A meta-analysis of the effectiveness of crew resource management training in acute care domains

Training for a mass casualty incident: Conception, development, and implementation of a crew-resource management course for forward surgical teams

BACKGROUND

Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. The purpose of this article is to describe the development of a crew-resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service.

METHODS

The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development of an aircrew-like CRM training combining lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness; (3) Implementation of teamwork evaluation tools.

RESULTS

A multidisciplinary team designed a conceptual framework for FST preparedness, 24 French FSTs completed a high-quality training that takes into account both technical and nontechnical skills to maintain quality of combat care during mass-casualty incidents, FSTs' CRM skills were assessed using an audio/video recording of a simulated mass-casualty incident.

Ambulance professionals' experiences of teamwork in the context of a team training programme - a qualitative study

BACKGROUND

Teamwork in the context of ambulance services exhibits unique characteristics, as this environment involves a small core team that must adapt to a dynamic team structure that involves health care professionals and emergency services. It is essential to acquire a deeper understanding of how ambulance teams operate. Therefore, this study aimed to explore the experiences of ambulance professionals with teamwork and how they were influenced by the implementation of a team training programme.

METHODS

A qualitative descriptive study was conducted involving ambulance professionals who took part in focus group interviews carried out both before and after the implementation of a team training program across seven ambulance stations within a Norwegian hospital trust. The data were analysed using reflexive thematic analysis based on a deductive-inductive approach.

RESULTS

Our analysis revealed 15 subthemes that characterised ambulance professionals' experiences with teamwork and a team training programme, which were organised according to the five main themes of team structure, communication, leadership, situation monitoring, and mutual support. Ambulance professionals' experiences ranged from the significance of team composition and interpersonal and professional relationships to their preferences regarding different communication styles and the necessity of team leaders within the ambulance service. The team training programme raised awareness of teamwork, while the adoption of teamwork tools was influenced by both individual and contextual factors. The Introduction/Identity, Situation, Background, Assessment and Recommendation (ISBAR) communication tool was identified as the most beneficial aspect of the programme due to its ease of use, which led to improvements in the structure and quality of consultations and information handover.

CONCLUSIONS

This study documented the diverse characteristics and preferences associated with teamwork among ambulance professionals, emphasising the particular importance of proficient partnerships in this context. Participation in a team training programme was perceived as a valuable reminder of the significance of teamwork, thus providing a foundation for the enhancement of communication skills.

TRIAL REGISTRATION

ClinicalTrials.gov-ID: NCT05244928.

The human factor and ergonomics in Patient Safety

The human condition is linked to error in any activity that is performed, and the healthcare world is no exception. The origin of human error does not lie within the perversity of human nature, instead, it has its origins in latent failures in the healthcare environment and is a consequence of the processes and procedures applied. The science of the Human Factor deals with the application of knowledge to people (capabilities, characteristics and limitations), with the design and the management of the equipment they use and with the environments in which they work and the activities they carry out. Part of the Human Factor are the non-technical skills. These skills greatly influence people's behavior and, therefore, their performance and the quality of healthcare in a very complex socio-technical system.

Flipped Classroom: Improved team performance during resuscitation training through interactive pre-course content - a cluster-randomised controlled study

BACKGROUND

Resuscitation is a team effort, and it is increasingly acknowledged that team cooperation requires training. Staff shortages in many healthcare systems worldwide, as well as recent pandemic restrictions, limit opportunities for collaborative team training. To address this challenge, a learner-centred approach known as flipped learning has been successfully implemented. This model comprises self-directed, asynchronous pre-course learning, followed by knowledge application and skill training during in-class sessions. The existing evidence supports the effectiveness of this approach for the acquisition of cognitive skills, but it is uncertain whether the flipped classroom model is suitable for the acquisition of team skills. The objective of this study was to determine if a flipped classroom approach, with an online workshop prior to an instructor-led course could improve team performance and key resuscitation variables during classroom training.

METHODS

A single-centre, cluster-randomised, rater-blinded study was conducted on 114 final year medical students at a University Hospital in Germany. The study randomly assigned students to either the intervention or control group using a computer script. Each team, regardless of group, performed two advanced life support (ALS) scenarios on a simulator. The two groups differed in the order in which they completed the flipped e-learning curriculum. The intervention group started with the e-learning component, and the control group started with an ALS scenario. Simulators were used for recording and analysing resuscitation performance indicators, while professionals assessed team performance as a primary outcome.

RESULTS

The analysis was conducted on the data of 96 participants in 21 teams, comprising of 11 intervention groups and 10 control groups. The intervention teams achieved higher team performance ratings during the first scenario compared to the control teams (Estimated marginal mean of global rating: 7.5 vs 5.6, p < 0.01; performance score: 4.4 vs 3.8, p < 0.05; global score: 4.4 vs 3.7, p < 0.001). However, these differences were not observed in the second scenario, where both study groups had used the e-learning tool.

CONCLUSION

Flipped classroom approaches using learner-paced e-learning prior to hands-on training can improve team performance.

TRIAL REGISTRATION

German Clinical Trials Register ( https://drks.de/search/de/trial/DRKS00013096 ).

Teaching Before, During, and After a Surgical Resuscitation

Teaching during a surgical resuscitation can be difficult due to the infrequency of these events. Furthermore, when these events do occur, the trainee can experience cognitive overload and an overwhelming amount of stress, thereby impairing the learning process. The emergent nature of these scenarios can make it difficult for the surgical educator to adequately teach. Repeated exposure through simulation, role play, and "war games" are great adjuncts to teaching and preparation before crisis. However, surgical educators can further enhance the knowledge of their trainees during these scenarios by using tactics such as talking out loud, targeted teaching, and debriefing.

Team Dynamics in the Operating Room: How Is Team Performance Optimized?

Health care requires the effort of a team, and nowhere is this more evident than in the care of the surgical patient. No single clinician can perform all aspects of the continuum of surgical care. The basic operating room (OR) team consists of nurses, technicians, surgeons, and anesthesiologists with unique and well-defined roles and expertise in perioperative care. The modern OR team continues to grow and evolve in size, diversity, and complexity to meet the needs of growing patient and procedural complexity. This growing complexity makes achieving optimal team performance paramount and challenging.

Effectiveness of nontechnical skills educational interventions in the context of emergencies: A systematic review and meta-analysis

INTRODUCTION

In recent years, the importance of training healthcare professionals in nontechnical skills using effective methodologies has been increasingly recognised as a means of preventing clinical errors in the practice of health care. The aim of this study was to evaluate the effectiveness of educational interventions on nontechnical skills in the emergency medical services and/or critical care unit settings.

METHODS

A systematic search was carried out in the PubMed, SCOPUS, CINAHL, and Web of Science databases according to predetermined inclusion and exclusion criteria. After the initial search, 7952 records were selected after duplicates removed. Finally, a selection of 38 studies was included for quantitative analysis. Separate meta-analyses of standardised mean changes were carried out for each outcome measure assuming a random-effects model. Cochran's Q-statistic and I2 index were applied to verify study heterogeneity. Weighted analyses of variance and meta-regressions were conducted to test the influence of potential moderators and funnel plots using Duval and Tweedie's trim-and-fill method, and Egger's regression test were used to examine publication bias.

