LWW/JNCQ
JNCQ-D-13-00171
July 26, 2014
23:15
J Nurs Care Qual Vol. 29, No. 4, pp. 363–370 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Sustainability of Improvements in Perinatal Teamwork and Safety Climate Wendy C. Budin, PhD, RN-BC, FAAN; Susan Gennaro, DSN, RN, FAAN; Caitlin O’Connor, MS, RN, CPNP; Flavia Contratti, MS, RN, WHNP-BC, LCCE, CLC The purposes of this study were to describe changes in perinatal nurse (n = 70) and physician (n = 88) perceptions of teamwork and safety climate after implementing a 6-month Crew Resource Management training program and compare responses between nurses and physicians. The Teamwork and Safety Climate Survey was administered prior to and 1 year after the intervention. There were significant improvements in nurse and physician perceptions of teamwork and safety climate; however, physicians perceived teamwork more positive than nurses. Key words: Crew Resource Management, perinatal, safety climate, teamwork team training
C
HILDBIRTH in the United States is a frequent event that for most is long anticipated and results in the happy outcome of a new baby joining the family. Although for many couples, childbirth does have a happy outcome, in the United States, as in other countries, childbirth is not as safe as it could
Author Affiliations: NYU Langone Medical Center/New York University College of Nursing, New York (Dr Budin); William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Gennaro and Ms O’Connor); and NYU Langone Medical Center, New York (Ms Contratti). The authors hereby declare that they have no conflicts of interest, support sources, or funding to disclose. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Wendy C. Budin, PhD, RN-BC, FAAN, NYU Langone Medical Center, New York University College of Nursing, 545 First Ave, Greenberg Hall, SC1, Room 151, New York, NY 10016 (wendy.budin@ nyumc.org). Accepted for publication: April 3, 2014 Published ahead of print: May 7, 2014 DOI: 10.1097/NCQ.0000000000000067
be. In fact, over a period of 20 years, maternal mortality in the United States has risen from 12 maternal deaths per 100 000 live births in 1980 to 17 maternal deaths per 100 000 live births in 2008, with 28% to 50% of maternal deaths estimated to be preventable.1,2 Deaths due to hemorrhage and to complications from chronic diseases may be particularly responsive to changes made to improve teamwork and patient safety culture of perinatal units.1 Other preventable causes of maternal death include pulmonary embolus and failure to adequately monitor and treat blood pressure problems.3 Babies also die, but infant death has remained relatively stable over the past 20 years, with an overall 6.7 infants deaths per 1000 live births in the United States and a 6.2 stillbirth rate per 1000 live births.4 Improving obstetric (OB) safety is a priority, as the most common reason for hospitalization in the United States today is childbirth.5 Many organizations have implemented strategies to improve patient safety.6 One important precursor for improving patient safety is having a climate in which patient safety is valued.7 Patient safety climate encompasses team respect, comfort with reporting errors, 363
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
364
JNCQ-D-13-00171
July 26, 2014
23:15
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2014
fostering appropriate feedback, and open, receptive communication. However, the best way to foster teamwork and a positive patient safety climate among all members of the perinatal team has not yet been determined and the sustainability of programs to improve teamwork and patient safety climate is still in question. Given the current complex perinatal environment in which it has proven difficult to adequately identify and manage pregnancies at risk for poor outcomes,8 attention has turned to optimizing the safety of all women once they are hospitalized for childbirth.9 The American College of Obstetricians and Gynecologists Committee on Patient Safety and Quality Improvement continue to emphasize the importance of incorporating practices to improve the safety of the mothers and babies in their care.10 Therefore, the purposes of this study were to describe changes in nurse and physician perinatal caregiver perceptions of teamwork and safety climate after implementation of a comprehensive 6-month Crew Resource Management (CRM) training program at a large urban academic medical center and to compare responses between nurses and physicians. BACKGROUND A 2011 call to action endorses teamworkbased approaches be implemented in health care, specifically in perinatal units where interdisciplinary personnel often collaborate in caring for patients.11 In OB settings where morbidity and mortality constitute a lowfrequency but high-severity event, perinatal morbidity has been improved by the use of interdisciplinary team training programs including simulation, with a 37% decrease in perinatal morbidity in at least 1 medical center.12 Wagner et al13 found improved perinatal mortality after the implementation of their perinatal safety initiative, a multidisciplinary program that included team training, rounds, educational courses, simulation, and protocol standardization. Team training may also result in fewer malpractice claims and less money
spent on malpractice claims.14 Clearly, perinatal patient safety can be improved but the best ways to create sustainable improvement need further study. Many institutions have seen an increase in collaborative teamwork, resulting in improved patient safety and perceived safety climate following team training. For example, patient safety climate improved by 22% in a large academic medical center through a series of incremental patient safety interventions such as implementing team training programs, defining practice standards, developing the role of a patient safety nurse, starting a patient safety committee, and providing classes on topics such as fetal monitoring.15 However, given that different programs to improve patient safety and patient safety culture have been used and that some of those used to improve teamwork are proprietary,16 it is difficult to compare one set of interventions designed to improve patient safety in OB settings directly with another set of interventions. One type of team training that has been consistently used to improve teamwork is CRM. In a study of 239 nurses, nurse midwives, physicians, and technicians in a large university-affiliated hospital, a 2-day CRM training program was implemented and resulted in a positive change in teamwork and safety climate 1 year later (odds ratio [OR] 2.9, 95% confidence interval [CI] = 1.3-6.3, to OR = 4.7, 95% CI = 1.2-17.2).7 Other CRM programs have included simulation as a training modality.17 Riley et al12 found improved patient outcomes by using a combined in situ simulation and didactic training program. Simulation seems to be effective in training interdisciplinary health care teams that may not be as cost-effective as nonsimulation training.18 It is uncertain how well the improvements that result from simulation training are transferred to clinical practice sites.18 The CRM training in the classroom has the advantage of being more cost-effective to conduct than team training, which also requires simulation, allows more staff members to be trained simultaneously, and has been proven
