Safer Surgery part 17 potx

In order to further elucidate the individual team members’ contribution to the collaborative teamwork and the interpersonal interaction between team members, we need an observational beh

attributes and characteristics associated with leaders are requisites of followers as well, referred to as good leadership or as good followership Van Vugt (2006), who evaluated vast psychological literature on leadership as a database to test several evolutionary hypotheses about the leadership and followership in humans, found that leadership correlates well with initiative taking, trait measures of intelligence, specific task competencies, and several indicators of generosity, but he found no link between leadership and dominance Burke and co-workers (2006, p 302), who conducted a meta-analysis to examine the relationship between leadership behaviour

in teams and behaviourally based team performance outcomes found that:

Surprisingly, the results of the current literature review indicate the preponderance

of empirical research conducted to date to examine team leadership has largely been grounded in traditional leadership theory In other words, researchers are just transporting traditional theories of leadership to team settings This is

a concern because classical leadership theories have often been criticized for failing to fully appreciate and model the dynamism and complexities of team leadership (Kozlowski and Bell, 2002, Salas, Stagl and Burke, 2004, Ziegert 2004) In fact, most existing leadership theories are advanced as if ‘leader– follower relationships exist in a vacuum’ (House and Aditya 1997, p 445)

As current leadership theory and research predominantly refers to leader style, Avolio (2007) argues that future work needs to consider the dynamic interplay between leaders and followers Presumptions about leadership and followership – such as leaders are more important than followers, followers are only doing what they are told, followers get their energy and aims from the leader – should be challenged also in theory and research regarding medical teams

Our general working hypothesis is that all team members are important for successful goal achievement and that the roles and interaction between sub-teams, professions, specialities, leader and followers have to be further explored in relation to patient outcome Our specific working hypothesis is that training effectiveness will be better when these roles and interactions are identified for each sub-team, profession, speciality, leader and follower and used as targets in team training In order to further elucidate the individual team members’ contribution to the collaborative teamwork and the interpersonal interaction between team members, we need an observational behaviour instrument that allows for rating all team members’ team skills

Leadership and Followership; Attitudes in Teamwork

We consider leadership/followership, to be a significant element of teamwork,

in two aspects: attitudes and behaviours Dickinson and McIntyre (1997, p 25) explain team leadership:

Involves providing direction, structure, and support for other team members

It does not necessarily refer to a single individual with formal authority over

others Team leadership can be shown by several team members: explains to other team members exactly what is needed from them during assignment, listens to the concerns of other team member.

Thomas et al (2004, p 160) comment, regarding observation of neonatal resuscitation, that:

Leadership activities may include sharing of a mental model, assigning tasks, and sharing of information and opinion This may be rated for any provider at the resuscitation There is usually not a clear leader (either in deed or word),

so the observability rating is often 0 Lack of leadership was not obviously detrimental to the process of care.

Thus in a successful team, all team members, not only the formal leader but also the followers, embrace positive team attitudes such as team orientation, conflict efficacy, shared vision, team cohesion, interpersonal relations, mutual trust, task-specific teamwork attitudes, collective orientation and importance of teamwork Such leadership or followership attitudes facilitate a culture of non-negotiable mutual respect and trust so that effective teamwork can flourish

Leader Behaviour and Follower Behaviour

The reasoning regarding leader and follower attitudes does not apply to the issue

of leader behaviour and follower behaviour In contrast to attitudes, if several members of a team simultaneously apply some of the identified ‘leadership‘ behaviours, there is an obvious risk of confusion and conflict in the team, which jeopardizes team structure and process A leader is recognized by his/her leader behaviour which might include taking the initiative to prompt discussions, making decisions, verbalizing plans and having the ‘last word’ A situation when a follower simultaneously behaves in that manner, or shows other leader behaviours, will confuse other members as to who is the leader Tension arises and a prestige conflict between team members might result which undermines, rather than enhances, the leader’s position, and demoralizes the team Obviously, regarding certain behavioural elements there is a reciprocal relationship between leader behaviour and follower behaviour Another recognized behavioural element, such

as good communication, is identical for all team members In agreement with Thomas et al (2004), we seek behavioural markers that allow the rating of any team member’s team skills, whether as leader or as follower, or just as a good team member Accordingly, in agreement with Murray and Foster (2000) and Ostergaard et al (2004), we advocate using specified leader behaviours, follower behaviours and member behaviours as targets for team training to emphasize the complementary behaviours and to facilitate individual feedback to each individual team member

