes were typically only measured in the simulation setting immediately after interventions and rarely include all 4 IPEC domains. Most programs use CRM-based tools to assess teamwork and communication skills; these tools may not capture essential elements of interprofessional collaboration. The lack of explicit focus on interprofessional dynamics may be a missed opportunity to prepare participants for the challenges associated with interprofessional collaborative work. Given the cost, complexity, and resource-intensive nature of ISBTT programs, adding this element to ISBTT may increase the return on investment as it has the potential to further optimize interprofessional teamwork and thereby quality and safety of patient care. , Articles in this scoping review rarely described what theories informed the development of a program, including the choice of learning objectives and educational strategies, such as the approach to debriefing. Most of the described programs seem to implicitly rely on contact theory and the assumption that individuals from different professional groups will learn to collaborate by attending simulation sessions together. This assumption overlooks an important aspect of contact theory: equal status between individuals is a prerequisite for positive intergroup interactions. Healthcare professionals rarely meet this prerequisite because of hierarchy and power differentials between individuals. , , In a previous study of 7 ISBTT programs, we found that most programs focused on clinical skills acquisition, with minimal discussion of collaborative practice and few interactions between participants from different backgrounds. Similarly, an analysis of participant engagement during debriefing after ISBTT revealed that physician participants spoke more than any other professional group. Thus, while the programs included in this review enabled health professionals to learn with each other, they did not seem to promote learning from or about others. About half of the articles implicitly or explicitly described relying on conceptual frameworks such as CRM and TeamSTEPPS as the foundation for the content of ISBTT, but these may have limited applicability to all forms of interprofessional teamwork across all contexts in health care, especially if not applied in a manner that take their origin and limitations into account. While many ISBTT programs focus on crisis situations in which such CRM approaches may be useful, we and others have shown that interprofessional collaboration in low-acuity settings has characteristics that differ from collaboration in high-acuity settings. , Even in high-acuity settings, CRM principles may be difficult to apply to hierarchical healthcare teams. For example, the CRM dimension of situational awareness requires people to call out errors as they occur, which may be hampered by power dynamics between physicians, nurses, and other healthcare professionals on the team. Similarly, asking for help and getting input from team members may be challenging for physician team leaders, who traditionally function as highly autonomous decision makers. Certainly, power differences exist in aviation crews as well, but hierarchy in healthcare is uniquely complex. Of note, even in the airline industry where CRM is widely adopted, crew members do not always speak up with critical information because of hierarchy and team dynamics. Thus, traditional CRM approaches may be insufficient to teach healthcare professionals how to work collaboratively and navigate power discrepancies between individuals. Engaging with theoretical and conceptual frameworks developed to understand power and intergroup relations may help ISBTT programs adopt approaches to IPE in which barriers to collaboration are explicitly addressed, allowing learners to develop skills they can use in real-life practice. – For instance, French and Raven identified 6 different social bases of power that individuals can draw upon to influence others to act in a specific way. , These social bases of power can help examine relationships between physicians and other team members, understand factors that trigger interprofessional conflicts in clinical settings, and identify barriers to speaking up for patient safety. Applying these social bases to ISBTT programs could inform the content and format for debriefing simulations, so that these issues are discussed in a manner that helps participants learn to navigate power and mitigate conflict. Engaging with theoretical perspectives on power can also help programs recognize design features that inhibit or facilitate learning of interprofessional competencies. For example, the negotiated order perspective, a theory developed by Strauss and colleagues explains how healthcare professionals continuously seek to exert power over each other to achieve their respective patient care goals. Research has shown that these struggles over power rarely get acknowledged, nor do power discrepancies, which tend to aggravate power struggles. Translating this perspective to ISBTT may explain tensions that can occur in programs that expect inexperienced physician trainees to act as team leaders and give instructions to experienced nurses. In one study, this created complex interactions between the physician trainees, who have power due to their position, and the nurses, who have power due to their experience, yet this was never discussed in interprofessional conversations. When power differences exist but are not addressed during team training, the unspoken tensions originating from such differences may persist and become further normalized. As a result, team training may inadvertently and paradoxically exacerbate dysfunctional interactions between professional groups. , This unintended consequence can be mitigated by matching training and/or experience levels of participants to reduce power discrepancies or by including strategies that help participants navigate these complex power dynamics as they learn together. Another feature that may limit interprofessional learning is the ad hoc nature of most programs, which often rely on 1-time training, which prevents participants from building team cohesion