Teamwork in multi-person systems: a review and analysis

Lessons Learned From a Systematic, Hospital-Wide Implementation of the ABCDEF Bundle: A Survey Evaluation

Objective

We recently reported the first part of a study testing the impact of data literacy training on "assessing pain, spontaneous awakening and breathing trials, choice of analgesia and sedation, delirium monitoring/management, early exercise/mobility, and family and patient empowerment" [ABCDEF [A-F]) compliance. The purpose of the current study, part 2, was to evaluate the effectiveness of the implementation approach by surveying clinical staff to examine staff knowledge, skill, motivation, and organizational resources.

DESIGN

The Clark and Estes Gap Analysis framework was used to study knowledge, motivation, and organization (KMO) influences. Assumed influences identified in the literature were used to design the A-F bundle implementation strategies. The influences were validated against a survey distributed to the ICU interprofessional team.

SETTING

Single-center study was conducted in eight adult ICUs in a quaternary academic medical center.

SUBJECTS

Interprofessional ICU clinical team.

INTERVENTIONS

A quantitative survey was sent to 386 participants to evaluate the implementation design postimplementation. An exploratory factor analysis was performed to understand the relationship between the KMO influences and the questions posed to validate the influence. Descriptive statistics were used to identify strengths needed to sustain performance and weaknesses that required improvement to increase A-F bundle adherence.

MEASUREMENT AND RESULTS

The survey received an 83% response rate. The exploratory factor analysis confirmed that 38 of 42 questions had a strong relationship to the KMO influences, validating the survey's utility in evaluating the effectiveness of implementation design. A total of 12 KMO influences were identified, 8 were categorized as a strength and 4 as a weakness of the implementation.

CONCLUSIONS

Our study used an evidence-based gap analysis framework to demonstrate key implementation approaches needed to increase A-F bundle compliance. The following drivers were recommended as essential methods required for successful protocol implementation: data literacy training and performance monitoring, organizational support, value proposition, multidisciplinary collaboration, and interprofessional teamwork activities. We believe the learning generated in this two-part study is applicable to implementation design beyond the A-F bundle.

Exploring how healthcare teams balance the neurodynamics of autonomous and collaborative behaviors: a proof of concept

Team members co-regulate their activities and move together at the collective level of behavior while coordinating their actions toward shared goals. In parallel with team processes, team members need to resolve uncertainties arising from the changing task and environment. In this exploratory study we have measured the differential neurodynamics of seven two-person healthcare teams across time and brain regions during autonomous (taskwork) and collaborative (teamwork) segments of simulation training. The questions posed were: (1) whether these abstract and mostly integrated constructs could be separated neurodynamically; and, (2) what could be learned about taskwork and teamwork by trying to do so? The taskwork and teamwork frameworks used were Neurodynamic Information (NI), an electroencephalography (EEG) derived measure shown to be a neurodynamic proxy for the pauses and hesitations associated with individual uncertainty, and inter-brain EEG coherence (IBC) which is a required component of social interactions. No interdependency was observed between NI and IBC, and second-by-second dynamic comparisons suggested mutual exclusivity. These studies show that proxies for fundamental properties of teamwork and taskwork can be separated neurodynamically during team performances of ecologically valid tasks. The persistent expression of NI and IBC were not simultaneous suggesting that it may be difficult for team members to maintain inter-brain coherence while simultaneously reducing their individual uncertainties. Lastly, these separate dynamics occur over time frames of 15–30 s providing time for real-time detection and mitigation of individual and collaborative complications during training or live patient encounters.

Metrics for Human-Robot Team Design: A Teamwork Perspective on Evaluation of Human-Robot Teams

Metrics for human-robot teaming should extend to teams consisting of multiple human and robotic agents, and to teams working in complex, dynamic work domains. This work proposes that to comprehensively analyze and evaluate multi-human, multi-robot teams, traditional HRI metrics of performance and efficiency must be expanded upon to incorporate metrics of teamwork. We develop five distinct metrics to capture both ecological and cognitive aspects of teamwork found to be important in human-automation interaction, inspired by research in the cognitive systems engineering community. We demonstrate the application of these metrics in a spacecraft maintenance case study comparing multiple human-robot team architectures. The case study demonstrates that the teamwork metrics capture aspects of human-robot interaction not apparent when using only traditional performance and efficiency metrics. The paper concludes that the proposed teamwork metrics are complementary to existing metrics in HRI and should be included in the evaluation of human-robot teams.

