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Beuken JA, Bouwmans ME, Dolmans DH, Hoven MF, Verstegen DM. Qualitative expert evaluation of an educational intervention outline aimed at developing a shared understanding of cross-border healthcare. GMS JOURNAL FOR MEDICAL EDUCATION 2024; 41:Doc17. [PMID: 38779699 PMCID: PMC11106574 DOI: 10.3205/zma001672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/17/2024] [Accepted: 02/09/2024] [Indexed: 05/25/2024]
Abstract
Objectives Although cross-border healthcare benefits many patients and healthcare professionals, it also poses challenges. To develop a shared understanding of these opportunities and challenges among healthcare professionals, we designed an educational intervention outline and invited experts in healthcare and education to evaluate it. The proposed intervention was based on theoretical principles of authentic, team, and reflective learning. Methods Experts (N=11) received a paper outline of the intervention, which was subsequently discussed in individual, semi-structured interviews. Results Based on a thematic analysis of the interviews, we identified 4 themes: 1) using the experience you have, 2) learning with the people you work with, 3) taking the time to reflect on the past and future, and 4) adapting the intervention to its context. Conclusion According to the experts, the proposed intervention and its three underlying principles can enhance a shared understanding of cross-border healthcare. To unlock its full potential, however, they suggested adjusting the application of learning principles to its specific context. By situating learning in landscapes of practice, the intervention could contribute to the continuous development of cross-border healthcare.
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Affiliation(s)
- Juliëtte A. Beuken
- Maastricht University, School of Health Professions Education, Department of Educational Development and Research, Maastricht, The Netherlands
| | - Mara E.J. Bouwmans
- Maastricht University, School of Health Professions Education, Department of Educational Development and Research, Maastricht, The Netherlands
| | - Diana H.J.M. Dolmans
- Maastricht University, School of Health Professions Education, Department of Educational Development and Research, Maastricht, The Netherlands
| | - Michael F.M. Hoven
- Maastricht University, School of Health Professions Education, Department of Educational Development and Research, Maastricht, The Netherlands
| | - Daniëlle M.L. Verstegen
- Maastricht University, School of Health Professions Education, Department of Educational Development and Research, Maastricht, The Netherlands
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Gutgeld-Dror M, Laor N, Karnieli-Miller O. Assertiveness in physicians' interpersonal professional encounters: A scoping review. MEDICAL EDUCATION 2024; 58:392-404. [PMID: 37725417 DOI: 10.1111/medu.15222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/04/2023] [Accepted: 09/01/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE Good relationships between physicians, patients, families and the healthcare team are essential for high-quality care. Medical encounters are sometimes challenging. They may include conflicts, requiring physicians to be assertive: that is to share and protect their needs, rights and values while preserving those of others. Whereas assertiveness has been studied in patients and nursing staff (those with less power in healthcare), physicians' assertiveness, which must be mindful of these power differences, lacks a comprehensive review. Thus, this scoping review focuses on assertive communication in physicians' encounters. METHODS A literature search of four online databases: MEDLINE, Embase, PsycINFO and WoS, seeking articles on physicians' assertiveness as a communication style published until February 2022. The Joanna Briggs Institute approach and the Preferred Reporting Items for Systematic Reviews checklist underpinned the review protocol. RESULTS We identified 1513 articles relating to assertiveness, reviewed 153 full-text articles and selected 22 for full review, 68% from the last decade. The articles focused mainly on assertive communication and relationships with medical staff, with 54% focusing on bottom-up power relations. In 40% of the articles, no clear definition of assertiveness was included. Definitions included had varied focus: on self, on the other or both. Overall, assertiveness measures varied widely, precluding a methodical comparison. CONCLUSIONS Despite the growing interest in physicians' assertiveness, a clearer definition and in-depth exploration of assertiveness are needed alongside development of valid measures of assertiveness appropriate to physicians. Based on the review, we offer a relational definition of assertiveness as the capacity to communicate one's views, concerns, rights and needs while respecting others and preserving therapeutic, collegial and educational professional alliances. This definition may serve to expand research in the field while offering a professional alternative to problematic communication styles-passive and self-denying or paternalistic and aggressive -that obfuscate and thus undermine physician-patient relationships.
