Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 23-27
Teamwork in the trauma room evaluation of a multimodal team training program


1 Department of Emergency Medicine, University of South Florida, Tampa, FL, USA
2 Department of Psychology, University of South Florida, Tampa, FL, USA
3 Department of Psychology, Central Michigan University, 203 Sloan Hall, Mt. Pleasant, MI, USA

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Date of Submission21-Dec-2010
Date of Acceptance06-Jun-2011
Date of Web Publication22-Feb-2012
 

   Abstract 

Introduction: Poor teamwork leads to preventable medical errors, and thus negatively impacts medical care. One way to improve teamwork is training. A multimodality team training program was designed to impact the attitudes and behavior of first-year residents who will encounter medical situations in the trauma room. The training program included low-fidelity role plays, lectures, and high-fidelity simulation with feedback. Materials and Methods: The training program was a one-day workshop that was conducted twice, once for each of the two groups over two days at the beginning of the academic year in July. A total of 41 first-year interns (10 Emergency Medicine and 31 Surgery) were recruited for participation. Participants completed a Situational judgment test (SJT) on trauma teamwork before training. The training began with a low-fidelity simulation that served as an icebreaker to team concepts. Subsequently, a lecture with discussion provided key points regarding teamwork in the trauma room. A high-fidelity simulation then allowed participation in one of four trauma room scenarios with medical expert debriefing. The course concluded with a course summary and an assessment of participant attitudes regarding training along with a second administration of SJT. Results: Participant reactions to the training were positive overall. Results of SJT showed a positive effect for team training in three of the four possible comparisons. Conclusion: The program was well received by the residents. Results suggest that a comprehensive training approach using role play, lecture, and simulation can positively affect behavioral choices for teamwork in the trauma room.

Keywords: Simulation, team training, trauma teams

How to cite this article:
Peckler B, Prewett MS, Campbell T, Brannick M. Teamwork in the trauma room evaluation of a multimodal team training program. J Emerg Trauma Shock 2012;5:23-7

How to cite this URL:
Peckler B, Prewett MS, Campbell T, Brannick M. Teamwork in the trauma room evaluation of a multimodal team training program. J Emerg Trauma Shock [serial online] 2012 [cited 2019 Aug 18];5:23-7. Available from: http://www.onlinejets.org/text.asp?2012/5/1/23/93106



   Introduction Top


In 1999, the Institute of Medicine (IOM) reported that nearly 100,000 lives and approximately $25 billion are lost each year due to medical errors. [1] The IOM concluded that most such errors could be reduced through changes in the healthcare system, including the implementation of team training programs. As a result, there is a great need for valid and reliable training programs targeted towards teamwork in medical tasks. [2]

Despite the great potential that teamwork training has for improving team functioning, few studies have provided empirical assessments of teamwork training programs for medical teams. [3],[4],[5],[6],[7] Much of the existing work has focused on traditional, lecture-based training with moderate results. [8],[9],[10],[11] A number of training programs have been developed for applications in healthcare organizations (eg, TeamSTEPPS, ACRM). Although case reports of these training programs are generally positive, [12] empirical evaluations on the effects of such programs have been scarce. Thus, there is much to learn about the optimal training design, delivery, and evaluation approaches to teamwork training in medicine.

The current study provides an evaluation of a teamwork training program for residents who are beginning to work in a trauma room. The training used multiple methods, including low-fidelity role play, lecture, and high-fidelity simulation in order to maximize the impact of training and increase the chances of transfer of training to the work setting. It was hypothesized that the residents would demonstrate positive reactions to the training, exhibit more targeted behaviors after training than before as measured by the Situational judgment test (SJT), and exhibit more targeted behaviors after training than would comparable control residents.


   Materials and Methods Top


This study was conducted at Southeastern American Level I Trauma Center that is a university affiliated teaching hospital. This was a workshop conducted at the beginning of the academic year in July. A total of 41 first-year interns (10 Emergency Medicine and 31 Surgery) were recruited to participate in the study. Twenty interns took classes on day one and 21 on day two so as to keep the class size manageable. Participating interns had completed and passed the Advanced Trauma Life Support (ATLS) course. The sample was relatively representative demographically, with 18 women sounds better and 9 Asian, African-American, or Hispanic residents. This study was approved by the University Institutional Review Board.

