Managing teams managing crises: principles of teamwork to improve patient safety in the Emergency Room and beyond

Teamwork in community health committees: a case study in two urban informal settlements

BACKGROUND

Community health committees (CHCs) are mechanisms for community participation in decision-making and overseeing health services in several low-and middle-income countries (LMICs). There is little research that examines teamwork and internal team relationships between members of these committees in LMICs. We aimed to assess teamwork and factors that affected teamwork of CHCs in an urban slum setting in Nairobi, Kenya.

METHODS

Using a qualitative case-study design, we explored teamwork of two CHCs based in two urban informal settlements in Nairobi. We used semi-structured interviews (n = 16) to explore the factors that influenced teamwork and triangulated responses using three group discussions (n = 14). We assessed the interpersonal and contextual factors that influenced teamwork using a framework for assessing teamwork of teams involved in delivering community health services.

RESULTS

Committee members perceived the relationships with each other as trusting and respectful. They had regular interaction with each other as friends, neighbors and lay health workers. CHC members looked to the Community Health Assistants (CHAs) as their supervisor and "boss", despite CHAs being CHC members themselves. The lay-community members in both CHCs expressed different goals for the committee. Some viewed the committee as informal savings group and community-based organization, while others viewed the committee as a structure for supervising Community Health Promoters (CHPs). Some members doubled up as both CHPs and CHC members. Complaints of favoritism arose from CHC members who were not CHPs whenever CHC members who were CHPs received stipends after being assigned health promotion tasks in the community. Underlying factors such as influence by elites, power imbalances and capacity strengthening had an influence on teamwork in CHCs.

CONCLUSION

In the absence of direction and support from the health system, CHCs morph into groups that prioritize the interests of the members. This redirects the teamwork that would have benefited community health services to other common interests of the team. Teamwork can be harnessed by strengthening the capacity of CHC members, CHAs, and health managers in team building and incorporating content on teamwork in the curriculum for training CHCs.

Addressing leadership communication, parenting demands and mental health challenges: a mixed-methods case study of clinical and translational scientists during COVID-19

BACKGROUND

In March 2020, academic research centres in Colorado were closed to prevent the spread of COVID-19. Scientists and research staff were required to continue their work remotely with little time to prepare for the transition.

METHODS

This survey study used an explanatory sequential mixed-method design to explore clinical and translational researcher and staff experiences of the transition to remote work during the first 6 weeks of the COVID-19 pandemic. Participants indicated the level of interference with their research and shared their experiences of remote work, how they were impacted, how they were adapting and coping, and any short-term or long-term concerns.

RESULTS

Most participants indicated that remote work interfered with their research to a moderate or great degree. Participant stories illuminated the differences of remote work prior to and during COVID-19. They described both challenges and silver linings. Three themes that highlight the challenges of transitioning to remote work during a pandemic were: (1) Leadership communication: 'Leadership needs to revisit their communication strategy'; (2) Parenting demands: Parents are 'multitasked to death' every day and (3) Mental health challenges: The COVID-19 experience is 'psychologically taxing'.

CONCLUSIONS

The study findings can be used to guide leaders in building community, resiliency and support productivity during current and future crises. Potential approaches to address these issues are proposed.

Developing local crisis leadership - A research and training agenda

The crisis triggered by Covid-19 has exposed the interdependencies of modern society and sparked interest in local response to protracted and complex crisis situations. There has been a growing awareness and interest in the key roles of political and professional stakeholders, their emotional regulation and how they influence team performance and outcomes in dealing with uncertainty and complex crisis situations. While cognitive and behavioral aspects of crisis leadership are well researched, less is understood about how one can mitigate negative emotions, instill trust, or restore public faith and support of security forces and emergency response teams during crises. In addressing this gap, we propose a simplified conceptual roadmap for research and training of local crisis leadership. In this, we emphasize complex problem solving, team interaction, team context and technology and team training design. These four factors represent significant barriers if neglected. On the other side, they may be considerable force multipliers when better understood and managed. We suggest how seven research and training questions could be linked to the four conceptual factors and guide an evidence-based approach to develop local crisis leadership.

Learning practices of experienced healthcare teams and dyads in acute care settings: a scoping review

OBJECTIVES

To map the evidence on learning practices currently used by experienced healthcare teams and dyads. The hypothesis is that through reviewing the literature we will identify the number and array of current learning practices. Through the lens of collaboration, the authors' goal is to map current practice to guide future research, policy and practice.

SETTING

The review included studies from North America, Europe, Australasia and Asia. All studies were conducted in acute care settings such as operating rooms, emergency rooms, intensive care units and simulation centres.

PARTICIPANTS

The participants were experienced healthcare professionals who work in acute care settings of any age or any sex. The group was interprofessional including two or more disciplines and/or professions. Characteristics of the participants who were excluded were students, novices, healthcare professionals who work in non-acute care settings and single profession studies.

