Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

OBJECTIVE: To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates. STUDY DESIGN: Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500 g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects. RESULTS: We found variable prevalence of burnout across the NICUs surveyed (mean 25.2±10.1%). Healthcare-associated infection rates were 8.3±5.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 28±11% vs 17±19% physicians), day shift workers (30±3% vs 25±4% night shift) and workers with 5 or more years of service (29±2% vs 16±6% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=-0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04-1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34). CONCLUSION: Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.

Beyond "see one, do one, teach one": toward a different training paradigm.

In the process of acquiring new skills, physicians-in-training may expose patients to harm because they lack the required experience, knowledge and technical skills. Yet, most teaching hospitals use inexperienced residents to care for high-acuity patients in complex and dynamic environments and provide limited supervision from experienced clinicians. Multiple efforts in the last few years have started to address the problem of patient safety. Examples include voluntary incident-reporting systems and team training workshops for practising clinicians. Fewer efforts have addressed the deficits in training new physicians, especially related to knowledge, skills and competence. The current apprenticeship or "see one, do one, teach one" model is insufficient because trainees learn by practising on real patients, which is particularly an issue when performing procedures. Residents have expressed that they do not feel adequately trained to perform procedures safely by themselves. In this paper, we conduct an informal review of the impact of current training methods on patient safety. In addition, we propose a new training paradigm that integrates competency-based knowledge and clinical skills, with deliberate attitudinal and behavioural changes focused on patient safety in a safe medically simulated environment. We do so with the hope of creating a better marriage between the missions of training and patient safety.

Beyond "see one, do one, teach one": toward a different training paradigm.

In the process of acquiring new skills, physicians-in-training may expose patients to harm because they lack the required experience, knowledge and technical skills. Yet, most teaching hospitals use inexperienced residents to care for high-acuity patients in complex and dynamic environments and provide limited supervision from experienced clinicians. Multiple efforts in the last few years have started to address the problem of patient safety. Examples include voluntary incident-reporting systems and team training workshops for practising clinicians. Fewer efforts have addressed the deficits in training new physicians, especially related to knowledge, skills and competence. The current apprenticeship or "see one, do one, teach one" model is insufficient because trainees learn by practising on real patients, which is particularly an issue when performing procedures. Residents have expressed that they do not feel adequately trained to perform procedures safely by themselves. In this paper, we conduct an informal review of the impact of current training methods on patient safety. In addition, we propose a new training paradigm that integrates competency-based knowledge and clinical skills, with deliberate attitudinal and behavioural changes focused on patient safety in a safe medically simulated environment. We do so with the hope of creating a better marriage between the missions of training and patient safety.

Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.

OBJECTIVE: To add a team training and human error curriculum to the Neonatal Resuscitation Program (NRP) and measure its effect on teamwork. We hypothesized that teams that received the new course would exhibit more teamwork behaviors than those in the standard NRP course. STUDY DESIGN: Interns were randomized to receive NRP with team training or standard NRP, then video recorded when they performed simulated resuscitations at the end of the day-long course. Outcomes were assessed by observers blinded to study arm allocation and included the frequency or duration of six team behaviors: inquiry, information sharing, assertion, evaluation of plans, workload management and vigilance. RESULT: The interns in the NRP with team training group exhibited more frequent team behaviors (number of episodes per minute (95% CI)) than interns in the control group: information sharing 1.06 (0.24, 1.17) vs 0.13 (0.00, 0.43); inquiry 0.35 (0.11, 0.42) vs 0.09 (0.00, 0.10); assertion 1.80 (1.21, 2.25) vs 0.64 (0.26, 0.91); and any team behavior 3.34 (2.26, 4.11) vs 1.03 (0.48, 1.30) (P-values <0.008 for all comparisons). Vigilance and workload management were practiced throughout the entire simulated code by nearly all the teams in the NRP with team training group (100% for vigilance and 88% for workload management) vs only 53 and 20% of the teams in the standard NRP. No difference was detected in the frequency of evaluation of plans. CONCLUSION: Compared with the standard NRP, NRP with a teamwork and human error curriculum led interns to exhibit more team behaviors during simulated resuscitations.

Variation in caregiver perceptions of teamwork climate in labor and delivery units.

OBJECTIVE: To test the psychometric soundness of a teamwork climate survey in labor and delivery, examine differences in perceptions of teamwork, and provide benchmarking data. DESIGN: Cross-sectional survey of labor and delivery caregivers in 44 hospitals in diverse regions of the US, using the Safety Attitudes Questionnaire teamwork climate scale. RESULTS: The response rate was 72% (3382 of 4700). The teamwork climate scale had good internal reliability (overall alpha = 0.78). Teamwork climate scale factor structure was confirmed using multilevel confirmatory factor analyses (CFI = 0.95, TLI = 0.92, RMSEA = 0.12, SRMR(within) = 0.04, SRMR(between) = 0.09). Aggregation of individual-level responses to the L&D unit-level was supported by ICC (1) = 0.06 (P < 0.001), ICC (2) = 0.83 and mean r (wg(j)) = 0.83. ANOVA demonstrated differences between caregivers F (7, 3013) = 10.30, P < 0.001 and labor and delivery units, F (43, 1022) = 3.49, P < 0.001. Convergent validity of the scale scores was measured by correlations with external teamwork-related items: collaborative decision making (r = 0.780, P < 0.001), use of briefings (r = 0.496, P < 0.001) and perceived adequacy of staffing levels (r = 0.593, P < 0.001). CONCLUSION: We demonstrate a psychometrically sound teamwork climate scale, correlate it to external teamwork-related items, and provide labor and delivery teamwork benchmarks. Further teamwork climate research should explore the links to clinical and operational outcomes.

