The concept of shared mental models in healthcare collaboration

Knowing your team in the intensive care unit: an ethnographic study on familiarity

Effective interprofessional team function is integral to high-quality care in the intensive care unit (ICU). However, little is known about how familiarity develops among teams, which may be an important antecedent to effective team function and quality care. To examine team familiarity and how it impacts ICU team function and care, we conducted an ethnographic study in four ICUs (two medical ICUs, one mixed medical-surgical ICU, and one surgical ICU) in two community hospitals and one academic medical center. We conducted 57.5 h of observation, 26 shadowing experiences, and 26 interviews across the four ICUs sequentially. We used thematic analysis to examine familiarity among the team. We found that ICU team members become familiar with their team through interpersonal, relational interactions, which involved communication, time working together, social interactions, trust, and respect. Our findings underscore the relational aspect of effective teams and demonstrate that time working together, social interactions, communication, developing trust, and respect are pathways to familiarity and optimal team function. Leveraging unique and creative ways to enhance the relational aspects of ICU teams could be an area for future research and lead to improved ICU outcomes.

Team functioning in Neurorehabilitation: a mixed methods study

The objective of this study was to enhance understanding of team functioning in a neurorehabilitation team by identifying the factors that impede and facilitate effective interprofessional team collaboration. We focused on team identification, psychological safety, and team learning, and conducted the research at a neurorehabilitation center treating young patients with severe acquired brain injury in the Netherlands. A mixed-methods approach was employed, integrating quantitative data from questionnaires (N = 40) with qualitative insights from a focus group (n = 6) and in-depth interviews (n = 5) to provide a comprehensive perspective on team dynamics. Findings revealed strong team identification among participants, denoting a shared sense of belonging and commitment. However, limited psychological safety was observed, which negatively affected constructive conflict and team learning. Qualitative analysis further identified deficiencies in shared mental models, especially in shared decision-making and integrated care. These results highlight the crucial role of psychological safety in team learning and the development of shared mental models in neurorehabilitation settings. Although specific to neurorehabilitation, the insights gained may be applicable to enhancing team collaboration in various healthcare environments. The study forms a basis for future research to investigate the impact of improvements in team functioning on patient outcomes in similar settings.

Qualitative expert evaluation of an educational intervention outline aimed at developing a shared understanding of cross-border healthcare

Objectives

Although cross-border healthcare benefits many patients and healthcare professionals, it also poses challenges. To develop a shared understanding of these opportunities and challenges among healthcare professionals, we designed an educational intervention outline and invited experts in healthcare and education to evaluate it. The proposed intervention was based on theoretical principles of authentic, team, and reflective learning.

Methods

Experts (N=11) received a paper outline of the intervention, which was subsequently discussed in individual, semi-structured interviews.

Results

Based on a thematic analysis of the interviews, we identified 4 themes: 1) using the experience you have, 2) learning with the people you work with, 3) taking the time to reflect on the past and future, and 4) adapting the intervention to its context.

Conclusion

According to the experts, the proposed intervention and its three underlying principles can enhance a shared understanding of cross-border healthcare. To unlock its full potential, however, they suggested adjusting the application of learning principles to its specific context. By situating learning in landscapes of practice, the intervention could contribute to the continuous development of cross-border healthcare.

What factors in the workplace enable success in antimicrobial stewardship in paediatric intensive care? An exploration of antimicrobial stewardship excellence through thematic analysis of appreciative inquiry interviews with healthcare staff

OBJECTIVES

Antimicrobial resistance (AMR) is a major global health problem. Efforts to mitigate AMR prioritise antimicrobial stewardship (AMS) interventions. These interventions typically focus on deficiencies in practice and providing negative or normative feedback. This approach may miss opportunities to learn from success. We aimed to identify factors that enable success in AMS practices in the paediatric intensive care unit (PICU) by analysing the data obtained from interviews with staff members who had achieved success in AMS.

DESIGN

Qualitative study design using thematic analysis of appreciative inquiry interviews with healthcare staff.

SETTING

31-bedded PICU in the UK between January 2017 and January 2018.

PARTICIPANTS

71 staff who had achieved success in AMS in the PICU.

RESULTS

Six themes were identified: (1) cultural factors including psychological safety, leadership and positive attitude are important enablers for delivering good clinical care; (2) ergonomic design of the physical environment and ready availability of tools and resources are key elements to support good practice and decision-making; (3) expertise and support from members of the multidisciplinary team contribute to good care delivery; (4) clarity of verbal and written communication is important for sharing mental models and aims of care within the clinical team; (5) a range of intrinsic factors influences the performance of individual HCPs, including organisation skill, fear of failure, response to positive reinforcement and empathetic considerations towards peers; (6) good clinical care is underpinned by a sound domain knowledge, which can be acquired through training, mentorship and experience.

CONCLUSION

The insights gained in this study originate from frontline staff who were interviewed about successful work-as-done. This strengths-based approach is an understudied area of healthcare, and therefore offers authentic intelligence which may be leveraged to effect tangible improvement changes. The methodology is not limited to AMS and could be applied to a wide range of healthcare settings.

Embedding patient safety in a scaffold of interprofessional education; a qualitative study with thematic analysis

BACKGROUND

Regardless of a proliferation of interest in reducing unsafe practices in healthcare, threats to patient safety (PS) remain high. Moreover, little attention has been paid towards the role of interprofessional education (IPE) in enhancing PS. This qualitative study was conducted to unfold the insights of the senior medical, dental and health sciences students at the University of Sharjah (UoS) in the United Arab Emirates (UAE) about PS in an online IPE-based workshop.

METHODS

This inductive thematic analysis study was conducted on senior medical and health students at the Colleges of Medicine, Dental Medicine, Health Sciences, and Pharmacy of UoS. During an online workshop, students discussed plausible solutions for four real practice-based clinical scenarios with elements of unsafe healthcare practices. During the breakout rooms, the students exhibited high level of articulation and proactively participated in discussions. The data from the online workshop were transcribed and then coding, categorizing, and labelling of recurrent themes were carried out. Multiple individual deliberations, consolidation, incorporation of the identified preliminary themes, and merging and reorganizing sub-themes led to a final thematic framework.

RESULTS

This work delved into the perspectives of 248 students regarding teamwork, communication, problem-solving, and other aspects concerning PS in interprofessional settings in an online workshop. The iterative process of data transcription, curating and qualitative analysis surfaced 32 codes. Later, the inductive themaric analysis yielded five themes with distinct yet interconnected nested subthemes in the context of PS in IPE settings. These themes of information sharing and grounding (problem-solving, social skills), maintaining communication (clinical reasoning, shared mental model), executing interprofessional activities (collaborative practice, collaboration scripts), professional cognitive abilities (cognitive maturity, metacognition), and negotiating professional identities (systematic change, socio-economic scaffolding) emerged as fundamental pillars for enhancing PS in healthcare.

CONCLUSION

Our study demonstrated the outcome of an innovative and team-based workshop which embedded PS within a scaffold of IPE environment. This research calls for incorporation of the emerging areas of clinical reasoning, problem solving, collaborative practice, and shared mental model into medical curricula for structured IPE in improving PS domains in medical education. These findings underscore the need for multifaceted dimensions of IPE imperatives for cultivating collaborative competence.