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Affiliation(s)
- Maayan Gutgeld-Dror
- Department of Medical Education, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Cohen-Harris Resilience Centre, OTI The Israeli Autism Association, Tel Aviv, Israel
| | - Nathaniel Laor
- Cohen-Harris Resilience Centre, OTI The Israeli Autism Association, Tel Aviv, Israel
- Department of Psychiatry, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Child Study Center, Yale University, New Haven, Connecticut, USA
| | - Orit Karnieli-Miller
- Department of Medical Education, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Majidi SA, Fakoorfard Z, Safarmohammadi H, Kazemnezhad Leily E. The Relationship between Moral Intelligence and Patient Safety Culture in Nurses. J Caring Sci 2023; 12:241-247. [PMID: 38249999 PMCID: PMC10799267 DOI: 10.34172/jcs.2023.30501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/09/2021] [Indexed: 01/23/2024] Open
Abstract
Introduction Ethical issues are among the first concerns and important issues in the daily care of nurses, so that nurses always try to maintain and observe them in order to provide better and more basic care to patients. Moral intelligence (MI) can provide a framework for the proper functioning of nurses. The main purpose of this study was to determine the relationship between patient safety culture and the MI of nurses working in hospitals in Iran, Guilan province. Methods In the present study which was descriptive and correlational research, the sample was 400 nurses from Iran. Data were collected by a standardized and modified questionnaire "Hospital Survey on Patient Safety Culture (HSOPSC)", and "Lennick & Kiel's Moral Intelligence Scale". The collected data were analyzed by Spearman correlation and Friedman test via SPSS software version 13. Results The findings of the study showed that the relationship between the patient safety culture and MI, was significant, and the total MI score (P<0.0001 and r=0.30). Conclusion There is a positive correlation between MI of nurses and patient safety culture. Therefore, planning to increase the MI of nurses can lead to improve patients' safety culture.
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Affiliation(s)
- Seyed Ali Majidi
- Department of Nursing & Midwifery, Rasht Branch, Islamic Azad University, Rasht, Iran
| | - Zeinab Fakoorfard
- National Institute for Health Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamideh Safarmohammadi
- Poursina Education & Treatment Center, Guilan University of Medical Sciences, Guilan, Iran
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Ricotta DN, Freed JA, Hale AJ, Targan E, Smith CC, Huang GC. A Resident-as-Leader Curriculum for Managing Inpatient Teams. TEACHING AND LEARNING IN MEDICINE 2023; 35:73-82. [PMID: 35023796 DOI: 10.1080/10401334.2021.2009347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/25/2021] [Accepted: 11/10/2021] [Indexed: 06/14/2023]
Abstract
PROBLEM Leading inpatient teams is a foundational clinical responsibility of resident physicians and leadership is a core competency for inpatient physicians, yet few training programs have formal leadership curricula to realize this clinical skill. INTERVENTION We implemented a 4-module curriculum for PGY1 internal medicine residents. The program focused on the managerial skills necessary for daily clinical leadership, followed by clinical coaching. Interns were first introduced to foundational concepts and then given the opportunity to apply those concepts to real-world practice followed by clinical coaching. CONTEXT Using direct-observations and a previously published checklist for rounds leadership, this study sought to evaluate the workplace behavior change for novice residents leading inpatient teams for the first time. We conducted a prospective cohort study (March 2016 and August 2018) of internal medicine residents at a large tertiary academic medical center in Boston, MA. Trained faculty raters performed direct observations of clinical rounding experiences using the checklist and compared the findings to historical and internal controls. Questionnaires were distributed pre- and post- curriculum to assess satisfaction and readiness to lead a team. IMPACT We trained 65 PGY1 residents and raters conducted 140 direct observations - 36 in the intervention group and 104 among historical controls. The unadjusted mean score in rounds leadership skills for the intervention group was 19.0 (SD = 5.1) compared to 16.2 (SD = 6.2) for historical controls. Adjusting for repeated measures, we found significant improvement in mean scores for behaviors linked to the curricular objectives (p = 0.008) but not for general behaviors not covered by the curriculum (p = 0.2). LESSONS LEARNED A formal curriculum to train residents as leaders led to behavior change in the workplace in domains essential to rounds leadership. We also found that the curriculum was highly regarded in that all interns indicated they would recommend the curriculum to a peer. Moreover, the program may have assuaged some anxiety during the transition to junior year as 90% of interns surveyed felt more ready to start PGY2 year than historical trainings. We learned that while a robust, multi-faceted modular curriculum and clinical coaching successfully resulted in behavior change, the resources required to manage this program are significant and difficult to sustain. Future iterations could include asynchronous material and potentially peer-observation of rounds leadership to reduce the burden on faculty and program curricular time.
