To evaluate participant reactions and attitudes to crew resource management teamwork classroom-based training by comparing Likert responses before and after the intervention and exploring potential differences in attitudes across the different healthcare professionals.
Between 26 January and 27 March, 2015, a randomly selected sample of 240 frontline healthcare professionals offering direct patient care were recruited to undergo a 4-hour crew resource management classroom-based training programme. Participants were asked to complete a 22-item human factors attitude survey before and after training and a 10-item end-of-programme evaluation. Paired samples t-test was used to assess differences between the participants' pretest and posttest scores on each item.
A total of 167 (70%) from 17 different specialties underwent the training and 164 (68.3%) completed (139 nurses, 25 doctors) the survey. The nurses were of similar age to the doctors (38.2 vs 36.9, p=0.83) and were more likely to be women (75.6% vs 24.6%, p <0.001). Human factors attitude survey findings indicated that nurses valued the experience highly compared to doctors. The responses among the nurses revealed significant attitude shifts (p <0.05) in 20 of the 22 items whereas this was the case only for 9 items among the doctors.
Overall, the crew resource management classroom-based training programme appeared to have a positive effect on frontline healthcare professionals’ attitudes. The implementation of such programme is feasible and acceptable, especially for nurses, in a public hospital setting in Hong Kong.
Effective teamwork is found to play an important role in the healthcare industry and many underlying causes of adverse events in healthcare are due to the absence of non-technical skills, such as teamwork and communication, rather than technical skills.
CRM training has become a common teaching method for healthcare organizations. A recent study found that classroom-based training in hospitals resulted in improvement of knowledge (mean difference=1.5, p=0.002) and teamwork behaviour (mean difference=2.69, p=0.027).
The Multidisciplinary Simulation and Skills Centre in Queen Elizabeth Hospital (QEH) was set up in 2011. The training centre has built quality assurance (QA) from the beginning. The first step in QA was to ensure that our curriculum fulfils the CRM training guideline. This was achieved through accreditation in March 2014. As educators in the healthcare profession, we need to understand the nurses and doctors’ reactions toward the training, the shift in attitudes before and after the training and the differences in attitudes between doctors and nurses.
We randomly selected 240 healthcare professionals from QEH who worked as a team and provided direct care for the patients. Only those who were associate consultants, resident specialists, residents, advanced practice nurses and registered nurses were invited for this study. Participants were informed by the department heads about the training and participation was voluntary. A reminder email was sent to all participants one week before the study and informed consent was obtained on the day of the study.
Of the 240 participants who were invited to join the study, 164 of them showed up for the training (139 nurses and 25 doctors). The mean ages of nurses and doctors were 38.2 years and 36.9 years, respectively. Over 60% of them had more than 10 years of work experience and 24% of them had heard of CRM. Amongst the 164 participants, 42 were from the department of Medicine (25.6%), 8 (4.9%) were from the department of Surgery, 13 (7.9%) were from the department of Obstetrics & Gynaecology, 16 (9.7) were from the department of Paediatrics, 6 (3.7%) were from the Accident & Emergency department, 8 (4.9%) were from the Intensive Care Unit, 22 (13.4%) were from the department of Anaesthesiology & Operating Theatre Services, 10 (6.1%) were from the department of Clinical Oncology, 9 (5.5%) were from the department of Orthopaedics and Traumatology, 9 (5.5%) were from the department of Radiology & Imaging, and 21 (12.8%) from other departments such as Private Clinic and Neurosurgery.
Between 26 January and 27 March, 2015, MDSSC conducted 12 CRM classroom-based training programmes. The programmes were supported by the Hong Kong Hospital Authority (HA) and their goal was to improve patient safety. The programme curriculum design, content and training objectives addressed the staff learning needs among the four high-risk departments: Obstetrics & Gynaecology, Anaesthesiology & Operating Theatre Services, Intensive Care Unit, and Accidental & Emergency.
Leadership refers to the qualities that promote good teamwork, the ability to inspire team members to work coordinately, and the capability to give direct commands and listen to team members’ opinions. The training emphasizes interpersonal skills and the importance of leaders as well as followers to mutually respect each other to pursue common goals.