Identifying the unique behaviors embedded in the process of interprofessional collaboration in the ICU

Interprofessional collaboration (IPC) is an important aspect of high-quality care in intensive care units (ICUs). The practice of IPC, however, is complex and the components that constitute IPC are not well defined. We sought to identify distinct behaviors embedded in clinician workflow that indicate engagement in the IPC process. We conducted a clinical ethnography in two ICUs in southeastern Michigan. From March 2017 to March 2019, we collected 31 hours of observations and completed 12 separate clinician shadowings and 12 interviews with ICU nurses, physicians, and respiratory therapists. We applied an iterative analytical approach to identify two types of IPC behaviors which we a priori labeled as "enablers" (i.e. the ways clinicians transition into or facilitate collaboration) and "collaborative activities" (i.e. behaviors clinicians use to directly collaborate with other professionals). 18 IPC behaviors were identified - ten "enablers" and eight "collaborative activities." Specifically, the enablers include: active listening, approach, coordinating work, intraprofessional consultation, invitation, nonverbal accessibility, reflexive questioning, sending pages/call, validation, and verbal accessibility. The collaborative activities are: correction, fill in the gap, information exchange, negotiation, providing help, socializing, teaching/training, and troubleshooting. By identifying IPC behaviors embedded in clinician workflow, our results may support more focused assessments of IPC in practice and guide clinicians toward behaviors they can use to engage in the IPC process.

Discussion-based interprofessional education: A positive step toward promoting shared understanding between surgical residents and nurses

Interprofessional education during medical training may improve communication by promoting collaboration and the development of shared mental models between professions. We implemented a novel discussion-based intervention for surgical residents and nurses to promote mutual understanding of workflows and communication practices. General surgery residents and inpatient nurses from our institution were recruited to participate. Surveys and paging data were collected prior to and following the intervention. Surveys contained original questions and validated subscales. Interventions involved facilitated discussions about workflows, perceptions of urgency, and technology preferences. Discussions were recorded and transcribed for qualitative content analysis. Pre and post-intervention survey responses were compared with descriptive sample statistics. Group characteristics were compared using Fisher's exact tests. Eleven intervention groups were conducted (2-6 participants per group) (n = 38). Discussions achieved three aims: Information-Sharing (learning about each other's workflows and preferences), 2) Interpersonal Relationship-Building (establishing rapport and fostering empathy) and 3) Interventional Brainstorming (discussing strategies to mitigate communication challenges). Post-intervention surveys revealed improved nurse-reported grasp of resident schedules and tailoring of communication methods based on workflow understanding; however, communication best practices remain limited by organizational and technological constraints. Systems-level changes must be prioritized to allow intentions toward collegial communication to thrive.

Competency Assessment of General Surgery Trainees: A Perspective From the Global South, in a CBME-Naive Context

OBJECTIVE

Before proceeding with local implementation of competency-based medical education-related assessment practices designed and evaluated in the Global North, we sought to challenge the assumption that this would be perceived as both necessary and acceptable in our context where training and assessment is based on a traditional, knowledge-focused approach. The aim of this study was to determine the perspectives of general surgery trainees and consultants towards the assessment of competence, how this has been achieved previously, and how it should be performed in the future at the University of Cape Town (UCT), South Africa.

DESIGN

Semi-structured interviews were conducted with consultants and trainees. Interviews were transcribed and then analyzed using a Reflexive Thematic Analysis approach.

SETTING AND PARTICIPANTS

Ten consultants (5 senior and 5 junior) and 10 trainees (5 South African and 5 international) from the Division of General Surgery at UCT in August 2022.

RESULTS

Five unique themes were developed: (1) Assessment of competence is essential, (2) competence includes multiple domains of practice, (3) a surgeon must be able to operate, (4) previously used methods were inadequate to assess competence, and (5) frequent assessment with feedback is desired. The themes were considered in the context of Situated Learning Theory, particularly Communities of Practice and their role in the training for, and authentic assessment of, competence in general surgery trainees.

CONCLUSIONS

Participants described a need to develop and implement a new competency assessment program for general surgery training in this context, which is aligned with described competency-based medical education principles. Thoughtful integration of the formative and summative use of direct observation in the workplace, with a clear emphasis on procedural ability and the provision of high-quality feedback, may enhance the successful implementation of a strategy for competency-based assessment in general surgery training programs.

The Path Toward Fellow Designation in the Academy of Emergency Nursing: Understanding and Navigating the Process to Ensure Your Success

The Academy of Emergency Nursing was established to honor emergency nurses who have made enduring and substantial contributions that have had significant impact and continue to advance the emergency nursing specialty. Nurses who have been recognized as having made enduring and substantial contributions to emergency nursing achieve fellow status in the Academy of Emergency Nursing and are conferred the credential, Fellow of the Academy of Emergency Nursing. Academy of Emergency Nursing Board Members want to dismantle any structural barriers, clarify any misunderstandings or mysteries, and support diverse candidates by providing clear and equitable resources about the path toward fellow designation and the application process. Therefore, the purpose of this article is to support interested persons in their path toward Academy of Emergency Nursing fellow designation and give explicit details of each section of the application to develop a shared understanding among potential applicants, sponsors, and Fellows of the Academy of Emergency Nursing.

Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis

BACKGROUND

Accurate and timely diagnosis relies on sharing perspectives among team members and avoiding information asymmetries. Patients/Families hold unique diagnostic process (DxP) information, including knowledge of diagnostic safety blindspots-information that patients/families know, but may be invisible to clinicians. To improve information sharing, we co-developed with patients/families an online tool called 'Our Diagnosis (OurDX)'. We aimed to characterise patient/family contributions in OurDX and how they differed between individuals with and without diagnostic concerns.

METHOD

We implemented OurDX in two academic organisations serving patients/families living with chronic conditions in three subspecialty clinics and one primary care clinic. Prior to each visit, patients/families were invited to contribute visit priorities, recent histories and potential diagnostic concerns. Responses were available in the electronic health record and could be incorporated by clinicians into visit notes. We randomly sampled OurDX reports with and without diagnostic concerns for chart review and used inductive and deductive qualitative analysis to assess patient/family contributions.

RESULTS

7075 (39%) OurDX reports were submitted at 18 129 paediatric subspecialty clinic visits and 460 (65%) reports were submitted among 706 eligible adult primary care visits. Qualitative analysis of OurDX reports in the chart review sample (n=450) revealed that participants contributed DxP information across 10 categories, most commonly: clinical symptoms/medical history (82%), tests/referrals (54%) and diagnosis/next steps (51%). Participants with diagnostic concerns were more likely to contribute information on DxP risks including access barriers, recent visits for the same problem, problems with tests/referrals or care coordination and communication breakdowns, some of which may represent diagnostic blindspots.

CONCLUSION

Partnering with patients and families living with chronic conditions through OurDX may help clinicians gain a broader perspective of the DxP, including unique information to coproduce diagnostic safety.

