International Journal of Healthcare Simulation

Introduction

Non-technical skills (NTS), also referred to as behavioural skills [1,2], play a crucial role in cardiac arrest resuscitation performance, both in the simulated and clinical environments [3]. Poor performance in NTS has been highlighted in resuscitation teams [4] and it is recognized that team dynamics can influence the efficiency of clinical tasks being performed in resuscitation [5]. Due to positive impact on patient outcomes, an inpatient rapid response team or medical emergency team (MET) will respond to calls signalled due to patient deterioration or cardiac arrest in most hospitals [6,7]. In the United Kingdom (UK), the MET will usually comprise of a combination of medical and nursing staff and is an ad hoc team, the members of which may vary on a day-to-day basis. However, outcomes from cardiac arrest remain suboptimal and ensuring effective training interventions is key to enhancing patient safety [8,9]. There is evidence that team training can lead to improved patient outcomes [10–12] and that immersive simulation can be utilized in this context [13,14], which can build social capital for ad hoc teams [15].

Although NTS are recognized as important in improving team performance, further assessment is required to delineate more specifically which team behaviours are key to optimal performance. NTS are defined as the cognitive and interpersonal skills, such as leadership and teamwork, that contribute to efficient team performance [16]. There have been calls to use the term behavioural skills [2], defining them in a positive sense rather than ‘non-technical’ which could be seen as subordinate despite their importance [1]. Immersive simulation can provide a valuable modality and opportunity for research into such behaviours [17]. For example, previous research has used discourse analysis to examine team talk in medical emergencies, exposing communication strategies used to create shared team situational awareness [18,19]. Behavioural marker systems or NTS assessment surveys are tools that can measure teamwork and provide insight into behaviours that lead to successful performance [20]. Observing and understanding behaviour is enlightening but we must strive to better understand the specific team behaviours that can lead to successful, or unsuccessful, outcomes. Immersive simulation can provide an authentic environment to observe team behaviours to advance our understanding of teams in these contexts, and the specific aspects resulting in optimal performance in an objective manner. Absence of leadership can lead to unsuccessful outcomes [14,21]; however, it has been recommended that better understanding of the influence of specific team behaviours and team dynamics in such situations would be beneficial to guide training efforts [14,22,23].

Improving understanding of the importance of specific team behaviours in the setting of cardiac arrest could guide feedback provided in the debriefing session following simulated scenarios and aid medical educators more widely to focus on key areas. To investigate this and provide practically helpful information to trainers, defining the outcome of a successful team performance is key. Resuscitation guidelines recommend defibrillation as early as possible for shockable rhythm cardiac arrests [6], with improved outcomes when defibrillation is within 2 minutes [24,25]. Therefore, in the context of cardiac arrest with a shockable rhythm, one way of defining successful team performance is delivery of a shock within 2 minutes of arrest [24,25]. In the UK, the MET often includes internal medicine trainees who, as they progress through their training, will step into the role of team lead for resuscitation teams. It is recognized that junior doctors require training in NTS for managing emergency situations [26]. Better understanding their team behaviours leading to successful performance could inform such training strategies.

The aim of this pilot study was to determine whether teamwork behaviours among internal medical trainees differed when time to defibrillation (TTD) was less than 2 minutes, versus 2 minutes or more.

Methods

Results

Twenty-three videos involving 138 trainees were reviewed, including doctors from all four Scottish training regions. TEAM scores ranged from 19–39.5 (mean 28.2) out of a possible 44 and leadership scores ranged from 1.5–7.5/8 (mean 4.4). Mean TTD was 86.2 seconds (range 24–224 seconds), with 17/23 teams achieving defibrillation in under 2 minutes.

The Kolmogorov–Smirnov test showed that the data were normally distributed, and therefore we used Student’s t-test to compare difference between means. Those achieving fast TTD achieved higher TEAM scores than those achieving a slow TTD, and the result was statistically significant (30.1 ± 5.0 vs 22.9 ± 3.3, p = 0.004). This is shown below in Figure 1.

Figure 1:

Means and 95% confidence intervals for TEAM scores in the fast versus slow time-to-defibrillation groups.