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
July 26, 2014
23:15
Improvements in Perinatal Teamwork and Safety Climate to be effective.19 However, differences between various team members in perceptions of patient safety climate and improvements in team training have not been examined. In general, participants report high levels of satisfaction with the content and learning methods, noting improved communication, teamwork, and safety climate as a result.7 The effectiveness of team training programs has often been credited to the creation and encouragement of less hierarchical communication.20 As obstetrics requires a multitude of health care providers, physicians, nurses, midwives, and anesthesiologists working together, it is imperative that there is a common language for communicating with each other.21 Team training programs that incorporate interactive team-building exercises and role-playing flatten hierarchy and encourage open communication.22 Responsibilities are determined by task, not rank, and all team members are encouraged to use structured communication methods, including the 2-challenge rule when questioning a particular action, to voice their concerns.15,16 Reducing the hierarchy of team members to promote more fluent communication has led to improved safety because when everyone uses the same language, critical decision making is improved (such as decisions based on fetal monitoring [FHR] or on results from bilirubin screening in newborns).23 Structured communication and standardized processes provide reliability in high-risk OB environments and have decreased both maternal and infant mortality rates in large hospital systems.23 Adverse OB events decreased by 65% as a result of a patient safety program that emphasized communication, specifically regarding fetal assessment and FHR, as a lead component to improve maternal-fetal care in 16 Cincinnati-based perinatal units.21 Communication and standardization have also led to the development of preventive programs, such as postoperative thromboembolic prevention. Prevention programs are another key aspect of patient safety practices.24 Gender and role may make a difference in communication and team training out-
365
comes. Although traditional and simulation CRM training resulted in improved communication between different types of physicians (obstetricians and anesthesiologists),25 physicians and nurses may differ in training outcomes. In a study of 91 maternity staff members, physicians scored higher for attitudes toward safety climate than their nonmedical counterparts; male staff also scored higher than female staff.26 Sexton et al27 found that nurses reported lower levels of satisfaction with the degree of collaboration and teamwork than did physicians. The length of time that CRM is effective in improving teamwork and patient safety climate among health care providers is not known. Although studies have shown that team training effectively improves teamwork and patient safety climate among health care providers, research has not yet determined how long this effect lasts or whether continuous intervention is needed to maintain the change. A large multisite study by Nielsen et al28 found that 4 months after the utilization of a team training program, there was no significant change in perceived patient safety climate resulting from team training sessions of interdisciplinary OB health care providers. Riley et al12 found that safety attitudes did not change over the 2-year course of the study. However, another large tertiary study aimed at reducing perinatal mortality describes increased patient safety climate 18 months after the implementation of its initiative,12 and patient safety climate changes were sustained for over a year in another study.7 Collaborating researchers at the coordinating hospital Beth Israel Deaconess Medical Center suggest that it takes 9 to 12 months before teamwork interventions produced quantifiable improvements in adverse outcomes.28 Regularly scheduled team training intervention programs and interval refresher courses may be necessary to improve sustainability of positive changes in patient safety and patient safety culture. The current study was conducted to determine whether nurses and physicians in an academic medical center
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
366
July 26, 2014
23:15
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2014
differed in their response to CRM team training, how effective the team training was, and whether the results could be sustained for at least 1 year. METHODS Design A pre-post comparative design was used to determine whether there were changes in nurses’ and physicians’ perceptions of teamwork and safety climate 1 year after implementation of the CRM team training program. After institutional review board approval, the Teamwork and Safety Climate Survey27 was administered to eligible perinatal care providers at the beginning of the first 4-hour CRM team training session (T1 ) and again at the 2-hour refresher class (T2 ) 1 year after implementation. Demographic information was also assessed. Sample and setting Data were collected from registered nurses (RNs) (n = 70, T1 ; n = 58, T2 ) and physicians (n = 88, T1 ; n = 46, T2 ) who worked a minimum of 50% of full-time hours in the perinatal units at a large urban academic medical center in the northeast. The Labor & Delivery unit carries out approximately 4600 deliveries per year. There are 3 triage beds, 10 labor & deliver rooms, 3 operating rooms, a 3-bed postanesthesia care unit, and 4 antepartum beds. The mean age of the nurses in the sample was 35.9 years (SD = 11.6), and the mean age of physicians was 38.9 years (SD = 10.3). More than half of the nurses (n = 42; 62.7%) and the physicians (n = 53; 62.8%) worked 7 years or fewer in their specialty. Although the majority of the sample was white, non-Hispanic for both nurses (n = 37; 58.7%) and physician (n = 54; 70%), there were significantly more Asian physicians (n = 17; 22%) than Asian nurses (n = 3; 4.8%) and more black, nonHispanic nurses (n = 15; 23.8%) than black, non-Hispanic physicians (n = 1; 1.3%) (see Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A89)
