Supporting structures for team situation awareness and decision making: insights from four delivery suites

Rationale, aims and objectives ‘Human factors’ (non‐technical skills such as communication and teamwork) have been strongly implicated in adverse events during labour and delivery. The importance of shared ‘situation awareness’ between team members is highlighted as a key factor in patient safety. Arising from an ethnographic study of safety culture in the delivery suites of four UK hospitals, the aim of this study is to describe the main mechanisms supporting team situation awareness (TSA) and examine contrasting configurations of supports. Methods Stage I: 177 hours of lightly structured non‐participant observation (sensitizing concepts: safety culture, non‐technical skills, teamwork and decision making) analysed to identify a core organizing concept, main supporting categories and preliminary conceptual models. Stage II: (approximately 11 months after first observations) 104 hours of observation to test and elaborate stage I analyses. Results Handover, whiteboard use and a coordinator role emerged as the key processes facilitating work and team coordination. The interplay between these supporting processes and the contextual features of each site promoted or inhibited TSA. Three configurations of supports for TSA were evident. These are described. Conclusions Context configurations of supporting mechanisms and artefacts influence TSA, with implications for the maintenance of patient safety on delivery suites. A balanced model of supports for TSA is commended. Examining contrasting configurations helps reveal how local mechanisms or organizational, environmental and temporal factors might be manipulated to improve TSA.     

Preparing Tomorrow's Nurses for Collaborative Quality Care Through Simulation

Simulations were introduced into a 2nd semester associate degree nursing program as a teaching strategy designed to enhance learning, promote critical thinking, and bridge the gap between theory and practice. Minimizing error, promoting quality care, and establishing teamwork were among the main objectives. Decision making and completion of assignments and activities were shared. Simulation helps nursing students to build communication skills and collaborate characteristics essential to working within the interprofessional team in today's health care climate.     

Educating advanced practice nurses for collaborative practice in the multidisciplinary provider team

PURPOSE: To describe the use of a clinical decision-making work sheet as a tool to teach communication skills to advanced practice nurse (APN) students. Achievement of competencies in communication and documentation that utilize language and communication strategies that are shared with other health professionals promotes effective collaborative practice among members of the multidisciplinary provider team. DATA SOURCES: Review of the recent Institute of Medicine report on health professions education and other health professional literature. CONCLUSIONS: The Clinical Decision-Making Work Sheet helps APN students effectively communicate in real-world clinical settings. The clinical work sheet allows nurse practitioner students to communicate more effectively and efficiently, using a vocabulary that is shared with other members of the multidisciplinary health care provider team. Use of the tool in students' clinical-rotation settings facilitates effective application and refinement of the clinical decision-making skills that students learned in the advanced health assessment course. IMPLICATIONS FOR PRACTICE: Faculty have the responsibility to assist nurses as they transition from traditional nursing to APN roles. The work sheet facilitates learning the common language for data collection, clinical decision making, documentation, and reporting that is shared with other health professionals. Using the tool, students learn to efficiently organize information that supports communication and documentation that enhances their clinical problem-solving skills. Case presentation and documentation using the work sheet provide a basis for preceptor and student interaction and for student evaluation.     

Perceptions of patient participation amongst elderly patients with end-stage renal disease in a dialysis unit

Scand J Caring Sci; 2012; 26; 61–69
Perceptions of patient participation amongst elderly patients with end‐stage renal disease in a dialysis unit Aim: A patient’s right to influence treatment and health care has been guaranteed by Norwegian law since 1999. The aim of this study was to explore how elderly patients with end‐stage renal disease who are undergoing treatment with haemodialysis for the rest of their lives perceive patient participation in a dialysis unit. Methods: This study, which was inspired by critical discourse analysis, drew on data derived from transcribed interviews with 11 patients. Findings: Two discourses related to patient participation were identified. The first and dominant discourse was called the health‐care team’s power and dominance. Both environmental conditions and the team’s practice exercised power and control over the patients. The patients trusted the health‐care team, but some felt powerless and were afraid of what might happen if they refused to follow the instructions. The health‐care team owned the knowledge and decided what the patients needed to know. Most of all the patients wanted dialogue about the future. After years of treatment, patient identity seemed to be threatened by this situation. The second discourse is called the patients struggling for shared decision‐making. Some patients struggled to be involved in decision‐making about ‘dry weight’, diet, blood access and time of treatment when these factors threatened their well‐being and the quality of their daily lives. Conclusions: The elderly patients’ right to participate in their haemodialysis treatment did not seem to be well incorporated into the social practices of haemodialysis units. Changing the social practices in the dialysis units from a paternalistic ideology to an ideology of participation will require consideration of the context, the dialogue and the process of shared decision‐making with the patient.     

