Tom W. Reader

Developing a team performance framework for the intensive care unit

Objective:There is a growing literature on the relationship between teamwork and patient outcomes in intensive care, providing new insights into the skills required for effective team performance. The purpose of this review is to consolidate the most robust findings from this research into an intensive care unit (ICU) team performance framework. Data Sources:Studies investigating teamwork within the ICU using PubMed, Science Direct, and Web of Knowledge databases. Study Selection:Studies investigating the relationship between aspects of teamwork and ICU outcomes, or studies testing factors that are found to influence team working in the ICU. Data Extraction:Teamwork behaviors associated with patient or staff-related outcomes in the ICU were identified. Data Synthesis:Teamwork behaviors were grouped according to the team process categories of “team communication,” “team leadership,” “team coordination,” and “team decision making.” A prototype framework explaining the team performance in the ICU was developed using these categories. The purpose of the framework is to consolidate the existing ICU teamwork literature and to guide the development and testing of interventions for improving teamwork. Conclusions:Effective teamwork is shown as crucial for providing optimal patient care in the ICU. In particular, team leadership seems vital for guiding the way in which ICU team members interact and coordinate with others.

Communication skills and error in the intensive care unit.

Purpose of reviewPoor communication in critical care teams has been frequently shown as a contributing factor to adverse events. There is now a strong emphasis on identifying the communication skills that can contribute to, or protect against, preventable medical errors. This review considers communication research recently conducted in the intensive care unit and other acute domains. Recent findingsError studies in the intensive care unit have shown good communication to be crucial for ensuring patient safety. Interventions to improve communication in the intensive care unit have resulted in reduced reports of adverse events, and simulated emergency scenarios have shown effective communication to be correlated with improved technical performance. In other medical domains where communication is crucial for safety, the relationship between communication skills and error has been examined more closely, with highly detailed teamwork assessment tools being developed. SummaryCritical care teams perform many activities where effective communication is crucial for ensuring patient safety and reducing susceptibility to error. To develop valid team training and assessment tools for improving teamwork in the intensive care unit there is a requirement to better understand and identify the specific communication skills important for safety during the provision of intensive care medicine.

Patient complaints in healthcare systems: a systematic review and coding taxonomy

Background Patient complaints have been identified as a valuable resource for monitoring and improving patient safety. This article critically reviews the literature on patient complaints, and synthesises the research findings to develop a coding taxonomy for analysing patient complaints. Methods The PubMed, Science Direct and Medline databases were systematically investigated to identify patient complaint research studies. Publications were included if they reported primary quantitative data on the content of patient-initiated complaints. Data were extracted and synthesised on (1) basic study characteristics; (2) methodological details; and (3) the issues patients complained about. Results 59 studies, reporting 88 069 patient complaints, were included. Patient complaint coding methodologies varied considerably (eg, in attributing single or multiple causes to complaints). In total, 113 551 issues were found to underlie the patient complaints. These were analysed using 205 different analytical codes which when combined represented 29 subcategories of complaint issue. The most common issues complained about were ‘treatment’ (15.6%) and ‘communication’ (13.7%). To develop a patient complaint coding taxonomy, the subcategories were thematically grouped into seven categories, and then three conceptually distinct domains. The first domain related to complaints on the safety and quality of clinical care (representing 33.7% of complaint issues), the second to the management of healthcare organisations (35.1%) and the third to problems in healthcare staff–patient relationships (29.1%). Conclusions Rigorous analyses of patient complaints will help to identify problems in patient safety. To achieve this, it is necessary to standardise how patient complaints are analysed and interpreted. Through synthesising data from 59 patient complaint studies, we propose a coding taxonomy for supporting future research and practice in the analysis of patient complaint data.

Patient neglect in healthcare institutions: a systematic review and conceptual model

BackgroundPatient neglect is an issue of increasing public concern in Europe and North America, yet remains poorly understood. This is the first systematic review on the nature, frequency and causes of patient neglect as distinct from patient safety topics such as medical error.MethodThe Pubmed, Science Direct, and Medline databases were searched in order to identify research studies investigating patient neglect. Ten articles and four government reports met the inclusion criteria of reporting primary data on the occurrence or causes of patient neglect. Qualitative and quantitative data extraction investigated (1) the definition of patient neglect, (2) the forms of behaviour associated with neglect, (3) the reported frequency of neglect, and (4) the causes of neglect.ResultsPatient neglect is found to have two aspects. First, procedure neglect, which refers to failures of healthcare staff to achieve objective standards of care. Second, caring neglect, which refers to behaviours that lead patients and observers to believe that staff have uncaring attitudes. The perceived frequency of neglectful behaviour varies by observer. Patients and their family members are more likely to report neglect than healthcare staff, and nurses are more likely to report on the neglectful behaviours of other nurses than on their own behaviour. The causes of patient neglect frequently relate to organisational factors (e.g. high workloads that constrain the behaviours of healthcare staff, burnout), and the relationship between carers and patients.ConclusionA social psychology-based conceptual model is developed to explain the occurrence and nature of patient neglect. This model will facilitate investigations of i) differences between patients and healthcare staff in how they perceive neglect, ii) the association with patient neglect and health outcomes, iii) the relative importance of system and organisational factors in causing neglect, and iv) the design of interventions and health policy to reduce patient neglect.