PRIMARY AND SECONDARY OUTCOME MEASURES

Aligned to the protocol quantitative and qualitative analyses were conducted. Thematic analysis was used to evaluate and categorise the study findings. Secondary outcome measures were the different types of learning practices used together to produce excellence.

RESULTS

Most empirical studies were qualitative studies (46%), 31% were mixed methods and 23% were quantitative studies. There were also 24 reviews and 10 commentaries. The most frequent learning practices were structured observation and case scenarios (21%) followed by audio/video analysis and surveys (17%). Next was interviews and didactic presentations (12%) followed by prebriefing/debriefing and checklists (11%). Other learning practices accounted for less than 10%. Overall, 84 of the 86 publications, examined learning practices of teams larger than two participants.

CONCLUSIONS

While the quality of studies was high, and there was a broad range of empirical studies, reviews and commentaries, there was no consensus on best practice in determining which learning practices to use and measurement of the effect of these practices.

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.

Change of collective orientation through an interprofessional training with medical students and student nurses depending on presence and professional group

BACKGROUND

Teamwork is an important success factors for patient treatment. The willingness of a healthcare provider to work in a team can be descripted with the construct of "Collective Orientation" (CO). The level of CO can be trained and is related to team performance. In this study, we investigated the effect of a simulator-based interprofessional training on the subject of patient fall in a hospital setting upon participations CO. To evaluate whether the course could be integrated into a longitudinal education concept, the participants were medical students and student nurses. Since effects of simulations can be influenced by the perceived reality, the results were measured as a function of Presence.

METHOD

In this observation study, 62 medical students and student nurses took part in six one-day interprofessional simulation trainings with the topic patient fall. The primary outcome was the mean difference between the CO measured immediately before (T1) and after the training (T2). The Presence of the participants was measured by questionnaire immediately after the course (T2).

RESULTS

Cronbach´s alpha for all scales and measurement points was higher than 0.69. CO increases over all professional groups from M = 3.42 (SD = 0.39) to M = 3.68 (SD = 0.54) significantly (p < .00; r = .5). Only the subscale "Dominance" in the professional group of the student nurses did not increase significantly. There was no correlation between Presence and the change in CO.

CONCLUSION

The questionnaires of CO and Presence can be applied to medical students and student nurses. The simulation course with the topic patient fall influences the CO and can be integrated in a longitudinal curriculum of teamwork training. The subscale "Dominance" of student nurses did not change. Preparatory learning units may increase the effects. The perceived reality of the scenario is not a main success factor.

An analysis of trauma team communication using the verbal response mode taxonomy

BACKGROUND

Although 40 years has passed since the Institute of Medicine released its report "To Err Is Human," error counts are still high in healthcare. The understanding and training of nontechnical skills and teamwork thus remains a pertinent area for improvement. Most evaluation of nontechnical skills of trauma teams takes place in simulation rooms. The aim of this study was to determine if real trauma resuscitation communication could be analyzed using the speech classification system of verbal response modes, otherwise known as the verbal response mode taxonomy and, if so, if there is a predominant approach of verbally delivering messages.

METHODS

Video and audio recordings of 5 trauma team resuscitations were transcribed. Communication was coded using the verbal response mode taxonomy for both form and intent. The rate of mixed-mode communication (unmatched form and intent) and pure-mode communication were calculated and compared between the participants roles. Comparisons were made with simulated material published in other research.

RESULTS

The most frequent mixed-mode communication was acknowledgment in service of confirmation. Question in service of a question was the most used pure-mode communication. Six predominant roles were seen, which matched well with the roles in the simulations.

CONCLUSION

The verbal response mode taxonomy can be used to study communication during real trauma resuscitation, and it was found that pure-mode communication was predominant, meaning that the grammatical form matches the intent. Verbal response mode methodology is time consuming and requires analysts with domain knowledge. Comparisons show some differences between simulations and our material indicating that verbal response modes can be used to evaluate differences in communication.

Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study

BACKGROUND

Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA.

METHODS

An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure.

RESULTS

We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period.

CONCLUSIONS

An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.

A Systematic Scoping Review on Pedagogical Strategies of Interprofessional Communication for Physicians in Emergency Medicine

BACKGROUND

Interprofessional communication (IPC) is integral to interprofessional teams working in the emergency medicine (EM) setting. Yet, the coronavirus disease 2019 pandemic has laid bare gaps in IPC knowledge, skills and attitudes. These experiences underscore the need to review how IPC is taught in EM.

PURPOSE

A systematic scoping review is proposed to scrutinize accounts of IPC programs in EM.

METHODS

Krishna's Systematic Evidence-Based Approach (SEBA) is adopted to guide this systematic scoping review. Independent searches of ninedatabases (PubMed, Embase, CINAHL, Scopus, PsycINFO, ERIC, JSTOR, Google Scholar and OpenGrey) and "negotiated consensual validation" were used to identify articles published between January 1, 2000 and December 31, 2020. Three research teams reviewed the data using concurrent content and thematic analysis and independently summarized the included articles. The findings were scrutinized using SEBA's jigsaw perspective and funneling approach to provide a more holistic picture of the data.

