Objective
The objective of the study was to determine the effectiveness of multidisciplinary team training on organizational culture and team communication.
Study Design
The training included a 6-step protocol: (1) a pretest survey assessing cultural attitudes and perceptions, (2) a baseline high-fidelity simulation session, (3) invitational medical rhetoric instruction, (4) a second high-fidelity simulation session, (5) a posttest survey assessing changed cultural attitudes and perceptions, and (6) a debriefing with participants. Teams of 4 physicians trained together: 2 obstetricians and 2 anesthesiologists. Forty-four physicians completed the training protocol during 2010 and 2011.
Results
Paired-sample t tests demonstrated significant decreases in autonomous cultural attitudes and perceptions ( t = 8.23, P < .001) and significant increases in teamwork cultural attitudes and perceptions ( t = −4.05, P < .001). Paired-sample t tests also demonstrated significant increases in communication climate that invited participation and integrated information from both medical services ( t = −5.80, P < .001).
Conclusion
The multidisciplinary team training program specified in this report resulted in increased teamwork among obstetricians and anesthesiologists.
Increased attention has focused on patient safety since the Institute of Medicine reported on patient safety and standards of care in 1999. That report led to numerous efforts to improve patient safety. Approaches and solutions vary, but a common theme is a continued call for changed communication practices and organizational culture.
More recently the Joint Commission on Accreditation of Healthcare Organizations identified communication problems as a primary cause of 72% of perinatal deaths or permanent disabilities. Many communication problems reported by the Joint Commission arose from rigid hierarchical structures associated with organizational culture. Organizational culture is defined as combined attitudes, values, language, beliefs, customs, and assumptions; and safety culture is the application of safe organizational practices in clinical activities. Rigid hierarchy can result in silence and reduced teamwork through real or perceived intimidation.
The American Congress of Obstetricians and Gynecologists (ACOG) recently updated 2 opinions that specifically address barriers to safety culture. Patient Safety in the Surgical Environment recommends continuous communication among all surgical team members to reduce errors. The ACOG suggests attention to customs and assumptions at the beginning of a case. Preoperative briefing should clarify roles and responsibilities to promote communication and increase collaboration among team members. Another recent ACOG publication specifically addresses language, values, and attitudes as integral to safety culture. Although the report discusses a small percentage of physicians (3-5%) who engage in disruptive behavior, the noted disruptive behavior, disrespectful language, intimidation, criticism, and passive-aggressive behavior are discussed as barriers to positive and safe cultures.
Both of these ACOG publications suggest improved patient safety. However, policy statements or recommendations rarely result in quick clinical changes. Instead, improvements in patient safety depend on a safety culture that is built through organizational change. This organizational change does not occur instantly. The process is slow and gradual, resulting from awareness, instruction, training programs, and reenforcement of procedures.
It is important to start with baseline measures of the existing safety culture. Pettker et al (2011) used the term, safety climate, to indicate the quantitative description of the safety culture. Indicators of safety climate include attitudes and behaviors that are safe, respectful, and appropriate. The team of Pettker et al and others used the Safety Attitude Questionnaire (SAQ) to measure communication, attitudes, and culture. Both Pettker et al and Pronovost et al conducted patient safety and teamwork programs and recorded improved safety culture results with the SAQ. Although the outcomes were generally positive, Pronovost et al reported a large percentage of respondents indicated that it was difficult to speak up if a problem regarding patient care was perceived.
The resistance to speak up is a critical juncture for lapses in patient safety and likely arises from the rigid hierarchical structures that result in real or perceived intimidation and hence lack of teamwork. The hierarchical structures that contribute to lapses in patient safety result from cultural communication variables. Organizational culture and communication patterns either encourage or discourage hierarchy and perceived intimidation. Because effective communication is one hallmark of safe patient care, it is important to examine organizational climate for how respectful, clear, and direct is the communication between surgical team members. These critical variables are not specifically measured in the SAQ; instead they are measured as part of teamwork culture.