Contextualizing the tone of the operating room in practice: drawing on the literature to connect the dots

The study of teamwork in the operating room has made significant strides in uncovering key constructs which shape safe and effective intraoperative care. However, in recent years, there have been calls to understand teamwork in the operating room more fully by embracing the complexity of the intraoperative environment. We propose the construct of tone as a useful lens through which to understand intraoperative teamwork. In this article, we review the literature on culture, shared mental models, and psychological safety, linking each to the construct of tone. By identifying tone as a theoretical orientation to demonstrate the overlap between these concepts, we aim to provide a starting point for new ways to understand intraoperative team dynamics.

"Getting on the same page" enhancing team performance with shared mental models-case studies of evidence informed practice in elite sport

Within high performing, team invasion sports, collective decision making and coordination between teammates are essential characteristics. There is a wealth of evidence supportive of shared mental models as being an important construct to underpin team coordination. Yet, to this point, there is limited research considering the coaches' voices in the application of shared mental models in high performance sport, nor the challenges coaches face throughout the process. Given these limitations, we provide two case studies of evidence informed practice which privilege the voice of coaches who work in elite rugby union. In doing so, we aim to offer a deeper insight regarding the development, implementation, and continued use of shared mental models to enhance performance. Through these first-person case studies, we present the development of two shared mental models and the processes taken, challenges faced, and coaching methods used to underpin them. The case studies are then discussed with implications for coaches' practice supporting the development of their players' collective decision making.

A Conceptual Framework for Instructional Design of a High Acuity and Low Occurrence Event - Simulation Based Education Training of Residents, Medical Students, and Nurses in Anaphylaxis Utilizing Curated Educational Theories

The broad goal of this educational curriculum is utilization and optimization of Simulation-Based Education (SBE) in the training of residents, medical students, and nursing staff involved in the rapid and timely recognition of Anaphylaxis and its optimized treatment. A critical gap in Anaphylaxis Diagnosis, Management, and Treatment (ADAM) has been well established across medical disciplines. It is imperative to include all members of the healthcare team, as nurses and pharmacists play key roles in anaphylaxis recognition and care. Nurses and pharmacists are proficiently trained in the initial assessment of acute patient complaints, status, and in proper dosing/administration considerations. Anaphylaxis is a High Acuity and Low Occurrence (HALO) event. Delayed recognition and administration of epinephrine-autoinjector (EAI) is a patient safety concern. Suboptimal technique and expertise in this regard is common. Literature abounds with reports of physician trainee doubts and uncertainties in the recognition and optimized management of Anaphylaxis. Importantly, Anaphylaxis is frequently misdiagnosed in hospital emergency departments. SBE methodologies are ideal for instructing HALO experiences. The framework of the "Zone of Simulation Matrix" supports the utilization of a simulation experience in this instance. Learning will be effective, enhanced, and made durable by embedding numerous specifically curated educational theories. Given the paucity in training of residents and nursing staff in Anaphylaxis, such instruction is imperative. Of note, a special emphasis in this curricular framework is the debriefing experience. Considerations will be given to the psychological safety of the trainees and the importance of the heterogeneity of prior experiences. Precise diagnosis minimizes mortality. In the hospital setting, nurses are the first responders to critical HALO events, and there is a lack of awareness of ADAM by nursing students.

Improving safety and communication for healthcare providers caring for SARS-COV-2 patients

Background

Decreasing healthcare provider (HCP) exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus in emergency departments (EDs) is crucial. Approaches include limiting the HCP presence and ensuring sealed isolation rooms, which can result in communication difficulties. This quality improvement (QI) initiative aimed to decrease by 50% duration of isolation room door opening and increasing HCP-perceived communication clarity by one point on a five-point Likert scale.

Methods

This was a prospective, multi-stage project with three Plan-Do-Study-Act (PDSA) cycles between May and July 2020: (1) an educational intervention, (2) the introduction of a novel transceiver communication device, and (3) utilizing a clinical champion. Statistical Process Control XbarR charts were used to assess for special cause variation, and two-tailed Mann-Whitney U tests were used for statistical significance between Likert survey means. Qualitative responses underwent thematic analysis.

Results

Observation of 174 patient encounters was completed over 33 days, with 95 meeting the inclusion criteria. Door opening decreased from baseline (n=40; mean 72.97%) to PDSA 3 (n=21; mean 1.58%; p<0.0001). HCP-perceived communication clarity improved from baseline (n=36; mean 3.36) to PDSA-3 (n=49; mean 4.21; p<0.001). Survey themes included positive effects on communication and workflow, with some challenges on the integration of the new device into the clinical workflow. HCP-perceived errors, workarounds, and workflow pauses showed significant improvements.

Conclusion

This QI initiative with a novel transceiver showed significant decreases in isolation room door opening and increases in communication clarity. Future work will expand to operating rooms and intensive care units.

Interprofessional Identity in Health and Social Care: Analysis and Synthesis of the Assumptions and Conceptions in the Literature

Interprofessional identity (IPI) development is considered essential in reducing incongruency and improving interprofessional collaboration. However, noticeable differences in conceptualizations are being put forward in the literature, hindering interpretation of research findings and translation into practice. Therefore, a Concept Analysis and Critical Interpretative Synthesis of empirical research articles were conducted to explore the assumptions and conceptions of IPI. Independent literature screening by two researchers led to the inclusion and extraction of 39 out of 1334 articles. Through critical analysis, higher order themes were constructed and translated to a synthesizing argument and a conceptual framework depicting what constitutes IPI (attributes), the boundary conditions (antecedents) and the outcomes (consequences) of its development. The attributes refer to both IPI's structural properties and the core beliefs indicative of an interprofessional orientation. The antecedents inform us on the importance of IPI-fitting constructivist learning environments and intergroup leadership in enabling its development. This development may lead to several consequences with regard to professional wellbeing, team effectiveness and the quintuple aim. Given the educational orientation of this study, ways for facilitating and assessing the development of IPI among learners across the professional continuum have been proposed, although empirical research is needed to further validate links and mediating and moderating variables.

Advantages and challenges of fostering cognitive integration through virtual collaborative learning: a qualitative study

Background

The drastic shift from face-to-face classes to online learning due to the COVID-19 pandemic has enabled educators to ensure the continuity of learning for health professions students in higher education. Collaborative learning, a pedagogy used to facilitate knowledge integration by helping students translate theory from basic sciences to clinical application and practice, has thus been transformed from a face-to-face to a virtual strategy to achieve the learning objectives of a multi-disciplinary and integrated module.

Objectives

This study aimed to describe and evaluate, through focus group discussions, a virtual collaborative learning activity implemented to assist first year undergraduate nursing students to develop cognitive integration in a module consisting of pathophysiology, pharmacology, and nursing practice.

Methods

Fourteen first year undergraduate students and four faculty involved in facilitating the virtual collaboration participated in the study. Focus group discussions were conducted to elicit the perceptions of students and staff on the virtual collaborative learning session conducted at the end of the semester.