Communication is more than just talking. It is the process of using words and actions to convey meaning. “Closed loop” communication and “Situation-Background-Assessment-Recommendation (SBAR)” are effective tools for team communication and this session introduced how to use them effectively. Participants had the opportunity to learn and practice the difference between using open loop versus closed loop communication and non-SBAR versus SBAR.
Assertiveness is an important communication skill that involves standing up for one’s rights while respecting the rights of others. The purpose of this session is to teach the appropriate use of assertiveness to speak out when patient safety is at risk. The “5-Step Assertion Model”
Situational awareness refers to the ability to recognize adverse events and identify red flags. This session focuses on training the participants on how to manage red flags by performing the following three steps - See it, Say it and Fix it. Once the threats have been identified, open and assertive communication should apply; then team leaders should gather all the information and opinions from the teammates before making the final decision.
In summary, CRM classroom-based training teaches the participants explicit behavioural strategies to strengthen their skills through team building games and open discussions. Training enables participants to focus on the importance of patient safety and to recognize how the skills improve their performance at work.
| Item | Pre-training Mean (SD) | Post-training Mean (SD) | p-value |
|---|---|---|---|
| 1. Team leader and team members can improve decision-making skills through training. | 3.96 (0.56) | 4.23 (0.51) | <0.001 |
| 2. Team leader should encourage team members’ to raise questions during normal operations and emergencies. | 3.94 (0.61) | 4.30 (0.54) | <0.001 |
| 3. My performance is not adversely affected by working with an inexperienced or less capable team member. | 2.94 (0.84) | 3.20 (0.88) | <0.001 |
| 4. Team members should question the decisions or actions of the team leader during a procedure. | 3.65 (0.63) | 4.14 (0.52) | <0.001 |
| 5. Prior to the procedure, it is important for all team members to be familiar with the tasks and responsibilities of the other members of the team. | 4.09 (0.57) | 4.24 (0.53) | 0.003 |
| 6. My ability to detect adverse situations has a direct relationship to the quality of decisions I make. | 3.82 (0.59) | 4.14 (0.47) | <0.001 |
| 7. It is necessary for the team leader to explicitly tell team members that he/she wants their input. | 3.85 (0.57) | 4.14 (0.47) | <0.001 |
| 8. In response to unplanned events, the team leader should verbalize plans and ensure that the information is understood and acknowledged by all team members. | 4.08 (0.61) | 4.29 (0.53) | <0.001 |
| 9. Good communication and coordination are as important as technical proficiency for the safety of operative procedures. | 4.34 (0.57) | 4.48 (0.54) | 0.009 |
| 10. With trained and experienced staff members, good decisions are almost automatic in the planning and executing of operational requirements. | 3.82 (0.65) | 3.91 (0.68) | 0.12 |
| 11. A debriefing and critique of procedures and decisions after each event is an important part of developing and maintaining effective team coordination. | 3.95 (0.58) | 4.15 (0.56) | <0.001 |
| 12. A discussion of alternative methods does not make the team leader appear indecisive. | 3.55 (0.75) | 3.90 (0.61) | <0.001 |
| 13. Once team leaders have made a decision and announced it to the team, they should listen to the reservations on their decision from team members. | 3.82 (0.59) | 3.96 (0.53) | 0.01 |
| 14. Staff in my own department need training to “speak up” when they see something that is not right. | 3.71 (0.75) | 4.09 (0.74) | <0.001 |
| 15. Supervisors should be able to provide specific instruction and feedback on teamwork skill attainment. | 3.99 (0.39) | 4.17 (0.45) | <0.001 |
| 16. When making decisions, I gather as much information as time allows before making/executing my decision. | 3.92 (0.56) | 4.13 (0.51) | <0.001 |
| 17. It is just as important to note and debrief what was done well as it is to note and debrief what needs improvement. | 3.95 (0.53) | 4.15 (0.51) | <0.001 |
| 18. There are circumstances where another team member should assume control of the event. | 3.58 (0.65) | 3.82 (0.67) | <0.001 |
| 19. Recognizing adverse events is one of the most important keys to overall patient safety. | 4.17 (0.59) | 4.25 (0.56) | 0.12 |
| 20. If I perceive a problem with the event, I will speak up, regardless of who might be affected. | 3.66 (0.67) | 4.07 (0.61) | <0.001 |
| 21. The team formation and decision-making skills of team leaders are as important as their technical skills. | 3.91 (0.67) | 4.18 (0.48) | <0.001 |
| 22. During any procedure or shift, and in response to unplanned or unbriefed contingencies, the team leader should verbalize plans for procedures and should be sure that the information is understood and acknowledged by all team members. | 4.04 (0.51) | 4.20 (0.53) | <0.001 |
The Human Factors Attitude Survey (HFAS) was used to assess the attitudinal shifts related to team behaviour. This instrument was modified from an aviation-based attitudinal survey developed by the University of Texas and NASA.
