Publications by authors named "Michaela Kolbe"

25 Publications

  • Page 1 of 1

Team functioning across different tumour types: Insights from a Swiss cancer center using qualitative and quantitative methods.

Cancer Rep (Hoboken) 2021 Sep 28:e1541. Epub 2021 Sep 28.

Centre for Implementation Science, Health Service and Population Research Department, King's College, London, UK.

Background: Multidisciplinary care is pivotal in cancer centres and the interaction of all cancer disease specialists in decision making processes is state-of-the-art.

Aim: To describe differences of MDTMs by tumour type.

Methods: Twelve multidisciplinary team meetings (MDTMs) with participation of different cancer disease specialists at a tertiary hospital were assessed by an exploratory sequential mixed method approach with interviews, observations and a survey to address the following five topics: organisational structure and supporting technology; leadership; teamwork; decision-making, perceived value and motivation. Thirteen persons with different tumour specialities and levels of seniority were interviewed. The 12 MDTMs were observed twice by uninvolved persons and evaluated by the participating physicians with a survey.

Results: There were no systematic differences between MDTMs for different tumour types with the exception of the non-disease specific type MDTM, which was the only one for which the organisational structure was not driven by an electronic tool. However, several factors could be identified that generally influenced the functioning of the MDTMs. In particular, the quality of decision-making was highly dependent on the availability of case-based information and the presence of relevant cancer disease specialists. Leadership and teamwork were rated as important and were comparable across the MDTM. Team participants' motivation and perceived value of MDTMs was high across all meetings.

Conclusion: MDTM at a single institution did not demonstrate disease specific characteristics. An effective MDTM, irrespective of the tumour type, can be successfully structured by technical means and a chairperson coordinating the interaction of cancer disease specialists to improve the decision-making process.
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http://dx.doi.org/10.1002/cnr2.1541DOI Listing
September 2021

Team debriefings in healthcare: aligning intention and impact.

BMJ 2021 09 13;374:n2042. Epub 2021 Sep 13.

ETH Zurich, Switzerland.

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http://dx.doi.org/10.1136/bmj.n2042DOI Listing
September 2021

Associations of form and function of speaking up in anaesthesia: a prospective observational study.

Br J Anaesth 2021 12 10;127(6):971-980. Epub 2021 Sep 10.

Simulation Centre, University Hospital Zurich, Zurich, Switzerland; ETH Zurich, Zurich, Switzerland. Electronic address:

Background: Speaking up with concerns in the interest of patient safety has been identified as important for the quality and safety of patient care. The study objectives were to identify how anaesthesia care providers speak up, how their colleagues react to it, whether there is an association among speak up form and reaction, and how this reaction is associated with further speak up.

Methods: Data were collected over 3 months at a single centre in Switzerland by observing 49 anaesthesia care providers while performing induction of general anaesthesia in 53 anaesthesia teams. Speaking up and reactions to speaking up were measured by event-based behaviour coding.

Results: Instances of speaking up were classified as opinion (59.6%), oblique hint (37.2%), inquiry (30.7%), and observation (16.7%). Most speak up occurred as a combination of different forms. Reactions to speak up included short approval (36.5%), elaboration (35.9%), no verbal reaction (26.3%), or rejection (1.28%). Speaking up was implemented in 89.1% of cases. Inquiry was associated with an increased likelihood of recipients discussing the respective issue (odds ratio [OR]=13.6; 95% confidence interval [CI], 5.9-31.5; P<0.0001) and with a decreased likelihood of implementing the speak up during the same induction (OR=0.27; 95% CI, 0.08-0.88; P=0.03). Reacting with elaboration to the first speak up was associated with decreased further speak up during the same induction (relative risk [RR]=0.42; 95% CI, 0.21-0.83; P=0.018).

Conclusion: Our study provides insights into the form and function of speaking up in clinical environments and points to a perceived dilemma of speaking up via questions.
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http://dx.doi.org/10.1016/j.bja.2021.08.014DOI Listing
December 2021

Avatar-based patient monitoring in critical anaesthesia events: a randomised high-fidelity simulation study.

Br J Anaesth 2021 May 8;126(5):1046-1054. Epub 2021 Apr 8.

Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland. Electronic address:

Background: Failures in situation awareness cause two-thirds of anaesthesia complications. Avatar-based patient monitoring may promote situation awareness in critical situations.

Methods: We conducted a prospective, randomised, high-fidelity simulation study powered for non-inferiority. We used video analysis to grade anaesthesia teams managing three 10 min emergency scenarios using three randomly assigned monitoring modalities: only conventional, only avatar, and split-screen showing both modalities side by side. The primary outcome was time to performance of critical tasks. Secondary outcomes were time to verbalisation of vital sign deviations and the correct cause of the emergency, perceived workload, and usability. We used mixed Cox and linear regression models adjusted for various potential confounders. The non-inferiority margin was 10%, or hazard ratio (HR) 0.9.

