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Knowing what’s going on: situation awareness and team performance in interprofessional teams
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology. Umeå University, Faculty of Medicine, Department of Nursing.ORCID iD: 0000-0001-7974-6777
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Within critical care, it is necessary to have an awareness ofwhat is going on in order to be able to make the right decision at the right time.Situation awareness (SA) is a non-technical skill (NTS) that is important instressful, complex environments such as the intensive care unit (ICU).Deficiencies in NTS are well known to impact performance and thereby causeadverse events. More knowledge about how background factors are associatedto team performance and explore critical care team members experiencesteamwork are of importance to develop models for improving teamwork. Aneducational intervention aiming to improve SA during critical events might bevaluable to improve the performance of interprofessional teams. For this,instruments for assessment of SA and NTS are needed.

Aim The aim of this thesis was to test different instruments for measuringSA, team performance and task performance for feasibility and reliability; to investigate the relationship between team background characteristics, teamperformance and task performance; to evaluate an educational programme inSA for intensive care teams; and to explore team members’ experience ofteamwork.

Methods This thesis was based on data from 69 different video-recordedteam training sessions with a simulator as a patient (studies I–III) and ninefocus group interviews (Study IV). In Study I, the participants were 55 medicalstudents, and the sessions took place at a clinical training centre. Theparticipants in Study II (n=105) and III (n=75) were ICU staff members fromtwo different hospitals, and the sessions took place in situ at the respectiveICUs. In Study III, the participants were randomized into control orintervention group, where the intervention group received an educationalintervention comprising lectures and reflective discussions. The control grouponly performed team training without lectures and reflective discussions. Thetraining sessions were analysed with a focus on team and task performanceusing the TEAM instrument and the ABCDE checklist, respectively. Inaddition, a questionnaire (SAGAT) was used to assess individuals’ SA (StudyI and III). The data in Study I–III were quantitatively analysed. In Study IV,focus group interviews with staff members (n= 31) from the ICUs wereanalysed using qualitative content analysis.

Results The findings in Study I showed that SAGAT was feasible to use andthat the inter-rater reliability for the ABCDE checklist and the TEAMinstrument indicated sufficient stability. In Study II, higher age wasassociated with several aspects of good team performance such as teamwork,task management, team overall and total team. Prior team training withoutvideo was associated with better task performance, while prior education incommunication was negatively associated with leadership. In Study III, theresults demonstrated that the educational intervention improved theperformance of the intervention group in the TEAM subscales of leadershipand task management, as well as in the total score. In Study IV, the mainfinding presented as a theme was balancing knowledge and behaviour inteamwork. The interviews revealed three categories of aspects that facilitatevor act as barriers to teamwork: (1) having potential for excellence while copingwith members who do not act as team players; (2) creating a safe atmospherewhile working in an unknown environment and struggling to maintain one’spositions; and (3) being in a workflow without becoming overwhelmed.

Conclusions By implementing an educational programme focusing on SA,different parts of interprofessional team performance could be improved. Foroptimal interprofessional teamwork in the ICU, both knowledge andbehaviours were essential components. For the studies in this thesis, thedifferent instruments used were both feasible and reliable. High age wasrelated to good team and task performance, indicating that generic factors thatis associated with age might influence team and task performance.This thesis will probably contribute to a safer care of seriously ill patients at ICU.

Abstract [sv]

Att veta vad som händer vid akuta situationer inom intensivvård av svårt sjuka eller skadade är nödvändigt för att kunna ta rätt beslut vid rätt tidpunkt. Arbetsmiljön på intensivvårdsavdelningar (IVA) beskrivs därför som komplex och kräver välutbildad och erfaren personal. Brister i icke-tekniska färdigheter är ett problem i hälso- och sjukvården och inte minst inom intensivvården. Bristerna påverkar kvalitén i utförandet och orsakar vårdskador. Utifrån erfarenhet och kunskap inom flygindustrin har icketekniska färdigheter börjat komma i fokus inom akutsjukvård och intensivvård. En viktig del i icke-tekniska färdigheter ärsituationsmedvetenhet (eng; situation awareness, SA) och under de senaste årtiondena har modeller för SA och teamarbete utvecklats. I dagsläget finns endast ett fåtal studier som specifikt utvärderar utbildning i SA i interprofessionella team, in situ och med hjälp av simulering. Föreliggandeavhandling har därför fokus på interprofessionella IVA-team, SA och teamprestation och förmåga att hantera och genomföra arbetsuppgifter. 

