Patient safety research: Teamwork in the ICU

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Patient safety research Teamwork in the ICU

• Tom Reader
• School of Psychology,
• University of Aberdeen

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Introduction

• Psychology Research Fellow
• Funded by Leverhulme Trust Fellowship
• Collaborate with Professors Rhona Flin Brian
  Cuthbertson
• Co-funded by Scottish Patient Safety Research
  Network (SPSRN) grant
• Interested in patient safety, teamwork and
  leadership in the intensive care unit (ICU)

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Patient safety in the ICU

• At least 5-10 of ICU admissions have been shown
  to experience iatrogenic complications (Giraud et
  al., 1993)
• 20 of European ICU patients experience a
  critical incident (Valentin et al., 2006)
• Most ICU errors are associated with medications
  and lines
• Root-cause analyses point towards the
  non-technical factors underlying AEs (Pronovost
  et al., 20062008)

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Patient safety and human factors in the ICU

• Analysis of 10 ICU critical incident studies
  (comprising 2,677 incidents) classified 50 of
  contributory factors as related to non-technical
  skills (Reader et al., 2006)

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The relationship between teamwork and safety in
ICU

• Systematic review of ICU teamwork literature
  (Reader et al., In Press)
• 35 Empirical studies
• 8 Observational studies
• 4 Simulator studies
• 2 Interview studies
• 17 Surveys
• 4 Error Analyses
• Studies have focused on a multitude of patient
  outcomes
• Synthesis of qualitative and qualitative data

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Dimensions of teamwork influencing safety in ICU

• Team communication E.g. Information transfer on
  patient treatment plans closed-loop
  communications speaking-up behaviours
  requesting team member assistance

• Team leadership E.g. Clear delegation of
  workload and prioritisation Ensuring team
  members are comfortable with care plans
  Leadership and responsibility delegated when
  appropriate Directive leadership during crises

• Team co-ordination E.g. Awareness of one
  anothers activities Workload distribution
  according to ability Cross-checking of plans
  Core duties clearly outlined

• Team decision-making E.g. Collaboration during
  decision-making when appropriate Discuss
  decisions with team leader Reduced discussion
  during emergencies and extreme pressure

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Factors found to influence teamwork behaviours

• Team related factors Team hierarchies Team
  member roles Team communication norms
  Individual team member knowledge, experience,
  attitudes and personalities Motivation Team
  training

• Task structure Task structure Protocols for
  completing task Complexity and importance of
  task Time pressure Available resources
  Ergonomic design of work environment

• Leader characteristics Leadership style
  Technical skills and prior task experience
  Personality Delegate and prioritisation skills
  Ability to assess abilities of team member
  Resilience to stress

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(Reader et al., 2008)
Influencing factors
Team processes
Output
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Summary

• Effective multidisciplinary teamwork shown as
  vital for patient safety in ICU
• Teamwork training/assessment models developed in
  other settings, no such package for the ICU
• Aspects of teamwork such as team mental models
  and team leadership have received minimal
  investigation

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ICU teamwork research in Scotland (Reader et al.,
2008)

• Reviewed critical incident data
• Investigated perceptions of communication in ICU
• Observed communication and decision-making during
  ICU rounds
• Studied extent to which ICU team develops a
  shared understanding of patient illnesses

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Teamwork Survey (Reader et al., 2007)

• Surveyed staff at 4 Scottish ICUs on perceptions
  of teamwork
• Found Scottish ICU staff to have mainly positive
  perceptions of teamwork
• Doctors had highly positive perception of
  communication openness with nurses
• Nurses had less positive perceptions
• Communication openness important for sharing
  information on aspects of patient care

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Decision-making during ICU round (Reader et al.,
In prep)

• Observational research in an ICU during morning
  rounds
• Observed communication patterns during
  discussions on patient care
• Studied extent to which teams formed shared
  assessments of patients during the ICU round
• Nurses report uninvolvement in decision-making
• Involvement by junior team members in
  decision-making associated with teams forming a
  shared understanding of patient conditions

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ICU leadership project (2008-2010)

• Team leadership in the ICU (Fleishman Zaccaro,
  2002 Yukl, 2006)
• this can be defined as the the behaviours and
  processes that a leader enacts in order to
  continually produce a highly coordinated and
  effective team

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(Reader et al., 2008)
Influencing factors
Team processes
Output
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Research aims

• Identify the team leadership skills important for
  leading multidisciplinary teams in the ICU
• Develop a taxonomy of team leadership skills for
  training leadership skills
• Integrate findings of research into team
  performance framework

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Method

• Cognitive task analysis (Crandell et al., 2006
  Flanagan, 1954)
• This will involve interviewing ICU consultants
  (n25) and senior registrars (n15) in order to
  elicit tacit knowledge (expert knowledge that
  underpins everyday behaviour) on leadership
  behaviours on the ICU floor

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Focus of interviews

• The most effective leadership activities used for
  managing the ICU floor
• Leadership behaviours during emergency events
• The general leadership skills/style perceived to
  be important for effectively leading
  multidisciplinary teams in the ICU.

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Questions of interest

• Leadership skills required for effective team
  leadership in the ICU?
• Leadership adaptively?
• Safety leadership?
• Leadership in anaesthesia key skills?

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Current SPSRN research projects (University of
Aberdeen)

• Enhancing Non-Technical Skills in Acute Medicine
  (Prof Rhona Flin)
• Intra-operative Surgical Decision Making
  (Dr Keryn Pauley)
• Theatre Nurses' Non-Technical Skills
  (Prof Rhona Flin Lucy Mitchell)
• Adverse events in acute healthcare
  (Dr David Williams)
• Doctors Handovers in Healthcare (Michelle
  Raduma)
• Safety Climate in Scottish Hospitals (Çakil
  Saraç)
• Clinical Leadership in Surgery (Sarah Parker)

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Contact details

• tom.reader_at_abdn.ac.uk

Scottish Patient Safety Research Network website
http//www.spsrn.ac.uk/projects.php