Toward the Development of the Perfect Medical Team: Critical Components for Adaptation

Implementing Learning from Excellence in a postanaesthesia care unit: a qualitative study of healthcare professionals' experiences after six months

BACKGROUND

Prevailing efforts to ensure patient safety have primarily focused on learning from errors and adverse events (Safety-I). However, it is advocated that complex systems also learn from success (Safety-II) and focus on healthcare professionals' well-being at work to increase resilience. Learning from Excellence is a British initiative designed to learn from successful practices and provide positive feedback to the staff. It has gained enthusiastic followers in several countries, including Norway. However, how it influences learning, well-being and quality improvement, has not been studied in-depth. This study intends to address these gaps. Thus, this study aimed to describe healthcare professionals' experiences with Learning from Excellence six months after its implementation in a postanaesthesia care unit.

METHODS

A qualitative descriptive design was applied. Learning from Excellence was implemented in a postanaesthesia care unit of a Norwegian university hospital between November 2022 and May 2023. Six semi-structured focus group interviews were conducted, from May to June 2023, with a convenience sample of nurses (n = 17) and physicians (n = 7). The data were analysed through inductive reflexive thematic analysis. The study adhered to the COREQ guidelines.

RESULTS

This study reports four prominent themes encapsulating healthcare professionals' experiences with Learning from Excellence. These themes were termed as follows: 1) 'Facilitates a more positive working climate', including sub-themes 'Helps spread positive feedback' and 'Feeling seen and motivated'; 2) 'Why don't I get any 'likes'?'; 3) 'Organisational learning is challenging', including sub-themes 'Hesitating to report' and 'Provides mostly superficial learning'; and 4) 'Success inspires quality improvement project'.

CONCLUSIONS

Implementing LfE mostly contributed to a positive working climate in a postanaesthesia care unit. For LfE to be worth implementing, it is essential to improve organisational learning, while minimising the negative effects of LfE, such as exclusivity issues.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05794490; first registered on March 4, 2023.

Teamwork in Clinical Medicine

Clinical teams are at the heart of healthcare value. Teamwork requires an appreciation of the unique geniuses of each team member as well as an understanding of team dynamics and larger organizational challenges. Effective teams leverage each member's unique talents within a culture of shared humility, service, and dedication. Although interpersonal communication is paramount, organizations that promote a culture of psychological safety to allow productive and necessary conflict are most effective at fostering shared commitment that allows real accountability and result-oriented, responsive systems. Healthy teams can serve to energize clinicians to provide outstanding service and high-value care.

Developing an Evidence-Based Interprofessional Algorithm to Apply Noninvasive Ventilation in Acute Exacerbation of COPD

BACKGROUND

When administered as first-line intervention to patients admitted with acute hypercapnic respiratory failure secondary to COPD exacerbation in conjunction with guideline-recommended therapies, noninvasive ventilation (NIV) has been shown to reduce mortality and endotracheal intubation. Opportunities to increase uptake of NIV continue to exist despite inclusion of this therapy in clinical guidelines. Prior studies suggest that efforts to increase NIV use in acute exacerbation of COPD (AECOPD) need to account for the complex and interprofessional nature of NIV delivery and the need for interprofessional team coordination.

RESEARCH QUESTION

We sought to develop an evidence-based interprofessional algorithm to apply NIV in AECOPD to improve the appropriate utilization of NIV in AECOPD.

STUDY DESIGN AND METHODS

In this prospective qualitative descriptive study, subject matter expert physicians, nurses, and respiratory therapists practicing in a variety of clinical settings caring for patients with AECOPD were recruited for semistructured interviews. The Consolidated Criteria for Reporting Qualitative Research checklist was followed for interview development. Interview themes applicable to interprofessional collaborative practice were identified using deductive thematic analysis. An NIV algorithm based on recent society guidelines was constructed. Interprofessional team tasks appropriate for each phase of the NIV process were integrated into the algorithm.

RESULTS

We present an interprofessional team-based algorithm for delivery of NIV in AECOPD inclusive of patient selection and initiation, titration, monitoring, and weaning of NIV. The goal is to increase appropriate uptake of NIV in the AECOPD population.