CRM team training procedure Five nurse-physician teams assigned by the hospital administrator in charge of OB operations attended a 3-day “Train the Trainer” program with CRM consultants to prepare for their roles as team trainers for the rest of the staff. Each nurse-physician team comprised a nurse and a physician member of the OB service line leadership including the OB service chief, chief OB resident, anesthesiologists, nurse managers, assistant nurse managers, clinical nurse specialists, and senior nurse clinicians. These nursephysician teams then were responsible to lead the rest of the staff through the CRM training. Over a 5- to 6-month period following the initial training, the nurse-physician teams provided CRM training to more than 300 members of the interdisciplinary perinatal staff. Each class had no more than 20 to 25 participants, with all disciplines represented. All staff members were required to attend an initial 4-hour class led by a nurse-physician team that included videos, lecture, and role-playing to incorporate the key principles of safety, communication, leadership, shared mental model, and error prevention. This article focuses on findings for nurses and physicians because they were the largest represented groups. Because communication was a key element that needed to improve, it was established that twice each day team meetings would be held with all disciplines present to improve communication and outcomes. The purpose of these meetings, which are in progress, is to review every patient’s status, plan of care, presence of appropriate personnel, and environmental constraints, that is, bed availability in the neonatal intensive care unit and Mother Baby Unit, and to provide the opportunity for cross-monitoring to ensure optimal patient safety. In addition, throughout the day if there are any issues or a patient care situation that concerns the RN or MD, a “huddle” is called to include the primary team, safety officer, charge nurse, and/or leadership to discuss and decide on a plan that is agreeable to
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
July 26, 2014
23:15
Improvements in Perinatal Teamwork and Safety Climate all. Should no agreement occur, then a chain of command is initiated. During the implementation, nurses and physicians identified the need for additional equipment and supplies. For example, 4 large flat screen TVs were purchased to support huddles, handoffs, situational awareness, and cross-monitoring. Another recommendation was to create and support the role of a medical safety officer. The safety officer is an attending obstetrician who provides 24/7 coverage on the unit, collaborating with nursing leadership to provide patient safety and optimal patient and staff satisfaction through communication and improved teamwork. There are currently 4 safety officers who rotate to provide 24/7 coverage. Some examples of how the safety officer might advocate for safety are by ensuring that physicians do not induce labor before 39 weeks, encouraging obstetricians to discontinue Pitocin when fetal heart tracing are nonreassuring, and assisting with huddles and briefings. After 1 year, all team members attended a mandatory 2-hour refresher class to reinforce and sustain the principles learned. Instrument The Teamwork and the Safety Climate subscales of Safety Attitudes Questionnaire (SAQ),27,29 were used in this study. Teamwork (6 items) was defined as the “perceived quality of collaboration between personnel.” Safety Climate (7 items) was defined as “perceptions of a strong and proactive organizational commitment to safety.” An example item for Teamwork is “Disagreements in this clinical area are resolved appropriately” and an example item for Safety Climate is “I would feel perfectly safe being treated here as a patient.” Each statement was rated using a 5-point Likert scale from disagree strongly to agree strongly. As prescribed by Sexton et al,27 we converted responses to a 100-point measurement as follows: disagree strongly = 0; disagree slightly = 25; neutral = 50; agree slightly = 75; and agree strongly = 100. We reversed the valence of the 2 negatively worded items. For respondent surveys with 4
367
or fewer missed or skipped items, we used item mean substitution to impute the item mean. We calculated the mean domain score for Teamwork and Safety Climate by totaling domain item scores and dividing by the total number of domain items. Composite scale reliability for the overall SAQ was assessed via the Raykov P coefficient. The P value for the SAQ was .90, indicating strong reliability. The Teamwork and Safety Climate subscales also demonstrated sound psychometric properties. The coefficient α values for each ranged from .72 to .89 in a variety of samples. The internal consistency results, in conjunction with the confirmatory factor analysis results, demonstrate that SAQ has good psychometric properties.29 Data analysis Because the survey was anonymous, there was no way to match responses; therefore, independent t tests were performed to determine whether there were differences in perceptions of teamwork and safety climate 1 year after implementation of the team training. In addition, ancillary analyses were performed using 1-sample t tests to determine whether levels of teamwork and safety climate differed in this large academic medical center from benchmarking data collected from similar types of medical centers as described by Sexton et al.29 RESULTS Results indicate a significant improvement in nurses’ perceptions of teamwork (t = −7.211, P = .000) and safety climate (t = −7.311, P = .000) 1 year after implementation of the CRM team training program. Physicians also showed a significant improvement for both teamwork (t = −7.277, P = .000) and safety climate (t = −5.823, P = .000) (Table 1). Prior to the intervention, physicians perceived teamwork climate to be significantly more positive (mean = 66.49, SD = 14.74) than nurses (mean = 55.60, SD = 14.36) (t = 4.67, P = .000), and postintervention physicians still rated
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
368
July 26, 2014
23:15
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2014
Table 1. Changes in Nurses’ and Physicians’ Perceptions of Teamwork and Safety Climate After CRM Team Training Data Collection Time
Nurse Teamwork Safety Climate Physician Teamwork Safety Climate aP
Time 1, M (SD)
Time 2, M (SD)
t
df
55.60 (14.36) 56.64 (15.85)
102.86 (74.33) 76.68 (14.93)
− 7.211a − 7.311a
126 126
66.49 (14.74) 60.48 (16.47)
85.44 (13.46) 77.70 (15.81)
− 7.277a − 5.823a
132 132
< .000. Time 1: nurse, n = 70; physician: n = 88. Time 2: nurse, n = 58; physician, n = 46.
teamwork more positive (mean = 85.44, SD = 13.46) than nurses (mean = 74.33, SD = 14.95) (t = 3.931, P = .000). There were no significant differences in perceptions of safety climate between nurses and physicians either before or after intervention (Table 2). Ancillary analyses consisting of a series of 1-sample t tests were also performed to compare results of this study sample of nurse and physician perinatal caregivers with other samples that Sexton et al29 used for benchmarking purposes. When compared with a large sample of nurses and physicians working in a variety of inpatient settings (11 sites, N = 1532), the postintervention mean for Teamwork for our study sample (79.0, SD =
15.88) was significantly more positive than the mean (64.3, SD = 16.6) of the comparative benchmark sample (t = 10.27, P = .000). When compared with the mean (65.7, SD = 9.0) of a benchmark sample of US intensive care unit caregivers (53 sites, N = 3029), the postintervention mean of our sample (79.07, SD = 15.8) was also significantly more positive (t = 9.3, P = .000). For Safety Climate, the current sample mean (77.2, SD = 15.40) was also significantly more positive than the means for both the benchmark sample of US caregivers in inpatient units (60.6, SD = 16.0) and the mean for the benchmark sample of US intensive care unit caregivers (68.8, SD = 17.4) (t = 6.05, P = .000).
