Co-ACT--a framework for observing coordination behaviour in acute care teams

A Safety Approach for Improving Security - Effective Coordination Strategies at the Airport Security Screening Checkpoint

OBJECTIVE

This study aimed to analyze effective teamwork at security checkpoints by investigating how security crews communicate in different (routine and threat) situations.

BACKGROUND

Working at an airport security screening checkpoint is challenging. Although tasks and processes are highly regulated and standardized due to legal requirements, security screeners must be trained to deal with unforeseen threat situations involving high levels of uncertainty. Therefore, security crews need to engage in flexible and adaptive coordination according to the situation and circumstances.

METHOD

We conducted a field study with 20 airport security screening crews comprising 100 security screeners. Teamwork in terms of interaction between crew members was measured, differentiating between proactive "push" communication and information on request representing "pull" communication. Furthermore, non-task related communication was assessed.

RESULTS

While crews showed non-task related communication more in routine situations, both task-related "push" and "pull" communication occurred more in threat situations. In terms of team performance, we could show significant positive effects of proactive "push" communication and non-task related interaction in threat situations.

CONCLUSION

Our results underscore the specific setting of airport security screening and the challenges that arise for teamwork. This study investigates professional screeners and passengers in the field. In contrast to other high-risk areas, security crews are confronted with a third party that complicates coordination strategies considered effective in previous studies.

APPLICATION

Our findings recommend situation-specific communication strategies for practical training for airport security screening crews.

Observation of behavioural skills by medical simulation facilitators: a cross-sectional analysis of self-reported importance, difficulties, observation strategies and expertise development

BACKGROUND

The association between team performance and patient care was an immense boost for team-based education in health care. Behavioural skills are an important focus in these sessions, often provided via a mannikin-based immersive simulation experience in a (near) authentic setting. Observation of these skills by the facilitator(s) is paramount for facilitated feedback with the team. Despite the acknowledgement that trained facilitators are important for optimal learning, insight into this observation process by facilitators is limited.

OBJECTIVES

What are the self-reported current practices and difficulties regarding the observation of behavioural skills amongst facilitators during team training and how have they been trained to observe behavioural skills?

METHODS

This cross-sectional study used a pilot-tested, content-validated, multi-linguistic online survey within Europe, distributed through a non-discriminative snowball sampling method. Inclusion was limited to facilitators observing behavioural skills within a medical team setting.

RESULTS

A total of 175 persons filled in the questionnaire. All aspects of behavioural skill were perceived as very important to observe. The self-perceived difficulty of the behavioural skill aspects ranged from slightly to moderately difficult. Qualitative analysis revealed three major themes elaborating on this perceived difficulty: (1) not everything can be observed, (2) not everything is observed and (3) interpretation of observed behavioural skills is difficult. Additionally, the number of team members health care facilitators have to observe, outnumbers their self-reported maximum. Strategies and tools used to facilitate their observation were a blank notepad, co-observers and predefined learning goals. The majority of facilitators acquired observational skills through self-study and personal experience and/or observing peers. Co-observation with either peers or experts was regarded as most learn some for their expertise development. Overall, participants perceived themselves as moderately competent in the observation of behavioural skills during team training.

CONCLUSIONS

Observation of behavioural skills by facilitators in health care remains a complex and challenging task. Facilitators' limitations with respect to attention, focus and (in)ability to perform concomitant tasks, need to be acknowledged. Although strategies and tools can help to facilitate the observation process, they all have their limitations and are used in different ways.

Human-AI teaming: leveraging transactive memory and speaking up for enhanced team effectiveness

In this prospective observational study, we investigate the role of transactive memory and speaking up in human-AI teams comprising 180 intensive care (ICU) physicians and nurses working with AI in a simulated clinical environment. Our findings indicate that interactions with AI agents differ significantly from human interactions, as accessing information from AI agents is positively linked to a team's ability to generate novel hypotheses and demonstrate speaking-up behavior, but only in higher-performing teams. Conversely, accessing information from human team members is negatively associated with these aspects, regardless of team performance. This study is a valuable contribution to the expanding field of research on human-AI teams and team science in general, as it emphasizes the necessity of incorporating AI agents as knowledge sources in a team's transactive memory system, as well as highlighting their role as catalysts for speaking up. Practical implications include suggestions for the design of future AI systems and human-AI team training in healthcare and beyond.

Measuring teamwork for training in healthcare using eye tracking and pose estimation

Teamwork is critical for safe patient care. Healthcare teams typically train teamwork in simulated clinical situations, which require the ability to measure teamwork via behavior observation. However, the required observations are prone to human biases and include significant cognitive load even for trained instructors. In this observational study we explored how eye tracking and pose estimation as two minimal invasive video-based technologies may measure teamwork during simulation-based teamwork training in healthcare. Mobile eye tracking, measuring where participants look, and multi-person pose estimation, measuring 3D human body and joint position, were used to record 64 third-year medical students who completed a simulated handover case in teams of four. On one hand, we processed the recorded data into the eye contact metric, based on eye tracking and relevant for situational awareness and communication patterns. On the other hand, the distance to patient metric was processed, based on multi-person pose estimation and relevant for team positioning and coordination. After successful data recording, we successfully processed the raw videos to specific teamwork metrics. The average eye contact time was 6.46 s [min 0 s - max 28.01 s], while the average distance to the patient resulted in 1.01 m [min 0.32 m - max 1.6 m]. Both metrics varied significantly between teams and simulated roles of participants (p < 0.001). With the objective, continuous, and reliable metrics we created visualizations illustrating the teams' interactions. Future research is necessary to generalize our findings and how they may complement existing methods, support instructors, and contribute to the quality of teamwork training in healthcare.