RESULTS

All the variables analysed had a significant effect size, with the exception of situational awareness (d+ = -0.448; 95% confidence interval [CI] = -1.034, 0.139). The highest mean effect size was found for knowledge (d+ = -0.925; 95% CI = -1.177, -0.673), followed by the mean effect sizes for global nontechnical skills (d+ = -0.642; 95% CI = -0.849, -0.434), team nontechnical skills (d+ = -0.606; 95% CI = -0.949, -0.262), and leadership nontechnical skills (d+ = -0.571; 95% CI = -0.877, -0.264). Similar mean effect sizes were found for attitude (d+ = -0.406; 95% CI = -0.769, -0.044), self-efficacy (d+ = -0.469; 95% CI = -0.874, -0.064), and communication nontechnical skills (d+ = -0.458; 95% CI = -0.818, -0.099). Large heterogeneity among the standardised mean changes was found in the meta-analyses (I2 > 75% and p < .001), except for self-efficacy where I2 = 58.17%, and there was a nonstatistical result for Cochran's Q. This great variability is also reflected in the forest plots.

DISCUSSION

The use of simulation interventions to train emergency and critical care healthcare professionals in nontechnical skills significantly improves levels of knowledge, attitude, self-efficacy, and nontechnical skills performance.

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process

OBJECTIVES

Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions.

METHODS

We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model.

RESULTS

We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions).

CONCLUSIONS

Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.

Applying Crew Resource Management tools in Emergency Response Driving and patient transport-Finding consensus through a modified Delphi study

BACKGROUND

Emergency Response Driving (ERD) comprises a significant risk to safety in Emergency Medical Services (EMS). Crew Resource Management (CRM) tools play a major role in securing actions in high-risk procedures. The aim of this study was to find consensus on the important factors to consider when applying CRM tools in ERD and patient transport.

METHODS

ERD experts (n = 50) were recruited for a modified three-round Delphi study. Round 1 was based on previous research. The experts evaluated the items as important, neutral, or not important. The predetermined level of consensus was set at ≥ 80%. Answers given to the open-ended questions were analyzed using inductive content analysis.

RESULTS

Predetermined consensus was reached on 64 of 86 presented items (74.4 %). The mean values of items reaching consensus varied between 3.81 and 4.86 on a five-point Likert scale. The items where consensus was reached were rated as "important" on a trichotomized scale.

CONCLUSION

Multiple important factors to consider when applying CRM tools to ERD and patient transport were highlighted. This study provides valuable information to consider regarding EMS safety improvements. Further scientific research is needed to develop comprehensive recommendations.

Improvement of Teamwork Nontechnical Skills Through Polytrauma Simulation Cases Using the Communication and Teamwork Skills (CATS) Assessment Tool

OBJECTIVE

To assess acquisition of nontechnical skills (NTS) through clinical simulation cases by healthcare personnel who participated in a Crisis Resource Management (CRM) training program for the initial care of polytraumatisms.

DESIGN

Pre-and postintervention study.

SETTING

Acute-care teaching hospital in Sabadell, Barcelona (Spain).

PARTICIPANTS

Healthcare personnel that composed teamworks providing initial care to polytraumatized patients attended 12-hour simulation training using a SimMan 3G manikin and performed exercises corresponding to 3 clinical scenarios. All simulations lasted 15 to 25 min and were video recorded. The CATS Assessment tool was used for analysis of teamwork NTS, which included 21 behaviors clustered into the categories of coordination, situational awareness, cooperation, communication, and crisis situation.

RESULTS

Three editions of the CRM training course were carried out with 12 trauma team groups composed by team leader, anesthesiologist, general surgeon, traumatologist, registered nurses, nursing assistant, and stretcher bearer. There were statistically significant (p <0.001) improvements in the speed of key times of total duration of case resolution, transfusion of hemoderivatives, Focused Assessment Sonography for Trauma, and chest and pelvic X-rays. The percentage of cases correctly resolved improved from 75% to 91.7% but differences were not statistically significant (p = 0.625). Precourse and postcourse results of CATS scores showed a statistically significant increase in the weighted total score as well as in all behavioral categories of coordination, situational awareness, cooperation, communication, and crisis situation.

CONCLUSIONS

Simulation-based training of NTS was associated with significant improvements in teamwork behaviors in the setting of the initial care of patients with polytraumatisms.

Critical Care Teamwork in the Future: The Role of TeamSTEPPS® in the COVID-19 Pandemic and Implications for the Future

At our institution, we observed inconsistency in the application of structural facilitators for interprofessional teamwork such as handoffs and communication of contingency planning, complete formation and engagement of teams on interprofessional rounds, regular situation monitoring, interprofessional huddles, use of "check back" during code situations, and standard debriefings after codes and procedures (TeamSTEPPS^®). To enhance team performance, we piloted TeamSTEPPS^® training and reinforcement for all healthcare team members in the medical intensive care unit (MICU), inclusive of trainees, advanced practice providers (APPs), nurses, and respiratory therapists rotating through the unit. Seven months after the training launch, the initial COVID-19 surge interrupted the reinforcement stage of the pilot providing an opportunity to study the retention of TeamSTEPPS^® principles and its potential role in response to a crisis. We conducted interprofessional focus groups after a year of crisis management during the pandemic. Themes revealed how TeamSTEPPS^® training impacted teamwork and communication, as well as factors that influenced the use of TeamSTEPPS^®. This work points to the value of team training in unexpected scenarios. Additional studies at multiple sites are needed to determine scalability for all MICU teams or for onboarding new team members.

Twelve tips for using tactical decision games to teach non-technical skills

Tactical decision games (TDGs) have been used in healthcare and other safety-critical industries to develop non-technical skills training (NTS). TDGs have been shown to be a realistic, feasible, and useful way of teaching NTS such as decision making, task prioritisation, situational awareness, and team working. Our 12-tips for using TDG to teach NTS are based on our experience of integrating them into an undergraduate medical and nursing programme. We cover how to design successful TDGs, how to facilitate and debrief them and how to integrate TDGs into curricula. We have found TDGs to be a cost-effective, low fidelity, and useful method of delivering NTS teaching, ideally as an adjunct to immersive simulation. Learners find them a useful way to be introduced to NTS in a safe and relaxed environment, with particular emphasis on critical decision making and prioritisation.

A scoping review of patient safety research carried out in the Republic of Ireland

Maintaining the highest levels of patient safety is a priority of healthcare organisations. However, although considerable resources are invested in improving safety, patients still suffer avoidable harm. The aims of this study are: (1) to examine the extent, range, and nature of patient safety research activities carried out in the Republic of Ireland (RoI); (2) make recommendations for future research; and (3) consider how these recommendations align with the Health Service Executive's (HSE) patient safety strategy. A five-stage scoping review methodology was used to synthesise the published research literature on patient safety carried out in the RoI: (1) identify the research question; (2) identify relevant studies; (3) study selection; (4) chart the data; and (5) collate, summarise, and report the results. Electronic searches were conducted across five electronic databases. A total of 31 papers met the inclusion criteria. Of the 24 papers concerned with measuring and monitoring safety, 12 (50%) assessed past harm, 4 (16.7%) the reliability of safety systems, 4 (16.7%) sensitivity to operations, 9 (37.5%) anticipation and preparedness, and 2 (8.3%) integration and learning. Of the six intervention papers, three (50%) were concerned with education and training, two (33.3%) with simplification and standardisation, and one (16.7%) with checklists. One paper was concerned with identifying potential safety interventions. There is a modest, but growing, body of patient safety research conducted in the RoI. It is hoped that this review will provide direction to researchers, healthcare practitioners, and health service managers, in how to build upon existing research in order to improve patient safety.