Table 2. Comparison Between Nurses’ and Physicians’ Perceptions of Teamwork and Safety Climate Pre- and Postintervention Role
Time 1: Preintervention Teamwork Safety Climate Time 2: Postintervention Teamwork Safety Climate aP
Nurse, M (SD)
Physician, M (SD)
t
df
55.60 (14.36) 56.64 (15.85)
66.49 (14.74) 60.48 (16.47)
4.67a 1.48
156 156
74.33 (14.95) 76.68 (14.93)
85.44 (13.46) 77.70 (15.81)
3.931a 0.336
102 102
< .000. Time 1: nurse, n = 70; physician: n = 88. Time 2: nurse, n = 58; physician, n = 46.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
July 26, 2014
23:15
Improvements in Perinatal Teamwork and Safety Climate DISCUSSION In this study, as in previous work, team training,7 in the form of a CRM program, resulted in improved perceptions of teamwork and patient safety climate that was sustained for at least a year. Baseline patient safety climate and perceptions of teamwork were high in this sample compared with national samples used for benchmarking purposes. It is, therefore, worth noting that 1 year of sustained improvements in both perceptions of teamwork and perceptions of patient safety climate occurred, given the relatively high baseline for both these factors. The improvements in teamwork and patient safety climate occurred for both nurses and physicians. However, as in other studies,20,27 nurses had lower levels of perceptions of teamwork than their physician counterparts. As a result of the CRM program, the sustained changes in teamwork and patient safety climate up to 1 year occurred without needing to do costly simulation as part of the training. The impact of this lowtech CRM training through a 4-hour class with a 2-hour booster is noteworthy. The content on teamwork and patient safety emphasized in the CRM training led the physicians and nurses in this perinatal area to collaboratively implement other interventions to ensure continued patient safety such as the patient safety officer, huddles, and other sustainable forms of open communication. The differences in the various other interventions to improve pa-
369
tient safety and patient safety climate make it difficult to compare one set of interventions against another as Sundar et al16 indicate, but at the same time, they support the ability of a specific set of interventions to change the climate in a unit so that changes are sustained. The assessment that open communication was a challenge in this unit led to the implementation of all the communication interventions (flat screen TVs, huddles, joint rounds, and safety officer) that were successful in ensuring that a high patient safety climate was maintained. For medical centers that want to implement team training and patient safety interventions, a careful examination of a business plan is important in ensuring that resources to support patient safety climate changes can be adequately implemented. One limitation of this study is that perceptions of patient safety climate were measured rather than actual changes in patient outcomes. Also, because the study occurred in an academic teaching hospital with a high patient volume in the northeast, the finding may not be generalized to other settings. It is possible that this intervention might not have had the same result in another type of hospital, because as part of a large academic teaching hospital, there were a large number of educationally well-prepared nurses working on the unit (with at least a BSN degree). Finally, we would have liked to have compared other team members with nurses and physicians but did not have enough participants to make statistical assessment meaningful.
REFERENCES 1. Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol. 2005;106(6):1228-1234. 2. Clark SL, Belfort MA, Dildy GA, et al. Maternal deaths in the 21st century: causes, prevention and relationship to cesarean delivery. Am J Obstet Gynecol. 2008;199(1):36c1-36c5. 3. Pronovost P, Holzmueller C, Ennen C, et al. Overview of progress in patient safety. Am J Obstet Gynecol. 2011;204(1):5-10.
4. Spong C, Iam J, Goldenberg R, et al. Disparities in perinatal medicine: preterm birth, stillbirth, and infant mortality. Obstet Gynecol. 2011;117(4):948-955. 5. Russo CA, Wier L, Steiner C. Hospitalizations related to childbirth, 2006. http://www.hcupus.ahrq.gov/ reports/statbriefs/sb71.pdf. Published April 2009. Accessed February 21, 2013. 6. Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(6): 47-52.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
370
JNCQ-D-13-00171
July 26, 2014
23:15
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2014
7. Haller G, Garnerin P, Morales MA, et al. Effect of Crew Resource Management training in a multidisciplinary obstetrical setting. Int J Qual Health Care. 2008;20(4):254-263. 8. Davey M, Watson L, Rayner JA, et al. Risk scoring systems for predicting preterm birth with the aim of reducing associated adverse outcomes. Cochrane Database Syst Rev. 2011;(11):CD004902. 9. Baker D, Gustafson S, Beaubien J, et al. Medical Teamwork and Patient Safety: The Evidenced Based Relation. American Institutes for Research Final Report. Rockville, MD: Agency for Healthcare Research and Quality; 2003. 10. Patient Safety in Obstetrics and Gynecology. ACOG Committee opinion no. 447.American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114:1424-1427. 11. The Association of Women’s Health, Obstetric and Neonatal Nurses. Quality patient care in labor and delivery: a call to action. J Obstet Gynecol Neonatal Nurs. 2012;41(1):151-153. 12. Riley W, Davis S, Miller K, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm Qual Patient Saf. 2011;37(8):357-364. 13. Wagner B, Meirowitz N, Shah J, et al. Comprehensive perinatal safety initiative to reduce adverse obstetric events. J Healthc Qual. 2012;34(1):6-15. 14. Mann S, Marcus R, Sachs B. Lessons from the cockpit: how team training can reduce errors on L&D. Contemp OB/GYN. 2006;51(1):1-7. 15. Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol. 2009;200(5):492.e1-492.e8. 16. Sundar E, Sundar S, Pawlowski J, et al. Crew resource management and team training. Anesthesiol Clin. 2007;25(2):283-300. 17. Meri´en AER, van de Ven J, Mol BW, et al. Multidisciplinary team training in a simulation setting for acute obstetric emergencies. Obstet Gynecol. 2010; 115:1021-1031. 18. Freeth D, Ayida G, Berridge EJ, et al. Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES):
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
promoting patient safety in obstetrics with teamworkfocused interprofessional simulations. J Contin Educ Health Prof. 2009;29(2):98-104. Pratt SD, Sachs BP. Team training: classroom training vs. high fidelity simulation. http://www.racgp .org.au/afp/200709/18554.Published March 2006. Accessed February 21, 2013. Simpson K, James D, Knox E. Nurse-physician communication during labor and birth: implications for patient safety. J Obstet Gynecol Neonatal Nurs. 2006;35(4):547-556. Simpson K, Kortz C, Knox E. A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and cost of liability claims. Jt Comm J Qual Patient Saf. 2009;35(11):565-574. Roberston B, Schumacher L, Gosman G, et al. Simulation-based crisis team training for multidisciplinary obstetric providers. Simul Healthc. 2009;4(2):77-83. Guise J, Segal S. Teamwork in obstetric critical care. Best Pract Res Clin Obstet Gynecol. 2008;22(5):937– 951. Clark SL, Meyers J, Frye DK, et al. Patient safety in obstetrics—the Hospital Corporation of America experience. Am J Obstet Gynecol. 2011;207(6):283-287. Kirshbaum K, Rask J, Brennan M, et al. Improved climate, culture, and communication through multidisciplinary training and instruction. Am J Obstet Gynecol. 2012;207(3):e1-e7. Siassakos D, Fox R, Hunt L, et al. Attitudes towards safety and teamwork in a maternity unit with embedded team training. Am J Med Qual. 2010;26(2):132137. Sexton J, Holzmueller C, Pronovost P, et al. Variation in caregiver perception of teamwork climate in labor and delivery units. J Perinatol. 2006;26(8):463-470. Nielsen P, Goldman M, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol. 2007;109(1):48-55. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44-53.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JNCQ-D-13-00171
