On a wing and a prayer: an assessment of modularized crew resource management training for health care professionals

What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness

OBJECTIVE

The aim of this article was to present an overview of the crew resource management (CRM) literature in healthcare. The first aim was to conduct an umbrella review on CRM literature reviews. The second aim was to conduct a new literature review that aims to address the gaps that were identified through the umbrella review.

METHODS

First, we conducted an umbrella review to identify all reviews that have focused on CRM within the healthcare context. This step resulted in 16 literature reviews. Second, we conducted a comprehensive literature review that resulted in 106 articles.

RESULTS

The 16 literature reviews showed a high level of heterogeneity, which resulted in discussing 3 ambiguities: definition, outcome, and information ambiguity. As a result of these ambiguities, a new comprehensive review of the CRM literature was conducted. This review showed that CRM seems to have a positive effect on outcomes at Kirkpatrick's level 1, 2, and 3. In contrast, whether CRM has a positive effect on level 4 outcomes and how level 4 should be measured remains undetermined. Recommendations on how to implement and embed CRM training into an organization to achieve the desired effects have not been adequately considered.

CONCLUSIONS

The extensive nature of this review demonstrates the popularity of CRM in healthcare, but at the same time, it highlights that research tends to be situated within certain settings, focuses on particular outcomes, and has failed to address the full scope of CRM as a team intervention and a management concept.

Microlearning for patient safety: Crew resource management training in 15-minutes

OBJECTIVES

We sought to establish the feasibility of chunking crew resource management (CRM) training into micro-size interventions and to compare different training approaches in the context of micro-learning.

DESIGN

We evaluated whether participants in micro-learning CRM activities achieved learning objectives following training. In a between-subjects design, groups were observed for behaviour during a simulation that was part of a 15-minute modular intervention and tested for recollection afterwards.

PARTICIPANTS

The 129 participants recruited for this study were medical students, who already had relevant experience treating patients.

INTERVENTIONS

The experimental setting involved three 5-minute components: video, simulation, and debriefing. Different groups viewed videos involving different didactic concepts: one group observed a videotaped concrete example of a medical care team applying a CRM tool (example group), and one group observed a videotaped lecture on the same topic (lecture group).

MAIN OUTCOME MEASURES

All simulations were videotaped and coded in detail for the occurrence of and time spent engaging in team behaviour and medical care. Questionnaires were administered before, immediately after, and two weeks after the intervention. We compared the groups' behaviour during the simulation (team cooperation and medical care), retention of knowledge from the training content, and results of the evaluation.

RESULTS

Both groups exhibited most of the behaviours included in the content of the instructional videos during the simulations and recollected information 2 weeks later. The example group exhibited significantly more of the training content during the simulation and demonstrated better retention 2 weeks later. Although the example group spent more time on team coordination, there was no difference in the number of executed medical measures.

CONCLUSION

Delivering CRM training in chunks of relatively short and highly standardised interventions appears feasible. In this study, the form of didactical presentation caused a difference in learning success between groups: a traditional lecture was outperformed by an instructional video demonstrating a practical example.

Crew resource management training in healthcare: a systematic review of intervention design, training conditions and evaluation

OBJECTIVES

Crew resource management (CRM) training formats have become a popular method to increase patient safety by consideration of the role that human factors play in healthcare delivery. The purposes of this review were to identify what is subsumed under the label of CRM in a healthcare context and to determine how such training is delivered and evaluated.

DESIGN

Systematic review of published literature.

DATA SOURCES

PubMed, PsycINFO and ERIC were searched through 8 October 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Individually constructed interventions for healthcare staff that were labelled as CRM training, or described as based on CRM principles or on aviation-derived human factors training. Only studies reporting both an intervention and results were included.

DATA EXTRACTION AND SYNTHESIS

The studies were examined and coded for relevant passages. Characteristics regarding intervention design, training conditions and evaluation methods were analysed and summarised both qualitatively and quantitatively.

RESULTS

Sixty-one interventions were included. 48% did not explain any keyword of their CRM intervention to a reproducible detail. Operating room teams and surgery, emergency medicine, intensive care unit staff and anaesthesiology came in contact most with a majority of the CRM interventions delivered in a 1-day or half-day format. Trainer qualification is reported seldomly. Evaluation methods and levels display strong variation.

CONCLUSIONS

Critical topics were identified for the CRM training community and include the following: the need to agree on common terms and definitions for CRM in healthcare, standards of good practice for reporting CRM interventions and their effects, as well as the need for more research to establish non-educational criteria for success in the implementation of CRM in healthcare organisations.