Therapists' experiences and perceptions of teamwork in neurological rehabilitation: Critical happenings in effective and ineffective teamwork

This paper reports the second part of an exploratory study into occupational therapists' and physiotherapists' perceptions and experiences of teamwork in neurological rehabilitation: the factors that were thought to influence effective and ineffective teamwork, and the meaning behind effective and ineffective teamwork in neurological rehabilitation. The study was undertaken through semi-structured interviews of 10 therapists from three different neurological rehabilitation teams based in the United Kingdom, and used the critical incident technique. Through analysis of the data, several main themes emerged regarding the perceived critical happenings in effective and ineffective teamwork. These were: team events and characteristics, team members' characteristics, shared and collaborative working practices, communication, specific organizational structures, environmental, external, and patient and family-related factors. Effective and ineffective team-work was perceived to impact on a number of levels: having implications for the team, the patient, individual team members, and the neurological rehabilitation service. The study supported the perceived value of team work within neurological rehabilitation. It also indicated the extensive and variable factors that may influence the team-working process as well as the complex and diverse nature of the process.     

Examining participant perceptions of an interprofessional simulation-based trauma team training for medical and nursing students

High quality care relies on interprofessional teamwork. We developed a short simulation-based course for final year medical, nursing and nursing anaesthesia students, using scenarios from emergency medicine. The aim of this paper is to describe the adaptation of an interprofessional simulation course in an undergraduate setting and to report participants’ experiences with the course and students’ learning outcomes. We evaluated the course collecting responses from students through questionnaires with both closed-ended and open-ended questions, supplemented by the facilitators’ assessment of students’ performance. Our data is based on responses from 310 students and 16 facilitators who contributed through three evaluation phases. In the analysis, we found that students reported emotional activation and learning outcomes within the domains self-insight and stress management, understanding of the leadership role, insight into teamwork, and skills in team communication. In subsequent questionnaire studies students reported having gained insights about communication, teamwork and leadership, and they believed they would be better leaders of teams and/or team members after having completed the course. Facilitators’ observations suggested a progress in students’ non-technical skills during the course. The facilitators observed that nursing anaesthesia students seemed to be more comfortable in finding their role in the team than the two other groups. In conclusion, we found that an interprofessional simulation-based emergency team training course with a focus on leadership, communication and teamwork, was feasible to run on a regular basis for large groups of students. The course improved the students’ team skills and received a favourable evaluation from both students and faculty.     

Therapists' experiences and perceptions of teamwork in neurological rehabilitation: critical happenings in effective and ineffective teamwork

This paper reports the second part of an exploratory study into occupational therapists' and physiotherapists' perceptions and experiences of teamwork in neurological rehabilitation: the factors that were thought to influence effective and ineffective teamwork, and the meaning behind effective and ineffective teamwork in neurological rehabilitation. The study was undertaken through semi-structured interviews of 10 therapists from three different neurological rehabilitation teams based in the United Kingdom, and used the critical incident technique. Through analysis of the data, several main themes emerged regarding the perceived critical happenings in effective and ineffective teamwork. These were: team events and characteristics, team members' characteristics, shared and collaborative working practices, communication, specific organizational structures, environmental, external, and patient and family-related factors. Effective and ineffective team-work was perceived to impact on a number of levels: having implications for the team, the patient, individual team members, and the neurological rehabilitation service. The study supported the perceived value of team work within neurological rehabilitation. It also indicated the extensive and variable factors that may influence the team-working process as well as the complex and diverse nature of the process.     