State of science: models and methods for understanding and enhancing teams and teamwork in complex sociotechnical systems

This state of the science review brings together the disparate literature of effective strategies for enhancing and accelerating team performance. The review evaluates and synthesises models and proposes recommended avenues for future research. The two major models of the Input-Mediator-Output-Input (IMOI) framework and the Big Five dimensions of teamwork were reviewed and both will need significant development for application to future teams comprising non-human agents. Research suggests that a multi-method approach is appropriate for team measurements, such as the integration of methods from self-report, observer ratings, event-based measurement and automated recordings. Simulations are recommended as the most effective team-based training interventions. The impact of new technology and autonomous agents is discussed with respect to the changing nature of teamwork. In particular, whether existing teamwork models and measures are suitable to support the design, operation and evaluation of human-nonhuman teams of the future. Practitioner summary: This review recommends a multi-method approach to the measurement and evaluation of teamwork. Team models will need to be adapted to describe interaction with non-human agents, which is what the future is most likely to hold. The most effective team training interventions use simulation-based approaches.

Decision-making during obstetric emergencies: A narrative approach

This study aims to explore how physicians make sense of and give meaning to their decision-making during obstetric emergencies. Childbirth is considered safe in the wealthiest parts of the world. However, variations in both intervention rates and delivery outcomes have been found between countries and between maternity units of the same country. Interventions can prevent neonatal and maternal morbidity but may cause avoidable harm if performed without medical indication. To gain insight into the possible causes of this variation, we turned to first-person perspectives, and particularly physicians’ as they hold a central role in the obstetric team. This study was conducted at four maternity units in the southern region of Sweden. Using a narrative approach, individual in-depth interviews ignited by retelling an event and supported by art images, were performed between Oct. 2018 and Feb. 2020. In total 17 obstetricians and gynecologists participated. An inductive thematic narrative analysis was used for interpreting the data. Eight themes were constructed: (a) feeling lonely, (b) awareness of time, (c) sense of responsibility, (d) keeping calm, (e) work experience, (f) attending midwife, (g) mind-set and setting, and (h) hedging. Three decision-making perspectives were constructed: (I) individual-centered strategy, (II) dialogue-distributed process, and (III) chaotic flow-orientation. This study shows how various psychological and organizational conditions synergize with physicians during decision-making. It also indicates how physicians gave decision-making meaning through individual motivations and rationales, expressed as a perspective. Finally, the study also suggests that decision-making evolves with experience, and over time. The findings have significance for teamwork, team training, patient safety and for education of trainees.

Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle

OBJECTIVES

Daily ICU interprofessional team rounds, which incorporate the ICU Liberation ("A" for Assessment, Prevention, and Manage Pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, support both the care coordination and regular provider communication necessary for Bundle execution. This article describes evidence-based practices for conducting effective interprofessional team rounds in the ICU to improve Bundle performance.

DESIGN

Best practice synthesis.

METHODS

The authors, each extensively involved in the Society of Critical Care Medicine's ICU Liberation Campaign, reviewed the pertinent literature to identify how ICU interprofessional team rounds can be optimized to increase ICU Liberation adherence.

RESULTS

Daily ICU interprofessional team rounds that foster ICU Liberation Bundle use support both care coordination and regular provider communication within and between teams. Evidence-based best practices for conducting effective interprofessional team rounds in the ICU include the optimal structure for ICU interprofessional team rounds; the importance of conducting rounds at patients' bedside; essential participants in rounds; the inclusion of ICU patients and their families in rounds-based discussions; and incorporation of the Bundle into the Electronic Health Record. Interprofessional team rounds in the ICU ideally employ communication strategies to foster inclusive and supportive behaviors consistent with interprofessional collaboration in the ICU. Patient care discussions during interprofessional team rounds benefit from being patient-centered and goal-oriented. Documentation of ICU Liberation Bundle elements in the Electronic Health Record may help facilitate team communication and decision-making.

CONCLUSIONS

Conducting high-quality interprofessional team rounds in the ICU is a key strategy to support ICU Liberation Bundle use.