Avhandlingen omfattar fyra delarbeten. För att genomföra studie II och III krävdes en initial studie (studie I) vars syfte var att kvalitetssäkra tre mätmetoder avseende användbarhet och reliabilitet: dels en teknik för att mäta situationsmedvetenhet (SAGAT), dels ett instrument för att mäta teamets prestation (TEAM instrument) och dels en checklista för att mäta teamets förmåga att hantera arbetsuppgifter (ABCDE checklist). Därefter analyserades relationen mellan teamets bakgrundskaraktäristika och teamets prestation och hantering av arbetsuppgifter (studie II). I studie III utvärderades ett utbildningsprogram med fokus på SA inklusive simuleringsövningar in situ. För att få en djupare förståelse för fenomenet teamarbete inom IVA, genomfördes en intervjustudie där tre personalgrupper som vanligen ingår i IVA-team intervjuades med fokus på erfarenheter om teamarbete.

Deltagarna i delstudie 1 var 55 läkarstudenter på termin sju som fördelades i 23 team. De två följande delstudierna (II och III) omfattade undersköterskor (n=30), sjuksköterskor (n=49) och läkare (n=26) som arbetade vid två intensivvårdsavdelningar vid två olika sjukhus i norra Sverige. Deltagarna i studie III delades slumpmässigt in i 11 team (interventionsgrupp) respektive 9 team (kontrollgrupp). I delstudie IV deltog 31 individer från delstudie II och III fördelade på nio fokusgrupper. 

Interventionen i delstudie III utgjordes av ett kort utbildningsprogram med fokus på att förstå betydelsen av situationsmedvetenhet i teamarbete samt hur den kan uppnås. Den första delen av utbildningen var webbaserad med korta lektioner om situationsmedvetenhet och samarbete varvat med instuderingsuppgifter och reflektionsfrågor. Deltagarna genomförde utbildningen individuellt en vecka före teamträningstillfället. Teamträningstillfället för interventionsgruppen inleddes med en reflektionstimme där olika reaktioner från webutbildningen diskuterades med fokus på hur de olika begreppen skulle omsättas i praktiken. Därefter genomförde teamet ett patientscenario in situ, på en intensivvårdsplats. Efter scenariet återsamlades teamet för en andra reflektion med fokus på hur teamet kan åstadkomma och bibehålla hög situationsmedvetenhet för att gemensamt kunna fatta rätt beslut. Teamträningen avslutades med ytterligare ett patientscenario in situ. Kontrollgruppen teamtränade utan att ha genomfört webutbildningen, utan reflektionen före scenario nummer ett, samt att reflektionen efter scenario nummer ett genomfördes utan specifikt fokus på situationsmedvetenhet.

Vid datainsamlingen till studie I-III genomförde deltagarna teamövningar innefattande olika scenarier med svårt sjuk patient (SimMan, en avancerad patientsimulator). Samtliga teamövningar videofilmades och analyserades avseende teamets samarbete och genomförande av arbetsuppgifter. I studie I och III mättes deltagarnas situationsmedvetenhet med frågeformulär under scenariet. Ett kort uppehåll gjordes där deltagarna svarade på frågor. En vecka efter avslutad övning fick deltagarna i studie I besvara en enkät om hur avbrottet påverkat det pågående scenariet. Data från dessa tre första studier analyserades med hjälp av statistiska metoder. Datainsamlingen till studie IV genomfördes med fokusgruppsintervjuer. Intervjuerna ljudinspelades och analyserades med kvalitativ innehållsanalys. 

Resultatet från studie I visade att det fanns en god samstämmighet mellan de fyra bedömare som skattade teamets prestation. Med hjälp av ett frågeformulär angav studenterna att tekniken som användes för att mäta teamets situationsmedvetenhet var användbart och användarvänligt.

Resultatet i delstudie II visade att det fanns ett positivt samband mellan genomsnittlig ålder och teamets övergripande prestation och samarbete, samt hur teamet prioriterade och hanterade arbetsuppgifter. Vidare visade resultatet att tidigare erfarenhet av att ha tränat i team också innebar bättre förmåga att hantera arbetsuppgifterna. Däremot visade analyserna att tidigare utbildning i kommunikation också innebar sämre ledarskap. 

Huvudresultatet i denna avhandling visar på positiva skillnader i prestation hos team som fått utbildning med fokus på situationsmedvetenhet jämfört med kontrollgruppen som inte fått utbildning. De team som erhållit utbildning presterade bättre. Förbättringen kunde mätas i subskalorna ledarskap och prioritering av arbetsuppgifter. Inga skillnader kunde dock påvisas i situationsmedvetenhet eller i genomförande av arbetsuppgifter. 