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Affiliation(s)
- Daniel N Ricotta
- Carl J. Shapiro Institute for Education and Research, Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jason A Freed
- Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew J Hale
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Elizabeth Targan
- Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - C Christopher Smith
- Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Grace C Huang
- Carl J. Shapiro Institute for Education and Research, Department of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Ulmer FF, Lutz AM, Müller F, Riva T, Bütikofer L, Greif R. Communication Patterns During Routine Patient Care in a Pediatric Intensive Care Unit: The Behavioral Impact of In Situ Simulation. J Patient Saf 2022; 18:e573-e579. [PMID: 34224500 DOI: 10.1097/pts.0000000000000872] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Effective communication minimizes medical errors and leads to improved team performance while treating critically ill patients. Closed-loop communication is routinely applied in high-risk industries but remains underutilized in healthcare. Simulation serves as an educational tool to introduce, practice, and appreciate the efficacy of closed-loop communication. METHODS This observational before-and-after study investigates behavioral changes in communication among nurses brought on by simulation team training in a pediatric intensive care unit (PICU). The communication patterns of PICU nurses, who had no prior simulation experience, were observed during routine bedside care before and after undergoing in situ simulation.One month before and 1 and 3 months after simulation (intervention), 2 trained raters recorded nurse communications relative to callouts, uttered by the sender, and callbacks, reciprocated by the recipient. The impact of simulation on communication patterns was analyzed quantitatively. RESULTS Among the 15 PICU nurses included in this study, significant changes in communication behavior were observed during patient care after communication-focused in situ simulation. The PICU nurses were significantly less likely to let a callout go unanswered during clinical routine. The effect prevailed both 1 month (P = 0.039) and 3 months (P = 0.033) after the educational exposure. CONCLUSIONS This observational before-and-after study describes the prevalence and pattern of communication among PICU nurses during routine patient care and documents PICU nurses transferring simulation-acquired communication skills into their clinical environment after a single afternoon of in situ simulation. This successful transfer of simulation-acquired skills has the potential to improve patient safety and outcome.
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Affiliation(s)
- Francis F Ulmer
- From the Department of Pediatrics, Section of Pediatric Critical Care
| | - Andrea M Lutz
- Department of Anesthesiology and Pain Therapy, Bern University Hospital, University of Bern
| | - Fabienne Müller
- From the Department of Pediatrics, Section of Pediatric Critical Care
| | - Thomas Riva
- Department of Anesthesiology and Pain Therapy, Bern University Hospital, University of Bern
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Buljac-Samardžić M, Dekker-van Doorn CM, Maynard MT. What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness. J Patient Saf 2021; 17:e929-e958. [PMID: 34852415 PMCID: PMC8612906 DOI: 10.1097/pts.0000000000000816] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | | | - M. Travis Maynard
- Department of Management, College of Business, Colorado State University, Fort Collins, Colorado
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Holtrop JS, Scherer LD, Matlock DD, Glasgow RE, Green LA. The Importance of Mental Models in Implementation Science. Front Public Health 2021; 9:680316. [PMID: 34295871 PMCID: PMC8290163 DOI: 10.3389/fpubh.2021.680316] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/10/2021] [Indexed: 01/11/2023] Open
Abstract
Implementation science is concerned with the study of adoption, implementation and maintenance of evidence-based interventions and use of implementation strategies to facilitate translation into practice. Ways to conceptualize and overcome challenges to implementing evidence-based practice may enhance the field of implementation science. The concept of mental models may be one way to view such challenges and to guide selection, use, and adaptation of implementation strategies to deliver evidence-based interventions. A mental model is an interrelated set of beliefs that shape how a person forms expectations for the future and understands the way the world works. Mental models can shape how an individual thinks about or understands how something or someone does, can, or should function in the world. Mental models may be sparse or detailed, may be shared among actors in implementation or not, and may be substantially tacit, that is, of limited accessibility to introspection. Actors' mental models can determine what information they are willing to accept and what changes they are willing to consider. We review the concepts of mental models and illustrate how they pertain to implementation of an example intervention, shared decision making. We then describe and illustrate potential methods for eliciting and analyzing mental models. Understanding the mental models of various actors in implementation can provide crucial information for understanding, anticipating, and overcoming implementation challenges. Successful implementation often requires changing actors' mental models or the way in which interventions or implementation strategies are presented or implemented. Accurate elicitation and understanding can guide strategies for doing so.
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Affiliation(s)
| | - Laura D Scherer
- School of Medicine, University of Colorado, Aurora, CO, United States
| | - Daniel D Matlock
- School of Medicine, University of Colorado, Aurora, CO, United States
| | - Russell E Glasgow
- School of Medicine, University of Colorado, Aurora, CO, United States
| | - Lee A Green
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada
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Abstract
OBJECTIVE Despite good intentions, mishaps in teamwork continue to affect patient's lives and plague the medical community at large and Emergency Medical Services (EMS) in particular. Effective and efficient management of patient care necessitates that sets of multiple teams (i.e., multiteam systems [MTSs] - EMS ground crews, EMS air crews, dispatch, and receiving hospital teams) seamlessly work together. Although advances have been made to improve teams, little research has been dedicated to enhancing MTSs especially in the critical yet often under studied domain of EMS. The purpose of this paper is to assist the pre-hospital community in strengthening patient care by presenting considerations unique to multiteam systems. METHODS We synthesized the literature pertinent to multi-team systems and emergency medical services. RESULTS From this synthesis, we derived five unique considerations: goals, boundary spanning, adaptation, leadership, and social identity. CONCLUSIONS MTSs are prevalent in prehospital care, as they define how multiple component healthcare teams work together to intervene in emergency situations. We provided some initial directions regarding considerations for success in EMS MTSs based on existing research, but we also recognize the need for further study on these issues.