Results: We analysed 52 teams performing 154 simulations. For performance of critical tasks during a scenario, split-screen was non-inferior to conventional (HR=1.13; 95% confidence interval [CI], 0.96-1.33; not significant in test for superiority); the result for avatar was inconclusive (HR=0.98; 95% CI, 0.83-1.15). Avatar was associated with a higher probability for verbalisation of the cause of the emergency (HR=1.78; 95% CI, 1.13-2.81; P=0.012). We found no evidence for a monitor effect on perceived workload. Perceived usability was lower for avatar (coefficient=-23.0; 95% CI, -27.2 to -18.8; P<0.0001) and split-screen (-6.7; 95% CI, -10.9 to -2.4; P=0.002) compared with conventional.

Conclusions: This study showed non-inferiority of split-screen compared with conventional monitoring for performance of critical tasks during anaesthesia crisis situations. The patient avatar improved verbalisation of the correct cause of the emergency. These results should be interpreted considering participants' minimal avatar but extensive conventional monitoring experience.
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http://dx.doi.org/10.1016/j.bja.2021.01.015DOI Listing
May 2021

"A debriefer must be neutral" and other debriefing myths: a systemic inquiry-based qualitative study of taken-for-granted beliefs about clinical post-event debriefing.

Adv Simul (Lond) 2021 Mar 4;6(1). Epub 2021 Mar 4.

Simulation Center, University Hospital Zurich, Rämistrasse 100, 8091, Zürich, Switzerland.

Background: The goal of this study was to identify taken-for-granted beliefs and assumptions about use, costs, and facilitation of post-event debriefing. These myths prevent the ubiquitous uptake of post-event debriefing in clinical units, and therefore the identification of process, teamwork, and latent safety threats that lead to medical error. By naming these false barriers and assumptions, the authors believe that clinical event debriefing can be implemented more broadly.

Methods: We interviewed an international sample of 37 clinicians, educators, scholars, researchers, and healthcare administrators from hospitals, universities, and healthcare organizations in Western Europe and the USA, who had a broad range of debriefing experience. We adopted a systemic-constructivist approach that aimed at exploring in-depth assumptions about debriefing beyond obvious constraints such as time and logistics and focused on interpersonal relationships within organizations. Using circular questions, we intended to uncover new and tacit knowledge about barriers and facilitators of regular clinical debriefings. All interviews were transcribed and analyzed following a comprehensive process of inductive open coding.

Results: In total, 1508.62 min of interviews (25 h, 9 min, and 2 s) were analyzed, and 1591 answers were categorized. Many implicit debriefing theories reflected current scientific evidence, particularly with respect to debriefing value and topics, the complexity and difficulty of facilitation, the importance of structuring the debriefing and engaging in reflective practice to advance debriefing skills. We also identified four debriefing myths which may prevent post-event debriefing from being implemented in clinical units.

Conclusion: The debriefing myths include (1) debriefing only when disaster strikes, (2) debriefing is a luxury, (3) senior clinicians should determine debriefing content, and (4) debriefers must be neutral and nonjudgmental. These myths offer valuable insights into why current debriefing practices are ad hoc and not embedded into daily unit practices. They may help ignite a renewed momentum into the implementation of post-event debriefing in clinical settings.
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http://dx.doi.org/10.1186/s41077-021-00161-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931165PMC
March 2021

A practical guide to virtual debriefings: communities of inquiry perspective.

Adv Simul (Lond) 2020 12;5:18. Epub 2020 Aug 12.

Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, USA.

Many simulation programs have recently shifted towards providing remote simulations with virtual debriefings. Virtual debriefings involve educators facilitating conversations through web-based videoconferencing platforms. Facilitating debriefings through a computer interface introduces a unique set of challenges. Educators require practical guidance to support meaningful virtual learning in the transition from in-person to virtual debriefings. The communities of inquiry conceptual framework offer a useful structure to organize practical guidance for conducting virtual debriefings. The communities of inquiry framework describe the three key elements-social presence, teaching presence, and cognitive presence-all of which contribute to the overall learning experience. In this paper, we (1) define the CoI framework and describe its three core elements, (2) highlight how virtual debriefings align with CoI, (3) anticipate barriers to effective virtual debriefings, and (4) share practical strategies to overcome these hurdles.
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http://dx.doi.org/10.1186/s41077-020-00141-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7422458PMC
August 2020

A Conceptual Framework for the Development of Debriefing Skills: A Journey of Discovery, Growth, and Maturity.