I fokusgruppsintervjuerna (delstudie IV) beskrev deltagarna sina erfarenheter av teamarbetet i det interprofessionella teamet som bestod av både främjande och hindrande aspekter: 1) att ha potential för excellens och samtidigt hantera teammedlemmar som inte agerar som lagspelare, 2) att skapa en säker atmosfär och samtidigt arbeta i en okänd omgivning och kämpa för att upprätthålla sin position i teamet, samt 3) att vara i ett flöde av arbetsuppgifter utan att bli överbelastad. Av kategorierna framgår att fenomenet teamarbete handlar om att balansera kunskap och beteende vilket också bildade temat i delstudien. Deltagarna upplevde att det var viktigt att arbeta i en trygg miljö som präglades av respekt och stöd på intensivvårdsavdelningen men även när de arbetade på exempelvis akutmottagningen. Det framkom också att även om arbetet kunde upplevas stressigt och rörigt kunde det ändå finnas ett flyt. 

Sammantaget bidrar avhandlingens resultat till att visa att en utbildning med fokus på situationsmedvetenhet kan förbättra hur team inom intensivvården presterar. Vidare har balansen i kunskap och beteende lyfts fram som viktigt för samarbetet inom teamet. De instrument som använts för att mäta deltagarnas prestationer och situationsmedvetenhet var tillförlitliga och användbara i denna kontext. Slutligen fanns ett positivt samband mellan hög ålder och god teamprestation, samt till genomförande av arbetsuppgifter. Detta samband fanns inte till yrkeserfarenhet vilket antyder att det i bakgrunden skulle kunna finnas någon icke teknisk färdighet som samvarierar med ålder.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2021. , p. 63
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2110
Keywords [en]
Critical care, interprofessional education, leadership, learning, situation awareness, simulation-based team training, team performance, teamwork
National Category
Nursing Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:umu:diva-178076ISBN: 978-91-7855-438-6 (electronic)ISBN: 978-91-7855-437-9 (print)OAI: oai:DiVA.org:umu-178076DiVA, id: diva2:1513483
Public defence
2021-01-29, Aula Biologica, Biologihuset, Umeå universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2021-01-08 Created: 2020-12-30 Last updated: 2023-05-17Bibliographically approved
List of papers
1. Reliability of instruments that measure situation awareness, team performance and task performance in a simulation setting with medical students
Open this publication in new window or tab >>Reliability of instruments that measure situation awareness, team performance and task performance in a simulation setting with medical students
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2019 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 9, no 9, article id e029412Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: The assessment of situation awareness (SA), team performance and task performance in a simulation training session requires reliable and feasible measurement techniques. The objectives of this study were to test the Airways-Breathing-Circulation-Disability-Exposure (ABCDE) checklist and the Team Emergency Assessment Measure (TEAM) for inter-rater reliability, as well as the application of Situation Awareness Global Assessment Technique (SAGAT) for feasibility and internal consistency.

DESIGN: Methodological approach.

SETTING: Data collection during team training using full-scale simulation at a university clinical training centre. The video-recorded scenarios were rated independently by four raters.

PARTICIPANTS: 55 medical students aged 22-40 years in their fourth year of medical studies, during the clerkship in anaesthesiology and critical care medicine, formed 23 different teams. All students answered the SAGAT questionnaires, and of these students, 24 answered the follow-up postsimulation questionnaire (PSQ). TEAM and ABCDE were scored by four professionals.

MEASURES: The ABCDE and TEAM were tested for inter-rater reliability. The feasibility of SAGAT was tested using PSQ. SAGAT was tested for internal consistency both at an individual level (SAGAT) and a team level (Team Situation Awareness Global Assessment Technique (TSAGAT)).

RESULTS: The intraclass correlation was 0.54/0.83 (single/average measurements) for TEAM and 0.55/0.83 for ABCDE. According to the PSQ, the items in SAGAT were rated as relevant to the scenario by 96% of the participants. Cronbach's alpha for SAGAT/TSAGAT for the two scenarios was 0.80/0.83 vs 0.62/0.76, and normed χ² was 1.72 vs 1.62.

CONCLUSION: Task performance, team performance and SA could be purposefully measured, and the reliability of the measurements was good.

Keywords
patient care team, resuscitation, situation awareness, task performance and analysis, teamwork
National Category
Other Medical Sciences not elsewhere specified
Identifiers
urn:nbn:se:umu:diva-163368 (URN)10.1136/bmjopen-2019-029412 (DOI)000497787600184 ()31515425 (PubMedID)2-s2.0-85072144998 (Scopus ID)
Available from: 2019-09-17 Created: 2019-09-17 Last updated: 2023-09-05Bibliographically approved
2. Factors Influencing Team and Task Performance in Intensive Care Teams in a Simulated Scenario
Open this publication in new window or tab >>Factors Influencing Team and Task Performance in Intensive Care Teams in a Simulated Scenario
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2020 (English)In: Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, ISSN 1559-2332, E-ISSN 1559-713X, Vol. 16, no 1, p. 29-36Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Healthcare teams and their performance in a complex environment such as that of intensive care units (ICUs) are influenced by several factors. This study investigates the relationship between team background characteristics and team as well as task performance.