July 26, 2014
23:15
J Nurs Care Qual Vol. 29, No. 4, pp. 363–370 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Sustainability of Improvements in Perinatal Teamwork and Safety Climate Wendy C. Budin, PhD, RN-BC, FAAN; Susan Gennaro, DSN, RN, FAAN; Caitlin O’Connor, MS, RN, CPNP; Flavia Contratti, MS, RN, WHNP-BC, LCCE, CLC The purposes of this study were to describe changes in perinatal nurse (n = 70) and physician (n = 88) perceptions of teamwork and safety climate after implementing a 6-month Crew Resource Management training program and compare responses between nurses and physicians. The Teamwork and Safety Climate Survey was administered prior to and 1 year after the intervention. There were significant improvements in nurse and physician perceptions of teamwork and safety climate; however, physicians perceived teamwork more positive than nurses. Key words: Crew Resource Management, perinatal, safety climate, teamwork team training
C
HILDBIRTH in the United States is a frequent event that for most is long anticipated and results in the happy outcome of a new baby joining the family. Although for many couples, childbirth does have a happy outcome, in the United States, as in other countries, childbirth is not as safe as it could
Author Affiliations: NYU Langone Medical Center/New York University College of Nursing, New York (Dr Budin); William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Gennaro and Ms O’Connor); and NYU Langone Medical Center, New York (Ms Contratti). The authors hereby declare that they have no conflicts of interest, support sources, or funding to disclose. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Wendy C. Budin, PhD, RN-BC, FAAN, NYU Langone Medical Center, New York University College of Nursing, 545 First Ave, Greenberg Hall, SC1, Room 151, New York, NY 10016 (wendy.budin@ nyumc.org). Accepted for publication: April 3, 2014 Published ahead of print: May 7, 2014 DOI: 10.1097/NCQ.0000000000000067
be. In fact, over a period of 20 years, maternal mortality in the United States has risen from 12 maternal deaths per 100 000 live births in 1980 to 17 maternal deaths per 100 000 live births in 2008, with 28% to 50% of maternal deaths estimated to be preventable.1,2 Deaths due to hemorrhage and to complications from chronic diseases may be particularly responsive to changes made to improve teamwork and patient safety culture of perinatal units.1 Other preventable causes of maternal death include pulmonary embolus and failure to adequately monitor and treat blood pressure problems.3 Babies also die, but infant death has remained relatively stable over the past 20 years, with an overall 6.7 infants deaths per 1000 live births in the United States and a 6.2 stillbirth rate per 1000 live births.4 Improving obstetric (OB) safety is a priority, as the most common reason for hospitalization in the United States today is childbirth.5 Many organizations have implemented strategies to improve patient safety.6 One important precursor for improving patient safety is having a climate in which patient safety is valued.7 Patient safety climate encompasses team respect, comfort with reporting errors, 363
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
364
JNCQ-D-13-00171
July 26, 2014
23:15
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2014
fostering appropriate feedback, and open, receptive communication. However, the best way to foster teamwork and a positive patient safety climate among all members of the perinatal team has not yet been determined and the sustainability of programs to improve teamwork and patient safety climate is still in question. Given the current complex perinatal environment in which it has proven difficult to adequately identify and manage pregnancies at risk for poor outcomes,8 attention has turned to optimizing the safety of all women once they are hospitalized for childbirth.9 The American College of Obstetricians and Gynecologists Committee on Patient Safety and Quality Improvement continue to emphasize the importance of incorporating practices to improve the safety of the mothers and babies in their care.10 Therefore, the purposes of this study were to describe changes in nurse and physician perinatal caregiver perceptions of teamwork and safety climate after implementation of a comprehensive 6-month Crew Resource Management (CRM) training program at a large urban academic medical center and to compare responses between nurses and physicians. BACKGROUND A 2011 call to action endorses teamworkbased approaches be implemented in health care, specifically in perinatal units where interdisciplinary personnel often collaborate in caring for patients.11 In OB settings where morbidity and mortality constitute a lowfrequency but high-severity event, perinatal morbidity has been improved by the use of interdisciplinary team training programs including simulation, with a 37% decrease in perinatal morbidity in at least 1 medical center.12 Wagner et al13 found improved perinatal mortality after the implementation of their perinatal safety initiative, a multidisciplinary program that included team training, rounds, educational courses, simulation, and protocol standardization. Team training may also result in fewer malpractice claims and less money
spent on malpractice claims.14 Clearly, perinatal patient safety can be improved but the best ways to create sustainable improvement need further study. Many institutions have seen an increase in collaborative teamwork, resulting in improved patient safety and perceived safety climate following team training. For example, patient safety climate improved by 22% in a large academic medical center through a series of incremental patient safety interventions such as implementing team training programs, defining practice standards, developing the role of a patient safety nurse, starting a patient safety committee, and providing classes on topics such as fetal monitoring.15 However, given that different programs to improve patient safety and patient safety culture have been used and that some of those used to improve teamwork are proprietary,16 it is difficult to compare one set of interventions designed to improve patient safety in OB settings directly with another set of interventions. One type of team training that has been consistently used to improve teamwork is CRM. In a study of 239 nurses, nurse midwives, physicians, and technicians in a large university-affiliated hospital, a 2-day CRM training program was implemented and resulted in a positive change in teamwork and safety climate 1 year later (odds ratio [OR] 2.9, 95% confidence interval [CI] = 1.3-6.3, to OR = 4.7, 95% CI = 1.2-17.2).7 Other CRM programs have included simulation as a training modality.17 Riley et al12 found improved patient outcomes by using a combined in situ simulation and didactic training program. Simulation seems to be effective in training interdisciplinary health care teams that may not be as cost-effective as nonsimulation training.18 It is uncertain how well the improvements that result from simulation training are transferred to clinical practice sites.18 The CRM training in the classroom has the advantage of being more cost-effective to conduct than team training, which also requires simulation, allows more staff members to be trained simultaneously, and has been proven
