Periodic Reporting for period 1 - TeamUp (Understanding and improving team decision making in uncertain environments)
Berichtszeitraum: 2020-04-01 bis 2022-03-31
According to the European Commission’s report „Patient Safety and Quality of Care" (2014), each year, 8 to 12% of hospitalized patients suffer from adverse events, mostly diagnostic errors. Environments such as the emergency room are particularly vulnerable with up to 35% diagnostic errors. Research into how to reduce diagnostic errors has so far focused on how to train, educate, or technically support the individual physician—thus largely neglecting an integral aspect of clinical diagnosis: its collaborative character. Yet, adverse events in patient care are often caused by failures in teamwork. Therefore, it is key to facilitate teamwork in order to reduce the unacceptably high incidence of diagnostic error worldwide, as was acknowledged by the National Academy of Medicine in 2015. Improving teamwork in healthcare has the potential to contribute to a reduction of diagnostic errors, avoid unnecessary treatments, save healthcare costs, and ultimately enhance patient safety.
The overall objective of the project «TeamUp» is thus to advance the understanding of decision processes in teams in uncertain environments such as the emergency room, and ultimately, to inform theory-based interventions to achieve diagnostic excellence. In detail, to scrutinize the determinants of high diagnostic accuracy, the project aims to (1) identify mechanisms and locate performance benefits of teams in the diagnostic decision process, (2) find effective ways to combine individual with teamwork, (3) identify interaction patterns that render teams successful, and (4) to transfer findings to teaching material for dissemination among end-users. To deliver these aims, the project draws on cognitive, social and organizational psychology, and diagnostic error research. Within TeamUp, a series of empirical studies including lab experiments, surveys and simulation studies with real emergency teams were conducted.
The overall objective of the project «TeamUp» is thus to advance the understanding of decision processes in teams in uncertain environments such as the emergency room, and ultimately, to inform theory-based interventions to achieve diagnostic excellence. In detail, to scrutinize the determinants of high diagnostic accuracy, the project aims to (1) identify mechanisms and locate performance benefits of teams in the diagnostic decision process, (2) find effective ways to combine individual with teamwork, (3) identify interaction patterns that render teams successful, and (4) to transfer findings to teaching material for dissemination among end-users. To deliver these aims, the project draws on cognitive, social and organizational psychology, and diagnostic error research. Within TeamUp, a series of empirical studies including lab experiments, surveys and simulation studies with real emergency teams were conducted.
First, we assessed in a lab experiment the performance of advanced medical students working alone or in a team of two per decision-making phase (i.e. information analysis vs. information synthesis) in order to determine which phase(s) would benefit most from teaming up. We found that teams outperformed individuals when analyzing information and integrating information suggesting that it pays off to delegate complex diagnoses to teams provided that time and resources are available.
Second, we surveyed health professionals with several years of work experience as nurse, midwife, or therapist concerning their attitudes toward their own professions and those of doctors using an established trait rating measure and a qualitative approach. We found that stereotypes of respondents were mostly related to academic, medical competence (being perceived as lower than that of doctors) and the traditional role relationship (strict hierarchy, dependence on doctors) that guides a lot of behavior, such as the little participation of nurses, midwives and therapists. Our results suggest that, to improve teamwork, interprofessional stereotypes in the workplace need to be addressed with the help of interprofessional education activities. Also, all health professionals need to be empowered to be full and equal members of the healthcare team.
Third, we conducted a quantitative observational study of real-world ad hoc interprofessional teams responding to a simulated cardiac arrest in an emergency room. When analyzing the team members’ and leader’s perceptions of teamwork quality, analyses revealed that team members seem to have better insight into their team’s teamwork than team leaders. This suggests that, as a practical consequence, the decision to debrief and the debriefing itself after a resuscitation should be informed by team members, not just leaders.
Fourth, we conducted a secondary analyses of data obtained during a large-scale field study to explore what situational and stable factors affect the perceived quality of teamwork during a specific team task, namely when a medical team comprising a senior (supervisor) and a junior (trainee) physician diagnoses a patient. We found that the patient-specific case clarity influenced the perceived teamwork quality positively, whereas the work experience of thesupervisor influenced the perceived teamwork quality of both supervisor and trainee negatively.
To identify interaction patterns that render teams successful, we conducted a prospective randomized study involving real emergency teams who had to diagnose and treat different “patients” with shortness of breath (presented by a training mannequin) in a simulator setting. The team-patient interactions were videotaped and coded. Analyses revealed that teams successfully adapted their information and action coordination behaviour to the different task demands.