Results

Three themes were generated from the thematic analysis of the students’ focus group scripts. These were: (1) achieving engagement and interaction, (2) supporting the collaborative process, and (3) considering practical nuances. The three themes were further subdivided into subthemes to highlight noteworthy elements captured during focus group discussions. Three themes also emerged from the focus group discussion scripts of faculty participants: (1) learning to effectively manage, (2) facing engagement constraints, and (3) achieving integration. These themes were further sectioned into salient subthemes.

Conclusion

The virtual collaborative learning pedagogy is valuable in fostering cognitive integration. However, meticulous planning considering various variables prior to implementation is needed. With better planning directed at addressing the learners’ needs and the faculty’s capabilities and readiness for online learning pedagogies, and with a strong institutional support to help mitigate the identified constraints of virtual collaborative learning, students and faculty will benefit.

Two mental models of integrated care for advanced liver disease: qualitative study of multidisciplinary health professionals

OBJECTIVES

The purpose of this paper is to present two divergent mental models of integrated advanced liver disease (AdvLD) care among 26 providers who treat patients with AdvLD.

SETTING

3 geographically dispersed United States Veterans Health Administration health systems.

PARTICIPANTS

26 professionals (20 women and 6 men) participated, including 9 (34.6%) gastroenterology, hepatology, and transplant physicians, 2 (7.7%) physician assistants, 7 (27%) nurses and nurse practitioners, 3 (11.5%) social workers and psychologists, 4 (15.4%) palliative care providers and 1 (3.8%) pharmacist.

MAIN OUTCOME MEASURES

We conducted qualitative in-depth interviews of providers caring for patients with AdvLD. We used framework analysis to identify two divergent mental models of integrated AdvLD care. These models vary in timing of initiating various constituents of care, philosophy of integration, and supports and resources needed to achieve each model.

RESULTS

Clinicians described integrated care as an approach that incorporates elements of curative care, symptom and supportive care, advance care planning and end-of-life services from a multidisciplinary team. Analysis revealed two mental models that varied in how and when these constituents are delivered. One mental model involves sequential transitions between constituents of care, and the second mental model involves synchronous application of the various constituents. Participants described elements of teamwork and coordination supports necessary to achieve integrated AdvLD care. Many discussed the importance of having a multidisciplinary team integrating supportive care, symptom management and palliative care with liver disease care.

CONCLUSIONS

Health professionals agree on the constituents of integrated AdvLD care but describe two competing mental models of how these constituents are integrated. Health systems can promote integrated care by assembling multidisciplinary teams, and providing teamwork and coordination supports, and training that facilitates patient-centred AdvLD care.

Stand up and Fight: A Case Study of a Professional Rugby Club Negotiating a COVID-19 Crisis, a Talent Development Perspective

A wealth of literature examines the role of challenge from an individual psychological perspective, but research investigating how a talent development system can proactively support athletes to successfully meet the ever-increasing demands of top-level professional sport is less prevalent. This study takes advantage of a naturally occurring but highly atypical developmental challenge as a result of COVID-19 to examine factors influencing the efficacy and effectiveness of the talent development pathway at Munster Rugby. Players and staff (n = 12) took part in semi-structured interviews exploring their experiences of the build-up to the event, the game itself, and the impact post-event. The data were subsequently analysed using Reflexive Thematic Analysis. Players and coaches highlight the groundwork undertaken to establish alignment and coherence, both horizontally and vertically across the talent development environment, and how this contributed to navigating the challenge successfully. The findings support the necessity of both the player and the talent development system being prepared to enable players to perform at the highest level. The findings point to an overlap between the development and performance phases of a player’s journey and the need to integrate short- and long-term objectives within a talent development system.

Deciphering Diversity of Mental Models in Neurodevelopmental Disorders: Knowledge Graph Representation of Public Data Using Natural Language Processing (Preprint)

Background

Understanding how individuals think about a topic, known as the mental model, can significantly improve communication, especially in the medical domain where emotions and implications are high. Neurodevelopmental disorders (NDDs) represent a group of diagnoses, affecting up to 18% of the global population, involving differences in the development of cognitive or social functions. In this study, we focus on 2 NDDs, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), which involve multiple symptoms and interventions requiring interactions between 2 important stakeholders: parents and health professionals. There is a gap in our understanding of differences between mental models for each stakeholder, making communication between stakeholders more difficult than it could be.

Objective

We aim to build knowledge graphs (KGs) from web-based information relevant to each stakeholder as proxies of mental models. These KGs will accelerate the identification of shared and divergent concerns between stakeholders. The developed KGs can help improve knowledge mobilization, communication, and care for individuals with ADHD and ASD.

Methods

We created 2 data sets by collecting the posts from web-based forums and PubMed abstracts related to ADHD and ASD. We utilized the Unified Medical Language System (UMLS) to detect biomedical concepts and applied Positive Pointwise Mutual Information followed by truncated Singular Value Decomposition to obtain corpus-based concept embeddings for each data set. Each data set is represented as a KG using a property graph model. Semantic relatedness between concepts is calculated to rank the relation strength of concepts and stored in the KG as relation weights. UMLS disorder-relevant semantic types are used to provide additional categorical information about each concept’s domain.

Results

The developed KGs contain concepts from both data sets, with node sizes representing the co-occurrence frequency of concepts and edge sizes representing relevance between concepts. ADHD- and ASD-related concepts from different semantic types shows diverse areas of concerns and complex needs of the conditions. KG identifies converging and diverging concepts between health professionals literature (PubMed) and parental concerns (web-based forums), which may correspond to the differences between mental models for each stakeholder.

Conclusions

We show for the first time that generating KGs from web-based data can capture the complex needs of families dealing with ADHD or ASD. Moreover, we showed points of convergence between families and health professionals’ KGs. Natural language processing–based KG provides access to a large sample size, which is often a limiting factor for traditional in-person mental model mapping. Our work offers a high throughput access to mental model maps, which could be used for further in-person validation, knowledge mobilization projects, and basis for communication about potential blind spots from stakeholders in interactions about NDDs. Future research will be needed to identify how concepts could interact together differently for each stakeholder.

Integration of Augmented Reality and Brain-Computer Interface Technologies for Health Care Applications: Exploratory and Prototyping Study

Background

Augmented reality (AR) and brain-computer interface (BCI) are promising technologies that have a tremendous potential to revolutionize health care. While there has been a growing interest in these technologies for medical applications in the recent years, the combined use of AR and BCI remains a fairly unexplored area that offers significant opportunities for improving health care professional education and clinical practice. This paper describes a recent study to explore the integration of AR and BCI technologies for health care applications.

Objective

The described effort aims to advance an understanding of how AR and BCI technologies can effectively work together to transform modern health care practice by providing new mechanisms to improve patient and provider learning, communication, and shared decision-making.

Methods

The study methods included an environmental scan of AR and BCI technologies currently used in health care, a use case analysis for a combined AR-BCI capability, and development of an integrated AR-BCI prototype solution for health care applications.

Results

The study resulted in a novel interface technology solution that enables interoperability between consumer-grade wearable AR and BCI devices and provides the users with an ability to control digital objects in augmented reality using neural commands. The article discusses this novel solution within the context of practical digital health use cases developed during the course of the study where the combined AR and BCI technologies are anticipated to produce the most impact.