Measuring Team Hierarchy During High-Stakes Clinical Decision Making: Development and Validation of a New Behavioral Observation Method

PURPOSE

Hierarchy is often cited as a cause of health care team failure; however, there are no validated measures of team hierarchy. Research on group processes in sociology provides a theoretical framework-status characteristics and expectation states (SCES)-that explains the mechanisms that produce the observable power and prestige order (status hierarchy) of the team. The authors use this formal theoretical framework to gather evidence of validity by adapting the method to measure the status hierarchy of medical teams.

METHOD

In this retrospective, secondary analysis, the authors analyzed archived videorecorded training exercises conducted between 2007 and 2010 of mixed-gender health care teams of first-year residents and nurses engaged in simulated, complex decision-making scenarios. Analyses were conducted in 2013 with data reanalyzed in July 2022. By adapting the SCES framework for the unique features of academic health care, they developed and refined a coding method from videos and transcripts. To examine validity, they consider the content, response process, internal structure, relation to other variables, and consequences of the framework.

RESULTS

Having established an acceptable level of coding reliability for key variables for videos and transcripts, the authors demonstrate relation to other variables, specifically detailing how the coding scheme delineates 2 status characteristics-occupation and gender. The mean numbers of statement types by gender and occupation were largely as predicted. Directives, question directives, patient work, and knowledge claims were more likely to be coded during video than transcript coding, whereas questions, statements of fact, and compliance were more likely to be coded during transcript than video coding. However, the relative rates of each statement type by status remained largely consistent among the coding methods.

CONCLUSIONS

This study provides important insight into the mechanisms by which hierarchy impacts team decision making and develops the necessary framework and measurement tool to perform larger studies.

Development of the "Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills" (TEAM-ENTS) behavioral marker system

BACKGROUND

Non-technical skills (NTS) are integral to team performance and subsequent quality and safety of care. Behavioral marker systems (BMSs) are now increasingly used in healthcare to support the training and assessment of team NTS. Within gastrointestinal endoscopy, this is an area of novel research. The aims of this study were to define the core relevant NTS for endoscopy teams and develop a preliminary framework for a team-based BMS known as TEAM-ENTS (Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills).

METHODS

This study was conducted in two phases. In phase 1, a literature review of team-based BMSs was performed to inform an interview study of core endoscopy team members. Cognitive task analysis was used to break down the NTS relevant to endoscopy teams. Framework analysis generated the structure for the preliminary TEAM-ENTS framework. In phase 2, a modified Delphi process was undertaken to refine the items of the framework.

RESULTS

Seven consultant endoscopists and six nurses were interviewed. The final coding framework consisted of 88 codes grouped into five overarching categories. In total, 58 participants were recruited to the Delphi panel. In the first round, nine elements and 37 behavioral descriptors did not meet consensus. Following item adjustment, merging and deletion, all remaining items met consensus thresholds after the second round. The refined TEAM-ENTS BMS consists of five categories, 16 elements, and 47 behavioral descriptors.

CONCLUSIONS

The refined TEAM-ENTS behavioral marker system was developed to reflect the core NTS relevant to endoscopy teams. Future studies will aim to fully validate this tool.

Exposure to incivility does not hinder speaking up: a randomised controlled high-fidelity simulation-based study

BACKGROUND

Speaking up with concerns is critical for patient safety. We studied whether witnessing a civil (i.e. polite, respectful) response to speaking up would increase the occurrence of further speaking up by hospital staff members as compared with witnessing a pseudo-civil (i.e. vague and slightly dismissive) or rude response.

METHODS

In this RCT in a single, large academic teaching hospital, a single simulated basic life support scenario was designed to elicit standardised opportunities to speak up. Participants in teams of two or three were randomly assigned to one of three experimental conditions in which the degree of civility in reacting to speaking up was manipulated by an embedded simulated person. Speaking up behaviour was assessed by behaviour coding of the video recordings of the team interactions by applying 10 codes using The Observer XT 14.1. Data were analysed using multilevel modelling.

RESULTS

The sample included 125 interprofessional hospital staff members (82 [66%] women, 43 [34%] men). Participants were more likely to speak up when they felt psychologically safe (γ=0.47; standard error [se]=0.19; 95% confidence interval [CI], 0.09-0.85; P=0.017). Participants were more likely to speak up in the rude condition than in the other conditions (γ=0.28; se=0.12; 95% CI, 0.05-0.52; P=0.019). Across conditions, participants spoke up most frequently by structuring inquiry (n=289, 31.52%), proactive (n=240, 26.17%), and reactive (n=148, 16.14%) instruction statements, and gestures (n=139, 15.16%).

CONCLUSION

Our study challenges current assumptions about the interplay of civility and speaking up behaviour in healthcare.

Developing adaptive performance: A conceptual model to guide simulation-based training design

Objectives

Effective emergency department care requires individuals and teams to adapt to changes in patient condition, team factors, environmental issues, and system-level challenges. Adaptability is often listed as an important skill for emergency medicine physicians; however, conceptual models describing the processes involved in adaptive performance have not been translated for health care settings. Similarly, educators have not described training design strategies that support the development of adaptive performance.

Methods

We examined the team science and health care literatures for key concepts in adaptive performance, health care team performance, and diagnostic decision-making. Using expert consensus, we integrated these concepts to develop the team adaptive performance model and to identify training design approaches that support the development of adaptability.

Results

We identify nine training principles supported by the team adaptive performance model and the adaptive learning system. Each training principle is accompanied by recommendations and mechanisms for implementation in emergency medicine simulation-based education.

Conclusion

Training experiences can be designed to target processes that support adaptive performance.

Behavioral responses to a cyber attack in a hospital environment

Technical and organizational steps are necessary to mitigate cyber threats and reduce risks. Human behavior is the last line of defense for many hospitals and is considered as equally important as technical security. Medical staff must be properly trained to perform such procedures. This paper presents the first qualitative, interdisciplinary research on how members of an intermediate care unit react to a cyberattack against their patient monitoring equipment. We conducted a simulation in a hospital training environment with 20 intensive care nurses. By the end of the experiment, 12 of the 20 participants realized the monitors' incorrect behavior. We present a qualitative behavior analysis of high performing participants (HPP) and low performing participants (LPP). The HPP showed fewer signs of stress, were easier on their colleagues, and used analog systems more often than the LPP. With 40% of our participants not recognizing the attack, we see room for improvements through the use of proper tools and provision of adequate training to prepare staff for potential attacks in the future.