Descriptive data were collected, analyzed and reported as mean±standard deviation. Pre- and post-test HFAS were analyzed by student’s t test. A p-value of less than 0.05 was considered significant. All analyses were performed using STATA 13 (College Station, Texas, USA).
Responses to the HFAS are summarized in
| Item No. | Nurse (n= 139) | Doctor (n=25) | |||||
|---|---|---|---|---|---|---|---|
| Pre Mean (SD) | Post Mean (SD) | p-value | Pre Mean (SD) | Post Mean (SD) | p-value | ||
| 1 | 3.96 (0.57) | 4.21 (0.52) | <0.001 | 3.88 (0.53) | 4.36 (0.49) | <0.001 | |
| 2 | 3.91 (0.59) | 4.31 (0.54) | <0.001 | 4.12 (0.73) | 4.28 (0.54) | 0.33 | |
| 3 | 3.04 (0.82) | 3.27 (0.87) | 0.003 | 2.40 (0.76) | 2.84 (0.85) | 0.02 | |
| 4 | 3.69 (0.61) | 4.16 (0.51) | <0.001 | 3.44 (0.71) | 4.04 (0.54) | <0.001 | |
| 5 | 4.05 (0.56) | 4.24 (0.52) | <0.001 | 4.32 (0.63) | 4.20 (0.58) | 0.38 | |
| 6 | 3.78 (0.61) | 4.12 (0.47) | <0.001 | 4.00 (0.41) | 4.24 (0.36) | 0.03 | |
| 7 | 3.85 (0.56) | 4.12 (0.46) | <0.001 | 3.88 (0.60) | 4.24 (0.52) | 0.009 | |
| 8 | 4.06 (0.59) | 4.28 (0.54) | <0.001 | 4.20 (0.71) | 4.32 (0.48) | 0.38 | |
| 9 | 4.33 (0.58) | 4.49 (0.54) | 0.008 | 4.36 (0.49) | 4.40 (0.50) | 0.75 | |
| 10 | 3.82 (0.65) | 3.94 (0.70) | 0.06 | 3.80 (0.65) | 3.72 (0.54) | 0.54 | |
| 11 | 3.96 (0.58) | 4.15 (0.55) | <0.001 | 3.92 (0.64) | 4.16 (0.62) | 0.06 | |
| 12 | 3.50 (0.73) | 3.86 (0.64) | <0.001 | 3.80 (0.87) | 4.08 (0.40) | 0.13 | |
| 13 | 3.81 (0.61) | 3.96 (0.54) | 0.02 | 3.88 (0.44) | 3.96 (0.45) | 0.43 | |
| 14 | 3.72 (0.76) | 4.08 (0.74) | <0.001 | 3.64 (0.70) | 4.16 (0.75) | 0.007 | |
| 15 | 3.99 (0.42) | 4.16 (0.45) | <0.001 | 4.04 (0.20) | 4.24 (0.44) | 0.02 | |
| 16 | 3.89 (0.57) | 4.12 (0.51) | <0.001 | 4.08 (0.49) | 4.24 (0.52) | 0.21 | |
| 17 | 3.91 (0.54) | 4.12 (0.49) | <0.001 | 4.12 (0.44) | 4.32 (0.63) | 0.17 | |
| 18 | 3.59 (0.64) | 3.79 (0.68) | <0.001 | 3.64 (0.70) | 4.00 (0.65) | 0.03 | |
| 19 | 4.12 (0.58) | 4.21 (0.56) | 0.13 | 4.44 (0.58) | 4.48 (0.51) | 0.71 | |
| 20 | 3.71 (0.64) | 4.05 (0.61) | <0.001 | 3.44 (0.77) | 4.20 (0.65) | <0.001 | |
| 21 | 3.91 (0.67) | 4.16 (0.49) | <0.001 | 3.96 (0.68) | 4.28 (0.46) | 0.07 | |
| 22 | 4.04 (0.53) | 4.19 (0.54) | 0.003 | 4.08 (0.40) | 4.24 (0.52) | 0.10 | |
The differences in attitudes between nurses and doctors are outlined in
In general, participants found that the CRM classroom-based training programme was useful, relevant and interesting. A summary of participant ratings for the full 10 questions is provided in
When asked to list the learning points applicable to work, participants most commonly responded to the CRM elements, such as situational awareness, leadership, assertiveness and communication skills.
