Communication and Teamwork in Patient Care: How Much Can We Learn From Aviation?

doi:10.1111/j.1552-6909.2006.00074.x

Journal of Obstetric, Gynecologic & Neonatal Nursing

Volume 35, Issue 4, July–August 2006, Pages 538-546

https://doi.org/10.1111/j.1552-6909.2006.00074.x Get rights and content

Objective

To identify evidence on the role of assertiveness and teamwork and the application of aviation industry techniques to improve patient safety for inpatient obstetric care.

Data sources

Studies limited to research with humans in English language retrieved from CINAHL, PubMed, Social Science Abstracts, and Social Sciences Citation Index, and references from reviewed articles.

Study selection

A total of 13 studies were reviewed, including 5 studies of teamwork, communication, and safety attitudes in aviation; 2 studies comparing these factors in aviation and health care; and 6 studies of assertive behavior and decision making by nurses. Studies lacking methodological rigor or focusing on medication errors and deviant behavior were excluded.

Data synthesis

Pilot attitudes regarding interpersonal interaction on the flight deck predicted effective performance and were amenable to behavior‐based training to improve team performance. Nursing knowledge was inconsistently accessed in decision making. Findings regarding nurse assertiveness were mixed.

Conclusions

Adaptation of training concepts and safety methods from other fields will have limited impact on perinatal safety without an examination of the contextual experiences of nurses and other health care providers in working to prevent patient harm.

Section snippets

The problem: What is known about the presence and effects of assertiveness in teams?

Theories of organizational safety have been applied to health care environments (Gaba, 2000). Normal accident theory (NAT) focuses on the complexity and “tight coupling” of system components as sources of accidents. From a NAT perspective, accidents are inevitable because the root causes of accidents can be traced to latent properties of the organizational system which, when triggered, result in a cascade of events which is not always caught by the system's technical or procedural defenses; and

Review of the literature

A literature search was conducted of PubMed, CINAHL, Social Science Abstracts, and the Social Sciences Citation Index. The search was limited to English language and human studies using the terms “patient safety,”“medical error,”“interprofessional relations,”“physician‐nurse relationships,”“communication,”“safety,”“obstetrics,”“assertion,” and “adverse events,”“teamwork climate,”“teamwork and medicine,”“medical error and team communication,”“human factors,” and “situation awareness.” Titles and

Human factors in aviation safety

Much of the interest in communication in health care has been generated through application of concepts from the aviation industry safety model of crew resource management (CRM) to the health care setting. The CRM movement grew out of recognition that human (rather than weather or equipment) factors were responsible for the majority of accidents and incidents in aviation (Helmreich, 2000). Aviation psychology researchers demonstrated that pilots’ attitudes affected performance and were amenable

State of the science & directions for research

When viewed together, high reliability, normal accident, and human factors theories indicate that errors will continue to occur in the provision of medical care, and a single‐minded focus on “system” level functions for preventing error may actually increase the potential for harm to occur (Knox, 2003, Rochlin, 1999, Weick, 2002), suggesting the need to improve medical teamwork and communication as a key strategy for preventing patient harm.