Behaviour markers for healthcare, many of them based on crew resource management (CRM) used in aviation (Gaba et al 1994, Flin et al 2003, Helmreich

et al 1999) and adapted to medical settings, such as ACRM (Anesthesia Crisis Resource Management; Howard et al 1992), Revised teamwork behaviour matrix (Small et al 1999), Team Dimensions Rating Form (Morey et al 2002), OTAS (Observational Teamwork Assessment for Surgery; Carthey et al 2003, Healey

et al 2004), ANTS (Anaesthetists’ Non-technical Skills; Fletcher et al 2003, Flin et al 2004a), EMCRM (Emergency Medicine Crisis Resource Management Behavioural Performance Evaluation; Reznek et al 2003, Wallin et al 2007), CARMA (Crisis Avoidance Resource Management for Anaesthetists; Flin et al 2004b), BARS (Behaviourally Anchored Rating Scales; Shapiro et al 2004), NOTSS (Surgeons’ Non-Technical skills in the operating theatre; Flin et al 2006, Yule et al 2008), Ottawa GRS (Ottawa Crisis Resource Management Global Rating Scale; Kim et al 2006), CATS (Communication and Teamwork Skills; Frankel et al 2007), are focused on the team leader alone (i.e., the anaesthetist

or the surgeon) and/or the team (e.g., the crew) Only the instrument designed

by Thomas et al (2004) – University of Texas behavioural markers for neonatal resuscitation (UTBMNR) – is explicitly constructed for summative assessment of any team member’s team skills

In summary, we need a behaviour-based assessment instrument suitable for gauging all team members’ teamwork skills on an individual basis that is widely applicable and reflects good practice across the healthcare professions, disciplines and medical environments, and that can be used as target for training, formative assessment for feedback and for summative evaluation of training

Description of the A-TeAM Scale

Development of the A-TEAM Scale

We used the decision loop (Figure 9.1) as a template for four behavioural categories:

‘Gathers information and communicates’, ‘Contributes to shared understanding’,

‘Makes collaborative decisions’, ‘Coordinates and executes tasks’, and added a fifth category, ‘Takes a team member role’, which has three subcategories: ‘All members’ behaviour’, ‘Leader behaviour’ and ‘Follower behaviour’ From our experience these categories are easy for trainees to comprehend We scanned the literature and sampled verbally defined behavioural elements from other scales and CRM programmes as generic behaviours of effective collaboration (Burke

et al 2004, Carthey et al 2003, Dickinson and McIntyre 1997, Fletcher et al

2003, Flin et al 2004a, Flin and Maran 2004, Flin et al 2006, Frankel et al 2007, Healey et al 2004, Howard et al 1992, Kim et al 2006, Moorthy et al 2006, Morey et al 2002, Morgan et al 2007, Murray and Foster 2000, Ostergaard et

al 2004, Ottestad et al 2007, Reznek et al 2003, Shapiro et al 2004, Small et

al 1999, Thomas et al 2004, Wallin et al 2007, Undre et al 2007) We selected

behavioural elements meeting two criteria: a trainee should, voluntarily, be able to display the behaviour at work, and the behaviour should be observable for trainees Behavioural elements related to the four categories – ‘Gathers information and communicates’, ‘Contributes to shared understanding’, ‘Makes collaborative decisions’, ‘Coordinates and executes tasks’ – were sorted to respective categories

In order to sort behavioural elements into the leader, follower and member sub-categories, we used our clinical experience of working in anaesthesia, intensive care and emergency medicine, and experience from acting as ‘consultant on call’

in hundreds of simulator scenarios with younger medical colleagues and nurses The intention was that a senior consultant would stay in a follower position to give

a second opinion and support to a younger, less experienced colleague Behaviours

by the consultant that immediately would dislodge this balance were categorized

as leader behaviour Examples of these behaviours were taking initiative to provide briefings, decision-making, confirming and verbalizing plans, and ‘having the last word’ Behaviours that stabilized the relationship, yet allowed use of all expertise available, were categorized as follower behaviours These behaviours were such

as giving the junior colleague suggestions to take initiative for briefings and decision-making, suggesting that he/she verbalize plans and let him/her ‘have the last word’ in order to support him/her as leader The vast majority of behaviours sampled were both leader and follower behaviours and as such categorized as team member behaviours