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
July 26, 2014
23:15
Improvements in Perinatal Teamwork and Safety Climate to be effective.19 However, differences between various team members in perceptions of patient safety climate and improvements in team training have not been examined. In general, participants report high levels of satisfaction with the content and learning methods, noting improved communication, teamwork, and safety climate as a result.7 The effectiveness of team training programs has often been credited to the creation and encouragement of less hierarchical communication.20 As obstetrics requires a multitude of health care providers, physicians, nurses, midwives, and anesthesiologists working together, it is imperative that there is a common language for communicating with each other.21 Team training programs that incorporate interactive team-building exercises and role-playing flatten hierarchy and encourage open communication.22 Responsibilities are determined by task, not rank, and all team members are encouraged to use structured communication methods, including the 2-challenge rule when questioning a particular action, to voice their concerns.15,16 Reducing the hierarchy of team members to promote more fluent communication has led to improved safety because when everyone uses the same language, critical decision making is improved (such as decisions based on fetal monitoring [FHR] or on results from bilirubin screening in newborns).23 Structured communication and standardized processes provide reliability in high-risk OB environments and have decreased both maternal and infant mortality rates in large hospital systems.23 Adverse OB events decreased by 65% as a result of a patient safety program that emphasized communication, specifically regarding fetal assessment and FHR, as a lead component to improve maternal-fetal care in 16 Cincinnati-based perinatal units.21 Communication and standardization have also led to the development of preventive programs, such as postoperative thromboembolic prevention. Prevention programs are another key aspect of patient safety practices.24 Gender and role may make a difference in communication and team training out-
365
comes. Although traditional and simulation CRM training resulted in improved communication between different types of physicians (obstetricians and anesthesiologists),25 physicians and nurses may differ in training outcomes. In a study of 91 maternity staff members, physicians scored higher for attitudes toward safety climate than their nonmedical counterparts; male staff also scored higher than female staff.26 Sexton et al27 found that nurses reported lower levels of satisfaction with the degree of collaboration and teamwork than did physicians. The length of time that CRM is effective in improving teamwork and patient safety climate among health care providers is not known. Although studies have shown that team training effectively improves teamwork and patient safety climate among health care providers, research has not yet determined how long this effect lasts or whether continuous intervention is needed to maintain the change. A large multisite study by Nielsen et al28 found that 4 months after the utilization of a team training program, there was no significant change in perceived patient safety climate resulting from team training sessions of interdisciplinary OB health care providers. Riley et al12 found that safety attitudes did not change over the 2-year course of the study. However, another large tertiary study aimed at reducing perinatal mortality describes increased patient safety climate 18 months after the implementation of its initiative,12 and patient safety climate changes were sustained for over a year in another study.7 Collaborating researchers at the coordinating hospital Beth Israel Deaconess Medical Center suggest that it takes 9 to 12 months before teamwork interventions produced quantifiable improvements in adverse outcomes.28 Regularly scheduled team training intervention programs and interval refresher courses may be necessary to improve sustainability of positive changes in patient safety and patient safety culture. The current study was conducted to determine whether nurses and physicians in an academic medical center
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
366
July 26, 2014
23:15
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2014
differed in their response to CRM team training, how effective the team training was, and whether the results could be sustained for at least 1 year. METHODS Design A pre-post comparative design was used to determine whether there were changes in nurses’ and physicians’ perceptions of teamwork and safety climate 1 year after implementation of the CRM team training program. After institutional review board approval, the Teamwork and Safety Climate Survey27 was administered to eligible perinatal care providers at the beginning of the first 4-hour CRM team training session (T1 ) and again at the 2-hour refresher class (T2 ) 1 year after implementation. Demographic information was also assessed. Sample and setting Data were collected from registered nurses (RNs) (n = 70, T1 ; n = 58, T2 ) and physicians (n = 88, T1 ; n = 46, T2 ) who worked a minimum of 50% of full-time hours in the perinatal units at a large urban academic medical center in the northeast. The Labor & Delivery unit carries out approximately 4600 deliveries per year. There are 3 triage beds, 10 labor & deliver rooms, 3 operating rooms, a 3-bed postanesthesia care unit, and 4 antepartum beds. The mean age of the nurses in the sample was 35.9 years (SD = 11.6), and the mean age of physicians was 38.9 years (SD = 10.3). More than half of the nurses (n = 42; 62.7%) and the physicians (n = 53; 62.8%) worked 7 years or fewer in their specialty. Although the majority of the sample was white, non-Hispanic for both nurses (n = 37; 58.7%) and physician (n = 54; 70%), there were significantly more Asian physicians (n = 17; 22%) than Asian nurses (n = 3; 4.8%) and more black, nonHispanic nurses (n = 15; 23.8%) than black, non-Hispanic physicians (n = 1; 1.3%) (see Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A89)
