Bastian Grande

TeamGAINS: a tool for structured debriefings for simulation-based team trainings

Background Improving patient safety by training teams to successfully manage emergencies is a major concern in healthcare. Most current trainings use simulation of emergency situations to practice and reflect on relevant clinical and behavioural skills. We developed TeamGAINS, a hybrid, structured debriefing tool for simulation-based team trainings in healthcare that integrates three different debriefing approaches: guided team self-correction, advocacy-inquiry and systemic-constructivist techniques. Methods TeamGAINS was administered during simulation-based trainings for clinical and behavioural skills for anaesthesia staff. One of the four daily scenarios involved all trainees, whereas the remaining three scenarios each involved only two trainees with the others observing them. Training instructors were senior anaesthesiologists and psychologists. To determine debriefing quality, we used a post-test-only (debriefing quality) and a pre-post-test (psychological safety, leader inclusiveness), no-control-group design. After each debriefing all trainees completed a self-report debriefing quality scale which we developed based on the Debriefing Assessment for Simulation in Healthcare and the Observational Structured Assessment of Debriefing. Perceived psychological safety and leader inclusiveness were measured before trainees’ first (premeasure) and after their last debriefing (postmeasure) at which time trainees’ reactions to the overall training were measured as well. Results Four senior anaesthetists, 29 residents and 28 nurses participated in a total of 40 debriefings resulting in 235 evaluations. Utility of debriefings was evaluated as highly positive. Pre-post comparisons revealed that psychological safety and leader inclusiveness significantly increased after the debriefings. Conclusions The results indicate that TeamGAINS could provide a useful debriefing tool for training anaesthesia staff on all levels of work experience. By combining state-of-the-art debriefing methods and integrating systemic-constructivist techniques, TeamGAINS has the potential to allow for a surfacing, reflecting on and changing of the dynamics of team interactions. Further research is necessary to systematically compare the effects of TeamGAINS’ components on the debriefing itself and on trainees’ changes in attitudes and behaviours.

Speaking up is related to better team performance in simulated anesthesia inductions: an observational study.

BACKGROUND:Our goal in this study was to test the relationship between speaking up—i.e., questioning, correcting, or clarifying a current procedure—and technical team performance in anesthesia. Hypothesis 1: team members’ higher levels of speaking up are related to higher levels of technical team performance. Hypothesis 2: team members will react to speaking up by either clarifying their procedure or initiating a procedural change. Hypothesis 3: higher levels of speaking up during an earlier phase of teamwork will be related to higher levels of speaking up during a later phase. METHODS:This prospective observational study involved 2-person ad hoc anesthesia teams performing simulated inductions of general anesthesia with minor nonroutine events (e.g., bradycardia) in a large teaching hospital. Subjects were registered anesthesia nurses and residents. Each team consisted of 1 nurse and 1 resident. Synchronized video and vital parameter recordings were obtained. Two trained observers blinded to the hypotheses coded speaking up and further team communication and coordination behavior on the basis of 12 distinct categories. All teamwork measures were quantified as percentage of total time spent on the respective teamwork category. Two experienced staff anesthesiologists blinded to the hypotheses evaluated technical team performance using a Delphi-validated rating checklist. Hypotheses 1 and 3 were tested using linear regression with residents’ and nurses’ levels of speaking up as 2 separate predictor variables. Hypothesis 2 was analyzed using lag sequential analysis, resulting in Z values representing the extent to which the observed value for a conditional transition significantly differs from its unconditional value. RESULTS:Thirty-one nurses and 31 residents participated. Technical team performance could be predicted by the level of speaking up from nurses (R2 = 0.18, P = 0.017) but not from residents (R2 = 0.19, P = 0.053); this result supports Hypothesis 1 for nurses. Supporting Hypothesis 2, residents reacted to speaking up with clarifying the procedure by providing information (Z = 18.08, P < 0.001), initiating procedural change by giving instructions (Z = 4.74, P < 0.001) and team member monitoring (Z = 3, P = 0.0013). Likewise, nurses reacted with clarifying the procedure by providing or evaluating information (Z = 16.09, P < 0.001; Z = 3.72, P < 0.001) and initiating procedural change by providing assistance (Z = 0.57, P < 0.001). Indicating a trend for Hypothesis 3, nurses’ level of speaking up before intubation predicted their level of speaking up during intubation (R2 = 0.15, P = 0.034), although this did not reach the Bonferroni-corrected significance level of P = 0.025. No respective relationship was found for residents (R2 = 0.15, P = 0.096). CONCLUSIONS:This study provides empirical evidence and shows mechanisms for the positive relationship between speaking-up behavior and technical team performance.