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Simulation in endoscopy: Practical educational strategies to improve learning

In gastrointestinal endoscopy, simulation-based training can help endoscopists acquire new skills and accelerate the learning curve. Simulation creates an ideal environment for trainees, where they can practice specific skills, perform cases at their own pace, and make mistakes with no risk to patients. Educators also benefit from the use of simulators, as they can structure training according to learner needs and focus solely on the trainee. Not all simulation-based training, however, is effective. To maximize benefits from this instructional modality, educators must be conscious of learners' needs, the potential benefits of training, and associated costs. Simulation should be integrated into training in a manner that is grounded in educational theory and empirical data. In this review, we focus on four best practices in simulation-based education: deliberate practice with mastery learning, feedback and debriefing, contextual learning, and innovative educational strategies. For each topic, we provide definitions, supporting evidence, and practical tips for implementation.

The effect of charismatic leadership on coordinated teamwork: a study in Turkey

Purpose

The purpose of this paper is to investigate the effect of behavioral dimensions constituting the essence of charismatic leadership (CL) on coordinated teamwork (CTW).

Design/methodology/approach

Data were collected from 113 members among 20 ad hoc project teams formed by specialists and assistant specialists employed in a public institution. Simple linear and multiple regression models were employed to analyze the effect of CL on CTW.

Findings

The behavioral dimensions of CL, which include possessing a strategic vision and articulation skill, sensitivity to the environment and sensitivity to member needs, were found to have a significant and positive effect on CTW, while the personal risk and unconventional behavior dispositions of a leader were found to render no significant effect on CTW.

Research limitations/implications

Having tested the effect of CL behaviors on CTW, this particular model provides salient implications in clarifying which CL behaviors particularly render a significant effect on CTW and the consequential effectiveness of teamwork. Nevertheless, there is a need for longitudinal studies conducted in a range of different sectors and institutions.

Originality/value

The originality of this empirical study is that it advances the grasp of the relationship between CTW and the behavioral factors of CL.

Transfer of Training: The Known and the Unknown

Transfer of training is one of the oldest topics of interest to industrial and organizational (I/O) psychologists. Drawing on several meta-analytic studies and recent empirical work, we first synthesize what is now reliably known with respect to the generalization and retention of learned knowledge and skills to work contexts. The second part of our review focuses on what is unknown—the significant gaps in our knowledge where we believe new directions in our research strategies are warranted. We offer three prescriptions: (a) going one step beyond most existing studies to offer greater precision in our specification and measurement of variables and interventions, (b) connecting the dots by focusing on transfer criteria and transfer trajectories, and (c) shifting the operative paradigm of research to examine contemporary learning from a problem-centered perspective. There is ample opportunity to increase the yield on enormous organizational investments in training if transfer scholars and practitioners are fully informed of what is known and prepared to systematically confront the unknown in new and innovative ways.

Military teams - A demand for resilience

BACKGROUND

The Royal Norwegian Naval Academy (RNoNA) has an interest in enhancing military teams' knowledge, skills and abilities to deal with complex situations and environments.

OBJECTIVE

The objective is to document the need for resilience in military teams and to expand the understanding of how such behavior can be meaningfully instilled through team training interventions.

METHOD

Norwegian military subject matter experts (SMEs) assessed the performance of military teams participating in complex military training exercises. Eight cadet teams at the RNoNA were assessed during two separate 4-hour simulator training exercises and a 48-hour live training exercise.

RESULTS

Positive Spearman rank correlation coefficients between resilience assessments in the simulator training exercises and the live training exercise were strongest when the simulator scenario emphasized resilience factors inherent in the live exercise, and weakest when the simulator scenario did not facilitate the task demands in the live exercise.

CONCLUSION

The study showed that resilience assessed in teams during simulator training exercises predicted their resilient behavior in a subsequent live training exercise and that the proper design of scenario-based simulator training can realistically and effectively represent resilience stressors found in live operations.

The Role of Teamwork in the Analysis of Big Data: A Study of Visual Analytics and Box Office Prediction

Historically, domains such as business intelligence would require a single analyst to engage with data, develop a model, answer operational questions, and predict future behaviors. However, as the problems and domains become more complex, organizations are employing teams of analysts to explore and model data to generate knowledge. Furthermore, given the rapid increase in data collection, organizations are struggling to develop practices for intelligence analysis in the era of big data. Currently, a variety of machine learning and data mining techniques are available to model data and to generate insights and predictions, and developments in the field of visual analytics have focused on how to effectively link data mining algorithms with interactive visuals to enable analysts to explore, understand, and interact with data and data models. Although studies have explored the role of single analysts in the visual analytics pipeline, little work has explored the role of teamwork and visual analytics in the analysis of big data. In this article, we present an experiment integrating statistical models, visual analytics techniques, and user experiments to study the role of teamwork in predictive analytics. We frame our experiment around the analysis of social media data for box office prediction problems and compare the prediction performance of teams, groups, and individuals. Our results indicate that a team's performance is mediated by the team's characteristics such as openness of individual members to others' positions and the type of planning that goes into the team's analysis. These findings have important implications for how organizations should create teams in order to make effective use of information from their analytic models.