Team leadership in the intensive care unit: the perspective of specialists.

Objectives:To identify the behaviors senior physicians (e.g., specialists, staff attendings) report using to lead multidisciplinary teams in the intensive care unit. Design:Semistructured interviews focusing on team leadership, crisis management, and development of an environment that enable effective team performance in the intensive care unit. Setting:Seven general intensive care units based in National Health Service hospitals in the United Kingdom. Participants:Twenty-five senior intensive care medicine physicians. Measurements and Main Results:Responses to a semistructured interview were transcribed and subjected to “content” analysis. The interview analysis focused on references to the “functional” behaviors used by leaders to manage team performance and the “team development behaviors” used to build the conditions that enable effective team performance. Seven of the interviews were coded by a second psychologist to measure inter-rater reliability. Inter-rater reliability (Cohens &kgr;) was acceptable for both scales (&kgr; = 0.72 and &kgr; = 0.75). In total, 702 functional leadership behaviors (behaviors for information gathering, planning and decision-making, managing team members) were coded as being used to manage the intensive care unit, along with 216 team development behaviors (for providing team direction and establishing team norms). These behaviors were grouped together in a theoretically driven framework of intensive care unit team leadership. Conclusions:Intensive care unit senior physicians report using a variety of leadership behaviors to ensure high levels of team performance. The data described in this study provide insight into the team leadership behaviors used by intensive care unit team leaders and have implications for the development of team leadership training and assessment tools.

Team situation awareness and the anticipation of patient progress during ICU rounds

Background The ability of medical teams to develop and maintain team situation awareness (team SA) is crucial for patient safety. Limited research has investigated team SA within clinical environments. This study reports the development of a method for investigating team SA during the intensive care unit (ICU) round and describes the results. Methods In one ICU, a sample of doctors and nurses (n=44, who combined to form 37 different teams) were observed during 34 morning ward rounds. Following the clinical review of each patient (n=105), team members individually recorded their anticipations for expected patient developments over 48 h. Patient-outcome data were collected to determine the accuracy of anticipations. Anticipations were compared among ICU team members, and the degree of consensus was used as a proxy measure of team SA. Self-report and observational data measured team-member involvement and communication during patient reviews. Results For over half of 105 patients, ICU team members formed conflicting anticipations as to whether patients would deteriorate within 48 h. Senior doctors were most accurate in their predictions. Exploratory analysis found that team processes did not predict team SA. However, the involvement of junior and senior trainee doctors in the patient decision-making process predicted the extent to which those team members formed team SA with senior doctors. Conclusions A new method for measuring team SA during the ICU round was successfully employed. A number of areas for future research were identified, including refinement of the situation awareness and teamwork measures.

Burnout in the ICU: Potential consequences for staff and patient well-being

Psychologically stressful situations, a physically demanding workload and a high requirement for technological skills can lead ICU caregivers to burnout.

Aviation and healthcare: a comparative review with implications for patient safety

Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.

The deepwater horizon explosion: non-technical skills, safety culture, and system complexity

The explosion and destruction of the Deepwater Horizon (DH) was a watershed moment for safety management in the US oil and gas industry. The 2011 National Oil Spill Commission investigation identified a range of operational behaviours and underlying safety management problems that were causal to the mishap. Yet, to date these have not been systematically considered within a human factors framework. To achieve this, we draw upon two applied psychology domains that are highly influential within safety research. First, we apply non-technical skills (NTS) (social and cognitive skills that underpin safe performance in complex work environments) theorem to understand operational activities in the lead-up and occurrence of the well blowout. NTS research is used to develop interventions for training and observing safety behaviours (e.g. decision-making, teamwork). Second, we apply safety culture theory to understand how the organisational and industry environment shaped the management of risk. Safety culture research is used to understand and change the socio-technical constraints and enablers of safety activity in high-risk workplaces. Finally, to integrate these perspectives, we take a systems-thinking perspective to understand the mishap. A common critique of accident narratives is their failure to systematically consider how the components of an incident interact together to escalate risk. From a systems-thinking perspective, understanding the interactions leading to the DH mishap is crucial for ensuring interventions are effective in preventing future mishaps. We develop an accident model that captures the various interactions and system factors leading to the blowout.

Teamwork and team training in the ICU: where do the similarities with aviation end?

The aviation industry has made significant progress in identifying the skills and behaviors that result in effective teamwork. Its conceptualization of teamwork, development of training programs, and design of assessment tools are highly relevant to the intensive care unit (ICU). Team skills are important for maintaining safety in both domains, as multidisciplinary teams must work effectively under highly complex, stressful, and uncertain conditions. However, there are substantial differences in the nature of work and structure of teams in the ICU in comparison with those in aviation. While intensive care medicine may wish to use the advances made by the aviation industry for conceptualizing team skills and implementing team training programs, interventions must be tailored to the highly specific demands of the ICU.