The design and delivery of crew resource management training: exploiting available resources

Team dynamics and clinician’s experience influence decision-making during Upper-GI multidisciplinary team meetings: A multiple case study

Background

The probability of undergoing treatment with curative intent for esophagogastric cancer has been shown to vary considerately between hospitals of diagnosis. Little is known about the factors that attribute to this variation. Since clinical decision making (CDM) partially takes place during an MDTM, the aim of this qualitative study was to assess clinician’s perspectives regarding facilitators and barriers associated with CDM during MDTM, and second, to identify factors associated with CDM during an MDTM that may potentially explain differences in hospital practice.

Methods

A multiple case study design was conducted. The thematic content analysis of this qualitative study, focused on 16 MDTM observations, 30 semi-structured interviews with clinicians and seven focus groups with clinicians to complement the collected data. Interviews were transcribed ad verbatim and coded.

Results

Factors regarding team dynamics that were raised as aspects attributing to CDM were clinician’s personal characteristics such as ambition and the intention to be innovative. Clinician’s convictions regarding a certain treatment and its outcomes and previous experiences with treatment outcomes, and team dynamics within the MDTM influenced CDM. In addition, a continuum was illustrated. At one end of the continuum, teams tended to be more conservative, following the guidelines more strictly, versus the opposite in which hospitals tended towards a more invasive approach maximizing the probability of curation.

Conclusion

This study contributes to the awareness that variation in team dynamics influences CDM during an MDTM.

Asymmetry of Authority or Information Underlying Insufficient Communication Associated with a Risk of Crashes or Incidents in Passenger Railway Transportation

Similar crashes or incidents may recur as a result of insufficient communication in uncertain and risky situations that potentially threaten safety. The common root causes of insufficient communication across a series of incidents and crashes must be explored in detail to prevent a vicious circle of similar incidents or crashes from occurring. This study summarizes a series of incidents and crashes (derailment due to excessive train speed) at JR West at the West Japan Railway Company (JR West) that are considered to have arisen from insufficient communication. The incidents included (i) resuming train service without confirming the number of passengers on board and leaving passengers behind the station at Higashi-Hiroshima station, (ii) continuing train service in spite of an apparent risk of a crash detected at Okayama station, and (iii) leaving the crack of the train hood as it was at Kokura station. We discuss the causes of insufficient communication (particularly in relation to the sharing of information) among the three branches of staff—the station staff, the conductor and train driver, and the train operation management center—that led to the incidents or crashes. Two factors contributed to the insufficient communication in the series of incidents and crashes: (a) Asymmetry of authority, which hinders the discussion of issues openly and equally among the branches concerned. (b) An unacceptable level of knowledge or information for all branches concerned.

Use of the theoretical domains framework and behaviour change wheel to develop a novel intervention to improve the quality of multidisciplinary cancer conference decision-making

BACKGROUND

Multidisciplinary Cancer Conferences (MCCs) are prospective meetings involving cancer specialists to discuss treatment plans for patients with cancer. Despite reported gaps in MCC quality, there have been few efforts to improve its functioning. The purpose of this study was to use theoretically-rooted knowledge translation (KT) theories and frameworks to inform the development of a strategy to improve MCC decision-making quality.

METHODS

A multi-phased approach was used to design an intervention titled the KT-MCC Strategy. First, key informant interviews framed using the Theoretical Domains Framework (TDF) were conducted with MCC participants to identify barriers and facilitators to optimal MCC decision-making. Second, identified TDF domains were mapped to corresponding strategies using the COM-B Behavior Change Wheel to develop the KT-MCC Strategy. Finally, focus groups with MCC participants were held to confirm acceptability of the proposed KT-MCC Strategy.

RESULTS

Data saturation was reached at n = 21 interviews. Twenty-seven barrier themes and 13 facilitator themes were ascribed to 11 and 10 TDF domains, respectively. Differences in reported barriers by physician specialty were observed. The resulting KT-MCC Strategy included workshops, chair training, team training, standardized intake forms and a synoptic discussion checklist, and, audit and feedback. Focus groups (n = 3, participants 18) confirmed the acceptability of the identified interventions.

