Gudela Grote

Diagnosis of safety culture in safety management audits

Based on the sociotechnical systems approach, an understanding of safety culture as deeply rooted assumptions about the interplay of people, technology, and organization in their relation to safety is presented. As a complement to audit methods aimed at assessing formal safety management, a questionnaire was developed which allows some indications of these assumptions to be captured by providing data on perceptions regarding operational safety, safety and design strategies, and personal job needs. Analyzing response patterns of different occupational, hierarchical, and organizational groups within a company in combination with formal audit results and the communicative validation of both in a feedback meeting can help the auditors as well as the members of the company to gain a deeper understanding of safety management and safety culture in that company. Results from seven audits in petrochemical plants are presented and discussed with respect to the validity and practicability of the chosen approach.

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.

Coordination in high-risk organizations: the need for flexible routines

In this article, we link the literatures on organizational routines and the management of uncertainties in order to establish the concept of flexible routines. Supported by flexible rules, this type of routine is argued to help achieve the right balance between standardization and flexibility, thus enabling resilience through loose coupling in high-risk organizations. The operationalization of the concept of flexible routine can help strategic decision-making regarding the design of high-risk systems as well as operational decision-making in the course of handling complex work processes. To underpin these arguments, findings from a case study on rules management in a railway organization are presented, where alignment of rules with the amount of uncertainty and actors’ competencies for handling uncertainties were analyzed. Implications for future research on flexible routines are discussed.

Uncertainty Management at the Core of System Design

How an organization handles uncertainties stemming from its own production processes and from its environment, is a central characteristic of its functioning. Many organizations, foremost those which have to handle substantial health and safety risks, aim at minimizing uncertainties. This is in contrast with newer organization theory which argues for enabling local competence for coping with uncertainties. Both approaches with their advantages and disadvantages will be discussed and consequences for system design drawn. # 2004 Elsevier Ltd. All rights reserved.

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.

Managing Nonroutine Events in Anesthesia: The Role of Adaptive Coordination

Objective: This field study aimed at examining the role of anesthesia teams’ adaptive coordination in managing changing situational demands, such as in nonroutine events (NREs). Background: Medical teams’ ability to adapt their teamwork (e.g., their coordination activities) to changing situational demands is crucial to team performance and, thus, to patient safety. Whereas the majority of previous studies on the matter have focused on critical but rare events, it has recently been pointed out that the effective management of NREs is a key challenge to medical teams. Hence this study investigated the relationship between coordination activities, NRE occurrence, and team performance. Method: We videotaped 22 anesthesia teams during standard anesthesia induction and recorded data from the vital signs monitor and the ventilator. Coordination was coded by a trained observer using a structured observation system. NREs were recorded by an experienced staff anesthesiologist using all three video streams. Checklist-based team performance assessment was also performed by an experienced staff anesthesiologist. Results: We found that anesthesia teams adapt their coordination activities to changing situational demands. In particular, the increased occurrence of NREs caused an increase in the time the teams spent on task management. A stronger increase in the teams’ task management (i.e., more adaptive coordination) was related to their performance. Conclusion: Our results emphasize the importance of adaptive coordination in managing NREs effectively. Application: This study provides valuable information for developing novel team training programs in health care that focus on adaptation to changing task requirements, for example, when faced with NREs.

Adaptive coordination and heedfulness make better cockpit crews

Team coordination during a simulated clean approach performed by 42 civil aviation cockpit crews was analysed. Several hypotheses regarding the adaptive use of implicit and explicit coordination, leadership and heedful interrelating were tested. The results indicate the adaptiveness of coordination to different levels of standardisation and task load and the general importance of explicit coordination for good performance. Leadership seems to be required mainly for work phases with little standardisation. In exploratory lag sequential analyses, heedful behaviour in the seven best and six worst performing crews was examined. The coordination sequences in high performance crews were found to be more succinct and well balanced, indicating that a shared sense of heedfulness is crucial for effectiveness. Theoretical implications for the conceptualisation of adaptive coordination and heedfulness and practical implications for improving crew training are discussed. Statement of Relevance: Analyses of team coordination during a simulated clean approach performed by civil aviation cockpit crews demonstrated the occurrence and effectiveness of adaptive coordination in response to different levels of task load and standardisation. Results also indicated the importance of heedful interrelating, both as a form of coordination and as a way of regulating the adaptiveness of coordination efforts. These findings have important implications for improving crew training, leadership practices and possibly also standard operating procedures.

Leadership in anaesthesia teams: the most effective leadership is shared

Background Leadership plays a crucial role in teams working in complex environments, and research has shown that shared leadership where all team members perform leadership functions is an effective strategy. The authors aimed to describe shared leadership patterns during anaesthesia induction and show how they are linked to team performance. Methods 12 anaesthesia teams consisting of one resident and one nurse during a simulated anaesthesia induction including a non-routine event (asystole) were videotaped, and two kinds of leadership behaviour (content-oriented and structuring) were coded. Team performance was operationalised as the reaction time to the non-routine event. The amount of leadership sharedness was compared between low- and high-performing teams by performing a univariate analysis of variance. Wilcoxon signed-rank tests were used to analyse the distribution of the two kinds of leadership behaviour among team members. Results Statistical analysis revealed that in high-performing teams, residents and nurses shared their leadership, while in low-performing teams, residents showed significantly higher levels of leadership behaviour than nurses. Further analyses revealed different distributions of leadership functions among team members. While residents of low-performing teams assumed both kinds of leadership behaviour, members of high-performing teams seemed to have distinct leadership roles: nurses mainly used content-oriented leadership behaviour, and residents tended to show structuring leadership behaviour. Conclusions The study documents the effectiveness of shared leadership in situations with high task complexity and indicates that a clear distribution of content-oriented and structuring leadership among team members is an effective strategy. The findings have implications for training in shared leadership and also give rise to a number of recommendations for further research. ClinicalTrials (http://www.clinicaltrials.gov) registration number is NCT00706108.

Careers and identity in flexible working: Do flexible identities fare better?

The relationship between personal identity and experience of individual career change and flexible working was investigated. Cluster analyses with survey data from 596 employees in 14 companies with varying levels of flexibility indicated the existence of four types of personal identity: the critical-flexible, self-determined, continuous, and job-centred type. The types were explicated further on the basis of narrative interviews with 59 individuals with either a continuous or discontinuous work biography. The types differed significantly in the identity dimensions biographical continuity, ecological consistency, and locus of control as well as in career-related self-esteem and satisfaction with their employment situation, especially their psychological contract. The continuous type expressed the highest and the critical-flexible type the least satisfaction. Consequences for career management and identity research are discussed.

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.