INTERPRETATION

The identified roles and responsibilities of an interprofessional team could be integrated into an interprofessional education program pertaining to use and management of NIV for patients with AECOPD emphasizing collaborative best practice, interprofessional team communication, and support of professional autonomy when appropriate.

Using the Operating Room Black Box to Assess Surgical Team Member Adaptation Under Uncertainty: An Observational Study

OBJECTIVE

Identify how surgical team members uniquely contribute to teamwork and adapt their teamwork skills during instances of uncertainty.

BACKGROUND

The importance of surgical teamwork in preventing patient harm is well documented. Yet, little is known about how key roles (nurse, anesthesiologist, surgeon, and medical trainee) uniquely contribute to teamwork during instances of uncertainty, particularly when adapting to and rectifying an intraoperative adverse event (IAE).

METHODS

Audiovisual data of 23 laparoscopic cases from a large community teaching hospital were prospectively captured using OR Black Box. Human factors researchers retrospectively coded videos for teamwork skills (backup behavior, coordination, psychological safety, situation assessment, team decision-making, and leadership) by team role under 2 conditions of uncertainty: associated with an IAE versus no IAE. Surgeons identified IAEs.

RESULTS

In all, 1015 instances of teamwork skills were observed. Nurses adapted to IAEs by expressing more backup behavior skills (5.3× increase; 13.9 instances/hour during an IAE vs 2.2 instances/hour when no IAE) while surgeons and medical trainees expressed more psychological safety skills (surgeons: 3.6× increase; 30.0 instances/hour vs 6.6 instances/hour and trainees: 6.6× increase; 31.2 instances/hour vs 4.1 instances/hour). All roles expressed fewer situation assessment skills during an IAE versus no IAE.

CONCLUSIONS

OR Black Box enabled the assessment of critically important details about how team members uniquely contribute during instances of uncertainty. Some teamwork skills were amplified, while others dampened when dealing with IAEs. The knowledge of how each role contributes to teamwork and adapts to IAEs should be used to inform the design of tailored interventions to strengthen interprofessional teamwork.

Improving the Discharge Process at the VA Palo Alto Through Change Management and Implementation of Project Re-Engineered Discharge

ABSTRACT

This quality improvement project demonstrates that nursing leadership with Project Re-Engineered Discharge can effect change in the discharge process and improve patient outcomes.

What can we learn from COVID-19?: examining the resilience of primary care teams

Introduction

The COVID-19 pandemic continues to place an unprecedented strain on the US healthcare system, and primary care is no exception. Primary care services have shifted toward a team-based approach for delivering care in the last decade. COVID-19 placed extraordinary stress on primary care teams at the forefront of the pandemic response efforts. The current work applies the science of effective teams to examine the impact of COVID-19-a crisis or adverse event-on primary care team resilience.

Methods

Little empirical research has been done testing the theory of team resilience during an extremely adverse crisis event in an applied team setting. Therefore, we conducted an archival study by using large-scale national data from the Veterans Health Administration to understand the characteristics and performance of 7,023 Patient Aligned Care Teams (PACTs) during COVID-19.

Results

Our study found that primary care teams maintained performance in the presence of adversity, indicating possible team resilience. Further, team coordination positively predicted team performance (B = 0.53) regardless of the level of adversity a team was experiencing.

Discussion

These findings in turn attest to the need to preserve team coordination in the presence of adversity. Results carry implications for creating opportunities for teams to learn and adjust to an adverse event to maintain performance and optimize team-member well-being. Teamwork can act as a protective factor against high levels of workload, burnout, and turnover, and should be studied further for its role in promoting team resilience.

Effects of Nurses' Perceptions of Patient Safety Rules and Procedures on Their Patient Safety Performance: The Mediating Roles of Communication about Errors and Coworker Support

Aim

This study aimed to (a) examine the relationship between staff nurses' perceptions of patient safety rules and procedures and their patient safety performance and (b) investigate potential mediators of this relationship.

Background

Implementation of effective management interventions to improve patient safety requires knowledge of the extent to which nurses' perceptions of a hospital's rules and procedures regarding patient safety affect their patient safety performance.