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Ricotta DN, Ranchoff BL, Beltran CP, Hale AJ, Freed JA, Huang GC. The Mindful Manager: Validation of a Rounding Leadership Instrument for Residents. J Gen Intern Med 2020; 35:1161-1166. [PMID: 31898139 PMCID: PMC7174453 DOI: 10.1007/s11606-019-05348-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 09/10/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In the context of inpatient general medicine, "rounding" refers to the process of seeing, assessing, and caring for patients as a team. The clinical leadership skills required of residents to lead rounds are essential to inpatient care and clinical education. Assessment of these skills has relevance to developing competent physicians; however, there is an absence of widely accepted tools to specifically measure this competency. OBJECTIVE To develop and collect validity evidence for a direct observation instrument of internal medicine residents' leadership skills during daily inpatient care rounds for future formative assessment. DESIGN Prospective observational study. PARTICIPANTS PGY2 and PGY3 internal medicine residents. MAIN MEASURES The authors collected inferences of validity evidence according to Kane's validity model. They performed direct observations of PGY2 and PGY3 residents by individual faculty and trained raters and measured inter-rater reliability, using the kappa statistic. Mixed linear regression models were used to compare PGY2 and PGY3 residents. Surveys captured faculty perceptions about value of the instrument. KEY RESULTS A total of 223 observations were performed in 92 unique individuals. Twenty-four faculty used the observation instrument, of which 18 (75%) completed the post-survey, and 100% agreed that the instrument represented the resident's global leadership abilities. Inter-rater reliability was strong, with an overall kappa statistic equaling 0.82. The mean performance for PGY2 and PGY3 residents was 15.9 (SD 5.1) and 17.7 (SD 4.1), respectively. Adjusting for repeated measures, there was no statistically significant difference between groups. CONCLUSIONS The authors reported evidence for all four stages of validity and use of the instrument in clinical practice. Their work provides a codification of best practices of rounding leadership, which directly impacts the education of trainees, care of hospitalized patients, and use for formative assessment. The instrument also has the potential to be used for summative assessment.
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Affiliation(s)
- Daniel N Ricotta
- Department of Medicine Beth, Israel Deaconess Medical Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Carl J. Shapiro Institute for Education and Research, Boston, MA, USA.
| | - Brittany L Ranchoff
- Department of Medicine Beth, Israel Deaconess Medical Center, Boston, MA, USA
- Carl J. Shapiro Institute for Education and Research, Boston, MA, USA
| | - Christine P Beltran
- Department of Medicine Beth, Israel Deaconess Medical Center, Boston, MA, USA
- Carl J. Shapiro Institute for Education and Research, Boston, MA, USA
| | - Andrew J Hale
- Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Jason A Freed
- Department of Medicine Beth, Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Grace C Huang
- Department of Medicine Beth, Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Carl J. Shapiro Institute for Education and Research, Boston, MA, USA
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Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systematic review of the past decade. HUMAN RESOURCES FOR HEALTH 2020; 18:2. [PMID: 31915007 PMCID: PMC6950792 DOI: 10.1186/s12960-019-0411-3] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 09/05/2019] [Indexed: 05/19/2023]
Abstract
BACKGROUND A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design. OBJECTIVES To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research. METHODS Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence. RESULTS Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements. CONCLUSION Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.
