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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
in reported sentinel events.
1–3
Contributing factors include a failure to
acknowledge human fallibility, communication barriers across hierarchies
and disciplines, and an increasingly complex hospital environment.
Within inpatient medical settings, nurses and physicians often differ in
their ratings of collaboration, and these discrepancies further highlight
opportunities for improving teamwork.
4
A team is defined as two or more individuals with specified roles
interacting adaptively, interdependently, and dynamically toward a shared
and common goal.
5
Elements of effective teamwork have been identified
through research conducted in aviation, the military, and more recently,
healthcare. Salas and colleagues have synthesized this research into five
core components: team leadership, mutual performance monitoring,
backup behavior, adaptability, and team orientation (see Table 1).
5
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K.J. O’Leary and N.L. Sehgal
Table 1. Core Components and Coordinating Mechanisms of Teamwork*
Teamwork Definition Behavioral Examples
Team leadership Direction and coordination • Facilitate team problem solving
of team members activities • Provide performance
expectations
• Clarify team member roles
• Assist in conflict resolution
Mutual performance Team members are able to • Identify mistakes and lapses
monitoring monitor one another’s in other team member actions
performance • Provide feedback to fellow
team members to facilitate
self-correction
Backup behavior Team members anticipate • Recognition of workload
and respond to one distribution problem
another’s needs • Shift work responsibilities to
underutilized members
Adaptability The team adjusts strategies • Identify cues that changes have
based on new information occurred and develop plan to
deal with changes
• Remain vigilant to changes in
internal and external
environment
(Continued)
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Teamwork in Hospital Medicine
Table 1. (Continued )
Teamwork Definition Behavioral Examples
Team orientation Team goals are prioritized • Take into account alternate
above individual goals solutions by teammates
• Increase task involvement,
information sharing, and
participatory goal setting
Shared mental model An organizing knowledge of • Anticipating and predicting one
the task of the team and how another’s needs
members will interact to • Identify changes in team,
achieve their goal task, or teammates
Closed-loop Acknowledgement and • Following up with team
communication confirmation of information members to ensure message
received received
• Acknowledging that message
was received
• Clarifying information received
Mutual trust Shared belief that team • Information sharing
members will perform their • Willingness to admit mistakes
roles and accept feedback
*Adapted from Salas et al.
38
Additionally, three supporting and coordinating mechanisms are essential
for effective teamwork: A shared mental model, closed-loop communication, and mutual trust (see Table 1).
5
Successful teams use these elements
to develop a culture for “speaking up” and situational awareness among
team members. Situational awareness refers to a person’s perception and
understanding of their dynamic environment. Human errors often result
from a lack of such awareness.
6
Challenges to Improving Teamwork
There are several important barriers to effective teamwork and communication in the hospital setting. Teams are large, formed in an ad hoc fashion, and membership is dynamic and often dispersed. Team members in
their respective disciplines care for multiple patients at the same time and
usually work in shifts, or rotations, resulting in team membership variability (few patients will have identical team membership) and instability
(each team has members joining and departing from the team).
Furthermore, while nurses and other hospital staff usually work on specific patient care units, physicians often care for patients on multiple units
and floors. Research has shown that nurses and physicians do not communicate consistently and often disagree on the plan of care for their
patients.
7
When communication does occur, clinicians may overestimate
how well their messages are understood by other team members, reflecting a phenomenon well-known in communication psychology related to
egocentric thought processes.
8,9
Ineffective communication and incomplete understanding of patients’ care creates and reinforces a culture of
low expectations and an environment unable to prevent and/or intercept
medical errors before they reach the patient.
Technology may serve as an additional barrier to effective communication despite the common notion that it serves to do the opposite. With
increasing use of electronic health records and the exchange of text-messages delivered via pager or email, we move to asynchronous modes of
communication which lack important face-to-face communication elements (tone of voice, expression, gesture, eye contact).
10,11
Assessment of Teamwork
Another major challenge in improving teamwork is the difficulty in measuring it. Assessment of teamwork entails measurement of knowledge,
skills and attitudes of teams composed of multiple individuals. Approaches
to evaluate interventions to improve teamwork include:
• self-assessment
• peer assessment
• direct observation
• survey of teamwork climate or culture
• measurement of clinical outcomes
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K.J. O’Leary and N.L. Sehgal
While self-report tools are easy to administer and can capture affective
components influencing team performance, they may not reflect actual
skills or team performance. Peer assessment includes the use of 360degree evaluations or multisource feedback, and provides evaluation of
individual performance. Direct observation offers a more accurate assessment of team-related behaviors using trained observers. Observers use
checklists and behaviorally anchored rating scales (BARS) to evaluate
individual and team performance. Checklists and BARS include specific,
observable behaviors reflective of optimal team performance. Teamwork
may also be assessed using survey tools to assess attitudes and teamwork
climate.