Methods

This correlational study involved a secondary analysis of cross-sectional survey data collected from 1,053 staff nurses in South Korea. Structural equation modeling was employed to test the proposed mediation model. Five standardized measures were used to assess key study variables: patient safety compliance, patient safety participation, nurses' perceptions of patient safety rules and procedures, communication about errors, and coworker support. Cronbach's alpha values for the scales ranged from 0.82 to 0.90.

Results

Nurses' perceptions regarding the usefulness and effectiveness of rules and procedures about patient safety were positively related to their patient safety performance, measured in terms of safety compliance and participation behaviors. Communication about errors and coworker support showed significant mediating effects on these relationships.

Conclusions

The findings indicate that the implementation of effective and useful rules and procedures for improving patient safety would facilitate error communication and coworker support, enhancing nurses' patient safety performance. Implications for Nursing Management. Hospital administrators and nurse managers should consider how they can foster conditions in which nurses perceive rules and procedures regarding patient safety as useful and effective.

Decision-making for pediatric cervical spine imaging after blunt trauma: Investigating team dynamics in the emergency department

Objective

Cervical spine imaging decision-making for pediatric traumas is complex and multidisciplinary. Implementing a risk assessment tool has the potential to reduce variation in these decisions and unnecessary radiation exposure for pediatric patients. We sought to determine how emergency department-trauma team dynamics may affect implementation of such a tool.

Methods

We interviewed (pediatric and general emergency physicians, trauma surgeons, neurosurgeons, orthopedic surgeons and ED nurses at 21 hospitals to ascertain how team dynamics affect the pediatric cervical spine imaging decision-making process. Data were coded following a framework-driven deductive coding process and thematic analysis was used.

Results

Forty-eight physicians, advanced practice providers, and nurses from 21 hospitals (inclusive of three US regions, trauma levels I-III, and serving towns/cities of various population sizes) were interviewed. Overall, emergency physicians and trauma surgeons indicate being generally responsible for pediatric cervical spine imaging decisions. Conflict often occurs between these specialties due to differential weighting of concerns for missing an injury versus avoiding radiation exposure. Participants described a lack of trust and unclear roles regarding ownership for the final imaging decision. Nurses commonly described low psychological safety that prohibits them from participating in the decision-making process.

Conclusions

Implementation of a standardized risk assessment tool for cervical spine trauma imaging decisions must consider perspectives of both emergency medicine and trauma. Policies to define appropriate use of standardized tools within this team environment should be developed.

The role of critical care nurses in shared decision-making for patients with severe heart failure: A qualitative study

AIM

Patients with severe heart failure undergo highly invasive and advanced therapies with uncertain treatment outcomes. For these patients, shared decision-making is necessary. To date, the nursing perspective of the decision-making process for patients facing difficulties and how nurses can support patients in this process have not been fully elucidated. This study aimed to clarify the perceptions of critical care nurses regarding situations with patients with severe heart failure that require difficult decision-making, and their role in supporting these patients.

METHODS

Individual semi-structured interviews were conducted with 10 certified nurse specialists in critical care nursing at nine hospitals in Japan. A qualitative inductive method was used and the derived relationships among the themes were visually structured and represented.

RESULTS

The nurses' perceptions on patients' difficult situations in decision-making were identified as follows: painful decisions under uncertainties; tense relationships; wavering emotions during decision-making; difficulties in coping with worsening medical conditions; patients' wishes that are difficult to realize or estimate; and difficulties in transitioning from advanced medical care. Critical care nurses' roles were summarized into six themes and performed collaboratively within the nursing team. Of these, the search for meaning and value was fundamental. Two positions underpin the role of critical care nurses. The first aims to provide direct support and includes partnerships and rights advocacy. The second aims to provide a holistic perspective to enable necessary adjustments, as indicated by situation assessments and mediation. By crossing various boundaries, co-creating, and forming a good circular relationship in the search for meaning and values, the possibility of expanding treatment and recuperation options may be considered.

CONCLUSIONS

Patients with severe heart failure have difficulty participating in shared decision-making. Critical care nurses should collaborate within the nursing team to improve interprofessional shared decision-making by providing decisional support to patients that focuses on values and meaning.