CONCLUSION

Myriad factors were found to influence MCC decision making. We present a novel application of the TDF and COM-B to the context of MCCs. We comprehensively describe the barriers and facilitators that impact MCC decision making and propose strategies that may positively impact the quality of MCC decision making.

Overcommitment: Management in Helicopter Emergency Medical Services in Norway

OBJECTIVE

Overcommitment in demanding rescue situations may put both rescuers and patients in danger. This study aimed at identifying individual approaches and organizational strategies that counteract instances in which rescuers commit more than is feasible, desirable, expected, recommended, or compellingly necessary. How is overcommitment managed by professional frontline rescuers during hazardous medical evacuation and rescue situations?

METHODS

In a qualitative, exploratory study, 9 focus group interviews were conducted with a total of 30 crewmembers from the Norwegian Helicopter Emergency Medical Service.

RESULTS

In this second article in a series of 2 articles on overcommitment, 12 commitment-moderating factors are presented. Air ambulance personnel pointed at sociological, cognitive, and organizational elements that may influence their degree of commitment in challenging and hazardous rescue situations.

CONCLUSION

Air ambulance personnel describe a team-based approach to adjust their level of commitment in medical evacuation and rescue missions. They rely on known, however important, nontechnical skills and organizational measures to combat overcommitment in demanding rescue situations. Some of their approaches to safe performance should be adoptable by other rescue units and less experienced voluntary, not-for-profit, rescue organizations.

Myths About Crew Resource Management Training

The science of individual and team training contradicts a number of mistaken assumptions about training effectiveness.

Creating an environment for patient safety and teamwork training in the operating theatre: A quasi-experimental study

INTRODUCTION

Positive safety and a teamwork climate in the training environment may be a precursor for successful teamwork training. This pilot project aimed to implement and test whether a new interdisciplinary and team-based approach would result in a positive training climate in the operating theatre.

METHOD

A 3-day educational module for training the complete surgical team of specialist nursing students and residents in safe teamwork skills in an authentic operative theatre, named Co-Op, was implemented in a university hospital. Participants' (n=22) perceptions of the 'safety climate' and the 'teamwork climate', together with their 'readiness for inter-professional learning', were measured to examine if the Co-Op module produced a positive training environment compared with the perceptions of a control group (n=11) attending the conventional curriculum.

RESULTS

The participants' perceptions of 'safety climate' and 'teamwork climate' and their 'readiness for inter-professional learning' scores were significantly higher following the Co-Op module compared with their perceptions following the conventional curriculum, and compared with the control group's perceptions following the conventional curriculum.

CONCLUSION

The Co-Op module improved 'safety climate' and 'teamwork climate' in the operating theatre, which suggests that a deliberate and designed educational intervention can shape a learning environment as a model for the establishment of a safety culture.

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time. This article presents data that show one such strategy, called the Effective Followership Algorithm, offering statistically significant improvements in team communication across the professional continuum from students and residents to experienced clinicians.

Critical social thinking

As technology, globalization, changing work demands, and a growing reliance on teams are changing the work environment, the social complexity surrounding work functions is increasing dramatically. While a variety of socially relevant knowledge, skills, and abilities (KSAs) have been examined, we argue that studying them in isolation is no longer sufficient, as individuals require a repertoire of KSAs that must be utilized in combination to be effective in complex social situations. Thus, we propose the construct critical social thinking (CST), a holistic, integrated approach to understanding the processes that enable individuals to function in such settings, and the KSAs that are necessary for each process. Because the significance of the CST construct is closely tied to the growing need for it in practice, we also integrate disparate training findings and link them to components of our conceptual model, enabling us to put forth initial insights regarding the approaches through which CST can be trained effectively.

Do team and individual debriefs enhance performance? A meta-analysis

OBJECTIVE

Debriefs (or "after-action reviews") are increasingly used in training and work environments as a means of learning from experience. We sought to unify a fragmented literature and assess the efficacy of debriefs with a quantitative review.