Impact of team composition on student perceptions of interprofessional teamwork: A 6-year cohort study

Interprofessional education (IPE) provides students with opportunities to learn about the roles and responsibilities of other professions and develop communication and teamwork skills. As different health professions have recognised the importance of IPE, the number of disciplines participating in IPE events is increasing. Consequently, it is important to examine the effect group structure has on the learning environment and student knowledge acquisition during IPE events. The purpose of this study was to determine the effect of group composition on student perceptions of interprofessional teamwork and collaboration when participating in a case-based IPE forum. To examine this construct, six cohorts of students were divided into two groups: Group-one (2010–2012) included students from five professions. Group-two (2013–2015) included students from 10 professions. The only other change for group-two was broadening the case scenarios to ensure a role for each profession. At the conclusion of the case-based IPE forums, both groups demonstrated a statistically significant increase in ‘readiness for interprofessional learning’ and ‘interdisciplinary education perceptions’. However, participants in group-one (2010–2012) demonstrated a greater change in scores when compared to group-two (2013–2015). It was concluded a case-based IPE forum with students from numerous health professions participating in a discussion about broad case scenarios was moderately effective at introducing students to other health professions and increasing their knowledge of others’ identities. However, a smaller grouping of professions with targeted cases was more effective at influencing student perceptions of the need for teamwork. When planning an IPE event, faculty should focus on intentional groupings of professions to reflect the social context of healthcare teams so all students can fully participate and experience shared learning.     

Contributions of team climate in the study of interprofessional collaboration: A conceptual analysis

The concept of team climate is widely used to understand and evaluate working environments. It shares some important features with Interprofessional Collaboration (IPC). The four-factor theory of climate for work group innovation, which underpins team climate, could provide a better basis for understanding both teamwork and IPC. This article examines in detail the common ground between team climate and IPC, and assesses the relevance of team climate as a theoretical approach to understanding IPC. There are important potential areas of overlap between team climate and IPC that we have grouped under four headings: (1) interaction and communication between team members; (2) common objectives around which collective work is organised; (3) responsibility for performing work to a high standard; and (4) promoting innovation in working practices. These overlapping areas suggest common characteristics that could provide elements of a framework for considering the contribution of team climate to collaborative working, both from a conceptual perspective and, potentially, in operational terms as, for example, a diagnostic tool.     

The influence of objective measurement tools on communication and clinical decision making in neurological rehabilitation

Rationale Routine collection of outcome measures is advocated to improve quality of care. However, there has been scant investigation of how measurement tools are used in clinical practice and what impact they may have. This paper compares two neuro‐rehabilitation teams, one which routinely used standardized measurement tools and the other which did not. We explore differences in communication and clinical decision making within multidisciplinary team (MDT) meetings to illuminate the influence measurement tools could have on clinical practice. Method Non‐participant observation of MDT meetings in two neurological rehabilitation units in England. Semi‐structured interviews were also carried out with at least one member of each profession in each team. Grounded theory techniques were used to analyse the data. Results Differences in team members' communication within MDT meetings underscored differences in the process of clinical decision making within the teams. Using measurement tools provided a shared understanding to facilitate communication by focusing discussion on the patient's abilities rather than individual professionals' contributions. This led to differences in the way team members identified the nature and cause of patients' problems, monitored their progress and planned for discharge. They provided a ‘neutral ground’ to reach a shared perspective between professionals, thereby avoiding conflict. Externally, use of the tools enabled objective discussion with patients and their families about their progress and was a vehicle to facilitate giving bad news. Conclusion Using standardized measurement tools can promote a patient‐focused approach to care, thus facilitating treatment planning and clinical decision making.     