Associations of form and function of speaking up in anaesthesia: a prospective observational study

BACKGROUND

Speaking up with concerns in the interest of patient safety has been identified as important for the quality and safety of patient care. The study objectives were to identify how anaesthesia care providers speak up, how their colleagues react to it, whether there is an association among speak up form and reaction, and how this reaction is associated with further speak up.

METHODS

Data were collected over 3 months at a single centre in Switzerland by observing 49 anaesthesia care providers while performing induction of general anaesthesia in 53 anaesthesia teams. Speaking up and reactions to speaking up were measured by event-based behaviour coding.

RESULTS

Instances of speaking up were classified as opinion (59.6%), oblique hint (37.2%), inquiry (30.7%), and observation (16.7%). Most speak up occurred as a combination of different forms. Reactions to speak up included short approval (36.5%), elaboration (35.9%), no verbal reaction (26.3%), or rejection (1.28%). Speaking up was implemented in 89.1% of cases. Inquiry was associated with an increased likelihood of recipients discussing the respective issue (odds ratio [OR]=13.6; 95% confidence interval [CI], 5.9-31.5; P<0.0001) and with a decreased likelihood of implementing the speak up during the same induction (OR=0.27; 95% CI, 0.08-0.88; P=0.03). Reacting with elaboration to the first speak up was associated with decreased further speak up during the same induction (relative risk [RR]=0.42; 95% CI, 0.21-0.83; P=0.018).

CONCLUSION

Our study provides insights into the form and function of speaking up in clinical environments and points to a perceived dilemma of speaking up via questions.

Reflection on the Fly: Development of the Team Reflection Behavioral Observation (TuRBO) System for Acute Care Teams

PURPOSE

Acute care teams work in dynamic and complex environments and must adapt to changing circumstances. A team process that helps teams process information and adapt is in-action team reflection (TR), defined as concurrent collective reflection on group objectives, strategies, or processes during an ongoing care event. However, the health care field lacks a means for systematically observing and ultimately training in-action TR in acute care teams. To bridge this gap, the authors developed a theoretically and empirically informed framework, Team Reflection Behavioral Observation (TuRBO), for measuring in-action TR.

METHOD

In 2018 at ETH, Zurich, Switzerland, the authors developed a theoretical framework based on the literature and theory. They then conducted exploratory reviews of preexisting videos of acute care teams training simulated emergencies. The authors adapted observation codes using an iterative approach. Using the developed coding framework, they coded 23 video recordings of acute care teams and provided validity evidence from the 3 sources: content, internal structure (interrater reliability), and relations to other variables.

RESULTS

The final TuRBO framework consists of 3 general dimensions-seeking information, evaluating information, and planning-that are further specified in 7 subcodes. Interrater agreement of the coding was substantial (κ = 0.80). As hypothesized, the data showed a positive relationship between in-action TR and team performance. Also, physicians spent significantly more time on in-action TR than nurses.

CONCLUSIONS

The TuRBO framework for assessing in-action TR in acute care teams provides positive validity evidence of the data. TuRBO integrates different team communication and calibration processes under the overarching concept of in-action TR and provides descriptive behavioral markers. TuRBO taps into powerful cultural and normative components of patient safety. This tool can augment team training that allows all team members to serve as an important resource for flexible, resilient, and safer patient care.

Teams in Transition: A Three-Wave Longitudinal Study of Reflection, Implicit and Explicit Coordination and Performance Improvements

Research has shown that team reflection is a critical transition process for coordination processes and team performance, but our understanding of its dynamics and relationship to action processes and performance is incomplete. The goal of the present study was to examine the long-term change in reflection in teams over time and explore whether these changes are related to implicit and explicit coordination processes and performance improvement. Drawing on the recurring phase model of team processes and team reflexivity theory, we hypothesized that team reflection is at least stable or increases over time for dissimilar tasks, that reflection trajectories are positively associated with implicit and negatively associated with explicit coordination in the later phases, and that implicit coordination mediates the relationship between team reflection and performance improvement. This model was tested in a three-wave longitudinal study (N = 175 teams) over a 2-months period. Results from growth curve modeling and structural equation modeling provided support for our hypotheses.

Development and Evaluation of the Taxonomy of Trauma Leadership Skills-Shortened for Observation and Reflection in Training: A Practical Tool for Observing and Reflecting on Trauma Leadership Performance

INTRODUCTION

Trauma leadership skills are increasingly being addressed in trauma courses, but few resources are available to systematically observe and debrief trainees' performances. The authors therefore translated their previously developed, extensive Taxonomy of Trauma Leadership Skills (TTLS) into a practical observation tool that is tailored to the vocabulary of clinician instructors and their workflow and workload during simulation-based training.

METHODS

In 2016 to 2018, the TTLS was subjected to practical evaluation in an iterative process of 2 stages. In the first stage, testing panels of trauma specialists observed excerpts from videotaped simulations and indicated from the list of elements which behaviors they felt were being shown. Any ambiguities or redundancy were addressed by rephrasing or combining elements. In the second stage, iterations were used in actual scenario training to observe and debrief trainees' performances. The instructors' recommendations resulted in further improvements of clarity, ease of use, and usefulness, until no new suggestions were raised.

RESULTS

The resultant "TTLS-Shortened for Observation and Reflection in Training" was given a simpler structure and more concrete and self-explanatory benchmarks. It contains 6 skill categories for evaluation, each with 4 to 6 benchmark behaviors.