The training and practice of crew resource management: recommendations from an inductive in vivo study of the flight deck

Crew resource management (CRM) is credited with saving 185 lives at Sioux City. While the theory behind CRM is well documented, there are few studies of how CRM manifests on the line. This inductive in vivo study had three objectives. First, to describe how CRM manifests. Secondly, to evaluate the efficacy of CRM vis-à-vis flight safety. Thirdly, to suggest improvements to the CRM training syllabus. The study produced five conclusions: First, CRM is durable under conditions of moderate strain. Secondly, crews embed and refine CRM through reflection and action. Thirdly, CRM facilitates and shapes social relations. Fourthly, mindlessness (Langer 1989 ) undermines CRM. Finally, the interruption of flight-deck routines by third-parties poses a threat to flight-safety. The paper recommends multi-profession CRM training as a means of improving communication and co-ordination in and around aircraft. The study's limitations include a monocultural flight-deck: flights were operated by pilots with European backgrounds. Mindful of Hofstede's ( 1980 ), Engle's ( 2000 ) and Helmreich and Merritt's ( 2001 ) examination of the relationship between culture and performance, the author suggests the study be repeated with carriers that employ pilots from a variety of cultures. Practitioner Summary: This in vivo study evaluates the efficacy of CRM vis-à-vis flight safety and supports a critique of the CRM syllabus. The author observed twenty sectors and attended a CRM training day. To improve safety and efficiency, it is recommended that airlines run multi-profession (inclusive) CRM training courses.

The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities

Communication failure is a significant source of adverse events in health care and a leading root cause of sentinel events reported to the Joint Commission. The Veterans Health Administration National Center for Patient Safety established Clinical Team Training (CTT) as a comprehensive program to enhance patient safety and to improve communication and teamwork among health care professionals. CTT is based on techniques used in aviation's Crew Resource Management (CRM) training. The aviation industry has reached a significant safety record in large part related to the culture change generated by CRM and sustained by its recurrent implementation. This article focuses on the improvement of communication, teamwork, and patient safety by utilizing a standardized, CRM-based, interprofessional, immersive training in diverse clinical areas. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate before and after CTT. The scores for all of the 27 questions on the questionnaire showed an increase from baseline to 12 months, and 11 of those increases were statistically significant. A recurrent training is recommended to maintain the positive outcomes. CTT enhances patient safety and reduces risk of patient harm by improving teamwork and facilitating clear, concise, specific and timely communication among health care professionals.

Development of a Virtual Crew Resource Management Training Program to Improve Communication

Crew Resource Management (CRM), a method focused on the management of human error and risk reduction, has shown promise in reducing communication failure in health care. The purpose of this project was to develop a virtual training program in CRM principles of effective leadership and followership, and evaluate the applicability to nurses working in the hospital setting. The intervention included the development of a virtual CRM training program consisting of a self-learning module and virtual simulation. Beta testing of the module was conducted by six nurses, followed by an evaluation of the training program by nurses (n = 5) in a general medicine department. Nurses reported the overall program to be worthwhile (X̄= 5; SD = 0.5), with great applicability to nursing care (X̄= 4.5, SD = 0.5). Nurses completing the simulation activity reported strong agreement to CRM applicability and training effectiveness. The CRM training module proved to be applicable to nursing care and is ready for widespread use to improve patient care and communication. J Contin Educ Nurs. 2017;48(11):525-532.

The basis of clinical tribalism, hierarchy and stereotyping: a laboratory-controlled teamwork experiment

OBJECTIVES

To examine the basis of multidisciplinary teamwork. In real-world healthcare settings, clinicians often cluster in profession-based tribal silos, form hierarchies and exhibit stereotypical behaviours. It is not clear whether these social structures are more a product of inherent characteristics of the individuals or groups comprising the professions, or attributable to a greater extent to workplace factors.

SETTING

Controlled laboratory environment with well-appointed, quiet rooms and video and audio equipment.

PARTICIPANTS

Clinical professionals (n=133) divided into 35 groups of doctors, nurses and allied health professions, or mixed professions.

INTERVENTIONS

Participants engaged in one of three team tasks, and their performance was video-recorded and assessed.

PRIMARY AND SECONDARY MEASURES

Primary: teamwork performance. Secondary, pre-experimental: a bank of personality questionnaires designed to assess participants' individual differences. Postexperimental: the 16-item Mayo High Performance Teamwork Scale (MHPTS) to measure teamwork skills; this was self-assessed by participants and also by external raters. In addition, external, arm's length blinded observations of the videotapes were conducted.