BACKGROUND

Used by the U.S. Army to improve performance for decades, and increasingly in medical, aviation, and other communities, debriefs systematize reflection, discussion, and goal setting to promote experiential learning. Unfortunately, research and theory on debriefing has been spread across diverse disciplines, so it has been difficult to definitively ascertain debriefing effectiveness and how to enhance its effectiveness.

METHOD

We conducted an extensive quantitative meta-analysis across a diverse body of published and unpublished research on team- and individual-level debriefs.

RESULTS

Findings from 46 samples (N = 2,136) indicate that on average, debriefs improve effectiveness over a control group by approximately 25% (d = .67). Average effect sizes were similar for teams and individuals, across simulated and real settings, for within- or between-group control designs, and for medical and nonmedical samples. Meta-analytic methods revealed a bolstering effect of alignment and the potential impact of facilitation and structure.

CONCLUSION

Organizations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs.

APPLICATION

Debriefs are a relatively inexpensive and quick intervention for enhancing performance. Our results lend support for continued and expanded use of debriefing in training and in situ. To gain maximum results, it is important to ensure alignment between participants, focus and intent, and level of measurement.

Crew resource management and teamwork training in health care: a review of the literature and recommendations for how to leverage such interventions to enhance patient safety

PURPOSE

In an attempt to enhance patient safety, health care facilities are increasingly turning to crew resource management (CRM) and other teamwork training interventions. However, there is still quite a bit about such training interventions that remain unclear. Accordingly, our primary intent herein is to provide some clarity by providing a review of the literature, in hopes of highlighting the current state of the literature as well as identifying the areas that should be addressed by researchers in this field going forward.

DESIGN/METHODOLOGY/APPROACH

We searched various electronic databases and utilized numerous relevant search terms to maximize the likelihood of identifying all empirical research related to the use of CRM training within health care. Additionally, we conducted a manual search of the most relevant journals and also conducted a legacy search to identify even more articles. Furthermore, given that as a research team we have experience with CRM initiatives, we also integrate the lessons learned through this experience.

FINDINGS

Based on our review of the literature, CRM and teamwork training programs generally appear beneficial to individual employees, the groups and teams within such settings, and overall health care organizations.

ORIGINALITY/VALUE

In addition to reviewing the literature that addressed CRM and teamwork training, we also highlight some of the more critical aspects of CRM training programs in order for such initiatives to be as successful as possible. Additionally, we detail various factors that appear essential to sustaining any benefits of CRM over the long haul.

Mannequin simulation identifies common surgical intensive care unit teamwork errors long after introduction of sepsis guidelines

INTRODUCTION

Groups of evidence-based guidelines were developed into a comprehensive treatment bundle as part of an international-based Surviving Sepsis Campaign to improve treatment of severe sepsis and septic shock. Conventional educational strategies of this sepsis treatment "bundle" may not ensure acceptable knowledge or completion of these specific tasks and may overlook other dynamic factors present during critical moments of a crisis. Simulation using multidisciplinary teams of clinicians through mannequin-based simulations (MDMS) may improve "bundle" compliance by identifying sepsis guideline errors, reinforcing knowledge, and exposing other potential causes of poor performance.

METHODS

Seventy-four clinicians participated in the MDMS 14 months after hospital-wide introduction of the sepsis bundle. Additionally, each team was given a sepsis treatment-learning packet before the training session. Twelve teams underwent a MDMS of a patient in septic shock. Two evaluators recorded completed sepsis guideline tasks in real time. Sessions were videotaped and reviewed with the team in a postscenario debriefing session. Pre/posttests were also administered.

RESULTS

Individual participants' pretest scores averaged 64.6% correct. Despite all but one team having at least one knowledgeable member with a pretest score of at least 80%, team task completion averaged only 60.4%. Team mean pretest scores and proportion of tasks completed were significantly correlated (P = 0.007), but correlations between specific tasks and related questions showed no relationship to knowledge.