RESULTS

IN TOTAL

18,809 titles and abstracts were identified after removal of duplicates, 76 full-text articles reviewed, and 19 full-text articles were analyzed. In total, four themes and categories were identified, namely: (a) indications and outcomes, (2) curriculum and assessment methods, (3) barriers, and (4) enablers.

CONCLUSION

IPC training in EM should be longitudinal, competency- and stage-based, underlining the need for effective oversight by the host organization. It also suggests a role for portfolios and the importance of continuing support for physicians in EM as they hone their IPC skills.

HIGHLIGHTS

• IPC training in EM is competency-based and organized around stages.• IPC competencies build on prevailing knowledge and skills.• Longitudinal support and holistic oversight necessitates a central role for the host organization.• Longitudinal, robust, and adaptable assessment tools in the EM setting are necessary and may be supplemented by portfolio use.

Simulation-Based Team Leadership Training Improves Team Leadership During Actual Trauma Resuscitations: A Randomized Controlled Trial

OBJECTIVES

Trauma resuscitations are complex critical care events that present patient safety-related risk. Simulation-based leadership training is thought to improve trauma care; however, there is no robust evidence supporting the impact of leadership training on clinical performance. The objective of this study was to assess the clinical impact of simulation-based leadership training on team leadership and patient care during actual trauma resuscitations.

DESIGN

Randomized controlled trial.

SETTING

Harborview Medical Center (level 1 trauma center).

SUBJECTS

Seventy-nine second- and third-year residents were randomized and 360 resuscitations were analyzed.

INTERVENTIONS

Subjects were randomized to a 4-hour simulation-based leadership training (intervention) or standard orientation (control) condition.

MEASUREMENTS AND MAIN RESULTS

Participant-led actual trauma resuscitations were video recorded and coded for leadership behaviors and patient care. We used random coefficient modeling to account for the nesting effect of multiple observations within residents and to test for post-training group differences in leadership behaviors while controlling for pre-training behaviors, Injury Severity Score, postgraduate training year, and days since training occurred. Sixty participants completed the study. There was a significant difference in post-training leadership behaviors between the intervention and control conditions (b1 = 4.06, t (55) = 6.11, p < 0.001; intervention M = 11.29, SE = 0.66, 95% CI, 9.99-12.59 vs control M = 7.23, SE = 0.46, 95% CI, 6.33-8.13, d = 0.92). Although patient care was similar between conditions (b = 2.00, t (55) = 0.99, p = 0.325; predicted means intervention M = 62.38, SE = 2.01, 95% CI, 58.43-66.33 vs control M = 60.38, SE = 1.37, 95% CI, 57.69-63.07, d = 0.15), a test of the mediation effect between training and patient care suggests leadership behaviors mediate an effect of training on patient care with a significant indirect effect (b = 3.44, 95% CI, 1.43-5.80). Across all trauma resuscitations leadership was significantly related to patient care (b1 = 0.61, SE = 0.15, t (273) = 3.64, p < 0.001).

CONCLUSIONS

Leadership training resulted in the transfer of complex skills to the clinical environment and may have an indirect effect on patient care through better team leadership.

Cognitive aids with roles defined (CARD) for obstetrical crises: a multisite before-and-after cohort study

PURPOSE

Patient outcome during an obstetrical emergency depends on prompt coordination of an interprofessional team. The cognitive aids with roles defined (CARD) is a cognitive aid that addresses the issue of teamwork in crisis management. This study evaluated the clinical impact of implementing the CARD cognitive aid during emergency Cesarean deliveries.

METHODS

We conducted a prospective before-and-after cohort trial at the maternity units of two Canadian academic hospital campuses. Both sites received didactic online training regarding teamwork during crises, which involved training on using CARD for the "CARD" campus (intervention) and no mention of CARD at the "no CARD" campus (control). The primary outcome was the total time to delivery after the call for an emergency Cesarean delivery. Secondary outcomes included specific intervals of time within the time to delivery and clinical outcomes for both the babies and mothers.

RESULTS

We analyzed data from 267 eligible emergency Cesarean deliveries that occurred between January 11 2014 and December 31 2017. The use of CARD did not significantly change the median [interquartile range] time to delivery of the baby during an emergency Cesarean delivery from the pre-intervention to the post-intervention time period (17 [12-28] vs 15 [13-20], respectively; median difference, 2; 95% confidence interval, -1 to 5; P = 0.36). The clinical outcomes for the baby or the mother and other secondary outcomes also did not change.

CONCLUSIONS

The CARD cognitive aid did not significantly improve time-based or clinical maternal and neonatal outcomes of emergency Cesarean delivery at our academic maternity unit.