For each category, we condensed the vast number of sampled behavioural elements so that the sum of them would be limited and not tax the observer’s, trainee’s or trainer’s, limited working memory, and hence easy to use as target for training, formative assessment and feedback

Using A-TEAM as Target for Training, Formative Assessment and Feedback

The A-TEAM form should be presented and discussed with trainees and demonstrated by trainers before practice During practice, non-active trainees can observe and grade active participants using an A-TEAM protocol, which enhances learning All elements are directly observable; the text is short and in simple language During feedback, trainers have the opportunity to further elucidate behaviour issues related to coordination using A-TEAM During training, observers and trainers use the following four grades for classifying team member behaviours:

Poor: Behaviour that intentionally counteracts desirable team behaviour.

In need of considerable improvement: Behaviour that neither counteracts

nor fully contributes to desirable team behaviour

Good: Behaviour that really helps in solving the task and strives towards

desirable team behaviour, but is not excellent

Proficient: Proficient behaviour, role model.

•

•

•

•

The result of the development process is presented in Table 9.1 There are five main categories of behaviours, and the first, ‘Takes a membership role’, is divided into three subcategories Each category and subcategory is defined separately Examples of behavioural elements representative for each category are given for four grades in columns, read from left to right with increasing proficiency The grades ‘Good’ and ‘Proficient’ are used as targets for training, while all grades are used for feedback and assessment of training outcome

During debriefing, advantages and disadvantages of using leader and follower behaviours can be discussed in relation to conflicts and outcome for the (simulated) patient Future research may elucidate in which situations leader behaviour, follower behaviour and member behaviour are of particular importance for patient outcome and integrated in training

Using A-TEAM for Summative Assessment

All elements to be assessed for each category are directly observable, so no further assumptions/interpretations have to be made by the observers Active verbs are used for describing observable behaviours Global rating of an individual’s team skills and/or global rating of the complete team performance can also be registered

if needed

Scoring Method in Summative Assessment

For feedback during training, it is easier to ‘pinpoint’ the most important behaviours observed using four grades However, for evaluation of training and for research purposes, it is statistically correct to handle these ordinal data as binary data All raw data are converged into the following two stages:

0 = Poor and in need of considerable improvement

1 = Good and proficient

In summary, the A-TEAM instrument is designed for both training and research purposes All team members are scored in terms of the occurrence and quality of certain behaviours Hence, it will assist team performance assessment

in a variety of real and simulated clinical events and can be used in the study of the relationship between the teamwork process and teamwork outcome, as well as for feedback during training of instructors and trainees People with quite different educational backgrounds should be able to use the scale Lipshitz (2005, p 370) argued that pure factual reports: ‘without interpretation are either impossible or not meaningful’

Human beings do not simply perceive, but elaborate and interpret information and reflect upon it (cognition) and so the observer is an interpreter of raw data

By using video recordings, good observational data can be obtained and the observer takes advantage of the serendipity Discrepant observations are not

Table 9.1 The A-TeAM scale for assessment of individual team

behaviour

1 Takes a team member role

All members’ behaviour

A team member participates actively in all relevant aspects of teamwork and task work, observes other team members’ performance and activities, and provides and accepts feedback and

assistance

Does not give or

welcome any support.

Does not

acknowledge other

members.

Work on his/her own.

Does not give or take

advice gracefully.

Support others only

if challenged, not spontaneously.

Supports in a reluctant way.

Supports others, e.g.,

by helping when obviously needed.

Accepts and gives support directly Acknowledges and involves others frequently.

Asks quickly for help when needed.

Protests clearly against inaccuracies Leader behaviour

A team leader takes initiative to provide structure and direct team- and task work.

Does not identify

himself/herself as

person in charge of

the situation.

Makes no final

decisions.

Tries to ‘do it all’.

Does not take

initiatives.

Tries to make decisions and give orders but very unclear and vague.

Takes initiative, but not in time when needed.

Makes decisions, but not clear enough.

Gives orders, but not directed.

Makes final decisions Gives clear orders Takes initiatives to e.g., short briefings; confirms and verbalizes decisions Accepts a non-leading role when appropriate.

Follower behaviour

A team follower supports the leader’s initiatives, and assumes assigned responsibilities and directives.

Challenges the leader

in an obstructive way.

Stands back, takes a

‘hands-off approach’.

Demonstratively does

not participate in

briefings.

