Gender, power and leadership: the effect of a superior's gender on respiratory therapists' ability to challenge leadership during a life-threatening emergency.

BACKGROUND: Effective communication within teams is crucial, especially in crisis situations. Hierarchy gradients between team members can contribute to communication failures and are influenced by many factors. The effect of gender on team performance has not been well studied. The objective of this study was to examine the effect of the physician's gender on respiratory therapists' ability to effectively challenge clearly incorrect clinical decisions during a life-threatening crisis. METHODS: Respiratory therapists were recruited to take part in a high-fidelity simulation of can't-intubate can't-oxygenate scenarios. They were randomized into two groups, either assisting a male or a female anaesthetist in managing an airway crisis during which the anaesthetist made incorrect clinical decisions. Two independent raters scored the performances using the modified Advocacy-Inquiry Score (min 1, max 6). RESULTS: Twenty-nine subjects completed the study. The median best challenge score when the staff anaesthetist was female was 4 (3-5 IQR [2-6 range]) compared with 3 (3-3[0-3]) for challenges to a male anaesthetist (P=0.017). The median of the total challenges against a female staff member 11 (7.3-14.8 [2-18]) was significantly higher compared with 4 (3.5-7 [2-11.5]) for a male staff (P=0.006). CONCLUSIONS: The study showed a significant effect of superiors' gender on a respiratory therapist's ability to challenge leadership. A female staff anaesthetist was challenged more often and with greater assertiveness and effectiveness. This has implications for an educational intervention targeting the ability to challenge a wrong decision by a supervisor and emphasizing the effect of gender on the willingness to speak up.

Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency.

A key factor that may contribute to communication failures is status asymmetry between team members. We examined the effect of a consultant anaesthetist's interpersonal behaviour on trainees' ability to effectively challenge clearly incorrect clinical decisions. Thirty-four trainees were recruited to participate in a video-recorded scenario of an airway crisis. They were randomised to a group in which a confederate consultant anaesthetist's interpersonal behaviour was scripted to recreate either a strict/exclusive or an open/inclusive communication dynamic. The scenario allowed trainees four opportunities to challenge clearly wrong decisions. Performances were scored using the modified Advocacy-Inquiry Score. The highest median (IQR [range]) score was 3.0 (2.2-4.0 [1.0-5.0]) in the exclusive communication group, and 3.5 (3.0-4.5 [2.5-6.0]) in the inclusive communication group (p = 0.06). The study did not show a significant effect of consultant behaviour on trainees' ability to challenge their superior. It did demonstrate trainees' inability to challenge their seniors effectively, resulting in critical communication gaps.

Does warm-up using mental practice improve crisis resource management performance? A simulation study.

BACKGROUND: Mental practice (MP) is defined as the 'symbolic rehearsal of a physical activity in the absence of any gross-muscular movements' and has been used in sport and music to enhance performance. In healthcare, MP has been demonstrated to improve technical skill performance of surgical residents. However, its effect on crisis resource management (CRM) skills has yet to be determined. We aimed to investigate the effect of warm-up with MP on CRM skill performance during a simulated crisis scenario. METHODS: Following ethics board approval, 40 anaesthesia residents were randomized. The intervention group performed 20 min of MP of a script based on CRM principles. The control group received a 20 min didactic teaching session on an unrelated topic. Each subject then managed a simulated cardiac arrest. Two CRM experts rated the video recordings of each performance using the previously validated Ottawa GRS. The time to start chest compressions, administer epinephrine, and give blood was recorded. RESULTS: There was no significant difference between the intervention and control groups: total Ottawa GRS score was 24.50 (18.63-28.88 [6.50-34.50]) (median (inter-quartile range [range]) vs 20.50 (13.00-29.13 [6.50-34.50]) (P=0.53); the time to start chest compressions 146.0 s (138.0-231.0 [115.0-323.0]) vs 162.5 s (138.0-231.0 [100.0-460.0]) (P=0.27), the time to epinephrine administration 163.0 s (151.0-187.0 [111.0-337.0]) vs 187.0 s (164.0-244.0 [115.0-310.0]) (P=0.09), and the time to blood administration 220.5 s (130.8-309.0 [92.0-485.0]) vs 252.5 (174.5-398.8 [65.0-527.0]) (P=0.48). CONCLUSION: Unlike technical skills, warm-up with MP does not seem to improve CRM skills in simulated crisis scenarios.

Effect of sleep deprivation on labour epidural catheter placement.

BACKGROUND: Epidural catheter insertion for labour analgesia is an invasive procedure with potential serious complications, often performed by a sleep-deprived clinician. The aim of this study was to examine the effects of sleep deprivation on physicians of variable levels of experience performing this procedural skill in the clinical setting. METHODS: After institutional review board approval, anaesthetists of three levels of experience were recruited: novice residents (<30 epidurals, n=9), experienced residents (>100 epidurals, n=8), and attending anaesthetists (>500 epidurals, n=12). All participants were measured twice, rested and sleep deprived in a random order while performing a labour epidural for analgesia. Our primary outcome measures were scores achieved on the Imperial College Surgical Assessment Device (ICSAD) (measuring path length, number of movements, and time), task-specific checklist (CL), and global rating scale (GRS). Sleep deprivation was documented by the ActiGraph and Epworth sleepiness scale. RESULTS: Subjects were adequately sleep deprived for their sleep deprivation observation. Data were analysed with a two-way mixed design analysis of variance. No significant difference in the effect of sleep deprivation on performance was detected between the groups on the ICSAD measures of movement (P=0.86), path length (P=0.79), and time (P=0.80), or for the CL (P=0.65), and GRS (P=0.86). CONCLUSIONS: The performance of this procedural skill in a clinical setting does not seem to be affected by sleep deprivation irrespective of the level of experience.

Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial.

BACKGROUND: Retention of skills and knowledge after neonatal resuscitation courses (NRP) is known to be problematic. The use of cognitive aids is mandatory in industries such as aviation, to avoid dependence on memory when decision-making in critical situations. We aimed to prospectively investigate the effect of a cognitive aid on the performance of simulated neonatal resuscitation. METHODS: Thirty-two anaesthesia residents were recruited. The intervention group had a poster detailing the NRP algorithm and the control group did not. Video recordings of each of the performances were analysed using a previously validated checklist by a peer, an expert anaesthetist, and an expert neonatologist. RESULTS: The median (IQR) checklist score in the control group [18.2 (15.0-20.5)] was not significantly different from that in the intervention group [20.3 (18.3-21.3)] (P=0.08). When evaluated by the neonatologist, none of the subjects correctly performed all life-saving interventions necessary to pass the checklist. A minority of the intervention group used the cognitive aid frequently. CONCLUSIONS: Retention of skills after NRP training is poor. The infrequent use of the cognitive aid may be the reason that it did not improve performance. Further research is required to investigate whether cognitive aids can be useful if their use is incorporated into the NRP training.