Crew Resource Management for Obstetric and Neonatal Teams to Improve Communication During Cesarean Births

Reliability of the Behaviorally Anchored Rating Scale (BARS) for assessing non-technical skills of medical students in simulated scenarios

PURPOSE

Caring for critically ill patients requires non-technical skills such as teamwork, communication, and task management. The Behaviorally Anchored Rating Scale (BARS) is a brief tool used to assess non-technical skills. The investigators determined inter- and intra-rater reliability of the BARS when used to assess medical students in simulated scenarios.

METHOD

The investigators created simulation scenarios for medical students during their pediatric clerkship. Content experts reviewed video recordings of the simulations and assigned BARS scores for four performance components (Situational Awareness, Decision-Making, Communication, and Teamwork) for the leader and for the team as a whole. Krippendorff's alpha with ordinal difference was calculated to measure inter- and intra-rater reliability.

RESULTS

Thirty medical students had recordings available for review. Inter- and intra-rater reliability for performance components were, respectively, Individual Situational Awareness (0.488, 0.638), Individual Decision-Making (0.529, 0.691), Individual Communication (0.347, 0.473), Individual Teamwork (0.414, 0.466), Team Situational Awareness (0.450, 0.593), Team Decision Making (0.423, 0.703), Team Communication (0.256, 0.517), and Team Teamwork (0.415, 0.490).

CONCLUSIONS

The BARS demonstrated limited reliability when assessing medical students during their pediatric clerkship. Given the unique needs of this population, a modified or new objective scoring system for assessing non-technical skills may be needed for medical students.

Healthcare team communication training in the United States: A scoping review

The purpose of this literature review was to identify interventions designed to improve healthcare team communication in the United States. We conducted a review of peer-reviewed, English-language articles describing interventions aimed at improving healthcare team communication. We analyzed articles that met pre-specified inclusion and exclusion criteria and characterized who is testing communication interventions, the rationale for testing, and ways of measuring effectiveness. We descriptively categorized the strength and types of study findings. Thirty articles were retained in our analysis. Most assessments were conducted by academic medical centers, the Veterans Health Administration, and teaching hospitals. Interventions sought to improve teamwork, patient safety, clinical outcomes, costs of care, and enhance provider job satisfaction and well-being. Intervention strategies included didactic lectures, simulation, Crew Resource Management, quality improvement, or a combination of these approaches. The vast majority employed a pre-post survey design and measured outcomes using participant feedback. Many assessments failed to utilize a social science theory or communication-specific measures. Interventions with the best training content were conducted at academic medical centers, used a pre-post design, and utilized statistical analysis to analyze results. While interventions for improving healthcare team communication are diverse and have uneven effectiveness, early markers of success merit continued development and assessment.

OUP accepted manuscript

Background

Human factors (HF) integration can improve patient safety in the operating room (OR), but the depth of current knowledge remains unknown. This study aimed to explore the content of HF training for the operative environment.

Methods

We searched six bibliographic databases for studies describing HF interventions for the OR. Skills taught were classified using the Chartered Institute of Ergonomics and Human Factors (CIEHF) framework, consisting of 67 knowledge areas belonging to five categories: psychology; people and systems; methods and tools; anatomy and physiology; and work environment.

Results

Of 1851 results, 28 studies were included, representing 27 unique interventions. HF training was mostly delivered to interdisciplinary groups (n = 19; 70 per cent) of surgeons (n = 16; 59 per cent), nurses (n = 15; 56 per cent), and postgraduate surgical trainees (n = 11; 41 per cent). Interactive methods (multimedia, simulation) were used for teaching in all studies. Of the CIEHF knowledge areas, all 27 interventions taught ‘behaviours and attitudes’ (psychology) and ‘team work’ (people and systems). Other skills included ‘communication’ (n = 25; 93 per cent), ‘situation awareness’ (n = 23; 85 per cent), and ‘leadership’ (n = 20; 74 per cent). Anatomy and physiology were taught by one intervention, while none taught knowledge areas under work environment.

Conclusion

Expanding HF education requires a broader inclusion of the entirety of sociotechnical factors such as contributions of the work environment, technology, and broader organizational culture on OR safety to a wider range of stakeholders.

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.

Using eye-tracking augmented cognitive task analysis to explore healthcare professionals' cognition during neonatal resuscitation

AIM

We aimed to describe the cognitive processes of healthcare providers participating as airway leads in delivery room neonatal resuscitations using eye-tracking assisted debriefing to facilitate recall and provide situational context.

METHODS

Delivery room neonatal resuscitations were recorded using eye-tracking glasses worn by participants who acted as airway leads. These glasses analyze eye-movements to produce an audio-visual recording approximating what was "seen" by the participant and marking their visual attention. Participants then reviewed and debriefed their recordings. Debriefing involved a retrospective think-aloud prompted by eye-tracked recordings and an integrated semi-structured interview. Debriefing sessions were transcribed and subjected to thematic analysis.

RESULTS

Eight healthcare providers participated in 10 interviews; two providers participated twice in two separate resuscitations. Most visual attention was directed at the infant (62%), with 16% directed to monitors/gauges, 3% to team members. Five major themes emerged including situation awareness, performance, working in teams, addressing threats to performance, and perception of eye-tracking. Information processing was complex and involved top-down and bottom-up processing of environmental stimuli, integration of knowledge/experience, and anticipation of patient response. Despite the focus on individual cognition, interpersonal interactions and teamwork emerged as key aspects of resuscitation performance. Potential threats to performance include equipment issues, mental stress, distractions, and parental presence. Eye-tracking recordings were well-received by the participants.