Training content

Participants completed a survey on a demographics form and a pre-test situational judgment test (described subsequently). The first exercise was a role play designed to serve as an icebreaker and demonstrate ineffective teamwork. The exercise featured a science fiction scenario in which all trainees received a loosely scripted personalities and instructions on their contribution to the team while adopting the scripted personality. The team was given a problem to solve, and the scripted personalities were designed to cause breakdowns in teamwork, thus illustrating the difficulty of problem-solving without effective teamwork. After the role play, participants were debriefed on the personalities being played and the real purpose of the exercise. Thereafter, the trainers guided participant discussion on the dynamics that led to poor teamwork and poor task performance.

The next exercise was a wilderness survival exercise designed to illustrate how groups may outperform individuals. [13] Participants must choose the best answer to multiple choice questions about surviving in the wilderness, first individually, and then within groups. Typically, the group score was better than the individual score, which demonstrated to the participants that working in groups may benefit them. After these first two role plays, residents were directed to consider links between the role plays and teamwork in the trauma room.

Following these exercises, teamwork concepts were explicitly provided to participants in the form of a brief lecture given by a psychologist and an attending physician. The lecture was meant to complement the exercises by giving clear information about the recently demonstrated concepts in the context of medical teamwork including error framing and management techniques, learning from mistakes, and managing a problematic team member. The lecture recognized the unique role of the first-year residents and the challenges before such residents in handling resuscitations in the trauma room.

After the lecture, 5-6 participants were assigned as teams to complete emergency medical tasks within a high-fidelity medical simulation. The scenarios were developed by the researchers and an expert physician in trauma resuscitation who was affiliated with the teaching hospital. Along with the participants, a confederate (recruited from nursing staff) was instructed to cause a specific issue in teamwork. A total of four scenarios were run in order to allow participation of all trainees. The confederate played different roles within the trauma team structure in different scenarios. The confederates used were a respiratory therapist, an Emergency Department (ED) nurse, and an orthopedic resident was played by a senior ED resident and a senior surgical resident as a trauma surgeon who were not otherwise involved in the study. The confederate thus provided opportunities for the residents to deal with common teamwork issues of leadership, deviations from standard procedures, prioritizing tasks, and dealing with interpersonal distractions. The residents were assigned medical roles but knew neither the details of the patient nor the problem(s) to be presented by the confederate prior to running the scenarios. These scenarios were also recorded and broadcast live to a viewing room, so that trainees not currently participating in the scenario could watch and learn from the role play.

To facilitate feedback and guided discussion, the video was played back to the entire group. Trainers provided comments on specific issues and critical incidents and also asked questions to the participants in order to encourage an interactive discussion. Ineffective behaviors were highlighted, and trainers were then asked to suggest more effective behaviors. The course concluded with a course summary and administration of a survey measuring reactions to the training and a second administration of the situational judgment test.

Measures

Pre-training questionnaire

Prior to training, the participants were asked to provide demographic and occupational information. This questionnaire also asked whether the participant had been involved in any prior teamwork training programs (none had). Because trainee interest in training often relates to training success, [14] the scale also asked participants to indicate their interest in participation in the training.

Behavioral intentions

Given the practical difficulty of measuring trainee behaviors during later medical emergencies, the training was validated using a SJT for behavioral responses to teamwork issues in medical emergency tasks. SJTs on teamwork skills provide valuable insight on trainee knowledge for appropriate behavior, and they have produced strong relations to performance. [15] Although SJTs are not commonly used in medical educational research, there are no validated measures for assessment of individual behavioral responses to teamwork issues in the trauma room; moreover, SJT can assess behavioral choices, and not just attitudes or values. Therefore, Subject Matter Experts (SMEs) constructed items that reflected previous or potential issues in trauma room teamwork. The items asked trainees to choose behavioral responses to critical teamwork incidents in the trauma room. The items reflected situations that were analogous, but not identical, to medical scenarios used in the training scenarios, such as how to deal with an ineffective leader, inappropriate comments by a team member, or procedural errors that need correction.