No size fits all - a qualitative study of factors that enable adaptive capacity in diverse hospital teams

Introduction

Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. By examining how performance emerges in everyday work in different healthcare settings, the research seeks to receive knowledge of the enablers for adaptive capacity. Hospitals are defined as complex organizations with a large number of actors collaborating on increasingly complexity tasks. Consequently, most of today's work in hospitals is team based. The study aims to explore and describe what kind of team factors enable adaptive capacity in hospital teams.

Methods

The article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation (115 h) and interviews (30), followed by a combined deductive and inductive analysis of the material.

Results

The study identified four main themes of team related factors for enabling adaptive capacity; (1) technology and tools, (2) roles, procedures, and organization of work, (3) competence, experience, knowledge, and learning, (4) team culture and relations.

Discussion

Investigating adaptive capacity in four different types of teams allowed for consideration of a range of team types within healthcare and how the team factors vary within and across these teams. All of the four identified team factors are of importance in enabling adaptive capacity, the various attributes of the respective team types prompt differences in the significance of the different factors and indicates that different types of teams could need diverse types of training, structural and relational emphasis in team composition, leadership, and non-technical skills in order to optimize everyday functionality and adaptive capacity.

Analysis of shared cognitive tasks in the application of non-invasive ventilation to patients with COPD exacerbation

Interprofessional teamwork plays a key role in the uptake of evidence-based interventions, such as noninvasive ventilation (NIV) for patients with exacerbated Chronic Obstructive Pulmonary Disease (COPD). We aimed to identify the shared cognitive tasks in interprofessional teams using NIV for patients with COPD exacerbation. We used a cognitive task analysis approach (CTA) to engage nurses, rapid response team members, respiratory therapists, and physicians involved in the use of NIV to treat patients with COPD exacerbation. Clinicians participated in a semi-structured interview (n = 21) that elicited cognitions needed to treat COPD exacerbation. Three shared cognitive tasks were identified: Complete a thorough assessment, Formulate a care plan, and Continuously monitor patient status. Findings attest to the importance of having access to up-to-date information and expertise necessary to make accurate clinical inferences for patient assessment. Shared understanding of the formulated care plan among all members of the care team was important to its execution. Continuous monitoring was crucial; however, this cognitive task relied on patient assessment skills and ongoing collaboration within the clinical care team. Application of NIV for patients with COPD exacerbation may require enhancing collaboration through nontechnical skills and interprofessional training.

In situ simulation-based team training and its significance for transfer of learning to clinical practice-A qualitative focus group interview study of anaesthesia personnel

BACKGROUND

Anaesthesia personnel are an integral part of an interprofessional operating room-team; hence, team-based training in non-technical skills (NTS) are important in preventing adverse events. Quite a few studies have been done on interprofessional in situ simulation-based team training (SBTT). However, research on anaesthesia personnel's experiences and the significance for transfer of learning to clinical practice is limited. The aim of this study is to explore anaesthesia personnel's experience from interprofessional in situ SBTT in NTS and its significance for transfer of learning to clinical practice.

METHODS

Follow-up focus group interviews with anaesthesia personnel, who had taken part in interprofessional in situ SBTT were conducted. A qualitative inductive content analysis was performed.

RESULTS

Anaesthesia personnel experienced that interprofessional in situ SBTT motivated transfer of learning and provided the opportunity to be aware of own practice regarding NTS and teamwork. One main category, 'interprofessional in situ SBTT as a contributor to enhance anaesthesia practice' and three generic categories, 'interprofessional in situ SBTT motivates learning and improves NTS', 'realism in SBTT is important for learning outcome', and 'SBTT increases the awareness of teamwork' illustrated their experiences.

CONCLUSIONS

Participants in the interprofessional in situ SBTT gained experiences in coping with emotions and demanding situations, which could be significant for transfer of learning essential for clinical practice. Herein communication and decision-making were highlighted as important learning objectives. Furthermore, participants emphasized the importance of realism and fidelity and debriefing in the learning design.