Conclusions

As one of the pioneering efforts in the area of AR and BCI integration, the study presents a practical implementation pathway for AR-BCI integration and provides directions for future research and innovation in this area.

How Knowledge Mapping Can Bridge the Communication Gap Between Caregivers and Health Professionals Supporting Individuals With Complex Medical Needs: A Study in Fragile X Syndrome

The challenges of caring for children with complex health needs, such as intellectual disability (ID) and autism spectrum disorder (ASD), are multiple and experienced by both caregivers and health professionals. Fragile X syndrome (FXS) is the most common single gene cause of ID and ASD, and provides a pertinent model to understand these complexities of care, as well as the communication challenges experienced between caregivers and healthcare professionals. In recent years both caregivers and healthcare professionals have recognized the need for enhancing communication both in clinical and research settings. Knowledge mapping has emerged as a tool to support quality communication between team participants. Here we review how differences in mental models, as well as challenges related to health literacy and knowledge transfer can have an impact on communication. Next, we present different knowledge mapping approaches used in complex situations, with a focus on concept maps and care maps. Finally, we highlight the potential benefits and limitations of mapping to improve communication issues related to caring for individuals with FXS and potentially other neurodevelopmental disorders (NDDs).

Enhancing Implementation of Complex Critical Care Interventions through Interprofessional Education

Background: Many critical care interventions that require teamwork are adopted slowly and variably despite strong evidence supporting their use. We hypothesize that educational interventions that target the entire interprofessional team (rather than professions in isolation) are one effective way to enhance implementation of complex interventions in the intensive care unit (ICU). Objective: As a first step toward testing this hypothesis, we sought to qualitatively solicit opinions about team dynamics, evidence translation, and interprofessional education as well as current knowledge, attitudes, and practices surrounding the use of one example of a team-based practice in the ICU-preventive postextubation noninvasive ventilation (NIV). Methods: We conducted a qualitative evaluation using semistructured interviews and focus groups with nurses, respiratory therapists, and physicians working in four ICUs in four hospitals within an integrated health system. ICUs were selected based on variation in academic versus community status. We iteratively analyzed transcripts using a thematic content analysis approach. Results: From December 2018 to January 2019, we conducted 32 interviews (34 people) and 3 focus groups (20 people). Participants included 31 nurses, 15 respiratory therapists, and 8 physicians. Participants had favorable views of how their teams work together but discussed ways team dynamics (e.g., leader inclusiveness) impact care coordination. Participants viewed interprofessional education favorably and shared suggestions regarding preferred content and delivery (e.g., include both profession-specific and team-oriented content). Though participants reported frequently using NIV as a treatment, they described rarely using NIV as a preventive strategy, and nurses and respiratory therapists described challenges to use such as perceived patient discomfort. There were ICU-specific differences in management of patients at a high risk for respiratory failure after extubation, with some preferring to delay extubation. Conclusion: Participants reported optimism that interprofessional education can be an acceptable and effective way to improve translation of evidence into practice. Participants also detailed patient-specific and ICU-wide barriers to the implementation of preventive postextubation NIV. This information about teamwork in the ICU, suggestions for interprofessional education, and barriers and facilitators to use of a target evidence-based practice can inform the development of novel educational strategies in ways that increase acceptability, appropriateness, and feasibility of the intervention.

A Qualitative Study: What Do Nurses in Charge in Emergency Departments Do?

Background

The nurse-in-charge (NIC) role has been implemented in many emergency departments (EDs) to assist with smooth operations and coordination across the ED, together with the emergency physician in charge (EPIC). This work aims to describe the problem-solving approaches used by NICs and the coordination of their role with other team members.

Methods

Observations and semi-structured interviews were performed with NICs in a single centre, where NICs were purposively sampled for a variety of experience levels. During the observations, field notes were taken for every action conducted by the NIC in ED; the semi-structured interviews involved a combination of question prompts and a blank diagram of the ED that the NICs were asked to annotate. Constant comparative analysis based on grounded theory methodology was used for this qualitative study. 

Results

Eight different problem-solving approaches were identified. These are placing, targeting, guiding, juggling, chasing, team-leading, escalating and de-escalating. The last three were exclusive to NICs, whereas the others were shared to some degree with the EPIC. Seven team situational awareness processes used by NICs for coordination with other team members were identified, leading to a discussion on team synchronisation and shared awareness mechanisms. In particular, shared internal models amongst the NICs and also other team members provide a framework for analysing how team members function together in a healthcare setting. 

Conclusions

Emergency department NICs have a number of problem-solving approaches that have been defined and shown to have a degree of overlap with the emergency physician in charge. Shared awareness between the NIC and other ED team members facilitate decision-making and smooth coordination. These findings provide a better understanding of the role of the NIC and are useful for describing solutions for patient flow.

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care

BACKGROUND

Patients and families are important contributors to the diagnostic team, but their perspectives are not reflected in current diagnostic measures. Patients/families can identify some breakdowns in the diagnostic process beyond the clinician's view. We aimed to develop a framework with patients/families to help organisations identify and categorise patient-reported diagnostic process-related breakdowns (PRDBs) to inform organisational learning.

METHOD

A multi-stakeholder advisory group including patients, families, clinicians, and experts in diagnostic error, patient engagement and safety, and user-centred design, co-developed a framework for PRDBs in ambulatory care. We tested the framework using standard qualitative analysis methods with two physicians and one patient coder, analysing 2165 patient-reported ambulatory errors in two large surveys representing 25 425 US respondents. We tested intercoder reliability of breakdown categorisation using the Gwet's AC1 and Cohen's kappa statistic. We considered agreement coefficients 0.61-0.8=good agreement and 0.81-1.00=excellent agreement.

RESULTS

The framework describes 7 patient-reported breakdown categories (with 40 subcategories), 19 patient-identified contributing factors and 11 potential patient-reported impacts. Patients identified breakdowns in each step of the diagnostic process, including missing or inaccurate main concerns and symptoms; missing/outdated test results; and communication breakdowns such as not feeling heard or misalignment between patient and provider about symptoms, events, or their significance. The frequency of PRDBs was 6.4% in one dataset and 6.9% in the other. Intercoder reliability showed good-to-excellent reliability in each dataset: AC1 0.89 (95% CI 0.89 to 0.90) to 0.96 (95% CI 0.95 to 0.97); kappa 0.64 (95% CI 0.62, to 0.66) to 0.85 (95% CI 0.83 to 0.88).

CONCLUSIONS

The PRDB framework, developed in partnership with patients/families, can help organisations identify and reliably categorise PRDBs, including some that are invisible to clinicians; guide interventions to engage patients and families as diagnostic partners; and inform whole organisational learning.