Trainees and a set of four SMEs chose, for each item, their most likely and least likely response out of total of four options. The SMEs included attending physicians, two specialized in general trauma resuscitation and one in neonatal resuscitation, along with the last one as an attending emergency physician. A total of 15 situational judgment items were administered. The SJT was scored by giving a point for every response that reflected the modal expert response. Five items were only partially scored while computing scale totals, as experts provided more than one mode for either the most or least likely response. Thus, the potential range of scores on the situational judgment test was 0-25. Because categorical variables were used, the kappa coefficient was used to calculate inter-rater agreement (0.68). This coefficient corrects for chance agreement, resulting in a lower (but more accurate) index of true rater agreement than would be produced by simply measuring the proportion of item agreement among SME ratings.

Reactions

Trainee utility reactions were measured using a scale that asked participants about the degree to which they liked the training and the degree to which they believed the training would be useful. Because these questions are training specific, and reaction measures were not assessed until after the team had completed the training.

Statistical analysis

Residents completed study measures before and after the training module for two separate training days. Trainees were assigned randomly to training days. Therefore, situational judgment test scores could be compared within groups pre-test to post-test, and each group's pretest scores could serve as the control group for the other group's post-test scores. Reactions to training could not be compared to a control group, but if training is poorly received, then it is likely to be rejected, so it is important to assess and report trainee reactions.

Paired and independent t-tests were computed to assess mean differences in situational judgment test total scores. Independent t-tests were planned contrasts between pre-training measures for the first day and post-training measures for the second day, and vice versa. Paired t-tests were used to test whether situational judgment test scores improved from pre-test to post-test within groups. Thus, four different t-tests were computed, two between groups and two within groups.

To better understand any training effects, the responses to individual items were also analyzed in detail using frequency tables and chi-square goodness-of-fit tests. The goodness-of-fit test treated the observed frequencies from pre-training SJT item responses as the expected frequencies for post-training SJT responses. A Chi-square then estimated the degree of fit between the observed post-training responses to the expected frequencies for each response option (most and least likely for each item). A significant chi-square suggested a significant effect of training on item responses, based on shifts in the frequency distribution.


   Results Top


[Table 1] presents the means, standard deviations, and inter-correlations of continuous variables in the study (five residents provided missing data). The level of interest in training did not relate to any of the study variables except the reaction measures; thus, using this variable as a covariate in additional analyses was deemed unnecessary. SJT scores also did not relate to trainee reactions. That is, performance on the situational judgment test was not related to resident reactions to the training. The distributions of all continuous variables appeared approximately normal, suggesting that the data met the assumptions for mean comparisons.
Table 1: Descriptive statistics and correlations for study measures

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Situational judgment test scores were compared between groups. Post-training scores of Group 1 (M=17.29, SD=1.99) for the teamwork SJT were significantly higher than pre-training score (M=13.77, SD=3.01, t=4.39, P<0.01) of group 2, showing a strong effect size (d=1.38). When post training scores of Group 2 (M=16.55, SD=1.99) were compared to pre-test scores of Group 1 (M=15.63, SD=4.06), the result was in the expected direction, but not significantly different (t=0.81, n.s.) and the effect size was moderate (d=0.26).

Situational judgment test scores were also compared within groups, pre-test to post-test, once for each group. For Group 1, there was a marginal difference for SJT scores (t=1.95, P<0.10) and a moderate effect size (d=0.34). For Group 2, there was a large mean difference between pre- and post-training (t=2.78, P <0.01). This difference reflected a strong effect size (d=0.82).

Item analysis for SJT

The data suggest a significant effect of training on at least one of the two responses (most or least likely) for SJT items, save for two items. Not all shifts following training resulted in higher scores on the situational judgment test (several items showed shifts from one distractor to another and few items showed shifts away from the scored response). Illustrative results for three items (items 3, 4, and 7) are presented in which the shift improved scores on SJT in order to better illustrate how the training resulted in improved scores. For item 3, the shift occurred for responses to the least likely response, while for the other two items, the shift occurred for the most likely response. Item 3 presented a situation where the team leader hesitated to make a time-critical decision. After the training, more residents chose 'call a team meeting' as the action to avoid in that situation than before the training. Although calling for a discussion is clearly a team-oriented response, it is not the best choice during a crisis with limited time to respond. For item 4, the given situation involved people making distracting jokes during the resuscitation, and the appropriate response was to direct attention back to the task at hand. In item 7, the team leader was fixated upon something and had forgotten the ABC protocol. According to experts, the most appropriate response in this situation is to remind the leader of the protocol, and as seen in [Table 2], participants were more likely to choose this action following training.
Table 2: Summary results from Chi-square goodness-of-fit analyses on SJT items

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A summary of results from Chi-square goodness-of-fit analyses for all SJT items are summarized in [Table 2].