To more precisely measure respectful, clear, and direct communication, our research team constructed a survey to measure safety climate through cultural communication variables associated with collaboration, interdependence, participation, and integration of information. The result was Practices in the Operating Room survey (PRIOR). A percentage of questions measure general approaches to cultural communication variables, whereas others assume differences of opinion between physician groups (ie, anesthesia and obstetrics) to measure how priorities are negotiated among a surgical team. Questions include inherent disagreement over priority setting and contrasting perspectives during a patient case. The PRIOR survey is used as a pretest and posttest in the 6-step training protocol that specifically targets improved patient safety culture through changes in attitudes, values, language, and customs.
Materials and Methods
This study was conducted at the University of New Mexico Health Science Center during 2010 and 2011 with approval from the institutional review board. The physicians who participated in the study were scheduled according to their clinical schedules. Each training session was conducted with a second- and a fourth-year resident from each medical service. The 4 participants, 2 obstetrics and gynecology residents, and 2 anesthesiology residents, engaged in each 2-hour training session conducted at a high-fidelity simulation laboratory located on the medical campus.
After informed consent was obtained, the training sessions utilized a 6-step protocol that included the following: (1) a pretest survey (PRIOR) to measure cultural attitudes, perceptions, and customs; (2) a baseline high-fidelity simulation session; (3) invitational medical rhetoric (IMR) training; (4) a second high-fidelity simulation session; (5) a posttest survey (PRIOR) to measure the changes in cultural attitudes, perceptions, and customs; and (6) a debriefing with participants.
Detailed training protocol
Step 1 consisted of informed consent procedures and a pretest (PRIOR). The PRIOR measures medical culture within 7 communication domains. (The PRIOR is available from the corresponding author.)
Step 2 consisted of a baseline simulation session. The scenario was written and administered by multidisciplinary teams of physicians to simulate an obstetric patient with preeclampsia. Incomplete patient briefing was intentionally given to each team of physicians. The briefing administered to the anesthesiologist team lacked a vital piece of patient information that was obtained through discussion with the obstetricians. Patient briefing administered to the team of obstetricians also omitted vital patient information obtainable through discussion with the anesthesiologists. The best outcome for patient care depended on the collaboration of information across medical services. The simulation was completed in 20 minutes and was remotely observed to provide examples for IMR instruction delivered during Step 3.
Step 3 consisted of instruction in IMR. Specific terminology for IMR was a modification of a text used for undergraduate education at multiple universities. The IMR instruction lasted 20 minutes and followed a standardized procedure contained in a PowerPoint presentation. The procedure included the following: (1) a contemporary definition of rhetoric: verbal/nonverbal communication and patterned reactions; (2) a discussion of common default rhetoric that results in alienation and silencing; (3) an introduction to IMR as an alternative that invites participation; and (4) an explanation of a mnemonic device (ABCs) to remember IMR.
Each instructional session was customized with examples from the baseline simulation session conducted in step 2. Participants were also asked to recall experiences during patient cases during which speaking style and rhetoric provoked positive and negative responses. An example of default rhetoric and a patterned response of silence occurred during 1 simulation when a physician barked an order that the rest of the team followed. The simulation patient died as a result of a detail withheld by another team member who did not question the order. IMR instruction included alternative language choices that participants personalized according to their own speaking style. At the end of the instruction, participants were asked to use the alternative rhetoric during the next simulation session.
Step 4 consisted of a simulation session with a different patient case. The second scenario simulated an obstetric patient with fetal distress/abruption resulting in postpartum hemorrhage. This case was also written and administered by a multidisciplinary team of physicians. Again, incomplete patient briefing was intentionally given to each team of physicians to necessitate collaboration across medical services for best patient care. The second simulation was completed in approximately 20 minutes and was also remotely observed to discern whether changes in rhetoric occurred among team members and what outcomes resulted. The remote observation also provided examples for the feedback session during step 6.
Step 5 consisted of posttest administration of the PRIOR survey to measure changes in medical culture on the 7 communication domains. It was hypothesized that changes in the cultural communication on the 7 dimensions would occur after the participants participated in IMR instruction and practical application during the second simulation.
Step 6 consisted of debriefing with participants. Physicians and communication experts debriefed both medical decisions and rhetoric patterns used in both patient cases. Specific examples were cited from the simulation sessions and invitational medical rhetoric instruction to facilitate discussion and provide personalized feedback.