and social capital over time. The lack of team cohesion may be aggravated in the interprofessional context because of preexisting intergroup bias. , Although not all articles fully described the professional background and role of facilitators, many did not seem to utilize facilitators representing the profession of all participants. This may decrease some participants' psychological safety and their willingness to admit mistakes and show vulnerability, which in turn hampers learning. , In addition, when facilitators come from different professional backgrounds, they model interprofessional work for the participants, and expand their own interprofessional competencies. This empowers them to become change agents that may benefit interprofessional collaboration in clinical settings. From the data reported, it is difficult to understand whether and how the ISBTT programs described in the included articles led to changes in interprofessional collaborative behaviors. The majority of programs only assessed behaviors in 1 or 2 domains, teamwork and communication, whereas the domain values and ethics was rarely addressed. For the teamwork and communication competencies, the majority of programs relied on assessment instruments based on CRM frameworks. A recent literature review revealed that validity evidence in studies using these instruments during interprofessional simulation tends to be limited to measures of internal consistency, and whether they measure behaviors relevant to interprofessional collaboration is unclear. For example, prior studies suggest that team members are more likely to give and accept intraprofessional feedback as opposed to interprofessional feedback. , Thus, participants' intraprofessional teamwork and communication behaviors may differ from interprofessional behaviors, and assessment instruments that do not differentiate between the 2 may not adequately capture all IPEC domains. In addition, the focus on high-acuity situations may not allow for detection of more subtle teamwork and communication behaviors that play into collaborative practice in other settings. Lastly, most ISBTT programs only measured behaviors immediately after the trainings and in a simulated context. This makes it difficult to assess whether simulation participants were able to use what they had learned in other contexts. Findings from this scoping review need to be considered in light of several limitations. First, this review did not include articles in which assessment of collaborative behaviors was only based on self-reported data from simulation participants. This may have led to the exclusion of articles that discussed theory more rigorously or reported on programs with more robust design features, but did not have outcome measures beyond self-assessment. Second, most ISBTT programs described in the included articles revolved around high-acuity scenarios that do not reflect the diversity of collaborative work healthcare professionals perform on a day-to-day basis. This highlights a gap in the literature, and likely reflects the currently limited use of simulation for practice of interprofessional collaboration in low-acuity settings. Third, this review focused on in-person ISBTT programs. We developed this selection criterion to exclude programs held in virtual environments as they rely on different pedagogical approaches and methods. However, we may have failed to include articles describing how ISBTT programs adapted to a virtual format as a result of the COVID-19 pandemic, which broke out while we were conducting this review. Finally, this review focused on ISBTT as a form of IPE to examine ways in which we might improve interprofessional collaboration. While we believe that education plays an important role in supporting such improvements, other factors such as institutional cultures and health care systems likely contribute to the effectiveness of collaborative work. 

Our findings can guide (re)design of ISBTT programs to augment their impact on interprofessional collaborative practice. This redesign could involve adding “learning with, from and about each other” as an explicit program goal and ensuring that the way ISBTT is delivered achieves this goal. In addition, redesign could involve engaging with theoretical concepts related to power and intergroup relations, and building in approaches that equip simulation participants with skills to build social capital, manage conflicts, and navigate power discrepancies. To this end, programs may use debriefing to create space for participants to reflect upon and discuss how power dynamics, hierarchies, and conflicts influence their collaboration. , , , , , Reflecting upon these topics requires skillful facilitation, and thus facilitator training to ensure they possess the relevant skills is essential. It may also be useful to design scenarios in such a way that learning objectives related to collaborative practice are explicitly included and elements of collaborative practice come to the foreground. Programs may also benefit from addressing specific design features that may enhance interprofessional learning. These features include involving facilitators from the same professions as simulation participants, favoring longitudinal experiences to support acquisition of collaborative competencies and team cohesion, and targeting participants at similar levels of training to reduce power discrepancies. , It should be noted, however, that some of these elements have been incompletely studied. For example, whether matching the profession of simulation participants and facilitators is always the best approach and whether the skill of a facilitator may be more important than their background has not been examined. Similarly, whether there are specific facilitation or other strategies that allow for effective learning even when there are power differences between members of interprofessional teams, deserves further exploration. Lastly, to assess whether ISBTT programs live up to their promise, it may be helpful to examine how simulation participants demonstrate all IPEC domains in simulation and in clinical settings, which will require new assessment tools. 