A key purpose of CRM training is to overcome the fallibility of human beings, by implementing non-technical skills such as communication, leadership, situational awareness and assertiveness in a high-risk setting.
| Question from Programme Evaluation | Mean ± SD (Responses %) |
|---|---|
| How interesting did you find this lecture? | 3.98±0.63 (83.53) |
| How useful did you find this lecture? | 4.02±0.61 (85.97) |
| What did you think about the structure of the teaching? | 3.98±0.59 (84.75) |
| Did you think that the case studies were useful and relevant? | 4.01±0.63 (83.53) |
| Did you think that the discussion was useful? | 3.98±0.64 (81.70) |
| What did you think of the instructor in terms of teaching? | 4.09±0.54 (89.63) |
| What did you think about the timing of this lecture? | 3.84±0.69 (73.78) |
| What did you think of the relevance of this topic to your job? | 4.06±0.68 (84.67) |
| Did you think that the lecture could increase patient safety and quality care? | 4.06±0.65 (84.76) |
| Overall, how satisfying did you find this lecture? | 4.01±0.62 (85.97) |
Effective communication plays an important role in improving patient safety. Recent studies support that standardization of communication can improve patient outcomes.
A high degree of learning satisfaction shows that frontline healthcare professionals enjoyed learning CRM. From 74 to 89% of participants rated the programme as very high for programme satisfaction, programme usefulness, the relevance to practice, and instructor performance, and the programme could improve patient safety and quality of care. They also indicated the importance of acquiring CRM skills, such as communication skills, assertiveness, decision-making and situational awareness. According to West et al.
Our study also demonstrated that the nurses showed a greater positive shift in attitudes towards patient safety than doctors. Although the doctors rated higher overall in pre-tests, the nurses demonstrated a greater mean difference in ratings after training, indicating that doctors may be less receptive to learning CRM through classroom-based training. One reason could be that they emphasize the importance of their roles in patient safety so they easily understand the needs of CRM through games, videos and lectures. Another reason could be that doctors are more interested in scenario-based simulation training rather than classroom-based training. An earlier study
Although many different teaching programmes in medical education have been using high-fidelity simulation, it is very costly. We believe our programme to be beneficial to our frontline healthcare professionals since it is both inexpensive and logistically feasible. Our programme costs approximately HK$47,500 (US$6,129) for 164 participants, CRM instructors, materials and audio visual support.
There were several limitations to this study. First, the study included a risk of selection bias, as the participants were volunteers. However, the random selection process and the relatively large sample aimed to minimize selection bias. Furthermore, it was undertaken in a single hospital so its generalization to other CRM classroom-based programmes may be limited. Thirdly, the study findings are limited by the number of participants and the changes in attitude were self-reported. Finally, although statistically significant improvements in attitude were shown in the survey, it is not possible to determine whether these improvements are clinically relevant.
In summary, CRM classroom-based training appears to be highly valued by participants, especially nurses. It focuses on improving interprofessional cooperation and team performance and, ultimately, improves patient safety. Future research should investigate the benefits and impact of CRM training over a longer period of time.
The MDSSC team would like to express its gratitude to Hospital Authority Head Office (HAHO) for their support and contribution in this study. We also thank to the CRM trainers: Dr Chan Wai-man, Dr Kwok Kam-hung, Dr Lam Kam-wah, Dr Mark Hor-kee, Dr Sin Kai-cheuk, Ms Lam Sui-yi, Ms Lee Lai-ha, Ms Lee Wing-sze, Ms Leung Lai-chu and Mr Wong Chi-yip. Without their support the study could have not been completed.
The authors declare that they have no conflict of interest.