Practices in the Operating Room Survey (PRIOR)
The PRIOR survey used a previously validated cultural communication survey modified to capture specific operating room cultural detail. Anesthesiologists and surgeons at the University of New Mexico Health Science Center collaborated on the modifications.
The PRIOR survey utilizes a series of statements to which respondents answer with agreement or disagreement on a 5-point Likert scale (strongly disagree/disagree/neutral/agree/strongly agree). Agreement with a statement is indicated by the categories agree or strongly agree. The PRIOR measures medical culture within the following 7 communication domains: (1) independence (preferred autonomy), (2) interdependence (preferred collaboration and teamwork), (3) self-concern (protection of self-image), (4) awareness of others (conscientious of others’ image), (5) dominate (insistence during disagreement), (6) avoid (ignore during disagreement), and (7) integrate (collaborate during disagreement). The survey has 47 questions and takes approximately 10 minutes to complete. Sample questions include: “I consult with other physicians during surgery,” “I usually propose a middle ground for breaking deadlocks,” and “I maintain conducive working relationships in the operating room.” The PRIOR has been validated in surgical health care settings, and results maintain the anonymity of respondents.
Software (IBM SPSS, version 18, Chicago, IL) was used for analysis of the data. Analysis of variance (ANOVA) showed that obstetrician and anesthesiologist scores were similar on all 7 variables. Because there was a nonsignificant variance between obstetrician and anesthesiologist survey responses, data from both physician groups were combined. t tests were conducted with the combined data (n = 44) to test for changed scores from the pretest to the posttest surveys for all physicians.
Practices in the Operating Room Survey (PRIOR)
The PRIOR survey used a previously validated cultural communication survey modified to capture specific operating room cultural detail. Anesthesiologists and surgeons at the University of New Mexico Health Science Center collaborated on the modifications.
The PRIOR survey utilizes a series of statements to which respondents answer with agreement or disagreement on a 5-point Likert scale (strongly disagree/disagree/neutral/agree/strongly agree). Agreement with a statement is indicated by the categories agree or strongly agree. The PRIOR measures medical culture within the following 7 communication domains: (1) independence (preferred autonomy), (2) interdependence (preferred collaboration and teamwork), (3) self-concern (protection of self-image), (4) awareness of others (conscientious of others’ image), (5) dominate (insistence during disagreement), (6) avoid (ignore during disagreement), and (7) integrate (collaborate during disagreement). The survey has 47 questions and takes approximately 10 minutes to complete. Sample questions include: “I consult with other physicians during surgery,” “I usually propose a middle ground for breaking deadlocks,” and “I maintain conducive working relationships in the operating room.” The PRIOR has been validated in surgical health care settings, and results maintain the anonymity of respondents.
Software (IBM SPSS, version 18, Chicago, IL) was used for analysis of the data. Analysis of variance (ANOVA) showed that obstetrician and anesthesiologist scores were similar on all 7 variables. Because there was a nonsignificant variance between obstetrician and anesthesiologist survey responses, data from both physician groups were combined. t tests were conducted with the combined data (n = 44) to test for changed scores from the pretest to the posttest surveys for all physicians.
Results
Forty-four physicians (22 obstetricians and 22 anesthesiologists) from the University of New Mexico Health Science Center participated in the multidisciplinary team training sessions during 2010 and 2011. Participation was determined by scheduled availability on each medical service. Eighteen men (41%) and 26 women (59%) participated. The age of participants was determined through self-report on 5 categories (≤25, 26-32, 33-39, 40-46, 47-53, or ≥54). The average age was 26-32 years as indicated by 72% of the participants. The majority of the participants reported white ethnicity (57%), 14% Asian, 11% Hispanic, 2% multiethnic, and 16% did not respond.
The comparison of obstetrician and anesthesiologist scores demonstrated nonsignificant variance on all 7 cultural communication domains. Table 1 shows mean scores with SD for both obstetricians and anesthesiologists. The scores are very similar on both physician groups before and after the IMR training. The ANOVA results shown in Table 1 verify the lack of significant difference between obstetricians and anesthesiologists. All of the P values listed in the column on the far right are above the threshold of .05.