   Discussion Top


The purpose of the present study was to validate a teamwork training program for emergency medicine and surgery interns in the trauma room. Teamwork behavioral intentions were assessed using an SJT that presented critical incidents in the trauma teamwork. We thought this to be important for the educational process to evaluate the individuals' teamwork capabilities, as other studies have mainly looked at the outcomes of the training process. [16],[17],[18],[19] Although outcomes are important, it is necessary to evaluate how those outcomes were achieved by the team members. In particular, the immediate purpose of a team training program is to improve the teamwork behaviors in trainees. Thus, we believe that an important question to ask is: "Did the training make a team member a better team player?"

Behavioral choices to SJT items are one index of whether the training resulted in better team players. The SJT scale score demonstrated an overall scale effect in three of the four group comparisons planned by the study, and more than half of the items showed a significant or marginal effect in responding from before and after training. In several instances, the post- training resident responses matched the expert responses more closely than pre-training responses. Even in cases where response shifts did not necessarily match expert ratings, there was an increase in resident assertiveness on item responses. Although situational judgment tests provide information about choices in difficult situations, the scores do not reflect perfect agreement about appropriate behavior by experts. Unfortunately, perfect agreement among experts is likely to be achieved only in simple situations calling for a response that is likely to also be endorsed by novices. Thus, interpretation of the results should be based more on total scores, which represent summaries of tendencies across multiple situations, and less on the scores for any individual item. Examination of individual items may still prove useful; however, determining which scenarios had the greatest effect on the pre- and post-training mean differences in the SJT total scores.

There are many elements of the training that may explain its positive effect on SJT responses. An active training approach, such as a role play, should serve as the primary focus for teamwork training. While some of the previous teamwork studies have attempted to train teamwork using only lecture-based methods, [9] this study saw a positive shift from primary use of role plays, with a complementary lecture. Furthermore, the fidelity of the medical role plays to critical teamwork incidents in the trauma room served as another valuable asset in the training. [17],18] By having task-related scenarios to practice and observe ineffective and effective behaviors, trainees effectively learned the training content. The feedback provides a mechanism for trainees to reflect upon previous behaviors and adapt accordingly in future situations.

Limitations

Although the sample of residents was appropriate for the study, there are not many first- year residents in a given year. Therefore, a design containing large numbers in each group and a placebo-training control group was not feasible. Because of the small sample available, the effects of specific training features were not examined in this study (eg, a no-lecture control group). Rather, the training evaluation reflected the overall effect of training. Future training studies may address this issue by comparing different training approaches to a sample of teams.

Unlike the majority of literature in teamwork training, this study was not an outcome-based study. We chose to measure trainee behaviors by their responses to an SJT that presented critical incidents in trauma teamwork. Although this training was designed to measure the behavioral choices of trainees in specific situations, it does not necessarily indicate their actual behaviors on the job. Obtaining adequate outcome data requires tracking participant performance for several months following the training. Furthermore, the base rate for critical incidents and teamwork errors in medicine is relatively low, so it may be difficult to obtain an adequate sample of errors to determine whether a reduction in errors was due to a training program. However, future research should attempt to collect and analyze such data.


   Conclusion Top


Although teamwork training in the field of medicine is a valuable endeavor, previous studies on teamwork training have shown moderate results by using traditional educational methods (eg, a lecture or presentation) and neglecting criteria that are focused on teamwork skills. The use of more active training methods in addition to a lecture tends to yield a more effective training program. [20] The current study sought to improve on previous training studies by providing a comprehensive program that featured lecture, role plays, task simulations, and feedback. Results from this study suggested that such a comprehensive training approach can positively affect trainee reactions and behavioral choices for teamwork in the trauma room. Such a result is consistent with the concept that teamwork training will result in improved patient care.

 
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Correspondence Address:
Bradley Peckler
Department of Emergency Medicine, University of South Florida, Tampa, FL
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.93106

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