Red Team Performance for Improved Computer Security

This research attempts to develop a human factors understanding of red team assessment strategies in computer and information security. Red teaming is an advanced form of assessment that can be used to identify weaknesses in a variety of security systems. The purpose of this research is to identify and define the various dimensions of red team effectiveness with the aim of improving red team performance. A study of a red team was conducted in collaboration with Sandia National Laboratories Information Design Assurance Red Team (IDART). The design of the study included semi-structured individual interviews and focus groups with red team members and observation of red team practices. The analysis yielded various dimensions of red team effectiveness from the customer, management, individual, and team member perspectives.

Regional Multiteam Systems in Cancer Care Delivery

Teamwork is essential for addressing many of the challenges that arise in the coordination and delivery of cancer care, especially for the problems that are presented by patients who cross geographic boundaries and enter and exit multiple health care systems at various times during their cancer care journeys. The problem of coordinating the care of patients with cancer is further complicated by the growing number of treatment options and modalities, incompatibilities among the vast variety of technology platforms that have recently been adopted by the health care industry, and competing and misaligned incentives for providers and systems. Here we examine the issue of regional care coordination in cancer through the prism of a real patient journey. This article will synthesize and elaborate on existing knowledge about coordination approaches for complex systems, in particular, in general and cancer care multidisciplinary teams; define elements of coordination derived from organizational psychology and human factors research that are applicable to team-based cancer care delivery; and suggest approaches for improving multidisciplinary team coordination in regional cancer care delivery and avenues for future research. The phenomenon of the mobile, multisystem patient represents a growing challenge in cancer care. Paradoxically, development of high-quality, high-volume centers of excellence and the ease of virtual communication and data sharing by using electronic medical records have introduced significant barriers to effective team-based cancer care. These challenges urgently require solutions.

Distributed cognition in Search and Rescue: loosely coupled tasks and tightly coupled roles

The perceptual cycle model (PCM) underpins much Ergonomics research, particularly in a team context, for example in its theoretical underpinning of distributed situation awareness. Despite this, the PCM framework it has not been explicitly applied to explore team processes, which is surprising given the prevalence of teamwork in safety critical systems. This paper explores team processes in the context of search and rescue (SAR) by applying the PCM and an association classification scheme with a network analysis approach utilising the event analysis of systemic teamwork (EAST) method. Data were collected via observations and communication recordings during training flights with SAR crews and were amalgamated into a representative case study. The analysis demonstrates how the SAR team function within a distributed perceptual cycle whereby the actions of one team member become world information for another team member. Advancements to the EAST method are proposed and the implications of the research are discussed. Practitioner Summary: This paper explores the perceptual cycle interactions of SAR crews using a novel EAST approach. The analysis demonstrates how the crew function as a distributed cognitive unit and applications in terms of training and design are discussed.

What can acute medicine learn from qualitative methods?

PURPOSE OF REVIEW

The contribution of qualitative methods to evidence-based medicine is growing, with qualitative studies increasingly used to examine patient experience and unsafe organizational cultures. The present review considers qualitative research recently conducted on teamwork and organizational culture in the ICU and also other acute domains.

RECENT FINDINGS

Qualitative studies have highlighted the importance of interpersonal and social aspects of healthcare on managing and responding to patient care needs. Clear/consistent communication, compassion, and trust underpin successful patient-physician interactions, with improved patient experiences linked to patient safety and clinical effectiveness across a wide range of measures and outcomes. Across multidisciplinary teams, good communication facilitates shared understanding, decision-making and coordinated action, reducing patient risk in the process.

SUMMARY

Qualitative methods highlight the complex nature of risk management in hospital wards, which is highly contextualized to the demands and resources available, and influenced by multilayered social contexts. In addition to augmenting quantitative research, qualitative investigations enable the investigation of questions on social behaviour that are beyond the scope of quantitative assessment alone. To develop improved patient-centred care, health professionals should therefore consider integrating qualitative procedures into their existing assessments of patient/staff satisfaction.