Simul Healthc 2020 Feb;15(1):55-60

From the KidSim-ASPIRE Research Program, Alberta Children's Hospital, Departments of Pediatrics and Emergency Medicine (A.C.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Departments of Pediatrics and Medical Education (W.E.), Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Simulation Center (M.K.), UniversitatsSpital Zurich, Zurich, Switzerland; Department of Emergency Medicine (M.M.), NYC Health + Hospitals/Harlem, Health + Hospitals/Simulation Center, Columbia University; Department of Obstetrics and Gynecology (K.B.), NYC Health + Hospitals/Jacobi, Albert Einstein College of Medicine, New York, NY; and KidSIM Simulation Program (V.G.), Alberta Children's Hospital, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Statement: Despite the critical importance of debriefing in simulation-based education, existing literature offers little guidance on how debriefing skills develop over time. An elaboration of the trajectory through which debriefing expertise evolves would help inform educators looking to enhance their skills. In this article, we present a new conceptual framework for the development of debriefing skills based on a modification of Dreyfus and Dreyfus' model of skill development. For each of the 3 stages of debriefing skill development-discovery, growth, and maturity, we highlight characteristics of debriefers, requisite knowledge, and key skills. We propose how faculty development experiences map to each stage of debriefing skill development. We hope the new conceptual framework will advance the art and science of debriefing by shaping future faculty development initiatives, research, and innovation in debriefing.
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http://dx.doi.org/10.1097/SIH.0000000000000398DOI Listing
February 2020

Laborious but Elaborate: The Benefits of Really Studying Team Dynamics.

Front Psychol 2019 28;10:1478. Epub 2019 Jun 28.

Institute for Psychology, University of Göttingen, Göttingen, Germany.

In this manuscript we discuss the consequences of methodological choices when studying team processes "in the wild." We chose teams in healthcare as the application because teamwork cannot only save lives but the processes constituting effective teamwork in healthcare are prototypical for teamwork as they range from decision-making (e.g., in multidisciplinary decision-making boards in cancer care) to leadership and coordination (e.g., in fast-paced, acute-care settings in trauma, surgery and anesthesia) to reflection and learning (e.g., in post-event clinical debriefings). We draw upon recently emphasized critique that much empirical team research has focused on describing team states rather than investigating how team processes dynamically unfurl over time and how these dynamics predict team outcomes. This focus on statics instead of dynamics limits the gain of applicable knowledge on team functioning in organizations. We first describe three examples from healthcare that reflect the importance, scope, and challenges of teamwork: multidisciplinary decision-making boards, fast-paced, acute care settings, and post-event clinical team debriefings. Second, we put the methodological approaches of how teamwork in these representative examples has mostly been studied centerstage (i.e., using mainly surveys, database reviews, and rating tools) and highlight how the resulting findings provide only limited insights into the actual team processes and the quality thereof, leaving little room for identifying and targeting success factors. Third, we discuss how methodical approaches that take dynamics into account (i.e., event- and time-based behavior observation and micro-level coding, social sensor-based measurement) would contribute to the science of teams by providing actionable knowledge about interaction processes of successful teamwork.
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http://dx.doi.org/10.3389/fpsyg.2019.01478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611000PMC
June 2019

Twelve tips for integrating team reflexivity into your simulation-based team training.

Med Teach 2018 07 27;40(7):721-727. Epub 2018 Apr 27.

c Departments of Pediatrics and Medical Education , Northwestern University Feinberg School of Medicine , Chicago , IL , USA.

Due to increasing complexity in healthcare, clinicians must often make decisions under uncertain conditions in which teams must be flexible and process emerging information "on the fly" in order to adapt to changing circumstances. A crucial strategy that helps teams to adapt, learn, and develop is team reflexivity (TR) - a team's ability to collectively reflect on group objectives, strategies, processes, and outcomes of past and current performance and to adapt accordingly. We provide 12 evidence-based tips on incorporating TR into simulation-based team training (SBTT). The first three points elaborate on basic principles of TR, when TR can take place and why it matters. The following nine tips are then organized according to three phases in which teams are able to engage in TR: pre-action, in-action, and post-action. SBTT represents an ideal venue to train various TR behaviors that foster team learning and improve patient care.
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http://dx.doi.org/10.1080/0142159X.2018.1464135DOI Listing
July 2018

Difficult airway management and training: simulation, communication, and feedback.

Curr Opin Anaesthesiol 2017 Dec;30(6):743-747

aInstitute of Anesthesiology bSimulation Center cInstitute of Anesthesiology, University Hospital of Zurich, Zurich, Switzerland.

Purpose Of Review: Successful and sustainable training and learning of the management of difficult and normal airway is essential for all clinically active anesthesiologists. We emphasize the importance of a continuously updated learning and training environment based on actual knowledge, best available equipment, standardized procedures, and educational theory.

Recent Findings: In the past, most of the training were based on 'learning by doing' under the supervision of superiors or experienced colleagues. This has been recognized as insufficient and training has evolved to its recent level by structuring it into technical, methodological, and behavioral components. Additionally, a large part of it has been shifted away from learning on patients to simulated scenarios in designated environments. The contents, structure, components, and succession of components have been refined according to the steadily evolving and available instruments. Increasingly, team interaction and behavioral aspects gained more attention and became part of standardized education units that are tailored to the learners' clinical role and level of experience.

