Objective: Critical changes are needed to improve the confounding problem of patient safety from quality, moral and ethical concerns (IOM, 1999). The aviation industry’s successful teamwork model is proposed as a solution to the interdisciplinary and interpersonal conflict contributing to more than one third of health care errors. Human performance factors from social, cognitive and organizational psychology provided understandings to develop training to change attitudes about airline crew interaction and safety. Changes in attitudes changed behaviors for a new aviation culture of teamwork that improved safety (Helmreich, 1997). Phase one of a multi phase study on understanding interdisciplinary teamwork in health care answered the questions: How do health care providers describe the way people work together in a neonatal intensive care unit? What is the influence on outcomes? How do health care providers’ descriptions compare with the aviation model of teamwork behaviors?
Design: A qualitative descriptive design was used for the study.
Population, Sample, Setting: A volunteer sample of providers from a Neonatal Intensive Care Unit in a large urban teaching hospital in a major medical center of southwestern United States comprised seven focus groups (N=36). Transport nurses, staff nurses, residents, fellows, and attending physicians met according to discipline in five of the groups while two were mixed groups of the disciplines plus representatives of nursing assistants, respiratory therapists and pharmacists.
Variables: The variable of interest in the study is to understand how people work together to provide insights on teamwork behaviors to improve patient safety. The study findings were compared with the aviation model of teamwork behaviors for development of an interdisciplinary health care professional training program similar to Crew Resource Management in aviation.
Method: Researchers used a Guided Interview format with a series of open-ended questions to elicit descriptions of how providers work together. Interviews were tape recorded and transcribed for qualitative analysis. Each participant completed a Demographic Form requesting information such as age, gender, education, certification, and work experience. Analysis followed standard qualitative descriptive procedures beginning with reading and re-reading the transcripts to understand the whole and highlighting relevant data bits. Those were synthesized into patterns of data with further reflective analysis to identify descriptive elements to give clarity and meaning to the themes.
Findings: An inventory of the major themes in the way health care providers work together provided a new model of teamwork. The way people work together Depends on the Personal Characteristics of the people, Impacts Relationships, Influences and is Influenced by Workplace Factors, Affects Teamwork, Influences Outcomes, and Drives the Processes of Care. Each themes was further described by descriptive elements for added meaning. Personal characteristics of the people, their reputation, skills, knowledge, and decision making determined the level of trust and respect that emerged as people work together and influenced the way people work together by impacting relationships, both to promote effective relationships and as inhibitors including hierarchies. Relationships were influenced by and influenced Work Place Factors including nature of the work, how work was organized, communication, the working environment and how providers viewed their work. Descriptions of Teamwork contrasted views of how teams work together and limitations to teamwork. The way people work together influenced outcomes through hierarchies, complex environmental factors, system of checks and balances, potential for errors, errors, and responses to errors. The summation of the way people work together Drives Processes of Care, described in what happens in codes, admission to the NICU, adverse events, and deliveries.
Conclusions: Factors that influence relationships, either to promote relationships or to inhibit, significantly impact teamwork and have some variation among providers. To create a safer healthcare system, providers must understand teamwork as a complementary relationship of interdependence. Comparison of the teamwork related behaviors was consistent with the behaviors that provide error countermeasures in aviation: briefings, workload distribution, plans stated, contingency planning, monitor / cross check, workload management, vigilance, automation management, inquiry, assertiveness, evaluation of plans, adaptability, and conflict resolution (Helmreich & Merritt, 1998).
Implications: Continuing efforts to adapt the aviation model will enable healthcare to examine human performance factors related to work place factors, leadership, and communication among all levels of providers. Healthcare providers need explicit instruction in communication and teamwork to replace the distant and strained relationships that contribute to the problems in patient safety. The findings are the basis for new theoretical approaches to patient safety and teamwork training that will be measured in future research. The study was supported by The Agency for Healthcare Research and Quality.
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