CONCLUSION

Inadequate completion of the sepsis guideline tasks during the MDMS could not be explained by inadequate pretest knowledge alone. MDMS may be a useful tool in identifying and exploring these unknown factors.

A multi-level approach of evaluating crew resource management training: a laboratory-based study examining communication skills as a function of team congruence

The article proposes a multi-level approach for evaluating communication skills training (CST) as an important element of crew resource management (CRM) training. Within this methodological framework, the present work examined the effectiveness of CST in matching or mismatching team compositions with regard to hierarchical status and competence. There is little experimental research that evaluated the effectiveness of CRM training at multiple levels (i.e. reaction, learning, behaviour) and in teams composed of members of different status and competence. An experiment with a two (CST: with vs. without) by two (competence/hierarchical status: congruent vs. incongruent) design was carried out. A total of 64 participants were trained for 2.5 h on a simulated process control environment, with the experimental group being given 45 min of training on receptiveness and influencing skills. Prior to the 1-h experimental session, participants were assigned to two-person teams. The results showed overall support for the use of such a multi-level approach of training evaluation. Stronger positive effects of CST were found for subjective measures than for objective performance measures. STATEMENT OF RELEVANCE: This work provides some guidance for the use of a multi-level evaluation of CRM training. It also emphasises the need to collect objective performance data for training evaluation in addition to subjective measures with a view to gain a more accurate picture of the benefits of such training approaches.

Simulation for the training of human performance and technical skills: the intersection of how we will train health care professionals in the future

AIMS

The aims of this research are to begin to understand health care teams in their operational environment, establish metrics of performance for these teams, and validate a series of scenarios in simulation that elicit team and technical skills. The focus is on defining the team model that will function in the operational environment in which health care professionals work.

METHODS

Simulations were performed across the United States in 70- to 1000-bed hospitals. Multidisciplinary health care teams analyzed more than 300 hours of videos of health care professionals performing simulations of team-based medical care in several different disciplines. Raters were trained to enhance inter-rater reliability.

RESULTS

The study validated event sets that trigger team dynamics and established metrics for team-based care. Team skills were identified and modified using simulation scenarios that employed the event-set-design process. Specific skills (technical and team) were identified by criticality measurement and task analysis methodology.

DISCUSSION

In situ simulation, which includes a purposeful and Socratic Method of debriefing, is a powerful intervention that can overcome inertia found in clinician behavior and latent environmental systems that present a challenge to quality and patient safety. In situ simulation can increase awareness of risks, personalize the risks, and encourage the reflection, effort, and attention needed to make changes to both behaviors and to systems.

Developing expert medical teams: toward an evidence-based approach

Current health care literature cites communication breakdown and teamwork failures as primary threats to patient safety. The unique, dynamic environment of the emergency department (ED) and the complexity of patient care necessitate the development of strong interdisciplinary team skills among emergency personnel. As part of the 2008 Academic Emergency Medicine Consensus Conference on "The Science of Simulation in Healthcare," our workshop group identified key theory and evidence-based recommendations for the design and implementation of team training programs. The authors then conducted an extensive review of the team training literature within the domains of organizational psychology, aviation, military, management, and health care. This review, in combination with the workshop session, formed the basis for recommendations and need for further research in six key areas: 1) developing and refining core competencies for emergency medicine (EM) teams; 2) leadership training for emergency physicians (EPs); 3) conducting comprehensive needs analyses at the organizational, personnel, and task levels; 4) development of training platforms to maximize knowledge transfer; 5) debriefing and provision of feedback; and 6) proper implementation of simulation technology. The authors believe that these six areas should form an EM team training research platform to advance the EM literature, while leveraging the unique team structures present in EM to expand team training theory and research.

Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation

BACKGROUND

Trauma resuscitations require a high level of team performance. This study evaluated the impact of a comprehensive effort to improve trauma care through multidisciplinary education and the use of simulation training to reinforce training and evaluate performance.