A Qualitative Examination of Interprofessional Teamwork for Infection Prevention: Development of a Model and Solutions

Health care-associated infections (HAIs), such as central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), are associated with patient mortality and high costs to the health care system. These are largely preventable by practices such as prompt removal of central lines and Foley catheters. While seemingly straightforward, these practices require effective teamwork between physicians and nurses to be enacted successfully. Understanding the dynamics of interprofessional teamwork in the HAI prevention context requires further examination. We interviewed 420 participants (physicians, nursing, others) across 18 hospitals about interprofessional collaboration in this context. We propose an Input-Mediator-Output-Input (IMOI) model of interprofessional teamwork in the context of HAI prevention, suggesting that various organizational processes and structures facilitate specific teamwork attitudes, behaviors, and cognitions, which subsequently lead to HAI prevention outcomes including timeliness of line and Foley removal, ensuring sterile technique, and hand hygiene. We then propose strategies to improve interprofessional teamwork around HAI prevention.

Associations between safety outcomes and communication practices among pediatric nurses in the United States

PURPOSE

To gain a deeper understanding of RNs communication related to patient safety.

RESEARCH AIMS

To determine: (1) the associations between the communication of registered nurses (RNs) within their health care teams and the frequency that they reported safety events; (2) the associations between RNs' communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs' communication had improved from 2016 to 2018.

THEORETICAL FRAMEWORK AND METHODS

We used the United Kingdom's Safety Culture model as the theoretical framework for this study. Our secondary data analysis from the Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture included 2016 (n = 5298) and 2018 (n = 3476) using multiple regression models to determine associations between responses for Communication Openness and Feedback & Communication About Error, and outcome responses for Frequency of Events Reported and Overall Perceptions of Safety.

RESULTS

Our findings were: 1). In both 2016 and 2018 datasets, Feedback About Error had a greater impact on Reporting Frequency than Open Communication; 2). Feedback About Error had a greater impact on Safety Perceptions than Open Communication; 3). Open Communication and Feedback About Error and their associations with Reporting Frequency and Safety Perceptions showed little change; and, 4). The proportion of variance was low, indicating factors other than Open Communication and Feedback About Error were involved with Reporting Frequency and Safety Perceptions.

CONCLUSION

Pediatric RNs' communication, reporting, and perceptions of patient safety have not improved. (245 words).

Prevalence of Effective Audit-and-Feedback Practices in Primary Care Settings: A Qualitative Examination Within Veterans Health Administration

OBJECTIVE

The purpose of this study is to uncover and catalog the various practices for delivering and disseminating clinical performance in various Veterans Affairs (VA) locations and to evaluate their quality against evidence-based models of effective feedback as reported in the literature.

BACKGROUND

Feedback can enhance clinical performance in subsequent performance episodes. However, evidence is clear that the way in which feedback is delivered determines whether performance is harmed or improved.

METHOD

We purposively sampled 16 geographically dispersed VA hospitals based on high, low, consistently moderate, and moderately average highly variable performance on a set of 17 outpatient clinical performance measures. We excluded four sites due to insufficient interview data. We interviewed four key personnel from each location (n = 48) to uncover effective and ineffective audit and feedback strategies. Interviews were transcribed and analyzed qualitatively using a framework-based content analysis approach to identify emergent themes.

RESULTS

We identified 102 unique strategies used to deliver feedback. Of these strategies, 64 (62.74%) have been found to be ineffective according to the audit-and-feedback research literature. Comparing features common to effective (e.g., individually tailored, computerized feedback reports) versus ineffective (e.g., large staff meetings) strategies, most ineffective strategies delivered feedback in meetings, whereas strategies receiving the highest effectiveness scores delivered feedback via visually understood reports that did not occur in a group setting.

CONCLUSIONS

Findings show that current practices are leveraging largely ineffective feedback strategies. Future research should seek to identify the longitudinal impact of current feedback and audit practices on clinical performance.

APPLICATION

Feedback in primary care has little standardization and does not follow available evidence for effective feedback design. Future research in this area is warranted.

[How to improve the quality of healthcare services and patient safety by adopting strategies from the aviation sector?]