There is good evidence from the aviation industry that

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Much policy focus has been afforded to the role of “whistleblowers” in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 h of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), we studied how personnel gave voice to concerns about patient safety or poor practice. We observed much low-level social control occurring as part of day-to-day functioning on the wards, with challenges and sanctions routinely used in an effort to prevent or address mistakes and norm violations. Pre-emptions were used to intervene when patients were at immediate risk, and included strategies such as gentle reminders, use of humour, and sharp words. Corrective interventions included education and evidence-based arguments, while sanctions that were applied when it appeared that a breach of safety had occurred included “quiet words”, bantering, public exposure or humiliation, scoldings and brutal reprimands. These forms of social control generally functioned effectively to maintain safe practice. But they were not consistently effective, and sometimes risked reinforcing norms and idiosyncratic behaviours that were not necessarily aligned with goals of patient safety and high-quality healthcare. Further, making challenges across professional boundaries or hierarchies was sometimes problematic. Our findings suggest that an emphasis on formal reporting or communication training as the solution to giving voice to safety concerns is simplistic; a more sophisticated understanding of social control is needed.
Team training for safer birth
2015, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
However, the same methods have failed to result in improvements in teamwork on labour wards [2]. In order to achieve better outcomes for mothers and babies, it is essential that team-training interventions are simple and relevant to the maternity care setting [78,79]. Therefore, research has focussed on the development of training tools that are specific and applicable to obstetric emergencies, typically involving ‘skills and drills’ training.
Effective and coordinated teamworking is key to achieving safe birth for mothers and babies. Confidential enquiries have repeatedly identified deficiencies in teamwork as factors contributing to poor maternal and neonatal outcomes. The ingredients of a successful multi-professional team are varied, but research has identified some fundamental teamwork behaviours, with good communication, proficient leadership and situational awareness at the heart. Simple, evidence-based methods in teamwork training can be seamlessly integrated into a core, mandatory obstetric emergency training. Training should be an enjoyable, inclusive and beneficial experience for members of staff. Training in teamwork can lead to improved clinical outcomes and better birth experience for women.
Perceptions of time spent on safety tasks in surgical operations: A focus group study
2014, Safety Science
The drive for effectiveness and productivity in health care combined with a high percentage of adverse events in hospitals occurring in the operating room, suggest that more knowledge about safety in surgery is warranted. As a step in this direction, explorations of safety in surgical operations should account for the unique operational perspective of health care providers. In this article, we explore one particular safety aspect of surgical operations: frontline personnel’s perceptions of operating room time, both in itself and in relation to the WHO’s Surgical Safety Checklist. Specifically, we provide results from a focus group study undertaken in a surgical section of a Norwegian university hospital. The study included a total of 14 participants from the professions that typically comprise an operating team; surgeons, nurses, and anesthetists. Based on a content analysis of the collected material, we believe that strengthening both the structural conditions surrounding surgery and the safety mentality of managers and operating personnel can prevent compromises in safety tasks and instead allow priority to planning, diagnosis and checklists, with associated potential for improvement in awareness, preparedness, and systemizing as well as reduction in total operating room time. This might represent a key factor in improving patient safety in surgical operations. We also identify a need for deeper explorations that shed further light on the complexity of the operating room time phenomenon.
Planning a Collaborative Conference to Provide Interdisciplinary Education With a Focus on Patient Safety in Obstetrics
2014, Nursing for Women's Health
Collaboration is an important component of evidence‐based practice in modern health care. A number of publications have touted the benefits of “team training” to improve obstetric outcomes during emergent situations. In August 2011, the Ohio sections of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the American Congress of Obstetricians and Gynecologists (ACOG) held a joint conference that focused on interdisciplinary education to promote patient safety. This joint venture drew more than 120 attendees, 12 exhibitors and 17 poster displays. Evaluations were positive and attendees cited planned practice changes for themselves as well as for their respective institutions.
"Attention on the flight deck": What ambulatory care providers can learn from pilots about complex coordinated actions
2013, Patient Education and Counseling
Citation Excerpt :
There is a rich literature that explores adopting aviation constructs to make medical practice safer and more effective. For example, in a review of the application of aviation industry techniques to improve patient safety for inpatient obstetric care [6], the authors noted that, whereas pilot attitudes regarding interpersonal interaction on the flight deck predicted effective performance and were amenable to behavior-based training to improve team performance, their adoption in healthcare, including Crew Resource Management Training [7–10], are unlikely to have an impact on safety without including the experiences of nurses and other health care professionals who provide care [6]. Others have concluded that team training and adoption of standardized processes and behaviors that are effective in improving operational performance in aviation and can potentially have a similar benefit in healthcare [11,12].
Technical and interpersonal challenges of using electronic health records (EHRs) in ambulatory care persist. We use cockpit communication as an example of highly coordinated complex activity during flight and compare it with providers’ communication when computers are used in the exam room.
Maximum variation sampling was used to identify two videotapes from a parent study of primary care physicians’ exam room computer demonstrating the greatest variation. We then produced and analyzed visualizations of the time providers spent looking at the computer and looking at the patient.
Unlike the cockpit which is engineered to optimize joint attention on complex coordinated activities, we found polar extremes in the use of joint focus of attention to manage the medical encounter.
We conclude that there is a great deal of room for improving the balance of interpersonal and technical attention that occurs in routine ambulatory visits in which computers are present in the exam room.
Using well-known aviation practices can help primary care providers become more aware of the opportunities and challenges for enhancing the physician patient relationship in an era of exam room computing.
Reducing risk in maternity by optimising teamwork and leadership: An evidence-based approach to save mothers and babies
2013, Best Practice and Research: Clinical Obstetrics and Gynaecology
Poor teamwork results in preventable morbidity and mortality for mothers and babies. Suboptimal communication and lack of leadership cost not only lives but also money that is diverted from clinical care to insurance and litigation. Avoidable harm is usually not the result of staff failing their duty of care, it is the result of poor training failing hard-worked staff. A few simple teamwork and leadership behaviours can make a huge difference to outcome and experience for women and their companions, yet they are often missing from maternity care. Recent research has identified the problems and solutions, including the best way to train maternity teams to make a palpable difference. We describe simple yet evidence-based methods to improve teams and leaders.

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View full text

Clinical IssuesCommunication and Teamwork in Patient Care: How Much Can We Learn From Aviation?

Objective

Data sources

Study selection

Data synthesis

Conclusions

Section snippets

The problem: What is known about the presence and effects of assertiveness in teams?

Review of the literature

Human factors in aviation safety

State of the science & directions for research

Annals of Thoracic Surgery

Journal of Professional Nursing

Journal of Perianesthesia Nursing

Journal of Obstetric, Gynecologic, and Neonatal Nursing

International Journal of Nursing Studies

Current Anaesthesia Critical Care

Lifelines

Analyzing communication sequences for team training needs assessment

Human Factors

The clinical landscape of critical care: Nurses’ decision‐making

Journal of Advanced Nursing

Time as a catalyst for tension in nurse‐surgeon communication

Association of Operating Room Nurses Journal

Structural and organizational issues in patient safety: A comparison of health care to other high‐hazard industries

California Management Review

Difference in safety climate between hospital personnel and naval aviators

Human Factors

An investigation into the assertive behaviour of trained nurses in general hospital settings

Journal of Advanced Nursing

The complexity of team training: What we have learned from aviation and its applications to medicine

Quality and Safety in Health Care

On error management: Lessons from aviation

British Medical Journal

Why crew resource management? Empirical and theoretical bases of human factors training in aviation

Cockpit resource management: Exploring the attitude‐performance linkage

Aviation, Space, and Environmental Medicine

The evolution of crew resource management training in commercial aviation

International Journal of Aviation Psychology

Collaboration: A concept analysis

Journal of Advanced Nursing

To err is human

Crossing the quality chasm: A new health system for the 21st century

Keeping patients safe: Transforming the work environment of nurses

Who is flying this plane anyway? What mishaps tell us about crew member role assignment and air crew situation awareness

Human Factors

Clinical Issues
Communication and Teamwork in Patient Care: How Much Can We Learn From Aviation?