Are we at risk of groupthink in our approach to teamwork interventions in health care?

CONTEXT: The incidence of medical error, adverse clinical events and poor quality health care is unacceptably high and there are data to suggest that poor coordination of care, or teamwork, contributes to adverse outcomes. So, can we assume that increased collaboration in multidisciplinary teams improves performance and health care outcomes for patients? METHODS: In this essay, the authors discuss some reasons why we should not presume that collective decision making leads to better decisions and collaborative care results in better health care outcomes. RESULTS: Despite an exponential increase in interventions designed to improve teamwork and interprofessional education (IPE), we are still lacking good quality data on whether these interventions improve important outcomes. There are reasons why some of the components of 'effective teamwork', such as shared mental models, team orientation and mutual trust, could impair delivery of health care. For example, prior studies have found that brainstorming results in fewer ideas rather than more, and hinders rather than helps productivity. There are several possible explanations for this effect, including 'social loafing' and cognitive overload. Similarly, attributes that improve cohesion within groups, such as team orientation and mutual trust, may increase the risk of 'groupthink' and group conformity bias, which may lead to poorer decisions. CONCLUSIONS: In reality, teamwork and IPE are not inherently good, bad or neutral; instead, as with any intervention, their effect is modified by the persons involved, the situation and the interaction between persons and situation. Thus, rather than assume better outcomes with teamwork and IPE interventions, as clinicians and educators we must demonstrate that our interventions improve the delivery of health care.

Impact of peer pressure on accuracy of reporting vital signs: An interprofessional comparison between nursing and medical students.

The hierarchical relationship between nursing and medicine has long been known, yet its direct influence on procedural tasks has yet to be considered. Drawing on the theory of conformity from social psychology, we suggest that nursing students are likely to report incorrect information in response to subtle social pressures imposed by medical students. Second-year medical and third-year nursing students took vital signs readings from a patient simulator. In a simulation exercise, three actors, posing as medical students, and one nursing student participant all took a total of three rounds of vital signs on a high-fidelity patient simulator. In the first two rounds the three actors individually stated the same correct vital signs values, and on the third round the three actors individually stated the same incorrect vital sign values. This same procedure was repeated with actors posing as nursing students, and one medical student. A two-way analysis of variance (ANOVA) revealed that nursing student participants (M = 2.84; SD = 1.24) reported a higher number of incorrect vital signs than did medical student participants (M = 2.13; SD = 1.07), F (1,100) = 5.51, p = 0.021 (Cohen's d = 0.61). The study indicated that social pressure may prevent nursing students from questioning incorrect information within interprofessional environments, potentially affecting quality of care.

The good and bad of group conformity: a call for a new programme of research in medical education.

CONTEXT: Given that a significant portion of medical education occurs in various social settings (small groups, large classes, clinical environments), it is critical to examine how group members interact. One type of influence on these interactions is conformity, whereby an individual changes his or her own behaviour to match incorrect responses of others in a group. Conformity to peer pressure has been replicated in experimental research conducted in many countries over the last 60 years. There is newly emerging empirical evidence of this effect in medical education, suggesting that subtle motivations and pressures within a group may prevent students from challenging or questioning information that seems incorrect. OBJECTIVES: This narrative review aims to present an overview of theory and findings in research into conformity in the fields of social psychology, business, sociology and aviation theory to demonstrate its direct relevance to medical education and the health professions. METHODS: We searched online databases (MEDLINE, PubMed, PsycINFO and ProQuest) from the University of Calgary catalogue. We also searched citations in articles reviewed and references provided by colleagues. We limited our narrative review to publications released between 1950 and 2012. RESULTS: Group conformity behaviour may be one of a number of communication challenges associated with interprofessional care, and may represent a factor contributing to the burden of adverse events. This paper calls for a new programme of research into conformity in medical education that provides systematic empirical evidence of its relevance and applications in education, health care and practice. CONCLUSIONS: This review reveals decades of anecdotal and empirical evidence that conformity is a pervasive phenomenon across disciplines. Further research is needed to elucidate which situations pose the greatest risk for the occurrence of conformity, how to manage it in practice and its implications for patient safety.