CRM team training procedure Five nurse-physician teams assigned by the hospital administrator in charge of OB operations attended a 3-day “Train the Trainer” program with CRM consultants to prepare for their roles as team trainers for the rest of the staff. Each nurse-physician team comprised a nurse and a physician member of the OB service line leadership including the OB service chief, chief OB resident, anesthesiologists, nurse managers, assistant nurse managers, clinical nurse specialists, and senior nurse clinicians. These nursephysician teams then were responsible to lead the rest of the staff through the CRM training. Over a 5- to 6-month period following the initial training, the nurse-physician teams provided CRM training to more than 300 members of the interdisciplinary perinatal staff. Each class had no more than 20 to 25 participants, with all disciplines represented. All staff members were required to attend an initial 4-hour class led by a nurse-physician team that included videos, lecture, and role-playing to incorporate the key principles of safety, communication, leadership, shared mental model, and error prevention. This article focuses on findings for nurses and physicians because they were the largest represented groups. Because communication was a key element that needed to improve, it was established that twice each day team meetings would be held with all disciplines present to improve communication and outcomes. The purpose of these meetings, which are in progress, is to review every patient’s status, plan of care, presence of appropriate personnel, and environmental constraints, that is, bed availability in the neonatal intensive care unit and Mother Baby Unit, and to provide the opportunity for cross-monitoring to ensure optimal patient safety. In addition, throughout the day if there are any issues or a patient care situation that concerns the RN or MD, a “huddle” is called to include the primary team, safety officer, charge nurse, and/or leadership to discuss and decide on a plan that is agreeable to
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
July 26, 2014
23:15
Improvements in Perinatal Teamwork and Safety Climate all. Should no agreement occur, then a chain of command is initiated. During the implementation, nurses and physicians identified the need for additional equipment and supplies. For example, 4 large flat screen TVs were purchased to support huddles, handoffs, situational awareness, and cross-monitoring. Another recommendation was to create and support the role of a medical safety officer. The safety officer is an attending obstetrician who provides 24/7 coverage on the unit, collaborating with nursing leadership to provide patient safety and optimal patient and staff satisfaction through communication and improved teamwork. There are currently 4 safety officers who rotate to provide 24/7 coverage. Some examples of how the safety officer might advocate for safety are by ensuring that physicians do not induce labor before 39 weeks, encouraging obstetricians to discontinue Pitocin when fetal heart tracing are nonreassuring, and assisting with huddles and briefings. After 1 year, all team members attended a mandatory 2-hour refresher class to reinforce and sustain the principles learned. Instrument The Teamwork and the Safety Climate subscales of Safety Attitudes Questionnaire (SAQ),27,29 were used in this study. Teamwork (6 items) was defined as the “perceived quality of collaboration between personnel.” Safety Climate (7 items) was defined as “perceptions of a strong and proactive organizational commitment to safety.” An example item for Teamwork is “Disagreements in this clinical area are resolved appropriately” and an example item for Safety Climate is “I would feel perfectly safe being treated here as a patient.” Each statement was rated using a 5-point Likert scale from disagree strongly to agree strongly. As prescribed by Sexton et al,27 we converted responses to a 100-point measurement as follows: disagree strongly = 0; disagree slightly = 25; neutral = 50; agree slightly = 75; and agree strongly = 100. We reversed the valence of the 2 negatively worded items. For respondent surveys with 4
367
or fewer missed or skipped items, we used item mean substitution to impute the item mean. We calculated the mean domain score for Teamwork and Safety Climate by totaling domain item scores and dividing by the total number of domain items. Composite scale reliability for the overall SAQ was assessed via the Raykov P coefficient. The P value for the SAQ was .90, indicating strong reliability. The Teamwork and Safety Climate subscales also demonstrated sound psychometric properties. The coefficient α values for each ranged from .72 to .89 in a variety of samples. The internal consistency results, in conjunction with the confirmatory factor analysis results, demonstrate that SAQ has good psychometric properties.29 Data analysis Because the survey was anonymous, there was no way to match responses; therefore, independent t tests were performed to determine whether there were differences in perceptions of teamwork and safety climate 1 year after implementation of the team training. In addition, ancillary analyses were performed using 1-sample t tests to determine whether levels of teamwork and safety climate differed in this large academic medical center from benchmarking data collected from similar types of medical centers as described by Sexton et al.29 RESULTS Results indicate a significant improvement in nurses’ perceptions of teamwork (t = −7.211, P = .000) and safety climate (t = −7.311, P = .000) 1 year after implementation of the CRM team training program. Physicians also showed a significant improvement for both teamwork (t = −7.277, P = .000) and safety climate (t = −5.823, P = .000) (Table 1). Prior to the intervention, physicians perceived teamwork climate to be significantly more positive (mean = 66.49, SD = 14.74) than nurses (mean = 55.60, SD = 14.36) (t = 4.67, P = .000), and postintervention physicians still rated
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
368
July 26, 2014
23:15
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2014
Table 1. Changes in Nurses’ and Physicians’ Perceptions of Teamwork and Safety Climate After CRM Team Training Data Collection Time
Nurse Teamwork Safety Climate Physician Teamwork Safety Climate aP
Time 1, M (SD)
Time 2, M (SD)
t
df
55.60 (14.36) 56.64 (15.85)
102.86 (74.33) 76.68 (14.93)
− 7.211a − 7.311a
126 126
66.49 (14.74) 60.48 (16.47)
85.44 (13.46) 77.70 (15.81)
− 7.277a − 5.823a
132 132
< .000. Time 1: nurse, n = 70; physician: n = 88. Time 2: nurse, n = 58; physician, n = 46.
teamwork more positive (mean = 85.44, SD = 13.46) than nurses (mean = 74.33, SD = 14.95) (t = 3.931, P = .000). There were no significant differences in perceptions of safety climate between nurses and physicians either before or after intervention (Table 2). Ancillary analyses consisting of a series of 1-sample t tests were also performed to compare results of this study sample of nurse and physician perinatal caregivers with other samples that Sexton et al29 used for benchmarking purposes. When compared with a large sample of nurses and physicians working in a variety of inpatient settings (11 sites, N = 1532), the postintervention mean for Teamwork for our study sample (79.0, SD =
15.88) was significantly more positive than the mean (64.3, SD = 16.6) of the comparative benchmark sample (t = 10.27, P = .000). When compared with the mean (65.7, SD = 9.0) of a benchmark sample of US intensive care unit caregivers (53 sites, N = 3029), the postintervention mean of our sample (79.07, SD = 15.8) was also significantly more positive (t = 9.3, P = .000). For Safety Climate, the current sample mean (77.2, SD = 15.40) was also significantly more positive than the means for both the benchmark sample of US caregivers in inpatient units (60.6, SD = 16.0) and the mean for the benchmark sample of US intensive care unit caregivers (68.8, SD = 17.4) (t = 6.05, P = .000).