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Affiliation(s)
- Martina Buljac-Samardzic
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Bayle building, p.o. box 1738, 3000 DR Rotterdam, The Netherlands
| | - Kirti D. Doekhie
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Bayle building, p.o. box 1738, 3000 DR Rotterdam, The Netherlands
| | - Jeroen D. H. van Wijngaarden
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Bayle building, p.o. box 1738, 3000 DR Rotterdam, The Netherlands
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Majidi SA, Alizadeh S, kouchakzadeh Talami S, Safarmohammadi H, Kazemnezhad Leily E, Motagi M, Barzegar M. Patient Safety Culture from the Viewpoint of Nurses: A Cross-Sectional Study in 2016. JOURNAL OF RESEARCH DEVELOPMENT IN NURSING AND MIDWIFERY 2019. [DOI: 10.29252/jgbfnm.16.2.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Gowda D, Dubroff R, Willieme A, Swan-Sein A, Capello C. Art as Sanctuary: A Four-Year Mixed-Methods Evaluation of a Visual Art Course Addressing Uncertainty Through Reflection. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:498-509. [PMID: 30365424 DOI: 10.1097/acm.0000000000002019] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE Engagement with visual art is a promising modality for addressing issues of uncertainty via reflective practice, one that is being increasingly used in health science education. An elective museum-based course for first-year medical students was created by two medical schools and led by an art educator experienced in medical education. The course, Observation and Uncertainty in Art and Medicine, sought to help students explore experiences of uncertainty and to develop reflective capacity through engagement with visual art. METHOD The course was run and evaluated from 2014 to 2017, with 47 students participating over the 4 years, with 12 students enrolled per year. Before and after the course, students were given the Groningen Reflection Ability Scale (GRAS) for reflective ability, the Tolerance for Ambiguity scale for ambiguity, and Best Intentions Questionnaire for personal bias awareness, and 35 students (74%) completed all of the scales. Focus group interviews and narrative postcourse evaluations were conducted, coded, and thematically analyzed. RESULTS Statistically significant improvement was found in GRAS scores. Qualitative themes included student enhancement of observational skills, awareness of the subjectivity and uncertainty of perception, exploration of multiple points of view, and recognition of the course as a place for restoration and connection to classmates. CONCLUSIONS Incorporating visual art into medical education is an effective pedagogical method for addressing competencies central to training, including observation, reflection, and self-care.
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Affiliation(s)
- Deepthiman Gowda
- D. Gowda is director of clinical practice, Program in Narrative Medicine, director, Foundations of Clinical Medicine, and associate professor of medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; ORCID: http://orcid.org/0000-0001-7124-7615. R. Dubroff is assistant professor of clinical medicine, Weill Cornell Medical College, New York, New York. A. Willieme is founder and director, ArtMed inSight, Cambridge, Massachusetts. A. Swan-Sein is director, Center for Education Research and Evaluation, and assistant professor of educational assessment in pediatrics and dental medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; ORCID: http://orcid.org/0000-0002-3139-4626. C. Capello is associate director, Office of Curriculum and Educational Development, director, Office of Academic Assistance, and associate professor of geriatrics education in medicine, Weill Cornell Medical College, New York, New York
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Assessment of Hospital Nurses’ Moral Intelligence: A Cross-Sectional Study in Guilan Province, North of Iran. ACTA ACUST UNITED AC 2018. [DOI: 10.5812/semj.62299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Martinchek M, Bird A, Pincavage AT. Building Team Resilience and Debriefing After Difficult Clinical Events: A Resilience Curriculum for Team Leaders. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2017; 13:10601. [PMID: 30800803 PMCID: PMC6338182 DOI: 10.15766/mep_2374-8265.10601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 06/21/2017] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Burnout is prevalent among medical trainees and faculty. Resilience, the ability to cope well with stress and thrive during challenges, has been a focus of initiatives to combat burnout. However, curricula teaching resilience skills are needed. Since residents experience challenging and stressful clinical events often, and would like to discuss these events with their teams, resilience skills may help trainees cope after such events. Additionally, resilience skills may help trainees address other challenges they face as team leaders. Leadership training is an important component of physician professional development. METHODS This advanced resilience training curriculum consists of two interactive workshops that include didactics, skills practice, and reflection. The first workshop focuses on applying resilience skills to team leadership, while the second focuses on structured team debriefing after difficult clinical events. This curriculum is intended for learners who are health care team leaders, such as senior residents, fellows, or faculty. It may be used with learners who have completed introductory resilience training or with those without prior training. RESULTS The curriculum was rated highly by senior residents, who reported feeling more comfortable leading their teams after difficult clinical events and talking about these events following this curriculum. The majority of residents thought the workshops should be continued. DISCUSSION This novel curriculum teaches learners to apply resilience skills during team leadership and difficult clinical scenarios. It was well received by senior residents and may be used with a variety of learners across health professions and training levels.