Extending the role of nursing assistants in mental health inpatient settings: A multi-method study

With continued growth in the demand for nursing care, many organizations have incorporated nursing assistants into the acute care workforce. However, role descriptions are often generic and do not provide clarity in specialist areas such as mental health inpatient settings. Issues have been noted regarding the role of assistants, delegation, and their integration with the nursing team. This study extended an existing set of care activities and explored the perceptions of nursing assistants and registered nurses regarding these activities. A modified Delphi approach added 14 new care activities for nursing assistants. A follow-up survey found significant differences between nursing assistants and registered nurses regarding utilization of the activities, delegation, teamwork, and role clarity. Future research must incorporate the perspectives of those with lived experience of mental health issues, and develop an understanding of the interactions between nursing assistant care activities and other factors such as local supports, skillmix, and the practice environment, as these may impact how an organization can introduce nursing assistants to specialty areas while maintaining consumer and staff safety.

One chance to get it right: improving clinical handovers for better symptom control at the end of life

Poor communication contributes to morbidity and mortality, not only in general medical care but also at the end oflife. This leads to issues relating to symptom control and quality of care. As part of an international project focused on bereaved relatives' perceptions about quality of end-of-life care, we undertook a quality improvement (QI) project in a general hospital in Córdoba city, Argentina.By using two iterative QI cycles, we launched an educational process and introduced a clinical mnemonic tool, I-PASS, during ward handovers. The introduction of the handover tool was intended to improve out-of-hours care.Our clinical outcome measure was ensuring comfort in at least 60% of dying patients, as perceived by family carers, during night shifts in an oncology ward during the project period (March-May 2019). As process-based measures, we selected the proportion of staff completing the I-PASS course (target 60%) and using I-PASS in at least 60% of handovers. Participatory action research was the chosen method.During the study period, 13/16 dying patients were included. We received 23 reports from family carers about the level of patient comfort during the previous night.Sixty-five per cent of healthcare professionals completed the I-PASS training. The percentage of completed handovers increased from 60% in the first Plan-Do-Study-Act (PDSA) cycle to 68% in the second one.The proportion of positive reports about patient comfort increased from 63% (end of the first PDSA cycle) to 87% (last iterative analysis after 3 months). Moreover, positive responses to 'Did doctors and nurses do enough for the patient to be comfortable during the night?' increased from 75% to 100% between the first and the second QI cycle.In conclusion, we achieved the successful introduction and staff training for use of the I-PASS tool. This led to improved perceptions by family carers, about comfort for dying patients.

Relational Quality Between the RN and Nursing Assistant: Essential for Teamwork and Communication

OBJECTIVE

Nurse (RN) and nursing assistant (NA) relational quality was examined along with associations between relational quality and evaluations of teamwork and communication.

BACKGROUND

RN and NA teams constitute the primary nursing care delivery method, and the quality of their relationship affects system capacity for improving patient outcomes; adverse events are linked to communication and teamwork breakdowns.

METHODS

RN (N = 889) and NA (263) relational quality was examined using a cross-sectional secondary analysis from system assessment with the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture.

RESULTS

RN and NA perceived relational quality indicated significant differences in teamwork and safety grade ratings, with both groups reporting perceived teamwork as high when patient safety grade was low.

CONCLUSIONS

This study supports the benefits of improving the RN-NA teamwork-communication relationship. An enhanced RN-NA relational quality can be used by nurse leaders to optimize patient care delivery outcomes.

The Importance of Mental Models in Implementation Science

Implementation science is concerned with the study of adoption, implementation and maintenance of evidence-based interventions and use of implementation strategies to facilitate translation into practice. Ways to conceptualize and overcome challenges to implementing evidence-based practice may enhance the field of implementation science. The concept of mental models may be one way to view such challenges and to guide selection, use, and adaptation of implementation strategies to deliver evidence-based interventions. A mental model is an interrelated set of beliefs that shape how a person forms expectations for the future and understands the way the world works. Mental models can shape how an individual thinks about or understands how something or someone does, can, or should function in the world. Mental models may be sparse or detailed, may be shared among actors in implementation or not, and may be substantially tacit, that is, of limited accessibility to introspection. Actors' mental models can determine what information they are willing to accept and what changes they are willing to consider. We review the concepts of mental models and illustrate how they pertain to implementation of an example intervention, shared decision making. We then describe and illustrate potential methods for eliciting and analyzing mental models. Understanding the mental models of various actors in implementation can provide crucial information for understanding, anticipating, and overcoming implementation challenges. Successful implementation often requires changing actors' mental models or the way in which interventions or implementation strategies are presented or implemented. Accurate elicitation and understanding can guide strategies for doing so.

Identifying teamwork-related needs of the medical emergency team: Nurses' perspectives

BACKGROUND

The role of medical emergency team (MET) in managing deteriorating patients and enhancing patient safety is greatly affected by teamwork.

AIMS

To identify teamwork-related needs of the MET from MET nurses' perspectives. To assess the associations between MET nurses' perceptions of teamwork and their work experience and education.

STUDY DESIGN

A quantitative, descriptive correlational design.

METHODS

Registered intensive care unit (ICU) nurses (n = 50) who were members of the MET in an acute tertiary care hospital answered a modified version of the team assessment questionnaire in 2017. Data were analysed using descriptive statistics, the Kruskal-Wallis test, and the univariate analysis of variance method. The reporting of this study adheres to the strengthening the reporting of observational studies (STROBE) guidelines.

RESULTS

Participants showed least agreement with the items presenting leadership skills (mean = 2.6, SD = 0.68). Approximately 50% nurses disagreed that the MET had adequate resources, training, and skills. The majority of nurses (80%) felt that their responsibilities as a MET member interfered with taking care of their own ICU patients. Many nurses (64%) felt that they did not have a voice in MET's decision-making process. Approximately 50% nurses felt that they were not recognized for their individual contribution, and they were uncertain regarding MET's policies for dealing with conflicts. The amounts of MET nurses' work experience and education were associated with MET skills and function, respectively.

CONCLUSION

Key teamwork elements of the MET that need improvements include decision-making and conflict resolution skills, valuing team members, and team leadership. Practicing shared mental models, implementing the TeamSTEPPS curricula at hospitals for training ICU nurses, and simulation-based team-training programmes may be beneficial in improving teamwork of MET members.

RELEVANCE TO CLINICAL PRACTICE

This study revealed key teamwork elements of the MET that need improvements. Our findings may contribute to improve teamwork, thereby optimizing MET function, and enhancing patient outcomes.

Analyzing clinical and system drivers of satisfaction in the intensive care unit as a component of high quality care

BACKGROUND

Quality improvement in the intensive care unit has transitioned from focusing on mortality to improving care and reducing morbidity.

OBJECTIVE

This study prospectively investigated clinical and system drivers of family satisfaction in a large quaternary hospital ICU.

METHODS

A validated tool was distributed to family members and a registry chart analysis was conducted. The aims were to assess associations with high or low family satisfaction to evaluate unit-level satisfaction. Candidate predictors were selected from univariate logistic regressions and finalized in a multivariate model by a stepwise selection approach.

RESULTS

Overall, 75% (n = 188) of respondents (n = 250) indicated high satisfaction. Respondents with higher satisfaction had a Plan of the Day posted (OR = 3.3, 95% CI: 1.63, 6.89, p = 0.001), and did not live with the patient (OR =0.5, 95% CI: 0.25, 0.96, p = 0.044).