CONCLUSIONS

The TTLS-Shortened for Observation and Reflection in Training is an important addition to other trauma assessment tools because of its specific focus on leadership skills. It helps set concrete performance expectations, simplify note taking, and target observations and debriefings. One central challenge was striking a balance between its conciseness and specificity. The authors reflected on how the decisions for the resultant structure ease and leverage the conduct of observations and performance debriefing.

Investigating voice in action teams: a critical review

Team communication is considered a key factor for team performance. Importantly, voicing concerns and suggestions regarding work-related topics-also termed speaking up-represents an essential part of team communication. Particularly in action teams in high-reliability organizations such as healthcare, military, or aviation, voice is crucial for error prevention. Although research on voice has become more important recently, there are inconsistencies in the literature. This includes methodological issues, such as how voice should be measured in different team contexts, and conceptual issues, such as uncertainty regarding the role of the voice recipient. We tried to address these issues of voice research in action teams in the current literature review. We identified 26 quantitative empirical studies that measured voice as a distinct construct. Results showed that only two-thirds of the articles provided a definition for voice. Voice was assessed via behavioral observation or via self-report. Behavioral observation includes two main approaches (i.e., event-focused and language-focused) that are methodologically consistent. In contrast, studies using self-reports showed significant methodological inconsistencies regarding measurement instruments (i.e., self-constructed single items versus validated scales). The contents of instruments that assessed voice via self-report varied considerably. The recipient of voice was poorly operationalized (i.e., discrepancy between definitions and measurements). In sum, our findings provide a comprehensive overview of how voice is treated in action teams. There seems to be no common understanding of what constitutes voice in action teams, which is associated with several conceptual as well as methodological issues. This suggests that a stronger consensus is needed to improve validity and comparability of research findings.

An observational study of self-monitoring in ad hoc health care teams

BACKGROUND

Working in ad hoc teams in a health care environment is frequent but a challenging and complex undertaking. One way for teams to refine their teamwork could be through post-resuscitation reflection and debriefing. However, this would require that teams have insight into the quality of their teamwork. This study investigates (1) the accuracy of the self-monitoring of ad hoc resuscitation teams and their leaders relative to external observations of their teamwork and (2) the relationship of team self-monitoring and external observations to objective performance measures.

METHODS

We conducted a quantitative observational study of real-world ad hoc interprofessional teams responding to a simulated cardiac arrest in an emergency room. Teams consisting of residents, consultants, and nurses were confronted with an unexpected, simulated, standardized cardiac arrest situation. Their teamwork was videotaped to allow for subsequent external evaluation on the team emergency assessment measure (TEAM) checklist. In addition, objective performance measures such as time to defibrillation were collected. All participants completed a demographic questionnaire prior to the simulation and a questionnaire tapping their perceptions of teamwork directly after it.

RESULTS

22 teams consisting of 115 health care professionals showed highly variable performance. All performance measures intercorrelated significantly, with the exception of team leaders' evaluations of teamwork, which were not related to any other measures. Neither team size nor cumulative experience were correlated with any measures, but teams led by younger leaders performed better than those led by older ones.

CONCLUSION

Team members seem to have better insight into their team's teamwork than team leaders. As a practical consequence, the decision to debrief and the debriefing itself after a resuscitation should be informed by team members, not just leaders.

Managing psychological safety in debriefings: a dynamic balancing act

Debriefings should promote reflection and help learners make sense of events. Threats to psychological safety can undermine reflective learning conversations and may inhibit transfer of key lessons from simulated cases to the general patient care context. Therefore, effective debriefings require high degrees of psychological safety-the perception that it is safe to take interpersonal risks and that one will not be embarrassed, rejected or otherwise punished for speaking their mind, not knowing or asking questions. The role of introductions, learning contracts and prebriefing in establishing psychological safety is well described in the literature. How to maintain psychological safety, while also being able to identify and restore psychological safety during debriefings, is less well understood. This review has several aims. First, we provide a detailed definition of psychological safety and justify its importance for debriefings. Second, we recommend specific strategies debriefers can use throughout the debriefing to build and maintain psychological safety. We base these recommendations on a literature review and on our own experiences as simulation educators. Third, we examine how debriefers might actively address perceived breaches to restore psychological safety. Re-establishing psychological safety after temporary threats or breaches can seem particularly daunting. To demystify this process, we invoke the metaphor of a 'safe container' for learning; a space where learners can feel secure enough to work at the edge of expertise without threat of humiliation. We conclude with a discussion of limitations and implications, particularly with respect to faculty development.

Development and impact of an endoscopic non-technical skills (ENTS) behavioural marker system

Background

Non-technical skills (NTS) are crucial to effective team working in endoscopy. Training in NTS has been shown to improve team performance and patient outcomes. As such, NTS training and assessment are now considered essential components of the endoscopy quality assurance process. Across the literature, other specialties have achieved this through development of behavioural marker systems (BMS). BMS provide a framework for assessing, training and measuring the NTS relevant to healthcare individuals and team. This article describes the development and impact of a novel BMS for endoscopy: the endoscopic non-technical skills (ENTS) system.

Methods

The initial NTS taxonomy for endoscopy was created through a combination of literature review, staff focus groups and semi-structured interviews, incorporating the critical decision method. Framework analysis was conducted with three individual coders and generated a skills list which formed the preliminary taxonomy. Video observation of Bowel Cancer Screening endoscopists was used to identify exemplar behaviours which were mapped to relevant skills in the NTS taxonomy. Behavioural descriptors, derived from video data, were added to form the basis of the ENTS system.

Results

A taxonomy of 33 skills in 14 separate categories were identified through framework analysis. Following video analysis and behaviour mapping, 4 overarching categories and 13 behavioural elements were identified which formed the ENTS framework. The endoscopy (directly observed procedural skills) 4-point rating scale was added to create the final ENTS system. Since its development in 2010, the ENTS system has been validated in the assessment of endoscopy for trainees nationally. ENTS informs a number of training initiatives, including a national strategy to improve NTS for all endoscopists.