Twelve tips to guide effective participant recruitment for interprofessional education research.

BACKGROUND: The success of research in interprofessional education is largely due to the participation of students. Their recruitment is, however, perhaps the most challenging part of any study, and, yet, is a key determinant of the results. AIM: The aim of this article is to provide a "how to guide" for medical education researchers to facilitate the recruitment of students across health professions. RESULTS: The 12 tips are (1) establish clear expectations with your research team from the start; (2) do your homework: invest time and energy in pre-recruitment preparation; (3) develop a plan: be realistic about your resources; (4) create a "Buzz" about your interprofessional research; (5) prepare multiple communication methods - can't just rely on one! (6) engage volunteers across professions to participate; (7) address the participant's willingness to take part in the research; (8) demonstrate good interpersonal skills; (9) be diligent in tracking participants; (10) show appreciation and share results; (11) consider participant incentives: are they really important? (12) maintain tenacity - no one said interprofessional recruitment was easy! CONCLUSIONS: Interprofessional studies offer numerous logistical, administrative and scheduling challenges; the 12 tips are provided to help medical education researchers develop and manage the successful recruitment of students across the health professions.

Commissioning Clinical Spaces During a Pandemic: Merging Methodologies of Human Factors and Simulation.

OBJECTIVES: The objective of this case study is to demonstrate the value of applying tabletop and simulation techniques to highlight high-risk, high-impact outcomes and organizational recommendations in the commissioning of a new clinical spaces. PURPOSE/AIM: Generalizability of lessons learned from this case study aim to support other health organizations in commissioning of clinical spaces during communicable disease outbreaks. BACKGROUND: COVID-19 challenged our healthcare system, requiring teams to prepare in a short span of time. Bridging expertise of human factor and simulation teams provided a novel, interdisciplinary, and timely approach to evaluate and commission spaces. METHODS: Human factors and simulation teams were enlisted to conduct an evaluation of a new space prior to readiness for delivery of safe patient care. An adapted tabletop evaluation and subsequent systems integration simulation was conducted. The goal of the tabletop exercise was to identify and define processes and risks to tested in the physical space using simulation. RESULTS: Applying both human factors science and systems simulation proactively identified the highest risk, highest impact outcomes, validated existing processes and allowed for refining of potential solutions and recommendations of the new space. A strong working relationship between teams fostered an opportunity to share information, debrief, evaluate, and adapt methods while applying timely changes based on emergent findings. CONCLUSIONS: These combined methodologies are important tools that can be learned and applied to healthcare commissioning of new clinical spaces in the identification of high-risk, high-impact outcomes affecting staff and organizational preparedness and safety.

Qualitative Examination of Shared Decision-Making in Canada's Largest Health System: More Work to be Done : Shared Decision-Making-More Work to be Done.

Background: Shared Decision-Making (SDM) is an inclusive approach where patients and providers work in partnership to make health care decisions that are grounded in clinical best practice and align with patient preferences and values. Despite a growing recognition that SDM can lead to improved outcomes and reductions in unnecessary health investigations, tensions exist between patient agency and a historically paternalistic model of health care. As an evolving ideology, the Research Team sought to better understand the current state, challenges, and implementation opportunities of SDM practices across the health system. Methods: This study used a cross-sectional quality improvement design utilizing semistructured interviews to gather information from focus group participants. Five open-ended, qualitative questions were used to generate discussion on the perceptions of SDM and its role in clinical appropriateness in a variety of clinical contexts in our health system. A total of 12 focus groups (n = 95 participants) representative of patients and families, leaders, physicians, and frontline clinicians were engaged in the study. Results: Through a consensus-based approach, study results identified 4 recommendations based on 4 themes: Time, Communication, System Design, and Clinical Appropriateness. Conclusion: There are no easy solutions to the challenges of enabling SDM; however, success will be dependent upon recognizing the importance of patient agency, while maintaining an inclusive and continuous stakeholder engagement with both patients and providers. Implementation of the 4 recommendations at the organizational level highlighted in this study can serve as a road map for other health care institutions and will require a gradual approach to transform the general principles of SDM into tangible solutions to meet the emerging needs at both the local and system level.