Those achieving fast TTD achieved higher mean scores in every TEAM item, as shown in Figure 2.

Figure 2:

Means and 95% confidence intervals for individual TEAM item scores for the fast versus slow time-to-defibrillation groups.

When analysing the statistical significance of the differences in these means, only one of the differences is significant at the 5% level (with the Bonferroni correction). This is item 7 – ‘the team adapted to changing situations’ (see Table 1).

Table 1:

Comparison of TEAM items, with mean scores (and standard deviations) for each group, and p-value for the t-test comparison. Highlighted in bold is the statistically significant difference

TEAM item	Fast TTD group Mean (SD)	Slow TTD group Mean (SD)	p-value
1. The team leader let the team know what was expected of them through direction and command	2.47 (0.91)	1.41 (0.38)	0.01272
2. The team leader maintained a global perspective	2.44 (1.10)	1.67 (0.68)	0.12414
3. The team communicated effectively	2.53 (0.62)	1.83 (0.52)	0.02355
4. The team worked together to complete the tasks in a timely manner	2.68 (0.64)	2.25 (0.69)	0.18096
5. The team acted with composure and control	2.74 (0.64)	2.08 (0.49)	0.03475
6. The team morale was positive	2.53 (0.62)	1.92 (0.92	0.08152
7. The team adapted to changing situations	3.09 (0.32)	2.42 (0.38)	0.00036
8. The team monitored and reassessed the situation	3.06 (0.30)	2.67 (0.41)	0.02036
9. The team anticipated potential actions	3.00 (0.43)	2.42 (0.38)	0.00812
10. The team prioritized tasks	2.74 (0.53)	2.17 (0.41)	0.02782
11. The team followed approved standards and guidelines	2.79 (0.53)	2.08 (0.20)	0.00482

Discussion

This observational pilot study assessed the team behaviours of IMT doctors in simulated cardiac arrest scenarios using the TEAM tool and measuring the TTD. The analysis shows that higher TEAM scores are associated with a faster TTD. When analysing individual TEAM score items, there was a statistically significant difference between the fast TTD and slow TTD groups in the skill element of adaptability.

Although the majority of teams (17 out of 23) achieved defibrillation within 2 minutes, there is evidence of significant delays in defibrillation in studies exploring real clinical practice [24,36]. Given that higher TEAM scores were associated with a faster TTD in this cohort, this suggests we should strive to improve TEAM scores where possible [14]. Utilization of the TEAM tool as part of IMT simulation training could be considered to try to achieve this by providing formative assessment and tangible suggestions for improvement.

From our analysis, fast TTD and slow TTD groups showed a statistically significant difference in item 7 within the team work category, ‘the team adapted to changing situations’. This suggests that adaptability is a key team behaviour required for successful performance. It is a recognized core component of teamwork defined as the ‘ability to adjust strategies based on information gathered from the environment’ leading to an altered course of action in response to changing conditions [37]. It is through breaking down the components of teamwork that we will develop a clearer understanding of what constitutes good teamwork and how best to provide training for successful performance [37]. Adaptability must be maintained in emergency situations [38] and is reliant on shared mental models and performance monitoring leading to coordinated action [37]. Adaptive coordination has been shown to be important in performance in anaesthesia in moving from implicit to explicit coordination whereby explicit coordination statements are expressed in an unambiguous manner with the intent to coordinate behaviour [39–41]. This would apply in the scenario of this study with the recognition of cardiac arrest as a cue which prompts a shift to the cardiac arrest algorithm and coordination of early defibrillation [42]. The importance of cue recognition and this shift could be a focus for training and a key learning point during the simulation debriefing session, particularly if there has been a delay to defibrillation due to a lack of adaptability. Adaptive behaviours have also been included in a taxonomy from a recent scoping review of the NTS required by ad hoc teams, suggesting teams with a strong team mental model with regular situation updates will have improved adaptability, another potential focus for training for success [43]. Considering adaptability and the related concepts such as cue recognition and explicit coordination are important in helping learners understand what adaptability in teamwork means and what we should be striving towards in practical terms [44].