Teamwork Training With a Multiplayer Game in Health Care: Content Analysis of the Teamwork Principles Applied

BACKGROUND

In health care, teamwork skills are critical for patient safety; therefore, great emphasis is placed on training these skills. Given that training is increasingly designed in a blended way, serious games may offer an efficient method of preparing face-to-face simulation training of these procedural skills.

OBJECTIVE

This study aimed to investigate the teamwork principles that were used during gameplay by medical students and teamwork experts. Findings can improve our understanding of the potential of serious games for training these complex skills.

METHODS

We investigated a web-based multiplayer game designed for training students' interprofessional teamwork skills. During gameplay, 4 players in different roles (physician, nurse, medical student, and student nurse) had to share information, prioritize tasks, and decide on next steps to take in web-based patient scenarios, using one-to-one and team chats. We performed a qualitative study (content analysis) on these chats with 144 fifth-year medical students and 24 health care teamwork experts (as a benchmark study) playing the game in groups of 4. Game chat data from 2 scenarios were analyzed. For the analysis, a deductive approach was used, starting with a conceptual framework based on Crew Resource Management principles, including shared situational awareness, decision-making, communication, team management, and debriefing.

RESULTS

Results showed that most teamwork principles were used during gameplay: shared situational awareness, decision-making (eg, re-evaluation), communication (eg, closed loop), and team management (eg, distributing the workload). Among students, these principles were often used on a basic level. Among experts, teamwork principles were used with more open forms of speak up and more justification of decisions. Some specific Crew Resource Management principles were less observed among both groups, for example, prevention of fixation errors and use of cognitive aids. Both groups showed relatively superficial debriefing reflections.

CONCLUSIONS

Playing a multiplayer game for interprofessional teamwork appears to facilitate the application of teamwork principles by students in all important teamwork domains on a basic level. Expert players applied similar teamwork principles on a moderately high complexity level. Some teamwork principles were less observed among both students and expert groups, probably owing to the artifacts of the game environment (eg, chatting instead of talking). A multiplayer game for teamwork training can elicit the application of important, basic teamwork principles, both among novices and experts, and provides them with a flexible, accessible, and engaging learning environment. This may create time for exercising more complex skills during face-to-face training.

Improving team effectiveness using a program evaluation logic model: case study of the largest provincial simulation program in Canada

Historically simulation-based education (SBE) has primarily focused on program development and delivery as a means for improving the effectiveness of team behaviours; however, these programs rarely embed formal evaluations of the programs themselves. Logic models can provide simulation programs with a systematic framework by which organizations and their evaluators can begin to understand complex interprofessional teams and their programs to determine inputs, activities, outputs and outcomes. By leveraging their use, organizational leaders of simulation programs can contribute to both

Self-efficacy and application of skills in the workplace after multidisciplinary trauma masterclass participation: a mixed methods survey and interview study

Purpose

The most complex injuries are usually least often encountered by trauma team members, limiting learning opportunities at work. Identifying teaching formats that enhance trauma skills can guide future curricula. This study evaluates self-assessed technical and nontechnical trauma skills and their integration into novel work situations for multidisciplinary trauma masterclass participants.

Methods

This mixed methods study included participants of a multidisciplinary 3-day trauma masterclass. Ratings of trauma skills were collected through pre- and postcourse questionnaires with 1-year follow-up. Qualitative semi-structured interviews 9 months postcourse focused on the course format and self-perceived association with technical and nontechnical skills applied at work.

Results

Response rates of pre- and postcourse questionnaires after 1 day, 3 months, and 1 year were respectively 72% (51/71), 85% (60/71), 34% (24/71), and 14% (10/71). Respondents were surgeons (58%), anesthesiologists (31%), and scrub nurses (11%). Self-efficacy in nontechnical (mean 3.4, SD 0.6 vs. mean 3.8, SD 0.5) and technical (mean 2.9, SD 0.6 vs. mean 3.6, SD 0.6) skills significantly increased postcourse (n = 40, p < 0.001). Qualitative interviews (n = 11) demonstrated that increased self-efficacy in trauma skills was the greatest benefit experienced at work. Innovative application of skills and enhanced reflection demonstrate adaptive expertise. Small-group case discussions and the operative porcine laboratory were considered the most educational working formats. The experienced faculty and unique focus on multidisciplinary teamwork were highly valued.

Conclusion

Course participants’ self-assessed work performance mostly benefited from greater self-efficacy and nontechnical skills. Future trauma curricula should consider aligning the teaching strategies accordingly.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-02159-8.

Improving technical and non-technical skills of emergency medicine residents through a program based on high-fidelity simulation

We evaluated the effectiveness of a training program with high-fidelity simulation (HFS) to improve technical (TS) and non-technical skills (NTS) of residents in Emergency Medicine. We conducted a 2-year training program for the management of a critical patient based on HFS (6 sessions for every year, four teams who performed 4 scenarios per session). At the beginning of the training program, all participants received a presentation of Crisis Resource Management (CRM) principles. Each session covered a different topic in Emergency Medicine Curriculum. TSs were measured as the proportion of completed tasks in the following areas: airway, breathing, circulation, disability and exposure (ABCDE) assessment and management, completion of anamnesis based on AMPLE (allergy, medications, previous illness, last meal and event) scheme, diagnostic and therapeutic assessment. NTSs were rated by the Clinical Teamwork Scale (CTS). Scores' values and the percentage of correctly performed actions were presented as median with interquartile range. Friedmann non-parametric test was employed to evaluate the trend of TS and NTS over the following sessions. Among the TS, the assessment and management of ABCDE and completion of therapeutic tasks improved (all p < 0.05). The completion of diagnostic tasks (p = 0.050) tended toward significant improvement. The overall CTS score (first session 61 ± 17, last session 84 ± 16, p < 0.001) as well as Communication (first 13.7 ± 3.6, last 18.7 ± 3.5, p < 0.001), Situational Awareness (first 5.3 ± 1.8, last 6.4 ± 1.4, p = 0.012) and Role Responsibility subscores (first 9.7 ± 2.8, last 12.1 ± 3.7, p < 0.001) increased through the following sessions. Therefore, HFS has proven to be an effective instrument to improve TS and NTS among Emergency Medicine residents.

Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation

Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings.

We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking.

Small groups (n = 121) and survey ranking (n = 54) were used with

This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of

Instrumentation failure during microlaryngoscopy

Equipment failure can be a cause of morbidity during surgical procedures. We present two cases where a broken surgical instrument, a heart-shaped curved micro-grasper, colloquially termed ‘sweetheart’ micro-forceps, compromised patient safety during microlaryngoscopy. We discuss the importance of thorough safety protocols and communication between team members to mitigate this risk. Microinstruments used during microlaryngoscopy are at risk of failure or breakage due to their small size. Surgeons must be alert to the risk of equipment failure during surgery as a potential cause of patient morbidity. In our patient, loss of the broken instrument in the respiratory tract could have resulted in iatrogenic aspiration, respiratory infection and would have necessitated rigid bronchoscopy for removal. Instruments and equipment must checked and communicated by the surgical team before and after use to prevent potential patient morbidity.

