Learning from critical case reviews: emergent themes and their impact on practice

Organizational learning in hospitals: A realist review

AIM

To establish a middle-range theory of organizational learning in hospitals.

DESIGN

A realist review of the literature, conducted according to established standards for realist and meta-narrative evidence syntheses. Middle-range theory development was performed according to Smith and Liehr's recommendations.

DATA SOURCES

Two comprehensive scientific databases and six discipline-focused databases spanning health care, life sciences, business, sociology, and psychology were searched from inception to 12 May 2016.

REVIEW METHODS

Citations meeting the inclusion criteria were appraised using the Mixed Methods Appraisal Tool. Data extraction was guided by a focus on the contextual factors, mechanisms, and outcomes associated with organizational learning.

RESULTS

The initial search yielded 2,332 citations, 147 of which were ultimately included in the review. The included citations were generally of high quality. Reviewed evidence indicates certain aspects of organizational context can be conducive to mechanisms of organizational learning, leading to a range of positive organizational outcomes.

CONCLUSION

This review updates and expands on a previous review of the literature on organizational learning in hospitals, refines the concept of organizational learning in hospitals, and provides a middle-range theory of organizational learning in hospitals.

IMPACT

This updated review provides a strong evidence base for future work on the topic of organizational learning in hospitals. The refined concept of organizational learning makes it possible to develop reliable, valid research instruments that better reflect of the full scope of organizational learning. Finally, the middle-range theory guides researchers and clinical leaders as they advance the science and practice of organizational learning.

Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique

Situation awareness (SA) is an important human factor and necessary for effective teamwork and patient safety. Human patient simulation (HPS) with video feedback allows for a safe environment where health care professionals can develop both technical and teamwork skills. It is, however, very difficult to observe and measure SA directly. The Situation Global Assessment Technique (SAGAT) was developed by Endsley to measure SA during real-time simulation. Our objective was to measure SA among team members during simulation of acute pediatric care scenarios on the medical ward and its relationship with team effectiveness. Twenty-four pediatric teams, consisting of two nurses, one resident, and one consultant, participated in three acute care scenarios, using high-fidelity simulation. Individual SAGAT scores contained shared and complimentary knowledge questions on different levels of SA. Within each scenario, two "freezes" were incorporated to assess SA of each team members' clinical assessment and decision-making. SA overlap within the team (team SA) was computed and compared to indicators of team effectiveness (time to goal achievement, consensus on primary problem, diagnosis, task prioritization, leadership, and teamwork satisfaction). In 13 scenarios (18%), the team failed to reach the primary goals within the prescribed time of 1200 s. There was no significant difference in failure of goal completion between the scripted scenarios; however, there was a significant difference between scenario 3 and the other scenarios in time to goal completion. In all three scenarios, SA overlap level 2 (consensus on primary problem during the first freeze and consensus on diagnosis during the second freeze) leads to significantly faster achievement of the predefined goals. There was a strong relationship between team SA on the primary problem and diagnosis and team SA on task prioritization. Consensus on leadership within the team was low. Teamwork satisfaction was more influenced by knowledge about the importance of the assigned task than outcome of the scenario.Conclusion: The use of SAGAT enables us to measure SA of team members during real-time simulation of acute care scenarios. Although there is no direct connection between team SA and goal achievement, SAGAT provides insight in differences in SA among team members, and the process of shared mental model formation. By measuring SA, issues that may improve team effectiveness (prioritizing tasks, enhancing shared mental models, and providing leadership) can be trained and assessed during medical team simulation, enhancing teamwork in health care settings. What is known? • Teamwork skills such as communication, leadership, and situational awareness have become increasingly recognized as essential for good performance in pediatric resuscitation. However, the assessment of pediatric team performance in these clinical situations has been traditionally difficult. • The Situation Awareness Global Assessment Technique (SAGAT) is a method of objectively and directly measuring SA during a team simulation using "freezes" at predetermined points in time with participants reporting on "what is going on" from their perspective on the situation. What is new? • We assessed SA, and its relationship with team effectiveness, in multidisciplinary pediatric teams performing simulated critical events in critically ill children on the medical ward using the SAGAT model, outside the emergency room setting. • In all three scenarios, consensus on the primary problem (shared mental model) leads to faster achievement of predefined goals. Consensus on leadership was overall low, without a significant impact on goal achievement.