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Affiliation(s)
- Michelle Martinchek
- Fellow in Geriatrics, Department of Medicine, University of Chicago Division of the Biological Sciences The Pritzker School of Medicine
| | - Amber Bird
- Assistant Professor of Clinical Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Amber T. Pincavage
- Assistant Professor, Department of Medicine, University of Chicago Division of the Biological Sciences The Pritzker School of Medicine
- Internal Medicine Co-Clerkship Director, University of Chicago Division of the Biological Sciences The Pritzker School of Medicine
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Balakrishnan M, Falk-Smith N, Detman LA, Miladinovic B, Sappenfield WM, Curran JS, Ashmeade TL. Promoting teamwork may improve infant care processes during delivery room management: Florida perinatal quality collaborative's approach. J Perinatol 2017; 37:886-892. [PMID: 28406486 DOI: 10.1038/jp.2017.27] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 02/08/2017] [Accepted: 02/14/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND LOCAL PROBLEM: Inadequate understanding of compliance with standardized evidence-based DR management. INTERVENTIONS Promote inter-professional teamwork and a bundle of interventions focusing on resuscitation team roles, equipment check, and debriefing using QI methodology. Optimize delivery room (DR) management to achieve 10-min SPO2 targets, delayed-cord clamping (DCC), team role assignment and debriefings in >50% of deliveries, and achieve normothermia in >75% of infants. METHODS Over 15 months (Epoch 1 to 5), nine Florida hospitals implemented a DR management plan for infants <31 weeks gestational age or <1500 g (N=814) using quality improvement methodology. RESULTS There was increased compliance of DCC (36 to 66%), role assignment (53 to 98%), debriefing rates (33 to 76%) and having all seven pre-delivery preparedness components fulfilled (34 to 75%). There were no significant improvements in admission temperatures or SPO2 targeting. When 7 vs 0 items of pre-delivery preparedness were completed, we saw improvements in thermoregulation (57% vs 72%), SPO2 targeting (60% vs 78%) and DCC compliance (43 to 67%). CONCLUSION Promoting teamwork by increasing pre-delivery preparedness is associated with improvement of thermoregulation, SPO2 targeting and DCC compliance.
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Affiliation(s)
- M Balakrishnan
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
| | - N Falk-Smith
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - L A Detman
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - B Miladinovic
- Center for Comparative Effectiveness Research, Division of Evidence-Based Medicine, Department of Internal Medicine, University of South Florida Health, Tampa, FL, USA
| | - W M Sappenfield
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, Department of Community and Family Health, College of Public Health, University of South Florida Health, Tampa, FL, USA
| | - J S Curran
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
| | - T L Ashmeade
- Division of Neonatology, Department of Pediatrics, University of South Florida Health, Tampa, FL, USA
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Ward H, Card SE, Chipperfield D, Sheppard SM, Bulk F, Giesbrecht W. Interprofessional Skills Learning Guide: A Multimedia E-Book for Small-Group or Individual Learning. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2016; 12:10425. [PMID: 31008205 PMCID: PMC6464415 DOI: 10.15766/mep_2374-8265.10425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 04/28/2016] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Redefining learning space beyond physical classrooms with fixed resources is necessary to address challenges of interprofessional learning in a clinical setting. This multimedia e-book introduces recognized team skills of shared mental models, situational awareness, and the SBAR (situation, background, assessment, and recommendation) communication tool for individual or small-group learning. The e-book was derived from work done to develop an interprofessional small-group interactive learning tool for use in a clinical environment where resources, including meeting space, time, and facilitators, were limited. It is designed for individuals early in their clinical training but who have had previous clinical experience. METHODS Utilizing readings, a series of videos, and reflective questions, a virtual narrator guides learners through an interactive case regarding a virtual chronic obstructive pulmonary disease patient preparing for discharge. RESULTS Thirty-two responders evaluated the learning content as being clinically relevant. Comments encouraged all health care providers to become familiar with these interprofessional tools. DISCUSSION Electronic, human, and space resources are often limited, especially in the clinical/education interface of the hospital or clinic environment for embedded interprofessional learning opportunities. The multimedia e-book provides a stand-alone learning resource for individuals or small groups of the same or different professions, with the opportunity for interactive learning with minimal space and human resource requirements.
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Affiliation(s)
- Heather Ward
- Associate Professor, Department of Medicine, University of Saskatchewan College of Medicine
| | - Sharon Elizabeth Card
- Associate Professor, Department of Medicine, University of Saskatchewan College of Medicine
| | | | - Suzanned M. Sheppard
- Director of Interprofessional Practice, Education, and Research, Saskatoon Health Region
| | - Franke Bulk
- Manager of E-learning and Innovative Programs, Gwenna Moss Centre for Teaching Effectiveness, University of Saskatchewan
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Kang E, Massey D, Gillespie BM. Factors that influence the non-technical skills performance of scrub nurses: a prospective study. J Adv Nurs 2015; 71:2846-57. [DOI: 10.1111/jan.12743] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Evelyn Kang
- NHMRC Research Centre for Clinical Excellence in Nursing Interventions (NCREN) & Centre for Healthcare Practice Innovation (HPI); Griffith Health Institute; Griffith University; Gold Coast Queensland Australia
| | - Debbie Massey
- School of Nursing and Midwifery; Griffith University; Gold Coast Queensland Australia
| | - Brigid M. Gillespie
- NHMRC Research Centre for Clinical Excellence in Nursing Interventions (NCREN) & Centre for Healthcare Practice Innovation (HPI); Griffith Health Institute; Griffith University; Gold Coast Queensland Australia
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Sculli GL, Fore AM, Sine DM, Paull DE, Tschannen D, Aebersold M, Seagull FJ, Bagian JP. Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork. J Healthc Risk Manag 2015; 35:21-30. [PMID: 26227290 DOI: 10.1002/jhrm.21174] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time. This article presents data that show one such strategy, called the Effective Followership Algorithm, offering statistically significant improvements in team communication across the professional continuum from students and residents to experienced clinicians.