The Effect of Health Information Technology on Health Care Provider Communication: A Mixed-Method Protocol

Background

Communication failures between physicians and nurses are one of the most common causes of adverse events for hospitalized patients, as well as a major root cause of all sentinel events. Communication technology (ie, the electronic medical record, computerized provider order entry, email, and pagers), which is a component of health information technology (HIT), may help reduce some communication failures but increase others because of an inadequate understanding of how communication technology is used. Increasing use of health information and communication technologies is likely to affect communication between nurses and physicians.

Objective

The purpose of this study is to describe, in detail, how health information and communication technologies facilitate or hinder communication between nurses and physicians with the ultimate goal of identifying how we can optimize the use of these technologies to support effective communication. Effective communication is the process of developing shared understanding between communicators by establishing, testing, and maintaining relationships. Our theoretical model, based in communication and sociology theories, describes how health information and communication technologies affect communication through communication practices (ie, use of rich media; the location and availability of computers) and work relationships (ie, hierarchies and team stability). Therefore we seek to (1) identify the range of health information and communication technologies used in a national sample of medical-surgical acute care units, (2) describe communication practices and work relationships that may be influenced by health information and communication technologies in these same settings, and (3) explore how differences in health information and communication technologies, communication practices, and work relationships between physicians and nurses influence communication.

Methods

This 4-year study uses a sequential mixed-methods design, beginning with a quantitative survey followed by a two-part qualitative phase. Survey results from aim 1 will provide a detailed assessment of health information and communication technologies in use and help identify sites with variation in health information and communication technologies for the qualitative phase of the study. In aim 2, we will conduct telephone interviews with hospital personnel in up to 8 hospitals to gather in-depth information about communication practices and work relationships on medical-surgical units. In aim 3, we will collect data in 4 hospitals (selected from telephone interview results) via observation, shadowing, focus groups, and artifacts to learn how health information and communication technologies, communication practices, and work relationships affect communication.

Results

Results from aim 1 will be published in 2016. Results from aims 2 and 3 will be published in subsequent years.

Conclusions

As the majority of US hospitals do not yet have HIT fully implemented, results from our study will inform future development and implementation of health information and communication technologies to support effective communication between nurses and physicians.

Investigating information-processing performance of different command team structures in the NATO Problem Space

The structure of command teams is a significant factor on their communications and ability to process, and act upon, information. The NATO Problem Space was used in this study to represent three of the main dimensions in the battle-space environment: familiarity, rate of change, and strength of information position. Results show that the five common team structures (chain, Y, circle, wheel and all-connected) did not generally perform as predicted in team literature. Findings suggest that under dynamic and highly variable conditions, high levels of synchronisation and trust should be present. On the other hand, synchronisation and trust are less important in hierarchical, highly centralised structures, because team members are more willing to accept the authority of a single leader and this tight control ensures that these teams can perform well as long as the Problem Space is familiar, information is explicit and the environment does not change. Practitioner Summary: Some types of team structures are better suited to particular constraints of the battle-space than others. This research has shown that the much touted all-connected structure is often the worst performing structure and that the traditional hierarchy of command and control has much merit in the digital information age.

Endoscopic non-technical skills team training: The next step in quality assurance of endoscopy training

AIM: To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes.

METHODS: A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day’s training utilising real clinical examples. Pre and post-course evaluation comprised participants’ patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected.

RESULTS: Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training.

CONCLUSION: A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams’ knowledge and safety attitudes.

Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics

INTRODUCTION

Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care.

MATERIAL AND METHODS

We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity.

RESULTS

4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001).

CONCLUSIONS

Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures.

IMPLICATIONS

Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.

Re-validating the Observational Teamwork Assessment for Surgery tool (OTAS-D): cultural adaptation, refinement, and psychometric evaluation

BACKGROUND

The nontechnical and team skills of surgical teams are critical for safety and efficiency in the operating room. Assessment of nontechnical and team skills can facilitate improvement by encouraging both self-reflection and team reflection, identifying training needs, and informing operating room (OR) team training approaches. The observational teamwork assessment for surgery (OTAS) tool is a well-validated and robust tool for capturing teamwork in the operating room. The aims of the present study were to systematically adapt and refine the OTAS for German-speaking OR staff and to test the adapted assessment tool (OTAS-D) for psychometric properties and metric equivalence.

METHODS

The study was carried out in three stages: at stage 1, OTAS was translated into German. At stage 2, experienced German OR experts (surgeons, OR nurses, anesthetists) were interviewed. At stage 3, two blinded assessors observed 11 general surgical operations (general surgical and vascular procedures) and interrater reliability was tested for refined OTAS-D behavioral exemplars and scorings.