Emergency cricothyroidotomy in difficult airway simulation – a national observational study of Air Ambulance crew performance

Background

Advanced prehospital airway management includes complex procedures carried out in challenging environments, necessitating a high level of technical and non-technical skills. We aimed to describe Norwegian Air Ambulance-crews’ performance in a difficult airway scenario simulation, ending with a “cannot intubate, cannot oxygenate”-situation.

Methods

The study describes Air Ambulance crews’ management of a simulated difficult airway scenario. We used video-observation to assess time expenditure according to pre-defined time intervals and technical and non-technical performance was evaluated according to a structured evaluation-form.

Results

Thirty-six crews successfully completed the emergency cricothyroidotomy with mean procedural time 118 (SD: ±70) seconds. There was variation among the crews in terms of completed procedural steps, including preparation of equipment, patient- monitoring and management. The participants demonstrated uniform and appropriate situational awareness, and effective communication and resource utilization within the crews was evident.

Conclusions

We found that Norwegian Air Ambulance crews managed a prehospital “cannot intubate, cannot oxygenate”-situation with an emergency cricothyroidotomy under stressful conditions with effective communication and resource utilization, and within a reasonable timeframe. Some discrepancies between standard operating procedures and performance are observed. Further studies to assess the impact of check lists on procedural aspects of airway management in the prehospital environment are warranted.

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

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

Impact of Teamwork and Communication Training Interventions on Safety Culture and Patient Safety in Emergency Departments: A Systematic Review

OBJECTIVES

This study aimed to narratively summarize the literature reporting on the effect of teamwork and communication training interventions on culture and patient safety in emergency department (ED) settings.

METHODS

We searched PubMed, EMBASE, Psych Info CINAHL, Cochrane, Science Citation Inc, the Web of Science, and Educational Resources Information Centre for peer-reviewed journal articles published from January 1, 1988, to June 8, 2018, that assessed teamwork and communication interventions focusing on how they influence patient safety in the ED. One additional search update was performed in July 2019.

RESULTS

Sixteen studies were included from 8700 screened publications. The studies' design, interventions, and evaluation methods varied widely. The most impactful ED training interventions were End-of-Course Critique, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), and crisis resource management (CRM)-based training. Crisis resource management and TeamSTEPPS CRM-based training curriculum were used in most of the studies. Multiple tools, including the Kirkpatrick evaluation model, the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture, the TeamSTEPPS Teamwork Attitudes Questionnaire, the Safety Attitudes Questionnaire, and the Communication and Teamwork Skills Assessment, were used to assess the impact of such interventions. Improvements in one of the domains of safety culture and related domains were found in all studies. Four empirical studies established improvements in patient health outcomes that occurred after simulation CRM training (Kirkpatrick 4), but there was no effect on mortality.

CONCLUSIONS

Overall, teamwork and communication training interventions improve the safety culture in ED settings and may positively affect patient outcome. The implementation of safety culture programs may be considered to reduce incidence of medical errors and adverse events.

What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness

OBJECTIVE

The aim of this article was to present an overview of the crew resource management (CRM) literature in healthcare. The first aim was to conduct an umbrella review on CRM literature reviews. The second aim was to conduct a new literature review that aims to address the gaps that were identified through the umbrella review.

METHODS

First, we conducted an umbrella review to identify all reviews that have focused on CRM within the healthcare context. This step resulted in 16 literature reviews. Second, we conducted a comprehensive literature review that resulted in 106 articles.

RESULTS

The 16 literature reviews showed a high level of heterogeneity, which resulted in discussing 3 ambiguities: definition, outcome, and information ambiguity. As a result of these ambiguities, a new comprehensive review of the CRM literature was conducted. This review showed that CRM seems to have a positive effect on outcomes at Kirkpatrick's level 1, 2, and 3. In contrast, whether CRM has a positive effect on level 4 outcomes and how level 4 should be measured remains undetermined. Recommendations on how to implement and embed CRM training into an organization to achieve the desired effects have not been adequately considered.

CONCLUSIONS

The extensive nature of this review demonstrates the popularity of CRM in healthcare, but at the same time, it highlights that research tends to be situated within certain settings, focuses on particular outcomes, and has failed to address the full scope of CRM as a team intervention and a management concept.

Institutionalizing an interprofessional simulation education program: an organizational case study using a model of strategic change

Initiatives to implement interprofessional simulation education programs (ISEP) often fail due to lack of support, resources from management or proper integration into the organization system. This paper aims to identify factors that ensure the successful implementation of an ISEP. Further, the study explores the potential effects an ISEP can have on organizational processes and culture. The case study describes the implementation process of an ISEP in a non-academic community hospital using interviews, participative observations and archival data over six years. A thematic approach has been used to analyze the data guided by Kotter's 8-step model for organizational change. Strategies for a successful implementation of an ISEP include: 1) make a case for interprofessional simulation-based education (SBE), 2) search for healthcare champions, 3) define where the ISEP will lead the organization, 4) spread the word about interprofessional SBE, 5) ensure that structures, skills and supervisors align with the change effort, 6) win over smaller entities, 7) enable peer feedback and create more change, 8) institutionalize the ISEP. Indicators of how the ISEP impacted hospital culture are presented and discussed. ISEPs - if implemented effectively - provide powerful opportunities to span boundaries between professional groups, foster interprofessional collaboration, and eventually improve patient care.

A Systematic Review of Interventions to Improve Healthcare Experiences and Access in Autism

Autistic individuals report barriers to accessing and receiving healthcare, and experience increased morbidity and mortality. This systematic review synthesizes 31 research studies evaluating interventions implemented to improve the healthcare experiences and/or access of autistic persons. Interventions were most commonly patient-focused (58.1%), focused on supporting the autistic individual to engage with, tolerate, or anticipate medical procedures, care, or settings. Fewer studies were provider-focused (48.4%) or organization-focused (6.5%). Interventions were typically evaluated using measures of reactions (45.2%) or behavior (48.4%), and outcomes were predominantly positive (80.6%). Further research is imperative and should look to how providers and organizations must change. Future research must be inclusive of the autistic community, must measure what matters, and must offer complete detail on interventions implemented.

Safety Checklists for Emergency Response Driving and Patient Transport: Experiences from Emergency Medical Services

BACKGROUND

Emergency response driving (ERD) is considered one of the most significant occupational risk factors affecting both patient and traffic safety in emergency medical services (EMS). The majority of the risk factors in ERD are crew related and could be affected positively with crew resource management (CRM). The aim of this study was to examine how the safety checklists developed for ERD and patient transport are experienced in practical work in EMS by paramedics.

METHODS

Safety checklists for ERD and patient transport were developed and then piloted in practical work among 30 paramedics in five different EMS areas around Finland for a two-month period in fall 2019. Afterward, semistructured thematic interviews were performed with the pilot participants, and the material was analyzed using inductive content analysis.

