Robert L. Helmreich

Error, stress, and teamwork in medicine and aviation: cross sectional surveys

Abstract Objectives: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. Design: Cross sectional surveys. Setting: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. Participants: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). Main outcome measures: Perceptions of error, stress, and teamwork. Results: Pilots were least likely to deny the effects of fatigue on performance (26% v70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. Conclusions: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.

On error management: lessons from aviation

Pilots and doctors operate in complex environments where teams interact with technology. In both domains, risk varies from low to high with threats coming from a variety of sources in the environment. Safety is paramount for both professions, but cost issues can influence the commitment of resources for safety efforts. Aircraft accidents are infrequent, highly visible, and often involve massive loss of life, resulting in exhaustive investigation into causal factors, public reports, and remedial action. Research by the National Aeronautics and Space Administration into aviation accidents has found that 70% involve human error.1 In contrast, medical adverse events happen to individual patients and seldom receive national publicity. More importantly, there is no standardised method of investigation, documentation, and dissemination. The US Institute of Medicine estimates that each year between 44 000 and 98 000 people die as a result of medical errors. When error is suspected, litigation and new regulations are threats in both medicine and aviation. #### Summary points In aviation, accidents are usually highly visible, and as a result aviation has developed standardised methods of investigating, documenting, and disseminating errors and their lessons Although operating theatres are not cockpits, medicine could learn from aviation Observation of flights in operation has identified failures of compliance, communication, procedures, proficiency, and decision making in contributing to errors Surveys in operating theatres have confirmed that pilots and doctors have common interpersonal problem areas and similarities in professional culture Accepting the inevitability of error and the importance of reliable data on error and its management will allow systematic efforts to reduce the frequency and severity of adverse events Error results from physiological and psychological limitations of humans.2 Causes of error include fatigue, workload, and fear as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making.3 In both aviation …

A short version of the Attitudes toward Women Scale (AWS).

A short (25-item) version of the Spence-Helmreich (1972) Attitudes toward Women Scale (AWS) is presented. Correlations between scores on the short and the full (55-item) version for groups of male and female students and groups of their parents were.95 or above. The results of a factor analysis and part-whole correlations also indicated the similarity of the two forms. Normative data for the student and parent samples are described.

Discrepant attitudes about teamwork among critical care nurses and physicians.

ObjectiveTo measure and compare critical care physicians’ and nurses’ attitudes about teamwork. DesignCross-sectional surveys. SettingEight nonsurgical intensive care units in two teaching and four nonteaching hospitals in the Houston, TX, metropolitan area. SubjectsPhysicians and nurses who worked in the intensive care units. Measurements and Main ResultsThree hundred twenty subjects (90 physicians and 230 nurses) responded to the survey. The response rate was 58% (40% for physicians and 71% for nurses). Only 33% of nurses rated the quality of collaboration and communication with the physicians as high or very high. In contrast, 73% of physicians rated collaboration and communication with nurses as high or very high. By using factor analysis, we developed a seven-item teamwork scale. Multivariate analysis of variance of the items yielded an omnibus (F [7, 163] = 8.37;p < .001), indicating that physicians and nurses perceive their teamwork climate differently. Analysis of individual items revealed that relative to physicians, nurses reported that it is difficult to speak up, disagreements are not appropriately resolved, more input into decision making is needed, and nurse input is not well received. ConclusionsCritical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other. As evidenced by individual item content, this discrepancy includes suboptimal conflict resolution and interpersonal communication skills. These findings may be the result of the differences in status/authority, responsibilities, gender, training, and nursing and physician cultures.

Masculine Instrumentality and Feminine Expressiveness: Their Relationships with Sex Role Attitudes and Behaviors

Data from the Bem Sex Role Inventory (BSRI) and the Personal Attributes Questionnaire (PAQ) Masculinity and Femininity scales have led to the hypothesis that androgynous individuals are more “behaviorally flexible” than others, manifesting both masculine and feminine role behaviors. Sex-role androgyny is also said to have other beneficial consequences such as high self esteem. The content of these instruments, however, is largely confined to socially desirable instrumental (masculine) and expressive (feminine) personality traits. A review of the literature indicates that these abstract trait dimensions have only minimal relationships with sex-role attitudes and sex-role behaviors not tapping instrumentality and expressiveness, and provide little support for the general behavioral flexibility hypothesis. Although PAQ and BSRI findings cannot be generalized to sex-role behaviors in general, the literature suggests that instrumentality and expressiveness per se have important implications. Appreciation of their contributions may be advanced more rapidly if these trait dimensions are disentangled from global concepts of sex-roles or masculinity, femininity, and androgyny.