Summary: We present the details of the Zurich Airway Training and Simulation program, which has been constantly updated to the actual state of knowledge and available equipment.
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http://dx.doi.org/10.1097/ACO.0000000000000523DOI Listing
December 2017

How to debrief teamwork interactions: using circular questions to explore and change team interaction patterns.

Adv Simul (Lond) 2016 15;1:29. Epub 2016 Nov 15.

1University Hospital Zurich, Simulation Center, Rämistrasse 100, 8091 Zurich, Switzerland.

We submit that interaction patterns within healthcare teams should be more comprehensively explored during debriefings in simulation-based training because of their importance for clinical performance. We describe how can be used for that purpose. Circular questions are based on social constructivism. They include a variety of systemic interviewing methods. The goals of circular questions are to explore the mutual dependency of team members' behavior and recurrent behavior patterns, to generate information, to foster perspective taking, to "fluidize" problems, and to put actions into relational contexts. We describe the nature of circular questions, the benefits they offer, and ways of applying them during debriefings.
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http://dx.doi.org/10.1186/s41077-016-0029-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806384PMC
November 2016

SafAIRway: an airway training for pulmonologists performing a flexible bronchoscopy with nonanesthesiologist administered propofol sedation: A prospective evaluation.

Medicine (Baltimore) 2016 Jun;95(23):e3849

Institute of Anesthesiology Simulation Center, University Hospital Zurich ETH Zurich Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland.

Nonanesthesiologist administered propofol (NAAP) sedation for flexible bronchoscopy is controversial, because there is no established airway management (AM) training for pulmonologists. The aim was to investigate the performance and acceptance of a proposed AM algorithm and training for pulmonologists performing NAAP sedation. The algorithm includes using 3 maneuvers including bag mask ventilation (BMV), laryngeal tube (LT), and needle cricothyrotomy (NCT). During training (consisting of 2 sessions with a break of 9 weeks in between), these maneuvers were demonstrated and exercised, followed by 4 consecutive attempts to succeed with each of these devices. The primary outcome was the improvement of completion time needed for a competent airway. Secondary outcomes were the trainees' overall reactions to the training and algorithm, and the perceptions of psychological safety (PS). The 23 staff members of the Department of Pulmonology performed a total of 552 attempts at AM procedures (4 attempts at each of the 3 maneuvers in 2 sessions), and returned a total of 42 questionnaires (4 questionnaires were not returned). Median completion times of LT and NCT improved significantly between Sessions 1 and 2 (P = 0.005 and P = 0.04, respectively), whereas BMV was only marginally improved (P = 0.05). Trainees perceived training to be useful and expressed satisfaction with this training and the algorithm. The perception of PS increased after training. An AM algorithm and training for pulmonologists leads to improved technical AM skills, and is considered useful by trainees and raised their perception of PS during training. It thus represents a promising program.
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http://dx.doi.org/10.1097/MD.0000000000003849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907671PMC
June 2016

Using educational video to enhance protocol adherence for medical procedures.

Br J Anaesth 2016 May;116(5):662-9

Institute of Anaesthesiology, University and University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland

Background: Better education of clinicians is expected to enhance patient safety. An important component of education is adherence to standard protocols, which are mainly available in written form. Believing in the potential power of videos, we hypothesized that the introduction of an educational video, based on an institutional standard protocol, would foster adherence to the protocol.

Methods: We conducted a prospective intervention study of 425 anaesthesia procedures and teams (202 pre-video and 223 post-video) involving 1091 team members (516 pre-video and 575 post-video) in seven individual operating areas (with a total of 30 operating rooms) in a university hospital. Failure of adherence to safety-critical tasks during rapid sequence anaesthesia inductions was assessed during systematic on-site observations pre- and post-introduction of an educational video demonstrating evidence-based and best practice guidelines.

Results: The odds for failure of adherence to safety-critical tasks between the pre- and post-intervention period were reduced, odds ratio 0.34 (95% confidence interval 0.27-0.42, P<0.001). The risk for failure of adherence was reduced significantly for eight of the 14 safety-critical tasks (all P<0.001).

Conclusions: This study provides empirical evidence for the effectiveness of an educational video to enhance adherence to a standard protocol during complex medical procedures. The introduction of a video can reduce failure of adherence to safety-critical tasks and contribute to patient safety. We recommend the introduction of videos to improve protocol adherence.
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http://dx.doi.org/10.1093/bja/aew030DOI Listing
May 2016

Improving Anesthesiologists' Ability to Speak Up in the Operating Room: A Randomized Controlled Experiment of a Simulation-Based Intervention and a Qualitative Analysis of Hurdles and Enablers.