METHODS: This study included 105 professionals (26 teams), working at the ICUs of 2 hospitals in Northern Sweden. The team-based simulation training sessions were video recorded, and thereafter, team performance and task performance were analyzed based on ratings of the TEAM instrument and the ABCDE checklist.

RESULTS: The final analyses showed that a higher age was significantly associated with better total team performance (β = 0.35, P = 0.04), teamwork (β = 0.04, P = 0.04), and task management (β = 0.04, P = 0.05) and with a higher overall rating for global team performance (β = 0.09, P = 0.02). The same pattern was found for the association between age and task performance (β = 0.02, P = 0.04). In addition, prior team training without video-facilitated reflection was significantly associated with better task performance (β = 0.35, P = 0.04). On the other hand, prior team training in communication was significantly associated with worse (β = -1.30, P = 0.02) leadership performance.

CONCLUSIONS: This study reveals that a higher age is important for better team performance when caring for a severely ill patient in a simulation setting in the ICU. In addition, prior team training had a positive impact on task performance. Therefore, on a team level, this study indicates that age and, to some extent, prior team training without video-facilitated reflection have an impact on team performance in the care of critically ill patients.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2020
Keywords
Simulation, nontechnical skills, crisis resource management, clinical competence, teamwork, simulation-based team training, intensive care
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-171296 (URN)10.1097/SIH.0000000000000462 (DOI)000615898000005 ()32433185 (PubMedID)2-s2.0-85101896628 (Scopus ID)
Available from: 2020-06-01 Created: 2020-06-01 Last updated: 2023-09-05Bibliographically approved
3. Do team and task performance improve after training situation awareness?: A randomized controlled study of interprofessional intensive care teams
Open this publication in new window or tab >>Do team and task performance improve after training situation awareness?: A randomized controlled study of interprofessional intensive care teams
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2021 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 29, no 1, article id 73Article in journal (Refereed) Published
Abstract [en]

Background: When working in complex environments with critically ill patients, team performance is influenced by situation awareness in teams. Moreover, improved situation awareness in the teams will probably improve team and task performance. The aim of this study is to evaluate an educational programme on situation awareness for interprofessional teams at the intensive care units using team and task performance as outcomes.

Method: Twenty interprofessional teams from the northern part of Sweden participated in this randomized controlled intervention study conducted in situ in two intensive care units. The study was based on three cases (cases 0, 1 and 2) with patients in a critical situation. The intervention group (n = 11) participated in a two-hour educational programme in situation awareness, including theory, practice, and reflection, while the control group (n = 9) performed the training without education in situation awareness. The outcomes were team performance (TEAM instrument), task performance (ABCDE checklist) and situation awareness (Situation Awareness Global Assessment Technique (SAGAT)). Generalized estimating equation were used to analyse the changes from case 0 to case 2, and from case 1 to case 2.

Results: Education in situation awareness in the intervention group improved TEAM leadership (p = 0.003), TEAM task management (p = 0.018) and TEAM total (p = 0.030) when comparing cases 1 and 2; these significant improvements were not found in the control group. No significant differences were observed in the SAGAT or the ABCDE checklist.

Conclusions: This intervention study shows that a 2-h education in situation awareness improved parts of team performance in an acute care situation. Team leadership and task management improved in the intervention group, which may indicate that the one or several of the components in situation awareness (perception, comprehension and projection) were improved. However, in the present study this potential increase in situation awareness was not detected with SAGAT. Further research is needed to evaluate how educational programs can be used to increase situation awareness in interprofessional ICU teams and to establish which components that are essential in these programs.

Trial registration: This randomized controlled trial was not registered as it does not report the results of health outcomes after a health care intervention on human participants.

Place, publisher, year, edition, pages
BioMed Central, 2021
Keywords
Critical care, Interdisciplinary health team, Leadership, Patient safety, Simulation training, Situation awareness, Team performance
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-177979 (URN)10.1186/s13049-021-00878-2 (DOI)000657440600003 ()34078432 (PubMedID)2-s2.0-85107224687 (Scopus ID)
Funder
Region Västerbotten, VLL-663801Region Västerbotten, VLL-836931Region Västerbotten, RVB-930528The Kempe Foundations
Note

Originally included in thesis in manuscript form with title: "Do team performance and task performance improve in intensive care teams after training situation awareness: a randomized controlled study with in situ simulation team training"

Available from: 2020-12-30 Created: 2020-12-30 Last updated: 2024-01-17Bibliographically approved
4. Balancing between knowledge and behaviour in teamwork-experiences in interprofessional ICU teams
Open this publication in new window or tab >>Balancing between knowledge and behaviour in teamwork-experiences in interprofessional ICU teams
(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-177980 (URN)
Available from: 2020-12-30 Created: 2020-12-30 Last updated: 2023-05-17

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