Adaptation in anaesthesia team coordination in response to a simulated critical event and its relationship to clinical performance

BACKGROUND Recent studies in anaesthesia and intensive care indicate that a teams ability to adapt its coordination activities to changing situational demands is crucial for effective teamwork and thus, safe patient care. This study addresses the relationship between adaptation of team coordination and markers of clinical performance in response to a critical event, particularly regarding which types of coordination activities are used and which team member engages in those coordination activities. METHODS Video recordings of 15 two-person anaesthesia teams (anaesthesia trainee plus anaesthesia nurse) performing a simulated induction of general anaesthesia were coded, using a structured observation system for coordination activities. The simulation involved a critical event-asystole during laryngoscopy. Clinical performance was assessed using two separate reaction times related to the critical event. RESULTS Analyses of variance revealed a significant effect of the critical event on team coordination: after the occurrence of the asystole, team members adapted their coordination activities by spending more time on information management-a specific type of coordination activity (F(1,28)=15.17, P=0.001). No significant effect was found for task management. The increase in information management was related to faster decisions regarding how to respond to the critical event, but only for trainees and not for nurses. CONCLUSIONS Our findings support the claim that adaptation of coordination activities is related to improved team performance in healthcare. Moreover, adaptation and its relationship to team performance were found to vary with regard to type of coordination activities and team member.

Monitoring and talking to the room: autochthonous coordination patterns in team interaction and performance

This paper builds on and extends theory on team functioning in high-risk environments. We examined 2 implicit coordination behaviors that tend to emerge autochthonously within high-risk teams: team member monitoring and talking to the room. Focusing on nonrandom patterns of behavior, we examined sequential patterns of team member monitoring and talking to the room in higher- and lower-performing action teams working in a high-risk health care environment. Using behavior observation methods, we coded verbal and nonverbal behaviors of 27 anesthesia teams performing an induction of general anesthesia in a natural setting and assessed team performance with a Delphi-validated checklist-based performance measure. Lag sequential analyses revealed that higher-performing teams were characterized by patterns in which team member monitoring was followed by speaking up, providing assistance, and giving instructions and by patterns in which talking to the room was followed by further talking to the room and not followed by instructions. Higher- and lower-performing teams did not differ with respect to the frequency of team member monitoring and talking to the room occurrence. The results illustrate the importance of patterns of autochthonous coordination behaviors and demonstrate that the interaction patterns, as opposed to the behavior frequencies, discriminated higher- from lower-performing teams. Implications for future research and for team training are included. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Briefing and debriefing during simulation-based training and beyond: Content, structure, attitude and setting

In this article, we review the debriefing literature and point to the dilemma that although debriefings especially intend to enhance team (rather than individual) learning, it is particularly this team setting that poses risks for debriefing effectiveness (e.g., preference-consistent information sharing, lack of psychological safety inhibiting structured information sharing, ineffective debriefing models). These risks can be managed with a mindful approach with respect to content (e.g., specific learning objectives), structure (e.g., reactions phase, analysis phase, summary phase), attitude (e.g., honesty, curiosity, holding the trainee in positive regard) and setting (e.g., briefings to provide orientation and establish psychological safety). We point to the potential of integrating systemic methods such as circular questions into debriefings, discuss the empirical evidence for debriefing effectiveness and highlight the importance of faculty development.

Agency and communion predict speaking up in acute care teams

Speaking up with suggestions, problems, or doubts is important—especially in health care action teams where each team member’s input can be crucial for the treatment of a patient. Implementing a high-fidelity simulation study, we investigated individual predictors of speaking up in acute care teams (ACTs). Participants were 27 physicians and 27 nurses from a hospital who completed measures on self-perceived agency (i.e., assertiveness, persistence, independence) and communion (i.e., helpfulness, friendliness, sociability). In two-person teams, they managed simulated critical events that required speaking up. In line with our hypotheses, we found that agency positively and communion negatively predicted actual speaking up behavior. We discuss the differential effects of agency and communion on speaking up and thereby highlight theoretical and practical implications.