RESULTS

The German OR experts confirmed the applicability and content validity of the vast majority of translated behavioral exemplars. After their evaluation, 32 items were changed slightly, six were changed substantially, and one item was added. During observations, perfect and substantial interobserver agreement was found for 77 behavioral exemplars (67.1 % of the items, kappa coefficient >0.60). Rating at all OTAS behaviors showed acceptable levels of reliability (intraclass correlation coefficients >0.72).

CONCLUSIONS

The OTAS-D is a tool for valid and reliable assessment of nontechnical skills that contribute to safe and effective surgical performance in ORs staffed by German-speaking professionals. Furthermore, our study serves as an example for systematically adapting and customizing well-established observational tools across different healthcare environments.

Team performance in networked supervisory control of unmanned air vehicles: effects of automation, working memory, and communication content

OBJECTIVE

Assess team performance within a net-worked supervisory control setting while manipulating automated decision aids and monitoring team communication and working memory ability.

BACKGROUND

Networked systems such as multi-unmanned air vehicle (UAV) supervision have complex properties that make prediction of human-system performance difficult. Automated decision aid can provide valuable information to operators, individual abilities can limit or facilitate team performance, and team communication patterns can alter how effectively individuals work together. We hypothesized that reliable automation, higher working memory capacity, and increased communication rates of task-relevant information would offset performance decrements attributed to high task load.

METHOD

Two-person teams performed a simulated air defense task with two levels of task load and three levels of automated aid reliability. Teams communicated and received decision aid messages via chat window text messages.

RESULTS

Task Load x Automation effects were significant across all performance measures. Reliable automation limited the decline in team performance with increasing task load. Average team spatial working memory was a stronger predictor than other measures of team working memory. Frequency of team rapport and enemy location communications positively related to team performance, and word count was negatively related to team performance.

CONCLUSION

Reliable decision aiding mitigated team performance decline during increased task load during multi-UAV supervisory control. Team spatial working memory, communication of spatial information, and team rapport predicted team success.

APPLICATION

An automated decision aid can improve team performance under high task load. Assessment of spatial working memory and the communication of task-relevant information can help in operator and team selection in supervisory control systems.

'Achieving ensemble': communication in orthopaedic surgical teams and the development of situation awareness--an observational study using live videotaped examples

Focused dialogue, as good communication between practitioners, offers a condition of possibility for development of high levels of situation awareness in surgical teams. This has been termed "achieving ensemble". Situation awareness grasps what is happening in time and space with regard to one's own unfolding work in relation to that of colleagues, and is necessary to maintain patient safety throughout a surgical list. We refined a typology, initially developed for use in studying the dynamics of teams in aviation safety, of 10 kinds of communication within two broad areas: 'Reports', or authoritative acts of communication setting up a monological or authoritative climate; and 'Requests', or facilitative acts of communication setting up a dialogical or participatory climate. We systematically mapped how orthopaedic surgical teams use verbal communication through analysis of videotaped operations using the typology. We asked: 'do orthopaedic surgical teams set up the conditions of possibility for the emergence of situation awareness through effective communication?' We found that orthopaedic surgical teams tend to produce monological rather than dialogical climates. Dialogue increases with more complex cases, but in routine work, communication levels are depressed and one-way, influenced by surgeons working within a traditionally hierarchical and authoritative culture. We suggest that such a monological climate inhibits development of situation awareness and then compromises patient safety. The same teams, however, generate potentially rich educational climates through exchange of profession-specific knowledge and skills, and we suggest that where technical skill exchange is good, non-technical or interpersonal communication skill levels can follow.

Impact of virtual training environments on the acquisition and transfer of knowledge

Virtual training environments are appropriate to train complex tasks that require collaboration and interaction among the members of a team, especially if training in reality is not possible, too expensive or too dangerous. The field study reported in this paper compared three training conditions (virtual condition, standard condition, and control condition). The participants were police officers who were being trained in the communication between ground forces and a helicopter crew during an operation. This task (like many other tasks of the police, fire brigade and emergency services) is of high complexity and has no single "correct" solution, is based on specialization of tasks within a team, requires intensive communication among team members, and consists of situations in which human beings are in danger. Learning outcomes and knowledge transfer were measured as dependent variables. The results validate that virtual training was as efficient as standard training with regard to knowledge acquisition, and it was even more efficient with regard to knowledge transfer. With regard to the perceived value of the training, the participants judged standard training to be better than virtual training (except for training satisfaction, where no difference was found between standard and virtual training). These results indicate that virtual training is an effective tool for training in complex tasks that require collaboration and cannot fully be trained for in reality.