CONCLUSION

Retrospective think-aloud prompted by point-of-view eye-tracked recordings is a useful means of examining cognition of healthcare providers during neonatal resuscitation. Themes identified in this project aligned with existing models of clinical reasoning.

Effectiveness of Communication Interventions in Obstetrics-A Systematic Review

(1) Background: Obstetric work requires good communication, which can be trained through interventions targeting healthcare providers and pregnant women/patients. This systematic review aims to aggregate the current state of research on communication interventions in obstetrics. (2) Methods: Using the PICOS scheme, we searched for studies published in peer-reviewed journals in English or German between 2000 and 2020. Out of 7018 results, 71 studies were included and evaluated in this synthesis using the Oxford Level of Evidence Scale. (3) Results: The 63 studies that included a communication component revealed a positive effect on different proximal outcomes (i.e., communication skills). Three studies revealed a beneficial effect of communication trainings on distal performance indicators (i.e., patient safety), but only to a limited extent. Most studies simultaneously examined different groups, however, those addressing healthcare providers were more common than those with students (61 vs. 12). Only nine studies targeted expectant mothers. Overall, the evidence level of studies was low (only 11 RCTs), with 24 studies with an evidence level I-II, 35 with level III, and 10 with level IV. (4) Conclusions: Communication trainings should be more frequently applied to improve communication of staff, students, and pregnant women and their partners, thereby improving patient safety.

Improving Team Performance and Patient Safety on the Job Through Team Training and Performance Support Tools: A Systematic Review

Introduction

Efforts to improve teamwork in health care have received considerable attention. The current systematic review was conducted to identify recent studies that implemented practices to improve teamwork and were associated with positive improvements on the job.

Methods

Electronic searches of 2 databases (i.e., CINAHL and MEDLINE) were conducted to identify relevant articles published between 2008 and 2018.

Results

Twenty articles were selected for inclusion in this review. The studies most often used quasiexperimental designs and interventions were applied in a variety of hospital settings including labor and delivery, operating rooms, and emergency departments. Across studies, measures assessing teamwork skills on the job were most often collected and showed sustained improvements up to 12 months. Moreover, evidence of improved clinical processes (e.g., compliance with guidelines and efficiency) and increased patient safety (e.g., reduction in adverse events) was found in both studies of team training interventions, as well as in those that introduced performance support tools (e.g., checklist).

Conclusions

The results of the current review are consistent with previous research and add to the evidence base on the practices to improve teamwork within hospital settings. Although efforts to improve teamwork have spread to other health care settings such as office-based care, published studies are lagging behind.

A mixed-methods evaluation of the MOREOB program in Ontario hospitals: participant knowledge, organizational culture, and experiences

BACKGROUND

MOREOB (Managing Obstetrical Risk Efficiently) is a patient safety program for health care providers and administrators in hospital obstetric units. MOREOB has been implemented widely in Canada and gradually spread to the United States. The main goal of MOREOB is to build a patient safety culture and improve clinical outcomes. In 2013, 26 Ontario hospitals voluntarily accepted provincial funding to participate in MOREOB. The purpose of our study was to assess the effect of MOREOB on participant knowledge, organizational culture, and experiences implementing and participating in the program at these 26 Ontario hospitals.

METHODS

A convergent parallel mixed-methods study in Ontario, Canada, with MOREOB participants from 26 hospitals. The quantitative component used a descriptive pre-post repeated measures design to assess participant knowledge and perception of culture, administered pre-MOREOB and after each of the three MOREOB modules. Changes in mean scores were assessed using mixed-effects regression. The qualitative component used a qualitative descriptive design with individual semi-structured interviews. We used content analysis to code, categorize, and thematically describe data. A convergent parallel design was used to triangulate findings from data sources.

RESULTS

308 participants completed the knowledge test, and 329 completed the culture assessment at all four time points. Between baseline and post-Module 3, statistically significant increases on both scores were observed, with an increase of 7.9% (95% CI: 7.1 to 8.8) on the knowledge test and an increase of 0.45 (on a scale of 1-5, 95% CI: 0.38 to 0.52) on the culture assessment. Interview participants (n = 15) described improvements in knowledge, interprofessional communication, ability to provide safe care, and confidence in skills. Facilitators and barriers to program implementation and sustainability were identified.

CONCLUSIONS

Participants were satisfied with their participation in the MOREOB program and perceived that it increased health care provider knowledge and confidence, improved safety for patients, and improved communication between team members. Additionally, mean scores on knowledge tests for obstetric content and culture assessment improved. The MOREOB program can help organizations and individuals improve care by concentrating on the human and organizational aspects of patient safety. Further work to improve program implementation and sustainability is required.

Providers' Reports of Environmental Conditions and Resources at Births in the United States

Environmental conditions and resources that may influence provider's behaviors have been investigated in birth environments focusing on location rather than conditions and available resources. Using a descriptive, cross sectional design, we surveyed a random sample of certified nurse-midwives (CNMs), obstetricians, family practice physicians, and certified professional midwives (CPMs) to describe conditions, resources, and workforce present during U.S. births. In all, 1,243 midwives and physicians reported most environmental resources were present at almost 100% of births they attended. Conditions varied: room noise acceptability restriction of phone calls/texts from any source and lighting kept to a minimum. Trainees were present at most births regardless of setting and provider type. The impact of room noise, phone calls/texting, and lighting on outcomes should be determined. The roles and impact of personnel, including trainees, should be described. The extent to which clusters of resources are associated with outcomes might provide new directions for interventions that improve care.