An anesthesia preinduction checklist to improve information exchange, knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia teams

BACKGROUND: An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members’ perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked). METHODS: A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork. RESULTS: One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P < 0.001), knowledge of critical information: 100% vs 90% (P < 0.001), perception of safety: 91% vs 84% (P < 0.001), perception of teamwork: 90% vs 86% (P = 0.028), and clinical performance: 93% vs 93% (P = 0.60). CONCLUSIONS: This study provides empirical evidence that the use of a preinduction checklist significantly improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams—all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork.

Why didn’t you say something? Effects of after-event reviews on voice behaviour and hierarchy beliefs in multi-professional action teams

ABSTRACT Team decision-making can go wrong when individuals fear to voice suggestions or concerns to higher status team members. We investigate how after-event reviews (AERs) can be used to promote voice behaviour and hierarchy-attenuating beliefs in multi-professional action teams. We hypothesized that (1) lower status team members will speak up more following an assertiveness-specific AER (ASAER) as compared to a teamwork-generic AER (TGAER) and (2) that an ASAER leads to stronger endorsement of hierarchy-attenuating beliefs than the TGAER. To test these hypotheses, we implemented simulations of medical emergencies with 20 healthcare teams consisting of low (i.e., nurses) and high-status (i.e., physicians) professions. After participating in one of the two AERs, teams managed a simulation in which a higher status confederate engaged in potentially harmful actions. Behavioural coding of the videotaped simulations and assessment of team members’ hierarchy beliefs supported both hypotheses: nurses spoke up more following the ASAER than following the TGAER and both professional groups reported significantly higher levels of hierarchy-attenuating beliefs following the ASAER as compared to the TGAER. We discuss how AERs can affect upward voice and increase awareness for the potential downsides of status hierarchies in multi-professional teams.

How to debrief teamwork interactions: using circular questions to explore and change team interaction patterns

We submit that interaction patterns within healthcare teams should be more comprehensively explored during debriefings in simulation-based training because of their importance for clinical performance. We describe how circular questions can be used for that purpose. Circular questions are based on social constructivism. They include a variety of systemic interviewing methods. The goals of circular questions are to explore the mutual dependency of team members’ behavior and recurrent behavior patterns, to generate information, to foster perspective taking, to “fluidize” problems, and to put actions into relational contexts. We describe the nature of circular questions, the benefits they offer, and ways of applying them during debriefings.

Simulation With PARTS (Phase-Augmented Research and Training Scenarios): A Structure Facilitating Research and Assessment in Simulation.

Introduction Assessment in simulation is gaining importance, as are scenario design methods increasing opportunity for assessment. We present our approach to improving measurement in complex scenarios using PARTS [Phase-Augmented Research and Training Scenarios], essentially separating cases into clearly delineated phases. Methods We created 7 PARTS with real-time rating instruments and tested these in 63 cases during 4 weeks of simulation. Reliability was tested by comparing real-time rating with postsimulation video-based rating using the same instrument. Validity was tested by comparing preintervention and postintervention total results, by examining the difference in improvement when focusing on the phase-specific results addressed by the intervention, and further explored by trying to demonstrate the discrete improvement expected from proficiency in the rare occurrence of leader inclusive behavior. Results Intraclass correlations [3,1] between real-time and postsimulation ratings were 0.951 (95% confidence interval [CI], 0.794–0.990), 1.00 (95% CI, — to —), 0.948 (95% CI, 0.783–0.989), and 0.995 (95% CI, 0.977–0.999) for 3 phase-specific scores and total scenario score, respectively. Paired t tests of prelecture-postlecture performance showed an improvement of 14.26% (bias-corrected and accelerated bootstrap [BCa] 95% CI, 4.71–23.82; P = 0.009) for total performance but of 28.57% (BCa 95% CI, 13.84–43.30; P = 0.002) for performance in the respective phase. The correlation of total scenario performance with leader inclusiveness was not significant (rs = 0.228; BCa 95% CI. −0.082 to 0.520; P = 0.119) but significant for specific phase performance (rs = 0.392; BCa 95% CI, 0.118–0.632; P = 0.006). Conclusions The PARTS allowed for improved reliability and validity of measurements in complex scenarios.