Conclusions

The ENTS system is a clinically relevant tool, validated for use in trainee assessment. The use of ENTS will be important to the future of training and quality assurance in endoscopy.

Nurses’ voice: the role of hierarchy and leadership

Purpose

Voicing concerns and suggestions is crucial for preventing medical errors and improving patient safety. Research suggests that hierarchy in health-care teams impair open communication. Hierarchy, however, can vary with changing team composition, particularly during acute care situations where more senior persons join the team later on. The purpose of this study is to investigate how changes in hierarchy and leadership were associated with nurses’ voice frequency and nurses’ time to voice during simulated acute care situations.

Design/methodology/approach

This study’s sample consisted of 78 health-care providers (i.e. nurses, residents and consultants) who worked in 39 teams performing complex clinical scenarios in the context of interprofessional, simulation-based team training. Scenarios were videotaped and communication behaviour was coded using a systematic coding scheme. To test the hypotheses, multilevel regression analyses were conducted.

Findings

Hierarchy and leadership had no significant effect on nurses’ voice frequency. However, there were significant relationships between nurses’ time to voice and both hierarchy (γ = 30.00, p = 0.002; 95 per cent confidence interval [CI] = 12.43; 47.92) as well as leadership (γ = 0.30, p = 0.001; 95 per cent CI = 0.12; 0.47). These findings indicate that when more physicians are present and leadership is more centralised, more time passes until the first nurses’ voice occurred.

Originality/value

This study specifies previous findings on the relationships between hierarchy, leadership and nurses’ voice. Our findings suggest that stronger hierarchy and more centralised leadership delay nurses’ voice but do not affect the overall frequency of voice.

An evidence based framework for the Temporal Observational Analysis of Teamwork in healthcare settings

OBJECTIVE

Effective teamwork is critical to patient safety across multiple healthcare settings. However, current observational tools assessing teamwork performance tend to be developed for specific settings or tasks and do not capture temporal features of interaction. This study aimed to develop a valid and reliable observational teamwork behaviour framework, which is based on healthcare practice, applicable across a variety of healthcare contexts and can be used to capture temporal team dynamics.

METHODS

Team interactions were audio-visually recorded during routine simulation training at two large clinical education centres specialising in physical and mental healthcare. The framework was based on theoretical models of teamwork and was developed in three steps: 1-micro analysis of verbal and nonverbal behaviour during recorded scenarios (n = 20); 2-iterative test and refine cycles; 3-final behavioural framework applied to a cohort of acute emergency scenarios (n = 9) by two raters to assess inter-rater agreement.

RESULTS

The framework contains twenty-three specific verbal and nonverbal behaviours that can be identified during observations. Behaviours are grouped conceptually based on their function resulting in thirteen behavioural functions, which cluster into five overarching teamwork domains. Inter-rater agreement was excellent (Cohen's Kappa = .84, SE = 0.03).

CONCLUSION

We present a valid and reliable behavioural framework, grounded in teamwork theory and empirical observations of clinical team behaviour. This framework enables analysis of the nuances and temporal features of clinical practice in depth and across a wide range of clinical contexts and settings. Use of this framework will advance our understanding of teamworking in healthcare.

Laborious but Elaborate: The Benefits of Really Studying Team Dynamics

In this manuscript we discuss the consequences of methodological choices when studying team processes "in the wild." We chose teams in healthcare as the application because teamwork cannot only save lives but the processes constituting effective teamwork in healthcare are prototypical for teamwork as they range from decision-making (e.g., in multidisciplinary decision-making boards in cancer care) to leadership and coordination (e.g., in fast-paced, acute-care settings in trauma, surgery and anesthesia) to reflection and learning (e.g., in post-event clinical debriefings). We draw upon recently emphasized critique that much empirical team research has focused on describing team states rather than investigating how team processes dynamically unfurl over time and how these dynamics predict team outcomes. This focus on statics instead of dynamics limits the gain of applicable knowledge on team functioning in organizations. We first describe three examples from healthcare that reflect the importance, scope, and challenges of teamwork: multidisciplinary decision-making boards, fast-paced, acute care settings, and post-event clinical team debriefings. Second, we put the methodological approaches of how teamwork in these representative examples has mostly been studied centerstage (i.e., using mainly surveys, database reviews, and rating tools) and highlight how the resulting findings provide only limited insights into the actual team processes and the quality thereof, leaving little room for identifying and targeting success factors. Third, we discuss how methodical approaches that take dynamics into account (i.e., event- and time-based behavior observation and micro-level coding, social sensor-based measurement) would contribute to the science of teams by providing actionable knowledge about interaction processes of successful teamwork.

Ability to predict team members' behaviors in ICU teams is associated with routine ABCDE implementation

PURPOSE

Poor coordination may impede delivery of the Awakening, Breathing Coordination, Delirium monitoring/management and Early exercise/mobility (ABCDE) bundle. Developing a shared mental model (SMM), where all team members are on the same page, may support coordination.

MATERIALS AND METHODS

We administered a survey at the 2016 MHA Keystone Center ICU workshop. We measured different components of SMMs using five items from a validated survey, each on a 5-point Likert scale (strongly agree-strongly disagree). We measured self-reported routine ABCDE implementation using a single item 4-point Likert scale (ABCDE is routine-Made no steps to implement ABCDE). We examined the relationship between SMMs and routine ABCDE implementation using logistic regression, adjusting for confounders.

RESULTS

Among the 206 (75%) responses, 157 (84%) reported using the ABCDE bundle and 80 (51% of 157) reported routine use. When clinicians agreed it was difficult to predict team members' behaviors, the odds of reporting routine ABCDE implementation significantly decreased [0.26 (0.10-0.66)]. Other SMM components related to knowing team members' skills, access to information, team adaptability, and team help behavior, were not significantly associated with the outcome.