Short forms of the Texas Social Behavior Inventory (TSBI), an objective measure of self-esteem

Two short (16 item) forms of the Helmreich, Stapp, and Ervin (1974) Texas Social Behavior Inventory, a validated, objective measure of self-esteem or social competence are presented. Normative data and other statistics are described for males and females. Correlations between each short form and long (32-item) scale were.97. Factor analysis and part-whole correlations verified the similarity of the two forms. The utility of the scale in research is described.

A psychometric analysis of the Personal Attributes Questionnaire

The psychometric properties of the Personal Attributes Questionnaire were examined in independent samples of male and female high school students, college students, and adults. In each of the six samples a two-factor structure (masculinity/instrumentality and femininity/expressivity) paralleling the empirically derived scales was found. Additional factor analyses of negative masculine and feminine traits were reported. Discriminant analyses revealed highly significant differentiation between the sexes. The reliabilities (Cronbach alpha) of the unit-weighted scales in each sample were also satisfactory.

The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units

BackgroundExecutive walk rounds (EWRs) are a widely used but unstudied activity designed to improve safety culture in hospitals. Therefore, we measured the impact of EWRs on one important part of safety culture – provider attitudes about the safety climate in the institution.MethodsRandomized study of EWRs for 23 clinical units in a tertiary care teaching hospital. All providers except physicians participated. EWRs were conducted at each unit by one of six hospital executives once every four weeks for three visits. Providers were asked about their concerns regarding patient safety and what could be done to improve patient safety. Suggestions were tabulated and when possible, changes were made. Provider attitudes about safety climate measured by the Safety Climate Survey before and after EWRs. We report mean scores, percent positive scores (percentage of providers who responded four or higher on a five point scale (agree slightly or agree strongly), and the odds of EWR participants agreeing with individual survey items when compared to non-participants.ResultsBefore EWRs the mean safety climate scores for nurses were similar in the control units and EWR units (78.97 and 76.78, P = 0.458) as were percent positive scores (64.6% positive and 61.1% positive). After EWRs the mean safety climate scores were not significantly different for all providers nor for nurses in the control units and EWR units (77.93 and 78.33, P = 0.854) and (56.5% positive and 62.7% positive). However, when analyzed by exposure to EWRs, nurses in the control group who did not participate in EWRs (n = 198) had lower safety climate scores than nurses in the intervention group who did participate in an EWR session (n = 85) (74.88 versus 81.01, P = 0.02; 52.5% positive versus 72.9% positive). Compared to nurses who did not participate, nurses in the experimental group who reported participating in EWRs also responded more favorably to a majority of items on the survey.ConclusionEWRs have a positive effect on the safety climate attitudes of nurses who participate in the walk rounds sessions. EWRs are a promising tool to improve safety climate and the broader construct of safety culture.

Translating teamwork behaviours from aviation to healthcare: development of behavioural markers for neonatal resuscitation

Improving teamwork in healthcare may help reduce and manage errors. This paper takes a step toward that goal by (1) proposing a set of teamwork behaviours, or behavioural markers, for neonatal resuscitation; (2) presenting a data form for recording observations about these markers; and (3) comparing and contrasting different sets of teamwork behaviours that have been developed for healthcare. Data from focus groups of neonatal providers, surveys, and video recordings of neonatal resuscitations were used to identify some new teamwork behaviours, to translate existing aviation team behaviours to this setting, and to develop a data collection form. This behavioural marker audit form for neonatal resuscitation lists and defines 10 markers that describe specific, observable behaviours seen during the resuscitation of newborn infants. These markers are compared with those developed by other groups. Future research should determine the relations among these behaviours and errors, and test their usefulness in measuring the impact of team training interventions.

Group interaction and flight crew performance

Publisher Summary This chapter focuses on the group performance process as it affects crew effectiveness in multi-pilot operations. This task is a classic small group performance situation where a number of social, organizational, and personality factors are relevant to flight safety. The chapter reviews factors and research that supports this conclusion. The technical proficiency standards and the accompanying pilot selection criteria were developed largely for single-pilot operations and were more or less maintained for multipilot operations. In many ways, this is somewhat paradoxical. The flight of a sophisticated multipilot transport aircraft is a highly structured group performance situation where a number of interpersonal factors are relevant to crew effectiveness. Those characteristics associated with the right stuff are the wrong stuff as far as effective group function is concerned, and therein lies the paradox. Despite the fact that studies of group performance have implicated many variables, group performance problems have received relatively little attention in the aviation research and training communities until recently. Group-level input factors include dimensions such as group size, prior history, structure, composition, and cohesiveness. Awareness of these types of pilot performance problems is gradually increasing, but unfortunately, this heightened awareness has been stimulated in large part by a series of tragic accidents.