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Blumenthal DM, Bernard K, Fraser TN, Bohnen J, Zeidman J, Stone VE. Implementing a pilot leadership course for internal medicine residents: design considerations, participant impressions, and lessons learned. BMC MEDICAL EDUCATION 2014; 14:257. [PMID: 25433680 PMCID: PMC4261637 DOI: 10.1186/s12909-014-0257-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 11/18/2014] [Indexed: 05/26/2023]
Abstract
BACKGROUND Effective clinical leadership is associated with better patient care. We implemented and evaluated a pilot clinical leadership course for second year internal medicine residents at a large United States Academic Medical Center that is part of a multi-hospital health system. METHODS The course met weekly for two to three hours during July, 2013. Sessions included large group discussions and small group reflection meetings. Topics included leadership styles, emotional intelligence, and leading clinical teams. Course materials were designed internally and featured "business school style" case studies about everyday clinical medicine which explore how leadership skills impact care delivery. Participants evaluated the course's impact and quality using a post-course survey. Questions were structured in five point likert scale and free text format. Likert scale responses were converted to a 1-5 scale (1 = strongly disagree; 3 = neither agree nor disagree; 5 = strongly agree), and means were compared to the value 3 using one-way T-tests. Responses to free text questions were analyzed using the constant comparative method. RESULTS All sixteen pilot course participants completed the survey. Participants overwhelmingly agreed that the course provided content and skills relevant to their clinical responsibilities and leadership roles. Most participants also acknowledged that taking the course improved their understanding of their strengths and weaknesses as leaders, different leadership styles, and how to manage interpersonal conflict on clinical teams. 88% also reported that the course increased their interest in pursuing additional leadership training. CONCLUSIONS A clinical leadership course for internal medicine residents designed by colleagues, and utilizing case studies about clinical medicine, resulted in significant self-reported improvements in clinical leadership competencies.
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Affiliation(s)
- Daniel M Blumenthal
- />Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB 800, Boston, MA 02114 USA
- />Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Ken Bernard
- />Department of Emergency Medicine, Partners Healthcare, Harvard Medical School, Boston, MA USA
| | - Traci N Fraser
- />Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB 800, Boston, MA 02114 USA
| | - Jordan Bohnen
- />Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jessica Zeidman
- />Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB 800, Boston, MA 02114 USA
- />Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Valerie E Stone
- />Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, MA USA
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Shift change handovers and subsequent interruptions: potential impacts on quality of care. J Patient Saf 2014; 10:29-44. [PMID: 24553442 DOI: 10.1097/pts.0000000000000066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Two statistical surveys in France revealed both widespread dissatisfaction about shift change handovers and the feeling of being frequently disturbed by interruptions. Shift change handovers (SCHs) are being reduced or eliminated in France to reduce staff costs. The objective of our study is to clarify the consequences of short SCHs on efficiency, team function, and quality of care. METHODS Real-time task ergonomic analysis of 29 state-registered nurses (RNs), 18 nursing aides (NAs), and 14 full-time physicians was conducted in various departments of general and university hospitals. RESULTS The average time available to RNs for sharing information during SCHs was 15 minutes at the beginning of the work session and 13 minutes at the end. There were, on average, 50 interruptions of activity, and these interruptions occupied 16% of the working time. Consequently, less time was available for direct care, although the number of such acts was increased. Periods for preparation of care, writing, seeking information, or equipment were very numerous. The mean number of changes of activity was very large: 260 per work session. For NAs, SCHs were similar to those for RNs at the beginning of the work session (mean = 18 minutes) but shorter at the end (10 minutes). The mean number of interruptions was 30 and caused 10.3% of the working time to be lost with 164 changes of activity. For physicians, SCHs were even shorter and, in many cases, nonexistent. The mean number of interruptions was 30 (11.4% of their working time, 153 changes of activity). Shift change handovers were mostly conducted separately for RNs, NAs, and physicians. DISCUSSION A better sharing of knowledge between the different health-care workers, and especially at the beginning of the work session, could reduce interruptions and potentially improve quality of care.