Acad Med 2016 Apr;91(4):530-9

D.B. Raemer is associate professor of anaesthesia, Harvard Medical School, faculty member, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, and senior director of clinical programs, Center for Medical Simulation, Boston, Massachusetts. M. Kolbe is faculty member, Organization, Work and Technology Group, Department of Management, Technology and Economics, ETH Zurich, and director, Simulation Center, University Hospital Zurich, Zurich, Switzerland. R.D. Minehart is assistant professor of anaesthesia, Harvard Medical School, faculty member, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, and teaching faculty, Center for Medical Simulation, Boston, Massachusetts. J.W. Rudolph is assistant clinical professor of anaesthesia, Harvard Medical School, faculty member, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, and director, Institute for Medical Simulation, Center for Medical Simulation, Boston, Massachusetts. M.C.M. Pian-Smith is associate professor of anaesthesia, Harvard Medical School, faculty member, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, and teaching faculty, Center for Medical Simulation, Boston, Massachusetts.

Purpose: The authors addressed three questions: (1) Would a realistic simulation-based educational intervention improve speaking-up behaviors of practicing nontrainee anesthesiologists? (2) What would those speaking-up behaviors be when the issue emanated from a surgeon, a circulating nurse, or an anesthesiologist colleague? (3) What were the hurdles and enablers to speaking up in those situations?

Method: The authors conducted a simulation-based randomized controlled experiment from March 2008-February 2011 at the Center for Medical Simulation, Boston, Massachusetts. During a mandatory crisis management course for practicing nontrainee anesthesiologists from five Boston institutions, a 50-minute workshop on speaking up was conducted for intervention (n = 35) and control (n = 36) groups before or after, respectively, an experimental scenario with three events. The authors analyzed videos of the experimental scenarios and debriefing sessions.

Results: No statistically significant differences between the intervention and control group subjects with respect to speaking-up actions were observed in any of the three events. The five most frequently mentioned hurdles to speaking up were uncertainty about the issue, stereotypes of others on the team, familiarity with the individual, respect for experience, and the repercussion expected. The five most frequently mentioned enablers were realizing the speaking-up problem, having a speaking-up rubric, certainty about the consequences of speaking up, familiarity with the individual, and having a second opinion or getting help.

Conclusions: An educational intervention alone was ineffective in improving the speaking-up behaviors of practicing nontrainee anesthesiologists. Other measures to change speaking-up behaviors could be implemented and might improve patient safety.
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http://dx.doi.org/10.1097/ACM.0000000000001033DOI Listing
April 2016

Simulation With PARTS (Phase-Augmented Research and Training Scenarios): A Structure Facilitating Research and Assessment in Simulation.

Simul Healthc 2015 Jun;10(3):178-87

From the Institute of Anesthesiology (C.J.S., A.M., M.D., A.K., D.R.S., B.G.), University Hospital Zürich; and Department of Management, Technology, and Economics Organization (M.W., M.K., G.G.), Work and Technology Group, ETH Zürich, Zürich, Switzerland.

Introduction: Assessment in simulation is gaining importance, as are scenario design methods increasing opportunity for assessment. We present our approach to improving measurement in complex scenarios using PARTS [Phase-Augmented Research and Training Scenarios], essentially separating cases into clearly delineated phases.

Methods: We created 7 PARTS with real-time rating instruments and tested these in 63 cases during 4 weeks of simulation. Reliability was tested by comparing real-time rating with postsimulation video-based rating using the same instrument. Validity was tested by comparing preintervention and postintervention total results, by examining the difference in improvement when focusing on the phase-specific results addressed by the intervention, and further explored by trying to demonstrate the discrete improvement expected from proficiency in the rare occurrence of leader inclusive behavior.

Results: Intraclass correlations [3,1] between real-time and postsimulation ratings were 0.951 (95% confidence interval [CI], 0.794-0.990), 1.00 (95% CI, --to--), 0.948 (95% CI, 0.783-0.989), and 0.995 (95% CI, 0.977-0.999) for 3 phase-specific scores and total scenario score, respectively. Paired t tests of prelecture-postlecture performance showed an improvement of 14.26% (bias-corrected and accelerated bootstrap [BCa] 95% CI, 4.71-23.82; P = 0.009) for total performance but of 28.57% (BCa 95% CI, 13.84-43.30; P = 0.002) for performance in the respective phase. The correlation of total scenario performance with leader inclusiveness was not significant (rs = 0.228; BCa 95% CI. -0.082 to 0.520; P = 0.119) but significant for specific phase performance (rs = 0.392; BCa 95% CI, 0.118-0.632; P = 0.006).

Conclusions: The PARTS allowed for improved reliability and validity of measurements in complex scenarios.
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http://dx.doi.org/10.1097/SIH.0000000000000085DOI Listing
June 2015

Briefing and debriefing during simulation-based training and beyond: Content, structure, attitude and setting.

Best Pract Res Clin Anaesthesiol 2015 Mar 28;29(1):87-96. Epub 2015 Jan 28.