Teamwork and quality during neonatal care in the delivery room.

OBJECTIVE: Experts believe good teamwork among health care providers may improve quality. We sought to measure the frequency of team behaviors during delivery room care and to explore how these behaviors relate to the quality of care. STUDY DESIGN: We video recorded neonatal resuscitation teams then used independent observers to measure teamwork behaviors and compliance with Neonatal Resuscitation Program (NRP) guidelines (a measure of quality of care). RESULTS: Observer agreement was either fair or good for all teamwork behaviors except workload management, vigilance, and leadership, for which agreement was slight. All teams (n=132) exhibited the behaviors information sharing and inquiry, and all but one team exhibited vigilance and workload management. Other behaviors were present less often: assertion in 19.9% of teams, teaching 16.7%, leadership 19.7%, evaluation of plans 12.9%, and intentions stated 9.1%. Factor analysis identified three fundamental components of teamwork: communication (comprised of information sharing and inquiry); management (workload management and vigilance); and leadership (assertion, intentions shared, evaluation of plans, and leadership). All three components were weakly but significantly correlated with independent assessments of NRP compliance and an overall rating of the quality of care. CONCLUSION: Most team behaviors can be reliably observed during delivery room care by neonatal resuscitation teams, and some are infrequently used. We found weak but significant and consistent correlations among these behaviors with independent assessments of NRP compliance and an overall rating of the quality of care. These findings support additional efforts to study team training for delivery room care and other areas of healthcare.

Translating teamwork behaviours from aviation to healthcare: development of behavioural markers for neonatal resuscitation.

Improving teamwork in healthcare may help reduce and manage errors. This paper takes a step toward that goal by (1) proposing a set of teamwork behaviours, or behavioural markers, for neonatal resuscitation; (2) presenting a data form for recording observations about these markers; and (3) comparing and contrasting different sets of teamwork behaviours that have been developed for healthcare. Data from focus groups of neonatal providers, surveys, and video recordings of neonatal resuscitations were used to identify some new teamwork behaviours, to translate existing aviation team behaviours to this setting, and to develop a data collection form. This behavioural marker audit form for neonatal resuscitation lists and defines 10 markers that describe specific, observable behaviours seen during the resuscitation of newborn infants. These markers are compared with those developed by other groups. Future research should determine the relations among these behaviours and errors, and test their usefulness in measuring the impact of team training interventions.

Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center.

BACKGROUND: Despite the emphasis on patient safety in health care, few organizations have evaluated the extent to which safety is a strategic priority or their culture supports patient safety. In response to the Institute of Medicine's report and to an organizational commitment to patient safety, we conducted a systematic assessment of safety at the Johns Hopkins Hospital (JHH) and, from this, developed a strategic plan to improve safety. The specific aims of this study were to evaluate the extent to which the culture supports patient safety at JHH and the extent to which safety is a strategic priority. METHODS: During July and August 2001 we implemented two surveys in disparate populations to assess patient safety. The Safety Climate Scale (SCS) was administered to a sample of physicians, nurses, pharmacists, and other ICU staff. SCS assesses perceptions of a strong and proactive organizational commitment to patient safety. The second survey instrument, called Strategies for Leadership (SLS), evaluated the extent to which safety was a strategic priority for the organization. This survey was administered to clinical and administrative leaders. RESULTS: We received 395 completed SCS surveys from 82% of the departments and 86% of the nursing units. Staff perceived that supervisors had a greater commitment to safety than senior leaders. Nurses had higher scores than physicians for perceptions of safety. Twenty three completed SLS surveys were received from 77% of the JHH Patient Safety Committee members and 50% of the JHH Management Committee members. Management Committee responses were more positive than Patient Safety Committee, indicating that management perceived safety efforts to be further developed. Strategic planning received the lowest scores from both committees. CONCLUSIONS: We believe this is one of the first large scale efforts to measure institutional culture of safety and then design improvements in health care. The survey results suggest that strategic planning of patient safety needs enhancement. Several efforts to improve our culture of safety were initiated based on these results, which should lead to measurable improvements in patient safety.

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

OBJECTIVES: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. DESIGN: : Cross sectional surveys. SETTING: : Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. PARTICIPANTS: : 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). MAIN OUTCOME MEASURES: : Perceptions of error, stress, and teamwork. RESULTS: : Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. CONCLUSIONS: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.

Analyzing cockpit communications: the links between language, performance, error, and workload.

The importance of communication on the flightdeck is discussed and the application of a new computer-based linguistic method of text analysis is introduced. Preliminary results from a NASA B727 simulator study indicate that specific language variables are moderately to highly correlated with individual performance, individual error rates, and individual communication ratings. Also, language use was found to vary as a function of crew position and level of workload during the flight. Use of the first person plural (we, our, us) increases over the life of a flightcrew, and Captains speak more in the first person plural than First Officers or Flight Engineers. Language use in initial flights was associated with performance and error in subsequent flights. These are preliminary data, in that this method of linguistic analysis is currently being developed and integrated with a content-coding method of communication analysis and models of threat and error.