CONCLUSION

Increasing awareness of team members' behaviors may be a mechanism to improve the implementation of complex care bundles like ABCDE.

Monitoring teamwork: a narrative review

A narrative review was carried out to identify articles on monitoring of teamwork, with particular relevance to anaesthetists. The papers reviewed showed that team monitoring takes place both implicitly and explicitly in the anaesthetic environment. No single optimal model of teamwork monitoring for all situations was identified. Most of the studies identified were of a pre-intervention, post-intervention design, without randomisation or control group. Information shared during a formal briefing is more likely to be recalled, and provides a basis for a shared team mental model. A number of studies appeared to show that targeted teamwork training has a positive impact on both teamwork and patient safety.

Team talk and team decision processes: a qualitative discourse analytical approach to 10 real-life medical emergency team encounters

OBJECTIVES

Explore the function of three specific modes of talk (discourse types) in decision-making processes.

DESIGN

Ten real-life admissions of patients with critical illness were audio/video recorded and transcribed. Activity-type analysis (a qualitative discourse analytical method) was applied.

SETTING

Interdisciplinary emergency teams admitting patients with critical illness in a Norwegian university hospital emergency department (ED).

PARTICIPANTS

All emergency teams consisted of at least two internal medicine physicians, two ED nurses, one anaesthetist and one nurse anaesthetist. The number of healthcare professionals involved in each emergency team varied between 11 and 20, and some individuals were involved with more than one team.

RESULTS

The three discourse types played significant roles in team decision-making processes when negotiating meaning. Online commentaries (ONC) and metacommentaries (MC) created progression while offline commentaries (OFC) temporarily placed decisions on hold. Both ONC and MC triggered action and distributed tasks, resources and responsibility in the team. OFC sought mutual understanding and created a broader base for decisions.

CONCLUSION

A discourse analytical perspective on team talk in medical emergencies illuminates both the dynamics and complexity of teamwork. Here, we draw attention to the way specific modes of talk function in negotiating mutual understanding and distributing tasks and responsibilities in non-algorithm-driven activities. The analysis uncovers a need for an enhanced focus on how language can trigger safe team practice and integrate this knowledge in teamwork training to improve communication skills in ad hoc emergency teams.

Differences in talking-to-the-room behaviour between novice and expert teams during simulated paediatric resuscitation: a quasi-experimental study

Background

Team coordination represents an important factor for clinical performance. Research in this area suggests that not only behaviour frequencies but also patterns of team coordination constitute a central aspect of teamwork. However, little is known about potential differences in coordination patterns between novice teams (ie, teams of inexperienced members) and expert teams (ie, teams of experienced members). The current study addresses this gap by investigating the use of talking-to-the-room-an important implicit coordination behaviour-in novice teams versus expert teams.

Aim

To illustrate differences in coordination behaviour between novice and expert teams. This will provide important knowledge for simulation-based training.

Methods

The study was conducted in the context of two resuscitation training courses (introductory course and refresher course) for staff members at a children's hospital. Volunteers from both courses participated in the study. They were randomly assigned to 16 teams each consisting of one physician and two nurses. The study used a quasi-experimental design with two conditions (novice vs expert). Participants of the introductory course were assigned to the novice condition (eight teams), and participants of the refresher course were assigned to the expert condition (eight teams). All teams completed the same standardised paediatric resuscitation scenario. They were videotaped during the simulation, and team coordination behaviour was coded using Co-ACT.

Results

Lag-sequential analysis of 1902 distinct coordination acts revealed that novice teams and expert teams differed significantly in their coordination behaviour. Expert teams were characterised by patterns in which implicit coordination behaviour (ie, talking to the room) was followed by further implicit coordination behaviour and not followed by explicit coordination behaviour (ie, instructions), whereas the reverse was found for novice teams.

Conclusion

The current study highlights role of coordination patterns for understanding teamwork in healthcare and provides important insights for team training.

DE-CODE: a coding scheme for assessing debriefing interactions

Debriefings are crucial for learning during simulation-based training (SBT). Although the quality of debriefings is very important for SBT, few studies have examined actual debriefing conversations. Investigating debriefing conversations is important for identifying typical debriefer-learner interaction patterns, obtaining insights into associations between debriefers' communication and learners' reflection and comparing different debriefing approaches. We aim at contributing to the science of debriefings by developing DE-CODE, a valid and reliable coding scheme for assessing debriefers' and learners' communication in debriefings. It is applicable for both direct, on-site observations and video-based coding.

Methods

The coding scheme was developed both deductively and inductively from literature on team learning and debriefing and observing debriefings during SBT, respectively. Inter-rater reliability was calculated using Cohen's kappa. DE-CODE was tested for both live and video-based coding.

Results

DE-CODE consists of 32 codes for debriefers' communication and 15 codes for learners' communication. For live coding, coders achieved good inter-rater reliabilities with the exception of four codes for debriefers' communication and two codes for learners' communication. For video-based coding, coders achieved substantial inter-rater reliabilities with the exception of five codes for debriefers' communication and three codes for learners' communication.

Conclusion

DE-CODE is designed as micro-level measurement tool for coding debriefing conversations applicable to any debriefing of SBT in any field (except for the code medical input). It is reliable for direct, on-site observations as well as for video-based coding. DE-CODE is intended to allow for obtaining insights into what works and what does not work during debriefings and contribute to the science of debriefing.