Medical Student Leadership in Emergency Medicine

Emergency medicine is a profession that requires good leadership skills. Emergency physicians must be able to instill confidence in both the staff and patients, inspire the best in others, have the enthusiasm to take on a surplus of responsibilities, and maintain calmness during unexpected circumstances. Accordingly, residency program directors look carefully for leadership qualities and potential among their applicants. Although some people do have a predisposition to lead, leadership can be both learned and taught. In this article, we provide medical students with the tools that will help them acquire those qualities and thus make them more desirable by program directors.

The Influence of Visibility on Medical Teamwork in Emergency Departments: A Mixed-Methods Study

AIM

This mixed-methods study delivers empirical evidence on the influence of visibility on healthcare teamwork in Emergency Departments (EDs). This study researchers hypothesized that with changes of visibility in EDs, teamwork among medical staff members will be impacted.

BACKGROUND

Prior research results suggest that visibility can influence health-setting efficacy. Teamwork is one of the components of each healthcare system that can be supported by environmental design.

METHOD

Visibility in four subject sites from the same healthcare system was objectively measured by morphology plan analyses. Teamwork among medical staff members was the behavioral variable of interest and explored through field observations, interviews, and surveys.

RESULTS

The qualitative outcomes demonstrated that teamwork can be enhanced by improved visibility, while the quantitative findings supported the idea that some specific measures of visibility were correlated with teamwork.

CONCLUSION

This study provides a model for future research on the association between healthcare staff behavior and ED plan configuration. The enhancement of ED design, considering the significance of visibility, enhances the perceptions of nurses and physicians in terms of teamwork.

Impacts of Nursing Unit Design on Visibility and Proximity and Its Influences on Communication, Privacy, and Efficiency

OBJECTIVES

This study examines the role of visibility and proximity on nurse communication patterns, perception of privacy, and efficiency in double-corridor nursing units.

BACKGROUND

Nurses are extremely important for the quality of healthcare. The literature suggests that visibility and proximity have a substantial impact on the delivery of care and staff experience. However, few studies have empirically examined nursing units in China.

METHOD

Questionnaire surveys, observations, and simulations of medication administration tasks were employed.

RESULTS

Visibility and proximity influenced communication patterns, perceptions of privacy, and efficiency. The type of wall in the medication room could impact nurses' perception of privacy and efficiency. A partial glass wall in the medication room could achieve balance between privacy and visibility. A medication room that is adjacent to and is easily accessed from the nurse station (NS) could provide efficient communication and efficient work. The partition type between the NS and the doctor's office and the layout of the medication room could impact communication patterns. The relative position of the NS, medication room, and disposal room could influence the flow of medication administration tasks, and a geographically contiguous spatial layout could enhance work efficiency.

CONCLUSIONS

The findings contribute to the body of knowledge on the impact of visibility and proximity on nurses' communication patterns, perception of privacy, and efficiency. Recommendations to improve the design of double-corridor nursing units are also provided.

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.

Role network measures to assess healthcare team adaptation to complex situations: the case of venous thromboembolism prophylaxis

Hospitals are complex environments that rely on clinicians working together to provide appropriate care to patients. These clinical teams adapt their interactions to meet changing situational needs. Venous thromboembolism (VTE) prophylaxis is a complex process that occurs throughout a patient's hospitalisation, presenting five stages with different levels of complexity: admission, interruption, re-initiation, initiation, and transfer. The objective of our study is to understand how the VTE prophylaxis team adapts as the complexity in the process changes; we do this by using social network analysis (SNA) measures. We interviewed 45 clinicians representing 9 different cases, creating 43 role networks. The role networks were analysed using SNA measures to understand team changes between low and high complexity stages. When comparing low and high complexity stages, we found two team adaptation mechanisms: (1) relative increase in the number of people, team activities, and interactions within the team, or (2) relative increase in discussion among the team, reflected by an increase in reciprocity.   Practitioner Summary: The reason for this study was to quantify team adaptation to complexity in a process using social network analysis (SNA). The VTE prophylaxis team adapted to complexity by two different mechanisms, by increasing the roles, activities, and interactions among the team or by increasing the two-way communication and discussion throughout the team. We demonstrated the ability for SNA to identify adaptation within a team.

Starting to Think Like an Expert: An Analysis of Resident Cognitive Processes During Simulation-Based Resuscitation Examinations

STUDY OBJECTIVE

Simulation is commonly used to teach crisis resource management skills and assess them in emergency medicine residents. However, our understanding of the cognitive processes underlying crisis resource management skills is limited because these processes are difficult to assess and describe. The objective of this study is to uncover and characterize the cognitive processes underlying crisis resource management skills and to describe how these processes vary between residents according to performance in a simulation-based examination.

METHODS

Twenty-two of 24 eligible emergency medicine trainees from 1 tertiary academic center completed 1 or 2 resuscitation-based examinations in the simulation laboratory. Resident performance was assessed by a blinded expert using an entrustment-based scoring tool. Participants wore eye-tracking glasses that generated first-person video that was used to augment subsequent interviews led by an emergency medicine faculty member. Interviews were audio recorded and then transcribed. An emergent thematic analysis was completed with a codebook that was developed by 4 research assistants, with subsequent analyses conducted by the lead research assistant with input from emergency medicine faculty. Themes from high- and low-performing residents were subsequently qualitatively compared.