Performs task duties, but only on demand

Does not support the leader verbally or in other ways.

Supports the leader both verbally and in other ways Takes a

‘hands-on approach’.

Supports the leader Takes a ‘hands on’ approach.

Challenges constructively Requests and participates actively

in briefings.

Takes over leadership

if required.

2 gathers information and communicates

All team members actively gather and exchange information.

Poor In need of

improvement Good Proficient Does not

communicate at all.

Masters through oral

or body language.

Engages in

unnecessary

conversation.

Makes inappropriate

comments.

Communicates vaguely, quietly or continuously without pause.

Communicates in round terms, but not aimed at a team member.

Does not give feedback.

Communicates in round terms Uses closed-loop communication Uses SBAR format for briefings Calls out critical information during emergent events Makes good eye contact.

Uses team members’ names.

3 Contributes to a shared understanding of the situation

In collaboration, all team members develop and maintain a common understanding of the situation, and have team situational awareness.

Poor In need of

improvement Good Proficient Does not share any

information.

Demonstratively

does not contribute.

Reports findings unclearly.

Gets distracted by non-essentials.

Acts independently

on symptoms without confirming with others

Reports findings (positive and negative) in a clear and concise way.

Does not try to explain things

to others when obviously needed to.

Interprets information in a timely manner Shares information and explains core events, thus making them understandable

to the whole team

4 Makes collaborative decisions

In collaboration, all team members consider options, resources and risks to be able to take decisions.

Poor In need of

improvement Good Proficient Defies any attempts

to decision and

does not state an

alternative.

Demonstratively

does not take part

Makes decision right away without discussing alternatives with the team though time and opportunity exists.

Contributes with ideas, but does not state any own opinion.

Re-evaluates, discusses and takes other alternatives in consideration with other team members before reaching a conclusion Actively drives the decision process forward

Table 9.1 Continued

always unreliable observations reducing the validity and reliability of findings, but could be signs of originality and perceptiveness of the observer As in most true discoveries, the observer can shift his/her focus from originally defined data collection to also include observation of new phenomena Since the locus of exploratory observational studies is on discovery, several techniques should be used to broaden the set of observations and maximize the observers’ opportunity for uncovering interesting data Roth and Patterson (2005, p 382) have exemplified some good techniques: (i) broadly sampling domain practice (e.g., multiple trainees at several different levels of experience, many test sites), (ii) using multiple converging techniques (e.g., field observations, interviews, questionnaires), and (iii) using several observers (who bring different conceptual frameworks for observation and interpretation)

In future studies, A-TEAM could also be used in exploratory observational studies as contrasted with studies designed to test specific research hypotheses on human decision-making in complex medical domains

Application in the Operating Theatre

Optimal surgical performance includes both technical and non-technical aspects Regarding the latter, the equal importance of leadership and followership challenges the current dogma with respect to leadership We outline a new hypothesis regarding the teamwork process in the operating theatre and identify the equal importance of leadership and followership, as well as the ability to engage in reciprocal rotation of these functions depending on the situation There

5 Coordinates and executes tasks

A team member coordinates his/her tasks in a timely and integrated manner with other team members’ activities, facilitating the performance of other members’ jobs.

Poor In need of

improvement Good Proficient Does not coordinate

at all.

Acts on his/her own.

Stops others.

Carries out

inappropriate courses

of action.

Does not adhere to

guidelines.

Obstructs but does not stop.

Does not change plans despite new information.

Coordinates, but not for the whole team.

Keep things progressing, but not in a clear and efficient way.

Coordinates his/her activities with others.

Adapts to any changes in the present situation Prioritizes tasks Tells others of plan for further care Adheres to guidelines.

Table 9.1 Concluded

is a clear need for more awareness of these metacognitive aspects in the surgical community Patient safety on the agenda facilitates this evolution

The A-TEAM instrument could be applicable in many different surgical challenges from simple surgical procedures to demanding and complex tasks such

as liver transplantation, cardiothoracic surgery and spinal surgery where system failure is deleterious The results should also be coupled to traditional performance variables and patient outcome Regarding inability or failure of followership in the operating room (OR), Lingard et al (2004a), for example, observed a failure in 30 per cent of communication events during surgical procedures Of these failures,