CONCLUSION

This study indicates that communication and transparency of plans contributes to family satisfaction with ICU care.

Improving patient safety in two French hospitals: why teamwork training is not enough

PURPOSE

The persistent challenges that healthcare organizations face as they strive to keep patients safe attests to a need for continued attention. To contribute to better understanding the issues currently defying patient safety initiatives, this paper reports on a study examining the aftermath of implementing a national team training program in two hospital units in France.

DESIGN/METHODOLOGY/APPROACH

Data were drawn from a longitudinal qualitative study analyzing the implementation of a French patient safety program aimed at improving teamwork in hospitals. Data collection took place over a four-year period (2015-2019) in two urban hospitals in France and included multiple interviews with 31 participants and 150 h of observations.

FINDINGS

Despite explicit efforts to improve inter-professional teamwork, three main obstacles interfered with healthcare professionals' attempts at safeguarding patients: perspectival variations in what constituted "patient safety", a paradoxical injunction to do more with less and conflicting organizational priorities.

ORIGINALITY/VALUE

This paper exposes patient safety as misleadingly consensual and identifies a lack of alignment between stakeholders in the complex system that is a hospital. This ultimately interferes with patient safety objectives and highlights that even well-equipped, frontline actors cannot achieve long-term results without more systemic organizational changes.

Are we on the same page? Exploring stakeholders' shared mental models of mobile health in rural Nigeria

Despite the benefits promised by mobile health, the introduction of these solutions is often met with resistance from various stakeholders. This article adopts a shared mental model approach to unearth the current perceptions, concerns, and mentalities of key stakeholders engaged in the provision of healthcare in Nigeria. These include policy makers, academics, healthcare professionals, and health information systems developers. Interviews and focus groups were used to examine stakeholders' views across three mental models: (1) the technology, (2) processes, and (3) the team. Our investigations reveal disparities in stakeholders' existing mental models and their perceptions of the proposed mobile health solution. We argue that fostering a common understanding of mobile health, as well as elucidating an improved understanding of processes and team behaviours, will mitigate the risk of resistance among stakeholders involved in the design and delivery of community healthcare services and culminate in a positive attitude towards new mobile health solutions among these stakeholders. We highlight the need to enhance communication and training from national to rural levels to promote complementary mental models and positively influence team performance.

The Effect of Evaluator Training on Inter- and Intrarater Reliability in High-Stakes Assessment in Simulation

AIM

The aim of this study was to evaluate the effectiveness of a training intervention in achieving inter- and intrarater reliability among faculty raters conducting high-stakes assessment of clinical performance in simulation.

BACKGROUND

High-stakes assessment of simulation performance is being adopted in nursing education. However, limited research exists to guide best practices in training raters, which is essential to ensure fair and defensible assessment.

METHOD

A nationwide sample of 75 prelicensure RN program faculty participated in an experimental, randomized, controlled study.

RESULTS

Participants completing a training intervention achieved higher inter- and intrarater reliability than control group participants when using a checklist evaluation tool. Mixed results were achieved by participants when completing a global competency assessment.

CONCLUSION

The training intervention was effective in helping participants to achieve a shared mental model for use of a checklist, but more time may be necessary to achieve consistent global competence decisions.

Silence is golden: the role of team coordination in health operations

Purpose

This study investigates the relationships between team dynamics and performance in healthcare operations. Specifically, it explores, through wearable sensors, how team coordination mechanisms can influence the likelihood of surgical glitches during routine surgery.

Design/methodology/approach

Breast surgeries of a large Italian university hospital were monitored using Sociometric Badges – wearable sensors developed at MIT Media Lab – for collecting objective and systematic measures of individual and group behaviors in real time. Data retrieved were used to analyze team coordination mechanisms, as it evolved in the real settings, and finally to test the research hypotheses.

Findings

Findings highlight that a relevant portion of glitches in routine surgery is caused by improper team coordination practices. In particular, results show that the likelihood of glitches decreases when practitioners adopt implicit coordination mechanisms rather than explicit ones. In addition, team cohesion appears to be positively related with the surgical performance.

Originality/value

For the first time, direct, objective and real time measurements of team behaviors have enabled an in-depth evaluation of the team coordination mechanisms in surgery and the impact on surgical glitches. From a methodological perspective, this research also represents an early attempt to investigate coordination behaviors in dynamic and complex operating environments using wearable sensor tools.

"Getting Everyone on the Same Page": Interprofessional Team Training to Develop Shared Mental Models on Interprofessional Rounds

AIM

This study aimed to evaluate the effect of a team training program to support shared mental model (SMM) development in interprofessional rounds.

DESIGN AND PARTICIPANTS

A three-arm randomized controlled trial study was conducted for interprofessional teams of 207 health profession learners who were randomized into three groups.

PROGRAM DESCRIPTION

The full team training program included a didactic training part on cognitive tools and a virtual simulation to support clinical teamwork in interprofessional round. Group 1 was assigned to the full program, group 2 to the didactic part, and group 3 (control group) with no intervention. The main outcome measure was team performance in full scale simulation. Secondary outcome was interprofessional attitudes.

PROGRAM EVALUATION

Teamwork performance and interprofessional attitude scores of the full intervention group were significantly higher (P < 0.05) than those of the control group. The two intervention groups had significantly higher (P < 0.05) attitude scores on interprofessional teamwork compared with the control group.

DISCUSSION

Our study indicates the need of both cognitive tools and experiential learning modalities to foster SMM development for the delivery of optimal clinical teamwork performances. Given its scalability and practicality, we anticipate a greater role for virtual simulations to support interprofessional team training.

Are perspective-taking outcomes always positive? Challenges and mitigation strategies

BACKGROUND

Engaging in perspective-taking often has positive outcomes for both healthcare providers and patients. Perspective-taking by healthcare providers has been linked to increased patient satisfaction and compliance, patients' positive perceptions of healthcare providers' interpersonal skills, and a reduction in judgmental attitudes toward individuals who engage in health-risk behaviors. The positive outcomes that are associated with perspective-taking are often highlighted in the literature. However, less discussed are the negative outcomes.

AIM

This paper discusses the positive and negative outcomes associated with perspective-taking and presents potential methods for mitigating negative outcomes.

CONCLUSION

When designing and implementing perspective-taking interventions, educators and researchers should consider potential negative intervention outcomes and strategies to attenuate these outcomes.

Planning and managing a complex multisite study in the age of technology

A 2-year long, multisite research study that evaluated cardiopulmonary resuscitation skill decay among nursing students was conducted at 10 schools of nursing across the United States. The study was conducted in two phases and required carefully timed sessions for skill performance. Multisite studies in nursing education need to be carefully planned. Time delays should be anticipated with processes and Institutional Review Board protocols across sites. All team members were trained and consistently supported during the entire study. While challenges and obstacles were identified, innovative solutions were implemented that assisted the research team to successfully complete the study. The use of new and existing technology allowed the team to surmount many of the challenges encountered in this study. The purpose of this article is to describe the logistics, processes, challenges, and lessons learned related to conducting a complex multisite study.