Developing a taxonomy of coordination behaviours in nuclear power plant control rooms during emergencies

This study aims to develop a taxonomy of coordination behaviours during emergencies in nuclear power plants (NPPs). We summarised basic coordination behaviours from literature in aviation, health care and nuclear field and identified coordination behaviours specific to the nuclear domain by interviewing and surveying control crew operators. The established taxonomy includes 7 workflow stages and 24 basic coordination behaviours. To evaluate the reliability and feasibility of the taxonomy, we analysed 12 videos of operators' training sessions by coding coordination behaviours with the taxonomy and the inter-rater reliability was acceptable. Further analysis of the frequency, the duration and the direction of the coordination behaviours revealed four coordination problems. This taxonomy provides a foundation of systematic observation of coordination behaviours among NPP crews, advances researchers' understanding of the coordination mechanism during emergencies in NPPs and facilitate the possibility to deepen the understanding of the relationships between coordination behaviours and team performance. Practitioner Summary: A taxonomy of coordination behaviours during emergencies in nuclear power plants was developed. Reliability and feasibility of the taxonomy was verified through the analysis of 12 training sessions. The taxonomy can serve as an observation system for analysis of coordination behaviours and help to identify coordination problems of control crews.

Promoting Learning and Patient Care Through Shared Reflection: A Conceptual Framework for Team Reflexivity in Health Care

Health care teams are groups of highly skilled experts who may often form inexpert teams because of a lack of collective competence. Because teamwork and collaboration form the foundation of effective clinical practice, factors that promote collective competence demand exploration. The authors review team reflexivity (TR), a concept from the psychology and management literatures, and how it could contribute to the collective competence of health care teams. TR captures a team's ability to reflect collectively on group objectives, strategies, goals, processes, and outcomes of past, current, and future performance to process key information and adapt accordingly. As an overarching process that promotes team functioning, TR builds shared mental models as well as triggering team adaptation and learning.The authors present a conceptual framework for TR in health care, describing three phases in which TR may occur: pre-action TR (briefing before patient care), in-action TR (deliberations during active patient care), and post-action TR (debriefing after patient care). Depending on the phase, TR targets either goals, taskwork, teamwork, or resources and leads to different outcomes (e.g., optimal preparation, a shared mental model, adaptation, or learning). This novel conceptual framework incorporates various constructs related to reflection and unites them under the umbrella of TR. Viewing reflection through a team lens may guide future research about team functioning, optimize training efforts, and elucidate mechanisms for workplace learning, with better patient care as the ultimate goal.

Variation and adaptation: learning from success in patient safety-oriented simulation training

Simulation is traditionally used to reduce errors and their negative consequences. But according to modern safety theories, this focus overlooks the learning potential of the positive performance, which is much more common than errors. Therefore, a supplementary approach to simulation is needed to unfold its full potential. In our commentary, we describe the learning from success (LFS) approach to simulation and debriefing. Drawing on several theoretical frameworks, we suggest supplementing the widespread deficit-oriented, corrective approach to simulation with an approach that focusses on systematically understanding how good performance is produced in frequent (mundane) simulation scenarios. We advocate to investigate and optimize human activity based on the connected layers of any setting: the embodied competences of the healthcare professionals, the social and organizational rules that guide their actions, and the material aspects of the setting. We discuss implications of these theoretical perspectives for the design and conduct of simulation scenarios, post-simulation debriefings, and faculty development programs.

Important Non-Technical Skills in Video-Assisted Thoracoscopic Surgery Lobectomy: Team Perspectives

BACKGROUND

Safety in the operating room is dependent on the team's non-technical skills. The importance of non-technical skills appears to be different for minimally invasive surgery as compared with open surgery. The aim of this study was to identify which non-technical skills are perceived by team members to be most important for patient safety, in the setting of video-assisted thoracoscopic surgery (VATS) lobectomy.

METHODS

This was an explorative, semistructured interview-based study with 21 participants from all four thoracic surgery centers in Denmark that perform VATS lobectomy. Data analysis was deductive, and directed content analysis was used to code the text into the Oxford Non-Technical Skills system for evaluating operating teams' non-technical skills.

RESULTS

The most important non-technical skills described by the VATS teams were planning and preparation, situation awareness, problem solving, leadership, risk assessment, and teamwork. These non-technical skills enabled the team to achieve shared mental models, which in turn facilitated their efforts to anticipate next steps. This was viewed as important by the participants as they saw VATS lobectomy as a high-risk procedure with complementary and overlapping scopes of practice between surgical and anesthesia subteams.

CONCLUSIONS

This study identified six non-technical skills that serve as the foundation for shared mental models of the patient, the current situation, and team resources. These findings contribute three important additions to the shared mental model construct: planning and preparation, risk assessment, and leadership. Shared mental models are crucial for patient safety because they enable VATS teams to anticipate problems through adaptive patterns of both implicit and explicit coordination.

Fields of promoted actions for facilitating multitasking activity during a medical emergency

Background

An adverse clinical event requires emergency team coordination and multitasking activity. Based on studies in ecological psychology, we propose that a structured ambient environment can implicitly facilitate these requirements.

Method

We designed a new configuration of work in which spatial zones were specified as fields of promoted actions for doctors, nurses and nursing auxiliaries. 6 emergency teams were confronted with scenarios in a simulation setting, either with a traditional configuration of work or with the new configuration.

Results

Significantly, each kind of caregiver respected the delimited spatial zones: 91.5% of occupation time for doctors, 97.1% for nurses and 95.3% for nursing auxiliaries. The mean durations of occupation of a same zone by the nursing auxiliaries and another caregiver decreased significantly, thus reducing the likelihood of mutual disturbance. Readiness for multitasking activity measured before and after experiencing the work configuration increased significantly among caregivers. An ergonomic evaluation scale showed a high level of satisfaction among caregivers (68.5 points out of 100). Participants also indicated the advantages and disadvantages of this new work configuration.

Conclusions

This study is a first step towards recommendations to standardise the positioning of emergency team members and for a new spatial arrangement of equipment.