RESULTS

Paramedics experienced that use of ERD and patient transport safety checklists improved safety, and deployment of the checklists required systematic planning. Use of the safety checklists was seen as changing the mindset of the ERD drivers to a more safety critical stance and increasing a systematic approach to ERD. Paramedics also stated that when deploying the checklists in EMS, their use should be standardized as a nationwide operating model and that service-dependent fine-tuning is required.

CONCLUSION

This study's findings support the use of ERD and patient transport safety checklists in practical work in EMS for promoting safety. In addition to safety checklists, other sections of CRM and its applications to EMS should also be studied.

[Crew resource management in emergency centers]

The treatment of critically ill patients in the emergency room poses major challenges to the treatment teams. Good teamwork is essential for patient care and patient safety. Between 60 and 70% of all errors in high-risk areas-such as medicine-are assigned to the field of "human factors". In aviation, after several aircraft disasters, the concept of "Crew Resource Management" (CRM) was developed in the 1980s to avoid such errors and has since established itself in many high-security industries. In contrast to medicine, there has long been a legal obligation in aviation to conduct regular CRM training. Introduced into medicine by anesthesiologists in 1990 because of its potential, CRM training has so far found its way into emergency medicine especially, even without it being a legal obligation. For trauma room treatment of polytrauma patients, the disciplines involved already offer a specially developed training concept in which teaching of CRM principles is the main focus (HOTT®-Schockraumsimulation). In addition to dedicated private providers of CRM training and individual concepts developed at an institutional level, several common course concepts for the care of emergency patients also integrate CRM principles to varying degrees into their curricula and teaching methods. Level IA evidence for CRM training is still missing also due to systematic difficulties not only in medicine, but also in other high-risk areas. However, further implementation of regular CRM training in medicine should not be suspended for this very reason.

Learning about stress from building, drilling and flying: a scoping review on team performance and stress in non-medical fields

Background

Teamwork is essential in healthcare, but team performance tends to deteriorate in stressful situations. Further development of training and education for healthcare teams requires a more complete understanding of team performance in stressful situations. We wanted to learn from others, by looking beyond the field of medicine, aiming to learn about a) sources of stress, b) effects of stress on team performance and c) concepts on dealing with stress.

Methods

A scoping literature review was undertaken. The three largest interdisciplinary databases outside of healthcare, Scopus, Web of Science and PsycINFO, were searched for articles published in English between 2008 and 2020. Eligible articles focused on team performance in stressful situations with outcome measures at a team level. Studies were selected, and data were extracted and analysed by at least two researchers.

Results

In total, 15 articles were included in the review (4 non-comparative, 6 multi- or mixed methods, 5 experimental studies). Three sources of stress were identified: performance pressure, role pressure and time pressure. Potential effects of stress on the team were: a narrow focus on task execution, unclear responsibilities within the team and diminished understanding of the situation. Communication, shared knowledge and situational awareness were identified as potentially helpful team processes. Cross training was suggested as a promising intervention to develop a shared mental model within a team.

Conclusion

Stress can have a significant impact on team performance. Developing strategies to prevent and manage stress and its impact has the potential to significantly increase performance of teams in stressful situations. Further research into the development and use of team cognition in stress in healthcare teams is needed, in order to be able to integrate this ‘team brain’ in training and education with the specific goal of preparing professionals for team performance in stressful situations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00865-7.

A Systematic Review of Trauma Crew Resource Management Training: What Can the United States and the United Kingdom Learn From Each Other?

OBJECTIVE

Crew Resource Management (CRM) training incorporates methods such as simulation, debrief, and teamwork training to emphasize human factors skills. This systematic review aimed to assess differences in CRM between UK and USA trauma personnel.

DESIGN

A structured search of the databases MEDLINE and Embase in addition to unstructured reference review and Google Scholar search was undertaken without time restraint to identify articles describing CRM training courses of trauma personnel. Predetermined criteria for inclusion included comprehensive reports of CRM training in trauma personnel with participant assessment. Articles were analyzed for course details and descriptions, Kirkpatrick domains and levels utilized, and measure items and outcomes.

RESULTS

Twenty-nine full-text articles (24 USA, 5 UK) met predetermined criteria. UK-based CRM had a heavy emphasis on doctors while USA-based CRM reached a range of multidisciplinary civilian and military professionals. UK-based CRM focused on skills outcomes using pre- and post-training questionnaires, whereas USA-based training focused on behavior and nontechnical skills utilizing validated standardized measures. CRM-based training, and particularly courses incorporating simulation and multidisciplinary methods, resulted in significantly improved preparedness for trauma, emergency skills, and clinical behavioral change.

CONCLUSIONS

CRM training has the potential to give significant benefits to participant learning, teamwork behaviors, and clinical care outcomes. The USA appears to utilize a focused multidisciplinary and human factors approach to trauma training, which could be adopted by UK institutions to improve cohesive team performance and patient care.

Exploring the role of simulation to foster interprofessional teamwork among medical and nursing students: A mixed-method pilot investigation in Hong Kong

Effective teamwork is a critical component of maintaining patient safety. However, there is lack of clarity on the best teaching approach to interprofessional teamwork training in medical and nursing curricula. This study aimed to compare the effects of blended classroom plus clinical simulation versus clinical simulation alone on teamwork attitudes, perceptions and performance in medical and nursing students in Hong Kong. This was a pilot study with a mixed-method research design, with both quantitative and qualitative evaluations. Students who studied medicine or nursing courses at a university in Hong Kong were invited to this study. They were assigned into two groups: clinical simulation alone versus blended classroom plus clinical simulation. The primary outcome was attitudinal change related to teamwork behaviours, which was measured using the Human Factors Attitude Survey. The secondary outcomes were perceptions of team-based learning and teamwork performance, which were accessed by the Team-Based Learning Student Assessment Instrument and Ottawa Global Rating Scale, respectively. Four focus group interviews were conducted after the training sessions. Conventional content analysis using inductive coding was performed with the qualitative data. Forty-six students participated in this study. There was a significant increase in the participants' positive attitudes on teamwork for both groups (intervention: MD = 5.36 and control: MD = 3.6, p <.05); however, there was no significant difference on increasing positive attitudes between the groups (estimate = 1.76, 95% CI [-8.59, 5.06], p = .61). Qualitative analysis identified four themes: (1) reconsidering professional roles in managing patients; (2) embodying the experience to share responsibility and complement each other's skills; (3) realizing the importance of trust and communication; and (4) engaging to achieve the mission within a limited time. This pilot study found that a blended classroom did not further improve teamwork attitudes, perceptions and performance in medical and nursing students compared with clinical simulation alone. Qualitative findings showed that students had reconsidered their professional roles in managing patients and realized the importance of teamwork in caring patients.

Why We Fail to Rescue During Critical Events

Many factors come together probabilistically to affect clinician response to critical events in the operating room; no 2 critical events are alike. These factors involve 4 primary domains: (1) the event itself, (2) the individual anesthetist(s), (3) the operating room team, and (4) the resources available and environments in which the event occurs. Appreciating these factors, anticipating how they create vulnerabilities for error and poor response, and actively addressing those vulnerabilities (before events occur as well as during) will help clinicians manage critical event response more effectively and avoid errors.