University Hospital Zurich, Zurich, Switzerland. Electronic address:

In this article, we review the debriefing literature and point to the dilemma that although debriefings especially intend to enhance team (rather than individual) learning, it is particularly this team setting that poses risks for debriefing effectiveness (e.g., preference-consistent information sharing, lack of psychological safety inhibiting structured information sharing, ineffective debriefing models). These risks can be managed with a mindful approach with respect to content (e.g., specific learning objectives), structure (e.g., reactions phase, analysis phase, summary phase), attitude (e.g., honesty, curiosity, holding the trainee in positive regard) and setting (e.g., briefings to provide orientation and establish psychological safety). We point to the potential of integrating systemic methods such as circular questions into debriefings, discuss the empirical evidence for debriefing effectiveness and highlight the importance of faculty development.
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http://dx.doi.org/10.1016/j.bpa.2015.01.002DOI Listing
March 2015

An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.

Anesth Analg 2015 Oct;121(4):948-956

From the Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland; Organization, Work and Technology Group, ETH Zurich, Zurich, Switzerland; Department of Anesthesia and Intensive Care Medicine, Regional Hospital Männedorf, Männedorf, Switzerland; Division of Biostatistics, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland; and Crew Resource Management, Swiss International Air Lines Ltd., Zurich Airport, Kloten, Switzerland.

Background: An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked).

Methods: A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork.

Results: One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P < 0.001), knowledge of critical information: 100% vs 90% (P < 0.001), perception of safety: 91% vs 84% (P < 0.001), perception of teamwork: 90% vs 86% (P = 0.028), and clinical performance: 93% vs 93% (P = 0.60).

Conclusions: This study provides empirical evidence that the use of a preinduction checklist significantly improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams-all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork.
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http://dx.doi.org/10.1213/ANE.0000000000000671DOI Listing
October 2015

Monitoring and talking to the room: autochthonous coordination patterns in team interaction and performance.

J Appl Psychol 2014 Nov 15;99(6):1254-67. Epub 2014 Sep 15.

Institute of Anaesthesiology, University Hospital Zurich.

This paper builds on and extends theory on team functioning in high-risk environments. We examined 2 implicit coordination behaviors that tend to emerge autochthonously within high-risk teams: team member monitoring and talking to the room. Focusing on nonrandom patterns of behavior, we examined sequential patterns of team member monitoring and talking to the room in higher- and lower-performing action teams working in a high-risk health care environment. Using behavior observation methods, we coded verbal and nonverbal behaviors of 27 anesthesia teams performing an induction of general anesthesia in a natural setting and assessed team performance with a Delphi-validated checklist-based performance measure. Lag sequential analyses revealed that higher-performing teams were characterized by patterns in which team member monitoring was followed by speaking up, providing assistance, and giving instructions and by patterns in which talking to the room was followed by further talking to the room and not followed by instructions. Higher- and lower-performing teams did not differ with respect to the frequency of team member monitoring and talking to the room occurrence. The results illustrate the importance of patterns of autochthonous coordination behaviors and demonstrate that the interaction patterns, as opposed to the behavior frequencies, discriminated higher- from lower-performing teams. Implications for future research and for team training are included. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
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http://dx.doi.org/10.1037/a0037877DOI Listing
November 2014

In response.

Anesth Analg 2013 May;116(5):1184-1186

ETH ZurichZurich, Switzerland Institute of PsychologyUniversity of ZurichZurich, Switzerland Institute of Physicians for Anaesthesia and Intensive CareKlinik Hirslanden ZurichZurich, Switzerland Département de Psychologie, Industrial Psychology and Human FactorsUniversity of FribourgFribourg, Switzerland Institute of AnesthesiologyUniversity Hospital ZurichZurich, Switzerland.

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http://dx.doi.org/10.1213/ANE.0b013e31828c43f3DOI Listing
May 2013

Team coordination during cardiopulmonary resuscitation.

J Crit Care 2013 Aug 15;28(4):522-3. Epub 2013 May 15.

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http://dx.doi.org/10.1016/j.jcrc.2013.03.009DOI Listing
August 2013

TeamGAINS: a tool for structured debriefings for simulation-based team trainings.

BMJ Qual Saf 2013 Jul 22;22(7):541-53. Epub 2013 Mar 22.

Organization, Work, Technology Group, Department of Management, Technology, and Economics, ETH Zurich, Switzerland.

Background: Improving patient safety by training teams to successfully manage emergencies is a major concern in healthcare. Most current trainings use simulation of emergency situations to practice and reflect on relevant clinical and behavioural skills. We developed TeamGAINS, a hybrid, structured debriefing tool for simulation-based team trainings in healthcare that integrates three different debriefing approaches: guided team self-correction, advocacy-inquiry and systemic-constructivist techniques.