12–14
Higher ratings of collaboration and teamwork have been
associated with better patient outcomes in observational studies.
15–17
The
ultimate goal of teamwork efforts is to improve patient outcomes.
However, it is often difficult to clearly link improved outcomes with
teamwork interventions because patient outcomes are affected by a number of factors and because hospitals frequently engage in multiple, simultaneous efforts to improve care.
Examples of Successful Interventions
Team Training
Formal teamwork training programs have been implemented in several clinical environments, including emergency departments, operating rooms,
labor and delivery suites, and intensive care units.
18–21
These “closed” environments provide the advantage of having all providers identify with a unitbased setting, whereas most medical units have the added challenge of
having nurses who are unit-based and physicians (and others) who are often
service-based with patients housed on several different units.
The effectiveness of these teamwork training programs is mixed.
While many demonstrate increased knowledge of teamwork principles,
attitudes about the importance of teamwork, and overall safety climate,
evidence for the ability to improve patient outcomes or reduce errors is less
compelling.
22
In the hospital medicine setting, a multifaceted teamwork
87
Teamwork in Hospital Medicine
training program improved provider safety knowledge and attitudes and
patient perceptions of teamwork and communication.
23–25
Daily Goals of Care
In intensive care unit (ICU) settings, physicians and nurses work in proximity, allowing interdisciplinary discussions to occur at the bedside. The
finding that professionals in operating rooms and ICUs have widely discrepant views on the quality of collaboration
10, 11
indicates that proximity,
alone, is not sufficient for effective communication. Researchers have
used daily goals of care forms for bedside ICU rounds in an effort to standardize communication about the daily plan of care.
26, 27
The forms define
essential goals of care for patients and their use has resulted in significant
improvements in teams’ understanding of those daily goals. The daily
goals forms provide structure to the interdisciplinary conversations during
rounds in order to enhance collaboration and create a shared understanding of patients’ plans of care (i.e. shared mental model).
Interdisciplinary Rounds
Interdisciplinary Rounds (IDRs) have been used for many years as a means
to assemble team members in a single location
28–31
and the use of IDR has
been associated with lower mortality among ICU patients.
32
IDR may be
particularly useful for clinical settings in which team members are traditionally dispersed in time and place. Early research demonstrated improved
ratings of collaboration on the part of physicians.
30,31
Recently, O’Leary
and colleagues studied the effect of Structured Inter-Disciplinary Rounds
(SIDRs).
33,34
SIDR combines a structured format for communication, similar to a daily goals of care form, with a forum for regular interdisciplinary
meetings. The use of SIDR resulted in significantly higher ratings of the
quality of collaboration and teamwork climate on both a non-teaching hospitalist unit and a resident teaching unit. The majority of clinicians in the
studies agreed that SIDR improved patient care, improved the efficiency of
their work day, and that SIDR should continue indefinitely.
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K.J. O’Leary and N.L. Sehgal
Nurse-Physician Unit Co-Leadership
Leadership plays a key role in shaping team culture and norms.35Nursephysician co-leadership is one recommended strategy for a model to
improve the quality and safety of care on hospital units.
36,37
The model
includes a new role, a physician unit leader, who partners with the nurse
manager to collaboratively take ownership for and accountability of care
delivery on that unit. At the University of Pennsylvania Health System,
the model is known as Unit Based Clinical Leadership.
36
Nurse managers and unit physician leaders co-lead weekly IDR, operations meetings, orientation of housestaff, and ongoing performance improvement
projects.
Conclusions
In summary, teamwork is critically important to provide safe and effective
care. Despite the noted challenges in implementation and evaluation, a
number of interventions demonstrate promise for improving teamwork.
Future efforts must carefully measure the impact of efforts to assess their
effectiveness on patient care and also to demonstrate the utility of
resources invested. The optimal approach is implementation of one or
more interventions with adaptations to fit unique clinical settings and
local culture.
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