RESULTS

Higher-performing residents were better able to anticipate, selectively attend to relevant information, and manage cognitive demands, and took a concurrent (as opposed to linear) approach to managing the simulated patient.

CONCLUSION

The results provide new insights into residents' cognitive processes while managing simulated patients in an examination environment and how these processes vary with performance. More work is needed to determine how best to apply these findings to improve crisis resource management education.

The Impact of Environmental Design on Teamwork and Communication in Healthcare Facilities: A Systematic Literature Review

The purpose of this systematic review is to investigate the current knowledge about the impact of healthcare facility design on teamwork and communication by exploring the relevant literature. Teamwork and communication are behavioral factors that are impacted by physical design. However, the effects of environmental factors on teamwork and communication have not been investigated extensively in healthcare design literature. There are no published systematic reviews on the current topic. Searches were conducted in PubMed and Google Scholar databases in addition to targeted design journals including Health Environmental Research & Design, Environment and Behavior, Environmental Psychology, and Applied Ergonomics. Inclusion criteria were (a) full-text English language articles related to teamwork and communication and (b) involving any healthcare built environment and space design published in peer-reviewed journals between 1984 and 2017. Studies were extracted using defined inclusion and exclusion criteria. In the first phase, 26 of the 195 articles most relevant to teamwork and 19 studies of the 147 were identified and reviewed to understand the impact of communication in healthcare facilities. The literature regarding the impact of built environment on teamwork and communication were reviewed and explored in detail. Eighteen studies were selected and succinctly summarized as the final product of this review. Environmental design, which involves nurses, support staff, and physicians, is one of the critical factors that promotes the efficiency of teamwork and collaborative communication. Layout design, visibility, and accessibility levels are the most cited aspects of design which can affect the level of communication and teamwork in healthcare facilities.

Making Electronic Health Records (EHRs) Work: Informal Talk and Workarounds in Healthcare Organizations

A key provision of the American Recovery and Reinvestment Act of 2009 mandated that electronic health records (EHR) be adopted in US healthcare organizations by 2015. The purpose of this study is to examine the communicative processes involved as healthcare workers implement an EHR and make changes, known as workarounds. Guided by theories in social influence, and diffusion of innovations, we conducted a survey of healthcare professionals using an EHR system in an organization. Our structural equation modeling (SEM) and multiple regression results reveal coworker communication, in the form of informal social support and feedback, play an important role in whether people engage in workarounds. Understanding this relationship is important because our study also demonstrates that workarounds predict healthcare employees' overall satisfaction with the EHR system. Specifically, workarounds are associated with higher perceptions of the EHR's relative advantage, higher perceptions of EHR implementation success, and lower levels of resistance to EHR change. This study offers a health communication contribution to the growing research on EHR systems and demonstrates the persuasive effects that coworkers have on new technology use in healthcare organizations.

Dedication increases productivity: an analysis of the implementation of a dedicated medical team in the emergency department

Background

In several European countries, emergency departments (EDs) now employ a dedicated team of full-time emergency medicine (EM) physicians, with a distinct leadership and bed-side emergency training, in all similar to other hospital departments. In Portugal, however, there are still two very different models for staffing EDs: a classic model, where EDs are mostly staffed with young inexperienced physicians from different medical departments who take turns in the ED in 12-h shifts and a dedicated model, recently implemented in some hospitals, where the ED is staffed by a team of doctors with specific medical competencies in emergency medicine that work full-time in the ED.

Our study assesses the effect of an intervention in a large academic hospital ED in Portugal in 2002, and it is the first to test the hypothesis that implementing a dedicated team of doctors with EM expertise increases the productivity and reduces costs in the ED, maintaining the quality of care provided to patients.

Methods

A pre–post design was used for comparing the change on the organisational model of delivering care in our medical ED. All emergency medical admissions were tracked in 2002 (classic model with 12-h shift in the ED) and 2005/2006 (dedicated team with full-time EM physicians), and productivity, costs with medical human resources and quality of care measures were compared.

Results

We found that medical productivity (number of patients treated per hour of medical work) increased dramatically after the creation of the dedicated team (X²_KW = 31.135; N = 36; p < 0.001) and costs with ED medical work reduced both in regular hours and overtime. Moreover, hospitalisation rates decreased and the length of stay in the ED increased significantly after the creation of the dedicated team.

Conclusions

Implementing a dedicated team of doctors increased the medical productivity and reduced costs in our ED. Our findings have straightforward implication for Portuguese policymakers aiming at reducing hospital costs while coping with increased ED demand.

An exploration of emergency nurses' perceptions, attitudes and experience of teamwork in the emergency department

BACKGROUND

Teamwork may assist with increased levels of efficiency and safety of patient care in the emergency department (ED), with emergency nurses playing an indispensable role in this process.