Team Displays Work, Particularly with Communication Breakdown: Performance and Situation Awareness in a Simulated Forest Fire

A team display provides integrated information required by teams performing command and control tasks in complex situations. This study assessed the impact of such an information display using the C3Fire micro-world simulation of command and control tasks when managing forest fire incidents. The study focused on the impact of the team display when teamwork was interrupted by communication breakdown. The findings show that performance was significantly better with the team display, in terms of a lower mean number of lost houses, particularly when there was a communication breakdown. In addition, the presence of the team display was associated with better situation awareness. In practical terms, the study shows that a team display facilitates performance and situation awareness. In theoretical terms, there may be other cognitive processes and contributing factors to the benefit of the team display in addition to facilitating situation awareness.

Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence

AIM

To review the literature on the use of simulation in the development of non-technical skills in nursing

BACKGROUND

The potential risks to patients associated with learning 'at the bedside' are becoming increasingly unacceptable, and the search for innovative education and training methods that do not expose the patient to preventable errors continues. All the evidence shows that a significant proportion of adverse events in health care is caused by problems relating to the application of the 'non-technical' skills of communication, teamwork, leadership and decision-making.

RESULTS

Simulation is positively associated with significantly improved interpersonal communication skills at patient handover, and it has also been clearly shown to improve team behaviours in a wide variety of clinical contexts and clinical personnel, associated with improved team performance in the management of crisis situations. It also enables the effective development of transferable, transformational leadership skills, and has also been demonstrated to improve students' critical thinking and clinical reasoning in complex care situations, and to aid in the development of students' self-efficacy and confidence in their own clinical abilities.

CONCLUSION

High fidelity simulation is able to provide participants with a learning environment in which to develop non-technical skills, that is safe and controlled so that the participants are able to make mistakes, correct those mistakes in real time and learn from them, without fear of compromising patient safety. Participants in simulation are also able to rehearse the clinical management of rare, complex or crisis situations in a valid representation of clinical practice, before practising on patients.

Why simulation-based team training has not been used effectively and what can be done about it

Advanced medical education simulators are broadly used today to train both technical/procedural and team-based skills. While there is convincing evidence of the benefits of training technical skills, this is not the case for team-based skills. Research on medical expertise could drive the creation of a new regime of simulation-based team training. The new regime includes first the understanding of complex systems such as the hospital and the operating room; then the performance of work-place assessment; thirdly, the deliberate training of weaknesses and team performance skills; and lastly the understanding of the underlying mechanisms of team competence. A new regime of deliberate training proposed by the author, which would need to be evaluated and validated, could elucidate the underlying mechanisms of team competence while providing evidence of the effect of simulation-based team training.

Effective teamworking in gastroenterology

The majority of healthcare provision within the NHS is delivered by teams, but most attempts at improving team functioning are limited to promoting working relationships within the team. This contrasts with other high risk industries, where formalised team training is recognised to be of paramount importance in reducing error. Some medical specialities have adapted such training methodologies with the aim of improving productivity and clinical outcomes. There are many teams within gastroenterology that could benefit from such attention. Formal analysis of team objectives and identification of essential task sequences can allow redesign of team organisation and enable structured training to strengthen team cohesion, enhance critical team skills and improve clinical outcomes. The challenge is to change teams of experts into expert teams.

Developing a high-performance team training framework for internal medicine residents: the ABC'S of teamwork

OBJECTIVES

Effective teamwork and communication can prevent error and mitigate harm. High-performance team training was developed in the aviation industry for flight crews and is being incorporated in health care settings, such as emergency departments, operating rooms, and labor and delivery suites. We translated and adapted high-performance teamwork and communication principles from other industries and other disciplines to an inpatient internal medicine environment.

METHODS

We selected key principles from aviation and anesthesia crew training programs in 2004 and organized them into the ABC'S of teamwork. These included appropriate Assertiveness, effective Briefings, Callback and verification, Situational awareness, and Shared mental models. Based on this content, we developed a training session for internal medicine residents and faculty, and evaluated learners' patient safety attitudes and knowledge before and after training with a written survey.