"Hand-it-on": an innovative simulation on the relation of non-technical skills to healthcare

Non-technical skills (NTS) are an integral part of the abilities healthcare professionals need to optimally care for patients. Integrating NTS into the already complex tasks of healthcare can be a challenge for clinicians. Integrating NTS into simulation-based training increases the demands for simulation instructors with regard to scenario design, conduct, and debriefing. We introduce a simulation game, Hand-it-on, that can trigger discussions on how NTS can influence work processes. Hand-it-on aims to help clinicians and simulation instructors alike to improve their understanding of NTS concepts and where they can apply them in their work. It complements existing approaches to teaching NTS by limiting the complexity of the game and by removing medical content, allowing learners to concentrate on NTS. Hand-it-on is relevant for groups and teams working across the range of different healthcare contexts. During Hand-it-on, participants stand in a circle and hand on everyday objects to each other according to simple rules, resulting in many events that can be debriefed in relation to safe patient care. We describe both the conduct of Hand-it-on and ideas on how to debrief participants. We provide variations that can be used in different contexts, focusing the exercise on different learning goals. We also offer the theoretical rationale for using an out-of-context simulation in combination with other forms of teaching. Although we did not evaluate Hand-it-on formally, oral feedback from participants and the replication of Hand-it-on by many simulation teams support its value.

Systematic Behavioral Observation for Emergent Team Phenomena

The use of moving images to generate data for behavioral analysis has long been a methodology available to organizational researchers. In this article, we draw from previous research in team dynamics to describe and discuss various methodological approaches to using video recorded behavior as a source of quantitative data. More specifically, we identify and examine key decision points for researchers and illustrate benefits and drawbacks to consider. The article concludes with suggestions for ways in which quantitative video-based approaches could be improved.

Taxonomy of Trauma Leadership Skills: A Framework for Leadership Training and Assessment

PURPOSE

Good leadership is essential for optimal trauma team performance, and targeted training of leadership skills is necessary to achieve such leadership proficiency. To address the need for a taxonomy of leadership skills that specifies the skill components to be learned and the behaviors by which they can be assessed across the five phases of trauma care, the authors developed the Taxonomy of Trauma Leadership Skills (TTLS).

METHOD

Critical incident interviews were conducted with trauma team leaders and members from different specialties-emergency physicians, trauma surgeons, anesthesiologists, and emergency ward nurses-at three teaching hospitals in the Netherlands during January-June 2013. Data were iteratively analyzed for examples of excellent leadership skills at each phase of trauma care. Using the grounded theory approach, elements of excellent leadership skills were identified and classified. Elements and behavioral markers were sorted and categorized using multiple raters. In a two-round verification process in late 2013, the taxonomy was reviewed and rated by trauma team leaders and members from the multiple specialties for its coverage of essential items.

RESULTS

Data were gathered from 28 interviews and 14 raters. The TTLS details 5 skill categories (information coordination, decision making, action coordination, communication management, and coaching and team development) and 37 skill elements. The skill elements are captured by 67 behavioral markers. The three-level taxonomy is presented according to five phases of trauma care.

CONCLUSIONS

The TTLS provides a framework for teaching, learning, and assessing team leadership skills in trauma care and other complex, acute care situations.

Assessing neurosurgical non-technical skills: an exploratory study of a new behavioural marker system

RATIONALE, AIMS AND OBJECTIVES

The management of non-technical skills is a major factor affecting teamwork quality and patient safety. This article presents a behavioural marker system for assessing neurosurgical non-technical skills (BMS-NNTS). We tested the BMS during deep brain stimulation surgery.

METHOD

We developed the BMS in three stages. First, we drew up a provisional assessment tool based on the literature and observation tools developed for other surgical specialties. We then analysed videos made in an operating room (OR) during deep brain stimulation operations in order to ensure there were no significant omissions from the skills list. Finally, we used five videos of operations to identify the behavioural markers of non-technical skills in verbal communications.

RESULTS

Analyses of more than six hours of observations revealed 3515 behaviours from which we determined the neurosurgeon's non-technical skills behaviour pattern. The neurosurgeon frequently engaged in explicit coordination, situation awareness and leadership behaviours. In addition, the neurosurgeon's behaviours differed according to the stage of the operation and the OR staff members with whom she was communicating.

CONCLUSIONS

Our behavioural marker system provides a structured approach to assessing non-technical skills in the field of neurosurgery. It can also be transferred to other surgical specialties and used in surgeon training curricula.

Agency and Communion Predict Speaking Up in Acute Care Teams

Speaking up with suggestions, problems, or doubts is important—especially in health care action teams where each team member’s input can be crucial for the treatment of a patient. Implementing a high-fidelity simulation study, we investigated individual predictors of speaking up in acute care teams (ACTs). Participants were 27 physicians and 27 nurses from a hospital who completed measures on self-perceived agency (i.e., assertiveness, persistence, independence) and communion (i.e., helpfulness, friendliness, sociability). In two-person teams, they managed simulated critical events that required speaking up. In line with our hypotheses, we found that agency positively and communion negatively predicted actual speaking up behavior. We discuss the differential effects of agency and communion on speaking up and thereby highlight theoretical and practical implications.

Teamwork and Collaboration

Safety and quality of health care depend on collaborative efforts of multiprofessional and multidisciplinary teams of care providers. Team research in aviation and the military has produced a wealth of knowledge in terms of concepts and intervention strategies to improve team performance. Research on collaborative work in health care in the past 20 years has uncovered unique characteristics and requirements of teams in hospitals and other health care settings and has provided early assessment of the utility of the theoretical concepts, methodologies, and interventions developed outside health care. In this chapter, we review a set of concepts that have been used in characterizing teams in health care and in improving teamwork. These concepts include the organizational shell to capture the sociotechnical environment in which teams reside as well as nontechnical skills, team leadership, team mental models, and so on. We will review a number of leading interventions to enhance team performance, such as teamwork training (e.g., TeamSTEPPS) and structured communication (e.g., SBAR). Future directions are suggested on better understanding of the interdependencies between teams and their organizational shell, such as standardization of operating procedures and training, and to focus on the patient in terms of teamwork improvement.