Longitudinal team training programme in a Norwegian surgical ward: a qualitative study of nurses' and physicians' experiences with teamwork skills

OBJECTIVES

Teamwork and interprofessional team training are fundamental to ensuring the continuity of care and high-quality outcomes for patients in a complex clinical environment. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based team training programme intended to facilitate healthcare professionals' teamwork skills. The aim of this study is to describe healthcare professionals' experiences with teamwork in a surgical ward before and during the implementation of a longitudinal interprofessional team training programme.

DESIGN

A qualitative descriptive study based on follow-up focus group interviews.

SETTING

A combined gastrointestinal surgery and urology ward at a hospital division in a Norwegian hospital trust.

PARTICIPANTS

A convenience sample of 11 healthcare professionals divided into three professionally based focus groups comprising physicians (n=4), registered nurses (n=4) and certified nursing assistants (n=3).

INTERVENTIONS

The TeamSTEPPS programme was implemented in the surgical ward from May 2016 to June 2017. The team training programme included the three phases: (1) assessment and planning, (2) training and implementation and (3) sustainment.

RESULTS

Before implementing the team training programme, healthcare professionals were essentially satisfied with the teamwork skills within the ward. During the implementation of the programme, they experienced that team training led to greater awareness and knowledge of their common teamwork skills. Improved teamwork skills were described in relation to a more systematic interprofessional information exchange, consciousness of leadership-balancing activities and resources, the use of situational monitoring tools and a shared understanding of accountability and transparency.

CONCLUSIONS

This study suggests that the team training programme provides healthcare professionals with a set of tools and terminology that promotes a common understanding of teamwork, hence affecting behaviour and communication in their daily clinical practice at the surgical ward.

TRIAL REGISTRATION NUMBER

ISRCTN13997367.

Educational Interventions to Enhance Situation Awareness: A Systematic Review and Meta-Analysis

STATEMENT

We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes.

Teamwork and Safety Attitudes in Complex Aortic Surgery at a Dutch Hospital: Cross-Sectional Survey Study

BACKGROUND

Improving teamwork in surgery is a complex goal and difficult to achieve. Human factors questionnaires, such as the Safety Attitudes Questionnaire (SAQ), can help us understand medical teamwork and may assist in achieving this goal.

OBJECTIVE

This paper aimed to assess local team and safety culture in a cardiovascular surgery setting to understand how purposeful teamwork improvements can be reached.

METHODS

Two cardiovascular surgical teams performing complex aortic treatments were assessed: an endovascular-treatment team (ETT) and an open-treatment team (OTT). Both teams answered an online version of the SAQ Dutch Edition (SAQ-NL) consisting of 30 questions related to six different domains of safety: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions. In addition, one open-ended question was posed to gain more insight into the completed questionnaires.

RESULTS

The SAQ-NL was completed by all 23 ETT members and all 13 OTT members. Team composition was comparable for both teams: 57% and 62% males, respectively, and 48% and 54% physicians, respectively. All participants worked for 10 years or more in health care. SAQ-NL mean scores were comparable between both teams, with important differences found between the physicians and nonphysicians of the ETT. Nonphysicians were less positive about the safety climate, job satisfaction, and working climate domains than were the physicians (P<.05). Additional education on performed procedures, more conjoined team training, as well as a hybrid operating room were suggested by participants as important areas of improvement.

CONCLUSIONS

Nonphysicians of a local team performing complex endovascular aortic aneurysm surgery perceived safety climate, job satisfaction, and working conditions less positively than did physicians from the same team. Open-ended questions suggested that this is related to a lack of adequate conjoined training, lack of adequate education, and lack of an adequate operating room. With added open-ended questions, the SAQ-NL appears to be an assessment tool that allows for developing strategies that are instrumental in improving quality of care.

Interventions to improve team effectiveness within health care: a systematic review of the past decade

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.

An interprofessional team training intervention with an implementation phase in a surgical ward: A controlled quasi-experimental study

Despite a growing awareness of the importance of interprofessional teamwork in relation to patient safety, many hospital units lack effective teamwork. The aim of this study was to explore if an interprofessional teamwork intervention in a surgical ward changed the healthcare personnel's perceptions of patient safety culture, perceptions of teamwork, and attitudes toward teamwork over 12 months. Healthcare personnel from surgical wards at two hospitals participated in a controlled quasi-experimental study. The intervention consisted of six hours of TeamSTEPPS team training and 12 months for the implementation of teamwork tools and strategies. The data collection was conducted among the healthcare personnel in the intervention group and the control group at baseline and at the end of the 12 month study period. The results within the intervention group showed that there were significantly improved scores in three of 12 patient safety culture dimensions and in three of five perceptions of teamwork dimensions after 12 months. When comparing between groups, significant differences were found in three patient safety culture measures in favor of the intervention group. The results of the study suggest that the teamwork intervention had a positive impact on patient safety culture and teamwork in the surgical ward.

A complex teamwork intervention in a surgical ward in Norway

Objectives

Interprofessional team training has a positive impact on team behavior and patient safety culture. The overall objective of the study was to explore the impact of an interprofessional teamwork intervention in a surgical ward on structure, process and outcome. In this paper, the implementation of the teamwork intervention is reported to expand the understanding of the future evaluation results of this study.

Results

The evidence-based Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was implemented in three phases according to the program’s implementation plan, which are built on Kotter’s organizational change model. In the first phase, a project group with the leaders and researchers was established and information about the project was given to all health care personnel in the ward. The second phase comprised 6 h interprofessional team training for all frontline health care personnel followed by 12 months implementation of TeamSTEPPS tools and strategies. In the third phase, the implementation of the tools and strategies continued, and refresher training was conducted.

Trial registration Trial registration number (TRN) is ISRCTN13997367. The study was registered retrospectively with registration date May 30, 2017

How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis

OBJECTIVES

To investigate the relationship between teamwork and clinical performance and potential moderating variables of this relationship.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed was searched in June 2018 without a limit on the date of publication. Additional literature was selected through a manual backward search of relevant reviews, manual backward and forward search of studies included in the meta-analysis and contacting of selected authors via email.

ELIGIBILITY CRITERIA

Studies were included if they reported a relationship between a teamwork process (eg, coordination, non-technical skills) and a performance measure (eg, checklist based expert rating, errors) in an acute care setting.

DATA EXTRACTION AND SYNTHESIS

Moderator variables (ie, professional composition, team familiarity, average team size, task type, patient realism and type of performance measure) were coded and random-effect models were estimated. Two investigators independently extracted information on study characteristics in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

The review identified 2002 articles of which 31 were included in the meta-analysis comprising 1390 teams. The sample-sized weighted mean correlation was r=0.28 (corresponding to an OR of 2.8), indicating that teamwork is positively related to performance. The test of moderators was not significant, suggesting that the examined factors did not influence the average effect of teamwork on performance.

CONCLUSION

Teamwork has a medium-sized effect on performance. The analysis of moderators illustrated that teamwork relates to performance regardless of characteristics of the team or task. Therefore, healthcare organisations should recognise the value of teamwork and emphasise approaches that maintain and improve teamwork for the benefit of their patients.

Evaluating Teamwork in the Neonatal Intensive Care Unit: A Survey of Providers and Parents

BACKGROUND

A unified vision of team mission, psychologically safe practice environment, effective communication, and respect among team members are key characteristics of an effective interdisciplinary neonatal intensive care unit (NICU) team.