METHOD

A descriptive, exploratory approach was used, drawing on principles from phenomenology and symbolic interactionism. Convenience, purposive sampling was used in a major metropolitan ED. Semi structured interviews were conducted, audio recorded, and transcribed verbatim. Transcripts were analysed using thematic analysis.

RESULTS

Three major themes emerged from the data. The first theme 'when teamwork works' supported the notion that emergency nurses perceived teamwork as a positive and effective construct in four key areas; resuscitation, simulation training, patient outcomes and staff satisfaction. The second theme 'team support' revealed that back up behaviour and leadership were critical elements of team effectiveness within the study setting. The third theme 'no time for teamwork' centred around periods when teamwork practices failed due to various contributing factors including inadequate resources and skill mix.

DISCUSSION

Outcomes of effective teamwork were valued by emergency nurses. Teamwork is about performance, and requires a certain skill set not necessarily naturally possessed among emergency nurses. Building a resilient team inclusive of strong leadership and communication skills is essential to being able to withstand the challenging demands of the ED.

An exploration of the factors that influence the successful implementation of the World Health Organization Surgical Safety Checklist

This study presents an exploration of the factors which influence the successful implementation of the WHO Surgical Safety Checklist. A mixed methodological approach using a questionnaire was sent to 348 healthcare professionals in a single NHS trust who use the WHO checklist. 103 questionnaires were returned; five were incomplete and discarded. Data was analysed from 98 questionnaires. Results were evaluated alongside recommendations from a previous audit that took place in this trust in 2013. 63% of surgeons and 54% of anaesthetists within the trust remain untrained as regards the surgical safety checklist. Sign out was the poorest performing component; time out also needed improvement. The biggest obstacle in successful implementation was found to be disengagement of the surgical team. Simulation and team training can enhance non-technical skills, improving communication between staff. The study concludes that differing staff perceptions were found to create barriers to successful implementation of the checklist. Training of all staff is necessary for effective communication within the operating theatre.

Effect size of contributory factors on adverse events: an analysis of RCA series in a teaching hospital

BACKGROUND

One of the most important concerns of health care systems in the world is the patient safety issues. Root Cause Analysis is a systematic process for identifying root causes and contributory factors of problems or events. The objective of this study is to review RCA reports to determine the effect size of contributory factors on adverse events through an organizational perspective.

METHODS

This study was conducted in a tertiary care teaching hospital in 2014. The process of root cause analysis was taken from National Patient Safety Agency framework. We calculated descriptive statistics to determine the frequency distribution of contributory factors on each adverse event.

RESULTS

Having the process of 16 adverse events reviewed, 38 care or service delivery problems were identified which showed that 317 contributory factors and underlying causes had led to these problems. Accordingly, the most important contributory factors included the following: Task factors (20 %), education and training factors (16 %), communication factors (14 %), and team and social factors (13 %).

CONCLUSIONS

RCA is an effective method of problem solving used for identifying the root causes of initial errors and finding ways to prevent the recurrences. In this study, lack of effective communication skills of nurses and other clinical staff when interacting with colleague and communicating with patients, failure to comply with health care provision standards, lack of adequate supervision on implementation of clinical guidelines and issues related to the organizational culture were the main determining factors which have been considered for implementing preventive measures with regard to the hospital specifications.

Assessing Team Leadership in Emergency Medicine: The Milestones and Beyond

BACKGROUND

Team leadership is a critical skill for emergency medicine physicians that directly affects team performance and the quality of patient care. There exists a robust body of team science research supporting team leadership conceptual models and behavioral skill sets. However, to date, this work has not been widely incorporated into health care team leadership education.

OBJECTIVE

This narrative review has 3 aims: (1) to synthesize the team science literature and to translate important concepts and models to health care team leadership; (2) to describe how team leadership is currently represented in the health care literature and in the Accreditation Council for Graduate Medical Education Milestones for emergency medicine; and (3) to propose a novel, evidence-based framework for the assessment of team leadership in emergency medicine.

METHODS

We conducted a narrative review of the team science and health care literature. We summarized our findings and identified a list of team leadership behaviors that were then used to create a framework for team leadership assessment.

RESULTS

Current health care team leadership measurement tools do not incorporate evidence-based models of leadership concepts from other established domains. The emergency medicine milestones include several team leadership behaviors as part of a larger resident evaluation program. However, they do not offer a comprehensive or cohesive representation of the team leadership construct.

CONCLUSIONS

Despite the importance of team leadership to patient care, there is no standardized approach to team leadership assessment in emergency medicine. Based on the results of our review, we propose a novel team leadership assessment framework that is supported by the team science literature.

Citizenship-behavior, cooperation and job satisfaction of medical and nursing teams in an Israeli hospital

Purpose

– The purpose of this paper is to investigate into the relationships among citizenship behavior within medical and nursing teams, cooperation among these teams within hospital units and job satisfaction of members of those teams.