36 per cent had observable consequences such as delay, tension among team members or procedural error These results are supported by another observational study (Wiegmann et al 2007) focusing on the effects of disruptions of the surgical process (e.g., communication failures, equipment problems) Their study found that surgical errors increased significantly with increased disruptions and that teamwork and communication problems were the strongest predictors of surgical errors Communication is a very important causal factor in errors made in surgery (Gawande et al 2003) An observational study in paediatric cardiac and orthopaedic surgery found that effective teamwork was associated with fewer minor problems per operation (i.e., negative events that were seemingly innocuous but many of which contributed to major problems), higher intra-operative performance (i.e., fewer key operating tasks were disrupted) and shorter operating times (Catchpole

et al 2007)

Achievement of medical goals and patient safety are the main objectives for teamwork in medicine In the operating theatre patient outcome can be quantified

in mortality, morbidity, time to recovery, absence of iatrogenic injury i.e., a technically successful surgical procedure, time of low oxygen saturation etc The team’s task work gives information whether the team has executed procedures, algorithms and routines as planned and expected Task work can be related to patient outcome to provide information whether team performance is effective The individual, interpersonal teamwork behaviour gives information on how

a team member contributes to coordination of task work and to internal team structure and process Assessment of team skills is necessary for feedback during training and as such a formative assessment

The aggregate of all team members’ behaviour gives information on the teams’ internal effectiveness and can be related to task execution (Lingard et al 2004a, Catchpole et al 2007, Ottestad et al 2007) and to patient outcome (Catchpole et

al 2007, Wiegmann et al 2007) Further analysis of the individual, interpersonal teamwork behaviour can provide information whether a certain subteam of members, such as surgical (Moorthy et al 2005, Undre et al 2007), anaesthetic (Undre et al 2007), nursing (Undre et al 2007), leader or followers, or a specific leadership style (Cooper and Wakelam 1999, Entin and Serfaty 1999, Klein et

al 2006, Marsch et al 2005, Tschan et al 2006), have favourable impact on task execution and patient outcome Although team performance is a collective effort, there is lack of information on the impact of the quality of followers’ behaviour

on teamwork, team performance and patient outcome Observational studies of teamwork have identified patterns of communication, coordination and leadership that support effective teamwork However, only a few studies could establish a direct link between specific teamwork behaviours and clinical performance or patient outcome

Communication Patterns Supporting Effective Teamwork

Among the most prominent themes in communication research in healthcare are the effects of interruptions and tensions on effective team functioning For example, ethnographic studies showed that tensions in team communications in the operating room often evolve around the issues of time, safety and sterility, resources and work roles (Lingard et al 2002 and 2004b) In medicine, CRM and simulation traditionally emerged within anaesthesia and intensive care Human reliability from a team perspective is the focus Within the different fields

of surgical intervention, until recently, simulation was most commonly focused

on technical skills i.e., manual dexterity of the operating surgeon High fidelity and full procedural simulation in image guided surgery have clearly emerged

as contemporary state-of-the-art training tools which are being embedded into curricula and as part of certification procedures in surgical education and training Since metrics are inherent in image guided surgical simulators, the trainee gets evidence-based feedback and learning curves as well as proficiency gains can easily be monitored Extensive validation studies are convincing and demonstrate transfer of skills acquired in surgical simulators to real surgery performed on patients (Ahlberg et al 2007, Seymour et al 2002, Grantcharov et al 2004) Factors underpinning technical performance such as visual spatial abilities, working memory and computer game experience have also been demonstrated (Enochsson et al 2004, Hedman et al 2006 and 2007, Kolga Schlickum et al 2008) However, several initiatives now also focus on non-technical OR skills of surgeons and the whole surgical team (e.g., Moorthy et al 2006) This evolution transforms simulation towards systems orientation and points out that the result

of surgery is neither related to patient pathophysiology nor the surgeons’ technical skills alone but rather to the competence of the whole perioperative team

Traditionally, the OR team consists of the surgeons (attending staff and residents), the scrub nurse, the anaesthetist, the anaesthesia nurse and nurse assistants As in all high hazard fields, it is clear and evident that communication skills are crucial for outcome Increasing clinical complexity requires a reciprocal increase in communication skills not only within professions and disciplines, but also across professional culture barriers A multidisciplinary and transprofessional approach is needed As in other high risk industries, surgery requires a minimum amount of system redundancy One major challenge is the unpredictable nature

of surgery and the ability of the whole team to be able to shift from working

in a routine mode to a state of emergency accommodating rapid and efficient