METHODS

For a 1-year period, expanded trauma education including monthly trauma simulation sessions using high-fidelity simulators was implemented. All members of the multidisciplinary trauma resuscitation team participated in education, including simulations. Each simulation session included 2 trauma scenarios that were videotaped for debriefing as well as subsequent analysis of team performance. Scored simulations were divided into early (initial 4 months) and late (final 4 months) for comparison.

RESULTS

For the first year of the program, 160 members of our multidisciplinary team participated in the simulation. In the early group, the mean percentage of appropriately completed tasks was 65%, whereas in the late group, this increased to 75% (P < .05). Improvements were also observed in initial assessment, airway management, management of pelvic fractures, and cervical spine care.

CONCLUSIONS

Training of a multidisciplinary team in the care of pediatric trauma patients can be enhanced and evaluated through the use of high-fidelity simulation. Improvements in team performance using innovative technology can translate into more efficient care with fewer errors.

Crew resource management in healthcare: the evolution of teamwork training and MedTeams

The crew resource management training program was developed by the aviation industry in response to critical and fatal errors by the flight team. This article examines the evolution and application of crew resource management to the healthcare industry. The goal of this evolution was to increase patient safety through better communication and teamwork. To accomplish this goal, teamwork training programs, such as MedTeams, are being introduced to healthcare professionals. Clinical studies have yet to show conclusive results of these training programs. Further studies are ongoing and necessary.

Crew resource management and team training

This article reviews medical team training using the principles of crew resource management (CRM). It also briefly discusses crisis resource management, a subset of CRM, as applied to high-acuity medical situations. Guidelines on setting up medical team training programs are presented. Team training programs are classified and examples of simulation-based and classroom-based programs are offered and their merits discussed. Finally, a brief look at the future of team training concludes this review article.

An Intervention to Enhance Nursing Staff Teamwork and Engagement

Numerous studies have concluded that work group teamwork leads to higher staff job satisfaction, increased patient safety, improved quality of care, and greater patient satisfaction. Although there have been studies on the impact of multidisciplinary teamwork in healthcare, the teamwork among nursing staff on a patient care unit has received very little attention from researchers. In this study, an intervention to enhance teamwork and staff engagement was tested on a medical unit in an acute care hospital. The results showed that the intervention resulted in a significantly lower patient fall rate, staff ratings of improved teamwork on the unit, and lower staff turnover and vacancy rates. Patient satisfaction ratings approached, but did not reach, statistical significance.

Target-focused medical emergency team training using a human patient simulator: effects on behaviour and attitude

CONTEXT

Full-scale simulation training is an accepted learning method for gaining behavioural skills in team-centred domains such as aviation, the nuclear power industry and, recently, medicine. In this study we evaluated the effects of a simulator team training method based on targets and known principles in cognitive psychology.

METHODS

This method was developed and adapted for a medical emergency team. In particular, we created a trauma team course for novices, and allowed 15 students to practise team skills in 5 full-scale scenarios. Students' team behaviour was video-recorded and students' attitude towards safe teamwork was assessed using a questionnaire before and after team practice.

RESULTS

Nine of 10 observed team skills improved significantly in response to practice, in parallel with a global rating of team skills. In contrast, no change in attitude toward safe teamwork was registered.

CONCLUSION

The use of team skills in 5 scenarios in a full-scale patient simulator environment implementing a training method based on targets and known principles in cognitive psychology improved individual team skills but had no immediate effect on attitude toward safe patient care.

Teamwork as an essential component of high-reliability organizations

Organizations are increasingly becoming dynamic and unstable. This evolution has given rise to greater reliance on teams and increased complexity in terms of team composition, skills required, and degree of risk involved. High-reliability organizations (HROs) are those that exist in such hazardous environments where the consequences of errors are high, but the occurrence of error is extremely low. In this article, we argue that teamwork is an essential component of achieving high reliability particularly in health care organizations. We describe the fundamental characteristics of teams, review strategies in team training, demonstrate the criticality of teamwork in HROs and finally, identify specific challenges the health care community must address to improve teamwork and enhance reliability.