Design/methodology/approach

– Data were gathered via questionnaires, administered to 107 doctors and nurses of a small hospital in Israel, regarding their job satisfaction, their evaluation of the citizenship behavior within their own professional team (medical or nursing) and the extent of cooperation of their own team with the other professional team. Preacher and Hayes’s mediation analyses were carried out on the data.

Findings

– The findings show that medical–nursing cooperation mediates the relationship between citizenship behavior within the professional team (medical or nursing) and job satisfaction. When analyzed separately for doctors and nurses, results show that job satisfaction is predicted by the cooperation between the medical and nursing staff within hospital units, for nurses only. Citizenship behavior is shown to predict job satisfaction for each of the two professional sectors. Although for nurses, both factors affect their levels of job satisfaction, whereas for the doctors, cooperation affects citizenship behavior within the medical team, which, in turn, affects their job satisfaction.

Research limitations/implications

– The research sample is small and culturally specific, thus limiting the generalization potential of this study.

Originality/value

– The unique nature of teamwork within hospital departments is hereby investigated. The findings shed light on a critical issue of hospital human resource management, which has not been previously investigated, and may have practical implications regarding hospitals’ overall management policies.

Network measures for characterising team adaptation processes

The aim of this study was to advance the conceptualisation of team adaptation by applying social network analysis (SNA) measures in a field study of a paediatric cardiac surgical team adapting to changes in task complexity and ongoing dynamic complexity. Forty surgical procedures were observed by trained human factors researchers, and communication processes amongst team members were recorded. Focusing on who talked to whom, team communication structures, in response to changing task demands, were characterised by various network measures. Results showed that in complex procedures, the communication patterns were more decentralised and flatter. Also, in critical transition phases of the procedure, communication was characterised by higher information sharing and participation. We discuss implications for team adaptation theory and teamwork observation methods.

PRACTITIONER SUMMARY

The reasons for this study were to advance our conceptualisation of team adaptation processes and to further quantify team observation methods. We found that the surgical team studied adapted to complexity of surgical procedures by adopting flatter communication patterns. We quantified team observation methods by applying SNA techniques.

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

BACKGROUND

Acute care teams (ACTs) represent action teams, that is, teams in which members with specialised roles must coordinate their actions during intense situations, often under high time pressure and with unstable team membership. Using behaviour observation, patient safety research has been focusing on defining teamwork behaviours-particularly coordination-that are critical for patient safety during these intense situations. As one result of this divergent research landscape, the number, scope and variety of applied behaviour observation taxonomies are growing, making comparison and convergent integration of research findings difficult.

AIM

To facilitate future ACT research by presenting a framework that provides a shared language of teamwork behaviours, allows for comparing previous and future ACT research and offers a measurement tool for ACT observation.

METHOD

Based on teamwork theory and empirical evidence, we developed Co-ACT-the Framework for Observing Coordination Behaviour in ACT. Integrating two previous, extensive taxonomies into Co-ACT, we also suggested 12 behavioural codes for which we determined inter-rater reliability by analysing the teamwork of videotaped anaesthesia teams in the clinical setting.

RESULTS

The Co-ACT framework consists of four quadrants organised along two dimensions (explicit vs implicit coordination; action vs information coordination). Each quadrant provides three categories for which Cohen's κ overall value was substantial; but values for single categories varied considerably.

CONCLUSIONS

Co-ACT provides a framework for organising behaviour codes and offers respective categories for succinctly measuring teamwork in ACTs. Furthermore, it has the potential to allow for guiding and comparing ACTs study results. Future work using Co-ACT in different research and training settings will show how well it can generally be applied across ACTs.

Outcomes from a labor and delivery team training program with simulation component

We evaluated the implementation of a labor and delivery unit team training program that included didactic sessions and simulation training with an active clinical unit. Over an 18-month follow-up time period, our team training program showed improvements in patient outcomes as well as in perceptions of patient safety including the dimensions of teamwork and communication.

The effects of extended work under sleep deprivation conditions on team-based performance

Teamwork is becoming increasingly common in today's workplaces; however, little research has examined how well teams perform under sleep deprivation conditions. The purpose of the current study was to examine the effect of extended work under sleep deprivation conditions on team performance. A total of 24 participants were sleep deprived for 30 h and completed 16 h of sustained operations during the last portion of the sleep deprivation period. The participants completed the Wombat, a complex task including vigilance and cognitive components, with a partner in four 24-min testing sessions during the sustained operations period. The results indicated that team performance increased during the work period while, within each testing session, team performance on vigilance tasks remained stable and overall performance decreased. The current results suggest that performance on two-person teams results in improved performance but does not fully counteract the decreases in performance within each work period. Performance in two-person teams increased across an extended work shift under sleep deprivation conditions. However, vigilance performance remained stable while overall performance decreased when examining performance in 8-min segments. These results suggest that averaging team-based performance over a longer testing period may mask the negative effects of sleep deprivation. STATEMENT OF RELEVANCE: Performance in two-person teams increased across an extended work shift under sleep deprivation conditions. However, vigilance performance remained stable while overall performance decreased when examining performance in 8-min segments. These results suggest that averaging team-based performance over a longer testing period may mask the negative effects of sleep deprivation.