Correction to: COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

[This corrects the article DOI: 10.1186/s41077-020-00138-w.].

Use of Virtually Facilitated Simulation to Improve COVID-19 Preparedness in Rural and Remote Canada.

Background: The Alberta Health Services' Provincial Simulation Program (eSIM) is Canada's largest simulation program. The eSIM mobile simulation program specializes in delivering simulation-based education (SBE) to rural and remote communities (RRC). During the COVID-19 pandemic, a quality improvement project involving rapid cycle in situ virtually facilitated simulation (VFS) for COVID-19 airway management and health systems preparedness in RRC was successfully implemented. Methods: Between April 24 and July 31, 2020, a team of six rural simulationists (four nurses and two physicians) provided 24 VFS sessions with virtual debriefing to 200 health care providers distributed across 11 RRC in Alberta and the Northwest Territories, covering a geographic area of approximately 169,028 km2. Results: Video analysis of sequential VFS rapid cycle sessions using a standardized observational tool indicated decreased personal protective equipment (PPE) breaches by 36.6% between the first and third cycles. Teams demonstrated increased competency with airway management such as correct use of bag-valve-mask ventilation, and implementation of health system process improvements, such as incorporation of an intubation checklist. Improvements occurred on average over 2.2 rapid cycles completed within 1.3 weeks per RRC. Postsession self-reported participant electronic surveys indicated self-reported improvement in clinical management, teamwork behavior, and health systems issues outcome measures which were categorized based on the Crisis Resource Management and Systems Engineering Initiative for Patient Safety (SEIPS) frameworks. Of the 48 survey respondents, 86.1% reported that VFS was equivalent or superior to in-person simulation. The cost of VFS was 62.9% lower than comparable in-person SBE. Conclusion: VFS provides a rapidly mobilizable and cost-effective way of delivering high-quality SBE to geographically isolated communities.

Building impactful systems-focused simulations: integrating change and project management frameworks into the pre-work phase.

Healthcare organizations strive to deliver safe, high-quality, efficient care. These complex systems frequently harbor gaps, which if unmitigated, could result in harm. Systems-focused simulation (SFS) projects, which include systems-focused debriefing (SFD), if well designed and executed, can proactively and comprehensively identify gaps and test and improve systems, enabling institutions to improve safety and quality before patients and staff are placed at risk.The previously published systems-focused debriefing framework, Promoting Excellence and Reflective Learning in Simulation (PEARLS) for Systems Integration (PSI), describes a systematic approach to SFD. It includes an essential "pre-work" phase, encompassing evidence-informed steps that lead up to a SFD. Despite inclusion in the PSI framework, a detailed description of the pre-work phase, and how each component facilitates change management, was limited.The goal of this paper is to elucidate the PSI "Pre-work" phase, everything leading up to the systems-focused simulation and debriefing. It describes how the integration of project and change management principles ensures that a comprehensive collection of safety and quality issues are reliably identified and captured.

Goals, Recommendations, and the How-To Strategies for Developing and Facilitating Patient Safety and System Integration Simulations.