Teamwork as an essential component of high-reliability organizations

Organizations are increasingly becoming dynamic and unstable. This evolution has given rise to greater reliance on teams and increased complexity in terms of team composition, skills required, and degree of risk involved. High-reliability organizations (HROs) are those that exist in such hazardous environments where the consequences of errors are high, but the occurrence of error is extremely low. In this article, we argue that teamwork is an essential component of achieving high reliability particularly in health care organizations. We describe the fundamental characteristics of teams, review strategies in team training, demonstrate the criticality of teamwork in HROs and finally, identify specific challenges the health care community must address to improve teamwork and enhance reliability.

My copilot is a nurse—Using crew resource management in the OR

Crew resource management (CRM) has been used for more than 20 years in the aviation industry to teach individual error countermeasures by developing nontechnical (ie, cognitive, social) skills based on the observed traits of successful individuals and crews. The health care industry began to investigate aviation CRM after the Institute of Medicine's report, To Err is Human: Building a Safer Health System, recommended that medicine adopt aviation's approach to safety and error management. Initial results of implementing CRM in health care arenas have demonstrated reduced adverse outcomes, reduced errors, reduced length of stay, improved nurse retention, and changed attitudes and behaviors toward teamwork.

Personalentwicklung und Training

Zusammenfassung. Führungskräfte und Mitarbeiter müssen kontinuierliche Anpassungsleistungen in immer kürzeren Zyklen erbringen, individuelle und kollektive Wissensbestände verändern sich, nicht automatisierbare Aufgaben werden komplexer und deren Bewältigung kognitiv anspruchsvoller. Diese Entwicklungen erfordern ein Ressourcenmanagement, das auf ständige Weiterentwicklung der beruflichen Handlungskompetenz ausgerichtet ist. Die Förderung und Entwicklung kompetenter Organisationsmitglieder mit dem Ziel der Wissensvermittlung, Verhaltensmodifikation und Persönlichkeitsentwicklung geschieht auf individueller, gruppenbezogener und organisationaler Ebene in vielfältiger Art und Weise und ist äußerst facettenreich. Eine zukunftsorientierte und wirksame Personalentwicklung ist ohne psychologisches Grundlagen- und Methodenwissen nicht mehr durchführbar. Der Beitrag leistet eine aktuelle Bestandsaufnahme deutscher und angloamerikanischer psychologischer Forschungsarbeiten zur Personalentwicklung. Die State of the Art-Analyse und Diskussion folgt dabei einem Phasenmodell, aufgeteilt nach Analyse, Intervention, Evaluation und Transfer.

The science of training: a decade of progress

This chapter reviews the training research literature reported over the past decade. We describe the progress in five areas of research including training theory, training needs analysis, antecedent training conditions, training methods and strategies, and posttraining conditions. Our review suggests that advancements have been made that help us understand better the design and delivery of training in organizations, with respect to theory development as well as the quality and quantity of empirical research. We have new tools for analyzing requisite knowledge and skills, and for evaluating training. We know more about factors that influence training effectiveness and transfer of training. Finally, we challenge researchers to find better ways to translate the results of training research into practice.

Team training in the skies: does crew resource management (CRM) training work?

The aviation community has invested great amounts of money and effort into crew resource management (CRM) training. Using D. L. Kirkpatrick's (1976) framework for evaluating training, we reviewed 58 published accounts of CRM training to determine its effectiveness within aviation. Results indicated that CRM training generally produced positive reactions, enhanced learning, and promoted desired behavioral changes. However, we cannot ascertain whether CRM has an effect on an organization's bottom line (i.e., safety). We discuss the state of the literature with regard to evaluation of CRM training programs and, as a result, call for the need to conduct systematic, multilevel evaluation efforts that will show the true effectiveness of CRM training. As many evaluations do not collect data across levels (as suggested by D. L. Kirkpatrick, 1976, and by G. M. Alliger, S. I. Tannenbaum, W. Bennett, Jr., & H. Traver, 1997), the impact of CRM cannot be truly determined; thus more and better evaluations are needed and should be demanded.