Methods: TeamGAINS was administered during simulation-based trainings for clinical and behavioural skills for anaesthesia staff. One of the four daily scenarios involved all trainees, whereas the remaining three scenarios each involved only two trainees with the others observing them. Training instructors were senior anaesthesiologists and psychologists. To determine debriefing quality, we used a post-test-only (debriefing quality) and a pre-post-test (psychological safety, leader inclusiveness), no-control-group design. After each debriefing all trainees completed a self-report debriefing quality scale which we developed based on the Debriefing Assessment for Simulation in Healthcare and the Observational Structured Assessment of Debriefing. Perceived psychological safety and leader inclusiveness were measured before trainees' first (premeasure) and after their last debriefing (postmeasure) at which time trainees' reactions to the overall training were measured as well.

Results: Four senior anaesthetists, 29 residents and 28 nurses participated in a total of 40 debriefings resulting in 235 evaluations. Utility of debriefings was evaluated as highly positive. Pre-post comparisons revealed that psychological safety and leader inclusiveness significantly increased after the debriefings.

Conclusions: The results indicate that TeamGAINS could provide a useful debriefing tool for training anaesthesia staff on all levels of work experience. By combining state-of-the-art debriefing methods and integrating systemic-constructivist techniques, TeamGAINS has the potential to allow for a surfacing, reflecting on and changing of the dynamics of team interactions. Further research is necessary to systematically compare the effects of TeamGAINS' components on the debriefing itself and on trainees' changes in attitudes and behaviours.
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http://dx.doi.org/10.1136/bmjqs-2012-000917DOI Listing
July 2013

Co-ACT--a framework for observing coordination behaviour in acute care teams.

BMJ Qual Saf 2013 Jul 19;22(7):596-605. Epub 2013 Mar 19.

Organization, Work, Technology Group, ETH Zurich, Zurich, Switzerland.

Background: Acute care teams (ACTs) represent action teams, that is, teams in which members with specialised roles must coordinate their actions during intense situations, often under high time pressure and with unstable team membership. Using behaviour observation, patient safety research has been focusing on defining teamwork behaviours-particularly coordination-that are critical for patient safety during these intense situations. As one result of this divergent research landscape, the number, scope and variety of applied behaviour observation taxonomies are growing, making comparison and convergent integration of research findings difficult.

Aim: To facilitate future ACT research by presenting a framework that provides a shared language of teamwork behaviours, allows for comparing previous and future ACT research and offers a measurement tool for ACT observation.

Method: Based on teamwork theory and empirical evidence, we developed Co-ACT-the Framework for Observing Coordination Behaviour in ACT. Integrating two previous, extensive taxonomies into Co-ACT, we also suggested 12 behavioural codes for which we determined inter-rater reliability by analysing the teamwork of videotaped anaesthesia teams in the clinical setting.

Results: The Co-ACT framework consists of four quadrants organised along two dimensions (explicit vs implicit coordination; action vs information coordination). Each quadrant provides three categories for which Cohen's κ overall value was substantial; but values for single categories varied considerably.

Conclusions: Co-ACT provides a framework for organising behaviour codes and offers respective categories for succinctly measuring teamwork in ACTs. Furthermore, it has the potential to allow for guiding and comparing ACTs study results. Future work using Co-ACT in different research and training settings will show how well it can generally be applied across ACTs.
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http://dx.doi.org/10.1136/bmjqs-2012-001319DOI Listing
July 2013

Speaking up is related to better team performance in simulated anesthesia inductions: an observational study.

Anesth Analg 2012 Nov 25;115(5):1099-108. Epub 2012 Sep 25.

ETH Zurich, CH-8032 Zurich, Switzerland.

Background: Our goal in this study was to test the relationship between speaking up--i.e., questioning, correcting, or clarifying a current procedure--and technical team performance in anesthesia. Hypothesis 1: team members' higher levels of speaking up are related to higher levels of technical team performance. Hypothesis 2: team members will react to speaking up by either clarifying their procedure or initiating a procedural change. Hypothesis 3: higher levels of speaking up during an earlier phase of teamwork will be related to higher levels of speaking up during a later phase.

Methods: This prospective observational study involved 2-person ad hoc anesthesia teams performing simulated inductions of general anesthesia with minor nonroutine events (e.g., bradycardia) in a large teaching hospital. Subjects were registered anesthesia nurses and residents. Each team consisted of 1 nurse and 1 resident. Synchronized video and vital parameter recordings were obtained. Two trained observers blinded to the hypotheses coded speaking up and further team communication and coordination behavior on the basis of 12 distinct categories. All teamwork measures were quantified as percentage of total time spent on the respective teamwork category. Two experienced staff anesthesiologists blinded to the hypotheses evaluated technical team performance using a Delphi-validated rating checklist. Hypotheses 1 and 3 were tested using linear regression with residents' and nurses' levels of speaking up as 2 separate predictor variables. Hypothesis 2 was analyzed using lag sequential analysis, resulting in Z values representing the extent to which the observed value for a conditional transition significantly differs from its unconditional value.