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Havyer RDA, Wingo MT, Comfere NI, Nelson DR, Halvorsen AJ, McDonald FS, Reed DA. Teamwork assessment in internal medicine: a systematic review of validity evidence and outcomes. J Gen Intern Med 2014; 29:894-910. [PMID: 24327309 PMCID: PMC4026505 DOI: 10.1007/s11606-013-2686-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/17/2013] [Accepted: 10/02/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Valid teamwork assessment is imperative to determine physician competency and optimize patient outcomes. We systematically reviewed published instruments assessing teamwork in undergraduate, graduate, and continuing medical education in general internal medicine and all medical subspecialties. DATA SOURCES We searched MEDLINE, MEDLINE In-process, CINAHL and PsycINFO from January 1979 through October 2012, references of included articles, and abstracts from four professional meetings. Two content experts were queried for additional studies. STUDY ELIGIBILITY Included studies described quantitative tools measuring teamwork among medical students, residents, fellows, and practicing physicians on single or multi-professional (interprofessional) teams. STUDY APPRAISAL AND SYNTHESIS METHODS Instrument validity and study quality were extracted using established frameworks with existing validity evidence. Two authors independently abstracted 30 % of articles and agreement was calculated. RESULTS Of 12,922 citations, 178 articles describing 73 unique teamwork assessment tools met inclusion criteria. Interrater agreement was intraclass correlation coefficient 0.73 (95 % CI 0.63-0.81). Studies involved practicing physicians (142, 80 %), residents/fellows (70, 39 %), and medical students (11, 6 %). The majority (152, 85 %) assessed interprofessional teams. Studies were conducted in inpatient (77, 43 %), outpatient (42, 24 %), simulation (37, 21 %), and classroom (13, 7 %) settings. Validity evidence for the 73 tools included content (54, 74 %), internal structure (51, 70 %), relationships to other variables (25, 34 %), and response process (12, 16 %). Attitudes and opinions were the most frequently assessed outcomes. Relationships between teamwork scores and patient outcomes were directly examined for 13 (18 %) of tools. Scores from the Safety Attitudes Questionnaire and Team Climate Inventory have substantial validity evidence and have been associated with improved patient outcomes. LIMITATIONS Review is limited to quantitative assessments of teamwork in internal medicine. CONCLUSIONS There is strong validity evidence for several published tools assessing teamwork in internal medicine. However, few teamwork assessments have been directly linked to patient outcomes.
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Teamwork climate and patient safety attitudes: associations among nurses and comparison with physicians in Taiwan. J Nurs Care Qual 2013; 28:60-7. [PMID: 22732676 DOI: 10.1097/ncq.0b013e318262ac45] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The TeamSTEPPS Teamwork Attitudes Questionnaire and Safety Attitudes Questionnaire were distributed to the nurses in a county hospital in Taiwan. Nurses (n = 407) had lower scores in Team Structure, Communication, and Situation Monitoring than physicians (n = 76). A structural equation model demonstrated a positive association between teamwork climate and safety attitudes (β = 0.78, P < .01). Teamwork climate is the most important determinant for patient safety attitudes among nurses.
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McComb S, Simpson V. The concept of shared mental models in healthcare collaboration. J Adv Nurs 2013; 70:1479-88. [PMID: 24237202 DOI: 10.1111/jan.12307] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2013] [Indexed: 11/27/2022]
Abstract
AIM To report an analysis of the concept of shared mental models in health care. BACKGROUND Shared mental models have been described as facilitators of effective teamwork. The complexity and criticality of the current healthcare system requires shared mental models to enhance safe and effective patient/client care. Yet, the current concept definition in the healthcare literature is vague and, therefore, difficult to apply consistently in research and practice. DESIGN Concept analysis. DATA SOURCES Literature for this concept analysis was retrieved from several databases, including CINAHL, PubMed and MEDLINE (EBSCO Interface), for the years 1997-2013. METHODS Walker and Avant's approach to concept analysis was employed and, following Paley's guidance, embedded in extant theory from the team literature. RESULTS Although teamwork and collaboration are discussed frequently in healthcare literature, the concept of shared mental models in that context is not as commonly found but is increasing in appearance. Our concept analysis defines shared mental models as individually held knowledge structures that help team members function collaboratively in their environments and are comprised of the attributes of content, similarity, accuracy and dynamics. CONCLUSION This theoretically grounded concept analysis provides a foundation for a middle-range descriptive theory of shared mental models in nursing and health care. Further research concerning the impact of shared mental models in the healthcare setting can result in development and refinement of shared mental models to support effective teamwork and collaboration.
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Affiliation(s)
- Sara McComb
- Schools of Nursing and Industrial Engineering, Purdue University, West Lafayette, Indiana, USA
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Jeffs L, Abramovich IA, Hayes C, Smith O, Tregunno D, Chan WH, Reeves S. Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. BMJ Qual Saf 2013; 22:923-30. [DOI: 10.1136/bmjqs-2012-001720] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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