Effect of interprofessional clinical education programme length on students’ attitudes towards teamwork

This article reports on a study involving a range of health professions students who participated in similar one-semester (short) or two-semester (long) interprofessional clinical education programmes that focused on clinical assessment of senior citizens living independently in the community. Students’ attitudes towards teamwork skills and perceptions of their own teamwork skills both before and after the programmes were assessed using two validated scales. Osteopathic medical student participants reported no significant changes in attitudes towards interprofessional healthcare teamwork skills or their perceptions of their own interprofessional teamwork skills after either the one- or two-semester programmes. For athletic training, speech–language pathology, exercise sciences, public health, and nursing students, though, attitudes towards teamwork skills significantly improved (p < .05) after the one-semester programme; and perceptions of their own team skills significantly improved (p < .05) after both the one- and two-semester programmes. Overall, this study provides some support for interprofessional teamwork attitude change, but with a significant difference between medical as compared to nursing, allied health, and public health students.     

The impact of team processes on psychiatric case management

Title. The impact of team processes on psychiatric case management Aim. This paper is a report of a study to identify the structures and interactions within community mental health teams that facilitate or impede effective teamwork and psychiatric case management. Background. Effective case management requires close collaboration between case managers or care co‐ordinators and other members of the multidisciplinary mental health team, yet there has been little research into this relationship. Method. A multiple case study of seven United Kingdom community mental health teams was conducted between 1999 and 2001, using qualitative methods of participant observation, semi‐structured interviews and document review. Findings. Factors were identified that impacted on the ability of care co‐ordinators to act effectively: ‘structure and procedures’; ‘disrespect and withdrawal’; ‘humour and undermining’; ‘safety and disclosure’. Care co‐ordination was enhanced when team structures and policies were in place and where team interactions were respectful. Where members felt disrespected or undermined, communication, information sharing and collaboration were impaired, with a negative impact on the care provided to service users. Conclusions. Teams require clear operating procedures alongside interprofessional trust and respect to ensure that there is open, safe and reflective participation. Further research is required to identify how best to bring about collaborative, effective teamwork in mental healthcare.     

Multidisciplinary teams in geriatric wards: myth or reality?

This paper argues that the rhetoric of multidisciplinary teamwork is central to the provision of health care generally and geriatric care in particular. Yet the notion of teamwork is poorly defined, and the supposed benefits for patients are not always readily apparent. Looking at teamwork in practice, examples from research are used to illustrate how multidisciplinary decision making and work with patients can, under particular circumstances, take on the appearance of collaboration amongst a team of expert colleagues, which co-opts patients and relatives to the status of team members. But very often, multidisciplinary work with patients is coordinated not by mutual collaboration amongst a team of equals, but by means of established work routines which are broadly applied to whole categories of patients, and by the operation of the traditional hierarchy of social relations in health care. For long stay patients, the pervasiveness of the teamwork mythology and the frequent concurrent withdrawal of other professionals can, at worst, leave the nurses in the invidious position of having responsibility, but no formal or legal authority for caring for their patients: work which no other professional is anxious to do. This leads to negative outcomes for patients as well as for nurses.
Finally, it is stressed that analysis of multidisciplinary teamwork both in theory and in practice is vital if we are to understand the conditions under which multidisciplinary teamwork both flourishes, and can be demonstrated to be a necessary condition for the creation of positive care outcomes for geriatric patients in hospital. This paper seeks to raise some of the issues which must be confronted in this endeavour.     

Shared decision‐making in mental and behavioural health interventions

Elements of shared decision‐making (ie, collaboration, patient preferences, and working alliance) have long been discussed and studied in the field of clinical psychology; however, research indicates that shared decision‐making is not typically used in clinical practice. Instead, clinicians often rely on a paternalistic approach. In this article, we provide a narrative review of the existing research supporting shared decision‐making for mental and behavioural health concerns, we discuss several barriers that impede its use in actual clinical practice, and we provide recommendations for increasing shared decision‐making when working with patients.     