Table 2. Comparison Between Nurses’ and Physicians’ Perceptions of Teamwork and Safety Climate Pre- and Postintervention Role
Time 1: Preintervention Teamwork Safety Climate Time 2: Postintervention Teamwork Safety Climate aP
Nurse, M (SD)
Physician, M (SD)
t
df
55.60 (14.36) 56.64 (15.85)
66.49 (14.74) 60.48 (16.47)
4.67a 1.48
156 156
74.33 (14.95) 76.68 (14.93)
85.44 (13.46) 77.70 (15.81)
3.931a 0.336
102 102
< .000. Time 1: nurse, n = 70; physician: n = 88. Time 2: nurse, n = 58; physician, n = 46.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00171
July 26, 2014
23:15
Improvements in Perinatal Teamwork and Safety Climate DISCUSSION In this study, as in previous work, team training,7 in the form of a CRM program, resulted in improved perceptions of teamwork and patient safety climate that was sustained for at least a year. Baseline patient safety climate and perceptions of teamwork were high in this sample compared with national samples used for benchmarking purposes. It is, therefore, worth noting that 1 year of sustained improvements in both perceptions of teamwork and perceptions of patient safety climate occurred, given the relatively high baseline for both these factors. The improvements in teamwork and patient safety climate occurred for both nurses and physicians. However, as in other studies,20,27 nurses had lower levels of perceptions of teamwork than their physician counterparts. As a result of the CRM program, the sustained changes in teamwork and patient safety climate up to 1 year occurred without needing to do costly simulation as part of the training. The impact of this lowtech CRM training through a 4-hour class with a 2-hour booster is noteworthy. The content on teamwork and patient safety emphasized in the CRM training led the physicians and nurses in this perinatal area to collaboratively implement other interventions to ensure continued patient safety such as the patient safety officer, huddles, and other sustainable forms of open communication. The differences in the various other interventions to improve pa-
369
tient safety and patient safety climate make it difficult to compare one set of interventions against another as Sundar et al16 indicate, but at the same time, they support the ability of a specific set of interventions to change the climate in a unit so that changes are sustained. The assessment that open communication was a challenge in this unit led to the implementation of all the communication interventions (flat screen TVs, huddles, joint rounds, and safety officer) that were successful in ensuring that a high patient safety climate was maintained. For medical centers that want to implement team training and patient safety interventions, a careful examination of a business plan is important in ensuring that resources to support patient safety climate changes can be adequately implemented. One limitation of this study is that perceptions of patient safety climate were measured rather than actual changes in patient outcomes. Also, because the study occurred in an academic teaching hospital with a high patient volume in the northeast, the finding may not be generalized to other settings. It is possible that this intervention might not have had the same result in another type of hospital, because as part of a large academic teaching hospital, there were a large number of educationally well-prepared nurses working on the unit (with at least a BSN degree). Finally, we would have liked to have compared other team members with nurses and physicians but did not have enough participants to make statistical assessment meaningful.
REFERENCES 1. Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol. 2005;106(6):1228-1234. 2. Clark SL, Belfort MA, Dildy GA, et al. Maternal deaths in the 21st century: causes, prevention and relationship to cesarean delivery. Am J Obstet Gynecol. 2008;199(1):36c1-36c5. 3. Pronovost P, Holzmueller C, Ennen C, et al. Overview of progress in patient safety. Am J Obstet Gynecol. 2011;204(1):5-10.
4. Spong C, Iam J, Goldenberg R, et al. Disparities in perinatal medicine: preterm birth, stillbirth, and infant mortality. Obstet Gynecol. 2011;117(4):948-955. 5. Russo CA, Wier L, Steiner C. Hospitalizations related to childbirth, 2006. http://www.hcupus.ahrq.gov/ reports/statbriefs/sb71.pdf. Published April 2009. Accessed February 21, 2013. 6. Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(6): 47-52.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
370
JNCQ-D-13-00171
July 26, 2014
23:15
JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2014
7. Haller G, Garnerin P, Morales MA, et al. Effect of Crew Resource Management training in a multidisciplinary obstetrical setting. Int J Qual Health Care. 2008;20(4):254-263. 8. Davey M, Watson L, Rayner JA, et al. Risk scoring systems for predicting preterm birth with the aim of reducing associated adverse outcomes. Cochrane Database Syst Rev. 2011;(11):CD004902. 9. Baker D, Gustafson S, Beaubien J, et al. Medical Teamwork and Patient Safety: The Evidenced Based Relation. American Institutes for Research Final Report. Rockville, MD: Agency for Healthcare Research and Quality; 2003. 10. Patient Safety in Obstetrics and Gynecology. ACOG Committee opinion no. 447.American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114:1424-1427. 11. The Association of Women’s Health, Obstetric and Neonatal Nurses. Quality patient care in labor and delivery: a call to action. J Obstet Gynecol Neonatal Nurs. 2012;41(1):151-153. 12. Riley W, Davis S, Miller K, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm Qual Patient Saf. 2011;37(8):357-364. 13. Wagner B, Meirowitz N, Shah J, et al. Comprehensive perinatal safety initiative to reduce adverse obstetric events. J Healthc Qual. 2012;34(1):6-15. 14. Mann S, Marcus R, Sachs B. Lessons from the cockpit: how team training can reduce errors on L&D. Contemp OB/GYN. 2006;51(1):1-7. 15. Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol. 2009;200(5):492.e1-492.e8. 16. Sundar E, Sundar S, Pawlowski J, et al. Crew resource management and team training. Anesthesiol Clin. 2007;25(2):283-300. 17. Meri´en AER, van de Ven J, Mol BW, et al. Multidisciplinary team training in a simulation setting for acute obstetric emergencies. Obstet Gynecol. 2010; 115:1021-1031. 18. Freeth D, Ayida G, Berridge EJ, et al. Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES):
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
promoting patient safety in obstetrics with teamworkfocused interprofessional simulations. J Contin Educ Health Prof. 2009;29(2):98-104. Pratt SD, Sachs BP. Team training: classroom training vs. high fidelity simulation. http://www.racgp .org.au/afp/200709/18554.Published March 2006. Accessed February 21, 2013. Simpson K, James D, Knox E. Nurse-physician communication during labor and birth: implications for patient safety. J Obstet Gynecol Neonatal Nurs. 2006;35(4):547-556. Simpson K, Kortz C, Knox E. A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and cost of liability claims. Jt Comm J Qual Patient Saf. 2009;35(11):565-574. Roberston B, Schumacher L, Gosman G, et al. Simulation-based crisis team training for multidisciplinary obstetric providers. Simul Healthc. 2009;4(2):77-83. Guise J, Segal S. Teamwork in obstetric critical care. Best Pract Res Clin Obstet Gynecol. 2008;22(5):937– 951. Clark SL, Meyers J, Frye DK, et al. Patient safety in obstetrics—the Hospital Corporation of America experience. Am J Obstet Gynecol. 2011;207(6):283-287. Kirshbaum K, Rask J, Brennan M, et al. Improved climate, culture, and communication through multidisciplinary training and instruction. Am J Obstet Gynecol. 2012;207(3):e1-e7. Siassakos D, Fox R, Hunt L, et al. Attitudes towards safety and teamwork in a maternity unit with embedded team training. Am J Med Qual. 2010;26(2):132137. Sexton J, Holzmueller C, Pronovost P, et al. Variation in caregiver perception of teamwork climate in labor and delivery units. J Perinatol. 2006;26(8):463-470. Nielsen P, Goldman M, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol. 2007;109(1):48-55. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44-53.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