PURPOSE: The aim of this article is to outline overall goals, recommendations, and provide practical How-To strategies for developing and facilitating patient safety and system integration (PSSI) simulations for healthcare team members and organizations. BACKGROUND: Simulation is increasingly being used as a quality improvement tool to better understand the tasks, environments, and processes that support the delivery of healthcare services. These PSSI simulations paired with system-focused debriefing can occur prior to implementing a new process or workflow to proactively identify system issues. They occur as part of a continuous cycle of quality improvement and have unique considerations for planning, implementation, and delivery of healthcare. METHOD: The Delphi technique was used to develop the recommendations and How-To strategies to guide those interested in conducting a PSSI simulations. The Delphi technique is a structured communication technique and systematic process of gathering information from a group of identified experts through a series of questionnaires to gain consensus regarding judgments on complex processes, where precise information is not available in the literature. The Delphi technique permitted an iterative and multistaged approach to transform expert opinions into group consensus. RESULTS: The goals, recommendations, and How-To strategies include a focus on project management, stakeholder engagement, sponsorship, scenario design, prebriefing and debriefing, and evaluation metrics. The intent is to proactively identify system issues and disseminate actionable findings. CONCLUSIONS: This article highlights salient features to consider when using simulation as a strategy and tool for patient safety and quality improvement.

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

Healthcare resources have been strained to previously unforeseeable limits as a result of the COVID-19 pandemic of 2020. This has prompted the emergence of critical just-in-time COVID-19 education, including rapid simulation preparedness, evaluation and training across all healthcare sectors. Simulation has been proven to be pivotal for both healthcare provider learning and systems integration in the context of testing and integrating new processes, workflows, and rapid changes to practice (e.g., new cognitive aids, checklists, protocols) and changes to the delivery of clinical care. The individual, team, and systems learnings generated from proactive simulation training is occurring at unprecedented volume and speed in our healthcare system. Establishing a clear process to collect and report simulation outcomes has never been more important for staff and patient safety to reduce preventable harm. Our provincial simulation program in the province of Alberta, Canada (population = 4.37 million; geographic area = 661,848 km2), has rapidly responded to this need by leading the intake, design, development, planning, and co-facilitation of over 400 acute care simulations across our province in both urban and rural Emergency Departments, Intensive Care Units, Operating Rooms, Labor and Delivery Units, Urgent Care Centers, Diagnostic Imaging and In-patient Units over a 5-week period to an estimated 30,000 learners of real frontline team members. Unfortunately, the speed at which the COVID-19 pandemic has emerged in Canada may prevent healthcare sectors in both urban and rural settings to have an opportunity for healthcare teams to participate in just-in-time in situ simulation-based learning prior to a potential surge of COVID-19 patients. Our coordinated approach and infrastructure have enabled organizational learnings and the ability to theme and categorize a mass volume of simulation outcome data, primarily from acute care settings to help all sectors further anticipate and plan. The goal of this paper is to share the unique features and advantages of using a centralized provincial simulation response team, preparedness using learning and systems integration methods, and to share the highest risk and highest frequency outcomes from analyzing a mass volume of COVID-19 simulation data across the largest health authority in Canada.

Summative Assessment of Interprofessional "Collaborative Practice" Skills in Graduating Medical Students: A Validity Argument.

PURPOSE: To describe how the authors developed an objective structured clinical examination (OSCE) station to assess aspects of collaborative practice competency and how they then assessed validity using Kane's framework. METHOD: After piloting the collaborative practice OSCE station in 2015 and 2016, this was introduced at the Cumming School of Medicine in 2017. One hundred fifty-five students from the class of 2017 and 22 students from the class of 2018 participated. To create a validity argument, the authors used Kane's framework that views the argument for validity as 4 sequential inferences on the validity of scoring, generalization, extrapolation, and implications, RESULTS: Scoring validity is supported by psychometric analysis of checklist items and the fact that the contribution of rater specificity to students' ratings was similar to OSCE stations assessing clinical skills alone. The claim of validity of generalization is backed by structural equation modeling and confirmatory factor analysis that identified 5 latent variables, including 3 related to collaborative practice ("provides an effective handover," "provides mutual support," and "shares their mental model"). Validity of extrapolation is argued based upon the correlation between the rating for "shares their mental model" and the rating on in-training evaluations for "relationship with other members of the health care team," in addition to the association between performance on the collaborative practice OSCE station and the subsequent rating of performance during residency. Finally, validity of implications is supported by the fact that pass/fail decisions on the collaborative practice station were similar to other stations and by the observation that ratings on different aspects of collaborative practice associate with pass/fail decisions. CONCLUSIONS: Based upon the validity argument presented, the authors posit that this tool can be used to assess the collaborative practice competence of graduating medical students and the adequacy of training in collaborative practice.