Strategies to address management challenges in larger intensive care units

AIM

To illustrate the need for and suggest strategies that will enhance sustainable management of a large intensive care unit (ICU).

BACKGROUND

The challenges faced by intensive care nursing in South Africa are well documented. However, there appear to be no strategies available to assist nurses to manage large ICUs or for ICU managers to deal with problems as they arise.

METHODS

Data sources to illustrate the need for strategies were challenges described by ICU managers in the management of large ICUs. A purposive sample of managers was included in individual interviews during compilation of evidence regarding the challenges experienced in the management of large ICUs. The challenges were presented at the Critical Care Society of Southern Africa Congress held on 28 August to 2 September 2012 in Sun City North-West province, South Africa.

RESULTS

Five strategies are suggested for the challenges identified: divide the units into sections; develop a highly skilled and effective nursing workforce to ensure delivery of quality nursing care; create a culture to retain an effective ICU nursing team; manage assets; and determine the needs of ICU nurses.

CONCLUSION

ICUs need measures to drive the desired strategies into actions to continuously improve the management of the unit. Future research should be aimed at investigating the effectiveness of the strategies identified.

IMPLICATIONS FOR NURSING MANAGEMENT

This research highlights issues relating to large ICUs and the strategies will assist ICU managers to deal with problems related to large unit sizes, shortage of trained ICU nurses, use of agency nurses, shortage of equipment and supplies and stressors in the ICU. The article will make a contribution to the body of nursing literature on management of ICUs.

Challenges encountered by critical care unit managers in the large intensive care units

BACKGROUND

Nurses in intensive care units (ICUs) are exposed regularly to huge demands interms of fulfilling the many roles that are placed upon them. Unit managers, in particular, are responsible for the efficient management of the units and have the responsibilities of planning, organising, leading and controlling the daily activities in order to facilitate the achievement of the unit objectives.

OBJECTIVES

The objective of this study was to explore and present the challenges encountered by ICU managers in the management of large ICUs.

METHOD

A qualitative, exploratory and descriptive study was conducted at five hospital ICUs in Gauteng province, South Africa. Data were collected through individual interviews from purposively-selected critical care unit managers, then analysed using the matic coding.

RESULTS

Five themes emerged from the data: challenges related to the layout and structure of the unit, human resources provision and staffing, provision of material resources, stressors in the unit and visitors in the ICU.

CONCLUSION

Unit managers in large ICUs face multifaceted challenges which include the demand for efficient and sufficient specialised nurses; lack of or inadequate equipment that goes along with technology in ICU and supplies; and stressors in the ICU that limit the efficiency to plan, organise, lead and control the daily activities in the unit. The challenges identified call for multiple strategies to assist in the efficient management of large ICUs.

Interventions to improve team effectiveness: a systematic review

OBJECTIVES

To review the literature on interventions to improve team effectiveness and identify their 'evidence based'-level.

METHODS

Major data bases (PubMed, Web of Science, PsycInfo and Cochrane Library) were systematically searched for all relevant papers. Inclusion criteria were: peer-reviewed papers, published in English between January 1990 and April 2008, which present empirically based studies focussing on interventions to improve team effectiveness in health care. A data abstraction form was developed to summarize each paper. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

RESULTS

Forty-eight papers were included in this review. Three categories of interventions were identified: training, tools, and organisational interventions. Target groups were mostly multidisciplinary teams in acute care. The majority of the studies found a positive association between the intervention and non-technical team skills. Most articles presented research with a low level of evidence. Positive results in combination with a moderate or high level of evidence were found for some specific interventions: Simulation training, Crew Resource Management training, Team-based training and projects on Continuous quality improvement.

CONCLUSIONS

There are only some studies available with high quality evidence on interventions to improve team effectiveness. These studies show that team training can improve the effectiveness of multidisciplinary teams in acute (hospital) care.