BACKGROUND AND OBJECTIVE

The World Health Organization recognizes patient safety as a priority as part of its global strategy to improve the quality of health services. However, several initiatives need to be integrated and systematized to increase the reliability of healthcare systems. This article discusses several management strategies developed in the aviation sector that have led to a drastic decrease in the accident rate. The aim is to describe each strategy and contrast them with their application in the healthcare sector.

METHODS

Different results and recommendations from the literature and institutions such as the World Health Organization and the International Civil Aviation Organization were consulted and compiled. A synthesis of the identified strategies was made, highlighting examples of their application and impact.

RESULTS

Five key strategies were identified: 1) no-blame incident reporting systems, 2) systematic use of checklists, 3) recurrent training and use of simulation, 4) management of fatigue and work schedules, and 5) management of teamwork.

CONCLUSIONS

The strategies from the aviation sector are presented as a valuable reference for improving patient safety and the quality of healthcare services. They should be consolidated and harmoniously integrated into the design and management of health systems.

Improving Training Motivation and Transfer in Hospitals: Extension of a Conceptual Model

Health-care professionals undergo numerous training programs each year in order to fulfill licensure requirements and organizational obligations. However, evidence suggests that a substantial amount of what is taught during training is never learned or transferred back to routine work. A major contributor to this issue is low training motivation. Prior conceptual models on training transfer in the organizational sciences literature consider this deficit, yet do not account for the unique conditions of the hospital setting. This chapter seeks to close this gap by adapting conceptual models of training transfer to this setting that are grounded in organizational science. Based on theory and supplemented by semistructured key informant interviews (i.e., organizational leaders and program directors), we introduce an applied model of training motivation to facilitate training transfer in the hospital setting. In this model, training needs analysis is positioned as a key antecedent to ensure support for training, relevant content, and perceived utility of training. We posit that these factors, along with training design and logistics, enhance training motivation in hospital environments. Further, we suggest that training motivation subsequently impacts learning and transfer, with elements of the work environment also serving as moderators of the learning-transfer relationship. Factors such as external support for training content (e.g., from accrediting bodies) and allocation of time for training are emphasized as facilitators. The proposed model suggests there are factors unique to the hospital work setting that impact training motivation and transfer that should be considered when developing and implementing training initiatives in this setting.

Patient safety in Work Environments: Perceptions of Pediatric Healthcare Providers in Taiwan

BACKGROUND

Extensive research on the link between the organizational characteristics of the work environment and patient safety in a healthcare organization has been conducted; yet, only a few studies have concentrated on care providers in a pediatric unit.

OBJECTIVES

To determine the correlation between different work environment factors impacting patient safety in a pediatric care unit from the perspective of registered nurses working in these units.

DESIGN

Cross-sectional design.

DATA SOURCES AND METHODS

The study was conducted with 155 registered nurses from a pediatric unit in a medical center in Taiwan with the Chinese version of the Safety Attitudes Questionnaire (SAQ) 2014-2017.

RESULTS

Teamwork climate, higher job satisfaction, and better working conditions are linked to positive perceptions of patient safety culture. Emotional exhaustion is negatively related to most dimensions of patient safety.

CONCLUSION

Teamwork climate, job satisfaction, working conditions, and emotional exhaustion were identified as critical factors impacting the patient safety climate.

IMPLICATIONS FOR NURSING OR HEALTH POLICY

Investments to improve teamwork climate, job satisfaction, and working conditions and reduce emotional exhaustion may have a positive effect on patient safety in pediatric care units.

Can Teamwork Promote Safety in Organizations?

In this review, we conceptualize teamwork as the linchpin driving safety performance throughout an organization. Safety is promoted by teams through various mechanisms that interact in a complex and dynamic process. We press pause on this dynamic process to organize a discussion highlighting the critical role played by teamwork factors in the engagement of safe and unsafe behavior, identifying five team-level emergent states that enable effective teamwork and safety: psychological safety, team trust, collective efficacy, shared mental models, and situation awareness. Additionally, we consider foundational conditions that support team-driven safety, the development of safety culture, and the importance of team safety climate in shaping performance. We discuss leveraging teams to generate safety and identify directions for future research investigating the relationship between teamwork and safety. Overall, we submit that researchers and practitioners would benefit from taking a systems perspective of safety by integrating principles of team science to better understand and promote safety in organizations.