Results: Thirty-one nurses and 31 residents participated. Technical team performance could be predicted by the level of speaking up from nurses (R(2) = 0.18, P = 0.017) but not from residents (R(2) = 0.19, P = 0.053); this result supports Hypothesis 1 for nurses. Supporting Hypothesis 2, residents reacted to speaking up with clarifying the procedure by providing information (Z = 18.08, P < 0.001), initiating procedural change by giving instructions (Z = 4.74, P < 0.001) and team member monitoring (Z = 3, P = 0.0013). Likewise, nurses reacted with clarifying the procedure by providing or evaluating information (Z = 16.09, P < 0.001; Z = 3.72, P < 0.001) and initiating procedural change by providing assistance (Z = 0.57, P < 0.001). Indicating a trend for Hypothesis 3, nurses' level of speaking up before intubation predicted their level of speaking up during intubation (R(2) = 0.15, P = 0.034), although this did not reach the Bonferroni-corrected significance level of P = 0.025. No respective relationship was found for residents (R(2) = 0.15, P = 0.096).

Conclusions: This study provides empirical evidence and shows mechanisms for the positive relationship between speaking-up behavior and technical team performance.
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http://dx.doi.org/10.1213/ANE.0b013e318269cd32DOI Listing
November 2012

Interactions of team mental models and monitoring behaviors predict team performance in simulated anesthesia inductions.

J Exp Psychol Appl 2011 Sep;17(3):257-69

Center for Organizational and Occupational Sciences, ETH Zurich, Zurich, Switzerland.

In the present study, we investigated how two team mental model properties (similarity vs. accuracy) and two forms of monitoring behavior (team vs. systems) interacted to predict team performance in anesthesia. In particular, we were interested in whether the relationship between monitoring behavior and team performance was moderated by team mental model properties. Thirty-one two-person teams consisting of anesthesia resident and anesthesia nurse were videotaped during a simulated anesthesia induction of general anesthesia. Team mental models were assessed with a newly developed measurement tool based on the concept-mapping technique. Monitoring behavior was coded by two organizational psychologists using a structured observation system. Team performance was rated by two expert anesthetists using a performance-checklist. Moderated multiple regression analysis revealed that team mental model similarity moderated the relationship between team monitoring and performance; a higher level of team monitoring in the absence of a similar team mental model had a negative effect on performance. Furthermore, team mental model similarity and accuracy interacted to predict team performance. Our findings provide new insights on factors influencing the relationship between team processes and team performance in health care. When investigating the effectiveness of a specific team coordination behavior, team cognition has to be taken into account. This represents a necessary and compelling extension of the popular process-outcome relationship on which previous teamwork research in health care has focused. Moreover, the current study adds further external validity to the concept of team mental models by highlighting its usefulness in health care.
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http://dx.doi.org/10.1037/a0025148DOI Listing
September 2011

Leadership in anaesthesia teams: the most effective leadership is shared.

Qual Saf Health Care 2010 Dec 14;19(6):e46. Epub 2010 May 14.

ETH Zurich, Department of Management, Technology, and Economics, Kreuzplatz 5, CH-8032 Zurich, Switzerland.

Background: Leadership plays a crucial role in teams working in complex environments, and research has shown that shared leadership where all team members perform leadership functions is an effective strategy. The authors aimed to describe shared leadership patterns during anaesthesia induction and show how they are linked to team performance.

Methods: 12 anaesthesia teams consisting of one resident and one nurse during a simulated anaesthesia induction including a non-routine event (asystole) were videotaped, and two kinds of leadership behaviour (content-oriented and structuring) were coded. Team performance was operationalised as the reaction time to the non-routine event. The amount of leadership sharedness was compared between low- and high-performing teams by performing a univariate analysis of variance. Wilcoxon signed-rank tests were used to analyse the distribution of the two kinds of leadership behaviour among team members.

Results: Statistical analysis revealed that in high-performing teams, residents and nurses shared their leadership, while in low-performing teams, residents showed significantly higher levels of leadership behaviour than nurses. Further analyses revealed different distributions of leadership functions among team members. While residents of low-performing teams assumed both kinds of leadership behaviour, members of high-performing teams seemed to have distinct leadership roles: nurses mainly used content-oriented leadership behaviour, and residents tended to show structuring leadership behaviour.

Conclusions: The study documents the effectiveness of shared leadership in situations with high task complexity and indicates that a clear distribution of content-oriented and structuring leadership among team members is an effective strategy. The findings have implications for training in shared leadership and also give rise to a number of recommendations for further research. ClinicalTrials (http://www.clinicaltrials.gov) registration number is NCT00706108.
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http://dx.doi.org/10.1136/qshc.2008.030262DOI Listing
December 2010
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