Leadership sharing in maternity emergency teams: a retrospective cohort study in simulation

Coleadership in Maternity Teams, a Randomized, Counterbalanced, Crossover Trial in Simulation

OBJECTIVE

This study aimed to measure the effect of a coleadership model on team performance compared with singular leadership model in simulated maternity emergencies.

METHODS

A randomized, counterbalanced, crossover trial was performed at 2 tertiary maternity hospitals. Teams of obstetric physicians and nurse/midwives responded to 2 simulated maternity emergencies in either a singular or coleadership model. The primary outcome measure was teamwork rated with the Auckland Team Behavior tool. Secondary outcome measures included clinical performance (completion of critical tasks, time to critical intervention, documentation), self-rated teamwork (TEAM tool) and workload. Participants also answered a survey assessing their views on the coleadership model. Paired t tests and mixed-effects linear regression considering team as a random effect were used to estimate the unadjusted and adjusted associations between leadership model and the outcomes of interest.

RESULTS

There was no difference between leadership models for the primary outcome of teamwork (5.3 vs. 5.3, P = 0.91). Clinical outcome measures and self-rated teamwork scores were also similar. Team leaders reported higher workload than other team members, but these were not different between the leadership models. Participants viewed coleadership positively despite no measured objective evidence of benefit.

CONCLUSIONS

A coleadership model did not lead to a difference in team performance within simulated maternity emergencies. Despite this, participants viewed coleadership positively.

Clinicians' attitudes towards a co-leadership structure for maternity emergency teams: An interview study

Shared leadership improves team performance in many domains and is present in some interprofessional healthcare teams. Despite the dominant paradigm of a singular obstetrician leader in maternity emergencies, co-leadership, a specific form of shared leadership, has been identified as a potentially beneficial to clinical care. This qualitative interview study addresses the gaps in knowledge regarding clinician attitudes toward co-leadership and how a co-leadership structure might be implemented within a maternity care setting. Twenty-five clinicians (midwives, obstetricians and anaesthetists) working in the birthing units of two tertiary maternity units were interviewed and a conventional content analysis conducted. Clinicians viewed co-leadership as potentially beneficial to patient care through improved leadership performance and co-leader back up behavior. Implementation of co-leadership was thought to require a supportive organizational culture, agreed patient management protocols and the participation in simulation training. Enacting co-leadership required adaptable leadership sharing practices, effective communication, and high levels of trust between the co-leaders. These findings inform the future implementation strategies for co-leadership in interprofessional healthcare teams.

Interprofessional teamwork for managing medical deterioration in pregnancy: what contributes to good clinical performance in simulated practice?

Objectives

To identify the patterns of teamwork displayed by interprofessional teams during simulated management of medical deterioration in pregnancy and examine whether and how they are related to clinical performance in simulated practice.

Design

Exploratory observational cohort study.

Setting

Interprofessional clinical simulation training with scenarios involving the management of medical deterioration in pregnant women.

Participants

Seventeen simulated scenarios involving 62 qualified healthcare staff working within the National Health Service attending clinical simulation training (midwives (n=18), obstetricians (n=24) and medical physicians (n=20)).

Main outcome measure(s)

Teamwork behaviours over time, obtained through detailed observational analysis of recorded scenarios, using the Temporal Observational Analysis of Teamwork (TOAsT) framework. Clinician rated measures of simulated clinical performance.

Results

Scenarios with better simulated clinical performance were characterised by shared leadership between obstetricians and midwives at the start of the scenario, with obstetricians delegating less and midwives disseminating rationale, while both engaged in more information gathering behaviour. Towards the end of the scenario, better simulated clinical performance was associated with dissemination of rationale to the team. More delegation at the start of a scenario was associated with less spontaneous sharing of information and rationale later in the scenario. Teams that shared their thinking at the start of a scenario continued to do so over time.

Conclusions

Teamwork during the opening moments of a clinical situation is critical for simulated clinical performance in the interprofessional management of medical deterioration in pregnancy. Shared leadership and the early development of the shared mental model are associated with better outcomes.

Comparison of clinical outcomes between nurse practitioner and registrar-led medical emergency teams: a propensity-matched analysis

OBJECTIVE

Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls.

METHODS

The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group.

RESULTS

A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p = 0.015).

CONCLUSION

Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

Effect of simulation training on nurse leadership in a shared leadership model for cardiopulmonary resuscitation in the emergency department

OBJECTIVE

Empowering a senior nurse in a shared leadership role has been proposed as a more efficient set up for the cardiac arrest team in ED. In this model, a senior nurse leads the cardiac arrest algorithm which allows cognitive off-loading of the lead emergency physician. The emergency physician is then more available to perform tasks such as echocardiography and exclude reversible causes. Simulation provides an opportunity for training and practice of this shared leadership model. We hypothesised that a structured simulation training programme that focused on implementing a nurse and doctor shared leadership model for cardiopulmonary resuscitation (CPR), would improve leadership and teamwork quality in the setting of cardiac arrest as measured by a Trauma Non-technical Skills (T-NOTECHS) teamwork scale.

METHODS

Fifteen senior ED nurses participated in this pre-interventional post-observational study. Training consisted of a didactic course on team leadership and crisis resource management (CRM) followed by 4 × 10-min resuscitation scenarios with a structured debrief focusing on team leadership skills and CRM. The primary outcome was measured on scenarios 1 and 4 using a modified T-NOTECHS teamwork scale.

RESULTS

A statistically significant increase in the T-NOTECHS scale was detected for the measures of leadership (P = 0.0028), CRM (P = 0.0001), adherence to New Zealand Resuscitation Council ALS algorithm (P = 0.0088) and situational awareness (P = 0.0002).

CONCLUSION

The present study shows that a short simulation training programme improved nurse leadership and teamwork performance in the setting of a shared leadership model for CPR in the ED which could easily be replicated in other departments.