PURPOSE

A quality improvement team in a quaternary NICU surveyed parents, physicians, and nurses on perceptions of teamwork to identify opportunities for improvement.

DESIGN/METHODS

Parents and healthcare staff (n = 113) completed an anonymous survey from May to July of 2014 to assess team roles and membership, team qualities, shared mission, psychological safety, hierarchy, communications, and conflict awareness. An expert panel assigned questions into one or more characteristics of team intelligence.

RESULTS

Physicians, nurses, and parents perceive their roles and the composition of the healthcare team differently. Most providers reported a shared mission and having a cooperative spirit as their teams' best attributes. While most nurses chose safety as most important, the majority of doctors chose treatment plan. Parents consider tenderness toward their infant, providing medical care and answers to their questions important. All expressed varying concerns about psychological safety, conflict resolution, and miscommunications.

IMPLICATIONS FOR PRACTICE

This survey identifies strengths and gaps of teamwork in our NICU and provides insight on necessary changes that need to be made to improve collaboration among the interdisciplinary care team including parents.

IMPLICATIONS FOR RESEARCH

This quality improvement report identifies aspects of team care delivery in NICUs that require further study. The concept of team intelligence and its impact on team effectiveness invites in-depth exploration.

Microlearning for patient safety: Crew resource management training in 15-minutes

OBJECTIVES

We sought to establish the feasibility of chunking crew resource management (CRM) training into micro-size interventions and to compare different training approaches in the context of micro-learning.

DESIGN

We evaluated whether participants in micro-learning CRM activities achieved learning objectives following training. In a between-subjects design, groups were observed for behaviour during a simulation that was part of a 15-minute modular intervention and tested for recollection afterwards.

PARTICIPANTS

The 129 participants recruited for this study were medical students, who already had relevant experience treating patients.

INTERVENTIONS

The experimental setting involved three 5-minute components: video, simulation, and debriefing. Different groups viewed videos involving different didactic concepts: one group observed a videotaped concrete example of a medical care team applying a CRM tool (example group), and one group observed a videotaped lecture on the same topic (lecture group).

MAIN OUTCOME MEASURES

All simulations were videotaped and coded in detail for the occurrence of and time spent engaging in team behaviour and medical care. Questionnaires were administered before, immediately after, and two weeks after the intervention. We compared the groups' behaviour during the simulation (team cooperation and medical care), retention of knowledge from the training content, and results of the evaluation.

RESULTS

Both groups exhibited most of the behaviours included in the content of the instructional videos during the simulations and recollected information 2 weeks later. The example group exhibited significantly more of the training content during the simulation and demonstrated better retention 2 weeks later. Although the example group spent more time on team coordination, there was no difference in the number of executed medical measures.

CONCLUSION

Delivering CRM training in chunks of relatively short and highly standardised interventions appears feasible. In this study, the form of didactical presentation caused a difference in learning success between groups: a traditional lecture was outperformed by an instructional video demonstrating a practical example.

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study

OBJECTIVE

To study the effect of an intervention based on Crew Resource Management team training, including a tool for structured communication, on adverse perinatal and maternal outcomes.

DESIGN

Stepped wedge.

SETTING

The Netherlands.

POPULATION OR SAMPLE

Registry data of 8123 women referred from primary care to a hospital during childbirth, at ≥ 32.0 weeks of singleton gestation and with no congenital abnormalities, in the period 2012-15.

METHODS

Obstetric teams of five hospitals and their surrounding primary-care midwifery practices participated in the intervention. In total, 49 team training sessions were organised for 465 care professionals (75.5% participated). Adverse perinatal and maternal outcomes before, during and after the intervention were analysed using multivariate logistic regression analyses.

MAIN OUTCOME MEASURES

Adverse Outcome Index (AOI-5), a composite measure involving; intrapartum or neonatal death, admission to neonatal intensive care unit, Apgar < 7 at 5 minutes, postpartum haemorrhage and/or perineal tear.

RESULTS

In total, an AOI-5 score was reported in 11.3% of the study population. No significant difference was found in the incidence of the AOI-5 score after the intervention compared with before the intervention (OR 1.07: 95% CI 0.92-1.24).

CONCLUSIONS

We found no effect of the intervention on adverse perinatal and maternal outcomes for women who were referred during childbirth. Team training is appreciated in practice, but evidence on the long-term impact is still limited. Upcoming studies should build on previous research and consider more sensitive outcome measures.

TWEETABLE ABSTRACT

A cluster randomised team training intervention showed no effect on adverse perinatal and maternal outcomes for women referred during childbirth.

Crew resource management training in healthcare: a systematic review of intervention design, training conditions and evaluation

OBJECTIVES

Crew resource management (CRM) training formats have become a popular method to increase patient safety by consideration of the role that human factors play in healthcare delivery. The purposes of this review were to identify what is subsumed under the label of CRM in a healthcare context and to determine how such training is delivered and evaluated.

DESIGN

Systematic review of published literature.

DATA SOURCES

PubMed, PsycINFO and ERIC were searched through 8 October 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Individually constructed interventions for healthcare staff that were labelled as CRM training, or described as based on CRM principles or on aviation-derived human factors training. Only studies reporting both an intervention and results were included.

DATA EXTRACTION AND SYNTHESIS

The studies were examined and coded for relevant passages. Characteristics regarding intervention design, training conditions and evaluation methods were analysed and summarised both qualitatively and quantitatively.

RESULTS

Sixty-one interventions were included. 48% did not explain any keyword of their CRM intervention to a reproducible detail. Operating room teams and surgery, emergency medicine, intensive care unit staff and anaesthesiology came in contact most with a majority of the CRM interventions delivered in a 1-day or half-day format. Trainer qualification is reported seldomly. Evaluation methods and levels display strong variation.

CONCLUSIONS

Critical topics were identified for the CRM training community and include the following: the need to agree on common terms and definitions for CRM in healthcare, standards of good practice for reporting CRM interventions and their effects, as well as the need for more research to establish non-educational criteria for success in the implementation of CRM in healthcare organisations.

Identifying and reducing risks in functional endoscopic sinus surgery through a hierarchical task analysis

Objective

To develop a hierarchical task listing of steps required to perform successful Functional Endoscopic Sinus Surgery (FESS). To complete a technical and human factor analysis of tasks resulting in the identification of errors, frequency of occurrence, severity, and reduction through remediation.

Methods

A triangulation of methods was used in order to derive the steps required to complete a FESS: 1) a literature review was carried out of published descriptions of FESS techniques; 2) observations of three FESS; 3) interviews with surgeons on FESS techniques. Data sets were combined to develop a task analysis of a correct approach to conducting FESS. A review by 12 surgeons, and observation of 25 FESS resulted in refinement of the task analysis. With input from five consultant surgeons and one consultant anesthetist, a Systematic Human Error Reduction and Prediction Approach (SHERPA) was used to identify the risks and mitigating steps in FESS.

Results

Ten tasks and 49 subtasks required for a correct approach to completing FESS were identified based on literature review and expert consensus. A risk score for each subtask was calculated from a suitable risk matrix. Risk reduction methods at each subtask were detailed. High‐scoring subtasks were evaluated and varying strategies examined to reduce the likelihood and mitigate the impact of error. The study demonstrates the usefulness of the HTA and SHERPA approach in standardization and optimization of clinical practice in order to improve patient safety.