Simulation training and its debriefing can contribute to improving teamwork and thus patient care. When conducting debriefings, there are several design factors that can potentially influence learning outcomes. In an experimental study, we showed that the use of a cognitive aid can help to direct the focus on certain topics or learning objectives and facilitate time management through pre-structuring; however, a difference in learning outcomes (in terms of the quality of teamwork) could not be identified. Besides the influence of a certain structure or script, a strong influence from the individual guiding the debriefing is likely.
To transfer theoretical and empirical insights from TeamUp and related research into training material for practical use in healthcare, material for a team-training module was developed and tested during two workshops with medical students at the University of Bern. Feasibility of and satisfaction with the workshop were judged as high.
Second, we surveyed health professionals with several years of work experience as nurse, midwife, or therapist concerning their attitudes toward their own professions and those of doctors using an established trait rating measure and a qualitative approach. We found that stereotypes of respondents were mostly related to academic, medical competence (being perceived as lower than that of doctors) and the traditional role relationship (strict hierarchy, dependence on doctors) that guides a lot of behavior, such as the little participation of nurses, midwives and therapists. Our results suggest that, to improve teamwork, interprofessional stereotypes in the workplace need to be addressed with the help of interprofessional education activities. Also, all health professionals need to be empowered to be full and equal members of the healthcare team.
Third, we conducted a quantitative observational study of real-world ad hoc interprofessional teams responding to a simulated cardiac arrest in an emergency room. When analyzing the team members’ and leader’s perceptions of teamwork quality, analyses revealed that team members seem to have better insight into their team’s teamwork than team leaders. This suggests that, as a practical consequence, the decision to debrief and the debriefing itself after a resuscitation should be informed by team members, not just leaders.
Fourth, we conducted a secondary analyses of data obtained during a large-scale field study to explore what situational and stable factors affect the perceived quality of teamwork during a specific team task, namely when a medical team comprising a senior (supervisor) and a junior (trainee) physician diagnoses a patient. We found that the patient-specific case clarity influenced the perceived teamwork quality positively, whereas the work experience of thesupervisor influenced the perceived teamwork quality of both supervisor and trainee negatively.
To identify interaction patterns that render teams successful, we conducted a prospective randomized study involving real emergency teams who had to diagnose and treat different “patients” with shortness of breath (presented by a training mannequin) in a simulator setting. The team-patient interactions were videotaped and coded. Analyses revealed that teams successfully adapted their information and action coordination behaviour to the different task demands.
Simulation training and its debriefing can contribute to improving teamwork and thus patient care. When conducting debriefings, there are several design factors that can potentially influence learning outcomes. In an experimental study, we showed that the use of a cognitive aid can help to direct the focus on certain topics or learning objectives and facilitate time management through pre-structuring; however, a difference in learning outcomes (in terms of the quality of teamwork) could not be identified. Besides the influence of a certain structure or script, a strong influence from the individual guiding the debriefing is likely.
To transfer theoretical and empirical insights from TeamUp and related research into training material for practical use in healthcare, material for a team-training module was developed and tested during two workshops with medical students at the University of Bern. Feasibility of and satisfaction with the workshop were judged as high.
The results of TeamUp contribute to research and training of teamwork under uncertainty by:
1. providing evidence for
• synergistic effects of teams during two important steps when reaching a diagnostic decision, namely during information analysis and integration,
• adaptive behaviour and leadership in high-risk situations,
• team members and leaders having limited and different insights into the quality of their team processes, and
• a very limited benefit of differential diagnosis checklists (at least, if they take a static form of a list).
2. providing guidance for
• interprofessional education (IPE) developers about which interprofessional stereotypes among healthcare professionals exist,
• medical educators about which concrete material to use for teaching non-technical skills for decision making under uncertainty, and
• simulation trainers on how to more effectively structure debriefings.
1. providing evidence for
• synergistic effects of teams during two important steps when reaching a diagnostic decision, namely during information analysis and integration,
• adaptive behaviour and leadership in high-risk situations,
• team members and leaders having limited and different insights into the quality of their team processes, and
• a very limited benefit of differential diagnosis checklists (at least, if they take a static form of a list).
2. providing guidance for
• interprofessional education (IPE) developers about which interprofessional stereotypes among healthcare professionals exist,
• medical educators about which concrete material to use for teaching non-technical skills for decision making under uncertainty, and
• simulation trainers on how to more effectively structure debriefings.