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

Development and reconstruction of new healthcare facilities and spaces has the potential for latent safety threats to emerge, specifically unintentional harm that could affect actual patients once the facility opens, such as missing equipment, inefficient setup, or insufficient space for procedures. Process-orientated simulation and testing is a novel innovation in healthcare. The aim of process-orientated simulations and debriefing is to examine the process of care, rather than the outcome of care. These simulations, which take place in actual patient care settings and environments prior to occupancy, are an emerging strategy that can be used to test new environments and new healthcare facilities to ensure that the spaces created match the needs of the staff and administration, while proactively identifying latent safety threats prior to delivering patient care. In turn, these simulations can be also be used as part of the new site orientation and training plan. The aim of this paper is to examine a case study describing the use of the novel innovation of process-orientated simulations to test the opening of a new 300-bed healthcare facility.

PEARLS for Systems Integration: A Modified PEARLS Framework for Debriefing Systems-Focused Simulations.

STATEMENT: Modern healthcare organizations strive for continuous improvement in systems and processes to ensure safe, effective, and cost-conscious patient care. However, systems failures and inefficiencies lurk in every organization, often emerging only after patients have experienced harm or delays. Simulation and debriefing, focused on identifying systems gaps, can proactively lead to improvements in safety and quality. Systems-focused debriefing requires a different approach than traditional, learner-focused debriefing. We describe PEARLS for Systems Integration, a conceptual framework, debriefing structure and script that facilitators can use for systems-focused debriefing. The framework builds on Promoting Excellence And Reflective Learning in Simulation, using common debriefing strategies (plus/delta, focused facilitation, and directive feedback) in a modified format, with new debriefing scripts. Promoting Excellence And Reflective Learning in Simulation for System Integration offers a structured framework, adaptable for debriefing systems-focused simulations, to identify systems issues and maximize improvements in patient safety and quality.

A descriptive case study of the changing nature of nurses' work: The impact of managing infectious diseases requiring isolation.

Methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and Clostridium difficile have increased in health care facilities worldwide. The complexity of caring for patients with infectious comorbidities has impacted nurses' daily work. A mixed-methods study at 1 community hospital in Ontario, Canada, demonstrated the cumulative effect of additional time spent on infection prevention and control measures resulted in trade-offs, cutting corners, and raised concerns about the quality and continuity of care.

An experimental study on the impact of clinical interruptions on simulated trainee performances of central venous catheterization.

BACKGROUND: Interruptions are common in the healthcare setting. This experimental study compares the effects of interruptions on simulated performances of central venous catheterization during a highly versus minimally complex portion of the task. METHODS: Twenty-six residents were assigned to interruptions during tasks that are (1) highly complex: establishing ultrasound-guided venous access (experimental group, n = 15) or (2) minimally complex: skin cleansing (control group, n = 11). Primary outcomes were (a) performance scores at three time points measured with a validated checklist, (b) time spent on the respective tasks, and (c) number of attempts to establish venous access. RESULTS: Repeated measure analyses of variances of performance scores over time indicated no main effect of time or group. The interaction between time and group was significant: F (2, 44) = 4.28, p = 0.02, and partial eta2 = 0.16, indicating a large effect size. The experimental group scores decreased steadily over time, while the control group scores increased with time. The experimental group required longer to access the vein (148 s; interquartile range (IQR) 60 to 361 vs. 44 s; IQR 27 to 133 s; p = 0.034). Median number of attempts to establish venous access was higher in the experimental group (2, IQR 1-7 vs. 1, IQR 1-2; p = 0.03). CONCLUSIONS: Interruptions during a highly complex task resulted in a consistent decrement in performance scores, longer time required to perform the task, and a higher number of venous access attempts than interruptions during a minimally complex tasks. We recommend avoiding interrupting trainees performing bedside procedures.