Conclusion

Hierarchical Task Analysis and SHERPA are valuable tools to deconstruct expert performance and to highlight potential errors in FESS. The HTA and SHERPA approach to surgical procedures are useful learning and assessment tools for novice surgeons. The information derived offers the opportunity to improve surgical training and enhance patient safety by identifying high‐risk steps in the procedure, and how risk can be mitigated.

Level of Evidence

2c Outcomes Research

Disturbing and distressing: a mixed methods study on the psychological impact of end of life care on junior doctors

BACKGROUND

The Irish Medical Council has identified gaps in knowledge and communications skills of new-entrant doctors in legal, ethical and practical aspects of end of life care.

AIMS

To determine the frequency with which junior doctors deal with end of life care and patient death and to evaluate the impact this has on their psychological wellbeing.

DESIGN

A questionnaire was distributed to junior doctors to determine the frequency with which the participants had managed a patient at end of life. An abbreviated Posttraumatic Stress Disorder Checklist-Civilian version was used to evaluate psychological distress. Critical incident technique interviews explored the challenges of caring for patients at end of life.

SETTING/PARTICIPANTS

A total of 110 junior doctors in two teaching hospitals in Ireland completed the questionnaire: 39 (35.5%) interns and 71 (64.5%) senior house officers. In addition, 31 interviews were carried out with interns, senior house officers and registrars.

RESULTS

The majority (81.8%) had pronounced a death with 39.4% of senior house officers doing so more than 10 times. Three quarters (75.5%) had discussed end of life with a patient's family. Of the 110 respondents that completed the posttraumatic stress disorder checklist, 11.8% screened positively for posttraumatic stress disorder. Challenges identified at interview included lack of knowledge and preparedness, difficulty communicating with family members, a lack of support and a feeling of failure.

CONCLUSIONS

Junior doctors are regularly carrying out tasks related to end of life care, resulting in high levels of psychological distress. Further training and a change in culture are required.

Human factors and non-technical skills: Teamwork

Making mistakes is part of being human and human error is normal in all areas of life (Bromiley and Mitchell 2009). In some contexts this is of little consequence, but in environments where human safety and well-being are at stake it is vital that such error is minimised. The operating theatre is one such safety critical environment. Research suggests, however, that certain factors predispose to human error. Some or all of these factors may be present in the operating theatre and, therefore, have the potential to compromise patient safety.

Healthcare teams as complex adaptive systems: understanding team behaviour through team members' perception of interpersonal interaction

BACKGROUND

Complexity science has been introduced in healthcare as a theoretical framework to better understand complex situations. Interdisciplinary healthcare teams can be viewed as Complex Adaptive Systems (CAS) by focusing more on the team members' interaction with each other than on the characteristics of individual team members. Viewing teams in this way can provide us with insights into the origins of team behaviour. The aim of this study is to describe the functioning of a healthcare team as it originates from the members' interactions using the CAS principles as a framework and to explore factors influencing workplace learning as emergent behaviour.

METHODS

An interview study was done with 21 palliative home-care nurses, 20 community nurses and 18 general practitioners in Flanders, Belgium. A two-step analysis consisted of a deductive approach, which uses the CAS principles as coding framework for interview transcripts, followed by an inductive approach, which identifies patterns in the codes for each CAS principle.

RESULTS

All CAS principles were identified in the interview transcripts of the three groups. The most prevalent principles in our study were principles with a structuring effect on team functioning: team members act autonomously guided by internalized basic rules; attractors shape the team functioning; a team has a history and is sensitive to initial conditions; and a team is an open system, interacting with its environment. The other principles, focusing on the result of the structuring principles, were present in the data, albeit to a lesser extent: team members' interactions are non-linear; interactions between team members can produce unpredictable behaviour; and interactions between team members can generate new behaviour. Patterns, reflecting team behaviour, were recognized in the coding of each CAS principle. Patterns of team behaviour, identified in this way, were linked to interprofessional competencies of the Interprofessional Collaboration Collaborative. Factors influencing workplace learning were identified.

CONCLUSIONS

This study provides us with insights into the origin of team functioning by explaining how patterns of interactions between team members define team behaviour. Viewing healthcare teams as Complex Adaptive Systems may offer explanations of different aspects of team behaviour with implications for education, practice and research.

Safer paediatric surgical teams: A 5-year evaluation of crew resource management implementation and outcomes

Objective

Evaluate longitudinal changes in technical and non-technical skills (teamwork, situation monitoring, communication and leadership), safety culture, and clinical outcomes before and after implementation of a crew resource management (CRM) safety program.

Design

A multi-level prospective single case study in accordance with the SQUIRE-guidelines for reporting quality improvement efforts.

Setting

Large university paediatric surgical service.

Participant(s)

All 153 managers and staff.

Interventions

Training of staff in CRM, systematic risk assessments, and the redesign of work practices captured and reinforced through the development, implementation and refinement of SOPs.

Main Outcome Measure(s)

Data were collected related to: 1) Relevance of CRM training (survey), 2) Safety culture (survey), 3) Team behaviours in clinical practice (non-participatory observations with MedPACT protocol) and 4) Effects on perioperative care for laparoscopic appendectomies-a representative and frequently performed surgical procedure (electronic medical records and administrative data for length of stay, unplanned readmissions and returns to the Operating Room).

Results

Non-technical skills, the use of safety tools, as well as adherence to guidelines for appendectomies all improved significantly over time. Significant safety culture improvements were found in teamwork across and within units, supervisors' expectations and actions, non-punitive response to adverse events, and perceptions of overall patient safety. Unplanned readmissions following appendectomy declined significantly.

Conclusions

Implementation of a comprehensive CRM program including associated safety tools created sustained adherence to new work practices and improved non-technical and technical skills, surgical outcomes and safety culture.

Improving knowledge and behavior of leadership and followership among the interprofessional team

OBJECTIVES

To examine virtual training on Crew Resource Management (CRM) principles of effective leadership and followership on participants' knowledge, applicability, and intended behaviors.

METHODS

Graduate students (n=41) from four health disciplines participated in the training, which included a self-learning module (e.g., didactic content and video vignettes) and an optional virtual simulation exercise. Knowledge was examined via a 10-item pre/post knowledge test. Applicability of the training and intended behaviors was measured post-training via an 11-item survey. T-test and Analysis of variance were applied to compare knowledge scores, as well as to determine variation in discipline responses.

RESULTS

Knowledge improved significantly post-training (t₍₄₀₎=10.47, p<0.001). Pharmacy students scored significantly lower on the post-knowledge test than medicine and nursing students [F_(2,36)=5.99, p=0.006]. On average, participants completing the module reported learning new skills and knowledge (M=4.17, SD=0.54) and intended to use skills/knowledge gained from the training in clinical practice (M=4.29, SD=0.56). No differences were noted among responses from the various disciplines. Those completing the simulation exercise (n=10) found value in the experience, again noting strong application to practice (M=4.9, SD=0.32) and intended use in practice (M=4.9, SD=0.32).

CONCLUSIONS

The CRM training was valuable and applicable to practice. Use of a virtual platform may provide an avenue for minimizing current barriers to successful interprofessional education by allowing participants to connect in various geographical locations. The module is ready for widespread use in health professional education.