How actionable are staff behaviours specified in policy documents? A document analysis of protocols for managing deteriorating patients

BACKGROUND

To optimise care of deteriorating patients, healthcare organisations have implemented rapid response systems including an "afferent" and "efferent" limb. Afferent limb behaviours include monitoring vital signs and escalating care. To strengthen afferent limb behaviour and reduce adverse patient outcomes, the National Early Warning Score was implemented in the UK. There are no published reports of how National Early Warning Score guidance has translated into trust-level deteriorating patient policy and whether these documents provide clear, actionable statements guiding staff.

AIM

To identify how deteriorating patient policy documents provide "actionable" behavioural instruction for staff, responsible for actioning the afferent limb of the rapid response system.

DESIGN

A structured content analysis of a national guideline and local policies using a behaviour specification framework.

METHODS

Local deteriorating patient policies were obtained. Statements of behaviour were extracted from policies; coded using a behaviour specification framework: Target, Action, Context, Timing and Actor and scored for specificity (1 = present, nonspecific; 2 = present, specific). Frequencies and proportions of statements containing elements of the Target, Action, Context, Timing and Actor framework were summarised descriptively. Reporting was guided by the COREQ checklist.

RESULTS

There were more statements related to monitoring than escalation behaviour (65% vs 35%). Despite high levels of clear specification of the action (94%) and the target of the behaviour (74%), context, timing and actor were poorly specified (37%, 37% and 33%).

CONCLUSION

Delay in escalating deteriorating patients is associated with adverse outcomes. Some delay could be addressed by writing local protocols with greater behavioural specificity, to facilitate actionability.

RELEVANCE TO CLINICAL PRACTICE

Numerous clinical staff are required for an effective response to patient deterioration. To mitigate role confusion, local policy writers should provide clear specification of the actor. As the behaviours are time-sensitive, clear specification of the time frame may increase actionability of policy statements for clinical staff.

Utilizing an SBAR Workshop With Baccalaureate Nursing Students to Improve Communication Skills

This study evaluated the effectiveness of the Situation-Background-Assessment-Recommendation (SBAR) technique to reduce anxiety and increase self-confidence levels regarding health care communication among undergraduate nursing students. Baccalaureate nursing students (n = 35) completed anxiety and self-confidence questionnaires before and after an SBAR communication workshop and subsequent simulation. A statistically significant increase in postintervention self-confidence scores was noted with no significant difference in anxiety levels. The findings support the use of SBAR as an organizing tool to promote nursing students' self-confidence during communication; however, further efforts are needed to qualitatively examine how this tool promotes these changes.

Simulation Training Improves Resuscitation Team Leadership Skills of Nurse Practitioners

INTRODUCTION

In the current era of limited physician trainee work hours, limited nurse practitioner orientation times, and highly specialized care settings, frontline providers have limited opportunities for mentored resuscitation training in emergency situations. We aimed to evaluate the effectiveness of a pilot program to improve resuscitation team leadership skills of nurse practitioners using simulation-based training.

METHODS

Seven nurse practitioners underwent a 4-hour simulation course in pediatric cardiac emergencies. Pre- and post-course surveys were conducted to evaluate previous emergency leadership experience and self-reported comfort in the team lead role. The time to verbalization of a shared mental model to the team was tracked during the simulations.

RESULTS

The increases in self-reported comfort level in team leading, sharing a mental model, and differential diagnosis were statistically significant. Average time to shared mental model significantly decreased between simulations.

DISCUSSION

Simulation can improve code leadership skills of nurse practitioners. These preliminary findings require confirmation in larger studies.

The electronic health record's impact on nurses' cognitive work: An integrative review

BACKGROUND

Technology use can impact human performance and cognitive function, but few studies have sought to understand the electronic health record's impact on these dimensions of nurses' work.

OBJECTIVE

The purpose of this review was to synthesize the literature on the electronic health record's impact on nurses' cognitive work.

DESIGN

Integrative review.

DATA SOURCES

MEDLINE/PubMed, CINAHL, Embase, Web of Science, and PsycINFO.

REVIEW METHODS

The literature search focused on 3 concepts: the electronic health record, cognition, and nursing practice, and yielded 4910 articles. Following a stepwise process of duplicate removal, title and abstract review, full text review, and reference list searches, a total of 18 studies were included: 12 qualitative, 4 mixed-methods, and 2 quantitative studies from the United States (13), Scandinavia (2), Australia (1), Austria (1), and Canada (1). The Mixed Methods Appraisal Tool was used to assess the quality of eligible studies.

RESULTS

Five themes identified how nurses and other clinicians used the electronic health record and perceived its impact: 1) forming and maintaining an overview of the patient, 2) cognitive work of navigating the electronic health record, 3) use of cognitive tools, 4) forming and maintaining a shared understanding of the patient, and 5) loss of information and professional domain knowledge. Most studies indicated that forming and maintaining an overview of the patient at both the individual and team level were difficult when using the electronic health record. Navigating the volumes of information was challenging and increased clinicians' cognitive work. Information was perceived to be scattered and fragmented, making it difficult to see the chronology of events and to situate and understand the clinical implications of various data. The template-driven nature of documentation and limitations on narrative notes restricted clinicians' ability to express their clinical reasoning and decipher the reasoning of colleagues. Summary reports and handoff tools in the electronic health record proved insufficient as stand-alone tools to support nurses' work throughout the shift and during handoff, causing them to rely on self-made paper forms. Nurses needed tools that facilitated their ability to individualize and contextualize information in order to make it clinically meaningful.

CONCLUSION

The electronic health record was perceived by nurses as an impediment to contextualizing and synthesizing information, communicating with other professionals, and structuring patient care. Synthesizing and communicating information at the individual and team levels are known drivers of patient safety. The findings from this review have implications for electronic health record design.

Ability to predict team members' behaviors in ICU teams is associated with routine ABCDE implementation

PURPOSE

Poor coordination may impede delivery of the Awakening, Breathing Coordination, Delirium monitoring/management and Early exercise/mobility (ABCDE) bundle. Developing a shared mental model (SMM), where all team members are on the same page, may support coordination.

MATERIALS AND METHODS

We administered a survey at the 2016 MHA Keystone Center ICU workshop. We measured different components of SMMs using five items from a validated survey, each on a 5-point Likert scale (strongly agree-strongly disagree). We measured self-reported routine ABCDE implementation using a single item 4-point Likert scale (ABCDE is routine-Made no steps to implement ABCDE). We examined the relationship between SMMs and routine ABCDE implementation using logistic regression, adjusting for confounders.

RESULTS

Among the 206 (75%) responses, 157 (84%) reported using the ABCDE bundle and 80 (51% of 157) reported routine use. When clinicians agreed it was difficult to predict team members' behaviors, the odds of reporting routine ABCDE implementation significantly decreased [0.26 (0.10-0.66)]. Other SMM components related to knowing team members' skills, access to information, team adaptability, and team help behavior, were not significantly associated with the outcome.

CONCLUSION

Increasing awareness of team members' behaviors may be a mechanism to improve the implementation of complex care bundles like ABCDE.