RESULTS

At baseline, there were few significant differences between the professions in collective orientation, most of the personality factors, Machiavellianism and conservatism. Teams generally functioned well, with effective relationships, and exhibited little by way of discernible tribal or hierarchical behaviours, and no obvious differences between groups (F (3, 31)=0.94, p=0.43).

CONCLUSIONS

Once clinicians are taken out of the workplace and put in controlled settings, tribalism, hierarchical and stereotype behaviours largely dissolve. It is unwise therefore to attribute these factors to fundamental sociological or psychological differences between individuals in the professions, or aggregated group differences. Workplace cultures are more likely to be influential in shaping such behaviours. The results underscore the importance of culture and context in improvement activities. Future initiatives should factor in culture and context as well as individuals' or professions' characteristics as the basis for inducing more lateral teamwork or better interprofessional collaboration.

Expectations and requests regarding team training interventions to promote interdisciplinary collaboration in medical rehabilitation--A qualitative study

BACKGROUND

Interdisciplinary teamwork and team interventions are highly valued in the rehabilitation sector because they can improve outcomes of care for persons with complex health problems. However, little is known about expectations and requests regarding team interventions, especially in medical rehabilitation. This study aimed to explore how clinical managers and health professionals within multidisciplinary rehabilitation teams describe their expectations and requests regarding team-training interventions in the field of medical rehabilitation.

METHODS

Considering the methodology of qualitative research, data were collected using semi-structured interviews and focus groups at five rehabilitation clinics in Germany. We conducted face-to-face interviews with 5 clinical managers and 13 department heads of health care teams as well as five focus groups with a total of 35 members of interdisciplinary rehabilitation teams. Afterwards, the data were analyzed through qualitative content analysis encompassing data coding and using inductive thematic analysis.

RESULTS

The exploration of team members' and clinical managers' descriptions showed that, to them, interdisciplinary team training programs should include a wide array of training contents. Seven common core themes emerged from the interviews, including participation of employees, leadership, communication, team meetings, team composition, coordination, and equal esteem. Additionally, 13 themes were identified by either managers or team members. The body of expectations regarding team training content in healthcare spans the continuum of changes on the team and organizational levels. On the organizational level, a number of structural factors were mentioned (e.g. improving the general conditions for team meetings, organized workshops to exchange interdisciplinary experiences, and leadership training), and on the team level, changes in procedural factors were listed (e.g. optimizing the consecutive planning and coordination of patient treatments, clarity with regard to roles and responsibilities of team members, and mutual esteem and appreciation between different professions).

CONCLUSIONS

The synthesis underscores that there is meaningful heterogeneity in team training needs; training interventions should be locally adapted for each clinic in terms of training content and training strategies. Tailored team interventions are important for rehabilitation clinics. Future work should evaluate employed team training concepts over time as well as training contents, implementation strategies, and learning outcomes. This includes using robust study designs and evaluating team-training effects.

Development and validation of an instrument for measuring the quality of teamwork in teaching teams in postgraduate medical training (TeamQ)

Background

Teamwork between clinical teachers is a challenge in postgraduate medical training. Although there are several instruments available for measuring teamwork in health care, none of them are appropriate for teaching teams. The aim of this study is to develop an instrument (TeamQ) for measuring teamwork, to investigate its psychometric properties and to explore how clinical teachers assess their teamwork.

Method

To select the items to be included in the TeamQ questionnaire, we conducted a content validation in 2011, using a Delphi procedure in which 40 experts were invited. Next, for pilot testing the preliminary tool, 1446 clinical teachers from 116 teaching teams were requested to complete the TeamQ questionnaire. For data analyses we used statistical strategies: principal component analysis, internal consistency reliability coefficient, and the number of evaluations needed to obtain reliable estimates. Lastly, the median TeamQ scores were calculated for teams to explore the levels of teamwork.

Results

In total, 31 experts participated in the Delphi study. In total, 114 teams participated in the TeamQ pilot. The median team response was 7 evaluations per team. The principal component analysis revealed 11 factors; 8 were included. The reliability coefficients of the TeamQ scales ranged from 0.75 to 0.93. The generalizability analysis revealed that 5 to 7 evaluations were needed to obtain internal reliability coefficients of 0.70. In terms of teamwork, the clinical teachers scored residents' empowerment as the highest TeamQ scale and feedback culture as the area that would most benefit from improvement.

Conclusions

This study provides initial evidence of the validity of an instrument for measuring teamwork in teaching teams. The high response rates and the low number of evaluations needed for reliably measuring teamwork indicate that TeamQ is feasible for use by teaching teams. Future research could explore the effectiveness of feedback on teamwork in follow up measurements.