RESULTS

More than 50 residents participated in the module. The percentage of correct answers on a question related to key teamwork principles increased from 35% before training to 67% after training (P = 0.03). Before training, 65% of the residents reported that they "would feel comfortable telling a senior clinician his/her plan was unsafe"; this increased to 94% after training (P = 0.005). After the training session, residents were able to provide examples from their clinical practice that emphasized all of the ABC'S of teamwork.

CONCLUSIONS

Teamwork principles can be adapted from other disciplines and applied to internal medicine. After a single session, residents displayed greater knowledge of teamwork principles and reported changed attitudes toward key teamwork behaviors.

The famous five factors in teamwork: a case study of fratricide

The purpose of this paper is to propose foundations for a theory of errors in teamwork based upon analysis of a case study of fratricide alongside a review of the existing literature. This approach may help to promote a better understanding of interactions within complex systems and help in the formulation of hypotheses and predictions concerning errors in teamwork, particularly incidents of fratricide. It is proposed that a fusion of concepts drawn from error models, with common causal categories taken from teamwork models, could allow for an in-depth exploration of incidents of fratricide. It is argued that such a model has the potential to explore the core causal categories identified as present in an incident of fratricide. This view marks fratricide as a process of errors occurring throughout the military system as a whole, particularly due to problems in teamwork within this complex system. Implications of this viewpoint for the development of a new theory of fratricide are offered. STATEMENT OF RELEVANCE: This article provides an insight into the fusion of existing error and teamwork models for the analysis of an incident of fratricide. Within this paper, a number of commonalities among models of teamwork have been identified allowing for the development of a model.

Team Member Personality, Performance and Stress in a RoboFlag Synthetic Task Environment

Effective teamwork is an important component in the control of multiple unmanned vehicles (UVs). Personality traits of individual team members may be a factor influencing overall team performance and individual levels of perceived workload and stress. In this study, a multiple UV environment was simulated by use of the RoboFlag game. Participants played the RoboFlag game individually or in two-person teams and were presented with this sequence of task-phases: RoboFlag alone, RoboFlag with a secondary task, RoboFlag alone. It was predicted that the RoboFlag performance would relate to ‘Big Five’ personality traits. It was also expected that Neuroticism would relate to higher workload and stress, especially in more demanding task conditions. The results suggested that the influence of personality is generally limited, but may sometimes be important. Specifically, high Neuroticism individuals showed higher workload and stress in a team player condition, which may impose social as well as task demands.

Communication and team situation awareness in the OR: Implications for augmentative information display

Team Situation Awareness (TSA) is one of the critical factors in effective Operating Room (OR) teamwork and can impact patient safety and quality of care. While previous research showed a relationship between situation awareness, as measured by communication events, and team performance, the implications for developing technology to augment and facilitate TSA were not examined. This research aims to further study situation-related communications in the cardiac OR in order to uncover potential degradation in TSA which may lead to adverse events. The communication loop construct-the full cycle of information flow between the participants in the sequence-was used to assess susceptibility to breakdown. Previous research and the findings here suggest that communication loops that are open, non-directed, or with delayed closure, can be susceptible to information loss. These were quantitatively related to communication indicators of TSA such as questions, replies, and announcements. Taken together, both qualitative and quantitative analyses suggest that a high proportion of TSA-related communication (63%) can be characterized as susceptible to information loss. The findings were then used to derive requirements and design a TSA augmentative display. The design principles and potential benefits of such a display are outlined and discussed.

Promoting Work Motivation in Organizations

What are the best interventions that Work and Organizational Psychology offers today for promoting high work motivation in organizations? This paper seeks to answer this question in two steps. First, we briefly summarize the main findings from 26 meta-analyses concerned with traditional practices such as goal setting, feedback, work design, financial incentives, or training. These practices can improve both organizational performance and the well-being of organizational members. Second, we examine in more depth a new, increasingly important high performance work practice: Employee involvement in organizational leadership (EIOL). This approach is built on theories focusing on organizational participation, shared leadership, and organizational democracy. We also illustrate recently constructed measurement instruments for assessing these constructs. This synopsis leads us to the development of a new integrative, multilevel model of EIOL. The model includes several mediator (e.g., knowledge exchange) and moderator variables (e.g., self-leadership competencies of actors) that explain why and when this approach is effective. We conclude that future research should focus on cross-level interactions of different forms of organizational participation, shared leadership, and organizational democracy, and seek to identify the processes mediating their interplay.