Partners in care: investigating community nurses’ understanding of an interdisciplinary team‐based approach to primary care

Aim. This study investigated community nurses understanding of teamwork in primary care. Background. Internationally trends indicate a movement towards the development of primary care as a key element in health service delivery. This will have implications for the organisation of community nursing services by creating the need for more coherent integrated structures for service delivery. In this context, teamwork is associated with a range of positive outcomes including higher levels of quality care and job satisfaction. Design. A research study was undertaken to investigate community nurses’ understanding of an interdisciplinary team‐based approach to primary care using a qualitative research design. Focus groups were held with community nurses working in the areas of public health nursing, general nursing and practice nursing. Methods. Three focus groups were established. Twenty seven participants were recruited to form three groups comprising public health nurses (n = 10), general nurses (n = 10) and practice nurses (n = 7). A sequenced‐questioning framework guided the systematic process of data collection. Data analysis engaged a thematic content analysis framework. Results. The analysis of the data revealed the following themes: teamwork, promoting community services, promoting health, professional roles and skills and knowledge for primary care. Conclusion. Nurses can contribute significantly to the re‐orientation and development of primary care services. There must be greater efforts to encourage interdisciplinary approaches. The outcomes of this study can inform strategies for effective team working in primary care. Collective team efforts enhance patient care and effective teamwork requires a greater understanding of group processes and team development. Relevance to clinical practice. Nurses clearly articulated their contribution to primary care, but recognised that there are many challenges to overcome. An enhanced primary care team has the potential to allow the public access to both the individual and collective skills and knowledge of team members.     

Shared decision‐making in maternity care: Acknowledging and overcoming epistemic defeaters

Shared decision‐making involves health professionals and patients/clients working together to achieve true person‐centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision‐making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision‐making for caesarean section. The team concluded that shared decision‐making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision‐making (defeaters) are disclosed. Informed consent is not shared decision‐making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision‐making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required.     

Teaching interprofessional teamwork skills to health professional students: A scoping review

An expanding body of literature is examining interprofessional teamwork and its effect in healthcare. To produce capable healthcare professionals prepared to participate in interprofessional roles, teamwork training must begin early in health professional students’ training. The focus of this scoping review was to explore interprofessional education (IPE) studies designed to teach and/or assess interprofessional teamwork skills to students from two or more different health professions, to find and describe effective pedagogy and assessment strategies. Using a scoping review methodology, 1,106 abstracts were reviewed by three teams of investigators. Eligibility criteria were inclusion of students in interprofessional teams, an intervention to improve interprofessional teamwork skills and assessment of outcomes related to teamwork. Thirty-three studies met the criteria for inclusion. The literature was varied in terms of study design, teaching methods and assessment measures for interprofessional teamwork. The lack of rigorous, comparable studies in this area makes recommending one teaching method or assessment measure over another difficult. Regardless of teaching method, it appears that most learning activities where interprofessional teams interact result in positive changes in student perceptions and attitudes towards IPE and practice. As health education programs seek to incorporate more interprofessional activities into their respective programs, it is important to review methods and measures that would best fit their individual program. This review highlights the importance of standardising the reporting of methods and outcomes for those who wish to incorporate the studied methods into their curricula.     

Psychological safety and emergency department team performance: A mixed-methods study

Objectives

Team culture underpins team performance. Psychological safety – ‘a shared belief held by members of a team that the team is safe for interpersonal risk taking’ – is a critical component of team culture for high-performing teams across contexts. However, psychological safety in ED teams has not been well explored. We aimed to explore this core teamwork concept in the ED.

Methods

This was a sequential mixed-methods study of nursing and medical staff at a large tertiary care ED in Australia from October 2020 to March 2021. First, participants completed the ‘Team Learning and Psychological Safety Survey’ and a narrative questionnaire. These findings informed semi-structured interviews. We determined median psychological safety and compared results across role and length of time working in the department. Qualitative results were analysed using a deductive thematic analysis using a previously generated framework for enablers of psychological safety at the individual, team and organisational levels.

Results

The survey was completed by 72/410 participants and 19 interviews were conducted. The median psychological safety score was 37/49 (IQR 13). Psychological safety was not experienced universally, with nurses and new staff experiencing lower levels. Individual, team and organisational factors impacted psychological safety. The primary force shaping psychological safety was familiarity with colleagues and leaders.

Conclusion

Familiarity of team members and leaders was critical to the development of psychological safety within the ED. Fostering familiarity should be a focus for frontline leadership each shift and a priority in broader departmental decisions for those seeking to enhance the psychological safety of their teams.