Nursing staff teamwork and job satisfaction

AIM

The aim of the present study was to explore the influence of unit characteristics, staff characteristics and teamwork on job satisfaction with current position and occupation.

BACKGROUND

Teamwork has been associated with a higher level of job satisfaction but few studies have focused on the acute care inpatient hospital nursing team.

METHODS

This was a cross-sectional study with a sample of 3675 nursing staff from five hospitals and 80 patient care units. Participants completed the Nursing Teamwork Survey (NTS).

RESULTS

Participants' levels of job satisfaction with current position and satisfaction with occupation were both higher when they rated their teamwork higher (P<0.001) and perceived their staffing as adequate more often (P<0.001). Type of unit influenced both satisfaction variables (P<0.05). Additionally, education, gender and job title influenced satisfaction with occupation (P<0.05) but not with current position.

CONCLUSIONS

Results of this present study demonstrate that within nursing teams on acute care patient units, a higher level of teamwork and perceptions of adequate staffing leads to greater job satisfaction with current position and occupation.

IMPLICATIONS FOR NURSING MANAGEMENT

Findings suggest that efforts to improve teamwork and ensure adequate staffing in acute care settings would have a major impact on staff satisfaction.

The famous five factors in teamwork: a case study of fratricide

The purpose of this paper is to propose foundations for a theory of errors in teamwork based upon analysis of a case study of fratricide alongside a review of the existing literature. This approach may help to promote a better understanding of interactions within complex systems and help in the formulation of hypotheses and predictions concerning errors in teamwork, particularly incidents of fratricide. It is proposed that a fusion of concepts drawn from error models, with common causal categories taken from teamwork models, could allow for an in-depth exploration of incidents of fratricide. It is argued that such a model has the potential to explore the core causal categories identified as present in an incident of fratricide. This view marks fratricide as a process of errors occurring throughout the military system as a whole, particularly due to problems in teamwork within this complex system. Implications of this viewpoint for the development of a new theory of fratricide are offered. STATEMENT OF RELEVANCE: This article provides an insight into the fusion of existing error and teamwork models for the analysis of an incident of fratricide. Within this paper, a number of commonalities among models of teamwork have been identified allowing for the development of a model.

Can cultural differences lead to accidents? Team cultural differences and sociotechnical system operations

OBJECTIVE

I discuss cultural factors and how they may influence sociotechnical system operations.

BACKGROUND

Investigations of several major transportation accidents suggest that cultural factors may have played a role in the causes of the accidents. However, research has not fully addressed how cultural factors can influence sociotechnical systems.

METHOD

I review literature on cultural differences in general and cultural factors in sociotechnical systems and discuss how these differences can affect team performance in sociotechnical systems.

RESULTS

Cultural differences have been observed in social and interpersonal dimensions and in cognitive and perceptual styles; these differences can affect multioperator team performance.

CONCLUSION

Cultural factors may account for team errors in sociotechnical systems, most likely during high-workload, high-stress operational phases. However, much of the research on cultural factors has methodological and interpretive shortcomings that limit their applicability to sociotechnical systems.

APPLICATION

Although some research has been conducted on the role of cultural differences on team performance in sociotechnical system operations, considerable work remains to be done before the effects of these differences can be fully understood. I propose a model that illustrates how culture can interact with sociotechnical system operations and suggest avenues of future research. Given methodological challenges in measuring cultural differences and team performance in sociotechnical system operations, research in these systems should use a variety of methodologies to better understand how culture can affect multioperator team performance in these systems.

Nonlinear dynamics of team performance and adaptability in emergency response

OBJECTIVE

The impact of team size and performance feedback on adaptation levels and performance of emergency response (ER) teams was examined to introduce a metric for quantifying adaptation levels based on nonlinear dynamical systems (NDS) theory.

BACKGROUND

NDS principles appear in reports surrounding Hurricane Katrina, earthquakes, floods, a disease epidemic, and the Southeast Asian tsunami. They are also intrinsic to coordination within teams, adaptation levels, and performance in dynamic decision processes.

METHOD

Performance was measured in a dynamic decision task in which ER teams of different sizes worked against an attacker who was trying to destroy a city (total N = 225 undergraduates). The complexity of teams' and attackers' adaptation strategies and the role of the opponents' performance were assessed by nonlinear regression analysis.

RESULTS

An optimal group size for team performance was identified. Teams were more readily influenced by the attackers' performance than vice versa. The adaptive capabilities of attackers and teams were impaired by their opponents in some conditions.

CONCLUSION

ER teams should be large enough to contribute a critical mass of ideas but not so large that coordination would be compromised. ER teams used self-organized strategies that could have been more adaptive, whereas attackers used chaotic strategies.

APPLICATIONS

The model and results are applicable to ER processes or training maneuvers involving dynamic decisions but could be limited to nonhierarchical groups.